Every finding on record at Maple Grove Senior Living LLC

Based on observation, interview, and record review, 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 and control the development and transmission of communicable diseases and to implement interventions to protect facility residents. The deficient practice had the potential to affect the entire facility census of 68.Observations during initial tour on 01/13/2026 revealed no isolation signage or signage indicating Enhanced Barrier Precautions at the entrance or on the door for rooms 402-A, 407-A, or 433-A. Observation on 01/14/2026 revealed housekeeping staff collecting garbage from residents' rooms without donning gloves prior to collecting garbage or practicing hand hygiene after completing task. Additionally, interviews and record review revealed the facility failed to establish written standards and procedures for a documented water management program based on nationally accepted standards.The findings include: Review of facility policy Infection Prevention and Control Program revised 10/2018, revealed an infection and control program (IPCP) was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Implementation included the program was developed to address the facility's specific infection control needs with the program being based on accepted national infection prevention and control standards. Further review revealed the IPCP was facility wide involving all disciplines and individuals; and prevention of infections included implementing appropriate isolation precautions when necessary following established guidelines sign as those of Centers for Disease Control (CDC).Review of facility policy titled Policies and Practices-Infection Control revised 10/2018, revealed the facility's infection control policies and practices were intended to maintain a safe, sanitary and comfortable environment and prevent and manage diseases and infections. Added review revealed the objectives of the program were to prevent, detect, investigate, and to control infections in the facility.1(a). Review of facility signage Enhanced Barrier Precautions (EBP) indicated everyone must clean hands upon entering and exiting room. Further review of signage revealed providers, and staff must also wear gloves and a gown for high contact resident care activities which included dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs and or toileting. Added review of signage revealed providers and staff must wear gloves and gowns for residents with devices to include feeding tube and resident with any skin opening requiring a dressing.Review of facility policy titled Handwashing/Hand Hygiene revised 08/2019 revealed the facility considered hand hygiene to be primary means to prevent the spread of infections.Review of R4's face sheet revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes with foot ulcer, peripheral vascular disease, vascular dementia, and kidney disease.Review of R4's physician's orders revealed an order for EBP placed on 01/13/2026 related to wound.Review of R4's comprehensive care plan (CCP) dated 01/16/2025 revealed focus was for the resident to be in EBP related to wound requiring dressing. Further review revealed interventions included the use of gown and gloves for high contact care activities and when providing wound care.Review of wound care notes dated 01/13/2026 revealed a wound to left medial foot with duration of greater than 186 days. Further review of wound physician notes revealed diabetic wound to left medial heel with duration greater than ten days.Observation on 01/13/2026 at 11:22 AM revealed R4 was not in the room. Added observation revealed a heel lift bootie was lying on bed. Further observation revealed a laminated Stop sign saying to see nurse before entering room was posted on wall outside R4's room, no signage for EBP or Personal Protective Equipment (PPE) bin noted.During an interview with Certified Nurse Aide (CNA)7 on 01/14/2026 at 3:30 PM she stated R4 has had a wound ever since she has worked here which was one year today.1(b). Review of R5's face sheet revealed the resident admitted to facility on 11/21/2021. Diagnoses included vascular dementia, reflux disease, and gastroparesis (delay in gastric emptying).Review R5's order set revealed order was placed on 10/27/2024 for EBP for infection control due to ostomy.Observation on 01/13/2026 at 11:45 AM revealed a laminated Stop sign posted on door frame of room [ROOM NUMBER] that stated to see nurse before entering. Further observation revealed there was a PPE bin hanging on the door into the room and the door was open.During an interview with the Infection Prevention Nurse on 01/13/2026 at 11:46 AM she stated the stop sign meant that R5 was in EBP due to having a feeding tube in place.1(c) Review of R8's face sheet revealed resident was admitted to facility on 03/20/2021. Diagnoses included heart failure, vascular dementia, peripheral vascular disease, and pressure ulcer to left heel.Review of R8's order set revealed order was placed on 01/13/2026 for EBP related to wound.Review of R8's CCP dated 10/05/2025 revealed EBP-Infection Control was identified as focus related to Stage 3 pressure ulcer to left heel. Further review revealed interventions placed included the use of gown and gloves for high contact care activities and wound care.Review of wound therapy note dated 01/13/2026 revealed wound to left lateral heel had a duration of greater than seventy-nine (79) days.Observation of R8's room on 01/13/2026 at 11:50 AM revealed a bin containing PPE was hanging on the bathroom door however, no isolation signage was posted on wall outside room or room door.During an interview with Certified Nurse Aide (CNA)7 on 01/14/2026 at 3:30 PM she stated R4 has had a wound ever since she has worked here which was one year today. She stated R8 developed a wound to foot about 6 months ago and the nurses do the treatment, and the resident is turned every 2 hours unless she refuses. She stated she has had training on infection control and knew to wear PPE if having contact with the resident during care for prevention of spreading germs.During an interview with Registered Nurse (RN)2 on 01/15/2026 at 2:15 PM she stated she has had training on infection control and signage should be placed at room entrance so staff would know what to wear prior to entering the room. She stated EBP precautions are placed for residents with different conditions and did include having a feeding tube and wound. She stated PPE should be worn for any high touch resident care.During an interview with the Unit Manager on 01/15/2026 at 2:34 PM he stated if the proper signage is not posted at the room needing isolation his concern would be the staff may not know what PPE to wear. He added if the proper PPE is not worn the bacteria or germs could spread, impacting the residents.2. Observation on 01/14/2026 at 8:43 AM revealed Housekeeper (HK)1 rounding on the 400 hall. Further observation revealed she entered rooms [ROOM NUMBER] emptying trash into a larger bag she was carrying without donning gloves or practicing hand hygiene upon entry to rooms or exiting the rooms.During an interview with Housekeeper (HK)1 on 01/14/2026 at 2:54 she stated her tasks included cleaning resident rooms. HK1 stated she has had training on infection control, and she should wear PPE when performing cleaning tasks, including emptying garbage to not spread germs and keeping the residents safe.3. Review of facility policy Legionella Water Management Program revised 07/2017, revealed the facility was committed to the prevention, detection and control of water-borne contaminants, to include Legionella. Further review revealed the purposes of the water management program were to identify areas in the water system where Legionella bacteria can grow and spread; and to reduce the risks of Legionnaire's disease and was based on the Centers for Disease Control and Prevention, and American Society of Heating and Air-Conditioning Engineers (ASHRAE) recommendations for developing a Legionella water management program. The policy also stated the program would include a detailed diagram and description of the water system, identify areas in system that encourage the growth and spread of waterborne bacteria which included water tanks, water heaters, filters, and medical equipment to include C-pap machines. Added review revealed that the water program included a process that identified situations that could lead to Legionella growth which included construction, water main breaks, water temperature, pressure, stagnation, and inadequate disinfectants. Further review of policy revealed the programs would include a plan for when control limits were not met and/or effective with the water management program reviewed annually.Review of facility documents titled Water System Flush revealed initials next to the dates on 10/20/2025 and on 12/18/2025 indicating the water system had been flushed; however, no specifics were included in documentation including areas and time of flushes.Review of a hand drawn diagram on notebook paper titled Masonic Homes Shelbyville revealed a diagram indicating areas of water intake to boiler and water tanks, however no diagram was given for entire water system in building.Review of document titled Lab Sample ID 482676 with collection date of 05/12/2025 from an outside lab company, revealed Legionella was not detected in potable and non-potable water.During an interview with Plant Operation Director (POD) on 01/15/2026 at 4:50 PM when asked if he had a risk assessment to identify where Legionella or any other water borne germs could grow, he stated he did not really know what that was and has not had any training on Legionella. When asked the process and how often he assessed the facility water system for any stagnant water, water leaks inside and outside he stated he walked through sometimes just checking everything but did not really have a scheduled time. When asked if the water was checked for chlorine levels, he stated he was unsure and did not know if the water company provided those levels to facility. He stated there was no diagram of the facility water system at this time with exception of a drawing for the water tanks in basement. He stated the last time there was a water line break was about 2-3 weeks ago but was unsure if the lines had been flushed after repair and was unsure of water used by residents. When asked if facility had areas for dead legs (areas where low flow occur due to lines capped or not in use) he stated he did not think so but could not say for sure. He stated facility had no decorative fountains or hot tubs, but facility did have two cooling towers. When asked how the cooling towers were monitored or chemicals added, he stated an outside company checked them and was pretty sure they (the outside company) added chemicals. He stated the facility checked water for Legionella yearly and the last time was last year sometime. When asked about monitoring water temperatures for proper levels to kill Legionella, he stated the water tanks/boiler are set to one hundred twenty (120) degrees Fahrenheit (F). However, when asked for documentation of temperature checks of the tanks, the POD stated there were none. When the POD was asked what control measures were used to monitor for prevention of waterborne illnesses, he stated he did not really know.During an interview with the Infection Preventionist (IP) nurse on 01/15/2026 at 10:36, she stated the facility Maintenance was responsible for the water plan and there had been no cases of Legionella in facility. She stated she trained staff on infection control, and her expectation was for staff to follow their training and follow signage. She stated if a resident had a wound or on a tube feed, the resident should be in EBP and there should be appropriate signage placed at the entrance to the room. During an interview with the Director of Nursing (DON) on 01/15/2026 at 10:36 AM she stated if someone was emptying garbage, they should be wearing gloves and practicing hand hygiene to prevent possible infection.The Director of Nursing (DON) in additional interview on 01/15/2026 at 4:43 PM stated her tasks included oversite of the clinical operation of facility and operation of building, adding she depended on department heads to keep her updated of any concerns. She stated as the DON it was her expectation for all staff to follow their infection control training to prevent transferring germs and bacteria between residents and staff. She added proper signage should be placed when needed and staff should be practicing hand hygiene and donning gloves when needed.During an interview with Administrator on 01/15/2026 at 5:23 PM she stated her tasks included oversight of daily operations of the facility and she depended on the DON for the clinical part and other department managers in other areas. She stated it was her expectation for all staff to follow their infection control training to protect the residents. When asked if gloves should be worn by staff when emptying garbage, she stated yes to prevent risk of infection. She stated the facility had no water diagram. She stated the facility has had no cases of Legionella, but her concern was for residents' safety if the water system was not being monitored properly.

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately, but not later than 2 hours after the allegation was made for 1 of 1 resident files investigated for abuse, Resident 16. On 01/09/2026, Resident (R)16 alleged to Certified Nurse Aide (CNA)6 and Licensed Practical Nurse (LPN)2 that she had been raped by an unidentified man. CNA6 and LPN2 failed to report the allegation to administration and the allegation was not reported to the State Survey Agency until 01/12/2026.The findings include:Review of facility policy titled Abuse Prevention Program, dated 12/2016, revealed the facility required staff training and orientation which included abuse prevention, identification, and reporting. Further review revealed the policy of the facility was to report any allegations of abuse within timeframes as required by federal requirements.Review of facility policy titled Abuse Investigation and Reporting, dated 07/2017, revealed an alleged abuse should be reported immediately, but not later than two hours.Review of facility self-reported incident form, Initial Report, revealed an allegation of sexual abuse was reported to staff by R16 on 01/09/2026 at 11:54 PM and was not reported by the staff. Further review revealed the allegation was identified through a medical record review on 01/12/2026 at 1:00 PM. Facility investigation was initiated and required notifications were made.Review of facility self-reported incident form, Final Reports/ 5 Day Follow-Up revealed the alleged incident occurred on 01/09/2026 and Administrator was notified on 01/12/2026 at 1:00 PM. An assessment and interview with R16 revealed no physical injuries, no psychosocial or emotional distress, and denial of any sexual abuse or mistreatment. Interviews were conducted with pertinent staff. All residents were either interviewed or had skin assessments that did not result in any findings of abuse, all staff received mandatory education on abuse prevention, identification, and reporting. Conclusion of the facility investigation resulted in allegation not supported by evidence.Review of R16's admission Record revealed the facility admitted her on 05/29/2024 with diagnoses of neoplasm of pituitary gland, chronic pain syndrome, blindness, insomnia, hoarding disorder, and psychotic disorder with delusions.Review of R16's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating significant for intact cognitive function. Section E-Behavior listed delusions for potential indicator of psychosis.Review of R16's Electronic Medical Records (EMR) revealed a Behavior Note dated 01/09/2026 at 11:57 PM documented by Licensed Practical Nurse (LPN)2, indicating R16 reported a camera was in the ceiling and that whoever had put it there had raped her. Further review revealed LPN2 documented R16 was lying in bed covered, without any signs or symptoms of pain or discomfort and would continue to monitor.In interview with R16 on 01/13/2026 at 11:52 AM, she stated she recalled making the allegation of sexual abuse but now believed it was only a dream. R16 stated she had a nightmare and when she awoke, she believed the rape was occurring, so she reported it to the staff that was working. R16 further stated that, when she reported it, a nurse came in and asked her questions and she realized it was only a dream, did not believe she was raped, and felt safe at the facility.Interview with Certified Nursing Assistant (CNA) 6 on 01/15/2026 at 4:46 PM, revealed on 01/09/2026 she answered R16's call light and when she entered the room R16 alleged being videotaped while raped. CNA6 stated she asked R16 where and when it occurred and she pointed to the sprinkler on the ceiling, she told her she needed to report it to the nurse, left the room and told LPN2. CNA6 stated she returned to R16's room with LPN2, who again reported the same allegation, and neither herself nor LPN2 reported the allegation. Lastly, CNA6 stated she had training on abuse that included reporting but did not report it because R16 had a brain tumor that caused hallucinations, and she believed the rape hadn't occurred. Interview with LPN2 on 01/15/2026 at 11:22 AM, stated CNA6 reported R16 had made an allegation of rape, and they both went to the resident's room. LPN2 stated R16 pointed to a sprinkler in the ceiling, told him it was a camera, people were watching her, and stated she had been raped. He stated he re-oriented her, told her it was a sprinkle in case of a fire, and she was safe. Based on prior education for abuse, LPN2 stated he knew the expectation was to report allegations immediately, however due to R16 having a history of delusions, and no signs of an assault, he documented the behavior but did not report it.Interview with North Unit Manager on 01/15/2026 at 5:07 PM, revealed R16 had a history of delusions, had reported to staff she had been raped, and they did not report it per facility policy. He stated the facilities policy and procedure was to report any allegation of abuse immediately, and proper procedure would have been to notify the on-call manager so the investigation and notifications could be made within the required two hours.In interview with Director of Nursing (DON) on 01/15/2026 at 4:24 PM, the DON stated every Monday the management team pulled the previous 72 hours of charting and performed a review. The DON stated a progress note for R16 identified an allegation of sexual assault had been made but no report had been received. She stated she called CNA6 and LPN2 and they both reported R16 had made the allegation, however based on her history of delusions neither staff believed it had occurred and did not report it. DON stated the expectation was that all staff were to report any allegation of abuse made by any resident, regardless of their diagnoses or past history of allegations. Interview with Administrator on 01/15/2026 at 4:35 PM stated the weekend report had been reviewed, a progress note identified an allegation of abuse was made to staff and they failed to report it to management. Administrator stated R16 was immediately assessed, notifications were made, and an investigation started. She stated during interviews with CNA6 and LPN2 they both believed the allegation had not occurred, they assessed her safety and did not feel they had any further obligation to report. Administrator stated the policy, and expectation was that all staff would report any allegation of abuse immediately to management, regardless of the reporting sources history or mental status.

Based on observation, staff interview, and facility policy review, it was determined the facility failed to ensure kitchen staff properly used beard guards to restrain hair while in a food prep area of the kitchen; clean pans were air dried prior to storage; and fans used in the dishwashing area of the kitchen were free of dust/contaminants. These failures had the potential to increase the risk of foodborne illness and had the potential to affect 70 of 72 residents (two residents received nutrition exclusively via tube feedings) in the facility who received dietary services. The findings include: 1. Review of the facility policy, Dietary Employee Sanitation Policy, dated 07/2024, revealed, Policy: All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department . Hair restraints are required and should cover all hair on the head. [NAME] nets are required when facial hair is visible . During an observation and interview on 07/29/2024 at 9:03 AM, the Dietary [NAME] (DC) was observed in the food preparation area of the kitchen with a full beard approximately 0.50 inch in length wearing only a surgical mask for COVID-19 prevention but failed to wear a beard restraint. The surgical mask failed to cover the sides of the face and failed to cover the entire beard. The DC confirmed he was not wearing a beard guard to contain his beard, I should have a beard guard on, not just the mask. During an observation and interview on 07/29/2024 at 9:15 AM, the Dietary Manager (DM) confirmed Dietary Staff (DS) 2 was in a food prep area of the kitchen wearing only a surgical mask and he failed to be wearing a beard guard while having a full beard approximately 0.50 inches in length. The surgical mask failed to cover the sides of the face and failed to cover the entire beard. This had the potential to allow hair to fall onto the food being prepared. The DM stated, he should be wearing a beard guard. During an interview on 08/01/2024 at 11:55 AM, the Administrator stated, it's my expectation . that beards need to be covered . 2. Review of the facility policy, Washing Instructions on Pots and Pans, dated 07/2024, revealed, Process: . Pots and pans should be inverted when drying to allow for drain. Allow pots and pans to air dry. Pots and pans are not to be stacked or 'nested' when drying. During an observation and interview on 07/29/2024 at 9:15 AM, Dietary Staff (DS) 1 confirmed five pans six inches by six inches by six inches deep, four pans six inches by six inches by four inches deep, two pans 12 inches by 18 inches by four inches deep, three pans 12 inches x 24 inches x four inches deep, and three pans 12 inches x 24 inches x six inches deep clean and ready for use were still wet when they were unstacked. The pans were found to have been stacked wet and not allowed to air dry. DS1 stated, they should be dry before they are put away, they are supposed to air dry before stacking. During an interview on 08/01/2024 at 11:55 AM, the Administrator stated, it's my expectation that . pots and pans should be air dried . 3. During an observation and interview on 07/29/2024 at 9:15 AM, the Dietary Manager (DM) confirmed the two fans operating in the dishwashing area, blowing over the clean dishes were dirty. The cages covering the fan blades were noted to be covered with dirt and dust. This had the potential to allow the dirt and or dust to be blown onto the clean items. The DM stated, they need to be cleaned so the dirt doesn't blow onto anything. During an interview on 08/01/24 at 11:55 AM, the Administrator stated, it's my expectation that . the fans should be clean and not blowing dirt.

Based on record review, interview, and policy review, it was determined the facility failed to have documentation of pneumococcal vaccines being offered and/or given for three of five residents (Resident (R) 3, R13, and R27) reviewed for immunizations out of a total sample of 21 residents. This failure of not being able to provide documentation increased the risk of infection against pneumonia. The findings include: Review of facility policy, Pneumococcal Vaccine, dated 03/2024 revealed Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumococcal infections. Staff will be offered pneumococcal vaccine upon hire and ongoing as indicated by the CDC [Centers for Disease Control and Prevention] guidelines. Policy Interpretation and Implementation: 1. Residents/staff will be reviewed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series unless medically contraindicated or the resident/staff have already been vaccinated. 2. Before receiving a pneumococcal vaccine, the resident or legal representative/staff shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine . 4. Residents/representatives/staff have the right to refuse vaccination. Refusals or administration will be documented in the medical record for residents and in the employee file for staff. 5. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current CDC recommendations at the time of the vaccination. Review of the CDC website Pneumococcal Vaccination: Summary of Who and When to Vaccinate, reviewed 09/22/2023, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older . For adults [AGE] years or older who have only received a PPSV23 [Pneumococcal Polysaccharide Vaccine], CDC recommends you . May give 1 dose of PCV [Pneumococcal Conjugate Vaccine] 15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended . For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete . 1. Review of R3's undated Face Sheet located in the electronic medical record (EMR) under the Face sheet tab revealed the facility admitted R3 on 12/02/2020 and was older than [AGE] years of age at the time of admission. Review of R3's Vaccines located on the facility provided document Masonic Homes of Kentucky Immunization Record revealed R3 received Pneumococcal Conjugate Vaccine (PCV) 13 on 12/02/2021. There was no documentation that follow-up doses of pneumonia vaccinations were, administered, refused, or received outside of the facility. 2. Review of R13's undated Face Sheet located in the EMR under the Face sheet tab revealed the facility admitted R13 on 11/16/2022 and was older than [AGE] years of age at the time of admission. Review of R13's Vaccines located on the facility provided document Masonic Homes of Kentucky Immunization Record revealed R13 received Pneumococcal Polysaccharide (PPSV) 23 on 11/16/2022. There was no documentation that follow-up doses of pneumonia vaccinations had been offered, administered, refused, or received outside of the facility. 3. Review of R27's undated Face Sheet located in the EMR under the Face sheet tab revealed the facility admitted R27 on 10/12/2017 and was older than [AGE] years of age at the time of admission. Review of R27's Vaccines located on the facility provided document Masonic Homes of Kentucky Immunization Record revealed R27 received PPSV23 on 10/09/2020. There was no documentation that follow-up doses of pneumonia vaccinations had been offered, administered, refused, or received outside of the facility. During an interview on 08/01/2024 at 10:15 AM, the Infection Preventionist stated, I was not aware that we needed to offer follow-up pneumococcal vaccinations if they only received one dose. I thought they only needed the one dose. During an interview on 08/01/2024 at 10:35 AM, the Director of Nursing (DON) stated, We were not aware that we needed to offer additional doses of the pneumococcal vaccines to the residents.

Based on observation, staff interview, record review and policy review, it was determined the facility failed to observe infection control guidelines during a wound care dressing change for one of 21 sampled residents (Resident (R) 64) and during tracheostomy care for one of one facility residents (R3) with a tracheostomy. These failures had the potential to spread infections and/or cause the residents to potentially take antibiotics for infections that could have been prevented. The findings include: 1. Review of R64's undated Face Sheet, located under the Face Sheet tab in the electronic medical record (EMR), revealed R64 was admitted to the facility on [DATE] with the diagnosis of pressure ulcer of left buttock. Review of R64's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/2024 revealed R64 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which represented the resident was cognitively intact. R64 was also coded for a stage four pressure ulcer. Review of R64's Physician's Orders, provided by the facility and dated 05/21/2024, revealed Anasept (a broad-spectrum antimicrobial cleanser) 0.057% topical gel twice a day apply to left ischium (lower and back region of the hip bone) with calcium alginate and collagenase powder. Apply skin prep to entire bottom prior to applying bordered gauze. Review of R64's Care Plan, dated 04/25/2024 and located under the Care Plan tab in the EMR, revealed a Problem stating [R64] has area of concern to her l. [sic] (left) buttock with pressure properties stage 4. The interventions in place were 1. Complete weekly skin assessment. 2. Complete [NAME] Scale Risk Assessment on admission, quarterly, and as needed. 3. Treatment care as ordered, see current treatment record and physician's orders; monitor effectiveness of and response to treatment as ordered. 4. Monitor for pain related to alteration in skin integrity and medicate as needed per physician's orders. During wound care observation on 07/31/2024 at 1:46 PM with Registered Nurse (RN) 1, the following failures were noted: 1. RN1 took his clipboard into R64's room with the clean dressing supplies on top of it which RN1 worked from. 2. The overbed table contained personal items of R64. RN1 moved these to one side and placed his clipboard that had his clean dressing supplies beside these items. RN1 did not clean the overbed table nor place a barrier down before he placed the clipboard with the dressing supplies on the table. 3. RN1 attempted to clean the wound but had to place weight from his hand on the bed so that the linen would not touch the exposed wound. Once the hand was removed and RN1 turned to get the clean supplies to dress the wound, the linens on the bed touched the wound that had been cleaned. 5. Clean gloves were placed in RN1's pocket and were taken out when new gloves were needed. 6. After cleaning the wound, RN1 removed the Anasept ointment container from its bag, touching the container. RN1 then removed ointment from the container and replaced the ointment in its bag. Without changing gloves. RN1 cleaned the wound and placed a new dressing on the wound. 7. The clipboard taken in R64's room was returned to the wound care cart and RN1 did not clean the clipboard with a disinfectant wipe. During an interview on 07/31/2024 at 2:12 PM, RN1 stated, I always take my clipboard into the resident's room with their meds [medicines] or dressing supplies on it. When asked if this was best practice, RN1 replied I guess not . I did not realize that I did not change my gloves before I put on the new dressing. I should have wiped the table down, but I did not. The tube of Anasept was almost gone so I took it in the room with me. When asked if he cleaned the tube of medication with a bleach wipe, he stated, No. RN1 also stated, I did not think I needed something on the sheets because I did not think they would be touching the wound. But I see that I should have. During an interview on 07/31/2024 at 5:15 PM, the Infection Preventionist (IP), who was also the Staff Development nurse, stated, A nurse is not to take their clipboard in the resident's rooms. The IP confirmed the overbed table should be wiped with a disinfectant wipe before a barrier is put on the table and the nurse should change their gloves after cleaning a wound and before applying the new dressing to the resident's wound. During an interview on 07/31/2024 at 5:30 PM, the Director of Nursing (DON) stated, A nurse should not use their clipboard to place medicines or dressing supplies on and take it into the resident's room. The overbed tables should be wiped down with the bleach wipe and place a barrier down on it to lay your clean supplies on. The DON confirmed the nurse should change gloves between cleaning the wound and applying a new dressing to the wound. 2. Review of R3's undated Face Sheet, located under the Face Sheet tab in the EMR, revealed R3 was admitted to the facility on [DATE] with the diagnosis of chronic respiratory failure and tracheostomy and a new onset of shingles. Review of R3's quarterly MDS with an ARD of 05/23/2024 revealed R3 was coded as having a tracheostomy. Review of R3's Physician Orders provided by the facility revealed an order dated 07/27/2024 which was for contact isolation due to the resident having shingles to her left shoulder blade. During an observation on 07/31/2024 at 8:25 AM, RN1 was observed taking a personal clipboard in R3's room and laying it on the overbed table. RN1 performed tracheostomy care as ordered by the physician. When returning to the hallway, RN1 took the clipboard into the hallway and the clipboard was not cleaned. During an interview on 07/31/2024 at 5:15 PM, the IP stated, The nurse should not take a clipboard in the contact isolation room and if they do, they are to clean it with a bleach wipe. During an interview on 07/31/2024 at 5:30 PM, the DON stated, The nurse should not take any personal items into the isolation room,

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure discontinued controlled medication, awaiting destruction, were kept double-locked and in a permanently affixed compartment. The findings include: Review of the facility's policy, Narcotic/Scheduled Drug Tracking Policy, revised (MONTH) (YEAR), revealed discontinued medication would be removed from the medication cart and stored in the Director of Nursing's (DON) office under double-lock. Interview with the DON, on 04/11/19 at 11:45 AM, revealed when the facility discharged a resident, or if the medication order changed, the resident's controlled medications were removed from the medication cart and put in a cabinet in her office. Observation of the DON's office, on 04/11/19 at 12:15 PM, revealed controlled medication, awaiting to be destroyed, was stored in a two (2) drawer metal cabinet with a single lock and not permanently affixed. The cabinet contained 28 tablets of [MEDICATION NAME], 80 tablets of [MEDICATION NAME] 5 milligram (mg), 20 tablets of [MEDICATION NAME] 15 mg, 13 tablets [MEDICATION NAME] mg, 36 tablets of [MEDICATION NAME] 0.5 mg, 326 tablets of [MEDICATION NAME] 5-325 mg, 82 tablets of [MEDICATION NAME] 7.5-325 mg, 8 tablets of [MEDICATION NAME] 3.75 mg, 19 tablets of [MEDICATION NAME] 0.25 mg, 30 tablets of [MEDICATION NAME] 0.5 mg, 15 tablets of [MEDICATION NAME] 1 mg, 147 tablets of [MEDICATION NAME] 50 mg, 45 capsules of [MEDICATION NAME] 5 mg, 131 capsules of [MEDICATION NAME] 300 mg, 5 [MEDICATION NAME] 25 microgram patches, 91 milliliters (ml) of [MEDICATION NAME] 20 mg/1 ml, 270 ml of Hycet 15 mg/1 ml, and 135.5 ml of [MEDICATION NAME] 2 mg/1 ml. Interview with the Administrator, on 04/12/19 at 4:52 PM, revealed when controlled medications were discontinued, the nurse took them out of the medication cart, and then they were locked in the DON's office. She did not know if the cabinet in the DON's office was permanently affixed to anything.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure infection control practices were followed for one (1) of twenty (20) sampled and one (1) unsampled residents, Unsampled Resident A. Observation revealed Unsampled Resident A touched his/her roommate's bed remote and afterwards, did not wash his/her hands with soap and water. Unsampled Resident A's roommate had a [DIAGNOSES REDACTED]. The findings include: Review of the facility's policy, Cohorting of Residents, dated January 2016, revealed the infection control committee would provide accommodations to prevent the transmission of infectious agents that were spread by direct or indirect contact with the patient or the patient's environment. Cohorted residents were permitted to ambulate in other sections of the facility and socialize with other residents so long as the resident washed their hands prior to leaving the room. Observation, on 11/20/16 at 12:32 PM, revealed Unsampled Resident A and sampled Resident #4 shared a room, there was a sign outside the room that stated to see the nurse prior to entering along with Personal Protective Equipment available for use. Resident #4 was lying in bed and Unsampled Resident A was sitting in a wheelchair beside Resident #4's bed. Resident #4 asked Unsampled Resident A to pick up Resident #4's bed remote that had dropped on the floor. Unsampled Resident A reached down, picked the bed remote off the floor, and handed it to Resident #4. Unsampled Resident A then proceeded to watch television. Interview with Resident #4's Physician via the telephone, on 11/22/2016 at 11:48 AM, revealed Resident #4 had an active Clostridium Difficile infection and began antibiotics on 11/15/2016, that were administered daily. He stated Resident #4 would continue the antibiotic regimen until 11/29/2016. He stated that due to the reoccurrence of Clostridium Difficile in Resident #4, he planned to start a second round of antibiotics and keep the resident on contact precautions. Review of Resident #4's quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident was interviewable. Interview with Resident #4, on 11/22/2016 at 9:01 AM, revealed the resident knew he/she was diagnosed with [REDACTED]. Resident #4 stated staff did not inform him/her why employees wore a gown and gloves when they entered the room. Resident #4 stated staff did not explain to him/her what contact isolation meant. Review of Unsampled Resident A's quarterly MDS, dated on 11/4/2016, revealed the facility assessed the resident with a BIMS score of fifteen (15) out of fifteen (15) and determined the resident was interviewable. Interview with Unsampled Resident A, on 11/22/2016 at 9:08 AM, revealed staff did not inform him/her why employees wore a gown and gloves when they entered the room. Unsampled Resident A stated he/she did not receive any education on hand hygiene or about not touching Resident #4 or his/her belongings. Unsampled Resident A stated if Resident #4 asked him/her to pick up an item that had fallen on the floor; he/she would pick it up. Unsampled Resident A stated staff did not tell him/her not to touch Resident #4's items and did not give instructions on what to do after touching Resident #4 or his/her belongings. Unsampled Resident A stated he/she washed his/her hands after using the restroom but did not wash his/her hands before leaving the room unless they were dirty. Unsampled Resident A asked if he/she should be worried that he/she would catch something from Resident #4. Interview with the Infection Control Nurse, on 11/22/2016 at 09:15 AM, revealed the facility's process for implementing new contact precautions included educating the resident and the resident's roommate. She stated staff informed the resident and roommate's families as well. She stated the floor nurse was responsible for implementing the isolation initiation steps listed on a checklist. She stated the checklist was the only form of documentation the facility used to document new contact isolation precautions on Resident #4. She stated staff educated Resident #4 and Unsampled Resident A verbally and then checked it off on the checklist. She stated no other documentation was completed. Interview with Registered Nurse #1, on 11/22/2016 at 10:45 AM, revealed the nurse who cared for a resident placed on isolation precautions utilized the facility's isolation process in the task computer program. She stated the program was a checklist of tasks to complete and once completed, staff checked them off as completed in the task program. She stated communication to staff members, informing and educating the resident, informing and educating the resident's roommate, and notifying the roommate's responsible party, were on the checklist to complete. She stated no other documentation was required. She stated there was not a formal education policy for educating residents and their roommates. She stated she educated Resident #4 and Unsampled Resident A about hand hygiene on 11/15/16, according to the checklist, but did not do follow up education. She stated there was no facility policy about educating the resident or the resident's roommate after completing the initial education. She stated Unsampled Resident A was occasionally non-compliant with certain activities and if staff witnessed the resident leaving his/her room, staff would remind Unsampled Resident A to wash his/her hands. Interview with Director of Nursing, on 11/22/2016 at 1:24 PM, revealed the facility's process for initiating isolation precautions for residents was for the nurse to click and verify completion on the task list items in the computer. She stated the nurses were not required to do additional documentation, the checklist was the only form of documentation. She stated that without documentation of education for the resident and the resident's roommate, there was no way to know which residents were educated, when they were educated, or what education staff provided. She stated Unsampled Resident A was at risk of spreading Clostridium Difficile to other residents if proper hand hygiene was not followed, because he/she was self-ambulatory and traveled throughout the facility.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to have an effective system in place to ensure staff followed infection control practices related to hand hygiene by staff, use of Personal Protective Equipment (PPE) by staff and visitors, and disposal of sharps by staff during medication pass. Two (2) of three (3) Licensed Practical Nurses, (LPN #1 and #2). LPN #1 was observed in Resident #7's room, to untie an isolation gown with contaminated gloves, remove the gown then the contaminated gloves leaving the room without hand washing. LPN #1 used hand sanitizer to sanitize her hands after providing resident care when the sanitizer was ineffective against Resident #7's infection of Clostridium difficile Colitis. LPN #1 disposed of a syringe and needle without ensuring the sharps went down into the sharps container during medication pass. LPN #2 prepared medications and cleaned up a spill after which she administered medication without hand washing. One (1) of one (1) visitor was observed not using personal protective equipment (PPE) while adjusting the sheets on the bed and placing Resident #7's soiled personal clothing in a bag. Two (2) of five (5) Certified Nurse Assistants (CNA #2 and #3) were observed to enter the Resident #7's contact isolation room without donning PPE. CNA #2 entered the room to deliver a clean bedpan, opened the bathroom door with bare hands and CNA #3 entered to turn off the call light and bring the resident water with bare hands. The findings include: Review of the facility policy regarding Contact Precautions, not dated, revealed Clostridium difficille could be transmitted both directly and indirectly. Indirect contact would involve someone coming into contact with an inanimate object that had been in the resident's environment. Team members would use isolation precautions when caring for a resident who had a communicable disease that could be tramsmitted by direct contact with the resident. The staff was to wash their hands with soap and water before and after each resident contact. Review of the facility's policy regarding Hand Washing Policy, revised July 2013, revealed hands were to be washed before handling medications and after each resident's medication pass. In addition, if hands were not visibly soiled, hands may be decontaminated with an alcohol based hand rub, and when in doubt, wash hands. Review of the facility's policy regarding Sharps Disposal, dated August 2010, revealed sharps waste included needles, scalpels, razors or other sharp instruments used for resident care procedures. All such instruments should be segregated from other waste and placed in puncture resistant containers immediately after use. Immediately or as soon as possible after use, contaminated sharps should be placed in a sharps container. 1. Review of the clinical record for Resident #7, revealed the facility admitted the resident on 07/14/15 with [DIAGNOSES REDACTED]. diff), Congestive Heart Failure and Hypertension. The resident had nonhealing fractures of the right leg from previous falls prior to admission. Review of Resident #7's admission Minimum Data Set (MDS) assessment, dated 08/07/15, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 and determined the resident was alert, oriented and able to be interviewed. The resident had returned from a hospital stay for Congestive Heart Failure and was in isolation for a bowel infection. The facility further assessed the resident as requiring total assistance with transfers and extensive assistance for turning, dressing, grooming, and hygiene. Further the resident was incontinent of bowel and bladder. The resident received antibiotics for the infection. Review of Resident #7's care plan, dated 09/30/15, revealed the resident had an active infection with Clostridium difficille and required Isolation. The resident was experiencing mood symptoms of crying and feeling down. Interview with CNA #2, on 09/29/15 at 11:01 AM, revealed the Resident Summary contained instrutions for the CNAs to provide care to a resident. Review of the Resident Summary, dated 09/29/15, revealed Resident #7 required contact isolation for [DIAGNOSES REDACTED] and experienced incontinent episodes. The resident used a bedpan related to a fracture of the right leg. The resident was prescribed bedrest by the physician. Observation of Resident #7, on 09/29/15 at 10:03 AM, revealed the resident had turned the call light on and when CNA #3 entered the room without PPE and turned the call light off. The resident requested water and the CNA left and returned with water. The CNA donned gloves prior to entering the room; however, she did not don a gown to stand next to the bed and deliver the water. Interview with CNA #3, on 09/29/15 at 12:21 PM, revealed she was educated by the facility on isolation. She stated since some residents were allowed out of their rooms while on isolation, she felt she did not need to wear a gown in the resident's room unless she provided direct care. She stated germs could be passed to other residents. Observation of Resident #7, on 09/30/15 at 8:20 AM, revealed CNA #2, entered Resident #7's room without PPE, opened the bathroom door and left a new bedpan for the resident. Interview with CNA #2, 09/30/15 at 4:19 PM, revealed she did not wear PPE when entering Resident #7's room as she did not intend to provide direct care. She stated this was the way she understood isolation. She stated she was aware the reisdent had an infection of the bowel. She stated it was possible to spread an infection to other residents. Observation of Resident #7, on 09/30/15 9:25 AM, revealed LPN #1 removed PPE by untying the neck of the gown while wearing contaminated gloves and removing the gown first. She removed her gloves next and exited the room without handwashing. She was noted to apply hand sanitizer on the way out of the room. Interview with LPN #1, on 09/30/15 at 9:50 AM, revealed she had received education from the facility regarding isolation; however, she was not aware the gloves were removed first when exiting a isolation room. She stated that Resident #7 had C. diif in the stool and alcohol did not kill the spores. She stated she should have washed her hands with soap and water before leaving the isolation room to prevent spreading the infection. Interview with the Director of Nursing, on 10/01/15 at 3:33 PM, revealed nursing staff were trained on contact precautions. She stated staff could spread infection directly and indirectly. 2. Observation, on 09/30/15 at 8:10 AM, during the morning medication pass, revealed LPN #2, failed to wash her hands or use hand sanitizer after touching the lidded trash can affixed to the medication cart. LPN #2 spilled Med Pass supplement several times while attempting to pour it into a plastic 30 milliliter (ml) cup. As LPN #2 poured the Med Pass, she spilled the liquid onto the med cart, used tissues to clean up the spills, and lifted the trash can lid to deposit the soiled tissues. LPN #2 touched the lid and inside the trash can with her hands, five (5) separate times, and she failed to use the hand sanitizer available at the med cart or wash her hands with soap and water. LPN #2 continued to prepare the Med Pass supplement for the next resident on her med pass assignment. In addition, LPN #2 opened the unit dose blister packs of medications for the resident and dropped them into a med cup, but had still not sanitized her hands after touching the inside of the trash can and it's lid. Interview, on 10/01/15 at 10:25 AM, with LPN #2 revealed she should have washed or sanitized her hands after she touched the trash can affixed to the side of the med cart. LPN #2 stated the med cart trash can was considered dirty, and by touching the trash can, and then touching the med cart, she felt she contaminated the med cart's surface where she was preparing medications for residents. LPN #2 stated her initial thought was she should have put away the medications she was setting up and washed her hands at a nearby sink. LPN #2 stated she thought she just froze up. LPN #2 stated she typically kept hand sanitizer on her med cart and had hand sanitizer available for use when she was conducting the medication pass on the morning of 09/30/15. LPN #2 stated the facility had provided hand washing/hand hygiene education within the past six (6) months. 3. Observation, on 09/30/15 at 9:45 AM, revealed LPN #1 attempted to deposit a 10 ml syringe and needle into the sharps container affixed to the med cart when she was preparing an intramuscular injection. The nurse placed the syringe and needle in a concave cradle on top of the sharps container, but did not ensure it was deposited all the way into the sharps container before she walked away from the med cart. The sharps container was at hands reach and eye level for anyone passing by, including residents/visitors or others who would propel through the hallway in a wheelchair. LPN #1 proceeded to take medication to a resident's room, and knocked on the resident's door. At that point, the surveyor asked LPN #1 to come to the med cart and observe the syringe/needle that was lying on top of the sharps container. The nurse then deposited the needle/syringe all the way into the sharps container. Interview, on 09/30/15 at 9:52 AM, with LPN #1 revealed it was not ok for the needle to be left resting on top of the sharps container. LPN #1 stated a resident could obtain the syringe and she did not notice she had not completely deposited the needle into the sharps container. Interview, on 09/30/15 at 3:30 PM with the Magnolia Unit Coordinator, revealed she expected nurses assigned to medication pass to wash and/or sanitize their hands whenever they touched something that would be considered unclean, and the trash can at the med cart would be considered unclean. The Unit Coordinator stated staff were periodically observed on their med pass process and technique by corporate staff and by staff from the organization that provided the facility with contracted pharmacy services. Interview, on 10/01/15 at 2:40 PM, with the Director of Nursing (DON) revealed staff passing medications should, at a minimum, use hand sanitizer any time their hands became contaminated by touching items considered dirty. The DON stated the trash can on the med cart and its lid would be considered dirty, and the nurse should have sanitized her hands after touching it and before continuing to prepare the resident's supplement and medications. The DON stated sharps (needles/syringes) should be completely deposited in the facility's sharps containers. The facility's residents would have access to any sharp item not completely secured and out of reach. The DON stated her concern was the potential a cognitively impaired resident could have accessed the syringe/needle that was not deposited in the sharps container, and all of the testing and follow up that would have been necessary if there had been a needle stick injury.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure staff followed their policy regarding standards of practice for one (1) of nineteen (19) sampled residents and one (1) unsampled resident, Unsampled Resident A. LPN #1 administered an intramuscular (IM) injection to Unsampled Resident A, and failed to aspirate for blood prior to injecting the medication per facility policy; however, aspirated after the injection was completed and obtained blood in the hub of the needle. The findings include: Review, of the facility's policy regarding Intramuscular Medication Administration, not dated, revealed after positioning the resident, selecting the site for the injection, and cleaning the site with alcohol, the nurse was to insert the needle at a 90-degree angle, using a quick dart-like thrust. The nurse was to then pull back on the plunger to see if the needle was in a blood vessel. If blood appeared, the needle was to be withdrawn, new equipment and medication was to be secured and the procedure was to be repeated. Review, of the Lippincott Manual of Nursing Practice, Tenth Edition, 2014, General Considerations for Intramuscular Injections, page 1426, revealed after penetrating the injection site, aspirate (pull back on the syringe's plunger) to check for a blood vessel puncture. If blood vessel puncture occurred, remove the needle, discard, and start again. Review, of the clinical record for Unsampled Resident A, revealed the facility admitted the resident on 11/26/13 with [DIAGNOSES REDACTED]. On 09/29/15, Unsampled Resident A was diagnosed with [REDACTED]. The first dose of the medication was administered on 09/30/15 by Licensed Practical Nurse (LPN) #1. Observation, on 09/30/15 at 9:25 AM, revealed LPN #1 reconstituted the Ertapenem 1 GM with 3.2 milliliters (mls) of 1% [MEDICATION NAME] Solution, using a 10 ml syringe to accommodate the volume of medication to be prepared. Once LPN #1 prepared the medication, she then drew up the reconstituted medication from the vial into two (2) separate 3 ml syringes, as she stated the medication would not fit into just one 3 ml syringe. However, LPN #1 also stated that residents usually did not like receiving two (2) injections for delivery of the medicine. LPN #1 then proceeded to take the syringes of medication to Unsampled Resident A. Continued observation, revealed after positioning Unsampled Resident A on his/her left side, LPN #1 selected the injection site, the gluteal area of the resident's right hip. LPN #1 cleansed the skin at the site with alcohol and administered the first injection which contained 3 ml of the reconstituted Ertapenem. LPN #1 did not pull back on the plunger (did not aspirate) to ensure the needle did not hit a blood vessel, but proceeded to inject the medication. After the medicine was delivered, LPN #1 pulled back on the plunger and stated she did so to be sure the needle did not hit a vein. LPN #1 then cleansed another site on Unsampled Resident A's right gluteal area with alcohol and administered the remaining medication (about 0.1ml) via a second injection. Once again LPN #1 did not pull back with the plunger (did not aspirate) prior to delivering the medication. When LPN #1 removed the second syringe/needle from the resident a small amount of red substance (about 0.1-0.2 ml) was observed in the barrel of the syringe. Interview, on 09/30/15 at 10:02 AM, with LPN #1 revealed she thought the red substance in the syringe used to deliver Unsampled A's medication was blood, and she said this could have meant the needle hit the vein while she administered the second injection. LPN #1 stated she was supposed to aspirate before administering medication by the intramuscular route, but that she failed to do so. LPN #1 stated she was supposed to pull back slightly on the syringe prior to administering the injection to ensure the needle entered the muscle rather than a vein. LPN #1 stated Unsampled Resident A's antibiotic was ordered to be administered in the muscle, not in the vein. Interview, on 09/30/15 at 3:30 PM, with the Magnolia Unit Coordinator, revealed prior to actually injecting medication, nurses were to pull back on the syringe's plunger to determine if the needle had hit a blood vessel, and to prevent administering the medication incorrectly. The Unit Coordinator stated the facility kept six (6) ml syringes on hand and that the larger syringe should have been used to deliver Unsampled Resident A's medication. She stated providing the medicine via one injection would have prevented additional discomfort experienced from the second injection. Interview, on 10/01/15 at 3:00 PM, with the Director of Nursing (DON) revealed the Centers for Disease Control (CDC) guidance did not indicate aspiration was necessary prior to giving an intramuscular injection (IM). However, she stated, according to the facility's policy, licensed nurses were to pull back slightly with the syringe's plunger (check for aspiration of blood) prior to administering an intramuscular injection. She stated the appropriate size syringe and needle should be selected for the amount of IM medication to be administered. The DON stated that 1 injection would be preferred over 2 injections to minimize the resident's discomfort and to prevent unnecessary breaks in the integrity of the resident's skin. She stated the facility kept six (6) ml syringes on hand and the larger syringe could have been used to deliver just one (1) injection to Unsampled Resident A. Interview, on 10/01/15 at 5:10 PM, with the Registered Pharmacist (RPh), employed by the facility's contracted Pharmacy Service, revealed Unsampled Resident A was on a blood thinner which might make him/her slightly more prone to bleeding and the blood thinner could enhance the return of blood in the barrel of the syringe with an injection.

Based on interviews, record review, and facility policy review, it was determined the facility failed to follow it's Abuse Policy to report an allegation of abuse for one (1) of four (4) sampled residents, (Resident #1). The findings include: Review of the facility's Abuse Policy, revised July 2014, revealed on page four (4) of six (6) under item number seven (7) revealed if there was an allegation of abuse, neglect, or exploitation, the Administrator would notify the Department for Community Based Services (DCBS), the Office of the Inspector General (OIG), and if a suspected crime had been committed, the local police. Notifications would be made within two (2) hours of the facility notification. Review of the facility's investigation conducted on 02/25/15 after notification of the alleged physical abuse of Resident #1, revealed no evidence that DCBS or the OIG had been notified of the allegation. Interview with Assistant Director of Nursing, on 03/03/15 at 2:05 PM, revealed when she was notified of the alleged incident of physical abuse against Resident #1 by a Certified Nursing Assistant (CNA), a video was reviewed, staff and two (2) students and their instructor were interviewed, the incident was reported to the Administrator and no futher action had been taken by the facility to notify DCBS or OIG. In addition, she stated the Abuse Policy did state the DCBS and OIG were to have been notified. Interview with the Administrator, on 03/03/15 at 3:40 PM, revealed after viewing the video, he and staff investigating the alleged physical abuse allegation came to the decision the incident was unsubstantiated and DCBS, not OIG, were notified. In addition, he stated the Abuse Policy directed that DCBS and OIG were to be notified.

Based on interviews and record review, it was determined the Administrator failed to follow the Abuse Policy which stated to notify the appropriate agencies of an allegation of suspected Abuse when an allegation of physical abuse towards Resident #1 was reported to the facility. The findings include: Review of the facility's Abuse Policy, revised July 2014, revealed the Department for Community Based Services (DCBS), the Office of the Inspector General (OIG), and if applicable the local Police Department were to notified. Review of the facility's investigation of an alleged physical abuse against Resident #1 on 02/25/15, revealed no evidence was available that DCBS or OIG had been notified of the allegation. Interview with the Assistant Director of Nursing, on 03/03/15 at 2:05 PM, revealed she was the staff member to whom the allegation of physical abuse had been reported to. This was done by a local school's Clinical Instuctor on 02/25/15. She had only reported the allegation to the Administrator and the Social Services Director. She stated, she had not notified DCBS or OIG. Interview with the Administrator, on 03/03/15 at 3:40 PM, revealed the alleged physical abuse allegation had been reported to him on 02/25/15. He stated the facility investigated the allegation; however, could not substantiate the allegation and therefore did not report the allegation to DCBS or OIG. In addition, he stated the facility policy stated to report any alleged allegation of abuse to DCBS, OIG, and if applicable the Local Police.

Based on observation, interview and record review, it was determined the facility failed to conduct a thorough investigation into one (1) of ten (10) sampled residents. Resident #1 reported a missing wallet, containing $85.00 dollars and driver's license. The facility failed to interview all staff on duty during the time frame identified. In addition, the facility failed to notify appropriate law enforcement agencies once determination was made there was a possibility a staff member had taken the wallet and its contents. The findings include: Review of the facility's Abuse Reporting and Prevention policy revealed any allegation from facility staff, residents, or other persons related to the facility, relating to actual or suspected abuse would be thoroughly investigated in-house by the Administrator and/or designated facility staff. If there was an allegation made of abuse, neglect or exploitation, the Administrator, or designee, would notify the Department for Community Based Services and Licensure & Regulation immediately. If there was a suspicion of a crime, the Administrator, or designee, would notify the Office of the Secretary and other law enforcement agencies as required by federal or state governing bodies within two hours. If any employee was deemed responsible for the reported act(s) of abuse, that employee would be instructed to report directly to the Administrator and Department Head for appropriate disciplinary action, up to and including termination of employment. Review of Resident #1's Admission Minimum Data Set (MDS) assessment, completed on 09/18/14, revealed a Brief Interview Mental Status (BIMS) exam was conducted and the resident scored a fourteen (14) out of fifteen (15) indicating cognitively intact. Interview with Resident #1, on 10/28/14 at 11:10 AM, revealed the last time Resident #1 had seen the wallet was on 10-17-14 when it was secured in the locked box. Resident #1 stated Sunday morning church services were about to begin and wanted to take money to put in the offering plate. Resident went to the locked box to retrieve the wallet and found it missing. Resident #1 immediately reported the missing wallet to staff. Continued interview with Resident #1 revealed the wallet was leather, brown in color and contained $85.00 dollars: four (4) $20.00 dollar bills; and one (1) $5.00 dollar bill, along with a driver's license, social security card, and insurance card. Resident #1 stated the wallet was kept in a locked box in the second drawer and the key was kept hidden in the bottom drawer. Resident #1 requested police notification; however, the facility staff said they wanted to handle it in house. Resident #1 continued to state concerns about identity theft due to the types of cards in the wallet. Resident #1 stated a few days later facility staff informed him they had viewed the surveillance videos and thought they knew who might have taken wallet, but could not be certain. Telephone interview with CNA #1, on 10/29/14 at 1:55 PM, revealed Resident #1 reported a wallet missing from the locked box around 9:15 AM on 10/19/14. She stated the resident told her the wallet contained money, a driver's license, a social security card and insurance cards. The CNA notified LPN #1 regarding Resident #1's report of a missing wallet. CNA #1 stated while Resident #1 reported a missing wallet and contents to LPN, she search the resident's belongings and room; however, the search was unsuccessful in locating the wallet or its contents. Telephone interview with LPN #1, on 10/29/14 at 1:37 PM, revealed Resident #1 reported a wallet containing money, identification, insurance card and social security card as missing. A search was conducted, but was unsuccessful in locating the missing wallet or its contents. LPN #1 did not feel the need to do any further investigation due to the belief the wallet was just misplaced by the resident. LPN #1 stated Social Services conducted investigations regarding missing items, and since it was Sunday, she left a voice mail for the Social Services Director regarding the missing wallet. Telephone interview with Resident #1's immediate Family Member/Power of Attorney, on 10/28/14 at 8:04 AM, revealed they were in the facility on 10/19/14 at 09:45 AM to attend church with Resident #1. The Family Member stated Resident #1 informed them of the missing wallet. The Family Member stated they had removed the social security and insurance cards a couple of weeks ago, but left the $85.00 dollars, driver's license and a Kroger card in the wallet. The Family Member stated they spoke with nursing staff and they were aware of the missing wallet and had notified Social Services. The Family Member stated Resident #1 wanted a police report to be made, but the facility told them they had regulations to follow and wanted to investigate before calling the police. Continued interview with the immediate Family Member revealed Social Services informed them the facility surveillance videos were reviewed, and a weekend employee was identified as the thief and the individual had self-terminated. The Family member stated it seemed like more should have been done. Interview with the DON, on 10/29/14 at 11:30 AM, revealed they did not call the police on 10/20/14 when they received notification of a missing wallet. She continued to state they should have contacted the police when they made their other required notifications. She stated notifying the police was on their checklist form as one of the tasks to complete, she was just not sure why they didn't. Interview with the Social Services Director (SSD), on 10/28/14 at 14:50 PM, revealed she had reviewed the surveillance video of the time CNA #1 provided care to Resident #1 and did not find any suspicious behavior. Continued interview revealed she did not notify the police department once a determination was made regarding the possibility that CNA #1 could have taken the resident's wallet until the Administrator directed her to do so on 10/28/14. She stated she called and gave a report to the Sheriff 's office at 12:20 PM on 10/28/14. She also stated they had not questioned all staff on duty during the identified time frame the wallet was missing, and was not aware of this until today. Continued interview with the DON, on 10/29/14, revealed she called CNA #1 twice on the evening of 10/20/14 and left messages with a male that answered the phone. The DON stated, CNA #1 did not return calls and she did not make any other attempts to contact CNA #1. The DON also stated she did not direct staff to contact her if CNA #1 called or came into the facility. The DON stated the determination that it was possible CNA#1 had taken the wallet was made because she: left early on Friday; did not come to work on Saturday or Sunday; was having financial difficulties; and self-terminated. She stated there were two different lists developed to account for statements and a correlation of the two was not completed to ensure everyone had been interviewed. Interviews, on 10/28/14 at 1:35 PM and 1:45 PM with the Staffing Coordinator and the Business Office Manager revealed they both had spoken with CNA #1 over the phone around 9:00 AM on 10/28/14. The Business Manager stated CNA #1 came to the facility on [DATE] to speak with her about her payroll check. The manager was not aware the Administrator needed to speak with CNA#1. Interview, on 10/28/14 at 1:00 PM, with CNA#2 revealed she worked the morning of 10/17/14 until about 10:00 AM. She said she spoke with the Unit Coordinator and requested to leave early and would not be coming back. CNA#1 stated her payroll check was short and she needed to leave to take care of business. She said she was in Resident #1's room several times assisting both Resident #1 and #2. She stated she did not see resident's wallet or money while in the room. She also stated she did not open the lock box or take $85.00 dollars from Resident #1. CNA#1 stated the DON did try to contact her on Monday, but they had yet to have a conversation. CNA #2 stated she made the decision not to return because she believed the facility was not paying her correctly. She also stated that she was in the facility on 10/20/14 and she did call the facility on 10/28/14 around 8:45 AM to inquire about hours on next check and was not told she needed to be interviewed for an allegation of suspected misappropriations. Review of the surveillance video on 10/29/14 of footage for 10/17/14 from 6:11 AM to 11:33 AM (time frame CNA #2 worked and would have had access to Resident #1's wallet) revealed CNA #2 entered Resident #1' s room at 7:04 AM, 7:12 AM, and 7:54 AM with no suspicious behavior noted. In addition, four (4) other staff members were viewed entering and exiting Resident #1's room during 6:11 AM and 11:33 AM timeframe with no suspicious behavior noted. Interview with the Administrator, on 10/28/14 at 11:50 AM, revealed he was out of town during the time Resident #1's missing wallet was being investigated. He also stated he was not aware appropriate law enforcement agencies had not been contacted. In addition, he was not aware the DON and Social Service Director (SSD) had not interviewed all potential staff identified during shifts the wallet was missing. He stated he had a telephone conversation with the DON and SSD to review the findings of the investigation, but he was not informed of the incomplete investigation and that all authorities were not contacted. He stated he did not question the thoroughness of the investigation or provide any direction to call the police during their telephone conversation. Continued interview, on 10/29/14 at 3:00 PM, with the Administrator revealed he believed the facility completed a thorough investigation even though, Nursing and Social Services did not: interview all potential staff on duty during the time frame of the event; document a patient assessment on the day of the allegation; or notify the police timely.

Based on observation, interview and record review, it was determined the facility failed to follow their policy and procedures for investigating an allegation of misappropriation of a resident's property for one (1) of ten (10) sampled residents. (Resident #1) The findings include: Review of the facility's Abuse Reporting and Prevention policy revealed consistent monitoring/intervention would be carried out by all supervisory staff in an effort to teach and prevent escalation of an event; and, signs of stress/burnout. Any allegation from facility staff, residents, or other persons related to the facility, relating to actual or suspected abuse would be thoroughly investigated in-house by the Administrator and/or designated facility staff. The Administrator, or designee, would initiate an in-house investigation into any allegations and make appropriate determinations related to reporting of events to the Department of Social Services and Licensure & Regulation of the state of Kentucky. If there was an allegation made of abuse, neglect or exploitation, the Administrator, or designee, would notify the Department for Community Based Services and Licensure & Regulation immediately. If there was a suspicion of a crime, the Administrator, or designee, would notify the Office of the Secretary and other law enforcement agencies as required by federal or state governing bodies within two hours. Each supervisor, Department Head or designee would immediately inform the Administrator, or designee of the report and receive directions for further steps to be followed. As soon as possible, all information related to a report of abuse, would be obtained in writing from all persons with knowledge of the reported incident. Pertinent interviews would be conducted in a confidential, professional manner with a need to know priority of information. These interviews would include the resident, if possible, the individual reporting the event, all staff on duty at the time of the event with any probable first hand information, any other individual present in the area at the time of the reported incident. These interviews would be put in writing and discussed only by those with responsibility for determining substantiation of the report. If any employee was deemed responsible for the reported act(s) of abuse, that employee would be instructed to report directly to the Administrator and Department Head for appropriate disciplinary action, up to and including termination of employment. Continued review of policy revealed the charge nurse would complete an assessment of the Resident's condition. Review of Resident #1's Admission Minimum Data Set (MDS) assessment, completed on 09/18/14, revealed a Brief Interview Mental Status (BIMS) exam was conducted and the resident scored a fourteen (14) out of fifteen (15) indicating cognitively intact. Interview with Resident #1, on 10/28/14 at 11:10 AM, revealed the last time Resident #1 had seen the wallet was on 10/17/14 when it was secured in the locked box. Resident #1 stated Sunday morning church services were about to begin and wanted to take money to put in the offering plate. Resident went to locked box to retrieve wallet and found it missing. Resident #1 immediately reported missing wallet to staff. Telephone interview with Resident #1's immediate Family Member/Power of Attorney, on 10/28/14 at 8:04 AM, revealed Social Services informed them the facility surveillance videos were reviewed, and a weekend employee was identified as the thief and the individual had self-terminated. The Family Member stated, it seems like more should have been done. Review of Resident #1's medical record revealed the nursing staff did not complete an assessment of Resident #1 for psychological effects from the missing wallet as per their policy. Telephone interview with LPN #1, on 10/29/14 at 1:37 PM, revealed she did not complete a nursing assessment because she believed the wallet was misplaced and not stolen. Interview with the DON, on 10/29/14 at 11:30 AM, revealed they did not call the police on 10/20/14 when they received notification of the missing wallet, because the report at first was treated as a misplaced wallet not one that was stolen. She continued to state they should have contacted the police when they made their determination and other required notifications. She stated notifying the police was on their checklist form as one of the tasks to complete, she was just not sure why they didn't, once there was a suspicion of a crime (as stated per policy). Interview with the Social Services Director, on 10/28/14 at 2:50 PM revealed when she began her investigation on 10/20/14 and she treated it as a misplaced wallet, a search was conducted and laundry was called. After the determination was made that CNA#2 could have taken the wallet, again a decision to call the police was not made. She stated she had not notified the police until the Administrator directed her to do so on 10/28/14. She stated she called and gave a report to the Sheriff 's office at 12:20 PM on 10/28/14. She also stated they had not questioned all staff on duty during the identified time frame the wallet was missing, and was not aware of this until today. Continued interview with DON, on 10/29/14 revealed she called CNA #1 twice on the evening of 10/20/14. The DON stated, CNA #1 did not return calls and she did not make any other attempts to contact the CNA. The DON also stated she did not direct staff to let her know if CNA #1 called or came into the facility. The DON stated the determination that it was possible CNA#1 had taken the wallet was made, because she: left early on Friday; did not come to work on Saturday or Sunday; was having financial difficulties; and, self-terminated. In addition, the DON was not aware all staff on duty during the identified time frame the wallet was missing had not been questioned. She stated there were two different lists developed to account for statements and a correlation of the two was not completed to ensure everyone had been interviewed. Further discussion with the DON revealed re-education of all staff on abuse and misappropriation of resident belongings, as an effort to teach and prevent escalation of an event of abuse (per policy), had not been provided as of 10/29/14, but was scheduled for 11/04/14. Interview, on 10/28/14 at 1:00 PM, with CNA #2 revealed she worked the morning of 10/17/14 until about 10:00 AM. CNA #1 stated the DON did try to contact her on Monday, but they had yet to have a conversation. CNA #2 stated she made the decision not to return because she believed the facility was not paying her correctly. She also stated she was in the facility on 10/20/14 and she did call the facility on 10/28/14 around 8:45 AM to inquire about hours on the next check and was not told she needed to be interviewed for an allegation of suspected misappropriations. Review of the surveillance video on 10/29/14 of footage for 10/17/14 from 6:11 AM to 11:33 AM (time frame CNA #2 worked and would have had access to Resident #1's wallet) revealed CNA #2 entered Resident #1's room at 7:04 AM, 7:12 AM, and 7:54 AM with no suspicious behavior noted. In addition, four (4) other staff members were viewed entering and exiting Resident #1's room during 6:11 AM and 11:33 AM timeframe with no suspicious behavior noted. Interviews, on 10/28/14 at 1:35 PM and 1:45 PM, with the Staffing Coordinator and the Business Office Manager revealed they both had spoken with CNA #1 over the phone around 9:00 AM on 10/28/14. The Business Manager stated CNA #1 came to the facility on [DATE] to speak with her about her payroll check. The manager was not aware the Administrator needed to speak with CNA #1. Interview with the Administrator, on 10/28/14 at 11:50 AM, revealed he was out of town during the time Resident #1's missing wallet was being investigated. The Administrator stated the faxed report to OIG was enough information for a thorough investigation. He further stated he would have to find out if the police were notified. He returned and stated the facility had not notified law enforcement. In addition, he was not aware the DON and Social Service Director (SSD) had not interviewed all potential staff identified during shifts the wallet was missing. He stated he had a telephone conversation with the DON and SSD to review the findings of the investigation, but he was not informed of the incomplete investigation and that all authorities were not contacted. He stated he did not question the thoroughness of investigation or provide any direction to call police during their telephone conversation. Continued interview, on 10/29/14 at 3:00 PM, with the Administrator revealed he believed the facility followed their policy and procedure and completed a thorough investigation even though, Nursing and Social Services did not: interview all potential staff on duty during the time frame of the event; document a patient assessment on the day of the allegation; or notify the police timely.

Based on observation and interview, it was determined the facility failed to ensure handrails were securely fastened to the wall on three (3) of the seven (7) resident hallways. The findings include: The facility did not provide a policy regarding maintenance of the handrails. Observations during the environment tour, on 07/17/14 at 1:25 PM, revealed the handrail beside room 406, between rooms 408 and 410, and between rooms 302 and 304 were found loose and not firmly secured to the wall. The handrail located by room 308, which extended to the end of the hall was found loose and the back board it was attached to easily pulled out of the wall. Interview with the Maintenance Assistant, on 07/17/14 at 2:50 PM, revealed handrails were assessed monthly to ensure they were secure and was last completed at the end of June, 2014. The Maintenance Assistant revealed he was not aware of the loose sections of handrails but stated they were an older type of handrail that tends to come loose more easily. The Maintenance Assistant revealed handrails should be secured to the wall for resident safety.

Based on observation, interview, and review of the facility's admission packet containing Residents' Rights For Residents in Kentucky Long-Term Care Facilities, it was determined the facility failed to ensure the survey results were readily available to residents for three (3) of three (3) nursing units. The findings include: Review of the Residents' Rights for Residents in Kentucky Long-Term Care Facilities in the facility's admission packet revealed each resident and the responsible party and/or guardian had the right to have access to all inspection reports on the facility. Observation, on 07/15/14 at 9:18 AM, of the Rehabilitation Unit entrance located on the same level as resident rooms, revealed there was no survey book in the waiting area for review. Observation of the Main entrance area on the upper level at 9:35 AM, revealed the survey book was located on a table by the business office. Staff had to propel and transport residents up and down an inclind ramp to the Main entrance, that separated the resident's from access to the survey book. Interview with the Maintenance Director, on 07/17/14 at 6:09 PM, revealed he had measured a distance of two hundred eighty-eight (288) feet from the main entrance by the survey book to the central nursing station located at the bottom of the ramp. Interview with Certified Nursing Assistant (CNA) #2, on 07/17/14 at 1:50 PM, revealed she was not aware of any residents who could self-propel themselves up the ramp because it was too steep. The CNA revealed staff have always had to help them up the ramp. The CNA revealed she had not seen a survey book accessible on the lower level. Interview with the Unit Secretary, on 07/17/14 at 1:55 PM, revealed she could not recall a survey binder located on the lower level for residents' to view. Interview with the Central Unit Coordinator, on 07/17/14 at 2:00 PM, revealed she was told there was a survey binder at the Rehabilitation entrance. While the Unit Coordinator was looking around the waiting area at the Rehabilitation entrance, the Business Office Manager was observed walking through the entrance and handing a survey binder to the Administrative Assistant behind the desk. Interview with the Administrative Assistant, on 07/17/14 at 2:02p PM, revealed she normally kept the binder in the bottom of the cabinet behind the desk. The Administrative Assistant revealed she was not aware the survey binder needed to be accessible to the residents. Interview with the Business Office Manager, on 07/17/14 at 2:03 PM, revealed the resident could still access the binder if they came behind the desk and removed it from the cabinet. Observation of the desk revealed it was enclosed by a wooden swinging door. Continued interview with the Business Office Manager revealed she did not know if wheelchairs could fit through the opening with the swinging door, did not know if the residents were aware of the survey binder location in the cabinet, and did not know if residents and visitors were even allowed behind the desk. Interview with the Central Unit Coordinator, on 07/17/14 at 2:05 PM, revealed the survey book should be readily accessible for residents to review and was a resident's right to have access to the survey book. Interview with Administrator, on 07/17/14 at 3:45 PM, revealed he was aware access to the survey book was a resident right; however, he did not see where the ramp created a problem for the residents because the residents could go outside and wheel themselves to the other entrance to access the survey binder. The Administrator revealed he was not aware of another binder ever being kept at the Rehabilitation entrance. Interview during the Quality of Life Assessment Group Interview, on 07/15/14 at 3:45 PM, revealed Resident #14 was not aware of a survey information binder, nor was the resident knowledgeable of the location of the survey binder to review.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure food was served to all residents under sanitary conditions. Five (5) of six (6) Dietary employees failed to observe the facility's hand washing policy while washing their hands. The findings include: Review of the facility's Hand Washing Policy, dated 05/2012, revealed hands were washed before and after handling food. During the hand washing procedure, hands were to be vigorously rubbed together for twenty (20) seconds, generating friction on all surfaces of the forearms, hands, and fingers. Observation of the lunch meal in the main dining room kitchen, on 07/02/13 at 11:15 AM, revealed Dietary Aide (DA) #1 was observed to leave the serving line and open drawers and the refrigerator to obtain supplies. Prior to returning to the serving line, she removed her gloves and washed her hands. She was noted to rub hands together with soap and water and timed for six (6) seconds. Observation of the lunch meal in the main dining room kitchen, on 07/02/13 at 11:19 AM, DA #2 was observed to leave the serving line and open cabinets and drawers obtaining supplies. Prior to returning to the serving line, she removed her gloves and washed her hands using soap and water. She rubbed her hands with soap and water and was timed for eleven (11) seconds. Observation of the lunch meal in the main dining room kitchen, on 07/02/13 at 11:25 AM, the Dietary Manager was observed to enter the kitchen and wash her hands. She was noted to rub her hands with soap and water and timed for ten (10) seconds. Interview with DA #1, on 07/02/13 at 11:30 AM, revealed she had received training on hand washing several months ago. She stated hands were to be washed with soap and water for twenty (20) seconds. She stated she did not time the length of time she performed this task. She stated hands were washed to prevent the spread of infection. Interview with DA #2, on 07/02/13 at 11:36 AM, revealed she was trained on hand washing in the past. She stated hand washing with soap and water was needed for twenty (20) seconds to stop infection. Interview with the Dietary Manager, on 07/02/13 at 11:45 AM, revealed she did supervise the staff to ensure procedures were followed regarding hand washing. She stated hand washing should be done for twenty (20) seconds to prevent the spread of infection. She stated everyone was nervous because surveyors were observing and so mistakes were made. Observation of the Bistro Dining Room, on 07/02/13 at 11:42 AM, revealed the serving line for lunch was in progress. DA #4 was noted to leave the serving line and go to a back area. When he returned, he removed his gloves and washed his hands with soap and water timed for six (6) seconds. He then returned to the serving line. Continued observation of the Bistro Dining Room, on 07/02/13 at 11:55 AM, revealed DA #5 left the serving line and opened the refrigerator and several drawers for supplies. Prior to returning to the serving line, she was noted to wash her hands with soap and water and timed rubbing hands for five (5) seconds. Interview with DA #4, on 07/02/13 at 12:05 PM, revealed he had been trained on hand washing for twenty (20) seconds in the past. He stated he did not time the amount of time spent rubbing hands with soap and water. He stated germs were spread if hands were not washed correctly. Interview with DA #5, on 07/02/13 at 12:10 PM, revealed she had received training on hand washing in the past. She stated she had not timed herself during the hand washing. She stated hand washing prevented the spread of disease. Interview with the In-service Coordinator for the facility, on 07/03/13 at 10:00 AM, revealed all staff were trained on hand washing during orientation. She stated she and the Dietary Manager were both responsible to train staff on hand washing and the Dietary Manager was responsible to monitor the staff in the kitchen. She stated hands must be rubbed with soap and water for twenty (20) seconds to prevent the spread of infection.

Based on observation, interview and review of the Resident Information Packet, it was determined the facility failed to provide a comfortable sound level in the Bistro dining room during the lunch meal on 07/02/13. The noise from two (2) televisions were at an uncomfortable level for one (1) of twenty-one (21) sampled residents, Resident #13. The findings include: Review of the Resident Information Packet provided to the residents upon admission, revealed under the Resident's Rights section the resident would be treated with consideration, respect, and with full recognition of the resident's dignity and individuality. Observation, on 07/02/13 at 11:20 AM, revealed two television sets on, both approximately three feet apart, were on different channels with the volume on at a level in which both televisions could be heard at the same time. The residents were entering the dining room for their noon meal. Residents were observed being asked what they would like for their lunch; however, at no time were the residents asked if they wanted the televisions on, if the sound was too loud, or if it was distracting to have two (2) different stations playing different programs at the same time. Continued observation revealed Resident #13 entered the Bistro in a wheelchair. Resident #13 was then placed at a table directly in front of one of the televisions, with his/her back to the television and the sound near his/her ears. Resident #13 was not asked if he/she wanted the television on or if the volume was too loud for the resident. Interview, on 07/02/13 at 11:25 AM, with Resident #13 revealed the resident was not hard of hearing. Resident #13 stated, related to the television behind him/her and the sound level, he/she didn't see the remote here or he/she would have turned it off. Following his/her statement, which was heard by staff present in the dining room, a staff member tried three (3) different remotes before the sound was lowered on the television next to Resident #13. Resident #13 continued by stating that's a whole lot better. Resident #13 stated he/she did not watch much television . In addition, Resident #13 had not been asked if the sound was too loud or if he/she minded sitting with his/her back to the television while it was on. Interview, on 07/03/13 at 3:00 PM, with the Director of Nursing (DON) revealed residents had asked for the televisions to be on in the morning and evening in order to watch the news. She revealed the noise level of the televisions were not monitored.

Based on observation, interview, review of facility's policies, the Centers for Disease Control (CDC) Guideline for Handwashing Techniques, and the facility's Performance Evaluation for Mini Neb Administration, it was determined the facility failed to store oxygen equipment properly to prevent the spread of infection for one (1) (Resident #3) of the twenty (20) sampled residents, and four (4) unsampled residents. Unsampled Residents A, B, D and E, who were receiving oxygen treatments. In addition, the facility failed to ensure staff changed their goves and washed their hands when moving from dirty to clean during skin assessments for six (6) of ten (10) sampled residents, Resident #2, #3, #4, #6, #8 and #12. Additionally, the facility failed to ensure staff washed their hands prior to putting gloves on to perform catheter care for one (1) of three (3) sampled residents with a catheter, Resident #17. The findings include: Review of the facility's policy regarding Oxygen Therapy, Revised 04/09, revealed for the purpose of infection control, the oxygen equipment was to be labeled with the date and time, and to be stored in a zip-lock bag at bedside when not in use. Review of the facility's Performance Evaluation Mini Neb Administration, Revised 04/09, revealed the atomizer was to be rinsed out after use and stored in a zip-lock bag at bedside. Review of the facility's RN/LPN Orientation Checklist revealed new employees were in-serviced and checked off on the care of oxygen equipment. Observation, on 05/01/12 starting at 7:00 AM, during the facility tour revealed Unsampled Resident E sitting in a wheelchair with an oxygen tank on the back of the wheelchair. The tank had oxygen tubing and a nasal cannula wrapped around the top of the tank, uncovered and undated. In addition, at the bedside of Unsampled Resident E was an uncovered mini-neb with droplets in the chamber. Residents #3 and Unsampled Resident A each had oxygen tubing with nasal cannula coiled up and placed on top of their oxygen concentrator in their room, uncovered and unlabeled. On the bed of Unsampled Resident B was an uncovered, undated nasal cannula and tubing. In the room of Unsampled Resident D was oxygen tubing with a nasal cannula lying across the air conditioning/heating unit, uncovered and undated. Interview, on 05/02/12 at 3:30 PM, with the North Unit Coordinator revealed oxygen equipment, nasal cannulas, tubing and mini-nebs, were to be stored in the resident's room in a baggie when not in use. She stated the storage was for infection control, to prevent contamination of the equipment. If contaminated, a resident may become ill. Interview, on 05/02/12 at 4:15 PM, with the South Unit Coordinator revealed oxygen equipment was to be stored in bags in resident's rooms when not in use. She revealed this was for infection control and to keep the equipment clean. Failure to store the equipment properly may result in an infection to the resident. She stated there had been training on the use and storage of oxygen equipment. She stated "all of us" were responsible to monitor the equipment for proper storage. Interview, on 05/02/12 at 4:37 PM, with the Assistant Director of Nursing (ADON) revealed oxygen equipment was to be stored in a baggie in the resident's room when not in use. This was to keep it clean, she stated, for infection control purposes. It was revealed the staff had been trained on the storage of oxygen equipment and there was a risk of infection to the residents if not stored properly. She stated no one person was responsible to monitor the oxygen equipment, that everyone was responsible. Oxygen equipment and infection control were monitored within the facility as part of their Quality Assurance (QA) program, she revealed. Interview, on 05/03/12 at 11:50 AM, with the Director of Nursing (DON) revealed oxygen tubing with nasal cannulas and nebulizer's were to be stored covered and the staff had been trained to store oxygen equipment in that manner. She revealed no one person was responsible to monitor the oxygen equipment but numerous people in different capacities within the facility, to include the Infection Control Committee and QA Committee, were to monitor the oxygen equipment. Review of the facility's policy regarding Standard Infection Precautions, Revised 06/11, revealed hand hygiene was to be performed each time gloves were removed. Review of the Centers for Disease Control (CDC) Guideline for Handwashing Techniques, dated 10/25/02, revealed after gloves were removed, hands should be washed with a non-antimicrobial or an antimicrobial soap and water or disinfected with an alcohol-based hand rub. In addition, it stated to change gloves during patient care if moving from a contaminated body site to a clean body site. Review of the facility's Infection Prevention Team policy, Reviewed 01/14/11, revealed to prevent the spread of infection the staff was required to wash their hands or use hand sanitizer after each direct resident contact for which hand washing was indicated by acceptable professional practice. Review of the facility's policy regarding Urinary Tract Infections, Reviewed 09/10, revealed standard infection control practices were to be utilized in managing catheters. Review of the facility's Basic Infection Control/Prevention of UTI (urinary tract infection) attached to the Urinary Tract Infections policy revealed to wash hands before and after all procedures. Review of the facility's policy regarding Skin/Hydration Assessment, revised 11/09, revealed the policy did not include any information or practice related to washing hands before the assessment, upon going from clean to non-clean during the assessment or upon the completion of the assessment. Handwashing was not included in the policy. 1) Observation, on 05/02/12 at 11:00 AM, during the skin assessment of Resident #3 performed by Licensed Practical Nurse (LPN) #1, revealed the assessment was started with the feet of the resident. The buttock and peri area were assessed and touched with the gloved hands of LPN #1. LPN #1 moved up the body of Resident #3 with the assessment, concluding at the resident's head. The head of the resident was touched with the same gloves which were worn to assess the peri and buttock area of the resident. Gloves were not changed, or hands washed, when moving from a non clean area to a clean area. Interview, on 05/02/12 at 3:05 PM, with LPN #1 revealed she was aware she should have changed gloves and washed her hands when she went from dirty to clean during the skin assessment of Resident #3. She revealed the reason to wash her hands was for infection control and the failure to wash may cause the resident to become ill from different infections. 2) Observation, on 05/03/12 at 9:20 AM, during the catheter care of Resident #17 performed by Certified Nursing Assistant (CNA) #1, revealed CNA #1 had just completed assisting a nurse with a dressing change in the area of the peri-anal region and helped hold the resident on his/her side. CNA #1 then changed gloves to perform the catheter care but did not wash her hands as indicated in the policy for Basic Infection Control/Prevention of UTI. Interview, on 05/03/12 at 9:35 AM, with CNA #1 revealed she had been in-serviced on when to wash her hands and put on gloves. She revealed she was aware she should have washed her hands before putting on gloves to perform the catheter care on Resident #17. She stated the reason to wash her hands and change gloves before starting the catheter care was to prevent cross contamination. 3) Observation, on 05/01/12 at 2:30 PM, during Residnet #4's skin assessment with LPN # 3 revealed she touched the resident's privacy curtain with her dirty gloves after a skin assessment. Interview attempted, on 05/03/12 at 3:00 PM, with LPN #3 without an answer or returned call. 4) Observation, on 05/02/12 at 9:20 AM, during Resident #8's skin assessment with the South Unit Coordinator nurse in the South Wing shower room while sitting in a shower chair revealed she failed to her wash hands and put on gloves prior to resident contact. The Unit Coordinator from the South Wing completed her skin assessment with Resident #8 and walked out of the shower room to the South Unit nursing desk and sat down in front of the computer at the desk. Interview, on 05/03/12 at 10:10 AM, with the South Unit Coordinator nurse revealed the facility policy was to wash her hands before entering a room, before she had provided care to Residnet #8 and she should have put gloves on before performing a skin assessment. The nurse confirmed the facility had provided her with the orientation education on infection control and handwashing which she had completed a skills check off before she started working on the floor. The South Unit Coordinator nurse revealed the lack of handwashing and glove use put everybody at risk for the spread of infection and contamination issues. She further stated as the Unit Coordinator it was her role to monitor facility staff on the South Wing for infection control issues and retrain as needed. 5) Observation, on 05/02/12 at 9:55 AM, revealed during a skin assessment for Resident #2, the Registered Nurse (RN) did not change her gloves or wash her hands after assessing the resident ' s buttocks and peri area. The RN then assessed the resident's face and disconnected the resident's feeding tube. Interview, on 05/03/12 at 10:15 AM, with RN #1 revealed the nurse stated she should have changed her gloves and washed her hands after assessing Resident #2's buttocks and peri area. The RN stated she had been trained to conduct skin assessments and to change gloves and wash hands after assessing the resident's buttocks and peri areas, however stated she sometimes took short cuts when she got busy. She stated not washing hands or changing gloves was an infection control issue and could spread organisms from the peri area to other areas of the skin. 6) Observation, on 05/02/12 at 9 AM , revealed during the skin assessment for Resident #6, Licensed Practical Nurse (LPN) #1 started the assessment at the feet, moved to the legs, and the abdomen. LPN #1 removed Resident #6's [DEVICE] dressing, cleansed the site with Dial liquid gel soap, removed her gloves, applied clean gloves, and cleansed the [DEVICE] site with a packaged container of water. LPN #1 removed her gloves, donned clean gloves, patted the site dry with a clean 4X4 gauze, applied Remedy antifungal cream with a cotton-tipped applicator, and taped a clean 4x4 gauze over the site. LPN #1 did not remove her gloves, wash her hands, and don clean gloves, but continued the skin assessment touching Resident #6's perineal area, buttocks, and back. LPN #1 cleaned stool from Resident #6's anal area, completed the assessment touching the resident's groin and arms, and then dressed and covered Resident #6 with a blanket before removing her gloves and washing her hands. Observation, on 05/02/12 at 2:50 PM, revealed during a skin assessment for Resident #12, LPN #1 started the assessment at Resident #12's feet, moved to the legs, the perineal area, buttocks, arms, and ears. LPN #1 assisted Resident #6 with getting dressed before she removed her gloves and washed her hands. Interview, on 05/02/12 at 3:05 PM, with LPN #1 revealed she normally began skin assessments at the residents' heel/toe area and moved upward. LPN #1 stated she should have removed her gloves and washed her hands after cleaning stool from Resident #6's anal area, and that she should have donned clean gloves before she continued the skin assessment. LPN #1 stated she should have removed her gloves, sanitized her hands, and donned clean gloves after touching the perineal area and buttocks of Resident #12. Interview, on 05/02/12 at 3:15 PM, with the North Unit Coordinator revealed when performing a skin assessment, you were to wash your hands and change gloves after you assessed the peri area. She stated the purpose to wash your hands and change your gloves was to prevent contamination, germs and illness. In addition, the policies for Hand Hygiene and Skin Assessment were located on the computer for staff to access. Continued interview, on 05/02/12, at 3:20 PM, with the North Unit Coordinator revealed training on how to conduct skin assessments occurred during the facility's orientation of newly hired nurses. The Unit Coordinator stated she did not conduct random checks of the nurses' clean technique methods. Interview, on 05/02/12 at 4:30 PM, with the ADON revealed after assessing the peri area on a resident during a skin assessment, you were to wash your hands and change gloves, then finish your assessment. She revealed the reason for washing hands and changing gloves was to prevent cross contamination. Infection was always a risk if you failed to wash hands and change gloves, she revealed. Interview, on 05/02/12 at 4:50 PM, with the Education Director revealed all new hires were trained on infection control and the importance of wearing gloves and washing hands. She stated numerous in-services were held throughout the year, to include when to wash hands, and when to wear gloves. A new hire was partnered with a trainer and their orientation documentation was turned into the educator. This included a skin assessment check-off. No specific means to monitor skin assessments after orientation were revealed. Interview, on 05/03/02 at 11:50 AM, with the Director of Nursing (DON) revealed she did not monitor the process of conducting skin assessments of residents. She stated staff were trained to wash hands and change gloves after assessing a resident's soiled area of the body to a clean area, and after assessing the resident's peri area, based upon nursing standards of practice.

Based on observation, interview and record review the facility failed to maintain their Infection Control Program to ensure personal laundry was processed and stored in a clean environment. The findings include: The facility Infection Prevention Team policy (Reviewed 01/14/11) revealed the purpose of the program was to provide a sanitary environment to help prevent the transmission of disease and infection. The facility Infection Prevention Team procedure revealed laundry was to be stored and processed to prevent the spread of infection. The facility had no policy for laundry at the time requested. The facility had no documentation of the Laundry Area Cleaning Schedule at the time requested. Observation on 03/22/11 at 10:10am revealed a thick coating of lint on all the pipes, completely around the pipes and above the area Resident clothes were processed. A long rack of clean clothes were hanging uncovered beneath a thick coating of lint on the pipes and on the metal structure above them. Interview on 03/22/11 at 1:05pm with Housekeeper #3, who is the laundry worker for the facility, revealed she cleans the pipes of dust twice a year using a feather duster. Interview on 03/22/11 at 1:15pm with the Housekeeping Supervisor revealed she was responsible for the pipes to remain dust free. She cleans the pipes from dust every month or so.

Based on observation, record review and interview it was determined the facility failed to store, prepare, distribute, and serve food under sanitary conditions. The facility failed to prevent cross-contamination of food, maintain the temperature of a dairy product, and properly seal and date opened food items. The findings include: Review of the facility's kitchen policy on Infection Control Practices dated 01/2006 revealed that while serving food, store serving utensil in the food with the handle extending out of the food. Review of the facility's kitchen policy for Minimum Temperature at Point of Service to Resident and not dated, revealed chilled foods should be held below fifty-five (55) degrees Farenheit. Review of the facility's policy on Refrigerated Storage and not dated, revealed all foods will be properly wrapped and/or stored in sealed containers and dated, labeled and monitored so they are used by the specified use-by date. Review of the facility's policy on Frozen Storage and not dated, revealed all frozen foods will be properly wrapped, dated labeled and monitored so it is used by the specified use-by date. Review of in-service education record titled All Topic within Kitchen dated 03/03/11 revealed the topic of proper storage, dating and labeling food items. Review of in-service education record titled Neighbor Food Allergies dated 03/17/11 revealed the topic of monitoring Residents tickets for food allergies and using caution when preparing food trays. Observation of the walk-in cooler on 03/20/11 at 3:20pm revealed a five (5) pound container of four-bean salad opened and not dated. Observation of the walk-in freezer on 03/20/11 at 3:25pm revealed a box of ground beef frozen patties opened, unsealed, and not dated. Observation of the tray line on 03/21/11 at 11:30pm revealed the dietary helper consecutively leaving the spoon handle for the rice in the container of food after preparing three food trays. While preparing the fourth tray, the dietary helper reached in to retrieve the spoon handle and touched the food with her gloves smearing pureed beets into the rice. Individual cups of sour cream were noted in an un-iced container sitting on the steam table. Observation of food temperatures during tray line on 03/21/11 at 4:30pm revealed a temperature of the sour cream at thirty-one (31) degrees Farenheit. Observation of food temperatures for a test tray on 03/21/11 at 6:00pm revealed a sour cream temperature of sixty-eight (68) degrees. Interview with the Dietary Helper on 03/21/11 at 11:30am revealed she was unaware of the potential risks in cross-contamination to the residents in regards to infection control and food allergies. Interview with the Director of Dietary Services on 03/21/11 at 11:35am revealed that a recent in-service had been conducted on cross-contamination and food allergies. She also reported that the Dietary Helper had been in attendance. The Director of Dietary Services stated that the residents could potentially be at risk for allergic reactions if a food allergy exists, and could potentially cause illness. Interview with the Director of Dietary Services on 03/21/11 at 6:35pm revealed that sour cream should be at a temperature of thirty-five (35) to forty (40) degrees Farenheit at the time of service to the resident to prevent spoilage or curdling of the dairy product. She also stated that serving sour cream at an unsafe temperature could potentially cause illness. Interview with the Director of Dietary Services on 03/23/11 at 9:00am revealed that twice a day she does a walk-in tour of the cooler and freezer to ensure items are properly sealed and dated, but was not there the day the items were found. She also revealed that in-services are provided frequently to kitchen employees to reinforce proper food storage procedures. The Director of Dietary Services also revealed that the container with sour cream should have been placed in ice and not stored on the steam table during tray line. She stated this practice could have caused bacteria growth resulting in a potential illness. The Director of Dietary Service stated that the Dietary Helper does not normally serve the food, but had been trained on proper procedure. The Director of Dietary Service confirmed she is responsible for ensuring the kitchen employees are following the facility's policy and procedures. Interview with the Administrator on 03/23/11 at 10:00am confirmed she is ultimately responsible for ensuring the kitchen is following the facility's policies for storage, preparation, and distribution for food.