Every finding on record at Maple Health and Rehabilitation

Based on interview, record review, and review of facility policy, the facility failed to ensure that the electronic medical record reflected the resident's choice of code status for one of 19 sampled residents (Resident (R) 3) reviewed for advance directives. Record review revealed R3 initially expressed a desire to initiate a code status of Do Not Resuscitate (DNR). However, the code status reflected in the physician order was to be Full Code with no documented evidence that this was the resident and/or their health surrogate's current choice. The findings include:Review of the facility policy titled, Advance-Directive-Policy, reviewed 04/2026, revealed the facility would support and facilitate a resident's rights to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.Review of R3's Face Sheet revealed the facility admitted the resident on 07/16/2026, with diagnoses which included Alzheimer's dementia, type 2 diabetes mellitus, and coronary artery disease.Review of R3's Advance Directives/Medical Treatment Decisions document dated 07/16/2026, revealed a Medical Power of Attorney was signed by the Power of Attorney (POA) with a code status of DNR. Review of R3's Code Status Consent Form dated 07/16/2026, (date R3 was admitted ) revealed a DNR code status per telephone consent by the POA as R3 was admitted from the hospital.Review of R3's Code Status Consent Form dated 07/17/2026, revealed a DNR code status consent signed in person by the POA.Review of a Physician Order dated 07/16/2026, indicated R3's code status to be Full Code.During an interview on 08/20/2026 at 9:20 AM, the family member (F) 2 of R3 stated she was the POA and her wish for him was to be DNR, stating He would not want anything done.During an interview on 08/20/2026 at 9:45 AM, the Director of Nursing (DON) stated the floor nurse got the code status of the resident on the consent form when admitted to the facility. She was not sure why the consent form signed did not get updated by the floor nurse from full code (code resident had while in the hospital) to DNR.During an interview on 08/20/2026 at 10:00 AM, the Admissions Director stated she scanned R3's signed consent form into the Matrix banner (electronic medical record) and gave the original to medical records. During an interview on 08/20/2026 10:22 AM, the Administrator stated she wanted the resident's matrix banner and the physician's order to reflect the same code status.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the mechanical lift slings were maintained according to the manufacturer's recommendations for one (1) of three (3) sampled residents (Resident #1). Per the manufacturer's recommendations for the use of the mechanical lift slings, the slings had a limited warranty for a period of one (1) year from the date of initial use. Further, the sling would not be used when ripped, torn, or frayed. However, interview with the Administrator revealed the mechanical lift Sling #25, used on Resident #1, was purchased on 07/24/2018 and was utilized for a period of over four (4) years without staff monitoring the usage of the sling. Further, the Administrator revealed the Sling #25 was observed to be worn and frayed, after the resident's fall. On 12/11/2021, Resident #1 sustained a fall from a full mechanical lift after the blue strap on the lift sling snapped. Resident #1 sustained a [CONDITION(S)] and pelvic fracture related to the fall. The findings include: Review of the facility's policy titled, Falls Management Program Guidelines, undated, revealed the facility strived to maintain a hazard free environment, mitigate fall risk factors and implement preventative measure. Per review of the policy, the facility recognized even the most vigilant efforts would not prevent all falls and injuries. In those cases, intensive efforts would be directed toward minimizing or prevention of injury. Review of the facility policy's titled, Lifting Machine, Using a Mechanical, undated, revealed the purpose of the procedure was to establish the general principles of safe lifting using a mechanical lifting device. Further, the policy revealed it was not a substitute for the manufacturer's training and instructions. Additionally, the policy revealed that before a resident was lifted, staff were to double check the security of the sling attachment and check the stability of the straps. Further, the sling care included to discard any worn, frayed or ripped slings. Review of the manufacturer's recommendations, dated June 2020, included a limited warranty for a period of one (1) year from the date of initial use. Further review of the recommendation revealed a warning for staff to not use if ripped, torn or frayed. Interview with the Director of Nursing (DON), on 02/23/2022 at 1:41 PM, revealed the facility assessed twenty (20) residents who required the utilization of the mechanical lift; however, there was no documented evidence the facility had a system in place to ensure the mechanical lift slings were documented for the usage of the slings, for the safety of the residents. Review of an electronic mail document, from the manufacturer's Vice President, received on 02/24/2022 at 10:16 PM, revealed the slings were warranted for one (1) year; however, the sling did not have a life expectancy due to the amount of usage of the slings, how it was used, and the number of washings it was subjected to. Further, the Vice President revealed each time the sling was utilized, it would be inspected by the caregiver to ensure the loops were not damaged or frayed. Further review of the electronic mail revealed that if the sling was damaged or frayed, it would not be used. Review of Resident #1's medical record revealed the facility admitted the resident on 09/06/2021 and readmitted the resident on 12/12/2021, with diagnoses which included [CONDITION(S)] (MS), [CONDITION(S)] (CHF), and [CONDITION(S)]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 11/19/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8), out of fifteen (15), indicating moderate cognitive impairment. Further review of the MDS Assessment revealed the facility assessed the resident as requiring two (2) person assist with transfers. Review of the facility's Incident Report, dated 12/11/2021 at 3:35 AM, revealed Resident #1 sustained a fall while being transferred back to his/her bed using a mechanical lift. Further review of the document revealed the resident hit his/her head with bleeding noted. Review of the facility's documentation titled, Sling Audit for Whole Building, dated 12/11/2021, revealed all the slings in the building were checked for being torn, ripped, and/or frayed, by the laundry department. Further review of the audits revealed twenty-one (21) of the slings utilized for the mechanical lift were found to be in good condition and four (4) slings were taken out of use, to include Sling #25. Additionally, further review of the audits revealed no documented evidence the facility had a system in place for determining the usage' and/or the number of times the slings were washed. Review of the resident's Post Fall Documentation, dated 12/11/2021, revealed Resident #1 was transferred to an acute care setting after the resident fell from the mechanical lift while being transferred back to bed from the Broda chair. The Advanced Practice Registered Nurse (APRN) was notified and orders were received to send the resident to the emergency room for evaluation. Further, the resident had bleeding from the scalp and complained of left hip pain. Further review of the resident's Post Fall Review, dated 12/11/2021, revealed the fall was in the residents room and the resident was in the Broda chair prior to the fall. Staff were assisting the resident back to his/her bed when the fall from the lift occurred. The APRN and the resident's daughter were notified. The fall was reviewed by the Interdisciplinary Team. Continued review revealed the Root Cause was determined as a fall noted while the resident was being transferred back to bed and the resident hit his/her head causing his/her head to bleed. Review of Resident #1's Progress Notes, dated 12/11/2021, documented by the Director of Nursing (DON) revealed the resident had a fall in the facility while being transferred back to his/her bed. Per review, the resident was noted to have blood on the floor after hitting his/her head. The Advanced Practice Registered Nurse (APRN) was notified and an order was received to send the resident to the emergency room for evaluation of the laceration to the back of his/her head. Review of the Hospital Admission Summary, dated 12/11/2021, revealed Resident #1 presented with a an Acute Closed Pelvic Fracture after a fall from a mechanical lift. Further, the resident hit his/her head, which caused a superficial laceration. Further review revealed the laceration was glued together and sealed with a bandaid. Review of the Physician's Discharge Summary, dated 12/12/2021, revealed Resident #1 was transferred to the emergency room . Per review, it was determined the resident had a superficial scalp laceration which was glued together and was also sustained a pelvic fracture. Further review of the document revealed the resident was admitted overnight on 12/11/2021 and returned to the facility the following day, 12/12/2021. Interview with Resident #1, on 02/22/2022 at 3:44 PM, revealed he/she was alert, and oriented to person. Per interview, the resident recalled the incident and stated, it was not their fault. The resident denied pain during the interview. Interview with Certified Nursing Assistant (CNA) #1, on 02/22/2022 at 1:18 PM, revealed on 12/11/2021 at 3:30 AM, CNA #2 assisted her with transferring the resident from his/her Broda chair to his/her bed with the mechanical lift. CNA #1 stated she checked the sling straps connected to the sling for any tears, frayed or worn areas prior to transferring the resident. Per interview, CNA #1 revealed she did not identify any concerns with the sling straps or the mechanical lift, prior to transferring the resident to his/her bed. CNA #1 revealed she attached the sling loops to the mechanical lift, placed the resident on the lift, lifted the resident approximately three (3) feet in the air, when the blue strap on the green sling snapped. Per interview, the resident fell to the floor landing on his/her back/ left side. CNA #1 revealed the resident was noted to have bleeding from his/her scalp and complained of left hip pain. She stated the resident was not moved and Registered Nurse (RN) #1 was called to the resident's room immediately. Further interview revealed, observation of the sling, after the resident's fall, revealed the blue loop on the sling was frayed above the location of the break. Interview with Certified Nursing Assistant (CNA) #2, on 02/23/2022 at 9:14 AM, revealed she helped CNA #1 transfer Resident #1 from the Broda chair during the early morning hours of 12/11/2021. She stated the resident already had a green/large sling beneath him/her from the lift to the chair earlier in the evening. CNA #2 stated she estimated the resident was two (2) to three (3) feet in the air when the strap on the sling broke and the resident fell to the floor. CNA #2 recalled the resident was bleeding from the back of his/her head and complained of hip pain after the fall. Interview with Registered Nurse (RN) #1, on 02/22/2022 at 2:27 PM, revealed CNA #1 and CNA #2 attempted to transfer Resident #1 from the Broda chair back to his/her bed using the full mechanical lift. RN #1 stated she heard a scream and went to Resident #1's room and noted the resident lying on the green lift sling on the floor. Per interview, the resident had a [CONDITION(S)] and pressure was held to the laceration, to control the bleeding. RN #1 stated she called the Advanced Practical Registered Nurse (APRN) on call who gave orders to send the resident to the emergency room for evaluation. She further stated she called Emergency Medical Services (EMS) to transport the resident and was told it would be a while, but they arrived within ten (10) to fifteen (15) minutes. Per interview, the EMS staff lifted the resident from the floor using a sheet. Interview with the Laundry Supervisor, on 02/23/2022 at 2:00 PM and on 02/25/2022 at 10:07 AM, revealed the laundry staff were responsible for washing the slings on a delicate wash cycle with no bleach and the slings were hung to air dry. She stated after Resident #1's accident, she inspected the resident's sling, and it showed the sling's upper blue loop, which attached to the mechanical lift, was frayed. Per interview, she stated the sling should not have been used. Continued interview with the Laundry Supervisor, on 02/23/2022 at 2:00 PM, revealed prior to the incident involving Resident #1, she was responsible for inspecting each mechanical lift sling twice a month. Per interview, she stated her inspection included checking for the slings that were worn, torn, and/or frayed. The Laundry Supervisor stated; however, there was no system in place to determine the number of times a sling was utilized by other residents. Interview with the Director of Nursing (DON), on 02/23/2022 at 1:41 PM, revealed the facility had twenty (20) residents that used the mechanical lift for transfers. Per interview, she stated it was nursing staff's responsibility to inspect the resident's sling prior to use to ensure there were no signs of fraying or tearing. Further interview revealed CNA #1 and CNA #2 were using the correct sling during the transfer on 12/11/2021 involving Resident #1; however, the sling broke and caused the resident to fall. The DON stated after the fall the sling was examined and the loop was worn, frayed, and the blue strap was broken. Interview with the Administrator, on 02/24/2022 at 11:45 AM, revealed on 12/22/2021, the morning of Resident #1's incident, the DON called her at home and told her Resident #1 had been involved in an incident with the mechanical lift and the resident was being sent to the hospital for an evaluation. The Administrator stated after this notification, she left home and went to the facility to ensure there was an immediate audit of the slings. Per interview, she stated four (4) out of twenty-five (25) slings, this included Sling #25. The Administrator stated Sling #25 was purchased on 07/24/2018 and was utilized for a period of over four (4) years. She stated the sling was not removed from use, until after the resident's fall on 12/11/2021. Per interview, the sling the resident fell from was observed to be worn, frayed, and the blue strap was broken. Further interview with the Administrator revealed the laundry staff were provided in-service on identifying the proper way to care for the sling and to dispose of the slings, used for the mechanical lift, if they were frayed, torn, or ripped. Per interview, the Administrator stated the staff were not documenting the number of times a sling was used / washed. She further stated that monitoring the integrity of the slings was important to ensure the safety of the residents. Interview with the Medical Director, on 02/25/2022 at 12:11 PM, revealed she was notified of Resident #1's fall from the mechanical lift. She further revealed she had been in close contact with the facility and participates in Quality Assurance and Performance Improvement (QAPI) meetings. The Medical Director stated she expected the equipment, including mechanical lift slings, to be in good working order to ensure the residents were safe.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure thirteen (13) of twenty-two (22) sampled residents was treated with respect, dignity and in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Observation of dining service on 03/19/19 and 03/20/19, revealed twelve (12) residents on the Reflections Unit were served milk in paper cartons. In addition, observation revealed staff failed to knock on Resident #10's door before entering his/her room. The findings include: Review of the facility policy, Attachment F: Resident Rights, not dated, revealed the resident has the right to be treated with consideration, respect and full recognition of his or her dignity and individuality, including privacy in treatment and in care for his or her personal needs. any policy or interview stating not one. 1. Observation of meal service on the Reflections Unit on 03/19/19 at 11:52 AM and 03/20/19 at 11:49 AM, revealed staff served twelve (12) of fifteen (15) residents milk in paper cartons and not in cups. Interview with Certified Nurse Aid (CNA) #1 on 03/21/19 at 1:25 PM, revealed they always serve the milk in the cartons to the residents and the residents don not seem to mind. Interview with Licensed Practical Nurse (LPN) #5 on 03/21/19 at 1:28 PM, revealed milk cartons are served to the residents because they may be more familiar to the Dementia population. She stated she felt it was because the residents grew up in school using milk cartons and she did not view it as a dignity issue. Interview with the Director of Nursing (DON) on 03/21/19 at 2:39 PM, revealed she was not sure why the residents' drinks were not served in cups, as they were in the main dining area. She stated she could understand why it may be considered a dignity issue, as drinking out of a glass or cup may be more home-like. The DON stated the dining experience should be home-like for all residents in the facility. 2. Record review revealed the facility admitted Resident #10 on 03/02/18 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #10's cognition as intact with a Brief Interview for Mental Status Score (BIMS) of fifteen (15) which indicated the resident was interviewable. Interview with Resident #10 on 03/20/19 at 8:57 AM revealed staff do not knock on door when they come in. During the resident interview on 03/20/19 at 9:09 AM, this surveyor observed the Activities Assistant walk into the room without knocking. Phone interview with the Activities Assistant on 03/21/19 at 10:24 AM revealed he should have knocked on the resident's door. He stated he was nervous since State was in the building but he usually knocked before entering the residents' rooms. Interview with the Activities Director on 03/21/19 at 10:19 AM revealed she expected all her employees to knock on the resident's door and ask for permission before entering the resident's room.

Based on interview, record review and review of the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for two (2) of twenty-two (22) sampled residents (Residents #11 and #89). Staff failed to accurately code Resident #11's MDS assessment related to Activities of Daily Living (ADL) and Resident #89's MDS assessment related to antipsychotic medications. The findings include: Review of the Long-Term Care Facility RAI 3.0 User's Manual, on Coding instructions for Section G Functional Status, revealed total dependence (4) should be coded if full staff performance occurred every time during the entire 7-day look back period for Activities of Daily Living Self-Performance. Further review revealed the most support provided over all shifts, regardless of resident's self-performance classification, should be coded for ADL Support Provided. 1. Record review revealed the facility admitted Resident #11 to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION]. Review of the MDS Section G-Functional Status, revealed the resident was coded as total dependence with full staff performance, requiring physical assistance of two plus staff for eating (4/3). However, interview with Certified Nurse Aid #1 on 03/21/19 at 1:25 PM, revealed the CNA's code resident care and staff assistance on the Kiosk during each shift. She stated staff are trained on ADL coding upon hire and as needed. CNA #1 stated Resident #11's requires the assistance of one (1) staff member for meals. 2. Record review revealed the faclity admitted Resident #89, on 02/08/18 with [DIAGNOSES REDACTED]. Review of a quarterly Mininimum Data Set (MDS) assessment, dated 03/08/19, revealed section N 0410 of the MDS indicated Resident #89 received seven (7) days of antipsychotic medication, however, review of section N0450 of the MDS assessment revealed the resident did not receive antipsychotic medications since admission/entry or reentry. Interview with MDS Coordinator #1 on 03/21/19 at 1:14 PM, revealed staff are trained on ADL coding upon hire and as needed. She stated no resident should require the assistance of two staff members with eating and Resident #11's coding as a 4/3 with eating was done in error. MDS Coordinator #1 stated Section N of Resident #89's MDS assessment was just an oversight, as the resident's Medication Administration Record [REDACTED]. Interview with MDS Coordinator #2 on 03/21/19 at 1:31 PM, revealed she should have followed up with the CNA's who coded Resident #11 required the assistance of two (2) staff with eating because it was coded inaccurately. MDS Coordinator #2 further stated she should have submitted a correction for the MDS assessment because no resident requires the assistance of two staff with eating. Interview with the Director of Nursing (DON) on 03/21/19 at 2:39 PM, It should only require one staff to feed a resident and the MDS assessment for Resident #11 must have been coded incorrectly. She furthre stated the CNA's get ADL training annually, upon hire and if they need additional training. The DON stated she would expect the MDS assessments to be coded accurately.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of twenty-two (22) sampled residents (Resident #90). Observations on 03/20/19, revealed staff failed to follow interventions to administer oxygen (O2) at 2 liters per minute (LPM) via nasal cannula for Resident #90. The findings include: Review of the facility's policy, Care Plans, dated 01/01/19, revealed the facility will ensure residents have a person-centered plan of care that supports the resident in making their own choices, having control of their daily lives and addresses their assessed needs. The care plan will address care needs identified through the comprehensive assessment, through implementation of the baseline care plan and describes services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The plan of care will be stated clearly and will identify the resident problems, measurable goals to be achieved, which include timetables to meet resident's needs, and the interventions to be followed by staff in providing the resident care. Record review revealed the facility admitted Resident #90 on 02/08/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 02/15/19, revealed the facility assessed Resident #'90's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of Resident #90's Comprehensive Care Plan, dated 02/19/19, revealed an intervention for O2 per physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. However, observations on 03/20/19 at 8:58 AM and 2:07 PM, revealed Resident #90's oxygen concentrator was on three (3) LPM via nasal cannula. Interview with Resident #90 on 03/20/19 at 2:07 PM, revealed he/she does not touch the settings on the concentrator, only the nurses do. Interview with Licensed Practical Nurse #4 on 03/20/19 at 2:30 PM, revealed she checked Resident #90's oxygen setting for day shift and it was on two (2) liters at that time. She stated she would go correct the setting as the concentrator may have gotten bumped or possibly a family member may have changed the setting without staff's knowledge. LPN #4 checked Resident #90's oxygen saturation and it was ninety-six (96) percent. Interview with the Director of Nursing (DON) on 03/21/19 at 2:39 PM, revealed she expected the nurses to follow the residents care plan and physician's orders [REDACTED].

Based on observation, interview, record review and review of the facility's standards of practice, it was determined the facility failed to ensure the services provided or arranged by the facility meet professional standards of quality for one (1) of twenty-two (22) sampled residents (Resident #29) related to medications being left at bedside without nursing supervision. Observation on 03/19/19 revealed a medication cup containing five (5) pills was left unattended on Resident #29's bedside table. The findings include: Review of the facility policy, Safe Medication Administration, not dated, revealed nursing should stay with the patient until the medication is taken, provide help as necessary, and do not leave medications at the bedside without a health care provider's order. Record review revealed the facility readmitted Resident #29 on 03/04/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 10/04/18, revealed the facility assessed Resident #'29's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was interviewable. During initial tour of Resident #29's room, on 03/19/19 at 10:31 AM , revealed a medication cup containing five (5) pills on the resident's bedside table. Interview with Resident #29 on 03/19/19 at 10:31 AM, revealed the nurse came in and handed him/her the medications and left the room. Resident #29 stated he/she was feeling sick to his/her stomach and chose not to take them at that time and put them on the bedside table. Interview with Licensed Practical Nurse (LPN) #4 on 03/19/19 at 3:02 PM, revealed she placed the medication cup in Resident #29's hand and turned her back. She stated she thought the resident had taken the medications. LPN #4 further revealed she should have watched the resident take the medications instead of turning her back. She stated she completed a medication pass as part of her orientation and was checked off on the skill and it was facility policy to watch the residents take their medications and not leave them unattended. Interview with the Director of Nursing (DON) on 03/21/19 at 2:39 PM, revealed the nurse's should watch the residents take their medications before leaving the room. The DON stated staff do medication pass observations audits yearly for the nurses and it is also a skill check off done upon hire.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide oxygen (O2) therapy according to the physician's orders [REDACTED].#90). Observations on 03/20/19, revealed staff failed to ensure Resident #90, received O2 at two (2) liters per minute (LPM) per the physician's orders [REDACTED]. The findings include: Review of the facility's policy, Oxygen Therapy Concentrator Set-UP, dated 01/01/07, revealed the facility is to administer oxygen in a safe manner in accordance with accepted standards of practice and according to state and federal requirements and nursing should adjust the meter to prescribed rate. Record review revealed the facility admitted Resident #90 on 02/08/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 02/15/19, revealed the facility assessed Resident #'90's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of Resident #90's Comprehensive Care Plan, dated 02/19/19, revealed an intervention for O2 per physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the (MONTH) 2019 Treatment Administration Record (TAR) revealed O2 at 2 LPM continuously every shift. Further review revealed the TAR had been initialed by Licensed Practical Nurse (LPN) #4 on 03/20/19 for day shift which meant O2 was observed in place at 2 LPM. Observations on 03/20/19 at 8:58 AM and 2:07 PM, revealed Resident #90's oxygen concentrator was on three (3) LPM via nasal cannula. Interview with Resident #90 on 03/20/19 at 2:07 PM, revealed he/she does not touch the settings on the concentrator, only the nurses do. Interview with Licensed Practical Nurse #4 on 03/20/19 at 2:30 PM, revealed she had checked Resident #90's oxygen setting for day shift and it was on two liters at that time. She stated she would go correct the setting and stated the concentrator may have gotten bumped or possibly a family member may have changed the setting without staffs knowledge. LPN #4 checked Resident #90's oxygen saturation and it was ninety-six (96) percent. Interview with the Director of Nursing (DON) on 03/21/19 at 2:39 PM, revealed the nurses check the oxygen settings once each shift and verify the check on the residents TAR. She stated the resident's daughter was in on that day and may have altered the setting. She revealed the nurses may need to start following behind the family to ensure nothing has been altered. The DON further stated she expected the nurses to follow the residents care plan and physician's orders [REDACTED].

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for a total of five (5) medications on three (3) medication carts. Observation of three (3) of six (6) medication carts revealed four (4) insulin pens not dated when opened and one (1) outdated vial of insulin in the medication cart. The findings include: Review of the facility's policy, titled Medication Labels and Packaging, last revised 10/31/09, revealed if the efficacy of a drug was affected by opening a multi-dose vial/bottle, the vial or bottle should be dated and initialed when it was opened for the first time. Additional review revealed medications should be discarded by the expiration date unless indicated by the pharmacy and/or manufacturer's instructions to discard sooner. Observation of three (3) of six (6) medication carts, on 03/20/19 at 1:43 PM, revealed four (4) insulin pens not dated when opened and one (1) outdated vial of insulin in the medication carts. Interview with Licensed Practical Nurse (LPN) #4, on 03/20/19 at 2:25 PM and LPN #5 at 2:26 PM revealed multi-dose vial medications were to be dated when opened and insulin's should be discarded after thirty-one (31) days unless otherwise specified. Interview with Registered Nurse (RN) #1, on 03/20/19 at 2:49 PM, revealed multi-dose vials of medications were to be dated when opened and expired medications were to be removed from the medication cart. Interview with the Director of Nursing (DON), on 03/21/19 at 2:45 PM revealed she expected insulin to be dated when opened and expired medications to be removed from the medication cart.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure staff follow hand hygiene practices consistent with accepted standards of practice for one of twenty-two (22) sampled residents. Observation on while providing care.(Resident #51). related to not washing hands during [DEVICE] care. The findings include: Review of the facility policy Hand Hygiene revealed the purpose is to decrease the risk of transmission of infection by appropriate hand hygiene. The policy revealed: Hand washing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues. Although antiseptics and other handwashing/hand hygiene agents do not sterilize the skin they can reduce microbial contamination depending on the type and the amount of contamination, the agent used, the presence of residual activity and the handwashing/hand hygiene technique followed. Hands should be washed when hands are visibly dirty or contaminated with proteinaceous material, are visibly soiled with blood or other body fluids, after going to the restroom, before eating, before performing a procedure, and after providing care to a resident. Record review revealed the facility readmitted Resident #51 on 01/21/19 with [DIAGNOSES REDACTED]. Observation of Licensed Practical Nurse (LPN) #1 on 03/20/19 at 9:21 AM revealed he did not wash his hands prior to starting gastrostomy tube care and failed to wash his hands after he removed the old dressing. He then obtained a wash cloth and washed around the [DEVICE] site and placed the soiled wash cloth in sink, donned gloves and dried around site without washing his hands. He removed his gloves after placing the dressing and did not wash hands again. He removed trash from room, picked up dirty washcloth and left the room without donning gloves or washing hands. Interview with LPN #1 on 03/20/19 at 9:32 AM, revealed he would not do anything different. He revealed, that is the way I do it. Interview on 03/21/19 at 9:52 AM with LPN #1 revealed when he got back to the desk, he realized that he had not washed his hands prior to starting. He stated he should have washed his hands after removing the dressing, and after completing the procedure. He revealed he should have completed the care differently. Interview on 03/21/19 at 1:33 PM with the Staff Development Coordinator (SDC) revealed LPN #1 should have washed his hands when entering room, after removing soiled dressing, after placing clean dressing and after disposing of the trash. She stated hand washing education was provided at least quarterly and as often as needed.

Based on interview, record review, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to ensure the services provided or arranged by the facility, meet professional standards of quality for one (1) of twenty-two (22) sampled residents (Resident #12). On 01/22/18, the licensed nurse failed to check for gastrostomy tube ([DEVICE]) placement prior to administering medications per physician's orders [REDACTED].>The findings include: Review of the KBN AOS #14 Patient Care Orders, last revised (MONTH) 2010, revealed a Licensed Practical Nurse (LPN) will administer medications/treatment as authorized by a physician, or advanced practice registered nurse. Record review revealed the facility admitted Resident #12 on 01/16/16 with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. However, observation on 02/20/18 at 11:40 AM, revealed LPN #2 did not check [DEVICE] placement prior to administering medication or flushes. Interview with LPN #2, on 02/20/18 at 11:48 AM, revealed she was aware of the need to check for placement and residual of a [DEVICE] prior to administering medications or flushes, however, she just forgot to do it. Interview with the Director of Nursing (DON), on 02/22/18 at 10:51 AM, revealed she expected the nursing staff to follow the physician's orders [REDACTED].

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to provide appropriate care and treatment to prevent complications of enteral feeding for one (1) of twenty-two (22) sampled residents (Resident #12). Resident #12 was to be administered medications per gastrostomy tube ([DEVICE]); however, observation on 02/20/18 revealed the licensed nurse failed to check for placement prior to the administration of medication and flushes. The findings include: Review of the facility's policy and procedure, titled Medication via Feeding Tube dated 10/31/10, revealed the [DEVICE] placement should be checked by verifying aspiration of gastric fluid and by auscultation of insufflate air. Record review revealed the facility admitted Resident #12 on 01/16/16 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) Assessment, dated 12/06/17, revealed a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Further review of the MDS assessment revealed, in Section K the resident required a feeding tube for nutrition and medications. Review of the Comprehensive Care Plan, (no revision date), revealed the resident required assistance with water flushes and he/she would be free from aspiration through the review date. Review of physician's orders [REDACTED]. Observation of a medication pass, on 02/20/18 at 11:40 AM, revealed Licensed Practical Nurse (LPN) #2 had prepared two (2) different medications into two (2) cups and two (2) cups of flushes for between administering of each medication. However, further observation revealed LPN#2 began to administer a flush of water to the [DEVICE] without checking for placement first, and was stopped by the surveyor before she administered any flush or medication. Interview with LPN #2, on 02/20/18 at 11:48 AM, revealed she was aware of the facility's policy and the need to check for placement and residual of a [DEVICE] prior to administering medications or flushes, however, she just forgot to do it. Interviews on 02/20/18 with LPN #1 at 2:00 PM and Registered Nurse (RN) #1 at 2:40 PM, revealed [DEVICE] placement should be checked prior to administering medication or flushes. Interview with the Director of Nursing (DON), on 02/22/18 at 10:51 AM, revealed she expected nurses to check for placement of a [DEVICE] prior to administering medications.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases for one (1) of twenty-two (22) sampled residents (Resident #27). Observation during a medication pass revealed the Licensed Nurse dropped a medication on top of the medication cart then proceeded to pick up the medication and administer it to Resident #27. The findings include: Review of the facility's policy and procedure titled, Administering Medications, not dated, revealed all medications were to be administered only as prescribed and infection control protocols were to be maintained at all times. Record review revealed the facility admitted Resident #27, on 07/23/16 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 01/04/18 revealed the facility assessed Resident #27's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable Observation of medication administration pass, on 02/21/18 at 8:20 AM revealed Medication Aide (MA) #1 dropped a pill ([MEDICATION NAME] {antidepressant}), on top of the medication cart and then picked it up with bare hands and placed it in the medication cup with other medications to be administered to Resident #27. Interview with Medication Aide #1, on 02/21/18 at 8:20 AM, revealed she would not normally give a pill that had been dropped on top of the medication cart but would pull another one to administer. Interviews on 02/20/18 with Licensed Practical Nurses (LPN) #1 at 2:00 PM, LPN #2 at 2:33 PM, and Registered Nurse (RN) #1 a 2:40 PM; and, LPN #3 on 02/22/18 at 9:00 AM, revealed they would not administer a medication after it had been dropped on top of the medication cart, but would discard it and administer another one. Interview with the Director of Nursing (DON), on 02/22/18 at 10:51 AM, revealed she expected the nursing staff to discard the contaminated pill and get another one to administer.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide services according to the written plan of care for one (1) of four (4) sampled residents (Resident #1). Resident #1 was care planned to receive physical assistance of two (2) staff with bed mobility; however, on 10/16/17 State Registered Nursing Assistant (SRNA) #1 failed to obtain assistance from another staff member to reposition Resident #1 in bed. The findings include: Review of the facility's policy titled, Care Plans - Comprehensive dated 08/01/13, revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. It further states the comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS). It also states the care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. Review of facility's policy titled, Using the Care Plan, dated 08/01/13, revealed the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Record review revealed the facility readmitted Resident #1 on 08/20/14 with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Activities of Daily Living (ADL) Self Care Deficit Care Plan, dated 08/21/14, and State Registered Nurse Aide (SRNA) Kardex/Care Plan, not dated, revealed to provide the assistance of two (2) staff for bed mobility. However, interview with SRNA #1 on 10/31/17 at 1:45 PM, revealed she did not ask any staff for any assistance for turning and repositioning Resident #1 during her shift on 10/16/17. She stated SRNA #4 assisted her to reposition Resident #1 at approximately 9:30 PM on 10/15/17; however, when she checked Resident #1 at approximately 12:30 AM on 10/16/17 she didn't seek assistance with repositioning Resident #1. She stated she was aware the care plan calls for two (2) staff assistance when turning and repositioning Resident #1 but she does it by herself at times because the resident does not need assistance at times even though the care plan calls for two (2) staff assistance. She stated she knows she is expected to follow the facility care plans. She stated on 10/16/17 at approximately 3:00 AM when she entered Resident #1's room, she found Resident #1 on the floor and made the nurse aware. Interview with SRNA #4 on 11/01/17 at approximately 3:10 PM, revealed she assisted SRNA #1 with an incontinent check of Resident #1 and assisted SRNR #1 with repositioning of Resident #1 at 9:30 PM on 10/15/17 prior to the end of her off shift at 10:00 PM. She stated she had never seen Resident #1 be able to roll over or be able to do anything more than move his/her head and hands/arms. She stated all staff are expected to follow the resident care plans. Interviews on 11/01/17 with SRNA #2 at 11:29 AM, SRNA #3 at 8:43 AM, and Licensed Practical Nurse (LPN) #1 at 1:31 PM, revealed all staff are expected to follow the care plans for all residents. The SRNA's and LPN stated Resident #1 was unable to roll over or reposition his/herself in bed without staff assistance. Interviews on 10/31/17 with Unit Manager #1 at 2:25 PM, and Registered Nurse (RN) #1 at 3:55 PM, revealed they expected all staff to follow all resident care plans. Interview with MDS Coordinator on 11/01/17 at 9:18 AM, revealed Resident #1's MDS assessments and care plans were accurate and reflected Resident #1's true status. He stated staff are expected to follow the facility care plans and it would not be appropriate for staff to use less assistance than what a resident is care planned for. Interview with the Director of Nursing (DON) on 11/01/17 at 10:13 AM, revealed she expected the staff to follow the residents' care plans. She stated the SRNA Kardex/care plan guides for each resident are located at the nurse's station.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents was provided adequate supervision to prevent accidents (Resident #1). Resident #1 was assessed and care planned to require extensive assistance of two (2) staff for bed mobility (how resident moves from side to side and positions self while in bed) and transfers. On 10/16/17, State Registered Nursing Assistant (SRNA) #1 failed to ensure she obtained the assistance of another staff when she repositioned Resident #1 in bed. Resident #1 was later found in the floor with his/her arm punctured by the recliner lever. In addition, the facility failed to conduct a thorough investigation which included interviewing staff who cared for Resident #1 to determine if the resident was capable of rolling him/herself out of bed and/or if any staff had assisted SRNA #1 with Resident #1's bed mobility to try to determine the root cause of the fall. The findings include: Review of the facility's policy and procedure titled, Accidents and Incidents, dated 08/01/13, revealed it is the policy of the facility to provide a safe and healthful work environment. The charge nurse and/or department supervisor shall conduct an immediate investigation of the accident or incident regarding the circumstances surrounding the accident/incident. Review of the facility's policy and procedure titled, Falls and Falls Risk, managing, dated 08/01/13, revealed if underlying causes cannot be readily identified or corrected; staff will try various interventions, based on assessment of the nature of the fall and in conjunction with attending physician, staff will identify and implement relevant interventions. Record review revealed the facility readmitted Resident #1 on 08/20/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/21/17, revealed the facility assessed Resident #1's cognition as severely impaired with the inability to perform a Brief Interview of Mental Status (BIMS), indicating the resident was not interviewable. Further review of the MDS revealed Resident #1 was assessed to require extensive assistance with two (2) persons for physical assistance with bed mobility and transfers. Review of Resident #1's Comprehensive Activities of Daily Living (ADL) Self Care Deficit Care Plan, dated 08/21/14, and State Registered Nurse Aide (SRNA) Kardex/Care Plan, not dated, revealed to provide two (2) staff for bed mobility. Review of a facility Incident/Accident Report, dated 10/16/17 at 3:00 AM, revealed Resident #1 fell out of bed and his/her right arm hit the lever of a recliner which pierced the resident's skin. Further review of the incident report revealed Resident #1 was sent to the emergency room (ER) to be evaluated. Review of the Follow-up Assessment Form, dated 10/16/17 at 3:00 AM, revealed Resident #1 rolled out of bed and his/her arm hit the lever on recliner. Review of the Hospital X-Ray Report, dated 10/16/17, revealed Resident #1 was found to have a puncture wound after fall to posterior right elbow. Review of facility investigation, not dated, revealed there was no documented evidence the facility interviewed staff to ask if they had been following Resident #1's care plan or if other staff on duty had assisted SRNA #1 with positioning of Resident #1 during the shift. Attempted interview with Resident #1, on 10/31/17 at 9:10 AM, revealed he/she was nonverbal and did not respond to any questions asked. Interview with SRNA #1, on 10/31/17 at 1:45 PM, revealed on 10/16/17 at approximately 3:00 AM she looked into Resident #1's room and she could not see Resident #1 in bed so she stepped back to ensure she was in Resident #1's room. She stated after she saw the name plate for Resident #1, she entered Resident #1's room and found Resident #1 lying face down on the floor with Resident #1's right arm laying on the recliner lever. She then informed the nurse of Resident #1 being found in the floor. She stated she did not ask any staff for any assistance for turning and repositioning Resident #1 during the shift. She stated an off going SRNA assisted her to reposition Resident #1 at approximately 9:30 PM on 10/15/17 and then when she checked Resident #1 at approximately 12:30 AM on 10/16/17 she didn't seek assistance with repositioning Resident #1 due to she did not need assistance. She revealed she was aware the care plan calls for two (2) staff assistance when turning and repositioning Resident #1 but she does it by herself often due to the resident not needing assistance even though the care plan calls for two (2) staff assistance. She stated Resident #1 is to have his/her bed in a low position and the bed was in a low position after she provided positioning at approximately 12:30 AM on 10/16/17. She stated the bed was still in a low position when she found Resident #1 in the floor at approximately 3:00 AM on 10/16/17. Interview with SRNA #2 on 11/01/17 at 11:29 AM, revealed she was working the unit back by Resident #1's unit on the night Resident #1 had a fall on 10/16/17. She stated she did not think Resident #1 could turn him/herself over out of bed, but if Resident #1 was not positioned properly and his/her upper body was close to the edge of the bed he/she could come out of bed and fall. She stated SRNA #1 did not come ask her for any assistance with turning or repositioning Resident #1 during the shift Resident #1 fell and no one had interviewed her to see if she had assisted with Resident #1. Interview with SRNA #3, on 11/01/17 at 8:43 AM, revealed she was working the unit back by Resident #1's unit on the night Resident #1 had a fall on 10/16/17. She stated SRNA #1 did not ask her for any assistance of turning and repositioning Resident #1 during the shift and no one had asked her if she had assisted with Resident #1's positioning that night. She stated she was familiar with Resident #1 due to she had worked with him/her many times. She stated she did not believe Resident #1 could have rolled him/herself out of bed due to this resident didn't have the strength or ability to do such. She stated she informed the DON and Unit Manager she did not believe the resident rolled him/herself out of bed. Interview with Registered Nurse (RN) #1 on 10/31/17 at 3:55 PM, revealed herself and SRNA #1 were the staff on duty on the unit Resident #1 resides on, on the night Resident #1 fell on [DATE]. She stated she responded to Resident #1's room after SRNA #1 informed her she had found Resident #1 in the floor. She stated when she responded to SRNA #1's request to come the resident's room, she found Resident #1 lying face down with his/her arm laying on the recliner lever. She revealed she asked SRNA #1 if she was changing Resident #1 when the fall occurred because she did not believe Resident #1 was capable of rolling him/herself at all and definitely was not able to roll him/herself out of a bed. She stated she informed the Director of Nursing (DON) of the incident directly after it had happened and she informed the DON she did not believe Resident #1 was physically able to roll him/herself out of a bed. She revealed she was never questioned by the DON any further regarding the incident. She also stated she was not asked by SRNA #1 to assist with any turning or reposition of Resident #1 prior to Resident #1 having the fall at approximately 3:00 AM on 10/16/17. She stated she is always available for SRNA's when they need assistance turning/repositioning residents that require assistance of two (2) staff. Interview with Licensed Practical Nurse (LPN) #1 on 11/01/17 at 1:31 PM, revealed she has worked Resident #1's unit for about a year and was very familiar with Resident #1 due to working with him/her over the last year. She stated she has never known Resident #1 to turn or position him/herself and did not believe Resident #1 could have rolled him/herself out of bed. Interview with Unit Manager #1 on 10/31/17 at 2:25 PM, revealed she expected all staff to provide the assistance that each resident needs based on their assessed and care planned needs. She stated as far as she knew, Resident #1 had an unwitnessed fall and that was the facility's determination of the fall/incident. She also revealed she did not think Resident #1 could have rolled him/herself over and out of bed. Interview with Physical Therapy Assistant (PTA) #1 on 10/31/17 at 11:31 AM, revealed Resident #1 is on the therapy case load and she worked with the resident. She stated Resident #1 is unable to make position changes or independently roll him/herself over. Interview with Certified Occupational Therapy Assistant (COTA) #1 on 10/31/17 at 11:40 AM, revealed Resident #1 is on occupational therapy case load. She stated she could not see how Resident #1 could have rolled him/herself out of bed due to this resident's inability to make even simple position changes. Interview with COTA #2 on 10/31/17 at 12:00 PM, revealed she has been working with Resident #1 on the therapy case load and Resident #1 is unable to perform any bed mobility tasks or turn self. Interview with facility Medical Director on 11/01/17 at 2:31 PM, revealed she did not believe Resident #1 was physically capable of turning self over or rolling out of a bed. Interview with the DON, on 11/01/17 at 10:13 AM, revealed the facility determined the root cause for Resident #1's fall on 10/16/17 was that it was an unwitnessed fall from the bed and the facility could not determine the exact cause. She stated they could not rule out initially that it was staff error, but due to the fact SRNA #1 was a good employee she did not ultimately think it was staff error that caused the fall. She revealed the facility could not find a root cause as to how the resident was injured, but the possible reasons for the incident were either the resident had taken self out of bed or staff error caused it. She stated she expected staff to ensure the minimum assessed staff assistance was used for all residents. She stated the facility went with the idea Resident #1 rolled out of bed by him/herself due to someone had said Resident #1 had rolled out of bed on his/her own before. She revealed after the surveyor entered the building for this complaint investigation on 10/31/17 it was determined the facility did not have any information of Resident #1 having rolled out of the bed before. She stated this fall on 10/16/17 was actually Resident #1's first fall. She stated the misinformation she had of Resident #1 having rolled out of bed before did direct her into believing this is what happened on 10/16/17 when Resident #1 was found in the floor. She also stated the interventions that were put into place after Resident #1's fall on 10/16/17 were directed toward the resident rolled him/herself out of bed. She stated the intervention the facility implemented as a basis of the findings that they believed the resident rolled him/herself out of bed was to put tennis balls over the levers of recliners, implement a winged mattress and Resident #1's bed was placed against the wall with only one side open. She revealed the Executive Director wanted to do a follow up meeting with RN #1 who was on duty, but the RN was unable to come in and she was supposed to call RN #1 back and set up a follow up meeting, but she failed to do so. Further interview with the DON, on 11/01/17 at 2:59 PM, revealed the facility investigation should have been more thorough and she had not identified the CNA had not been following the care plan for bed mobility. She stated as of 11/01/17 the facility has implemented a performance improvement action plan related to re-educating staff on following plans of care for all residents. She stated also, disciplinary actions would be done on the staff identified not following plans of care.

Based on interview, record review, and facility policy and procedure review, it was determined the facility failed to report an allegation of abuse to the State Survey Agency for one (1) of eighteen (18) sampled residents (Resident #13). The findings include: Review of the facility policy and procedure titled, Abuse, dated 07/28/14, revealed all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency.) Record review revealed the facility admitted Resident #13 on 05/19/11 with diagnoses, which included Alzheimer's Dementia, [MEDICAL CONDITION], Unspecified [MEDICAL CONDITION], and Mood Disorder. Review of the annual Minimum Data Set (MDS) assessment, dated 12/23/15, revealed the facility assessed Resident #1's cognition as severely impaired. During the Abuse Prohibition Review (Task 5G) part of the survey process, Certified Nurse Aide (CNA) #1 was interviewed on 01/28/16 at 8:40 AM, regarding any involvement in identifying abuse and neglect. CNA #1 stated she reported to the Charge Nurse (Registered Nurse {RN} #4), on 01/26/16 at approximately 11:00 AM, CNA #2 was rough when handling Resident #13 during a bed bath. Further interview with CNA #1, on 01/28/16 at 9:00 AM, revealed during a bed bath for Resident #13, she observed CNA #2 block the resident's attempt to strike out at her and in the process had pinned the resident's arm to the mattress, with both of her hands and stated you will not hit me. CNA #1 stated the resident had a serious startle reflex and a history of combative behaviors and felt CNA was excessively' rough with this resident. Interview with CNA #2, on 01/28/16 at 11:15 AM, revealed her and CNA #5 were administering a bed bath to Resident #13 on 01/26/16, when CNA #1 and CNA #4 entered the room. CNA #2 stated she was attempting to dry the resident's underarm with a towel when the resident reached out to take a swing at me, and she laid his/her arm down on the bed with one (1) hand and an opened palm, then held it there for a few seconds and did not recall saying anything to the resident. CNA #1 revealed the Assistant Director of Nurses (ADON) approached her and stated there had been a complaint of roughness with Resident #13 and she was taken off the floor. She stated she wrote out a statement, and was sent home until after investigation. The CNA stated she talked to the DON afterwards and was told to be more gentle with this resident. Interview with CNA #5, on 01/28/16 at 12:50 PM, revealed she was assisting CNA #2 with Resident #13's bed bath on 01/26/16 and she did not think CNA #2 used both of her hands to hold the resident's forearm down. She stated CNA #2 placed one open hand on the resident's arm and laid it on the bed and only for a few seconds and she never heard CNA #2 say anything to the resident. Interview with CNA #4, on 01/28/16 at 1:30 PM, revealed the resident had a history of [REDACTED]. CNA #4 stated CNA #2 held the resident's forearm and placed it on the bed and stated, You are not going to hit me . She stated this was not said loudly but the CNA stated she had to leave the room, as it upset her. The CNA stated she and CNA #1 left the room and reported this to RN #4. Interview with RN #4, on 01/29/16 at 3:50 PM, revealed when CNA #1 and #4 reported the incident ot her, she reported to the ADON and CNA #2 was taken off the floor. Interview with the ADON, on 01/29/16 at 1:50 PM, revealed she was in charge on 01/26/16 and started the investigation and stated she felt CNA #2 was responding to the resident more in frustration than with any intent to harm. She stated she did not feel this was an allegation of abuse, after interviewing all four (4) CNAs involved and did not report this to the State Agency. However, she stated skin assessments were completed on Resident #13 and other non-interviewable residents on the unit as well as interviews with residents who were cognitive and there were no concerns noted. Interview with the Director of Nursing (DON), on 01/28/16 at 9:12 AM, revealed she also did not feel this was an allegation of abuse and did not need to report to the State Agency. The DON stated her investigation revealed CNA #2 put her hand on top of the resident's arm to keep from being struck. She further stated the CNA was educated and counseled about not rushing through care and being gentler with the resident, but felt there was no intent to harm the resident.

Based on interview, record review, review of the facility's investigative report and Abuse policy, it was determined the facility failed to implement their Abuse policy when they failed to report an allegation of mistreatment and report the results of their investigation to the State Agency, for one (1) of eighteen (18) sampled residents (Resident #13). The findings include: Review of the facility policy and procedure titled, Abuse, dated 07/28/14, revealed all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Record review revealed the facility admitted Resident #13 on 05/19/11 with [DIAGNOSES REDACTED]. Interview with Certified Nurse Aide (CNA) #1, on 01/28/16 at 8:40 AM and 9:00 AM, revealed during a bed bath for Resident #13, she observed CNA #2 block the resident's attempt to strike out at her . CNA #1 stated CNA #2 then pinned the resident's arm to the mattress, with both of her hands and stated, You will not hit me. CNA #1 revealed the resident had a serious startle reflex and a history of combative behaviors and felt CNA was excessively' rough with this resident. CNA #1 stated she reported the incident to the Charge Nurse (Registered Nurse {RN} #4), on 01/26/16 at approximately 11:00 AM. Interview with the Assistant Director of Nursing (ADON), on 01/29/16 at 1:50 PM, revealed the Charge Nurse reported the allegation to her and she started an investigation. The ADON stated she felt CNA #2 was responding to the resident more in frustration than with any intent to harm. She further stated she did not feel the facility failed to follow the abuse policy because there was no intent to harm the resident and she did not feel this was not an allegation of abuse. Interview with the Director of Nursing (DON), on 01/28/16 at 9:12 AM, revealed she did not follow the Abuse Policy because she felt this was not an allegation of abuse and did not need to be reported to the State Agency. The DON stated her investigation revealed CNA #2 put her hand on top the resident's arm to keep from being struck and there was no intent to harm the resident.

Based on observation, interview and review of facility policy, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as was possible related to a green D oxygen cylinder being stored in a standing position unsecured on the floor in the hallway outside resident room #40. Additionally, a liquid oxygen portable tank was in a standing position unsecured beside a D oxygen cylinder located just inside the emergency exit door. The findings include: Review of the facility's policy titled, Fire Prevention/Life Safety Training, dated 10/17/07 revealed oxygen cylinders must be chained individually or secured in stand. Review of the facility's policy titled, Life Safety Management Plan, dated 12/11/04, revealed exits are kept clear to include areas directly affected, as well as all other exits. Observation during general tour of the C hall, on 06/24/15 at 5:20 AM, revealed a green D size oxygen cylinder was standing freely on the floor and unsecured in the hallway outside room #40. Additionally, there was a recliner blocking the emergency exit door and a liquid oxygen portable tank was standing unsecured beside a D oxygen cylinder both located just inside the emergency exit door beside room #40. Interview with Registered Nurse (RN) #1, on 06/24/15 at 5:40 AM, revealed the oxygen cylinder was there when she arrived to work on 06/23/15 at 6:00 PM. She indicated that she had moved the cylinders into room #40. She stated the recliner had been in front of the exit door earlier that shift. Interview with Certified Nurse Aide (CNA) #1, on 06/24/15 at 6:15 AM, revealed she was new and had never been told what to do with or how to use oxygen cylinders. She stated she had only been shown how to use the Liquid Portables which are to be secured to the back of the resident wheelchair when in use or stored in the oxygen room when not in use. Interview with the Director Of Nursing (DON), on 06/25/15 at 2:42 PM, revealed she expected all oxygen cylinders to be kept secured and all exits to be kept clear at all times.

Based on observation, interview, record review, medication shipment log review and facility policy review, it was determined the facility's system to ensure pharmacy services were provided to meet the needs of one (1) of five (5) sampled residents was effective (Resident #2). Resident #2 was admitted to the facility on [DATE] and the facility failed to ensure Intravenous Medication (an antibiotic) was available for administration which caused the resident to miss two (2) doses. The findings include: Review of the facility policy titled, Physician Orders, dated 11/12/12, revealed an appropriate copy of orders should be transmitted to the pharmacy for dispensing. Review of the facility policy titled, Delivery and Receipt of Routine Deliveries, dated 01/01/13, revealed the pharmacy and facility should coordinate to determine the delivery dates and times as soon as possible after the execution of the Pharmacy Services Agreement or pharmacy Consult Agreement. Record review revealed the facility admitted Resident #2 on 06/04/15 at 6:00 PM with [DIAGNOSES REDACTED]. Review of the Physician admission orders [REDACTED]. Review of the transferring hospital Medication Reconciliation Sheet revealed Resident #2 received his/her last dose of Acyclovir at 2:00 PM on 06/04/15 and should have received the next dose at 10:00 PM on 06/04/15. However, review of the June 2015 Medication Administration Record [REDACTED]. Review of the Admission Physician Orders that were faxed from the transferring hospital revealed the orders were received into the facility at 1:44 PM on 06/04/15; however, review of the Nursing Notes, revealed the Licensed Practical Nurse (LPN) documented the orders were faxed to pharmacy on 06/04/15 at 6:31 PM. Review of the Pharmacy Shipment Detail Report, dated 06/05/15 at 2:49 AM, revealed the Acyclovir 800 mg was not shipped from the pharmacy. Interview with the Unit Manager for the A and C halls, on 06/24/15 at 8:53 AM, revealed the computer system was down one (1) time during June 2015 but it was not while this resident was here. She stated intravenous (IV) orders were faxed over to the pharmacy and if not available they arrange for the backup pharmacy to deliver the ordered medications. She stated Resident #2 was only here over night and left Against Medical Advice (AMA) the next morning on 06/05/15. She stated the resident left AMA at approximately 7:00 AM on 06/05/15. Interview with Licensed Practical Nurse (LPN) #2, on 06/25/15 at 10:55 AM, revealed she was working on 06/04/15 when the orders were faxed to the facility. She stated the orders were reconciled with the physician and placed in the computer on hold because all orders require two (2) nurses to review them before releasing them to the pharmacy. Once the orders are confirmed, all narcotics and IV medications orders are faxed to the pharmacy and the pharmacy should be notified of the admission. She confirmed Resident #2 had not arrived to the facility prior to her shift ending. Interview with LPN #3, on 06/25/15 at 7:57 AM, revealed she was working the night Resident #2 was admitted and the orders had been faxed over to pharmacy upon arrival. She stated the medications did not arrive on the shipment, so she called the pharmacy and was informed that it was coming from the backup pharmacy; however, she never followed up on the delivery. She confirmed she never notified the physician that the medication was never given as ordered. Interview with the facility's Chief Pharmacist, on 06/24/15 at 11:25 AM, revealed there was never an order faxed to pharmacy for Acyclovir 800 mg to be given IV. He stated all IV medications ordered should be faxed to the pharmacy to be dispensed. Additionally, he confirmed a call had been placed to the pharmacy at 8:15 PM on 06/04/15 by LPN #3 to inform them Resident #2 had been admitted to the facility and that all medications including controlled medications needed to be sent. Interview with the Attending Physician, on 06/25/15 at 8:50 AM, revealed he had never seen Resident #2 due to his/her short stay in the facility but was made aware that the resident had been admitted on [DATE]. He stated he had not been notified the resident had not received his Acyclovir 800 mg as ordered. He revealed he expected all medications to be administered and he was to be notified if not given as ordered.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure services were provided to maintain a sanitary and comfortable interior. Observations on 12/16/14 and 12/17/14 revealed four (4) residents' Broda chairs were noted to be in need of repair and/or cleaning and three (3) residents' wheelchairs were in need of repair and/or cleaning. The findings include: Review of the facility's policy titled, "Work Practices: Cleaning," with a revision date of 10/31/10, revealed that patient care items are to be cleaned, disinfected, or sterilized. Observations on 12/16/14 at 7:32 PM and 12/17/14 between 7:58 AM and 8:27 AM revealed seven chairs that were soiled and/or in need of repair. Broda chairs for Residents #3, C, and D were observed to be soiled with a white substance on the armrests as well as the lower section of the chair. Residents D and #4's Broda chair armrests were observed to be chipped, torn, cracked, and in need of repair. In addition, the wheelchair for Resident E was soiled with a white substance on the armrest and seat. Residents F and G's wheelchair armrests were torn and cracked. Interview with State Registered Nurse Aide (SRNA) #3 on 12/17/14 at 9:03 AM revealed third shift staff normally cleans residents' equipment such as Broda chairs and wheelchairs and they are pretty good about cleaning them. Further interview with SRNA #3 revealed she was unaware of Resident #3's Broda chair being soiled. According to SRNA #3, she reported soiled resident equipment to the nurse. Interview with SRNA #4 on 12/17/14 at 9:17 AM revealed, "Everyone is responsible" for cleaning Broda chairs, wheelchairs, and/or resident equipment when dirty; "technically, third shift" SRNAs are responsible. According to SRNA #4, she was not aware that Residents C and D's Broda chairs were dirty and in need of cleaning. Interview with Registered Nurse (RN) #2 on 12/17/14 at 9:12 AM revealed SRNAs are responsible for cleaning resident equipment. RN #2 stated there were cleaning schedules in the SRNA task book. Further interview with RN #2 revealed she was not aware that Resident #3's Broda chair was soiled. RN #2 stated the resident's chair definitely needed cleaning. Interview with the Maintenance Director on 12/17/14 at 10:00 AM revealed all staff was required to complete a work order form for needed repairs and to place the form in a notebook maintained at each nurses' station. He reported that he checked the work order notebook daily. The Maintenance Director stated that he was not aware of the Broda chairs and wheelchairs that were in need of repair and had not seen work orders for the identified areas. In addition, the Maintenance Director stated he randomly monitored the facility for areas in need of repair and had not identified any concerns. Interview with the facility's Director of Nursing (DON) on 12/17/14 at 9:52 AM revealed she was not aware of the soiled Broda chairs and wheelchairs and/or the Broda chairs and wheelchairs in need of repair/replacement. The DON said staff is required to complete Maintenance request forms if they identify equipment that needs to be repaired or replaced. Further interview with the DON revealed Maintenance staff is responsible for repairing and/or replacing Broda chairs and wheelchairs.

Based on interview, personnel record review, and review of facility policy, it was determined the facility failed to ensure the Nurse Aide Abuse Registry check was requested/obtained upon hire for one (1) of five (5) employees (Employee #3). Employee #3's date of hire was 11/24/14; however, there was no evidence the facility had checked the status of Employee #3 on the State Nurse Aide Abuse Registry. The findings include: Review of the facility's policy, "Abuse," with a revision date of 04/09/04, revealed all potential employees would be queried to determine the individual's status on the State (Kentucky) Nurse Aide Registry. Review of the personnel record on 12/17/14 at 10:36 AM for Employee #3 revealed the employee's hire date was 11/24/14; however, no documentation of a status check of the Nurse Aide Abuse Registry was found. The facility hired Employee #3 to work in the Dietary Department as a cook. Interview with the Staff Development Coordinator on 12/17/14 at 10:50 AM revealed she was responsible for checking the Nurse Aide Abuse Registry on all potential new hires. Further interview with the Staff Development Coordinator revealed she only checked the status of a potential employee on the State Nurse Aide Abuse Registry if they were applying for a nursing position. According to the Staff Development Coordinator, she had not checked the State Nurse Aide Abuse Registry for the status of Employee #3 since Employee #3 had applied and was hired for a non-nursing position.