Every finding on record at Hyden Health and Rehabilitation Center

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were free from abuse for one (1) of five (5) sampled residents (Resident #1). On 05/05/2022, staff observed Resident #1 and Resident #2 kissing, and Resident #2 touching Resident #1's genitals. Although the facility placed Resident #1 on one on one (1:1) observation; there was no documented evidence the facility considered Resident #2 as the possible perpetrator or implemented interventions to prevent possible further sexual abuse to other residents by Resident #2. The findings include: Review of the facility policy titled Abuse, Neglect, Misappropriation and Exploitation Policy, revised January 2018, revealed the facility did not condone or tolerate resident abuse by anyone to include other residents. According to the policy, sexual abuse was non-consensual sexual contact of any type with a resident including disrobing and touching inappropriately. Review of the facility investigation, dated 05/05/2022 at 9:30 AM, related to a resident-to-resident incident for sexual abuse, revealed State Registered Nurse Aide (SRNA) #1 entered Resident #2's room and observed Resident #1 and Resident #2 kissing. SRNA #1 called for assistance and SRNA #2 came to assist in separating the residents. According to the investigation, as SRNA #2 approached the residents, observation revealed Resident #1's pants were unzipped, and Resident #2 was touching Resident #1's genitals. Further review revealed Resident #1 was placed on one-to-one (1:1) supervision. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 04/01/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS Assessment, revealed the facility assessed the resident to wander daily with no impact or intrusion on privacy of others. Review of Resident #1's Comprehensive Plan of Care, dated 04/20/2022, revealed the resident was an elopement risk, utilized a secure care bracelet, had periods of confusion, and was unaware of limitations/safety hazards. The goal stated the resident would remain within the safety perimeters of the nursing facility. Care plan interventions were listed including: redirect the resident as needed and offer diversional activities. Review of Resident #1's Nurse's Note, dated 05/05/2022 at 10:00 AM, completed by Registered Nurse (RN) #1, revealed during breakfast Resident #1 was found in another resident's room kissing the resident. The other resident had his/her hands in Resident #1's pants, touching Resident #1's genitals. Resident #1 was immediately removed from the room. After the incident, Resident #1 was assessed to have no injuries and a one-to-one (1:1) sitter was placed with the resident due to the resident's ability to ambulate and behaviors. According to the Note, the resident's physician and responsible party were notified of the incident with no further orders and the resident was resting quietly in the room. Further review of Resident #1's Comprehensive Plan of Care, dated 04/20/2022, revealed an intervention was added to the plan of care on 05/05/2022, for a one-to-one (1:1) sitter due to wandering and inappropriate behavior. Observation of Resident #1, conducted on 05/25/2022 at 9:40 AM, 10:47 AM, 11:59 AM and 1:45 PM; and 05/26/2022 at 10:13 AM and 1:48 PM, revealed the resident was being supervised with one-to-one (1-1) staff sitting at the resident's doorway observing the resident. There was no evidence of injuries, bruising, or other signs/symptoms of abuse observed. Attempts to interview Resident #1, on 05/25/2022 at 11:55 AM, regarding the incident and abuse concerns were not successful due to the resident's cognition. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 01/04/2007 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly MDS Assessment, dated 04/21/2022, revealed the facility assessed the resident as having a BIMS score of twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility and as totally dependent on two (2) staff for transfers. Continued review revealed the resident required a wheelchair and assistance of staff for mobility. Review of Resident #2's Comprehensive Plan of Care, dated 05/04/2022, revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal stated the resident would maintain ability to make simple care decisions and maintain manageable behavior patters through the next care plan date. Interventions included social services consults as needed, psych consults as needed, observe for changes in mental status, encourage socialization with others when appropriate, and observe for interactions with others. Review of Resident #2's Nurse's Notes, dated 05/05/2022 at 10:00 AM, completed by Registered Nurse (RN) #1, revealed Resident #2 had another resident in his/her room during breakfast at 9:30 AM. Staff observed Resident #2 and the other resident kissing and Resident #2 was observed by staff touching the other resident's genitals. Further review revealed Resident #2's Comprehensive Plan of Care, dated 05/04/2022, was updated on 05/05/2022, with documentation of the resident-to-resident sexual abuse incident as a problem. However, no new interventions or approaches were added to the plan of care in order to protect other residents from potential sexual abuse by Resident #2. Observation of Resident #2, on 05/25/2022 from 10:51 AM to 1:49 PM; and on 05/26/2022 at 10:14 AM, revealed the resident was lying-in bed with no injuries, bruising or signs of abuse observed. Interview with Resident #2, on 05/25/2022 at 10:51 AM, revealed the resident would not discuss the incident. The resident stated he/she did not know Resident #1 and had no concerns related to abuse by residents or staff and felt safe at the facility. Interview with State Registered Nurse Aide (SRNA) #2, on 05/25/2022 at 1:52 PM, revealed when she was coming out of another resident's room, she observed Resident #1 in Resident #2's room and then she saw Resident #1 kiss Resident #2. SRNA #2 stated she called for assistance from SRNA #1 and Licensed Practical Nurse (LPN) #1 who were working on the same hall, and they immediately came to help separate the residents. Further, SRNA #1 escorted Resident #1 back to his/her room. Additional interview with SRNA #2, revealed she had not seen Resident #1 wandering that morning or attempting to enter any other resident's room and she was not aware Resident #1 was in Resident #2's room. SRNA #2 stated she was not aware of any prior behaviors of Resident #2 inappropriately touching another resident. Interview with SRNA #1, on 05/25/2022 at 12:48 PM, revealed she was walking down the hallway when she was alerted by SRNA #2, that Resident #1 was in Resident #2's room and and the residents were kissing. According to SRNA #1, when she entered the room to separate the residents, Resident #1 was sitting on Resident #2's bed. She further stated Resident #2 had his/her hand in Resident #1 pants touching the resident's genitals. Further, she asked Resident #1 to come out of the room. She stated, then Resident #2 became upset and asked why Resident #1 had to leave. SRNA#1 stated she escorted Resident #1 back to his/her room and stayed with him/her until the nurse came to assess the resident. Per interview, SRNA #1 had not witnessed Resident #1 enter any other resident's room and she had never witnessed Resident #2 inappropriately touching any other resident. SRNA #1 stated Resident #1 was placed on one-to-one (1:1) supervision and was monitored after the incident and the supervision was ongoing. SRNA #1 stated the nurse talked with Resident #2, but she was unaware of any interventions put in place to prevent Resident #2 from touching other residents inappropriately. Interview with Licensed Practical Nurse (LPN) #1, on 05/25/2022 at 2:17 PM, revealed she was working at the nurse's station at the time of the incident and was not aware Resident #1 had entered Resident #2's room until SRNA #2 notified her that Resident #1 and Resident #2 were kissing. LPN #1 stated she went immediately to Resident #2's room and when she arrived SRNA #1 was escorting Resident #1 out of the room. Per interview, SRNA #1 informed LPN #1, that Resident #1 had his/her pants unbuttoned and Resident #2 was touching Resident #1's genitals. Further interview with LPN #1, revealed after the incident she noted Resident #2's clothes were intact. She stated she assessed Resident #2 and he/she voiced no complaints and no injuries were noted. She further stated she assessed Resident #1 with no concerns or injuries noted. Continued interview revealed LPN #1 alerted the Director of Nursing (DON) and the Administrator of the incident immediately. Further, she contacted both residents' families and the physician regarding the incident. Per interview, Resident #1 was placed on one-to-one supervision which was ongoing. The LPN stated she did not consider that Resident #2 could have been the perpetrator because the resident had been at the facility a long time and to her knowledge, the resident had never displayed behaviors such as inappropriately touching other residents. She stated Resident #1 was new to the facility and staff was still getting to know the resident. Interview with Registered Nurse (RN) #1, on 05/25/2022 at 4:40 PM, revealed she had documented the incident involving Resident #1 on Resident #2's in both residents' Nurse's Notes. However, she stated no interventions were implemented for Resident #2 after the incident as she did not believe Resident #2 was the perpetrator. She stated Resident #2 had no prior history of inappropriately touching other residents and she did not recognize the actions of Resident #2 toward Resident #1 as possible abuse. Interview with the Director of Nursing (DON), on 05/25/2022 at 2:55 PM, revealed she was notified of the incident involving Resident #1 and #2 by LPN #1, on 05/05/2022, immediately after it was witnessed by staff. Further, she stated she made sure the residents were separated and safe and then she and the Administrator started an investigation. Per interview, Resident #1 had not wandered into any other resident rooms; however, since Resident #1 did wander and was new to the facility, there was the potential for another incident. Therefore, Resident #1's supervision was increased to one to one (1:1) until the resident's behaviors could be further evaluated. The DON further stated she felt the safety of the other residents was addressed by placing Resident #1 on one to one (1:1) supervision. Continued interview revealed she had not considered Resident #2 could have perpetrated the contact with Resident #1 because Resident #2 did not ambulate, could not get out of bed without assistance, and had never had any prior history of inappropriately touching other residents. Interview with the Administrator, on 05/31/2022 at 1:26 PM, revealed she was at the facility at the time of the incident involving Resident #1 and Resident #2 on 05/05/2022. Per interview, she was notified of the incident by the DON and the incident was discussed with the management team. Per interview, neither resident had any previous encounters of touching residents inappropriately. Continued interview revealed the facility placed Resident #1 on one-to-one (1:1) supervision in an attempt to prevent further incidents. Per interview, the facility felt resident safety was addressed by placing Resident #1 on one to one (1:1) supervision and having the resident evaluated by the psychiatrist for this possible new behavior. Additional interview revealed there were no new interventions implemented to prevent possible further sexual abuse by Resident #2. Per interview, this was because the facility did not consider Resident #2 as the alleged perpetrator as the resident could not get out of bed independently and did not have any previous history of inappropriate sexual behaviors.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to revise the Comprehensive Plan of Care for one (1) of five sampled residents (Resident #2). On 05/05/2022, Resident #2 was involved in a resident-to-resident sexual abuse incident involving Resident #1, after Resident #1 wandered into Resident #2's room. Staff observed Resident #2 kissing Resident #1 and touching Resident #1's genitals. However, there was no documented evidence the facility revised Resident #2's Comprehensive Care Plan with interventions to address the inappropriate touching by Resident #2 in order to prevent further potential abuse by Resident #2. The findings include: Review of the facility policy titled Care Plan Policy & Protocol, revised September 2017, revealed the care plan shall be periodically reviewed and revised by the interdisciplinary team after each assessment and on an as needed basis. Further review of the policy revealed the care plan will be updated as indicated with changes in condition. Review of the facility investigation for a resident-to-resident incident for sexual abuse, dated 05/05/2022 at 9:30 AM, revealed Resident #2 was observed kissing Resident #1 and touching Resident #1's genitals after Resident #1 wandered into Resident #2's room. According to the investigation, the residents were separated, and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's clinical record revealed the facility admitted the resident on 01/04/2007 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) Assessment, dated 04/21/2022, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility and as totally dependent on two (2) staff for transfers. Additional review of the MDS Assessment, revealed the resident required a wheelchair and required assistance of staff for mobility. Per the MDS Assessment, the resident did not have limited range of motion and did not have any behaviors. Resident #2's Comprehensive Care Plan, dated 05/04/2022, revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal revealed the resident would maintain ability to make simple care decision and maintain manageable behavior patters through the next care plan date. Additional review revealed the plan of care was updated on 05/05/2022 to indicate the resident-to-resident sexual abuse incident as a problem. However, no interventions or approaches were added to the resident's plan of care to address the kissing or inappropriate touching of the genitals of another resident in order to prevent recurrence. Resident #1's clinical record revealed the facility admitted the resident on 04/01/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of the MDS Assessment, revealed the facility assessed the resident to wander daily with no impact or intrusion on privacy of others. Resident #1's Comprehensive Plan of Care, dated 04/20/2022, revealed the resident was an elopement risk, utilized a secure care bracelet, had periods of confusion, and was unaware of limitations/safety hazards. The goal revealed the resident would remain within the safety perimeters of the nursing facility. Care plan interventions included: redirect the resident as needed and offer diversional activities. Additional care plan review revealed interventions were added to the plan of care on 05/05/2022 for the resident to have a one-to-one (1:1) sitter due to wandering and inappropriate behavior. Interview with Licensed Practical Nurse (LPN #1), on 05/25/2022 at 2:17 PM, revealed she was working at the nurse's station at the time of the incident monitoring the hallway and was not aware Resident #1 had entered Resident #2's room until she was notified by State Registered Nurse Aide (SRNA) #2, that Resident #1 and Resident #2 were kissing. The LPN stated when she arrived at Resident #2's room, SRNA #1 was escorting Resident #1 out of the room. Per interview, SRNA #1 informed her Resident #1 had his/her pants unbuttoned and Resident #2 was touching Resident #1's genitals. Continued interview revealed Resident #1 was placed on one-to-one (1:1) supervision which was ongoing; however, to her knowledge there were no new interventions care planned or implemented for Resident #2. The LPN stated she had not considered that Resident #2 could have instigated the incident as the resident had been at the facility a long time and to her knowledge had never touched other residents inappropriately. Interview with Registered Nurse (RN) #1, on 05/25/2022 at 4:40 PM, revealed she was responsible for trending and tracking incidents. She stated she had documented updated Resident #2's care plan on 05/05/2022 to indicate the resident-to-resident sexual abuse incident as a problem. However, she further stated she did not revise Resident #2's care plan with any new interventions in order to prevent further sexual abuse incidents by Resident #2 because she did not believe Resident #2 was the perpetrator. She stated Resident #2 had no prior history of inappropriate touching and she did not recognize the actions of Resident #2 toward Resident #1 as possible abuse. Interview with the Care Coordinator, on 05/26/2022 at 1:53 PM, revealed she was responsible for updating resident care plans after any changes in condition or incidents. Per interview, she did not revise Resident #2's plan of care with interventions to prevent sexual abuse towards other residents after the incident involving Resident #1 and Resident #2. She stated she had not considered Resident #2 as the alleged perpetrator. Per interview, Resident #2 had been at the facility a long time and had not had any previous incidents of sexual abuse or inappropriately touching other residents. Interview with the Director of Nursing (DON), on 05/25/2022 at 2:55 PM, revealed she was notified of the incident involving Resident #1 and #2 by LPN #1 on 05/05/2022. Per interview, the facility made the required notifications and investigated the incident and placed Resident #1 on one-to-one (1:1) supervision. Further interview with the DON, revealed Resident #2 did not have any history of inappropriate touching other residents or sexual abuse and she did not consider Resident #2 as the alleged perpetrator of the incident. Therefore, she felt no additional interventions needed to be care planned for Resident #2 to prevent further potential abuse because the supervision of Resident #1 had been addressed. Per interview, she considered Resident #1 being more of a concern because the resident did wander and was new to the facility. Interview with the Administrator, on 05/31/2022 at 1:26 PM, revealed the incident involving Resident #1 and Resident #2 was discussed with the management team and Resident #1 was placed on one-to-one (1:1) supervision. Per interview, neither resident had any previous sexual encounters. Further interview revealed the facility didn't consider Resident #2 as the alleged perpetrator because the resident could not get out of bed independently and did not have any previous history of inappropriate sexual behaviors. She stated she felt resident safety was addressed by placing Resident #1 on one-to-one (1:1) supervision and having the resident evaluated by the psychiatrist for possible new behavior. Further interview with the Administrator, revealed no new interventions were added to Resident #2's plan of care because the facility felt the incident had been addressed. However, she admitted there could be the potential for another incident of sexual abuse if a resident wandered into Resident #2's room.

Based on interview, record review and review of facility policy, it was determined that the facility failed to ensure each resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza (flu) immunization for three (3) of five (5) residents (Resident #1, #2, and #3). The facility also failed to document in the resident's medical record that the education was provided. In addition, the facility policy did not include that education (related to benefits and side effects) would be provided prior to the influenza immunization being offered and that the resident's record would include documentation of the education and of the immunization being offered. The findings include: Review of facility policy titled Vaccination Policy, dated 09/2014, revealed: Flu vaccine will be administered annually to all resident unless medically contraindicated. Further review of the policy revealed If the resident refuses the pneumococcal or the flu vaccine, educate them and/or their resident representative. Document on the bottom of the Vaccination Consent Form by checking the appropriate box indicating they were fully informed of the health risks and have them sign the form. Record review revealed the facility admitted Resident #1 on 04/12/11, with [DIAGNOSES REDACTED]. Further review of the resident record revealed the resident's responsible party signed Vaccination Policy on 04/12/11. The facility Vaccination Record revealed the resident had received the Flu vaccine on 10/16/2019, and 10/07/2020. However, the resident's record contained no evidence the resident or the resident's representative was provided education regarding the benefits and potential side effects of the influenza (flu) immunization. Record review revealed the facility admitted Resident #2 on 08/24/2018, with [DIAGNOSES REDACTED]. Further review of the resident record revealed the resident had signed consent to receive flu consent on 04/26/2019. The facility Vaccination Record revealed the resident had received the Flu vaccine on 10/07/2020. However, the resident's record contained no evidence the resident or the resident's representative was provided education regarding the benefits and potential side effects of the influenza (flu) immunization. Record review revealed the facility admitted Resident #3 on 05/05/2015, with [DIAGNOSES REDACTED]. Further review of the resident record revealed the resident had signed but not dated, consent to receive Flu vaccine. The facility Vaccination Record revealed the resident had received the Flu vaccine dated 10/16/2019, and 10/07/2020. However, the resident's record contained no evidence the resident or the resident's representative was provided education regarding the benefits and potential side effects of the influenza (flu) immunization. Interview on 11/30/2020 at 4:26 PM, with the Director of Nursing revealed the facility had the resident or responsible party sign the Vaccine Consent Form upon admission. If the resident refused either the pneumococcal or flu vaccine, they will sign the bottom of the form. The Director of Nursing stated that the vaccine is then offered annually, after verbal consent. She further stated all residents, unless contraindicated, are offered the vaccine every year and if the resident refuses there is a note put in the nursing notes. Further interview with the Director of Nursing revealed the facility was unaware that education needed to be provided and documented annually when offering the immunization.

Based on observation, interview, record review, and facility policy review it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for three (3) of twenty-two (22) sampled residents (Resident #13, Resident #52, and Resident #59). Resident #13 and Resident #52 had [DIAGNOSES REDACTED]. In addition, the facility failed to develop an individualized care plan for Resident #59 related to activity interventions. The findings include: Review of the facility policy titled Care Plan Policy and Protocol, with a revision date of (MONTH) (YEAR), revealed the facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs that were identified in the resident's comprehensive assessment. 1. Review of the record for Resident #59 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 99, indicating the resident was not able to complete the interview. Further review of the assessment revealed the resident was rarely/never understood and therefore could not be interviewed related to daily and activity preferences. Reveiw of the staff assessment of daily and activity preferences revealed that none of the above was marked for the resident's preferences. Review of the Care Area Assessment (CAA) summary dated 03/14/19 revealed the resident triggered due to not participating in activities. The CAA summary further stated that the resident likes to stay to him/herself and does not like crowds. The summary stated that the resident is encouraged to participate in facility activities and staff talks with the resident and he/she will allow. The CAA summary stated proceed to care plan for this area. Review of the comprehensive care plan dated 03/15/19 revealed no evidence of a care plan for activities for Resident #59. Observation of Resident #59 on 07/30/19 at 4:00 PM revealed the resident ambulated independently in the hallway from his/her room. Staff approached the resident, took the resident by the hand, and walked with the resident back to his/her room. On 07/31/19 at 10:01 AM, Resident #59 ambulated from his/her room to the nurses' station and then back to the resident's room. The resident sat down on the bed. The resident was unable to answer when asked what is your name? At 10:46 AM on 07/31/19, the resident was noted to be sitting on the side of the bed, looking out the window. There was no television or radio in the resident's room. On 08/01/19 at 11:36 AM the resident was observed sitting on the bed, looking out the window. There was no television or radio noted in the room. Observation on 08/01/19 at 2:53 PM revealed Resident #59 was sitting in his/her room on the side of the bed, looking out the window. Interview with the Activities Director on 08/01/19 at 1:24 PM revealed that she does 1:1 activities with Resident #59 a few times per week because the resident does not do well with crowds or group activities. The Activities Director further stated that the facility's Interdisciplinary Team (IDT) meets quarterly and she tells the team the activities that she is providing for the resident and the resident's response. She stated the IDT discusses the resident's care and care plan; however, the resident did not have a written plan of activities and she does not develop the care plan for activities. Interview on 08/01/19 at 3:26 PM with the MDS Coordinator revealed that she was told that the Activities Department developed the activity plan and that a care plan for activities was not mandatory so therefore they did not develop a care plan for Resident #59. Interview with the Director of Nursing (DON) on 08/01/19 at 5:07 PM revealed there had been a misunderstanding regarding activities care plans. The DON stated that if a resident triggers for a care plan from the MDS assessment, then a care plan should be developed. She stated she was unsure why the care plan had not been developed, but it should have been. 2. Review of Resident #13's medical record revealed the facility admitted the resident on 07/17/15 with [DIAGNOSES REDACTED]. Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired, with no speech, rarely/never understood, and rarely/never understands. Section G of the MDS revealed the resident was totally dependent on staff for all Activities of Daily living (ADLs) and required assistance of two (2) persons with bed mobility. Section I (Active Diagnoses) of the MDS revealed the resident was marked for [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION]. Further review of the resident's record Kardex (care plan used by nursing assistants to care for residents) revealed the resident had been assessed to require total assistance with all ADLs and the Kardex was flagged with stickers indicating the resident was HIGH FALL RISK and [MEDICAL CONDITION] DISORDER. Review of Resident #13's Fall Risk Evaluation, (a tool to score how much the resident is at risk of falling) dated 04/22/19, revealed the resident scored 12. The instructions for the Fall Risk Evaluation revealed a total score of 10 or greater indicated that the resident should be considered at HIGH RISK for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. Review of Resident #13's care plan dated 05/13/19 revealed he/she was care planned for potential for falls related to [DIAGNOSES REDACTED]. Further review of the resident's care plan revealed he/she was care planned for [MEDICAL CONDITION] disorder with interventions to administer medications as ordered, note the length of the [MEDICAL CONDITION], notify the MD with any changes, observe for signs and symptoms of impending [MEDICAL CONDITION], obtain labs, obtain vital signs, and prevent injury during [MEDICAL CONDITION] activity. There were no interventions regarding safety precautions prior to [MEDICAL CONDITION]. 3. Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #52's MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, non-verbal, totally dependent on staff for all Activities of Daily living, and required assistance of two persons with bed mobility. In addition the MDS revealed the resident had an active [DIAGNOSES REDACTED]. Interviews on 08/01/19 at 2:56 PM with the Clinical Coordinator and at 3:26 PM with the MDS Care Coordinator revealed any resident at risk for falls should have interventions in place to ensure the resident's bed was kept in the low position. However, the intervention had not been placed on Resident #52's care plan. In addition the staff stated any resident who had a [DIAGNOSES REDACTED]. However, safety interventions had not been added to Resident #52's care plan. Interview on 08/01/19 at 5:08 PM with the Director of Nursing (DON) revealed Resident #52 should have interventions listed on the care plan related to bed positioning and a [DIAGNOSES REDACTED].

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within fourteen (14) days after completion for two (2) unsampled residents (Resident #1 and Resident #191). Review of Resident #1's MDS assessments revealed the facility had completed an annual MDS assessment with a completion date of 07/08/19 for Resident #1. Review of a validation report revealed the assessment was not transmitted until 07/30/19, which was eight (8) days late. Review of Resident #191's MDS assessments revealed a re-entry MDS assessment with a completion date of 07/12/19. Review of a validation report revealed the assessment was not transmitted until 07/30/19, which was four (4) days late. The findings include: Review of the facility's policy, Electronic Transmission of the MDS, dated (MONTH) (YEAR), revealed all MDS assessments would be completed and electronically transmitted in accordance with the current OBRA regulations governing the transmission of MDS data. Review of the RAI 3.0 User's Manual, Version 1.16, dated (MONTH) (YEAR), Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Entry and Death in Facility tracking records information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). Review of the CMS Submission Report, MDS 3.0 NH Final Validation Report, dated 07/30/19, revealed the facility received a warning error message -3810c, record submitted late, submission date was more than 14 days after V0200C2 on this new (A0050 equals 1) comprehensive assessment (A0310A equals 01, 03, 04, or 05) for Resident #1. The facility received a warning error message -3810a, record submitted late, submission date was more than 14 days after A1600 on this new (A0050 equals 1) entry tracking record for Resident #191. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 05/20/15, with [DIAGNOSES REDACTED]. Review of Resident #1's annual MDS completed by the facility on 07/08/19 revealed the assessment had not been transmitted until 07/30/19 (eight days late). 2. Review of Resident #191's medical record revealed the facility admitted the resident on 12/06/16, with [DIAGNOSES REDACTED]. Review of a re-entry MDS assessment completed by the facility on 07/12/19 revealed the assessment had not been transmitted until 07/30/19 (four days late). Interview conducted with the MDS Coordinator on 08/01/19 at 4:21 PM, revealed the MDS had not been transmitted. The MDS Coordinator stated the assessment was required to be transmitted within fourteen (14) days, but it had been missed. Interview with the Director of Nursing (DON) on 08/01/19 at 4:51 PM, revealed the MDS Coordinator was responsible for ensuring MDS assessments were transmitted timely. The DON stated Resident #1's and Resident #191's assessments had been missed. The DON stated she randomly reviewed MDS assessments to ensure accuracy and timely transmission and had not identified any previous concerns with MDS assessments not being transmitted timely.

Based on observation, interview, record review, and facility policy review it was determined that the facility failed to ensure an ongoing program of activities was developed to meet the needs of one (1) of twenty-two (22) sampled residents (Resident #59). Observations on 07/30/19, 07/31/19, and 08/01/19 revealed Resident #59 was either in his/her room or in the hallway and not involved in any activities. Review of the medical record revealed no care plan for the resident to receive any type of activities and interview with the Activities Director revealed there was no written plan for activities for Resident #59. The findings include: Review of the facility policy titled Protocol for Activity Program, revised (MONTH) 2019, revealed the purpose of the policy was to ensure that there will be an ongoing program of activities to meet the interests and the physicial, mental, and psychosocial well-being of each resident. Review of the record for Resident #59 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 99, indicating the resident was not able to complete the interview. Further review of the assessment revealed the resident was rarely/never understood and therefore could not be interviewed related to daily and activity preferences. Reveiw of the staff assessment of daily and activity preferences revealed that none of the above was marked for the resident's preferences. Review of the Care Area Assessment (CAA) summary dated 03/14/19 revealed that the resident likes to stay to him/herself and does not like crowds. The summary stated that the resident is encouraged to participate in facility activities and staff talks with the resident and he/she will allow. Review of the comprehensive care plan dated 03/15/19 revealed no evidence of a care plan for activities for Resident #59. Review of the Kardex for Resident #59 revealed the resident enjoys country music, Bingo, sitting on the front porch, outings, and watching TV. Observation of Resident #59 on 07/30/19 at 4:00 PM revealed the resident ambulated independently in the hallway from his/her room. Staff approached the resident, took the resident by the hand, and walked with the resident back to his/her room. On 07/31/19 at 10:01 AM, Resident #59 ambulated from his/her room to the nurses' station and then back to the resident's room. The resident sat down on the bed. The resident was unable to answer when asked what is your name? At 10:46 AM on 07/31/19, the resident was noted to be sitting on the side of the bed, looking out the window. There was no television or radio in the resident's room. On 08/01/19 at 11:36 AM the resident was observed sitting on the bed, looking out the window. There was no television or radio noted in the room. Review of the (MONTH) Activity Participation Record for (MONTH) 2019 for Resident #59 revealed the only activity documented for Resident #59 for the month of (MONTH) was talking or conversing. The documentation did not include how long the activity lasted. The record did have a place to document the resident response to the acitivity, and an e was noted by each entry. Interview with State Registered Nursing Assistant (SRNA) #4 on 08/01/19 at 11:42 AM revealed that she was assigned to care for Resident #59 on 08/01/19. The SRNA stated that the resident had [MEDICATION NAME] in his/her drawer and he/she would color sometimes for an activity. She further stated if talking or conversing was marked as an activity, then they would have had a conversation with the resident. SRNA #4 further stated that the e documented on the participation record indicated that the resident enjoyed the activity, but was unable to explain how they determined if the resident enjoyed the activity. Review of the Activity Log for 1:1 Activities for (MONTH) 2019 revealed that 1:1 activities had been provided for Resident #59 thirteen (13) times during the month of July, on 07/01/19, 07/03/19, 07/05/19, 07/08/19, 07/10/19, 07/12/19, 07/15/19, 07/17/19, 07/22/19, 07/24/19, 07/29/19, 07/29/19, and 07/31/19. The activities provided were documented as lotion therapy, walked around the nurses station, music therapy, relaxing music, magazine, looked at pictures, tactile, walked and looked out window, water beads/warm, colored/conversed about weather, and folded towels. The activity log did not include how long the activity took place, but did include the resident's response to the activity which ranged from resident relaxed to resident was hard to focus. Interview with the Activities Director on 08/01/19 at 1:24 PM revealed that she does 1:1 activities with Resident #59 a few times per week because the resident does not do well with crowds or group activities. She stated that she tries different things with the resident to ensure the resident is relaxed and enjoying the activity. She stated that the resident used to have a television in his/her room, but a few months ago (she could not remember the exact date) the resident seemed to become agitated with the television and it was removed from his/her room. The Activities Director further stated that the facility's Interdisciplinary Team (IDT) meets quarterly and she tells the team the activities that she is providing for the resident and the resident's response. She stated the resident did not have a written plan of activities.

Based on observation, interview, record review, and policy review it was determined that the facility failed to ensure that the environment remained as free as possible from accident hazards related to a [DIAGNOSES REDACTED].#13 and Resident #52). There was no evidence the facility had developed a care plan with specific interventions to ensure resident safety related to the residents' [MEDICAL CONDITION] disorder. Observations during the survey revealed the residents' beds were left at above waist height position. The findings include: Interview with the Director of Nursing (DON) on 08/01/19 at 5:08 PM revealed the facility had a policy titled Giving Female Perineal Care and a policy titled Turning and positioning the person (no development or revised date on either). The DON stated both policies stated that after care was rendered to Lower the bed to its lowest position. 1. Review of Resident #13's medical record revealed the facility admitted the resident on 07/17/15 with [DIAGNOSES REDACTED]. Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired, with no speech, rarely/never understood, and rarely/never understands. Section G of the MDS revealed the resident was totally dependent on staff for all Activities of Daily Living (ADLs) and required two (2) staff persons to assist with bed mobility. Section I (Active Diagnoses) of the MDS revealed the resident was marked for [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION]. Further review of the resident's record Kardex (care plan used by nursing assistants to care for residents) revealed the resident had been assessed to require total assistance with all ADLs and the Kardex was flagged with stickers indicating the resident was HIGH FALL RISK and [MEDICAL CONDITION] DISORDER. Review of Resident #13's Fall Risk Evaluation, (a tool to score how much the resident is at risk of falling) dated 04/22/19, revealed the resident scored 12. The instructions for the Fall Risk Evaluation revealed a total score of 10 or greater indicated that the resident should be considered at HIGH RISK for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. Review of Resident #13's care plan dated 05/13/19 revealed he/she was care planned for potential for falls related to [DIAGNOSES REDACTED]. There were no interventions on the care plan related to bed position. Further review of the resident's care plan revealed he/she was care planned for [MEDICAL CONDITION] disorder with interventions to administer medications as ordered, note the length of the [MEDICAL CONDITION], notify the MD with any changes, observe for signs and symptoms of impending [MEDICAL CONDITION], obtain labs, obtain vital signs, and prevent injury during [MEDICAL CONDITION] activity. There were no interventions regarding safety precautions to prevent injury in case of a [MEDICAL CONDITION]. Observation of Resident #13 on 07/30/19 at 11:37 AM revealed the resident in bed with eyes closed. Further observation revealed the bed was in a high position and there were no side rails on the bed. Observation of Resident #13 on 07/31/19 at 12:51 during [MEDICAL CONDITION] care revealed the resident's bed was in a high position. After staff completed the [MEDICAL CONDITION] care, the bed was left in the same position. Observation of Resident #13 on 07/31/19 at 3:16 PM revealed the bed was in a high position. Observation of Resident #13 on 08/01/19 at 10:37 AM revealed the bed was in a high position. 2. Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #52's MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, with no speech, rarely/never understood, and rarely/never understands. Section G of the MDS revealed the resident was totally dependent on staff for all Activities of Daily Living and required assistance of two persons with bed mobility. Section I (Active Diagnoses) of the MDS revealed the resident was marked for [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION]. Further review of the resident's record Kardex revealed the resident had been assessed to require total assistance with all ADLs and the Kardex was flagged with stickers indicating the resident was HIGH FALL RISK and [MEDICAL CONDITION] DISORDER. Review of Resident #52's Fall Risk Evaluation, dated 06/03/19, revealed the resident scored 12. The instructions for the Fall Risk Evaluation revealed a total score of 10 or greater indicated that the resident should be considered at HIGH RISK for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. Review of Resident #52's care plan, review date of 06/14/19, revealed they he/she was care planned for potential for falls related to [DIAGNOSES REDACTED]. Further review of the resident's care plan revealed interventions related to the resident's [MEDICAL CONDITION] disorder that included administer medications as ordered, hold tube feeding for one hour before and after administration of [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]), note the length of the [MEDICAL CONDITION], notify the MD with any changes, observe for signs and symptoms of impending [MEDICAL CONDITION], obtain labs, obtain vital signs, and prevent injury during [MEDICAL CONDITION] activity. The care plan did not include specific safety interventions to ensure the resident's safety or prevent injuries during the [MEDICAL CONDITION]. Observation of Resident #52 on 07/30/19 at 11:37 AM revealed the resident was in bed with eyes closed. The bed was noted in a high position with no side rails. Observation of Resident #52 on 07/31/19 at 1:31 PM revealed the resident was in bed with his/her eyes closed and the bed was in a high position. Observation of Resident #52 on 08/01/19 at 10:15 AM revealed the resident was in bed with his/her eyes closed and the bed was in a high position. Interview on 08/01/19 at 10:30 AM with Stated Registered Nursing Assistants (SRNAs) #5 and #6 revealed that Residents #13 and #52 require the total assistance of two (2) staff members. Both SRNAs agreed that they were not aware of either resident having a fall and both agreed that the usual position for both residents' beds was at a higher position. Interview on 08/01/19 at 2:56 PM with the Clinical Coordinator revealed she updated the care plan and Kardex as needed. She stated that any resident with [MEDICAL CONDITION] would be considered at higher risk for falls. The Coordinator agreed that any resident at risk for falls should have the bed lowered after care. The Coordinator stated she does rounds daily and had not noticed a problem with beds being in a high position. Interview on 08/01/19 at 3:26 PM with the MDS Care Coordinator revealed the resident should be care planned for safety concerns if they have a [DIAGNOSES REDACTED]. Interview on 08/01/19 at 5:08 PM with the DON revealed the residents should not have been in beds raised at that height and stated, I can see that would be a problem. The DON agreed there should have been a care plan regarding safety with residents with [MEDICAL CONDITION] activity being in a high bed. She stated that she does daily rounds and never had a concern with beds being in a high position.

Based on observation, interview, record review, and review of the facility policy, it was determined that the facility failed to maintain an effective infection control and prevention program for one (1) of twenty-two (22) sampled residents (Resident #77). Observation of Resident #77 on 07/31/19 during care revealed that State Registered Nurse Aide (SRNA) #1 failed to wash/sanitize her hands after removing the resident's soiled breif and before applying a clean brief. The findings include: Review of the facility's Guidelines For Hand Hygiene policy, undated, revealed that hands should be decontaminated before having direct contact with residents, after contact with body fluids or excretions, and if moving from a contaminated body site to a clean body site during care. Review of Resident #77's medical record revealed the facility admitted the resident on 12/22/18, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #77 was incontinent of bowel and bladder and required the assistance of one (1) person for care. Observation of Resident #77 on 07/31/19 at 9:24 AM, revealed SRNA #1 was providing care and perineal incontinence care to the resident. Upon entering the room, SRNA #1 did not wash or decontaminate her hands before starting care (vital signs). SRNA #1 then proceeded to remove a soiled brief, perform perineal care, and apply a clean brief without changing the contaminated gloves and/or washing her hands. An interview with SRNA #1 on 07/23/19 at 9:24 AM revealed that SRNA #1 did know that she should have changed gloves after removing the soiled bried and cleaning the resident but said she forgot. SRNA #1 revealed that they have in-services on Mondays and Fridays and that the last hand washing in-service was on Monday. An interview with the Clinical Coordinator on 08/01/19 at 11:00 AM revealed that education concerning perineal incontinence care and hand washing is provided upon hire, quarterly, annually, as needed, and during monthly in-services. She had no concerns prior to this incident. An interview with the Director of Nursing (DON) on 08/01/19 at 2:30 PM revealed that education concerning perineal incontinence care and hand washing is provided upon hire, annually, during regular in-services, and during random spot checks. The DON also revealed that SRNA #1 did not follow the policy and procedures concerning perineal incontinence care and hand washing. An interview with the Infection Control Nurse on 08/01/19 at 3:00 PM revealed that SRNA #1 did not follow policy and procedures for perineal incontinence care and hand washing. She revealed that staff are trained upon hire, quarterly, annually, during monthly in-services, and as needed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to address monitoring and supervising bed rail usage for six (6) of twenty-five (25) residents (Resident #189, #82, #56, #33, #16, and #18). The findings include: Review of the facility's policy titled, Care Plan Policy & Protocol, revised (MONTH) (YEAR), revealed the facility would develop a comprehensive care plan for each resident within seven (7) days after the completion of the comprehensive assessment which would include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. The policy further stated the Kardex would also be utilized as a guide for Nurse Aides in providing care on a daily basis. As part of the care plan, the Kardex would reflect person-centered care preferences. 1. Review of a closed record for Resident #189 revealed the facility admitted the resident on 10/24/14. The resident's [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to complete the interview. Further review of the MDS revealed the resident required extensive assistance of two (2) staff members for bed mobility. The resident was also assessed to have limitation in range of motion to both lower extremities. The MDS indicated the resident did not use any type of restraint. Review of a RESTRAINT/BED RAIL USE ASSESSMENT FORM signed as completed on 10/24/14 revealed the resident utilized bed rails that enabled the resident to participate in activities of daily living. Review of Resident #189's plan of care revealed the facility identified that the resident had the potential for falls/injury and developed an intervention of Bilateral ½ side rails in use to aid with bed mobility. However, the plan of care did not direct staff how often to monitor the resident's bed rail use or direct the frequency of supervision of the resident using bed rails. 2. Review of the medical record for Resident #82 revealed the facility admitted the resident on 11/20/13, with [DIAGNOSES REDACTED]. Review of a Restraint/Bed Rail Consent Form, dated 11/20/13, revealed the facility assessed Resident #82 to require bilateral half bed rails to assist with the resident's turning and repositioning. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #82 to have a BIMS score of three (3), which indicated the resident had severely impaired cognition and was therefore not interviewable. The MDS also revealed the resident did not require the use of any restraints. Review of Resident #82's comprehensive care plan dated 03/05/18 and a review of the resident's Kardex (document that lists the care the resident requires) revealed the facility developed an intervention for the resident to continue to have half bed rails to aid with bed mobility. However, there was no evidence the facility developed interventions to monitor/supervise the resident's bed rail usage. 3. Review of the medical record for Resident #56 revealed the facility admitted the resident on 12/17/17 with [DIAGNOSES REDACTED]. Observation of Resident #56 on 05/07/18 at 6:25 PM revealed the resident was in bed positioned on his/her right side, with a half bed rail on each side of the bed. Review of the significant change MDS dated [DATE] for Resident #56 revealed the facility assessed the resident to have a BIMS score of four (4), which indicated the resident had impaired cognition and was not interviewable. The assessment also revealed the resident did not require the use of any restraints. Review of the Quarterly Physical Restraint Elimination Device Use Assessment form dated 03/23/18 for Resident #56 revealed the facility assessed the resident to require bilateral half bed rails to assist with turning and repositioning. Review of Resident #56's comprehensive care plan dated 04/03/18 revealed the facility also developed an intervention for the resident to have half bed rails to aid with bed mobility. However, there was no evidence the facility developed interventions to monitor and supervise the resident's bed rail usage and no evidence monitoring/supervision was being provided. 4. Review of the medical record for Resident #33 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #33 on 05/09/18 at 9:12 AM and on 05/10/18 at 9:27 AM revealed the resident's bed had half bed rails. Further review of Resident #33's medical record revealed the facility completed a Quarterly Physical Restraint Elimination/Device Use Assessment on 03/08/18, which stated the resident continued to require bed rails to assist in bed mobility. Review of the Annual MDS assessment dated [DATE] revealed Resident #33 was assessed to have a BIMS score of fifteen (15), indicating the resident was cognitively intact and interviewable. The MDS further revealed the resident did not utilize a physical restraint. Review of Resident #33's Comprehensive Care Plan dated 03/13/18 revealed the facility developed an intervention for the resident to utilize half bed rails to aid with bed mobility. However, there was no evidence the facility developed a care plan with interventions to monitor and supervise the resident's bed rail usage. 5. Review of the medical record for Resident #16 revealed the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of Resident #16 on 05/08/18 at 10:17 AM and on 05/10/18 at 10:09 AM revealed half bed rails were raised and in use by the resident. Review of a Quarterly Physical Restraint Elimination/Device Use Assessment completed for Resident #16 on 02/09/18 revealed the resident utilized bed rails to aid with bed mobility. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #16 was assessed to have a BIMS score of fifteen (15), indicating the resident was mentally cognitive and therefore interviewable. The MDS assessment further revealed the resident did not utilize a physical restraint. Review of Resident #16's Comprehensive Care Plan revealed the facility developed a care plan dated 08/14/17 with an intervention to utilize for the use of bed rails for turning and repositioning. However, there was no evidence the facility developed interventions for monitoring and supervision of the bed rails. 6. Review of the medical record for Resident #18 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #18 on 05/07/18 at 6:45 PM and on 05/10/18 at 9:24 AM revealed the resident's bed rails were down bilaterally and not in use. However, further review of the medical record revealed the facility completed a Restraint/Bed Rail Use Assessment Form on 11/05/17, which stated Resident #18 required bed rails as an enabler to aid in weakness and bed mobility. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #18 was unable to complete a BIMS score, and was not interviewable. Review of Resident #18's Comprehensive Care Plan revealed the facility developed a care plan on 11/15/17, with an intervention for the resident to utilize bilateral half bed rails to aid with bed mobility as an intervention. Further review of the Comprehensive Care Plan revealed no evidence the facility developed interventions for monitoring and supervision of the bed rails. Interview with Registered Nurse #1 on 05/10/18 at 6:45 PM revealed the Admission Assessment Packet for residents includes a Bed Rail Assessment Form. RN #1 revealed she was responsible upon admission of a resident to assess the resident to determine if the resident is a candidate for bed rails. RN #1 further stated she did not develop a Comprehensive Care Plan Focus and/or Intervention specifically for monitoring/supervising residents' bed rail usage. However, RN #1 stated she should have developed interventions regarding the monitoring and supervision of bed rails. Interview with Licensed Practical Nurse (LPN) #1 on 05/02/18 at 4:10 PM revealed staff did not document any specific monitoring on bed rail use. Interview with the Registered Nurse (RN) #2, the Clinical Coordinator/MDS Coordinator, on 05/02/18 at 2:45 PM, revealed staff did not document monitoring or supervision of the bed rail use. Interview with the Director of Nursing (DON) on 05/10/18 at 7:10 PM revealed she randomly monitored Comprehensive Care Plans and stated staff should monitor and supervise residents with bed rails daily and record in the resident's medical record. However, the DON stated the facility did not develop residents' Comprehensive Care Plans with interventions regarding monitoring and supervising bed rail usage.

Based on observation, interview, record review, and review of the facility's bed rail policy, it was determined the facility failed to ensure alternatives to bed rails were attempted, risks and benefits of bed rails were reviewed with the resident/responsible party, and consent was obtained prior to installation of bed rails, and/or failed to provide specific direct monitoring and supervision for six (6) of twenty-five (25) residents who utilized bed rails (Residents #189, #82, #56, #33, #16, and #18). The findings include: Review of the facility's policy titled Proper Use Of Bed Rails, revised (MONTH) 2010, revealed bed rails could be used to restrain residents or to assist in mobility and transfer of residents. The policy stated the resident/Responsible Party would be consulted on the appropriateness of the bedrail use, the risks and benefits of the use of bed rails would be discussed, and a consent form would be signed. In addition, the use of bed rails must be addressed in the resident's care plan. The policy also revealed the resident would be observed frequently for safety. 1. Review of a closed record for Resident #189 revealed the facility admitted the resident on 10/24/14. The resident's [DIAGNOSES REDACTED]. The resident was listed as having a history of falls and a [MEDICAL CONDITION] Infarction. A letter in the resident's record dated 12/09/14 revealed a state guardian had been appointed for Resident #189. The resident was discharged from the facility in (MONTH) (YEAR) and was no longer a resident of the facility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 99, which indicated the resident was unable to complete the interview. Further review of the MDS revealed the resident required extensive assistance of two (2) staff members for bed mobility. The resident was also assessed to have limitations in range of motion to both lower extremities. The MDS indicated the resident did not use any type of restraint. Review of a RESTRAINT/BED RAIL USE ASSESSMENT FORM signed as completed on 10/24/14 revealed increased weakness and [MEDICAL CONDITION] were listed as the specific medical symptoms that required the use of the restraint/bed rail. The form indicated the use of the bed rail promoted self-mobility while in bed and provided safe bed parameters. The facility indicated on the form that the bed rails enabled the resident to participate in activities of daily living. The assessment did not include an evaluation of the alternatives to the use of bed rails that were attempted or how those alternatives failed to meet the resident's needs. Review of the additional information received on 05/03/18 revealed a Statement of Acknowledgement form with no date. The form had the resident's initials by the area of the form for the resident signature and was signed by the former Admission Clerk. The form listed that the resident had been given an admission packet which included: 1. Description of all available services . 12. General information . The form did not specifically list bed rails. A form titled CONSENT AND AUTHORIZATION was also provided on 05/03/18 which was signed by the resident and dated 11/21/14. This form listed that Side (bed) rails may be placed on my bed and raised for my protection. There was also a Guide to Safety form provided which was not signed or dated and this form included the risks and benefits of bed rail use. There was no evidence that the Consent and Authorization form signed by the resident contained the risks and benefits of bed rail use or a statement that this information was reviewed with the resident. Further review of the additional information provided revealed no consent form for bed rail use signed by the resident's guardian. An interview with the former Admission Clerk was conducted on 05/03/18 at 4:37 PM. The clerk stated she no longer worked at the facility. Per the clerk, residents/families/responsible parties were provided with an admission packet upon admission to the facility. The Admission Clerk stated she did not remember the specific information she gave the resident or families, but thought the packet contained information on bed rails. The Clerk stated she did not remember the risks, but thought the benefit was keeping the resident from getting hurt. Interview with the resident's guardian on 05/07/18 at 2:30 PM revealed she did not recall the facility going over the risks of bed rail use for Resident #189 or signing consent for the use of bed rails. The guardian stated the resident was appointed an emergency guardian on 12/09/14. According to the letter in the resident's record, the state guardian interviewed was the same guardian appointed on 12/09/14. Further review of Resident #189's medical record revealed no documented evidence that facility staff monitored and supervised the use of bed rails for this resident. The resident's plan of care for potential for falls/injury had an intervention of Bilateral ½ side rails in use to aid with bed mobility. The plan of care did not direct staff on how often to monitor the resident's bed rail use or direct the frequency of supervision of the resident using bed rails. Interview with Licensed Practical Nurse (LPN) #1 on 05/02/18 at 4:10 PM revealed staff did not document any specific monitoring regarding bed rail use. Interview with Registered Nurse (RN) #2, the Clinical Coordinator/MDS Coordinator, on 05/02/18 at 2:45 PM revealed staff did not document monitoring or supervision of bed rail usage. Interview with RN #1, the Medicare Coordinator/Infection Control Nurse, on 05/02/18 at 12:20 PM and 2:30 PM revealed she had recently changed positions and was the nurse who completed MDS assessments and tracked incidents until her recent change in position. RN #1 stated she had completed bed rail assessments during the MDS process and the assessments were completed with an admission, annual, significant change, or quarterly MDS. When asked if bed rails were sometimes discontinued after an assessment of the bed rails, RN #1 stated that if a resident experienced a fall while utilizing bed rails, then staff might consider discontinuing the use of the bed rails. The RN stated if staff thought the bed rails were a problem, then they would be removed/not used. Interviews were conducted with the Director of Nursing (DON) on 05/01/18 at 2:50 PM, and 05/02/18 at 12:10 PM and 4:50 PM. Initially the DON stated that if bed rails were not considered a restraint, risks and benefits were not reviewed and a consent for use was not obtained from the resident or responsible party. The DON stated Resident #189 liked to have bed rails and would get upset if staff did not raise them after providing care. In a later interview, the DON stated that staff do review risks and benefits of bed rail use with residents/responsible parties upon admission and quarterly. The DON stated that the facility started using a new bed rail assessment form in (MONTH) (YEAR) which listed the assessment of risks verses benefits. The DON further stated that Resident #189 had a behavior of leaning over the bed rails to spit. According to the DON, staff did not document that resident bed rail usage was monitored or supervised; however, staff made rounds several times per day and observed residents for any problems. Interview with Resident #189's attending physician on 05/01/18 at 3:55 PM revealed the physician had cared for Resident #189 for several years. The physician stated that the resident routinely utilized the bed rails to move about in bed. Per the physician, the benefits of bed rail usage for this resident outweighed the risks, as it permitted the resident to be mobile while in bed. Interview with the Administrator on 05/01/18 at 2:50 PM and 05/02/18 at 4:50 PM revealed the facility assessed every bed with bed rails prior to use and Maintenance completed a risk of entrapment evaluation of every bed when the bed was received, with any mattress change, and bi-annually. The Administrator asked the Maintenance Director to demonstrate the evaluation of the bed for entrapment risks. The Administrator stated Resident #189 had a mattress change in (MONTH) (she believed on 03/13/18). Per the Administrator, the facility did not keep track of the bed each resident was using. She stated the beds were numbered, but the facility did not monitor which bed a resident utilized. Review of the Bed System/Maintenance Log revealed documentation of a bed assessment after the change in mattress for two (2) beds on 03/13/18. However, further review of Resident #189's medical record revealed no assessment of Resident #189 related to bed rail use after the mattress change. 2. Review of the medical record for Resident #82 revealed the facility admitted the resident on 11/20/13, with [DIAGNOSES REDACTED]. Observation of Resident #82 on 05/07/18 at 6:55 PM, revealed the resident was in bed on his/her back with bilateral half bed rails on both sides of the bed. Review of a Restraint/Bed Rail Consent Form signed by Resident #82 on 11/20/13, revealed the resident had been assessed to require bilateral half bed rails to assist with the resident's turning and repositioning. The benefits of the bed rails were to enable bed mobility, better positioning, assist with transfer in and out of bed, and to enable the resident to feel secure by setting bed parameters. The facility listed the risks as being skin tears or abrasions. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severely impaired cognition and was not interviewable. The MDS also revealed the resident required total assistance of two (2) persons for bed mobility and for turning and repositioning. Further review of the MDS revealed the resident had not sustained any falls since the previous assessment and did not require the use of any restraints. Review of Resident #82's comprehensive care plan dated 03/05/18, revealed the resident continued to require half bed rails in use to aid with bed mobility. However, there was no documented evidence facility staff were monitoring and supervising the resident's use of bed rails. 3. Review of the medical record for Resident #56 revealed the facility admitted the resident on 12/17/17, with [DIAGNOSES REDACTED]. Observation of Resident #56 on 05/07/18 at 6:25 PM revealed the resident was in bed, positioned on his/her right side, and half bed rails (rails on the upper portion of the bed) were on both sides of the bed. Review of Resident #56's significant change Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident had impaired cognition and was not interviewable. The facility also assessed the resident to require the extensive assistance of two (2) persons for bed mobility and for turning and repositioning. According to the MDS, the resident had not sustained any falls since the previous assessment and did not require the use of any restraints. Review of the Quarterly Physical Restraint Elimination/Device Use Assessment form dated 03/23/18 revealed the facility assessed Resident #56 to require bilateral half bed rails to assist the resident with turning and repositioning. The form revealed the benefits of the bed rails were to provide safe bed parameters and to assist with turning and repositioning. Review of Resident #56's comprehensive care plan dated 04/03/18 also revealed an intervention for the resident to have half bed rails to aid with bed mobility. However, further review of Resident #56's medical record revealed no documentation that indicated the facility was monitoring and supervising the resident's use of bed rails. 4. Observation of Resident #33 on 05/09/18 at 9:12 AM and 05/10/18 at 9:27 AM revealed the resident's bed had a half bed rail on both sides of the resident's bed. Review of the medical record for Resident #33 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed the facility completed a Restraint/Bed Rail Use Assessment Form upon admission on 02/23/17. The form indicated the resident used bed rails as an enabler to aid in bed mobility. The facility completed a Quarterly Physical Restraint Elimination/Device Use Assessment on 03/08/18, which stated the resident continued to require bed rails to assist with bed mobility. Review of Resident #33's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #33 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact and interviewable. The MDS further revealed the resident was assessed to not use bed rails while in bed as a physical restraint. Review of Resident #33's Comprehensive Care Plan dated 03/13/18 revealed the facility developed an intervention for the resident to utilize bilateral half bed rails to aid with bed mobility. However, there was no evidence staff monitored/supervised the resident's use of the bed rails. 5. Review of the medical record for Resident #16 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #16 on 05/08/18 at 10:17 AM and 05/10/18 at 10:09 AM revealed the resident's upper half bed rails were raised and in use by the resident. Review of a Restraint/Bed Rail Use Assessment Form completed for Resident #16 on 08/10/17, revealed the resident utilized bed rails as an enabler to aid in bed mobility. Review of a Quarterly Physical Restraint Elimination/Device Use Assessment completed on 02/09/18, revealed the resident continued to utilize bed rails to aid with bed mobility. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was assessed to have a BIMS score of fifteen (15), indicating the resident was not cognitively impaired and was interviewable. The MDS assessment further revealed the resident was assessed to not use bed rails as a physical restraint. Review of Resident #16's Comprehensive Care Plan revealed the facility developed a care plan for the resident dated 08/14/17, which stated the resident required the use of bed rails for turning and repositioning. However, a review of the medical record for Resident #16 revealed no documented evidence the facility was monitoring and supervising the resident's use of bed rails. 6. Review of the medical record for Resident #18 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #18 on 05/07/18 at 6:45 PM and 05/10/18 at 9:24 AM revealed the resident's bed rails were not in use. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #18 was unable to complete the Brief Interview for Mental Status (BIMS). Further review of the MDS Assessment revealed the resident was assessed to not utilize a physical restraint. Review of a Restraint/Bed Rail Use Assessment Form for Resident #18 dated 11/05/17 revealed the resident utilized bed rails as an enabler to aid in bed mobility due to weakness. Review of Resident #18's Comprehensive Care Plan dated 11/15/17 revealed the resident continued to utilize half bed rails to aid in bed mobility. However, there was no documented evidence the facility monitored Resident #18's bed rail usage. Interview with State Registered Nursing Assistant (SRNA) #1 on 05/10/18 at 3:55 PM revealed that prior to the survey she had never been instructed to monitor residents' bedrail usage. Interview conducted with SRNA #3 on 05/07/18 at 4:00 PM, revealed she monitored residents to ensure the resident was not too close to the bedrail and monitored to ensure the bedrail was up. The SRNA stated she did not document the observations anywhere. Interview conducted with SRNA #8 on 05/10/18 at 5:39 PM revealed she reviewed the resident's Kardex (document that lists the care the resident required) at the beginning of the shift to determine the care needs for the resident. She stated she looked to see if the resident was utilizing the bed rails if they were required, but did not monitor/supervise the resident until after the survey was initiated. Interview conducted with Licensed Practical Nurse (LPN) #3 on 05/10/18 at 4:05 PM revealed she did not routinely monitor bed rail usage and would not document anything regarding bed rails unless she observed something wrong. Interview conducted with LPN #1 on 05/10/18 at 4:10 PM revealed she did not routinely monitor bed rail usage. The LPN stated the nurse aides would let her know if anything was wrong.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure medications were safely stored. Observation of medication pass on 04/30/18 and 05/01/18 revealed medication carts were observed to be unlocked and unattended with a bottle of insulin left on top of the cart. In addition, Resident #38 was observed to have a medication cup with two (2) pills at bedside. The findings include: Review of the facility policy titled Medication Storage in the Facility, dated (MONTH) 2007, revealed medications and biologicals were required to be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The policy stated medications were accessible only to licensed nursing personnel or staff members lawfully authorized to administer medications. According to the policy, medication rooms, carts, and supplies were locked or attended by persons with authorized access. 1. Observation of medication administration on 04/30/18 at 4:55 PM revealed the medication cart was left unlocked and unattended for approximately five (5) minutes while Licensed Practical Nurse (LPN) #4 entered a resident room to administer medication. A bottle of [MEDICATION NAME]was observed on top of the cart while the medication cart was unattended. Observation of the medication cart on 05/01/18 at 9:30 AM revealed the cart was outside a resident room and was unlocked and unattended for approximately three (3) minutes while Kentucky Medication Aide (KMA) #1 was in a resident room administering medication. Interview with LPN #4 on 05/01/18 at 4:55 PM revealed she was trained on how to correctly store and administer medication. She stated she should have returned the insulin to the medication cart and secured the cart prior to walking away. Interview with KMA #1 on 05/01/18 at 3:25 PM revealed she had also been trained on how to properly store medications. KMA #1 acknowledged that she should not have left the medication cart unlocked and unattended. Interview with the Director of Nursing (DON) on 05/03/18 at 12:35 PM revealed she monitored staff while administering medications and had not identified any concerns with medication storage or administration. The DON stated it was her expectation for staff to follow the facility's policy on medication storage and administration, and secure the medication cart prior to walking away. 2. Observation and interview with Resident #38 on 04/30/18 at 2:30 PM revealed the resident was alert and resting in bed. The resident stated he/she had received too much medication this morning and pointed to a medication cup sitting on his/her bedside table. Resident #38 said that there were four (4) capsules in his/her morning medication, instead of the two (2) capsules that he/she normally received. The resident stated he/she did not take all of the medication, as he/she was only supposed to take two (2) capsules. Licensed Practical Nurse (LPN) #1 was notified of the unsecured medication on Resident #38's bedside. Interview with LPN #1 on 04/30/18 at 2:45 PM revealed the medication in the cup at Resident #38's bedside was [MEDICATION NAME]. The LPN stated she had given the resident two (2) 100 milligram (mg) capsules that morning. The LPN and surveyor reviewed the resident's available medications and confirmed the medication was [MEDICATION NAME]. The LPN and surveyor also reviewed the resident's Medication Administration Record [REDACTED]. LPN #1 stated that nursing staff was required to observe residents take their medication and she had observed Resident #38 take his/her medication that morning and could not explain why the resident had medication at the bedside. Review of Resident #38's medical record with LPN #1 revealed the resident had a [MEDICATION NAME] level obtained on 04/27/18, and the resident's [MEDICATION NAME] level was 12 (therapeutic range 10-20).

Based on observation, interview, and facility policy review, it was determined the facility failed to store food under sanitary conditions for an undetermined number of residents who receive snacks. Observation during initial tour of the kitchen on 05/07/18 at 5:50 PM, revealed uncovered foods stored on a shelf in the kitchen, and bowls of food in the refrigerator unlabeled and undated. The findings include: Review of the facility's policy titled Purchasing, Receiving and Storage, undated, revealed food would be stored and protected from contamination. Review of the facility's policy titled Leftover Food Usage, last reviewed (MONTH) 2012, revealed foods would be clearly labeled with the date and time that the food was first prepared. Observation during the initial tour of the kitchen on 05/07/18 at 5:50 PM, revealed a box of Quik Oats opened and not covered on a shelf in the kitchen. Further observation of the kitchen revealed a bowl of watermelon, a bowl of mixed fruit, and a bowl of deviled eggs in the refrigerator, that was not labeled with the date and time the food was prepared as required by the facility's policy. Interview with the Dietary Manager on 05/10/18 at 4:10 PM, revealed any opened food item on the shelf should be covered or stored in an airtight container. The Dietary Manager further revealed any item in the refrigerator should be labeled with a date. The Dietary Manager stated the bowl of watermelon, bowl of mixed fruit, and bowl of deviled eggs were going to be used for the evening snack cart.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to establish and maintain an effective infection control program to prevent urinary tract infection for two (2) of twenty-five (25) residents (Residents #62 and #8). Observation on 04/30/18 and 05/01/18 revealed Resident #62 and Resident #8's indwelling urinary catheter collection bags were observed to be on the floor. The findings include: Review of the facility policies titled Protocol for Use of Indwelling Catheters, and Giving Catheter Care, not dated, revealed the policies did not address how staff should secure a urinary catheter collection bag to prevent possible contamination and infection. Interview with the DON on 05/10/18 at 7:10 PM, revealed staff were expected to follow the facility's policies and procedures, and acknowledged that to prevent the spread of infection an indwelling urinary catheter collection bag should not touch the floor. 1. Observation of Resident #8 on 04/30/18 at 10:30 AM and 05/01/18 at 10:05 AM and 10:45 AM revealed the resident's urinary catheter collection bag was touching the floor. Review of Resident #8's medical record revealed the facility admitted the resident on 12/06/16 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set((MDS) dated [DATE] revealed the facility assessed Resident #8 to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severely impaired cognition and was not interviewable. Further review of the MDS revealed that the resident had not been diagnosed with [REDACTED]. Review of Resident #8's comprehensive care plan dated 11/07/18 and revised 02/05/18, and the resident Kardex (document that lists the care the resident required), revealed the facility identified that the resident utilized an indwelling urinary catheter, but the documents did not direct staff how to ensure the urinary catheter drainage was free from possible contamination. 2. Observation of Resident #62 on 04/30/18 at 4:20 PM and 05/01/18 at 10:05 AM and 10:45 AM revealed Resident #62's indwelling urinary catheter drainage bag was lying on the floor. Review of the medical record for Resident #62 revealed the facility readmitted the resident on 02/08/18 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the facility had assessed the resident to have a Brief Interview for Mental Status(BIMS) score of three (3), which indicated the resident had severely impaired cognition and was not interview able. The MDS also revealed that Resident #62 had not been diagnosed with [REDACTED]. Review of Resident #62's comprehensive care plan dated 03/09/18 with a revision date of 04/16/18, and the resident's Kardex (document that lists the care the resident required), revealed the facility identified that the resident utilized an indwelling urinary catheter, but the documents did not direct staff how to ensure the urinary catheter drainage was free from possible contamination. Interview with State Registered Nursing Assistant (SRNA) #9 on 05/01/18 at 1:50 PM revealed he/she was not aware that Resident #8 and Resident #62's urinary catheter drainage bags had been touching the floor. SRNA #9 reported that he/she reviewed each resident Kardex to determine the residents' care needs. The SRNA stated residents' urinary catheter bags should not have been touching the floor. Interview with SRNA #8 on 05/01/18 at 2:00 PM revealed the SRNA knew that a urinary catheter bag was not supposed to touch the floor. The SRNA acknowledged that when a catheter bag was on the floor the resident was at risk for infection.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure two (2) allegations of abuse were immediately reported to the Administrator, the State Survey Agency, and Adult Protective Services for two (2) of three (3) sampled residents (Resident #1 and Resident #3). Staff witnessed Licensed Practical Nurse (LPN) #1 tell Resident #1, Shut Up, God D**n it, and witnessed LPN #1 telling Resident #3 to shut up and holding the resident down; however, the facility failed to ensure the allegations were reported as required. The findings include: A review of the facility policy titled Abuse Policy, with a revision date of November 2016, revealed all allegations of abuse were required to be reported immediately to the Director of Nursing (DON) and/or the Administrator of the facility and to other officials in accordance with state law, including the state survey and certification agency. The policy did not address the requirement to report abuse allegations no later than two hours after the allegation is made. A review of a facility investigation dated 11/14/17 revealed Nurse Aide (NA) #1 reported that on an unknown date on night shift, she heard sounds like Resident #1 was hitting and knocking items in his/her room. NA #1 stated she witnessed Licensed Practical Nurse (LPN) #1 get up from the nurses' station and go into Resident #1's room and state, Shut Up, God D**n it. On 11/29/17 at 10:59 AM, a telephone interview with NA #1 revealed during an evening shift (exact date and time unknown) she witnessed LPN #1 walk into Resident #1's room and yell, Stop it! God d**n it! NA #1 stated she did not report the incident until the facility initiated an investigation into another allegation of abuse regarding LPN #1. A telephone interview conducted with State Registered Nurse Aide (SRNA) #2 on 11/29/17 at 12:38 PM revealed approximately two (2) weeks ago LPN #1 also told Resident #3 to shut up and held Resident #3 down. SRNA #2 stated she did not report the allegation until the next day when she reported the allegation to the Administrator. SRNA #2 stated she had been trained on abuse and reporting abuse and did not know why she did not report the alleged abuse immediately. An interview conducted with the Administrator on 11/29/17 at 3:15 PM, revealed NA #1 reported the allegation involving Resident #1 on 11/14/17, while the facility was investigating a prior incident that also involved LPN #1. The Administrator stated NA #1 should have reported the alleged occurrence of abuse immediately. Continued interview with the Administrator revealed SRNA #2 also reported the allegation involving Resident #3 while the facility was conducting the investigation. However, the Administrator stated SRNA #2 reported that LPN #1 told Resident #3 to shut up, but did not report that LPN #1 held the resident down. The Administrator stated the facility should have reported the incident involving Resident #3 to the state survey agency; however, at the time of the allegation, the facility did not report the incident because SRNA #2 stated that LPN #1's tone was not abusive.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to complete a Minimum Data Set (MDS) assessment to accurately reflect the status for one (1) of nineteen (19) sampled residents (Resident #3). Review of Resident #3's MDS with a quarterly assessment reference date of 03/02/16 revealed Resident #3 was assessed to have no functional limitation in range of motion impairment on both sides of the body. However, observations on 03/16/16 and on 03/17/16 revealed Resident #3 had impairment in range of motion on both sides of the body (upper extremity). The findings include: Review of the facility policy and procedure titled MDS, with a revision date of July 2015, revealed the facility would conduct a comprehensive and accurate assessment that described the resident's capability to perform daily life functions. Review of Resident #3's medical record revealed the facility admitted Resident #3 on 03/02/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #3 to have no functional limitations on both sides of his/her body. Observations of Resident #3 on 03/16/16 at 10:00 AM, 10:17 AM, 10:54 AM, and 1:23 PM, and on 03/17/16 at 1:42 PM revealed Resident #3 had limited range of motion in the left hand and in the right hand. Interview with State Registered Nurse Aide (SRNA) #1 on 03/16/16 at 11:23 AM revealed Resident #3 has had contractures to both the left and right hand for at least two years. Interview with Registered Nurse (RN) #2 on 03/16/16 at 10:54 AM revealed Resident #3 had contractures to the left and right hands. Further interview revealed there were no devices/interventions for both hands. Interview with the Rehabilitation Manager on 03/17/16 at 1:42 PM revealed the SRNAs were usually good about letting the Rehabilitation Department know about range of motion concerns and contractures in residents. Further interview with the Rehab Manager revealed she was aware of Resident #3's functional limitation and Occupational Therapy was treating the resident for limited range of motion. Interview with the MDS Coordinator on 03/17/16 at 1:58 PM revealed she gets information from Therapy regarding range of motion and contractures and the team meets to discuss each resident individually. Further interview with the MDS Coordinator revealed she was aware that Resident #3's left and right hands were stiff, but did not consider them to be contracted. The MDS Coordinator stated she was under the impression if Resident #3 had limited functional ability she did not have to code on the MDS. Interview with the Clinical Coordinator on 03/17/16 at 3:40 PM revealed the SRNAs were responsible for keeping the nurses informed of any changes with the residents. Interview with the Director of Nursing (DON) on 03/17/16 at 4:58 PM revealed she had not identified any concerns with MDS accuracy in the facility.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive plan of care was developed for one (1) of nineteen (19) sampled residents (Resident #3) to address the resident's limited range of motion. Resident #3 was observed on 03/16/16 and 03/17/16 to have contractures to the left and right hands. However, the facility failed to develop an individualized care plan for Resident #3 that addressed his/her limited range of motion needs. The findings include: A review of the facility's Care Plan Policy and Protocol, with a revision date of August 2012, revealed the facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Further review of the policy revealed the care plan will be updated as indicated with changes in condition, physician orders, etc. Additional review of the policy revealed the Kardex will also be utilized as a guide for Nurse Aides in providing care on a daily basis. Resident #3 was observed on 03/16/16 at 10:00 AM, 10:17 AM, 10:54 AM, and 1:23 PM, and on 03/17/16 at 1:42 PM. Observations revealed Resident #3 had limited range of motion in the left hand and in the right hand. Review of Resident #3's medical record revealed the facility admitted Resident #3 on 03/02/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], the significant change dated 11/07/14, and the significant change dated 09/21/15 revealed the facility assessed Resident #3 to have no impairment on both sides of his/her body. Review of the quarterly care plan meeting note dated 02/29/16 revealed the facility had noted stiffness in Resident #3's joints, and the resident was receiving occupational therapy (OT) for limited range of motion and OT would make recommendations. Interview with State Registered Nurse Aide (SRNA) #1 on 03/16/16 at 11:23 AM revealed Resident #3 has had contractures to both the left and right hand for at least two years. Interview with Registered Nurse (RN) #2 on 03/16/16 at 10:54 AM revealed Resident #3 had contractures to the left and right hand. Further interview with RN #2 revealed there were no devices/interventions for the resident's hands related to contractures/limited range of motion. Interview with the Rehabilitation Manager on 03/17/16 at 1:42 PM revealed the SRNAs usually let the Rehabilitation staff know when there were concerns with range of motion and contractures. An interview with the MDS Coordinator on 03/16/16 at 10:00 AM revealed that when a resident had limited range of motion, a care plan should be developed. Further interview revealed she was responsible to develop the care plan. Further interview with the MDS Coordinator revealed she was waiting to hear from Therapy because they were trying to determine the best intervention for Resident #3. Interview with the Director of Nursing (DON) on 03/17/16 at 4:58 PM revealed the care plan was developed by the MDS Coordinator along with the Clinical Supervisor, Nurse Aides, family, etc. Further interview with the DON revealed she would expect the care plan to address the care needs of each resident. Interview with the Administrator on 03/17/16 at 5:12 PM revealed MDS Coordinators develop the care plans and the Clinical Coordinators do the updates to the care plan. Further interview with the Administrator revealed limited range of motion and contractures should be addressed in the care plan. Additional interview with the Administrator revealed she had not identified any problems/concerns with care plans being developed.

Based on observation, interview, record review, and review of the facility's policy and procedure it was determined the facility failed to provide care in accordance with each resident's written plan of care for two (2) of nineteen (19) sampled residents (Resident #1 and Resident #12). Resident #1 was observed to have a scabbed rash on 03/15/16 and 03/16/16; however, the facility failed to identify the rash and obtain treatment. In addition, observation during incontinence care on 03/17/16 revealed State Registered Nurse Aide (SRNA) #3 failed to provide treatment according to the resident's care plan for Resident #12. The findings include: Review of the facility's policy titled Care Plan Policy and Protocol, dated August 2012, revealed the facility would develop a comprehensive care plan for each resident to meet the resident's medical and nursing needs. Further review revealed the Kardex would be utilized as a guide for Nurse Aides in providing care on a daily basis. Review of the facility's policy and procedure titled Notification of Change in Resident's Status, not dated, revealed the facility would notify the resident's attending physician for status changes which included any need to alter treatment. Review of the facility's policy titled Protocol for Incontinence care, not dated, revealed residents who are incontinent would be checked for incontinence every two hours and cleaned and dried if indicated. 1. Record review revealed the facility readmitted Resident #1 on 07/11/15 with [DIAGNOSES REDACTED]. Review of a Comprehensive Care Plan dated 10/27/15 revealed Resident #1 was at risk for altered skin integrity. Further review revealed interventions which included notifying the physician with any changes. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of 11, indicating Resident #1 was interviewable. Review of a facility Skin Integrity assessment dated [DATE] revealed Licensed Practical Nurse (LPN) #1 had assessed Resident #1's skin integrity as warm and dry to touch with no documented evidence of a rash. Observations on 03/15/16 at 10:00 AM and 11:36 AM, and on 03/16/16 at 9:05 AM and 10:11 AM, revealed Resident #1 had a scabbed rash on his/her neck and arms. Observation on 03/16/16 at 11:30 AM revealed LPN #1 performed a skin assessment on Resident #1. Further observation revealed Resident #1 was observed by the LPN to have a scabbed rash on his/her neck and arms. Interview with Resident #1 on 03/16/16 at 11:35 AM revealed he/she had the rash for several weeks. Further interview revealed Resident #1 stated the rash itched. Interview with LPN #1 on 03/16/16 at 11:38 AM revealed she was Resident #1's nurse on 03/15/16 and 03/16/16. LPN #1 stated she had assessed Resident #1 during each shift but stated she had not noticed the rash. LPN #1 stated the rash was a change of condition for the resident and the physician should have been notified. Further interview revealed she did not know how the rash was missed. Interview with SRNA #2 on 03/17/16 at 4:25 PM revealed she had worked with Resident #1 on 03/15/16 but did not observe a rash on the resident. Further interview revealed she was trained to check the Kardex (Nurse Aide Care Plan) every day at the beginning of each shift. 2. Record review revealed the facility admitted Resident #12 on 01/01/14 with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #12's cognition as severely impaired with a BIMS score of zero, indicating Resident #12 was not interviewable. Review of a Comprehensive Care Plan updated on 01/22/16 revealed Resident #12 was assessed to have a self-care deficit and required assistance with all areas of Activities of Daily Living (ADLs). Further review revealed Resident #12 had a care plan goal to remain clean, dry, and well groomed. Additional review revealed an intervention to check Resident #12 for incontinence and provide incontinence care as needed. Observation during incontinence care on 03/17/16 at 1:00 PM revealed Resident #12 had been incontinent of urine. Further observation revealed SRNA #3 removed a brief that was soiled with urine, applied a barrier cream, and secured a new brief on the resident without cleaning the urine and drying the resident of the urine. Interview with SRNA #3 on 03/17/16 at 1:05 PM revealed she was trained to use soap and water during incontinence care to remove the urine before applying a new brief. SRNA #3 stated this was important to help prevent infections. SRNA #3 stated, I must have just got in a hurry. SRNA #3 stated she was responsible for checking the Kardex at the beginning of each shift and was to provide the resident's care according to the care guide. Interview with the Director of Nursing (DON) on 03/17/16 at 1:30 PM and 5:30 PM revealed Resident #1 was often noncompliant and refused care at times. The DON stated the staff should have noticed the change of status for Resident #1 and notified the physician per the policy and procedure and according to the resident care plan. Additionally, the DON stated all staff has been trained on proper techniques to provide incontinence care. The DON stated she expected the staff to use the proper techniques each time incontinence care was performed. Further interview revealed she expected staff to check the care plan each shift and to follow the care plan.

Based on observation, interview, record review, and review of the facility's policy and procedures it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of nineteen (19) sampled residents (Resident #1). Observation of Resident #1 on 03/15/16 at 10:00 AM and 11:36 AM revealed Resident #1 had a scabbed rash on his/her neck and arms that was unidentified by the facility. The findings include: Review of the facility's policy and procedure titled Notification of Change in Resident's Status, not dated, revealed the facility would notify the resident's attending physician for status changes which included any need to alter treatment. Record review revealed the facility readmitted Resident #1 on 07/11/15 with [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of 11, indicating Resident #11 was interviewable. Review of a facility Skin Integrity assessment dated [DATE] revealed Licensed Practical Nurse (LPN) #1 had assessed Resident #1's skin integrity as warm and dry to touch with no documented evidence of a rash. Observations on 03/15/16 at 10:00 AM and 11:36 AM, and on 03/16/16 at 9:05 AM and 10:11 AM, revealed Resident #1 had a scabbed rash on his/her neck and arms. Observation on 03/16/16 at 11:30 AM revealed LPN #1 performed a skin assessment on Resident #1. Further observation revealed Resident #1 was observed by the LPN to have a scabbed rash on his/her neck and arms. Interview with Resident #1 on 03/16/16 at 11:35 AM revealed he/she had the rash for several weeks. Further interview revealed Resident #1 stated the rash itched. Interview with LPN #1 on 03/16/16 at 11:38 AM revealed she was Resident #1's nurse on 03/15/16 and 03/16/16. LPN #1 stated she had assessed Resident #1 during each shift but had not noticed the rash. LPN #1 stated the rash was a change of condition for the resident. Further interview revealed she did not know how the rash was missed. Interview with State Registered Nurse Aide (SRNA) #2 on 03/17/16 at 4:25 PM revealed she had worked with Resident #1 on 03/15/16 but did not observe a rash on the resident. Interview with the Director of Nursing (DON) on 03/17/16 at 5:30 PM revealed Resident #1 was often noncompliant and refused care at times. The DON stated the staff should have noticed the change of status for Resident #1 and notified the physician of the rash.

Based on observation, interview, record review, and review of the facility's policy and procedure it was determined the facility failed to ensure a resident who was incontinent of urine was provided appropriate treatment and services to prevent Urinary Tract Infections for one (1) of nineteen (19) sampled residents (Resident #12). Observation during incontinence care on 03/17/16 revealed State Registered Nurse Aide (SRNA) #3 failed to use proper technique to prevent urinary tract infections for Resident #12. The findings include: Review of the facility's policy titled Protocol for Incontinence care, not dated, revealed residents who are incontinent would be checked for incontinence every two hours and cleaned and dried if indicated. Record review revealed the facility admitted Resident #12 on 01/01/14 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #12's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero, indicating Resident #12 was not interviewable. Observation during incontinence care on 03/17/16 at 1:00 PM revealed Resident #12 had been incontinent of urine. Further observation revealed SRNA #3 removed a brief that was soiled with urine, applied a barrier cream, and secured a new brief on the resident. Further observation of the incontinence care revealed SRNA #3 did not clean the area of incontinence or remove the old barrier cream before applying a new layer of barrier cream and securing the new brief. Interview with SRNA #3 on 03/17/16 at 1:05 PM revealed she was trained to use soap and water during incontinence care to remove the urine before applying a new brief. SRNA #3 stated this was important to help prevent infections. SRNA #3 stated, I must have just got in a hurry. Interview with the Director of Nursing (DON) on 03/17/16 at 1:30 PM revealed all staff had been trained on proper techniques to provide incontinence care. The DON stated she expected the staff to use the proper techniques each time incontinence care was performed.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to ensure one (1) of nineteen (19) sampled residents (Resident #3) received appropriate treatment and services to increase range of motion and/or to prevent further risk of injury. Observations of Resident #3 on 03/16/16 and on 03/17/16 revealed Resident #3 to have limited range of motion/contractures in the left hand and the right hand. Review of the record for Resident #3 revealed the limited range of motion had not been assessed or a care plan developed to address the resident's left and right hand limitations in range of motion. The findings include: Review of the facility's policy, Protocol for Restorative Nursing Program, developed February 2015, revealed the Restorative Nursing Program assists residents in maintaining abilities and functions as possible within limits of disease/diagnosis, etc. Further review of the policy revealed any resident with noted decline in ADL (activities of daily living) function, range of motion (ROM), mobility, restraint use, unsteady gait, etc. should be evaluated per the Interdisciplinary Team for possible participation in the Restorative Program or need for a therapy referral. Review of Resident #3's medical record revealed the facility admitted Resident #3 on 03/02/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #3 to have no functional limitation on both sides of his/her body. Review of the quarterly care plan meeting note dated 02/29/16 revealed the facility had noted stiffness in Resident #3's joints and that the resident was receiving occupational therapy (OT) for limited range of motion and OT would make recommendations. Interview with State Registered Nurse Aide (SRNA) #1 on 03/16/16 at 11:23 AM revealed Resident #3 has had contractures to both the left and right hand for at least two years. Interview with Registered Nurse (RN) #2 on 03/16/16 at 10:54 AM revealed Resident #3 had contractures to the left and right hands. Further interview revealed there were no devices/interventions for the resident's hands. Interview with the Rehabilitation Manager on 03/17/16 at 1:42 PM revealed the SRNAs were usually good about letting Rehabilitation staff know about range of motion and contracture concerns in residents. The Rehabilitation Manager further stated that she was aware that Resident #3 had limitations in his/her hands and that Occupational Therapy was treating the resident for the limited range of motion. An interview with the MDS Coordinator on 03/16/16 at 10:00 AM revealed a care plan should have been developed for Resident #3. Further interview with the MDS Coordinator revealed she was waiting for Occupational Therapy's input because they were trying to determine the best intervention for Resident #3. Interview with the Clinical Coordinator on 03/17/16 at 3:40 PM revealed the SRNAs or floor nurses were responsible for letting the Clinical Coordinators know if any change of condition occurred with a resident. Further interview with the Clinical Coordinator revealed if a resident developed a contracture or limited range of motion, she would expect to be notified, and a care plan intervention should be added to the care plan. Interview with the Director of Nursing (DON) on 03/17/16 at 4:58 PM revealed a resident with contractures and/or limited range of motion should have interventions in place, determined by the Therapy Department. Further interview with the DON revealed she had not identified any concerns with residents with limited range of motion receiving appropriate treatment and services to increase range of motion. Further interview with the DON revealed she was not aware Resident #3 had contractures to the left and right hands.