Every finding on record at Middlesboro Nursing and Rehabilitation Facility

Based on observation, interview, record review and facility policy review, the facility failed to administer medications in accordance with provider order and established nursing practice for 1 of 19 sampled residents, Resident 3 (R3).Review of facility investigation, and interviews with Licensed Practical Nurse (LPN) 2, revealed R3 received medications per rectum rather than the ordered oral route.The findings include:Review of facility policy, Medication Administration Policy, subtitled Medication Preparation, last reviewed 12/22/2025, revealed the facility would ensure medications were administered as prescribed in accordance with manufacturers' specifications, as well as good nursing principles and practices. Further review revealed medication tablets may be crushed or capsules emptied out when it is safe to do so and when a resident has difficulty swallowing or is tube-fed and with a specific order from the prescriber. Continued review revealed the need for crushing medications must have been indicated on the resident's orders and the MAR medications were administered in accordance with written orders of the prescriber.Review of facility policy, Medication Administration Policy, subtitled Medication Administration, last reviewed 8/04/2024, revealed medications were administered in accordance with written orders of the prescriber. Further review revealed if a dose of scheduled medication was refused, a rationale should be given.Review of facility policy, Medication Discrepancy Report, dated 08/16/2011, revealed medication errors and drug reactions must be reported immediately to the Director of Nursing (DON), the resident's attending physician and the resident's responsible party, following a thorough assessment. Further review revealed a medication error was forwarded to the QAPI committee for analysis and would become part of the QAPI Committee minutes.Review of R3's admission Record revealed the facility admitted the resident from an acute care facility on 12/19/2022 with diagnoses including Unspecified cerebrovascular disease, Paranoid schizophrenia, and bipolar disorder. Review of R3's initial Minimum Data Set (MDS) assessment revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated he was cognitively intact. Further review of R3's medical record revealed he was discharged to inpatient psychiatric service on 05/21/2024. Continued review revealed R3 was his own responsible party.Review of R3's orders revealed, as of 04/16/2023, his diet was Controlled Carbohydrate (CCHO) with regular texture and thin liquids. Further review revealed R3 took medications whole.Review of R3's April 2023 Medication Administration Record revealed, on 4/16/2023 there were 14 medications scheduled at 8:00 PM and 9:00 PM, that LPN3 had administered. Those medications were:Atorvastatin Calcium, 20 milligrams (mg) by mouth (po) at bedtime (hs)Finasteride 5 mg po hsTrazodone Hydrochloride 75 mg po hsAmitiza 8 mcg po twice daily (bid)Benztropine Mesylate 0.5 mg po bidCelecoxib 100 mg po hsHaloperidol 2 mg po bidMetoprolol 25 mg, 1/2 tablet, po bidMucinex 60 mg po bidBaclofen 10 mg po three times a day (tid)Depakote Sprinkles 125 mg po tidGabapentin 100 mg po tidPolyethylene Glycol powder 17 gram po tidSucralfate 1 gram po before meals and hsReview of R3's progress notes revealed there was no documented evidence the route of medication administration had changed on 04/16/2023.Review of facility's General Investigation (Quality Assurance/Confidential), signed by the DON and the Administrator on 4/17/2023, revealed R3 stated to the resident had requested medication be administered rectally and the nurse followed his request. The incident was documented as a medication error. Further review revealed nursing assessment revealed R3 was alert and oriented and had sustained no injury. Continued review revealed he had made no complaints and was educated during the interview regarding medication administration. Additional review revealed the nurses received a verbal reprimand and re-education, including the 5 Rights of Medication Administration, and the different routes of medication administration. R3 was his own responsible party but his daughter was notified, as well as the physician, and he was educated about the correct route of medication administration. Review of the risk and causal factors to the incident revealed R3 requested medications be administered rectally rather than by mouth and the nurse followed his request. The nurses were educated via phone after they had departed from the shift for verbal reprimand and education provided along with follow up education regarding Five Rights of Medication Administration and that she should have contacted the nurse practitioner or physician to request further instruction. Continued review revealed R3 received assessment on the following two days with no changes noted. Additional review revealed nurse interviews were that R3 refused to take his medication by mouth but would take them rectally, and they had complied with his request by crushing meds and administration per rectum. They reported he had exhibited no change in condition for the rest of the shift. Review of the Nurse Practitioner progress note, dated 04/18/2023, revealed the visit was at the request of the facility and was unremarkable for change of condition or any new complaints. Review of Employee Conference with LPN 3, dated 04/17/2023, revealed she received verbal reprimand regarding administering medication per rectum. She received education that the physician had to give an order to change the route of administration. She was further educated to call the DON or Assistant Director of Nursing (ADON) for direction when she was in a situation that she did not know what to do. Continued review revealed LPN 3 voiced understanding and verbalized she would administer medications per the ordered route. Additional review revealed LPN 2 received the same reprimand and education though while she voiced understanding, she stated she thought she was not doing anything wrong. Review of QAPI Summary, dated 04/20/2023, revealed the agenda item of Review of the 5 Rights of Medication Administration. Review of Medication Report, dated 01/09/2023, revealed LPN 3 had been successfully checked off for medication administration approximately three months prior to the incident.Review of the in-service record, revealed all licensed nursing staff were educated on the topic of Medication Administration from 04/17/2023 - 04/21/2023 in face-to-face format. Further review revealed specific focus on route of administration with follow up on medication passes by the Quality Assurance nurse, the ADON and DON. Further review revealed education covered the five rights of medication administration with key takeways that correct medication administration requires close attention to detail, that the five rights are the right patient, right drug, right time, right dose and right route and that understanding medication routes of administration helps improve medication safety. Continued review revealed 20 medication administration reminders, including the 5 Rights of Medication Administration.LPN 3 was not available for interview, as she is no longer employed at the facility, moved out of state and no contact information was known for her.During interview with LPN 2 on 06/10/2026 at 9:40 PM, she stated R3 did receive medications rectally on one occasion. She stated LPN 3 was a new graduate and had reported R3 refused to take his medication orally but had stated he would only take them if given rectally. She stated LPN3 crushed the medication as directed when administering with applesauce but placed in lubricant and administered rectally as the resident had requested. She stated he did not scream out in pain or report feeling as though he had been raped. She further stated that she did not remember the date when this occurred, but it was quite a while before he was discharged . LPN2 stated she rounded on him later and he was in no distress and was pleasant with no report of feeling violated. She stated it was consistently apparent when he refused his psychiatric medications as evidenced by changing moods and behavior and that he felt better when he did have them. She stated the appropriate strategy if he refused medications and requested a different route would be to call the provider to notify and ask if he/she had different orders. During interview with LPN 4 on 06/12/2026 at 9:45 AM, she stated it was necessary to call the provider for an order to change a medication, including the route. During interview with LPN 5 on 06/12/2026 at 9:55 AM, he stated if a resident refused medication and wanted it via different route, first should educate them then would call the provider to report. At that point, he would be up to their judgement. In further interview, he stated the bottom line was a nurse has to give medications how they are ordered.During interview with LPN 6 on 06/12/2026 at 10:05 AM, she stated if a resident refused oral medications and wanted a different route, she could not do that without a provider order, so would have to call and report the refusal. During interview with RN 2, a member of QAPI, on 06/12/2026 at 1:47 PM, she stated they took the medication error issue to QAPI, and part of that process was all the nurses had medication pass education with the five rights, what to do if there is a question (notify provider), then audits consisting of observation of medication pass with various nurses. She stated she did not recall how long the audits went on but did remember they were being done to ensure that all the nurses were carrying out the education as provided. She stated any nurse should call the doctor to notify of an issue with medication and obtain guidance for what he or she wants the nurse to do.During interview with LPN 8, who was a member of QAPI, on 06/12/2026 at 1:56 PM, she stated, QAPI met on 04/20/2023 after this incident happened on 04/16/2023. She stated there was education afterwards with the nursing staff about medication administration. She stated it was addressed immediately, making sure staff were aware of what had happened, what to do in that situation if it were to come up again. She stated there were observations/spot check/audits of medication pass after this and on a routine basis where they watch for residents to be receiving their medication in a timely manner and correctly.During interview with ADON on 06/11/2026 at 10:07 AM, she stated the incident with R3 was three years ago. She stated she did not recall why the staff came to tell her about the rectal administration. She stated she had talked to R3 that morning after she had been notified and he was fine, did not report feeling violated, did not mention feeling like he was raped. She stated the two nurses were working together, and that one was a new graduate. She stated she did not recall who specifically gave the medicine, but after reviewing the original investigation, she felt like it was the new grad, who is no longer employed at the facility. In further interview, she stated the implication was that the resident stated he would not take his meds orally but he, himself, stated he would take them rectally. She stated she did not recall the discussion of what led to that decision on the part of the nurse or how it came to light that leadership was made aware. She stated they were educated they must follow the order as written and if resident requested otherwise, the provider had to give an order to change the route of administration. In continued interview, she stated their actions following this incident, investigation and education, was following it with audits/spot checks to ensure compliance.During interview with Nurse Practitioner (NP) on 06/11/2026 at 4:06 PM, she stated she did not recall R3 having swallowing difficulties at that time. She stated she did not remember being called about R3 refusing medications or for a different order. In further interview, she stated receiving the medications per rectum would not have hurt him physically and the medications would still work. During interview with the Medical Director (MD) on 06/12/2026 at 10:26 AM, he stated if an order was written for a medication to be administered by mouth, the nurse should contact the physician for clarification and direction if the resident preferred another route. He stated safety with giving medication rectally would depend on the medication, but generally oral medications were safe for rectal administration and was doubtful of harm potential. During interview with the DON on 06/12/2026 at 11:49 AM, she stated she was part of the QA/QAPI process and was in attendance at the meeting following the incident. She stated she found out about R3's incident because the following morning he had told the nurse he got meds in his butt, so the nurse alerted her. She stated she went to see him and educated him that the nurses could not give meds except the way they were ordered, that they would have to call the doctor that to be ordered. She stated he huffed about that. She stated she called the nurses right away and they received a verbal reprimand and documented it on QA conference form. She stated she provided Medication administration re-education to all the nurses over the next few days and also placed laminated references in the narcotics book so they were always available on the cart. This included 5 Rights, what to do if out of a medication, what to do if there is any question. In further interview, she stated they followed this with audits/spot checks of medication administration to ensure compliance. In additional interview, she stated he had no change of condition in response to the incident. He transferred to inpatient psych later on, like a year later, so not related. During interview with Administrator on 06/12/2026 at 3:33 PM, she stated her expectation for a situation like that with medication administration, was to give in accordance with the MAR, or call the doctor to ask for guidance or further instructions. She stated the first leadership response was assessing and interviewing the resident. In further interview, she stated they initiated education with the nurses to ensure they all understood the five rights and reaching out to the physician for order changes. She also stated they have not had an issue since, that it was a single incident. In continued interview, she stated they conducted spot checks/audits with medication administration and interviewed residents who could engage about the circumstances. She stated they asked them if there were any issues with the medications, and how they were given. Then, she stated they took the issue to Quality Assurance/QAPI, just 3 days later after education was started, assessments and audits.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure all alleged violations of abuse, which involved four (4) of five (5) sampled residents (Resident #2, #3, #4 and #5) were reported to the administrator of the facility and other officials, that included the State Survey Agency immediately but not later than two (2) hours after the allegation was made and in accordance with State Laws. Interviews with staff and review of resident records revealed Resident #2 was observed lying in bed with Resident #1 which was reported to the Administrator and State Agencies as required. During the investigation, interviews with staff and record review revealed Resident #2 had exhibited inappropriate sexual behaviors previously toward other residents (Resident #3, #4 and #5), on three (3) different occasions. However, there was no evidence the facility identified the incidents as potential abuse and reported the incidents to the Administrator and State Agencies as outlined in the facility policy. The findings include: Review of the facility policy titled Reporting Abuse of Facility Management dated [DATE] revealed facility employees must immediately report any incident or suspected incident of neglect or resident abuse, to the Administrator. According to the policy, abuse is defined as the willful infliction of injury, unreasonable confinement or intimidation. The policy also defined sexual abuse as, but not limited to, sexual harassment, sexual coercion or sexual assault. Review of the facility investigation dated [DATE] revealed Resident #1 had went in Resident #2's room and got in bed with him/her. According to the investigation Resident #2's hands were on top of Resident #1's chest, on top of his/her clothes. The facility reported the alleged incident as required, and unsubstantiated any abuse occurred. Review of Resident #2's record revealed the resident was admitted to the facility on [DATE], with current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had a Brief Interview for Mental Status (BIMS) score of eight (8) indicating moderately impaired cognition. Observations of Resident #2 on [DATE] at approximately 10:30 AM revealed the resident's room was located across the hall from Resident #1. Resident #2 was up in a wheelchair in the doorway of his/her room. Further observations on [DATE] at approximately 12:15 PM, 2:00 PM, and 4:00 PM revealed the resident remained in a wheelchair, in his/her room. Interview with Resident #2, on [DATE] at approximately 10:30 AM, revealed he/she stated Resident #1 entered his/her room and got in the bed with the resident. Resident #2 stated he/she had not touched Resident #1 but stated Resident #1 had kissed him/her on the lips, but it did not bother him/her at all. Resident #2 also stated he/she would like to give the surveyor a long hug if all the rules wasn't in place by the government. Interview with Kentucky Medication Aide (KMA) #1, on [DATE] at 2:15 PM, revealed on [DATE] she witnessed Resident #1 lying in Resident #2's bed with him/her, and the residents were cuddling like a couple. She stated she immediately reported the incident to the nurse as required. However, further interview with the KMA revealed she had previously witnessed (unknown date/time) Resident #2 lying in bed with Resident #3 (now deceased ) and Resident #2 attempted to put his/her hand up Resident #3's shirt. She reported the incident immediately to a nurse as required, but was unable to recall who she reported the incident to. Interview with State Registered Nurse Aide (SRNA) #1, on [DATE] at 3:00 PM, revealed she recalled hearing about an incident that occurred with Resident #2 and Resident #3 but was unable to remember what/when the incident occurred. Interview with SRNA #2, on [DATE] at 3:20 PM, revealed Resident #2 called other female residents [NAME] and attempted to get other female residents to come in and lay down with him/her. SRNA #2 stated she had received in report (date/time unknown) that Resident #3 had been observed in bed with Resident #2, but was unable to recall when the incident occurred. She stated Resident #2's sexually inappropriate behaviors had been reported to nurses in the facility and we all know the resident is sexually inappropriate. Interview with SRNA #3, on [DATE] at 1:10 PM, revealed Resident #2 would tell her he/she would like to have a good time with her, and had also been observed to say come in my room and talk to me to other female residents in the facility. She also recalled an incident where Resident #3 was observed in Resident #2's bed but was unable to recall when the incident occurred. She also stated the residents sexually inappropriate behaviors had been reported to nurses in the facility when they occurred. Review of Resident #2's nurse's notes dated [DATE] at 6:37 PM revealed Registered Nurse (RN) #1 documented Resident #2 asked another resident (Resident #4) Can I feel up your shirt? Documentation also indicated Resident #2 had been stalking residents in their doorways, and seeking inappropriate physical contact from the opposite gender. Interview with RN #1, on [DATE] at 4:45 PM, revealed she completed the documentation on [DATE] when Resident #2 asked Resident #4 if he/she could feel up his/her shirt. She stated she immediately separated the residents and passed the incident on to the oncoming shift (unable to recall what nurse took report at the time). However, she stated she had not reported the incident to Administrative staff because she did not see the incident as potential abuse. Review of Resident #2's nurses notes revealed on [DATE] at 3:41 AM, Licensed Practical Nurse (LPN) #2 documented Resident #2 was observed in his/her wheelchair and was setting in the doorway of another resident (Resident #5) and stated to him/her I was hoping your covers would be down. The note indicated Resident #2 laughed when he/she was told the behavior was inappropriate and he/she was redirected back to his/her room. Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 4:35 PM revealed she primarily works the night shift and at an unknown date/time she observed Resident #2 at Resident #5's doorway, which was across the hall from his/her room, and the resident stated I was hoping your covers would be down, to Resident #5. LPN #2 stated Resident #5 was unsure what Resident #2 meant by the statement made to him/her. The LPN reported the incident to the oncoming shift (unable to recall who) and also stated she had not reported the incident to Administrative staff because she did not think it was a reportable incident. Interview with Unit Coordinator (UC) #1, on [DATE] at 4:10 PM, revealed staff had not reported any incidents of Resident #2 making sexually inappropriate comments to other residents in the facility. However, she stated staff had been trained on abuse/neglect and should have immediately reported the incidents to Administrative staff as outlined in the facility policy. Interview with the Administrator, on [DATE] at 6:15 PM, revealed staff had been trained to report any incident of suspected abuse to Administrative staff immediately. However, she stated staff had failed to notify her of Resident #2's sexual behaviors directed toward other residents in the facility. She also stated she would have reported all allegations of abuse or suspected abuse to State Agencies as required, if she had been notified.

Based on observation, interview, record review, and review of facility investigation and policy, it was determined the facility failed to ensure all alleged violations of abuse were thoroughly investigated. Review of a facility investigation revealed on [DATE] Resident #2 was observed lying in bed with his/her arms around Resident #1. Interviews with staff and review of resident records indicated Resident #2 had exhibited inappropriate sexual behaviors toward other residents, on at least three (3) different occasions, prior to the incident that occurred on [DATE]. Further interviews also indicated Resident #1 wandered into other resident rooms at times, as he/she had difficulty finding his/her room. However, interviews with the Administrator and review of the facility investigation revealed no evidence the facility identified Resident #2's prior sexual behaviors directed towards other residents, or that Resident #1 wandered in/out of other resident rooms at times. The findings include: Review of the facility policy titled Abuse Investigation dated [DATE] revealed all reports of resident abuse, neglect and injuries of unknown source should be promptly and thoroughly investigated by facility management. The policy also stated staff members (on all shifts) who had contact with the resident during the period of the alleged incident should also be interviewed. According to the policy, the resident's medical record should also be reviewed, to determine events leading up to the incident. The policy provided no direction on interviewing or evaluating other residents in the facility, in the event of a resident to resident incident. Review of the facility investigation dated [DATE] revealed Resident #1 had went in Resident #2's room and got in bed with him/her. According to the investigation, Resident #2's hands were on top of Resident #1's chest, on top of his/her clothes. The facility unsubstantiated that abuse occurred. However, there was no evidence the facility interviewed or assessed other residents in the facility during their investigation. Further review of the investigation also provided no evidence, that staff on all shifts were interviewed to determine if Resident #2 had any behaviors after he/she was found in bed with Resident #1. Review of Resident #2's record revealed the facility admitted him/her to the facility on [DATE], with current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had a Brief Interview for Mental Status (BIMS) score of eight (8) indicating moderate cognitive impairment. Review of Resident #1's record revealed the facility admitted the resident on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident rejected care, exhibited physical and verbal behavioral symptoms directed toward others and wandered in the facility, one to three days during the assessment period. The assessment also indicated Resident #1 was not interviewable and was assessed to have a Brief Interview for Mental Status (BIMS) score of seven (7), indicating severe cognitive impairment. Observations of Resident #2 on [DATE] at approximately 10:30 AM revealed the resident's room was located across the hall from Resident #1. Resident #2 was up in a wheelchair in the doorway of his/her room. Further observations on [DATE] at approximately 12:15 PM, 2:00 PM, and 4:00 PM revealed Resident #2 remained in a wheelchair, in his/her room. Interview with Resident #2, on [DATE] at approximately 10:30 AM, revealed Resident #1 entered his/her room and got in the bed with the resident. Resident #2 stated he/she had not touched Resident #1 but stated that Resident #1 had kissed him/her on the lips, but it didn't bother him/her at all. The resident also informed the surveyor that he/she would like to give the surveyor a long hug if all the rules wasn't in place by the government. Interview with Kentucky Medication Aide (KMA) #1, on [DATE] at 2:15 PM, revealed on [DATE] she witnessed Resident #1 lying in Resident #2's bed with him/her, and the residents were cuddling like a couple. She also stated she had previously witnessed (unknown date/time) Resident #2 lying in bed with Resident #3 (now deceased ) and Resident #2 attempted to put his/her hand up Resident #3's shirt. She stated no one had questioned her in regards to Resident #2 or Resident #1's history of behaviors, even though she was the staff member that initially reported the incident on [DATE]. Interview with State Registered Nurse Aide (SRNA) #1, on [DATE] at 3:00 PM, revealed she heard about an incident that occurred with Resident #2 and Resident #3 but was unable to remember what/when the incident occurred. She also stated she had not been interviewed by anyone regarding Resident #1 and Resident #2's history of behaviors. Interview with SRNA #2, on [DATE] at 3:20 PM, revealed Resident #2 called other female residents [NAME] and attempted to get other female residents to come in and lay down with him/her. SRNA #2 stated she had received in report (date/time unknown) that Resident #3 had been observed in bed with Resident #2. However, the SRNA stated she had not been questioned by Administrative staff regarding Resident #2's behaviors. Review of Resident #2's nurse's notes dated [DATE] at 6:37 PM revealed Registered Nurse (RN) #1 documented that Resident #2 asked another resident (Resident #4) Can I feel up your shirt? Documentation also indicated Resident #2 had been stalking residents in their doorways, and seeking inappropriate physical contact from the opposite gender. Interview with RN #1, on [DATE] at 4:45 PM, and review of her documentation revealed on [DATE] at 6:37 PM Resident #2 had been stalking residents in their doorways, and seeking inappropriate physical contact from the opposite gender. Review and interview also indicated Resident #2 asked Resident #4 if he/she could feel up his/her shirt. The nurse stated no one at the facility had questioned her regarding Resident #2's history of behaviors. Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 4:35 PM and review of Resident #2's nurses notes revealed on [DATE] at 3:41 AM, LPN #2 documented that Resident #2 was observed in his/her wheelchair and was setting in the doorway of Resident #5's room. Resident #2 stated to Resident #5, I was hoping your covers would be down. According to the LPN, Resident #2 laughed when he/she was redirected back to his/her room and informed the behavior was inappropriate. According to the LPN, no one from facility management had asked her about either resident's behaviors. Interview with the Administrator on [DATE] at 6:15 PM revealed she was responsible to ensure all allegations of abuse were thoroughly investigated in the facility. She stated the only residents that were assessed or interviewed after the incident occurred on [DATE] were Resident #1 and Resident #2. She also stated she had interviewed approximately five (5) staff members during the investigation, which was working when the incident occurred and had not identified that Resident #1 wandered in/out of other resident rooms or that Resident #2 exhibited sexual behaviors towards other residents. The Administrator stated she felt like she had conducted a thorough investigation.

Based on observation, interview, record review, and review of a facility investigation and policies, it was determined the facility failed to ensure two (2) of five (5) sampled residents (Residents #1 and #2) received appropriate dementia treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Resident #1, who was cognitively impaired and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Although, the facility had developed interventions to address Resident #1's wandering behaviors, the facility failed to implement the interventions to prevent the resident from wandering into unsafe areas. Resident #2, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the facility investigation, Resident #2's hand was on top of Resident #1's breast, on top of' his/her clothes. However, the facility failed to identify Resident #2's sexual behaviors and failed to develop, implement or revise the resident's care plan with interventions to prevent/reduce the resident's known behaviors. The findings include: Interview with the Administrator on [DATE] at 6:15 PM indicated the facility utilized the information tool titled Ain't Misbehavin' or Behavior as Communication dated 2007, to care for residents with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] According to the tool, Dementia is the progressive loss of memory, thinking skills, judgement, and verbal communication skills. The tool also stated residents with Dementia exhibited behaviors, which was a form of communication and was never meaningless, even when staff was not able to understand the residents message through his/her behaviors. However, no information or direction was included in the information tool, to provide direction to staff on caring for residents with Dementia which exhibited sexual behaviors directed toward others. In addition, the tool had no information related to residents that wander into others personal space or have difficulty finding his/her room. Review of the policy titled Behavior Tracking Protocol not dated, revealed residents would be monitored daily for certain behaviors determined by the MDS/RAI (Minimum Data Set Assessment/Resident Assessment Instrument). The policy also stated behaviors that are not easily altered and/or have a negative impact on the resident would be addressed in the resident's plan of care. Review of the facility investigation dated [DATE] at approximately 3:00 PM, revealed Resident #1 had gone into Resident #2's room and got in bed with him/her. The investigation also stated Resident #2's hands were on top of Resident #1's chest, on top of his/her clothes. According to the investigation, the facility unsubstantiated abuse had occurred or that Resident #1 wandered into other residents rooms. However, according to the investigation, staff were educated to redirect Resident #1 if he/she attempted to enter other resident's rooms. (a) Observations of Resident #1 on [DATE] at approximately 10:15 AM revealed the resident resided across the hall from Resident #2. Resident #1 was awake lying in his/her bed, and continued observations on [DATE] at approximately 12:20 PM, 2:05 PM, and 3:55 PM revealed the resident remained in his/her bed. Review of Resident #1's record revealed the facility admitted the resident on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident rejected care, exhibited physical and verbal behavioral symptoms directed toward others and wandered in the facility, one to three days during the assessment period. The assessment also indicated Resident #1 was not interviewable and was assessed to have a Brief Interview for Mental Status (BIMS) score of seven (7) indicating severe cognitive impairment. Review of Resident #1's comprehensive care plan reviewed/revised on [DATE] revealed the resident had a problem of wandering as evidenced by intruding on the privacy and activities of others. The facility developed interventions that staff would document all incidents of wandering and would help him/her recognize his/her room by using identifiable objects such as brightly colored name sign, [NAME] on the door, etc. According to the care plan, Resident #1 had an impaired thought process related to Dementia and the interventions developed by the facility included to provide an activity calendar in his/her room and reality orientation during waking hours and do not support confusion. Review of Resident #1's nurse aide care plan provided no evidence the nurse aides were directed to ensure interventions were implemented to assist the resident in locating his/her room, by using identifiable objects such as brightly colored name sign, or a [NAME] on the residents door as outlined in his/her comprehensive care plan. Observations were conducted of Resident #1 and his/her room on [DATE] at approximately 10:15 AM, 12:20 PM, 2:05 PM, and 3:55 PM. There was no [NAME] on the residents' door, and no brightly colored sign was observed to assist Resident #1 in locating his/her room as outlined in the residents care plan. Interview with State Registered Nurse Aide (SRNA) #1, on [DATE] at 3:00 PM, revealed Resident #1 wanders in/out of other residents rooms and has trouble remembering where his/her room is located. She also acknowledged no direction was included on the residents nurse aide care plan, for staff to ensure a [NAME] or a brightly colored sign was on/outside the residents door to assist the resident in finding his/her room. Interview with SRNA #3, on [DATE] at 1:10 PM, revealed Resident #1 frequently wandered into other residents rooms, and had difficulty remembering where his/her room was located. Interview with SRNA #2, on [DATE] at 3:20 PM, revealed Resident #1 wandered in the facility and would forget the location of his/her room. Interview with RN #1, on [DATE] at 4:45 PM, Resident #1 wandered throughout the facility and would wander into other residents rooms and take things, which didn't belong to him/her. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 4:35 PM, revealed Resident #1 frequently wandered in and out of other resident's rooms in the facility. She stated staff redirected the resident back to his/her room, when the behaviors occurred. (b) Review of Resident #2's record revealed the facility admitted him/her on [DATE], and his/her current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he/she exhibited physical behavioral symptoms directed toward others, one to three days during the assessment period. The MDS also indicated Resident #2 had a Brief Interview for Mental Status (BIMS) score of eight (8) indicating moderate cognitive impairment. Review of Resident #2's nurse's notes revealed on [DATE] at 6:37 PM, Registered Nurse (RN) #1 documented Resident #2 asked another resident (Resident #4) Can I feel up your shirt? Documentation also indicated Resident #2 had been stalking residents in their doorways, and seeking inappropriate physical contact from the opposite gender. Interview with RN #1, on [DATE] at 4:45 PM, revealed Resident #2 had inappropriate sexual behaviors directed towards staff and other residents, of the opposite gender. She stated she was working on [DATE] when Resident #2 asked Resident #4, if he/she could feel up his/her shirt. The RN stated she had not implemented any new interventions or updated resident care plans after Resident #1 and Resident #2's behaviors were identified and stated she was not responsible to update resident care plans. Review of Resident #2's nurses notes revealed on [DATE] at 3:41 AM, LPN #2 documented Resident #2 was up in his/her wheelchair sitting in the doorway across from his/her room and stated to the another resident (Resident #5), I was hoping your covers would be down. The note indicated Resident #2 laughed when staff redirected the resident back to his/her room and was informed he/she was being inappropriate. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 4:35 PM, revealed she primarily worked the night shift and at an unknown date/time Resident #2's alarm was sounding. The LPN stated she observed Resident #2 at Resident #5's doorway, which was across the hall from his/her room, and the resident stated I was hoping your covers would be down, to Resident #5. LPN #2 stated Resident #5 was unsure what Resident #2 meant by the statement made to him/her. The LPN reported the incident to the oncoming shift. LPN #2 stated she had not implemented any new interventions after Resident #2's behavior and stated she was not responsible to update resident care plans. Review of the facility investigation dated [DATE] at approximately 3:00 PM indicated Resident #1 had gone into Resident #2's room and got in bed with him/her. The investigation also stated Resident #2's hands were on top of Resident #1's chest, on top of his/her clothes. Observations of Resident #2 on [DATE] at approximately 10:30 AM revealed the residents' room was located across the hall from Resident #1. Resident #2 was up in a wheelchair in the doorway of his/her room. Further observations on [DATE] at approximately 12:15 PM, 2:00 PM, and 4:00 PM revealed the resident remained in a wheelchair, in his/her room. Interview with Resident #2 on [DATE] at approximately 10:30 AM, revealed the resident stated Resident #1 entered his/her room and got in the bed with him/her. The resident stated he/she had not touched Resident #1 but stated he/she had kissed him/her on the lips, but it did not bother him/her at all. Resident #2 was unsure why Resident #1 came into his/her room and stated that had not happened before. Resident #2 also stated to the surveyor he/she would like to give the surveyor a long hug if all the rules wasn't in place by the government. Review of Resident #2's comprehensive care plan, not dated revealed the facility identified he/she received medication with potential side effects because he/she had Inappropriate Sexual Behaviors, which the facility implemented for staff to observe for significant side effects of the medication. However, no interventions were included related to the residents identified behavior. Review of Resident #2's care plan also indicated he/she had Dementia with thought process impairment, and interventions included provide an activity calendar in the residents room and reality orientation during waking hours and do not support confusion. Resident #2's care plan also revealed he/she wandered at night and the resident leaves his/her room at night and wanders into other residents rooms, and as a result the facility implemented a motion sensor alarm above the residents door at bedtime. According to the care plan, staff identified Resident #2 was sexually inappropriate at times with staff during care (abuse language and grabbing), and staff were directed to redirect the resident when being sexually inappropriate and to inform him/her the statements were unacceptable. Further review of his/her care plan indicated the resident would go outside his/her room, up and down the facility hallways looking into other women resident rooms. Interventions implemented included; staff to redirect him/her as needed and ask the resident to return to his/her room, motion sensor alarm above his/her doorway to be utilized at bedtime, to alert staff the resident left his/her room. Review of Resident #2's nurse aide care plan revealed staff were directed to utilize a motion sensor alarm at bedtime, above his/her doorway to alert staff he/she is leaving his/her room. The care plan also instructed staff to redirect him/her as needed and ask the resident to return to his/her room, and to also redirect Resident #2, when he/she was sexually inappropriate and inform him/her the behavior was unacceptable. Interview with Kentucky Medication Aide (KMA) #1, on [DATE] at 2:15 PM, revealed on [DATE] she witnessed Resident #1 lying in Resident #2's bed with him/her. She stated Resident #1's eyes were closed and Resident #2 was smiling. She also stated the residents were cuddling like a couple with Resident #2's right arm lying flat on the bed, with Resident #1's head laying on his/her arm and Resident #2's left arm was observed across Resident #1's breast outside his/her clothing. She stated the nurse was notified immediately and Resident #1 was removed from Resident #2's room. The KMA stated Resident #1 wandered throughout the facility at times, and frequently forgets where his/her room is located, and has asked staff in the past where his/her room was. She also stated Resident #1 had been observed to wander into other residents rooms and take their personal belongings and staff had been instructed to redirect the resident when those behaviors occur. The KMA stated the residents resided across the hall from each other when the incident occurred and Resident #1 or Resident #2 was not on an increased level of supervision at the time of the interview or before the incident occurred. She also acknowledged no interventions had been implemented to prevent Resident #2 from wandering back into Resident #1's room again. Continued interview with the KMA revealed she had previously witnessed Resident #2 attempting to put his/her hand up Resident #3's shirt; however, she was unable to recall when, but stated it's been a while back. She also stated Resident #3 was now deceased and the incident was reported to a nurse; however, she was unable to recall which nurse. Interview with State Registered Nurse Aide (SRNA) #1, on [DATE] at 3:00 PM, Resident #2 made inappropriate sexual comments to staff and she recalled hearing about an incident with Resident #2 and Resident #3 but was unable to remember what she recalled hearing or when the incident occurred. Interview with SRNA #2, on [DATE] at 3:20 PM, revealed Resident #2 had been observed to call other female residents [NAME] and attempt to get other female residents to come in and lay down with him/her. She also stated she recalled receiving in report (date/time unknown) that Resident #3 had been observed in bed with Resident #2. Interview with SRNA #3, on [DATE] at 1:10 PM, revealed Resident #2 would tell her he/she would like to have a good time with her, and had also been observed to say come in my room and talk to me to other female residents in the facility. She also stated she recalled an incident where Resident #3 was observed in Resident #2's bed but was unable to recall when the incident occurred. Interview with Unit Coordinator (UC) #1, on [DATE] at 4:10 PM, revealed Resident #2's alarm had been implemented on [DATE] so the resident could be redirected back to his/her room during the night shift, because staff had reported he/she was staring into other residents rooms. However, she stated no one had reported any incidents of Resident #2 making sexual comments to other residents but stated staff should have informed her of the resident's behaviors. She also stated Resident #1 wandered into other resident's rooms at times, and liked to collect things, and stated the resident was easily redirected when he/she wandered into other resident's personal space. She also stated behaviors were monitored in the facility by staff reporting them to each other and the aides also documented behaviors, which were discussed in the morning meetings Monday-Friday. The UC acknowledged new interventions had not been implemented and care plans had not been reviewed/revised when behaviors occurred for Resident #1 and Resident #2. Interview with the Administrator, on [DATE] at 6:15 PM, revealed monitoring behaviors in the facility was a group effort. She stated nurse aides monitor and document behaviors every shift, and those behaviors are discussed in the morning meetings. She stated she was not aware Resident #1 wandered in/out of other residents' rooms and stated staff were expected to report any new or change in behaviors to Administrative staff. She also stated staff were expected to implement resident care plans and a bright colored sign or a [NAME] should have been on/outside Resident #1's door as outlined in his/her plan of care. The Administrator stated she was not aware of Resident #2's sexual behaviors directed towards other residents and stated staff should have reported the behaviors to her. Per the Administrator, resident care plans were reviewed/revised after information was gathered in the morning meetings. The Administrator stated she expected staff to review/revise care plans after behaviors occurred to include new interventions in attempts to manage residents with Dementia that exhibit behaviors in the facility.

Based on observation, interview, record review, and review of facility policy, it was determined that food served to residents during the evening meal on 09/25/19 was not palatable. Interviews with unsampled residents and a palatability test revealed the food was not seasoned and tasted bland. The findings include: Review of the facility policy, Food Service Department Goals, undated, revealed it was the policy of the facility to provide nutritious meals in a variety of combinations that were appetizing and flavorful. During the initial tour conducted on the morning of 09/24/19, five (5) unsampled residents stated that the food served at the facility did not have enough seasoning and tasted bland. A palatability test was conducted at 5:15 PM on 09/25/19 for the evening meal. The meal consisted of pepper steak, rice, and oriental vegetables. The regular consistency rice and oriental vegetables tasted bland and unseasoned. The pureed rice tasted bland and pasty. Interview with the Dietary Manager at 4:00 PM on 09/26/19 revealed that foods should be prepared according to the recipe; however, the cook failed to follow the recipe and had only added a little salt and butter to the rice and vegetables.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to establish and maintain an effective infection control program designed to provide a safe and sanitary environment to prevent the transmission of disease and infection for two (2) of nineteen (19) sampled residents (Residents #9 and #11) and one (1) unsampled resident (Resident A). Observations of blood glucose monitoring on 05/17/17 for Resident A and Resident #9 revealed Registered Nurse (RN) #1 failed to wash/sanitize her hands prior to performing blood glucose monitoring for Resident A and after performing blood glucose monitoring for Resident #9. RN #1 failed to clean the blood glucose monitor prior to checking Resident A and Resident #9's blood glucose. In addition, observation of medication administration on 05/16/17 revealed staff failed to wash/sanitize their hands while administering eye drops to Resident #11. The findings include: 1. Review of the facility's policy titled Glucometer Decontamination, undated, revealed after performing blood glucose testing the nurse shall perform hand hygiene, don gloves, and use the disinfectant wipe to clean all external parts of the glucometer. The policy revealed gloves were required to then be removed and hand hygiene performed. Interview conducted with the Director of Nursing (DON) on 05/18/17 at 5:15 PM, revealed staff was required to clean blood glucose testing devices when removing them from the medication cart and after performing testing. Review of the facility's policy titled Hand Hygiene, undated, revealed staff was required to wash/sanitize their hands with a non-microbial or antimicrobial soap and water when hands were visibly dirty, before and after changing a dressing, before performing invasive procedures, and after performing care for a resident. Observation on 05/17/17 at 11:20 AM revealed RN #1 performed blood glucose testing for Resident A. Prior to blood glucose testing the RN was observed to take the blood glucose testing device out of a medication cart drawer and donned gloves without first washing/sanitizing her hands. The RN failed to sanitize the device prior to testing Resident A's blood glucose. After the testing was completed, RN #1 removed her gloves and sanitized her hands with hand sanitizer but failed to clean/sanitize the blood glucose testing device before conducting a test for another resident. Further observation on 05/17/17 at 11:25 AM revealed RN #1 performed blood glucose testing for Resident #9 with the same blood glucose testing device that was not sanitized after it was used for Resident A. After the testing was completed, RN #1 failed to remove her gloves or wash/sanitize her hands prior to cleaning the blood glucose testing device with a bleach wipe. Interview conducted with RN #1 on 05/17/17 at 5:00 PM revealed she believed she was not required to wash/sanitize her hands prior to donning gloves, only after performing blood glucose testing. The RN stated she also did not clean the blood glucose testing device after removal of the device from the medication cart because it had already been cleaned prior to placing it in the medication cart. The RN stated she did not realize that she did not clean the blood glucose monitoring device after performing blood glucose testing for Resident A. She stated she was aware the device required sanitization after use. RN #1 stated she was required to wash/sanitize her hands and don clean gloves after performing blood glucose testing and prior to cleaning the blood glucose monitoring device. Interview with the Director of Nursing (DON) on 05/18/17 at 5:15 PM revealed staff was required to wash/sanitize their hands prior to donning of gloves. The DON stated all nurses were required to complete competencies on blood glucose monitoring upon hire and at least annually and had not identified a concern with RN #1 cleaning blood glucose testing devices, washing/sanitizing her hands, or donning clean gloves. 2. Review of the facility's policy titled Eye Drop Administration, undated, revealed hands were required to be washed/sanitized before and after administration of eye drops to each eye. Review of Resident #11's medical record revealed the facility admitted the resident on 04/13/16, with [DIAGNOSES REDACTED]. Review of Resident #11's physician orders [REDACTED]. Observation of medication administration for Resident #11 on 05/16/17 at 4:07 PM revealed Kentucky Medication Aide (KMA) #1 instilled eye drops in both the resident's eyes without washing or sanitizing her hands prior to administering the drops in each eye. Interview with KMA #1 on 05/18/17 at 3:22 PM revealed she forgot to wash or sanitize her hands prior to eye drop administration, but was aware she was supposed to wash and sanitize her hands before instilling eye drops in each eye. Interview with Licensed Practical Nurse (LPN) #1, the Unit Coordinator, on 05/18/17 at 3:44 PM, revealed staff should always wash or sanitize their hands before and after administering eye drops into each eye. LPN #1 revealed she had not identified any concerns with handwashing during eye drop administration in the past. Interview conducted with the Director of Nursing (DON) on 05/18/17 at 5:15 PM, revealed staff was required to wash/sanitize their hands prior to and after administering eye drops to each eye.

Based on interview, record review, and facility policy review, the facility failed to ensure an accurate clinical record was maintained for one (1) of nineteen (19) sampled residents (Resident #9). The facility admitted Resident #9 on [DATE] and the resident's responsible party changed the code status from Full Code to Do Not Resuscitate (DNR) on [DATE]. However, the facility failed to ensure Resident #9's resuscitative status was accurate on the Certified Nurse Aide (CNA) Worksheet or referred to as the blue sheet. The findings include: Review of the facility policy titled Advance Directive, dated [DATE], revealed information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Further review of the policy revealed Do Not Resuscitate (DNR) indicated that in case of respirator or cardiac failure the resident, legal guardian, health care proxy, or representative (sponsor) had directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods were to be used. Interview with the Administrator on [DATE] at 5:30 PM revealed there was no policy related to accuracy of medical records. Review of the medical record revealed the facility admitted Resident #9 on [DATE]. Further review of Resident #9's medical record revealed he/she was readmitted to the facility on [DATE] and review of the Kentucky Emergency Medical Services Do Not Resuscitate (DNR) Order revealed Resident #9's responsible party signed the form on [DATE] for Resident #9 to be a DNR. Additional review of the medical record revealed the physician orders, nursing plan of care, and medical record chart sticker all revealed Resident #9 was a DNR, however, the CNA worksheet revealed Resident #9 was a full code. Interview with CNA #1 on [DATE] at 1:16 PM revealed Resident #9 was a full code and she knew this by the CNA blue sheet. Interview with CNA #2 on [DATE] at 1:22 PM revealed Resident #9 was a full code and she also knew this by Resident #9's CNA blue sheet. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 1:25 PM revealed Resident #9 was recently changed to a DNR after a hospital visit on [DATE]. Further interview with LPN #1 revealed a Certified Medication Technician (CMT) #1 was responsible to ensure the code status was accurately reflected in the resident's CNA blue sheet. Interview with CMT #1 on [DATE] at 2:39 PM revealed she was responsible for updating Resident #9's CNA blue sheet once a week, but did not have a chance to update/revise the blue sheet because she had been filling in for other staff. Interview with the Director of Nursing (DON) on [DATE] at 2:45 PM revealed the CNA blue sheets were updated weekly. Further interview with the DON revealed the facility conducts monthly audits and compares blue sheets to residents to ensure they match and are accurate. Additional interview with the DON revealed, No, the blue sheet should not have revealed full code. Further interview with the DON revealed she had identified some problems in the past with blue sheets needing to be revised. Interview with the Administrator on [DATE] at 3:48 PM revealed she did not think the inaccuracy of code status on the CNA Worksheet was a problem.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure privacy was provided during personal care (incontinence care) for one (1) of nineteen (19) sampled residents (Resident #13). Observation of incontinence care for Resident #13 revealed staff failed to pull the curtain around the bed and close the door to provide privacy during care. The findings include: Review of the facility's policy titled Dignity, dated 08/01/13, revealed the residents had the right for the staff to promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of the medical record for Resident #13 revealed the facility admitted the resident on 04/09/15 with [DIAGNOSES REDACTED]. Further review of the record revealed Resident #13 had a physician's orders [REDACTED]. Observation of catheter care was conducted on 04/30/15 at 10:10 AM with Certified Nurse Aide (CNA) #1 and CNA #2. Observations of the room revealed the door to Resident #13's room was open and the privacy curtain was not pulled around Resident #13's bed when catheter care was provided allowing the resident to be seen from the hallway. Interview with CNA #1 on 04/30/15 at 10:27 AM revealed the curtain, blinds, and door should be closed if the resident could be seen from the hallway. Interview with CNA #2 on 04/30/15 at 10:32 AM revealed staff should pull the curtains around the bed if the door was left open. Interview with Licensed Practical Nurse (LPN) #1 on 04/30/15 at 11:00 AM revealed the staff was to close doors and curtains when providing resident care. Interview with the Director of Nursing (DON) on 04/30/15 at 11:15 AM revealed the facility taught all nursing staff to close the door and pull the curtain for privacy when providing care.

Based on observation, interviews, record review, and review of facility policies, it was determined the facility failed to provide care according to the plan of care related to catheter care for two (2) of nineteen (19) sampled residents (Resident #13 and Resident #16). Review of the record for Resident #13 and Resident #16 revealed physician's orders for indwelling catheters and care plan interventions for catheter care. Observations of catheter care revealed the indwelling catheters for Resident #13 and Resident #16 were not anchored to the residents' legs according to the facility policy. The findings include: Review of the facility policy, Using the Care Plan, dated 08/01/13 revealed the care plan would be used to develop the resident's daily care routines. The policy further stated care and documentation must be consistent with the resident's care plan. Review of the facility policy titled Catheter Associated Urinary Tract Infection (CAUTI) Prevention, undated, revealed a leg strap or tape was to be used to secure the indwelling catheter properly to prevent movement of the catheter. The policy also stated hand hygiene should be done immediately before and after inserting or manipulating a catheter. 1. Review of the medical record for Resident #13 revealed the facility readmitted the resident on 04/09/15 with [DIAGNOSES REDACTED]. Further review of the record revealed a physician's order for an indwelling catheter dated 04/09/15 to be changed monthly. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 required the total assistance of two (2) persons for toileting and bathing. The MDS also revealed Resident #13 was cognitively impaired and not interviewable. Review of the Comprehensive Care Plan for Resident #13 dated 04/03/15 revealed staff was required to perform indwelling catheter care every shift and as needed. Observation of incontinence care for Resident #13 on 04/30/15 at 10:10 AM with Certified Nurse Aide (CNA) #1 and CNA #2 revealed the catheter tubing of the resident's indwelling urinary catheter was not secured to the resident's leg. Interview with CNA #1 on 04/30/15 at 10:27 AM revealed catheters were required to be anchored to the leg. The CNA stated she was required to check each resident's care plan every day, and should have ensured the catheter was anchored to the resident's leg. Interview with CNA #2 on 04/30/15 at 10:32 AM revealed she was required to check each resident's care plan every shift, and stated some catheters were required to be anchored to the resident's leg and some were not. 2. Review of the medical record for Resident #16 revealed the facility admitted the resident on 01/29/15 with [DIAGNOSES REDACTED]. Further review of the record revealed a physician's order for an indwelling catheter dated 01/29/15 and the catheter was to be changed monthly. Review of the Comprehensive Care Plan for Resident #16 revealed catheter care was to be performed every shift and as needed. Observation of incontinence care for Resident #16 on 04/30/15 at 9:50 AM revealed CNA #3 and CNA #4 performed incontinence care and catheter care without securing the catheter tubing to the resident's leg according to facility policy. Interview with CNA #3 on 04/30/15 at 10:30 AM, revealed indwelling catheters were supposed to be anchored to the resident's leg. Interview with CNA #4 on 04/30/15 at 11:15 AM revealed catheters were to be anchored to the leg. Interview with the Director of Nursing on 04/30/15 at 11:20 AM, revealed indwelling catheters were required to be anchored at all times. The DON stated she made rounds frequently and had not identified any concerns with staff performing catheter care in accordance with the care plan and facility policy.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received appropriate treatment to prevent urinary tract infections, pulling, pressure, or damage to the urethra for two (2) of nineteen (19) sampled residents (Resident #13 and Resident #16). Observation of catheter care revealed Resident #13 and Resident #16 had indwelling urinary catheters that were not secured according to facility policy. In addition, facility staff failed to conduct appropriate hand hygiene before donning gloves for catheter care of Resident #16. The findings include: Review of the facility policy titled Catheter Associated Urinary Tract Infection (CAUTI) Prevention, undated, revealed a leg strap or tape was to be used to secure the indwelling catheter properly to prevent movement of the catheter. The policy also stated hand hygiene should be done immediately before and after inserting or manipulating a catheter. An additional policy titled Hand Hygiene, undated, revealed hand washing was to be done before performing an invasive procedure and after providing care to a resident. 1. Observation of incontinence care for Resident #16 on 04/30/15 at 9:50 AM revealed Certified Nurse Aide (CNA) #3 and CNA #4 knocked on the resident's door, closed the door, explained to the resident what procedure they were doing, and donned gloves. The CNAs did not wash their hands prior to donning gloves. Observations revealed CNA #3 and CNA #4 proceeded to perform incontinence care without washing their hands. In addition, during incontinence care, the indwelling catheter tubing was not secured to Resident #16's leg according to the facility policy. Review of the medical record for Resident #16 revealed the facility admitted the resident on 01/29/15 with [DIAGNOSES REDACTED]. Further review of the record revealed a physician's order for an indwelling catheter dated 01/29/15. Review of the Quarterly Minimum Data Set (MDS) assessment with a reference date of 02/27/15 revealed Resident #16 required the extensive assistance of two persons for assistance with toileting and bathing. Review of the Comprehensive Care Plan dated 02/11/15 revealed catheter care was to be provided every shift and as needed. Interview with CNA #3 on 04/30/15 at 10:30 AM revealed indwelling catheters were supposed to be anchored to the resident's leg. CNA #3 stated she puts on gloves and does catheter care prior to washing her hands. Interview with CNA #4 on 04/30/15 at 11:15 AM revealed catheters were supposed to be anchored to the leg and if they were not the CNA is to inform the charge nurse. CNA #4 stated she provided care wearing gloves and then washes her hands after care is complete. 2. Observation of incontinence care for Resident #13 on 04/30/15 at 10:10 AM revealed the catheter tubing of the resident's indwelling urinary catheter was not secured to the leg according to the facility policy to prevent damage to the urethra. Review of the medical record for Resident #13 revealed the facility readmitted the resident to the facility on [DATE] with a physician's order for an indwelling catheter dated 04/09/15. The record further revealed the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #13 required the total assistance of two persons with toileting and bathing. Interview with CNA #1 on 04/30/15 at 10:27 AM revealed indwelling catheters were required to be anchored to the resident's leg and CNA #1 acknowledged that Resident #13's catheter was not anchored according to facility policy. Interview with CNA #2 on 04/30/15 at 10:32 AM revealed she stated that some catheters were to be anchored, and some were not. Interview with License Practical Nurse (LPN) #1 on 04/30/15 at 10:40 AM revealed indwelling catheters were to be anchored and the charge nurse was responsible to assure it was completed. Further interview revealed staff was trained to wash their hands before catheter care was performed. Interview with Registered Nurse (RN) #1 on 04/30/15 at 11:05 AM revealed she monitored and ensured the aides were performing care correctly and that hands were washed upon entering and, depending on procedure, in between if necessary and upon leaving. RN #1 stated Stat locks (indwelling catheter securing device) were used on every resident that had an indwelling catheter. Interview with the Director of Nursing (DON) on 04/30/15 at 11:20 AM, revealed staff anchored catheters unless there is a reason (resident request for them not to be anchored or if contraindicated) and it is documented on the care plan. The DON further stated the nurses were responsible for ensuring the residents' catheters were secured. The DON stated that hand hygiene/hand washing was to be done before putting gloves on for catheter care.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents' environment remained as free of accident hazards as possible for one (1) of thirty-three (33) residents on the Southeast Unit of the facility (Resident #9). The facility assessed Resident #9 to wander. Observation during medication administration on 04/30/15 at 11:30 AM revealed Registered Nurse (RN) #1 walked into Room 119 B and left the medication cart unlocked. Resident #9 was observed ambulating in the hall near the medication cart while the cart was unattended and unlocked. The findings include: Review of the facility policy titled Medication Storage in the Facility, undated, revealed medication carts were to be kept locked or attended by persons with authorized access. Review of the medical record for Resident #9 revealed the facility admitted the resident on 12/16/14 with a [DIAGNOSES REDACTED]. Observation during medication administration on 04/30/15 at 11:30 AM revealed Registered Nurse (RN) #1 walked into Room 119 B to perform blood glucose testing. RN #1 closed the privacy curtain and left the medication cart unlocked. Observation further revealed Resident #9 was ambulating in the hall near the medication cart. Interview conducted with RN #1 on 04/30/15 at 2:30 PM revealed she was aware she should have locked the medication cart any time the cart was out of her eyesight. Interview conducted with the Director of Nursing (DON) on 04/30/15 at 2:45 PM revealed staff was required to lock the medication cart when in a resident room with the privacy curtain closed. The DON stated RN #1 should have locked the medication cart prior to going into the resident's room to perform blood glucose monitoring and closing the privacy curtain.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to establish and maintain an effective infection control program designed to provide a safe and sanitary environment to prevent the transmission of disease and infection for one (1) of nineteen (19) sampled residents (Resident #4) and two (2) unsampled residents (Resident A and Resident B). Observation of wound care for Resident #4 revealed Registered Nurse (RN) #1 was observed to remove a dressing from the package, return to the treatment cart, come back to the resident's bedside, and proceed to perform wound care without washing/sanitizing her hands. RN #1 was then observed after performing Resident #4's wound care to clean the scissors used during the dressing change and the overbed table without donning gloves. In addition, observations of blood glucose monitoring for Resident A and Resident B revealed RN #1 cleaned both Resident A and Resident B's blood glucose monitor without donning gloves after performing blood glucose testing. The findings include: Review of the facility's policy titled Glucometer Decontamination, undated, revealed after performing blood glucose testing, the nurse shall perform hand hygiene, don gloves, and use the disinfectant wipe to clean all external parts of the glucometer. The policy revealed gloves would then be removed and hand hygiene performed. Review of the facility's policy titled Hand Hygiene, undated, revealed staff was required to wash/sanitize their hands when hands were visibly dirty, before and after changing a dressing, before performing invasive procedures, and after performing care to a resident with a non-microbial or antimicrobial soap and water. Review of the facility's policy titled Wound Care/Treatment Guidelines, undated, revealed supplies would be placed on a clean surface and hand hygiene would be performed. The policy did not address staff requirement to don gloves when cleaning the surface used to hold the dressing supplies during wound care, nor did it address cleaning of scissors utilized during wound care. 1. Review of the medical record for Resident #4 revealed the facility admitted the resident on 11/26/14, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#4's right elbow with Normal Saline, apply an antimicrobial dressing every three days and as needed. Observation on 04/29/15 at 10:05 AM of wound care for Resident #4 revealed RN #1 placed the dressing supplies for Resident #4's wound care on a paper towel placed on the resident's overbed table. The RN removed the antimicrobial dressing from the package and returned to the treatment cart. RN #1 obtained a pair of scissors from the cart, returned to the resident's bedside, and did not wash/sanitize her hands prior to performing wound care. RN #1 was then observed after performing Resident #4's wound care to discard her gloves in the trash, clean the scissors used during the dressing change with an alcohol prep, and clean the overbed table with a paper towel and water, without donning gloves. Interview conducted with RN #1 on 04/30/15 at 2:30 PM revealed she was required to wash/sanitize her hands any time she left during wound care and came back. The RN stated she should have washed/sanitized her hands when she returned to the treatment cart. The RN stated she felt it was all right to clean the scissors used during wound care and Resident #4's overbed table with her bare hands because she washed/sanitized her hands afterwards. 2. Observation on 04/30/15 at 11:10 AM of blood glucose testing revealed RN #1 performed blood glucose testing for Resident A. After the testing was completed, RN #1 removed her gloves, sanitized her hands with hand sanitizer, and then cleaned the blood glucose-monitoring machine with a bleach wipe, without donning gloves. Observation on 04/30/15 at 11:30 AM of blood glucose testing revealed RN #1 performed blood glucose testing for Resident B. After the testing was completed, RN #1 removed her gloves, sanitized her hands with hand sanitizer, and then cleansed the blood glucose-monitoring machine with a bleach wipe, without donning gloves. Interview conducted with RN #1 on 04/30/15, at 2:30 PM, revealed she stated she was not required to wear gloves when cleaning blood glucose testing machines. Interview conducted with the Director of Nursing (DON) on 04/30/15 at 2:45 PM revealed she had completed dressing audits with RN #1, and had identified a concern with the RN establishing a clean surface. The DON stated she had in-serviced the RN on wound care and had completed the in-service with her on 01/30/15. The DON stated staff was required to don gloves when cleaning blood glucose-monitoring machines. The DON stated all nurses were required to complete competencies on blood glucose monitoring twice a year and the last one completed by RN #1 was on 09/18/14. The DON stated she had not identified a concern with RN #1 cleaning blood glucose-monitoring machines without wearing gloves.

Based on interviews with facility residents and direct care staff, and review of the facility policy, it was determined the facility failed to ensure sufficient nursing staff was available on a daily basis to meet the residents' needs for care and assistance to promote each resident's physical, mental and psychosocial well-being, thus enhancing their quality of life for one (1) of three (3) sampled residents (Resident #3) and five (5) of six (6) unsampled residents (Residents A, C, D, E, and F). Interviews conducted with facility residents and staff on 04/24/15 revealed residents were required to wait extended amounts of time (up to an hour) during the evening shift (3:00 PM to11:00 PM) to receive assistance with toileting or to be transferred to bed due to an insufficient amount of staff on duty during those hours. The findings include: Review of the facility policy titled "Staffing Posting Direct Care Daily Numbers," dated 08/01/13, revealed no information on how the facility was to ensure adequate staffing was available to meet the residents' needs, and to provide assistance to the residents in a timely manner. Review of the "SRNA Call Bell Management Policy," not dated, revealed staff was required to respond promptly to call bells. The policy stated an unanswered call bell created a "huge" safety risk for the resident due to unmet needs, and caused residents to have a sense of insecurity and mistrust due to lack of response to call bells. The policy further stated when the SRNA's (State Registered Nurse Aide) partner was gone to lunch or break, the SRNA would be available on their hall to respond to call bells. Review of a list of residents provided by facility staff, indicated Resident #3, and Residents A, C, D, E, and F had been assessed by facility staff to be interviewable with a Brief Interview for Mental Status (BIMS) score of 8 or greater for each resident. Interview with Resident C on 04/24/15 at 9:30 AM (assessed by facility staff to have a BIMS score of 15) revealed he/she waits "at least 30 minutes in the evenings" to get assistance into bed because "staff are saying they're going on breaks." The resident stated he/she waited one hour "the other evening" (unable to recall exact date) to receive assistance to bed after it was requested. Interview with Resident #3 (assessed by facility staff to have a BIMS score of 15) on 04/24/15 at 09:50 AM revealed he/she had waited "as long as one hour" to receive assistance with toileting from facility staff. The resident stated he/she had been informed by facility staff that assistance could not be provided at the time it was requested because "someone was on break." Resident #3 stated, "It's always in the evenings when I have trouble getting help." The resident continued to state he/she had waited as long as 40 minutes to be transferred to bed after help was requested. Interview with Resident E on 04/24/15 at 10:00 AM (assessed by facility staff to have a BIMS score of 9) revealed he/she waited "every evening, sometimes up to 30 minutes, to go to the bathroom." The resident stated, "I think evening shift needs more help." Interview with Resident D on 04/24/15 at 10:20 AM (assessed by facility staff to have a BIMS score of 15) revealed he/she waited "in the evenings sometimes up to one hour to get help to go to the bathroom." The resident stated, "It's an every evening thing here. I know I'm gonna have to wait." He/she stated staff had informed him/her "somebody's on break and that I will have to wait until they come back before they can help me." The resident stated this usually occurred in the evening. Interview with Resident F on 04/24/15 at 1:10 PM (assessed by facility staff to have a BIMS score of 15) revealed he/she had "trouble getting help to go to the bathroom all the time in the evenings." The resident stated, "They keep saying it'll be a while or that someone's on break." The resident stated, "I'll give them a while and ring again, but I wait at least half hour on most days to get help in the evenings." Interview with Resident A on 04/24/15 at 1:15 PM (assessed by facility staff to have a BIMS score of 10) revealed, "It's hard to get help to go to the bathroom, mostly in the evenings." He/she stated it takes at least 20 minutes, and sometimes 30 minutes to receive assistance to the bathroom. The resident stated, "Sometimes staff has said they need more help in the evenings." The resident stated at times staff would come in, turn the call light off, and never return to provide the assistance that had been requested. During an interview with SRNA #1 on 04/24/15 at 1:30 PM, the SRNA stated, "sometimes we work short" (insufficient amount of staff). The SRNA stated that sometimes someone would stay over until 6:00 PM, but after that time, especially if a staff member is on break or gone to lunch it is difficult to meet the residents' needs. SRNA #1 further stated if someone "needs to go to bed, it can be hard to help them, and they are probably waiting longer than they should have to wait." Interview with SRNA #2 on 04/24/15 at 3:25 PM revealed the staff "work short staffed at times." The SRNA acknowledged at times, related to the facility staffing, "you have to tell them" (the residents) "that it will be a minute before you can assist them, and it's really tough during meal service." The SRNA stated, "At times, residents are required to wait up to 30 minutes to get assistance once requested." Interview with Licensed Practical Nurse (LPN) #1 on 04/24/15 at 3:36 PM revealed, "I've had to stop multiple times during medication passes to help toilet a resident, especially during meal services. There's not enough of us." The LPN stated residents which required a Hoyer lift for assistance with transfers "always have to wait too long to be provided with assistance, especially during meal service." Interview with SRNA #3 on 04/24/15 at 3:50 PM revealed, "At least one time a week we're working short" (insufficient amount of staff). The SRNA stated residents have to wait longer than 15 minutes for assistance and there was not enough staff at times. SRNA #3 stated, "Residents have to wait longer than they should." Interview with the Director of Nursing (DON) on 04/24/15 at 5:30 PM revealed the facility conducted monthly call light audits and no concerns had been identified related to insufficient staff. The DON stated "a while back" they added an 11:00 AM to 7:00 PM staff person to help with meal service and changed employee lunch times so "fewer people were off the floor at the same time." The DON stated she had not received any complaints and was not aware of any concerns on the facility's evening shift related to inadequate staffing or residents not receiving assistance timely.

Based on interviews and review of the facility Resident Council minutes and the facility policy it was determined the facility failed to actively search for a resolution and keep the resident informed of its progress toward resolutions for one (1) of three (3) sampled residents (Resident #3) and two (2) of six (6) unsampled residents (Residents A and C). A review of Resident Council minutes and interviews with facility residents revealed care concerns had been voiced to facility staff; however, no resolution was attempted or follow-up toward resolution discussed with the residents. The findings include: Review of the facility policy titled "Filing Grievances/Complaints," dated August 2013, revealed residents may file a grievance or complaint concerning treatment, medical care, or behavior of other residents or staff members without fear of threat or reprisal in any form. The policy also stated the resident would be informed of the findings of the actions that would be taken to correct any identified problems. Review of a list of residents provided by facility staff indicated Resident #3, and Residents A and C had been assessed by facility staff to be interviewable, with a Brief Interview for Mental Status (BIMS) score of 10 or greater for each resident. 1. Interview with Resident C on 04/24/15 at 9:30 AM (assessed by facility staff to have a BIMS score of 15) revealed he/she waits "at least 30 minutes in the evenings" to get assistance into bed because "staff are saying they're going on breaks." The resident stated he/she had voiced the care concern of not receiving assistance timely to the nurse (later identified as Licensed Practical Nurse #2) on 04/22/15. The resident stated no one had ever followed up with him/her related to the care concern voiced (two days earlier), and the resident still "had to wait" after the concern had been reported to the nurse. Interview with Licensed Practical Nurse (LPN) #2 on 04/24/15 at 2:30 PM confirmed Resident C had voiced a care concern related to "having to wait" after assistance was requested to be transferred to bed on 04/22/15. The LPN stated she had not notified administrative staff of the resident's concern voiced related to care and treatment, and had not been trained on the facility's grievance forms. However, the LPN stated she had notified the Registered Nurse (RN) of the complaint voiced by the resident. Interview with RN #1 on 04/24/15 at 3:00 PM confirmed she had been notified of Resident C's care concern that was voiced on 04/22/15. The RN stated she had not notified administrative staff or written it down on the 24-hour report sheet as required but stated, "I should have." 2. Review of the Resident Council minutes dated 10/29/14 revealed Resident #3 voiced care concerns related to "having to wait over an hour" to receive assistance with toileting. Interview with Resident #3 (assessed by facility staff to have a BIMS score of 15) on 04/24/15 at 09:50 AM revealed he/she had waited "as long as one hour" to receive assistance with toileting from facility staff. The resident stated he/she had "told them months ago during resident meetings" related to the concern of not receiving assistance timely with toileting. However, the resident stated since the concern had been voiced, "It's still the same here," and no staff members had conducted any follow-up related to the complaint voiced. 3. Review of the Resident Council minutes dated 10/29/14 revealed Resident A voiced care concerns related to staff not answering the call light timely when assistance was required with toileting. Interview with Resident A on 04/24/15 at 1:15 PM (assessed by facility staff to have a BIMS score of 10) revealed, "It's hard to get help to go to the bathroom, mostly in the evenings." He/she stated a complaint had been voiced in resident meetings, "but it's not gotten any better." Resident A stated "no one ever followed up" with him/her about the complaint and it remained a problem in the facility. Interview with the Director of Nursing (DON) on 04/24/15 at 5:30 PM revealed she had not been made aware of the complaint voiced from Resident C on 04/22/15. However, she stated staff should have followed the facility policy and notified administrative staff of the resident's complaint as required. The DON stated she reviewed Resident Council minutes and had conducted staff in-services and call light audits related to complaints of care and treatment from Resident #3 and Resident A. Even though the DON was aware and had reviewed the resident's complaints, she stated a follow-up to reach a resolution for the resident's voiced concerns had not been conducted as outlined in the facility policy.

Based on interview, record review, and a review of the facility's policies, the facility failed to ensure the resident and/or resident's responsible party was provided information regarding appeal rights for two of nineteen sampled residents (Residents # 18 and #19) when a Medicare Non-Coverage letter was issued. The findings include: Review of the facility's Medicare Beneficiary Notice policy dated May 2012 revealed the Advance Beneficiary Notice (ABN) would be given to beneficiaries to convey that Medicare would not likely provide coverage in specific cases. The policy noted the ABN would identify the items or services that might not be covered by Medicare. The policy also indicated that the date of the non-coverage and the appeal information regarding rights to appeal and directions on how to request an appeal would be provided. 1. Record review revealed an Advance Beneficiary Notice (ABN) was issued to Resident #18 on 02/01/14 when the resident no longer required medically necessary skilled care on a daily basis and only needed restorative care. The ABN noted the coverage ended on 02/02/14; however, there was no evidence the facility provided the resident or his/her responsible party information regarding the resident's appeal rights or how to file an appeal. 2. Record review revealed Resident #19 was issued an ABN notice on 05/17/13 after daily skilled care was not required. The notice stated the coverage ended on 05/21/13. However, there was no evidence the facility provided the resident or his/her responsible party information regarding appeal rights or how to file an appeal. Interview conducted with the facility's Bookkeeper on 02/13/14, at 1:30 PM revealed she had not been trained to provide the appeal information to residents who still had Medicare Part A days remaining. The bookkeeper stated she provided that information to the residents who were receiving Medicare Part B benefits, but not to Medicare Part A recipients.

Based on observation, interviews, and a review of the facility's policies, it was determined the facility failed to ensure food items were prepared under sanitary conditions. Observations of the noon meal on 02/11/14 revealed Dietary Employees #1 and #2 failed to change their gloves or wash their hands when they left an area of meal preparation and before they returned to the area of meal preparation after direct contact had been made with other surfaces in the kitchen area. The findings include A review of the facility's policy for Glove Use (no date) revealed staff must replace disposable (single-use) gloves as soon as practical when the gloves become contaminated, torn, or punctured, exhibit signs of deterioration, or when their ability to function as a barrier is compromised. In addition, the policy revealed staff must perform hand hygiene after gloves are removed. 1. An observation of the noon meal preparation was conducted on 02/11/14 at 11:42 AM. During the meal preparation, Dietary Employee #1 left the cook stove area, went to the three-compartment sink area of the kitchen located across the room, and picked up a spatula with her gloved hands. The employee returned to the cook stove, began to prepare a grilled cheese sandwich, then left the cook stove area again, and obtained several small plates while wearing the same gloves. Dietary Employee #1 was then observed to return to the cook stove, continued preparation of the grilled cheese sandwich and, on one occasion during the preparation of the sandwich, touched the grilled cheese sandwich while wearing the same gloves. An interview was conducted with Dietary Employee #1 on 02/11/14 at 11:52 AM. The employee acknowledged she should have changed her gloves and washed her hands before she returned to the cook stove area after she obtained supplies. 2. An observation conducted on 02/11/14 at 11:48 AM of Dietary Employee #2 revealed the employee left the steam table area and went to the confectioner's oven while wearing gloves. The employee was observed to put oven mitts on directly over her gloved hands. Dietary Employee #2 proceeded to remove a pan of cornbread from the oven while wearing the oven mitts, then removed the oven mitts from her gloved hands, and returned to the steam table to serve food. However, Employee #2 failed to remove her gloves and wash her hands after she removed the oven mitts from her hands and was observed to return to the steam table to continue serving food. An interview was conducted with Dietary Employee #2 on 02/11/14 at 11:53 AM. The employee stated gloves should be changed any time she left the steam table. An interview was conducted with the Dietary Manager (DM) on 02/11/14 at 11:55 AM. The DM stated employees should change gloves any time they go from one area to another or come into contact with other objects.

Based on facility policy, observation, interview, and record review, it was determined the facility failed to ensure food served to residents was palatable. Observations and interviews revealed food items were not seasoned and, as a result, were not palatable. The findings include: A review of the facility's Nutrition policy/procedures (no date) revealed the residents would be served attractive and tasty foods. A group interview meeting was conducted at 10:30 AM on 03/25/13 with six alert residents in attendance. All six residents agreed the food served at the facility did not have enough (if any) seasoning. Observation of the noon meal in the dining room at 11:50 AM on 03/25/13 revealed 16 residents were eating in the dining room. Eleven of the sixteen residents received carrots on their meal trays. All 11 residents in the dining room refused to eat the carrots served. Interview with the 11 residents at 12:10 PM on 03/25/13 revealed the residents refused to eat the carrots because the carrots did not have any seasoning and did not taste good. A test tray was requested for the noon meal on 03/25/13 and was removed from the meal cart at 12:42 PM. A palatability test conducted of the test tray at 12:43 PM on 03/25/13 revealed the red bliss potatoes (regular and pureed) were bland and did not have any seasoning. In addition, the pureed red bliss potatoes tasted starchy. The regular and pureed carrots were bland and did not have any seasoning. The Dietary Manager (DM) participated in the food palatability test conducted on 03/25/13. The DM agreed/confirmed the red bliss potatoes and the carrots (regular and pureed) were bland and did not contain any seasoning. A review of the red bliss recipe revealed the potatoes should have been seasoned with margarine and ground [MEDICATION NAME]. A review of the buttered carrots recipe revealed the carrots should have been seasoned with margarine and salt. An interview was conducted with the Administrator at 1:00 PM on 03/25/13. The Administrator stated she had gone to the kitchen and tasted the potatoes, and the potatoes should have had salt added. In addition, the Administrator tasted the pureed red bliss potatoes and stated they tasted awful.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure facility staff notified the physician of a significant change in the resident's condition that had the potential for physician intervention for one of nineteen sampled residents (Resident #19). A review of the closed medical record revealed on 02/07/13, at 12:45 PM, facility staff assessed Resident #19 and noted they were unable to gain the resident's attention without the use of "painful stimulation." Documentation in the nurse's notes on 02/07/13, at 8:00 PM, revealed facility staff had assessed Resident #19 to be lethargic, unresponsive, and "refused medication." In addition, documentation revealed on 02/08/13, at 7:00 AM, facility staff assessed Resident #19 and noted the resident was congested, and had "little response with painful stimuli." However, based on documentation, staff failed to notify Resident #19's physician of the change in the resident's condition until 02/08/13, at 9:05 AM (a timeframe of sixteen hours and twenty minutes after facility staff had initially documented a change in the resident's status on 02/07/13, at 12:45 PM). The findings include: A review of the facility's policy titled, "Changes In A Resident's Condition Or Status," dated 11/28/12, revealed it was the policy of the facility to notify the resident, his/her attending physician, and his/her representative of changes in the resident's condition and/or status. The policy also stated the facility would immediately consult the resident's physician if there was a significant change in the resident's physical, mental, or psychosocial status. A review of the medical record for Resident #19 revealed the facility admitted the resident on 05/05/11, with [DIAGNOSES REDACTED]. A review of an annual Minimum Data Set (MDS) assessment for Resident #19 dated 01/10/13, revealed facility staff assessed the resident to have severely impaired cognition, inattention, and disorganized thinking. A review of nurse's notes for Resident #19 dated 02/07/13, at 12:45 PM, revealed facility staff had implemented one to two minutes of painful stimulation in an effort to obtain the resident's attention. Also, documentation on 02/07/13, at 1:05 PM, revealed the resident had congested lung sounds. A nurse's note dated 02/07/13, at 8:00 PM, revealed the resident had refused medications, and was assessed to be lethargic and unresponsive. In addition, documentation on 02/08/13, at 7:00 AM, revealed the resident had very little response with painful stimuli, was "congested and gurgling." A nurse's note dated 02/08/13, at 9:05 AM, revealed a nurse attempted to notify the physician of Resident #19's condition, unsuccessfully. A nurse's note dated 02/08/13, at 11:04 AM, revealed the resident was sent to the hospital. A review of the hospital record for Resident #19 revealed the resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]." An interview with Licensed Practical Nurse (LPN) #2 on 03/27/13, at 2:55 PM, revealed he had been responsible for administering medications to Resident #19 on 02/07/13, at 8:00 PM, and stated Resident #19 refused to take his/her 8:00 PM medications. In addition, LPN #2 stated the resident was lethargic at that time and he had notified the resident's Charge Nurse. The LPN also stated he was not responsible to notify the physician of the resident's condition, and stated it was the Charge Nurse's responsibility to notify the physician. An interview conducted with LPN #3 on 03/27/13, at 3:05 PM, revealed she was the Charge Nurse for Resident #19 on 02/07/13, at 8:00 PM, and was responsible for notifying the physician with any change in the resident's condition. The LPN stated on 02/07/13, at 8:00 PM, Resident #19 was lethargic, did not want to eat or drink, and refused medications. The LPN stated the resident was only responsive to painful stimuli (rubbing the fist over the sternum). The LPN stated she should have notified Resident #19s physician of the change in the resident's condition, but could not recall if she had notified the physician. An interview conducted with Registered Nurse (RN) #1 on 03/27/13, at 2:00 PM, revealed she had been responsible for the care of Resident #19 at the facility on the 6:00 AM day shift on 02/07/13 and 02/08/13. The RN stated she had assessed Resident #19 on 02/07/13, at 12:45 PM and at 1:05 PM. RN #1 acknowledged she had not called the resident's physician after "pinching the resident's arm" for one to two minutes in an effort to stimulate a response on 02/07/13, at 12:45 PM and 1:05 PM, or after she had assessed the resident to have congested lung sounds on 02/07/13, at 1:05 PM. The RN stated after "looking back" she should have notified the resident's physician. RN #1 also stated that on 02/08/13, at 7:00 AM, she had not called the physician because she was waiting for the physician's office to open to notify the physician. The RN stated the physician was hard to notify unless he was in the office. According to RN #1, she had access to the physician's "beeper" number if the physician was needed after office hours, but had not attempted to contact the physician using the "beeper" number until she had called the physician's office at 9:05 AM and learned the office was closed. The RN revealed she was required to notify the physician with any changes in a resident's condition and she was to notify the nursing supervisor or the Medical Director if she was unable to reach a physician. RN #1 acknowledged she had not notified the Director of Nursing (DON) (the supervisor on duty) until 02/08/13, at approximately 10:30 AM, and stated she should have notified the physician and DON sooner. An interview conducted with the physician of Resident #19 on 03/27/13, at 3:50 PM, revealed facility staff should have notified him of Resident #19's condition when the resident first experienced a change in condition (less responsive than usual) on 02/07/13, at 12:45 PM. The physician stated the facility had his "beeper" number as well as his home telephone number and he expected to be notified any time the resident had a change in his/her cognition. The physician stated he expected to be notified when the resident refused the medication on 02/07/13, at 8:00 PM, as well as when the resident had been assessed to be congested and gurgling on 02/08/13, at 7:00 AM. According to the physician, as a result of the resident's change in condition, he would have immediately sent the resident to the acute care hospital. An interview conducted with the Director of Nursing (DON) on 03/27/13, at 4:15 PM, revealed staff was expected to notify the physician with any change in condition. The DON stated she reviewed the daily report sheets which were filled out by the nurses every day to ensure staff promptly notified the physicians, and had not identified any concern with physicians not being notified promptly.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure services were provided in accordance with the written plan of care for two of three sampled residents (Residents #1 and #2). The facility assessed Resident #1 to require the assistance of two staff members for all transfers. However, on 11/22/12, only one facility staff member transferred the resident from the bed to the wheelchair. Further, Resident #2 was assessed to require the use of two side rails when in bed. Observation on 11/28/12, revealed Resident #2 in bed with only one side rail raised. The findings include: A review of the facility policy "Care Plan-Using the Plan," dated 01/09/03, revealed it was the policy of the facility for staff to utilize each resident's care plan in the development of each resident's daily care routines. In addition, the policy revealed each resident's daily care was required to be consistent with the resident's plan of care. 1. A review of Resident #1's medical record revealed the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident #1's transfer instructions dated 11/19/12, revealed the facility assessed the resident to require moderate to maximum assistance of two staff members for transfers from bed to chair, chair to bed, and toilet transfers. A review of Resident #1's care plan for 06/01/12, revealed facility staff had identified Resident #1 to have impaired physical mobility and assessed the resident to require the assistance of two staff members for all transfers. A review of Resident #1's nursing notes dated 11/22/12, at 7:45 AM, revealed one facility staff member, a nursing assistant, was transporting Resident #1 in a wheelchair into the restroom, when the resident leaned forward and fell from the wheelchair. Further review revealed nursing assistants were educated on utilizing two staff members during transfer. State Registered Nurse Aide (SRNA) #1 stated in interview conducted on 11/28/12, at 12:45 PM, that she had transferred Resident #1 on 11/22/12, at approximately 7:30 AM, and that she was aware Resident #1 required two staff members for all transfers. SRNA #1 acknowledged that on 11/22/12, she transferred Resident #1 from the bed to the wheelchair by herself and without the assistance of another staff member. SRNA #1 stated they "should have had two to transfer" the resident "from the bed to the chair" on the morning of 11/22/12. SRNA #1 stated even though she failed to have assistance when she transferred Resident #1 from the bed to the wheelchair, the resident sustained [REDACTED]. Interview with the Unit Manager on 11/28/12, at 2:55 PM, revealed staff was required to follow each resident's plan of care when providing care for the resident. The Unit Manager stated she was not aware SRNA #1 had transferred Resident #1 from the bed to the wheelchair by herself and without the assistance of another staff member in accordance with the resident's plan of care. The Unit Manager acknowledged that on the morning of 11/22/12, there should have been two staff members to transfer Resident #1 from the bed to the wheelchair. 2. A review of Resident #2's medical record revealed the facility admitted the resident on 11/07/12. The resident's [DIAGNOSES REDACTED]. A review of Resident #2's care plan dated 11/19/12, revealed the resident required the use of two side rails for bed mobility. A review of Resident #2's care plan dated 11/19/12, revealed staff had identified the resident to have a potential for falls and staff was to ensure both of the side rails on the resident's bed were raised when the resident was in bed in an effort to prevent falls. Observation of Resident #2 on 11/28/12, at 4:45 PM, revealed the resident in bed, eyes closed, with one side rail up. Interview with the Assistant Director of Nursing (ADON) on 11/28/12, at 3:40 PM, revealed staff was to place both side rails up when Resident #2 was in bed to prevent falls from the bed. Further interview with the ADON at 5:00 PM, revealed the Rehabilitation Manager had placed the resident in bed and failed to utilize two side rails as required. Interview with the Rehabilitation Manager on 11/30/12, at 9:00 AM, revealed she was aware Resident #2 was assessed to require the use of two side rails when in bed and "just forgot."

Based on observation, interview, and record review, the facility failed to ensure one of nineteen sampled residents (Resident #8) received services with reasonable accommodations of the resident's individualized needs. Observations conducted on 02/28/12, at 12:41 PM, 3:30 PM, and 5:30 PM, revealed the resident's call light was not placed within the resident's reach and, as a result, the resident was unable to call for assistance from staff when needed. The findings include: An interview with the Facility Administrator on 02/29/12, at 3:00 PM, revealed the facility did not have a policy related to the use of call bells within the facility. Review of the medical record for Resident #8 revealed the facility admitted the resident on 10/05/11, with [DIAGNOSES REDACTED]. Review of the quarterly assessment for Resident #8 dated 01/17/12, revealed the resident's vision was severely impaired. Further review of the quarterly assessment revealed the facility had assessed Resident #8 to require extensive assistance with bed mobility, transfers, toileting, and personal hygiene. Review of Resident #8's comprehensive care plan, last revised date of 01/17/12, revealed facility staff was to frequently reinforce the use of the call light with the resident and was to ensure the call light was within the resident's reach. Review of Resident #8's CNA worksheet revealed staff was to keep a call bell clipped to the resident's shirt or to the top of the sheet on the resident's bed. Observations conducted on 02/28/12, at 12:41 PM, 3:30 PM, and 5:35 PM, revealed Resident #8's call light was attached to the side rail of the bed at the top and behind the resident. During the observations conducted at 12:41 PM and 3:30 PM, Resident #8 attempted to locate the call light within his/her immediate surroundings on the bed and was unable to do so due to his/her impaired vision. The resident requested assistance from the surveyor during both observations and stated, "I can't find it; can you tell me where it is?" An interview with Certified Medication Technician (CMT) #3 on 02/29/12, at 10:05 AM, revealed she had observed multiple occasions when the resident's call light was not within the resident's reach. Interview revealed CMT #3 had been instructed to ensure the call light was in the resident's hand, and the CMT stated she would place it in the resident's hand when she observed it not to be within reach of the resident. An interview with Certified Nursing Assistant (CNA) #3 on 02/29/12, at 10:15 AM, revealed Resident #1 required assistance from staff for toileting and required the use of a call light to gain staff attention to meet his/her needs. The CNA stated she had observed Resident #8's call light not within the resident's reach on occasion, and would place the call light within reach so the resident could call for assistance when needed. An interview with Registered Nurse (RN) #2 on 02/29/12, at 10:20 AM, revealed facility staff had been instructed to ensure Resident #8's call light was within reach at all times. RN #2 continued to state he made rounds daily to ensure resident call lights were accessible to the residents. An interview with the Director of Nursing (DON) on 03/01/12, at 4:30 PM, revealed facility staff had been instructed to ensure Resident #8's call light was within the resident's reach at all times. Further interview revealed the DON, staff nurses, and CMTs were to make daily rounds to ensure all resident call lights were within reach. The DON stated she was unaware staff had failed to ensure Resident #8's call light was within his/her reach.