Every finding on record at Kingsbrook Lifecare Center

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, 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 affecting 4 of 26 sampled residents, Residents (R) 57, R60, R87, and R132. Observations on 06/02/2025 and 06/04/2025 revealed opened packages of resident items, clothing, and equipment that were stored in unclean areas; staff providing direct care for residents in Enhanced Barrier Precautions (EBP) that did not wear appropriate personal protective equipment (PPE), dispose of PPE properly, and perform required hand hygiene; staff holding clean linen against their person; and staff, after performing fingersticks to measure blood glucose levels, did not clean and disinfect two glucometers according to the manufacturer's instructions and the required dwell times for the sanitizing wipes. The findings include: Review of the CDC Guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care was completed. It stated staff should ensure the proper selection and use of PPE based on the nature of the patient interaction and potential for exposure to blood, body fluids, and/or infectious materials. Review of the CDC Guidelines How to Safely Remove Personal Protective Equipment Example 1, no date, revealed to remove all PPE before exiting the room. The policy stated if the outside of the gloves were contaminated, they should be removed first in the sequence of PPE removal. Further review revealed to perform hand hygiene when hands became contaminated and immediately after removing all PPE. Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], revised May 2023, revealed the facility maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. Review of the facility's policy titled, Standard Precautions, revised September 2024, revealed standard precautions would be applied to all residents, regardless of diagnosis or infection status. It stated hand hygiene must be performed using soap and water or alcohol-based hand rub (ABHR), especially when hands were visibly soiled or after contact with contaminated items. Per the policy, gloves should be removed before touching non-contaminated surfaces or other residents, and hands should be washed to prevent transferring microorganisms. Additionally, the policy stated shared equipment must be cleaned and disinfected before use on another resident. Review of the facility's policy titled, Infection Control Manual/Enhanced Barrier Precautions[EBP], dated 03/31/2025, revealed EBP reduced the transmission of multidrug-resistant organisms (MDRO) by staff wearing gloves and a gown during high-contact resident care. These high-contact activities included dressing, bathing, transferring patients, providing hygiene care, changing linens, changing briefs, and during device care or use. Review of the facility's policy titled, Care of Glucose Monitoring Equipment, revised February 2010, revealed the purpose of the policy was to prevent the direct transmission of an infectious agent through a contaminated device. Per the policy, it stated to clean the glucose monitoring equipment following the manufacturer's recommendations between every use. Review of the [Product Name] Blood Glucose Monitoring System Cleaning and Disinfecting Operations and Procedure Manual, revised 10/18/2023, revealed the blood glucose meters (glucometers) needed to be cleaned and disinfected after each use. The manual stated cleaning and disinfecting was accomplished according to the manufacturer's guidelines with an Environmental Protection Agency (EPA) registered disinfectant or germicide that was approved for a health care setting. Per the manual, the glucometer was to be stored in its original storage case. Additionally, Sani-Cloth Germicidal Wipes were approved for use with this brand of glucometer. Review of the Sani-Cloth Germicidal Wipe package instructions revealed to thoroughly clean and disinfect the glucometer surface, which must be thoroughly wet, and allow the treated surfaces to remain wet for three minutes, then air dry. Review of R132's admission Record revealed the facility admitted R132 on 06/04/2024 with diagnoses that included congestive heart failure, respiratory failure with hypoxia, and sepsis. Review of R132's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/04/2025, revealed a Brief Interview for Mental Status [BIMS] score of 13 out of 15, which indicated the resident was cognitively intact. Review of R87's admission Record revealed the facility admitted R87 on 02/16/2022 with diagnoses that included type 2 diabetes, anemia, and atrial fibrillation. Review of R87's admission MDS, with an ARD of 04/05/2025, revealed a BIMS score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R87's Order summary Report, revealed the resident was place in EBP for a colostomy. 1. Observation of R60's room on 06/02/2025 at 11:42 AM revealed an open package of skin wipes and a tube of barrier cream were observed on the bathroom sink. On the floor, between the toilet and the wall, was an opened bag of incontinence pads and a bag of opened briefs. 2. Observation on 06/02/2025 at 11:47 AM, of R132's room, under EBP, revealed contaminated gloves and trash were on the floor in the bathroom, and the resident's clothing was left on the bathroom floor. Additionally, dirty clothes were placed on the bedside table. A used nebulizer's tubing and mouthpiece were discovered lying on top of the resident's mail in a plastic basket. State Registered Nurse Aide (SRNA) 1 was observed providing direct care to R132, but he failed to don (put on) the appropriate PPE. During an interview with R132 on 06/02/2025 at 11:42 AM, she stated staff might wear gloves while providing direct care, but she did not remember them gowning up. She stated she had a lot of belongings but would prefer that staff did their part to keep the room tidy. During an interview with Unit Manager (UM) 1 on 06/02/2025 at 11:47 AM, she stated the staff should maintain a clean and sanitary environment by ensuring that rooms were tidy and supplies were put away. She stated resident equipment, supplies, and personal belongings should not be stored on sinks or floors and respiratory equipment should be cleaned and stored in a plastic bag. Additionally, UM1 stated that nurses and nurse managers should conduct regular walk-throughs in the rooms to verify they were clean, organized, and equipment was stored in a sanitary manner. Furthermore, the UM stated that SRNA1 should wear the appropriate PPE when providing direct care to residents under EBPs. She stated all staff had participated in multiple in-service training sessions regarding PPE and EBPs. UM1 stated she did not know why the residents' supplies were not stored properly. She stated adhering to infection prevention and control practices (IPCP) was important to prevent the spread of infection and cross-contamination. 3. a. Observation on 06/02/2025 at 12:07 PM revealed Registered Nurse (RN) 7 used a shared glucometer to measure R57's blood sugar. Further observation revealed RN7 wiped the glucometer with a sanitizing wipe for less than 15 seconds. Continued observation revealed the glucometer stayed wet for less than 45 seconds. In an immediate interview, RN7 stated she did not know how long the glucometer needed to remain wet in order to kill bacteria and viruses that could be on the glucometer. She stated disinfection was important for infection control. b. Observation of RN1 on 06/04/2025 at 3:45 PM revealed she performed a blood glucose check on R87. RN1 completed a fingerstick; however, the glucose meter displayed an error message. RN1 disposed of the used test strip and placed the contaminated glucometer on top of the medication cart without any barrier. After removing her gloves, RN1 did not perform hand hygiene before putting on a new pair of gloves and picking up a different glucometer. She conducted another fingerstick, disposed of the test strip, and once again placed the contaminated glucometer on the medication cart without a barrier, neglecting to perform hand hygiene. RN1 then took a Sani-Cloth Germicidal Wipe and cleaned the surface of the first glucometer for 8.53 seconds before setting it on a clean barrier to dry. Subsequently, she wiped the surface of the second glucometer for 5.26 seconds and also placed it on a clean barrier to dry. After this, she removed her gloves, again without performing hand hygiene. During an immediate interview with RN1, she stated she was taught to wipe the glucometer clean and let it dry for three to five minutes. When asked by the State Survey Agency (SSA) Surveyor to explain what kill/dwell time meant, RN1 was unable to explain. Continued interview revealed RN1 reviewed the Sani-Cloth Germicidal Wipe instructions and stated that the object must remain wet for a full three minutes and then be left to air dry for complete disinfection to take place. 4. Observation of SRNA3 on 06/02/2025 at 1:02 PM, revealed she was holding clean linen against her person while walking in the hallway. During an interview with SRNA3 on 06/02/2025 at 1:02 PM, she stated she should not hold linen against her body during transport, as it might contaminate the clean linen. She stated she received training on infection control policies and procedures during orientation and multiple in-service trainings. SRNA3 further stated that following IPCP was important to prevent the spread of infection and cross-contamination. 5. Observation on 06/02/2025 at 2:00 PM revealed SRNA3 doffed (took off) her gown while still wearing contaminated gloves. After removing the gloves, she walked out of the room without performing hand hygiene while in a EBP room. During an interview with SRNA3 on 06/02/2025 at 2:02 PM, she stated she took off the gown the way she was trained. She stated she did not know to remove gloves first if wearing a reusable gown, and to her knowledge, there was no difference between taking off a disposable gown and a reusable gown. She stated she was going to perform hand hygiene after she disposed of her trash. 6. Observation of room [ROOM NUMBER] on 06/02/2025 at 2:15 PM revealed two cloth gowns were not hung up in a sanitary manner; one was placed on a chair, and the other was bundled up and placed on top of a dirty laundry basket. During an additional interview with UM1 on 06/02/2025 at 2:30 PM, she stated the staff should hang up reusable gowns on the provided hooks when doffed. She stated if the gown was soiled, it should be bagged and taken to the dirty utility room. Again, she stated that adhering to infection prevention and control practices (IPCP) was important to prevent the spread of infection and cross-contamination. During an interview with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 06/04/2025 at 10:23 AM, she stated the facility adhered to CDC's guidelines and followed the facility's infection prevention and control policies (IPCP). She stated all EBP rooms had signs on the doors leading into the room. The IP/SDC stated gowns and gloves must be worn whenever staff entered an EBP room if they were providing a high-level of care. She stated all staff needed to remove gloves and perform hand hygiene prior to performing care and before leaving a resident's room. According to the IP/SDC, all staff members received education related to IPCP. The IP further stated nursing staff should follow the facility policy and manufacturer's guidelines to clean and disinfect the glucometer. In continued interview with the IP/SDC on 06/04/2025 at 10:23 AM, the IP stated she was unsure why staff did not follow isolation precautions despite having been educated on the importance of observing the signs posted on doors. She stated all staff was trained upon hire in the use of PPE and isolation precautions, including EBP. The IP/SDC stated it was her expectation that all staff adhered to the facility's policies and procedures to help prevent the spread of infections. She stated it was important for the health and safety of the residents. During an interview with the Director of Nursing (DON) on 06/04/2025 at 2:43 PM, he stated the IP was responsible to oversee IPCP and ensure that staff was following facility policy based on CDC guidelines. The DON further stated following IPCP was important to prevent the spread of infection and cross-contamination. He stated he had received infection control training upon hire, and it was reviewed many times throughout the year. During an interview with the Administrator on 06/05/2025 at 10:46 AM, she stated the quality department and the infection prevention team were responsible for engaging upper leadership and nursing leadership to implement infection control practices. She stated everyone had a responsibility to follow the facility policies related to infection control, which was essential in preventing the spread of infections and cross-contamination. The Administrator stated further that all staff members had received infection control training upon hire, which was reviewed multiple times throughout the year. She stated it was her expectation that staff adhered to the infection prevention protocols in the facility, as this impacted the health quality of residents, staff, and their families. Additionally, she stated nursing leaders were expected to conduct audits for cleanliness, and adherence to CDC guidelines was essential. During a telephone interview with the Medical Director on 06/05/2025 at 3:41 PM, she stated following IPCP was important to prevent the spread of infection and cross-contamination. The Medical Director stated staff should follow facility policies and procedures for the safety and well-being of the residents.

4. Review of R130's closed admission Record revealed the facility admitted the resident on 03/19/2025 with diagnoses including orthopedic aftercare following surgical amputation, insomnia, depression, and anxiety disorder. Review of R130's MDS, with an ARD of 03/25/2025, revealed the facility assessed the resident with a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed R130 denied depression symptoms such as feeling hopeless. Continued review revealed the facility assessed the resident as being free from delusions, hallucinations, and behaviors during the look back period. Review of R130's CCP, dated 03/20/2025, revealed the facility assessed the resident as at risk for side effects of psychotropic medications she was ordered due to a history of psychosis, hallucinations, and delusions. Further review revealed the facility included interventions such as observing the resident for worsening of her psychiatric condition and worsening confusion. Review of the staff interviews from the Facility Investigation, dated 04/02/2025, revealed on 04/02/2025, State Registered Nurse Aide (SRNA) 11 was giving report to SRNA12 and stated R130 had acted crazy that night. Further review revealed R130 overheard SRNA11 and called out, I'm not crazy! Continued review revealed the Social Services Director interviewed R130, who was upset, and stated she had not been sleeping and requested a room change. Review of R130's Discharge Summary, dated 04/10/2025, revealed the facility discharged R130 home on [DATE] according to her discharge plan. The State Survey Agency (SSA) Surveyor attempted an interview with R130 via phone; however, the number available for her had been disconnected. In an interview on 06/04/2025 at 8:03 PM, SRNA11 stated she did tell SRNA12 during report that R130 had acted crazy through the night. She stated, when she realized R130 had overheard her, she immediately told the nurses, who were also in report. SRNA11 stated she had been disciplined for her unprofessional comment and had learned to be more careful with what she said because a resident who overheard a careless comment could be offended. In an interview on 06/05/2025 at 10:45 AM, Licensed Practical Nurse (LPN) 5 stated she recalled hearing SRNA11 state R130 had overheard her say the resident was crazy during report. She further stated it was inappropriate for a staff member to say something like that because it could offend a resident and was also dismissive of medical symptoms the resident could be experiencing. In an interview on 06/05/2025 at 10:59 AM, Resident Care Manager (RCM) 1 stated her expectations for staff while giving report were for staff to speak quietly in the hallway. She further stated she expected staff to communicate clinical information in a professional manner, using clinical terms rather than slang. Per interview, RCM1 stated SRNA11 had a loud voice and made a poor choice of words that undermined R130's dignity while the resident was hallucinating. In continued interview, RCM1 stated R130 was briefly upset about SRNA11's comment, but was primarily upset about not being able to sleep. Per interview, R130 reported feeling better after a nap and continued participating in her normal activities. Additionally, RCM1 stated SRNA11 did not take care of or interact with R130 following the incident. RCM1 stated someone in upper management officially disciplined SRNA11 for her lack of professionalism, and RCM1 re-educated staff on the importance of speaking respectfully about residents. In an interview on 06/05/2025 at 2:18 PM, the Social Worker stated her role in investigating resident concerns about staff members was to interview any staff present at the time of the incident, as well as all interviewable residents to determine if any of them had a similar concern. In further interview, the Social Worker stated SRNA11 admitted she did call R130 crazy during report. Per interview, SRNA11 reported to the Social Worker she did not realize until after R130 called out, I'm not crazy! that the resident could hear her. The Social Worker stated R130's primary concern was not sleeping and requested a move to a private room to help her sleep better. Additionally, the Social Worker stated she followed up with R130 over the next few days and did not observe any psychosocial changes, and the resident reported feeling much better after sleeping. In an interview on 06/05/2025 at 11:17 AM, the Director of Nursing (DON) stated staff made him aware of SRNA11's inappropriate comment about R130 when he arrived at work that morning, shortly after the incident. He further stated he immediately suspended SRNA11 pending investigation. Per interview, the Social Worker conducted staff and resident interviews and determined SRNA11 did state that R130 was acting crazy, and R130 did overhear her. In continued interview, the DON stated the facility found no further concerns in the course of the investigation and brought SRNA11 back to work after official disciplinary action. Additionally, the DON stated he came in on night shift when SRNA11 was working to observe her and to personally talk to her about why it was important to protect the resident's dignity. In an interview on 06/05/2025 at 11:23 AM, the Director of Resident Care Services stated she conducted the meeting with SRNA11 and the night shift supervisor in which she gave SRNA11 the notice of official disciplinary action based on her unprofessional comment about R130's behavior. She further stated she instructed the night shift supervisor to observe SRNA11 more frequently to ensure she was meeting expectations to speak to and about residents respectfully. Based on observation, interview, record review, review of the facility's investigation report, and review of the facility's policy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 26 sampled residents, Resident (R) 99, R110, R117, and R130. The findings include: Review of the facility's policy titled, Resident Rights, revised 10/2022, revealed the resident had the right to a dignified existence, self-determination, including privacy and the right to participate in decisions and care planning. 1. Review of R117's admission Record revealed the facility admitted her on 04/01/2025 with diagnoses of acute kidney failure, congestive heart failure, and hyponatremia. Review of R117'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 15 out of 15, indicative of intact mental cognition. Further review revealed R117 was not admitted with any form of bladder appliance, was not on a urinary toileting program, and experienced frequent urinary incontinence. Review of R117's Physician Orders, dated 05/20/2025 revealed an order for an indwelling urinary catheter with catheter care every shift and as needed, intake and output every shift, and incontinence products as needed. Observation made on 06/02/2025 at 12:57 PM revealed R117 was lying in bed with the urinary catheter bag visible on entry to the resident's room. The drainage bag was placed on the bed frame, with no dignity bag covering in place. Observation made on 06/02/2025 at 4:03 PM revealed R117 was sitting in the wheelchair in the therapy gym participating in physical therapy with her urinary drainage bag visible and hooked on the wheelchair frame, with no dignity bag covering in place. Observation made on 06/03/2025 at 9:09 AM revealed R117 was lying in bed with her urinary drainage bag visible on entry to her room. It was placed on the bed frame, with no dignity bag covering in place. In an interview with R117 on 06/03/2025 at 9:09 AM, she stated she had a catheter placed at the hospital on an unknown date, and since its placement, she had never had any covering over the collection bag and was unaware what it was and that it was an option. R117 stated she had been going to therapy every day and had been concerned about the catheter bag being out where everyone could see it. In a follow up interview with R117 on 06/04/2025 at 9:30 AM, she stated she had asked staff if they could provide her with a covering for her catheter bag, and they immediately obtained one, placed it, and she was happy it was in place. In an interview with State Registered Nurse Aide (SRNA) 4 on 06/04/2025 at 9:26 AM, she stated dignity coverings for catheter bags were placed upon resident request, but not on a routine basis. In an interview with Registered Nurse (RN) 2 on 06/04/2025 at 9:37 AM, she stated to her knowledge it was not in the facility's catheter policy to place a dignity bag, but they were placed if the resident requested it as a preference. RN2 stated R117 had a dignity bag in place when she came on shift today and was unaware when or who had placed it. 2. Review of R99's admission Record revealed the facility admitted the resident on 10/10/2022 with diagnoses to include obstructive uropathy, benign prostatic hyperplasia, and congestive heart failure. Review of the R99's quarterly MDS, with an ARD of 05/21/2025, revealed the facility assessed the resident to have a BIMS score of 13 of 15, which indicated the resident was cognitively intact. Review of R99's Comprehensive Care Plan [CCP], not dated, revealed the facility assessed the resident as requiring a catheter for alterations in urinary elimination related to benign prostatic hyperplasia. The care plan for R99 did not include an intervention to provide a dignity bag cover. Observation of the 100 Hall on 06/03/2025 at 8:01 AM revealed R99's door was open. R99 was in the bed. The resident's catheter collection bag was visible from the hallway, contained urine, and had no dignity bag cover. Interviews with Resident R99 were attempted; however, none were successful. The resident was under Hospice care and was asleep during the interview attempts. 3. Review of R110's admission Record revealed the facility admitted the resident on 11/22/2024 with diagnoses to include obstructive uropathy, benign prostatic hyperplasia, and congestive heart failure. Review of the R110's quarterly MDS, with an ARD of 05/28/2025, revealed the facility assessed the resident to have a BIMS score of 10 of 15, which indicated the resident had moderate cognitive impairment. Review of R110's CCP, not dated, revealed the facility assessed the resident as requiring a catheter related to obstructive uropathy and required a suprapubic catheter. The care plan for R110 did not include an intervention to provide a dignity bag cover. Observation of the 100 Hall on 06/03/2025 at 9:02 AM revealed R110's door was open. The resident was in her room lying supine in bed. The resident's suprapubic catheter collection bag was visible from the hallway, contained urine, and had no dignity bag cover. During an interview with R110 on 06/03/2025 at 9:05 AM, the resident stated she would like the urine collection bag covered. During an interview with SRNA13 on 06/05/2025 at 10:20 AM, she stated dignity bag covers for catheter collection bags were not routinely used but were provided upon resident request. During an interview with Unit Manager (UM) 1 on 06/03/2025 at 11:27 AM, she stated to her knowledge, the facility's catheter policy did not require the use of dignity bags. She stated dignity covers were provided only if a resident requested them as a preference. During an interview with the Director of Nursing (DON) on 06/05/2025 at 2:43 PM, she stated it was her expectation that staff followed the facility's policy to maintain residents' privacy and dignity. She stated it was important to provide a dignity bag cover for the closed urine collection bag to maintain the resident's dignity. During a telephone interview with the Medical Director on 06/05/2025 at 3:41 PM, she stated staff should follow facility policies and procedures for the dignity, safety, and well-being of the residents.

Based on interview, record review, review of the facility's agreement with the dialysis center, and review of the facility's policy, the facility failed to ensure that residents requiring dialysis received services consistent with professional standards of practice by failing to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 2 of 3 residents receiving dialysis, Resident (R) 64 and R123. The findings include: Review of the facility's policy titled, Continuum of Care with Dialysis Center, revised 10/2017, revealed the facility's intent was to maintain effective communication with the dialysis center to provide the best continuum of care and outcomes for all residents receiving hemodialysis. Additional review revealed nursing would provide the dialysis center with a current medication list. Further review revealed the dialysis center would send labs, diet, and weight sheets back to the facility following treatment for nursing to review and place in the resident's medical record. Review of the facility's agreement with the dialysis center Long Term Care Facility Outpatient Dialysis Service Coordination Agreement, signed by the facility on 06/10/2022 and signed by the dialysis center on 06/13/2022, revealed mutual obligations in collaboration of care by both parties by ensuring documented evidence of collaboration of care and communication between the two entities. 1. Review of R64's admission Record revealed the facility admitted the resident on 11/01/2021 with diagnoses to include stage 4 chronic kidney disease (CKD), dependence on renal dialysis, and anemia in CKD. Review of the R64's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/09/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 of 15, which indicated the resident was cognitively intact. Review of R64's Comprehensive Care Plan [CCP], not dated, revealed the facility assessed the resident as requiring hemodialysis due to renal failure. Interventions included dialysis every Tuesday, Thursday, and Saturday, evaluate access device for bruit, thrill as ordered, and observe for signs and symptoms of hypo/hypertension and infection. Record review of R64's dialysis folder revealed there was no completed Dialysis Communication Record to include dialysis center communication to the facility and the post-dialysis assessment to the facility. Further review indicated the communications regarding the continuum of care were either incomplete or entirely blank for dialysis sessions on 04/05/2025, 04/22/2025, 04/29/2025, 05/03/2025, 05/06/2025, 05/08/2025, and 05/16/2025. 2. Review of R123's admission Record revealed the facility admitted him on 05/12/2025 with diagnoses of Parkinson's disease, end stage renal disease, and dependence on renal dialysis. Review of R123's admission MDS, with an ARD of 05/18/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicative of intact mental cognition. Further review revealed dependence on hemodialysis therapy. Review of R123's Order Summary Report for May 2025 revealed a physican order for dialysis every Monday, Wednesday, and Friday, at the dialysis clinic specific location with chair time of 10:30 AM, and transport to pick up at 10:00 AM. Further review revealed an order to monitor dialysis port to right chest every shift. Review of R123's Electronic Medical Record (EMR) document titled Dialysis Communication Record, dated 05/19/2025, revealed sections post dialysis assessment and post dialysis vital signs were blank. Review of R123's dialysis folder revealed Dialysis Communication Record, dated 05/30/2025, with the section prior to dialysis/center nurse assessment data missing the assessment of the access site and had no nurse signature. Further review revealed the sections dialysis center communication to facility, post dialysis assessment, and post dialysis vital signs were blank. Review of R123's dialysis folder revealed Dialysis Communication Record, dated 06/04/2025, with the section prior to dialysis/center nurse assessment data missing the assessment of the access site and had no nurse signature. Further review revealed the sections dialysis center communication to facility, post dialysis assessment, and post dialysis vital signs were blank. In an interview with Registered Nurse (RN) 3 on 06/04/2025 at 9:35 AM, she stated that dialysis residents had a folder that went with them to treatment, which contained all pertinent information needed, including medication lists. She stated the dialysis center completed the post dialysis portion and sent the folder back with the resident. She stated the resident's nurse reviewed the information upon their return, and if any new diet orders or recommendations were made, the care nurse would notify the doctor and obtain new orders. In an interview with RN2 on 06/04/2025 at 9:37 AM, she stated she was the nurse for R123, and the dialysis folder was sent out with R123 to his treatment, she completed the communication form, and upon his return she would review the dialysis center information for his post dialysis vital signs, weight, how much fluid was removed, and any new recommendations. In a follow-up interview with RN2 on 06/04/2025 at 4:33 PM, following R123's return from the dialysis center, she stated she did not know why the Dialysis Communication Record was not completed, and she did not know why the folder only contained forms for 05/30/2025 and 06/04/2025. She stated she had not received any report from the dialysis center via phone, fax, or written documentation, and she had not attempted to call the dialysis center for report or information. In an interview with the Dialysis Clinic Manager on 06/05/2025 at 2:45 PM, she stated the expectation was for residents to arrive to the dialysis center with a folder that contained a face sheet, medication list, and any pertinent information that would be important for dialysis staff to know. The Dialysis Clinic Manager stated after the dialysis was completed, the staff completed their form Daily Transfer Sheet that included the pre- and post-dialysis weight and vital signs along with other pertinent information. She stated that form was placed in the folder which was sent back to the facility with the resident. She stated it would be her expectation for the facility to call and request a verbal report over the phone and request a fax of the form with the information if it had not been received upon the resident's return to the facility. In an interview with the Director of Nursing (DON) on 06/04/2025 at 2:29 PM, he stated the purpose for communication between the facility and the dialysis center was to ensure continuation of care for residents. The DON stated residents were sent to dialysis with a folder that had a transfer report that included a list of medications. The DON stated his expectation was for the RN or Charge Nurse on the unit to ensure the paperwork was completed prior to the resident leaving the facility and review it upon return for completed information. He stated he was unaware the forms were not being completed. In a follow-up interview with the DON on 06/04/2025 at 4:40 PM, he was asked by the State Survey Agency (SSA) Surveyor to review R123's dialysis folder after returning from treatment, and he stated the forms were not completed. The DON stated his expectation was that facility staff received a report from the dialysis center on every resident that had treatment, every time they had treatment. In an interview with the Administrator on 06/05/2025 at 10:46 AM, she stated it was her expectation that staff adhered to the facility's protocols, as they impacted the health quality of residents.

Based on interview, record review, review of the Kentucky Medicaid Nurse Aide Testing Procedures Manual and Study Guide, and review of the facility's policy, the facility failed to ensure residents received care planning to meet the resident's physical, mental, and psychosocial needs for 1 of 26 residents reviewed for care planning (Resident (R) 99). The facility failed to develop care plan interventions to address care of R99's uncircumcised penis, resulting in worsening of an infection of the resident's penis that required surgical intervention. Refer to F684 The findings include: Review of the facility's policy titled, Comprehensive Plan of Care (CCP), revised 11/2002, revealed the purpose was to provide an individualized plan of care for each resident, by means of a written document which included input from all disciplines involved in the provision of care. Further review revealed the Director of Nursing (DON) or Minimum Data Set (MDS) Coordinator, served as the coordinator of the interdisciplinary team (IDT), and the care planning team consisted of the resident if he/she chose; the Medical Director as necessary; MDS Coordinators; Physical, Speech, Audiological and Occupational Therapists as involved in resident care; Dietary Supervisor; Activities Director; Social Services Director; and others at the option of the resident, including family. Further review revealed the CCP must describe the services to be provided for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well being with measurable objectives and timetables to meet the resident's needs in the Comprehensive Assessment. Continued review revealed each problem, with goals and approaches related to the problem, was written on the care plan and updated quarterly, annually, and whenever significant changes occurred. Continued review of the policy revealed the CCP would have documented disciplines responsible to have implemented interventions, the date of the problems identified, and the goal date as well as the interventions planned and the date initiated. Review of the Kentucky Medicaid Nurse Aide Testing Procedures Manual and Study Guide, dated 01/01/2024, revealed for peri care for a male, to retract the foreskin for an uncircumcised person and to return the foreskin to its natural position, if uncircumcised. Review of R99's Admission Record revealed the facility admitted R99 on 02/11/2024 after an acute care admission at a nearby hospital. His admitting diagnoses included myocardial infarction, congestive heart failure (CHF), and chronic kidney disease, stage 4. Review of R99's admission Minimum Data Set (MDS), dated [DATE], revealed his Brief Interview for Mental Status (BIMS) assessment yielded a score of 14 out of a possible 15, indicating his cognitive status was intact. Further review of the MDS revealed the skin assessment showed no wounds, lesions, or moisture associated skin disruption. Review of R99's Care Plan revealed a focus for pressure ulcer risk, initiated 03/27/2024, with the intervention of aides conducting a skin inspection during care and bathing and then report to the nurse any areas of redness or skin breakdown. Further review revealed no other interventions related to maintaining perineal skin. Continued review revealed a focus for change in urinary elimination related to incontinence, initiated on 04/04/2024, with interventions of observe for incontinence approximately every 2 hours and as needed, and provide incontinence care. Additional review revealed a focus of risk for complications related to diabetes disease process, initiated 03/22/2024, with an intervention initiated at the same time to observe skin during daily care for areas of altered skin integrity and notify the nurse. Review of the care plan revealed no other focus related to skin care or assessments and none related to the care of his uncircumcised penis. Review of R99's Kardex (care plan used by State Registered Nurse Aides (SRNA)), undated, revealed SRNAs must perform skin inspection during care/bathing and report to the nurse of any area of skin breakdown or redness. Review of R99's initial Skilled Nursing Assessment, dated 02/13/2024, revealed no skin issues. In addition, review of R99's nursing assessments after 02/13/2024 and until 04/12/2024 revealed varying observations that included redness, excoriation, and scattered discolorations to the skin but no penile wound. Review of the Nurse Progress Note, dated 04/12/2024 at 6:45 PM, revealed the nursing supervisor responded to a request for assistance after the staff nurse retracted R99's foreskin to evaluate drainage reported by the aide. Further review revealed the nurse found an open wound to the top of R99's penis with a moderate amount of malodorous tan drainage noted. Review of the Nurse Progress Note, dated 04/13/2024 at 12:45 AM, revealed R99's foreskin was found to be retracted, and the tip of the penis was very swollen, red, and hard. Further review revealed his penis required elevation to reduce swelling before the foreskin could be returned to a normal position. Review of the Physician's Order Note, dated 04/14/2024 at 12:16 PM, revealed the Nurse Practitioner (NP) found R99 to have open lesion to the glans penis. Further review revealed the wound had purulent yellow and tan drainage, and the glans were noted to be erythematous with a lesion noted to the dorsal surface. Additional review revealed the decision was made to transfer R99 to an area hospital emergency department (ED) for evaluation of possible options for treatment. Review of the hospital's Operative Note, dated 04/17/2024 at 5:09 PM, revealed R99 underwent penile ulcer debridement and partial excision of the glans penis after assessment of the wound. Further review revealed the wound was a 3 centimeter (cm) by 3 cm area with necrosis and granulation tissue that was excised. During interview with R99 on 06/25/2024 at 10:07 AM, he stated he was sent to the hospital and had surgery due to an infection of his penis. He stated the staff should have assessed him upon admission to the facility. R99 stated he was having a burning sensation for months, but they (staff) wanted no part of looking or examining him. During interview with R99's family on 06/26/2024 at 1:32 PM, he stated an aide found the wound, contacted the nurse, who contacted the physician and sent R99 to the hospital emergency department (ED). He stated the ED physician told them the wound was a result of total neglect, and it should never have happened. During interview with SRNA6 on 06/25/2024 at 10:48 AM, she stated R99 stated he used to be able to do perineal (peri) care himself, but that he had reported the stinging and nobody had looked at it. She stated the head of the penis was so hard from swelling she could not retract the foreskin and went for the nurse. She stated they were able to loosen the skin with moisture and discovered the wound/ulcer and alerted the supervisor. SRNA6 stated she later went upstairs to R99's previous unit and asked all the aides, who were not aware of the wound. During interview with Licensed Practical Nurse (LPN) 6 on 06/26/2024 at 5:28 PM, she stated she was not aware of R99's penis ulcer. She stated she did not do his daily assessments as they would have been completed on night shift. She stated nurse aides were expected to report any concerns to nurses, and some of the aides reported he wanted to do his own care. She stated at the time he was admitted and earlier on he walked to the bathroom with his walker. LPN 6 also stated daily assessments were head to toe, including backs and buttocks, and when nurse aides did care or bathing, they reported issues also. During interview with LPN18 on 06/27/2024 at 2:49 PM, she stated the expectation was that aides looked at skin during care and/or showers and reported any changes. During interview with LPN9 on 06/28/2024 at 11:35 AM, she stated if nurses were doing their skin assessments, they would know if a resident was uncircumcised. She stated she did not recall having seen that addressed on a care plan, but it would be reasonable to include it. She also stated there was not an option in the care plan to add it, but it might be added in the Additional Information box to free hand write it rather than use a check box. During interview with LPN4 on 06/28/2024 at 12:15 PM, she stated the nurses conducted daily head to toe assessments on the skilled unit. She stated head to toe really meant full body, including the peri area and the foreskin. She stated information like circumcision status should be passed on in report. She stated the expectation was for nurses to retract the foreskin during skin assessments and that was especially important with residents who were more independent. She also stated she understood the MDS had begun capturing circumcision status and had populated that information onto the SRNA Kardex tasks. She further stated the SRNA task lists could be customized. During interview with RN1 on 06/28/2024 at 11:44 AM, she stated on initial assessment the fact that a new resident was uncircumcised would be apparent. She further stated there was a box for other in the assessment form that gave a dropdown box where that sort of detail could be documented, but she was not sure it would pop up in the care plan to use. She did state the admission Care Plan had a section that asked about grooming, hygiene care, and toileting. During additional interview with RN2 on 06/28/2024 at 11:51 AM, she stated whether something was captured on the care plan depended on an issue being flagged, but identifying peri care needs should be in a care plan. During interview with the MDS Nurse on 06/28/2024 at 1:45 PM, she stated the nurse could add additional text through the comment box and that would be reviewed in the clinical meeting and by the MDS nurse as well. She stated sometimes an order would be added for something that needed to be care planned, and then it got picked up in the clinical meeting because staff ran an order report for the clinical meeting every morning. She additionally stated they could add a custom intervention for a particular issue only for the one resident. She stated it would be appropriate to add peri care for an uncircumcised male to a care plan, but she did not recall adding that to a care plan. During interview with the Medical Director on 06/26/2024 at 2:07 PM, she stated the incident with R99 was something that had led to a lot of education, particularly around differences with peri care for circumcised versus uncircumcised males. She stated staff was also educated on the expectation of regular skin assessments, including peri area skin. She stated it also brought discussions of when to allow more privacy and when to increase care. During interview with the Director of Nursing (DON) on 06/28/2024 at 2:07 PM, she stated for SRNAs, she expected them to look at the whole body, observe all the skin, and to be sure to retract the foreskin for an uncircumcised male and report any redness or changes to the nurse. The DON stated it had not been their normal practice to care plan for uncircumcised male peri care, but it should have been done. During interview with the Administrator on 06/28/2024 at 2:39 PM, she stated it would be reasonable to incorporate peri care into the care plan.

Based on interview, record review, review of the Kentucky Medicaid Nurse Aide Testing Procedures Manual and Study Guide, and review of Mosby's Textbook for Nursing Assistants, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs for 1 of 3 residents assessed for skin care (Resident (R) 99). Staff failed to re-assess identified redness under R99's penile foreskin, even though the resident was complaining of pain during urination, which resulted in worsening of an infection that required surgical intervention. The findings include: Review of the Kentucky Medicaid Nurse Aide Testing Procedures Manual and Study Guide, dated 01/01/2024, revealed for perineal care for an uncircumcised male, to retract the foreskin and to return the foreskin to its natural position. Review of Giving Male Perineal Care from Mosby's Textbook for Nursing Assistants, page 370, revealed providing peri care to an uncircumcised male required retracting the foreskin, grasping the penis, cleaning the tip in a circular motion, starting at the meatus and working outward, then rinsing the tip with another washcloth using the same circular motion, then returning the foreskin to its natural position after rinsing. Review of the Male Perineal Care check off sheet, dated 02/14/2024, revealed the staff member should grasp the penis, retract the foreskin if the person is uncircumcised and return the foreskin to its natural position after cleaning. Review of R99's Admission Record revealed the facility admitted R99 on 02/11/2024 after an acute care admission at a nearby hospital. His admitting diagnoses included myocardial infarction, congestive heart failure (CHF), and chronic kidney disease, stage 4. Review of R99's admission Minimum Data Set (MDS), dated [DATE], revealed his Brief Interview for Mental Status (BIMS) assessment yielded a score of 14 out of a possible 15, indicating his cognitive status was intact. Further review of the MDS revealed the skin assessment showed no wounds, lesions, or moisture associated skin disruption. Review of R99's Kardex (care plan used by State Registered Nurse Aides (SRNA)), undated, revealed SRNAs must perform skin inspection during care/bathing and report to the nurse of any area of skin breakdown or redness. Review of R99's initial Skilled Nursing Assessment (SNA), dated 02/13/2024, revealed no skin issues, and continued review through 03/16/2024 revealed no skin issues. However, the SNA, dated 03/17/2024, revealed redness to coccyx and buttocks, with no notation of the foreskin of the penis. The SNA, dated 03/19/2024, revealed the addition of redness of the groin, and on 03/28/2024, addition of excoriation was added. Further review of R99's SNA, dated 04/05/2024 and 04/06/2024, revealed redness and excoriation to his groin and buttocks. Additional review from 04/07/2024 to 04/10/2024 revealed no mention of skin problems to R99's penile area. Review of R99's Nurse Progress Note, dated 04/10/2024 at 3:30 PM, revealed R99 transferred to a different unit at that time (from second floor to first floor). Review of R99's Nurse Progress Note, dated 04/12/2024 at 6:30 PM, revealed SRNA6 called Licensed Practical Nurse (LPN) 7 to R99's room to assess the resident's penis due to noted drainage and the penis appeared abnormal. Further review revealed she notified the evening nurse supervisor to further assess. The note stated the nurse supervisor responded at 6:45 PM, and another nurse, LPN9, retracted R99's foreskin. Per the note, R99 had an open wound to the top of his penis with a moderate amount of malodorous tan drainage. Continued review revealed the area was cleansed and covered with a dry sterile dressing, and the on-call physician was contacted for orders. Further review of the note revealed at 10:23 PM, R99's penile wound and drainage was swabbed and sent to the lab for culture, an indwelling urinary catheter was placed without incident, and Bactroban (generic name mupirocin, an ointment used to treat skin infections) was applied to the wound. Review of R99's Nurse Progress Note, dated 04/13/2024 at 8:22 AM, revealed an order was obtained for mupirocin external ointment 2%, to be applied to penile wound topically three times per day for 5 days. Further review of the note revealed an order to cleanse the penile wound with normal saline, gently pat dry, then apply mupirocin ointment liberally to the wound and surrounding skin. Review of R99's Nurse Progress Note, dated 04/13/2024 at 12:45 AM, revealed R99's penile assessment at that time found his foreskin was retracted, and the tip of the penis very swollen, red, and hard. Further review revealed his penis required elevation to reduce swelling before the foreskin could be returned to a normal position. Review of R99's Physician's Order Note, dated 04/14/2024 at 12:16 PM, revealed the Nurse Practitioner (NP) found R99 to have an open lesion to the glans with a culture done and results pending. The note stated the current treatment was Bactroban applied to the wound three times per day and an indwelling urinary catheter. Further review revealed the wound had purulent yellow and tan drainage, and the glans were noted to be erythematous with a lesion noted to the dorsal surface. Continued review revealed the wound bed was covered with thick yellow/tan slough with purulent drainage, and the foreskin was difficult to return to the normal position due to edema and pain. Additional review revealed the decision was made to transfer R99 to an area hospital emergency department (ED) for evaluation of possible options for treatment. Review of Other Note, dated 04/14/2024 at 5:07 PM, revealed R99 was admitted to the hospital for treatment of the penile wound. Review of R99's hospital ED Provider Note, dated 04/14/2024, revealed the resident was admitted to the hospital on 04/14/2024 due to balanoposthitis (inflammation of the foreskin and glans penis in uncircumcised males) and wound infection of the penis. Further review revealed his assessment revealed erythema to the foreskin, balanitis, and posthitis. Review of the hospital's Nursing Note, dated 04/14/2024 at 2:05 PM, revealed the provider was at the bedside of R99 and assessed the wound to the right side of his penis to have drainage and odor present upon inspection. Review of R99's culture report of the penile wound drainage done at the facility, with the results dated 04/15/2024 at 11:32 AM, revealed it was positive for Klebsiella oxytoca (a bacterium found in hospital acquired infections and having multiple drug resistance to commonly used antibiotics and Streptococcus intermedius bacterium). Review of the hospital's Operative Note, dated 04/17/2024 at 5:09 PM, revealed R99 underwent penile ulcer debridement and partial excision of glans penis after assessment of the wound. Further review revealed the wound was a 3 centimeter (cm) by 3 cm area with necrosis and granulation tissue that was excised. Review of R99's hospital Discharge Summary, dated 04/18/2024, revealed R99 would be discharged on oral antibiotics to complete the course and was discharged back to the facility on [DATE]. Review of R99's quarterly MDS skin assessment, dated 05/15/2024, only revealed moisture associated skin damage and the applications of ointments/medications other than to feet. During interview with R99 on 06/25/2024 at 10:07 AM, he stated when he was on the second floor, he had complained hourly of burning in his private area and asked for something to treat it, and they did nothing. He stated when he moved down to the first floor, they immediately found the infection, and he was sent to the hospital and had surgery the following day. R99 further stated it was better now and the wound nurse checked it daily. He stated the nurse who found the problem was doing the initial assessment because he was new to the unit. He also stated in his opinion, this should have been assessed at admission to the facility. R99 stated he was having the burning for months before moving downstairs, but they wanted no part of looking or examining it. He also stated he literally felt, when he was moved to the first floor, they were just moving him because there was nothing they could do. During interview with R99's family member on 06/26/2024 at 1:32 PM, he stated an aide found the wound and contacted the nurse, who contacted the physician and sent R99 to the hospital ED. He stated the ED physician told them the wound was a result of total neglect, and it never should have happened. He stated he understood the ED nurse scolded the facility's staff over the phone as well. In continued interview, he stated when R99 did have surgery after transfer to the hospital, the surgeon had him observe the wound, and it looked like a roasted marshmallow that was burned, black, and crusty. During interview with SRNA6 on 06/25/2024 at 10:48 AM, she stated R99 told her he used to be able to do perineal (peri) care himself, but he had reported the stinging and nobody had looked at it. She stated the head of the penis was so hard from swelling she could not retract the foreskin and went for the nurse. She stated they were able to loosen the skin with moisture and discovered the wound/ulcer and alerted the supervisor. SRNA 6 stated she later went upstairs to R99's previous unit and talked with all the aides, who were not aware of the wound. During interview with SRNA19 on 06/26/2024 at 5:41 PM, she stated for a while R99 did his own care and staff was helping him; then later staff started doing more. SRNA19 stated after the nurse got a powder order for a groin rash, staff was really trying to keep his groin area as dry as possible. She stated he started using the urinal because he was having a harder time walking, and she remembered him complaining of pain, which staff thought was from a rash. She stated she thought there was a plan for R99 to see the doctor, and she had communicated concerns about his pain to the nurse and NP. During interview with SRNA3 on 06/28/2024 at 11:59 AM, she stated she did not receive training for peri care specific for an uncircumcised male in her nurse aide school and also not during orientation at the facility. She stated the only reason she knew how to do peri care on an uncircumcised male was from caring for a family member. During interview with SRNA14 on 06/28/2024 at 12:07 PM, she stated she had not received peri care training in school nor in facility orientation. She stated SRNA3 taught her what to do when caring for a male resident who was uncircumcised. During interview with LPN6 on 06/26/2024 at 5:28 PM, she stated R99 complained of burning when urinating, so a cream and powder were ordered, and she thought there was a urinalysis (UA) ordered. She stated she was not aware of the penis ulcer. She stated she did not do his daily assessments as they would have been completed on night shift. In further interview, she stated nurse aides were expected to report any concerns to nurses, and some of the aides reported he wanted to do his own care. She stated at the time he was admitted and earlier on he walked to the bathroom with his walker. LPN6 also stated daily assessments were head to toe, including backs and buttocks, and when nurse aides did care or bathing, they reported issues also. She stated aides completed shower sheets as well, and someone always assisted residents with showers. During telephone interview with LPN16 on 06/26/2024 at 5:52 PM, she stated R99 had complained of burning in that area. She stated he would normally use his call light, get assistance to the bathroom, and staff would stand by outside the bathroom. She stated he did his own care, and he was set up for baths when not showering. She stated she had not completed his skin assessments because night shift would have done his, so she had never seen his wound. She also stated their head to toe assessments were expected to be complete as all of it had to be charted. LPN 16 also stated a skin assessment should have captured a wound. She stated he had complained of discomfort in the groin area some time back, and he had not wanted her to look. However, she stated R99 did allow it. She stated she retracted his foreskin, and the skin was reddened on the shaft under the foreskin, with no wound at that time. She stated she had placed in the NP/Medical Director book for R99 to be seen. She stated she did not recall the date, but it was fairly soon after admission. During interview with LPN9 on 06/27/2024 at 2:35 PM, she stated she was working as midnight supervisor when the wound was discovered and was asked to look at it with the evening supervisor. She stated the wound was like open skin on the right side, and it did not look swollen or black. She stated she did pull back the foreskin and there was a little hole. She stated nurses were expected to complete head to toe skin assessments every day, including the peri area. She stated head to toe skin assessment was expected to include retracting the foreskin, as this was just a standard of nursing practice. LPN9 stated she was not aware of the wound or any skin irritation prior to the observation or treatment for that. She stated staff had received re-education on peri care since this incident, including to be sure to retract the foreskin for assessment and to pull it back down after assessment. During interview with LPN18 on 06/27/2024 at 2:49 PM, she stated for skin protection, aides should look for redness during activities of daily living (ADL) care. She stated the nurses looked at residents during medication administration as well, such as for reddened heels. She stated she expected aides to look at the residents' skin during care and/or showers and report any changes. During telephone interview with LPN17 on 06/27/2024 at 8:33 PM, she stated the expectation was that nurses would follow the standard of care and retract the foreskin during skin assessments for uncircumcised males. She stated a lot of nurses did not do this, but they should. With R99, she stated he would try to cover himself and wanted to limit what he allowed the staff to see. LPN 17 stated R99 had initially been fairly self-sufficient, such as walking to the bathroom with just a standby assist, but even with that level of independence, nurse aides would have had to attend showers and would have observed his skin. During interview with LPN4 on 06/28/2024 at 12:15 PM, she stated the nurses conducted daily head to toe assessments on the skilled unit. She stated head to toe really meant full body, including the peri area and foreskin. She stated R99 had complained of burning when he urinated a couple of times, so staff suspected a urinary tract infection (UTI), and staff collected a urine sample. When the UA was negative, she stated staff thought it was irritation because he did have redness in the groin. She stated information like circumcision status should be passed on in report. She stated the expectation was for nurses to retract the foreskin during skin assessments, and it was especially important with residents who were more independent. During telephone interview with Registered Nurse (RN) 1 on 06/26/2024 at 6:03 PM, she stated she did not care for R99 directly, but nurses were to lay eyes on each resident daily with a head to toe assessment, including all skin. She further stated when nurse aides reported something new, the nurses must assess it. She stated they must follow the schedule per protocol for conducting assessments so that every resident got a look every day. She stated night shift nurses did skin assessments on residents in odd numbered rooms while day shift staff did assessments for residents in even numbered rooms. RN1 stated for any finding that might require treatment, the nurses were expected to call the NP or the physician. RN1 stated the expectation was that nurse aides must report to nurses any skin changes observed during ADL care and showers. During interview with RN10 on 06/27/2024 at 3:36 PM, she stated upon admission, the wound care nurses did skin assessments. She stated R99 did not have a wound at admission that she remembered. She stated she recalled he was prescribed creams or something based on itching. She stated he went to the hospital and had the debridement, and the wound care nurses were aware of it already upon his return due to collaboration with the wound care physician. When he returned, staff formed R99's plan of care to continue here. RN10 stated R99 had necrotic tissue, so he had mechanical debridement via Santyl ointment, which pulled that tissue off for removal. She stated the wound improved over the first couple of weeks, and then the order was switched to exufiber, a calcium alginate wound treatment. RN10 stated a head to toe assessment included assessing all skin, including the back, buttocks, and peri areas. She stated that also included retracting the foreskin of uncircumcised males. During interview with RN1 on 06/28/2024 at 11:44 AM, she stated on initial assessment, the fact a new resident was uncircumcised would be apparent. She further stated there was a box for other in the assessment form that gave a dropdown box where that sort of detail could be documented. During interview with Staff Development Assistant/Infection Prevention Nurse (SDC/IP) on 06/28/2024 at 9:27 AM, she stated in the annual Skills Fair nursing staff were instructed on head to toe assessment and how to chart it. She stated the facility did a competency with nursing department staff upon hire and did ongoing peri care audits. She stated nursing leaders, including herself, did ongoing face-to-face, one-on-one education and could add education based on observed patterns, such as an increase in urinary tract infections (UTI) could lead to reeducation on peri care. She stated head to toe assessments meant everywhere, and skin assessments had to include backs, buttocks, and peri area, including retracting the foreskin of the penis. She stated the outcome of good peri care and hygiene was less infection because the best place for bacteria to grow was a place that was warm, dark, and moist. During interview with the Quality Manager on 06/27/2024 at 9:25 AM, she stated staff nurses were expected to complete daily charting for residents who were in for a rehabilitation stay and weekly for long term residents. She stated that night shift nurses completed the charting for residents in odd numbered rooms, while day shift completed the charting for residents in even numbered rooms. She stated the charting included a complete head to toe assessment, including skin. She stated skin assessments meant complete head to toe, looking at every nook and cranny. During telephone interview with the NP on 06/27/2024 at 7:18 PM, she stated she was alerted by staff of the wound that was located on R99's penis. She stated that when she assessed the resident she found he was uncircumcised, but he looked normal until she retracted the foreskin and found a wound with yellow slough and eschar. She stated it was so painful for him to have the skin retracted, she felt he needed a urology consult and possibly IV antibiotics. She stated it was a weekend when she saw him, and she felt R99's wound would be addressed more quickly if he went to the ED. She stated before she assessed the resident and found the wound, R99 had complained of burning with urination, so a UA and other labs were ordered, and those had negative results. She stated R99 was getting calmoseptine (a moisture barrier ointment) and then miconozole (an anti-fungal powder) thinking it was caused by excoriation over the general skin in the groin. She stated she was unsure of the facility's policy for skin assessments. She also stated on one hand, with an alert and oriented resident, it was difficult to assess how invasive the staff should be with him, but if a resident did not have an issue with it, staff should examine the skin. In retrospect, she stated she felt retraction of R99's foreskin and inspecting it should have been part of his skin assessment. During interview with the Medical Director on 06/26/2024 at 2:07 PM, she stated the incident with R99 was something that led to a lot of education, particularly around differences with peri care for circumcised versus uncircumcised males. She stated staff was also educated on the expectation of regular skin assessments, including peri area skin. She stated it also brought discussions of when to allow more privacy and when to increase care. She further stated she had seen R99 the day or two before the wound was discovered, but he had not mentioned concerns for pain or other indicators of the wound. She stated the NP was in the building on the day the wound was found and responded to the nurse's request for R99's assessment. She stated they started treatment, but the wound was so painful, they transferred R99 to the hospital the following day or two. She stated R99 had mentioned to staff that it burned when he urinated, and in response, a UA was done, which was negative for infection. Further, she stated they thought the burning was from excoriation, so an anti-fungal powder was ordered. In further interview with the Medical Director, on 06/26/2024 at 2:07 PM, she stated R99 said he had reported this issue, but he really did not talk as much until after he returned from the hospital. The Medical Director stated early in R99's admission, he was able to do his own peri care. She stated R99 was discharged on oral levofloxacin (an antibiotic). However, she stated the resident insisted on the IV route, and she consulted with the surgeon. She stated R99's surgeon confirmed his plan had been prophylactic oral antibiotics because R99 probably did not need them. The Medical Director stated R99 was so insistent, she ordered IV levofloxacin, and it was for three doses every other day due to consideration of his renal function. During interview with the Director of Nursing (DON) on 06/28/2024 at 2:07 PM, she stated she expected SRNAs to look at the whole body, observe all the skin, be sure to retract the foreskin for an uncircumcised male, and report any redness or changes to the nurse. She stated she expected nurses to do a complete skin assessment and that was head to toe, front and back, and a thorough look at the peri area, heels, and everywhere. She stated it was important to take good care of skin because if not done, the residents' skin could break down and create a portal of entry for bacteria, which could cause discomfort, pain, and infection. She stated nursing staff mostly used Mosby's as a standard of care, they had the resource in the building, and staff could have accessed it via the intranet. She stated nurses and aides got checked off on peri care during their education on it. During interview with the Administrator on 06/28/2024 at 2:39 PM, she stated her expectation was that SRNAs would observe the resident's skin during any care episode and report redness or changes to the nurse. She also stated her expectation of nurses would be to protect dignity and respect of personal choice but also ensure the integrity of the skin.

Based on observation, interview, record review, review of the website www.drugs.com, and review of the facility's policy, the facility failed to ensure drugs and biologicals were stored according to professional standards for 1 of 3 medication room refrigerators and 3 of 4 medication carts. Proper temperature control for the medication room refrigerator on the Forest Heights Unit was not maintained, and staff failed to notify the Maintenance Director of the equipment failure. Staff failed to write the expiration date on three insulin pens (two in the medication cart on the Forest Heights Unit and one in the medication cart on the Garden View Unit) based on the date they were removed from refrigeration. Staff failed to discard two tramadol pills in the medication cart on the Shoreline Unit after the packaging was damaged . The findings include: Review of the facility's policy titled, Medication Storage in the Facility, not dated, revealed medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Review of the website www.drugs.com revealed, for both the unopened insulin glargine pen and the unopened insulin aspart pen, when stored at room temperature (below 86 degrees Fahrenheit (F)), they must be used within 28 days. 1. Observation on 06/26/2024 at 8:41 AM of the medication cart on the Shoreline Unit revealed two tramadol (an opioid pain relief medication) pills in a blister pack that had been damaged and taped over. In an immediate interview, Registered Nurse (RN) 4 stated she did not know how the packaging had been damaged, but whoever had placed the tape over the packaging should have instead wasted the pills with another nurse as witness. In an interview on 06/28/2024 at 8:40 AM, the Resident Care Manager (RCM) for the Shoreline Unit stated her expectation for a nurse who accidentally damaged a blister package for a controlled substance such as tramadol was for the nurse to waste the pills in the damaged container with another nurse. She further stated this was important because the pills could be contaminated and could create the risk of narcotics diversion. In an interview on 06/28/2024 at 2:05 PM, the Director of Nursing (DON) stated the tramadol pills observed in a damaged blister pack should have been wasted with another nurse. In an interview on 06/28/2024 at 2:34 PM, the Administrator stated staff should have notified the RCM when the packaging for a narcotic was damaged. She further stated her expectation was for two nurses to waste the medications in the damaged packaging and follow up with the pharmacy for any further instructions. 2. Observation on 06/26/2024 at 9:29 AM of the medication cart on the Garden View B Unit with Licensed Practical Nurse (LPN) 12 revealed an unopened glargine insulin pen (lowered blood sugar, given for diabetes) not dated. During interview with LPN 12 at the time of the observation she stated the insulin might not be effective and could cause the resident harm if out of date. She stated she would return the medication to the pharmacy and request a new medication. 3. Observation on 06/26/2024 at 10:10 AM revealed the medication room refrigerator temperature on the Forest Heights Unit was 33 degrees F. The refrigerator contained 23 unopened insulin pens, five vials of insulin, 113 suppositories, one container of skin barrier cream, two vials of lorazepam (an anti-anxiety agent) and 3 bags of intravenous ceftriaxone (an antibiotic). During interview with LPN4 RCM, at the time of the observation, she stated she did not know the correct temperature of the refrigerator. Review of the refrigerator's current Audit Sheet, dated 06/17/2024 to 06/26/2024 with LPN4 RCM, revealed the temperature was to be 36 to 45 degrees F. The sheet stated, If the temperature too high or too low, adjust thermostat and put in work order to maintenance department. The recorded temperature on 06/23/2024 was 30 degrees F; the recorded temperatures on 06/18/2024, 06/19/2024, 06/21/2024 and 06/25/2024 were 32 degrees F; and the recorded temperatures on 06/26/2024 and 06/27/2024 were 34 degrees F. The only documentation that maintenance was notified was on 06/27/2024. Review of past Audit Sheet, dated 06/01/2024 to 06/16/2024, revealed the temperature on 06/06/2024 was 28 degrees F; the temperatures on 06/03/2024, 06/05/2024, 06/08/2024, 06/09/2024, 06/13/2024, and 06/16/2024 were 30 degrees F; the temperatures on 06/02/2024, 06/04/2024, 06/07/2024, 06/11/2024, 06/12/2024, 06/14/2024, and 06/15/2024 were 32 degrees F; and the temperature on 06/01/2024 was 34 degrees F. During interview with the Maintenance Supervisor on 06/28/2024 at 8:22 AM, he stated he did not receive notifications that the refrigerator temperatures on the Forest Heights Unit were out of range from 06/01/2024 to 06/27/2024. During interview with Pharmacist 2 on 06/28/2024 at 10:43 AM, he stated the facility called him on 06/27/2024 and reviewed each medication that was in the refrigerator on the Forest Heights Unit. He stated none of the medications were harmed by the colder temperatures. 4. Observation on 06/27/2024 at 9:52 AM of the medication cart on the Forest Heights B Hall with LPN 16 revealed two unopened insulin pens, glargine and aspart, which were not dated. During interview with LPN 16 at the time of the observation, she stated the insulins would be returned to the pharmacy. She stated they might not be effective if they were out of date, and they could cause harm to the residents. During interview with the DON on 06/28/2024 at 8:50 AM, she stated she was not made aware of the temperature of the refrigerator being out of range. She stated she also was not notified that the insulin pens were not dated. She stated staff should have notified the Maintenance Director of the temperatures being out of range. She also stated staff should date insulin pens when they were taken out of the refrigerator. During interview with the Administrator on 06/28/2024 at 2:34 PM, the Administrator stated her expectation for the medication refrigerator temperatures was for staff to check the thermometers in the refrigerators daily and notify maintenance if the temperature was found to be out of range. She further stated she did not know what the practice was regarding labeling an insulin pen that was removed from the refrigerator for use, but the DON would be able to speak to that process. 44000

Based on observation, interview and review of facility Policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation during initial tour on [DATE] of the kitchen, revealed there was an accumulation of dust on the dish room ceiling, above the kitchen production area and on the ceiling in the refrigerator walk-in. In addition, the temperature logs for the walk-in refrigerator, freezer and dry storage were incomplete. Additionally, Resident #35 was observed to have multiple perishable food items in his/her room. The findings include: Review of the kitchen document titled Weekly Cleaning Schedule undated, revealed it did not include a schedule for cleaning dust on the ceiling. Review of the facility Policy titled Refrigerated Storage dated ,[DATE], revealed a variety of foods are stored under refrigeration and the temperatures are low enough to safely keep perishable foods. Per Policy, each refrigerator contains a thermometer and temperature charts are to be documented daily. Review of the Refrigerated Storage, Policy, revised (MONTH) 2006, revealed the facility will store, prepare and serve foods in accordance with federal, state and local sanitary codes. Further review revealed it is essential that refrigerator temperatures be low enough to safely keep most perishable foods and refrigerator temperatures that are consistently thirty eight (38) degrees Fahrenheit or below will provide this safety margin. 1. Observation on [DATE] at 11:26 AM, during initial kitchen tour, revealed there was dust accumulation on the ceiling of the walk-in cooler near the fans. Observation on [DATE] 8:38 AM, revealed the ceiling vents over the production area and the ceiling vents in the dish room had an accumulation of dust. Interview on [DATE] at 2:00 PM, with Dietary Aide #1, revealed staff cleaned their assigned area and their area of production. Per interview, the Supervisor assigned the daily cleaning and checked the areas assigned. Further interview revealed the Maintenance staff dusted the ceiling once a week to prevent cross contamination of dust from the ceiling to the food. Interview on [DATE] at 2:19 PM, with the Dietary Manager, revealed the Supervisor assigned the daily cleaning, and made rounds to ensure areas were cleaned as assigned. Further interview revealed Maintenance staff was responsible to clean the kitchen ceiling; however, it may need to be cleaned more frequently as there was a dust build up which could fall into the food and cause cross contamination. Interview on [DATE] at 2:29 PM, with the Dietary Supervisor, revealed staff assigned cleaning tasks daily and staff were to clean their work area of the kitchen. Per interview, Maintenance was responsible for cleaning the kitchen ceiling. Per interview, the ceiling needed to be cleaned regularly to prevent dust from falling into the food. Per interview, dietary staff could inform Maintenance of the need to have the ceiling dusted and cleaned verbally or through work orders. Interview on [DATE] at 2:38 PM, with the Maintenance Director, revealed the kitchen ceiling was cleaned bi-annually. Further interview revealed if the ceiling needed cleaned more often due to an accumulation of dust, kitchen staff could fill out a work order and Maintenance would ensure the ceiling was cleaned. 2. Observation on [DATE] at 11:15 AM, during initial kitchen tour revealed Temperature logs for the walk-in refrigerator, walk-in freezer and Dry storage were had incomplete documentation. Review of the kitchen temperature logs, titled Temperature Chart-Storage Areas, dated ,[DATE], revealed the freezer temperature log had no documented temperatures for the 16th, 17th and 25th; the refrigerator temperature log had no documentation of temperatures for the 16th, 17th and 25th and the dry storage temperature log had incomplete documentation of temperatures for the 16th, 17th and 25th. Interview on [DATE] at 2:00 PM, with Dietary Aide #1, revealed kitchen staff were responsible to record temperatures on the temperature chart morning and evening and report to the supervisor if temperatures were not in proper range. Per interview, this was important to ensure food which was stored in the refrigerator, freezer and dry storage did not spoil. Interview on [DATE] at 2:19 PM, with the Dietary Manager, revealed the walk-in refrigerator and freezer temperatures, as well as dry storage needed to be monitored daily to ensure food was stored at proper temperatures to prevent food from spoiling. Interview on [DATE] at 2:29 PM, with the Dietary Supervisor, revealed the temperature logs of the kitchen equipment and dry storage were to be recorded in the morning and evening. Per interview, this was important temperature to ensure equipment was working correctly for proper food storage. Interview on [DATE] at 3:43 PM, with the Director of Nursing (DON), revealed dust accumulated in areas of the kitchen could fall into the food and cause physical cross contamination. Further interview revealed temperature logs for the equipment and dry storage in the kitchen needed to be monitored and documented daily to ensure equipment was running properly and to prevent the spoilage of foods. Interview on [DATE] at 4:35 PM, with the Administrator, revealed dust was not to accumulate in the kitchen as this was to be a clean and sanitary environment. Further interview revealed temperature logs for the equipment and dry storage in the kitchen needed to be completed on a daily basis to ensure the equipment was functioning properly to prevent food from spoiling. 3. Review of Resident #35's clinical record revealed the facility readmitted the resident on [DATE]. Per record review, the resident's [DIAGNOSES REDACTED]. Review of the Nurse's Progress Note, dated [DATE], revealed flies were noted in the resident's room and the nurse had a hard time moving around in the resident's room as the resident demanded the nurse not step on anything. Further review of the Note, revealed there was an immense amount of clutter in the room. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #35 as having a Brief interview for Mental Status score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Continued review of the MDS Assessment revealed the facility assessed the resident as having no mood indicators or behaviors, and no rejection of care during the assessment period. Additional review of the MDS Assessment, revealed the facility assessed the resident as supervision or set up help only for ADL's (Activities of Daily Living) with the exception of locomotion off unit which the resident required limited assistance of one (1) staff. Review of the Physician's Order Sheet and Progress Notes dated [DATE] revealed a progress note which stated, patient does hoard. Review of Resident the Comprehensive Care Plan, initiated [DATE], revealed the resident had episodes of behaviors as evidenced by: Hoarding. The goal revealed the resident would have no episodes of behavior through next review with a target date of [DATE]. The interventions included: approach in calm non threatening manner; attempt to guide away from source of distress before agitation escalates; attempt to identify cause for resistance and reduce/eliminate if possible; attempt to identify factual basis for concerns/behaviors and resolve if possible; avoid commands using do's and don't's; give resident as many choices as possible about care and activities and identify trigger stimuli and educate staff to avoid as much as possible. Review of Resident #35's Monthly (MONTH) 2019 Physician's Orders, revealed a current order initiated [DATE], which stated, (MONTH) have psychiatric eval as needed. Review of the Physician's Progress Note, dated [DATE], revealed the patient does not always take medications; hoarding; and continues to keep food/letters in room. Observation of Resident #35, on [DATE] at 4:10 PM, revealed the resident was observed sitting in a chair beside the bed and window, and there was large amounts of mail, paper, and other items in the room. Further observation revealed there were two (2) meal trays with perishable food under the lids, on the floor beside the bed; and also several unopened cups of puddings. In addition, there was six (6) cups of a pink colored drink on the bedside table which were not covered, labeled or dated. Interview with Resident #35, on [DATE] at 4:10 PM, during the observation, revealed the two (2) cups of the pink drink were from today ([DATE]) and the other two (2) cups of pink liquid were from yesterday ([DATE]). The resident did not mention the final two (2) cups of pink drink. Continued interview revealed a friend brought the resident six (6) hot dogs once, and he/she ate them from a Friday to a Wednesday, and they didn't ruin. Resident #35 stated he/she did not have a refrigerator, but he/she would know if food had spoiled. On [DATE] at 2:04 PM, the Resident Care Manager (RCM) unlocked Resident #35's door and entered the room with the State Agency Representative. The RCM stated the resident was at an appointment and requested the room be locked when he/she left the facility, but staff kept a key to the room. Observation of Resident #35's room revealed there was more than fifty (50) assorted containers of yogurt, which were not refrigerated, stacked in the room. There was also two (2) meal trays observed on the floor beside the bed in the same place as observed the prior day, [DATE], with perishable food under the lids. Interview with the RCM at the time of the observation, confirmed the meal trays were delivered on [DATE] meal. There were two (2) additional meal trays noted with perishable foods observed, which the RCM stated was delivered today, [DATE] at breakfast and lunch. Additional observation revealed the six (6) uncovered, unlabeled or undated cups of a pink colored drink that were observed on [DATE] were still the bedside table. There were three (3) additional cups observed on the bedside table, which were covered, but undated, revealing a total of nine (9) cups of fluids in the room. Interview on [DATE] at 2:32 PM, with State Registered Nurse Aide (SRNA) #6, revealed Resident #35 could feeding himself/herself, and was kind of a hoarder. Further interview revealed Resident #35 had refused to allow her to remove meal trays when she was assigned to the resident and would scold her and tell her, no. SRNA #6 further stated when she asked the resident the reason he/she didn't want the tray removed, the resident told her he/she was saving it, and the food would be good. Additional interview revealed someone brought the resident six (6) hot dogs and the resident told him/her they lasted six (6) days. Per interview, Resident #35 informed her he/she received the hot dogs on a Saturday and when she saw the resident on a Monday, the resident still had one (1) hot dog left. SRNA #6 could not recall the date of this incident. SRNA #6 stated Resident #35 did not have a refrigerator and the yogurt and perishable food trays being left in the resident's room could spoil which could definitely be a health issue for the resident. SRNA #6 further stated Resident #35 could get food poisoning and could get really sick with vomiting and diarrhea if the resident ate spoiled food. Interview on [DATE] at 2:48 PM, with Licensed Practical Nurse (LPN) #7, revealed Resident #35 used to have a care taker who helped manage him/her, and the care taker could help keep him/her calm while staff removed leftover food from the room. However, at present the resident would not allow staff to remove the food trays from his/her room. Per interview, yogurt should be refrigerated and leftover food trays should be picked up within two (2) hours of delivery; however, Resident #35 would not allow this. LPN #7 revealed Resident #35 did not have a refrigerator in his/her room as residents weren't allowed to have refrigerators. Continued interview revealed she honestly did not think the resident ate the left over food, but there was no way to know for sure. Additional interview revealed there could be possible negative outcomes for Resident #35, if he/she were to eat expired food, such as food poisoning, upset stomach, and diarrhea. Interview with the Dietary Manager, on [DATE] at 2:52 PM, revealed perishable food which was not refrigerated and was left at room temperature, could grow bacteria and could cause food poisoning if ingested. Interview with the Facility Operations Manager, on [DATE] at 2:45 PM, revealed the facility needed to work with Resident #35 in finding a solution to storing food in the facility refrigerator that could be accessed by the RCM upon the resident's request. Further interview revealed this could be a goal to provide better quality of life for the resident. Interview on [DATE] at 3:18 PM, with the RCM, revealed it was a pattern for Resident #35 to leave perishable foods in his/her room. She stated the resident could get sick from eating these foods; however, she felt the resident's body was accustomed to eating the left over foods. The RCM stated Resident #35 did not have a refrigerator. Interview on [DATE] at 3:56 PM, with the Social Services Manager, revealed she had talked to Resident #35 several times related to hoarding behaviors and leaving old food in the room. Continued interview revealed she would refrigerate the resident's yogurt, but the resident would refuse this. Per interview, the resident had told the Social Services Manager, he/she did not drink the cups of liquids in the room, but would rinse the cups out and recycle them. Further interview revealed the resident also told her, he/she did not eat the leftover food, but stated he/she was going to give it to kids, or staff. Per interview, when the resident gave staff food, staff would discard of the food. Additional interview revealed if the resident consumed improperly stored food, it could it make the resident sick. Interview on [DATE] at 3:58 PM, and [DATE] at 4:31 PM, with the Director of Nursing (DON), revealed she was familiar with Resident #35's hoarding behaviors, and staff had tried to educate the resident on the risks of leaving leftover food in his/her room. Per interview, all perishable food should be stored properly to keep from spoiling and that was not occurring for this resident. Interview with the Administrator, on [DATE] at 4:14 PM, [DATE] at 5:05 PM, revealed Resident #35 had a right to keep food in his/her room, but perishable foods must be stored properly in a refrigerator, and he was unaware of the resident keeping hot dogs in the room. Per interview, he was unaware of the resident eating any of the stored perishable food he/she kept in the room, but was aware he/she would offer it to staff and they would discard the food. Further interview, revealed if the resident ate spoiled food this could have a negative outcome for the resident. Additional interview revealed it was important for the facility to follow the policies related to food storage.

Based on observation, interview, record review and review of the facility's Policies, it was determined the facility failed to ensure residents were free of significant medication errors for one (1) of twenty-five (25) sampled residents (Resident #277). Observation of medication administration, on 03/29/19 at 9:01 AM, on Forest Heights Unit, A-Hall, revealed Licensed Practical Nurse (LPN) #8 crushed Potassium Chloride Extended-Release (ER) and [MEDICATION NAME] Extended Release (ER) and administered the medication to Resident #277. Potassium Chloride Extended-Release (ER) and [MEDICATION NAME] Extended Release (ER) were two (2) medications that were listed on the facility's Oral Dosage Forms That Should Not Be Crushed List. The findings include: Review of the facility's Policy titled, Medication Administration-General Guidelines, effective 04/2002, revealed it was the policy of the facility to provide resident medications as ordered. Further policy review revealed the facility would administer medications according to the Five (5) Rights of medication administration that included the following: 1. Right Resident 2. Right Route 3. Right Dose 4. Right Time 5. Right Medication. Review of the facility's documentation of Oral Dosage Forms That Should Not Be Crushed, copyright (YEAR), revealed the following medications should not be crushed: Drug Name: Potassium Chloride Extended-Release (ER) | Drug Class: Electrolyte | Form: Tablet, Extended Release (ER). Further review of facility's documented list of medications that should not be crushed revealed the following: Drug Name: [MEDICATION NAME] Extended Release (ER) | Drug Class: Beta-Blocker | Slow-Release (SR) |Form: Tablet, Extended Release (ER). Continued review revealed all medications listed on the provided documentation/list as Slow-Release were documented as such to designate any special-release medication form such as extended-release, delayed-release, sustained release and/or controlled release. Additional review revealed alternate forms of Potassium Chloride and [MEDICATION NAME] were available. Review of Resident #277's clinical record revealed the facility readmitted the resident on 03/06/19 with [DIAGNOSES REDACTED]. Review of Resident #277's (MONTH) 2019 Physician's Order Summary, dated 03/28/19, revealed an order to administer [MEDICATION NAME] M20 Tablet Extended Release (ER) 20 MEQ (Potassium Chloride Crystals), one (1) tablet by mouth twice daily for potassium deficit. Continued review revealed an order to administer [MEDICATION NAME] ER Tablet (Extended Release 24-hour) 75 milligram (mg) by mouth daily for Hypertension. Further review revealed there was no documented evidence of a Physician's Order to crush Resident #277's medications. Observation of medication pass, on 03/28/19 at 9:01 AM, for Resident #277, revealed the nurse crushed one (1) Potassium Chloride Extended Release (ER) twenty (20) Milliequivalents (MEQ) Tablet, crushed three (3) [MEDICATION NAME] ER twenty-five (25) Milligram (MG) tablets, crushed one (1) [MEDICATION NAME] (HCL) 100 Milligram (MG) Tablet, and crushed one (1) [MEDICATION NAME] 500 mg Tablet. Then, the nurse opened one (1) [MEDICATION NAME] 20 mg Delayed-Release (DR) Capsule and opened one (1) Duloxetine 30 mg DR Capsule and placed the contents of each crushed tablet and each opened capsule into a medication cup. The nurse further mixed the contents with vanilla pudding, and administered the preparation as a bolus. Interview with Resident #277, on 03/28/19 at 9:10 AM, revealed he/she was given medications crushed by staff all the time and he/she hated the way the pills tasted when they were crushed up. Resident #277 stated, although it was the quickest way to take the pills, he/she would prefer to take the medicine whole, just like he/she used to do before coming to stay at the facility. Resident #277 stated he/she could not recall there being any staff discussion with him/her related to his/her desire to have pills taken whole or crushed. Interview with LPN #8, on 03/28/19 at 9:20 AM, revealed the nurse was aware of the need for a Physician's Order to crush medications. However, she was unaware there was not an order to crush Resident #277's medications. Further interview revealed, I am a new nurse and I was trained on this medicine cart to crush this resident's medications. That's the only reason I did it that way. Continued interview revealed LPN #8 had received facility provided training and orientation on the use of the Electronic Health Record (EHR) system; however, was unable to explain or demonstrate the process of locating Resident #277's Physician's Orders in the EHR. Further interview with LPN #8, revealed she was unaware of the list of Oral Dosage Forms That Should Not Be Crushed provided to the facility by the facility's pharmacy. She further stated she was never taught Potassium, [MEDICATION NAME] and other Extended-Release, Slow-Release, and/or Controlled-Release medications should not be crushed. Interview with LPN #9, on 03/29/19 at 9:50 AM, revealed she was assigned to administer medications on Forest Heights Unit B-Hall. Per interview, there had to be a Physician's Order to crush medications. Continued interview revealed multiple copies of the list of Oral Dosage Forms That Should Not Be Crushed were kept in binders located at each of the nursing stations on every unit and remained accessible to all staff, at all times. Per interview, the medications on this list should not be crushed due to the possible side effects. Interview with Forest Heights Unit Resident Care Manager (RCM) #1, on 03/28/19 at 9:45 AM and at 03:22 PM, revealed LPN #8 should not have crushed any of Resident #277's medications prior to administration, as there was no Physician's Orders to crush this resident's medications. Further interview revealed LPN #8 should not have crushed Potassium Chloride ER twenty (20) MEQ Tablet and should not have crushed [MEDICATION NAME] ER twenty-five (25) MG three (3) Tablets as the medications were documented on the Oral Dosage Forms That Should Not Be Crushed List. Interview with the Consultant Pharmacist, on 03/29/19 at 4:19 PM, revealed a Physician's Order was required before crushing medications. Further interview revealed LPN #8, Should never have crushed Potassium Chloride ER Tablets because it is one of the drugs on our DO NOT CRUSH LIST. The Pharmacist stated, Potassium Chloride ER was an extended release tablet that could cause gastro-intestinal upset, a potential spike in potassium, and several other negative or adverse effects if crushed; depending on the resident's condition and history of pre-existing conditions. Per interview, if a resident already had increased potassium levels in the body at the time the crushed dose was administered, the resident could potentially have negative cardiac side effects. Continued interview revealed staff should never crush [MEDICATION NAME] ER Tablets for the exact same reason. The Pharmacist stated [MEDICATION NAME] was on the Pharmacy's DO NOT CRUSH LIST or Oral Dosage Forms That Should Never Be Crushed List, and if crushed could cause gastric irritation and/or potentially negative cardiac side effects such as [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] (dizziness) and [MEDICAL CONDITION]. Additional interview revealed a Physician's Order was required to change dosage form of any medication prior to administration and alternative forms of [MEDICATION NAME] ER and Potassium Chloride ER were available for use. Further, staff had been in-serviced and were aware of the need for Physician's Orders for crushing medications or combining medications to administer as a bolus. Interview with the Director of Nursing (DON), on 03/29/19 at 5:56 PM, revealed LPN #8 should have ensured there was a Physician's Order to crush medications and to administer medications as a bolus prior to crushing or combining any of Resident #277's medications. Continued interview revealed LPN #8 failed to follow standards of practice by crushing medications which were on the DO NOT CRUSH list; which could have led to a negative outcome for this resident. Additional interview revealed LPN #8 would need to be re-educated related to medication administration as well as locating the Physician's Orders on the EHR. Interview with the Administrator, on 03/29/19 at 6:23 PM, revealed he expected nursing staff to follow the facility's policies and procedures regarding medication administration. Further interview revealed LPN #8 should have obtained a Physician's Order prior to crushing any of Resident #277's medication. Continued interview revealed the Administrator expected staff to have the ability to reference the resource material provided to them such as the DO NOT CRUSH list provided by the Pharmacy and to be knowledgeable of medications that could not be crushed. Additional interview revealed staff should absolutely be knowledgeable of how to locate a Physician's Order.

Based on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement Comprehensive Care Plans for each resident, to meet a resident's medical, nursing, and mental and psychosocial needs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being related to ongoing [MEDICAL CONDITION] medication monitoring for one (1) of twenty-five (25) sampled residents (Resident #56). Resident #56's Comprehensive Care Plan, dated 08/14/18, revealed interventions to observe for effectiveness of medications; and observe for side effects of medication. However, there was no documented evidence during January, (MONTH) or Mach of 2019, of ongoing monitoring for efficacy and adverse consequences of [MEDICATION NAME] Concentrate which was prescribed for a [DIAGNOSES REDACTED]. (Refer to F-758) The findings include: Review of facility's Policy, titled Comprehensive Plan of Care, revised (MONTH) 2002, revealed the comprehensive care plan must describe services to be furnished to attain or maintain the resident's highest physical, mental, and psychosocial well-being. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of the facility's Medication Monitoring and Management Policy, undated, revealed the facility staff would perform ongoing monitoring for appropriate, effective, and safe medication use. Additionally, the information gathered during the ongoing monitoring would be incorporated into a Comprehensive Care Plan (CCP) that reflects parameters for monitoring the resident's condition, ongoing need for the medication, what was monitored, and who was responsible for monitoring. Review of Resident #56's medical record revealed the facility admitted the resident on 11/01/17 with [DIAGNOSES REDACTED]. Review of Resident #56's Comprehensive Care Plan, dated 08/14/18, revealed the resident was at risk for side effects and adverse reactions due to [MEDICAL CONDITION] medication. The goal revealed the resident would be free of harm/injury related to medication daily. There were several interventions including: observe for effectiveness of medications; observe for side effects of medication including drowsiness; and report any signs and symptoms to the Physician. Review of Resident #56's physician's orders [REDACTED]. ([MEDICATION NAME] is an antipsychotic drug-[MEDICAL CONDITION] drug) Review of Resident #56's Medication Administration Record [REDACTED]. Review of Resident #56's Weekly Nursing Assessments, dated 01/12/19, 01/19/19, 01/25/19, and 01/26/19 revealed there was no documented evidence of hallucinations or delusions in the neurological section. Review of Resident #56's Monthly Behavior Monitoring, dated (MONTH) 2019, revealed worksheets for [MEDICATION NAME] related to Depression; [MEDICATION NAME] related to Dementia; and [MEDICATION NAME] related to Alzheimer's. All these forms were blank, indicating no behaviors. However, there was no documented evidence of a Monthly Behavior Monitoring worksheet for [MEDICATION NAME]. Review of Resident #56's Nursing Notes, Social Services Notes, and Physician's Progress Notes, for (MONTH) 2019, revealed no documented evidence of ongoing monitoring related to [MEDICAL CONDITION] drugs. Review of Resident #56's Abnormal Involuntary Movement Scale (AIMS) (exam used for assessing side effect of antipsychotic drugs), dated 01/30/19, revealed the resident scored zero (0), indicating the resident was at low risk for movement disorders. Review of Resident #56's Quarterly Minimum Data Set (MDS) Assessment, dated 01/30/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), indicating severe cognitive impairment; and a Mood Interview score of zero (0), which indicated no depression; and no presence of behaviors. Further review revealed the facility assessed the resident as receiving seven (7) days of [MEDICAL CONDITION] medication. Review of Resident #56's (MONTH) Weekly Nursing Assessments, dated 02/02/19, 02/09/19, 02/16/19, and 02/23/19, revealed there was no documented evidence of hallucinations or delusions in the neurological section. Review of the physician's orders [REDACTED]. Further review revealed palliative care needed to be discussed with the family related to chronic [MEDICAL CONDITION], Diabetes, and progressive Dementia. However, the Note did not discuss the use of or efficacy and adverse consequences for [MEDICATION NAME]. Review of Resident #56's Pharmacy Consultation Report, dated 02/10/19, revealed the Consultant Pharmacist evaluated the current dose of [MEDICATION NAME] 0.5 milligrams (mg) every day (QD) and one (1) mg at bed time (HS) and recommended attempting a Gradual Dose Reduction (GDR); however, there was no response from the Provider related to this Report in (MONTH) 2019. Review of the Social Services Progress Note, dated 02/22/19, revealed the resident was alert, but disoriented. Additionally, Resident #56 would not answer direct questions, but would recite his/her ABC's or talk about family. However, the Note did not discuss the use of or efficacy and adverse consequences for [MEDICATION NAME]. Review of Resident #56's physician's orders [REDACTED]. Review of Resident #56's Medication Administration Record [REDACTED]. Review of Resident #56's Monthly Behavior Monitoring, for (MONTH) 2019, revealed worksheets for [MEDICATION NAME] related to Depression; [MEDICATION NAME] related to Dementia; and [MEDICATION NAME] related to Alzheimer's. All the forms were blank, indicating no behaviors. However, there was no documented evidence of a Monthly Behavior Monitoring sheet for [MEDICATION NAME]. Review of Resident #56's Nursing Progress Notes, dated (MONTH) 2019, revealed there was no documented evidence of ongoing monitoring related to [MEDICAL CONDITION] drugs for efficacy and adverse consequences. Additional review of the Pharmacy Consultation Report, dated 02/10/19, revealed the Advanced Registered Nurse Practitioner (ARNP) signed the Pharmacy Consultation Report, which was dated 02/10/19, on 03/05/19. The ARNP agreed with the Consultant Pharmacist to attempt a Gradual Dose Reduction (GDR) to discontinue [MEDICATION NAME] 0.5 mg daily, and continue [MEDICATION NAME] one (1) mg at bedtime. Additional review revealed the APRN would re-evaluate in ten to fourteen (10-14) days. Review of Resident #56's physician's orders [REDACTED]. Further review revealed orders, with a start date of 03/05/19, for [MEDICATION NAME] tablet; give one (1) mg orally, one (1) time at bedtime related to Unspecified Dementia without Behavioral Disturbance. Review of Resident #56's Medication Administration Record [REDACTED]. Review of Resident #56's (MONTH) Weekly Nursing Assessments, dated 03/09/19, 03/16/19, and 03/23/19, revealed there was no documented evidence of hallucinations or delusions in the neurological section. Review of Resident #56's Monthly Behavior Monitoring, for (MONTH) 2019, revealed worksheets for [MEDICATION NAME] related to Depression; [MEDICATION NAME] related to Dementia; and [MEDICATION NAME] related to [MEDICAL CONDITION]. All these forms were blank, indicating no behaviors. However, there was no documented evidence of a Monthly Behavior Monitoring sheet for [MEDICATION NAME]. Review of Resident #56's Nursing, and Social Services Progress Notes, dated (MONTH) 2019, revealed there was no documented evidence of ongoing monitoring related to [MEDICAL CONDITION] drugs for efficacy and adverse consequences. Review of the ARNP Progress Note, dated 03/18/19 at 3:20 PM, revealed she would re-evaluate [MEDICAL CONDITION] medication adjustment in two to three (2-3) weeks; if no increase in hallucinations, then consider decreasing the [MEDICATION NAME] dose at night. Further review revealed Subjective (S) Resident stated, please I'm not so good; I get upset when the little kids find things. Objective (O) patient in normal confused state. Talking more about little kids, but not yelling out and seemed to be sleeping per usual. No change in his/her mental status. No Acute distress, lungs clear to auscultation bilaterally, Abdomen soft, non-tender, bowel sounds present, vital signs stable, and weight 236.8 pounds. Hallucinations at baseline, despite the decrease in [MEDICATION NAME]. Will continue [MEDICATION NAME] one (1) mg at HS (night) for a few more weeks, then consider decreasing HS [MEDICATION NAME]. However, there was no further documented evidence Resident #56's [MEDICAL CONDITION] drugs use had ongoing monitoring for efficacy or adverse consequences, to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related to [MEDICATION NAME]. Observation of Resident #56, on 03/26/19 at 11:30 AM, revealed the resident was in the parlor sitting upright in a broda chair, with his/her legs dangling down. Further observation revealed the resident's eyes were closed, mouth was open, head was tilted to the right, and he/she was receiving oxygen per nasal cannula. Continued observation of Resident #56, on 03/26/19 at 1:04 PM, revealed the resident was sitting reclined in a broda chair, at bedside. Additional observation revealed the resident's eyes were closed, mouth was open, and he/she was receiving oxygen per nasal cannula. Observation of Resident #56, on 03/27/19 at 8:00 AM, revealed the resident was sitting reclined in his/her broda chair, leaning towards the right, at the dining room table with the meal tray in front of him/her on the table, covered. Further observation revealed the resident was receiving oxygen per nasal cannula, and the resident's eyes were closed. Interview with Licensed Practical Nurse (LPN) #15, on 03/28/19 at 9:41 AM revealed he was assigned to Resident #56 on the day shift. Per interview, the CCP should be followed to provide necessary care to residents. He stated this was important to ensure quality care was provided and resident's needs were met. Further, he stated there should have been Monthly Behavior Monitoring worksheets for daily use of [MEDICATION NAME] for Resident #56. Continued interview with LPN #15, revealed Resident #56's [MEDICATION NAME] dose had recently been reduced and it was important to closely monitor the resident related to the drug reduction to ensure efficacy of the drug. Interview with the Resident Care Manager (RCM) for Shoreline Hallway where Resident #56 resided, on 03/28/19 at 3:01 PM, revealed she expected the facility policy related to implementing the CCP to be maintained. Additionally, she stated Resident #56's CCP related to monitoring [MEDICAL CONDITION] medication, should have been implemented by the nursing staff related to [MEDICATION NAME]. Further interview revealed implementing the CCP would ensure quality care and standards of practice were provided to the resident. Interview with Social Services, on 03/28/19 at 3:17 PM, revealed Resident #56's CCP should have been implemented related to providing ongoing monitoring of [MEDICAL CONDITION] medication to ensure high-risk medication was necessary and at a therapeutic dose related to [MEDICATION NAME] medication. Further, it was important to implement the CCP to ensure resident care needs were met. Interview with ARNP, on 03/28/19 at 2:45 PM, revealed she expected nursing staff to implement the CCP related to ongoing monitoring of [MEDICAL CONDITION] medications. Per interview, this monitoring was important to ensure providers could attempt reductions, and keep the medication regime therapeutic. Further, it was important to ensure ongoing monitoring of [MEDICAL CONDITION] medications was maintained to ensure health care providers could quickly assess the residents' needs and adjust medications as necessary so residents were not in distress or fearful. Per interview, this was especially important in Resident #56's case, to ensure the resident was not fearful. Further, she stated ongoing monitoring and assessment by direct care nursing staff, related to Resident #56's [MEDICATION NAME] medication to ensure the medication was not negatively effecting him/her was imperative. Interview with the Director of Nursing (DON) on 03/28/19 at 3:33 PM revealed she expected the facility policy and regulation related to implementing the CCP to be followed related to monitoring [MEDICAL CONDITION] medications. Additional interview revealed Resident #56 should have had ongoing monitoring of efficacy and adverse consequences related to [MEDICATION NAME] use. Further, it was important to implement the CCP for each resident receiving [MEDICAL CONDITION] medications to ensure adverse consequence did not interfere with resident care, daily routine and mental status. Interview with the Administrator on 03/28/19 at 5:45 PM revealed he expected facility policy and regulation to be maintained related to implementation of the CCP. Additionally, Resident #56 should have had ongoing monitoring in place related to [MEDICAL CONDITION] drug use related to [MEDICATION NAME], as per facility policy. Further, it was important for CCP to be followed by all staff to ensure residents receive appropriate care and their needs were met.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure that its medication error rates were not five percent (5%) or greater. Observation of medication pass, on 03/28/19 at 9:01 AM, for Resident #277, revealed the nurse crushed one (1) Potassium Chloride Extended Release (ER) twenty (20) Milliequivalents (MEQ) Tablet, crushed three (3) [MEDICATION NAME] ER twenty-five (25) Milligram (MG) tablets, crushed one (1) [MEDICATION NAME] (HCL) 100 Milligram (MG) Tablet, and crushed one (1) [MEDICATION NAME] 500 mg Tablet. Then, the nurse opened one (1) [MEDICATION NAME] 20 mg Delayed-Release (DR) Capsule and opened one (1) Duloxetine 30 mg DR Capsule and placed the contents of each crushed tablet and each opened capsule into a medication cup. The nurse further mixed the contents with vanilla pudding, and administered the preparation as a bolus. However, there was no documented evidence of a Physicians' Order to crush the medications or to administer the medications in a bolus for this resident. This observation revealed six (6) medication errors out of a total of thirty-three (33) medication opportunities, resulting in an eighteen percent (18%) medication error rate. The findings include: Review of the facility's Policy titled, Medication Administration-General Guidelines, effective 04/2002, revealed it was the policy of the facility to provide medications as ordered. Further policy review revealed the facility would administer medications according to the Five (5) Rights of medication administration that included the following: 1. Right Resident 2. Right Route 3. Right Dose 4. Right Time 5. Right Medication. Review of the facility's Policy titled, Administration of Crushed Oral Medications, effective 11/2017, revealed it was the policy of the facility to ensure medications were administered as prescribed and in accordance with current standard nursing principles and practices. Further policy review, revealed the facility would ensure crushed oral medications would be administered individually and would not be combined and given together as a bolus administration. If the physician/prescriber and the interdisciplinary team had evaluated the resident and determined administration of crushed oral medications as a single oral bolus outweighed the risk of administering crushed medications individually, the physician/prescriber would do the following: A) Write a physician's orders [REDACTED]. B) Include the rationale for crushing and administering oral medications at once in resident's clinical record. C) Ensure the oral bolus administration of crushed medications was addressed in resident's plan of care. D) Ensure resident and/or representative was informed of rationale of crushing and administering oral medications. E) Monitor resident for any adverse effects of bolus administration of crushed medications. Additional policy review revealed the facility staff would periodically re-evaluate the resident's need for medications to be administered together as a bolus. Observation of medication pass, on Forest Heights Unit, A-Hall, on 03/28/19 at 9:01 AM, for Resident #277, revealed Licensed Practical Nurse (LPN) #8 crushed one (1) Potassium Chloride Extended Release (ER) twenty (20) Milliequivalents (MEQ) (ER is a formulation of the tablet used to slow the release of potassium into the gastro-intestinal tract) Tablet; crushed three (3) [MEDICATION NAME] ER twenty-five (25) Milligram (MG) tablets; crushed one (1) [MEDICATION NAME] (HCL) 100 Milligram (MG) Tablet; and crushed one (1) [MEDICATION NAME] 500 mg Tablet. The nurse then opened one (1) [MEDICATION NAME] 20 mg Delayed-Release (DR) Capsule and opened one (1) Duloxetine 30 mg DR Capsule and placed contents of each crushed tablet and each opened capsule into a medication cup. The nurse mixed the contents with vanilla pudding, and administered the preparation as a bolus. However, there was no documented evidence of Physicians' Orders to crush the medications or to administer the medications in a bolus for this resident. This observation accounted for six (6) medication errors, out of a total of thirty-three (33) medication opportunities observed during medication pass, to result in an eighteen percent (18%) medication error rate. Interview with LPN #8, on 03/28/19 at 9:20 AM, revealed she was aware she should have had a physician's orders [REDACTED]. Further interview revealed she was unaware she did not have a physician's orders [REDACTED].#277, stating, I am a new nurse and I was trained on this medicine cart to crush this resident's medications. That's the only reason I did it that way. Continued interview revealed LPN #8 had received facility provided training and orientation on the use of the Electronic Health Record (EHR) system. However, when asked to pull up Resident #277's physician's orders [REDACTED].#8 was unable to explain or demonstrate the process of locating a physician's orders [REDACTED]. Interview with LPN #9, who was assigned to administer medications to residents on Forest Heights Unit B-Hall, on 03/29/19 at 9:50 AM, revealed staff was to ensure there was a physician's orders [REDACTED]. In addition, LPN #9 advised there would need to be a specific physician's orders [REDACTED]. Further interview revealed the interdisciplinary team and the Physician would first have to evaluate/assess the resident to ensure crushing the medications or administering the crushed medications in a bolus would not be contraindicated and the benefits outweighed the risks, prior to an order being obtained. Interview with Forest Heights Unit Resident Care Manager (RCM) #1, on 03/28/19 at 9:45 AM and at 3:22 PM, revealed a physician's orders [REDACTED]. Further interview revealed LPN #8 should not have crushed Potassium Chloride ER twenty (20) MEQ Tablet and should not have crushed [MEDICATION NAME] ER twenty-five (25) MG three (3) Tablets as the medications were documented on the Oral Dosage Forms That Should Not Be Crushed List and also there was not a physician's orders [REDACTED]. Continued interview revealed there also had to be a physician's orders [REDACTED]. Additional interview revealed there must also be an assessment documented in the medical record if medications were to be crushed and/or combined crushed medications administered as bolus and this must be care planned, which was not the situation for Resident #277. Interview with the Consultant Pharmacist, on 03/29/19 at 4:19 PM, revealed a physician's orders [REDACTED]. Further interview revealed LPN #8 should never have crushed Potassium Chloride ER Tablets because it is one of the drugs on our DO NOT CRUSH LIST. The Pharmacist explained, Potassium Chloride ER was an extended release tablet that could cause gastro-intestinal upset, a potential spike in potassium, and several other negative or adverse effects if crushed; depending on the resident's condition and history of pre-existing conditions. Per interview, if a resident already had increased potassium levels in the body at the time the crushed dose was given, the resident could potentially have negative cardiac side effects. Further interview revealed staff should never crush [MEDICATION NAME] ER Tablets for the exact same reason. Continued Pharmacist interview revealed [MEDICATION NAME] was on the Pharmacy's DO NOT CRUSH LIST or Oral Dosage Forms That Should Never Be Crushed List, and if crushed could cause gastric irritation and/or potentially negative cardiac side effects such as [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] (dizziness) and [MEDICAL CONDITION]. Additional interview with the Pharmacist, revealed a physician's orders [REDACTED]. Per interview, staff had been in-serviced and were aware of the need for physician's orders [REDACTED]. Interview with the Director of Nursing (DON), on 03/29/19 at 5:56 PM, revealed LPN #8 should have obtained a physician's orders [REDACTED].#277's medications. Further interview revealed LPN #8 should have ensured a physician's orders [REDACTED]. Continued interview revealed LPN #8 failed to follow standards of practice by crushing medications which were on the DO NOT CRUSH list. Further, the nurse failed to follow facility policy by mixing Resident #277's medications into a vanilla pudding and administering the bolus preparation to the resident without a physician's orders [REDACTED].#8 would need to be re-educated prior to receiving another medication administration assignment. The DON further stated LPN #8 was familiar with obtaining/receiving and locating the physician's orders [REDACTED]. Interview with the Administrator, on 03/29/19 at 6:23 PM, revealed he expected nursing staff to follow the facility's policies and procedures regarding medication administration. Further interview revealed LPN #8 should have obtained a physician's orders [REDACTED]. Continued interview revealed the Administrator expected staff to have the ability to reference the resource material provided to them such as the DO NOT CRUSH list provided by the Pharmacy and should have knowledge of medications that could not be crushed. Additional interview revealed staff should absolutely know how and where to locate a physician's orders [REDACTED].

Based on observation, interview, record review and review of facility Policy, it was determined the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of twenty-five (25) sampled residents (Resident #35). Resident #35 exhibited hoarding behaviors including hoarding of papers which were stacked against the walls of the resident's room and were all over the resident's bed. In addition, there was hoarding of left over food and perishable foods. Although there was a physician's orders [REDACTED]. In addition, there was no documented evidence the facility addressed Resident #35's hoarding behavior through behavioral management to ensure necessary person-centered care and services were implemented related to the resident's hoarding behaviors. The findings include: Review of facility Behavior Management Policy, revised (MONTH) (YEAR), revealed it is the policy of the facility that staff be aware of each residents' current health status and regular activity, and be able to promptly identify changes that may indicate a change in condition. Further review revealed the procedure included the following: 1. The facility will document resident's behavior changes. 2. If a resident's behavior becomes harmful to self or others the nursing staff must notify the resident's physician and resident's designated responsible party. The Social work Services Director will also be notified. 3. Resident behavior changes and care will clearly and objectively be documented in the resident's medical record. 4. Resident behavior changes will be dealt with through the behavioral management program and interdisciplinary care planning. Specific goals and approaches will be developed for that particular resident so that his/her care is delivered in a consistent and coordinated manner. 5. If the facility is unable to care for the resident's changing needs, nursing will assist social services in finding appropriate alternate placement. Continued review of the Policy, revealed when a normally alert and competent resident verbally or physically exhibits behavioral problems, possible causes should be investigated to determine if it is an isolated incident or the start of a behavioral pattern. The resident's Physician and designated family contact should be called. Review of the facility Comprehensive Care plans Policy, revised November, 2002, revealed the facility will provide an individualized Plan of Care for each resident, by means of a written document which includes input from all disciplines involved in the provision of care. Further review revealed the Comprehensive Care Plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the Comprehensive Assessment; and any services that are not provided due to the resident's exercise of their rights, including the right to refuse treatment. Review of the Refrigerated Storage, Policy, revised (MONTH) 2006, revealed the facility will store, prepare and serve foods in accordance with federal, state and local sanitary codes. Further review revealed it is essential that refrigerator temperatures be low enough to safely keep most perishable foods and refrigerator temperatures that are consistently thirty eight (38) degrees Fahrenheit or below will provide this safety margin. Review of Resident #35's medical record revealed the facility readmitted the resident on [DATE]. Per record review, the resident had [DIAGNOSES REDACTED]. Further record review revealed there were no mental health [DIAGNOSES REDACTED]. Review of the Social Services Progress Note, dated [DATE], revealed the Social Service Worker met with the resident that date in his/her room, with the Maintenance Director, Life Safety Director, Social Workers, and RCM (Resident Care Manager), regarding some concern over the mess {he/she}has in there. Continued review revealed staff discussed safety concerns for the resident and staff taking care of the resident and staff offered for someone to come in and help him/her get organized and make the room safe. Per the Note, the resident was kind of in agreement, but also said he/she did not want to throw anything away. Further review of the Note, revealed staff were going to come up with some interventions for the resident and hopefully the resident would compromise some for his/her safety. Review of the Social Services Progress Notes, dated [DATE], revealed the Resident was AxOx3 (alert and oriented times three) and was able to make wants and needs known. After assessment, Resident's PHQ-9 (Resident Mood Interview over the last two weeks) score was 0 (zero) and BIMS (Brief Interview for Mental Status) was 15 (fifteen). (A BIMS score of fifteen (15) indictes no cognitive impairment). No behavioral issues at this time. Further review revealed it was noted for the MDS assessment dated [DATE], the resident did have some hoarding issues that social services and housekeeping had talked to him/her about. Review of the Social Services Progress Notes, dated [DATE], revealed Resident is AxOx3 (alert and oriented times three) and was able to make wants and needs known. After assessment, Resident's PHQ-9 (Resident Mood Interview over the last two weeks) score was 0 (zero) and BIMS (Brief Interview for Mental Status) was 15 (fifteen). No behavioral issues at this time. Continued review revealed it was noted for the MDS Assessment, dated [DATE], the resident did have some hoarding issues that social services and housekeeping had talked to him/her about. Review of the Social Services Progress Note, dated [DATE], revealed Resident is AxOx3 (alert and oriented times three) and able to make wants and needs known. After assessment, Resident's PHQ-9 (Resident Mood Interview over the last two weeks) score was 0 (zero) and BIMS (Brief Interview for Mental Status) was 15 (fifteen). No behavioral issues at this time. Additional review revealed it was noted for the MDS Assessment, dated [DATE], the resident did have some hoarding issues that social services and housekeeping had talked to him/her her about. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15 indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as having no mood indicators, no behaviors, and no rejection of care during the assessment period. Further review of the MDS Assessment revealed the facility assessed the resident as requiring supervision or set up help only for most ADLs (Activities of Daily Living). However, per the MDS Assessment, the resident required limited assistance of one (1) staff for locomotion off unit; supervision with one (1) person physical assist for walking in corridor; and limited assistance of one (1) person for transfers. Review of the Nurse's Progress Note, dated [DATE], revealed Resident #35 refused to take medications in front of the nurse; and told the nurse to just leave the medications on the table. Per the Note, the nurse explained the importance of the nurse making sure the resident received all medications prescribed and the resident stated he/she would be fine. Further review of the Note, revealed flies were noted in the resident's room and the nurse had a hard time moving around in the resident's room as the resident demanded the nurse not step on anything. The nurse documented there was an immense amount of clutter in the room. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #35 as having a Brief interview for Mental Status score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS Assessment revealed the facility assessed the resident as having no mood indicators or behaviors, and no rejection of care during the assessment period. Further review of the MDS Assessment, revealed the facility assessed the resident as supervision or set up help only for ADL's (Activities of Daily Living) with the exception of locomotion off unit which the resident required limited assistance of one (1) staff. Review of the Social Services Progress Note, dated [DATE], revealed the Social Services Worker met with patient to update his/her annual assessments. Both the PHQ-9, score of 0 (zero) and BIMS, score of 0 (zero) remained the same. Review of the physician's orders [REDACTED]. Review of Resident #35's Comprehensive Care Plan, initiated [DATE], revealed the resident had episodes of behaviors as evidenced by: Hoarding. The goal stated the resident would have no episodes of behavior through next review with a target date of [DATE]. Interventions included: approach in calm non threatening manner; attempt to guide away from source of distress before agitation escalates; attempt to identify cause for resistance and reduce/eliminate if possible; attempt to identify factual basis for concerns/behaviors and resolve if possible; avoid commands using do's and don't's; give resident as many choices as possible about care and activities and identify trigger stimuli and educate staff to avoid as much as possible. Review of Resident #35's Monthly (MONTH) 2019 physician's orders [REDACTED]. Further review revealed a current order initiated [DATE], which stated, (MONTH) have psychiatric eval as needed. Review of the Physician's Progress Note, dated [DATE], revealed patient does not always take medications; hoarding; and continues to keep food/letters in room. However, further review of the medical record revealed there was no documented evidence evidence a psychiatric evaluation was discussed with or offered to Resident #35, as per the physician's orders [REDACTED].#35's hoarding behavior through behavioral management and interdisciplinary care planning to ensure necessary person-centered care and services were implemented related to the resident's hoarding behaviors. Observation of Resident #35, on [DATE] at 4:10 PM, revealed the resident was observed sitting in a chair beside the bed and window, and his/her legs were propped up on another chair. The resident's room had large amounts of mail, paper, and other items in the room; and the bed was covered in paper items, mail, and framed photos. Continued observation revealed there were pieces of paper woven through the slats of the window blinds, and paper items stacked along the walls of the room, allowing only a narrow path in the center of the room to walk. Further observation revealed there were two (2) meal trays with perishable food under the lids, on the floor beside the bed; and several unopened cups of puddings. There was also six (6) cups of a pink colored drink on the bedside table which were not covered, labeled or dated. Interview with Resident #35 on [DATE] at 4:10 PM, during the observation, revealed two (2) cups of the pink drink were from today ([DATE]) and two cups of pink liquid were from yesterday ([DATE]). The resident did not elaborate on the final two (2) cups of pink drink. Resident #35 stated he/she did not waste. Continued interview revealed the mail in the room was left over from when the resident and spouse were both critically ill and couldn't open and read the mail. Per interview, the resident's spouse did live in the facility, but passed away in December, (YEAR). Further interview revealed a friend brought the resident six (6) hot dogs once, and the resident stated he/she ate them from a Friday to a Wednesday, and they didn't ruin. Per interview, he/she did not have a refrigerator, but he/she would know if food had spoiled. Further interview revealed he/she would tell staff to leave his/her her meal tray in the wheel chair and he/she would eat in his/her room. Resident #35 stated he/she could ambulate and tried to take care of himself/herself. Additional interview revealed he/she did not sleep in the bed, but slept in the chair. Per interview, the bed was used as his/her desk. On [DATE] at 2:04 PM, the Resident Care Manager (RCM) unlocked the door to Resident #35's room and entered the room with the State Agency Representative. The RCM stated the resident was at an appointment and requested the room be locked when he/she left the facility, but staff had the key to the room. Continued interview revealed Resident #35 would know if anything had been touched. Observation of Resident #35's room revealed more than fifty (50) assorted containers of yogurt, which were not refrigerated, stacked in the room. There was two (2) meal trays observed on the floor beside the bed in the same place as observed the prior day, [DATE], with perishable food under the lids. Interview with the RCM at the time of the observation verified the meal trays were delivered on [DATE] meal. There were two (2) additional meal trays noted with perishable foods observed, which the RCM stated was delivered today, [DATE] for breakfast and lunch. Continued observation revealed the six (6) uncovered, unlabeled or undated cups of a pink colored drink that were observed on [DATE] were still the bedside table. There were three (3) additional cups observed on the bedside table, which were covered, but undated, for a total of nine (9) cups of fluids in the room. Observation on [DATE] at 8:57 AM, revealed Resident #35 was in the wheel chair propelling towards the resident's room while male staff were bringing boxes with yogurt, butter packages, and other items out of the room. Resident #35 stated he/she had saved the meal trays for when he/she returned from the doctor and when he/she entered the room, the trays were gone. Resident #35 then told facility staff they needed to give him/her $20.00 for the four (4) food trays which were removed from his/her room and and stated this was really upsetting. Resident #35 further stated the door was locked when he/she left for his/her appointment, but someone entered his/her room and drank the lemonade and stole the boxes which were in his/her room. Interview on [DATE] at 2:32 PM, with State Registered Nurse Aide (SRNA) #6, revealed Resident #35 required supervision, but could basically do everything for himself/herself including feeding self. SRNA #6 stated Resident #35 was kind of a hoarder and did not let people in his/her room often. SRNA #6 further stated she had been in the resident's room and it was full of clutter. Per interview, Resident #35 told her the papers were his/her spouses fan mail. Continued interview revealed Resident #35 had refused to allow her to remove meal trays when she was assigned to the resident and would scold her and tell her, no. SRNA #6 stated when she asked the resident the reason he/she didn't want the tray removed, the resident told her he/she was saving it, and the food would be good. Further interview revealed someone brought the resident six (6) hot dogs and the resident told him/her they lasted six (6) days. Per interview, Resident #35 told her he/she received the hot dogs on a Saturday and when she saw the resident on a Monday, the resident had one (1) hot dog left. SRNA #6 was unable to provide specific dates the resident had the hot dogs, but stated she just started working at the facility in February, 2019, so it had not been that long ago. Per interview, Resident #35 did not have a refrigerator and the yogurt and perishable food trays being left in the resident's room could spoil which could definitely be a health issue for the resident. SRNA #6 stated Resident #35 could get food poisoning and could get really sick with vomiting and diarrhea if the resident ate spoiled food. Interview on [DATE] at 2:48 PM, with Licensed Practical Nurse (LPN) #7, revealed she had worked as an LPN since (MONTH) (YEAR), but worked as a SRNA at the facility since (YEAR). She stated she worked with Resident #35 as an aide and a nurse. Continued interview revealed Resident #35 moved back to this unit after the resident's spouse passed away. LPN #7 stated the resident used to have a care taker who helped manage him/her, and the care taker could help keep him/her calm while staff removed leftover food from the room. However, at present the resident would not allow staff to remove the food tray from the room. Per interview, yogurt should be refrigerated and leftover food trays should be picked up within two (2) hours of delivery; but Resident #35 would not allow this. LPN #7 stated Resident #35 did not have a refrigerator in his/her room and residents weren't allowed to have refrigerators. Continued interview revealed she honestly did not think the resident ate the left over food but there was no way to know. Further interview revealed there could be possible negative outcomes for Resident #35, if he/she were to eat expired food, such as food poisoning, upset stomach, and diarrhea. Additional interview revealed she did not know if Resident #35 had ever been seen by a psychiatrist. Interview on [DATE] at 3:13 PM, with LPN #6, revealed yogurt should be refrigerated. Further interview revealed Resident #35 hoarded meal trays and then tried to give some of the food to staff. Per interview, if Resident #35 ate spoiled food, he/she could have gastrointestinal upset, and could get sick with diarrhea or vomiting. Interview with the Dietary Manager, on [DATE] at 2:52 PM, revealed room temperature food which was not refrigerated could grow bacteria and could cause food poisoning. Interview with the Facility Operations Manager, on [DATE] at 2:45 PM, revealed the facility needed to work with Resident #35 in finding a solution to storing food in the facility refrigerator that could be accessed by the RCM. Continued interview revealed this could be a goal to provide better quality of life for the resident. Interview on [DATE] at 3:18 PM, with the RCM, revealed food trays and left over food were removed from the resident's room on [DATE], prior to the resident returning from his/her appointment. Further interview revealed the resident was upset when he/she learned of this and the facility reimbursed the resident for the food trays as per the resident's request. Further interview revealed all other food items that facility staff removed from the resident's room were returned. When questioned if the foods left in the resident's room such as yogurt could be spoiled, the RCM stated it could be. Further interview with the RCM, revealed it was a pattern for this resident to leave perishable foods in his/her room. She stated the resident could get sick from eating these foods, but she felt the resident's body was accustomed to eating the left over foods. The RCM stated Resident #35 did not have a refrigerator. Further interview revealed they had tried to have Resident #35 seen by psychiatric services and the resident refused; however, there was no documented evidence of this. Further interview with the RCM, revealed Resident #35 had a recent endoscope and dilation and referral to GI (gastrointestinal) for complaints of bright red blood in stool. Interview on [DATE] at 3:56 PM, with the Social Services Manager, revealed she had talked to Resident #35 several times related to hoarding behaviors and leaving old food in the room; however, the resident denied having hoarding behaviors. Per interview, Resident #35 was offered grief counseling after the resident's spouse died and the resident refused. Per interview, she thought the resident's hoarding behaviors got worse after the resident's spouse passed. When the Social Services Manager was questioned if Resident #35's hoarding behavior would warrant psychiatric evaluation, the Social Services Manager stated she thought she had offered the resident a psychiatric appointment in the past, but probably didn't document this, and did not recall when this occurred. Further interview revealed she would refrigerate the resident's yogurt, but the resident would refuse this. Per interview, the resident had told the Social Services Manager, he/she did not drink the cups of liquids in the room, but would rinse them out and recycle them. Continued interview revealed the resident also told her, he/she did not eat the leftover food, but stated he/she was going to give it to kids, or staff. Per interview, when the resident gave staff food, staff would dispose of the food. Additional interview with the Social Services Manager, revealed if the resident consumed improperly stored food, it could it make the resident sick. Interview on [DATE] at 3:58 PM, and [DATE] at 4:31 PM, with the Director of Nursing (DON), revealed she was familiar with Resident #35's hoarding behaviors, and staff had tried to educate the resident on the risks of leaving leftover food in the room. However; per interview, the resident liked to feel like he/she was helping staff by offering them food, which they would accept and then discard. Further interview revealed all perishable food should be stored properly to keep from spoiling and that was not occurring for this resident. When questioned if the facility Behavior Management Policy was followed, or if there was any behavior modification program for this resident, the DON revealed there was no documented evidence the resident's behaviors were discussed related to behavior management as per facility policy. When questioned if physician's orders [REDACTED]. Per interview, to her knowledge there was no documented evidence the resident had been offered a psychiatrist consult, and if it had been offered and refused, the facility should try again. Further interview with the DON, revealed she expected staff to follow physician's orders [REDACTED]. Interview with the Administrator, on [DATE] at 4:14 PM, [DATE] at 5:05 PM, revealed Resident #35 had a right to make choices even when the resident did not make good choices. The Administrator stated Resident #35 had a right to keep food in his/her room, but perishable foods must be stored properly in a refrigerator, and and he was unaware of the resident keeping hot dogs in the room. Further interview revealed he was unaware of the resident eating any of the stored perishable food he/she kept in the room, but was aware he/she would offer it to staff and they would discard the food. When questioned if Resident #35 had been seen for a psychiatric evaluation as per the Physician Orders, the Administrator stated the order was written as, (MONTH) have psychiatric eval as needed. When questioned if the resident's behaviors related to hoarding behaviors would warrant a psychiatric evaluation, the Administrator stated the resident would have to be willing, and he was not sure if this service had been offered to the resident. He stated he would not say verbatim he had offered the resident a psych consult. Continued interview revealed the facility had offered the resident vast resources, such as providing staff needed to help the resident declutter and get things out of the facility to the resident's home; however, he was aware there was no documented evidence of a lot of the things the facility had done for the resident, related to the resident's behaviors of hoarding. Further interview revealed it was his expectation the facility would follow Policies and Procedures of the facility, including policies related to Behavior Management.

Based on observation, interview, and review of the facility's Policies, it was determined 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 one (1) of five (5) residents reviewed for infections out of a total of twenty-five (25) sampled residents (Resident #277). Observation of medication administration on 03/28/19 revealed staff failed to perform proper hand hygiene prior to preparation of medications, before entering resident's room and during administration of eye medication for one (1) of twenty-five (25) sampled residents, Resident #277. The findings include: Review of the facility's Policy titled, Handwashing, dated 12/2001 and revised 02/2003, revealed the facility recognized handwashing as the most basic yet most effective means of preventing and controlling the spread of infection. Further review of the facility's Handwashing Policy revealed, Every staff member had a responsibility to recognize the importance of and carry out good hand washing techniques not only to protect the residents they serve, but also themselves. Continued review revealed staff would reduce their chances of spreading an infection to residents or acquiring an infection themselves by [MEDICATION NAME] effective hand hygiene. Additional Policy review revealed the facility would ensure ongoing staff monitoring of staff utilization of appropriate timing and technique of handwashing during compliance rounds, infection control rounds, and other infection control monitoring programs. Review of the facility's Policy titled, Infection Prevention and Control Program, dated 04/01/13 and revised on 12/2017, revealed the purpose of the facility's policy was to provide a safe, sanitary and comfortable environment for all residents, staff and visitors. Further Policy review revealed the facility's program would include surveillance, reporting and tracking as well as prevention and control of infections to improve clinical outcomes. Continued review revealed the Infection Prevention and Control Program would prevent the development and transmission of communicable diseases and infections. Additional Policy review revealed the facility would identify and monitor all Infection Control issues, problems, and concerns through the monthly Quality Assurance and Performance Improvement meeting. Review of Resident #277's clinical record revealed, the facility readmitted the resident on 03/06/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 03/13/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) Score of five (5) out of fifteen (15), which indicated the resident was severely cognitively impaired. Further review of the Admission MDS revealed the facility assessed the resident to require extensive physical assistance of one for bed mobility, transfer, dressing and personal hygiene. Continued review revealed Resident #277 required limited physical assistance of one with eating. Observation of a medication administration performed by Licensed Practical Nurse (LPN) #8, on 03/28/19 at 9:09 AM, revealed LPN #8 preparing Resident #277's morning medications without washing or sanitizing hands. Further observation revealed LPN #8 entered Resident #277's room and administered oral medications without washing or sanitizing her hands after entering the resident's private bathroom to don clean gloves. Continued observation of the medication administration revealed LPN #8 using the same-gloved index finger of her right hand to administer eye medication to Resident #277's right eye following the administration of medication to the resident's left eye without washing/sanitizing hands or changing gloves. LPN #8 failed to utilize proper hand hygiene prior to and during administration of Resident #277's medications. Interview with LPN #8, on 03/28/19 at 9:20 AM, revealed she was the nurse assigned to administer medications and treatments to Resident #277 on 03/28/19. Further interview revealed she should have washed her hands prior to preparing Resident #277's medications; however, she was a new nurse and had failed to wash her hands because she was nervous about the survey process. Continued interview with LPN #8 revealed she should have washed and/or sanitized her hands prior to entering the resident's room to prevent the potential spread of germs, illness, disease or infection to or from the resident to her and vice versa as this was an infection control concern. Additional interview with LPN #8 revealed she was not aware of the need to remove gloves, wash/sanitize hands, and don clean gloves following the administration of resident's medication into left eye and prior to administration of medication in to right eye. LPN #8 stated she was taught to administer the resident's eye drops without washing/sanitizing hands and changing gloves between administration of medication into the left and right eye. Further, LPN #8 revealed she was not aware this was an infection control issue although she had received facility provided training on Infection Control and Prevention upon hire two (2) months ago. Interview with Resident Care Manager (RCM) #1, on 03/28/19 at 9:45 AM, revealed she was in charge of the unit on which Resident #277 resided. RCM #1 revealed she expected staff to wash/sanitize hands prior to preparing and administering each resident's medications, prior to entering a resident's room and before donning clean gloves to provide any resident care. Further interview with RCM #1 revealed she expected staff to remove soiled gloves after the administration of eye medication, wash/sanitize hands, don clean gloves and administer medication to resident's other eye as ordered to prevent the potential spread of bacteria, germs or infection from one eye to the other when same gloved finger is being used. RCM #1 explained this was an infection control topic that staff had received facility provided training on upon hire, quarterly and as needed. Continued interview with RCM #1 revealed she expected staff to utilize proper hand hygiene and standard precautions for all residents for infection control, as residents were vulnerable population and could become very ill, very quickly. RCM #1 added she was disappointed this was found on her unit and with her LPN. Interview with Registered Nurse Quality Manager (QM) #1, on 03/28/19 at 5:44 PM, revealed she expected staff to follow the facility's policy and practices for Infection Control when administering medications and providing any direct resident care. Further interview revealed she expected staff to wash/sanitize their hands and apply clean gloves before preparing and administering any resident medication, including eye drops. QM #1 stated once staff have washed and or sanitized their hands and applied clean gloves, then administered the resident's medications to the first eye, they should then remove their soiled gloves, wash/sanitize their hands again, re-apply clean gloves and administer medication in resident's other eye. She stated that proper hand hygiene and gloving technique will help to prevent the potential spread of bacteria, germs or infection in to the resident's other eye. QM #1 added this was an Infection Control and Prevention issue explaining the facility had provided educational material and training to all staff upon hire, quarterly, and as needed when issues or concerns are identified during Infection Control rounds or monthly Quality Assurance and Performance Improvement conferences. Interview with Director of Nursing (DON), on 03/28/19 at 5:56 PM, revealed she expected staff to practice proper hand hygiene and gloving technique when providing direct resident care. DON explained she expected staff to follow the facility's policies and procedures when caring for residents. Further interview with the DON revealed she expected staff to wash/sanitize hands prior to preparation and administration of resident's medications, including medications administered into the eye. Continued DON interview revealed she would expect LPN #8 to know to wash/sanitize their hands following administration of medication into resident's eye, before administration of medication into the resident's other eye to prevent potential cross contamination of bacteria or germs from that eye to the other eye or from staff to the resident or vice versa. Continued interview with the DON revealed she expected LPN #8 to wash/sanitize hands prior to entering a resident's room to decrease the potential transfer of illness, diseases or germs to resident, visitors or other staff members. Additional interview with the DON revealed she expected staff to wash and or sanitize hands before applying clean gloves. The DON continued to explain she and other administrative staff members work hard in an attempt to identify, monitor and track infection control and prevention concerns and will continue to provide educational and training material to staff as those issues arise. Interview with Facility Administrator, on 03/28/19 at 6:23 PM, revealed he expected staff to wash/sanitize hands prior to providing any direct resident care. Further interview with the Administrator revealed he expected LPN #8 to wash her hands prior to preparing and administering Resident #277's medications, including eye medicines. Continued Administrator interview revealed he expected LPN #8 to wash/sanitize her hands prior to entering the resident's room to administer medications. The Administrator added it was his expectation LPN #8 changed her soiled gloves following administration of medication in the resident's left eye, washed her hands, and donned clean gloves prior to administration of medication in to the resident's right eye. Further, the Administrator revealed he expected staff to follow the Facility's Infection Prevention and Control Policy and Practices to prevent the potential spread of bacteria, germs, viruses, diseases and illnesses to residents, staff, visitors/family members, vendors and others in the facility.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure residents who use [MEDICAL CONDITION] drugs receive adequate monitoring for efficacy and adverse consequences, to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one (1) of two (2) residents reviewed for [MEDICAL CONDITION] medications out of (25) sampled residents (Resident #56). Resident #56 was prescribed scheduled [MEDICATION NAME] Concentrate (antipsychotic [MEDICAL CONDITION] drug) related to Unspecified Dementia without Behavioral Disturbance, on 06/29/18; however, there was no documented evidence during January, (MONTH) or Mach of 2019, of ongoing monitoring for efficacy and adverse consequences for the [MEDICAL CONDITION] drug. The findings include: Review of the facility's [MEDICAL CONDITION] Medication Management Program Policy, revised (MONTH) (YEAR), revealed the facility would monitor behaviors and adverse consequences of [MEDICAL CONDITION] medication for residents receiving [MEDICAL CONDITION] medications. Further, all residents on [MEDICAL CONDITION] medications would be monitored for episodes of behaviors and behaviors would be documented on behavior sheets. Continued review revealed the facility staff would perform ongoing monitoring for appropriate, effective, and safe medication use. Additionally, the information gathered during the ongoing monitoring would be incorporated into a Comprehensive Care Plan (CCP) that reflects parameters for monitoring the resident's condition, ongoing need for the medication, what was being monitored, and who was responsible for monitoring. Review of Resident #56's medical record revealed the facility admitted the resident on 11/01/17 with [DIAGNOSES REDACTED]. Review of Resident #56's Comprehensive Care Plan, dated 08/14/18, revealed the resident was at risk for side effects and adverse reaction due to [MEDICAL CONDITION] medication. The goal stated the Resident would be free of harm/injury related to medication daily. Interventions included: observe for effectiveness of medications; observe for side effects of medication including drowsiness; and report any signs and symptoms to the Medical Director. Review of Resident #56's physician's orders [REDACTED]. Review of Resident #56's Medication Administration Record [REDACTED]. Review of Resident #56's Weekly Nursing Assessments, dated 01/12/19, 01/19/19, 01/25/19, and 01/26/19 revealed no documented evidence of hallucinations or delusions in the neurological section. Review of Resident #56's Monthly Behavior Monitoring, for (MONTH) 2019, revealed worksheets for [MEDICATION NAME] related to Depression; [MEDICATION NAME] related to Dementia; and [MEDICATION NAME] related to Alzheimer's. All forms were blank, indicating no behaviors. However, there was no Monthly Behavior Monitoring sheet for [MEDICATION NAME]. Review of Resident #56's Nursing Notes, Social Services Notes, and Physician's Progress Notes, dated (MONTH) 2019, revealed no documented evidence of ongoing monitoring related to [MEDICAL CONDITION] drugs. Review of the Abnormal Involuntary Movement Scale (AIMS) (exam used for assessing side effect of antipsychotic drugs), dated 01/30/19, revealed the resident scored zero (0), indicating the resident was at low risk for movement disorders. Review of Resident #56's Quarterly Minimum Data Set (MDS) Assessment, dated 01/30/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), indicating severe cognitive impairment; and a Mood Interview score of zero (0), indicating no depression; and no presence of behaviors. Additional review revealed the facility assessed the resident as receiving seven (7) days of [MEDICAL CONDITION] medication. Review of Resident #56's (MONTH) Weekly Nursing Assessments, dated 02/02/19, 02/09/19, 02/16/19, and 02/23/19, revealed no documented evidence of hallucinations or delusions in the neurological section. Review of physician's orders [REDACTED]. Further, palliative care needed to be discussed with the family related to chronic [MEDICAL CONDITION], Diabetes, and progressive Dementia. However, there was no documented evidence of the use of or efficacy and adverse consequences for the [MEDICAL CONDITION] drug. Review of Resident #56's Pharmacy Consultation Report, dated 02/10/19, revealed the Consultant Pharmacist evaluated the current dose of [MEDICATION NAME] 0.5 milligrams (mg) every day (QD) and one (1) mg at bed time (HS) and recommended attempting a Gradual Dose Reduction (GDR). However, there was no response from the Provider related to this Report in (MONTH) 2019. Review of Resident #56's Social Services Progress Note, dated 02/22/19, revealed the resident was alert, but disoriented. Additionally, the resident would not answer direct questions, but would recite his/her ABC's or talk about family. However, there was no documented evidence of the use of or efficacy and adverse consequences for the [MEDICAL CONDITION] drug. Review of Resident #56's physician's orders [REDACTED]. Review of Resident #56's Medication Administration Record [REDACTED]. Review of Resident #56's Monthly Behavior Monitoring, for (MONTH) 2019, revealed worksheets for [MEDICATION NAME] related to Depression; [MEDICATION NAME] related to Dementia; and [MEDICATION NAME] related to Alzheimer's. All forms were blank, indicating no behaviors. However, there was no Monthly Behavior Monitoring sheet for [MEDICATION NAME]. Review of Resident #56's Nursing Progress Notes, dated (MONTH) 2019, revealed no documented evidence of ongoing monitoring related to [MEDICAL CONDITION] drugs for efficacy and adverse consequences. Additional review of the Pharmacy Consultation Report, dated 02/10/19, revealed the Advanced Registered Nurse Practitioner (ARNP) signed the Pharmacy Consultation Report, dated 02/10/19, on 03/05/19. The ARNP agreed with the Consultant Pharmacist to attempt a Gradual Dose Reduction (GDR) to discontinue [MEDICATION NAME] 0.5 mg daily, and to continue [MEDICATION NAME] one (1) mg at bedtime. Further review revealed the APRN would re-evaluate in ten to fourteen (10-14) days. Review of Resident #56's physician's orders [REDACTED]. Further review revealed an order, with a start date of 03/05/19, for [MEDICATION NAME] tablet; give one (1) mg orally, one (1) time at bedtime related to Unspecified Dementia without Behavioral Disturbance. Review of Resident #56's Medication Administration Record [REDACTED]. Review of Resident #56's (MONTH) Weekly Nursing Assessments, dated 03/09/19, 03/16/19, and 03/23/19, revealed no documented evidence of hallucinations or delusions in the neurological section. Review of Resident #56's Monthly Behavior Monitoring, for (MONTH) 2019, revealed worksheets for [MEDICATION NAME] related to Depression; [MEDICATION NAME] related to Dementia; and [MEDICATION NAME] related to Alzheimer's. All forms were blank, indicating no behaviors. However, there was no Monthly Behavior Monitoring sheet for [MEDICATION NAME]. Review of Resident #56's Nursing, and Social Services Progress Notes, dated (MONTH) 2019, revealed no documented evidence of ongoing monitoring related to [MEDICAL CONDITION] drugs for efficacy and adverse consequences. Review of the Progress Note, dated 03/18/19 at 3:20 PM, revealed the ARNP was to re-evaluate [MEDICAL CONDITION] medication adjustment in two to three (2-3) weeks; if no increase in hallucinations, then consider decreasing the [MEDICATION NAME] dose at night. Additional review revealed Subjective (S) Resident stated, please I'm not so good; I get upset when the little kids find things. Objective (O) patient in his/her normal confused state. Talking more about little kids but not yelling out and seems to be sleeping per usual. No change in mental status. No Acute distress, lungs clear to auscultation bilaterally, Abdomen soft, non-tender, bowel sounds present, vital signs stable, weight 236.8 pounds. Hallucinations at baseline despite the decrease in [MEDICATION NAME]. Will continue [MEDICATION NAME] one (1) mg at HS (night) for a few more weeks, then consider decrease HS [MEDICATION NAME]. However, there was no further documented evidence Resident #56's [MEDICAL CONDITION] drugs use had ongoing monitoring for efficacy or adverse consequences, to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Observation of Resident #56, on 03/26/19 at 11:30 AM, revealed the resident was in the parlor sitting upright in a broda chair, with his/her legs not reclined, but dangling down. Continued observation revealed the resident's eyes were closed, mouth was open, head was tilted to the right, and he/she was receiving oxygen per nasal cannula. Further observation of Resident #56, on 03/26/19 at 1:04 PM, revealed the resident was sitting reclined in a broda chair, at bedside. Continued observation revealed the resident's eyes were closed, mouth was open, and he/she was receiving oxygen per nasal cannula. Observation of Resident #56, on 03/27/19 at 8:00 AM, revealed he/she was sitting reclined in his/her broda chair, leaning towards the right, at the dining room table with the meal tray in front of him/her on the table, covered. Continued observation revealed the resident was receiving oxygen per nasal cannula. Further, the Resident's eyes were closed. Interview with Licensed Practical Nurse (LPN) #15, on 03/28/19 at 9:41 AM, revealed he was assigned to Resident #56 on the day shift. Per interview, residents who receive [MEDICAL CONDITION] medication received ongoing monitoring for efficacy and adverse consequences. Additional interview revealed monitoring was documented in the Nursing Notes and on a Monthly Behavior Monitoring worksheet, which was the responsibility of the direct care Nurses. LPN #15 further stated all staff were to report to the nurse if the residents were exhibiting any signs or symptoms of adverse reactions and/or behaviors. Continued interview revealed the night shift nurses removed the Monthly Behavior Monitoring worksheets from the binder at the nurse's station, at the end of the month and gave them to the Resident Care Manager (RCM) to review and to discuss with the Director of Nursing (DON). Per interview, the night shift nurses were responsible to make new Monthly Behavior Monitoring sheets for each resident that received [MEDICAL CONDITION] medications and place it in the binder at the nursing station during monthly change over. Additional interview with LPN #15, revealed it was his role to ensure residents receiving [MEDICAL CONDITION] medications were monitored ongoing for efficacy and adverse consequences including behaviors and to ensure there was continued communication with staff, resident, families and face to face observations of residents. Further interview revealed it was important to maintain ongoing monitoring of residents receiving [MEDICAL CONDITION] medication to ensure the residents were receiving the most therapeutic medication and dose because if the wrong medication or dose was administered it could be detrimental to a resident's health or even be considered a chemical restraint. Continued interview with LPN #15, revealed Resident #56 did receive [MEDICATION NAME], and the dose had recently been reduced. Per interview, Resident #56 did have hallucinations; however, it had been awhile since he had observed the resident talk about seeing children. Further, the Resident should have a Monthly Behavior Monitoring worksheet for daily use of [MEDICATION NAME]. Interview with the Resident Care Manager (RCM) for Shoreline Hallway, on 03/28/19 at 3:01 PM, revealed she expected the facility policy related to monitoring residents on [MEDICAL CONDITION] medication and behavior monitoring to be maintained by direct care staff. Continued interview revealed SRNAs should report to the nurse any adverse consequences and behaviors residents were exhibiting; and the nurse should document reported behaviors or observed actions on the Monthly Behavior Monitoring worksheet daily. Per the RCM, all residents who receive a [MEDICAL CONDITION] medication should have a Monthly Behavior Monitoring sheet for each medication, and Resident #56 should have had a Monthly Behavior Monitoring worksheet for [MEDICATION NAME]. Additional interview revealed Monthly Behavior Monitoring documentation was by exception; and if the resident had no reported or observed behaviors, the worksheet would be blank. Per the RCM, Social Services reviewed the Monthly Behavior Monitoring worksheets daily, talked with the nurses and ensured follow up as necessary, and discussed behaviors with the RCM. Further, it was the responsibility of the night shift nurse, during monthly change over, to make new Monthly Behavior Monitoring worksheets for each resident that received [MEDICAL CONDITION] medications; and each [MEDICAL CONDITION] medication should have a separate sheet. Per the RCM, Resident #56's Monthly Behavior Monitoring worksheets for the last three (3) months were missed due to human error because there was not a specific process in place to ensure residents receiving a [MEDICAL CONDITION] medication had a new Monthly Behavior Monitoring sheet initiated during switch over each month. Continued interview with the RCM for Shoreline Hallway, revealed she ensured ongoing monitoring of residents who received [MEDICAL CONDITION] medication by communicating with social services daily related to concerns with resident behaviors documented on the Monthly Behavior Monitoring worksheet. Additionally, behaviors were reviewed during weekly Focus meetings which included the RCMs, social services, Minimum Data Set (MDS) nurse, dietary, DON, and occasionally the provider. However, the RCM stated the facility process for monitoring and review of [MEDICAL CONDITION] medication did not include ensuring a Monthly Behavior Monitoring worksheet was in place for each resident receiving a [MEDICAL CONDITION] medication. Further, it was important to monitor high-risk drugs such as [MEDICATION NAME] to ensure the resident was not receiving unnecessary medication, and was receiving the most therapeutic dose. Per interview, ongoing monitoring assisted with ensuring necessary medication changes were made. Interview with Social Services, on 03/28/19 at 3:17 PM, revealed she reviewed the Monthly Behavior Monitoring worksheets each morning for documented behaviors. Continued interview revealed she spoke with the nurses and the RCMs to see if any behaviors had been reported to them as well. Per interview, if there was a behavior documented or reported she would look into it further and find out if the behavior was still present. She stated if it was a continued behavior, she would ensure there was an intervention in place related to the behavior. Additional interview revealed she attended the weekly Focus meeting where the Interdisciplinary team (IDT) talked about behaviors and made ongoing revisions to the care plan as needed. Further interview revealed residents receiving [MEDICAL CONDITION] medications should have a Monthly Behavior Monitoring worksheet for each [MEDICAL CONDITION] medication and it was the responsibility of the night shift nurse to ensure a worksheet was initiated and placed in the binder at the nurse's station. However, she stated there was not a process in place to ensure each resident had a sheet for each [MEDICAL CONDITION] medication. Per interview, it was important to provide ongoing monitoring of residents who receive a [MEDICAL CONDITION] medication to ensure high-risk medications are necessary and at a therapeutic dose. Further, she revealed Resident #56 should have had a Monthly Behavior Monitoring worksheet related to [MEDICATION NAME]. Interview with the ARNP, on 03/28/19 at 2:45 PM, revealed she expected nursing staff to document a daily assessment for one to two (1-2) weeks for patients who receive [MEDICAL CONDITION] medication with recent changes in the medication. Additionally, she stated she expected documented ongoing monitoring of adverse consequences such as behaviors and changes in mental status for all residents who receive [MEDICAL CONDITION] medications. Continued interview revealed she spoke with staff and patients, and reviewed documentation in the Progress Notes, and Monthly Behavior Monitoring worksheets, when gathering information related to [MEDICAL CONDITION] drug use. Further, ongoing monitoring of [MEDICAL CONDITION] medications was important to ensure providers could attempt reductions, keep the medication regime therapeutic, and document unsuccessful attempts. Additional interview with the ARNP, revealed she was unaware Resident #56 did not have a Monthly Behavior Monitoring sheet for [MEDICATION NAME] for the last three (3) months. She stated Resident #56 had been receiving [MEDICATION NAME] for two (2) years now related to fearful hallucination. Per interview, a Gradual Dose Reduction (GDR) during the end of last year failed because the Resident had hallucinations of little kids, and became fearful, and cried. She stated the most recent GDR attempt on 03/05/19 had been successful, and the resident was not exhibiting negative behaviors such as being fearful, and crying; however, did report seeing little kids. Further, it was important that ongoing monitoring was maintained to ensure health care providers could quickly assess the residents needs and adjust medications as necessary so residents were not distressed and not fearful. Per interview, this was true especially in Resident #56's case, because it was important he/she was not fearful. Further interview revealed ongoing monitoring and assessment by direct care nursing staff, of Resident #56's [MEDICATION NAME] was imperative to ensure the medication was not negatively effecting him/her. Interview with the DON, on 03/28/19 at 3:33 PM, revealed she expected the facility policy and regulation related to [MEDICAL CONDITION] medication use and behavior monitoring to be followed. Additional interview revealed residents who receive a [MEDICAL CONDITION] medication should have ongoing monitoring of efficacy and adverse consequences. Continued interview revealed ongoing monitoring should be documented on a Monthly Behavior Monitoring worksheet and Progress Note. Per interview, there should have been Monthly Behavior Monitoring worksheets for Resident #56 related to [MEDICATION NAME]. Further interview revealed night shift nursing staff were responsible to ensure Monthly Behavior Monitoring worksheets were in place for each [MEDICAL CONDITION] medication for each resident, and Social Services and the RCM were responsible to review the worksheets routinely and follow up with the provider with any concerns. Per interview, behaviors and [MEDICAL CONDITION] drug use were reviewed weekly in Focus meeting and daily in clinical meetings on each unit. Further, it was important to maintain ongoing monitoring of residents receiving [MEDICAL CONDITION] medications to ensure adverse consequences did not interfere with resident care, daily routine and mental status. Interview with the Pharmacy Consultant, on 03/28/19 at 4:10 PM, revealed she was at the facility at least once a month. Per interview, she expected nursing staff to provide ongoing monitoring of efficacy and adverse consequences for residents who received [MEDICAL CONDITION] medications. Continued interview revealed it was important to have ongoing documentation to assist with providing the resident with the most therapeutic medication; at the lowest possible dose. Additional interview revealed ongoing monitoring provided supportive evidence if a medication was therapeutic when recommending possible reduction. Further, she was familiar with Resident #56 and the resident should have had a Monthly Behavior Monitoring worksheet and/or Progress Notes related to [MEDICATION NAME] use. Per interview, Resident #56 had a recent dose reduction and ongoing monitoring should have been implemented to ensure the Resident did not have adverse consequence(s) related to the medication change. Interview with the Administrator, on 03/28/19 at 5:45 PM, revealed he expected facility policy and regulation to be maintained for [MEDICAL CONDITION] medication use and behavior monitoring. Per interview, each resident receiving [MEDICAL CONDITION] medications should have ongoing monitoring for adverse reactions and effectiveness of the medication. Additional interview revealed Resident #56 should have had ongoing monitoring in place for [MEDICATION NAME] medication as per facility policy. Further, it was important for ongoing monitoring to be maintained to ensure residents remained at their highest practicable functional ability and did not receive unnecessary medications.

Based on interview and record review, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for one (1) of twenty-five (25) sampled residents (Resident #64). Resident #64, sustained a fall on 01/26/19, and the facility conducted aRoot Cause Analysis with corrective action including interventions for a Reacher/Grabber and to Keep the resident in populated areas; however, the Comprehensive Care Plan was not revised with the new interventions. The findings include: Review of facility's Policy, titled Comprehensive Plan of Care, revised (MONTH) 2002, revealed the comprehensive care plan must describe services to be furnished to attain or maintain the resident's highest physical, mental, and psychosocial well-being. Further review revealed the care plan will be updated quarterly, whenever significant changes occur, or annually. 1. Review of Resident #64's medical record revealed the facility admitted the resident on 10/30/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 02/13/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Further review revealed the facility assessed Resident #64 as not walking in the room; and as having no falls since Admission or the prior Assessment. (Refer to F-641) Review of Resident #64's Comprehensive Care Plan, initiated 11/16/18 and revised 02/14/19, revealed the resident was at high risk for falls due to [MEDICAL CONDITION] with [MEDICAL CONDITION] and due to receiving antidepressant medication. The goal initiated 11/16/18, and revised 02/14/19, with a target date of 05/15/19, revealed the resident would be free of falls and fall related injuries every day. The interventions initiated 11/18/19 included: assist with transfers, monitor per falling star program, and sensor pad to bed and chair AAT (at all times). Review of Resident #64's (MONTH) 2019 Monthly Physician's Orders, revealed orders initiated 11/09/18 for nonskid footwear; orders initiated 01/28/19 for sensor pad to bed every shift for Fall Prevention Check Placement and check function every shift; orders initiated 01/28/19 for Sensor Pad to chair every shift for Fall Prevention, Check Placement and function every shift; and orders initiated 01/30/19 for a reacher/grabber every shift. Observation of Resident #64 on 03/27/19 at 9:11 AM, revealed he/she was in bed with the head of the bed elevated. The resident had a bolster/concave mattress on the bed, and there was an Alarm box on the wall behind the bed. Resident #64 stated he/she had a fall recently, but he/she could not recall the date of the fall. Continued interview revealed he/she fell from the wheelchair, but he/she was not hurt. Review of the facility Fall Incident Report Form, revealed Resident #64 had a fall on 01/26/19 at 11:00 AM, in the solarium near his/her room. Resident #64 fell from his/her wheel chair when reaching for his/her catheter bag that fell from the wheel chair and he/she toppled forward striking his/her head on the floor and sustaining a skin tear to the right side top of the eyebrow. Review of the Root Cause Analysis, revealed the date of the event was 01/26/19, and the facility investigated to determine the root cause of the fall. Corrective action documented was for the resident to have a Reacher/Grabber and to Keep the resident in populated areas. However, further review of Resident #64's Comprehensive Care Plan, initiated 11/16/18 and revised 02/14/19, revealed there was no documented evidence Resident #64's Plan of Care was reviewed or revised to include the corrective action interventions for Reacher/Grabber and to Keep the resident in populated areas. Interview on 03/28/19 at 3:39 PM, with MDS Nurse #2, revealed care plans were revised according to Physician's orders, and new interventions were added to the Care Plan only if there were Physician's Orders for the interventions. She stated the Fall Incident Report Form for Resident #64 related to the fall sustained on 01/26/19, revealed the corrective interventions for the fall included the reacher/grabber and to Keep the resident in populated areas. Continued interview revealed Resident #64's Physician's Orders included an order for [REDACTED]. Interview with MDS Nurse #3, on 03/28/19 at 3:51 PM, revealed Resident #64 had Physician's Orders for the reacher/grabber, and the Care Plan should have been revised with this intervention. Further interview revealed there was not a Physician's Order to Keep in populated area, and therefore the Care Plan would not need to be revised with this intervention. Interview on 03/28/19 at 4:31 PM, with the Director of Nursing (DON), revealed the facility normally ensured Physician's Orders were written for new fall interventions, and a copy of the orders was sent to the MDS staff in order to revise the care plans from the orders. Further interview revealed Resident #64's Care Plan should have been revised with interventions for Reacher/grabber and to keep the resident in populated areas. Continued interview revealed the facility had falls meetings weekly and MDS staff attended; therefore, the Care Plan should have been revised with these interventions. Further interview with the DON, revealed it was her expectation for MDS staff to follow the RAI Manual. Interview with the Administrator, on 03/28/19 at 5:05 PM, revealed after a fall occurred an initial fall report was completed, immediate interventions were placed, and the fall was reviewed in the fall meeting to ensure interventions were appropriate. Continued interview revealed the facility ensured Physician's Orders were obtained for selected interventions after a fall and the Care Plan was to be revised with these interventions. The Administrator further stated if you don't know what care to provide you can't provide the appropriate care.

Based on observation, interview and review of the facility's Policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (1) of twenty-five (25) total sampled residents (Resident #29). Observation of staff member with residents in the Parlor Dining Room located on The Forest Heights Unit, on 03/27/19, revealed State Registered Nursing Assistant (SRNA) #1 obtaining vital signs for one (1) of twenty-five (25) total sampled residents, Resident #29. The findings include: Review of the facility's Policy titled, Social Services Resident Rights, revised 11/2017 revealed the facility recognized each resident's right to a dignified existence and self-determination. Further review revealed it was the policy of the facility to ensure resident's rights were promoted and protected. Continued policy review revealed the facility would provide Resident Rights education to staff annually. Review of Resident #29's clinical record revealed the facility admitted the resident on 07/14/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/09/19, revealed the facility assessed Resident #29 to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15) indicating the resident was moderately cognitively intact. Further review of the MDS revealed the facility assessed Resident #29 to require limited physical assistance of one (1) for bed mobility and locomotion on the unit, required extensive physical assistance of one (1) for transfers, walking in the room and corridor, locomotion off unit, dressing, toilet use and personal hygiene. Continued review of the Quarterly MDS revealed the facility assessed Resident #29 to require supervision with set up help only with eating/dining. Observation, on 03/27/19 at 8:32 AM, revealed State Registered Nursing Assistant (SRNA) #1 in Parlor Dining Room, located on The Forest Heights Unit, obtaining Resident #29's blood pressure and pulse with facility's digital monitoring equipment. Further observation revealed Resident #29 sitting in his/her wheelchair at dining room table with three (3) other female residents present. Continued observations revealed two (2) additional female residents and one male resident in the Parlor Dining Room as SRNA #1 obtained the resident's vital signs. Additional observation revealed SRNA #1 engaged in conversation with Social Worker Manager (SWM), not Resident #29, and continued obtaining resident's vital signs. Interview with SRNA #1, on 03/27/19 at 8:40 AM, revealed she was the staff member assigned to duty on Forest Heights Unit A-Hall and would provide direct care for Resident #29 on 03/27/19 from 6:30 AM until 3:00 PM as per her usual day-shift routine. Further interview with the SRNA revealed she obtained the resident's vital signs as directed by Licensed Practical Nurse (LPN) #2, who was also assigned to Forest Heights A-Hall. SRNA #1 reported she knew she should not obtain vital signs or provide any direct resident care in the dining room or other public area because this was a resident rights violation and dignity issue. SRNA #1 added she realized she had violated the resident's rights as soon as she placed the blood pressure cuff on his/her arm but did not want to stop in the middle of the procedure, therefore, she continued to obtain the rest of Resident #29's vital signs until she had completed them to provide to LPN #2. Continued interview revealed obtaining vital signs in the Dining Room could cause embarrassment to the resident as he/she may not want others to see him/her as requiring medical treatment or may not want other staff or residents/visitors to know he/she required vital signs be monitored and this could be a dignity concern. SRNA #1 reported her normal routine would be to obtain the resident's vital signs and other direct care in the resident's room or bathroom with the curtain and/or door closed to provide privacy. Interview with SRNA #2, on 03/27/19 at 9:06 AM, revealed she was the staff responsible for assisting SRNA #1 on A-Hall this day and was therefore familiar with Resident #29's care. In addition, A-Hall was SRNA #2's usual assignment from 6:30 AM until 3:00 PM on most days. Further interview with SRNA #2 revealed, Absolutely no resident care was to be provided in the Parlor Dining Room or any other public area. We are to provide resident care in the resident's room or other private area. SRNA #2 continued, We all know that is a dignity/confidentiality/privacy concern. Continued interview revealed resident care was to be provided in a private setting and only by authorized personnel qualified to do so. SRNA #2 advised if direct care was performed in a dining room or other public setting other residents, family members and unauthorized staff could potentially acquire resident clinical or personal information and this would be a violation of the resident's right to privacy and confidentiality. Interview with the facility's Social Worker Manager (SWM), on 03/27/19 at 9:16 AM, revealed she serviced the needs of the residents residing on The Forest Heights Unit, which included Rooms #201-224. Further interview revealed it was inappropriate to perform any direct resident care in a public area because it violated the resident's rights to dignity and privacy/confidentiality. Further interview revealed SRNA #1 should have obtained Resident #29's blood pressure, pulse and other vital signs in the resident's room or other discreet location to protect the resident's right to privacy, dignity and confidentiality. Continued interview with SWM revealed direct care should always be delivered in a private, discreet location to ensure unauthorized staff, visitors, and other residents are not able to receive or access the resident's medical information or compromise the resident's care. The SWM added that would be a violation of the resident's rights and could become a dignity concern. Additional interview with the SWM revealed she had failed to request SRNA #1 refrain from obtaining Resident #29's vital signs in the Parlor Dining Room because she was not paying attention to the SRNA's actions at the time. SWM added, if she had realized SRNA #1 had been obtaining the resident's vital signs, she would have told her to stop because she would not want Resident #29 to be in an uncomfortable situation. Interview with Licensed Practical Nurse (LPN) #2, on 03/27/19 at 9:32 AM , who was assigned to administer medications and treatments to residents on The Forest Heights Unit, A-Hall from 6:30 AM until 7:00 PM, revealed resident care was to be delivered in private setting and only by authorized personnel to respect resident's dignity and privacy. Further LPN interview revealed direct care delivered in the dining room or other public location would be considered a violation of the resident's rights and a dignity/privacy issue. Continued interview with LPN #2 revealed resident medical information and clinical treatment was to remain private with direct care expected to be delivered in private setting to maintain the resident's dignity. Interview with Quality Control/Transitional Care Registered Nurse (QC/TC), on 03/28/19 at 5:44 PM, revealed staff are to obtain vital signs and perform other direct resident care in the resident's room or other discreet location with the door closed and the curtains pulled. Further interview revealed staff are provided intense two (2) day training upon hire and annually relating to the importance of Resident Rights and respecting the resident's rights related to dignity and confidentiality most specifically. Continued interview with the QC/TC revealed it may be embarrassing for a resident to have staff obtain his/her vital signs in the dining room or other public area as he/she may (in the resident's mind), she explained, may appear sickly or needy in the eyes of his/her peers who are also residing in the facility. This, QC/TC added, is definitely a dignity issue and a violation of the resident's rights and will require re-education and re-training. Interview with The Forest Heights Unit Resident Care Manager (RCM) #1, on 03/27/19 at 9:42 AM revealed staff are to perform all resident care in the resident's room with the door closed and the privacy curtain pulled to maintain resident dignity, confidentiality and privacy. Further interview with RCM #1 revealed it would never be appropriate or acceptable to obtain a resident's vital signs (blood pressure, pulse, etc.) or to provide any other direct resident care in the Parlor Dining Room due to privacy/confidentiality/dignity concerns. Interview with the Director of Nursing (DON), on 03/28/19 at 5:56 PM, revealed she expected staff to perform all direct care in resident's room or other private/discreet location as this was a dignity, privacy and confidentiality issue. Further interview with the DON revealed she expected staff to maintain resident dignity at all times by adhering to the facility's Resident Rights Policy. Continued DON interview revealed she expected all staff to treat each resident with respect and dignity. Interview with Licensed Nursing Home Administrator (LNHA), on 03/28/19 at 6:23 PM, revealed his expectations were for staff to perform all direct resident care in private to maintain privacy and confidentiality. The LNHA explained a private location could be a resident's room, a bath/shower room, or other discreet location where only authorized staff were present and involved in the delivery of care to the resident. Further interview revealed the LNHA expected staff to adhere to the facility's Resident Rights Policy and to respect all resident's right to dignity, privacy and confidentiality and never perform any resident care in a public area for other residents or unauthorized staff to have access to resident clinical information as this would be a violation of the resident's privacy and confidentiality.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for one (1) of twenty-five (25) sampled residents (Resident #64). Although Resident #64 sustained a fall on 01/26/19, this fall was not reflected on the Quarterly MDS assessment dated [DATE]. The findings include: Review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, revised (MONTH) 2011, revealed under Chapter 3, Section J1800, if this is not the first assessment, review period from the day after the Assessment Reference Date (ARD) of the last MDS Assessment to the ARD of the current Assessment. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Review nursing home incident reports, fall logs and the medical record (physician, nursing, therapy, and nursing assistant notes). Ask the resident and family about falls during the look back period. 1. Review of Resident #64's medical record revealed the facility admitted the resident on 10/30/18 with [DIAGNOSES REDACTED]. Review of the Admission Assessment, dated 11/16/18, revealed the facility assessed Resident #64 as having no falls. Review of the facility Fall Incident Report Form, revealed Resident #64 had a fall on 01/26/19 at 11:00 AM in the solarium near the resident's room. Per the Report, the resident fell from his/her wheel chair when reaching for his/her catheter bag and he/she toppled forward striking his/her head on the floor and sustaining a skin tear to the right side top of the eyebrow. Review of the Root Cause Analysis Section, revealed the facility investigated to determine the root cause of the fall and corrective action was to give the resident a Reacher/Grabber and Keep the resident in populated areas. Review of the Quarterly MDS Assessment, dated 02/13/19, revealed the facility assessed Resident #64 as scoring a twelve (12) out of fifteen (15) on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as not ambulating in the room and as having no falls since Admission or the prior Assessment. Interview with Resident #64, on 03/27/19 at 9:11 AM, revealed he/she had a fall at the facility, but he/she could not recall the date of the fall. Continued interview revealed when he/she fell , it was from the wheelchair, and he/she did not sustain injury from the fall. Interview on 03/28/19 at 3:39 PM, with MDS Nurse #2, revealed the facility utilized the RAI Manual for guidance in completing MDS assessments. She stated when she was completing MDS Assessments she reviewed the medical record, assessed the resident and interviewed the resident. She further stated she had completed the MDS assessment dated [DATE] for Resident #64, and coded the resident as having no falls. After reviewing the medical record documentation related to Resident #64's fall on 01/26/19, she stated she had coded the MDS assessment dated [DATE], incorrectly related to falls and she would need to complete a correction to the MDS assessment. Interview on 03/28/19 at 4:31 PM, with the Director of Nursing (DON), revealed Resident #64 did sustain a fall on 01/26/19 and the MDS Assessment, dated 02/13/19, should have been coded to reflect the fall. Continued interview revealed the facility had falls meetings weekly and MDS staff attended the meetings and should have been aware of the fall that occurred on 01/26/19 for Resident #64 Further interview with the DON, revealed it was her expectation MDS staff follow the RAI Manual for guidance in completing the MDS Assessments. Interview with the Administrator, on 03/28/19 at 5:05 PM, revealed it was his expectation the MDS Assessments were coded correctly as the Comprehensive Care Plan was derived from the MDS Assessment.

Based on interviews, record reviews, and review of the facility's policies, it was determined the facility failed to ensure allegations of neglect/abuse were reported immediately, but not later than two (2) hours after the allegation was reported for one (1) out of twenty-nine (29) sampled residents, Resident #112. Resident #112 informed State Registered Nurse Aide (SRNA) #2 that SRNA #1 neglected to care for the resident on the night shift of 04/08/18 and 04/09/18. SRNA #2 stated she informed Licensed Practical Nurse (LPN) #1 about the allegation of neglect/abuse, but admitted she did not report the allegation to anyone else when LPN #1 did not respond, as per the facility's policy. The findings include: Review of the facility's policy entitled, Nursing Policy and Procedure Section 14.2 Freedom from Abuse Neglect and Exploitation Including Elder Justice Act, last revised (MONTH) (YEAR), revealed it was the responsibility of the staff, facility consultants, attending physicians, family members, visitors, etc, to promptly report any willful infliction of injury or suspected incident of neglect or resident abuse. Further review revealed any covered individual observing an incident of resident abuse or suspecting resident abuse must promptly report such an incident to a member of nursing staff or management. Continued review revealed, failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. Additionally, the facility's policy stated if a covered individual failed to report within mandated time frames, the care individual would be subject to a civil money penalty. Review of the facility's policy entitled, Nursing Policy and Procedure, Recognizing Signs/Symptoms of Abuse/Neglect, last revised (MONTH) (YEAR), revealed it would not condone any form of resident abuse or neglect. Continued review revealed, to aid in the abuse prevention, all personnel would report any signs and symptoms of abuse/neglect to their supervisor or to management immediately. Further review revealed, to assist in recognizing incidents of abuse, the definition would be provided. Additional review revealed, under Section (e), neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of Resident #112 revealed, the resident was admitted by the facility on 03/07/18, with [DIAGNOSES REDACTED]. Review of Resident #112's Admission Minimum Data Set (MDS) Assessment, dated 03/14/18, revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Interview with Resident #112, on 04/10/18 at 03:00 PM, revealed, on Sunday night close to midnight, he/she messed all over him/herself. The resident stated, he/she was throwing up and had diarrhea all night, adding, it was coming out of both ends. Per interview, the resident stated he/she pressed his/her call light and SRNA #1 responded to the call light and left the room without bringing anyone to assist him/her. Continued interview with the resident revealed, he/she thought SRNA #1 was neglectful because he did not assist him/her with care. The resident stated it was like he was here to collect a check and needed to show more [MEDICATION NAME] for the resident's needs. Further interview with the resident revealed, he/she did not know if he/she reported these allegations to anyone because he/she was nauseated and did not feel well. Interview with SRNA #1, on 04/11/18 at 8:00 PM, revealed he worked night shift on 04/08/18 to 04/09/18, from 11 PM to 7 AM. SRNA #1 stated, he recalled Resident #112 that night. SRNA #1 stated all of the resident's call lights were going off and he was covering for some of the aides that were out on break. SRNA #1 stated, Resident #112 was calling out and he went to the resident's room to check on him/her. SRNA #1 stated, the resident had a wash basin and was throwing up in it. SRNA #1 stated, he wiped the resident's face, then went to inform the resident's nurse, LPN #1 about the resident's condition. SRNA #1 stated he was not aware the resident was soiled. SRNA #1 stated he did not return because he was not assigned to care for the resident that night. SRNA #1 stated, the resident's aide was SRNA #2. Interview with SRNA #2, on 04/11/18 at 9:48 PM, revealed she worked on 04/08/18 and 04/09/18. SRNA #2 stated, she recalled being assigned to care for Resident #112. SRNA #2 stated, when she returned from break, the resident told her that a gentleman came into her room and just turned her call light off, without providing care or assistance. Continued interview with SRNA #2 revealed, there was only one gentlemen that worked that shift and knew the resident was referring to SRNA #1. SRNA #2 stated, she did not know how long the resident was left soiled before she returned to assist him/her, but continued to care for the resident and apologized for the actions of SRNA #1. SRNA #2 stated, she thought the resident was making allegations of neglect/abuse, because SRNA #1 did not provide care to the resident before turning off his/her call light. SRNA #2 stated, she reported the allegations to her Charge Nurse, LPN#1. Interview with Charge Nurse/LPN #1, on 04/11/18 at 8:50 PM, reveled she worked the night/morning of 04/08/18 and 04/09/18. Per interview, LPN #1 stated she was Resident #112's nurse and recalled an aide, whom she could not remember, but thought it was SRNA #1, who reported to her the resident did not feel well. LPN #1 stated, she went into the resident's room to care for the resident. LPN #1 stated, the resident nor SRNA #2 reported SRNA #1 was neglectful in the resident's care, but should have. LPN #1 stated, if she had been notified, she would have assessed the situation and followed the facility's abuse protocol. Review of a Nursing Note, documented by LPN #1, on 04/09/18 at 1:32 AM, revealed the resident was noted to have vomiting and nausea. Additional interview with SRNA #2, on 04/12/18 at 9:43 AM, revealed she did not follow up with LPN #1 after reporting the resident's allegation of neglect/abuse. SRNA #2 stated, she did not see SRNA #1 leave the floor and he continued to provide resident care. SRNA #2 stated, she should have notified the Director of Nursing (DON) when she saw SRNA #1 continue with resident care. Interview with the Administrator and Director of Nursing (DON), on 04/12/18 at 4:16 PM, revealed, when an allegation of abuse was reported and/or observed, it would be their expectation staff would reported it to the DON and the Administrator. Continued interview revealed, the allegation should be reported within two (2) hours. Further interview revealed, staff telephone numbers were posted for staff to call and notify the Administrative staff of allegations of neglect/abuse. Additionally, the Administrator and DON stated, if an employee did not feel comfortable notifying the Administrator and/or DON, the employee should have reported the allegation to the state agency. Finally, the Administrator and DON revealed staff were in-serviced on abuse, which included how to report abuse. They stated this was important for the safety of the residents.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable environment for each resident. Observation on 02/21/17, during facility tour, revealed bed pans, bath pans, emesis basins and denture cups which were not stored properly, and were not bagged or labeled for resident identification. The findings include: Review of the facility's Bed Pans, Wash Basins, Bedside Commodes, Denture Cups and Emesis Basin Policy, dated August 15, 2013, revealed the facility must maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Per policy, bedpans, bath pans, emesis basins, denture cups and bedside commodes should be stored in proper storage areas. Observation on 02/21/17 at 1:30 PM, during facility tour, revealed a denture cup on the sink which was unlabeled for resident identification and five (5) bath pans stacked in a wheelchair not bagged or labeled for resident identification, in the bathroom of semi-private room 108. Observation on 02/21/17 at 1: 35 PM, revealed a denture cup on the sink which was unlabeled for resident identification in the bathroom of semi-private room 111. Observation on 02/21/17 at 1:45 PM, revealed a bath pan stored on the floor which was not bagged or labeled for resident identification in the bathroom of semi-private room 122. Observation on 02/21/17 at 1:45 PM, revealed an unbagged bed pan which was not labeled for resident identification stored on the hand rail in bathroom 204. Observation on 02/21/17 at 1:50 PM, revealed an emesis basin which was not bagged or labeled for resident identification stored on the hand rail in the bathroom of semi-private room 120. Observation on 2/21/17 at 1:51 PM, revealed a bed pan in the tub of the bathroom in room 206 which was not bagged or labeled for resident identification. Interview on 02/22/17 at 9:40 AM, with State Registered Nurse Aide (SRNA) #1, revealed bath pans, bed pans, emesis basins, and denture cups should be labeled to identify the resident in which the item belonged. Per interview, all items should be bagged to prevent cross contamination and maintain a sanitary environment. Continued interview revealed the SRNA's were responsible for labeling and bagging personal hygiene items and storing them properly after use. Interview on 02/22/17 at 9:43 AM, with SRNA #2, revealed personal items such as denture cups, bed pans, and emesis basins should be bagged and labeled to prevent cross contamination. Continued interview revealed all staff should make sure these items were stored properly. Interview on 02/22/17 at 10:00 AM, with Licensed Practical Nurse (LPN) #2/day shift charge nurse for the Shoreline Unit, revealed all personal hygiene items should be bagged and labeled for resident identification to prevent cross contamination. Interview on 02/23/17 at 6:05 PM, with the Director of Nursing (DON), revealed she expected all staff to ensure each residents' personal items were labeled and bagged to prevent cross contamination and to maintain a safe and sanitary environment. Interview on 02/23/17 at 6:23 PM, with the Administrator, revealed he expected staff to bag and label residents' belongings and to follow the facility policies.

Based on interview, record review, review of the facility's policy, and review of the facility's investigation, it was determined the facility failed to ensure all alleged violations involving abuse were reported to State Agencies in accordance with State Law. In addition, the facility failed to ensure all alleged violations of abuse or injuries of unknown origin were thoroughly investigated and failed to ensure protection of residents from potential abuse while the investigation was in progress for one (1) unsampled resident (Unsampled Resident B). On 01/21/17, it was reported to the facility Social Worker, Unsampled Resident B had a bruise on the inner corner of his/her right eye which was intentionally caused by a State Registered Nurse Aide (SRNA) employed by the facility. However, there was no documented evidence the facility reported the allegation to State Agencies, completed a thorough investigation, or protected residents during the investigation. The findings include: Review of the facility's Policy titled, Resident Abuse, with a revision date of November 2016, revealed all residents had the right to be free from willful acts of physical abuse and also had the right to be treated with respect and dignity. Continued review revealed the facility would identify events such as suspicious bruising of residents, occurrences, patterns, and trends that constitute abuse. Further review revealed all reported incidents of abuse would be investigated and the facility would assure residents were protected from harm during the investigation. Continued review of the Policy revealed alleged incidents of abuse would be reported to the state agency and all other agencies as required. Review of the facility's Job Description titled, Social Worker, with a revision date of 06/01/12, revealed the Social Worker would understand the facility's commitment to comply with applicable state and federal law related to abuse and would report abuse/suspected abuse consistent with applicable law and regulation. Review of Unsampled Resident B's medical record revealed the facility admitted the resident on 11/02/12 and readmitted the resident on 09/12/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/02/16, revealed the facility assessed Unsampled Resident B to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS, revealed the facility assessed Unsampled Resident B as totally dependent on two (2) staff persons for physical assist during Activities of Daily Living (ADL's) for dressing, toilet use, and personal hygiene. Review of Nursing Progress Note for Unsampled Resident B, dated 01/22/17, completed by LPN #9, at 12:46 AM, revealed it was documented a bruise to the resident's right corner of his/her eye, purple in color and a bruise to the top of left hand that was red/purple in color. Continued review of the progress note revealed resident's spouse was notified and aware of bruise and stated understanding. Further review revealed supervisor and Medical Doctor (MD) notified. Review of Nursing Progress Note for Unsampled Resident B, dated 01/22/17, completed by LPN #10, at 11:39 AM, revealed the progress note was a late entry to reflect the date of 01/21/17 at 5:00 PM. Continued review of the progress note revealed the resident had a tiny bruise noted to the inner right eye with no redness or swelling around the area and the resident denied any discomfort. Further review of the progress note revealed staff stated to LPN #10 bruise had been there for a couple of days and was previously reported. Review of the facility's form titled, Incident Report, dated 01/21/17, completed by Licensed Practical Nurse (LPN) #9, revealed from verbal report from prior shift, Unsampled Resident B had a bruise to his/her right side of the nose, corner of the eye and left top of the hand. Review of the facility's Investigation Summary, dated 01/24/17, completed by the Social Worker, revealed the Social Worker was informed of an allegation at approximately midnight on 01/21/17 by the night shift supervisor. Continued review revealed the Social Worker was informed Unsampled Resident A had a bruise on the inner corner of his/her right eye and the resident's spouse reported to the facility an aide may have caused the injury. Further review revealed the following timeline: Social Worker notified the facility Administrator on 01/21/17 after receiving the notification; the Administrator called the facility and requested statements from nurses and aides on 01/21/17; the Administrator reviewed statements on 01/22/17; the Social Worker and the Administrator reviewed the statements together and the Social Worker made additional phone calls to more staff members for more statements including the resident's spouse; and on 01/24/17, the conclusion was made. Continued review of the Investigation Summary, under the section titled Final Summary, revealed it was determined by the facility, while the resident was being changed, SRNA #16's badge, who was no longer an employee of the facility, unintentionally struck the resident's right eye. The Final Summary revealed the aide was described as being very apologetic to the resident. However, there was no documented evidence of interview statements from Unsampled Resident B, SRNA#16 or from the resident's spouse. Also, there was also no documented evidence of interviews with interviewable residents related to abuse or skin assessments of non-interviewable residents. Interview, on 02/23/17 at 3:57 PM, with Unsampled Resident B, revealed he/she and a State Registered Nurse Aide (SRNA) were arguing because the aide was hurting him/her when she rolled the resident over to clean him/her up and she would not stop. Per interview, Unsampled Resident B then pushed the SRNA down, and she hit the resident in the face with something in her hand. Unsampled Resident A stated he/she pushed the aide again and the aide tried to hit him/her again, but he/she blocked with his/her hand. Continued interview with Unsampled Resident B, revealed the incident happened in January and it caused bruising to his/her eye and hand. Unsampled Resident A stated he/she did not remember when, but the SRNAs boss came in and spoke to him/her about it. Interview on 02/23/17 at 4:39 PM, with Licensed Practical Nurse (LPN) #9, revealed it was reported to her from LPN #10 during shift report around 7:15 PM to 7:30 PM, on 01/21/17, a bruise was found above Unsampled Resident A's left eye. Continued interview with LPN #9, revealed Unsampled B's spouse called her at 11:00 PM on 01/21/17 to report the bruise and stated Unsampled Resident B had words with an aide who pushed his/her glasses into his/her eye. Further interview with LPN #9, revealed it was the facility's practice to complete an Incident Report and notifications made when a bruised was discovered of unknown origin. LPN #9 stated she completed the Incident Report on 01/21/17, but was unsure when the incident allegedly occurred. Per interview, as far as she knew there was no skin assessments performed for non-interviewable residents after the allegation was made. She stated SRNA #16 worked last on 01/17/17. However, there was no documented evidence in the resident's medical record of a skin assessment. Interview, on 02/23/17 at 5:07 PM, with LPN #10, revealed she became aware of Unsampled Resident B having a bruise to his/her eye on 01/21/17, when an SRNA reported it to her. Per the interview, the SRNA also stated this had already been reported and taken care of. Continued interview revealed she then reported the bruise to the oncoming shift nurse during shift report. Further interview revealed she was in the resident's room while he/she was telling his/her spouse what had happened. LPN #10 stated she thought it was a wild story. LPN #10 further stated she wrote a statement for either the Social Worker or the Administrator and put the story in her statement. However, there was no documented evidence of a statement by LPN #10 as part of the investigation. Interview, on 02/23/17 at 5:46 PM, with the facility Social Worker (SW), revealed the allegation of abuse made by Unsampled Resident B only needed to be reported to State Agencies within twenty-four (24) hours, if the facility deemed abuse. Continued interview, revealed as a facility, they decided not to report the allegation to the state agency because their investigation indicated the injury to the resident's eye could have occurred by an employee badge while providing care; the resident's nose piece of his/her glasses; or by the resident digging at himself/herself. Per the SW, the allegation was investigated as an injury of unknown source and not an actual allegation of abuse. Further interview with the SW, revealed he did not interview Unsampled Resident B related to the allegation because the resident could become belligerent and aggressive. The SW further stated the facility did not interview other interviewable residents in order to find out if they were aware of any abuse at the facility. The SW stated he did interview Unsampled Resident B's spouse on the phone and the resident's spouse just wanted this looked into. However, there was no documented evidence of this interview with Unsampled Resident B's spouse. He stated he attempted to call SRNA #16, but was unable to get a hold of her and she was terminated for being a no call no show. Interview, on 02/23/17 at 6:05 PM, with the Director of Nursing (DON), revealed it was her expectation for the facility's abuse policy to be followed for any allegation of abuse. The DON further stated she felt Unsampled Resident B and SRNA #16/the potential perpetrator should have been interviewed during the course of the investigation. The DON stated it was important for the abuse policy to be followed in order to protect the residents. Interview, on 02/23/17 at 6:23 PM with the facility Administrator, revealed it was his expectation a thorough investigation be completed after an allegation of abuse and Unsampled Resident B should have been interviewed during the investigation because the resident was interviewable. He stated he was told Unsampled Resident B was interviewed and the resident complained he/she was hit by an aide during bathing. The Administrator stated when he spoke with staff the day it was reported, everyone denied there had been an incident; however, staff did state to him the resident had been difficult with care. The Administrator further stated he did not feel abuse occurred, but felt an injury could have occurred from the resident being difficult and agitated with care. Continued interview revealed he would expect all statements that were given by staff members to be included in the investigation. He further stated all interviews related to the allegation were to be documented and included in the investigation. The Administrator further stated, if the alleged perpetrator was not interviewed, then the reason would need to be documented in the investigation report as well. Continued interview with the Administrator, revealed he felt like regulatory reporting requirements were met as he did not feel the incident needed to be called in to the state agency. He stated he felt like the facility determined it was caused by SRNA #16's badge, so it wasn't injury of unknown source. However, there was no documented evidence the facility reported the abuse allegation to State Agencies.

Based on interview, record review, review of the facility's investigation summary, and review of the facility's policy, it was determined the facility failed to implement their written policies and procedures that prohibit abuse of residents. The facility failed to ensure all alleged violations involving physical abuse were identified as abuse and reported immediately to State Agencies as per state law. In addition, the facility failed to protect the residents and ensure all allegations involving abuse were thoroughly investigated for one (1) Unsampled Resident (Unsampled Resident B). On 01/21/17, it was reported to the facility Social Worker, Unsampled Resident B, had a bruise on the inner corner of his/her right eye. Although Unsampled Resident B reported the bruise was intentionally caused by a State Registered Nurse Aide (SRNA) employed by the facility, the facility failed to identify the allegation as abuse; failed to report the allegation to State Agencies; failed to protect the residents; and failed to complete a thorough investigation. The findings include: Review of the facility's Policy titled, Resident Abuse, with a revision date of November 2016, revealed all residents had the right to be free from willful acts of physical abuse and also had the right to be treated with respect and dignity. Continued review revealed the facility would identify events such as suspicious bruising of residents, occurrences, patterns, and trends that constitute abuse. Further review revealed all reported incidents of abuse would be investigated and the facility would assure residents were protected from harm during the investigation. Continued review of the Policy revealed alleged incidents of abuse would be reported to the state agency and all other agencies as required. Review of the facility's Job Description titled, Social Worker, with a revision date of 06/01/12, revealed the Social Worker would understand the facility's commitment to comply with applicable state and federal law related to abuse and would report abuse/suspected abuse consistent with applicable law and regulation. Review of Unsampled Resident B's clinical record revealed the facility admitted the resident on 11/02/12 and readmitted the resident on 09/12/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/02/16, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Further review of the MDS, revealed the facility assessed Unsampled Resident A as totally dependent on two (2) staff persons for physical assist during Activities of Daily Living (ADL's) for dressing, toilet use, and personal hygiene. Review of Nursing Progress Note for Unsampled Resident B, dated 01/22/17, completed by LPN #9, at 12:46 AM, revealed it was documented a bruise to the resident's right corner of his/her eye, purple in color and a bruise to the top of left hand that was red/purple in color. Continued review of the progress note revealed resident's spouse was notified and aware of bruise and stated understanding. Further review revealed supervisor and Medical Doctor (MD) notified. Review of Nursing Progress Note for Unsampled Resident B, dated 01/22/17, completed by LPN #10, at 11:39 AM, revealed the progress note was a late entry to reflect the date of 01/21/17 at 5:00 PM. Continued review of the progress note revealed the resident had a tiny bruise noted to the inner right eye with no redness or swelling around the area and the resident denied any discomfort. Further review of the progress note revealed staff stated to LPN #10 bruise had been there for a couple of days and was previously reported. Review of the facility's Incident Report, dated 01/21/17, completed by Licensed Practical Nurse (LPN) #9, revealed from verbal report from prior shift, Unsampled Resident B had a bruise to his/her right side of the nose, corner of the eye and left top of the hand. Review of the facility's Investigation Summary, dated 01/24/17, completed by the Social Worker, revealed the Social Worker was informed of an allegation at approximately midnight on 01/21/17 by the night shift supervisor. Further review revealed the Social Worker was informed Unsampled Resident A had a bruise on the inner corner of his/her right eye and the resident's spouse reported to the facility an aide may have caused the injury. Per the Summary, the following occurred: Social Worker notified the facility Administrator on 01/21/17 after receiving the notification; the Administrator called the facility and requested statements from nurses and aides on 01/21/17; the Administrator reviewed statements on 01/22/17; the Social Worker and the Administrator reviewed the statements together and the Social Worker made additional phone calls to more staff members for more statements including the resident's spouse; and on 01/24/17, the conclusion was made. According to the Investigation Summary, the section titled Final Summary, revealed it was determined by the facility, while the resident was being changed, SRNA #16's badge, who was no longer an employee of the facility, unintentionally struck the resident's right eye. Further review revealed the aide was described as being very apologetic to the resident. However, there was no documented evidence per the investigation of interview statements from Unsampled Resident B, SRNA #16, or from the resident's spouse. There was also no documented evidence of interviews with interviewable residents related to abuse or skin assessments of non-interviewable residents. Interview, on 02/23/17 at 3:57 PM, with Unsampled Resident B, revealed he/she and a State Registered Nurse Aide (SRNA) were arguing because the aide was hurting him/her when she rolled the resident over to clean him/her up and she wouldn't stop. Unsampled Resident B stated he/she then pushed the SRNA down, and the SRNA hit the resident in the face with something in her hand. Unsampled Resident A revealed he/she pushed the aide again and the aide tried to hit him/her again, but he/she blocked with his/her hand. Additional interview with Unsampled Resident B, revealed the incident happened in January and it caused bruising to his/her eye and hand. Unsampled Resident A revealed he/she did not remember when, but the SRNAs boss came in and spoke to him/her about it. Interview on 02/23/17 at 4:39 PM, with Licensed Practical Nurse (LPN) #9, revealed another nurse, LPN #10 reported to her during shift report around 7:15 PM to 7:30 PM, on 01/21/17, a bruise was found above Unsampled Resident A's left eye. Per interview, Unsampled B's spouse called her at 11:00 PM on 01/21/17 to report the bruise and stated Unsampled Resident B had words with an aide who pushed his/her glasses into his/her eye. Continued interview with LPN #9, revealed it was the facility's practice to complete an Incident Report and notifications made when a bruised was discovered of unknown origin. LPN #9 revealed she completed the Incident Report on 01/21/17, but was unsure when the incident allegedly occurred. She stated, as far as she knew there was no skin assessments performed for non- interviewable residents after the allegation was made. She stated the alleged perpetrator, SRNA #16 worked last on 01/17/17. However, there was no documented evidence in the resident's medical record of a skin assessment. Interview, on 02/23/17 at 5:07 PM, with LPN #10, revealed she became aware of Unsampled Resident B having a bruise to his/her eye on 01/21/17, when a SRNA reported it to her. Per interview, the SRNA also stated this had already been reported and taken care of. Per interview, she then reported the bruise to the oncoming shift nurse during shift report. She stated she was in the resident's room while he/she was telling his/her spouse what had happened. LPN #10 revealed she thought it was a wild story. LPN #10 further revealed she wrote a statement for either the Social Worker or the Administrator and put the story in her statement. However, there was no documented evidence of a statement by LPN #10 included in the investigation. Interview, on 02/23/17 at 5:46 PM, with the Social Worker (SW), revealed the allegation of abuse made by Unsampled Resident B only needed to be reported to State Agencies within twenty-four (24) hours, if the facility deemed abuse. Further interview, revealed as a facility, they decided not to report the allegation to the state agency because their investigation indicated the injury to the resident's eye could have occurred by an employee badge while providing care; the resident's nose piece of his/her glasses; or by the resident digging at himself/herself. The SW stated, the allegation was investigated as an injury of unknown source and not an actual allegation of abuse. Continued interview, revealed he did not interview Unsampled Resident B related to the allegation because the resident could become belligerent and aggressive. The SW further revealed the facility did not interview other interviewable residents in order to find out if they were aware of any abuse at the facility. Per interview, the SW did interview Unsampled Resident B's spouse on the phone and the resident's spouse just wanted this looked into. However, there was no documented evidence of the interview with Unsampled Resident B's spouse as part of the investigation. The SW stated he attempted to call the alleged perpetrator, but was unable to get a hold of her and she was terminated for being a no call no show. Interview, on 02/23/17 at 6:05 PM, with the Director of Nursing (DON), revealed it was her expectation for the facility's abuse policy to be followed for allegations of abuse. The DON revealed she felt Unsampled Resident B and SRNA #16/the potential perpetrator should have been interviewed during the course of the investigation. The DON further revealed it was important for the abuse policy to be implemented in order to protect the residents. Interview, on 02/23/17 at 6:23 PM with the facility Administrator, revealed it was his expectation a thorough investigation be completed after an allegation of abuse and Unsampled Resident B should have been interviewed during the investigation as the resident was interviewable. He further stated he was told Unsampled Resident B was interviewed and the resident complained he/she was hit by an aide during bathing. Per interview, he spoke with staff the day the allegation was reported, and everyone denied there had been an incident. However, he stated staff told him the resident had been difficult with care. The Administrator further revealed he did not feel abuse occurred, but felt an injury could have occurred from the resident being difficult and agitated with care. Additional interview revealed he would expect all statements received by staff members to be included in the investigation. He further revealed all interviews related to the allegation were to be documented and included in the investigation. The Administrator stated, if the alleged perpetrator was not interviewed, then the reason would need to be documented in the investigation report as well. Additional interview with the Administrator, revealed he felt like regulatory reporting requirements were met because he did not feel the incident needed to be called in to the state agency. He stated he felt like the facility determined it was caused by SRNA #16's name badge, so it wasn't injury of unknown source. However, there was no documented evidence the facility reported the Unsampled B's allegation of abuse to State Agencies.

Based on observation, interview, record review and review of the facility's Plan of Correction (POC) with a compliance date of 12/10/10, it was determined the facility failed to maintain a Quality Assessment and Assurance Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by repeated deficiencies related to the facility's failure to implement it's Abuse Policies, failure to ensure Comprehensive Plans of Care were reviewed and/or revised, failure to ensure services were provided in accordance with residents' Comprehensive Plan of Care, failure to ensure residents who enter the facility without pressure sores did not develop pressure sores, failure to ensure residents received adequate supervision and monitoring to ensure residents' safety, failure to ensure there was an effective Infection Control Program, and failure to ensure accurate maintenance of clinical records. Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure three (3) of fifty-nine (59) sampled residents, Residents #1, #2 and #29, were free from sexual abuse related to the facility's failure to follow it's Abuse Policies to ensure residents' safety through assessment, care planning and monitoring behaviors that lead to conflict; failed to report abuse to the Administration and Social Service Manager; and failed to deny the perpetrator unsupervised access to residents. State Registered Nursing Assistant (SRNA) #2 observed Resident #22 in Resident #1's room touching Resident #1's perineal area with his/her hands and mouth on 12/25/11 at 11:30 AM. Resident #1 had been adjudicated legally incompetent and incapable of making decisions for him/herself. Facility staff observed Resident #22 later that day, at approximately 4:00 PM, touching and rubbing Resident #2's thigh. On 01/05/12 at 9:50 AM, a Kentucky State Agency Surveyor observed Resident #22 rubbing Resident #29's left hand on his/her upper right thigh in the dining room and was observed rubbing Resident #29's left arm and kissing up and down his/her arm and hand. Resident #22 was then observed pulling Resident #29 by his/her arm while he/she was sitting in a Geri chair. No staff was monitoring Resident #22's behavior, despite the resident's sexual history beginning 12/25/11, in order to prevent recurrence of sexual abuse. The facility allowed Resident #22 access to thirty-two (32) cognitively impaired residents without establishing an effective behavior management policy and implementing effective supervision of Resident #22 to deny access to the residents of the facility and to prevent further abuse. Furthermore, the facility failed to identify other incidents of abuse/neglect through assessment of all residents of the unit after the 12/25/11 incident. (Refer to F-226) Based on the above findings, it was determined the facility's failure to ensure it's Quality Assurance identified and implemented appropriate plans of action to correct identified quality deficiencies; failure to follow it's abuse policies by failing to assess, implement a care plan and monitor a resident with a known history of sexual behavior since 12/25/11; failure to report sexual abuse immediately to administration; failure to deny the perpetrator access to other residents; and failure to provide adequate supervision to prevent further abuse recurrence is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 01/12/12 and was determined to exist on 12/25/11. After quality review conducted by the State Agency and the Center for Medicare and Medicaid Services (CMS) it was determined the investigation required reopening to gather additional information. The Survey was reopened for further investigation from 01/30/12 through 02/03/12. An acceptable credible Allegation of Compliance (AOC) for the removal of IJ was received on 01/23/12 with the facility alleging removal of IJ on 01/21/12. The State Agency verified Immediate Jeopardy was removed prior to exit on 02/03/12, with remaining non-compliance at 42 CFR 483.75 Administration at a S/S of a "E", while the facility's Quality Assurance continues to monitor. The findings include: 1. Based on observation, interview and record review, it was determined the facility failed to implement it's Abuse policies. This was a repeat deficiency for the facility which was cited for this deficiency 11/05/10. Review of the facility's Plan of Correction (POC), with a compliance date of 12/10/10, revealed nursing staff was to be educated on the Abuse Policies. Nursing staff was to be educated by the Staff Development Coordinator regarding all alleged abuse violations must be reported immediately to their supervisor who in turn would report to facility Administration. The Nursing Supervisor was to make rounds every shift to inquire of Charge Nurses about any incidents, including but not limited to, alleged abuse violations. This information was to be reported to Administration who would then report to the State Agency immediately. During the current survey interviews revealed Resident #22, who had a known history of sexual abuse towards staff, was observed by a State Registered Nursing Assistant (SRNA) to be in Resident #1's room touching Resident #1's perineal area with his/her hands and mouth on 12/25/11 at 11:30 AM. Later that day, at approximately 4:00 PM, Resident #22 was observed by staff touching and rubbing Resident #2's thigh. Staff failed to immediately report the alleged abuse to the facility's Administration as per facility policy. Interview with SRNA #2, who observed the alleged sexual abuse on 12/25/11, revealed he/she reported the incident to Licensed Practical Nurse (LPN) #2. Interview with SRNA #1 revealed he/she had witnessed SRNA #2 informing LPN #2 of the incident. Interview with LPN #2 revealed she did not recall the SRNA reporting the alleged sexual abuse to her, therefore the incident was not reported immediately to facility Administration as per facility policy. Interview with the Assistant Director of Nursing (ADON) revealed LPN #2 was disciplined for not reporting the alleged sexual abuse immediately as per the facility's policy. Interview with the Social Services (SS) Manager and Director of Nursing (DON) revealed the facility determined the facility's failure existed related to LPN #2's failure to report the incident involving Resident #22 and Resident #1. (Refer to F-226) 2. Based on observation, interview and record review, it was determined the facility failed to ensure Comprehensive Plans of Care were reviewed and/or revised. This was a repeat deficiency for the facility which was cited for this deficiency 11/05/10. Review of the facility's Plan of Correction (POC), with a compliance date of 12/10/10, revealed nursing staff was to be educated to update care plans. Minimum Data Set (MDS) staff was to be educated to ensure that changes were made to the care plans by verifying order changes against the care plan no later than the next business day. The MDS Coordinator was to conduct monthly audits of care plans. This was to be monitored through the facility's Performance Improvement (PI)/Quality Assurance (QA) process for one (1) year to ensure compliance and was then to be re-evaluated. Record review during the current survey revealed Comprehensive Plans of Care reviewed were not reviewed and/or revised to contain interventions which described residents' needs. Interview, on 01/14/12 at 12:00 PM, with the Quality Assurance (QA)/Staff Development Nurse revealed the MDS Coordinator was terminated in the fall. The QA/Staff Development Nurse stated this MDS Coordinator was to have performed random audits. According to the QA/Staff Development Nurse this MDS Coordinator had reported to the facility no concerns with her audits. However, concerns were identified and the MDS Coordinator was terminated. She stated a new MDS Coordinator was in place and had identified further concerns with residents' records. In addition, the QA/Staff Development Nurse stated she was going to "come up" with a more structured system to put in place to ensure this didn't happen again. 3. Based on observation, interview and record review, it was determined the facility failed to ensure services were provided in accordance with residents' Comprehensive Plan of Care. This was a repeat deficiency for the facility which was cited for this deficiency 11/05/10. Review of the facility's Plan of Correction (POC), with a compliance date of 12/10/10, revealed Registered Nurse (RN) Managers were to audit residents' records to compare all current physician's orders [REDACTED]. The Staff Development Nurse was to educate nursing staff on implementation of physician's orders [REDACTED]. The MDS staff was to be educated to ensure that changes were made to Care Plans by verifying orders against the Care Plan no later than the next business day. This was to be monitored by the facility via the PI/QA process for one (1) year to ensure compliance was achieved and maintained and then was to be re-evaluated. Record review during the current survey revealed the facility failed to ensure a written Do Not Resuscitate (DNR) order was obtained for one(1) resident. Interview, on 01/14/12 at 12:00 PM, with the QA/Staff Development Nurse revealed forms were being filled out for residents' DNR status, however orders were not being written. She stated therefore when audits were performed on the orders, the DNR status wasn't being "caught" related to the failure to obtain the change status. 4. Based on observation, interview and record review, it was determined the facility failed to ensure residents who enter the facility without pressure sores did not develop pressure sores. This was a repeat deficiency for the facility which was cited for this deficiency 11/05/10. Review of the facility's Plan of Correction (POC), with a compliance date of 12/10/10, revealed the Staff Development Nurse was to conduct education with nursing staff on facility protocols. Monthly audits were to be conducted. The Wound Nurse and/or designee was to review admission and readmission care plans to ensure any skin areas of concern and potential for skin breakdown/pressure areas were identified in the care planning process. This nurse was to report monthly in the PI/QA program meeting related to audit findings regarding pressure sore prevention, treatments, and services. This was to be monitored by the facility via the PI/QA process for one (1) year and then was to re-evaluate. Observation, on 01/11/12 of a skin assessment performed during the current survey revealed Resident #6 had an area of unidentified pressure on his/her right elbow. Interviews with staff revealed they were unaware of the Stage I Pressure Ulcer to Resident #6's right elbow. Interview, on 01/14/12 at 12:00 PM, with the QA/Staff Development Nurse revealed the facility had a system for weekly head-to-toe skin assessments performed by nursing staff. She stated SRNAs were to view the residents' skin in between for any new areas of concern. The SRNAs were to report any findings to the nurses. According to the QA/Staff Development Nurse any new areas would have treatment obtained and would be care planned. The QA/Staff Development Nurse stated audits were still being performed by the Wound Care Nurse. 5. Based on observation, interview, and record review, it was determined the facility failed to ensure residents received adequate supervision and monitoring to ensure residents' safety. This was a repeat deficiency for the facility which was cited for this deficiency 11/05/10. Review of the facility's Plan of Correction (POC), with a compliance date of 12/10/10, revealed the Staff Development Nurse was to conduct education with nursing staff on the investigative process for incidents, and necessary documentation for such. A Change in Condition form was to be put in place. Nursing Supervisors were to utilize the form to conduct weekly audits of follow up documentation by nursing staff. This was to be monitored by the facility via audits by the PI/QA process for one (1) year and then was to re-evaluate. Interview with facility staff revealed Resident #22, who had a history of [REDACTED]. Resident #22 was found in a female resident's room. The female resident's pants and pull up were pulled down and Resident #22 had his/her mouth and hands on the female resident's perineal area. Later that day Resident #22 was observed to be touching and rubbing another female resident's thigh. Interview with the Assistant Director of Nursing (ADON) revealed the nurse who SRNA #2 reported the alleged sexual abuse to had been disciplined for not reporting the allegations immediately to Administration. Interview with the QA/Staff Development Nurse revealed she felt the Plan of Correction (POC) had worked. She stated there was a failure of a particular nurse who did not follow up and report the allegation of sexual abuse. 6. Based on observation, interview and record review, it was determined the facility failed to ensure there was an effective Infection Control Program. This was a repeat deficiency for the facility which was cited for this deficiency 11/05/10. Review of the facility's Plan of Correction (POC), with a compliance date of 12/10/10, revealed all nurses were trained in infection control guidelines upon hire and annually thereafter at a minimum. The Infection Control/Staff Development Nurse was to conduct monthly audits. The monthly audits were to be monitored by the facility via the PI/QA process for one (1) year to ensure compliance was achieved and maintained and was then to be reevaluated. Observations during the environmental tour during the current survey revealed dirty equipment stored with clean equipment in clean utility rooms on two (2) of the facility's four (4) units. Additionally, during the dietary tour observations revealed improper hand sanitation during meal service. Interview with nursing staff revealed equipment was supposed to be sanitized prior to being placed in the clean utility rooms. Interview with the Infection Control (IC)/QA/Staff Development Nurse revealed staff were educated on Infection Control measures, and she felt the education worked. However, it was staff's noncompliance that caused the deficient practice identified during this survey. An acceptable credible Allegation of Compliance (AOC) was received on 01/23/12 which alleged removal of the IJ effective on 01/21/12, based on the following: 1) The Social Services Manager contacted all Power of Attorneys and/or applicable members of the residents on the locked dementia unit by telephone and interviewed them to determine whether they had observed or had any other knowledge of relevant safety concerns by 01/16/12. 2) All residents on the locked dementia unit were questioned by the Social Services Manager in an attempt to determine if any of the other residents were subjected to the behaviors of Resident #22 by 01/16/12. 3) All residents and their family members or healthcare representatives on the unit were also informed about the potential safety issue on the unit and the measures being taken to resolve the issue by 01/19/12. 4) Resident #22 was sent out to an Psychiatric hospital on [DATE] for evaluation and returned to the facility on [DATE]. The resident was placed on one (1) to one (1) supervision. 5) Resident #1 was placed on fifteen (15) minute checks on 12/26/11 due to behaviors which were discontinued on 01/03/12. Resident #1 was placed on one (1) to one (1) supervision on 01/13/12. 6) Alteration of Resident #22's psychoactive medications were made and the addition of pain medications was added during Resident #22's stay at the Psychiatric Hospital between 01/05/12 and 01/16/12. 7) Comprehensive Plans of Care were updated for Resident #22 on 01/19/12 and Resident #1 on 01/20/12 to address specific behaviors and specific interventions to ensure needs were being met. 8) All residents on all units received a physical and psycho-social evaluation to establish a safe base-line for implementation of house-wide corrective action measures by 01/18/12. The social services department conducted a psycho-social/safety evaluation on all residents on all units by 01/19/12. 9) The facility revised it's policies and procedures for reporting and investigating potential abuse and created a new rapid response protocol called "Code Protect" by 01/19/12. 10) All staff was educated regarding the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse by 01/18/12. 11) All staff was required to pass a competency with a score of 100 percent. This competency will become an annual requirement. 12) All leadership attended a one (1) hour in-service on the topics of abuse, resident competency, and the role of resident competency on the determination of abuse by 01/20/12. On 02/03/12, it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AOC, effective 01/21/12 based on the following; Observations, on 01/31/12, 02/01/12, 02/02/12 and 02/03/12 revealed Resident #22 was receiving one (1) on one (1) supervision. Review of the medical record and review of the Behavior/Mood and Behavior Patterns Sheet revealed the resident was receiving one (1) on one (1) supervision since returning from the Psychiatric Hospital. Interviews with staff including SRNA #18, on 02/03/12 at 12:40 PM, SRNA #19, on 02/03/12 at 12:55 PM, SRNA #20, on 02/03/12 at 2:35 PM, SRNA #21, on 02/03/12 at 1:45 PM, Charge Nurse #11, on 02/03/12 at 12:50 PM, Charge Nurse #12, on 02/03/12 at 1:05 PM, Midnight Supervisor #13 on 02/03/12 at 2:40 PM, LPN # 3 on 02/03/12 at 2:38 PM, Activities Assistants #32, on 02/03/12 at 1:10 PM and Activity Assistant #33, on 02/03/12 at 12:35 PM, the Risk Manager on 02/03/12 at 12:45 PM, the Dietary Manager, on 02/03/12 at 1:00 PM, and the Staff Development Coordinator, on 02/03/12 at 1:15 PM, revealed staff was aware of the facility's policy changes, the facility's revised policies and procedures for reporting and investigating potential abuse and the new rapid response protocol called "Code Protect". They were also aware of the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse and the requirement to pass a competency exam before working with residents. Interview with the Social Services Manager, on 02/03/12 at 3:15 PM, revealed she had completed the psycho-social evaluations to establish a safe base-line for implementation of house-wide corrective action measures and the Charge Nurses had completed the physical assessments of residents. Further review of documented evidence revealed physical assessments had been completed for all residents. Continued interview revealed she had contacted family members and interviewed residents as part of the psycho-social assessment. Review of the documented evidence revealed residents and/or families had been interviewed related to safety. Interview with Resident #58's responsible party, on 02/02/12 at 10:10 AM, revealed the facility had contacted him/her related to the resident's safety at the facility. Interview with an Unsampled Resident, on 02/02/12 at 11:15 AM, revealed someone had asked him/her how he/she felt about their safety at the facility and the resident stated he/she felt safe. Interview with the Director of Nursing (DON) and Administrator, on 02/03/12 at 5:30 PM, revealed the plan for Resident #22's care was to continue to re-evaluate him/her and seek guidance from the Medical Director (Physician #1) and would obtain additional psychiatric evaluations to see if there may be anything underlying occurring with the resident's psychiatric condition. The DON further stated Resident #1 and #22's Comprehensive Plans of Care had been updated to reflect the changes in care and supervision. Review of the Comprehensive Plans of Care reflected these changes. The Administrator and DON stated it will be determined by the Medical Director when Resident #22 is removed from one (1) on one (1) observation because he/she could not be allowed to co-mingle with other residents at this point without guidance and re-direction from the one (1) on one (1) supervision. The facility remained out of compliance at a lower scope and severity of an "E", a pattern deficiency with potential for more than minimal harm while the facility's Quality Assurance continues to monitor the effectiveness of the new systems and policies implemented and while the facility develops and implements the Plan of Correction (POC).

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to be administered in a manner which enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident, related to provision of care. The facility failed to ensure abuse and care plan policies and procedures were followed by staff. The facility failed to develop and implement a behavior management program to ensure residents' behaviors that could lead to conflict were assessed, care planned and monitored. The facility's administration failed to ensure residents' safety in regards to adequate supervision and monitoring, and failed to ensure the residents' environment remained as free of accident hazards as possible. The facility had been knowledgeable of Resident #22's history of sexually inappropriate behaviors towards other residents since 12/25/11; however, failed to assess, care plan and monitor Resident #22 related to these sexual behaviors in order to deny the Resident's access to other residents. On 12/25/11, a State Registered Nursing Assistant (SRNA) found Resident #22 in Resident #1's room. Resident #1's pants and pull-up (adult brief) were pulled down below his/her knees, and Resident #22's mouth and hands were noted to be touching Resident #1's perineal area. On that same date, facility staff observed Resident #22 inappropriately touching Resident #2. The facility failed to report the incidents timely to the Administrator and Social Services, failed to initiate an investigation timely and failed to deny the perpetrator access to residents. On 01/05/12, the Kentucky State Agency Surveyor observed Resident #22 inappropriately touching and kissing Resident #29's arm and attempting to pull the resident backwards in his/her Geri chair. The surveyor had to notify the facility staff of the situation, as no staff was observed monitoring Resident #22. The facility failed to identify the incidents as abuse and failed to identify Resident #22's behavior as a risk to the other thirty-two (32) cognitively impaired residents on the locked Dementia Unit. The facility failed to implement interventions to ensure residents' safety and failed to provide adequate supervision to protect residents and prevent recurrence of sexually inappropriate behaviors towards residents. Additionally, the facility failed to identify other incidents of abuse/neglect through the assessment of all residents of the unit after 12/25/11 to ensure adequate supervision was provided to protect residents from further abuse. Based on the above findings it was determined the facility's failure to have an effective system in place to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 01/12/12, was determined to exist on 12/25/11. After quality review conducted by the State Agency and the Center for Medicare and Medicaid Services (CMS) it was determined the investigation required reopening to gather additional information. The Survey was reopened for further investigation from 01/30/12 through 02/03/12. An acceptable credible Allegation of Compliance (AOC) for the removal of IJ was received on 01/23/12 with the facility alleging removal of IJ on 01/21/12. The state agency verified IJ was removed prior to exit on 02/03/12, with remaining non-compliance at 42 CFR 483.75 Administration at a S/S of a "E", while the facility's Quailty Assurance continues to monitor Administration's oversight in the facility's system to ensure adequate assessment, identification and implimentation of it's system for supervision to prevent accidents . The findings include: Review of the facility's policy, "Social Services, Resident Abuse", dated 09/2008, revealed all residents had the right to be free of verbal, sexual, physical, and mental abuse. Additionally, the policy stated all abuse allegations were to be reported immediately to Administration and Social Services. Further review revealed while the investigation is being conducted, accused individuals will be denied unsupervised access to residents. Review of the facility's policy titled, "Social Services. Reporting Abuse to Facility Management", dated 12/2001, revealed employees must report any suspected abuse or incidents of abuse to the Director of Nursing and/or Director of Social Services. Review of the facility's policy titled, "Social Services. Preventing Resident Abuse", dated 12/2001, revealed all alleged allegations will be responded to through an investigation process. The policy detailed the facility would assess, care plan, and monitor residents with behaviors that may lead to conflict in order to assist in resolving behavior issues. The program included assessing residents with signs and symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues. Review of the facility's policy titled "Care Conference-Interdisciplinary", revised 07/04, revealed the duties of all conference members were to assess resident's problems/needs, rehabilitation potential, educational needs and discharge plans. Further review revealed no documented evidence of who was responsible for developing the plan of care; however interview with the Director of Nursing (DON), on 01/13/12 at 7:41 PM, revealed nursing should revise or develop a care plan when there was a behavior change or an acute problem developed. Interview with the Social Service Manager, on 01/14/12 at 12:46 PM, revealed the facility had weekly focus meetings where behaviors were discussed; however the facility did not track and trend individual resident behaviors and there was no specific behavioral management program. Based on the discussion in the weekly meeting about resident behaviors, care plans were developed. Interview with the Administrator, on 01/14/12 at 4:12 PM, revealed it was his understanding the facility monitored behaviors by typically documenting behaviors in the medical record and he believed Social Services monitored resident behaviors. Interview with SRNA #5, on 01/06/12 at 9:00 AM, revealed she had cared for Resident #22 since 2010 and he/she had always made sexual comments. Interview with Licensed Practical Nurse (LPN) #1, on 01/07/11 at 4:58 PM, revealed she recalled Resident #22 unzipping his/her pants and exposing himself/herself several weeks ago. Interview with SRNA #1, on 01/04/12 at 1:15 PM, revealed when she provided care for Resident #22, he/she was often "touchy feely". Interview with SRNA #3, on 01/04/12 at 1:40 PM, revealed when she cared for Resident #22, he/she made sexual statements and gestures. Interview with LPN #3, on 01/13/12 at 12:15 PM, revealed she had heard Resident #22 making sexual remarks and hand gestures (as though he/she was touching his/her genitals). Interviews revealed on 12/25/11, at approximately 11:30 AM Resident #22 was observed in Resident #1's room whose pants and pull-ups (adult brief) were pulled down. Resident #22 was observed touching Resident #1's perineal area with his/her hands and mouth. Per interview with two (2) SRNA's, Licensed Practical Nurse (LPN) #2 was notified of this incident. Additionally, on 12/25/11 at approximately 4:00 PM, Resident #22 touched Resident #2's legs and LPN #1 separated Resident #22 from Resident #2. Record review revealed no documented evidence the facility staff "immediately notified" the Administrator, Social Services, and the Director of Nursing. Interview, on 01/14/12 at 3:10 PM, with the Administrator revealed he was not notified of the incident with Resident #22 and Resident #1 immediately on 12/25/11 as per the facility's policy and procedure, but was notified later that evening. (Refer to F-226) Additionally, staff interviews (LPN #1 and #2) revealed the facility did not implement increased supervision or measures to deny Resident #22 (the perpetrator) access to other residents of the facility. Further interview with the Administrator revealed no interventions were implemented until 11:00 PM, approximately twelve (12) hours after the first incident. There was no documented evidence the facility supervised or denied Resident #22 access to other residents from 11:30 AM on 12/25/11 until 11:00 PM that evening when fifteen (15) minute checks were implemented. However, with fifteen (15) minute checks the facility did not follow the policy by not denying Resident #22 access to other residents (Refer to F-226, F-279, and F-323). Additionally, a care plan was not developed for the resident's sexual behaviors until 12/27/11, two days after the two incidents. Furthermore, the care plan did not address supervision of Resident #22 in order to protect other residents of the facility from further abuse. The Director of Nursing and Social Services revealed, on 01/11/12 at 10:00 AM, that the findings of their investigation determined that abuse had not occurred because neither resident was resistant to the acts and the residents had a right to have sex because those desires did not recede due to their cognition. However, record review revealed Resident #1 had been adjudicated incompetent by a court of law and appointed a guardian. Interview with the resident #1's Physician revealed that legally Resident #1 could not make decisions for him/herself. Record review for Resident #22 revealed he/she was assessed and determined cognitively impaired. Interview with Resident #22's Physician revealed Resident #22 could not make decisions for him/herself and could not act with willful intent. Thus, neither resident, per Physician interviews, Guardian interview and record review, were capable of making decisions for themselves in order to give consent for sexual relations. However, the facility's investigation failed to identify neither resident could give consent; therefore had a finding that no abuse had occurred. The facility proceeded to discontinue fifteen (15) minutes checks for Resident #22 on 01/03/12 with no specific care plan documenting behavior management interventions to address Resident #22's history of sexually inappropriate behaviors since 12/25/11. On 01/05/12, the Kentucky State Agency Surveyor observed Resident #22 inappropriately touching and kissing Resident #29's arm and attempting to pull the resident backwards in his/her Geri chair. The Surveyor had to notify the facility staff of the situation, as the one activity aide staff leading the activity, who was sitting about ten (10) feet away and in direct visual field of the incident, did not intervene. No other staff member was observed monitoring Resident #22. There was no documented evidence that the facility identified Resident #22's behavior as a risk to the other thirty-two (32) cognitively impaired residents on the locked Dementia Unit. This failure prevented the facility from developing and implementing effective interventions to ensure residents' safety and prevented the facility from providing adequate supervision and protection for the residents in an effort to prevent recurrence of sexually inappropriate behaviors towards residents. Additionally, there was no documented evidence the facility had attempted to identify other incidents of abuse/neglect through assessment of all residents of the unit. Interview with the Social Services Manager, who was responsible for conducting investigations and assessments, revealed that she had not assessed any other residents on the unit to identify other incidents of abuse. Further interview with the Administrator, on 01/14/12 at 4:12 PM, revealed he did review the investigation of the incident and determined the facility's failure was in LPN #2 not reporting the incident immediately to her supervisor. The Administrator informed staff to put Resident #22 on one (1) to one (1) supervision after he was notified of the incident. While Nurses Notes revealed multiple entries of documentation stating staff was providing one to one supervision of Resident #22, interviews with staff revealed only one staff person, SRNA #6, on 12/26/11 provided one to one supervision during day shift. The facility could provide no other evidence that one to one supervision was being carried out. Interview with the Administrator, on 01/14/12 at 4:12 PM, revealed the Administration provided oversight for the facility by participating in the daily stand-up meeting or through informal discussions. He stated there was no system in place to follow-up on issues with the facility or residents other than having follow-up meetings. An acceptable credible Allegation of Compliance (AOC) was received on 01/23/12 which alleged removal of the IJ effective on 01/21/12, based on the following: 1) The Social Services Manager contacted all Power of Attorneys and/or applicable members of the residents on the locked dementia unit by telephone and interviewed them to determine whether they had observed or had any other knowledge of relevant safety concerns by 01/16/12. 2) All residents on the locked dementia unit were questioned by the Social Services Manager in an attempt to determine if any of the other residents were subjected to the behaviors of Resident #22 by 01/16/12. 3) All residents and their family members or healthcare representatives on the unit were also informed about the potential safety issue on the unit and the measures being taken to resolve the issue by 01/19/12. 4) Resident #22 was sent out to an Psychiatric hospital on [DATE] for evaluation and returned to the facility on [DATE]. The resident was placed on one (1) to one (1) supervision. 5) Resident #1 was placed on fifteen (15) minute checks on 12/26/11 due to behaviors which were discontinued on 01/03/12. Resident #1 was placed on one (1) to one (1) supervision on 01/13/12. 6) Alteration of Resident #22's psychoactive medications were made and the addition of pain medications was added during Resident #22's stay at the Psychiatric Hospital between 01/05/12 and 01/16/12. 7) Comprehensive Plans of Care were updated for Resident #22 on 01/19/12 and Resident #1 on 01/20/12 to address specific behaviors and specific interventions to ensure needs were being met. 8) All residents on all units received a physical and psycho-social evaluation to establish a safe base-line for implementation of house-wide corrective action measures by 01/18/12. The social services department conducted a psycho-social/safety evaluation on all residents on all units by 01/19/12. 9) The facility revised it's policies and procedures for reporting and investigating potential abuse and created a new rapid response protocol called "Code Protect" by 01/19/12. 10) All staff was educated regarding the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse by 01/18/12. 11) All staff was required to pass a competency with a score of 100 percent. This competency will become an annual requirement. 12) All leadership attended a one (1) hour in-service on the topics of abuse, resident competency, and the role of resident competency on the determination of abuse by 01/20/12. On 02/03/12, it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AOC, effective 01/21/12 based on the following; Observations, on 01/31/12, 02/01/12, 02/02/12 and 02/03/12 revealed Resident #22 was receiving one (1) on one (1) supervision. Review of the medical record and review of the Behavior/Mood and Behavior Patterns Sheet revealed the resident was receiving one (1) on one (1) supervision since returning from the Psychiatric Hospital. Interviews with staff including SRNA #18, on 02/03/12 at 12:40 PM, SRNA #19, on 02/03/12 at 12:55 PM, SRNA #20, on 02/03/12 at 2:35 PM, SRNA #21, on 02/03/12 at 1:45 PM, Charge Nurse #11, on 02/03/12 at 12:50 PM, Charge Nurse #12, on 02/03/12 at 1:05 PM, Midnight Supervisor #13 on 02/03/12 at 2:40 PM, LPN # 3 on 02/03/12 at 2:38 PM, Activities Assistants #32, on 02/03/12 at 1:10 PM and Activity Assistant #33, on 02/03/12 at 12:35 PM, the Risk Manager on 02/03/12 at 12:45 PM, the Dietary Manager, on 02/03/12 at 1:00 PM, and the Staff Development Coordinator, on 02/03/12 at 1:15 PM, revealed staff was aware of the facility's policy changes, the facility's revised policies and procedures for reporting and investigating potential abuse and the new rapid response protocol called "Code Protect". They were also aware of the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse and the requirement to pass a competency exam before working with residents. Interview with the Social Services Manager, on 02/03/12 at 3:15 PM, revealed she had completed the psycho-social evaluations to establish a safe base-line for implementation of house-wide corrective action measures and the Charge Nurses had completed the physical assessments of residents. Further review of documented evidence revealed physical assessments had been completed for all residents. Continued interview revealed she had contacted family members and interviewed residents as part of the psycho-social assessment. Review of the documented evidence revealed residents and/or families had been interviewed related to safety. Interview with Resident #58's responsible party, on 02/02/12 at 10:10 AM, revealed the facility had contacted him/her related to the resident's safety at the facility. Interview with an Unsampled Resident, on 02/02/12 at 11:15 AM, revealed someone had asked him/her how he/she felt about their safety at the facility and the resident stated he/she felt safe. Interview with the Director of Nursing (DON) and Administrator, on 02/03/12 at 5:30 PM, revealed the plan for Resident #22's care was to continue to re-evaluate him/her and seek guidance from the Medical Director (Physician #1) and would obtain additional psychiatric evaluations to see if there may be anything underlying occurring with the resident's psychiatric condition. The DON further stated Resident #1 and #22's Comprehensive Plans of Care had been updated to reflect the changes in care and supervision. Review of the Comprehensive Plans of Care reflected these changes. The Administrator and DON stated it will be determined by the Medical Director when Resident #22 is removed from one (1) on one (1) observation because he/she could not be allowed to co-mingle with other residents at this point without guidance and re-direction from the one (1) on one (1) supervision. The facility remained out of compliance at a lower scope and severity of an "E", a pattern deficiency with potential for more than minimal harm while the facility's Quality Assurance continues to monitor the effectiveness of the new systems and policies implemented to ensure the facility's Administration provides oversight and while the facility develops and implements the Plan of Correction (POC).

Based on observation, interview, record review and facility policy review it was determined the facility failed to ensure residents' safety through monitoring and supervision. The facility failed to ensure adequate supervision was provided to prevent resident to resident sexual abuse. The facility failed to adequately assess Resident #22's inappropriate sexual history and failed to develop and implement a Plan of Care to address Resident #22's sexual behaviors that would be effective in managing the resident's behaviors and protecting other residents of the facility. On 12/25/11, at approximately 11:30 AM State Registered Nursing Assistant (SRNA) #2 observed Resident #22 in Resident #1's room, Resident #1's pants and pull-up were pulled down below his/her knees while the resident was laying across the foot of the bed on his/her stomach and Resident #22 was behind Resident #1 touching Resident #1's perineal area with his/her hands and mouth. Later on 12/25/11, staff observed Resident #22 touching and rubbing Resident #2's thigh. On 01/05/12, Resident #22 was observed inappropriately touching and kissing Resident #29's arm and attempting to pull the resident backwards in his/her Geri chair. The facility failed to identify the incidents as abuse and failed to identify Resident #22's behavior as a risk to the other thirty-two (32) cognitively impaired residents on the locked Dementia Unit. The facility failed to implement interventions to ensure residents' safety and failed to provide adequate supervision to protect residents and prevent recurrence of sexually inappropriate behaviors towards residents. Additionally, the facility failed to identify other incidents of abuse/neglect through the assessment of all residents of the unit after 12/25/11 to ensure adequate supervision was provided to protect residents from further abuse. Based on the above findings, it was determined the facility's failure to properly assess and implement a plan of care to ensure adequate supervision for Resident #22 and to protect other residents from further abuse recurrence is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 01/12/12 and was determined to exist on 12/25/11. After quality review conducted by the State Agency and the Center for Medicare and Medicaid Services (CMS) it was determined the investigation required reopening to gather additional information. The Survey was reopened for further investigation from 01/30/12 through 02/03/12. An acceptable credible Allegation of Compliance (AOC) for the removal of IJ was received on 01/23/12 with the facility alleging removal of IJ on 01/21/12. The State Agency verified IJ was removed prior to exit on 02/03/12, with remaining non-compliance at 42 CFR 483.25 Quality of Care at a S/S of a "E", while the facility's Quality Assurance continues to monitor Administration's oversight in the facility's system to ensure adequate supervision to prevent accidents. In addition the facility failed to ensure a safe environment by failing to ensure the Soiled Utility Closet which contained hazardous chemicals was locked. The findings include: Review of the facility's policy entitled "Incident/Accident Reports, Resident", dated 09/2006, revealed an incident is defined as an unusual or unexpected event that is not consistent with the routine operation of the facility or the routine care of the resident. It continued to state, this includes every incident that occurs involving a resident, visitor, volunteer, other non-employee or employee. Review of the facility's policy titled, "Social Services. Resident-to-Resident Abuse", dated 12/2001, revealed the facility was to develop a plan of care that included interventions to prevent the recurrence of such incident. Record review revealed the facility admitted Resident #22, on 09/13/10, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/10/11, revealed the resident was assessed as being severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three (3). Further review revealed no documented evidence the facility assessed Resident #22 for sexually inappropriate behaviors. Review of Resident #22's Comprehensive Care Plan, last revised on 11/22/11 revealed no documented evidence the facility developed a plan of care to ensure adequate supervision related to sexual behaviors. Interview with SRNA #5, on 01/06/12 at 9:00 AM, revealed she had cared for Resident #22 since 2010 and he/she had always made sexual comments. Interview with Licensed Practical Nurse (LPN) #1, on 01/07/11 at 4:58 PM, revealed she recalled Resident #22 unzipping his/her pants and exposing himself/herself several weeks ago. Interview with SRNA #1, on 01/04/12 at 1:15 PM, revealed when she provided care for Resident #22, he/she was often "touchy feely". Interview with SRNA #3, on 01/04/12 at 1:40 PM, revealed when she cared for Resident #22, he/she made sexual statements and gestures. Interview with LPN #3, on 01/13/12 at 12:15 PM, revealed she had heard Resident #22 making sexual remarks and hand gestures (as though he/she was touching his/her genitals). Interview with SRNA #2, on 01/06/12 at 9:47 AM, revealed on 12/25/11 at 11:30 AM, she observed Resident #1 (adjudicated legally incompetent) laying across the foot of the bed on his/her stomach with his/her pants and pull up pulled down below his/her knees. Resident #22 was observed by SRNA #2 behind Resident #1 touching Resident #1's perineal area with his/her mouth and hands. SRNA #2 further stated she removed Resident #22 from Resident #1's room and told Licensed Practical Nurse (LPN) #2 what she had observed. She continued to state LPN #2 laughed and said did you remove him/her from Resident #1's room to which she replied yes. She cleaned Resident #22 and then left him/her at the nurses station and went back to clean Resident #1. Interview with SRNA #6, on 01/05/12 at 10:22 AM, revealed she was at the Nurse's station and heard SRNA #2 tell LPN #2 she had observed Resident #22 in Resident #1's room touching Resident # 1's perineal area with his/her hands and mouth. Interview with LPN #2, on 01/05/12 at 12:37 PM, revealed she had not initiated any special monitoring or supervision for Resident #22 or Resident #1 and had not done any physical assessments of either resident or Resident #1's roommate. Record review revealed no documented evidence the facility staff notified Administration, the Director of Nursing or Social Services of the incident even though review of the facility's Social Services Resident Abuse Policy, dated 09/2008, detailed all Abuse allegations must be immediately reported to the facility Administrator and the Social Services Manager. Interview with SRNA #4, on 01/05/12 at 9:36 AM, revealed he came to work on 12/25/11 at 2:30 PM and was told Resident #22 was in Resident #1's room with his/her face between Resident #1's legs. He further indicated LPN #1 was present. Further interview revealed he was in charge of providing care to Resident #22 on 12/25/11 and there were no special checks initiated on the resident while he was working and his shift ended at 11:00 PM. Interview with SRNA #5, on 01/06/12 at 9:00 AM, revealed she came to work at 6:30 PM on 12/25/11 and SRNA #2 told her she had observed Resident #22 in Resident #1's room. She stated SRNA #2 told her Resident #1's pants and pull-up were down and Resident #22 was touching Resident #1's perineal area with his/her hands and mouth. She further stated she was not aware of any special monitoring being put into place for Resident #22 or Resident #1. Interview with LPN #1, on 01/07/12 at 4:58 PM, revealed LPN #2 had told her nothing in report about the incident with Resident #22 and Resident #1. LPN #1 further stated there was no special monitoring for Resident #22 or Resident #1 initiated during her shift and there were no physical assessments of either residents or Resident #1's roommate completed during her shift. Further interview with SRNA #2 and LPN #1 revealed they had observed Resident #22 touching and rubbing Resident #2's thigh between 4:00 PM and 4:30 PM. It wasn't until after this incident that SRNA #2 informed LPN #1 of the previous incident with Resident #22 and #1 that had occurred that same date. LPN #1 revealed she did not take action related to either incident occurring with Resident #22 until 8:30 PM, when she notified the Weekend Supervisor of the incidents. Interview with the Evening Weekend Supervisor, on 01/05/12 at 3:24 PM, revealed she was doing her rounds, on 12/25/11 between 10:00 PM and 10:30 PM when she was told about the incident with Resident #22 and Resident #1. She stated she then called the Day Weekend Supervisor because she had received nothing in report from him and he had stated he knew nothing about the incident and then she called SRNA #2 and asked her what had happened and she stated she had found Resident #22 in Resident #1's room touching Resident #1's perineal area with his/her hands and mouth, she said she had separated the residents and told the Nurse. The Evening Weekend Supervisor stated she then called LPN #2 who said she had not been told about the incident. She stated then she called the Assistant Director of Nursing (ADON) and Social Services. She stated the facility began fifteen (15) minute checks at 11:00 PM for Resident #22, twelve (12 ) hours after the incident. Review of Resident #22's Comprehensive Care Plan revealed there was no Care Plan developed to address the resident's sexual behaviors until 12/27/11, two (2) days after the incidents involving Residents #22, #1 and #2. Review of Resident #22's Plan of Care for sexual behaviors, dated 12/27/11, revealed the facility had implemented several approaches to deal with the behavior which were to tell the resident calmly and firmly that this behavior was not acceptable whenever it occurred. It further stated to separate from peers if behavior becomes offensive to them, take Resident #22 to his/her room and provide privacy and to teach the resident about acceptable behavior. The Care Plan detailed staff was to be non-judgmental when confronting negative behavior and establish consistent staff approaches to deal with the problem; however, further review revealed the care plan did not detail what consistent approaches staff was to provide to deal with the problem. There was no documented evidence of any increased supervision being implemented related to the resident's sexual behaviors towards residents, nor interventions to deny Resident #22 access to other residents of the facility to ensure their safety and to prevent further recurrence of abuse. Review of the Nurses Notes revealed on 01/03/12 the facility discontinued the fifteen (15) minute checks. On 01/5/12, between 9:43 AM and 9:50 AM, Resident #22 was observed by the Kentucky State Agency Surveyor, rubbing Resident #29's left hand on his/her upper right thigh in the dining room on the locked unit during an activity while female residents were having their nails painted. There was one (1) Activity Aide in the room, sitting about ten (10) feet away, but within direct visual field of the incident, with approximately twelve (12) residents. No other staff was observed in the area. Resident #22 was also observed rubbing on Resident #29's left arm and kissing up and down his/her arm and hand. Resident #22 was then observed pulling Resident #29 backwards, by his/her arm while he/she was sitting in a Geri chair. The Kentucky State Agency Surveyor brought this incident to the attention of the Activity Aide when Resident #22 began pulling Resident #29 backwards. No staff was supervising/monitoring this resident to ensure no sexual behaviors were forced upon other residents despite the facility's knowledge of the resident's sexually inappropriate behavior history since 12/25/11. Interview with Activities Assistant #33, on 02/02/12 at 2:15 PM, revealed she observed Resident #22 holding Resident #29's arm and stating "you're coming with me". She further stated had she observed Resident #22 kissing Resident #29's arm and hand and rubbing Resident #29's hand on Resident #22's leg she would have seperated them immediately. Interview with the ADON, on 01/06/12 at 11:45 AM, revealed the facility had disciplined LPN #2, as she was the Charge Nurse on 12/25/11 and it was LPN #2's responsibility to have reported the incident between Resident #22 and Resident #1 to Administration. Interview with the Social Services Manager and Director of Nursing (DON), on 01/11/12 at 10:00 AM, revealed the facility's investigation did not determine abuse had occurred and it was determined the facility's failure existed secondary to the failure of LPN #2 to report the incident with Resident #22 and Resident #1. These staff stated they believed the residents had a right to have sex because those desires did not recede due to their cognition. However, record review revealed Resident #22 was assessed by the facility to have cognitive impairment. Interview with Resident #22's Power of Attorney, on 01/13/12 at 9:50 AM, revealed while the facility had previously informed him of the resident's increased sexual behaviors the resident was incapable of making decisions. Interview with Resident #22's Physician, Physician #1, on 01/13/12 at 11:27 AM, revealed he believed Resident #22 was unable to make decisions and did not have the cognitive ability to act willfully. Furthermore, Resident #1 was assessed by the facility to have cognitive impairment and had been adjudicated legally incompetent, with a court appointed guardian. Furthermore, interview with Resident #1's Guardian, on 01/12/12 at 6:40 PM, revealed if Resident #1 was in his/her right mind, this incident would not have occurred. She further stated Resident #1 was incapable of making decisions and she, as the resident's guardian, had given no permission for Resident #1 to perform sexual acts. Interview with the Administrator, on 01/14/12 at 4:12 PM, revealed he did review the investigation of the incident and determined LPN #2 not reporting the incident immediately to her supervisor was the failure; however, the facility could not provide evidence that they had identified the facility's failure to deny Resident #22 and #1 access to other residents to prevent further incidence or recurrence of potential sexual abuse. The Administrator was unable to provide evidence the facility adequately supervised or monitored Resident #22 and #1 after the incident which occurred on 12/25/11 at 11:30 AM to ensure the safety and well-being of other residents. Review of the census report for 12/25/11 revealed a total of thirty-two (32) residents living on the locked Dementia unit. Review of the facility's Roster Matrix revealed all thirty-two (32) residents residing on the locked Dementia unit were assessed as having cognitive impairment. Due to the facility's lack of supervision and monitoring, approximately five (5) hours later, Resident #22 inappropriately touched and rubbed Resident #2's thigh. Again, twelve (12) days later, there was no evidence the facility was adequately supervising or monitoring Resident #22 when Resident #22 was observed rubbing on Resident #29's left arm and kissing up and down Resident #29's arm and hand and Resident #22 was observed pulling Resident #29 by his/her arm while he/she was sitting in a Geri chair in the dining room of the locked unit during an activity which a staff member was leading. Even though the facility transferred Resident #22 to a psychiatric facility on 01/05/12 the facility anticipated the resident's return on 01/16/12; however, review of the facility's training documentation and Resident #22's current Care Plan revealed no detailed evidence of action the facility would take to ensure adequate supervision and resident safety to prevent sexual abuse recurrence. Additionally, there was no documented evidence that the facility had attempted to identify other incidents of abuse/neglect through assessment of all residents on the unit. Interview with the Social Service Manager, on 01/14/12 at 12:46 PM, who was responsible for conducting investigations and assessments, revealed that she had not assessed any other residents on the unit to identify other incidents of abuse. Therefore this failure to identify other incidents of abuse prevented the facility from assessing, developing and implementing necessary supervision that would be required to protect the residents of the locked unit. An acceptable credible Allegation of Compliance (AOC) was received on 01/23/12 which alleged removal of the IJ effective on 01/21/12, based on the following: 1) The Social Services Manager contacted all Power of Attorneys and/or applicable members of the residents on the locked dementia unit by telephone and interviewed them to determine whether they had observed or had any other knowledge of relevant safety concerns by 01/16/12. 2) All residents on the locked dementia unit were questioned by the Social Services Manager in an attempt to determine if any of the other residents were subjected to the behaviors of Resident #22 by 01/16/12. 3) All residents and their family members or healthcare representatives on the unit were also informed about the potential safety issue on the unit and the measures being taken to resolve the issue by 01/19/12. 4) Resident #22 was sent out to an Psychiatric hospital on [DATE] for evaluation and returned to the facility on [DATE]. The resident was placed on one (1) to one (1) supervision. 5) Resident #1 was placed on fifteen (15) minute checks on 12/26/11 due to behaviors which were discontinued on 01/03/12. Resident #1 was placed on one (1) to one (1) supervision on 01/13/12. 6) Alteration of Resident #22's psychoactive medications were made and the addition of pain medications was added during Resident #22's stay at the Psychiatric Hospital between 01/05/12 and 01/16/12. 7) Comprehensive Plans of Care were updated for Resident #22 on 01/19/12 and Resident #1 on 01/20/12 to address specific behaviors and specific interventions to ensure needs were being met. 8) All residents on all units received a physical and psycho-social evaluation to establish a safe base-line for implementation of house-wide corrective action measures by 01/18/12. The social services department conducted a psycho-social/safety evaluation on all residents on all units by 01/19/12. 9) The facility revised it's policies and procedures for reporting and investigating potential abuse and created a new rapid response protocol called "Code Protect" by 01/19/12. 10) All staff was educated regarding the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse by 01/18/12. 11) All staff was required to pass a competency with a score of 100 percent. This competency will become an annual requirement. 12) All leadership attended a one (1) hour in-service on the topics of abuse, resident competency, and the role of resident competency on the determination of abuse by 01/20/12. On 02/03/12, it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AOC, effective 01/21/12 based on the following; Observations, on 01/31/12, 02/01/12, 02/02/12 and 02/03/12 revealed Resident #22 was receiving one (1) on one (1) supervision. Review of the medical record and review of the Behavior/Mood and Behavior Patterns Sheet revealed the resident was receiving one (1) on one (1) supervision since returning from the Psychiatric Hospital. Interviews with staff including SRNA #18, on 02/03/12 at 12:40 PM, SRNA #19, on 02/03/12 at 12:55 PM, SRNA #20, on 02/03/12 at 2:35 PM, SRNA #21, on 02/03/12 at 1:45 PM, Charge Nurse #11, on 02/03/12 at 12:50 PM, Charge Nurse #12, on 02/03/12 at 1:05 PM, Midnight Supervisor #13 on 02/03/12 at 2:40 PM, LPN # 3 on 02/03/12 at 2:38 PM, Activities Assistants #32, on 02/03/12 at 1:10 PM and Activity Assistant #33, on 02/03/12 at 12:35 PM, the Risk Manager on 02/03/12 at 12:45 PM, the Dietary Manager, on 02/03/12 at 1:00 PM, and the Staff Development Coordinator, on 02/03/12 at 1:15 PM, revealed staff was aware of the facility's policy changes, the facility's revised policies and procedures for reporting and investigating potential abuse and the new rapid response protocol called "Code Protect". They were also aware of the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse and the requirement to pass a competency exam before working with residents. Interview with the Social Services Manager, on 02/03/12 at 3:15 PM, revealed she had completed the psycho-social evaluations to establish a safe base-line for implementation of house-wide corrective action measures and the Charge Nurses had completed the physical assessments of residents. Further review of documented evidence revealed physical assessments had been completed for all residents. Continued interview revealed she had contacted family members and interviewed residents as part of the psycho-social assessment. Review of the documented evidence revealed residents and/or families had been interviewed related to safety. Interview with Resident #58's responsible party, on 02/02/12 at 10:10 AM, revealed the facility had contacted him/her related to the resident's safety at the facility. Interview with an Unsampled Resident, on 02/02/12 at 11:15 AM, revealed someone had asked him/her how he/she felt about their safety at the facility and the resident stated he/she felt safe. Interview with the Director of Nursing (DON) and Administrator, on 02/03/12 at 5:30 PM, revealed the plan for Resident #22's care was to continue to re-evaluate him/her and seek guidance from the Medical Director (Physician #1) and would obtain additional psychiatric evaluations to see if there may be anything underlying occurring with the resident's psychiatric condition. The DON further stated Resident #1 and #22's Comprehensive Plans of Care had been updated to reflect the changes in care and supervision. Review of the Comprehensive Plans of Care reflected these changes. The Administrator and DON stated it will be determined by the Medical Director when Resident #22 is removed from one (1) on one (1) observation because he/she could not be allowed to co-mingle with other residents at this point without guidance and re-direction from the one (1) on one (1) supervision. 2. Observation during initial tour of the facility, on 01/10/12 at 10:05 AM, revealed the 'Soiled Utility' room on the 200 Unit was unlocked. Further observation revealed the room contained a bottle of Sanizide Plus Germicidal Solution, a container of PDI Sani-Dex ALC Antimicrobial Alcohol Gel Hand Wipes, and a paint can closer with a sharp edge. Review of the Sanizide Plus Germicidal Solution Material Safety Data Sheet (MSDS), dated 06/01, revealed exposure to this product may cause irritation to the upper respiratory tract if inhaled; burning and redness to the eyes if eye contact; skin irritations if contact with the skin; and if ingested may cause gastrointestinal irritation, nausea, vomiting and diarrhea. Review of the Material Safety Data Sheet (MSDS), dated 04/25/06, revealed PDI Sani-Dex ALC Antimicrobial Alcohol Gel Hand Wipes had the potential to cause moderate eye irritation; prolonged inhalation was irritating to the eyes and the respiratory tract and may cause headaches and dizziness, and other central nervous system effects; and if ingestion, get medical help or contact the Poison Control Center immediately. Observation, on 01/12/12 at 7:50 PM, revealed Resident #19, who the facility had assessed as being cognitively impaired wheeled herself/himself behind the nursing station on the 200 Unit where the unlocked Oxygen Storage/Soiled Utility Room was located. Interview, on 01/10/12 at 10:10 AM, with Registered Nurse (RN) #1 revealed the door was to be locked at all times because there were cognitively impaired residents who resided on the 200 Unit. Additional interview revealed staff must get a key from the nurse in charge to unlock the door. Interview, on 01/10/12 at 10:11 AM, with State Registered Nursing Assistant (SRNA) #9 revealed the 'Soiled Utility' room door was never locked and he had never had to obtain a key to unlock the door. Interview, on 01/10/12 at 10:12 AM, with SRNA #10 revealed she had never had to ask for a key to enter the 'Soiled Utility' room because she "just walked right in" when she needed to enter the room. The facility remained out of compliance at a lower scope and severity of an "E", a pattern deficiency with potential for more than minimal harm while the facility's Quality Assurance continues to monitor the effectiveness of the new systems and policies implemented to ensure residents are adequately supervised to prevent accidents and while the facility develops and implements the Plan of Correction (POC).

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to properly assess and develop a comprehensive care plan that described the services to be furnished by the facility for one (1) of fifty-nine (59) sampled residents (Resident #22) related to sexual behaviors. The facility failed to develop a care plan addressing Resident #22's known sexual history to ensure the safety of the residents of the facility. On 12/25/11 at 11:30 AM, Resident #22 was observed, by State Registered Nursing Assistant (SRNA) #2, in Resident #1's room touching Resident #1's perineal area with his/her hands and mouth. Resident #1 had been adjudicated legally incompetent by a court of law. Facility staff observed Resident #22 later that day at approximately 4:00 PM, touching and rubbing Resident #2's thigh. Review of the Nurses Notes revealed on 01/03/12, the facility discontinued the fifteen (15) minute checks. However, on 01/05/12 between 9:43 AM and 9:50 AM, Resident #22 was observed by the Kentucky State Agency Surveyor, rubbing Resident #29's left hand on his/her upper right thigh in the dining room on the locked unit during an activity while female residents were having their nails painted. There was one (1) Activity Aide in the room, sitting about ten (10) feet away, but within direct vision of the incident, with approximately twelve (12) residents. No other staff was observed in the area. Resident #22 was also observed rubbing on Resident #29's left arm and kissing up and down his/her arm and hand. Resident #22 was then observed pulling Resident #29 backwards, by his/her arm while he/she was sitting in a Geri chair. The Kentucky State Agency Surveyor brought this incident to the attention of the Activity Aide when Resident #22 began pulling Resident #29 backwards. No staff was observed supervising/monitoring this resident to ensure no sexual behaviors were forced upon other residents. The facility failed to develop and implement interventions to ensure supervision and monitoring of Resident #22 in order to prevent and deny him/her access to thirty-two (32) cognitively impaired residents. Based on the above findings, it was determined the facility's failure to properly assess and develop a comprehensive plan of care related to a resident's sexual behaviors is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 01/12/12 and was determined to exist, on 12/25/11. After quality review conducted by the State Agency and the Center for Medicare and Medicaid Services (CMS) it was determined the investigation required reopening to gather additional information. The Survey was reopened for further investigation from 01/30/12 through 02/03/12. An acceptable credible Allegation of Compliance (AOC) for the removal of IJ was received on 01/23/12 with the facility alleging removal of IJ on 01/21/12. The State Agency verified IJ was removed prior to exit on 02/03/12, with remaining non-compliance at 42 CFR 483.20 Resident Assessment at a S/S of a "E", while the facility's Quailty Assurance continues to monitor the developement of Care Plans related to residents' behaviors. (Refer to F-323 and F-226) The findings include: Review of the facility's policy titled "Care Conference-Interdisciplinary", revised 07/04, revealed the duties of all conference members were to assess resident's problems/needs, rehabilitation potential, educational needs and discharge plans. Continued review of the policy revealed the Minimum Data Set (MDS) Coordinator is responsible for ensure the comprehensive Plans of Care are implemented and maintained and responisble ro reviewing all existing entries on care plans and revising as necessary. Further review revealed no documented evidence of who was responsible for developing the plan of care; however, interview with the Director of Nursing (DON), on 01/13/12 at 7:41 PM, revealed nursing should revise or develop a care plan when there was a behavior change or an acute problem developed. Review of the facility's policy titled, "Social Services. Preventing Resident Abuse", dated 12/2001, revealed all alleged allegations will be responded to through an investigation process. The policy detailed the facility would assess, care plan, and monitor residents with behaviors that may lead to conflict in order to assist in resolving behavior issues. It continued to state, the program included assessing residents with signs and symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues. Review of the facility's policy titled, "Social Services. Resident-to-Resident Abuse", dated 12/2001, revealed the facility was to develop a plan of care that included interventions to prevent the recurrence of such incident. Record review revealed the facility admitted Resident #22, on 09/13/10, with [DIAGNOSES REDACTED]. On 01/13/12 at 11:27 AM, interview with Physician #1 revealed Resident #22 was not capable of making decisions. Interview with SRNA #5, on 01/06/12 at 9:00 AM, revealed she had cared for Resident #22 since 2010 and he/she had always made sexual comments. Interview with Licensed Practical Nurse (LPN) #1, on 01/07/11 at 4:58 PM, revealed she recalled Resident #22 unzipping his/her pants and exposing himself/herself several weeks ago. Interview with SRNA #1, on 01/04/12 at 1:15 PM, revealed when she provided care for Resident #22, he/she was often "touchy feely". Interview with SRNA #3, on 01/04/12 at 1:40 PM, revealed when she cared for Resident #22, he/she made sexual statements and gestures. Interview with LPN #3, on 01/13/12 at 12:15 PM, revealed she had heard Resident #22 making sexual remarks and hand gestures (as though he/she was touching his/her genitals). Interview with State Registered Nursing Assistant (SRNA) #2, on 01/06/12 at 9:47 AM, revealed on 12/25/11 at approximately 11:30 AM, she observed Resident #1 (adjudicated legally incompetent by a court of law) laying across the foot of the bed with his/her pants and pull-up (adult brief) pulled down below his/her knees. Resident #22 was observed by SRNA #2 behind Resident #1 touching his/her perineal area with his/her mouth and hands. SRNA #2 further stated she removed Resident #22 from Resident #1's room and told Licensed Practical Nurse (LPN) #2 what she had observed. Interview with LPN #2, on 01/05/12 at 12:42 PM, revealed she did not recall SRNA #2 reporting Resident #22's sexual behavior towards Resident #1, therefore a care plan was not initiated related to this behavior. Interview with LPN #1, on 01/07/12 at 4:58 PM, and interview with SRNA #2, on 01/06/12 at 10:00 AM, revealed they observed Resident #22, on 12/25/11 at approximately 4:30 PM, touching and rubbing Resident #2's upper leg. They further stated they redirected Resident #22 and encouraged him/her to stay with LPN #1 while she finished passing medication. LPN #1 continued to state that SRNA #2 informed her of a similar incident of sexual behavior with Resident #22 and Resident #1 earlier in the shift. Interview further revealed no care plan was developed and implemented to address Resident #22's sexual behaviors towards staff and residents despite the two incidents on 12/25/11. Review of the census report for 12/25/11 revealed there was a total of thirty-two (32) residents living on the locked Dementia Unit. Review of the facility's Roster Matrix revealed the facility assessed all thirty-two (32) residents residing on the locked Dementia Unit as having cognitive impairment. Review of the Care Plan revealed no documented evidence the facility developed a plan of care to address Resident #22's sexual behavior towards other residents after either incident. Continued review revealed the facility did not develop a care plan until 12/27/11 related to sexual behavior. Review of Resident #22's Plan of Care for sexual behaviors, dated 12/27/11, revealed the approaches to deal with the behavior were to tell the resident calmly and firmly that this behavior was not acceptable whenever it occurred. It further stated to separate from peers if behavior becomes offensive to them, take Resident #22 to his/her room and provide privacy, and to teach the resident about acceptable behavior. The Care Plan approaches further stated be non-judgmental when confronting negative behavior and establish consistent staff approaches to deal with problem. The facility did not detail what consistent staff approaches were to be provided to deal with the problem. There was no documented evidence of any increased supervision being implemented related to the resident's sexual behaviors towards other residents since 12/25/11, or to deny the resident access to other residents in order to prevent abuse recurrence. On 01/05/12 between 9:43 AM and 9:50 AM, Resident #22 was observed by the Kentucky State Agency Surveyor, rubbing Resident #29's left hand on his/her upper right thigh in the dining room on the locked unit during an activity while female residents were having their nails painted. There was one (1) Activity Aide in the room, sitting about ten (10) feet away, but within direct vision of the incident, with approximately twelve (12) residents. No other staff was observed in the area. Resident #22 was also observed rubbing on Resident #29's left arm and kissing up and down his/her arm and hand. Resident #22 was then observed pulling Resident #29 backwards, by his/her arm while he/she was sitting in a Geri chair. The Kentucky State Agency Surveyor brought this incident to the attention of the Activity Aide when Resident #22 began pulling Resident #29 backwards. No staff was supervising/monitoring this resident to ensure no sexual behaviors were forced upon other residents despite the facility's knowledge of the resident's history since 12/25/11. Interview with LPN #4, the Evening Weekend Supervisor and LPN #3, on 01/13/12 at 12:15 PM, revealed when asked about the accuracy of Resident #22's Comprehensive Care Plan they stated they thought the Social Services Worker or MDS Coordinator was responsible for developing the Care Plans. Interview with the Social Service Manager, on 01/14/12 at 12:46 PM, revealed behaviors were discussed in the weekly focus meetings; however, the facility did not track and trend individual resident behaviors and there was no specific behavioral management program. Based on the discussion in the weekly meeting about resident behaviors, care plans were developed. Interview with the Director of Nursing (DON), on 01/13/12 at 7:41 PM, revealed if nursing identified a change in behavior, then someone from nursing should have developed/updated a care plan to address the sexual behavior and put interventions in place to prevent further sexual behaviors. While the facility transferred Resident #22 to a psychiatric facility on 01/05/12 the facility anticipated the resident's return on 01/16/12; however, review of the facility's training documentation and Resident #22's current Care Plan revealed no detailed evidence of action the facility would take to ensure adequate supervision and resident safety to prevent sexual abuse recurrence. Additionally, there was no documented evidence that the facility had attempted to identify other incidents of abuse/neglect through assessment of all residents of the unit. Interview with the SSM, who was responsible for conducting investigations and assessments, revealed that she had not assessed any other residents on the unit to identify other incidents of abuse. An acceptable credible Allegation of Compliance (AOC) was received on 01/23/12 which alleged removal of the IJ effective on 01/21/12, based on the following: 1) The Social Services Manager contacted all Power of Attorneys and/or applicable members of the residents on the locked dementia unit by telephone and interviewed them to determine whether they had observed or had any other knowledge of relevant safety concerns by 01/16/12. 2) All residents on the locked dementia unit were questioned by the Social Services Manager in an attempt to determine if any of the other residents were subjected to the behaviors of Resident #22 by 01/16/12. 3) All residents and their family members or healthcare representatives on the unit were also informed about the potential safety issue on the unit and the measures being taken to resolve the issue by 01/19/12. 4) Resident #22 was sent out to an Psychiatric hospital on [DATE] for evaluation and returned to the facility on [DATE]. The resident was placed on one (1) to one (1) supervision. 5) Resident #1 was placed on fifteen (15) minute checks on 12/26/11 due to behaviors which were discontinued on 01/03/12. Resident #1 was placed on one (1) to one (1) supervision on 01/13/12. 6) Alteration of Resident #22's psychoactive medications were made and the addition of pain medications was added during Resident #22's stay at the Psychiatric Hospital between 01/05/12 and 01/16/12. 7) Comprehensive Plans of Care were updated for Resident #22 on 01/19/12 and Resident #1 on 01/20/12 to address specific behaviors and specific interventions to ensure needs were being met. 8) All residents on all units received a physical and psycho-social evaluation to establish a safe base-line for implementation of house-wide corrective action measures by 01/18/12. The social services department conducted a psycho-social/safety evaluation on all residents on all units by 01/19/12. 9) The facility revised it's policies and procedures for reporting and investigating potential abuse and created a new rapid response protocol called "Code Protect" by 01/19/12. 10) All staff was educated regarding the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse by 01/18/12. 11) All staff was required to pass a competency with a score of 100 percent. This competency will become an annual requirement. 12) All leadership attended a one (1) hour in-service on the topics of abuse, resident competency, and the role of resident competency on the determination of abuse by 01/20/12. On 02/03/12, it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AOC, effective 01/21/12 based on the following; Observations, on 01/31/12, 02/01/12, 02/02/12 and 02/03/12 revealed Resident #22 was receiving one (1) on one (1) supervision. Review of the medical record and review of the Behavior/Mood and Behavior Patterns Sheet revealed the resident was receiving one (1) on one (1) supervision since returning from the Psychiatric Hospital. Interviews with staff including SRNA #18, on 02/03/12 at 12:40 PM, SRNA #19, on 02/03/12 at 12:55 PM, SRNA #20, on 02/03/12 at 2:35 PM, SRNA #21, on 02/03/12 at 1:45 PM, Charge Nurse #11, on 02/03/12 at 12:50 PM, Charge Nurse #12, on 02/03/12 at 1:05 PM, Midnight Supervisor #13 on 02/03/12 at 2:40 PM, LPN # 3 on 02/03/12 at 2:38 PM, Activities Assistants #32, on 02/03/12 at 1:10 PM and Activity Assistant #33, on 02/03/12 at 12:35 PM, the Risk Manager on 02/03/12 at 12:45 PM, the Dietary Manager, on 02/03/12 at 1:00 PM, and the Staff Development Coordinator, on 02/03/12 at 1:15 PM, revealed staff was aware of the facility's policy changes, the facility's revised policies and procedures for reporting and investigating potential abuse and the new rapid response protocol called "Code Protect". They were also aware of the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse and the requirement to pass a competency exam before working with residents. Interview with the Social Services Manager, on 02/03/12 at 3:15 PM, revealed she had completed the psycho-social evaluations to establish a safe base-line for implementation of house-wide corrective action measures and the Charge Nurses had completed the physical assessments of residents. Further review of documented evidence revealed physical assessments had been completed for all residents. Continued interview revealed she had contacted family members and interviewed residents as part of the psycho-social assessment. Review of the documented evidence revealed residents and/or families had been interviewed related to safety. Interview with Resident #58's responsible party, on 02/02/12 at 10:10 AM, revealed the facility had contacted him/her related to the resident's safety at the facility. Interview with an Unsampled Resident, on 02/02/12 at 11:15 AM, revealed someone had asked him/her how he/she felt about their safety at the facility and the resident stated he/she felt safe. Interview with the Director of Nursing (DON) and Administrator, on 02/03/12 at 5:30 PM, revealed the plan for Resident #22's care was to continue to re-evaluate him/her and seek guidance from the Medical Director (Physician #1) and would obtain additional psychiatric evaluations to see if there may be anything underlying occurring with the resident's psychiatric condition. The DON further stated Resident #1 and #22's Comprehensive Plans of Care had been updated to reflect the changes in care and supervision. Review of the Comprehensive Plans of Care reflected these changes. The Administrator and DON stated it will be determined by the Medical Director when Resident #22 is removed from one (1) on one (1) observation because he/she could not be allowed to co-mingle with other residents at this point without guidance and re-direction from the one (1) on one (1) supervision. The facility remained out of compliance at a lower scope and severity of an "E", a pattern deficiency with potential for more than minimal harm while the facility's Quality Assurance continues to monitor the effectiveness of the new systems and policies implemented to ensure residents care plans are developed to address behaviors and while the facility develops and implements the Plan of Correction (POC).

Based on observation, interview, record review, review of the Director of Social Services job description, review of the Social Worker job description and review of the facility's policy, it was determined the facility failed to ensure two (2) of fifty-nine (59) sampled residents received social services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to identify Resident #22's history of expressing sexual behaviors which prevented Social Services from addressing and implementing interventions related to these sexual behaviors prior to the resident expressing sexual behaviors towards three (3) residents. Interviews with staff revealed Resident #22 had a history of [REDACTED]. Resident #22 was observed by State Registered Nursing Assistant (SRNA) #2 to be in Resident #1's room touching Resident #1's perineal area with his/her mouth and hands on 12/25/11 at 11:30 AM. Resident #22 was observed later that day, at approximately 4:00 PM, touching Resident #2's legs above the knees. The facility Social Services staff failed to accurately describe the occurrence to the Guardian of Resident #1 and failed to assess other residents to ensure they were not effected by these sexual behaviors. After the incident the facility's Social Service staff continued to fail to address and intervene related to Resident #22's continued sexually inappropriat behaviors. The facility's system of oversight for Social Services failed to edentify these issues as a failure in their system. Resident #22 resided on the locked Dementia Unit, which had a total census of thirty-two (32) cognitively impaired residents, on 12/25/11. Based on the above findings, it was determined the facility's failure to have an effective system in place to identify, assess and implement social services in order to protect residents from abuse is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 01/12/12 and was determined to exist on 12/25/11. After quality review conducted by the State Agency and the Center for Medicare and Medicaid Services (CMS) it was determined the investigation required reopening to gather additional information. The Survey was reopened for further investigation from 01/30/12 through 02/03/12. An acceptable credible Allegation of Compliance (AOC) for the removal of IJ was received on 01/23/12 with the facility alleging removal of IJ on 01/21/12. The State Agency verified IJ was removed prior to exit on 02/03/12, with remaining non-compliance at 42 CFR 483.15 Quality of Life at a S/S of a "E", while the facility's Quality Assurance continues to monitor medically related social services. The findings include: Review of the job description titled "Director of Social Services", dated 01/05/01, revealed responsibilities included assists direct care staff with behavioral assessments and development of alternative approaches. Responsibilities also included demonstrating assessment skills sufficient to evaluate residents' behavior, to collect data to evaluate psychosocial needs, risk factors for psychosocial needs, risk factors for psychosocial deterioration and residents' responses to interventions. Able to interpret and explain resident behavior to staff in a way that fosters understanding, facilitates treatment and respect for resident rights and minimizes use of chemical and physical restraints. Review of the job description titled "Social Worker", dated 08/01/03, revealed responsibilities which included assessments to identify residents with current needs for social service interventions to improve or maintain functional abilities and those residents at risk of psychosocial deterioration and to communicate residents' concerns and responses to interventions to interdisciplinary team members and direct care staff. Interview with the Administrator, on 01/14/12 at 4:12 PM, revealed it was his understanding the facility monitors behaviors by typically documenting behaviors in the medical record and he believed Social Services monitored resident behaviors. Interview with the Director of Social Services, on 02/03/12 at 3:30 PM, revealed he ensured all the Psycho-Social Assessments were completed on all residents. He further stated if there was a reported behavior the Social Services Worker would complete an assessment, document in the chart and ensure there was a Care Plan in place or a revision was made to the Care Plan if needed. Interview with the Social Services Manager, on 01/14/12 at 8:20 AM, revealed behaviors where discussed in the weekly meeting and should be documented on those minutes. Record review revealed the facility admitted Resident #22, on 09/13/10, with [DIAGNOSES REDACTED]. Review of the Quarterly Resident Assessment Instrument (RAI), dated 11/10/11, revealed the resident was assessed as being severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three (3). Review of the Physician orders, dated 11/16/10, revealed an order for [REDACTED]. Interview with Physician #1 (Medical Director), on 01/13/12 at 11:27 AM, revealed Resident #22 had been ordered Tagamet to decrease sexual desires because Tagamet had a side effect of decreasing sexual desires. However, review of the Comprehensive Care Plan revealed no documented evidence the facility addressed Resident #22's behaviors of sexual aggression. Interview with SRNA #5, on 01/06/12 at 9:00 AM, revealed she had cared for Resident #22 since 2010 and he/she had always made sexual comments. Interview with Licensed Practical Nurse (LPN) #1, on 01/07/11 at 4:58 PM, revealed she recalled Resident #22 unzipping his/her pants and exposing himself/herself several weeks ago. Interview with SRNA #1, on 01/04/12 at 1:15 PM, revealed when she provided care for Resident #22, he/she was often "touchy feely". Interview with SRNA #3, on 01/04/12 at 1:40 PM, revealed when she cared for Resident #22, he/she made sexual statements and gestures. Interview with LPN #3, on 01/13/12 at 12:15 PM, revealed she had heard Resident #22 making sexual remarks and hand gestures (as though he/she was touching his/her genitals). Review of the Nurse's Notes (NN) from Resident #22's clinical record, physician's orders [REDACTED].#1 had increased Tagamet from 300 milligrams (mg) to 400 mg daily; increased Seroquel from 25 mg to 50 mg every twelve (12) hours; and increased Depakote from 500 mg to 750 mg every twelve (12) hours. Review of NN from Resident #22's clinical record, dated 12/22/11, revealed Physician #1 had been in to check on Resident #22 and to review the resident's medications related to increased behaviors. Record review revealed no documented evidence Social Services addressed the increased behaviors. Interview with SRNA #2, on 01/06/12 at 9:47 AM, revealed on 12/25/11 at approximately 11:30 AM she observed Resident #1 laying across the foot of the bed with his/her pants and pull-up (attends) pulled down below his/her knees. Resident #22 was observed by SRNA #2 to be behind Resident #1 sitting in his/her wheel chair touching Resident #1's perineal area with his/her hands and mouth. SRNA #2 further stated she removed Resident #22 from Resident #1's room and told Licensed Practical Nurse (LPN) #2 what she had observed. Further interview revealed later on 12/25/11, Resident #22 touched and rubbed Resident #2's thighs at approximately 4:00 PM and was separated from Resident #2 by LPN #1. Interview with the Social Services Manager, on 01/06/12 at 12:16 PM, revealed she told Resident #1's Guardian he/she was laying in bed with his/her pants down and a resident of the opposite sex was fondling him/her. Interview with Resident #1's Guardian, on 01/12/12 at 6:40 PM, revealed he/she was told by the Social Worker, on 12/28/11, a resident of the opposite sex was in Resident #1's room and Resident #1's pants were undone and the residents were fondling one another. Further interview revealed she was not told Resident #1's pants and pull-up (attends) was pulled down below Resident #1's knees and Resident #1 was laying across the foot of the bed with the resident's stomach down on the bed while Resident #22 was behind Resident #1 touching Resident #1's perineal area with his/her hands and mouth. Further interview revealed had Resident #1 been in his/her right mind this situation would never have taken place and stated she had given no permission for Resident #1 to perform sexual acts. She revealed Resident #1 was incapable of making decisions. Interview with Physician #1, on 01/13/12 at 11:27 AM, revealed the facility had informed him Resident #1's Guardian was okay with the incident with Resident #22 and he did not consider it a problem if family was comfortable. He further stated legally Resident #1 had been determined to be unable to make decisions. Interview with Resident #22's Power of Attorney, on 01/13/12 at 9:50 AM, revealed the facility had informed him of the resident's sexual behaviors and he had never given permission for Resident #22 to perform sexual acts. He continued to state the resident was incapable of making decisions. Interview with the Social Services Manager, on 01/14/12 at 8:20 AM, revealed she did not ask Resident #1's Guardian or Resident #22's Power of Attorney if either resident had permission to perform sexual acts. She continued to state she did not do any tracking or trending of behaviors. She further stated she did not document when she interviewed residents to see if anyone had touched them inappropriately. Additionally, she stated she did not contact any family members/responsible parties except for one (1) whom she interviewed at the facility on the locked unit; however, this interview was not documented. Record review revealed no documented evidence Social Services staff had taken any action after the two (2) incidnets involving Resident #22 on 12/25/11. Observation, on 01/05/12 at 9:50 AM, revealed Resident #22, seated in a wheel chair, was touching and rubbing Resident #29's left hand on Resident #22's upper right thigh. Resident #22 was also noted rubbing on Resident #29's left arm and kissing up and down his/her arm and hand. Resident #22 was then observed to pull Resident #29, who was seated in a gerichaire, by his/her left arm backwards stating come with me. Interview with the Social Services Manager, on 02/03/12 at 3:15 PM, revealed she was responsible for reviewing the Social Services Worker's documentation and signing off that she had reviewed the documentation daily. She further indicated she was unaware of Resident #22's sexual behaviors until the investigation into the sexual behaviors expressed with Resident #1. She further stated she shared the same office with the Social Worker so they could communicate what was occurring with residents on a daily basis. Further interview, on 02/03/12 at 3:55 PM, revealed she did rounds on each unit everyday with the Unit Manager. She stated when she or the Social Worker reviewed the residents' charts they would review Nurses Notes, physician's orders [REDACTED]. On 02/03/12 at 3:15 PM, the Social Services Manager was shown a Nurse's Note, dated 01/17/12, which read an aide had attempted to change the resident's brief and Resident #22 started yelling damn you, exposed his/her genitals and continued to yell damn you. The Social Services Manager was also shown a note which was documented by a one (1) on one (1) sitter on a form titled "Behavior/Mood and Behavior Patterns Sheet", that noted a case in which the resident stated "come here and give me a kiss" on 01/21/12. The Social Services Manager stated she was unaware of either case and this was why it had not been documented in her notes dated 01/21/12, 01/23/12 and 01/30/12. She stated she had not been told of Resident #22 expressing sexual behaviors towards staff since his/her return from the psychiatric facility and she had not received a communication form from Nursing staff. Continued interview revealed she did not document, assess or make new interventions related to Resident #22's sexual behaviors after returning from the psychiatric facility secondary to Nursing did not inform her of these behaviors. Further interview revealed she had to learn through staff about behavior incidents. She stated if she had been aware of Resident #22 asking the State Registered Nursing Assistant (SRNA) for a kiss she might have contacted the Physician and discussed the incident, she would have discussed the incident with Resident #22 to let him/her know it was inappropriate and she would have noted behavior in her progress notes. When asked why she was unaware of these behaviors secondary to her reading over physician's orders [REDACTED]. Interview with the Director of Social Services, on 02/02/12 at 11:30 AM, revealed he was responsible for ensuring Social Worker and Social Services Manager's tasks were done. He stated he was not aware of Resident #22's sexual behaviors towards staff until 12/25/11. He indicated when an investigation was completed regarding an incident such as this, whomever was completing the investigation would be responsible for describing the events in detail to the family. He stated when he spoke to the family he would read from the incident report form what actually occurred, he stated he could not state this was how all the Social Services workers completed their investigation. The Social Services Director was asked to read the Nurse's Note, dated 01/17/12 and the note documented on the "Behavior/Mood and Behavior Patterns Sheet", dated 01/21/12, and in addition a Nurse's Note, dated 01/31/12, revealed Resident #22 was exposing his/her genitals and stating to the one (1) on one (1) sitter and stating "help me with this, will you please help me with this". He then reviewed the Social Services Manager notes, dated 01/21/12, 01/23/12 and 01/30/12. Further interview revealed the Social Services Manager should have gotten more details about what was going on with the resident. He continued to state she should have researched to see what could have been done for behaviors, should have documented interventions and followed up to monitor the resident's response to those interventions. He further stated he was unaware of Resident #22's sexual behaviors towards staff until the facility began investigating the incident which occurred with Resident #1. The facility was unable to provide evidence that Social Services had addressed the resident's sexually inappropriate behaviors through evaluation, assessment and intervention. Additionally there was no evidence the Social Services Director had identified problems with Social Services through his oversight of the social Services Manager and Social Services Worker. An acceptable credible Allegation of Compliance (AOC) was received on 01/23/12 which alleged removal of the IJ effective on 01/21/12, based on the following: 1) The Social Services Manager contacted all Power of Attorneys and/or applicable members of the residents on the locked dementia unit by telephone and interviewed them to determine whether they had observed or had any other knowledge of relevant safety concerns by 01/16/12. 2) All residents on the locked dementia unit were questioned by the Social Services Manager in an attempt to determine if any of the other residents were subjected to the behaviors of Resident #22 by 01/16/12. 3) All residents and their family members or healthcare representatives on the unit were also informed about the potential safety issue on the unit and the measures being taken to resolve the issue by 01/19/12. 4) Resident #22 was sent out to an Psychiatric hospital on [DATE] for evaluation and returned to the facility on [DATE]. The resident was placed on one (1) to one (1) supervision. 5) Resident #1 was placed on fifteen (15) minute checks on 12/26/11 due to behaviors which were discontinued on 01/03/12. Resident #1 was placed on one (1) to one (1) supervision on 01/13/12. 6) Alteration of Resident #22's psychoactive medications were made and the addition of pain medications was added during Resident #22's stay at the Psychiatric Hospital between 01/05/12 and 01/16/12. 7) Comprehensive Plans of Care were updated for Resident #22 on 01/19/12 and Resident #1 on 01/20/12 to address specific behaviors and specific interventions to ensure needs were being met. 8) All residents on all units received a physical and psycho-social evaluation to establish a safe base-line for implementation of house-wide corrective action measures by 01/18/12. The social services department conducted a psycho-social/safety evaluation on all residents on all units by 01/19/12. 9) The facility revised it's policies and procedures for reporting and investigating potential abuse and created a new rapid response protocol called "Code Protect" by 01/19/12. 10) All staff was educated regarding the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse by 01/18/12. 11) All staff was required to pass a competency with a score of 100 percent. This competency will become an annual requirement. 12) All leadership attended a one (1) hour in-service on the topics of abuse, resident competency, and the role of resident competency on the determination of abuse by 01/20/12. On 02/03/12, it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AOC, effective 01/21/12 based on the following; Observations, on 01/31/12, 02/01/12, 02/02/12 and 02/03/12 revealed Resident #22 was receiving one (1) on one (1) supervision. Review of the medical record and review of the Behavior/Mood and Behavior Patterns Sheet revealed the resident was receiving one (1) on one (1) supervision since returning from the Psychiatric Hospital. Interviews with staff including SRNA #18, on 02/03/12 at 12:40 PM, SRNA #19, on 02/03/12 at 12:55 PM, SRNA #20, on 02/03/12 at 2:35 PM, SRNA #21, on 02/03/12 at 1:45 PM, Charge Nurse #11, on 02/03/12 at 12:50 PM, Charge Nurse #12, on 02/03/12 at 1:05 PM, Midnight Supervisor #13 on 02/03/12 at 2:40 PM, LPN # 3 on 02/03/12 at 2:38 PM, Activities Assistants #32, on 02/03/12 at 1:10 PM and Activity Assistant #33, on 02/03/12 at 12:35 PM, the Risk Manager on 02/03/12 at 12:45 PM, the Dietary Manager, on 02/03/12 at 1:00 PM, and the Staff Development Coordinator, on 02/03/12 at 1:15 PM, revealed staff was aware of the facility's policy changes, the facility's revised policies and procedures for reporting and investigating potential abuse and the new rapid response protocol called "Code Protect". They were also aware of the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse and the requirement to pass a competency exam before working with residents. Interview with the Social Services Manager, on 02/03/12 at 3:15 PM, revealed she had completed the psycho-social evaluations to establish a safe base-line for implementation of house-wide corrective action measures and the Charge Nurses had completed the physical assessments of residents. Further review of documented evidence revealed physical assessments had been completed for all residents. Continued interview revealed she had contacted family members and interviewed residents as part of the psycho-social assessment. Review of the documented evidence revealed residents and/or families had been interviewed related to safety. Interview with Resident #58's responsible party, on 02/02/12 at 10:10 AM, revealed the facility had contacted him/her related to the resident's safety at the facility. Interview with an Unsampled Resident, on 02/02/12 at 11:15 AM, revealed someone had asked him/her how he/she felt about their safety at the facility and the resident stated he/she felt safe. Interview with the Director of Nursing (DON) and Administrator, on 02/03/12 at 5:30 PM, revealed the plan for Resident #22's care was to continue to re-evaluate him/her and seek guidance from the Medical Director (Physician #1) and would obtain additional psychiatric evaluations to see if there may be anything underlying occurring with the resident's psychiatric condition. The DON further stated Resident #1 and #22's Comprehensive Plans of Care had been updated to reflect the changes in care and supervision. Review of the Comprehensive Plans of Care reflected these changes. The Administrator and DON stated it will be determined by the Medical Director when Resident #22 is removed from one (1) on one (1) observation because he/she could not be allowed to co-mingle with other residents at this point without guidance and re-direction from the one (1) on one (1) supervision. The facility remained out of compliance at a lower scope and severity of an "E", a pattern deficiency with potential for more than minimal harm while the facility's Quality Assurance continues to monitor the effectiveness of the new systems and policies implemented to ensure residents receive medically related social services and while the facility develops and implements the Plan of Correction (POC).

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure three (3) of fifty-nine (59) sampled residents, Residents #1, #2 and #29, were free from sexual abuse related to the facility's failure to follow it's Abuse Policies to ensure residents' safety through assessment, care planning and monitoring behaviors that lead to conflict; failed to report abuse to the Administration and Social Service Manager; and failed to deny the perpetrator unsupervised access to residents. State Registered Nursing Assistant (SRNA) #2 observed Resident #22 in Resident #1's room touching Resident #1's perineal area with his/her hands and mouth on 12/25/11 at 11:30 AM. Resident #1 had been adjudicated legally incompetent and incapable of making decisions for him/herself. Facility staff observed Resident #22 later that day, at approximately 4:00 PM, touching and rubbing Resident #2's thigh. On 01/05/12 at 9:50 AM, a Kentucky State Agency Surveyor observed Resident #22 rubbing Resident #29's left hand on his/her upper right thigh in the dining room and was observed rubbing Resident #29's left arm and kissing up and down his/her arm and hand. Resident #22 was then observed pulling Resident #29 by his/her arm while he/she was sitting in a Geri chair. No staff was monitoring Resident #22's behavior, despite the resident's sexual history beginning 12/25/11, in order to prevent recurrence of sexual abuse. The facility allowed Resident #22 access to thirty-two (32) cognitively impaired residents without establishing an effective behavior management policy and implementing effective supervision of Resident #22 to deny access to the residents of the facility and to prevent further abuse. Furthermore, the facility failed to identify other incidents of abuse/neglect through assessment of all residents of the unit after the 12/25/11 incident. Based on the above findings, it was determined the facility's failure to follow it's abuse policies by failing to assess, implement a care plan and monitor a resident with a known history of sexual behavior since 12/25/11; failing to report sexual abuse immediately to administration; failing to deny the perpetrator access to other residents; and, failing to provide adequate supervision to prevent further abuse recurrence is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 01/12/12 and was determined to exist on 12/25/11. After quality review conducted by the State Agency and the Center for Medicare and Medicaid Services (CMS) it was determined the investigation required reopening to gather additional information. The Survey was reopened for further investigation from 01/30/12 through 02/03/12. An acceptable credible Allegation of Compliance (AOC) for the removal of IJ was received on 01/23/12 with the facility alleging removal of IJ on 01/21/12. The State Agency verified Immediate Jeopardy was removed prior to exit on 02/03/12, with remaining non-compliance at 42 CFR 483.13 Resident Behavior at a S/S of a "E", while the facility's Quality Assurance continues to monitor residents' behaviors. The findings include: Review of the facility's policy titled, "Social Services. Preventing Resident Abuse", dated 12/2001, revealed all alleged allegations will be responded to through an investigation process. The policy detailed the facility would assess, care plan, and monitor residents with behaviors that may lead to conflict in order to assist in resolving behavior issues. The program included assessing residents with signs and symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues. Interview with the Social Service Manager, on 01/14/12 at 12:46 PM, revealed behaviors were discussed in the weekly focus meetings; however; the facility did not track and trend individual resident behaviors and there was no specific behavioral management program. Review of the facility's policy titled, "Social Services. Resident Abuse", dated 09/2008, revealed all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. All abuse allegations ... must be reported immediately to the facility's Administrator and the Social Services Manager. Further review revealed while the investigation was being conducted, accused individuals would be denied unsupervised access to residents. Review of the facility's policy titled, "Social Services. Reporting Abuse to Facility Management", dated 12/01, revealed employees must report any suspected abuse or incidents of abuse to the Director of Nursing and/or Director of Social Services. Review of the facility's policy titled, "Social Services. Resident-to-Resident Abuse", dated 12/2001, revealed the facility was to develop a plan of care that included interventions to prevent the recurrence of such incident. Record review revealed the facility admitted Resident #22 on 09/13/10 with [DIAGNOSES REDACTED]. Interview with Resident #22's Power of Attorney, on 01/13/12 at 9:50 AM, revealed the resident was incapable of making decisions. Interview with Physician #1, on 01/13/12 at 11:27 AM, revealed he believed Resident #22 was not capable of making decisions. Interview with SRNA #5, on 01/06/12 at 9:00 AM, revealed she had cared for Resident #22 since 2010 and he/she had always made sexual comments. Interview with Licensed Practical Nurse (LPN) #1, on 01/07/11 at 4:58 PM, revealed she recalled Resident #22 unzipping his/her pants and exposing himself/herself several weeks ago. Interview with SRNA #1, on 01/04/12 at 1:15 PM, revealed when she provided care for Resident #22, he/she was often "touchy feely". Interview with SRNA #3, on 01/04/12 at 1:40 PM, revealed when she cared for Resident #22, he/she made sexual statements and gestures. Interview with LPN #3, on 01/13/12 at 12:15 PM, revealed she had heard Resident #22 making sexual remarks and hand gestures (as though he/she was touching his/her genitals). Review of Nurse's Notes (NN) from Resident #22's clinical record, dated 12/22/11, revealed Physician #2 had been in to check Resident #22 and to review the resident's medications related to increased behaviors. Review of NN, physician's orders [REDACTED]. Interview with State Registered Nursing Assistant (SRNA) #2, on 01/06/12 at 9:47 AM, revealed on 12/25/11 at approximately 11:30 AM, she observed Resident #1 (adjudicated incompetent by a court of law) laying across the foot of the bed with his/her pants and pull-up (adult brief) pulled down below his/her knees. SRNA #2 observed Resident #22 behind Resident #1 touching Resident #1's perineal area with his/her mouth and hands. SRNA #2 stated she removed Resident #22 from Resident #1's room, escorted Resident #22 to the nurses' station and told Licensed Practical Nurse (LPN) #2 what she had observed. Interview with LPN #2, on 01/05/12 at 12:37 PM, revealed she did not recall SRNA #2 reporting the incident and therefore did not report the incident to the Administrator as per the facility's policy. She stated she did not initiate any special monitoring or supervision for Resident #22. She stated she did not do any physical assessments of either resident. However, interview with SRNA #6, on 01/05/12 at 10:22 AM, revealed she was at the Nurse's Station and heard SRNA #2 tell LPN #2, at approximately 11:30 AM, that she had observed Resident #22 in Resident #1's room touching Resident #1's perineal area with his/her hands and mouth. Interview with LPN #1, on 01/07/12 at 4:58 PM, revealed LPN #2 had told her nothing in report about the incident with Resident #22 and Resident #1. Further interview with LPN #1 and SRNA #2 revealed they observed Resident #22 touching and rubbing on Resident #2's thigh between 4:00 PM and 4:30 PM on 12/25/11. At which time LPN #1 separated the residents and SRNA #2 informed LPN #1 of the previous incident that morning involving Resident #22 and #1. LPN #1 stated she instructed SRNA #2 to keep an eye on Resident #1. However, record review revealed no documented evidence LPN #1 reported the abuse to the Administrator, Social Service Manager, or the Director of Nursing as per the facility's policies; no evidence an investigation was initiated; and no evidence Resident #22's supervision was increased to ensure the safety of other residents as per the facility's policies. Further interview with LPN #1 revealed later that evening, on 12/25/11 between 8:00 PM and 8:30 PM, two (2) Nurses told her about Resident #22 and Resident #1's interaction. She stated it wasn't until that time that she called the Evening Weekend Supervisor and reported the incident to her about twenty (20) to thirty (30) minutes later when she came to the unit to do her rounds. Interview with the Evening Weekend Supervisor, on 01/05/12 at 3:24 PM, revealed she was doing her rounds between 10:00 PM and 10:30 PM when she was told about the incident with Resident #22 and Resident #1. She stated she then called the Day Weekend Supervisor because she had received nothing in report from him and he had stated he knew nothing about the incident. Then she called SRNA #2 and asked her what had happened and she stated she found Resident #22 in Resident #1's room touching Resident #1's perineal area with his/her hands and mouth and SRNA #2 told her she separated the residents and told the Nurse. The Evening Weekend Supervisor stated she then called LPN #2 who said she had not been told about the incident. She then called the Assistant Director of Nursing (ADON) and then Social Services. She stated they started fifteen (15) minute checks on Resident #22 at 11:00 PM. There was no documented evidence that the facility had taken measures to deny the perpetrator access to other residents of the locked Dementia unit where review of the census report for 12/25/11 revealed a total of thirty-two (32) residents resided on the locked Dementia Unit. Review of the facility's Roster Matrix revealed all thirty-two (32) residents residing on the locked Dementia Unit were assessed as having cognitive impairment. Interview with the Assistant Director of Nursing (ADON), on 01/06/12 at 11:45 AM, revealed the incident was reported to have happened at approximately 11:30 AM on 12/25/11; however, fifteen (15) minute checks were not initiated until 11:00 PM on 12/25/11, approximately twelve hours later. Review of the Care Plan revealed no documented evidence the facility developed a plan of care to address Resident #22's sexual behavior towards other residents after either incident. Continued review revealed the facility did not develop a care plan until 12/27/11 related to sexual behavior. Review of Resident #22's Plan of Care for sexual behaviors, dated 12/27/11, revealed the facility staff would tell the resident calmly and firmly that the behavior was not acceptable whenever it occurred. Staff was to separate Resident #22 from peers if behavior became offensive to them, take Resident #22 to his/her room and provide privacy, and to teach the resident about acceptable behavior. The Care Plan approaches further stated staff would be non-judgmental when confronting negative behavior and establish consistent staff approaches to deal with problem. The care plan did not detail what consistent staff approaches would be provided to deal with the problem. There was no documented evidence of any increased supervision being implemented related to the resident's sexual behaviors towards residents of the locked Dementia unit nor denying Resident #22's access to these residents to prevent the recurrence of sexual abuse. Interview with the Social Services Manager and Director of Nursing (DON), on 01/11/12 at 10:00 AM, revealed the facility's investigation did not determine abuse had occurred; however, did identify that the failure of LPN #2 to report the incident regarding Resident #22 and Resident #1. Further interview revealed it was believed the residents had a right to have sex because those desires did not recede due to their cognition. However, record review revealed Resident #1 had been adjudicated incompetent by a court of law and appointed a guardian. Record review for Resident #22 revealed he/she was assessed and determined to be cognitively impaired. Interview with Resident #22's Physician #1, on 01/13/12 at 9:50 AM, revealed Resident #22 could not make decisions for him/herself and could not act with willful intent. Thus, neither resident per Physician interview, record review, and Guardian interview were capable of making decisions for themselves in order to give consent for sexual relations. However, the facility's investigation did not identify that neither resident could give consent; therefore had a finding that no abuse had occurred. The facility's failure to follow their abuse policies and failure in identifying that neither resident could give consent for sexual relations prevented the facility from identifying the need to deny Resident #22's access to other residents within the locked unit and furthermore prevented them from developing and implementing a behavior management program per their policy to address behaviors that may lead to conflict. Review of the Nurse's Notes revealed the facility proceeded to discontinue fifteen (15) minute checks for Resident #22 on 01/03/12 with no specific care plan addressing supervision to deny access to other residents related to Resident #22's recent onset of sexual behaviors towards other residents of the facility. On 01/05/12 between 9:43 AM and 9:50 AM, the Kentucky State Agency Surveyor observed Resident #22 rubbing Resident #29's left hand on his/her upper right thigh in the dining room on the locked unit during an activity while female residents were having their nails painted. There was one (1) Activity Aide in the room, sitting about ten (10) feet away, but within direct vision of the incident, with approximately twelve (12) residents. No other staff was observed in the area. Resident #22 was observed rubbing on Resident #29's left arm and kissing up and down his/her arm and hand. Resident #22 was then observed pulling Resident #29 backwards, by his/her arm while he/she was sitting in a Geri chair. While the Activity Aide was present at the time of the incident, no staff intervened. No staff was supervising/monitoring this resident to ensure no sexual behaviors were forced upon other residents despite the facility's knowledge of the resident's history since 12/25/11 and the facility's policy "Preventing Resident Abuse" which detailed the facility would assess, care plan and monitor resident behaviors that may lead to conflict. Per record review Resident #22 was allowed to have full access to thirty-two (32) cognitively impaired residents without effective supervision to monitor sexual behaviors. While the facility transferred Resident #22 out to a Psychiatric facility per record review on 01/05/12 with the anticipated return to the facility; the facility could provide no evidence that Resident #22's current Care Plan detailed action the facility would take to ensure adequate supervision and resident safety to prevent sexual abuse recurrence. In addition, the facility had not developed policy and procedures for behavior management in order to comply with their Resident Abuse Policy. Additionally, there was no documented evidence that the facility had attempted to identify other incidents of abuse/neglect through assessment of all residents of the unit. Interview with the Social Services Manager, on 01/11/12 at 10:00 AM, who was responsible for conducting investigations and assessments, revealed that she had not assessed any other residents on the unit to identify other incidents of abuse. An acceptable credible Allegation of Compliance (AOC) was received on 01/23/12 which alleged removal of the IJ effective on 01/21/12, based on the following: 1) The Social Services Manager contacted all Power of Attorneys and/or applicable members of the residents on the locked dementia unit by telephone and interviewed them to determine whether they had observed or had any other knowledge of relevant safety concerns by 01/16/12. 2) All residents on the locked dementia unit were questioned by the Social Services Manager in an attempt to determine if any of the other residents were subjected to the behaviors of Resident #22 by 01/16/12. 3) All residents and their family members or healthcare representatives on the unit were also informed about the potential safety issue on the unit and the measures being taken to resolve the issue by 01/19/12. 4) Resident #22 was sent out to an Psychiatric hospital on [DATE] for evaluation and returned to the facility on [DATE]. The resident was placed on one (1) to one (1) supervision. 5) Resident #1 was placed on fifteen (15) minute checks on 12/26/11 due to behaviors which were discontinued on 01/03/12. Resident #1 was placed on one (1) to one (1) supervision on 01/13/12. 6) Alteration of Resident #22's psychoactive medications were made and the addition of pain medications was added during Resident #22's stay at the Psychiatric Hospital between 01/05/12 and 01/16/12. 7) Comprehensive Plans of Care were updated for Resident #22 on 01/19/12 and Resident #1 on 01/20/12 to address specific behaviors and specific interventions to ensure needs were being met. 8) All residents on all units received a physical and psycho-social evaluation to establish a safe base-line for implementation of house-wide corrective action measures by 01/18/12. The social services department conducted a psycho-social/safety evaluation on all residents on all units by 01/19/12. 9) The facility revised it's policies and procedures for reporting and investigating potential abuse and created a new rapid response protocol called "Code Protect" by 01/19/12. 10) All staff was educated regarding the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse by 01/18/12. 11) All staff was required to pass a competency with a score of 100 percent. This competency will become an annual requirement. 12) All leadership attended a one (1) hour in-service on the topics of abuse, resident competency, and the role of resident competency on the determination of abuse by 01/20/12. On 02/03/12, it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AOC, effective 01/21/12 based on the following; Observations, on 01/31/12, 02/01/12, 02/02/12 and 02/03/12 revealed Resident #22 was receiving one (1) on one (1) supervision. Review of the medical record and review of the Behavior/Mood and Behavior Patterns Sheet revealed the resident was receiving one (1) on one (1) supervision since returning from the Psychiatric Hospital. Interviews with staff including SRNA #18, on 02/03/12 at 12:40 PM, SRNA #19, on 02/03/12 at 12:55 PM, SRNA #20, on 02/03/12 at 2:35 PM, SRNA #21, on 02/03/12 at 1:45 PM, Charge Nurse #11, on 02/03/12 at 12:50 PM, Charge Nurse #12, on 02/03/12 at 1:05 PM, Midnight Supervisor #13 on 02/03/12 at 2:40 PM, LPN # 3 on 02/03/12 at 2:38 PM, Activities Assistants #32, on 02/03/12 at 1:10 PM and Activity Assistant #33, on 02/03/12 at 12:35 PM, the Risk Manager on 02/03/12 at 12:45 PM, the Dietary Manager, on 02/03/12 at 1:00 PM, and the Staff Development Coordinator, on 02/03/12 at 1:15 PM, revealed staff was aware of the facility's policy changes, the facility's revised policies and procedures for reporting and investigating potential abuse and the new rapid response protocol called "Code Protect". They were also aware of the detection of abuse, definition of abuse, facility policy and the impact of mental capacity on determinations of abuse and the requirement to pass a competency exam before working with residents. Interview with the Social Services Manager, on 02/03/12 at 3:15 PM, revealed she had completed the psycho-social evaluations to establish a safe base-line for implementation of house-wide corrective action measures and the Charge Nurses had completed the physical assessments of residents. Further review of documented evidence revealed physical assessments had been completed for all residents. Continued interview revealed she had contacted family members and interviewed residents as part of the psycho-social assessment. Review of the documented evidence revealed residents and/or families had been interviewed related to safety. Interview with Resident #58's responsible party, on 02/02/12 at 10:10 AM, revealed the facility had contacted him/her related to the resident's safety at the facility. Interview with an Unsampled Resident, on 02/02/12 at 11:15 AM, revealed someone had asked him/her how he/she felt about their safety at the facility and the resident stated he/she felt safe. Interview with the Director of Nursing (DON) and Administrator, on 02/03/12 at 5:30 PM, revealed the plan for Resident #22's care was to continue to re-evaluate him/her and seek guidance from the Medical Director (Physician #1) and would obtain additional psychiatric evaluations to see if there may be anything underlying occurring with the resident's psychiatric condition. The DON further stated Resident #1 and #22's Comprehensive Plans of Care had been updated to reflect the changes in care and supervision. Review of the Comprehensive Plans of Care reflected these changes. The Administrator and DON stated it will be determined by the Medical Director when Resident #22 is removed from one (1) on one (1) observation because he/she could not be allowed to co-mingle with other residents at this point without guidance and re-direction from the one (1) on one (1) supervision. The facility remained out of compliance at a lower scope and severity of an "E", a pattern deficiency with potential for more than minimal harm while the facility's Quality Assurance continues to monitor the effectiveness of the new systems and policies implemented to ensure residents are free from abuse and while the facility develops and implements the Plan of Correction (POC).

Based on observation, interview, and record review, it was determined the facility failed to ensure services provided meet professional standards of quality for four (4) of twenty-seven (27) sampled residents (Residents #8, #6, #3, and #24). Resident #8 was identified by the facility as being at risk for pressure ulcers; however, the facility failed to develop an Initial Plan of Care related to this issue. Resident #1 developed a Pressure Sore to the Left Heel which was unidentified by the facility, before the surveyor requested a skin assessment be conducted. In addition, Resident #8 had a physician's orders [REDACTED]. The facility failed to implement the order. Resident #6 was admitted with an abdominal incision site. The facility failed to develop an Admission/Initial Plan of Care related to the need to monitor the resident's incision site for signs and symptoms of infection, or to address the need to monitor the resident for risks and complications related to receiving anti-coagulant medication. The facility failed to develop an Admission/Initial Plan of Care which addressed the need to monitor Resident #24's incision sites for signs and symptoms of infection. Resident #3 had physician's orders [REDACTED]. The findings include: 1. Review of Resident #8's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed no Minimum Data Set (MDS) Assessment had been completed because of the recent admitted . Review of the Admission physician's orders [REDACTED]. Review of the facility's, "Risk Factors that increase a Resident's Susceptibility to Develop or to Not Heal Pressure Ulcers" form, revealed the facility assessed the resident as being at risk to develop pressure ulcers related to drugs affecting awareness; pain, altering mobility; fracture; and impaired mobility. Review of the Admission/Initial Care Plan dated 10/27/10, revealed no documented evidence the facility developed a Plan of Care to address the resident's potential for the development of pressure ulcers, although the facility had identified risk factors. Review of the "Resident Daily Care Record" dated 10/10 and 11/10, revealed the resident required the assistance of two (2) staff related to turning and repositioning, but it did not specify how often the resident was to be turned/repositioned. The Resident Daily Care Record failed to address the use of the abductor wedge, as a positioning device. Review of the Nurse's Note dated 10/27/10 at 5:00 PM, revealed the resident was admitted to the facility from the hospital with a Left Hip IM Nailing. Further review revealed the resident had a three (3) inch incision with eleven (11) staples and a two and a half (2.5) inch incision with ten (10) staples from the hip surgery, and a linear skin tear to the left thigh. According to the Note, the resident was alert and oriented, continent of bowel and bladder, and required the assistance of two (2) staff for transfers. Observation on 11/03/10 at 9:50 AM, during a skin assessment performed by the Wound Nurse, revealed the resident had a 3.25 cm x 2.5 cm Pressure Sore, located on the left heel. The Wound Nurse described the area as being purple in color with "suspected deep tissue injury". Observation, at this time, revealed the resident's abductor wedge was on a chair, by the resident's bed. Interview on 11/03/10 at 9:50 AM and at 10:30 AM with the Wound Nurse, revealed the resident's Pressure Ulcers had not been identified by the facility. He indicated he was not sure why the abductor pillow was not being used. Interview with Certified Nursing Assistant (CNA) #9 on 11/03/10 at 10:15 AM and 1:40 PM; Licensed Practical Nurse (LPN) #8 on 11/01/10 at 10:20 AM; and, CNA #30 on 11/03/10 at 2:30 PM revealed staff were unaware the resident should be utilizing an abductor wedge. Interview on 11/03/10 at 1:50 PM and on 11/04/10 at 4:00 PM with the Unit Manager, who was assigned to Resident #8's unit, revealed the resident should have had a Plan of Care, on admission, related to the risk for pressure due to decreased mobility and the need for turning and repositioning, as well as utilizing the abduction wedge. Interview on 11/03/10 at 3:30 PM with LPN #6/Evening Shift Supervisor, revealed she had completed the Admission Care Plan for the resident on 10/27/10 and should have ensured the resident had a Plan of Care to prevent skin breakdown due to decreased mobility. LPN #6 stated interventions to ensure turning and repositioning, and the use of the abductor wedge should have been in place. Interview on 11/04/10 at 9:00 AM with the resident, revealed he/she could turn him/herself to the right side but, had not been turning him/herself much. Resident #8 further stated he/she could not turn self to the right side due to pain. The resident stated staff had not been assisting him/her with turning in bed until yesterday when they found a "bedsore". 2. Review of Resident #6's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed there was no Minimum Data Set (MDS) Assessment or Comprehensive Assessment due to the recent admitted . Observation of a skin assessment on 11/03/10 at 9:45 AM revealed steri-strips were in place along the abdominal incision site. Review of the Admission Nurse's Notes dated 10/22/10 (no time noted) revealed the resident had an abdominal wound with thirty (30) staples which were intact with slight redness around the staples and scant drainage on the dressing. Review of the physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Review of the Admission Plan of Care revealed there was no plan of care to address the resident's abdominal incision site or the need to monitor the site for signs and symptoms of infection. Further review of the physician's orders [REDACTED]. physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the Admission Plan of Care revealed the anticoagulants, and complications and risk factors associated with the medication were not addressed. Interview on 11/05/10 at 9:50 AM, with Licensed Practical Nurse (LPN) #8 revealed she had admitted the resident on 10/22/10 and completed the Admission Plan of Care. She stated she should have completed a care plan to address monitoring the resident's abdominal incision site for signs and symptoms of infection. She further stated she should have completed a care plan to address the anticoagulant medication due to the risk of bleeding. Continued interview revealed, " I haven't had too much experience with Care Plans". 3. Review of Resident #24's closed record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Resident Data Collection dated 08/16/10, revealed the resident had a midsternal incision, two (2) harvest site incisions on the right lower leg and a one and a half (1.5) centimeter incision to the right groin catheter site. Review of the Admission Plan of Care revealed no plan of care to address the resident's incision sites or the need to monitor the sites for signs and symptoms of infection. Interview on 11/05/10 at 5:00 PM with the Director of Nursing revealed the Unit Managers were to review the new admission medical records the day of admission, or the next day, and should be checking the Admission Care Plans. She further stated she was unaware the Admission Care Plans were "not thorough". 4. Review of Resident #3's medical record revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident as having moderate impairment in cognitive skills and requiring extensive assistance with most Activities of Daily Living. Further review of the MDS revealed the facility assessed the resident as sustaining a fall in the past thirty-one (31) to one hundred eighty days (180). Review of the Resident Assessment Protocol Summary (RAPS) dated 01/08/10, revealed the resident had a history of [REDACTED]. Review of the Comprehensive Plan of Care dated 01/18/10, revealed the resident was at high risk for falls. The interventions included mats to the bedside while in the bed. Observation of Resident #3 on 11/02/10 at 4:45 PM, and 5:30 PM; and, on 11/03/10 at 9:10 AM, 10:00 AM, 1:45 PM and 3:05 PM revealed the resident was in bed and there was a fall mat on the floor on the left side of the bed. However, there was no fall mat on the right side of the bed. Interview on 11/03/10 at 4:00 PM with Certified Nursing Assistant (CNA) #31 revealed she was assigned to the resident consistently. She checked the State Registered Nursing Assistant (SRNA) Record and stated the resident was to have floor mats at all times. She further stated, she did not realize the resident was to have floor mats on both sides of the bed. Interview on 11/03/10 at 4:10 PM with the Unit Manager, who was assigned to the resident's unit, revealed she was not sure if the resident was to have fall mats. After reviewing the physician's orders [REDACTED]. Further observation of the resident on 11/04/10 at 9:00 AM and 11:30 AM revealed the resident had a fall mat on the left side of the bed, but no fall mat was observed on the right side of the bed, as per physician's orders [REDACTED]. Interview with the Unit Manager on 11/04/10 at 11:30 AM, revealed she had forgotten to tell anyone the resident needed another mat. Further interview with the Nurse Manager on 11/05/10 at 9:55 AM revealed the CNAs were to check safety devices to ensure they were in place at change of shift when they did walk through rounds from room to room.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who enters the facility without pressure sores did not develop pressure sores for one (1) of twenty-seven (27) sampled residents (Resident #8). Resident #8 acquired a Pressure Ulcer to the Left Heel which was described as a three (3) centimeter (cm) x two and a half (2.5) cm area, purple in color, with suspected deep tissue injury. The Pressure Ulcer was acquired at the facility, and unidentified by the facility, until the surveyor requested a skin assessment on 11/03/10, at 9:50 AM. The findings include: Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed the Minimum Data Set (MDS) Assessment had not been completed due to the recent admitted . Review of the facility's, "Risk Factors that increase a Resident's Susceptibility to Develop or to Not Heal Pressure Ulcers" form, revealed the resident was at risk of developing pressure ulcers related to drugs affecting awareness, pain altering mobility, fracture, impaired mobility, [MEDICAL CONDITION] Disease, [MEDICAL CONDITIONS], and abrasions/bruises. Review of the Admission Care Plan dated 10/27/10, revealed the resident had a [MEDICAL CONDITION] with a goal stating the resident would have maximum functional mobility. The interventions included full weight bearing status and monitor for pain. There was no plan of care to address the resident's potential for skin breakdown. Review of the Resident Daily Care Record (Nurse Aide Care Plan) dated 10/10 and 11/10, revealed the resident required the assistance of two (2) staff for turning and repositioning. However, the Record did not specify how often the resident was to be turned/repositioned. Review of the Nurses' Notes dated 10/27/10 at 5:00 PM, revealed the resident was admitted to the facility from the hospital with a three (3) inch incision with eleven (11) staples and a two and a half (2.5) inch incision with ten (10) staples from the hip surgery, and a linear skin tear to the left thigh. According to the Note, the resident was alert and oriented, was continent of bowel and bladder, and required the assistance of two (2) staff for transfers. Continued review of the Notes revealed there was no documented evidence of skin breakdown to the left heel. Review of the Wound Care Nurse's Notes dated 10/27/10 at 10:00 PM revealed the resident had staples to the left hip incision site and a skin tear to the left thigh. Continued review of the Wound Care Nurse's Notes dated 10/28/10 through 11/02/10, revealed there was no evidence of pressure ulcers on the left heel. Further review of the Nurse's Notes dated 10/28/10 through 11/02/10 revealed there was no documented evidence of skin breakdown to the left heel. In addition, there was no documented evidence the resident was being assisted with turning and repositioning. Review of the Admission physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Observation on 11/03/10 at 9:50 AM during a skin assessment performed by the Wound Nurse/Licensed Practical Nurse #14, revealed the resident had a Pressure Ulcer which the nurse described as a 3.25 cm x 2.5 cm Pressure Ulcer, purple in color with "suspected deep tissue injury." Further observation revealed the resident had staples in the left hip. Interview on 11/03/10 at 9:50 AM and at 10:30 AM with LPN #14 revealed the pressure area was new and had not been identified by the facility. He further stated staff relied on the resident to turn him/herself; however, the resident "was not doing that real well". Interview on 11/03/10 at 10:15 AM and 1:40 PM with Certified Nursing Assistant (CNA) #29 revealed she was assigned to the resident. She stated the resident turned and repositioned him/herself and the only thing she had done for the resident during the shift was to deliver the resident his/her breakfast tray. Continued interview revealed she was unaware the resident had any skin breakdown to the left heel. Continued interview revealed she checked the "nurse aide care plan" which was the "Resident Daily Care Record" when providing care. Interview on 11/03/10 at 10:20 AM with LPN #8 who was assigned to the resident on 11/02/10 and 11/03/10 on the day shift, revealed she was unaware the resident had skin breakdown. She stated she did rounds during the shift and the resident was to be assisted as needed with turning and repositioning. Phone interview on 11/03/10 at 2:30 PM with CNA #30, who was assigned to the resident on the evening and night shift for 11/02/10, revealed the resident turned and positioned him/ herself in the bed and did not need assistance. She stated the resident was continent and only needed the urinal emptied so she did not check his/her skin. She stated the aides went by the "Resident Daily Care Record" when providing care. Phone interview on 11/03/10 at 3:00 PM with CNA #19 revealed she was assigned to the resident on 11/02/10 on the day shift, and had assisted the resident with a bath on 10/28/10 and 11/01/10. She stated she was unaware of the resident having Pressure Ulcers; however, she did notice the resident's "bottom was kind of red". She further stated she informed LPN #8 and [MEDICATION NAME] was applied. Further interview revealed she did not assist the resident with turning and repositioning because the resident turned him/ herself. Interview on 11/03/10 at 1:50 PM and 11/04/10 at 4:00 PM with the Unit Manager, who was assigned to the resident, revealed the resident was unable to completely turn self to the side in the bed and should be assisted with turning and positioning. She was unaware staff were not turning and positioning the resident. Interview on 11/03/10 at 3:30 PM with LPN #6/Evening Shift Supervisor, revealed she had admitted the resident to the facility on [DATE] and completed the Admission/Initial Care Plan. She further stated the resident should have had a Plan of Care to prevent skin breakdown due to decreased mobility, with interventions to ensure turning and positioning. Interview on 11/05/10 at 5:00 PM with the Occupational Therapist (OT) revealed the resident was currently receiving Occupational Therapy and she had completed an evaluation to assess the resident's ability to to turn and position in the bed. She stated she would not depend on the resident to turn on his/her own because the resident needed reminders, guidance, and minimal assistance to turn in the bed. Review of the Plan of treatment for [REDACTED]. Interview on 11/04/10 at 9:00 AM with Resident #8, revealed he/she could turn him/herself to the right side; however, had not been turning him/herself much. Resident #8 further stated he/she could not turn self to the left side due to pain. Continued interview, revealed staff had not been assisting the resident with turning and positioning in bed until yesterday when they found a "bedsore". Review of the facility's, "Wound Care Polices and Procedures" revealed the purpose of the policy was to ensure residents admitted to the facility did not develop pressure ulcers, unless the clinical condition demonstrated they were unavoidable. The Policy further stated residents would be assessed for potential for pressure ulcer development on admission and a pressure ulcer risk assessment would be completed by the licensed nurse to determine appropriate interventions to prevent the development of pressure sores.