Every finding on record at Helmwood Healthcare

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of residents' property. The facility did not run the Office of Inspector General (OIG) Abuse Registry checks for 2 of 8 sampled newly hired employees. The findings include: Review of the Kentucky Revised Statutes (KRS) 209.032 revealed a vulnerable adult services provider, such as a long-term care facility was to, Query as to whether prospective or current employee has validated substantiated finding of adult abuse, neglect, or exploitation -- Administrative regulations -- Central registry of substantiated findings made on or after July 15, 2014. Continued review of the Statute revealed an employee included a person hired directly or through contract by a vulnerable adult services provider with duties that involved or might involve one-on-one contact with a resident. Further review revealed a vulnerable adult services provider was to query the cabinet as to if a validated substantiated finding of adult abuse, neglect, or exploitation was entered against an individual who was a prospective employee of the provider. Review of the facility's policy, Abuse, Neglect, and Exploitation, revised 04/28/2026, revealed the facility will, .develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Further review of the policy revealed Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident's property. Review of Dietary Aide 1's personnel file revealed her hire date was 02/25/2026. However, continued review revealed no documentation the facility completed the OIG Abuse Registry check for Dietary Aide 1. Review of Dietary Aide 2's personnel file revealed his hire date was 03/20/2026. Continued review revealed no documentation the facility completed the OIG Abuse Registry check for Dietary Aide 2. An interview with Human Resources (HR) on 05/21/2026 at 1:15 PM revealed she completes all the pre-employment checks for newly hired employees. She stated she does not run any potential employee through the OIG Abuse Registry check unless they have a license number. If they don't possess a license number, she stated she did not run their name through the Kentucky Board of Nursing (KBN) website. A second interview with HR on 05/21/2026 at 5:40 PM, she stated the importance of running the required pre-employment checks on all potential new employees is to keep the residents and the staff safe in the facility. When asked about a potential outcome of an employee with a history of abuse on the OIG abuse registry, that was not screened appropriately and hypothetically was hired, she stated the hypothetical employee could harm someone. An interview with the Director of Nursing (DON) on 05/21/2026 at 4:58 PM revealed HR was responsible for running all the abuse registry checks. The DON stated the importance of pre-employment checks was to keep the residents safe. An interview with the Administrator on 05/21/2026 at 5:16 PM revealed she stated HR was responsible for running all required pre-employment checks. The Administrator stated the facility does not want anyone working who has been convicted of any kind of abuse or neglect. She stated the importance of the pre-employment checks and stated, .we have to protect the residents as well as the staff.

Based on interviews, record review, and facility policy review, the facility failed to ensure that one of three residents (R) 49 was free from significant medication errors. The facility failed to obtain a new prescription from the provider in a timely manner resulting in the resident missing five consecutive nightly doses of a prescribed medication. The findings include: Review of the facility's policy, Pharmacy Services revised 08/14/2025, revealed, the pharmacist, in collaboration with the facility and medical director, should include within its services to develop mechanisms for communicating, addressing, and resolving issues related to pharmaceutical services. Additionally, the facility will strive to assure that medications are requested, received, and administered in a timely manner as ordered by the authorized prescriber (in accordance with state requirements), including physicians, advanced practice nurses, pharmacists, and physician assistants. Review of facility's policy, Medication Reordering revised 01/18/2026, revealed, it was the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. Further review revealed that acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner and each time a nurse administered medications and observed (6) or less doses left of one kind, that nurse will reorder the medication, time permitting. Review of the website https://www.drugs.com/medical-answers/long-gabapentin-withdrawal-3554130/ revealed Gabapentin (a medication used to treat seizures, nerve pain, and restless leg syndrome) should not be stopped suddenly without talking to a healthcare provider as stopping it suddenly can increase your risk of having withdrawal symptoms. Review of R49's electronic medical record, Face Sheet revealed the facility admitted R49 on 02/10/2022 with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, polyneuropathy, hereditary and idiopathic neuropathy. Review of R49's Minimum Data Sheet, (MDS) with an Assessment Reference Date of 02/24/2026 revealed the facility assessed R49 with a Brief Interview for Mental Status, (BIMS) score of 11 that indicated moderate cognitive impairment. Review of R49's physician's orders revealed an order of Gabapentin 300 milligram capsule to be given by mouth at bedtime, 9:00 PM, related to polyneuropathy, start date of 06/12/2025. Review of R49's Medication Administration Record, (MAR) revealed staff had not documented administration of Gabapentin 300 milligram from 05/01/2026 through 05/05/2026, referencing 11, indicating medication was not available. Review of R49's Progress Notes revealed, Registered Nurse, (RN) 2 documented waiting on delivery meaning from pharmacy, on 05/02/2026 at 9:01 PM for Gabapentin 300 milligram capsule. Additionally, on 05/03/2026 at 9:12 PM, RN2 documented waiting for script from MD that was notified of need on 05/02/2026.Review of facility's electronic medical record, Supply Details, revealed a last order/reorder date for Gabapentin 300 milligram capsule for R49 was on 04/28/2025 with a dispense date of 05/05/2026. Review of the contracted pharmacy Packing Slip, containing the Gabapentin, revealed a shipping date of 05/05/2026 and received signature date of 05/06/2026. In an interview with R49 on 05/19/2026 at 2:03 PM, stated a few weeks ago, the facility did not renew her prescription for a medication, she had run out and did not receive her scheduled doses for about four days. She continued that not taking her medication for those days she did not sleep and that feeling in the feet was something else.Attempts to reach Licensed Practical Nurse (LPN)4 for interview unsuccessful. LPN4 was the night shift nurse for R49 on 05/01 and 05/04-05/06 2026.In an interview on 05/21/2026 at 10:32 AM with Director of Nursing (DON), she stated she realized there was an issue on 05/04/2026 when she ran a report of medications that had been missed, not administered over the weekend. She stated the reason was because the pharmacy had not received the provider's prescription. She continued that staff should have notified her once the first dose had been missed, but they did not. In additional interview at 3:05 PM, DON stated Licensed Practical Nurse (LPN)4 should have followed up with pharmacy and the provider when the medication was still unavailable the following shift. In an interview on 05/21/2026 at 12:14 PM with a pharmacist from the contracted pharmacy, the pharmacist stated R49's prescription had run out and was in need of a new prescription from the provider. The pharmacy received the new provider prescription on 05/05/2026. In an interview on 05/21/2026 at approximately 3:30 PM with the Regional Nurse Consultant, she stated the incident was likely due to it occurring during a weekend. She continued that staff had attempted daily to reach the ordering provider, to which he replied he was unavailable at the time and would have to wait until Monday. In an interview on 05/21/2026 at 2:42 PM with Registered Nurse (RN)2, she stated she did not recall specific details regarding R49's Gabapentin running out but stated that prescriptions do run out and it is not an oddity. In an interview on 05/21/2025 at 2:57 PM with the Administrator, she stated her expectation was for staff to notify the DON or the nurse manager on duty if any doubt of medication not being administered in a timely manner. She stated she would not expect a resident to go five days without their medication.

Based on interview, record review, and facility policy review it was determined the facility failed to revise care plans for one (1) of seven (7) sampled residents (Resident #156). Resident #156 experienced a fall on 02/01/2020 and review revealed no evidence the facility updated the care plan interventions to prevent further falls. The finding include: Review of the facility policy, Care Plan Revision Upon Status Change, revised 11/22/17, revealed the purpose of this procedure provided a consistent process for reviewing and revising the care plan for those resident experiencing a status change. Upon identification of a change in status, the nurse notified the Minimum Data Set Coordinator, the physician, and the resident representative. Review of the clinical record revealed the facility admitted Resident #156 on 01/22/2020 with [DIAGNOSES REDACTED]. Review of facility incident report completed [DATE]20, for Resident #156's fall on 02/01/2020, revealed during a transfer staff lowered the resident to the floor after the resident's left knee gave out. Review of the baseline care plan completed 01/22/2020 for Resident #156, revealed the resident had a potential for falls. Continued review revealed no update to the care plan until notified of fall on [DATE]20. Review of the resident's fall risk evaluation dated 0[DATE]20, revealed resident had one to two (1-2) falls in the past three (3) months before admission; however the facility assessed the resident at low risk for falls. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as not steady, only able to stabilize with one (1) person staff assistance when moving from seated to standing position, walking, turning around, and surface to surface transfers and a Brief Interview for Mental Status (BI[CONDITION]) exam score of fifteen (15) out of fifteen (15) and determined Resident #156 was interviewable. Interview with Resident #156, on [DATE]20 at 09:44 AM, revealed the resident fell on [DATE] while transferring from the bed to the wheelchair. The Resident stated a Certified Nursing Assistant (CNA) was assisting him/her when the fall occurred. Resident #156 stated he/she experienced no injury or pain from the fall. Review of Registered Nurse #1's charted nursing note, dated 02/01/2020, revealed no documentation of the resident's fall during the shift. Interview with CNA #3, on [DATE]20 at 3:23 PM, revealed she assisted Resident #156 during a transfer from the bed to the wheelchair with the gait belt when his/her right knee gave out. CNA #3 continued to reveal she attempted to catch resident, however the safest approach was to ease resident to the floor. CNA #3 stated once Resident #156 was safe, she contacted RN #1 to assist resident to the wheelchair. CNA #3 revealed she reported RN #1 on 02/01/2020. Interview with RN #1, on [DATE]20 at 2:38 PM, revealed she was aware of Resident #156's fall however forgot to complete the process for a fall. Interview with the Assistant Director of Nursing (ADON), on [DATE]20 at 2:07 PM, revealed nursing staff updated resident care plans after a resident experienced a fall. The ADON stated nursing had access to update resident care plans and failing to update a care plan could lead to other incidents. Interview with the Director of Nursing (DON), on [DATE]20 at 2:59 PM, revealed nursing staff notified management staff of falls to assist with the immediate updates of interventions to prevent further resident falls. The DON stated staff then investigated resident falls and provided any further updates to care plan interventions. Interview with Administrator, on [DATE]20 at 4:16 PM, revealed she expected staff to follow the process for falls and update care plans accordingly. Continued interview with the Administrator revealed within 24-48 hours after an incident the facility expected an update to the resident care plan to prevent further falls. The Administrator stated failing to follow this process could lead to additional falls.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of seven (7) sampled residents (Resident #156) received adequate supervision to prevent falls. Resident #156 experienced a fall on 02/01/2020 and review revealed Registered Nurse (RN) #1 failed to complete an incident report and make the necessary notifications. The finding include: Review of the facility policy, Accidents and Supervision, revised 11/17/17, revealed the resident's environment remained free of accident hazards. Each resident received adequate supervision and assistive devices to prevent accidents. This included identified hazards and risks, evaluated and analyzed hazards, implemented interventions to reduce hazards and risk and monitoring for effectiveness and modified interventions. Review of the clinical record revealed the facility admitted Resident #156 on 01/22/2020 with [DIAGNOSES REDACTED]. Review of facility incident report completed [DATE]20, for Resident #156's fall on 02/01/2020, revealed during transfer staff lowered the resident to the floor when his/her left knee gave out. Review of the baseline care plan completed 01/22/2020 for Resident #156, revealed the resident had a potential for falls. Review of the resident's fall risk evaluation dated 0[DATE]20, revealed resident had 1-2 falls in the past three (3) months before admission however the facility assessed the resident at low risk for falls. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BI[CONDITION]) exam score of fifteen (15) out of fifteen (15) and determined Resident #156 was interviewable. Further review revealed the MDS assessed the resident as not steady, only able to stabilize with one (1) person staff assistance when moving from seated to standing position, walking, turning around, and surface to surface transfers. Review of the nursing note dated 02/01/2020, charted by Registered Nurse (RN) #1, revealed no documentation of the resident's fall during the shift. Interview with Resident #156, on [DATE]20 at 09:44 AM, revealed the resident had a fall on 02/01/2020 while transferring from the bed to the wheelchair. The Resident stated he/she had the assistance of a Certified Nursing Assistant (CNA) and she/he experienced no injury or pain from the fall. Interview with CNA #3, on [DATE]20 at 3:23 PM, revealed she assisted Resident #156 during a transfer from the bed to the wheelchair with the gait belt when his/her right knee gave out. CNA #3 continued to reveal she attempted to catch resident, however the safest approach was to ease resident to the floor. CNA #3 stated once Resident #156 was safe, she contacted RN #1 to assist resident to the wheelchair. CNA #3 revealed she reported RN #1 on 02/01/2020. Interview with RN #1, on [DATE]20 at 2:38 PM, revealed she was notified by CNA #3, Resident #156 fell while being transferred from his/her bed to the wheelchair. RN #1 explained when she arrived to the resident's room, the resident was sitting on the floor. Continued interview revealed, RN #1 completed a visual assessment, completed range of motion, and the resident reported she/he was not injured. RN #1 revealed she failed to document Resident #156's fall, complete an incident report or make appropriate contacts. RN #1 revealed she was aware of Resident #156's fall however forgot to complete the process for a fall. Interview with the Director of Nursing (DON), on [DATE]20 at 2:59 PM, revealed her job duties included supervision of all nursing staff and acting staff development coordinator. The DON revealed the fall investigation process included nursing staff completed a resident assessment, documented the fall in the resident's chart, completed an incident report, notified physician and family/power of attorney and notified management on duty. The DON stated the facility began an investigation into resident falls after receiving notification of the fall, which did not happen in this instance. Interview with Administrator, on [DATE]20 at 4:16 PM, revealed she expected staff to follow the process for falls. She continued to reveal the fall investigation process included documenting the fall incident, notification of the proper parties of the fall, completion of a head to toe assessment including injuries and pain. The Administrator reported nursing documentation was expected on the same day of any fall incident.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide a safe environment for one (1) of seventeen (17) sampled residents, Resident #17. Resident #17, whom the facility assessed as an elopement risk, exited the facility unsupervised on 08/28/18, when staff left a known unlocked exit door unattended. The findings include: Review of the facility's policy, Elopement and Wandering Residents, implemented 11/28/17, revealed the facility ensured residents who exhibited wandering behavior and were at risk for elopement received adequate supervision to prevent accidents in accordance with their person centered plan of care that addressed the unique factors that contributed to wandering. The policy further stated the facility had a systematic approach to monitoring and managing resident's risk for elopement and unsafe wandering including identification and assessment of risk, evaluation and analysis of hazards and risks, implemented interventions to reduce such hazards and risks, and monitored for the effectiveness as well as modified interventions when necessary. Review of Resident #17's clinical record revealed the facility admitted the resident on 07/27/18, with [DIAGNOSES REDACTED]. Review of Resident #17's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15) and determined the resident not interviewable. The facility assessed the resident did not display any wandering behavior. The resident used a walker and wheelchair for mobility. Review of Interdisciplinary Notes, dated 08/10/18, revealed Resident #17 self-transferred from the bed and walked to the North hall doorway and opened the door; staff was able to redirect. About five (5) minutes later, the resident again self-transferred out of bed and headed towards the doorway and staff redirected him/her. Review of a Physician Order, dated 08/10/18, revealed an order for [REDACTED]. Review of Resident #17's Care Plan, dated 08/10/18, revealed the resident wandered and was at risk for elopement. Interventions included placing a monitoring device on the resident that sounded an alarm when the resident got close to an exit door and elevator and if the resident eloped from the facility, implement facility protocol for locating the resident. Review of a facility Investigation, dated 09/01/18, revealed on 08/28/18, Resident #17 pressed the bar on the emergency exit door near his/her room long enough to deactivate the egress magnetic lock function and set off the emergency door alarm. Staff turned off the alarm that his/her wanderguard activated and redirected the resident away from the door and went to obtain the key to turn off the emergency door alarm and reset the magnetic lock. Before staff made it back to the door, the wanderguard alarm sounded again and staff found Resident #17 outside in the parking lot. Staff brought the resident back into the facility unharmed. Interview with Certified Nursing Assistant (CNA) #1, on 12/19/18 at 11:27 AM and 12/21/18 at 8:04 AM, revealed she worked first shift on 08/28/18, and Resident #17 attempted to exit the facility several times and made it out to the parking lot around 7:00 AM to 7:30 AM via the North exit door. She stated Resident #17 attempted to exit through the door and set off the alarm. She redirected the resident and went to the South hall to get the key to reset the lock on the door. As she was on her way back to the North hall with the key, the resident exited the building. The CNA further stated staff knew Resident #17 was an elopement risk because he/she had eloped from another facility and someone should have stayed with him/her, in addition, she stated the key should have been readily accessible. Interview with Maintenance Staff #1, on 12/19/18 at 3:55 PM, revealed the North hall egress door had a magnetic lock with a thirty (30) second delay. He explained a key had to be used to reset the magnetic lock on the door. Interview with CNA #2, on 12/20/18 at 8:40 AM, revealed a CNA from third shift told her Resident #17 had been up and down that night (08/27/18), had walked a lot, and did not want to go to sleep. Interview with Licensed Practical Nurse (LPN) #4, on 12/20/18 at 10:31 AM, revealed on 08/28/18, Resident #17 tried to get out the North hall egress door and the alarm went off. CNA #1 redirected the resident then went to the South hall to get the key to reset the door. LPN #4 stated she was getting report because it was shift change, nobody stayed with Resident #17 while the door was unlocked, and the resident went out the door to the parking lot. Interview with Registered Nurse (RN) #1, on 12/20/18 at 10:59 AM, via telephone, revealed Resident #17 often attempted to get out because the parking lot stimulated him/her. He stated there was only one (1) key to reset the egress door and it was kept on the South hall. When CNA #1 went to get the key, staff should have stayed by the unlocked door for resident safety. Interview with the Director of Nursing (DON), on 12/21/18 At 10:43 AM and 11:03 AM, revealed Resident #17 was alert with confusion, was known to be a wanderer, and the site of a parking lot reminded the resident of wanting to go shopping and he/she tried to find a door to get out to the parking lot. She stated staff should have stayed at the unlocked door while somebody got the key. She stated it was staff's responsibility to do everything possible so residents did not leave the facility unattended, and there should have been a key kept at the North egress door. The DON stated there was the potential for harm for residents because the door was left opened, and Resident #17 could have gotten hurt being outside unsupervised. Interview with the Administrator, on 12/20/18 at 8:07 AM and 10:18 AM, revealed staff did not stay with Resident #17 while the key was retrieved to reset the door, and the door was unlocked and the resident eloped. She stated the egress door had to be reset with a key and the key to reset the North hall egress was not readily available, it was on the nurse's key chain. She stated the facility could have made sure someone was at the door so no resident got out the unlocked door.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure controlled drugs were stored in separately locked, permanently affixed compartments for one (1) of eight (8) medication compartments. Observation revealed a box of emergency controlled medications stored in the refrigerator and not affixed to any surface. In addition, there was not a lock on the box. The findings include: Review of the facility's policy, Medication Storage, dated 11/28/17, revealed the facility stored all medications in designated areas to ensure sufficient security. Review of the facility's policy, Controlled Substance Administration and Accountability, dated 11/28/18, revealed the facility provided services compliant with state and federal regulations regarding monitoring the use of controlled substances and safeguards were in place in order to prevent controlled substance loss and diversion. Observation of the medication room refrigerator, on 12/20/18 at 11:02 AM, with Licensed Practical Nurse (LPN) #5 and Registered Nurse (RN) #2, revealed a plastic box in the refrigerator contained controlled medications and not affixed or attached to any surface. The box was closed with a thin plastic tie, there was no locking mechanism, and the box contained six (6) [MEDICATION NAME]/[MEDICATION NAME] (APAP) 5-325 milligram (mg) tablets, two (2) vials of injectable [MEDICATION NAME] 2 mg per milliliter (ml), and one (1) bottle of [MEDICATION NAME] Oral Solution, 20 mg per ml, with a labeled volume of 30 ml. Interview with RN #2, on 12/20/18 at 11:03 AM, revealed the facility stored emergency controlled medication in the plastic box in the medication room refrigerator, which was not affixed to any surface, and was closed with a plastic tie. The RN stated all nurses in the facility working on medication carts had keys to the medication room and refrigerator and could walk away with the box of controlled medication. Interview with the Assistant Director of Nursing (ADON), on 12/20/18 at 11:46 AM, revealed she and three (3) nurses working on medication carts had keys to the medication room, medication room refrigerator, and access to the emergency controlled medication box. She stated the box was closed with a plastic tie and was not permanently affixed to any surface within the refrigerator. The ADON further stated theft of controlled medication was a concern in the community. Interview with the Director of Nursing (DON), on 12/20/18 at 11:47 AM, revealed four (4) nurses at a time had access to the emergency controlled medication box. She stated if a nurse took medication out of the box without signing it out, no one would know until the box was counted again. The DON stated there were eight (8) compartments in the facility used to store controlled medications, two (2) on each of three (3) medication carts, one (1) destruction box, and one (1) emergency controlled medication box in the refrigerator. She stated the controlled medication box in the medication room refrigerator was not affixed to any surface. Interview with the Administrator, on 12/21/18 at 8:40 AM, revealed she was not aware there was an issue with the controlled medication box in the refrigerator. She stated the pharmacy had not alerted her there was an issue with how the box was stored. However, the Administrator stated she was aware three (3) nurses working on medication carts had keys to the medication room, refrigerator in the room, and access to the contents of the emergency controlled medication box. She stated she was not aware the ADON had keys to both the medication room and refrigerator, or if the DON had keys to the medication room. The Administrator stated she was not aware the facility used a plastic tie closure on the box instead of a locking mechanism, and was not aware the box was not permanently affixed it to any surface within the refrigerator.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide services meeting professional standards related to the administration and monitoring of a nebulizer treatment for one (1) of seventeen (17) sampled residents, Resident #23. The findings include: Review of the facility's policy, Nebulizer Therapy, revised 02/28/18, revealed nebulizer treatments should be administered by nursing staff as directed using proper technique and standard precautions. The policy further revealed the nebulizer should be kept vertical during the treatment and the nurse should observe the resident during the procedure for any change in condition. Review of the clinical record revealed the facility admitted Resident #23 on 08/02/17, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15) and determined the resident not interviewable. Review of Resident #23's Physician Order, dated 05/02/18, revealed an order for [REDACTED]. Observation of Resident #23, on 12/18/18 at 9:43 AM, revealed the resident in his/her room with a facemask in place and a nebulizer treatment in progress. Observation of Resident #23, on 12/18/18 at 10:11 AM, revealed the facemask was on top of the resident's head and the nebulizer was on. At 10:22 AM, the nebulizer cup and tubing were lying on Resident #23's chest and the facemask was lying in a drawer. The nebulizer was on the bedside table and running. Interview with Licensed Practical Nurse (LPN) #4, on 12/20/18 at 10:32 AM, revealed she did not monitor the administration of nebulizer treatments. The LPN stated she initiated the nebulizer treatment and relied on memory to return in about ten (10) minutes to reassess a resident's respiratory status. She stated it was important to assess the respiratory status pre and post treatment to ensure the treatment was effective. Interview with Registered Nurse (RN) #2, on 12/21/18 at 10:43 AM, revealed the medication nurse was responsible for monitoring residents for potential adverse reactions during nebulizer treatments. Interview with the Assistant Director of Nursing (ADON), on 12/21/18 at 11:09 AM, revealed it was important for the nurse to stay with the resident during a nebulizer treatment to monitor respiratory status and ensure the medication was administered. The ADON stated she was not aware of any concerns related to monitoring of nebulizer treatments. Interview with the Director of Nursing (DON), on 12/21/18 at 2:51 PM, revealed the nurse should visualize the resident during a nebulizer treatment to ensure the medication was administered and the resident had no adverse effects. The DON stated she had not identified any concerns related to the administration of nebulizer treatments. Interview with the Administrator, on 12/21/18 at 3:06 PM, revealed she was not aware of any concerns related to medication pass or nebulizer treatments.

Based on observation, interview, and facility policy review, it was determined the facility failed to implement an effective infection control program related to labeling and storage of resident personal hygiene supplies for one (1) of three (3) shower rooms. The findings include: Review of the facility's policy, Infection Prevention and Control Program, revised 11/17/17, revealed the facility would establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and prevent the development and transmission of communicable diseases and infections. Observation of the West Hall shower room, on 12/18/18 at 9:30 AM, revealed the following opened hygiene items stored in a plastic wash basin: one (1) 20 ounce (oz.) bottle of body lotion with no lid; one (1) 10 oz. bottle of body lotion; one (1) 2.6 oz. solid deodorant; one (1) 8 oz. bottle of goat milk lotion with a use by date of (MONTH) 2014; one (1) 4 oz. bottle of mouthwash; one (1) 4 oz. tube of skin repair cream; two (2) 4 oz. tubes of skin cream; and two (2) 11 oz. cans of shave cream. The hygiene items were not labeled with a resident name. Interview with Certified Nursing Assistant (CNA) #10, on 12/18/18 at 9:35 AM, revealed personal toiletries were for individual use only and should be labeled with the resident's name to prevent the spread of germs. Interview with Registered Nurse (RN) #2, on 12/21/18 at 10:43 AM, revealed she did not monitor the shower rooms unless someone reported a problem. The RN stated hygiene products should be labeled with the resident's name, room number, and date opened. She revealed staff could potentially use the unlabeled supplies on more than one resident, which could transfer germs or disease. Interview with the Assistant Director of Nursing (ADON), on 12/21/18 at 11:09 AM, revealed personal toiletries should be labeled with the resident's name to ensure they were not used on other residents and prevent the spread of infection. The ADON stated she was not responsible for infection control monitoring. Interview with the Director of Nursing (DON), on 12/21/18 at 2:51 PM, revealed staff used labeled washbasins to store and carry resident toiletries to the shower. The DON stated the shower rooms were pretty well kept and she was not aware of any concerns related to unlabeled supplies. Interview with the Administrator, on 12/21/18 at 3:06 PM, revealed she monitored the shower rooms daily and had not identified any concerns related to infection control.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have a system in place to develop and implement an effective plan to correct identified quality deficiencies in a timely manner related to transfers of a residents using lifts for one (1) of five (5) residents, Resident #1. While being transferred using a lift, Resident #1 fell and sustained injuries, including skin tears to the left wrist and right forearm and a laceration to the forehead. Review of the facility policy, Quality Assessment and Assurance, implemented 11/28/17, revealed the facility utilized a Quality Assessment and Assurance Committee to identify quality issues and develop and implement appropriate plans of action to correct identified quality deficiencies within the facility through an interdisciplinary approach. The findings include: Review of a facility investigation revealed on 05/28/18, Certified Nursing Assistant (CNA) #8, without any assistance, transferred Resident #1 via Hoyer Lift when the Resident fell out of the lift. Resident #1 sustained injuries to his/her left wrist and right forearm in addition to a laceration to the right side of his/her forehead. Resident #1 was sent out for emergency treatment where the laceration was sutured. Additionally, the Resident had a Computed Tomography (CT) scan of his/her head performed long with an X- [MEDICAL CONDITION] (X-Ray) of her pelvis which determined no further injuries. Resident #1 was returned to the facility on [DATE]. Review of the medical record revealed the facility admitted Resident #1 on 08/20/13 with [DIAGNOSES REDACTED]. Review of the emergency room Discharge Summary, dated 05/28/18, revealed Resident #1 was treated for [REDACTED]. The CT Scan revealed no [MEDICAL CONDITION] and the X-Rays revealed no fractures. Resident #1 was discharged to the care of the facility with skin care instructions for the laceration to the right forehead, a follow-up date for the removal of the sutures, and skin care for the left wrist and right forearm skin abrasions. Review of the quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status score of three (3) out of fifteen (15) and determined the resident was not cognitively intact or interviewable. The facility assessed the resident as totally dependent on staff for transfers and required the supervision of two plus nursing staff members to transfer the resident. Review of the current physician orders revealed an order dated 01/31/17, for a Hoyer Lift for all transfers on every shift. Review of the Comprehensive Care Plan, dated 06/28/18, revealed Resident #1 at risk for falls and included a goal for no serious injury related to falls. Interventions dated 01/24/18 included an assist of two (2) nursing staff and a sling lift for all transfers. Review of the manufacturer's instruction for the Invacare Manual/Electric Portable Patient Lift and S, Owner's Installation and Operating Instructions, Form No. 96-200, P/N 90 revealed on page 13, Invacare recommended two (2) assistants be used when positioning the resident on a sling. Continued review revealed on page 2, maintenance must be performed only by qualified personnel; and, page 33, the Maintenance Safety Inspection Checklist included monthly inspection and adjustment of the functionality of the Hoyer Lift. Observation of Resident #1, on 06/26/18 at 11:30 AM, revealed he/she was clean, groomed, dressed and sitting up in Broda chair in the South Hall dining room. Surveyor attempted conversation with Resident #1, however, he/she was non-responsive and non-verbal with surveyor. CNA #8, who transferred Resident #1 on 05/28/18, by herself, was not available for interview and attempts to reach by telephone were unsuccessful. Review of the facility investigation into the incident revealed CNA #8 stated she was aware policy required two (2) staff persons for resident transfers with mechanical lifts. Per facility investigation and interview there were no other witnesses to the transfer of Resident # 1 on the morning of 05/28/18. Interview with Licensed Practical Nurse (LPN) #2, on 06/28/18 at 2:25 PM, revealed she was working the morning of 05/28/18 when Resident #1 fell . LPN #2 stated she and the other two (2) nurses working that morning, heard a crash and ran into Resident #1's room, where they assessed and administered aid to Resident #1, prior to sending him/her out for treatment. LPN #2 revealed, CNA #8 was removed from the unit and an investigation was initiated regarding the transfer of Resident #1 on the Hoyer lift with one nursing staff present. Interview with CNA #5, on 06/26/18 at 3:20 PM, revealed she was working on 05/28/18 but she did not participate in the care of Resident #1 after the incident. She revealed she was knowledgeable regarding the policy and procedure of always using two (2) nursing staff to transfer a resident in a Hoyer Lift, and stated the information was taught in nursing assistant school in addition to facility orientation and yearly educational modules online. Interview with the Director of Nursing (DON), on 06/28/18 at 2:00 PM, revealed she was knowledgeable regarding the care of residents requiring transfer on a Hoyer Lift. She stated the nursing staff and nursing assistants received education during orientation and yearly educational updates regarding the necessity of always using two (2) nursing staff to transfer a resident on the Hoyer Lift. The DON revealed the nursing staff were re-educated regarding the Hoyer Lift policy of always using two (2) nursing assistants when transferring residents and added no records or audits were conducted to ensure the re-education was effective. She stated the nursing staff contacted maintenance regarding issues with the Hoyer Lift. Interview with the Environmental Services Director (ESD), on 07/03/18 at 10:00 AM, revealed the maintenance department, for which she supervised, was responsible for the maintenance of the Hoyer Lift. She stated she had observed the maintenance staff change the batteries of the lift and inspect the functionality of the lift, but did not specify if a schedule existed for inspection of the lifts. She was not knowledgeable regarding documentation of any routine maintenance of the lifts. The ESD stated she had no audits or records of inspections or maintenance of the lifts. Interview with the Medical Director, on 07/03/18 at 11:15 AM, revealed he was notified of Resident #1's incident, and ordered a transfer for further evaluation and treatment. The Medical Director revealed he regularly attended the Quality Assurance (QA) Meetings, held at the facility monthly. He stated he last attended the May, (YEAR) meeting. In addition, the Medical Director did not attend facility meetings related to the incident. The Medical Director did not attend the QA meeting in which the incident was discussed, and did not verbalize if he directed the facility to conduct a QA meeting, specific to this incident. Interview with the Assistant Administrator of the facility, on 07/03/18 at 2:00 PM, revealed Resident #1's fall was discussed in the management meetings on 05/28/18, 5/29/18 and in the QA meeting on 06/22/18. The Assistant Administrator stated the QA committee did not develop a plan to measure and evaluate the effectiveness of the re-education provided to staff after Resident #1 fell . In addition, the Assistant Administrator stated the facility did not hold an adHoc meeting, or establish an adHoc team, after the incident to discuss potential corrective actions. Interview with the Administrator, on 06/28/18 at 3:30 PM, revealed she came into the facility the day of the incident, 05/28/18, and the CNA was immediately removed from the care of patients, pending an investigation. She stated CNA #8 confirmed she failed to follow policy when transferring a resident on a Hoyer Lift but was in a hurry which resulted in the accident with Resident #1. The Administrator stated the incident was discussed at management meetings on 05/28/18 and 05/29/18 but no QA meeting was held specific to, or immediately following this incident. She stated the re-education of staff occurred, related only to using two (2) staff members for transfers with mechanical lifts, however, she did not verbalize if monitoring occurred regarding: maintenance of the lifts after the incident, staff use of lifts after the re-education, or if the facility assessed the effectiveness of the re-education.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the resident's environment was free from accident and hazards during a transfer for one (1) of five (5) residents, Resident #1. Resident #1 was injured during a transfer via a Hoyer Lift, and sustained skin tears to the left wrist and right forearm, and a laceration to the forehead. The findings include: Review of the policy, Safe Lifting and Movement of Residents, revised December, 2011, revealed the facility used appropriate techniques and devices to lift and move residents in order to protect the safety and well-being of staff and residents, and to promote quality care. Continued review revealed the Nursing staff, in conjunction with the rehabilitation staff, assessed individual residents' needs for transfer assistance on an ongoing basis. Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Residents requiring total lift transfer will have two staff members assisting with transfers for safety. Maintenance staff shall perform routine checks and maintenance of equipment and for lifting to ensure that it remains in good working order. Review of the manufacturer's instruction for the Invacare Manual/Electric Portable Patient Lift and Slings, Owner ' s Installation and Operating Instructions, Form No. 96-200, P/N 90 reveals on page 13, Invacare recommended two (2) assistants, one (1) on each side of the bed be used when positioning the resident on a sling, with one (1) assistant holding the resident, while the second assistant pushed the folded sling under that resident without rolling him/her over. Continued review of the manufacturer's instructions revealed six (6) month checks and lubrications of the equipment ensured continued reliability of the lift. Review of the facility policy, Accidents and Supervision, implemented 11/28/17, revealed the resident environment remained as free from accident hazards as possible, and each resident received supervision and assistive devices to prevent accidents. Review of a facility investigation revealed on 05/28/18, Certified Nursing Assistant (CNA) #8, with no other staff assistance, attempted to transfer Resident #1 from the bed to the wheelchair via a mechanical lift when, according to CNA #8, Resident #1 leaned forward and fell out of the lift. Resident #1 sustained a skin tear to his/her left wrist and right forearm along with a laceration to the right side of his/her forehead. Resident #1 was sent to an area emergency room where the laceration to his/her forehead was sutured. A Computed Tomography (CT) scan of his/her head was performed along with an X-[MEDICAL CONDITION] (X-Ray) of her pelvis. No additional injuries were found on the CT scan or the X-Ray. Resident #1 returned to the facility on [DATE]. Review of the medical record for Resident #1 revealed the facility admitted the resident on 08/20/13 with [DIAGNOSES REDACTED]. Review of the orders for Resident #1 revealed an order, dated 02/04/17, for comfort measures to include no antibiotic treatment, resident to remain at facility unless [MEDICAL CONDITION] and/or physician order. Continued review revealed on 01/31/17 the physician ordered a Hoyer Lift for all transfers on every shift. Review of the emergency room Discharge Summary, dated 05/28/18, revealed Resident #1 was transported to the emergency room via ambulance and treated for [REDACTED]. The CT Scan revealed no [MEDICAL CONDITION] and the X-Rays revealed no fractures. Resident #1 was discharged to the care of the facility with orders to include skin care instructions for the laceration to the right forehead, a follow-up date for the removal of the sutures, and skin care for the left wrist and right forearm skin abrasions. Review of the quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status score of three (3) out of fifteen (15) and determined the resident was not cognitively intact or interviewable. The facility assessed the resident totally dependent for transfers and required supervision of two plus nursing staff members for transfers. Review of Resident #1's Comprehensive Care Plan, dated 06/28/18, revealed the resident was at a risk for falls with a goal to have no serious injury related to falls. An intervention dated, 01/24/18, listed an assist of two (2) nursing staff and a sling lift for all transfers. Observation of Resident #1, on 06/26/18 at 11:30 AM, revealed he/she was clean, groomed, dressed and sitting up in a Broda chair in the South Hall dining room. Surveyor attempted conversation with Resident #1, however, he/she was non-responsive and non-verbal with surveyor. Resident #1 was responsive to nursing staff feeding him/her with cues. CNA #8, who transferred Resident #1 on 05/28/18, by herself, was not available for interview after multiple attempts per telephone. Review of the facility investigation revealed CNA #8 stated she did not ask for assistance with the mechanical lift transfer and she was aware of facility policy requiring two (2) staff members for transfers with mechanical lifts. (There were no witnesses, per facility and surveyor interview, to the transfer of Resident #1 on the morning of 05/28/18.) Interview with Licensed Practical Nurse (LPN) #2, on 06/28/18 at 2:25 PM, revealed she was present the morning of 05/28/18 when Resident #1 fell . LPN #2 she just completed shift report when she heard a crash and ran into Resident #1's room. LPN #2 stated she began to assess the situation and tend to Resident #1. She further revealed CNA #8 was removed from the floor and an investigation initiated regarding the transfer of Resident #1 on the Hoyer lift with only one nursing staff present. LPN #2 stated it was important two (2) staff members assisted with a mechanical lift transfer as the second staff member served as a second set of eyes, and aided in the prevention of accidents but she was not able to verbalize why two (2) staff members were not present for this transfer. Interview with LPN #4, on 07/02/18 at 12:04 PM, revealed facility nurses were instructed to observe CNA's when using a mechanical lift to transfer residents to ensure proper technique for the transfer. LPN #4 did not verbalize why the transfer of Resident #1 resulting in injuries, was not observed. Interview with CNA #5, on 06/26/18 at 3:20 PM, revealed she was knowledgeable regarding the policy and procedure of always using two (2) nursing staff to transfer a resident in a Hoyer Lift. She stated it was important to use two (2) staff members for a mechanical lift transfer as residents shift their bodies, or the resident could fall out and be injured. She stated the information was taught in nursing assistant school and at the facility during orientation and yearly educational modules online. Interview with CNA #7, on 07/02/18 at 3:22 PM, revealed it was important for two (2) staff members to be present when transferring a resident with a Hoyer lift as the lifts were not the most stable; and the second staff member served as a check and balance for the process, in addition to physical assistance. Interview with Registered Nurse (RN) #2, on 07/02/18 at 2:00 PM, revealed two (2) staff members were necessary when using a mechanical lift with resident transfers as it provided an additional set of eyes, and ensured resident safety. She stated a resident may be injured if only one (1) staff member performed the transfer with a mechanical lift. Interview with the Director of Nursing (DON), on 06/28/18 at 2:00 PM, revealed she was knowledgeable regarding the care of residents requiring transfer on a Hoyer Lift. She stated the nursing staff and nursing assistants received education during orientation and yearly educational updates regarding the necessity of always using two (2) nursing staff to transfer a resident on the Hoyer Lift. She stated she did not routinely make observations of staff performing transfers with mechanical lifts. She revealed the only observations of transfers with mechanical lifts she observed were those in which she assisted with the care of the resident; however, she kept no records of the observations. Interview with the Environmental Services Director (ESD), on 07/03/18 at 10:00 AM, revealed the maintenance department, which she supervised, was responsible for the maintenance of the Hoyer Lift. She stated she has observed the maintenance staff change the batteries of the lift and monitor the functionality of the lift. The ESD did not provide documentation of any routine maintenance or calibration of the lifts; nor, did she provide a schedule for routine maintenance of the lifts Interview with the Medical Director, on 07/03/18 at 11:15 AM, revealed he was immediately notified of Resident #1's fall and he ordered the transfer to an area hospital for further evaluation and treatment. Interview with the Administrator, on 06/28/18 at 3:30 PM, revealed she came into the facility the date it happened on 05/28/18, Memorial Day Holiday. She revealed the CNA was immediately removed from the care of patients, pending an investigation. She confirmed CNA #8 stated she was knowledgeable regarding the policy and procedure of the facility of always using two (2) nursing staff when transferring a resident on a Hoyer Lift, however she was in a hurry and made a mistake, which resulted in the injury of Resident #1.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement a comprehensive, person-centered, nursing care plan that reflected physician orders [REDACTED].#1. While being transferred via a mechanical lift, Resident #1 fell and sustained injuries, including skin tears to left wrist and right forearm, and a laceration to the forehead. The findings include: Review of facility policy, Comprehensive Care Plans, implemented 11/28/17, revealed: the facility developed and implemented a comprehensive person-centered care plan for each resident, consistent with the resident right's, including measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs identified in the resident's comprehensive assessment. In addition, staff documented the transfer and lifting needs of residents in the care plan. Review of the policy, Safe Lifting and Movement of Residents, revised December, 2011, revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, the facility used appropriate techniques and devices to lift and move residents. Continued review revealed nursing staff, in conjunction with rehabilitation staff, assessed a resident's needs for transfer assistance on an ongoing basis. Staff responsible for direct resident care received training in the use of manual and mechanical lifting devices and staff were observed for competency in use of mechanical lifts. In addition, periodic observations for adherence to policies and procedures regarding use of equipment and safe lifting techniques occurred. Residents requiring total lift transfer will have two (2) staff members assisting with transfers for safety. Review of a facility investigation revealed on 05/28/18, Certified Nursing Assistant (CNA) #8, by herself, attempted to transfer Resident #1 from the bed to the wheelchair via a Hoyer Lift when, according to CNA #8, Resident #1 leaned forward and fell out of the lift. Resident #1 sustained a skin tear to his/her left wrist and right forearm in addition to a laceration to the right side of his/her forehead. Resident #1 received sutures to the laceration on his/her forehead at an area emergency room with no internal injuries noted per a Computed Tomography (CT) scan of his/her head and an X- [MEDICAL CONDITION] (X-Ray) of his/her pelvis. Resident #1 returned to the facility on [DATE]. Continued review of the facility investigation revealed no updates occurred to the nursing care plan. Review of the medical record for Resident #1 revealed the facility admitted the resident on 08/20/13 with [DIAGNOSES REDACTED]. Review of the emergency room Discharge Summary, dated 05/28/18, revealed Resident #1 was treated for [REDACTED]. A CT Scan revealed no [MEDICAL CONDITION] and the X-Rays revealed no fractures. Resident #1 was discharged to the care of the facility with skin care instructions for the laceration to the right forehead, and abrasions to the left wrist and right forearm, and a follow-up date for removal of the sutures. Review of the quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) and determined the resident was not cognitively intact or interviewable. Continued review revealed the facility assessed the resident as totally dependent for transfers and required supervision of two plus (2+) nursing staff members to transfer the resident. Review of the current physician orders [REDACTED]. Continued review of the physician orders [REDACTED]. Review of the Comprehensive Care Plan for Resident #1, dated 06/28/18, revealed he/she depended on the staff for Average Daily Living (ADL) skills and required the assistance of staff for transfers. The care plan interventions began on 01/24/18 and included the following: explain all procedures prior to starting; advise Resident what was expected of him/her during the transfer; reassure Resident of safety as needed; keep hand on Resident to reassure of safety if needed; insure lift sheet is intact and correct size for Resident; and, may leave lift sheet under Resident if comfort in placing/removing sheet is problematic. Continued review of the Comprehensive Care Plan revealed the facility assessed the resident at risk for falls with a goal for no serious injuries related to falls. Interventions dated 01/24/18, included: assist of two (2) nursing staff and a sling lift for all transfers; explain all procedures prior to starting; advise Resident of expectations during the transfer; reassure Resident of safety as needed; keep hand on Resident to reassure of safety if needed; insure lift sheet intact and correct size for Resident; and may leave lift sheet under Resident if problematic during placement/removal. Further review of the Comprehensive Care Plan for Resident #1, dated 06/28/18, revealed a care plan update, dated 06/15/18 (two weeks after the fall), regarding skin impairment related to: laceration to the right forehead, skin tear to the lift wrist, and right forearm. The goal was for skin laceration and skin abrasions to heal by next review and resident will remain free of further development of skin impairments/ulcers. The interventions included: treatments per MD orders; skin assessments per MD orders; and to remove sutures on 06/04/18. Certified Nursing Assistant (CNA) #8, who transferred Resident #1 on 05/28/2018, by herself, without any assistance was not available for interview. Three (3) attempts were made per telephone to speak with CNA #8, on 07/02/18 at 11:44 AM, 2:18 PM, and 4:07 PM with no success. (Per surveyor interview and staff report there were no witnesses to the transfer of Resident #1 on the morning of 05/28/18.) However, review of the facility investigation into the incident revealed CNA #8 stated she knew two (2) staff members were required to assist with a resident transfer involving a mechanical lift but she did not ask for assistance. Interview with CNA #7, on 07/02/18 at 3:22 PM, revealed CNA's received resident care plan information during walking rounds at shift change, the electronic CNA charting system, and a paper care plan attached inside each resident's closet. CNA #7 stated it was important for two (2) staff members to be present when transferring a resident with a Hoyer lift as the lifts were not the most stable; and the second staff member served as a check and balance for the process, in addition to physical assistance. Interview with Licensed Practical Nurse (LPN) #2, on 07/02/18 at 12:04 PM, revealed facility nurses supervised CNA's by observation of the care they provided to the residents, including assistance with transfers. She stated it was important two (2) staff members assisted with resident transfers by mechanical lift, but could not verbalize why CNA #8 attempted to transfer Resident #1 without a second staff person. LPN #2 stated nurses were instructed to always observe CNA's when transferring residents to ensure correct technique was utilized but could not specify why CNA #8 was not supervised or observed during this specific transfer of Resident #1 resulting in injury. She stated it was important two (2) staff members assisting with a mechanical lift transfer served as a second set of eyes, and aided in the prevention of accidents. LPN #2 stated facility management updated resident care plans and notified facility nurses. Facility nurses initiated care plan interventions, and then passed the information on to the CNA's. Interview with Registered Nurse (RN) #2, on 07/02/18 at 2:00 PM, revealed she supervised nursing assistants in an on-going manner as they provided care to the residents. In addition, she assisted in providing the care and assistance with transfers. She stated two (2) staff members were necessary when using a mechanical lift with resident transfers as it provided an additional set of eyes, and ensured resident safety. RN #2 stated resident care plan information was passed to staff providing care through shift change report and the 24-hour report. Interview with the Director of Nursing (DON), on 06/28/18 at 2:00 PM, revealed changes to a resident's comprehensive care plan were made immediately in the case of a fall or immediate need. She stated care plan updates and care plans not followed were discussed in management meetings, and assigned to an appropriate staff member based on the care area. The DON did not know why the comprehensive care plan for Resident #1 was not updated immediately after the fall, nor followed, regarding additional fall interventions, or skin care interventions. The DON stated she supervised nursing staff when she made rounds on the units, ensuring staff completed their assignments, but added she did not watch CNA's perform resident transfers with a mechanical lift. Interview with the Administrator, on 06/28/18 at 3:30 PM, revealed she came into the facility on the date of the incident, 05/28/18. The administrator revealed the CNA was immediately removed from the care of patients, pending an investigation. She revealed CNA #8 stated she was knowledgeable regarding the policy and procedure of the facility to always use two nursing staff when transferring a resident on a Hoyer Lift, however, she was in a hurry that morning and made a mistake, which resulted in the injury of Resident #1. The Administrator stated she was aware the comprehensive care plan was not updated and stated the comprehensive care plan should be updated according to the policy and procedure of the facility. An interview with the Assistant Administrator (acting Administrator while Administrator was on vacation), on 07/03/18 at 2:00 PM, revealed nursing staff were to follow and implement nursing care plans, which were individually prepared for each resident. She stated the failure of not implementing the care plan for Resident #1 resulted in an injury to Resident #1 which required an emergency room visit resulting in sutures to a [MEDICAL CONDITION].

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. Observation revealed two (2) of three (3) medication carts were unlocked and unattended by authorized personnel during medication pass. The findings include: Review of the facility's policy regarding Storage of Medications, dated December 2011, revealed staff was not to leave medication carts containing drugs unattended while open and staff was to lock the carts when not in use. Observation of medication pass, on 09/14/16 at 12:30 PM, revealed an unlocked and unattended medication cart on the West Hall. Observation of medication pass, on 09/15/16 at 12:30 PM, revealed an unlocked and unattended medication cart on the North Hall. Interview with Licensed Practical Nurse (LPN) #2, on 09/15/16 at 2:30 PM, revealed she was the nurse assigned to the West Hall on 09/14/16. She stated she had the keys to the unlocked medication cart and was unaware she had left the cart unlocked during medication pass. LPN #2 stated she always locked the cart on both sides so no one could get into the medication cart and take medications. Interview with LPN #4, on 09/15/16 at 1:40 PM, revealed she was assigned to the North Hall on 09/15/16 and was in charge of the medication cart. LPN #4 stated she was unconscious of having left her medication cart unlocked. She further stated if she walked away from an unlocked medication cart, ambulatory residents or family members could have gotten into the cart and accessed the medications. Further interview with LPN #2, on 09/15/16 at 2:30 PM, revealed it was professional practice for nurses to lock medication carts when left unattended, even for a short amount of time. She had learned in nursing school of the importance of locking medication carts and the facility had trained her to do so as well. Interview with the Assistant Director of Nursing (ADON), on 09/15/16 at 8:20 AM, revealed the facility trained nurses in orientation about the importance of locking medication carts any time they walked away, even for a moment. She further stated the nurses were reminded during their monthly refresher education and annual safety in-service to lock the carts. The ADON further stated residents could be harmed if they accessed medications they were not suppose to have from an unlocked cart. Interview with the Director of Nursing, on 09/15/16 at 2:45 PM, revealed she was responsible for educating nursing staff on facility policies and federal regulations. She also relayed the ADON, LPN #3, and herself spot checked for unlocked medication carts on their daily rounds; however, they did not complete any documentation of their findings. She stated they were each assigned different hallways to monitor. She stated she monitored the North hallway and reported no recent issues with unlocked medication carts. In the past, the facility had written up nurses when they left a medication cart unlocked. The DON stated the facility had in-services to remind nurses to lock medication carts. She explained the facility restricted resident access to medication or sharps to reduce potential harm. According to the DON, the nurses had accidentally left the two (2) medication carts unlocked.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure staff followed appropriate infection control practices for two (2) of fifteen (15) sampled residents (Residents #9 and #10) and two (2) unsampled residents (Unsampled Residents B and C). Observations revealed staff failed to wear proper personal protective equipment (PPE) when entering Resident #9's isolation room; staff failed to perform proper hand hygiene during medication administration for Resident #10 and Unsampled Residents A, B, and C; and staff failed to sanitize re-usable equipment. The findings include: Review of facility's policy, Isolation - Categories of Transmission-Based Precautions, dated December 2011, revealed in addition to standard precautions, residents suspected or colonized with Methicillin Resistant Staphylococcus Aureus (MRSA) also receive contact isolation precautions. Staff must wear gowns for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Review of the facility's policy, Handwashing/Hand Hygiene, revised April 2010, revealed the facility considered hand hygiene the primary means to prevent the spread of infections. Staff must wash their hands for at least fifteen (15) seconds using soap and water or use Alcohol-based hand rub before and after direct resident contact. Staff must wash their hands for fifteen (15) seconds using soap and water before and after entering an isolation precaution setting. 1. Review of the facility's clinical record for Resident #9, revealed the facility admitted the resident on 08/10/16 with a [DIAGNOSES REDACTED]. Observation, on 09/13/16 at 8:42 AM, revealed Resident #9 was in isolation with contact precautions. Licensed Practical Nurse (LPN) #7 entered Resident #9's room after donning gloves only. LPN #7 removed the resident's breakfast tray from the room and placed it on a dietary cart in the hallway. LPN #7 returned to the resident's room and washed her hands with soap and water. Interview with LPN #7, on 09/13/16 at 8:44 AM, revealed Resident #9 was in isolation for MRSA. Observation, on 09/13/16 at 9:05 AM, revealed Housekeeper #2 removed her PPE and disposed of it appropriately. She then exited the room without washing her hands and retrieved brown paper towels from her housekeeping cart. She returned to Resident #9's room, entered without donning PPE, and put the paper towels in the paper towel dispenser over the sink. She used her bare hands to open the dispenser and touched the sink counter. She returned to her cart without washing her hands. Observation, on 09/13/16 revealed at 2:45 PM, revealed LPN #5 carried a cordless telephone from the nurse's station to Resident #9's room and handed it through the doorway to his/her daughter. Resident #9's family was not wearing any PPE. Resident #9's family returned the telephone to the nurse's station at 3:05 PM, handed it to LPN #5, and he placed it on the telephone cradle. Observation, on 09/14/16 at 8:14 AM, revealed LPN #6 entered Resident #9's room after donning a gown, gloves, and a mask. Interview with LPN #6, on 09/14/16 at 8:14 AM, revealed Resident #9 was in isolation for MRSA. LPN #6 stated when staff entered a room with contact isolation; they were to wear a gown, gloves, and a mask. LPN #6 stated the purpose of isolation precautions was to prevent the spread of infection from resident to staff and other residents. Interview with Housekeeper #2 on 09/15/16 at 2:30 PM, revealed whenever any staff person entered Resident #9's room for any reason, they donned a gown, gloves and mask. She further stated that staff also washed their hands prior to exiting Resident #9's room. She revealed she did not know what type of infection Resident #9 had but that he/she was highly contagious. Interview with LPN #5, on 09/15/16 at 2:45 PM, revealed all items taken into Resident #9's room were to remain in his/her room until the facility discharged the resident or staff appropriately sanitized the items for reuse. He further stated the cordless phone did not routinely go into contact isolation rooms; however, cleaning it with bleach wipes would render it safe for reuse. He then revealed that family was not responsible for cleaning equipment before reuse and Resident #9's family had not sanitized the cordless phone with bleach wipes before returning it to the nurse's station. Interview with the Infection Control Nurse (ICN), on 09/15/16 at 9:55 AM, revealed any time isolation signage was on a resident's door, staff was to wear a gown and gloves. The ICN stated staff were in-serviced on infection control and isolation precautions twice yearly and during new hire orientation. Staff received a flyer listing the types of isolation with the necessary precautions and signed a release stating they received education on isolation precautions and infection control. The ICN stated that twice yearly in-services were not enough. The ICN stated the purpose of infection control and isolation precautions was to prevent the spread of infection from resident to staff and resident to resident. Interview with Director of Nursing (DON), on 09/15/16 at 2:48 PM, revealed the facility instructed staff to utilize a gown and gloves when providing direct care for residents in isolation with contact precautions. The DON stated gown and gloves were not worn by staff if entering a resident room with contact precautions to only answer questions or if no direct or indirect contact was expected with the exception of housekeeping. Housekeepers could come into contact with body fluids on counters, floors, or on surfaces in the bathroom. The DON stated monitoring of staff compliance with isolation precautions occurred by direct observation and staff who were not compliant, were verbally re-educated about correct isolation precautions. The DON stated the staff using equipment in an isolation room must clean the equipment after use, before returning it to a common area. She stated the facility did not monitor staff for compliance with that expectation. She further stated staff should have sanitized the cordless phone at the nurse's station upon receipt. She expected nursing staff to wash their hands after all instances of patient care delivery or if soiled during care. The DON stated hand scrubbing with soap and hot water should last for at least thirty-five (35) seconds. The DON revealed the purpose of isolation precautions and routine hand hygiene was to prevent the spread of infection between residents and staff and resident to resident and not following correct contact precautions endangered staff and residents. 2. Observation of medication pass, on 09/14/16 at 11:50 AM, revealed LPN #2 entered Unsampled Resident B's bathroom and washed her hands for five (5) to eight (8) seconds before administering medications. Observation, on 09/14/16 at 12:25 PM, revealed after LPN #2 administered medication to Unsampled Resident C, she washed her hands for five (5) to eight (8) seconds and turned the water off by touching the hot and cold faucet handles with her bare left and right hands, respectively. Observation of medication pass, on 09/15/16 at 8:40 AM, revealed LPN #4 washed her hands for five (5) to eight (8) seconds following administration of Resident #10's medications. Interview with LPN #4, on 09/15/16 at 1:40 PM, revealed hand washing was important to prevent the spread of infection from resident to resident and resident to staff. She stated she was taught in school and facility orientation to wash her hands with soap and hot water for three (3) minutes or while singing her A,B,Cs all the way through. Interview with LPN #2 on 09/15/16 at 2:30 PM revealed she washed her hands between all residents. She stated she used soap and hot water and scrubbed her hands for seven (7) to eight (8) minutes, while singing Happy Birthday three (3) times. She further stated, it was important to turn off the faucet with paper towels. She explained the practice of washing hands prevented the spread of infection. Interview with Director of Nursing (DON), on 09/15/16 at 2:48 PM, revealed she expected nursing staff to wash their hands after all instances of patient care delivery or if soiled during care. The DON stated hand scrubbing with soap and hot water should last for at least thirty-five (35) seconds. She further revealed the purpose of routine hand hygiene was to prevent the spread of infection between residents and staff and resident to resident.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain a safe, hazard free environment as evidence of two (2) of two (2) housekeeping carts that contained cleaning chemicals were unlocked and accessible to residents. The findings include: Review of the facility's policy, Storage Areas Environmental Services, undated, revealed the facility stored housekeeping materials in a safe manner. Cleaning supplies were stored as instructed on the labels of the products. Interview with the Environmental Services Director, on 09/14/16 at 4:00 PM, revealed the facility did not have a policy pertaining to locking or supervising facility cleaning carts while on the resident floor. Review of the Safety Data Sheet for Clean on the Go NABC disinfectant, revised 05/07/15, revealed the product caused skin irritation and serious eye damage. Review of the Safety Data Sheet for Peroxy 4D, revised 04/28/15, revealed the product caused respiratory irritation, possible permanent tissue damage to the eye, and chemical burn to the skin. Ingestion of the product may result in vomiting, diarrhea, and distention of the esophagus and stomach. Review of the Safety Data Sheet for Clean on the Go Biorenewables Glass Cleaner, revised 11/04/14, revealed the product caused pain, nausea, vomiting and diarrhea if ingested, nasal discomfort and coughing if inhaled, and pain and swelling of the eye. Review of the Safety Data Sheet for Consume Eco-Lyser disinfectant, revised 08/17/15, revealed the product caused tissue damage to eyes and chemical burns to the skin, mouth, throat, and stomach. Observation of the housekeeping cart on the West Hall, on 09/14/16 at 9:15 AM, revealed staff placed the housekeeping cart outside and next to a resident room doorway while Housekeeper #1 cleaned the resident room. The cart was approximately two (2) feet away from the wall and the door of the cleaning cart stood open. Continued observation revealed Housekeeper #1 exited the resident room and pushed the housekeeping cart to the end of the West Hall and around a corner where staff could not observe the cart from the nurse's station. The housekeeper then walked back up the West Hall without the housekeeping cart. Observation of the housekeeping cart on the West Hall, on 09/14/16 at 9:18 AM, revealed the housekeeping cart stood unsupervised in the foyer of the Sun Room. The housekeeping cart was unlocked and positioned far enough away from the wall that allowed for the door to be opened. The housekeeping cart was not in view of the nurse's station. A resident in a wheelchair self-propelled in and out of the foyer and sunroom, passing the housekeeping cart several times. The housekeeping cart contained several chemicals including Clean on the Go NABC disinfectant, Peroxy 4D, Clean on the Go Biorenewables Glass Cleaner, and Consume Eco-Lyser disinfectant. The cart contained seven (7) spray bottles of cleaning solutions. Continuous observation of the housekeeping cart revealed Housekeeper #1 returned to the cart at 9:30 AM. Observation of a housekeeping cart on the South Hall, on 09/14/16 at 9:35 AM, revealed Housekeeper #2 placed the housekeeping cart outside and next to a resident room doorway while she cleaned the room. The housekeeper positioned the cart so that the door of the cart faced the wall. However, the space between the cart and the wall was wide enough to allow access to the cart's door and to the cleaning chemicals. Additionally, the cart was out of the housekeeper's view as she cleaned the room. Review of the facility's Brief Interview for Mental Status list, revealed the facility assessed twenty-two (22) residents as having cognitive impairment. Review of the facility's list of Residents Who Self-Ambulate/Self-Propel, dated 09/15/16 at 10:50 AM, revealed the facility had twenty-nine (29) residents who were able to self-ambulate or self-propel. Of those twenty-nine (29) residents, the facility identified nine (9) residents as having cognitive impairment. Interview with Housekeeper #1, on 09/14/16 at 9:30 AM, revealed she left the housekeeping cart unlocked and unsupervised in the foyer to the sunroom. Housekeeper #1 stated the facility did not instruct her to lock housekeeping carts while cleaning rooms. She stated the facility did train her to keep the door of the housekeeping cart closed and to keep the housekeeping cart positioned with the door of the cart near a wall so residents could not access the chemicals. She stated the facility stored chemicals in locked closets or on the cleaning cart. Housekeeper #1 stated it was important residents not access cleaning chemicals because some of the chemicals could be hazardous to the residents. Interview with Housekeeper #2, on 09/14/16 at 9:35 AM, revealed the facility trained housekeeping staff not to leave the housekeeping cart unattended and unlocked. She stated the facility did not mandate the housekeeping staff lock the housekeeping carts when the cart was in sight of the housekeeper. Housekeeper #2 stated housekeeping staff placed housekeeping carts in the locked clean linen room when taking a short break and took the cart to a locked area in the basement when taking a scheduled break. However, she stated the facility did not provide clear instructions on storage of the carts when a housekeeper took a short break. Interview with the Environmental Services Director, on 09/14/16 at 4:00 PM, revealed facility staff used Peroxy 4D and several other chemicals for cleaning. She stated the facility trained the housekeeping staff to store all chemicals on the cart behind the closed door of the cart. Staff should not leave the doors of the cleaning carts standing open. The Environmental Services Director stated the doors of the housekeeping carts locked; however, housekeepers did not previously have the keys to the carts. She stated housekeepers stored the housekeeping carts next to the doorway of resident rooms while they cleaned the room. The Environmental Services Director stated housekeepers were to place housekeeping carts in the locked soiled linen room or take the cart to the basement when going on break. She stated the facility trained housekeeping staff to never leave the housekeeping cart out of sight of staff and accessible to residents. She stated staff placed residents at risk of exposure to unsafe chemicals when they left an unlocked housekeeping cart unsupervised. Interview with the Director of Nursing, on 09/15/16 at 2:45 PM, revealed housekeeping staff were to lock housekeeping carts. She stated the housekeeping staff was not to walk away from a housekeeping cart while it was unlocked. She stated when staff left housekeeping carts unsupervised; residents were at risk of accessing chemicals that could be harmful to them. Interview with the Executive Director (ED), on 09/15/16 at 3:35 PM, revealed the Environmental Services Director reported to the ED. The ED stated she made rounds in the facility and had not previously identified unlocked and unsupervised housekeeping carts. She stated the facility mandated the housekeeping staff to lock carts anytime the carts were out of sight of staff. She stated the facility had not previously identified housekeeping chemicals on housekeeping carts as a possible hazard.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure staff cared for residents in a manner that maintained each resident's dignity for two (2) of fifteen (15) sampled residents (Residents #3 and #10) and three (3) unsampled residents (Unsampled Residents B, C, and D) on 2 (two) of 3 (three) halls. Observations revealed nursing staff entered residents' rooms and bathroom without knocking on the doors prior to entering. The findings include: Review of the facility's policy, Quality of Life - Dignity, dated December 2011, revealed residents' private space and property shall be respected at all times. Staff will knock and request permission before entering residents' rooms. Observation of medication pass, on 09/14/16 at 11:50 AM, revealed Licensed Practical Nurse (LPN) #4 entered Unsampled Resident B's room without knocking or requesting permission to enter. Observation of medication pass, on 09/14/16 at 12:00 PM, revealed LPN #2 entered Resident #3's room without knocking or requesting permission to enter. Observation of medication pass, on 09/14/16 at 12:25 PM, revealed LPN #2 entered Unsampled Resident C and Unsampled Resident D's room without knocking or requesting permission to enter. LPN #2 then entered the bathroom, while occupied by Unsampled Resident D, without knocking or requesting permission to enter. Upon exiting the bathroom, LPN #2 left the door open. Observation of medication pass, on 09/15/16 at 8:40 AM, revealed LPN #4 entered Resident #10's room without knocking or requesting permission to enter. Interview with LPN #4, on 09/15/16 at 1:40 PM, revealed she preferred to knock and request permission prior to entering all patient rooms, like she would their homes. Interview with LPN #2, on 09/15/16 at 3:30 PM, revealed she was trained to knock on the door and tell the resident why she was there. She would pull the curtain and close the door before providing care to residents to preserve their privacy. Interview with the Assistant Director of Nursing, on 09/15/16 at 8:20 AM, revealed it was her expectation that nursing staff knock and request to enter all patient rooms before providing care. She further stated staff was to close the doors, window shades, and privacy curtains to maintain the dignity of the resident. Interview with the Director of Nursing, on 09/15/16 at 2:45 PM, revealed it was the facility's policy to provide privacy to residents during personal care. She stated she monitored nursing staff's privacy compliance by watching them knock on doors prior to delivering care when she did her daily rounding.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to provide personal privacy during medication administration, via gastrostomy tube (G tube), for one (1) of fifteen (15) sampled residents (Resident #3). The findings include: Review of the facility's policy, Quality of Life-Dignity, dated December 2011, revealed the staff promoted, maintained, and protected resident privacy, including bodily privacy, during assistance with personal care and during treatment procedures. Review of the Residents' Rights, undated, revealed each resident was treated with consideration, respect, and full recognition of their dignity and individuality, including privacy in treatment and in care for personal needs. Review of the facility's Resident Handbook, dated 01/15/10, revealed the facility assured the personal privacy of all residents was protected, including personal care. Review of the facility's medical record for Resident #3, revealed the facility admitted the resident on 09/04/12 with [DIAGNOSES REDACTED]. Observation of medication pass, on 09/14/16 at 11:50 AM, revealed Licensed Practical Nurse (LPN) #2 administered medication to Resident #3 via his/her gastrostomy tube. LPN #2 did not close the privacy curtain or close the door to Resident #3's room prior to administering the medication. The medication administration required the resident's abdomen to be uncovered. Resident #3 was visible from the hallway to visitors, staff, and other residents walking in the hallway. Interview with LPN #2, on 09/14/16 at 12:00 PM, revealed she should have pulled the curtain and closed the door before administering medications to Resident #3. Further interview with LPN #2, on 09/15/16 at 2:30 PM, revealed the facility had provided training during initial orientation and annually regarding resident privacy. Interview with the Assistant Director of Nursing, on 09/15/16 at 8:20 AM, revealed the nurse should have closed the resident's door and closed the privacy curtain to provide the resident privacy while administering medication through the gastrostomy tube. She stated a passerby could have looked into the resident's room and it would be an invasion of privacy for a passerby to see a procedure that required abdominal exposure. Interview with the Director of Nursing (DON), on 09/15/16 at 2:45 PM, revealed it was the facility's policy to provide privacy to residents during personal care. The DON stated during her daily rounding she monitored nursing staff's privacy compliance by watching for closure of doors and curtains during personal care.

Based on observation, interview, record review and policy Personal Protective Equipment, it was determined the facility failed to follow an Infection Control Program for one (1) of one (1) unsampled residents, Resident A, as it related to peri-care. Staff were observed to cross contaminate and not use proper hand hygiene. The findings include: Review of the facility's Personal Protective Equipment - Gloves Policy, revised December 2011, revealed gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin and to wash hands after the removal of gloves. Review of Unsampled Resident A's record revealed he/she had not sustained any Urinary Tract Infections (UTI) since admission. Observation of Peri Care, on 06/18/14 at 10:17 AM, revealed Certified Nursing Assistant (CNA) #1 wiped Unsampled Resident A's peri area from front to back after Unsampled Resident A had a large bowl movement. Licensed Practical Nurse (LPN) #1 then applied a barrier cream to Unsampled Resident A's coccyx with her left hand, removed the soiled glove and asked CNA #1 to obtain a clean glove with CNA #1's contaminated hands. CNA #1 then touched Unsampled Resident A's shirt and was going to put the clean shirt on Unsampled Resident A, when she realized she needed more clean linen. CNA #1 then removed the soiled gloves, did not wash her hands and proceeded to the clean linen cart to obtain clean linen. CNA #1 then came back into Unsampled Resident A's room, did not wash her hands and donned clean gloves and placed a new draw sheet and clean shirt on Unsampled Resident A. Placed pillow under Resident #A's feet, removed the gloves and washed her hands. Interview with CNA #1, on 06/18/14 at 10:40 AM, revealed CNA #1 could not remember when her last in-service on peri-care was, but imagined it was within the last year. CNA #1 stated she knew when going from dirty to clean, that she was to remove her gloves, wash her hands and don clean gloves before touching the clean linen. CNA #1 stated she washed her hands to prevent the spread of infection. Interview with LPN #1, on 06/18/14 at 10:32 AM, revealed she did not recognize she had obtained a contaminated glove from CNA #1. LPN #1 stated that residents could receive UTI's if the staff utilized improper hand hygiene technique. LPN #1 stated the facility's policy was for staff members to wash their hands after removing contaminated gloves and that she was not following the facility's policy. LPN #1 stated she washed her hands to prevent the spread of infection. Interview with the Staff Development Coordinator, on 06/19/14 at 8:43 AM, revealed peri care training was not provided in new employee orientation, but on the floor with a preceptor. Staff were asked to utilize a check off list that was to be completed. The Staff Development Coordinator stated that he completed observations of staff doing peri care to ensure staff used proper technique. The Staff Coordinator stated there had been some problems with reoccurring UTI's and that they were trying to remove Foley catheters as quickly as possible. Continued interview at 10:00 AM, revealed he would do random audits with nurses and nurse aids. He stated if he found a concern, he would provide a teachable moment to re-train. The Staff Development Coordinator stated that all staff were in-serviced on survey readiness on 06/06/14 that included peri-care, hand washing and glove changes. He stated the last conducted where he observed hand washing and glove changes was on 03/10/14 and was scheduled to conduct another random audit in June 2014. The Staff Development Coordinator stated he observed two (2) nurses and two (2) aides and found no problems during the observations. Interview with the Administrator, on 06/19/14 at 10:00 AM, revealed infection control was brought to the QA (Quality Assurance) each meeting. The Staff Development Coordinator would track and trend the infections and conduct audits. The Administrator stated she was unaware of any problems found during the audits or with peri-care.

Based on interview, record review, and review of the facility's policy Voting Rights, it was determined the facility failed to assist one (1) of fourteen (14) sampled residents, Resident #8 to vote in the primary election on May 2014. The findings include: Review of the Voting Rights policy, reviewed December 2011, revealed the facility would help residents expressing a desire to exercise their right to vote achieve that right. The Activities Staff or designee would help residents with voter registration, obtaining absentee ballots and or obtaining transportation to voting sites. All requests for voting information should be directed to the Activities Department. Interview with Resident #8 during the Resident Council Meeting, on 06/17/14 at 3:30 PM, revealed the residents were not given the opportunity to vote in the primary election, nor offered absentee ballots. Interview with the Activity Director, on 06/18/14 at 10:16 AM, revealed residents did not request the opportunity to vote in the primary election. The Activity Director stated she did not ask the residents if they would like to vote, although she was responsible to ensure residents were given the opportunity to vote. The Activity Director stated that during the week of the primary's, she was on vacation and did not delegate to any staff members about this task.

Based on observation, record review, interview and facility policy review, it was determined the facility failed to remove narcotics from available stock for two (2) of three (3) unsampled residents and sixteen (16) sampled residents. Unsampled Resident A had three (3) vials of expired Ativan available in the refrigerator. deceased Unsampled Resident B's Ativan remained in the refrigerator. The findings include: Review of the facility's policy for Controlled Substance, revised 12/2011, revealed when a resident was discharged from the facility, Scheduled II drugs could not be returned to the pharmacy, but must be destroyed in accordance with established policies. The policy statement indicated the facility shall comply with all laws, regulations and requirements related to the handling, storage, disposal and documentation of Schedule II and other controlled substances. Review of the facility's policy for Discarding and Destroying Medications, revised 12/2011, revealed medications that could not be returned to the dispensing pharmacy shall be destroyed. Observation during tour of the Medication Room with Licensed Practical Nurse (LPN) #1, on 08/30/13 at 7:43 AM, revealed three (3), 2 mg/ml vials of Lorazepam (Ativan), that expired 10/2012 with a pharmacy label, and identified for Unsampled Resident A remained accessible in the refrigerator. In addition, deceased Unsampled Resident B had Ativan 0.5 mg/ml concentrate, 28.5 ml that remained in the refrigerator. Review of the Monthly Survey of the Medication Room Inspection, dated 12/12/12, as provided by the consulting pharmacy revealed the facility monthly controlled substance storage in section 3 did not identify Unsampled Resident A with outdated medications. The monthly survey of the medication room inspection, dated 02/19/13, revealed Unsampled Resident A was identified with Lorazepam (Ativan), expired on 10/2012. The medication room inspection, dated 04/16/13, revealed the facility monthly controlled substance storage in section 3, identified Unsampled Resident A with Lorazepam 2 mg/ml injectable, expired 10/2012, three (3) vials. The monthly survey of the medication room, dated 06/14/13 and 08/15/13 did not identify the expired Lorazepam (Ativan). In addition, the monthly survey of the medication room, dated 08/15/13, did not identify deceased Unsampled B's narcotic medications remained accessible in the refrigerator thirty-one (31) days after he/she had expired. Clinical record review of Unsampled Resident A revealed the facility admitted the resident on 06/22/10 with [DIAGNOSES REDACTED]. Clinical record review of Unsampled Resident B revealed the facility admitted the resident on 04/03/13 with [DIAGNOSES REDACTED]. The physician ordered Lorazepam (Ativan) on 07/14/13 for anxiety. Upon clinical record review, Unsampled Resident B passed away on 07/15/13, forty six (46) days prior. Interview with LPN #1 during tour of the medication room, on 08/30/13 at 7:43 AM, revealed they count the narcotics with each shift change. She reported the routine medication are returned to the pharmacy and the narcotics are given to the Director of Nursing (DON) or Assistant Director of Nursing (ADON) for disposal. She did report, once a resident was discharged , then the medication are pulled and sent back to the pharmacy or the DON was notified about the narcotics. Interview with the ADON, on 08/30/13 at 8:25 AM, revealed the expired medications were picked up by the pharmacy and the narcotics were destroyed by the ADON and the DON by putting them in an undesirable substance. She reported the consulting pharmacist did a monthly inspection report of the medication room. She reported only the narcotics are disposed of by the facility. She stated the expired medications should have been removed. She was not aware expired medications remained in the cabinet. However, the pharmacy did provide a monthly inspection report. Interview with the DON, on 08/30/13 at 8:30 AM, revealed the expired and discontinued narcotic medications are disposed of by the facility. The pharmacy did not accept the narcotics. She reported the expired medication should be removed when expired for disposal. She denied being aware the expired medication remained in the refrigerator ten (10) months past expiration and the deceased resident's medications remained in stock forty six (46) days.

Based on interview, record review and review of the facility's Abuse Investigation policy, it was determined the facility failed to ensure one (1) of the two (2) allegations of misappropriation of property was immediately reported to the Office of Inspector General (OIG) upon notice for Resident #8. The facility failed to report an allegation reported to them by Resident #8 when the resident told the facility he/she was missing twenty (20) dollars on 08/21/13 which was not reported to the OIG until the resident notified the state surveyors during a combined standard survey and an investigation for misappropriation of property on 08/30/13. The findings include: Review of the facility's policy Abuse Investigations, revised 12/2011, revealed all reports or resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by the facility management. All suspected violations and all substantiated incidents of abuse would be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. During interview, on 08/29/13 at 9:45 AM, with Resident #8 revealed he/she was missing twenty (20) dollars which was replaced by the facility. The resident also attended a Quality of Life group meeting, on 08/29/13 at 10:00 AM, and reported the missing money. The resident revealed the money came up missing between October 2012 and January 2013, but did not notify the facility until 08/22/13 during the care plan meeting. Review of the clinical record revealed the facility admitted Resident #8, on 10/02/13 with [DIAGNOSES REDACTED]. The facility assessed the resident on 08/14/13, utilizing the Minimum Data Set (MDS), Brief Interview for Mental Status (BIMS) that revealed a score of 15 indicating the resident was cognitively intact and had no behavioral or psychosocial concerns. On 08/29/13 at 12:45 PM, the Administrator reported the facility did not report the allegation to the OIG due to the elapsed time frame of the missing money. Further interview with the Administrator, on 08/29/13 at 4:18 PM, revealed the resident reported the missing money during the care plan meeting, which in turn was reported to her. The Administrator revealed it was determined the resident did have money, but they were unable to determine how much or when it disappeared due to the resident's condition at the time, and the time elapsed before it was reported. The Administrator revealed she initially did not think it was a reportable incident; however, in hindsight the Administrator felt the incident should have been reported to the OIG upon initial notification that the resident was missing money. The Administrator revealed she was aware of the requirement for reporting.