Every finding on record at Forest Springs Health Campus

Based on interview, record review, and review of the facility policy it was determined that the facility failed to establish an antibiotic stewardship program that included a system to monitor antibiotic use. The findings include:Review of the facility policy titled, Antibiotic Stewardship Guideline, reviewed 11/19/2025, revealed the purpose of the policy was to optimize the treatment of infections ensuring that residents who required an antibiotic were prescribed the appropriate antibiotic, to reduce the risk of adverse event, including the development of antibiotic resistant organisms from unnecessary or inappropriate antibiotic use encompass of facility wide system to monitor the use of antibiotics.Review of the facility's surveillance tracking for antibiotics revealed there was no surveillance of infections or antibiotic information available for review for November 2025. Further, the only information available for December was a list of prescribed antibiotics. The Executive Director verified the facility used McGreer's Criteria for prescribing antibiotics. An internet search revealed a chart listed under McGreer et al infection surveillance chart, dated March, 2025, which listed various types of human body systems and possible infections for each system. The chart further listed various symptoms to observe prior to initiating antibiotic treatment. Further record review of facility provided printed documents revealed information was not provided as to if the prescribed antibiotic met the McGreer's established criteria. Additionally, there was no information documented on the organism/pathogen for an ordered culture and sensitivity. In an interview with the Director of Health Services (DHS) on 12/11/2025 at 6:25 PM, she stated the Assistant Director (AD) was previously the Infection Preventionist, but that person left the position in October. She stated currently there was no AD and that she (DHS) was responsible for infection surveillance in the facility. She stated infection tracking was behind for November and December.Interview with the Administrator on 12/11/2025 at 7:04 PM, she stated she expected the facility to follow the Infection Control Policy and to follow up with clinical support if they had questions. She stated the clinical team met each morning, and antibiotics were discussed. She stated ultimately the DHS would be responsible for ensuring infection control measures were in place. She stated she was not aware infection surveillance for antibiotics for November was not completed until this date. The Administrator stated that the surveillance of infections was important to identify trends and make any changes to help decrease infections.

Based on interview and record review it was determined the facility failed to designate one or more individual(s), with the certification as the infection preventionist(s) (IP)(s) responsible for the facility's infection prevention and control program.The findings include:Review of the facility policy titled, Infection Prevention and Control Program, reviewed 12/17/2024, revealed the purpose of the policy established and maintained an infection prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Continued review revealed the campus would designate a member of the clinical team to monitor the campus's infection prevention and control program, to perform surveillance to identify, investigate, control, and prevent the spread of infection, and reporting for the infection prevention and control program.In review of facility documents provided to the State Survey Agency (SSA) at the entrance conference, no staff person was listed for the Infection Preventionist (IP) nor were training certificate(s) provided. Interview with the Executive Director (ED) on 12/09/2025 at 4:45 PM, he stated the previous IP was no longer working at the facility and the Director of Health Services (DHS) was completing those duties of the Infection Preventionist; however, she (DHS) had not received the specialized training. The regional nurse consultant was present and stated she oversaw the facility's Infection Control Program (ICP) but she was not at the facility daily.At approximately 5:00 PM on 12/09/2025. the ED provided a certificate and stated that the facility's Minimum Data Set (MDS) nurse had received the training. However, when asked if she (the MDS nurse) oversaw the ICP he stated that she did.The SSA requested a facility job description for the role of Infection Preventionist; however, the ED stated the facility did not have a job description as it was a designated position.In interview with the Director of Health Services (DHS) on 12/11/2025 at 6:25 PM, she stated she had been the DHC for six (6) months. The DHS stated the previous Assistant Director (AD) was the Infection Preventionist, but she had left the position in October. She stated she did not have an AD and that she was responsible for infection surveillance in the facility. She stated infection tracking was behind for November and December.Interview with the Executive Director on 12/11/2025 at 6:56 PM, he stated he expected staff to follow policies and procedures related to infections. He stated the facility did not have a job description for the Infection Preventionist, as it was a designation. He stated the Centers for Medicare and Medicaid Services (CMS) stated facilities have to have an IP not a particular position. He further stated the IP did not have a specific job list of duties.

Based on observation and interview it was determined that the facility failed to ensure the food equipment cart was clean. Observation of the food delivery cart on 10/22/19 revealed the back of the food delivery cart was dirty. The findings include: Interview with a Dining Service Support Employee revealed they did not have policies on cleaning in the kitchen. The Dining Service Support Employee did offer a weekly cleaning checklist for the week of 10/13/19 and the week of 10/20/19. The employee further revealed the food delivery cart would fall under the category of Utility Carts cleaned & Sanitized. Review of the checklist revealed it was checked off as being cleaned the week of 10/13/19 but was not marked off as being cleaned for the week of 10/20/19. Observation of the food delivery cart on 10/22/19 at 12:42 PM revealed the back outside of the cart to be dirty. The cart was observed to have a dried substance that spread down the back of the cart and an object resembling foil stuck to the back of the cart. Interview on 10/23/19 at 3:40 PM with the Dining Service Support Employee revealed that it is the responsibility of the night shift kitchen staff to clean the kitchen and apparently they had missed the back of the cart. He agreed that the food delivery cart was dirty. He further revealed there had been a lot of turnover in the kitchen recently, and the facility had just terminated the night shift person who was responsible for cleaning. Interview on 10/23/19 at 9:00 AM with the former Director of Nursing revealed there was no cleaning policy and procedure for the kitchen. Per the DON, the facility followed manufacturer recommendations related to cleaning in the kithchen. She further revealed that she had seen the back of the food delivery cart and agreed it was dirty and should have been cleaned. Interview on 10/24/19 at 3:48 PM with the Infection Control Nurse revealed she does surveillance in the kitchen about once a week. She furthered revealed that she looks at the fridge, ensures everyone is wearing hair nets, and observes hand hygiene. She further stated that she had not identified any concerns with the kitchen.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure oxygen therapy was provided as ordered for one (1) of fifteen (15) sampled residents. Resident #21 was observed receiving oxygen via nasal cannual and the oxygen concentrator was set on four and one-half (4.5) liters per minute (LPM) on 10/23/19 and on five (5) LPM on 10/24/19, which was not the ordered flow rate of three (3) LMP. The findings include: Review of the facility policy, Guidelines for the Administration of Oxygen, dated (MONTH) (YEAR), revealed the physician's order for the oxygen should be verified and the oxygen setting must be set and adjusted by a licensed nurse. Observation of Resident #21 on 10/23/19 at 9:24 AM, revealed the resident was in bed and oxygen was being delivered via nasal cannula and the oxygen concentrator was set on four and one-half (4.5) LPM. Further observation on 10/23/19, at 5:01 PM, revealed the resident was up in a motorized wheelchair in the dining room and the portable oxygen canister was set at two (2) LPM. Observation of Resident #21 on 10/24/19 at 8:48 AM, revealed the resident was lying in bed and oxygen was being delivered via nasal cannula at five (5) LMP per oxygen concentrator. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) significant change assessment, dated 09/04/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident had moderate cognitive impairment. The MDS further revealed the resident required oxygen therapy. Review of the physician order summary, dated 10/24/19, revealed Resident #21 had an order, dated 08/16/19, that stated oxygen was to be provided at three (3) LPM per nasal cannula, continuously. Review of the comprehensive care plan for Resident #21, dated 08/28/19, revealed a risk of potential complications related to [MEDICAL CONDITION] and the intervention to administer oxygen as per orders. Review of Resident #21's Aide Care Guide, undated, revealed in the comments section to ensure ear protectors are on while O2 (oxygen) is in use. Interview with Licensed Practical Nurse (LPN) #1 on 10/24/19 at 8:48 AM, revealed that the oxygen concentrator for Resident #21 should be set on three (3) LMP and stated she was not aware the concentrator was set on five (5) LPM. Further interview with the LPN, at 10:32 AM, revealed the previous shift had not reported to her any reason why the resident's oxygen would have been set on five (5) LPM, and at that time she set the concentrator to three (3) LMP as ordered. Interview with the former Director of Nursing (DON) and the DON on 10/24/19 at 5:21 PM, revealed residents receiving oxygen therapy are to have oxygen settings checked every shift to ensure it is being delivered as ordered. Both stated Resident #21's oxygen was not being delivered as ordered by the physician.

Based on observation, interview, and policy review it was determined that the facility failed to ensure that residents were provided meals with no greater than a 14-hour lapse between the evening meal and breakfast without the provision of a substantial nourishing evening snack. Observation on 10/23/19 at 6:30 PM revealed evening meal trays being sent to the floor. Observation on 10/24/19 at 9:30 AM revealed breakfast meal trays being sent to the floor, which is 15 hours between meals. Interview with one (1) unsampled resident and with the family of one (1) sampled resident revealed the residents had received supper on 10/23/19 at about 6:30 PM and received breakfast on 10/24/19 between 8:30 AM and 10:00 AM with no offering of an evening snack. The findings include: Review of facility policy titled Meal Service, effective date 05/31/16, revealed, Meal service will be no more than 16 hours between the evening meal and the breakfast meal if a substantial nourishing snack is provided at bedtime (14 hours if no snack is provided). Further review of the policy revealed, Meals will be served at the following hours: Breakfast Room Service: 7:30 AM and Dinner Room Service at 5:15 PM. Observation on 10/23/19 at 6:30 PM revealed supper trays being delivered to the floor. Observation on 10/24/19 at 9:30 AM revealed breakfast trays being delivered to the floor. Interview on 10/23/19 at 9:38 AM during resident council revealed unsampled Resident #22 stated he/she was never offered nighttime snacks. Interview on 10/24/19 at 9:57 AM with unsampled Resident #1 (end of 300 Hall) revealed he/she ate supper in the dining room on 10/23/19 at about 6:30 PM and had just received his/her breakfast in the room at 9:57 AM. Resident #1 stated he/she had not been offered a bedtime snack. Interview on 10/24/19 at 10:25 AM with the family of sampled Resident #187 (at the end of 100 hallway) revealed the resident had received the supper meal on 10/23/19 at about 6:30 PM and had received breakfast at 8:30 AM on 10/24/19. The family further revealed the family had spent every night with the resident and the resident had never been offered a bedtime snack. Furthermore, the Family Member stated there had been mornings when breakfast was as late as 9:30 AM. Per the family, Resident #187 had been in the facility since 10/05/19. Interview on 10/24/19 at 11:10 AM with Dining Support Service employee revealed the carts go out after the dining room is serviced. He further revealed the staff on the floor have access to the kitchen at all hours to fix snacks for the residents. He stated that snack carts are not sent out for nighttime snacks. He agreed that to go 15 hours without the offer of a meal was too long. He also mentioned there had been some recent turnovers in the staff in the kitchen. Interview on 10/24/19 at 5:12 PM with the former Director of Nursing revealed residents are not usually offered a night meal or snack unless the Registered Dietitian had made recommendations for the resident to have one. She further revealed the kitchen was always available for staff to make snacks for residents. She stated she had not identified a problem.

Based on observation, interview, and record review it was determined the facility failed to revise an individualized care plan and nurse aide care plan based on the Minimum Data Set (MDS) assessment dated [DATE]. The assessment revealed the resident required extensive assistance of two (2) or more persons to perform bed mobility, transfer, dressing and toileting. However, the care plan did not include that the resident required two (2) or more persons' assistance to perform these tasks. The findings include: A care plan policy was requested of the facility but as of exit on 10/24/19 the policy was not provided. Review of the Resident Assessment Instrument 3.0 User Manual, Version 1.17.1, dated (MONTH) 2019, revealed the completed MDS assessment must be analyzed and combined with other relevant information to develop an individualized care plan. Observation of Resident #21 on 10/24/19 at 9:51 AM, revealed State Registered Nurse Aide (SRNA) #2 transferred the resident from the bed to a motorized wheelchair using a mechanical lift. The SRNA performed the bed mobility of turning the resident from side to side to place the sling for the lift by herself. Further observation revealed the SRNA transferred the resident, via mechanical lift, from the bed to a motorized wheelchair without the assistance of another staff member. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) significant change assessment, dated 09/04/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident had moderate cognitive impairment. Further review of the MDS also revealed the resident required extensive assistance of two (2) or more persons to complete the tasks of bed mobility, transfers, dressing, and toileting. Review of the comprehensive care plan for Resident #21, dated 02/05/19, revealed the resident was to be transferred by the assistance of two (2) with a standing lift. Further review of the care plan revealed the resident required extensive assistance with bed mobility, transfers, and toileting, but without direction regarding the number of persons required per the MDS assessment. Review of the Aide Care Guide, undated, revealed the resident was to be transferred using the standing lift, without the number of persons required. In addition, the Aide Care Guide did not include the number of staff assistance required for bed mobility. Interview with SRNA #2 on 10/24/19 at 10:12 AM, revealed she always transferred Resident #21 by herself. She further stated the aides could find information regarding the amount of assistance and number of persons required by looking at the care guides located at the nurses' station. The SRNA found the care guide for Resident #21 and discovered the guide stated that the resident was to be transferred using the standing lift. The aide then stated they have been using a mechanical lift on him/her since the resident returned from the hospital. The records revealed the resident last returned from the hospital on [DATE]. Interview with SRNA #1 on 10/23/19 at 1:39 PM, revealed when transferring with a mechanical lift that sometimes one (1) person performs and sometimes two (2). SRNA #1 also stated resident requirements for assistance are found on the resident care guides at the nurses' station. Interview with the former Director of Nursing (DON) on 10/23/19 at 6:22 PM, revealed clinical care meetings are held daily, Monday through Friday, and changes and updates to the care plan are made at that time. Interview with the former DON on 10/24/19 at 3:23 PM, revealed she agreed that the MDS assessment, dated 09/04/19, showed Resident #21 to require extensive assistance of two (2) or more persons for the activities of bed mobility, transfers, dressing, and toileting. She also agreed that the comprehensive care plan, dated 02/05/19, did not reveal that the resident required two (2) or more persons for these activities. As well, the aide plan did not accurately reveal the resident's current level of required assistance for transfers, which was now per the use of a mechanical lift.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to provide one (1) of fifteen (15) sampled residents with notification regarding bed hold upon transfer out of the facility. Resident #39 did not receive notifications regarding bed hold when transferred to an acute care hospital. The findings include: Review of the facility policy, Bed Hold Policy, dated 11/18/16, revealed the campus will properly inform residents in advance of their option to make bed-hold payments as well as the amount of the facility's charge to hold a bed. Record review of Resident #39 revealed the resident was admitted to the facility on [DATE] at 3:48 PM with [DIAGNOSES REDACTED]. Further review of the resident's record revealed that on 09/20/19 at 11:24 AM the facility transferred the resident to an acute care hospital. Further review of the record revealed no documented evidence that the resident was given bed hold information when transferred to the hospital. Interview on 10/24/19 at 4:11 PM with the Director of Nursing (DON) revealed no bed hold was issued at discharge for Resident #39. The DON stated it was the floor nurse's responsibility to ensure the bed hold policy was given when residents left the facility via ambulance. Per the DON, the nursing staff had failed to issue Resident #39's bed hold notice on 09/20/19.

Based on interview and record review, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of six (6) sampled residents, Resident #4. Staff did not supervise Resident #4 while a Thera-band remained on the resident's lower extremities after the resident had completed therapy for the day. The finding includes: A policy related to Thera-Bands was requested but not provided. Review of Resident #4's clinical record revealed the facility admitted the resident on 05/26/17, with [DIAGNOSES REDACTED]. Review of Resident #4's Admission Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident to be cognitively intact and without behaviors. The resident received Physical Therapy (PT) and Occupational Therapy (OT) and displayed impairment on both upper and lower extremities. The facility assessed the resident with a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Interview with Resident #4's Family Member, on 07/12/17 at 4:00 PM, revealed she came to visit Resident #4 (unsure of the date) and the resident was sitting in a wheelchair with an exercise band (Thera-band) still attached to his/her ankles. The family member stated she talked to the Director of Nursing (DON) at the time and the DON told her PT/OT staff forgot to take the band off once therapy had been completed. Interview with Resident #4, on 07/12/17 at 5:30 PM, revealed he/she was aware a Thera-band had been left on his/her lower legs one day (unsure of the date) after the completion of therapy and it upset the family. Interview with the DON, on 07/13/17 at 3:00 PM, revealed PT/OT staff left a Thera-band on Resident #4's lower legs after therapy was completed. She was unable to state exactly when the incident occurred as the facility was unable to provide any evidence specific to the incident. She stated PT/OT staff came into the resident's room and removed it once the family member brought it to their attention, she thought within fifteen (15) minutes. The DON stated according to the previous Physical Therapist, the band was used as a positioning device. The DON stated she was concerned that staff had left the Thera-band on the resident. Interview with the Certified Occupational Therapy Assistant, on 07/14/17 at 8:10 AM, revealed a Thera-band was used for strengthening and should be taken off the resident when the resident was finished the PT/OT therapy session. She stated residents should not wear Thera-bands outside the gym because the band could cause an accident or skin breakdown if not properly monitored. Interview with the Physical Therapist (PT), on 07/14/17 at 8:50 AM, revealed Resident #4 used a Thera-band on his/her legs for resistance training. He stated PT/OT staff removed Thera-bands prior to dismissal from the gym, and residents should only use the bands under the supervision of a licensed Physical or Occupational Therapist. He stated a resident was at risk for skin breakdown, or possible falls, if the band was left on without supervision. Interview with the Physical Therapy Assistant, on 07/14/17 at 3:20 PM, revealed she remembered working with Resident #4 in the past and always made it a priority to remove the Thera-bands once exercise was completed. She stated staff should monitor residents if bands were in place; she stated the band was not used as a positional device, only for exercise. Interview with Licensed Practical Nurse (LPN) #6, on 07/14/17 at 2:10 PM, revealed Thera-bands were used in the therapy department and nursing staff should be notified if they were to be used outside the therapy department. She stated she would take off the band if she needed too. LPN #6 revealed an unsupervised Thera-band could cause skin breakdown. Interview with the Regional Director of Operations for Physical Therapy, on 07/13/17 at 4:20 PM, revealed Thera-bands were used for specific exercises, not as repositioning devices, and limited a resident's movement. He stated he expected PT/OT staff to remove Thera-bands because the resident or nursing staff would likely not be able to remove the band properly. He stated he was not aware PT/OT staff had left on Resident #4's Thera-band.

Based on interview, record review, and review of the facility's abuse policy, it was determined the facility failed to ensure an allegation of mistreatment was thoroughly investigated and reported to State Agencies for one (1) of six (6) sampled residents, Resident #4. The facility failed to investigate and report Resident #4's allegation of a staff member being rough while providing care. The findings include: Review of the facility's Abuse policy, revised 06/27/17, revealed the facility had developed and implemented a process, which strived to ensure the prevention and reporting of alleged resident abuse and neglect. The facility defined physical abuse as hitting, slapping, pinching, spitting, holding, or handling roughly. Any person with knowledge or suspicion of suspected violations shall report without fear of reprisal. Any suspected employee (s) was to be suspended pending the outcome of an abuse investigation. Any allegation of abuse was reported immediately, but no later than two (2) hours after the allegation was made, to the State Survey Agency and Adult Protective Services as well as a written report of the investigation outcome, including resident response and/or condition, final conclusion, and actions taken to prevent reoccurrence, submitted to the applicable State Agencies within five (5) days. Review of Resident #4's clinical record revealed the facility admitted the resident on 05/26/17, with [DIAGNOSES REDACTED]. Review of Resident #4's Admission Minimum Data Set (MDS), dated ,[DATE] /17, revealed the facility assessed the resident with a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Interview with Resident #4, on 07/12/17 at 5:30 PM, revealed Certified Nursing Assistant (CNA) #1 had been rough when providing care. Resident #4 stated he/she reported CNA #1 to the Administrator and told the Administrator CNA #1 had provided care in a rough manner and the resident did not want the CNA back in his/her room. The resident could not recall the exact date of the occurrence. Interview with CNA #1 via telephone, on 07/14/17 at 9:34 AM, revealed he was instructed (unsure of the date) by the Director of Nursing (DON) not to go into Resident #4's room for any reason. The CNA stated he never knew why he was not supposed to go back into the resident's room. Interview with Licensed Practical Nurse (LPN) #6, on 07/14/17 at 2:00 PM, revealed anytime a resident mentioned the word, rough, she would ask the resident to define what that term meant. LPN #6 stated she would first keep the resident safe, remove the alleged perpetrator from the resident's room, and immediately notify her supervisor. Interview with the Certified Medicine Technician (CMT), on 07/14/17 at 2:05 PM, revealed she would immediately report any allegation of abuse to the nurse and keep the resident safe. Interview with LPN #7, on 07/14/17 at 2:10 PM, revealed she would immediately remove the suspected perpetrator from the resident's room, and immediately report any allegation of abuse to the DON and Administrator. Interview with the DON, on 07/13/17 5:00 PM, revealed she was not aware Resident #4 reported CNA #1 had been rough with him/her. The DON revealed any report of suspected abuse should be immediately reported to the facility administration, investigated, and reported to State Agencies within two (2) hours. Interview with the Administrator, on 07/13/17 at 4:35 PM, revealed Resident #4 had reported to him (unsure of the date) that he/she did not want CNA #1 taking care of him/her anymore. The Administrator revealed he thought the resident had stated CNA #1 seemed rushed, and moved too fast when providing care to the resident, but could not remember the exact words the resident used because the resident voiced many complaints at the time. He went on to state CNA #1 had been removed from caring for Resident #4 per the resident's request. The Administrator revealed the facility did not suspend the CNA pending an investigation, did not report the allegation to State Agencies, or complete an investigation following Resident's #4 allegation. The facility could not produce any evidence that the resident had voiced a concern regarding Resident #4's allegation nor that CNA #1 had received counseling or been banned from the resident's room. The Administrator stated any allegation of abuse resulted in the employee being sent home pending the investigation, which would include staff and resident interviews. He stated the facility should immediately report incidents to the State Agency as well. The Administrator stated he understood an abuse investigation should have been started for Resident #4's allegation, and information pertaining to the allegation should have been clearly documented.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify the physician for two (2) of six (6) sampled residents, Resident #1 and #3, when Resident #1 and #3 missed multiple doses of physician prescribed medications. The findings include: Review of the facility's policy, Notification of Change in Condition, not dated, revealed the purpose of the policy was to ensure the physician was notified when there was a need to alter treatment significantly, for example, a need to discontinue an existing form of treatment or to commence a new form of treatment. Review of Resident #1's clinical record revealed the facility admitted the resident on 05/01/16, with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) and determined the resident not interviewable. The facility assessed the resident did not display any behaviors such as refusing care/medications. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's MAH, dated 02/01/17 to 02/28/17, revealed the facility did not administer the prescribed [MEDICATION NAME]-[MEDICATION NAME] 4:00 PM dose on 02/07/17. The facility did not administer both doses on 02/06/17 and 02/22/17. Documentation revealed the medication was not available on those dates. Review of Resident #1's Medications Administration History (MAH), dated 05/01/17 to 05/31/17, revealed the facility did not administer the prescribed Dorzolamide eye drops 8:00 AM dose on 05/18/17, and 05/31/17. The facility did not administer the 8:00 PM dose on 05/16/17, 05/17/17, 05/27/17, 05/28/17, 05/29/17, and 05/30/17. In addition, the facility did not administer both doses on 05/24/17, 05/25/17, and 05/26/17. Documentation revealed the medication was not available on those dates. Review of Resident #1's MAH, dated 06/01/17 to 06/30/17, revealed the facility did not administer the prescribed Cranberry Concentrate-[MEDICATION NAME] Acid daily dose 06/04/17 through 06/13/17, 06/16/17 through 6/21/17, and on 06/25/17. Documentation revealed the medication was not available on those dates. Review of Resident #3's clinical record revealed the facility admitted the resident on 02/04/17, with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS, dated [DATE], revealed the facility did not complete a BIMS for the resident due to the resident was rarely/never understood. The facility assessed the resident did not display any behaviors such as refusing care/medications. Interview with Resident #3's Family Member, on 07/12/17 at 11:00 AM, revealed the resident did not get his/her eye drops on time. Review of Resident #3's Physician order [REDACTED]. mg once a day between 6:00 AM - 10:00 AM for [MEDICAL CONDITION], and an order with a start date of 02/04/17, for [MEDICATION NAME] (for [MEDICAL CONDITION]) 0.4 mg once a day between 6:00 AM - 10:00 AM. Review of Resident #3's MAH, dated 02/01/17 to 02/28/17, revealed the facility did not administer the prescribed [MEDICATION NAME] 02/09/17 through 02/17/17, 02/20/17, and 02/23/17. Documentation revealed the medication was not available on those dates. Review of Resident #3's MAH, dated 03/01/17 to 03/31/17, revealed the facility did not administer the prescribed [MEDICATION NAME]-[MEDICATION NAME] Complex on 03/01/17, 03/02/17, 03/03/17, 03/04/17, 03/06/17, 03/08/17 through 03/18/17, and 03/21/17 through 3/31/17. Documentation revealed the medication was not available on those dates. Review of Resident #3's MAH, dated 06/01/17 to 06/30/17, revealed the facility did not administer the prescribed Dorzolamide eye drops AM dose on 06/02/17 and 06/13/17. The facility did not administer the PM dose on 06/01/17 and 06/07/17. The facility did not administer both doses on 06/06/17, 06/08/17, 06/09/17, and 06/10/17. Documentation revealed the medication was not available on those dates. Interview with a Certified Medical Technician, on 07/14/17 at 2:05 PM, revealed she would double check for the location of a missing prescribed medication, such as eye drops, and then notify the charge nurse that the medication was not available. She stated the charge nurse would then re-order the medication through the computer system. Interview with Licensed Practical Nurse (LPN) #1, on 07/12/17 at 3:20 PM, revealed when a medication was missing, staff could order the medication through the pharmacy. She stated a medication might arrive at the facility within two (2) to four (4) hours if ordered via the computer as stat (immediately). She also stated staff should notify the physician whenever there was the possibility of an omission of a medication dose because the physician might order a substitution for the missing medication. Interview with LPN #2, on 07/12/17 at 3:42 PM, revealed any medication could be re-ordered by a nurse when needed. She stated she would not omit any medication without notifying the physician. She also stated a resident missing a medication for [MEDICAL CONDITION] could put a resident at risk for developing intraocular (inside the eye) pressure. Interview with LPN #3, on 07/12/17 at 3:55 PM, revealed the pharmacy made two (2) deliveries to the facility daily to deliver medications. She stated staff should re-order any urgent medication as stat so the pharmacy would deliver the medication within two (2) to four (4) hours. She stated Dorzolamide was a medication that treated [MEDICAL CONDITION] and staff should order the medication stat to prevent damage to the eyes. The LPN stated it was not acceptable for staff not to act upon a missing medication. Interview with the Qualified Medication Associate (QMA), on 07/12/17 at 4:00 PM, revealed QMA's were not licensed and should notify the charge nurse of any missing medications. She stated omitting medication doses were not acceptable, and staff should notify the doctor. Interview with LPN #4, on 07/12/17 at 4:05 PM, revealed staff could order medication stat through the pharmacy. She stated staff should notify the physician if there were a problem and a medication was omitted. The nurse stated missing medication for [MEDICAL CONDITION] could put the resident at risk for increased pressure in the eyes. Interview with LPN #5, on 07/14/17 at 2:00 PM, revealed she would order missing doses of medications through the computer system, and then notify the pharmacy. She went on to state she would also notify the physician of any missed doses. Interview with LPN #6, on 07/14/17 at 2:10 PM, revealed she would re-order a missing medication through the computer system, and then call the pharmacy. The nurse stated [MEDICAL CONDITION] medications were significant; therefore, she would notify the physician if the medication could not be given. The LPN stated it was not acceptable not notifying the physician if the resident missed a whole day of prescribed medication. Interview with the Executive Director of the pharmacy, on 07/13/17 at 3:10 PM, revealed the pharmacy delivered medications to the facility twice a day, and within four (4) hours if the medication was ordered stat. He stated the facility determined which medications were stat and could re-order any medication through the computer system. He stated it did not make sense that a resident would receive medications in such a sporadic manner, such as skipping an evening dose on one (1) day, receive the morning dose the next day, and then miss an evening dose on the same day. He stated the pharmacy never dispensed just one (1) dose to the facility at a time unless the physician ordered it that way. Interview with Pharmacist #1, on 07/13/17 at 3:20 PM, revealed missed doses of [MEDICAL CONDITION] medications could cause increased intraocular pressure and it was not optimal to miss a day. She stated missed doses of [MEDICATION NAME]-[MEDICATION NAME] could cause the medication to wear off, which could present neurological symptoms for a resident such as rigidity or tremors. She stated the medication needed to maintain a steady level within the body, and skipped doses was not ideal. She went on to state medications could be skipped or omitted by a physician order [REDACTED]. Interview with the Director of Nursing, on 07/14/17 at 11:00 AM, revealed the facility expected residents to receive medications on time and any variance in dosing should be reported to the physician immediately. She stated she could not identify specifically why Resident #1 and #3 had missed so many doses of their various medications, but stated it was a facility concern.

Based on interview and record review, it was determined the facility failed to ensure residents received the necessary care and services to attain or maintain the highest practicable physical and mental well-being. Two (2) of six (6) sampled residents, Resident #1 and #3, did not receive medications as prescribed by the physician. The findings include: Record review of the facility's policy, Notification of Change in Condition, not dated, revealed the purpose of the policy was to ensure the physician was notified when there was a need to alter treatment significantly, for example, a need to discontinue an existing form of treatment or to commence a new form of treatment. Review of Resident #1's clinical record revealed the facility admitted the resident on 05/01/16, with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) and determined the resident not interviewable. The facility assessed the resident did not display any behaviors such as refusing care/medications. Review of Resident #1's Physician order [REDACTED]. The facility did not administer both doses on 02/06/17 and 02/22/17. Continued review of Resident #1's Physician order [REDACTED].#1's Medications Administration History (MAH), dated 05/01/17 to 05/31/17, revealed the facility did not administer the Dorzolamide eye drops 8:00 AM dose on 05/18/17, and 05/31/17. The facility did not administer the 8:00 PM dose on 05/16/17, 05/17/17, 05/27/17, 05/28/17, 05/29/17, and 05/30/17. In addition, the facility did not administer both doses on 05/24/17, 05/25/17, and 05/26/17. Further review of Resident #1's Physician order [REDACTED]. Review of Resident #3's clinical record revealed the facility admitted the resident on 02/04/17, with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS, dated [DATE], revealed the facility did not complete a BIMS on resident due to the resident was rarely/never understood. The facility assessed the resident did not display any behaviors such as the refusal of care/medications. Interview with Resident #3's Family Member, on 07/12/17 at 11:00 AM, revealed the resident did not get his/her eye drops on time. Review of Resident #3's Physician order [REDACTED].#3's MAH, dated 02/01/17 to 02/28/17, revealed the facility did not administer the [MEDICATION NAME] 02/09/17 through 02/17/17, 2/20/17, and 02/23/17. Continued review of Resident #3's Physician order [REDACTED].#3's MAH, dated 03/01/17 to 03/31/17, revealed the facility did not administer the [MEDICATION NAME]-[MEDICATION NAME] Complex on 03/01/17, 03/02/17, 03/03/17, 03/04/17, 03/06/17, 03/08/17 through 03/18/17, and 03/21/17 through 3/31/17. Further review of Resident #3's Physician order [REDACTED].#3's MAH, dated 06/01/17 to 06/30/17, revealed the facility did not administer the Dorzolamide eye drops AM dose on 06/02/17 and 06/13/17. The facility did not administer the PM dose on 06/01/17 and 06/07/17, and did not administer both doses on 06/06/17, 06/08/17, 06/09/17, and 06/10/17. Interview with a Certified Medical Technician, on 07/14/17 at 2:05 PM, revealed she would double check for the location of a missing prescribed medication, such as an eye drops, and then notify the charge nurse that the medication was not available. She stated the charge nurse would then re-order the medication through the computer system. Interview with Licensed Practical Nurse (LPN) #1, on 07/12/17 at 3:20 PM, revealed staff could order a missing medication through the pharmacy and the medication might arrive at the facility within two (2) to four (4) hours, if ordered via the computer as stat (immediately). She also stated staff should notify the physician whenever there was the possibility of omission of a medication dose because the physician might order a substitution. Interview with LPN #2, on 07/12/17 at 3:42 PM, revealed any medication could be re-ordered by a nurse when needed. She stated she would not omit any medication without notifying the physician. She also stated missing a medication for treatment of [REDACTED]. Interview with LPN #3, on 07/12/17 at 3:55 PM, revealed the pharmacy made two (2) deliveries to the facility daily to deliver medications. She stated staff should re-order any urgent medication as stat so the pharmacy would deliver the medication within two (2) to four (4) hours. She stated Dorzolamide was a medication that treated [MEDICAL CONDITION] and prevented damage to the eyes. The LPN stated it was not acceptable for staff not to act upon a missing medication. Interview with the Qualified Medication Associate (QMA), on 07/12/17 at 4:00 PM, revealed the QMA's were not licensed and should notify a charge nurse of missing medications. She stated omitting medication was not acceptable. Interview with LPN #4, on 07/12/17 at 4:05 PM, revealed staff could re-order any medication as stat through the pharmacy. The nurse stated missing a medication for [MEDICAL CONDITION] could put the resident at risk for increased pressure in the eyes. Interview with LPN #5, on 07/14/17 at 2:00 PM, revealed she would order missing medications through the computer system, and then notify the pharmacy. Interview with LPN #6, on 07/14/17 at 2:10 PM, revealed she would re-order missing medication through the computer system, and then call the pharmacy. The nurse stated [MEDICAL CONDITION] medications were significant; therefore, she would notify the physician if the medication could not be given. Interview with the Executive Director of the pharmacy, on 07/13/17 at 3:10 PM, revealed the pharmacy delivered medications to the facility twice a day, and within four (4) hours if the medication was ordered stat. He stated the facility determined which medications were stat and could re-order any medication through the computer system. He stated it did not make sense for a resident to receive medications in such a sporadic manner, such as skipping an evening dose on one (1) day, getting the morning dose on the next day, and then miss the evening dose that same day. He stated the pharmacy never dispensed just one (1) dose to the facility at a time unless the physician ordered it that way. Interview with Pharmacist #1, on 07/13/17 at 3:20 PM, revealed missed doses of [MEDICAL CONDITION] medications could cause increased intraocular pressure and it was not optimal to miss a day. She stated missed doses of [MEDICATION NAME]-[MEDICATION NAME] could cause the medication to wear off, which could cause the resident to have neurological symptoms such as rigidity or tremors. She stated the medication needed to maintain a steady level within the body, and skipping doses was not ideal. She went on to state medications were skipped or omitted per a physician order. Interview with the Director of Nursing, on 07/14/17 at 11:00 AM, revealed the facility expected residents to receive their medications on time. She stated she could not identify specifically why Resident #1 and #3 had missed so many doses of their various medications, but stated it was a facility concern.

Based on observation, interview, review of the facility's policy, and review of Safety Data Sheets (SDSs), it was determined the facility failed to have an effective system in place to ensure the resident environment remained as free from accident hazards as was possible. Observation on 06/02/17 at 12:55 AM revealed the facility's commercial kitchen was unlocked and unattended. The kitchen was observed to have a commercial stove, grill, deep fat fryer, commercial oven, commercial dishwashing machine and sprayer, knives, and butane lighters. Record review revealed the facility assessed two (2) residents to be at risk for wandering. The findings include: Observation on 06/02/17 at 12:55 AM revealed the facility's commercial kitchen was unlocked and unattended. Continued observation revealed the following hazardous items in the facility kitchen accessible to residents: a commercial stove that was hot to the touch, a grill that was hot to the touch, a deep fat fryer that was hot to the touch, a commercial oven, a commercial dishwashing machine and sprayer with hot water that were within easy access/reach, twelve (12) butcher knives, twelve (12) steak knives, and two (2) butane grill lighters stored within easy reach/access in the kitchen area. Further observation revealed the following chemicals accessible to residents: Concentrated Heavy Duty Grease Release (review of the SDS revealed the chemical was to be used as grill and oven cleaner and could cause severe skin burns, serious eye damage including blindness, and was harmful if swallowed); Ready to Use Glass and Plastic Cleaner (review of the SDS revealed the chemical was to be used as glass and surface cleaner and could cause eye irritation, skin irritation, and should not be swallowed); Array Solid Dish Machine Detergent (review of the SDS revealed the chemical was to be used in industrial dish machines and was harmful if swallowed, caused severe skin burns, and caused eye damage); Carbon Off (review of the SDS revealed the chemical was to be used for carbon removal and caused severe skin burns, eye damage, suspected of causing cancer, and medical attention should be sought if swallowed); Array Ultimate Sanitizer (review of the SDS revealed the chemical was to be used as a disinfectant and caused severe skin burns, serious eye damage, and if swallowed, a poison center should be contacted immediately); Array Bleach (review of the SDS revealed the chemical was liquid bleach and caused eye irritation, could cause respiratory irritation, caused skin irritation, and should not be swallowed); Brite Shine Wipes (review of the SDS revealed the chemical was to be used for polishing and cleaning and could cause skin irritation, eye irritation, and could be harmful if swallowed); Concentrated Quarry Grip Floor Cleaner (review of the SDS revealed the chemical was to be used as floor cleaner and traction treatment and should be avoided to the eyes and skin, and should not be swallowed); Mr. Clean Magic Eraser (review of the SDS revealed the chemical was to be used as a cleaning agent and could cause eye irritation, skin irritation, and if swallowed a physician should be contacted immediately); Heavy Duty Floor Cleaner (review of the SDS revealed the chemical was to be used as a cleaning agent and could cause skin irritation, eye irritation, and ingestion could cause transient gastrointestinal irritation). Observation and interview on 06/02/17 at 1:00 AM, with RN #1 revealed the RN identified several items in the unlocked and unattended kitchen that could cause harm to a resident, such as the gas stove's pilot light and several sharp knives. Continued interview revealed there was no way for the facility staff on duty during her shift to watch the kitchen door at all times to ensure residents did not go in the kitchen unattended. The RN stated the kitchen should only be accessible to facility staff due to the hazardous items in the kitchen. Interview on 06/02/17 at 6:12 PM with the Director of Dining Services revealed since the opening of the building two (2) years ago, the facility's commercial kitchen had always been unlocked at all hours. Continued interview revealed it was his expectation that if the Nursing Department identified the need to have the doors locked due to the potential risk or harm to a resident, the Nursing staff would tell him to lock the doors to the kitchen. The Director of Dining Services stated no risk had been identified. The Director further stated the residents who had been identified to wander the facility did not go to the kitchen doors, and the Director did not believe that a resident had the physical ability to open the doors. Continued interview revealed if the facility had identified a resident who was at risk, then knives would be a concern if the resident was not in a wheelchair. Continued interview revealed if a resident entered the kitchen that was not wheelchair bound, chemicals that could cause harm were accessible. Interview on 06/02/17 at 6:33 PM, with the Assistant Director of Nursing (ADON) revealed she was not concerned with the kitchen being unlocked and unattended because at the time it was discovered unlocked and unattended, there were no residents up and out of their rooms. Interview on 06/02/17 at 8:05 PM with the Director of Nursing (DON) revealed she saw the concern regarding the kitchen being unlocked and that a resident could be harmed if they got into the kitchen. The DON stated she was unaware the kitchen was kept unlocked at all times. Interview on 06/02/17 at 8:11 PM, with the facility Executive Director revealed he did not see the kitchen unlocked as a concern prior to the survey. Continued interview revealed the facility had not had any residents that they felt could/would get in the kitchen, but stated if a resident got in they could get hurt.

Based on observation, interview, and record review, it was determined that the facility failed to provide sufficient nursing staff on the third shift to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Interviews with residents, residents' family members, and staff revealed there was not enough staff on the third shift to assist residents with toileting, incontinence care, and answering of call lights. The findings include: Interview with the Administrator on 06/02/17 at 8:12 PM revealed the facility does not have a policy related to staffing for the facility. Observation of the facility staff conducted during the third shift on 06/02/17 at 12:15 AM revealed the facility was staffed with one (1) Registered Nurse (RN), one (1) Licensed Practical Nurse (LPN), and two (2) Certified Nurse Aides. Interview with Resident #6 on 05/30/17 at 3:55 PM, who had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact and interviewable, revealed staff told the resident not to ring the call light because the resident pushed the button too much. The resident stated staff told him/her that they could not go in the resident's room every five (5) minutes. Interview with Resident #6's family on 05/30/17 at 3:55 PM revealed they visited almost daily. They stated it took a long time for call lights to be answered and could take up to an hour for staff to assist Resident #6 because the resident required two (2) staff members for assistance. The family stated that during the evenings and weekends the nurse and one (1) CNA go to the dining room, leaving less staff to assist residents who are in their rooms. The family revealed many times they had to assist the resident because staff was not available. Resident #6's family stated they had addressed staffing concerns with the Administrator and the Assistant Director of Nursing. They stated staffing would get better for a while after speaking with them, but would return back to the same way. The family stated the Administrator told the family that staff would check on the resident every two (2) to three (3) hours; however, staff had not been checking the resident that often for the previous month. Interview with Resident #2's family on 05/30/17 at 4:20 PM revealed the family member visits daily and stays twelve (12) hours a day with the resident. He revealed the resident usually had to wait fifteen (15) to thirty (30) minutes for staff to answer the call light. He stated the resident required the assistance of two (2) at times; however, he must assist the resident a lot of times because when staff answered the call light, they stated they need to find help and then it took fifteen (15) more minutes before they returned. He stated in the meantime, the resident urinated on him/herself and sometimes had a bowel movement while waiting on staff. He further stated he did not understand why there was less staff on the weekends when there was the same amount of residents. On 05/30/17 at 4:30 PM, an interview with Resident #4, who had a BIMS score of fourteen (14), which indicated the resident was interviewable, revealed he/she had to wait fifteen (15) to twenty (20) minutes for someone to answer the call light. Interview on 05/31/17 at 3:10 PM revealed the resident had to wet on him/herself all the time waiting for someone to answer the call light and assist the resident. Interview with Resident #4's family on 06/01/17 at 10:13 AM revealed the resident had urinated on him/herself several times because call lights were not answered and the resident was not able to get help on the night shift. Interview with CNA #5 on 06/01/17 at 4:30 PM revealed the midnight shift was short-staffed at times and providing care to residents on two (2) hallways was difficult. She stated residents had to wait an average of fifteen (15) minutes. She further stated that when she answered a call light, she checked how urgent the resident's need was, turned off the call light, and prioritized which resident to care for first. Interview with CNA #1 on 06/02/17 at 12:30 AM, revealed it was very challenging to answer call lights on two (2) hallways on the third shift. CNA #1 stated that some residents required two (2) staff persons to assist and stated staff persons do the best we can. She further stated she and the nurse had to cover each other's breaks and lunch and if a resident required the assistance of two (2) staff persons, the resident had to wait until they could find another staff member who was not busy. CNA #1 stated she was unable to toilet or change residents every two (2) hours as required by their care plan. The CNA further stated that she had left notes and voiced concerns to department heads about staffing concerns and that she felt she was spread too thin. Interview with CNA #6 on 06/02/17 at 12:35 AM revealed the CNA was the only CNA assigned to two (2) separate hallways on the third shift. According to the CNA, she was not able to provide care or answer call lights timely because there was not enough staff in the facility. CNA #6 stated the facility was so big that if she was on one hallway providing care to residents, she did not know what was happening with the residents on the other hallway or if the residents needed anything. The CNA stated first shift staff had complained to her that residents were being left wet; however, CNA #6 stated she was not able to assist all the residents with incontinence care or answer call lights timely to assist residents to the bathroom because there was not enough staff. CNA #6 stated that if a resident needed the assistance of two staff persons she had to find another staff member to assist her and could not get back to the resident timely to prevent the resident from urinating on themselves. Interview with Licensed Practical Nurse #4 on 05/31/17 at 12:16 AM revealed the LPN worked the third shift and Resident #4 had stated on several occasions that he/she had activated the call light and no one responded. She further stated most nights were really busy as there were only two (2) nurses and two (2) CNAs. LPN #4 stated nurses had to assist the CNAs and often the nurses could not get their work done. LPN #4 stated she had reported the issue with staffing to the corporate staff who told her that she did not have good time management skills. Interview with LPN #1 on 06/02/17 at 12:58 AM revealed at times staff did not come to work on the third shift, leaving one (1) CNA to provide care for all the residents in the facility. LPN #1 stated nurses tried to find coverage if staff could not come to work; however, there had been occasions when she was unable to get staff to come to work. She stated she had contacted upper management in the past when the facility did not have enough staff, but they did not offer assistance and told her to work it out. LPN #1 stated if a resident required the assistance of two (2) staff persons, then the nurse and CNA must assist, leaving other residents having to wait for assistance. The nurse stated the CNAs have told her there was no way they were able to get their work done and often she was not able to complete documentation and had to complete late entries. LPN #1 stated she had talked with the Assistant Director of Nursing and the Director of Nursing regarding staffing needs on the night shift. Interview with the Assistant Director of Nursing (ADON) on 06/02/17 at 6:55 PM revealed they expected staff to provide quality care and would not expect a resident to urinate on him/herself waiting for staff to answer call lights. Interview with the Director of Nursing (DON) on 06/02/17 at 7:48 AM revealed facility staffing was determined by resident acuity and patient per day (PPD). She further revealed she and the ADON monitored staff five (5) to six (6) times a day and also came in on other shifts one (1) time per month. She stated that no staff person had voiced to her that they were unable to complete resident care according to the care plan. She further stated the midnight shift staff should prioritize resident needs, but would not expect the residents to urinate on themselves while waiting for staff to assist them. She revealed she recently held an in-service for staff and instructed staff not to turn off call lights if they needed to assist another resident, but to leave the light on as a reminder to go back. However, she stated staff continued to turn the lights off before tending to the resident's need. Interview with the Administrator on 06/02/17 at 8:12 AM revealed he monitored staffing through payroll, conversations with management, family call program, resident concern program, ambassador program, working the weekend every two (2) months, and working the night shift once a month. The Administrator stated he was aware that call lights took longer to be answered on the midnight shift and he had concerns previously with the timeliness of answering call lights. He also stated he expected staff to leave the call light on if they could not meet a resident's need before going on to another resident.

Based on interview, record review, and review of the Resident Assessment Instrument Manual, it was determined the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed no less than every three (3) months for one (1) of thirteen (13) sampled residents (Resident #7). Review of Resident #7's medical record revealed the facility completed the resident's initial MDS assessment on 09/17/16; however, the facility failed to complete a quarterly assessment until 03/31/17, approximately six (6) months later. The findings include: Interview with the Administrator on 06/02/17 at 8:10 PM, revealed the facility did not have a policy related to completing MDS assessments but the facility followed the Resident Assessment Instrument (RAI) guidelines. A review of the RAI User Manual Version 3.0 revealed a quarterly assessment must be completed at least every ninety-two (92) days following the previous OBRA (Omnibus Budget Reconciliation Act) assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. Review of Resident #7's medical record revealed the facility admitted the resident on 09/10/16, with [DIAGNOSES REDACTED]. Continued Review of Resident #7's medical record revealed the facility completed an Admission MDS assessment dated [DATE]. Further review of the medical record revealed the next assessment the facility completed of Resident #7 was a Quarterly MDS assessment on 03/01/17, indicating no evidence the facility had conducted a quarterly assessment within ninety-two (92) days of the 09/17/16 assessment. Interview conducted with the MDS Nurse on 06/02/17 at 7:30 PM revealed she was the corporate MDS Nurse and had been acting as an interim MDS Nurse at the facility since 04/28/17. The MDS Nurse was aware there were some MDS assessments that had not been completed timely by the previous MDS Nurse. She stated she was responsible for monitoring the completion of resident MDS assessments, but was not aware how many were late or had not been completed timely. Interview with the Director of Nursing (DON) on 06/02/17 at 7:40 PM revealed the MDS Nurse was responsible for completing resident MDS assessments. The DON stated she was aware some of the residents' MDS assessments were completed past their due date, but did not monitor MDS assessments for timely completion.

Based on interview, record review, and facility policy review the facility failed to have a system for preventing, identifying, reporting, and controlling infections and communicable diseases for two (2) of five (5) employees. The facility failed to screen Certified Nurse Aide #3 and a Dietary Aide for [DIAGNOSES REDACTED] (TB) upon hire as required by the facility's policy. The findings include: Review of the facility's policy, Guidelines for TB Control Plan for Employees-Kentucky, dated 08/17/16, revealed the Administrator shall designate an Infection Control Practitioner to monitor and implement the TB Control Program. The policy stated a baseline two-step [MEDICATION NAME] Skin Test (TST) was required upon hire, unless a Blood Assay for [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] (BAMT) (blood test to test for TB) had been completed. According to the policy, the first-step TB skin test should be started within the first week of employment, unless there was documentation that a one-step TST was negative within the last year. The policy stated the TST results, or BAMT results were required to be placed in the employee's medical file. Review of Certified Nurse Aide (CNA) #3's employee file revealed he began employment at the facility on 07/19/16; however, the facility did not conduct a TB skin test until 05/12/17, approximately ten (10) months after employment. Review of a Dietary Aide's employee file revealed she began employment on 03/21/17; however, the facility did not conduct a TB skin test until 06/01/17. Interview with the Assistant Director of Nursing on 06/02/17 at 6:55 PM revealed the Staffing Coordinator was responsible to ensure proper completion of the TB testing; however, the person responsible for ensuring previous TB skin tests were completed was no longer at the facility. Interview with the Accounts Payable staff member on 06/02/17 at 5:25 PM revealed in October 2016, she noticed some items missing from employee files and started auditing the files. She stated she discussed this issue with the Administrator and the Company and they started helping her with the audits when they had time. She stated, however, that the audit was not completed. She revealed the procedure for testing new employees for TB was for the test to be given on the first day of employment and read before the employee was out of orientation. She verified that CNA #3 had not had a TB skin test prior to May 2017. She also stated there was no evidence that the Dietary Aide had a TB skin test prior to yesterday, 06/01/17. Interview with the Administrator on 06/02/17 at 8:12 PM revealed he was not aware that employee files were not up to date and that all TB skin tests were not completed upon hire per policy.

Based on interview, record review, and facility policy review, it was determined that the facility failed to consult with the resident's physician and notify the resident's representative for one (1) of thirteen (13) sampled residents (Resident #4) of a change in condition and need to alter treatment when the resident had an intermittent nosebleed for approximately eighteen (18) hours. The findings include: Review of the facility's policy, Physician Notification Guideline, dated 11/28/16, revealed the resident's physician or practitioner was required to be notified of all diagnostic testing results or changes in resident condition in a timely manner so the resident's condition could be evaluated for need of provision in interventions for care. The policy stated resident assessments for change in condition should be completed in a timely manner. The policy further stated that the nurse should notify the physician by phone of abnormal lab results or the need for physician intervention during non-office hour times. Review of the facility's policy, Guidelines for Responsible Party Notification, dated 08/01/16, revealed staff was required to immediately assess residents and immediately notify the resident's responsible party of a change in the resident's condition. Review of the facility's policy, Guidelines for Change in Resident Condition, not dated, revealed upon assessment of resident change in status, the licensed professional nurse was required to initiate the appropriate 'Event' in the Electronic Health Record (EHR) in order to fully reflect and document the nursing process. The policy further stated notification of the resident's physician and responsible party would be documented in the EHR reflecting the date and time of the notification. Record review revealed the facility admitted Resident #4 on 03/28/17 with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed Resident #4 was interviewable with a Brief Interview for Mental Status (BIMS) score of fourteen (14). According to the facility provided BIMS score list dated 06/01/17, the resident's BIMS score was fifteen (15). Further review of the MDS revealed the resident required extensive assistance of one (1) person for transfers, bed mobility, and toileting. Review of Resident #4's physician orders [REDACTED]. Review of Resident #4's care plan dated 03/28/17 revealed the facility identified that the resident was at risk for Excessive Bleeding and Bruising. The care plan stated that staff should notify the resident's physician of abnormal bruising and/or bleeding. Interview with Resident #4 on 05/30/17 at 4:30 PM and on 05/31/17 at 10:52 AM and 3:10 PM revealed the resident had a nosebleed a couple of weeks ago that started at approximately 4:00 PM and lasted all night. The resident explained that CNA #3 assisted the resident to the toilet during the night and the resident's nose was bleeding. The resident stated he/she was trying to stop the bleeding and had toilet tissue with blood all over the floor because he/she could not reach the trash can. The resident stated the CNA came back into the room and assisted the resident back to bed. The resident stated he/she asked for the nurse; however, the CNA stated that no one could help the resident. Resident #4 stated his/her nose never stopped bleeding throughout the night and his/her family was never called. The resident stated by morning there was blood on the wall in the bathroom and bloody tissues on the floor in the bedroom and bathroom. Resident #4 stated the next morning the day shift staff finally took care of him/her and called the doctor and sent the resident to the hospital. The resident stated the hospital gave the resident a plug for his/her nose to use in case of another nosebleed. Review of nurse's notes dated 05/07/17 at 4:50 PM revealed staff administered nasal spray to Resident #4 due to a nosebleed. Further review revealed a nurse's note dated 05/09/17 at 9:50 PM that stated the documentation was a late entry for 05/07/17 at 3:00 AM (staff stated the date should have been 05/08/17). The note stated that the resident had a nosebleed and nasal spray was administered as ordered. The nurse's note stated staff informed the resident that it would help with the bleeding. The note further stated the resident was picking her nose, and staff asked the resident to leave his/her nose alone. There was no evidence the resident's physician or family was notified of the change in the resident's condition. Further review of nurse's notes dated 05/08/17 at 6:59 PM revealed the resident had a severe nosebleed and was transferred to the hospital for evaluation (hospital record states the resident arrived at the hospital on [DATE] at 11:52 AM). Interview with CNA #3 on 06/01/17 at 2:15 PM revealed he received report from the previous shift on 05/07/17 at approximately 2:30 PM that Resident #4 had a nosebleed. He further stated he assisted the resident with tissues that night and observed blood on the tissues that were on the floor near the trash can and in the resident's bed. He further stated that the resident seemed upset that his/her nose was bleeding. CNA #3 stated the resident requested the nurse and according to CNA #3, he notified the resident's nurse between 1:00 and 4:00 AM on 06/02/17. Interview with CNA #1 on 06/01/17 at 9:29 AM revealed when she went into Resident #4's room on 05/08/17 at approximately 12:00 or 1:00 AM, she observed bloody tissues, and it appeared that the resident had a nosebleed for a while. She stated she told the resident to try and not mess with his/her nose, to hold his/her nose, and to tilt his/her head back. She further stated Nursing was already aware as his/her nose had been bleeding on and off. Interview with LPN #3 on 05/31/17 at 1:19 PM revealed she provided care to Resident #4 the night of 05/07/17 (7:00 PM to 7:00 AM on 05/08/17). She stated the previous shift reported that the resident had nosebleeds on and off throughout the day. She further stated CNA #3 reported to her that the resident's nose was bleeding; however, when she assessed the resident, the resident's nose was not bleeding. LPN #3 stated there were bloody tissues on the resident's bedside table and she observed a clot in the resident's nose. LPN stated she administered saline spray in each nostril for the resident, but did not call the resident's physician or the family regarding the resident's nosebleeds. Interview with LPN #2 on 06/01/17 at 3:23 PM revealed she was the day shift nurse that came in on 05/08/17. She stated staff told her in report that Resident #4's nose had been bleeding but had stopped. LPN #2 stated a few minutes later she made rounds to check on patients and found Resident #4 lying in bed with his/her nose bleeding, with several bloody tissues in the bed, and blood on his/her shirt. The LPN stated that the resident asked for help to the bathroom and the resident's nose continued to bleed. LPN #2 stated she observed bloody tissues and towels on the resident's bathroom floor. The nurse then assisted the resident to a wheelchair and tried to stop the bleeding by applying pressure. LPN #2 stated she left the resident's room and when she returned approximately ten (10) minutes later, the resident's nose was still bleeding. LPN #2 stated she contacted the resident's physician and son and should have documented the notifications and the resident's assessment in the medical record. Interview with Resident #4's son on 06/01/17 at 10:13 AM revealed the resident had occasional nosebleeds, but never a nosebleed of that nature. He stated he and his wife walked in to visit and found the resident with a towel to his/her nose. He further revealed that there were thirty (30) to forty (40) bloody towels in the resident's bathroom and the resident had vomited blood. He stated he immediately asked staff what was going on and staff reported that the resident's nose had been bleeding all night and they could not get it to stop. Resident #4's son stated he requested that the resident go to the hospital. According to Resident #4's son, staff never notified him of the situation. Interview with the Assistant Director of Nursing (ADON) on 05/31/17 at 3:54 PM and on 06/01/17 at 5:26 PM revealed she was notified of Resident #4's nosebleed on 05/08/17. She stated she saw the resident's son and daughter-in-law in the hallway by the resident's room and they did not look happy. She further stated she went to the resident's room, the son was in the bathroom with the resident, blood was running down the resident's nose, and the resident told her that the resident had a nosebleed all night. The ADON stated there was blood in the sink, on the resident's clothing, and bloody washcloths on the floor in the bathroom. She stated she asked LPN #2 what was going on and the nurse stated that she had already called the resident's physician and received an order to send the resident to the hospital. The ADON further stated that with any change in condition the resident's physician and family should be notified and staff should have notified Resident #4's physician and family regarding the change in the resident's condition. Interview with the Director of Nursing (DON) on 06/91/17 at 6:04 PM revealed she expected that after all interventions failed to stop Resident #4's nosebleed the physician should have been called for further orders. Interview with Resident #4's physician on 06/01/17 at 3:16 PM revealed she expected staff to keep an eye on a nosebleed for a resident who was receiving [MEDICATION NAME] because it is an anti-platelet medication to thin the blood. She further stated if symptoms of a nosebleed persisted with treatment and there was a change in the resident's condition, she expected to be notified.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure drugs and biologicals in one (1) of four (4) medication carts and one (1) of four (4) treatment carts were stored in locked compartments. On 06/01/17 at 1:20 PM a medication cart on the Cherokee Parkway hallway was unlocked and unattended and on 06/02/17 at 12:20 AM, a treatment cart was observed unlocked and unattended leaving drugs and biologicals accessible to residents and visitors of the facility. The findings include: Review of the facility's policy titled Storage of Medications, revised January 2017, revealed medications and biologicals were to be stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. Continued review of the policy revealed the medication supply was only to be accessible to licensed facility personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review of the policy revealed medication carts and medication supplies were to be locked when not attended by persons with authorized access. 1. Observation on 06/01/17 at 1:20 PM, revealed an unlocked and unattended medication cart on the Cherokee Parkway hallway. Continued observation revealed no facility staff was present at the medication cart until 1:26 PM, six (6) minutes later, when the facility's Regional Support Nurse was made aware of the unlocked and unattended medication cart. Further observation and interview with the Regional Support Nurse confirmed the medication cart was unlocked by pulling the top two (2) drawers open. Observation and inventory of the medication cart on 06/01/17 at 1:27 PM, with LPN #8 revealed there were approximately 3,200 prescription medications accessible to residents and visitors of the facility that included medications to treat depression, seizures, diabetes, high blood pressure, heart arrhythmias, infection, fluid retention, high cholesterol, and pain. Interview on 06/01/17 at 1:38 PM, with Licensed Practical Nurse (LPN) #8 revealed she was the nurse assigned to the medication cart. Continued interview revealed she believed she locked the medication cart on the Cherokee Parkway hallway at 12:00 PM and went to the restorative dining room to assist with the lunch meal. Continued interview revealed it was important that the medication cart was locked when it was unattended for the safety of the residents because if a confused resident got into the medication cart and took a medication that was not prescribed for them, it would be a safety concern. 2. Observation on 06/02/17 at 12:20 AM, revealed an unlocked and unattended treatment cart on the Cherokee Parkway hallway. Continued observation of the treatment cart on 06/02/17 at 12:29 AM, revealed Registered Nurse (RN) #1 was answering a call light on the Cherokee Parkway hallway, and an inventory of the cart was taken with RN #1. The following were observed in the treatment cart unsecured and accessible to residents and visitors: Santyl Ointment (used to treat open wounds); Bactroban Ointment (treats skin infections); Nystatin Cream (treats fungal infections); Hydrocortisone Cream (treats inflammation); Bacitracin (prevents infections of minor cuts and burns); and McKesson Denture Cleanser (used to clean dentures). Interview on 06/02/17 at 12:41 AM, with RN #1 revealed she had not utilized the treatment cart since starting her shift at 10:00 PM on 06/01/17. Continued interview revealed the nurse (LPN #6) from the prior shift was still using the treatment cart until around 11:00 PM. RN #1 stated the treatment cart should have been locked when it was not in use and unattended because a resident could get into the treatment cart and eat, drink, or apply a treatment. Further interview with RN #1 revealed there were items in the unattended and unsecured treatment cart that could cause harm to a resident if ingested. On 06/02/17 at 7:28 PM, an interview with LPN #6 revealed that she clocked out and left the facility at 11:45 PM on 06/01/17. The LPN stated she thought she locked the treatment cart before she left the building. The LPN further stated the treatment cart should be locked at all times when it was unattended so residents could not get any treatments out of the cart. The LPN stated there were treatments in the cart that could hurt a resident. Interviews with the Assistant Director of Nursing (ADON) on 06/02/17 at 6:33 PM and with the Director of Nursing (DON) on 06/02/17 at 8:05 PM, revealed it was their expectation that medication and treatment carts were locked at all times when unattended because items contained in the carts were potentially harmful to residents. Interview on 06/02/17 at 8:11 PM, with the facility Executive Director revealed he expected a medication or treatment cart to be locked when it was unsupervised or not being used because there are items in the carts that could cause harm to a resident.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 Manual, it was determined that the facility failed to implement the comprehensive care plan for one (1) of thirteen (13) sampled residents (Resident #4). Resident #4's care plan required staff to notify the resident's physician of any bleeding; however, on 05/07/17, the resident had a nosebleed and bled intermittently until the resident was transferred to the hospital on [DATE] at approximately 11:52 AM. The facility failed to notify the resident's physician that Resident #4 had a nosebleed for approximately eighteen (18) hours. The findings include: Interview with the Minimum Data Sets (MDS) Coordinator on 06/02/17 at 7:30 PM revealed there was not a policy for following the care plan but the facility followed the RAI Manual regarding following the care plan. Review of the RAI 3.0 Manual, dated October 2015, revealed the care plan moved a resident toward resident-specific goals utilizing individual resident strengths and interdisciplinary expertise crafting the how of the resident care. The manual stated staff knowledge about the resident care goals and approaches put the course of action into motion by carrying out the how and when of resident care. Record review revealed the facility admitted Resident #4 on 03/28/17 with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed Resident #4 was interviewable with a Brief Interview for Mental Status (BIMS) score of fourteen (14). According to the facility provided BIMS score list dated 06/01/17, the resident's BIMS score was fifteen (15), which indicated the resident was cognitively intact and interviewable. Further review of the MDS revealed the resident required extensive assistance of one (1) person for transfers, bed mobility, and toileting. Review of Resident #4's physician orders [REDACTED]. Review of Resident #4's care plan dated 03/28/17 revealed the facility identified the resident was at risk for Excessive Bleeding and Bruising and developed interventions that included notifying the resident's physician of abnormal bruising and/or bleeding. Interview with Resident #4 on 05/30/17 at 4:30 PM and on 05/31/17 at 10:52 AM and 3:10 PM revealed the resident had a nosebleed a couple of weeks ago that started at approximately 4:00 PM and lasted all night. Resident #4 stated his/her nose never stopped bleeding throughout the night. Resident #4 stated the next morning the day shift staff finally took care of him/her and called the doctor and sent the resident to the hospital. Review of nurse's notes dated 05/07/17 at 4:50 PM revealed staff administered nasal spray to Resident #4 due to a nosebleed. Interview with CNA #3 on 06/01/17 at 2:15 PM revealed he received report from the previous shift on 05/07/17 at approximately 2:30 PM that Resident #4 had a nosebleed. He further stated he assisted the resident with tissues that night. He stated that the resident seemed upset that his/her nose was bleeding and the resident requested the nurse. According to CNA #3, he notified the resident's nurse of the resident's nosebleed between 1:00 and 4:00 AM on 05/08/17 (CNA #3 worked a 16-hour shift from 2:37 PM on 05/07/17 to 6:04 AM on 05/08/17. Interview with CNA #1 on 06/01/17 at 9:29 AM revealed when she went into Resident #4's room on 05/08/17 at approximately 12:00 or 1:00 AM, she observed bloody tissues, and it appeared that the resident had a nosebleed for a while. She stated she told the resident to try and not mess with his/her nose, to hold his/her nose, and to tilt his/her head back. She further stated she did not notify nursing staff because they were already aware that the resident's nose was bleeding. A review of nurse's notes dated 05/09/17 at 9:50 PM revealed a late entry for 05/07/17 at 3:00 AM (staff stated the date should have been 05/08/17) indicating that Resident #4 had a nosebleed and nasal spray was administered. The note further stated the resident was picking his/her nose, and staff asked the resident to leave his/her nose alone. There was no evidence the resident's physician or family was notified of the nosebleed. Interview with LPN #3 on 05/31/17 at 1:19 PM revealed she provided care to Resident #4 the night of 05/07/17 (7:00 PM on 05/07/17 to 7:00 AM on 05/08/17). She stated the previous shift reported that the resident had nosebleeds on and off throughout the day. She further stated CNA #3 reported to her that the resident's nose was bleeding; however, when she assessed the resident, the resident's nose was not bleeding. LPN #3 stated there were bloody tissues on the resident's bedside table and she observed a clot in the resident's nose. LPN #3 stated she administered saline spray in each nostril for the resident, but did not call the resident's physician or the family regarding the nosebleeds. Interview with LPN #2 on 06/01/17 at 3:23 PM revealed she was the day shift nurse that came in on 05/08/17. She stated staff told her in report that Resident #4's nose had been bleeding but had stopped. LPN #2 stated a few minutes later she made rounds to check on patients and found Resident #4 lying in bed with his/her nose bleeding, with several bloody tissues in the bed, and blood on his/her shirt. The LPN stated the resident asked for help to the bathroom and the resident's nose continued to bleed. LPN #2 stated she observed bloody tissues and towels on the resident's bathroom floor. The nurse then assisted the resident to a wheelchair and tried to stop the bleeding by applying pressure. LPN #2 stated she left the resident's room and when she returned approximately ten (10) minutes later, the resident's nose was still bleeding. LPN #2 stated she contacted the resident's physician and son and should have documented the notifications and the resident's assessment in the medical record. Interview with Resident #4's son on 06/01/17 at 10:13 AM revealed the resident had occasional nosebleeds, but never a nosebleed of that nature. He stated he and his wife walked in to visit and found the resident with a towel to his/her nose. He further revealed that there were thirty (30) to forty (40) bloody towels in the resident's bathroom and the resident had vomited blood. He stated he immediately asked staff what was going on and staff reported that the resident's nose had been bleeding all night and they could not get it to stop. Resident #4's son stated he requested that the resident go to the hospital. According to Resident #4's son, staff never notified him of the situation. Further review of nurse's notes dated 05/08/17 at 6:59 PM revealed Resident #4 had a severe nosebleed and was transferred to the hospital for evaluation. Review of the resident's hospital medical record revealed the resident arrived at the hospital on [DATE] at 11:52 AM. Interview with the Assistant Director of Nursing (ADON) on 05/31/17 at 3:54 PM and on 06/01/17 at 5:26 PM revealed she was notified of Resident #4's nosebleed on 05/08/17. She stated she went to the resident's room and observed the resident in the bathroom. The ADON stated blood was running down the resident's nose, and the resident told her that the resident had a nosebleed all night. The ADON stated there was blood in the sink, on the resident's clothing, and bloody washcloths on the floor in the bathroom. She stated LPN #2 reported that she had already called the resident's physician and received an order to send the resident to the hospital. The ADON further stated that with any change in condition the resident's physician should be notified and staff should have notified Resident #4's physician prior to that time regarding the change in the resident's condition. Interview with the Director of Nursing (DON) on 06/91/17 at 6:04 PM revealed she expected that after all interventions failed to stop Resident #4's nosebleed the physician should have been called for further orders. Interview with Resident #4's physician on 06/01/17 at 3:16 PM revealed she expected staff to keep an eye on a nosebleed for a resident who was receiving [MEDICATION NAME] because it is an anti-platelet medication to thin the blood. She further stated if symptoms of a nosebleed persisted with treatment, she expected to be notified. Interview with the Administrator on 06/02/17 at 8:12 PM revealed he expected staff to follow the care plan that directed the care for residents.

Based on interview and record review it was determined the facility failed to conduct a comprehensive Minimum Data Set (MDS) assessment at least every twelve (12) months for one (1) of thirteen (13) sampled residents (Resident #5). A review of assessments completed for Resident #5 revealed the resident was admitted to the facility on [DATE] and the facility had not completed a comprehensive MDS assessment since the resident's admission MDS dated [DATE], approximately fifteen (15) months. The findings include: Interview with the Administrator on 06/02/17 at 8:10 PM revealed the facility did not have a policy for completing a comprehensive MDS assessment. Review of the Resident Assessment Instrument User Manual Version 3.0 revealed the Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) . Review of the medical record for Resident #5 revealed the facility admitted the resident on 01/29/16 with [DIAGNOSES REDACTED]. A review of the MDS assessments completed for Resident #5 revealed the facility completed an admission comprehensive assessment on 02/05/16. However, there was no evidence the facility completed another comprehensive assessment of Resident #5 within twelve (12) months of the admission assessment. Interview conducted with the MDS Nurse on 06/02/17 at 7:30 PM revealed she was the corporate MDS Nurse and had been the interim MDS Nurse at the facility since 04/28/17. According to the MDS Nurse, she was aware the previous MDS Nurse had been completed MDS assessments past the due date, but did not know how many were past the due date. Further interview revealed she was not aware that Resident #5 had not had a comprehensive assessment within twelve (12) months as required. Interview with the Director of Nursing (DON) on 06/02/17 at 7:40 PM revealed the MDS Nurse was responsible for completing the resident MDS assessments. The DON stated she was aware that some resident MDS assessments were completed late, but was not aware that a comprehensive assessment had not been completed at least every twelve (12) months as required for Resident #5. According to the DON, she did not monitor to ensure MDS assessments were completed timely.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to store drugs and biologicals in locked compartments. Two (2) of four (4) medication carts were observed to be unlocked and unattended by authorized personnel during entrance to the facility for the standard survey. The findings include: Review of the facility's policy regarding Medication Storage in the Facility, dated 09/01/13, revealed medication carts were to be locked or attended by persons with authorized access (only licensed nurses, pharmacy personnel or certified medication technicians). Observation, on 05/31/16 at 3:55 PM, revealed an unlocked and unattended medication cart on the 100 Hall. Interview with the Director of Nursing (DON), on 05/31/16 at 3:58 PM, revealed Registered Nurse (RN) #1 was the nurse assigned to the 100 Hall at that time of day and RN #1 was off the hall. Observation, on 05/31/16 at 4:00 PM, revealed an unlocked and unattended medication cart on the 200 Hall. Interview with Licensed Practical Nurse (LPN) #1, on 05/31/16 at 4:05 PM, revealed she was the nurse assigned to the 200 Hall and she had the keys to the unlocked medication cart. She stated she had unlocked the cart and then left the cart unattended to throw something away in the soiled utility room. However, LPN #1 stated she could not see the medication cart to ensure no unauthorized person had access to the cart when she was in the utility room. Interview with RN #1, on 06/02/16 at 9:58 AM, revealed she was assigned to the 100 Hall on the afternoon of 05/31/16 when the medication cart was unlocked and unattended. However, she stated she was not sure if she had completed report and the narcotic count with the off-going nurse (Assistant Director of Nursing (ADON)) and was not sure if she or the off-going nurse had left the medication cart unlocked. RN #1 stated she did not want to place blame and acknowledged she had been trained to always have the medication cart locked or within sight because residents or other persons could have access to drugs/biologicals which could harm them. Further interview with LPN #1, on 06/01/16 at 3:23 PM, revealed it was professional practice to always have the medication carts locked or within sight and she had failed to do so on 05/31/16. She stated she only left the cart for a minute but knew it was wrong to do so. According to LPN #1 she had been trained to always lock medication carts and she had been inserviced to do so at the facility. Interview with the ADON, on 06/02/16 at 10:14 AM, revealed she had filled in as the unit nurse on the 100 Hall on 05/31/16, but she remembered she had completed report and the narcotic count with RN #1 at approximately 2:45 PM. She stated she did not remember leaving the medication cart unlocked after the narcotic count and she had turned the keys over to RN #1 at 2:45 PM. The ADON further stated residents could be harmed if they got medications from an unlocked cart which they were not supposed to have. Further interview with the DON, on 06/02/16 at 10:28 AM, revealed she and the ADON perform spot monitoring of the nurses' practice to include watching for unlocked medication carts; however, she did not do any documentation of their findings. The DON stated there had been no recognized problem with unlocked medication carts previously and the facility did inservices to remind nurses of locking medication carts and other job duties. According to the DON the two (2) medication carts that were unlocked was accidental.