Every finding on record at Morganfield Nursing and Rehabilitation Center

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for four (Resident (R)31, R37, R50, and R155). of 14 sampled residents. Staff failed to perform hand hygiene when indicated during wound care and medication administration, as well as clean multi-resident use equipment as indicated. The findings include: 1. Review of an undated facility policy titled, Hand Hygiene, revealed hand hygiene should be by using either handwashing, antiseptic hand wash, or antiseptic hand rub. and should be performed before and after glove use. The policy further stated gloves should be changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care. Record review of an Admission Face Sheet revealed the facility admitted R50 on 02/06/2025 with diagnoses including an unstageable pressure ulcer of the right buttock and type 2 diabetes mellitus. An observation of wound care for R50's pressure ulcer of the right buttock was conducted with Licensed Practical Nurse (LPN) 2 on 04/04/2025 at 9:31 AM. LPN 2 donned gloves prior to performing wound care; however, she failed to perform hand hygiene after removing soiled gloves three separate times. During an interview with LPN 2 on 04/04/2025 at 11:30 AM, she stated she should have washed her hands between glove changes, indicating that this failure could have contaminated R50's wound. During an interview with the Infection Prevention (IP) Nurse on 04/04/2025 at 2;00 PM, she stated she expected staff to always wash their hands between glove changes. She stated handwashing and having precautions in place would help prevent infections and stop the spread of infections. During an interview with the interim Director of Nursing/Regional Quality Manager (DON) on 04/04/2025 at 2:51 PM, she stated she expected staff to follow handwashing guidelines and infection control guidelines and protocols for all care including wound care. She stated if the guidelines were not followed, it would increase the risk for infection and that would be her concern, adding R50's wound could have been contaminated. During an interview with the Administrator on 04/04/2025 at 3:21 PM, she stated she expected staff to perform proper handwashing because that is the best prevention of contamination. 2. Review of the facility policy titled, Medication Administration Standard of Practice, with a review date of 10/2020, revealed that staff shall follow established infection control procedures for the administration of medications, as applicable. a. Observation on 04/03/2025 at 8:20 AM revealed LPN1 preparing medications for R31. While removing R31's Calcium Carbonate/Vitamin D3 from the multi-dose blister card, the tablet fell on to the top of the medication cart. LPN1 then, with a bare hand, picked up the tablet and placed it into the medication cup for administration. Additionally, LPN1 removed a Clonazepam 1 milligram (mg) tablet from the multi-dose blister card into her bare hand and placed the tablet into the medication cup, then proceeded to administer it to R31. b. Continued observation of LPN1, while preparing medications on 04/03/2025 at 8:35 AM, revealed LPN1 dropped R155's 1/2 tablet of Entresto out of the multi-dose blister card onto the top of the medication cart. LPN1 then used a bare hand to place the tablet into the medication cup for R155. Ongoing observation revealed LPN1 also used a bare hand to place R155's Sinemet tablet into the medication cup. c. After administering medication to R31, LPN1 then returned to the medication cart. At 8:48 AM, LPN1 failed to perform hand hygiene and began to prepare medications for R37. In an interview with LPN1 on 04/03/25 at 9:01 AM, she stated she received one or two days of training as an LPN at the facility. LPN1 stated the top of the medication cart is wiped off at the start of the shift, but she probably should get another pill if one is dropped on the top of the medication cart when preparing medications. LPN1 related that hand hygiene would be important to do between residents to prevent the spread of infection. 3. Review of the facility policy titled, Policies and Practices - Infection Control, with a revision date of 10/ 2018, revealed that an objective of the infection control policies and practices are to provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. No policy that described the actual processes for cleaning of specific resident-care equipment was provided prior to exit from the facility. Observation revealed that during the medication pass for R155 which began on 04/03/2025 at 8:35 AM, LPN1 used a reusable electronic wrist blood pressure cuff to perform a blood pressure check for both R31 and R155 without cleaning the equipment between residents. In an interview with LPN1 on 04/03/25 at 9:01 AM, she stated the blood pressure cuff probably should be cleaned between residents but no one explained that. In an interview with the IP Nurse on 04/04/25 at 2:03 PM, she stated she would expect the nurses to complete hand hygiene and clean reusable equipment to prevent the spread of infection. The IP Nurse indicated that that in-services on handwashing are provided yearly and as needed, adding that nursing staff are educated on infection prevention during the quarterly nursing meetings. In an interview with the interim DON on 04/04/25 at 2:53 PM, she stated it was her expectation to follow handwashing and infection control and protocols for all tasks including wound care and medication administration. In an interview with the Administrator on 04/04/25 at 3:56 PM, she stated that it was her expectation for staff to follow infection control and prevention policies to prevent the spread of infection. 47798

Based on observation, interview, facility policy review, and review of manufacturer's instructions, the facility failed to ensure drugs and/or biologicals used in the facility were current for use and/or labeled in accordance with currently accepted professional principles, including the expiration date when applicable. A review of one medication storage room and one of two medication carts revealed that a Tuberculin vial stored in the medication storage room refrigerator was opened but not labeled with a date so as to calculate its discard date. The findings include: Review of a facility policy titled, Label/Store Drugs and Biologicals Standard of Practice, reviewed 10/2020, revealed drugs and biologicals must be labeled in accordance with currently accepted professional principles, including the expiration date when applicable. The policy further stated if a multi-dose vial was opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specified a different date for the specific vial. Observation on 04/04/2025 at 10:30 AM of the medication storage room on Hall 2 revealed a house stock multi-dose vial of Aplisol tuberculin 5TU/0.1milliliters (ml) that was opened but was not dated. Review of manufacturer guidelines from PAR Pharmaceuticals (the manufacturer listed on the box containing the vial) revealed that vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. During an interview with Licensed Practical Nurse (LPN) 2 on 04/04/2025 at 10:40 AM, she stated when vials were opened, they should be dated with the date opened and then should be discarded in 30 days. LPN2 stated since the vial was not dated, it should be discarded, adding that if it was used, it may not be as effective. During an interview with the Interim Director of Nursing/Regional Quality Manager (DON) on 04/04/2025 at 2:51 PM, she stated the expectation was that any vial or box be dated immediately upon opening, then it should be monitored for the appropriate discard date. She stated the drug may not be as effective and she would worry about infections, organisms, and growth. During an interview with the Administrator on 04/04/2025 at 3:21 PM, she stated she expected staff to follow facility policy to ensure proper protocols related to vials being dated when opened were followed, as the facility did not want to do things outside of the manufacturer's guidance.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents had assistive devices to maintain hearing abilities for one (1) of thirteen (13) sampled resident (Resident #34). The findings include: Review of a facility policy titled, Resident Rights, undated, revealed a resident had the right to a dignified existence, self-determination, and communication which included access to persons and services inside and outside the facility. Review of Resident #34's medical record revealed the facility admitted the resident on 10/13/2023, with diagnoses which included mild cognitive impairment of uncertain or unknown etiology; sensorineural hearing loss bilateral; and altered mental status, unspecified. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #34 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact and interviewable. Review of Resident #34's Comprehensive Care Plan revealed the facility care planned the resident for Communication on 01/13/2024, related to his/her diagnosis of sensorineural hearing loss, bilateral upon admission. Interventions included: allow adequate time for the resident to comprehend and respond when speaking, be aware/responsive to nonverbal communication such as facial gestures, moaning, pointing and eye movement, face resident when speaking, notify the medical director or responsible party of changes as needed, refer for audiology as needed, refer to speech therapy as needed, remove as much background noise as possible when speaking to the resident and speak near the resident, focus resident's attention, speak clearly and slowly, rephrase as indicated and ckeck for understanding. However, continued review revealed the facility had not implemented the care plan until 01/13/2024. The care plan was not implemented until after the State Surveyor interviewed Resident #34. Review of a audiology note for Resident #34 dated 12/07/2023, revealed hearing aids were not indicated for the resident. Continued review revealed however, a personal amplifier or a pocket talker amplifier could be ordered for the resident if requested. During an interview with Resident #34 on 01/13/2024 at 11:51 AM, he/she stated he/she could not hear well out of either ear. The resident stated he/she saw a doctor a while ago and was supposed to get hearing aides but had not heard anything else about them. Resident #34 did not state if he/she had questioned staff about hearing aids. During an interview with Certified Nursing Assistant (CNA) #8 on 01/14/2024 at 4:30 PM, she stated Resident #34 was hard of hearing and she had to speak louder to him/her because of that. CNA #8 further stated Resident #34 had no hearing devices she was aware of. During an interview with Licensed Practical Nurse (LPN) #2 on 01/14/2024 at 4:35 PM, she stated Resident #34 had trouble hearing which had worsened over the past few months. LPN #2 stated Resident #34 did not have any hearing devices; however, his/her brother had stated he was going to look into that for the resident. LPN #2 further stated Resident #34 would benefit from some type of hearing device so he/she could communicate easier. The LPN further stated she communicated with Resident #34 by standing right in front of him/her and ensuring the lighting was adequate, then spoke right into the resident's ear. In addition, LPN #2 stated she would even use pen/paper to communicate with the resident if needed. During an interview with the MDS Coordinator on 01/14/2024 at 10:00 AM, she stated she forgot to hit the sign option after reviewing a resident's care plan a lot of times. The MDS Coordinator stated there was no way to know a care plan had been reviewed if it had not been signed off on. She further stated, the facility was in the process of updating its Electronic Medical Records system to make the process easier for staff to follow and be more compliant During an interview with the Social Services Director (SSD) on 01/14/2024 at 10:12 AM, she stated she was responsible for following up after three hundred and sixty (360) Physician care visits which were an in house provided service, however, had not received the audiology visit note for Resident #34. The SSD stated once she received a visit note, she followed up and if recommendations had been made for a device she looked at the resident's coverage or what options the resident might have. The SSD stated she had not spoken to Resident #34 about his/her hearing because she was not aware the audiology note was complete but it was her responsibility to follow up on physician visit notes. She further stated if follow up was not done the resident's condition might worsen, and he/she could have trouble communicating and socializing with other residents, peers and family. The SSD stated Resident #34's audiology visit should have been followed up on and the recommendations made by the audiologist should have been checked to see if the services recommended would have been covered. During an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated she expected nursing to follow up on any Physician recommendations. She further stated the recommendations should also be followed up on during Interdisciplinary (IDT) meetings. 44370

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents' grievances were thoroughly investigated to include a statement of findings with corrective actions taken for one (1) of thirteen (13) sampled residents (Resident #56). Review of a Grievance/Concern Form dated 10/14/2022, for Resident #56, revealed the grievance process was not implemented. The findings include: Review of the facility policy titled, Grievances Standard of Practice, revised 05/2020, revealed the residents and their family members might voice grievances in writing or verbally to the facility, or another entity that heard grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Per policy review, the facility was to make prompt efforts to resolve grievances. Continued review revealed the time frame that a resident would reasonably expect completion of the review of their grievance, and a written decision regarding his/her grievance, was to be within seventy-two (72) hours). Review further revealed with the Administrator's approval, the timeframe might be extended with communication to the resident, family or individual making the grievance. Closed record review for Resident #56 revealed the facility admitted the resident on 04/30/2020, with diagnoses to include Alzheimer's disease, unspecified; dementia in other diseases classified elsewhere with behavioral disturbance; and mood disorder due to known physiological condition with major depressive-like episode. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #56 to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) of fifteen (15) indicating the resident was severely cognitively impaired. Review of Resident #56's Care Plan titled, Impaired Bowel and Bladder Elimination, dated 06/15/2020, revealed the resident was at risk for impaired bowel and bladder elimination; incontinence of bowel and bladder frequently with impaired mobility; impaired cognition; and impaired communication. Continued review revealed the Care Plan included an intervention to provide and/or assist Resident #56 with incontinence care as needed. Review of a Grievance/Concern Form dated 10/14/2022, for Resident #56, revealed a family member of the resident had filed a grievance regarding him/her having been left soaked with urine, which included the sheet on his/her air mattress. However, further review of the Grievance/Concern Form revealed there was no documented evidence those concerns were ever investigated or had a resolution. Further review of the form revealed the Business Office Manager completed the grievance form and the Former Administrator completed the investigation and resolution sections of the form. During an interview with Resident #56's Family Members #4 and #5 on 01/10/2024 at 7:20 PM, they stated the resident was often soaked with urine when they visited and they thought it was due to the resident not being turned or changed as he/she should have been. Both Family Members #4 and #5 stated a grievance had been filed but nothing had ever changed. During an interview with the Social Services Director (SSD) on 01/14/2024 at 10:12 AM, she stated she was responsible for addressing grievances. The SSD stated the grievance made by Resident #56's family members should have been addressed and resolved; however, it did not look like that was ever done. The SSD further stated staff should have been re-educated and the issue should have been discussed with the Director of Nursing (DON). During an interview with the Former Administrator (FA) on 01/14/2024 at 1:40 PM, he stated he could not recall a grievance related to Resident #56 being left soiled or soaked in urine; however, if he signed off on the grievance then he must have seen it and would have been responsible for ensuring it was resolved completely. The FA stated he was responsible for signing off on the grievances as they were resolved. He stated if the issue regarding Resident #56 was not resolved, the resident could have more skin breakdown. The FA further stated if a concern was noted on a grievance form, then it should have been addressed and clinical staff re-educated on providing incontinent care. During an interview with the Director of Nursing (DON) on 01/15/2024 at 2:15 PM, she stated if there was a concern on the grievance, it should have been addressed and immediate correction made. During an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated she expected grievances to be investigated, completed, and resolved as soon as possible. The Administrator stated clinical staff should be re-educated on incontinent care and if that were not done, skin breakdown could occur.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure a care plan was developed to and implemented for two (2) of thirteen (13) sampled residents, Residents #34 and #44. The facility failed to develop Resident #44's care plan to include the resident's need for Hemodialysis. In addition, the facility failed to develop Resident #34's care plan to include his/her communication needs as the resident had a diagnosis of sensorineural hearing loss. The findings include: Review of the facility policy titled, Comprehensive Care Plans Standard of Practice dated 10/2020, revealed the policy's purpose was, for an individualized comprehensive care plan to be developed. Continued review revealed the individualized comprehensive care plan was to be developed to include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs. 1. Review of Resident #44's medical record revealed the facility admitted the resident on 10/24/2022, with diagnoses that included: unspecified cirrhosis of liver; chronic systolic heart failure; and chronic kidney disease stage 4, severe. Continued review of Resident #44's medical record revealed the resident began receiving hemodialysis on 12/19/2023. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/25/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated no cognitive impairment. During an interview with Resident #44 on 01/13/2024 at 11:40 AM, the resident stated he/she had started hemodialysis in December while in the hospital. Review of Resident #44's Physician Order dated 12/28/2023, revealed a treatment order to monitor the resident's right chest Perma Cath (a special catheter used for short-term dialysis treatment) for signs and symptoms of infection or bleeding. Continued review of the Order revealed if bleeding was noted, the first step was to confirm the clamps were closed. Further review revealed if bleeding continued to apply pressure and notify the Physician or Nurse Practitioner (NP). Further review of the orders revealed the resident had hemodialysis on Monday, Wednesday, and Friday. Review of Resident #44's Comprehensive Care Plan, dated 12/23/2022, revealed the resident had no plan of care in place to guide facility staff on his/her care should there be complications related to his/her hemodialysis. In an interview with the MDS Coordinator on 01/15/2024 at 12:46 PM, she stated she was responsible for residents' care plans. She stated the purpose of the care plans were to guide staff on caring for the residents safely. The MDS Coordinator stated she thought she had developed a dialysis care plan for Resident #44; however, had not done so. She stated she would finish the resident's care plan today. During an interview with the Director of Nursing (DON) on 01/15/2024 at 2:30 PM, she stated her expectations were for care plans to be person centered and when things came up, those should also be addressed on the care plan. She stated Resident #44 should have had a dialysis care plan developed upon return from the hospital. In an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated her expectation was for care plans to be developed, reviewed, and revised as needed when changes occurred. She stated the care plan was a guide staff on what kind of care residents needed. 47798 2. Review of Resident #34's medical record revealed the facility admitted the resident on 10/13/2023, with diagnoses to include mild cognitive impairment of uncertain or unknown etiology; sensorineural hearing loss, bilateral; and altered mental status, unspecified. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Resident #34 to have a BIMS score of fifteen (15) of fifteen (15) indicating he/she was cognitively intact and interviewable. Review of Resident #34's Comprehensive Care Plan for Communication revealed it had not been developed or implemented until 01/13/2024, even though the resident had a diagnosis of sensorineural hearing loss, bilateral upon admission. During an interview with the MDS coordinator on 01/15/2024 at 12:46 PM, she stated she was responsible for the comprehensive care plans and the floor nurse was responsible for implementing the baseline care plans. The MDS coordinator stated the purpose of care plans were to guide staff on caring for residents safely and how to take care of the residents. She stated she was unsure why Resident #34 did not have a care plan initiated but should have had one when admitted due to her hearing impairment. During an interview with the DON on 01/14/2024 at 2:30 PM, she stated care plans should be person centered and specific to address the resident's needs and conditions. The DON stated the MDS coordinator is the final check to review and compile the comprehensive care plans. The DON stated Resident #34 should have had a care plan initiated upon admission due to having hearing loss. During an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated she expected care plans to be implemented, revised, and reviewed. She stated this should be done during IDT meetings and when issues are identifed.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to review a resident's Comprehensive Person Centered Care Plan for one (1) of thirteen (13) sampled residents, Resident #43. Review of Resident #43's care plan revealed the care plan had not been reviewed since 08/10/2022. . The findings include: Review of the facility policy titled, Comprehensive Care Plans Standard of Practice dated 10/2020, revealed its purpose was for an individualized comprehensive care plan be developed for each resident. Continued review revealed the residents' individualized comprehensive care plans were to include measurable objectives and timetables to meet the residents' medical, nursing, mental, and psychosocial needs. Further review revealed the care plans were to be reviewed and updated when: there was a significant change in the resident's condition; when the desired outcome was not met; or when the resident had been readmitted to the facility from a hospital stay and at least quarterly. Review of Resident #43's medical record revealed the facility admitted the resident on 07/07/2022, with diagnoses which included: Type II diabetes mellitus with diabetic neuropathy unspecified; muscle weakness (generalized); and chronic kidney disease, stage 4 (severe). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #43 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15) indicating he/she was cognitively intact and interviewable. Review of Resident #43's Comprehensive Care plan for Falls dated 07/07/2022, revealed the last review date was 08/10/2022, and it had been signed by the MDS Coordinator. During an interview with the MDS Coordinator on 01/14/2024 at 10:00 AM, she stated she forgot to hit the sign option after reviewing a resident's care plan a lot of times. The MDS Coordinator stated there was no way to know a care plan had been reviewed unless it had been signed off on. She further stated the facility was in the process of updating their Electronic Medical Records (EMR) system to make the process easier for staff to follow and be more compliant. During an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated she expected residents' Care Plans to be updated, revised and reviewed during the Interdisciplinary Team (IDT) meetings. She stated an example of a potential outcome if revisions/updates were not completed, would be a resident could develop a pressure ulcer or have a pressure ulcer worsen. She further stated the care plan was a guide for staff on what kind of care residents needed.

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure one (1) of thirteen (13) sampled residents, (Resident #53) was not administered a psychotropic medication without an appropriate diagnosis. Resident #53 was administered an antipsychotic, Ziprasidone medication for a diagnosis of Dementia with Agitation. However, Ziprasidone was not approved by the Food and Drug Administration [FDA] for the treatment of behavior problems in older adults with dementia. The findings include: Review of the facility policy titled, Behavior and Psychoactive Medication Protocol dated 11/2020, revealed the facility strived to enhance the Quality of Life and Quality of Care of residents experiencing behaviors and were receiving psychoactive medications through the Behavior and Psychoactive Medication review process. Continued review revealed each resident was to receive individualized care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Per review, the facility's Interdisciplinary Team (IDT) was to work with the Physician to determine the appropriate diagnosis associated with a resident's symptoms, so the underlying causes of the symptoms were recognized and treated appropriately. Further review revealed the Physician orders and pharmacy reviews were to clinically support the diagnosis and the reason for the medication. According to policy review, an evaluation of risk versus benefits of the medication was to be shared with the resident and/or responsible party, and a gradual dose reduction of medications was to be attempted as recommended and as applicable. In addition, policy review further revealed the facility was to contract with psychiatric services to add to the Interdisciplinary Team's (IDT) approach in providing individualized support for applicable residents. Review of Resident #53's record revealed the facility admitted the resident on 12/08/2023, with diagnoses to include dementia; unspecified severity with agitation; hallucinations unspecified; major depressive order; and generalized anxiety disorder. Review of Resident #53's Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/14/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) of fifteen (15) indicating he/she had moderate cognitive impairment. Further review revealed Resident #53 received antipsychotic medication in the past seven (7) days and an indication was noted that an anti-psychotic was received. Review of Resident #53's Comprehensive Care Plan established on 01/02/2024, with an onset date of 12/08/2023, revealed the facility care planned the resident for Psychotropic Drug Use related to: having been admitted to the facility with psychoactive medications: Celexa, Diazepam, Ambien, Amitriptyline, and Trazadone. Further review revealed the interventions included: Address side effects as needed to promote/maintain dignity, gradual dose reduction as clinically appropriate, psych referrals as warranted, IDT to review effectiveness of medication regimen at least quarterly and as needed, observe for adverse effects of antipsychotic, antidepressant. Review of the hospital record dated 11/19/2023, for Resident #53 revealed he/she was admitted to the hospital on 11/19/2023, after a fall at home. Continued review revealed Resident #53's admitting diagnoses included dementia and confusion. Further review revealed on 11/20/2023, Ziprasidone (antipsychotic medication) twenty (20) milligrams (mg) by mouth twice daily was initiated. Review of the facility's admission orders for Resident #53 dated 12/8/2023, revealed the orders included Ziprasidone twenty (20) mg by mouth twice daily to be administered for diagnosis of Dementia, with unspecified severity and agitation. Review of the Consultant Pharmacist Report dated 12/18/2023, revealed a medication regimen review (MMR) was completed on admission with no recommendations made. Review of the Consultant Pharmacist Report dated 12/28/2023, revealed an MMR was completed with no recommendations. Review of the progress note dated 12/29/2023 at 2:02 PM, signed by the Advanced Practice Registered Nurse (APRN), revealed an order to increase Resident #53's Ziprasidone to twenty (20) mg three (3) times a day. Review of Electronic Health Record (EHR) for Resident #53 revealed no documented evidence Psychiatric (Psych) Services had been consulted for the resident. During an interview with the Family Nurse Practitioner (FNP) on 01/14/2024 at 12:07 PM, she stated Resident #53 had dementia with agitation as a diagnosis for the Ziprasidone. She stated she increased Resident #53's Ziprasidone medication on 12/29/2023, due to increased the resident's agitation both verbal and physical in the afternoon of 12/29/2023. The FNP stated instead of trying something new she just increased the dose of the Ziprasidone. She stated residents were usually referred to Psych services and she was not sure why Resident #53 had not been referred. The FNP further stated if the pharmacy made recommendations, she was unaware of the recommendations. In addition, she stated she was aware that medications required an indication for use and Resident #53 had episodes of agitation. In an interview with the Clinical Consultant Pharmacist on 01/14/2023 at 2:51 PM, she stated she printed the facility's admissions report weekly and monthly to review ordered medications and complete the Medication Regimen Review (MRR). She stated if a resident was receiving a psychotropic medication and she could not locate a diagnosis for its use, or the resident had an inappropriate diagnosis she would make the facility aware of that information. In an interview with the Director of Nursing (DON) on 01/15/2024 at 2:30 PM, she stated Resident #53 was admitted to the facility with antipsychotic medication and had a diagnosis of dementia with agitation. She stated Resident #53 had episodes of agitation, which included wandering and getting up and down out of his/her chair or bed. The DON stated she could not recall any recommendations related the MRR, and she could not speak to what the FNP did. In an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated residents should have a diagnosis in place for antipsychotic medications; however, it was up to the Physician or FNP to diagnose and treat residents. She stated, I can't answer that when asked about dose reduction and indications on antipsychotic's.

Based on observation, interview, and record review, it was determined the facility failed to honor one (1) of six (6) sampled residents meal preferences (Resident #5). The facility identified Resident #5 foods that accommodates his/her intolerance's and preferences. However, on 09/15/2021 during the lunch meal, the resident meal was inconsistent with his/her dietary card on the lunch meal tray. The findings include: Review of the facility's policy titled, Dining and Food Preferences, dated 09/02/2017, revealed individual dining, food, and beverage preferences are identified for all residents. The Dining Services Director, or designee, will interview the resident or resident representative to complete a Food Preference Interview within 48 hours of admission. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the management software system. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, allergies, intolerance's, and preferences. Upon meal service, any resident with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value. Record review revealed the facility admitted Resident #5 on 05/04/2021 with diagnoses which included Diabetes, Hypertension, [CONDITION(S)] Due To Excess Calories, [CONDITION(S)], Rash, and Other Non-Specific Skin Eruption. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as cognitively intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicates the resident was interviewable. Observation on 09/15/2021 at 12:25 PM, revealed Resident #5 was served his/her lunch meal tray in his/her bedroom. Observation of the resident's dietary card on the meal tray revealed Baked Macaroni and Cheese (1) cup; Sauteed Zucchini (1/2) cup; Parsley Dinner Roll (1) each; Margarine (1) each; Lemon Bar (1) bar; Tea of Choice (6) ounces (oz). However, the lunch meal tray consisted of Italian Sausage Stir Fry (instead of macaroni and cheese) and Garlic and [MEDICATION(S)] Roasted Red Skin Potatoes which was listed on the posted menu. In addition, Resident #5 was served cornbread rather than a parsley dinner roll. Observation on 09/15/2021 at 1:00 PM, revealed Resident #5 did not eat the Italian Sausage Stir Fry. However, the resident did eat two (2) of the roasted potatoes, the lemon bar, cornbread, and drank the lemonade which was served with the meal. Interview with Resident #5 on 09/15/2021 at 1:10 PM, revealed she did not eat the Italian Sausage Stir Fry and would have preferred the Macaroni and Cheese listed on the dietary meal card. Interview revealed the resident stated the food here is horrible. I have asked for alternate food choices in the past although, I didn't today. Today was one of many times the food served is not what is listed on meal ticket. Interview with State Registered Nurse Aide (SRNA) #1, on 09/15/2021 at 1:20 PM, revealed she served Resident #5's lunch tray. Interview revealed the SRNA stated, I looked at the meal card to check the diet listed on the meal card but I did not catch that she had the Italian Sausage Stir Fry instead of Macaroni and Cheese that was listed on the meal ticket. Interview revealed SRNA #1 failed to ensure Resident #5's meal served was consistent with the lunch meal ticket on the tray. Interview with the Dietary Account Manager, on 09/15/2021 at 2:15 PM, revealed the dietary cook prepared Resident #5's lunch meal tray. Interview revealed it is expected whomever prepared the resident's lunch tray to assure the meal was consistent with the lunch meal card. Interview with the Dietary Cook, on 09/15/2021 at 2:20 PM, revealed she was the person who prepared Resident #5's lunch tray. Interview revealed the Dietary Cook stated she should have asked the resident his/her food preference. Continued interview revealed it was her responsibility to assure the lunch meal served was what was listed on Resident #5's lunch meal card. Interview with the Director of Nursing, on 09/15/2021 at 3:15 PM, revealed Resident #5's lunch meal should have been consistent with the foods listed on the resident's lunch meal card. Interview revealed each resident's diet card should be consistent with the meal served. Interview with the Administrator, on 09/15/2021 at 3:30 PM, revealed he expected Resident #5's lunch tray meal to reflect the resident's lunch meal card unless the resident requested an alternate choice. Interview revealed he would expect dietary staff to converse with the resident before altering the meal listed on the resident's meal card.

Based on observation, interview, medical record review, and facility policy review the facility failed to maintain an effective infection control program for three (3) of twenty-nine (29) sampled residents (Resident #4, Resident #14, and Resident #28). The facility failed to follow their policy and physician order related to contact and droplet precautions for Resident #4 and failed to disinfect a blood glucose monitor per manufacturer guidelines for Resident #28. Resident #14 did not receive annual [MEDICATION NAME] testing. The findings include: 1. Review of the facility policy titled Isolation Categories of Transmission-Based Precautions, not dated, revealed Transmission-Based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Further review of the policy revealed residents who require droplet precautions will be placed in a private room if possible and the facility will implement a system to notify staff and visitors of the type of precaution the resident requires. Review of Resident #4's medical record revealed the facility admitted the resident on 05/11/2019 with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident had a Microbiology-Bacteriology report dated 02/07/2020 that indicated Resident #4 had a positive sputum culture for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA). Continued review of the medical record revealed a physician order for [REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #4 to have a BIMS (brief interview for mental status) score of fourteen (14) indicating the resident is cognitively intact. Review of the comprehensive care plan dated 02/07/2020 revealed an intervention for droplet precautions dated 02/12/2020. Observation of Resident #4's room on 12/11/2020 at 9:33 AM and again at 3:28 PM revealed there was no signage on the door related to isolation precautions or to see a nurse before entering. Interview with Resident #4 on 02/12/2020 at 2:55 PM revealed visitors have not been using personal protective equipment when entering the room. Resident #4 stated he/she has been treated for [REDACTED]. Interview with Kentucky Medication Aide (KMA) #1 on 02/11/2020 at 3:37 PM revealed Resident #4 was placed in isolation on 02/07/2020 due [MEDICAL CONDITION] in his/her sputum. KMA #1 acknowledged there should be signage on the door alerting staff and visitors to the isolation precautions. Observation of Resident #4's room on 02/12/2020 at 9:21 AM revealed signage on the door directing visitors to see the nurse before entering the room. Interview with RN #1 on 02/12/2020 at 2:39 PM revealed staff and visitors should see the nurse prior to entering Resident #4's room. The nurse would instruct staff and visitors on the type of personal protective equipment (PPE) to use when entering the room. Interview with State Registered Nurse Aide (SRNA) #2 on 02/13/2020 at 9:42 AM revealed she is knowledgeable of the type of isolation and the precautions for Resident #4. SRNA #2 acknowledged the signage was not on the door until yesterday, 02/12/2020. Interview with SRNA #3 on 02/13/2020 at 9:50 AM revealed she is aware of the type of isolation Resident #4 is in and the type of Personal Protective Equipment (PPE) to use when entering the room. SRNA #3 reported the signage that directs staff and visitors to see the nurse prior to entering the room was not posted on the door the entire time Resident #4 was in isolation. SRNA #4 stated she has seen visitors enter the room without using PPE. Interview with the Director of Nursing (DON) on 02/13/2020 at 5:52 PM revealed the nurse who takes the order for isolation is responsible for placing signage on the door directing staff and visitors to see the nurse prior to entering the room. The DON stated she made rounds daily to monitor resident care. The DON stated she was not aware of any concerns with isolation precautions and correct use of PPE. 2. Review of the facility policy titled, Cleaning and Disinfecting Blood Glucose Machines, undated, revealed it is the policy of the facility to clean/disinfect the blood glucose monitor machines after each use to prevent the spread of infection. Further review of the policy revealed staff were to clean the glucometer with an approved wipe, ensuring it is visibly wet for the recommended time. Review of the medical record for Resident #28 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident had physician orders for blood glucose monitor checks before meals, at bedtime, and as needed for signs and symptoms of hypo/[MEDICAL CONDITION]. Review of the resident's care plan revealed the resident was to receive blood glucose monitoring as ordered by the physician. Observation of blood glucose monitoring for Resident #28 on 02/13/2020 at 12:54 PM revealed Licensed Practical Nurse (LPN) #1 sanitized hands, donned gloves, obtained a blood specimen from Resident #28, and obtained a blood glucose monitor reading of 301 milligrams per deciliter (mg/dl). LPN #1 exited the room, placed the blood glucose monitor on a dry paper towel on a hard surface, removed gloves, sanitized hands, donned gloves, and proceeded to wipe the blood glucose machine with a Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipe for approximately thirty (30) seconds. LPN #1 then placed the blood glucose machine on a new clean dry paper towel on a hard surface to air dry. The blood glucose machine was dry within thirty (30) seconds after being placed on the paper towel. Review of the label on the Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipe container revealed to disinfect the surface it should be thoroughly wiped and kept wet for two (2) minutes using as many wipes as necessary to keep the surface wet for the entire contact time and allow to air dry. Interview with LPN #1 on 02/13/2020 at 3:38 PM revealed she was employed by an agency outside of the facility. LPN #1 further revealed she was taught and performed competency checks by the outside agency for the blood glucose monitoring procedure. LPN #1 revealed she was taught with a different type of cleaning wipe and it only required thirty (30) seconds contact to the device for it to be disinfected. LPN #1 also revealed that when she came to work at the facility she signed a contract that she had been trained in blood glucose monitoring including cleaning of the device. LPN #1 further revealed she was not aware this was a different type of disinfecting wipe and required longer contact with the blood glucose monitor. Interview with the Director of Nursing (DON) on 02/13/2020 at 6:01 PM revealed staff employed from an outside agency received two (2) to three (3) shifts of training at the facility before being assigned duties. The DON further revealed staff were trained and performed competency checks annually and as needed throughout the year. The DON revealed the blood glucose monitor required two (2) minutes of cleaning with a wet wipe to disinfect the device and was to be placed on a clean surface to allow to air dry. The DON further revealed she conducted random auditing of staff to monitor for correct cleaning of the blood glucose monitor and had not identified any concerns. 3. A review of the facility policy for [MEDICAL CONDITION] skin test titled Administration and Interpretation of [MEDICATION NAME] Skin Test, with a revision date of June 2010, revealed the facility will administer and interpret [MEDICATION NAME] skin tests in accordance with recognized guidelines and pertinent regulations. A review of the medical record for Resident #14 revealed the facility admitted the resident on 12/12/2018 with [DIAGNOSES REDACTED]. Further review of the record revealed no evidence that annual required [MEDICATION NAME] skin testing was conducted for Resident #14 in 2019. According to the medical record the most recent [MEDICATION NAME] skin testing conducted for Resident #14 was completed on 12/12/2018 when the resident was admitted to the facility. Interview with the facility Infection Control Preventionist on 02/13/2020 at 5:39 PM revealed she had recently assumed the duties of infection control in January 2020 and was responsible for ensuring residents received [MEDICATION NAME] skin testing. The Infection Control Preventionist stated she was not aware that Resident #14 had not received annual [MEDICATION NAME] skin testing in 2019 as required. Interview with the Director of Nursing (DON) on 02/13/2020 at 5:50 PM revealed the DON was aware that [MEDICATION NAME] Skin Testing was to be completed annually and had a monthly binder to track each resident. The DON stated residents were listed in a binder with the due date of the PPD (purified protein derivative). The DON stated she reviewed this binder every couple of months; however, she had not identified any problems and was not aware Resident #14 had not received [MEDICATION NAME] Skin Testing in 2019.

Based on observation, interview, record review, and a review of the facility care plan policy, it was determined the facility failed to follow the plan of care related to restraint use for one (1) of fifteen (15) sampled residents (Resident #7). Facility staff failed to remove Resident #7's seatbelt restraint during the noon meal on 02/11/2020 per the intervention in the resident's plan of care. The findings include: A review of the facility policy for following the plan of care titled Comprehensive Care Plans Standard of Practice, with a revision date of September 2017, revealed it was the practice of the facility to implement a person-centered care plan for each resident to meet the needs of the resident identified in the comprehensive assessment. In addition, the facility would ensure residents diagnosed with [REDACTED]. A review of Resident #7's medical record revealed the facility admitted the resident on 07/20/2017 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] completed for Resident #7 revealed the resident was assessed to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three (3). Per the MDS, the resident was assessed to utilize a trunk restraint daily. A review of the comprehensive plan of care developed for Resident #7 revealed the facility had addressed the resident's use of a physical restraint in the form of an alarming seat belt. Per the plan of care, the reason for the restraint use was abnormal posture and impaired cognition with poor safety awareness. The goal was listed for the resident to be free from complications associated with the use of a physical restraint. The interventions included application of the restraint seatbelt alarm when the resident was up in a wheelchair and release of the restraint for meals. Observation of Resident #7 during the noon meal service on 02/11/2020 at 1:25 PM revealed State Registered Nurse Aide (SRNA) #1 who was also a restorative aide assisted Resident #7 to eat; however, the restorative aide did not remove the lap belt restraint while assisting the resident to eat. Interview with SRNA #1 on 02/13/2020 at 3:51 PM revealed the SRNA knew that Resident #7's seatbelt restraint should have been released while the resident was eating lunch but SRNA #1 stated she forgot to remove the belt. Interview on 02/13/20 at 3:25 PM with the MDS/Restorative Supervisor revealed residents' restraints were monitored by observing residents during daily rounds, which were completed 2-4 times per day depending on the workload. The MDS/Restorative Supervisor stated staff receive yearly training on restraints and she reeducated staff when necessary related to restraint use. The MDS/Restorative Supervisor stated Resident #7's seatbelt restraint should be released during meals. Per the MDS/Restorative Supervisor, she was not aware that SRNA #1 failed to release Resident #7's seatbelt restraint during lunch on 02/11/2020. Interview with the Director of Nursing (DON) on 02/13/2020 at 5:59 PM revealed the DON made rounds daily during meal service to ensure staff are following the plan of care. According to the DON, Resident #7's plan of care should have been followed and the seat belt should have been released when the resident was eating.

Based on observation, interview, record review, and a review of the facility restraint policy it was determined the facility failed to ensure one (1) of fifteen (15) residents (Resident #7) was free from physical restraint. Resident #7's alarming seat belt was not released during the lunch meal on 02/11/2020. The findings include: A review of the facility restraint policy titled Restraint Standard of Practice, dated November 2016, revealed residents were to be free of restraints unless medically necessary and the least restrictive restraint method would be utilized. A review of the medical record for Resident #7 revealed the facility admitted the resident on 07/20/2017 with [DIAGNOSES REDACTED]. A review of the most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was assessed to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three (3). The resident was also assessed to utilize a trunk restraint daily. A review of physician orders [REDACTED].#7's restraint use revealed an intervention to release the restraint for meals and supervised activities as deemed safe. Observation of Resident #7 during the noon meal service on 02/11/2020 at 1:25 PM revealed State Registered Nurse Aide (SRNA) #1 who was also a restorative aide assisted Resident #7 to eat; however, the restorative aide did not remove the lap belt restraint while assisting the resident to eat. Interview with SRNA #1 on 02/13/2020 at 3:51 PM revealed the SRNA knew that Resident #7's seatbelt restraint should have been released while the resident was eating lunch but SRNA #1 stated she forgot to remove the belt. Interview on 02/13/2020 at 3:25 PM with the MDS/Restorative Supervisor revealed resident restraints were monitored by observing residents during daily rounds, which were completed 2-4 times per day depending on the workload. The MDS/Restorative Supervisor stated the staff receives yearly training on restraints and she reeducated staff when necessary related to restraint use. The MDS/Restorative Supervisor stated Resident #7's seat belt restraint should be released during meals. Per the MDS/Restorative Supervisor, she was not aware that SRNA #1 failed to release Resident #7's seatbelt restraint during lunch on 02/11/2020. Interview with the Director of Nursing (DON) on 02/13/2020 at 5:59 PM revealed the DON made rounds daily during meal service to ensure staff were following the residents' plan of care. According to the DON, Resident #7's plan of care should have been followed and the seatbelt should have been released when the resident was eating.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide adequate supervision for one (1) of three (3) sampled residents (Resident #1). On 11/20/19, Resident #1 was placed on 1:1 supervision due to stating he/she was going to harm self . However, on 11/21/19, Resident #1 was able to go to his/her room, closed the door, push a piece of furniture in front of the door, and lock the bathroom door, while she was on 1:1. Staff failed to keep the resident within arms reach at all times. The findings included: Review of facility policy titled, Accidents and Incident Process, last reviewed June 2019 revealed the purpose of the policy is to ensure the facility environment is as free from accident hazards over which the facility has control and that each resident receives adequate supervision and assistive devices to prevent avoidable accidents. Assessments and investigation are done in a systematic manner: Implementing interventions to reduce hazards and risks. Record review revealed the facility admitted Resident #1 on 10/18/19 and readmitted the resident on 11/17/19 with diagnoses which included Anxiety Disorder, Personality Disorder, Major Depressive Disorder, [CONDITION(S)] Disorder, [CONDITION(S)] Disorder, Post-Traumatic Stress Disorder, Major Depressive Disorder-Recurrent, Severe with Psych Symptoms, and Borderline Personality Disorder. Review of Admission Minimum Data Set (MDS) assessment, dated 08/27/19 revealed the facility assessed Resident #1 cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Further review of the MDS revealed the resident had no behaviors. Review of Resident #1's Comprehensive Care Plan for exhibits alteration in mood/behavior, dated 08/17/19 revealed an intervention that if the resident voices complaints of hearing voices in his/her head, or signs are noticed of resident hearing voices in head, report to nursing staff immediately and begin 1:1 intervention. Further review of the care plan revealed documentation dated 11/20/19 which read resident saw therapist at behavioral health and made statement of hearing voices telling to harm self-denied having plan, and stated is not going to act upon. Placed back on twenty-four (24) hour 1:1. Review of Departmental Note dated 11/21/19 at 5:03 PM by the MDS Nurse revealed Resident #1 had barricaded self in room by pushing wooden shelf [MEDICATION(S)] in front of door and chain locked bathroom door. Further review of the note revealed Resident #1 stated he/she was hearing voices to harm self but would never harm self or others and was tired of having the same 1:1 people for supervision Resident #1 had also stated he/she had been abused, an abuser, and had attempted suicide before. Review of 1:1 Supervision on 24 hour Resident Flow Record by Certified Nurse Aide (CNA) #1 for 11/21/19 at 4:00 PM revealed Resident #1 was agitated; and, at 4:15 PM, Resident #1 had barricaded him/herself in room by placing a dresser in front of door. Interview with CNA #1 on 12/18/19 at 4:07 PM revealed on 11/21/19 she was providing 1:1 supervision for Resident #1 related to suicidal thoughts and hearing voices. CNA #1 stated when Resident #1 took off to his/her room after the 4:00 PM smoke break in his/her wheelchair she was unable to keep up with him/her. She revealed when the resident arrived at his/her room, the resident slammed the door, and when she arrived at door, the resident had already barricaded him/herself in the room with his/her bedridden roommate. CNA #1 stated she was behind the resident when the resident did this. Interview with the MDS Nurse on 12/18/19 at 4:39 PM revealed she did not get into Resident #1's room until 4:55 PM or 5:00 PM. Interview with Licensed Practical Nurse (LPN) #2 on 12/18/19 at 3:25 PM revealed 1:1 supervision means that staff should stay with the resident. Interview with Assistant Director of Nursing (ADON) #1 and ADON #2 on 12/19/19 at 5:00 PM revealed 1:1 supervision means staff should be within touching distance of the resident (three {3} feet), and if a staff member sees someone on supervision speed up in movement, they should speed up as well. ADON #1 stated the dresser Resident #1 pulled in front of door was large and was 3.5-4 feet wide, approximately 4.5 foot tall, and stood out 2.5-3 feet from the wall, and had a lot of stuff on it. ADON #1 stated staff had to go through the door of the room to finally get in the room. Interview with the Director of Nursing (DON) on 12/19/19 at approximately 10:59 AM revealed part of our intervention(s) are to protect the other residents.

Based on record review, interview, and facility policy review, it was determined the facility failed to implement the care plans for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned for 1:1 Supervision; however, staff failed to ensure he/she was in arm reach of the resident and Resident #1 was able to wheel his/herself in a wheelchair to his/her room and barricade him/herself in the room with a bedridden resident. The findings include: Review of facility policy undated and entitled, Comprehensive Care Plans, revealed; the person centered care plan are developed to promote communication of the resident's needs, goals, and interventions to promote successful goal attainment, and to identify the professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status and/or functional levels, and to reflect goals. Record review revealed Resident #1 was admitted to the facility on [DATE] with readmission on 11/17/19 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Comprehensive Care Plan for exhibits alteration in mood/behavior, dated 08/17/19 revealed an intervention dated 11/20/19 to place the resident back on 24 hour 1:1 due to resident saw therapist at behavioral health and made statement of hearing voices telling to harm self-denied having plan. However, review of Departmental Note dated 11/21/19 at 5:03 PM revealed Resident #1 was able to wheel his/herself to his/her room and barricade self in room. The resident was able to push a wooden shelf [MEDICATION(S)] in front of door and chain lock the bathroom door while on 1:1 supervision. Interview with Certified Nursing Assistant (CNA) #1 on 12/18/19 at 4:07 PM revealed she was providing 1:1 supervision for Resident #1 on 11/21/19. She stated Resident #1 wheeled his/herself to his/her room after the 4:00 PM smoking break and she could not keep up with her. She revealed Resident #1 entered room, slammed the door, and when she arrived at the residents door, the room was already barricaded with a bedridden resident in the room. Interviews on 12/19/19 with CNA #4 at 4:00 PM, CNA #5 at 4:53 PM, and CNA #6 at 4:54 PM, revealed the care plans tell staff what should be done for residents and everyone should follow them. Interview with Registered Nurse (RN)/Staff Develpment Coordinator (SDC) on 12/19/19 at 4:30 PM revealed the care plans are resident specific related to behaviors and ensure resident safety. Interview with Social Service Director (SSD) on 12/19/19 at 4:15 PM revealed everyone should follow the care plan as the care plan is specific to the care needed for that resident. Interviews on 12/19/19 at 5:00 PM with Assistant Director of Nursing (ADON) #1 and ADON #2 revealed all staff should follow the care plan for the residents. The ADON's stated 1:1 supervision means the staff must be within touching distance of the resident (within (3) three feet of resident) at all times, and if a staff member sees someone on supervision speed up in movement, they should speed up as well. Interview with the Director of Nursing (DON) on 12/19/19 at approximately 10:59 AM revealed the intervention(s) are to protect the residents.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, in accordance with professional standards for food service safety. Kitchen observations on [DATE], revealed expired food was being kept in the back refrigerator uncovered, not dated or labeled; and, a scoop was being stored in the sugar in the sugar bin. Review of the Census and Condition, dated [DATE], revealed forty-two (42) of forty-five (45) residents received their food from the kitchen. The findings include: 1. Review of facility policy titled, Labeling and Dating, not dated, revealed all food should be dated upon receipt before being stored and food labels must include the food item, the date of preparation and the use by date. Observation of the kitchen on [DATE] at 10:17 AM, revealed a pan of jello being stored in the back refrigerator with no lid/cover and not labeling with a date of any kind. 2. Review of facility policy titled, Cross Contamination, not dated, revealed ready to eat foods should always be stored in a clean storage container with a clean cover/lid that is clearly labeled/dated. Further review of this policy, revealed there should never be a scoop stored in the sugar. Observation of the kitchen on [DATE] at 10:26 AM, revealed a scoop being stored in the sugar in the sugar bin. Interview with the Dietary Manager on [DATE] at 12:16 PM, revealed she expected all stored foods to be covered, labeled, and dated. She stated she expected there to be no scoops left in the sugar, flour or cornmeal at any time. Interview with District Dietary Manager on [DATE] at 11:27 AM, revealed the goal was to have all food covered, sealed, labeled, and dated. She stated she expected there to be no scoops in any bulk items.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure the accuracy and completion of Sections C of the Minimum Data Set (MDS) assessment for one (1) resident not in the selected sample of sixteen (16) residents (Unsampled Resident #40). The findings include: Review of the MDS 3.0 Manual, Chapter 3, Page C-1, dated (MONTH) (YEAR), revealed the intent of Section C: Cognitive Patterns was to determine the resident's attention, orientation, and the ability to recall new information. According to the manual, these items were crucial factors in care planning decisions, identifying needed supports, and identifying possible [MEDICAL CONDITION] behaviors. The manual stated that the interview items were to be conducted the day before or the day of the Assessment Reference Date (ARD). Review of a memo issued by The Centers for Medicare and Medicaid Services (CMS) in (MONTH) 2011 addressing the use of dashes revealed, Inappropriate use of a dash (-) has implications for the accuracy of quality measures and for communicating resident status at discharge to support coordination and continuity of care. Record review revealed the facility readmitted Unsampled Resident #40 on 01/11/18, with [DIAGNOSES REDACTED]. Further review of the MDS Section B-Hearing,, Speech, and Vision, revealed Unsampled Resident #40 was coded as rarely/never understands others and is rarely/never understood by others. Review of Section C0100 revealed if a resident is rarely/never understood the first box of zero (0) should be marked as indicated; however, the second box of one (1) was inaccurately marked. Interview with Social Services on 01/24/19 at 4:04 PM, revealed she had completed Section C0100 for Unsampled Resident #40 inaccurately, as the resident was rarely/never understood. She stated staff should have completed the section. She revealed she follows the RAI manual for coding instructions when completing resident assessments. Interview with the Director of Nursing (DON) on 01/24/19 at 4:46 PM, revealed she stated she would have expected social services to follow the RAI manual on coding section C of the MDS.

Based on observation, interview and review of facility policy, it was determined the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one (1) of sixteen (16) sampled residents (Resident #29). Resident #29 has frequent Urinary Track Infections (UTI's) and was currently receiving [MEDICATION NAME] (Antibiotic) Intravenous (IV) for a UTI. Observation on 01/29/19 revealed staff failed to provide appropriate perineal care per facility policy which could increase the risk for a UTI. The findings Include: Review of facility policy titled, Procedure Checklist-Providing Perineal Care, Copyright 2007, revealed: 9. For males: a. Retract the foreskin if needed, if present. b. Cleanse the penis using a circular motion. c. Replace foreskin and finish washing the shaft of the penis using firm [MEDICAL CONDITION]. d. Wash the scrotum using a clean portion of the washcloth with each stroke. Review of the facility policy titled, Giving a Complete Bed Bath, not dated, revealed after the genital area is cleansed, remove your gloves and decontaminate your hands. Record review reveled Resident #29 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #29's cognition to be intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS revealed Resident #29 required extensive assist of one (1) with hygiene and bathing. Observation of Resident #29's perineal care on 01/24/19 at 02:29 PM revealed Certified Nurse Aide (CNA) #4 was in the process of giving a bed bath to the resident and had just started perineal care. Further observation revealed CNA #4 failed to use different areas of the washcloth while cleaning the scrotum area, and failed to change gloves and wash hands after cleansing the genital area; per facility policy. Interview with CNA #4 on 01/24/19 at 3:00 PM revealed she felt she did use different areas of washcloth when cleaning the scrotum but should have washed her hands and changed gloves after giving perineal care. Interview with the Director of Nursing (DON) on 01/24/19 at 3:45 PM revealed the CNA giving care should have provided perineal care per facility policy. She stated the CNA should have washed her hands and changed gloves before and after performing perineal care.

Based on interview, record review, and review of facility investigation worksheets, revealed it was determined the facility failed to ensure the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for one (1) of sixteen (16) sampled residents (Resident #17). The facility failed to review and revise Resident #17's care plans to ensure they were not adding a repetitive intervention after falls. The findings include: Interview with the Director of Nursing (DON) on 01/24/19 at 11:42 AM, revealed the facility did not have a specific care plan policy and the facility follows the federal regulations related to care plan requirements. 1. Record review revealed the facility admitted Resident #17 on 12/04/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/10/18, revealed the facility assessed Resident #17's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable Review of facility fall investigation worksheet, dated 12/28/18, revealed Resident #17 was found on the floor beside his/her wheelchair and the root cause was determined to be the resident was attempting to self ambulate to get something to eat. Further review of the investigation worksheet revealed the intervention put in place related to this fall was for staff to offer a snack at bedtime. However, review of Resident #17 Comprehensive Risk for Falls Care Plan, last revised 10/04/18, revealed revealed there was already an intervention to offer snacks at bedtime during rounds. Interview with the MDS/Care Plan Coordinator on 01/24/19 at 11:03 AM, revealed the intervention of offering a bedtime snack should be more specific, as all residents are offered snacks at bedtime. Further intreview with the MDS/Care Plan Coordinator on 01/24/19 at 11:24 AM, revealed staff need to make sure they are not using repetitive interventions after a resident has additional falls. She stated she expected the care plans to be reviewed and revised which would limit repetitive interventions if the care plans were in fact reviewed and revised with any changes or new additions to the care plan. Interview with the Assistant Director of Nursing (ADON) on 01/24/19 at 11:48 AM, revealed she expected a new intervention to be put in place after every resident fall that matches what they are trying to accomplish. She stated they need to ensure it is not a repetitive intervention that is already in place. She revealed staff should be reviewing the care plan to ensure they are not implementing an intervention that was already put in place. Interview with the Director of Nursing (DON) on 01/24/19 at 4:46 PM, revealed all residents are offered snacks at bedtime. She stated staff should be reviewing and revising care plans with any new interventions that are specific to the resident involved and the circumstances.

Based on interview, record review, review of facility fall investigations, and review of facility policy, it was determined the facility failed to ensure two (2) of sixteen (16) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #4 and #17). Resident #4 and Resident 17 sustained falls; however, the facility failed to ensure interventions were put in place to address the root cause of the fall and/or failed to ensure the intervention was not already in place. The findings include: Review of the facility's policy titled, Fall Assessment/Intervention Process, last revised (MONTH) 2013, revealed at the time of a resident fall an appropriate intervention will be put in place. Record review revealed the facility admitted Resident #4 on 07/20/17 with [DIAGNOSES REDACTED]. Review of Resident #4's Annual Minimum Data Set (MDS) Assessment, dated 10/24/18, revealed the facility assessed Resident #4's cognition as severely impaired and unable to complete a Brief Interview for Mental Status (BIMS) score, which indicated the resident was not interviewable. Review of Resident #4's Comprehensive Risk for Falls Care Plan, last revised 10/24/18, revealed the resident was at risk for falls related to having Dementia, Hypertension, Constipation, Glucose Intolerance, Psychoactive Medications, Weakness, Impaired Mobility, Anxiety, and Depression. Further review of this care plan revealed an intervention, dated 10/13/17, for resident to be in supervised area when up in wheelchair; an intervention, dated 05/20/18, to reeducate staff for resident to be in supervised area when in wheelchair'; and an intervention, dated 12/15/18, for 'resident to be in supervised area when in wheelchair and offer to sit on couch. Review of facility fall investigation worksheet, dated 10/31/18, revealed Resident #4 was in the dining room and attempting to stand up from wheelchair and fell . The root cause was determined to be the resident was attempting to stand up in his/her wheelchair and lost his/her balance and fell . Further review of this investigation worksheet revealed the intervention put in place related to this fall was for CNA's to check this resident's brief for bowel movement on first round of day shift. Review of facility fall investigation worksheet, dated 11/13/18, revealed Resident #4 was found in the floor in his/her room. The root cause was determined to be the resident rolled out of bed while repositioning. Further review of this investigation worksheet revealed the intervention put in place related to this fall was for pillows to be used for positioning and resident to be checked for positioning on rounds. Interview with the MDS/Care Plan Coordinator on 01/24/19 at 11:00 AM, revealed the facility is expected to do a new appropriate intervention for all resident falls. She stated the interventions that were put in place for Resident #4 after a fall on 10/31/18 and 11/13/18 were interventions that were already in place for basic care and not new interventions to address these specific falls. Review of facility fall investigation worksheet, dated 11/23/18, revealed Resident #4 leaned forward to far and fell out of the wheelchair and when checked had a soiled brief on. The root cause was determined to be the resident was leaning over in wheelchair, leaned to far, fell out and needed to use the bathroom. Further review of this investigation worksheet revealed the intervention put in place related to this fall was for staff to assist resident and check and change after breakfast; however, this intervention did not address the resident leaning forward to far in the chair which caused her to fall out of wheelchair. Interview with the Assistant Director of Nursing (ADON) on 01/24/19 at 11:48 AM, revealed she expected a new intervention to be put in place after every resident fall that address the root cause of the fall. She stated staff need to ensure it is not a repetitive intervention that is already in place and should be reviewing the care plan to ensure they are not implementing an intervention that was already put in place. Interview with the Director of Nursing (DON) on 01/24/19 at 11:42 AM, revealed they should be reviewing and revising care plans to ensure new interventions are put in place for residents. She stated interventions should be more specific and not be actual interventions that should already be being provided as part of basic care. 2. Record review revealed the facility admitted Resident #17 on 12/04/18 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS Assessment, dated 12/10/18, revealed the facility assessed Resident #4's cognition as severely impaired with a BIMS score of four (4), which indicated the resident was not interviewable. Further review of the MDS Section G-Functional Status, revealed Resident #17 required limited assistance of one (1) staff for transfers and toileting. Review of Resident #17's Comprehensive Risk for Falls Care Plan, last revised 10/04/18, revealed this resident was at risk for falls related to Weakness, Impaired Mobility, and Dementia. Further review revealed an intervention to offer snacks at bedtime during rounds. Review of facility fall investigation worksheet, dated 12/28/18, revealed Resident #17 was found on the floor beside his/her wheelchair and the root cause was determined to be the resident was attempting to self ambulate to get something to eat. Further review of the investigation worksheet revealed the intervention put in place related to this fall was for staff to offer a snack at bedtime. However, the care plan last revised on 10/04/18, already had an intervention to offer snack at bedtime. Interview with Certified Nurse Aide (CNA) #2 on 01/24/19 at 3:22 PM, revealed Resident #17 gets up unassisted and will refuse staff's attempts to help him/her. She stated redirection is usually not effective because the resident just does not know to ask for help. She revealed she keeps a close eye on the resident to make sure he/she does not fall. Interview with the Housekeeping Supervisor on 01/24/19 at 9:29 AM, revealed he has witnessed Resident #17 self transfer from the wheelchair to the bathroom. He stated he has made nursing aware but has not seen Resident #17 fall. He revealed he has seen staff redirect the resident to keep him/her from trying to self transfer. Interview with the MDS/Care Plan Coordinator on 01/24/19 at 11:03 AM, revealed the intervention of offering a bedtime snack should be more specific, as all residents are offered snacks at bedtime. Interview with the Director of Nursing (DON) on 01/24/19 at 4:46 PM, revealed all residents are offered snacks at bedtime. She stated staff should be reviewing and revising care plans with new interventions that are specific to the resident involved and the circumstances.

Based on interview, and record review, it was determined the facility failed to develop a comprehensive person-centered care plan for one (1) of sixteen (16) sampled residents (Resident #29). Resident #29 had a [DIAGNOSES REDACTED]. address the resident's needs. The findings include: Interview with the Director of Nursing (DON) 01/22/19 03:46 PM revealed the facility did not have a Comprehensive Care Plan policy but followed the Resident Assessment Instrument (RAI) guidelines. Record review reveled Resident #29 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/15/18. revealed the facility assessed Resident 329's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of Resident #29's (MONTH) 2019 physician's orders [REDACTED]. five (2.5) liters per minute per nasal cannula to keep 02 saturation (sats) at 90 percent. Further review of the order revealed to also check 02 sats on room air every week, check 02 sats every shift, and change tubing every five (5) days. Review of Resident #29's Comprehensive Care Plans dated 11/27/18 revealed there was no care plan to address the resident's goals and interventions related to the use of 02. Interview with the Director of Nursing on 01/24/19 at 5:03 PM revealed her expectation was, as stated before, to follow the RAI guidelines for the use and the administration of 02 therapy.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were treated with respect and dignity in a manner that promoted maintenance or enhancement of his/her quality of life for one (1) resident not in the selected sample of sixteen (16) residents (Unsampled Resident #40). Observations on 01/22/19 revealed Certified Nurse Aide (CNA) #1 was observed standing over Unsampled Resident #40, while assisting the resident with his/her lunch. The findings include: Interview with the Director of Nursing (DON) on 01/24/19 at 4:46 PM, revealed the facility did not have a specific policy related to feeding residents. She stated the facility followed State and Federal regulations related to resident rights. Record review revealed the facility readmitted Unsampled Resident #40 on 01/11/18, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 01/10/19, revealed the facility failed to assess Resident #40's cognition. Observation on 01/22/19 at 12:29 PM, revealed CNA #1 standing over Unsampled Resident #40 assisting him/her with lunch as Resident #40 sat up in bed. Interview with CNA #1 on 01/24/19 at 10:15 AM, revealed she normally fed Unsampled Resident #40 while standing. She stated she should have been seated at eye level with the resident. Interview with the Director of Nursing (DON) on 01/24/19 at 4:46 PM, revealed she expected staff to honor resident's rights while providing care. She stated she felt it would be best practice if staff sat while feeding residents.

Based on interview, record review, review of the facility's policy/procedure, and hospital record reviews, it was determined the facility failed to ensure the physician received, was aware and responded to a notification of a resident's significant change in status for one resident (#1), in the selected sample of three residents. The facility failed to follow their "Notification of Resident Change in Condition" policy. On 01/26/12 the facility received a laboratory (lab) result regarding renal function for Resident #1. The lab value was a test for Blood, Urea, Nitrogen (BUN) of 119 (normal value 7-18 mg/dl) and Creatinine level of 3.6 (normal value 0.8-1.4 mg/dl), both values were critically elevated. While the facility notified the physician regarding multiple lab results on 01/26/12, the facility failed to ensure the attending physician was aware of the elevated BUN and Creatinine levels and failed to ensure the physician responded to those critical labs, per the facility's "Notification of Resident Change in Condition" policy. On 02/07/12, the facility transferred Resident #1 to the local hospital having symptoms of nausea and vomiting. The hospital admitted the resident with nausea, vomiting, blood in his/her urine and having a BUN of 166 and a resulting [DIAGNOSES REDACTED]. The findings include: A review of the facility's policy and procedure, "Notification of Resident Change in Condition," last revised August 2009, revealed the Licensed Nurse will immediately inform the resident's physician in the event of a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life-threatening conditions or complication.) Clinical complications are such things as [MEDICAL CONDITION] and/or onset of depression. A significant change in a life threatening situation, i.e., [MEDICAL CONDITION] or stroke, etc, emergency services will be contacted for immediate transport. For a significant change that does not require immediate medical intervention, the physician will be notified immediately and the facility would expect a response in one hour. If no response was received, in one hour, the facility was to make another attempt to contact the physician and if no response was received, in one hour, the facility would contact the Medical Director. The facility would expect a response from the Medical Director within 30 minutes. If no response was received, the facility would contact emergency services. In a non-significant change in condition that does not require immediate physician interventions, the Licensed Nurse would have placed one initial notification call to the attending physician. The date and time of the call would be documented on the 24 hour report sheet daily. Logged calls, identified as not having a physician's response, would result in the Licensed Nurse placing a second call to the attending physician. If no response was received from the attending physician by the end of business day, the Medical Director would be notified. A review of multiple laboratory values obtained at the hospital, dated from 12/08/11 through 12/15/11, prior to the resident's admission to the nursing facility, revealed the resident's BUN measured between 15-28 mg/dl (normal value 7-18 mg/dl), and the Creatinine level measured between 1.3-1.6 mg/dl (normal value 0.8-1.4 mg/dl). A record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) A review of the "Nutritional Risk" care plan, dated 12/21/11, revealed the resident was on diuretic therapy detailing the resident was receiving the medication [MEDICATION NAME], with a goal for the resident to be free of dehydration. Interventions included monitoring for signs and symptoms of dehydration and "monitor labs, (as needed)." A review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as moderately cognitively impaired and required the extensive assistance of two staff members with bed mobility, transfers, dressing, hygiene and bathing and the extensive assistance of one staff member for eating. A review of the laboratory (lab) values, dated 01/26/12, revealed the resident's BUN level was "High," with a result of 119 milligrams per deciliter (mg/dl), and the Creatinine level was "High," with a result of 3.6 mg/dl. A review of the nursing notes, dated 01/26/12 at 12:00 PM, revealed the laboratory results were received and the physician was "aware, awaiting orders." Record review revealed on 01/27/12 physician orders [REDACTED]. There was no documented evidence after 01/26/12 that the facility made any further attempts to have the physician address the critical lab values related to the BUN/Creatinine. An interview with Certified Nurse Aide (CNA) #1, on 02/21/12 at 10:30 AM, revealed the resident experienced nausea and vomited a moderate amount of "watery, yellow" emesis and had blood in his/her urine on 02/07/12 at approximately 12:00 PM. A review of a nursing note, dated 02/07/12 at 11:45 AM and 12:45 PM, revealed the resident received [MEDICATION NAME] 0.5 mg by mouth for shaking and anxiety. At 3:45 PM, the facility notified the physician regarding blood in the resident's urine. The physician ordered the resident be sent to the hospital for evaluation and treatment. The facility transferred the resident to the hospital at approximately 4:00 PM. A review of the initial emergency room visit, dated 02/07/12, and resulting laboratory tests revealed a BUN of 166 and a Creatinine value of 5.7. The resident was admitted to the hospital and treated for [REDACTED]. An interview with the Director of Nursing (DON,) on 02/21/12 at 12:25 PM, revealed the physician "was made aware" of the elevated BUN and Creatinine levels on 01/26/12 at 12:00 PM. The physician responded on 01/27/12 at 5:30 PM with orders for the treatment of [REDACTED]. The DON stated the licensed nurse should have been aware that the physician addressed the UTI, but not the BUN/Creatinine levels, and the physician should have been notified immediately. The elevated labs should have been placed on the 24-hour report as well as the lab tracking sheet and should have been monitored closely. An interview with Physician #1, on 02/21/12 at 2:03 PM and 5:03 PM, revealed "a BUN of 119 would have been a panic value" and the physician stated he was not made aware of the resident's results. When reviewing the U/A, he did not review the accompanying BUN/Creatinine values and "just missed it," stating the back-up system of calls from the hospital and the facility would usually have helped keep this from happening, but there were no calls to follow-up on the labs. The physician stated if he had been made aware of the "panic levels" of the BUN/Creatinine he "would have (ordered the resident be) sent out to the hospital and admitted ." He further revealed the elevated BUN would cause the nausea and vomiting.