Every finding on record at Knott County Health & Rehabilitation Center

The facility failed to store food in accordance with the manufacturers guidance for Meals, Ready to Eat (MRE) to be used as emergency meal supply. Furthermore, the facility failed to store water to be used for boil water advisories, and water dispensers in the facility in a climate-controlled area. The findings include:During the kitchen tour and observation of food storage areas, it was identified that the facility failed to store emergency food supply in accordance with manufacturer guidelines. Items were observed stored in a manner inconsistent with the directions provided by the manufacturer, which could affect food safety and quality. A facility policy for water and/or food storage was not provided by the facility.Observation on 09/09/2025 at 10:55 AM revealed 5-gallon container jugs of water used in the water dispensers and for cooking during a boil water advisory were sitting outside at the back of the facility under a covered porch area with no temperature control.Observation on 09/09/2025 at 11:00 AM revealed that the MREs utilized as the facility's emergency food supply were stored in an outside storage building that was not climate controlled.Review of the label revealed suggested storage conditions for the MREs were to store in a dry, cool, and dark location, with an optimal storage temperature of 55 degrees Fahrenheit. Further review of the label stated storing the product at a high temperature could increase the speed that nutrition and vitamins would degrade over time. During an interview on 09/10/2025 at 1:45 PM with the Dietary Manager (DM), the DM stated she was not aware of the manufacturer recommendations for the MREs to be stored at a temperature of 55 degrees Fahrenheit. The DM further stated she had no climate-controlled area to store the MREs that were to be used for emergency meals.The Administrator stated in interview on 09/10/2025 at 3:20 pm that her expectation was that all foods and water were to be safely stored. The Administrator further stated using foods not stored properly could cause illness to the residents. According to the Administrator, the facility would be disposing of the food that was stored in the outside storage building, and the facility was looking at a climate-controlled building or an area in the facility where the MREs would be stored in a climate-controlled area.

Based on observations, interviews, and record review conducted from 09/08/2025 - 09/10/2025, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Multiple environmental concerns were identified that had the potential to negatively impact the health, safety, and quality of life of residents. These issues were noted throughout resident rooms and common areas.The findings include:Review of the facility's policy titled Resident Rights, revised 12/2022, revealed residents have the right to a dignified existence.Review of the facility's policy titled Protocol for Maintenance Services, undated, revealed housekeeping and maintenance services will maintain a sanitary, orderly, and comfortable interior and environment.On 09/08/2025 at 5:20 PM, observation revealed a broken and loose floor tile and a ceiling tile with the corner cut out outside of the dining room. The dining room door and frame was observed to contain scuff marks, chipping paint, and with rust showing. Five strips of tape on the dining room floor were observed to be peeling, with dirt stuck to them. The wallpaper near the kitchen window and door was observed to be peeling from the wall. [NAME] paint was observed to be smeared on the gold push plates and window frames. The baseboards near the kitchen window were observed to be black with dirt, and the door frames contained visible rust. The window glass was observed to have chipped paint, revealing green paint beneath. Observation of the hand sanitizer dispenser outside the kitchen door revealed the dispenser did not dispense sanitizer.On 09/08/2025 at 5:45 PM, observation revealed white paint was smeared on the green wallpaper outside room [ROOM NUMBER]. The floor tiles outside of room [ROOM NUMBER] were observed to be discolored. The wallpaper outside room [ROOM NUMBER] was observed to be bubbling and peeling near the smoke doors. The hand sanitizer dispenser outside of room [ROOM NUMBER] was observed to contain tape reading 'needs changed' and the dispenser did not dispense sanitizer. The hand sanitizer dispenser outside of room [ROOM NUMBER] was also observed not to dispense sanitizer.On 09/09/2025 at 9:25 AM, observation revealed the hand sanitizer dispenser outside room [ROOM NUMBER] still had tape reading 'needs changed' and did not dispense sanitizer. The dispenser outside of room [ROOM NUMBER] was also observed not to dispense sanitizer. Floor tile discoloration and scuffed baseboards were observed outside of the nurses' station in the [NAME] K. [NAME] Wing. Chairs in the common area outside of the nurses' station were observed to be scuffed, chipped, and contained holes in the upholstery.On 09/09/2025 at 9:34 AM, observation revealed cracked floor tiles between rooms [ROOM NUMBERS] with indentations noted. The door to room [ROOM NUMBER] was observed to be cracked and was missing wood pieces.The door to room [ROOM NUMBER] was observed to be cracked and chipped. The door to room [ROOM NUMBER] was observed to be cracked with missing pieces noted. The baseboards at the exit door in the Troublesome Creek Way Hall were observed to be loose and gapped. [NAME] paint was observed to be smeared on the green wallpaper near the exit door. The hand sanitizer outside of room [ROOM NUMBER] was observed to be non-functional. The door to room [ROOM NUMBER] was observed to be cracked and was missing wood pieces. The men's bathroom door frame on Troublesome Creek Way Hall was observed to contain chipped paint and loose baseboards.On 09/09/2025 at 9:42 AM, observation revealed the exit door on the [NAME] K. [NAME] Hall contained white paint smeared on the green wallpaper. The baseboards at this exit were observed to be loose and were not attached to the wall.On 09/09/2025 at 9:43 AM, observation revealed throughout the facility, the wallpaper below bumper guards were ripped, discolored, and detached from the wall.On 09/09/2025 at 9:47 AM, observation revealed wallpaper was separated from the wall and chipped sheetrock was observed near the nurses' station on the [NAME] K. [NAME] Wing. The wallpaper was observed to be bubbled near the weight scale storage area. There was a three-inch hole observed in the wall leading to the linen closet on Troublesome Creek Way Hall.On 09/09/2025 at 9:52 AM, observation revealed white paint on the exit door signs in the laundry hall. [NAME] paint was also observed to be smeared on the silver metal push bars, and wallpaper was observed to be peeling from the wall at the laundry door. Baseboards near the wall outside the nurses' station was observed to be chipped and was missing pieces.On 09/09/2025 at 9:56 AM, observation revealed the door to room [ROOM NUMBER] was cracked and missing chunks of wood. The door to room [ROOM NUMBER] was observed to be chipped and was missing pieces. The door guard to room [ROOM NUMBER] was ripped apart.On 09/09/2025 at 9:59 AM, observation revealed four floor tiles broken at the smoke barrier doors on [NAME] D. [NAME] Road Hall.On 09/09/2025 at 10:05 AM, observation revealed a floor drain cover outside the nurses' station on the Trail Raiders Lane Hall was raised above floor level, creating an uneven walking path. Two holes were observed at the bottom corner of the exit door on the Trail Raiders Lane Hall, creating openings to the outside. [NAME] paint was observed to be smeared on the exit push bars and the emergency exit signs. The door frame to room [ROOM NUMBER] was observed to contain chipped paint showing multiple layers of paint. The door to room [ROOM NUMBER] was observed to be chipped and was missing wood. [NAME] paint was observed to be smeared on the green wallpaper near room [ROOM NUMBER].On 09/09/2025 at 10:20 AM, observation revealed the sink in room [ROOM NUMBER] was missing a side cover strip, and the sink in room [ROOM NUMBER] contained dents on the top of the sink. The floor in the TV room on the Trail Raiders Lane Hall was observed to contain several black scribble marks. The door to room [ROOM NUMBER] was observed to be cracked with missing wood pieces noted. The door nameplate outside of room [ROOM NUMBER] was observed to be broken, and the names of the residents living in room [ROOM NUMBER] were taped to the wall. The door to room [ROOM NUMBER] was observed to be cracked and have missing pieces. [NAME] paint was observed to be smeared on the green wallpaper outside of room [ROOM NUMBER].On 09/10/2025 at 4:00 PM, observation revealed a mold-like substance in the staff development office.During an interview with Resident (R)22 conducted on 09/09/2025 at 2:23 PM, R22 stated she has noticed several issues in the facility, including broken tiles, smeared paint on the wallpaper, and doors with cracks in them. R22 stated she would like to see these issues repaired, and further stated, If this were my home, I would have already had it fixed. R22 continued to state that she did not feel like the staff had enough time to do everything they needed to do.During an interview with Resident (R)36 conducted on 09/09/2025 at 2:23 PM, R36 stated she has informed housekeeping staff on multiple occasions that the corners of her room and the baseboards were dirty, and she would like them to be cleaned. R36 stated, The staff have not cleaned them. If I was able, I would do it myself.State Registered Nurse Aide (SRNA) 5 stated in interview on 09/10/2025 at 11:13 AM that they have mentioned issues such as smeared paint and discolored floor tiles to the Maintenance Director, but felt they were overlooked. SRNA 5 stated the housekeeping department must assist the maintenance department with tasks, causing housekeeping to be short-staffed and unable to adequately clean resident rooms and common areas. SRNA 5 continued to state there are several areas in the facility they would like to see cleaned and repaired, but these areas were overlooked due to a lack of available time.The Staff Development Nurse stated in interview on 09/10/2025 at 4:00 PM she first noticed the mold-like substance in the staff development office a couple of weeks ago, and it had continued to grow on the wooden shelf and curio cabinet. The Staff Development Nurse stated other employees noticed an odor in the office, but she had become accustomed to it. The Staff Development Nurse stated she should have notified housekeeping or maintenance about the mold-like substance but did not.During an interview with the Maintenance Director conducted on 09/10/2025 at 1:32 PM, the Maintenance Director stated he is the only employee in the department, but housekeeping would help when needed. The Maintenance Director stated he conducted a facility walkthrough once a year to identify issues such as major repairs, floor tile concerns, and wallpaper issues. He stated he felt the painting in the facility could look better, and improvements could be made if painter's tape and paint cloths were used to avoid smeared paint.The Housekeeping Supervisor stated in interview on 09/10/2025 at 1:36 PM she would like the maintenance department to have more than one staff member because housekeeping staff were pulled in too many directions. The Housekeeping Supervisor stated housekeeping staff have approximately twelve minutes to clean each resident's room, including sweeping, mopping, dusting, and cleaning resident bathrooms. She stated if housekeeping staff were not assisting the maintenance department, they would have more time to address environmental concerns and create a more homelike environment for residents.During an interview with the Administrator on 09/10/2025 at 2:26 PM, the Administrator stated she knew the painting in the facility was 'bad' but had to prioritize other tasks. The Administrator stated she expected resident rooms and common areas to be cleaned adequately and did not think twelve minutes was enough time to clean a resident's room. The Administrator stated the facility needs work.

Based on observation, interviews, and review of the facility's policy titled, Policy & Procedure for Bagging of Laundry/Linen, the facility failed to ensure linen was transported in a manner to prevent the spread of infection when Certified Nursing Assistant (CNA) #1 failed to follow the facility's policy to transport soiled linen in a barrel to the soiled utility room on one (1) of two (2) hallways observed for linen transport. The findings include: During the entrance conference on 11/16/20 at 8:45 a.m., the Administrator stated that the facility had a recent COVID-19 outbreak; however, none of the residents have active COVID. The COVID recovered and new admission residents requiring quarantine reside on Hall 100 unit. During an observation on Hall 100 on 11/16/20 at 10:25 a.m., Certified Nursing Assistant (CNA) #1 opened the door to room [ROOM NUMBER] and placed two large clear plastic bags filled with soiled linen outside in the hallway by the door frame. room [ROOM NUMBER] had signs on the door that read, Droplet Precautions, and Standard Precautions. CNA #1 removed her gown and gloves and washed her hands prior to exiting the room. She picked up the two plastic bags to take to the soiled utility room. CNA #1 dragged the bags down the hallway to the soiled utility room (approximately 74 feet). She did not place the bags in a container per facility policy. During an interview on 11/16/20 at 10:28 a.m., CNA #1 stated that the linen carts are usually in the hallway right outside the room but the carts were not there today. CNA #1 stated staff were taught to bag the soiled linen at the bedside, and then place the bagged linen in the linen carts in the hallway, a closed container, for transport to the soiled utility room. During an interview on 11/17/20 at 2:04 p.m., the Infection Control Preventionist (ICP) stated that Rooms #109-116 on the A Hall are designated for COVID recovered and re-admission residents requiring isolation. Disposal of the linen for the residents required staff to bag the soiled linen in the resident's room and place the linen in a linen barrel in the hallway just outside of the resident's room; isolation rooms should have a linen barrel near the resident's door. Linens from the COVID Unit should be bagged and transported to the soiled utility room via the barrel which is part of the routine procedure for handling soiled linens in the facility's poility's COVID-19 policy. Review of the facility's undated policy titled, Policy & Procedure for Bagging of Laundry/Linen, revealed all soiled laundry/linen will be bagged at the location where it was removed and taken out of the room and placed in the appropriate container. This facility utilizes Standard Precautions in the handling of all soiled laundry.

Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure medications were secured in a locked medication cart during medication pass. During observation of medication administration on 08/19/2020, the nurse left the medication cart unlocked and out of sight while administering medications to five (5) unsampled residents. The findings include: Review of the facility policy titled, Medication Storage in the Facility, dated June 2020, revealed medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Observations on 08/19/2020 between 12:05 PM and 12:25 PM, during medication pass on Unit 200 conducted by Registered Nurse (RN) #1, revealed the RN left the medication cart unlocked and out of eyesight while administering medications to five (5) unsampled residents. Interview with RN #1 on 08/19/2020 at 12:41 PM revealed she had been trained by the facility to lock the medication cart during medication pass when the medication cart was not in her eyesight. RN #1 further revealed she should have locked the medication cart each time she administered medications to a resident. RN #1 revealed she was nervous being with a surveyor and just forgot. Interview with the Director of Nursing (DON) on 08/19/2020 at 1:18 PM revealed RN #1 should have locked the medication cart during medication pass when administering medications to each resident. The DON further revealed staff who pass medications are trained to lock medication carts during orientation and annually. The DON also revealed she monitors for locked medication carts during rounds and by making spot checks during medication pass.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to provide services that met professional standards of quality for one (1) of twenty (20) sampled residents (Resident #65). Record review revealed a physician's orders [REDACTED]. However review of the monthly orders for (MONTH) and (MONTH) 2019 revealed the protein supplement had continued to be administered. The findings include: Review of the policy titled Protocol for Physician Orders, no date, revealed that any new physician's orders [REDACTED].g., Medication Administration Record [REDACTED]. Observation on 07/25/19 at 2:00 PM revealed that Licensed Practical Nurse (LPN) #1 administered a protein nutritional supplement to Resident #65. Review of the record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review further revealed that a physician's orders [REDACTED]. Further review of the record revealed that although the supplement had been discontinued, the order remained on the (MONTH) 2019 monthly orders. Further review of the MAR for 07/01/19 revealed the protein nutritional supplement had been given three (3) times a day up to 07/25/19. Interview on 07/25/19 at 3:40 PM with LPN #1 revealed that she was new to working with Resident #65 and was unaware that the protein nutritional supplement had been discontinued; therefore, she administered the supplement. Interview on 07/25/19 at 3:47 PM with Registered Nurse (RN) #2 revealed that she was the nurse to take off the new order that stated to discontinue the protein nutritional supplement. However, she stated that she did not transcribe the order nor did she remove the order from the MAR. RN #2 stated that she should have followed up with the order and transcribed it herself. Interview on 07/25/19 at 3:55 PM with RN #1 revealed she was the Unit Manager and stated there was a process to verify that orders from the previous day have been transcribed properly. RN #1 stated that she had not identified any concerns, that this was an oversight. Interview on 07/25/19 at 4:26 PM with the Director of Nursing (DON) revealed there is a process for transcribing physician's orders [REDACTED].

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty (20) sampled residents (Resident #65) received treatment and services to prevent complications of enteral feeding. Observation on 07/25/19 at 2:00 PM revealed that Licensed Practical Nurse (LPN) #1 gave medications through a gastrostomy tube ([DEVICE]) and failed to flush the [DEVICE] prior to administering the medications. The findings include: Review of the facility policy titled Medication Administration Policy, undated, revealed that [DEVICE]s should be flushed with at least 30 cubic centimeters (cc) of water before and after completing the medication administration. Observation of medication administration on 07/25/19 at 2:00 PM for Resident #65 revealed LPN #1 administered the following medications: [REDACTED]. Further observation revealed that LPN #1 did not flush the [DEVICE] with 30 cc of water prior to administering the medication per facility Medication Administration Policy. Interview conducted with LPN #1 on 07/25/19 at 4:00 PM revealed she should have flushed the [DEVICE] with 30 cc of water. LPN #1 stated she was nervous and forgot to flush the [DEVICE]. Interview conducted with the Director of Nursing (DON) on 07/25/19 at 4:10 PM revealed that the LPN should have flushed the [DEVICE] before giving medications with 30 cc of water and afterwards. She further revealed that she had not had any concerns before this issue occurred.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to maintain an effective infection control and prevention program for one (1) of twenty (20) sampled residents (Resident #136). Observation of Resident #136 revealed staff served a meal tray to the resident after touching her own hair multiple times. State Registered Nurse Aide (SRNA) #1 did not wash her hands before serving the meal tray. Staff then proceeded to prepare the resident's meal tray by opening the corn on the cob that was wrapped in aluminum foil and applying butter. Staff also continued to touch other food items on the resident's tray without washing/sanitizing her hands. The findings include: Review of the facility's Guidelines For Hand hygiene policy, undated, revealed that indications for hand washing included that before eating, staff wash their hands with a non-antimicrobial soap and water or with an antimicrobial soap and water. Review of the facility's Meal Pass Tips policy, undated, revealed that hands should be washed and sanitized between meal trays. Review of Resident #136's medical record revealed the facility admitted the resident on 07/17/19 with [DIAGNOSES REDACTED]. Review of Resident #136's Plan of Care, revealed the resident required the assistance of staff to set up meal trays. Observation of Resident #136 on 07/23/19 at 12:05 PM, revealed SRNA #1 was providing meal service to residents. As SRNA #1 walked down the hall to the meal cart to retrieve a meal tray, SRNA #1 was observed brushing her hair back with her ungloved hands multiple times before providing meal service. SRNA #1 retrieved a tray from the meal cart and delivered it to Resident #136. SRNA #1 did not wash or sanitize her hands after touching her hair multiple times. Further observations revealed SRNA #1 prepared Resident #136's food by opening the corn on the cob and putting butter on the corn and opened other packages for the resident that were on the resident's tray without washing or sanitizing her hands. An interview with SRNA #1 on 07/23/19 at 12:20 PM, confirmed she did not wash or sanitize her hands before setting up Resident 136's meal tray. The SRNA stated she was aware she should have washed her hands prior to setting up the meal tray and that she was unaware that she had touched her hair. SRNA #1 stated she guessed she did it out of habit. Interview with the Director of Nursing on 07/25/19 at 3:00 PM, revealed that SRNAs received infection control training upon hiring, every six (6) months, annually, and as needed. She stated the Handwashing Observation Tool training form had been completed by SRNA #1 on 06/27/19. She then stated SRNA #1 should have washed her hands before and after serving a resident's meal tray. The Director of Nursing stated SRNA #1's practice was a break in the infection control process because she was touching her hair and did not wash her hands. She also revealed she had no concerns prior to this incident.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an appropriate discharge was completed for one (1) of three (3) sampled residents (Resident #1). Review of the record revealed Resident #1 was discharged from the facility; however, the facility failed to ensure the resident's physician documented the reason for discharge in the medical record. The findings include: Review of the facility policy titled Transfer and Discharge Rights, dated November 2016, revealed the facility would permit each resident to remain in the facility until circumstances required transfer or discharge. The policy stated residents would not be transferred or discharged unless: it was necessary to meet the resident's welfare; the resident's health improved sufficiently and they no longer needed a skilled service; the safety of others could be endangered; the health of the individual could be endangered; the resident failed to pay after reasonable notice; and/or the facility ceased to operate. The policy stated if a discharge or transfer was required, the resident's physician would document the reason for the transfer or discharge in the resident's medical record. Review of Resident #1's medical record revealed the facility admitted the resident on 07/13/07, with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility conducted a Brief Interview for Mental Status (BIMS) and determined the resident was cognitively intact. Review of Resident #1's care plan, initiated on 03/09/17, revealed the resident had [DIAGNOSES REDACTED]. The facility developed interventions to address the resident's [DIAGNOSES REDACTED]. Review of the nurse's notes dated 10/05/17 revealed facility staff observed Resident #1 pacing, appearing agitated, and threatening to leave the facility. Review of physician orders dated 10/05/17 revealed an order to send the resident to the hospital for a psychiatric evaluation. Review of a police report dated 10/05/17 revealed Resident #1 was very distrustful, out of touch with reality, and very easily agitated. Review of a facility discharge notice dated 10/06/17 revealed the facility issued Resident #1 an immediate discharge notice that stated, the discharge is necessary for the resident's welfare and the resident's need cannot be met in the facility, the safety of individual and yourself in the facility is endangered, and the health of individuals in the facility is otherwise endangered. review of the resident's medical record revealed [REDACTED].#1's physician documented the reason the resident was being discharged from the facility as indicated in the facility policy. There was no evidence the physician documented what attempts were made to meet the resident needs and the service available at the receiving facility to meet the need. Interview with the facility Administrator and Director of Nursing (DON) on 12/05/17 at 4:29 PM revealed they thought the discharge was done appropriately and had not identified the lack of physician documentation regarding the discharge.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure staff followed the comprehensive plan of care for one of three residents (Resident #1). Review of an undated Kardex (a guide for the provision of resident care based on the resident assessment) revealed facility staff had assessed Resident #1 to be dependent and require the total assistance of two persons for transfers and bed mobility. However, interview with State Registered Nurse Aide (SRNA) #1 revealed she attempted to weigh Resident #1 using a bed scale on 04/21/16 without additional assistance. The findings include: Review of the facility policy entitled Care Plan Policy and Protocol, with a revision date of August 2012, revealed staff would utilize the information documented in each individualized Kardex as a guide to provide resident care. Review of Resident #1's medical record revealed the facility admitted the resident on 12/10/99 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 04/01/16, revealed facility staff assessed Resident #1 to require two staff persons to provide total assistance to transfer the resident and move the resident in bed (bed mobility). Continued review of the MDS revealed, based on the facility's assessment, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severely impaired cognition. Review of the Kardex for Resident #1, undated, revealed the facility identified the resident was at high risk for falls and noted two (2) persons were required to transfer the resident and assist with bed mobility. Interview conducted with SRNA #1 on 05/12/16, at 12:52 PM, revealed she was required to review the resident's Kardex at the beginning of every shift. Although SRNA #1 stated the nurse had given her a verbal report at the beginning of her shift and told her the resident needed two people to assist the resident, the SRNA stated she failed to obtain assistance when she weighed Resident #1 using the bed scale on 05/21/16 at approximately 7:00 PM because she thought the other SRNAs were busy. The SRNA stated she knew she should have gotten assistance prior to weighing Resident #1, but she believed she could safely do it alone. Interview conducted with the Director of Nursing (DON) on 05/12/16, at 3:20 PM, revealed SRNA #1 informed her on 04/22/16 that she attempted to weigh Resident #1 alone, without assistance. The DON stated staff was required to review the plan of care at the beginning of each shift. The DON stated she immediately removed SRNA #1 from resident care pending an investigation, and SRNA #1 would be terminated from employment for failure to follow the resident's plan of care.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure supervision to prevent accidents was provided for one of three residents (Resident #1). Review of a quarterly Minimum Data Set (MDS) assessment for Resident #1 dated 04/01/16, and a review of an undated Kardex (a guide for the provision of resident care based on the resident assessment) revealed the facility assessed Resident #1 to be dependent and require total assistance with two staff persons for transferring and bed mobility. However, State Registered Nurse Aide (SRNA) #1 weighed Resident #1 using a bed scale on 04/21/16, without additional assistance. The findings include: Interview with the Administrator on 05/12/16, at 12:05 PM, revealed the facility did not have a policy related to providing supervision to prevent accidents. Review of the facility policy entitled Care Plan Policy and Protocol, with a revision date of August 2012, revealed staff would utilize the information documented in each individualized Kardex as a guide to provide resident care. Review of Resident #1's medical record revealed the facility admitted Resident #1 on 12/10/99, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 04/01/16, revealed staff assessed Resident #1 to require two staff persons to provide total assistance to transfer the resident and for bed mobility. The MDS further revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired and not interviewable. Review of the undated Kardex for Resident #1 revealed the facility assessed the resident to be at high risk for falls and two (2) persons were required to transfer the resident and for bed mobility. Interview conducted with SRNA #1 on 05/12/16, at 12:52 PM, revealed she had provided care to Resident #1 on 04/21/16, and was aware the resident required two (2) staff persons to transfer the resident to a bed scale. Although SRNA #1 stated the nurse gave her a verbal report at the beginning of her shift and told her the resident needed two people to assist the resident, the SRNA stated she failed to obtain assistance when she weighed Resident #1 using the bed scale on 05/21/16 at approximately 7:00 PM. The SRNA stated she thought the other SRNAs were busy and felt she could weigh the resident safely by herself. The SRNA stated the resident sustained [REDACTED]. Interview with the Director of Nursing (DON) on 05/12/16 at 3:20 PM, revealed SRNA #1 informed her on 04/22/16, that she weighed Resident #1 without assistance the day before. The DON stated SRNA #1 was immediately removed from resident care and suspended pending an investigation and would be terminated from employment for failure to follow the resident's plan of care.

Based on interview, record review, and a review of the facility policy it was determined the facility failed to ensure an injury of unknown origin was reported to state agencies as required for one (1) of three (3) sampled residents (Resident #1). Interviews and review of Resident #1's record revealed Resident #1 was diagnosed with [REDACTED]. Interviews revealed the facility's Administrator was notified of the injury of unknown origin as required, and an investigation was conducted. The resident's right shoulder injury was not witnessed, and staff was unsure when or how the injury occurred. Interview with the facility Administrator revealed the facility had not reported the resident's injury of unknown origin because she had not determined through the facility's investigation that the resident's injury was a result of abuse or a facility failure. The Administrator stated she was unsure of the reporting requirements of injuries of unknown origin for facility residents. The findings include: Review of the facility policy titled Abuse Policy, last revised December 2011, revealed staff was required to report all allegations that involved mistreatment, neglect, or abuse, which included injuries of unknown source, to the Administrator and to state agencies in accordance with state law. Review of Resident #1's medical record revealed the facility admitted the resident on 12/01/08 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was totally dependent on two (2) staff members for bed mobility and transfers. Resident #1 was assessed to always be incontinent of bowel/bladder and to have severely impaired cognitive skills for daily decision-making. Staff had no Brief Interview for Mental Status (BIMS) score coded for the resident; therefore, he/she was not interviewable. review of the resident's medical record revealed [REDACTED].#1's right arm was red and swollen from the elbow area and down to the resident's forearm, and the resident's physician was notified. New orders were received, which included for Resident #1 to receive an outpatient Venous Duplex Scan to his/her right arm. Continued review of the record revealed the resident received the scan as ordered on [DATE], and no abnormalities were identified. Resident #1's record revealed the resident continued to have swelling to his/her right arm, and the resident was assessed by his/her physician in the facility on 04/13/16. Resident #1's physician ordered a diagnostic x-ray of the resident's right upper extremity, and Resident #1 was diagnosed with [REDACTED]. Review of the facility's investigation revealed the facility determined that Resident #1's shoulder was normal in appearance on 04/12/16, prior to the resident being transferred by ambulance to a local hospital to receive an outpatient scan ordered by his/her physician. On 04/12/16, the only abnormality noted to the resident's right upper extremity was redness/swelling, from the elbow area and down to the resident's forearm. Therefore, the facility's investigation concluded that the injury to the resident's shoulder had occurred when he/she received the diagnostic Doppler scan, because the swelling to his/her shoulder area had not been identified until 04/13/16, the day after the resident returned from having the scan completed. Interview with the facility Administrator on 04/20/16 at 4:00 PM revealed she was also a Registered Nurse (RN) and had assessed Resident #1 on 04/12/16. The Administrator stated she had observed the resident's right extremity, including his/her shoulder area, and the resident was observed to have redness and swelling, which began slightly above the elbow and continued down the forearm area. The Administrator stated the resident's shoulder was normal in appearance on 04/12/16 and no [MEDICAL CONDITION] or redness was observed to his/her shoulder at that time. The Administrator also stated she was responsible to conduct investigations related to abuse, neglect, and injuries of unknown origin in the facility. She stated she was notified immediately on 04/13/16 when Resident #1 was diagnosed with [REDACTED].#1 was transferred out of the facility on 04/12/16 for a diagnostic scan, but acknowledged the injury had not been witnessed therefore it was an injury of unknown origin. She stated she had not reported the resident's injury of unknown origin because she had not identified any neglect or abuse that had occurred in the facility and she was unsure about reporting requirements of injuries of unknown origin.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure an accurate clinical record was maintained for two (2) of nineteen (19) sampled residents (Residents #1 and #11). Resident #1 had two code status pages in the medical record and each had a different code status. Resident #11's code status was listed inaccurately on the resident's plan of care. The findings include: Review of the facility's Protocol for Obtaining Code Status Consent policy revealed the nurse will flag the front of the resident's medical record with a DNR or Full Code sticker/notation. For a resident that wishes to change their code status, a new form will be completed, the physician will be notified for a new order, and the sticker/notation on the medical record will be changed to reflect their current status. Interview with the Director of Nursing on [DATE] at 6:03 PM revealed it was the nurses' responsibility to ensure all records were updated and any changes included in the medical record. 1. Medical record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that upon admission Resident #1 was a Full Code (staff performs life-saving measures if a resident experiences cardiac or respiratory arrest). The resident's code status was changed to Do Not Resuscitate (DNR) when DNR documents were signed on [DATE]. Further review of the medical record revealed the Care Plan was updated on [DATE]; however, the previous Full Code status page form was not removed from the resident's medical record. The form listing the resident's new DNR code status was behind the Full Code status form. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 9:49 AM revealed staff could find the resident's code status by going to the front of the resident's medical record. LPN #1 said it was the nurses' responsibility to make sure paperwork is correct and to update the chart. Interview with the Director of Nursing (DON) on [DATE] at 6:03 PM revealed staff was to follow the Protocol for Obtaining Code Status Consent when obtaining status or if a status changed while a resident. Further interview revealed the nurse is to take the order, notify all parties involved, update the Nurse Aide Care Plan, and update the Code Status Page by removing the old page and making a new one. 2. Review of Resident #11's record revealed the facility admitted Resident #11 on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's code status sheet, undated, located on the first page of Resident #11's record revealed the resident had a code status of Full Code (wished to have CPR performed if needed). Continued review of Resident #11's record revealed a DNR/CPR Consent form dated [DATE] that indicated Resident #11 (who is his/her own responsible party) wished to have Cardiopulmonary Resuscitation (CPR) initiated by facility personnel in the event that Resident #11 was to be in cardiac or respiratory arrest. Review of Resident #11's most recent Nurse Aide Care Plan, undated, revealed Resident #11 to have a code status of Full Code. Review of Resident #11's most recent physician's orders [REDACTED].#11's code status to be Full Code. However, review of Resident #11's most recent Comprehensive Care Plan dated [DATE], and updated on [DATE], [DATE], and [DATE], revealed Resident #11 to have a code status of Do Not Resuscitate (DNR). Interview with State Registered Nurse Aide (SRNA) #1 on [DATE] at 6:02 PM revealed she would look at a resident's nurse aide care plan in order to verify a resident's code status. Continued interview with SRNA #1 revealed nurses were responsible for code status changes. Interview with the 100 Unit Manager (UM) on [DATE] at 6:11 PM revealed to determine a resident's code status she would look at the code status sheet in the front of a resident's record. Further interview with the UM revealed if a resident chose to change his/her code status the nurse that received the change would be responsible to ensure that all documents in the resident's record had been updated to reflect the change. The UM stated that upon admission the admitting nurse was responsible to ensure the resident's code status was documented in all appropriate places in the resident's record. Interview with Registered Nurse (RN) #1 on [DATE] at 6:22 PM revealed she had been the nurse to create the Comprehensive Care Plan for Resident #11. Further interview with RN #1 revealed she had made an error in documenting Resident #11's code status on the Comprehensive Care Plan. The RN said the resident's code status should have been listed as a Full Code instead of a DNR.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure care was provided in accordance with the resident's written plan of care for five (5) of nineteen (19) sampled residents (Residents #2, #6, #10, #12,and #16). Review of the comprehensive care plan for Resident #10 dated 04/03/14, revealed a care plan intervention for the resident to have padded side rails. However, the facility failed to ensure that Resident #10 had padded side rails. In addition, Residents #2, #6, #10, #12, and #16 had plan of care interventions for catheter care to be as ordered/needed. Further, Resident #6 had a care plan intervention to administer oxygen per physician's orders [REDACTED]. The findings include: Review of facility policy titled "Care Plan Policy & Protocol," with a revision date of August 2012, revealed the care plan shall be periodically reviewed and revised by the interdisciplinary team after each assessment and on an as needed basis. Continued review of facility policy revealed the Kardex would also be utilized as a guide for Nurse Aides in providing care on a daily basis and that the Kardex was a working tool that would be revised when indicated. A review of the facility's policy titled "Giving Catheter Care," (undated) revealed a resident's catheter tubing was to be coiled and secured. The policy was not specific regarding the manner or means of securing the catheter tubing. An interview with the Director of Nursing (DON) on 12/11/14 at 4:30 PM revealed catheters should be secured using a Cath-Secure device (a Cath-Secure device is a device used to secure the catheter to a resident's leg to prevent pulling). 1. Observations made on 12/09/14 at 5:30 PM and on 12/10/14 at 4:32 PM, revealed Resident #10 did not have padded side rails in place as indicated on the resident's comprehensive care plan. Review of Resident #10's medical record revealed the facility admitted the resident on 12/06/06, with [DIAGNOSES REDACTED]. Review of Resident #10's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #10 to have a Brief Interview for Mental Status (BIMS) score of 3, which indicated that Resident #10 had severe cognitive impairment. Review of Resident #10's comprehensive care plan dated 04/03/14, revealed the resident had potential for skin breakdown related to impaired mobility, incontinence, poor decision-making, thin fragile skin, and [MEDICAL CONDITION]. Further review of Resident #10's comprehensive care plan revealed an intervention to pad the resident's side rails. Review of Resident #10's Resident Kardex (Certified Nursing Assistant Care Plan), undated, revealed Resident #10 was to have three-quarter bilateral side rails but the facility failed to ensure the Nursing Assistant Care Plan included padding for the side rails. Interview with State Registered Nurse Aide (SRNA) #3 on 12/11/14 at 1:28 PM revealed SRNAs were responsible for applying padding to side rails as needed. SRNA #3 stated she had never noticed Resident #10 to have padded side rails in the two years she had worked at the facility, and was not aware that Resident #10 required padded side rails. Interview with Licensed Practical Nurse (LPN) #4 on 12/11/14 at 1:40 PM revealed she cared for Resident #10 daily and had worked for one year on the hallway where Resident #10 resided. Continued interview with LPN #4 revealed nurses and nurse aides were responsible for making sure padding was present on resident side rails, but she had not observed Resident #10 to have padded side rails at any time. Interview with Registered Nurse (RN) #1 on 12/11/14 at 1:55 PM revealed she was the Unit Coordinator for the unit on which Resident #10 resided. She stated the staff tried to work as a team to make sure residents' care plans were followed, but she was not aware that Resident #10 required padded side rails. Further interview with RN #1 revealed SRNAs were given any new resident care plan updates during shift report and that interventions should be on the Resident Kardex. She stated nursing staff was responsible for ensuring any new orders for residents were followed and that she conducted rounds twice a day (once in the morning and once in the evening) to ensure care plans were being followed and provided staff education as needed. Interview with the Medicare MDS Coordinator on 12/11/14 at 1:02 PM and 2:23 PM revealed that the MDS Coordinators were responsible for updating Resident Kardexes and that they were reviewed monthly for accuracy and updated as needed. She further stated she was not aware that Resident #10 was required to have padded side rails. Interview with the Medicaid MDS Coordinator on 12/11/14 at 3:15 PM revealed she had added the padded side rails to Resident #10's Comprehensive Care Plan following the resident's annual MDS assessment dated [DATE] as a precautionary measure. Continued interview with the Medicaid Coordinator revealed she failed to ensure that the intervention had been added to the Resident Kardex and to ensure that the intervention was implemented as noted on the care plan. Interview with the DON on 12/11/14 at 4:20 PM revealed she made rounds to ensure that staff was following residents' care plans. She stated rounds were also made by her, the nurses, or the SRNAs every two hours to ensure care plans were being followed. Continued interview with the DON revealed she was not aware that Resident #10 required padded side rails, but she thought Resident #10 may have had padded side rails at some point in the past. The DON stated that if Resident #10 no longer needed the padded side rails intervention, the care plan should have been updated to reflect that. Further interview with the DON revealed the Quality Assurance (QA) Nurse was responsible for ensuring that the MDS Coordinators, Unit Managers, and nurses were monitoring to ensure that all care plan interventions were being followed. 2. A review of the medical record for Resident #12 revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of Resident #12's most recent MDS assessment, dated 11/16/14, revealed the facility assessed the resident to have a score of 15 on the BIMS indicating the resident was cognitively intact. A review of Resident #12's care plan revealed staff was required to provide catheter care. An interview conducted with Resident #12 on 12/11/14 at 10:55 AM revealed staff did not ever secure the resident's indwelling urinary catheter while the resident was in the facility, but secured the urinary catheter to the resident's leg when the resident left the building. An interview conducted with SRNA #4 on 12/11/14 at 12:35 PM revealed the facility's catheter care policy was to notify the resident's nurse if the SRNA observed that a urinary catheter was not secured. The SRNA stated the resident's nurse was responsible for securing the resident's urinary catheter. The SRNA stated she had just performed care "about 30 minutes ago" for Resident #12 and the urinary catheter tubing was secured to the bed at that time. Further interview with SRNA #4 on 12/11/14 at 2:50 PM revealed the SRNA had checked Resident #12's catheter tubing after the interview at 12:35 PM and the tubing was not secured to the resident's thigh or the bed as required. An interview on 12/11/14 at 12:45 PM with LPN #1 revealed the LPN had not looked at Resident #12's catheter that day, but stated that urinary catheter tubing was usually secured to the bed. An interview conducted with the DON on 12/11/14 at 4:30 PM, revealed the DON made rounds daily to ensure care was provided to residents in accordance with the facility's urinary catheter care policy. Additional interview revealed the DON was not aware residents' catheters were not being secured by any manner or means to prevent pulling of the catheter tubing. Further interview revealed the facility had "Cath-Secures" in stock that should be used to secure catheters. The DON further stated she was not aware the facility's catheter care policy was not specific or gave no clear guidance as to how a resident's catheter tubing was to be secured. 3. A review of Resident #2's medical record revealed the facility admitted the resident on 12/02/13 and the resident had [DIAGNOSES REDACTED]. A review of the comprehensive care plan dated 09/16/14 revealed the facility developed a care plan to address the use of a urinary catheter for [MEDICAL CONDITION] with interventions to provide catheter care every shift and as needed. Observations of a skin assessment on 12/10/14 at 1:10 PM revealed Resident #2's indwelling urinary catheter tubing was not secured by any means to prevent pulling of the catheter tubing. An interview conducted with SRNA #1 on 12/11/14 at 12:40 PM, revealed the SRNA provided care to Resident #2 on 12/10/14. According to the SRNA, a "Cath-Secure" was not on the resident because the resident had not had any problems pulling on the catheter. 4. A review of Resident #6's medical record revealed the facility admitted the resident on 09/30/14 and had [DIAGNOSES REDACTED]. A review of the care plan dated 10/31/14 revealed the facility developed a care plan for Resident #6 that addressed the resident's urinary catheter with an intervention to have a "Cath-Secure" in place. Observation of urinary catheter care provided by SRNA #2 on 12/09/14 at 12:55 PM, revealed the resident's urinary catheter tubing was not secured by any manner or means to prevent pulling of the catheter tubing when the SRNA initiated catheter care. In addition, the SRNA did not secure the catheter tubing when catheter care was completed. An additional observation on 12/10/14 at 11:45 AM, of Resident #6's urinary catheter revealed the catheter was not secured by any manner or means. An interview conducted with SRNA #2 on 12/11/14 at 1:20 PM, revealed the SRNA was not aware of the facility policy for securing the indwelling catheter tubing and was not aware how the catheter tubing was required to be secured to prevent pulling. According to the SRNA, the catheter tubing was secured when the resident's catheter drainage bag was attached to the resident's bed frame. An interview conducted on 12/11/14 at 12:35 PM, with LPN #1 revealed the LPN had conducted an assessment of Resident #6's skin on 12/10/14 at 11:45 AM, and did not notice the resident's catheter was not secured because she did not normally conduct skin assessments. Additional interview revealed that if an SRNA noticed a resident's catheter was not secured, the SRNA should have informed the nurse. 5. A review of the medical record for Resident #16 revealed the facility admitted the resident from the hospital on [DATE], with an indwelling urinary catheter and with [DIAGNOSES REDACTED]. Further review of the record revealed the facility developed an admission care plan dated 12/05/14 with interventions to provide catheter care per facility protocol. Observation of Resident #16's catheter on 12/11/14 at 10:35 AM revealed no evidence the resident's urinary catheter was secured by any manner or means to prevent pulling/trauma. An interview conducted with SRNA #1 on 12/11/14 at 12:40 PM revealed Resident #16's catheter became unsecured while bathing the resident on 12/11/14, and the SRNA had not informed the resident's nurse so a "Cath-Secure" could be placed back on the resident. 6. A review of Resident #6's medical record revealed the facility admitted the resident on 09/30/14, with [DIAGNOSES REDACTED]. Further review revealed Resident #2 was receiving hospice services and had a history of [REDACTED]. A review of the comprehensive care plan for Resident #6 dated 10/31/14 revealed the facility developed a care plan that addressed the resident's respiratory condition related to asthma and congestive obstructive [MEDICAL CONDITION] disease ([MEDICAL CONDITION]) with interventions to administer oxygen as ordered by the physician. A review of Resident #6's December 2014 physician's orders [REDACTED]. Observations of Resident #6 conducted on 12/09/14 at 10:45 AM, 12:55 PM, 2:20 PM, 3:56 PM, and 5:30 PM, and on 12/10/14 at 8:45 AM and 9:40 AM, revealed the facility was administering oxygen to Resident #6 via a nasal cannula at 2 liters per nasal cannula, not at the physician-ordered 4 liters. An interview conducted on 12/11/14 at 1:25 PM, with LPN #3 revealed the LPN was not aware Resident #6 had orders for oxygen at 4 liters per minute. The LPN stated the resident's previous order was for oxygen at 2 liters per minute. An interview with the Unit Manager, RN #1, on 12/11/14 at 1:55 PM revealed she made rounds daily to ensure residents' oxygen was being administered as ordered and had not noticed Resident #6's oxygen was not being administered as required. An interview with the DON conducted on 12/11/14 at 4:30 PM revealed the DON made rounds daily to ensure care was being provided in accordance with the resident's plan of care. The DON was not aware the residents' catheters were not being secured to prevent pulling of the catheter tubing for Residents #2, #6, #12, and #16. In addition, the DON was not aware Resident #6's oxygen was not being administered as per physician orders.

Based on observation, interview, and record review it was determined the facility failed to ensure residents with indwelling urinary catheters received appropriate treatment and services to restore as much normal bladder function as possible for four (4) of nineteen (19) sampled residents. Observations revealed Residents #2, #6, #12, and #16 had indwelling urinary catheters that were not secured to prevent pulling of the catheter tubing as required by the facility's policy/procedure. The findings include: A review of the facility's policy titled "Giving Catheter Care," (undated) revealed a resident's catheter tubing was to be coiled and secured. The policy was not specific regarding the manner or means of securing the catheter tubing. An interview with the Director of Nursing (DON) on 12/11/14 at 4:30 PM revealed catheters should be secured using a Cath-Secure device (a Cath-Secure device is a device used to secure the catheter to a resident's leg to prevent pulling). 1. A review of Resident #2's medical record revealed the facility admitted the resident on 12/02/13 with [DIAGNOSES REDACTED]. A review of the comprehensive Minimum Data Set (MDS) assessment for Resident #2 dated 09/15/14 revealed the facility assessed the resident to require the use of an indwelling urinary catheter due to a [DIAGNOSES REDACTED]. A review of Resident #2's comprehensive care plan dated 09/16/14 revealed the facility developed a care plan to address the use of a urinary catheter for [MEDICAL CONDITION] with interventions to provide catheter care every shift and as needed. Observations of a skin assessment on 12/10/14 at 1:10 PM revealed Resident #2's indwelling urinary catheter tubing was not secured by any means to prevent pulling of the catheter tubing. An interview conducted with State Registered Nurse Aide (SRNA) #1 on 12/11/14 at 12:40 PM, revealed the SRNA provided care to Resident #2 on 12/10/14. According to the SRNA, the resident's "Cath-Secure" was not on the resident because the resident had not had any problems pulling on the catheter. 2. A review of Resident #6's medical record revealed the facility admitted the resident on 09/30/14 with [DIAGNOSES REDACTED]. A review of the most recent comprehensive MDS assessment for Resident #6 dated 10/09/14 revealed the resident was assessed to require a urinary catheter related to a [DIAGNOSES REDACTED]. A review of the care plan dated 10/31/14 revealed the facility developed a care plan for Resident #6 that addressed the resident's urinary catheter with an intervention to have a "Cath-Secure" in place. Observation of urinary catheter care provided by SRNA #2 on 12/09/14 at 12:55 PM revealed the resident's urinary catheter tubing was not secured by any manner or means to prevent pulling of the catheter tubing when the SRNA initiated catheter care. In addition, the SRNA did not secure the catheter tubing when catheter care was completed. An additional observation on 12/10/14 at 11:45 AM, of Resident #6's urinary catheter revealed the catheter was not secured by any manner or means. An interview conducted with SRNA #2 on 12/11/14 at 1:20 PM, revealed the SRNA was not aware of the facility policy for securing the indwelling catheter tubing and was not aware how the catheter tubing was required to be secured to prevent pulling. According to the SRNA, the catheter tubing was secured when the resident's catheter drainage bag was attached to the resident's bed frame. An interview conducted on 12/11/14 at 12:35 PM, with Licensed Practical Nurse (LPN) #1 revealed the LPN had conducted an assessment of Resident #6's skin on 12/10/14 at 11:45 AM, and did not notice the resident's catheter was not secured because she did not normally conduct skin assessments. Additional interview revealed that if an SRNA noticed a resident's catheter was not secured, the SRNA should have informed the nurse. 3. A review of the medical record for Resident #16 revealed the facility admitted the resident from the hospital on [DATE], with an indwelling urinary catheter and with [DIAGNOSES REDACTED]. Further review of the record revealed the facility developed an admission care plan dated 12/05/14 with interventions to provide catheter care per facility protocol. Observation of Resident #16's catheter on 12/11/14 at 10:35 AM revealed no evidence the resident's urinary catheter was secured by any manner or means to prevent pulling/trauma and no evidence a "Cath-Secure" was attached to the resident's catheter tubing. An interview conducted with SRNA #1 on 12/11/14 at 12:40 PM revealed Resident #16's catheter became unsecured while bathing the resident on 12/11/14 and the SRNA had not informed the resident's nurse that the resident's "Cath-Secure" had come off the resident's leg so that it could be replaced. 4. A review of the medical record for Resident #12 revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of Resident #12's most recent Minimum Data Set (MDS) assessment, dated 11/16/14, revealed the facility assessed the resident to have a score of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. An interview conducted with Resident #12 on 12/11/14 at 10:55 AM revealed staff had never secured the resident's indwelling urinary catheter while the resident was at the facility. Resident #12 stated facility staff secured the urinary catheter to the resident's leg only when the resident left the building. An interview conducted with SRNA #4 on 12/11/14 at 12:35 PM revealed the facility's catheter care policy was to notify the resident's nurse if the SRNA observed that a urinary catheter was not secured. The SRNA stated the resident's nurse was responsible for securing the resident's urinary catheter. The SRNA stated she had just performed care "about 30 minutes ago" for Resident #12 and the urinary catheter tubing was secured to the bed at that time. Further interview with SRNA #4 on 12/11/14 at 2:50 PM revealed the SRNA had checked Resident #12's catheter tubing after the interview at 12:35 PM and the tubing was not secured to the resident's thigh or the bed as required. An interview on 12/11/14 at 12:45 PM with LPN #1 revealed the LPN had not looked at Resident #12's catheter that day, but stated that urinary catheter tubing was usually secured to the bed. An interview conducted with the DON on 12/11/14 at 4:30 PM, revealed the DON was not aware residents' catheters were not being secured by any manner or means to prevent pulling of the catheter tubing. The DON stated the facility had "Cath-Secures" in stock that should be used to secure residents' urinary catheters. The DON further stated she was not aware the facility's catheter care policy was not specific or gave no clear guidance as to how a resident's catheter tubing was to be secured.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free from accident hazards related to side rails not being padded for one (1) of nineteen (19) sampled residents (Resident #10). Review of the comprehensive care plan for Resident #10 dated 04/03/14, revealed a care plan intervention for the resident to have padded side rails. However, the facility failed to ensure that Resident #10 had padded side rails. The findings include: Review of facility policy titled "Incident Investigation Policy," undated, revealed the policy did not specifically address ensuring residents were as free from accident hazards as possible. Observations made on 12/09/14 at 5:30 PM and on 12/10/14 at 4:32 PM revealed Resident #10 did not have padded side rails in place as indicated on the resident's comprehensive care plan. Review of Resident #10's medical record revealed the facility admitted the resident on 12/06/06, with [DIAGNOSES REDACTED]. Review of Resident #10's most recent Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Resident #10 to have a Brief Interview for Mental Status (BIMS) score of 3, which indicated that Resident #10 had severe cognitive impairment. Review of Resident #10's comprehensive care plan dated 04/03/14, revealed the resident had potential for skin breakdown related to impaired mobility, incontinence, poor decision-making, thin fragile skin, and heart disease. Further review of Resident #10's comprehensive care plan revealed an intervention to pad the resident's side rails. Review of Resident #10's Resident Kardex (Certified Nursing Assistant Care Plan), undated, revealed Resident #10 was to have three-quarter bilateral side rails, however, the facility failed to ensure the Nursing Assistant Care Plan included padding for the side rails. Interview with State Registered Nurse Aide (SRNA) #3 on 12/11/14 at 1:28 PM revealed SRNAs were responsible for applying padding to side rails as needed. SRNA #3 stated she had never noticed Resident #10 to have padded side rails in the two years she had worked at the facility, and was not aware that Resident #10 required padded side rails. Interview with Licensed Practical Nurse (LPN) #4 on 12/11/14 at 1:40 PM revealed she cared for Resident #10 daily and had worked for one year on the hallway where Resident #10 resided. Continued interview with LPN #4 revealed nurses and nurse aides were responsible for ensuring padding was present on resident side rails, but she had not observed Resident #10 to have padded side rails at any time. Interview with Registered Nurse (RN) #1 on 12/11/14 at 1:55 PM revealed she was the Unit Coordinator for the unit on which Resident #10 resided. She stated staff tried to work as a team to make sure residents' care plans were followed, but she was not aware that Resident #10 required padded side rails. Further interview with RN #1 revealed SRNAs were given any new resident care plan updates during shift report and that interventions should be on the Resident Kardex. She stated nursing staff was responsible for ensuring any new orders for residents were followed and that she conducted rounds twice a day (once in the morning and once in the evening) to ensure care plans were being followed and provided staff education as needed. Interview with the Medicare MDS Coordinator on 12/11/14 at 1:02 PM and 2:23 PM revealed that the MDS Coordinators were responsible for updating Resident Kardexes and that they were reviewed monthly for accuracy and updated as needed. She further stated she was not aware that Resident #10 was required to have padded side rails. Interview with the Medicaid MDS Coordinator on 12/11/14 at 3:15 PM revealed she had added the padded side rails to Resident #10's comprehensive care plan following the resident's annual MDS assessment dated [DATE] as a precautionary measure. Continued interview with the Medicaid Coordinator revealed she failed to ensure that the intervention had been added to the Resident Kardex and to ensure that the intervention was implemented as noted on the care plan. Interview with the Director of Nursing (DON) on 12/11/14 at 4:20 PM revealed she made rounds to ensure that staff was following residents' care plans. She stated rounds were also made by her, the nurses, or the SRNAs every two hours to ensure care plans were being followed. Continued interview with the DON revealed she was not aware that Resident #10 required padded side rails, but she thought Resident #10 may have had padded side rails at some point in the past. The DON stated that if Resident #10 no longer needed the padded side rails intervention, the care plan should have been updated to reflect that. Further interview with the DON revealed the Quality Assurance (QA) Nurse was responsible for ensuring that the MDS Coordinators, Unit Managers, and nurses were monitoring to ensure that all care plan interventions were being followed.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to administer oxygen at the physician prescribed rate for one (1) of nineteen (19) sampled residents. Resident #6 had physician's orders [REDACTED]. The resident's oxygen was observed to be administered at 2 liters per minute on 12/09/14 and 12/10/14. The findings include: A review of the facility's policy titled "Special Needs-Respiratory Care," (undated) revealed the purpose of the policy was to ensure residents received any necessary respiratory treatments including oxygen therapy. Further review of the policy revealed that respiratory care in the facility included oxygen and that all treatments should be ordered by the resident's physician. A review of Resident #6's medical record revealed the facility admitted the resident on 09/30/14 with [DIAGNOSES REDACTED]. Further review revealed Resident #2 was receiving hospice services and had a history of [REDACTED]. A review of the comprehensive care plan for Resident #6 dated 10/13/14 revealed the facility developed a care plan that addressed the resident's respiratory condition related to asthma and congestive obstructive [MEDICAL CONDITION] disease ([MEDICAL CONDITION]) with interventions to administer oxygen as ordered by the physician. A review of Resident #6's December 2014 physician's orders [REDACTED]. Observations of Resident #6 conducted on 12/09/14 at 10:45 AM, 12:55 PM, 2:20 PM, 3:56 PM, and 5:30 PM, and on 12/10/14 at 8:45 AM and 9:40 AM revealed the facility was administering oxygen to Resident #6 via a nasal cannula at 2 liters per nasal cannula, not at the physician ordered 4 liters. An interview conducted on 12/11/14 at 1:25 PM, with Licensed Practical Nurse (LPN) #3 revealed the LPN was not aware Resident #6 had orders for oxygen at 4 liters per minute. The LPN stated the resident's previous order was for oxygen at 2 liters per minute. An interview with the Unit Manager, Registered Nurse (RN) #1, on 12/11/14 at 1:55 PM revealed she made rounds daily to ensure residents' oxygen was being administered as ordered and had not noticed Resident #6's oxygen was not being administered as required.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure an infection control program, including hand washing and proper use of contact precautions, to prevent the development and transmission of disease/infection was maintained for two of eighteen residents (Resident #2 and Resident #9). Staff was observed to omit hand washing and glove changes during wound care provided to Resident #2. Record review revealed Resident #9 had a physician's order for contact precautions; however, proper signage was not displayed on the resident's door and the appropriate personal protective equipment (PPE) was not available for staff use prior to providing care for Resident #9. Staff was observed to provide catheter care and incontinence care for Resident #9 without wearing the appropriate PPE. The findings include: Review of the facility policy entitled Infection Control Program, not dated, revealed hand washing or use of an alcohol based hand rub should be used when moving from a contaminated body site to a clean body site during care. Further review of the policy revealed gloves should be changed during patient care if moving from a contaminated site to a clean body site. Continued review of the policy revealed health care personnel caring for patients on contact precautions should wear a gown and gloves for all interactions that may involve contact with the patient. Further review of the policy revealed staff should don PPE before entry to a patient room and discard before exiting a patient room. Continued review of the policy revealed residents with contact precautions should have a sign placed on their door alerting visitors to check with the nurse prior to visiting. 1. Review of the medical record for Resident #2 revealed the resident was admitted by the facility on 08/02/13 with [DIAGNOSES REDACTED]. Observations on 12/12/13 at 12:25 PM of Licensed Practical Nurse (LPN) #1 providing wound care for Resident #2 revealed the LPN washed her hands and donned gloves prior to beginning wound care/dressing change to an unstageable area on the resident's right hip; however, the LPN did not wash her hands or change her gloves after removing the old dressing and continuing with wound care. Continued observation of wound care provided for Resident #2 revealed LPN #1 continued with wound care by changing the protective dressings to the left hip and left shoulder without washing her hands or changing her gloves. Further observation of wound care provided by LPN #2 revealed the LPN removed the soiled glove and dated and initialed the dressings and then put the soiled glove back on her hand to assist with positioning the resident and cleaning up the supplies. Interview on 12/12/13 at 1:20 PM with LPN #1 revealed the LPN was supposed to wash her hands and change her gloves when moving from one area to another during wound care. The interview further revealed the LPN had recently been trained on use of gloves and hand washing; however, the LPN was nervous and just forgot. Interview on 12/12/13 at 4:47 PM with the Infection Control Registered Nurse (RN #1) revealed hand washing and glove changes should be done when providing wound care after removing a soiled dressing and when moving from one area to another. The interview further revealed the staff had been trained on hand washing and infection control guidelines in November 2013 and RN #1 had not identified any issues with staff not changing gloves or washing hands as required. Interview on 12/12/13 at 3:03 PM with the Director of Nursing (DON) revealed hand washing and glove changes should be done during wound care after removing a soiled dressing and when moving from one area to another. The DON denied any problems had been identified during rounds with appropriate hand washing or glove changes. 2. Review of the medical record for Resident #9 revealed the resident was admitted by the facility on 06/08/12 with [DIAGNOSES REDACTED]. A review of physician orders, dated 12/06/13, revealed Resident #9 had an order for [REDACTED]. Observations on 12/10/13, 12/11/13, and 12/12/13 of Resident #9's door revealed no signage in place or available PPE related to the resident being on contact precautions. Observation on 12/11/13 at 11:05 AM of State Registered Nurse Aide (SRNA) #3 and SRNA #5 providing incontinence care and catheter care to Resident #9 revealed the staff did not wear the appropriate PPE (gown) and did not don the PPE outside of the resident's room before entering the room. Interview on 12/12/13 with SRNA #3 at 10:12 AM and SRNA #5 at 10:17 AM revealed the staff was not made aware until 12/12/13 that Resident #9 was on contact precautions. The interview further revealed a sign and the proper equipment should have been placed on the resident's door so everyone would be aware the resident was on contact precautions and that a gown and gloves should have been worn when providing care to Resident #9. Continued interview revealed a resident's precautions are usually listed on the Kardex and passed on in report. The staff revealed they had recently been trained on the proper PPE for contact precautions. Interview on 12/12/13 at 2:05 PM with the Unit Manager (RN #2) revealed a sign and the proper PPE should be placed on a door for a resident on contact precautions. The interview further revealed a resident's precautions should also be listed on the Kardex so the information can be passed on in report. Continued interview revealed Resident #9 did have a sign on the door and the appropriate PPE available and was not sure what happened to it or how long it had not been in place. Interview on 12/12/13 at 10:25 AM with Infection Control RN #1 revealed Resident #9's urine was ESBL positive and staff should wear a gown and gloves when in contact with the resident's urine. The interview further revealed a sign and the appropriate PPE had been placed on the door when the contact precautions were ordered; however, the RN was not sure what happened to the sign and the PPE unless the resident's roommate may have taken it down. Continued interview revealed the RN made rounds to ensure contact precaution signs and PPE were on the door, but she had not identified that Resident #9's were not on the door. The interview further revealed staff was trained on contact precautions the week before. Interview on 12/12/13 at 3:03 PM with the DON revealed Resident #9 should have had a sign and PPE on the door for contact precautions and was not aware the resident did not have the appropriate signage and PPE on the door.

Based on interview, and a review of medical records, the facility's Abuse Policy, and the facility's investigation, it was determined the facility to ensure an allegation of abuse was immediately reported to the Administrator and/or administrative staff. The facility also failed to interview staff that had worked the day of the alleged incident, failed to interview residents being cared for by the alleged perpetrator, and failed to assess non-interviewable residents for injuries or increased behaviors for the day of the alleged incident. The findings include: Review of the facility's "Abuse Policy," revised December 2011, revealed in the "Reporting Policy and Procedures" section, "All allegations involving mistreatment, neglect, or abuse, including injuries of an unknown source, or misappropriation of resident property will be reported immediately to the Director of Nursing and/or the Administrator of the facility and to other officials in accordance with State law, including the state survey and certification agency." Continued review of the policy revealed personnel on the 7:00 AM to 3:00 PM shift were to report any allegations directly to the Unit Supervisor; the Unit Supervisor would report the allegation to the Director of Nursing (DON); and the DON would report the allegation to the Administrator. Review of the "Abuse and/or Resident Neglect Investigation" section of the policy revealed when a suspected incident of resident abuse was reported, the Administrator or DON would appoint a representative to investigate the incident. Further review revealed, "A thorough investigation shall be completed." The policy revealed staff could document the results of the investigation in an "Investigative Summary" report format or on a "Resident Abuse Investigation Report Form." Review of additional undated information provided by the facility entitled "Guidance for person conducting investigation" revealed the facility's investigation would consist of: a) An interview with the person reporting the incident, b) Statement of the resident's physical condition, c) Interviews with any witness to the incident, d) Interview with the resident, e) Review of the resident's medical record, f) Interviews with staff members (on all shifts) having contact with the resident during the period of the alleged incident, g) Interview the resident's roommate, h) Interviews with other residents in which the employee provided care to, and i) Review of all circumstances surrounding the incident. Review of the facility's investigation of an abuse allegation revealed on 11/14/13 at 12:30 PM, State Registered Nursing Aide (SRNA) #1 reported to Registered Nurse (RN) #1 that prior to the lunch meal on 11/11/13, she witnessed SRNA #2 cursing and roughly handling Resident #1. The investigation revealed the facility suspended SRNA #2 on 11/14/13 pending the results of the investigation and reported the allegation to Resident #1's physician, responsible party, and the appropriate state agencies. Documentation revealed RNs #1 and #2 conducted the investigation of the allegation on 11/14/13 but were unable to contact the SRNA to interview the alleged perpetrator, SRNA #2, and concluded the investigation on 11/14/13 (the same day the allegation was reported). Based on the review of the facility's investigation report by RN #2 and the Administrator's Summary documented by the Administrator, both dated 11/14/13, the facility failed to interview SRNA #2 (the alleged perpetrator), Resident #1, the resident's roommate, other residents for which SRNA #2 provided care, the person that reported the incident, and staff members (on all shifts) that had contact with the resident during the period of the alleged incident. Documentation also revealed the facility failed to obtain a statement and/or assessment of the resident's physical condition at the time the allegation was reported and failed to review the resident's medical record and document the circumstances that surrounded the incident as indicated in the facility's policy. In addition, the facility failed to document an assessment of the resident, and/or other residents, for evidence of injuries or changes in their behaviors that could indicate abuse had occurred. Interview on 12/03/13 at 3:10 PM with State Registered Nurse Aide (SRNA) #1 revealed on 11/11/13 SRNA #2 requested SRNA #1 to assist with incontinence care for Resident #1. SRNA #1 stated they had almost completed the incontinence care and Resident #1 became incontinent again and, as a result, they had to immediately provide incontinence care again. At that time, SRNA #1 stated SRNA #2 stated, "Oh my f---ing God," and left the room to gather more supplies. SRNA #1 also stated when SRNA #2 returned to Resident #1's room, SRNA #2 told the resident to "roll over," and when the resident did not roll, SRNA #2 "pushed" the resident roughly. According to SRNA #1, at that time, Resident #1 swung her arm back, hit SRNA #2 in the face, and SRNA #2 said, "Oh damn, she got me." The interview revealed SRNA #1 did not report the allegation because the Administrator and DON were not at the facility; they were out of town at a convention and SRNA #1 thought she was required to report the incident directly to the Administrator or DON. The SRNA stated when she returned to work on 11/14/13, she decided to report the allegation to RN #1. Interview on 12/03/13 at 2:30 PM with RN #1 confirmed SRNA #1 reported to her on 11/14/13 that on 11/11/13, while SRNA #2 provided direct care to Resident #1, she observed SRNA #2 curse at Resident #1 and handle the resident roughly. RN #1 stated she notified RN #2 of the allegation and both nurses conducted an investigation. RN #1 stated she and RN #2 interviewed SRNA #1, and RN #2 notified Administration and the state agencies and completed the paperwork. RN #1 stated she discussed the allegation with Resident #1's responsible party. The interview revealed RNs #1 and #2 initiated in-services on abuse to staff working on 11/14/13 but did not interview the staff about the alleged incident. RN #1 stated Resident #1 did not have a roommate at the time of the report, and at the time of the allegation the roommate was non-interviewable, and Resident #1 was non-interviewable, therefore, an interview was not conducted with the resident. RN #1 stated, "I would have only interviewed other staff or residents if they were 'involved' in the allegation." Interview on 12/03/13 at 2:00 PM with RN #2 confirmed RN #1 informed her on 11/14/13 that SRNA #1 had reported that SRNA #2 had cursed and treated Resident #1 roughly on 11/11/13. RN #2 stated staff that worked on 11/14/13 had also worked on the date of the alleged incident on 11/11/13, and had been interviewed but, because they had not witnessed the alleged incident, the interviews were not documented. RN #2 also stated an interview was attempted with Resident #1 without success due to the resident's cognition but was not documented. In addition, RN #2 reported staff had conducted a skin assessment of Resident #1 on 11/14/13, and had not identified any concerns. According to RN #2, SRNA #1 received a verbal reprimand for not immediately reporting the allegation of abuse, and SRNA #2 was suspended and would not be allowed to return to work unless the investigation by the Department for Community Based Services (DCBS) determined the allegation to be unsubstantiated. A review of the facility's schedules for 11/11/13 and 11/14/13 revealed although the nurses on the schedule had worked both days, SRNA #1 was the only SRNA that worked the same hours on 11/11/13 and 11/14/13, and as a result, interviews had not been conducted with the staff that worked with Resident #1 and/or SRNA #2 on the day of the alleged incident (11/11/13). On the day of the investigation, 12/03/13, an interview was conducted by telephone with SRNA #2 at 1:35 PM. SRNA #2 confirmed she was suspended from employment on 11/14/13 related to an allegation concerning Resident #1. SRNA #2 acknowledged she had said, "Damn she hit me in the face," when Resident #1 hit the SRNA when she and SRNA #1 provided incontinence care on 11/11/13. However, SRNA #2 denied that she had cursed at the resident or had been rough with Resident #1 when she provided care to the resident. A review of the personnel file of SRNA #2 revealed the facility had hired the SRNA on 03/11/13 and had submitted a request for a criminal background check of the employee on 03/06/13. Continued review of the personnel file revealed SRNA #2 had no reprimands for abuse or neglect. In addition, documentation revealed the facility had trained SRNA #2 on the facility's policy related to abuse upon hire. An interview was conducted with Resident #3 on 12/03/13 at 12:10 PM and revealed she had witnessed staff providing care to the resident's roommate (an unsampled resident) in a rough manner; however, Resident #3 was unable to recall the date or the name of the facility staff. Interview on 12/03/13 at 3:25 PM with the DON revealed the facility provided education to the nurses related to abuse and how to conduct an investigation during the orientation process at the time of employment. However, the interview revealed the facility's investigation process entitled "Guidance for person conducting investigation" was included in the nurses' orientation process but was not included in the annual in-services. The DON stated only the staff and residents involved in an allegation of abuse would have been interviewed during the course of an investigation of abuse. Interview on 12/03/13 at 4:50 PM with the Administrator revealed the nurse that received an allegation of abuse would conduct the investigation and notify the Administrative staff. The interview revealed the Administrator was responsible to ensure the investigation report was completed, that documentation was correct, and that in-services with staff were conducted. The Administrator confirmed she had been made aware of the allegation related to SRNA #2 and Resident #1, had reviewed the investigation, and acknowledged by signature that the investigation was complete. The Administrator stated the results of the facility's investigation were sent by "fax" to the appropriate state agencies.

Based on observation, interview, and a review of the facility's policies, it was determined the facility failed to provide effective maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Five resident room doors (resident rooms 110, 120, 156, 157, and 158) were observed to have chipped wood with sharp edges. Cracked tiles were observed in two different hallways. The findings include: A review of the facility's policy titled "Protocol for Completing the CQI Referral Form," which contained no date, revealed the form could be filled out by any staff member that identified a potential concern. The policy revealed the staff was to mark the appropriate department box to specify the department that was responsible for correcting the identified problem along with a brief description of the identified problem. The policy stated the form was then to be given to the Department Supervisor to review and for correction. Observations during the environmental tour of the facility on 12/06/12, at 9:30 AM, revealed the following areas to be in need of repairs: -Bedroom doors in resident rooms 110, 120, 156, 157, and 158 were observed to have chipped wood with sharp edges. -The hallway between the fire doors on the 100 Unit of the facility was observed to have cracked tiles. -The hallway between the nurses' station and the dayroom on the 200 Unit was observed to have cracked, raised tiles. An interview conducted with the Maintenance Supervisor on 12/06/12, at 11:45 AM, revealed he made rounds daily throughout the facility to check for cleaning and maintenance issues and had not identified the areas in need of repair or cleaning. The Maintenance Supervisor stated the facility utilized a Quality Improvement Referral Form which could be completed by any staff person that identified an area in need of repair or cleaning. The form was then to be given to the supervisor of the appropriate department or in a box on the maintenance office door. The Maintenance Supervisor also stated he had not received a request for the identified areas of concern. An interview conducted with the Administrator on 12/06/12, at 11:47 AM, revealed she receives a copy of all maintenance repair requests. The Administrator stated she also makes rounds daily to monitor for any repair issues. The Administrator stated the issues are also reviewed during the facility's Quality Assurance process.

Based on observation and interview, the facility failed to provide effective housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observations throughout the facility revealed soiled baseboards, soiled doors, doors with splintered edges, soiled toilet seats, a chipped lavatory, and a wheelchair in need of repair. The findings include: According to the facility's Administrator on 12/16/11, at 11:30 A.M., the facility did not have a policy related to maintenance/housekeeping needs of the facility. Observations of the facility from 12/14/11 through 12/16/11, revealed the following areas were in need of maintenance/housekeeping services: 1. Rough, splintered doors were observed in resident rooms 109, 123, 124, 151, 158, and 159. 2. Baseboards in resident rooms 103, 106, 107, 109, 115, 116, 117, 118, 120, 121, 122, 124, 151, 156, 158, 159, and 168 were observed to have a heavy buildup of dust and dirt. 3. Doors in resident rooms 105, 117, 121, 123, 126, 158, 159, and 168 were observed to have a heavy buildup of soil. 4. Toilet seats/bowls in resident rooms 114 and 123 were observed to be soiled and/or stained. 5. A chipped lavatory edge was observed in resident room 168. 6. The wheelchair in resident room 171-2 was observed to have a loose side panel and the wheelchair in resident room 105-2 was observed to have a torn/worn armrest with the cover missing. An interview with the Housekeeping Supervisor and the Maintenance Supervisor during the environmental tour on 12/16/11, revealed staff was to submit work requests for repairs needed in resident rooms. Both supervisors stated they made observations of resident rooms on a regular basis, but were unaware of these housekeeping/maintenance needs.