Every finding on record at Jordan Rehabilitation and Healthcare Center

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to follow the care plans for 1 of 3 sampled residents, Resident (R) 4. Resident 4 was identified as requiring a mechanical lift for transfers on her care plan. On 05/21/2026, during interview with Licensed Practical Nurse (LPN) 1, she stated CNA8 and CNA9 transferred R4 to the bed without using a mechanical lift on 05/08/2026.The findings include:Review of the facility's policy titled, Comprehensive Care Plans, 2025 revision, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and services that were identified in the resident's comprehensive assessment and meet professional standards of quality.Review of R4's admission Record revealed the facility admitted the resident on 01/16/2023 with diagnoses to include dementia, stroke, and reduced mobility. The facility assessed R4 to have a BIMS score of five out of 15, indicating the resident was severely cognitively impaired.Review of R4's Care Plan, initiated on 12/04/2025, revealed the resident was assessed for reduced mobility. Also, the resident was totally dependent on two staff for transferring with use of the mechanical lift (a device used to transfer residents from one surface to another).During an interview with Licensed Practical Nurse (LPN) 1 on 05/21/2026 at 4:38 PM, she stated on 05/08/2026, CNA8 and CNA9 were attempting to get R4 back to bed, and she was fighting the two CNAs. She stated CNAs called her to the room. LPN1 stated as she entered the room, CNA8 and CNA9 were attempting to assist R4 to bed, and R4 was swinging her arms and hitting the CNAs. She also stated she did not know R4 required a mechanical lift for transfers. During an interview with the Director of Nursing (DON) on 05/22/2026 at 8:44 AM, she stated R4 was care planned for use of mechanical lift for transfers. She further stated a mechanical lift was not used when R4 was transferred to the bed on 05/08/2026 by CNA8 and CNA9. She stated she expected staff to follow the care plan and use a machinal lift for resident transfers when it was listed as an intervention in the care plan. During an interview with the Administrator on 05/22/2026 at 8:45 AM, he stated he expected staff to follow the care plan for all residents concerning transfers.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure each resident's right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 6 of 28 sampled residents, Resident (R) 7, R9, R10, R28, R76, and R82.Review of each resident's document Behavior Modification Consent revealed the name of the medication, risks and benefits of the medication, and treatment alternatives/options were not specified.The findings include:Review of the facility's document Resident Rights, undated and found in the facility's admission packet, revealed the resident had a right to be informed of and participate in their treatment, which included the right to be fully informed in advance of the risks and benefits of proposed care, of treatment, and treatment alternatives.1. Review of R82's admission Record revealed the facility admitted R82 on 05/11/2012 with diagnoses of chronic obstructive pulmonary disease, anxiety disorder, and unspecified dementia. Review of R82's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/02/2026, revealed R82's cognitive function was severely impaired, and she rarely or never made decisions.Review of R82's Clinical Orders revealed an order for sertraline HCL (an antidepressant medication) that was started on 10/04/2025 and was currently still active.Review of R82's Behavior Modification Consent form, dated 07/29/2023, revealed the form authorized the use of specific behavior modification medication intervention identified in the individual plan of care but did not identify the specific medication(s) being consented to. Further review revealed the form did not include the medication name, dosage, frequency, route, diagnosis or clinical indication for use, targeted behaviors or symptoms, expected benefits, potential material risks or adverse effects specific to the medication, alternative treatment options, duration of treatment, monitoring parameters, or documentation reflecting the resident's or responsible party's opportunity to ask questions and make an informed decision regarding the proposed medication treatment.2. Review of R76's admission Record revealed the facility admitted R76 on 03/10/2026 with diagnoses of unspecified fracture of the left lower leg, anxiety disorder, depression, and abuse of other non-psychoactive substances.Review of R76's admission MDS, with an ARD of 03/20/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating R76 was cognitively intact.Review of R76's, Order Summary Report, dated 04/16/2026, revealed the resident received multiple psychotropic medications including lorazepam (benzodiazepine anxiolytic), Vraylar/cariprazine (atypical antipsychotic), venlafaxine (serotonin-norepinephrine reuptake inhibitor antidepressant), trazodone (serotonin antagonist/reuptake inhibitor antidepressant often used as a sedative), Remeron/mirtazapine (tetracyclic antidepressant), and Ambien/zolpidem (sedative-hypnotic non-benzodiazepine sleep agent). Review of R76's Behavior Modification Consent form, dated 03/10/2026, revealed the form authorized the use of specific behavior modification medication intervention identified in the individual plan of care but did not identify the specific medication(s) being consented to. Further review revealed the form did not include the medication name, dosage, frequency, route, diagnosis or clinical indication for use, targeted behaviors or symptoms, expected benefits, potential material risks or adverse effects specific to the medication, alternative treatment options, duration of treatment, monitoring parameters, or documentation reflecting the resident's or responsible party's opportunity to ask questions and make an informed decision regarding the proposed medication treatment.3. Review of R9's admission Record revealed the facility admitted R9 on 07/09/2023 with diagnoses of Huntington's Disease, unspecified dementia with mild psychotic disturbances, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder.Review of R9's quarterly MDS, with an ARD of 02/02/2026, revealed R9's cognitive function was severely impaired, and she never/rarely made decisions.Review of R9's Order Summary Report, dated 04/16/2026, revealed the resident received multiple psychotropic medications including Valium/diazepam (benzodiazepine/anxiolytic/sedative), Elavil/amitriptyline (antidepressant), Abilify/aripiprazole (antipsychotic), and Zoloft/sertraline (antidepressant).Review of R9's Behavior Modification Consent form, dated 07/29/2023, revealed the form authorized the use of specific behavior modification medication intervention identified in the individual plan of care, but did not identify the specific medication(s) being consented to. Further review revealed the form did not include the medication name, dosage, frequency, route, diagnosis or clinical indication for use, targeted behaviors or symptoms, expected benefits, potential material risks or adverse effects specific to the medication, alternative treatment options, duration of treatment, monitoring parameters, or documentation reflecting the resident's or responsible party's opportunity to ask questions and make an informed decision regarding the proposed medication treatment.4. Review of R10's admission Record revealed the facility admitted R10 on 01/16/2025 with diagnoses of dementia, post-traumatic stress disorder, and repeated falls.Review of R10's MDS, with an ARD of 01/16/2026, revealed the facility assessed the resident to have a BIMS score of three out of 15, indicating R10 was severely cognitively impaired.Review of R10's Clinical Orders revealed an order for quetiapine (an anti-psychotic medication) dated 12/10/2025 was active.Review of R10's Behavior Modification Consent form, dated as signed by R10's spouse and responsible party (RP) on 01/16/2025, revealed consent had been obtained for the use of specific behavior modification medication intervention. Further review revealed the signee understood the behavior modification medication was a part of a total comprehensive treatment program, and the medication intervention would only be utilized in specific instances when it had been determined to be necessary. Continued review revealed the signee understood she would be counseled by the physician or a member of nursing regarding the risk factors involved in both using and not using the ordered behavior modification intervention and agreed the benefits outweighed the risk factors. However, no specific documentation of the medication, its side effects, risks or alternative options had been documented for the use of quetiapine.5. Review of R28's admission Record revealed the facility admitted R28 on 12/17/2024 with diagnoses of unspecified dementia, altered mental status, and skin picking disorder.Review of R28's MDS, with an ARD of 06/23/2025, revealed the facility assessed the resident to have a BIMS score of six out of 15, indicating severe cognitive impairment.Review of R28's Clinical Orders revealed an order for haloperidol (an antipsychotic medication), dated 12/10/2025, and an order for lorazepam (a sedative-hypnotic medication), dated 04/03/2026, were both active.Review of R28's Behavior Modification Consent form, dated as signed by R28's family member, who was also her power of attorney (POA) on 12/17/2024, revealed consent had been obtained for the use of specific behavior modification medication intervention. Further review revealed the signee understood the behavior modification medication was a part of a total comprehensive treatment program, and the medication intervention would only be utilized in specific instances when it had been determined to be necessary. Continued review revealed the signee understood she would be counseled by the physician or a member of nursing regarding the risk factors involved in both using and not using the ordered behavior modification intervention and agreed the benefits outweighed the risk factors. However, no specific documentation of the medication, its side effects, risks, or alternative options had been documented for either the haloperidol or the lorazepam.6. Review of R7's admission Record revealed the facility admitted R7 on 09/15/2018 with diagnoses of major depressive disorder and other specified anxiety disorder. On 09/18/2025 the resident received a new diagnosis of schizophrenia, unspecified.Review of R7's quarterly MDS, with an ARD of 01/16/2026, revealed the facility assessed the resident to have a BIMS score of 11 out of 15, indicating R7 was moderately cognitively impaired.Review of R7s Clinical Orders, revealed an order for quetiapine (an anti-psychotic medication), dated 10/01/2025, was active. R7's active orders also included aripiprazole (an antipsychotic used to treat schizophrenia, dated 02/06/2026.Review of R7's Behavior Modification Consent form, dated as signed on 09/15/2018 by R7's family member, who was also the responsible party (RP), revealed consent had been obtained for the use of specific behavior modification medication intervention. Further review revealed the signee understood the behavior modification medication was a part of a total comprehensive treatment program, and the medication intervention would only be utilized in specific instances when it had been determined to be necessary. Continued review revealed the signee understood she would be counseled by the physician or a member of nursing regarding the risk factors involved in both using and not using the ordered behavior modification intervention and agreed the benefits outweighed the risk factors. However, no specific documentation of the medication, its side effects, risks, or alternative options had been documented for either the quetiapine or the aripiprazole.During an interview with the Director of Nursing (DON) on 04/16/2026 at 10:30 AM, she stated medication consent was obtained during the admission process through a general consent form. The DON stated the admission consent was a blanket consent and did not include medication-specific information, such as the name of the medication, the reason for use, potential risks, benefits, or possible side effects. The DON stated there was no separate consent process for individual psychotropic medications when ordered.During an interview with the Administrator on 04/16/2026 at 11:30 AM, he stated the admission consent was a blanket consent and was not intended to serve as consent for specific medications. The Administrator stated medication consents should include the medication name, the reason for use, and potential side effects.During an interview with the Senior [NAME] President of Regulatory Affairs (SVPRA) on 04/16/2026 at 4:00 PM, the SVPRA stated the facility did not have a written policy for obtaining consent for psychotropic medications and instead relied on the Centers for Medicare & Medicaid Services (CMS) guidelines for medication consent practices.

Based on observation, interview, record review, information from the Centers for Disease Control and Prevention (CDC), and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 40 sampled and supplemental residents, Resident (R) 66, R77, R35, R13, R42, R71, and R33.R66 was diagnosed with a communicable skin infection on 04/10/2026 and a contact precautions order was placed by the physician. However, observation on 04/14/2026 revealed no transmission-based precaution signage posted outside R66's room, and after Contact Precaution signage was posted, staff entered the room without donning (putting on) required personal protective equipment (PPE). Observation on 04/14/2026 revealed the common sinks shared between two resident-occupied rooms by R77, R35, and R13 were completely covered in clear plastic and inaccessible for use.Observations on 04/15/2026 and 04/16/2026 revealed staff used the mechanical lift for R42, R71, and R33 without disinfecting it between resident use. The findings include:Review of the facility's policy titled, Infection Prevention and Control Program, undated, revealed the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. The policy also indicated all staff was responsible for following the policies and procedures related to the program, and a resident with an infection or communicable disease would be placed on transmission-based precautions as recommended by the Centers for Disease Control and Prevention (CDC) guidelines. Further review of the policy revealed isolation signs were used to alert staff, family members, and visitors of transmission-based precautions. The policy also outlined that all staff would receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention program, including policies and procedures related to their job function; all staff would demonstrate competence in relevant infection control practices; and direct care staff would demonstrate competence in resident care procedures established by the facility.Review of the facility's undated policy, Mechanical Lift Cleaning, revealed, Mechanical lifts will be cleaned and disinfected between each resident use.Review of the CDC website at www.cdc.com revealed for residents in long term care facilities diagnosed with a shingles/herpes zoster infection, standard and contact precautions should be observed until all lesions were dried and crusted. It also stated lesions should be covered completely, and gloves and gowns should be used for direct care.Review of the admission Record revealed the facility admitted R66 on 03/14/2025 with diagnoses of encounter for orthopedic aftercare following a surgical amputation and bacteremia. An additional diagnosis of herpes zoster (shingles-a painful viral infection caused by the reactivation of the virus which also caused chickenpox) without complications was added on 04/10/2026.1. Observation on 04/14/2026 at 10:45 AM revealed no transmission-based precaution signage posted outside R66's room. Observation on 04/14/2026 at 12:00 PM revealed a Contact Precaution sign had been placed on R66's door indicating everyone must clean their hands, including before entering and when leaving the room and providers and staff must also put on gloves and a gown before entering the room and discard the gloves and gown before exiting the room. Additional observation revealed Certified Nursing Assistant (CNA) 4 entered R66's room with his lunch tray without putting on gloves or a gown.During an interview on 04/14/2026 at 12:15 PM with CNA4, she stated the Contact Precaution sign was new, and she had never seen it before. She stated R66 did not need to be on precautions because he did not have anything going on.Review of R66's Clinical Orders, dated 04/10/2026, revealed an order for an antiviral medication for R66's shingles had been entered by Registered Nurse (RN) 3, but no order for contact precautions had been entered.During an interview on 04/14/2026 at 12:30 PM with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), they stated they were not aware R66 did not have any transmission-based precaution signage posted outside his room and would fix it immediately.During an interview on 04/16/2026 at 4:50 PM with RN3, she stated she wrote the order for R66's antiviral medication for shingles and an order for Contact Precautions at the same time.Review of R66's Clinical Orders revealed an order for Contact Precautions due to shingles had been created by the Infection Preventionist (IP) on 04/14/2026 to begin on 04/10/2026 and end on 04/18/2026.During an interview on 04/14/2026 at 4:40 PM with the Infection Preventionist (IP), she stated residents with the shingles virus should be in contact isolation unless the rash had spread to another part of the body, and then the resident should be in airborne precautions. The IP further stated she did not know how R66 caught the virus, and the virus could possibly still be in the room.During an additional interview on 04/16/2026 at 9:13 AM with the IP, she stated she had been the IP at the facility since May 2020. The IP stated R66 was diagnosed with shingles on Friday, 4/10/2026, and she was not sure why Contact Precautions signage was not posted that same day. The IP also stated R66 was on Enhanced Barrier Precautions (EBP) for a wound on his foot, and that signage would have covered the gown and gloves precaution requirement for the contact precautions if the EBP signage had been on R66's door. The IP further stated the charge nurse that rounded with the physician was responsible for taking orders, entering them into the computer, and then following through with the order as needed. The IP stated she thought RN3 had rounded with the physician on 04/10/2026, and she would have been responsible for entering the order for any new medication and/or transmission-precautions and then placing the signage on R66's door. The IP stated she noticed R66 should have been placed on contact precautions during her general antibiotic rounds on 04/14/2026, but she was not sure if R66 had EBP signage on the resident's door at that time. The IP stated it was her expectation for staff to read the signage posted on R66's door and follow the guidance to prevent an infection from being spread to other residents. The IP stated again that R66 was already on EBP for his foot wound, so EBP signage should have been posted, and she was not sure why it was not.During an interview on 04/16/2026 at 10:00 AM with the ADON and the DON, they both stated all new orders were reviewed every morning by the clinical team which included the unit managers/charge nurses, the IP, the Minimum Data Set (MDS) nurse, the ADON, and the DON. They stated any new order for an antibiotic or antiviral would also include an order for transmission-based precautions if necessary, and they both expected the signage to be posted immediately and staff to follow the guidance as posted to prevent the spread of infection to other residents, staff, and visitors.During an interview on 04/16/2026 at 5:30 PM with the Administrator, he stated he expected any resident that required any form of transmission-based precaution to have signage on the door to safely guide staff and visitor contact with that resident.2. Observation on 04/14/2026 at 12:25 PM revealed the common sinks shared between two resident-occupied rooms were completely covered in clear plastic and inaccessible for use, which affected R77, R35, and R13.During an interview on 04/14/2026 at 3:15 PM with Certified Nursing Assistant (CNA) 7, she stated if she needed to wash her hands after caring for any of the residents in those rooms, she would have to go to the shower room down the hall. She stated the sinks in those rooms had been out of service for several days, and she thought they were clogged and needed to be fixed.During an interview on 04/14/2026 at 3:40 PM with the Maintenance Director, he stated the sinks shared a common drainpipe and had been out of order since Wednesday, 04/08/2026. He stated some parts were ordered but had not been received as of today. Observation on 04/15/2026 at 9:04 AM revealed R35, R77, and R13 were relocated to other rooms, and their previous rooms were left empty until the sinks could be repaired. 3. Observation on 04/15/2026 at 11:02 AM revealed CNA3 put the mechanical lift in an alcove in the hall on the 100 Unit. She then went into the clean linen room and got a brief. She then went into R71's room.During an interview with CNA3 on 04/15/2026 at 11:04 AM, she stated she had used the mechanical lift to get R42 out of bed. When asked how the lift was to be cleaned after use, she stated with alcohol wipes and pointed to the wipes next to the lift. When asked if she cleaned the lift after getting R42 out of bed she stated, No. When asked what could happen if the lift was not cleaned between residents, she stated, Germs could transfer to another resident. Observation on 04/16/2026 at 10:30 AM revealed CNA10 put the mechanical lift in an alcove in the hall on the 200 Unit. She then left and walked down the hall.During an interview with CNA10 just after the observation, she stated she had just used the lift to get R33 out of bed. When asked why she did not clean the lift, she stated, I was in a hurry.During an interview with the Infection Preventionist (IP) on 04/16/2026 at 10:57 AM, she stated staff was supposed to clean the mechanical lifts before and after each use, so infection between residents could not be spread. She further stated she did periodically monitor staff to ensure they were cleaning the lifts after each use. She also stated she had not found any issues with the cleaning of the lifts because staff knew she was watching. The IP stated staff was taught on cleaning the mechanical lifts in orientation and yearly.During an interview with the Director of Nursing (DON) on 04/16/2026 at 11:11 AM, she stated staff was taught how to clean the mechanical lifts in orientation and quarterly. She stated it was important to keep the lifts clean to prevent the spread of diseases. The DON stated staff should clean the lifts after each use with the germicidal wipes.During an interview with the Administrator on 04/16/2026 at 11:31 AM, he stated staff knew how to clean mechanical lifts by training given in orientation. He stated the nurse should also reeducate the staff on cleaning the lifts to make sure residents were not exposed to germs from other residents or staff.During continued interview on 04/16/2026 at 5:30 PM with the Administrator, he stated he relied on the nursing staff and the IP to ensure the infection prevention program was implemented per the facility's policies.

Based on observation, interview, record review, review of the facility's job description, and review of the facility's document and policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 9 sampled residents, Resident (R) 10, R17, and R28, related to falls.The findings include:Review of the facility's undated policy titled, Comprehensive Care Plans [CCP], revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that were identified in the resident's comprehensive assessment and met professional standards of quality but were not provided due to the resident's exercise of his/her right to refuse. The policy also revealed the CCP would be reviewed and revised by the IDT (Interdisciplinary Team) after each comprehensive and quarterly assessment and would include documentation of alternative interventions if needed.Review of the undated facility's document, Minimum Data Set (MDS) Coordinator, Job Description,, revealed the purpose of the MDS nurse was to conduct and coordinate the completion of the required Resident Assessment Instrument (RAI) and responsibility for the implementation and ongoing evaluation of each resident's comprehensive plan of care.1. Review of R10's admission Record revealed the facility admitted R10 on 01/16/2025 with diagnoses of dementia, post-traumatic stress disorder, and repeated falls.Review of R10's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/16/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of three out of 15, indicating R10 was severely cognitively impaired.Review of the facility's Interdisciplinary Team [IDT] Review Notes for each fall incident for R10 revealed the facility followed their process for review of the falls with identification of the root cause analysis for each fall, however resident specific interventions were not added to each resident's comprehensive care plan.Review of R10's Certified Nurse Aide (CNA) Kardex (a centralized and concise quick reference guide for daily resident care which was driven by the resident's CCP), dated 04/16/2026, revealed documented interventions as: make sure shoes were comfortable and not slippery, noting R10 preferred to wear tennis shoes; encourage R10 to use the call bell for assistance; ensure R10 had an unobstructed path to the bathroom and provide a safe environment, call light in reach, adequate low glare light, bed in lowest position with all wheels locked; avoid isolation; and R10 needed a safe environment with floors that were even and free from spills and clutter, and a call light or alarm system and personal items in reach.Review of R10's CCP, initiated on 01/31/2025, revealed R10 was at risk for falls due to confusion and wandering and had experienced actual falls. The goals for R10 included safety measures would be maintained to prevent or lessen an injury from falling and included R10 would resume usual activities without incident, and R10's injured areas would resolve without complication by the next review date. Interventions dated 02/24/2026 included: physician to evaluate, check range of motion daily, for no apparent acute injury, determine and address causative factors of the fall, monitor/document /report as needed for 72 hours to the physician for signs/symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, and pharmacy consult to evaluate medication.a. Review of R10's Fall Incident Report, dated 01/09/2026, revealed R10 sustained a fall with resulting redness to the jawline. Review of R10's CCP, dated 01/09/2026, revealed a documented intervention of physician to evaluate.b. Review of R10's Fall Incident Report, dated 02/04/2026, revealed R10 sustained a fall which resulted in a knot to the top of the head and had refused to put on footware.Review of R10's CCP, dated 02/04/2026, revealed a documented intervention of physician to evaluate and did not contain an intervention to address the resident's refusal to wear footwear. The intervention was not addressed on the CNA Kardex.c. Review of R10's Fall Incident Report, dated 02/06/2026, revealed R10 sustained a fall with no injury.Review of R10's CCP, dated 02/06/2026, revealed a documented intervention of physician to evaluate.d. Review of R10's Fall Incident Report, dated 02/17/2026, revealed R10 sustained a fall with no injury.Review of R10's CCP, dated 02/17/2026, revealed a documented intervention of physician to evaluate.e. Review of R10's Fall Incident Report, dated 02/21/2026, revealed R10 sustained a fall resulting in red/purple discoloration to her right arm and shoulder and a knot on the right side of her head.Review of R10's CCP, dated 02/21/2026, revealed a documented intervention of physician to evaluate.f. Review of R10's Fall Incident Report, dated 02/24/2026, revealed R10 sustained a fall resulting in a laceration to the top center of her head. R10 was sent to the hospital, received five staples to the top of her head, and had a Computed Tomography (CT) scan of her head which was negative for fracture but showed progression of her Alzheimer's.Review of R10's CCP, dated 02/24/2026, revealed a documented intervention of physician to evaluate.g. Review of R10's Fall Incident Report, dated 02/27/2026, revealed R10 sustained a fall with no injury.Review of R10's CCP, dated 03/04/2026, revealed a documented intervention of physician to evaluate.h. Review of R10's Fall Incident Report, dated 03/17/2026, revealed R10 sustained a fall resulting in a knot to her right temple.Review of R10's CCP, dated 03/17/2026, revealed a documented intervention of physician to evaluate dated 03/16/2026.i. Review of R10's Fall Incident Report, dated 03/25/2026, revealed R10 sustained a fall resulting in a laceration to the top of her head above her hairline. Review of R10's CCP, dated 03/25/2026, revealed a documented intervention of physician to evaluate. j. Review of R10's Fall Incident Report, dated 04/01/2026, revealed R10 sustained a fall with no injury.Review of R10's CCP, dated 04/01/2026, revealed a documented intervention of physician to evaluate. 2. Review of R17's admission Record revealed the facility admitted R17 on 09/06/2025 with diagnoses of unspecified dementia, adult failure to thrive, and non-infective gastroenteritis. Additional diagnoses of abnormalities of gait and mobility/lack of coordination and muscle weakness were added on 11/08/2025.Review of R17's quarterly MDS, with an ARD of 12/15/2025, revealed a BIMS could not be completed because the resident was rarely/never understood.Review of R17's CNA Kardex, dated 04/16/2026, revealed no interventions for falls or safety were documented.Review of R17's CCP, initiated on 10/17/2025, revealed goals included R17 would resume usual activities without further incident through the review date and interventions dated 10/10/2025 included physician to evaluate, check range of motion, continue interventions on the at-risk plan, for no apparent acute injury, determine and address causative factors of the fall, monitor/document /report as needed for 72 hours to physician for signs/symptoms of pain, bruises, change in mental status, and new onset confusion, sleepiness, inability to maintain posture, and agitation.a. Review of R17's Fall Incident Report, dated 01/02/2026, revealed R17 sustained a fall with no injuries.Review of R17's CCP, dated 01/02/2026, revealed documented interventions of mats to the floor by the bed and physician to evaluate. However, the intervention for the mats to the floor by R17's bed did not appear on his CNA Kardex.b. Review of R17's Fall Incident Report, dated 01/10/2026, revealed R17 sustained a fall with resulting redness to right outer knee.Review of R17's CCP, dated 01/12/2026, revealed a documented intervention of physician to evaluate.c. Review of R17's Fall Incident Report, dated 03/31/2026, revealed R17 sustained a fall which resulted in a skin tear to the left outer elbow. Review of R17's CCP, dated 04/01/2026, revealed documented interventions of physician to evaluate and treatment to the skin tear to the left outer elbow per current physician order.3. Review of R28's admission Record revealed the facility admitted R28 on 12/17/2024 with diagnoses of unspecified dementia, altered mental status, and skin picking disorder. Additional diagnoses of abnormalities of gait and mobility and muscle weakness were added on 12/13/2025.Review of R28's MDS, with an ARD of 06/23/2025, revealed the facility assessed the resident to have a BIMS score of six out of 15, indicating severe cognitive impairment.Review of the facility's Falls List, dated 04/15/2026, documenting falls for the past 120 days revealed R28 had four falls.a. Review of R28's Fall Incident Report, dated 01/19/2026, revealed R28 sustained a fall with no injury.Review of R28's CCP, dated 01/20/2026, revealed a documented intervention of physician to evaluate.b. Review of R28's Fall Incident Report, dated 02/25/2026, revealed R28 sustained a fall with resulting discoloration to the right hand.Review of R28's CCP, dated 02/26/2026, revealed a documented intervention of physician to evaluate. c. Review of R28's Fall Incident Report, dated 03/25/2026, revealed R28 sustained a fall with resulting redness to the right face/cheek.Review of R28's CCP, dated 03/26/2026, revealed a documented intervention of physician to evaluate. d. Review of R28's Fall Incident Report, dated 04/07/2026, revealed R28 sustained a non-injury fall.Review of R28's CCP, dated 04/09/2026, revealed a documented intervention of physician to evaluate.Review of R28's CNA Kardex, dated 04/16/2026, revealed documented interventions as: make sure shoes were comfortable and not slippery, noting R28 preferred to wear tennis shoes, encourage R28 to use call bell for assistance, ensure R28 had an unobstructed path to the bathroom, and ensure and provide a safe environment, call light in reach, adequate low glare light, bed in lowest position with wheels locked, and avoid isolation.During an interview on 04/15/2026 at 8:40 AM with Certified Nursing Assistant (CNA) 8, she stated she had worked at the facility for about a year, and she used the CNA Kardex for each resident that outlined their care, which was located on the computer and at the nurse's station in a care plan book. CNA8 also stated the CNA Kardex included safety needs for the resident to prevent falls, toileting assistance, diet, assistance needed with meals, and resident personal preferences for care or refusals of care.During an interview on 04/15/2026 at 8:48 AM with Licensed Practical Nurse (LPN) 1 and LPN2, they both stated the floor nurses did not update the care plans. They stated the floor supervisors, the MDS nurse, the Infection Preventionist (IP), and other department heads that attended clinical meetings in the morning did that. LPN1 stated the CNAs had a Kardex available on the computer that outlined the residents' plans of care and would include things like diet, activity, special needs or assistance, and fall interventions.During an interview on 04/15/2026 at 8:43 AM with Registered Nurse (RN) 3, she stated the CNA Kardex that outlined resident care was online but denied there was CNA Kardex book at the nurse's station. RN3 further stated the resident's CCP and the CNA Kardex with resident specific interventions and preferences for care were updated in the morning clinical meeting with new orders and interventions by the clinical team. RN3 stated it was important for fall interventions to be up to date on a resident's care plan as well as the CNA Kardex so all staff would know how to safely care for that resident and attempt to prevent falls.During an interview on 04/15/2026 at 9:13 AM with the Infection Preventionist (IP), she stated all care interventions for a resident should appear on their CCP. The IP further stated she did not update the resident's CCP, and the MDS nurse did that during the morning clinical meeting. She stated she was not sure if all nurses could update the resident's CCP. During an interview on 04/15/2026 at 10:42 AM with the MDS nurse, she stated resident orders were reviewed and added to the resident care plan every morning in clinical meeting, and every clinical team member played a role. She further stated everyone on the clinical team could update the resident's CCP, but she was not sure if there were any audits completed to ensure orders or interventions had been accurately added. The MDS nurse also stated the CNAs followed the CNA Kardex, which contained information from the resident's CCP. She stated the CNA Kardex outlined each resident's special needs or preferences for their care like toileting, meal assistance, infection control precautions, elopement risk, and falls prevention which transferred to the CNA Kardex from the interventions added to the resident's CCP. The MDS nurse then stated a resident's CCP was initiated on admission by the admitting nurse, completed with the resident's admission MDS by the MDS nurse, and updated with each quarterly, annual, or significant change of condition MDS by the MDS nurse. She stated due to a change in the facility's electronic documentation system, resident care plans were in the process of being transitioned to the new system which was not yet complete. The MDS nurse also stated the facility wanted the physician to evaluate a resident after each fall. However, she stated there should also be a resident specific intervention placed on the resident's CCP after the root cause for the fall had been identified.During an interview on 04/16/2026 at 10:00 AM with the Director of Nursing (DON), she stated the purpose of a resident's CCP was to outline the needs, care, and preferences each resident required while at the facility. The DON stated the resident's CCP provided the information on the CNA Kardex that each CNA used to provide resident specific care to each resident. The DON also stated it was the responsibility of the MDS nurse to update the resident's CCP with each resident's MDS. She stated since she was the supervisor for the MDS nurse, it was her responsibility to provide oversight and ensure all necessary care plans had been developed and updated as new interventions were added. The DON stated the intervention of physician to evaluate could be a part of the response to a resident fall, but a specific intervention addressing the root cause of the fall should also be implemented.During an interview on 04/16/2026 at 5:30 PM with the Administrator, he stated he relied on nursing staff to accurately develop and update the resident's CCP, and it was his expectation that all resident falls be completely investigated and the resident's care plan be accurate, current, and reflect the specific needs and wants of each resident.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide necessary activities of daily living care to maintain 1 of 2 sampled dependent residents in a clean manner, Resident (R) 11. The facility failed to ensure R11 had clean clothing, clean bed linens, and grooming assistance. The findings include:Review of the facility's policy titled, Activities of Daily Living [ADL] dated 2025, revealed the facility would provide care and services consistent with each resident's comprehensive assessment, needs, and choices. The policy further stated residents unable to perform activities of daily living would receive necessary services for bathing, dressing, grooming, and personal hygiene.Review of R11's admission Record revealed the facility admitted R11 on 10/18/2024 with diagnoses of dementia, atrial fibrillation, and limited mobility.Review of R11's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/12/2026, revealed R11 was severely cognitively impaired, had no Brief Interview for Mental Status [BIMS] score recorded, rarely or never made decisions, and required dependent assistance with bathing, dressing, and personal hygiene.Review of R11's Care Plan Report revealed R11 required total assistance with activities of daily living due to functional and cognitive limitations. Interventions, initiated on 11/06/2025 and revised on 01/28/2026, included staff providing the resident's dressing and grooming routine. Additional interventions included total assistance with dressing, bathing, grooming, toileting, transfers, bed mobility, and eating. Observation on 04/14/2026 at 8:44 AM revealed R11 was lying in bed wearing a t-shirt with dried brown stains around the neckline and chest area that were hardened to the touch. R11's blanket and bed linens contained similar dried brown stains, and his hair was uncombed and appeared disheveled.Observation and interview on 04/15/2026 at 4:00 PM, in the presence of Family Member (FM) 6, who stated staff had just provided personal care to R11. R11 remained in bed wearing the same stained t-shirt, with the same stained blanket and bed linens. R11's hair remained uncombed and disheveled. R11 repeatedly asked FM6 and the surveyor for a clean shirt during the observation. FM6 stated she visited R11 daily, and before entering the nursing facility, R11 had been particular about his personal cleanliness and preferred to be kept clean.During an interview on 04/15/2026 at 10:05 AM, Certified Nursing Assistant (CNA) 7 stated staff was responsible for ensuring residents were clean, dressed in clean clothing, had clean linens, and received grooming assistance. CNA7 stated she did not realize R11's shirt and bed linens were stained.During an interview on 04/16/2026 at 10:20 AM, the Director of Nursing (DON) stated staff was expected to keep residents clean and well-groomed. She stated staff should clean residents after each meal, comb their hair daily and as needed, and provide personal care in a manner that maintained dignity and respect.During an interview on 04/16/2026 at 10:40 AM, the Administrator stated residents should be kept clean at all times. He stated staff was expected to provide clean clothing, clean linens, and grooming assistance as needed.

Based on observation, interview, record review, review of the Activity Director job description, and review of the facility's policy, the facility failed to provide an ongoing program to support the residents' choice of activities based on their comprehensive assessment, care plan, and preferences, specifically one-to-one interaction, as directed for 2 of 2 sampled residents, Resident (R) 12 and R13. Observations from 04/14/26 through 04/16/2026 revealed R12 and R13 were in bed, dressed in bed clothing or a shirt only. No observations were made of staff providing one-to-one interaction.The findings include:Review of the undated policy titled Activities, revealed the facility provided an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. It also stated individual activities would be designed to support their physical, mental, and psychosocial well-being and encourage interaction within the community. Review of the undated job description for the Activity Director (AD) revealed it was the responsibility of the AD to direct the development, implementation, supervision, and ongoing evaluation of the activities program designed to meet the social, psychosocial, and therapeutic needs of the resident. This included matching the skills and abilities and interest of the resident and monitoring the response, documenting outcomes, and making revisions as necessary. 1. Review of the Care Plan [CP], located in the electronic medical record (EMR), revealed the facility admitted Resident (R) 12 on 06/17/2018 with diagnoses of dementia, anxiety, psychosis, and mood disturbance disorder. It also revealed a focus initiated on 01/30/2026 related to preference for self-directed activities, such as watching television. An intervention also dated 01/30/2026 encouraged one-to-one activities.Review of R12's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/12/2026, revealed no Brief Interview of Mental Status (BIMS) score was documented, but severe cognitive impairment was listed in her assessment for Cognitive Skills for Daily Decision Making. The MDS also revealed R12 had difficulty concentrating on things such as television. In addition, R12 was documented as non-ambulatory and did not use any type of mobility device, including mechanical lift, wheelchair or walker. It also revealed that the resident was dependent on staff for partial to moderate assist with eating and oral care, substantial to max assist with dressing, showering, personal hygiene, and bed mobility.Review of documentation that was printed from the EMR POC (Point of Care) entries dated 01/01/2026 through 04/06/2026, revealed the Certified Nursing Assistant (CNA) documentation for one-to-one activities for R12 was Not Applicable for all opportunities to document activities. Review of the Activity Department's form One-To-One Activities provided to R12 listed people watching, verbalization, and watching television. Documentation included Monday through Friday activities. No activities were documented on Saturdays or Sundays. Observations on 04/14/2026 at 1:05 PM and again at 3:12 PM revealed R12 wearing a shirt and a brief, resting with her eyes closed.Observations on 04/15/2026 at 10:25 AM, and at 1:28 PM revealed R12 was lying in bed with her eyes closed and was wearing the same shirt as on 04/14/2026 but with pajama pants. Observation on 04/16/2026 at 10:02 AM and again at 3:17 PM revealed R12 was lying in bed, with her eyes closed.No observation of active or passive activities was made during any of the observations. During an interview on 04/16/2026 at 1:22 PM with CNA10, she stated she did not think the resident got out of bed and was assisted with cleaning and meals. She stated she was not sure what types of things the resident would be interested in but noted she could review the care plan for that information. She stated residents getting out of bed or participating in some form of activity would be good for them to socialize, and might increase their quality of life. 2. Review of the CP, located in the EMR, revealed the facility admitted R13 on 03/07/2025 with diagnoses of cerebral infarction, traumatic brain injury, cognitive communication deficit, and severe dementia with agitation. The CP revealed R13 was dependent on enteral nutrition and received continuous bladder irrigation. Further review revealed the most recent update on 04/02/2026 revealed a focus of activities, noting a lack of interest related to immobility and an intervention of the resident's preference for one-to-one visits from activity staff, social services, and being read to. Also updated on 04/02/2026 was a focus related to falls that listed the resident's preference to stay in bed. Review of R13's annual MDS, with an ARD of 03/16/2026, revealed a diagnosis of severe cognitive impairment and a Brief Interview of Mental Status [BIMS] score that was blank. The functional abilities assessment revealed dependence on staff for maximum assistance for all ADLs. Additionally, documentation revealed the resident was bedbound and did not utilize a wheelchair. Review of documentation that was printed from the EMR POC (Point of Care) entries dated 01/01/2026 through 04/06/2026, revealed the CNA documentation for one-to-one activities for R13 was Not Applicable for all but three opportunities to document activities. One-to-one activity was documented by Activity Assistant 2 on one occasion, 01/20/2026. On 03/27/2026 and 04/06/2026, the Activity Director documented participation in group activities. Review of the Activity Department's form One-To-One Activities, for 01/01/2026 through 04/06/2026, revealed R13 participated in reading to self, phone, watching television, and socialization. There was no indication of one-to-one activities or the resident's response. Observation on 04/14/2026 at 12:55 PM revealed R13 lying in bed with her eyes closed with each pass-by of her room. Subsequent observations revealed the same on 04/14/2026 at 3:10 PM, 04/15/2026 at 10:12 AM and at 1:20 PM, 04/16/2026 at 9:48 AM, 11:40 AM, and at 3:01 PM. No observation of active or passive activities was made. During an interview on 04/16/2026 at 3:03 PM with CNA11, she stated R13 slept all day because she was awake most of the night and could not recall the last time she had been up in a Geri-chair. She stated that sometimes she turned on the television for the residents, but there were no activities at night. CNA11 stated that occasionally, R13 was given coloring pages. During an interview on 04/16/2026 at 10:49 AM, the Activity Director stated her schedule was Monday through Friday, 8:00 AM until 4:30 PM. She stated she also had an assistant scheduled to start working every other weekend beginning the next weekend, and another assistant who worked on Sundays. She stated the documentation of one-to-one activities was done by the Activity person who provided the care. After reviewing the recorded activities for R12 and R13, she stated the residents scheduled for one-to-one activities were provided with activities in their rooms. She stated the use of a telephone and receiving mail were more of a resident's right and that people watching was not a legitimate activity, much less a result of one-to-one interaction. She stated she could not explain how a resident with a severe cognitive deficit could read to herself or work word puzzles as listed on their activity log. She stated more appropriate activities for these residents might benefit their psychosocial welfare. She stated residents who were more active at different times of the day/week might benefit from the additional opportunities that the new schedule would present.During an interview on 04/16/2026 at 3:04 PM, Activity Assistant (AA) 1 stated one-to-one activities were provided for those unable to participate otherwise. She stated most of the time, this included residents with severe dementia. She stated she tried to find things that those types of residents would want to do. She stated some of the activities listed were things that residents had been observed doing, such as people watching. AA1 stated that it was not an activity that qualified as a one-to-one activity and that receiving mail or using the phone were not activities but more of a resident's right. AA1 stated there were areas where one-to-one activities could be more engaging. She stated not providing that type of activity could create resident isolation.During an interview on 04/16/2026 at 6:08 PM with the Director of Nursing (DON) and the Interim Administrator, the DON stated activities were an important part of resident care. She stated it provided them with ways to stay engaged with others, and it was especially important for those who could not get out, as most others could. Both the DON and the Administrator were made aware of observations and concerns regarding R12 and R13. The DON and Administrator stated their desire for staff to provide more meaningful interaction with residents who had severe cognitive deficits. The DON stated she expected staff would not only identify and meet the needs of residents but also document the results of those efforts with more clarity. The Interim-Administrator stated she agreed with the DON's statement.

Based on observation, interview, review of the facility's daily bedtime snack list, and review of the scientific article referenced by the National Institute of Health (NIH), the facility failed to provide substantial snacks to residents who needed assistance at meals as determined by review of the time between supper and breakfast was greater than 14 hours. Review of the facility meal service times, not dated, revealed total assist residents received supper at 4:30 PM and breakfast at 7:00 AM. The findings include: Review of the scientific article referenced by the National Institute of Health (NIH) in Nutrients titled What is Nutritious Snack Food? A Comparison of Expert and Layperson Assessments? 2017 [DATE]; 9(8):874 revealed the definition of a nutritious snack that contained preferred nutrients was food with a high percentage of essential nutrients relative to the energy content. Observation on 06/04/2025 at 8:10 AM revealed there was no ice cream observed in the [NAME] Unit nourishment refrigerator freezer compartment. Observation of the refrigerator on the [NAME] Unit revealed it had resident food items brought by residents' families, and no other snacks were available. In interviews with Resident Council members on 06/03/2025 at 10:00 AM, they voiced concern that snacks were not offered after the supper meal. They stated snacks were available at the nurses' station, but were not passed. Review of the facility's bedtime snacks, not titled or dated, for general residents without specific snacks, revealed Sunday: Peanut butter cracker 8 oz [ounces] milk, Tuesday: ice cream 4 oz, Thursday: banana bread 8 oz milk, and Saturday: Sherbet 4 oz. Review of the facility's bedtime snacks CCHO HS Snack List [controlled carbohydrate at bedtime], not dated, revealed Sunday: 1/2 c sugar free ice cream; Monday: Meat salad ½ sandwich, 8 ounces of milk; Tuesday: 8 ounces of milk and Sugar free cookies; Wednesday: 1/2 of a turkey, ham, or bologna sandwich with 8 ounces of milk; Thursday: sugar free sherbet; Friday: 2 ounces snack type cheese crackers, flavored water: and Saturday: 4 ounces of sugar free Jello. In an interview with the Dietary Manager on 06/05/2025 at 10:11 AM, she stated the breakfast meal was served at 7:20 AM, and the bedtime snack was taken to the unit at 7:30 PM, which was a substantial snack sandwich and milk. She stated not all total assisted residents received a labeled snack at bedtime. She stated extra sandwiches were sent for the residents each night. She stated each unit nourishment refrigerator contained ice cream, sherbet, cookies, and graham crackers for the residents. In an interview with the Registered Dietitian (RD) and Licensed Dietitian (LD) on 06/05/2025 at 10:49 AM, they stated they assumed residents received or were offered a snack at bedtime. In an interview with Licensed Practical Nurse (LPN) 1 on 06/05/2025 at 11:11 AM, she stated the State Registered Nurse Assistant (SRNA) passed the snacks at night. She stated all residents who did not have a snack labeled with their name were offered a snack. She stated there were no snacks available for residents later at night who were hungry. She stated the nourishment refrigerator freezer had ice cream; however, it was not stocked with sandwiches like they used to do. She stated residents who had an assigned snack received the bedtime snack. She stated residents who could not verbally ask for a snack would receive a snack if they had not eaten well that day. In an interview with the Director of Nursing (DON) on 06/05/2025 at 1:04 PM, she stated snacks were sent out around 7:30 PM, and staff passed them to the residents. She stated specific ordered snacks were labeled with the name of the resident, and extra snacks were available throughout the night. She stated ice cream was located in the freezers on the units. She stated her expectation was for all residents to receive a snack. In an interview with the Administrator on 06/05/2025 at 1:26 PM, he stated the best practice was for all the residents to be offered snacks at night.

Based on observation, interview, review of the United States Department of Agriculture (USDA) web site, and review of the facility's policies, the facility failed to store and serve food in a safe manner as determined by observations during the initial tour on 05/02/2025. These observations revealed food not labeled or dated in the dry storage, walk-in refrigerator, and the freezer. In addition, observations of the supper meal tray line on 06/02/2025 at 4:16 PM revealed the Dietary Manger and [NAME] improperly used the food thermometer, and Dietary Aide 1 used open utility carts with a wet top shelf. This had the potential to affect 92 residents that received food from the kitchen. The findings include: Review of the facility's policy titled, Food Storage, dated 2010, revealed all stock must be rotated with each new stock received. Per the policy, rotating stock was essential to ensure the freshness and highest quality of all foods. The policy stated old stock was always used first (first in-first out method), and food should be dated as it was placed onto the shelf. Review of the facility's policy titled, Cleaning Instructions: Food Carts, dated 2010, revealed food carts would be cleaned and sanitized immediately after each use. Review of the United Stated Department of Agriculture (USDA) web site https://www.fsis.usda.gov, undated, revealed the food thermometer should be placed in the thickest part of the food, away from bone, fat or gristle. For thin foods, the food thermometer should be inserted through the side until it reached the center of the food. Always check each piece of food to ensure they had reached the safe internal temperature. Observation during the initial kitchen tour with the Dietary Manager on 06/02/2025 at 1:14 PM revealed foods in the walk-in not dated and labeled, such as heads of lettuce, a large bag with mixed peppers, a case of whole tomatoes left open on the bottom shelf, various frozen food items out of the case not dated, and various foods in dry storage out of the case not dated. Observation of the Dietary Manager on 06/02/2025 at 4:16 PM during the supper meal tray line revealed she pushed the food thermometers through the plastic wrap of the food on the steam table. The [NAME] on 06/02/2025 at 4:26 PM stated the steam table is so hot it melted the plastic as she tried to read the thermometer in the plastic wrap. Continued observation of the Dietary Aide on 06/02/2025 at 4:20 PM revealed she pushed two utility carts with wet top shelves to the other side of the tray line. Observation of the Dietary Aide revealed she placed the food trays onto the wet top shelf of the utility cart going to the [NAME] Unit at 4:36 PM. In an interview with the Dietary Manager on 06/04/2025 at 8:55 AM, she stated to not pierce food with the thermometer through the plastic wrap or foil because there was a potential for cross contamination. She stated all foods should be labeled and dated and food rotated first in and first out (FIFO) to prevent the risk of bacterial growth. In an interview with the [NAME] on 06/05/2025 at 10:31 AM, she stated the proper way to take the food temperature was by pulling back the plastic or foil covering the food. She stated this would prevent the potential cross contamination of the food. In an interview with the Director of Nursing (DON) on 06/05/2025 at 1:09 PM, she stated her expectation was for staff to follow best practices for the food service. In an interview with the Administrator on 06/05/2025 at 1:28 PM, he stated his expectation was for staff to follow best practices for food service.

Based on interview, record review, review of the Postal Service Reform Act of 2022, and review of the facility's policy, the facility failed to ensure residents the right to receive mail, letters, and packages delivered to the facility. In interviews with Resident Council members, they stated they did not receive mail on Saturdays. This practice had the potential to affect all current 92 residents. The findings include: Review of the facility's policy titled, Resident's Rights For Residents in [State] Long-Term Care Facilities, not dated, revealed the resident had a right to exercise his or her rights as a resident of the facility and as a citizen of the United States. Review of the Postal Service Reform Act of 2022 (PSRA) confirmed mandated six-day mail delivery services (Monday through Saturday). In an interview with Resident (R) 71 during the Resident Council meeting on 06/03/2025 at 10:00 AM, the resident stated there was no one to bring mail to residents on Saturdays. In an interview with R12 during the Resident Council meeting on 06/03/2025 at 10:00 AM, she stated she knew of a resident who was waiting on a package on a Saturday, who was told it could not be delivered on Saturday as there was no staff member present to deliver it. In an interview with the Activities Team Leader (ATL) on 06/03/2025 at 3:01 PM, the ATL stated activities staff delivered resident mail, and there were no activities staff working on weekends, although jobs were posted with the plan to fill two more activities vacancies in order to have activities staff present on weekends. The ATL stated there was no one present to deliver mail on Saturdays, and Saturday's mail was not delivered until Mondays when staff was present to pick up and deliver mail. In an interview with the Social Services Director (SSD) on 06/03/2025 at 3:21 PM, she stated mail was held on the weekends at the post office. The SSD stated previously mail was delivered to the facility on weekends, but as there was no staff present to oversee delivery, residents were going through delivered mail. She stated to prevent potential loss, the facility had the post office start holding mail on Saturdays. She stated it had been that way since some time in 2021. In an interview with the Administrator on 06/05/2025 at 12:35 PM, he stated he was not aware residents were not getting mail on Saturdays. He stated the local post office had stopped delivery due to the pandemic in 2020, and he was not aware that was still in place. The Administrator stated he expected residents to receive uninterrupted mail service.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 1 of 24 sampled residents, Resident (R) 81. R81's Comprehensive Care Plan (CCP) stated his preference for individual activities. It did not, however, reflect any history of service-related, post-traumatic stress disorder (PTSD) potential triggers, or how to address them. The findings include: Review of the facility's policy titled, Care Planning - Interdisciplinary Team, revised 09/2013, stated the facility's Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan (CCP) for each resident. Review of R81's admission Record revealed the facility admitted the resident on 03/26/2025 with diagnoses of end stage renal disease (ESRD), diabetes mellitus, and depression. Review of R81's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of nine of 15, indicating moderate cognitive impairment. No diagnosis of post-traumatic stress disorder (PTSD) was listed. Review of R81's CCP revealed it was initiated on his admission date and most recently updated on 04/15/2025. Per the review, the resident's preference to stay in his room was listed as his activity preference. His treatment of depression and anxiety was documented with pharmacological interventions. No diagnosis of PTSD was listed. Review of R81's Brief Trauma Questionnaire, dated 03/26/2025, revealed two stressful or disturbing events, including military service and a heart attack. The form was not complete and did not address the emotional response or physical injury as a result of the event(s). Review of the facility's document Matrix, dated 06/02/2025, provided to the State Survey Agency (SSA) Surveyors upon survey entry, failed to list PTSD as a diagnosis for R81. Observation on 06/03/2025 at 3:38 PM revealed R81 was sitting in his room. He was in his wheelchair, fully dressed and clean. His affect was pleasant, and he verbally conversed without apparent difficulty. He was watching television and had his cell phone within reach. During an interview on 06/03/2025 at 3:38 PM, R81 stated he preferred activities in his room, he did not like sudden noises, and larger crowds made him uncomfortable. He stated he had service-related PTSD and depression, and he was on medications that helped a little. During an interview on 06/05/2025 at 10:59 AM with the Activities Team Leader, she stated she tried to encourage all the residents to join the group activities or make suggestions of areas they liked. She stated she was aware R81 preferred to have individual activities and preferred to watch movies, so his wife provided an extra online streaming service for him to watch movies and television shows. She stated she received her information about a resident's care from the care plan kept at the nurses' station. She stated she did not participate in any clinical or inter-disciplinary team meetings to discuss updates or concerns. She stated she was not aware of the diagnosis of PTSD and therefore was not aware of specific triggers related to that history. She stated if she had known there were things that made R81 uncomfortable, she could have better planned for those and encouraged him to come out of his room. She stated R81 had told her that he preferred to be alone versus in a crowd and enjoyed movies and television programs. She stated R81's outpatient hemodialysis was scheduled three times a week. During an interview on 06/04/2025 at 10:18 AM with the Minimum Data Set (MDS) Nurse, she stated she was not sure why the diagnosis of PTSD was not on his MDS because she had done a trauma questionnaire with him, which was her responsibility. She stated she was aware this needed to be applied to his MDS assessment. During an interview on 06/05/2025 at 9:00 AM with the Director of Nursing (DON), she stated she was unaware of R81's diagnosis of PTSD. She stated since this information was not available on R81's most recent care plan, dated 04/15/2025, she and the floor staff was likely unaware of any potential triggers. She stated she would follow-up. She stated the harm in not knowing this information would be the lack of prevention of unintended stress or anxiety to the resident. She stated she was aware that R81's preferences included staying in his room and individual versus group activities. She also stated she felt R81's scheduled hemodialysis, three times a week, contributed to his desire not to go out of his room. During an interview on 06/05/2023 at 12:43 PM with the Administrator, he stated it was his expectation that a baseline care plan would be done for all residents, and it would be updated with an intervention as needed. He stated it was important to have this in place so staff would know how best to care for the residents.

Based on observation, interview, record review, and review of the U.S. Food and Drug Administration's (FDA) guidelines, the facility failed to ensure the resident environment remained as free of accident hazards as was possible to ensure the safety of 1 of 5 residents reviewed for vaping safety. Observation on 06/02/2025 revealed R62 using a vape (e-cigarette) while wearing a nasal cannula that was delivering four liters of oxygen (O2) with R44 exposed to R62's second hand vaping aerosol. The findings include: Review of the facility's policy titled, Electronic Cigarettes Policy [e-cig, vape, vapor pen], undated, revealed the vaping policy did not address oxygen use. Further review revealed there was no provision for the storage of Nicotine liquid (e-juice), and the policy did not address the exposure risk of others to second hand smoke. Review of the U.S. Food and Drug Administration's (FDA) guidelines, Tips to Help Avoid Vape Battery Fires or Explosions, dated 04/12/2024, revealed there could be added dangers, for example, if a vape battery caught fire or exploded near flammable gasses or liquids, such as oxygen. Therefore, per the guidelines, Don't vape around flammable gasses or liquids, such as oxygen, propane, or gasoline. Review of the facility's education to the vaping residents/families provided by the facility revealed it was a copy of an educational handout from the Centers for Disease Control and Prevention (CDC), undated, which was an infographic that was two pages and detailed the dangers of e-cigarettes and vaping. The handout had warnings about nicotine, heavy metals, diacetyl, and other unnamed dangerous chemicals. However, oxygen was not mentioned on the education sheet or any danger paired with oxygen. Review of the facility's document Smokers, updated 06/02/2025, revealed R62 was listed as vapes only. R44 was not on the document. Review of R62's Face Sheet revealed the facility admitted the resident on 10/01/2024 for chronic obstructive pulmonary disease (COPD), chronic kidney disease, and type 2 diabetes mellitus. Review of R62's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/31/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating intact cognition. Review of R62's Comprehensive Care Plan [CCP], initiated 10/01/2024, revealed the resident used vaping daily for pleasure in room. Interventions included to monitor and report any changes in ability to vape; monitor for any safety concerns, potential risks, and resident's ability to safety vape and manage oxygen; and educate as needed on potential risks of smoking/vaping. Review of the facility's document Resident Safe Smoking Assessment for R62, dated 10/03/2024, revealed she vaped in her room, and staff was to monitor for safety concerns and potential risks. Review of R44's Face Sheet revealed the facility admitted the resident on 08/12/2025 with diagnoses of systemic lupus erythematosus, organ or system involvement unspecified; dysphagia; and type 2 diabetes mellitus Review of R44's quarterly MDS, with an ARD of 04/14/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating intact cognition. Observation on 06/02/2025 at 2:50 PM revealed R62, while in her room, using a vape while wearing a nasal cannula that was delivering four liters of oxygen (O2). R44, who was R62's roommate was present, resting in her own bed in the room. During an interview on 06/04/2025 at 12:35 PM, R62 stated she did not receive education on oxygen and vaping. R62 stated she did use oxygen via the nasal cannula while vaping. The resident stated she had been able to quit cigarettes due to using the vape. In an interview on 06/04/2025 at 12:38 PM, R44 stated she had not been educated on the dangers of second hand smoke from vaping. During an interview on 06/04/2025 at 3:45 PM with Kentucky Medication Aide (KMA) 1, she stated, I thought the rules about O2 use and smoking did not apply to vapes before I was educated on that this morning. I thought the vape would be ok, but I know if I see that occur again, I am to immediately inform the Nurse. During an interview on 06/04/2025 at 3:12 PM with the Director of Nursing (DON), she stated she thought it was okay to vape around oxygen. She stated, while she was not sure of all the dangers of oxygen, she thought the vape was safe with it. She stated, The vape would not alarm me as there is not an open spark or flame. It is safer than a cigarette. During interview with the Administrator on 06/03/2025 at 2:41 PM, he stated a patient should not vape while receiving oxygen. He further stated, As part of their assessment, also in their care plan, we assess them and document that we went through that assessment with each resident. He stated there had been no accidents or incidents in the past year with smoking or vaping.

Based on observation, interview, review of the manufacturers' directions for use (DFU), and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 24 sampled residents, Resident (R) 46. Observation on 06/03/2025 revealed R46's tube feeding, tubing, and continuous bladder irrigation tubing were left uncovered when disconnected from the resident. The findings include: Review of the facility's policy titled, Infection Control Program, last review date 08/24/2024, revealed the primary purpose of the facility's infection control program policies and procedures was to establish guidelines to follow to provide a safe and sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. It also stated it was the responsibility of the process improvement (PI) committee, through the Infection Control Preventionist, to ensure that infection control policies and procedures were implemented and followed. Review of the facility's policy titled, Enteral Nutrition, last review date 01/2014, revealed that staff caring for residents with feeding tubes would be trained on the potential adverse effects of tube feeding, such as feeding tube associated complications. Review of the manufacturer's DFU for the [Brand Name] of the tube feeding set with a 1000 milliliter (mL) flush bag, revealed it included a protective cap at the end of the tubing for use when the tubing was disconnected from the resident. Review of the manufacturer's DFU, provided by the facility, for the [Brand Name] Intravenous Administration Set, lot number 186249KS, used in R46's continuous bladder irrigation (CBI), revealed it had a tip protector on each end of the tubing for the protection of the tubing when not in use. Observation on 06/03/2025 at 9:58 AM, revealed R46 was out of her room and both, the tube from her tube feeding and the intravenous (IV) tubing from her CBI, were left connected to the source and with the other end, intended for the resident, open to air and without appropriate covering. During an interview on 06/02/2025 at 3:15 PM with Registered Nurse (RN) 2, she stated she was the nurse for R46, and she was unaware of a specific cover for the tube-feeding or the IV tubing. RN2 stated she was unsure if those were available but acknowledged that some type of covering should have been placed on both tubes. She stated by leaving the ends open and uncovered, they could be exposed to germs and could cause the resident to become ill. She stated she was provided Infection Control training at the facility, in person, by the Infection Preventionist (IP), but she could not recall the date. After the interview, RN2 removed the tubing from the room and subsequently hung new tubing with caps. During an interview on 06/04/2025 at 9:37 AM with the Infection Preventionist Nurse, she stated it was her expectation that staff would follow the policies of the facility. She stated the concern for leaving the tubing without an appropriate covering was an increased risk for infection to the resident. She stated she provided education to staff initially upon employment and again monthly and as needed. During an interview on 06/05/2025 at 10:45 AM with the Director of Nursing (DON), she stated it was her expectation that staff would follow the facility's infection control policies. She stated the concern of leaving the tubing uncovered was the increased risk of infection for the resident. During an interview on 06/05/2025 at 12:43 PM with the Administrator, he stated he expected the staff to follow regulatory guidelines and facility policy regarding infection control.

Based on observation, interview, review of a Centers for Disease Control and Prevention (CDC) document, and review of the facility's policy, the facility failed to develop and implement effective policies to ensure the smoking safety for all residents that used electronic cigarettes (e-cigarettes or vapes) for 1 of 5 residents that used e-cigarettes, Resident (R) 62 and R44, who was exposed to R62's second hand vaping aerosol. Observation on 06/02/2025 at 2:50 PM revealed R62, with R44 present, using a vape while wearing a nasal canula that was delivering four liters of oxygen (O2), and the facility's vaping policy did not address oxygen use or the exposure risk of others to second hand smoke. Refer to F689 The findings include: Review of the facility's policy titled, Electronic Cigarettes Policy [e-cig, vape, vapor pen], undated, revealed the vaping policy did not address oxygen use. Further review revealed there was no provision for the storage of Nicotine liquid (e-juice), and the policy did not address the exposure risk of others to second hand smoke. Review of a CDC document About E-Cigarettes (Vapes), dated 10/24/2024, revealed e-cigarettes or vapes were battery operated devices that heated a liquid and produced an aerosol that released particles in the air, known as vapor. It stated that bystanders could also breathe in the aerosol from what the smoker breathed out. Per the document, e-cigarettes typically contained nicotine, a very addictive substance. It also stated the aerosol was not harmless and could contain cancer-causing chemicals; heavy metals such as nickel, tin, and lead; tiny particles that could be inhaled deep into the lungs; and volatile organic compounds. Review of the U.S. Food and Drug Administration's (FDA) guidelines, Tips to Help Avoid Vape Battery Fires or Explosions, dated 04/12/2024, revealed there could be added dangers, for example, if a vape battery caught fire or exploded near flammable gasses or liquids, such as oxygen. Therefore, per the guidelines, Don't vape around flammable gasses or liquids, such as oxygen, propane, or gasoline. Observation on 06/02/2025 at 2:50 PM revealed R62, while in her room, using a vape while wearing a nasal cannula that was delivering four liters of oxygen (O2). R44, who was R62's roommate was present, resting in her own bed in the room. During an interview on 06/04/2025 at 12:35 PM, R62 stated she did not receive education on oxygen and vaping. R62 stated she did use oxygen via the nasal cannula while vaping. During an interview on 06/04/2025 at 12:38 PM, R44 stated she did not smoke or vape and had not been educated on the dangers of second hand smoke from vaping. During an interview with Registered Nurse (RN) 2 on 06/04/2025 at 3:50 PM, she stated, We have not really been educated about vapes when used with oxygen. In the outside world we see the vapes being used everywhere and you really don't think about it. But here if you stop and think about it, maybe we should look into updating our policies. During an interview with the Director of Nursing (DON) on 06/04/2025 at 3:12 PM, she stated that while she was not sure of all the dangers of oxygen but thought the vape was safe with it. She stated, The vape would not alarm me as there is not an open spark or flame. It is safer than a cigarette. The DON stated she was part of the policy drafting meetings. She stated they did not discuss second hand exposure to other residents and the healthcare workers. She stated, Most of our workers vape themselves. Going forward we will be more thorough with our assessments. We will update the policy to include no oxygen with use, and more monitoring. During an interview with the Administrator on 06/03/2025 at 2:41 PM, he stated he was unaware of a resident using a vape while on 02, but that should not occur. During an interview with the Medical Director on 06/03/2025 at 3:58 PM, he stated he had not had any instances of treating anyone who had been injured or became sick from the use of the vape. He stated he felt it was a safer alternative to cigarettes. The Medical Director stated, As I examine patients at [the facility], there has been no evidence of anyone suffering significant harm from second hand smoke. If it didn't cause an enormous disruption, I would prefer the nicotine liquid to be kept at the nursing station because misuse instead of intended use would be more of a risk. I would be open to information from staff as to keeping liquid for vapes. It could be overkill to keep at the nurses' station, or less potential for harm. He did not address the issue of a patient on O2 and vaping.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to store, prepare, distribute and serve food under sanitary conditions in accordance with professional standards for food service safety. Observation of the kitchen during tour, on 01/08/19, revealed the ceiling had the appearance of dust and a dark mold like substance around the vents. In addition, the can opener and mixer attachment area was soiled. The findings include: Review of the facility's policy, titled Cleaning Instructions: Food Preparation Appliances, undated, revealed small appliance such as the mixers and food processors would be cleaned and sanitized after each use. Review of the facility's policy, titled Cleaning Instructions: Can Opener, undated, revealed the can opener would be cleaned after each use. Review of the facility's Monthly Cleaning List, dated 12/2018, revealed the overhead lights and vents were to be cleaned every three (3) months. Interview with the Dietary Manager, on 01/11/19 at 8:40 AM, revealed the facility did not have a policy related to cleaning the ceiling or vents. Observation of the kitchen, on 01/08/18 at 4:31 PM, revealed the can opener blade was not clean, and the counter mixer stem was not clean. Continued observation revealed the ceiling vents appeared dusty over the production line, and over the resident cart area. Further observation revealed the ceiling tiles around the vents had a dark substance with a mold like appearance. Observation of the kitchen, on 01/11/19 at 8:40 AM, revealed the ceiling vents remained dusty over the production line, and over the resident cart area. Continued observation revealed the ceiling tiles around the vents had a dark substance with a mold like appearance. Interview with the Dietary Manager, on 01/11/19 at 8:40 AM, revealed the cook and assistant cook should clean the can opener and stand mixer after every use. Continued interview revealed the Dietary Aide was assigned to clean the ceiling monthly. Interview with the Head Cook, on 01/11/19 at 8:50 AM, revealed the stand mixer stem and clean can opener should be cleaned daily. Continued interview revealed she has found the can opener and stand mixer stem left solid. Per interview, the facility's cleaning assignment scheduled the ceiling to be cleaned every three months. Further interview revealed the ceiling dust, above the food production area, could get into the food and contaminate resident food with bacteria. Interview with Assistant Cook, on 01/11/19 at 8:54 AM, revealed the can opener was found not cleaned after use, and the stand mixer stem was found not clean. Continued interview revealed kitchen equipment should be cleaned after each use. Further interview revealed the ceiling dust could contaminate resident food. Per interview, Maintenance or the Dietary cleaning person was assigned to clean the vents. Interview with Maintenance Director, on 01/11/19 at 9:04 AM, revealed the kitchen staff were responsible for maintenance of the ceiling vents. Continued interview revealed the Dietary Department could request assistance as needed with the ceiling vents from maintenance. Further interview revealed the appearance of a dark mold like substance around the ceiling vents could be from past leaks in the ceiling. Interview with the Director of Nursing (DON), on 01/11/19 at 12:54 PM, revealed it was her expectation that staff would keep the kitchen equipment clean and keep the ceiling and vents dusted and clean. Interview with the Administrator, on 01/11/19 at 1:07 PM, revealed it was his expectation for the kitchen equipment and tools to be cleaned. Continued interview revealed it was also his expectation for the ceiling and vents to be clean.

Based on interview, record review, and review of the facility Policy, it was determined the facility failed to implement their abuse policy related to reporting allegations of abuse for one (1) of four (4) sampled residents (Resident #1). Resident #1 reported an allegation of abuse to State Registered Nurse Aide (SRNA) #5; on 07/04/17, at approximately 8:15 PM; however, SRNA #5 failed to immediately report the allegation to her supervisor. The findings include: Review of the facility Policy titled Abuse/Neglect, updated 05/15/17, revealed employees were to report any perceived instance of neglect or abuse without delay, to the first line of supervision available, who would in turn communicate the problem through lines of authority to the Administrator. Further review revealed reports to the Administrator considered valid must be reported to the regulatory agencies. Review of Employee Files for State Registered Nurse Aide (SRNA)#1, SRNA #2, SRNA #3, SRNA #4, and SRNA #5, revealed all had been trained on recognizing and reporting abuse. Further review, revealed background checks had been completed prior to hire for these SRNAs with no concerns identified. Review of Resident #1's medical record revealed the facility admitted the resident on 06/10/14 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], 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. Review of Resident #1's Comprehensive Care Plan, revealed a focus of mood and behavior last updated 06/22/17, which stated the resident became angry when not allowed to smoke anytime he/she wanted. The goal stated the resident would comply with the smoking policy. The approaches to this problem included educating resident as needed on smoking policy; and provide redirection as needed during periods of agitation or confusion. Review of the facility Resident Abuse Form, revealed on 07/05/17 at 4:00 AM, SRNA #5 reported an incident of physical abuse which occurred on 07/04/17 at 5:55 PM, involving Resident #1 and SRNA #1, SRNA #2, and SRNA #3. Further review revealed the Office of Inspector General was not notified of the incident until 07/05/17 at 6:25 AM. Witness statements were attached indicating the following allegations: Review of the Witness statement written by SRNA #4, dated 07/04/17, revealed while SRNA #4 was standing at the door to the resident's room; the curtain was pulled, but she could see the shadow of the resident's blanket being tossed over the resident by SRNA #3. Further review revealed SRNA#3 then ran back to the sink and all three girls (SRNA #1, SRNA #2 and SRNA #3) were laughing while the resident was yelling and cursing. Interview with SRNA #4 on 07/25/17 at 1:44 PM, revealed she entered the facility through the back door on 07/04/17, and observed SRNA #1, SRNA #2, and SRNA #3 in Resident #1's room with the privacy curtain pulled. She stated she observed SRNA #1 at the foot of Resident #1's bed casting Resident #1's blanket out in a fanning motion and rushing back to the sink where SRNA #2 and SRNA #3 were. She stated she heard the three (3) aides laughing, and wasn't sure why, and also overheard Resident #1 cursing. She further stated she did not believe any abuse was going on at that time, as Resident #1 cursed a lot, and was often agitated. Review of the Witness Statement written by SRNA #3, revealed Resident #1 wanted to go smoke and SRNA #1 pulled out a pen and asked do you want to puff this? Per the Statement, SRNA #1 ran to the sink and started to throw water at the resident. Further review revealed SRNA #2 put the residents head and foot of bed all the way up and then SRNA #1 put ice down the resident's shirt. Per the Statement, SRNA #3 then took the sheet and tossed it over the bed and the resident's face got covered, but the resident uncovered his/her face before SRNA #3 could help. Phone interview with SRNA #3, on 07/25/17 at 3:06 PM, revealed she, along with SRNA #1 and SRNA #2 were on their way to clock out on 07/04/17, when they responded to Resident #1's call light. She stated Resident #1 wanted to go smoke, and SRNA #3 informed him/her it wasn't time to go smoke. She further stated Resident #1 then began yelling and cursing. SRNA #3 stated Resident #1 had thrown his/her blanket on the floor, and she put it back on him/her. She further stated Resident #1 tossed the blanket back on the floor as he/she was upset he/she couldn't go smoke. Continued interview revealed she couldn't remember very clearly what had happened, and when questioned was not forthcoming with information. SRNA #3 stated she was terminated by the facility. Phone interview with SRNA #1, on 07/25/17 at 12:30 PM, revealed she, along with SRNA #2 and SRNA #3, were en-route to the time clock to clock out when they responded to Resident #1's call light on 07/25/17 at approximately 5:55 PM. She stated Resident #1 was uncovered, with only a shirt and briefs on, and wanted to go smoke. She further stated she told Resident #1 the smoke break had been at 5:00 PM, and night shift would get him/her up for the 8:00 PM smoke break, at which point Resident #1 began yelling and cursing them. Per interview Resident #1 would often become upset and curse the staff. Continued interview revealed SRNA #3 attempted to cover Resident #1 up, and accidentally covered Resident #1's head. She stated she did not believe SRNA #3 was being abusive. SRNA #1 denied the allegations related to putting ice down the resident's shirt, splashing water on the resident, offering the resident a pen to smoke or putting the bed up and down. She stated she was called in to the facility the following morning, suspended, and later terminated. Attempts to reach SRNA #2 during the investigation were unsuccessful. A phone message was left for SRNA #2 on 07/25/17 at 1:18 PM. SRNA #2 did not return the call. Review of SRNA #2's employee file revealed she had been terminated by the facility. Interview with SRNA #5, on 07/25/17 at 1:31 PM, revealed, when she was on her way to clock in on the evening of 07/04/17, she observed SRNA #1, SRNA #2, and SRNA #3 in Resident #1's room laughing, although she couldn't see what they were doing. She revealed she spoke with SRNA #4 later, who shared what she had observed, and then she questioned Resident #1 about it during the resident smoke break at approximately 8:15 PM. She further stated Resident #1 told her the nurse aides (SRNA #1, SRNA #2, and SRNA #3) were holding the blanket over him/her. She revealed no one had ever reported an allegation of abuse to her, and she was scared and freaking out, and although she knew abuse was to be reported immediately, she waited several hours until the following morning when she reported the incident to the Charge Nurse. The Charge Nurse was not available for interview during the course of the investigation. Interview with Resident #1, on 07/25/19 at 11:28 AM, revealed he/she denied any allegations and dismissed it all by saying the aides were just playing around, and he/she ignored them when they did. Interview with the Social Worker, on 07/25/17 at 10:47 AM, revealed she and Licensed Practical Nurse (LPN) #1 had spoken with Resident #1 the day after the incident, and Resident #1 shrugged his/her shoulders a lot when they asked questions. She revealed Resident #1 stated they (SRNA #1, SRNA #2, and SRNA #3) were playing, and he/she ignored them, which they didn't like. The Social Worker further stated she had observed no changes in Resident #1's attitudes or behaviors following the incident. Interview with LPN #1, on 07/25/17 at 2:12 PM, revealed she and the Social Worker spoke with Resident #1 following the incident, and Resident #1 reported the nurse aides involved in the incident (SRNA #1, SRNA #2, SRNA #3) were just playing. She revealed yelling and cursing were ordinary behaviors for Resident #1, and there had been no changes in his/her behaviors following the incident. Further interview revealed she thought Resident #1 would report if anyone was inappropriate or had hurt him/her. Per interview, she had never heard of any complaints on SRNA #1, SRNA #2, or SRNA #3, and they had been dependable and hard working. Interview with SRNA #6, on 07/25/17 at 12:49 PM, revealed it was not out of the ordinary for Resident #1 to yell and curse staff, especially when he/she didn't want to do something or when he/she wanted to smoke. She revealed Resident #1 frequently wanted to smoke at times other than scheduled smoke breaks. Per interview, she had observed no changes in Resident #1's behaviors. Interview with SRNA #7, on 07/25/17 at 1:01 PM, revealed Resident #1 often refused care, and could be cranky and abusive towards staff. She revealed she had observed no changes in Resident #1's behaviors since the incident. Interview with the Assistant Director of Nursing (ADON,) on 07/25/17 at 3:24 PM, revealed the DON had been called the morning of 07/05/17 by the Charge Nurse, and the DON had informed the ADON of the incident. The ADON stated the residents were interviewed related to abuse and she sat in on some of the resident interviews. She stated there were no concerns voiced related to the three (3) aides (SRNA #1, SRNA #2, and SRNA #3) and they denied being abused. She revealed staff had been trained to report immediately, and she speculated SRNA #5 may not have reported the incident because she may not have been certain whether or not abuse had occurred. The DON was unavailable for interview during the investigation. Interview with the Staff Development Coordinator, on 07/25/17 at 3:37 PM, revealed staff were trained on orientation and at least annually on identifying and reporting abuse immediately. She revealed the importance of reporting immediately was stressed through inservices, and immediately meant report as soon as an incident occurred, after they ensured the resident was safe. Interview with the Administrator, on 07/25/17 at 3:46 PM, revealed he received a call from the Charge Nurse at approximately 4:30 AM on 07/05/17 related to the abuse allegation and the report was sent to State Agencies at 6:30 AM on 07/05/17. He revealed the last facility inservice on abuse was earlier this year when the reporting requirements had changed, and it was stressed to staff not to delay in reporting. He stated the facility treated the situation as an abuse allegation, and it should have been reported to the Charge Nurse immediately.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible, and each resident receives adequate supervision to prevent accidents. Observation during initial tour, on 12/13/16, revealed a medical supply closet was found to be unlocked and unattended with medical supplies, equipment, and chemicals accessible to residents. In addition, observation revealed a medication left unattended and unsecured in a resident room accessible to other residents (Resident #9). The findings include: Review of the facility Wander List (list of residents who have the tendency to wander about the facility, and may have confusion), revealed thirty-five (35) wanderers on the East Unit. 1. Review of the facility's Supplies and Equipment, Nursing Services Policy, undated, revealed nursing services personnel must use assigned equipment and supplies with care to promote safety. Further review revealed supply rooms, utility rooms, and supply cabinets were to remain locked when not in use. Observation during initial tour, on 12/13/16 at 1:05 PM, revealed the medical supply closet door on the East Unit was unlocked and unattended. Further observation of the contents within the medical supply room revealed the following items: Five (5) 16 ounce bottles of Alcohol 70% Isopropyl, five (5) 1.0 ounce tubes of Sterile Lubricating Gel, eleven (11) 4 ounce bottles of Derma Daily Moisturizing Lotion, four (4) 8 ounce bottles of Hydrogen Peroxide 3%, six (6) 32 ounce bottles of Isopropyl Alcohol 91%, two (2) 13.3 ounce containers of Sani-Cloth HB PDI Disposable Wipes, seven (7) Safety Gillett Razors, three (3) gallon bottles of Derma Vera Skin and Hair Cleanser, six (6) 200 count boxes of Sterile Alcohol Prep Pads, five (5) 8 ounce bottles of DermaKlenz, two (2) 100 count boxes of Providone Iodine Pads, one (1) 40.5 ounce bottle of Purell Hand Sanitizer, one (1) 4 ounce bottle of Purell Hand Sanitizer, twelve (12) 100 milliliter (ml) bottles of 0.9% Sterile Saline, one (1) 7.5 ounce can of ByeBye Odor Eliminator, twelve (12) 4 ounce bottles of DawnMist Mouth Rinse. Review of Safety Data Sheets (SDS) for Alcohol 70% Isopropyl, dated 11/04/14, revealed eye contact may cause eye irritation and serious eye damage, and ingestion may cause irritation to the mucous membranes and gastrointestinal system. Review of the Safety Data Sheets (SDS) for Sterile Lubricating Gel, dated 01/07/15, revealed ingestion can cause digestive tract irritation, and irritation to the respiratory tract if inhaled. Review of the Safety Data Sheets (SDS) for Derma Daily Moisturizing Lotion, dated 04/01/99, revealed ingestion can cause gastrointestinal irritation. Review of the Safety Data Sheets (SDS) for Hydrogen Peroxide 3%, dated 05/11/15, revealed eye contact can cause eye irritation and serious eye damage, and exposure to skin can cause corrosion and irritation. Review of the Safety Data Sheets (SDS) for Isopropyl Alcohol 91%, dated 04/05/99, revealed irritation can occur to the respiratory tract if inhaled, the gastrointestinal system if ingested, and skin if contacted. Review of the Safety Data Sheets (SDS) for Sani-Cloth HB PDI Disposable Wipes, dated 02/11/15, revealed contact with the eyes can cause irritation, ingestion can cause gastrointestinal irritation, and avoid contact with skin. Review of the Safety Data Sheets (SDS) for Derma Vera Hair and Skin Cleanser, dated 10/04/13, revealed contact with the eyes can cause irritation, and ingestion can cause gastrointestinal irritation. Review of the Safety Data Sheets (SDS) for Sterile Alcohol Prep Pads, undated, revealed eye contact can cause irritation, harmful if swallowed or contact with skin, and an allergic skin reaction can occur. Review of the Safety Data Sheets (SDS) for DermaKlenz, dated 04/01/99, revealed contact with eyes or ingestion can cause irritation. Review of the Safety Data Sheets (SDS) for Providone Iodine Pads, dated 02/15/15, revealed contact with the eyes can cause irritation, ingestion can cause gastrointestinal irritation, and contact with skin can cause irritation. Review of the Safety Data Sheets (SDS) for Purell Hand Sanitizer, dated 01/16/15, revealed can cause skin irritation, eye irritation, and irritation of the gastrointestinal tract if ingested. Review of the Safety Data Sheets (SDS) for 0.9% Sterile Saline, dated 10/12/11, revealed can cause skin irritation, eye irritation, and irritation of the gastrointestinal system if ingested. Review of the Safety Data Sheets (SDS) for ByeBye Odor Eliminator, dated 09/10/95, revealed exposure to skin can cause irritation, and contact with the eyes can cause irritation. Review of the Safety Data Sheets (SDS) for DawnMist Mouth Rinse, dated 12/07/15, revealed can cause skin irritation, eye irritation, and to contact the Physician or Poison Control Center if ingested. Interview with Maintenance, on 12/13/16 at 1:15 PM, revealed he was not aware the door was not locking appropriately, and stated it appeared the door had dropped or fallen from the top of the door jam. Interview with Licensed Practical Nurse (LPN) #4, on 12/15/16 at 8:30 AM, revealed the medical supply closet door should be locked at all times for resident safety. Interview with State Registered Nurse Aide (SRNA) #3, on 12/15/16 at 10:55 AM, revealed the supply room doors were to be locked at all times and a code was needed to enter into the keypad. Further interview revealed a resident could enter the supply room and get something that could cause harm. SRNA #3 further stated if the door needed repair, the Maintenance Department should have been notified immediately. Interview with SRNA #4, on 12/15/16 at 11:00 AM, revealed the supply closet door was supposed to be locked. She further stated a work order for maintenance needed to be completed to notify the department of any requested repair. Further interview revealed a resident could enter the supply closet and ingest items, which posed a danger. Interview with Registered Nurse (RN)/Supervisor #1, on 12/15/16 at 11:05 PM, revealed supply closets were supposed to remain locked at all times, and a code was required to enter the room. RN#1 further stated the Maintenance Director should be notified to fix any repairs. Further interview revealed a resident could enter the supply room and get something that was dangerous if the door was not locked. Phone Interview with LPN #2, on 12/15/16 at 12:18 PM, revealed all the doors are were to be locked and keypads were used to enter the rooms containing medical equipment and supplies. LPN #2 further stated the doors needed to remain locked in order for residents to not enter as the contents in the room could be hazardous to the residents. LPN #2 further stated she had noticed the supply closet door on the East Unit had been somewhat difficult to lock recently. Interview with SRNA #9, on 12/15/16 at 2:00 PM, revealed the supply closet should remain locked at all times. Further interview revealed a resident could go in the supply room and be exposed to hazards. Additionally, SRNA #9 stated a work order for maintenance should have been completed in order to address the supply closet door not locking properly. Interview with the Quality Assurance/Assistant Director of Nursing/RN, on 12/15/16 at 2:10 PM, revealed the supply room doors should be locked all the time, and if the doors were malfunctioning, maintenance needed to be made aware. Further interview revealed a resident could get into the supply room and get hurt, fall, or ingest a product. Interview with the Director of Nursing (DON), on 12/15/16 at 4:00 PM, revealed it was her expectation that the medical supply room door was locked at all times. She stated a resident could wander into the room and get something he/she should not, which posed a danger. Further interview revealed team leaders checked the unit doors every shift; however, there was not an official system in place to document the monitoring of the doors completed by the team leaders. Additionally, she stated she expected the maintenance department be notified in order to address any environmental repairs. Interview with the Administrator, on 12/15/16 at 4:30 PM, revealed it was his expectation that all storage door areas remain locked. Further interview revealed there was the potential for a resident to enter the storage rooms, which could result in harm if the doors were not locked. 2. Review of the facility's Self Administration of Medication Policy, undated, revealed a resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician. Further review revealed failure of a resident to comply with the policy must be promptly reported to the Director of Nursing and/or the Attending Physician. Review of Resident #9's medical record revealed the facility admitted the resident on 01/15/16, with diagnoses, which included Psychosis, Episodic Mood Disorder, Coronary Artery Disease, Depression, Anxiety, Schizoaffective Disorder, Hypertension, Gastro-Esophageal Reflux Disease, and Type 2 Diabetes. Review of Resident #9's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of 15, indicating Resident #9 was cognitively intact. Review of Resident #9's Physician Orders, dated December 2016, revealed an order for [REDACTED]. Review of the Medication Administration Record (MAR), dated December 2016, revealed Resident #9 last received Gaviscon on 12/09/16 at 12:00 PM. Further review of Resident #9's Physician order [REDACTED]. Observation during initial tour, on 12/13/16 at 12:05 PM, revealed a clear medicine cup with thirty (30) milliliters (ml's) of a blue-green colored liquid medicine on top of Resident #9's nightstand. Interview with Resident #9, on 12/13/16 at 12:05 PM and 12/15/16 at 8:25 AM, revealed the resident referred to the medication as Mylanta. The resident also stated it was ordered by the Physician for heartburn, and he/she occasionally asked for the nurses to provide it when experiencing heartburn after meals. Further interview revealed sometimes the staff watched the resident take the medicine for heartburn, or they just left it at the bedside to take whenever he/she needed it. Interview with Kentucky Medication Aide/SRNA#5, on 12/14/16 at 10:00 AM, revealed she routinely administered medications to Resident #9. KMA/SRNA #5 stated Resident #9 took the medications without difficulty and without refusal. Further interview revealed there were no residents in the facility that self administered medications, which included Resident #9. She further stated, when passing medications, staff was required to remain with the resident to ensure the medications were taken as ordered. Additionally, she stated medications were not to remain at the bedside due to safety concerns. Interview with Licensed Practical Nurse/East Supervisor (LPN) #4, on 12/15/16 at 8:30 AM, revealed there were no residents allowed to self administer medications. LPN #4 also stated, appropriate practice included watching the residents take all the medications. Further interview revealed leaving the medicines at the bedside posed a risk for potential wandering residents that could ingest the medication. Interview with Registered Nurse/Supervisor (RN) #1, on 12/15/16 at 11:05 AM, revealed residents were not allowed to self administer medications. She also stated medications were not supposed to be left unattended at the bedside. Continued interview revealed residents were to be observed when taking the medication. Additionally, RN#1 stated, if a medication was left unattended at the bedside, another resident could take the medication. Phone interview with LPN #2, on 12/15/16 at 12:18 PM, revealed she often cared for Resident #9, and did pass medications that morning before being moved to the treatment cart. Continued interview revealed Resident #9 would normally request antacid medication following meals; however, she did not remember administering the medication that morning. LPN #2 also stated it was not good practice to leave medications at the bedside, and when administering medications to the residents, it was necessary to stay with them to monitor proper administration. She stated, leaving medications at the bedside could result in a resident missing a dose or another resident taking the medication when it was not prescribed. Interview with the Director of Nursing (DON), on 12/15/16 at 4:00 PM, revealed in order for a resident to self administer medications, a physician's orders [REDACTED]. She further stated Resident #9 was not permitted to self administer medications. Further interview revealed the medication should not have been left at the bedside, and staff administering medication was to stay with the resident to ensure appropriate consumption. In addition, the DON stated it was a resident safety concern to leave medications at the bedside. Interview with the Administrator, on 12/15/16 at 4:30 PM, revealed it was his expectation for nursing staff to stay with the residents when passing medications until the medication was consumed. He further stated the medication should not have been left at the bedside, and Resident #9 was not assessed to self administer medications. Continued interview revealed it was a resident safety concern, due to the fact that another resident could wander into the resident's room and ingest the medication.

Based on observation, interview, review of facility policy, and review of the Plan of Correction (POC) for the Standard Survey conducted 01/14/16, it was determined the facility failed to maintain a Quality Assessment and Assurance (QA) program that developed and implemented effective plans of action to correct quality deficiencies. This was evidenced by a repeat deficiency from the Standard Survey, conducted on 01/14/16, related to the facility's failure to have an effective system in place to ensure the residents' environment remained as free of accident hazards as possible at 42 CFR 483.25 Quality of Care (F-323). The findings include: Review of the facility Performance Improvement Program (PIP) Policy, reviewed 11/10/99, revealed the facility developed, implemented, and maintained an ongoing program to monitor and evaluate the quality of resident care. The facility established priorities by measuring processes that were high volume, high risk, and problem prone. All facility processes affected resident outcome and data was collected on an ongoing basis for many processes in order to judge whether or not they were effective and stable or required further assessment and modification. Review of the facility's Supplies and Equipment, Nursing Services Policy, undated, revealed medical supply rooms, utility rooms, and supply cabinets were to remain locked when not in use. Further review revealed all necessary repairs were to be reported to the maintenance supervisor. Review of the facility's Plan of Correction (POC) for the Standard Survey completed 01/14/16, with a compliance date of 03/02/16, revealed all staff were inserviced on 01/12/16, 01/13/16, 02/16/16, and 02/17/16 by the Staff Development Coordinator on the importance of ensuring all storage areas remained locked when not in use. Further review revealed the Environmental Service Director would conduct monthly rounds, which would include a checklist to identify potential problems. This auditing tool was presented and approved by the Performance Improvement Committee. Review of the monthly Environmental Surveillance Checklists, dated 01/2016, 02/2016, 03/2016, 04/2016, 05/2016, 06/2016, 07/2016, 08/2016, 09/2016, 10/2016, and 12/2016, revealed the Environmental Service Director audited the facility for inadequate security storage areas. However, the checklist dated 11/2016, revealed a need for a follow-up regarding a key less keypad to storage areas for proper functioning. In addition to the required need for the follow-up, there was no documented evidence of the corrective action taken to address the malfunctioning key less keypads to specific storage areas. Review of the Maintenance Work Orders, for the months of November 2016 and December 2016, revealed no documented evidence of a work order request to inform maintenance of needed repairs to the East Unit medical supply closet door. Observation during the initial tour, on 12/13/16 at 1:05 PM, revealed the medical supply closet door on the East Unit was unlocked and unattended. Interview with the Maintenance Supervisor, on 12/13/16 at 1:15 PM, revealed he was not aware the door was not locking appropriately, and stated it appeared the door had dropped from the top. Further interview revealed any staff member could fill out a work order for maintenance in order to make any necessary repairs; however, there had not been any issued work orders regarding the malfunctioning door lock. Interview with Licensed Practical Nurse (LPN) East Supervisor #4, on 12/15/16 at 8:30 AM, revealed storage supply room doors should be locked at all times. Further interview revealed nursing supervisors check the doors during rounds, but do not have to do any documentation. She also stated if something needed repair, staff were instructed to complete a work order or tell the maintenance department directly. Interview with Registered Nurse (RN) Supervisor #1, on 12/15/16 at 11:05 PM, revealed supply closets should always be locked, and only staff members had the codes to enter into the key pads. Continued interview revealed the nursing supervisors should do rounds on their units to make sure the doors are locked, and if doors were not locking, maintenance needed to be notified. Interview with the Environmental Service Director, on 12/15/16 at 11:30 AM and 12:15 PM, revealed she used an Environmental Surveillance Checklist once a month to check the doors and key pads. She stated upon the discovery by the State Surveyor of the unlocked door, she noticed the door had dropped at an angle, and therefore adjusted the door hinges. She also stated the Maintenance Department had not received a work order to address the East Unit medical supply storage door not locking properly. Further interview revealed the November monthly audit did indicate a key pad for a door was not working; however, she did not document the location or which door it actually was. Additionally, she stated the type of push button system might need to be changed, especially in storage areas that were used frequently. Interview with the Quality Assurance (QA) RN, on 12/15/16 at 2:10 PM, revealed the storage doors were supposed to be locked at all times to ensure resident safety. She stated stricter monitoring of the door locks should be implemented, which included utilizing a log sheet and documenting the completed rounds of the door checks. Interview with the Director of Nursing (DON), on 12/15/16 at 4:00 PM, revealed storage areas were to be locked at all times for resident safety concerns. She also stated the nursing supervisors did rounds every shift; however, they were not documenting the rounds were performed. Further interview revealed environmental concerns should be reported to the supervisor and maintenance department when discovered. Interview with the Administrator, on 12/15/16 at 4:30 PM, revealed the current monitoring system for the doors was reported to the Performance Improvement Committee monthly, and until this survey he felt as though the method was working appropriately. However, due to problems found on the survey with the supply door being unlocked, he felt the past system needed to be re-evaluated and a new system put in place to monitor the doors of the storage unit areas.

Based on observation, interview, record review, and review of the facility policies, it was determined the facility failed to provide an ongoing program of activities designed to meet the residents' interest and physical, mental, and psychosocial well-being for one (1) of eighteen (18) sampled residents (Resident #10). Resident #10's Pre-Admission Screening and Resident Review (PASRR) level 2 evaluation indicated the need for specialized services which included ongoing meaningful activities; however, there was no documented evidence the resident received these activities. The findings include: Review of the facility's policy titled, Activity Program, revised 03/28/01, revealed an ongoing program of activities was designed to meet the needs of each resident. Continued review of the policy revealed the purpose of the activity program was to encourage restoration to self-care and maintenance of normal activity which was geared to the individual resident's needs. Further review of the policy revealed activities were to be scheduled daily and residents were to be given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the program. Continued review of the policy revealed the facility's activity program was to consist of individual, small, and large group activities which were designed to meet the needs and interests of each resident and included, as a minimum: social activities, indoor activities, outdoor activities, activities away from the facility, religious programs, creative activities, intellectual and educational activities, exercise activities, individualized activities, in-room activities, community activities, and diversional activities. Review of the facility's policy titled, Individual Activities, revised 03/28/01, revealed individual activities would be provided for those residents whose physical disabilities prohibited movement to other types of activities and to those residents who did not wish to attend group activities. Continued review revealed individual activities were provided because residents had a need for personal identity or were unable to or did not wish to participate in group activities. Further review of the policy revealed for those residents whose physical disabilities prohibited movement to a group activity or those who did not wish to participate in group activities, the activity program was to provide activities which made maximum use of each resident's physical/mental abilities and to provide activities which were interesting to and involved the resident, which presented a challenge that could be met by the resident. Review of Resident #10's Pre-Admission Screening and Resident Review (PASRR) level 2 evaluation, dated 11/30/12, revealed the resident was to receive specialized services (individualized activities that were meaningful to the resident) due to having a [DIAGNOSES REDACTED]. Review of Resident #10's medical record revealed the facility admitted the resident on 04/02/13, and readmitted the resident on 11/23/16, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 04/11/16, revealed the facility assessed Resident #10 to have severely impaired metal status (never/rarely made decisions regarding tasks of daily life). Continued review of the MDS section F800 revealed the facility assessed Resident #10 to have no daily preferences or activity preferences. Review of Resident #10's Comprehensive Care Plan, revealed the facility identified on 04/28/16 a problem of the resident having cognitive loss/dementia with being unable to speak and make needs known due to being diagnosed with [REDACTED]. The care plan goal was for the resident to make eye contact daily and to not injure self. The care plan approach (intervention) was for activities and social services to visit one on one (1:1) to provide stimulation as resident could tolerate, read to the resident 1:1, sing to the resident 1:1, apply lotion for gentle touch and stimulation, doll therapy 1:1, keep daily routine simple and consistent, and to provide consistent caregivers as practicable to minimize stress. Review of Resident #10's Activity Log Sheet on 12/14/16 at 3:50 PM, dated December 2016, revealed no documented evidence the resident was offered activities or attended activities for the month of December. Continued review of Resident #10's Activity Log Sheet, under the Progress Notes dated 12/01/16, revealed Resident #10 watched television in his/her room and watched animals outside his/her window. Further review of the Activity Log Sheet Progress Notes, revealed it was documented the resident was informed of all activities and was encouraged to attend. Documentation further revealed staff was willing to take him/her to and from all activities of choice. It was also documented staff did one on one (1:1) activities with the resident; however, there was no 1:1 activities logged. Observation, on 12/14/16 at 9:58 AM, revealed an activities staff member in Resident #10's room offering and assisting Resident #10's roommate to a singing activity in the dining room. Continued observation revealed the activity staff complimented Resident #10 about the shirt he/she was wearing, but did not invite the resident to attend the singing activity. Interview, on 12/14/16 at 11:15 AM, with State Registered Nurse Aide (SRNA) #2, revealed Resident #10 enjoyed watching cartoons on the television because of the music and the colors. Continued interview revealed Resident #10 would stop hitting himself/herself for a while during the cartoon. Interview, on 12/15/16 at 2:25 PM, with SRNA #3 revealed when she provided care to Resident #10, she will talk to the resident but was not able to provide meaningful activities to the resident. SRNA #3 stated she wished she did have more time to do activities with the resident; however, there wasn't time due to the other residents needing care provided. Interview, on 12/15/16 at 2:00 PM, with the Activities SRNA, revealed she tried to have some type of interaction with Resident #10 at least three (3) times a week but she did not get to do an activity with the resident every day. Interview, on 12/14/16 at 2:30 PM, with Licensed Practical Nurse (LPN) #1, revealed Resident #10 was only offered meaningful activities by the activities department. LPN #1 stated the SRNA's did not have the time to do activities with the residents. LPN #1 further stated he has never seen Resident #10 out of bed to go to an activity. Post survey interview on 01/03/16 at 9:25 AM with the Activities Director, revealed it was her expectation that the activities staff offer and provide activities to the residents that were meaningful and that the activities be documented. Post survey interview on 01/03/16 at 9:45 AM, with the Director of Nursing revealed it was her expectation individualized meaningful activities were offered to residents to meet the resident's preferences and needs.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the plan of care was reviewed and revised by the Interdisciplinary Team (IDT) after each assessment and change in the resident for one (1) of eighteen (18) sampled residents (Resident #10). Interviews with staff revealed Resident #10 refused Range of Motion (ROM) exercises; however, the care plan was not revised to reflect the resident's behavior of refusing care. The findings include: Review of the facility's policy titled, Care Plans-Comprehensive, undated, revealed a comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. Continued review of the policy revealed care plans were revised as changes in the resident's condition dictated and reviews were to be made at least quarterly. Review of the facility's policy titled, Using the Care Plan, undated, revealed the nurse aide was responsible for reporting to the nurse or charge nurse any change in the resident's condition. Continued review of the policy revealed daily care and documentation must be consistent with the resident's care plan. Review of the facility's policy titled, ROM/Contracture Care, undated, revealed all residents were to be assessed on admission and quarterly, or more often as change of condition warranted, for risk factors for development of contractures. Further review of the policy revealed a program would be developed based on the resident's unique risk factors and involving formalized therapy and/or restorative nursing, as applicable and would be reflected in the interdisciplinary care plan and would be systematically and consistently followed. Review of Resident #10's medical record revealed the facility admitted the resident on 04/02/13, and readmitted the resident on 11/23/16, with [DIAGNOSES REDACTED]. Continued review of Resident #10's medical record revealed the resident was admitted to the facility with Joint Contractures. Review of Resident #10's Comprehensive Care Plan, revealed the facility identified on 04/28/16 the problem of the resident being at risk for pain related to decreased mobility, contractures and multiple medical conditions. Continued review of the Comprehensive Care Plan revealed no goals related to contractures or ROM. Further review of the Comprehensive Care Plan revealed an approach (intervention) of ROM to be provided daily by staff to prevent declines in mobility status. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/10/16, revealed the facility assessed Resident #10 to have severely impaired mental status (never/rarely made decisions regarding tasks of daily life). Continued review of the MDS revealed the facility assessed the resident as having impairment in functional limitation of ROM on both sides to his/her upper and lower extremities. Review of the current Physicians Orders dated December 2016, revealed an order to have hand mitts removed every two (2) hours and provide ROM exercises. The original order date was 06/30/14. Review of the Nursing Assistant's Daily Care Flow Sheet for Resident #10, dated December 2016, revealed no documented evidence the resident was offered ROM exercises. Continued review revealed no documented evidence of the resident refusing or accepting ROM exercises. Interview, on 12/14/16 at 11:00 AM, with State Registered Nurse Aide (SRNA) #1 revealed on this day she did not complete the ROM exercises because the resident seemed to tighten his/her fingers and she was afraid to do the exercises and pull on his/her fingers where they were so tight. SRNA #1 stated she did not report this to the nurse. Interview, on 12/14/16 at 11:15 AM, with SRNA #2, revealed Resident #10's restraint mitts were to be taken off every two (2) hours to attempt ROM exercises to his/her fingers. Continued interview with SRNA #2 revealed the resident tightened his/her hands and was very rarely acceptable to the ROM exercises. SRNA #2 stated there was no care plan to address the behavior of refusing care. SRNA #2 further stated she had made the nursing staff aware of the resident refusing the ROM in the past. Interview, on 12/15/16 at 5:26 PM, with Licensed Practical Nurse (LPN) #1, revealed Resident #10 was sometimes resistant and refused ROM exercises. Continued interview revealed Resident # 10's care plan did not address the resident refusing care. LPN #1 stated staff would not report to him if a resident refused care because he did not provide care to the residents and only passed medications. LPN #1 further stated, as an LPN, he did not have a lot to do with care planning. Interview, on 12/15/16 at 5:40 PM, with Registered Nurse (RN) #3, revealed SRNA's had reported to her, Resident #10 did sometimes resist care when the SRNA's attempted to provide ROM exercises. Continued interview with RN #3, revealed Resident #10 was not care planned for resisting care and she had not reported the resident resisting care to the MDS nurse, in order for the care plan to be revised to indicate the resident refused ROM. RN #3 further stated it would have been helpful if Resident #10's care plan would have reflected his/her behavior of resisting care so other interventions could have been put in place. Interview, on 12/15/16 at 5:58 PM, with the Director of Nursing (DON), revealed it was her expectation if a resident's resistance of care was deemed a problem, the care plan be revised. Continued interview revealed care plans were important because it directed the resident's care. Interview, on 12/15/16 at 6:02 PM, with the facility Administrator, revealed it was his expectation for care plans to be updated as needed. Continued interview revealed care plans were important because they were the basis and the building blocks for residents, care.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident with limited Range of Motion (ROM) receives appropriate treatment and services to prevent further decrease in range of motion for one (1) of eighteen (18) sampled residents (Resident #10). There was no documented evidence the facility's staff was providing ROM exercises as ordered by the physician. The findings include: Review of the facility's policy titled, ROM/Contracture Care, undated, revealed all residents were to be assessed on admission, quarterly, or more often as change of condition warrants, for risk factors for development of contractures. Continued review revealed a program was to be developed based on the resident's unique risk factors involving formalized therapy and/or restorative nursing, as applicable. The policy further stated the program would be reflected in the interdisciplinary care plan and would be systematically and consistently followed. Further review of the policy revealed formalized therapy was to work closely with nursing staff communicating and planning for goals and approaches so the team could be consistent in providing the care and services for maintaining joint mobility and for contracture care. Continued review of the policy revealed the protocol for ROM was ten (10) repetitions daily, seven days a week for prevention of contractures unless the resident was unable to tolerate ten (10) repetitions, then the program would be modified. The policy revealed active/active assertive range of motion (AAROM) and passive range of motion (PROM) was part of the basic State Registered Nurse Aide (SRNA) training and could be performed by all nursing assistants and nursing's primary responsibility was to preserve the residents' present ROM. Review of Resident #10's medical record revealed the facility admitted the resident on 04/02/13, and readmitted the resident on 11/23/16, with [DIAGNOSES REDACTED]. Continued review of the medical record revealed the resident was admitted to the facility with Joint Contractures. Review of Resident #10's Comprehensive Care Plan, revealed the facility identified on 04/28/16 the problem of the resident being at risk for pain related to decreased mobility, contractures and multiple medical conditions. Continued review of the Care Plan revealed no goals related to contractures or ROM. Further review of the Care Plan revealed an intervention for ROM to be provided daily by staff to prevent declines in mobility status. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/10/16, revealed the facility assessed Resident #10 to have severely impaired mental status (never/rarely made decisions regarding tasks of daily life). Further review of the MDS revealed the facility assessed the resident as having functional limitations to ROM and impairment on both sides to his/her upper and lower extremities. Review of Resident #10's current December 2016 Physicians Orders, revealed an order originally dated 06/30/14, to have hand mitts removed every two (2) hours and be provided ROM exercises. Review of the Nursing Assistant's Daily Care Flow Sheet for Resident #10, dated December 2016, revealed no documented evidence the resident was offered ROM exercises. Continued review revealed no documented evidence of the resident refusing or accepting ROM exercises. Observation, on 12/14/16 at 9:40 AM, revealed SRNA #1 removed Resident #10's soft hand mitt restraints, Continued observation revealed SRNA #1, did not attempt any ROM exercises to Resident #10's hands. Interview, on 12/14/16 at 11:00 AM, with SRNA #1, revealed on the morning of 12/14/16 she was supposed to perform ROM exercises to Resident #10's hands; however, she did not complete the exercises because the resident's fingers seemed tight and she was afraid to pull on them. Interview, on 12/14/16 at 11:15 AM, with SRNA #2, revealed Resident #10's soft restraint mitts were to be removed every two (2) hours and ROM exercises performed and documented on the Nursing Assistant's Daily Care Flow Sheet. Interview, on 12/15/16 at 2:00 PM, with the Activities SRNA, revealed she was to perform ROM exercises with Resident #10 when she did activities with the resident in the resident's room. Continued interview with the Activities SRNA, revealed she did not document the ROM exercises because she only documented ROM on residents who were in the restorative program. Interview, on 12/15/16 at 2:05 PM, with Registered Nurse (RN) #1, revealed it was her expectation SRNA's documented the ROM exercises performed with residents on the Nursing Assistant's Daily Care Flow Sheet. Continued interview revealed SRNA's should have documented if the resident refused the exercises. RN #1 revealed the documentation was important so there was a record of the exercises completed. Interview, on 12/14/16 at 12:40 PM, with the Therapy Program Manager, revealed she had not ever been able to get a true and accurate ROM assessment for Resident #10 due to his/her behavior of hitting himself/herself. Continued interview revealed she did not consider Resident #10 a candidate for therapy rehabilitation or restorative program; however, stated the nursing staff should be performing ROM exercises with the resident. Interview, on 12/15/16 at 2:55 PM with Resident #10's Attending Physician, revealed the purpose of his physician's orders [REDACTED]. The Attending Physician stated Resident #10's contractures had worsened due to lack of active exercise. Continued interview revealed it was important for staff to complete passive or active ROM exercises with Resident #10 to slow down the contracture disease process. The Physician stated it was important for the facility to be more diligent going forward with completing the ordered ROM exercises. Interview, on 12/15/16 at 3:55 PM, with the Director of Nursing (DON), revealed it was her expectation SRNA's perform ROM exercises with Resident #10 during routine care and per the care plan instructions. Continued interview with the DON revealed it was important for the ROM exercises to be performed to promote movement and mobility. Interview, on 12/15/16 at 4:25 PM, with the facility Administrator, revealed it was his expectation ROM exercises be carried out by staff because it was important to keep the residents at their highest level of functioning.