Every finding on record at Mt. Sterling Health & Rehab, LLC

Based on interview, record review, review of the facility's admission Packet, and review of the facility's policy, the facility failed to ensure residents were provided the right to formulate an advance directive for 12 of 19 sampled residents, Resident (R) 1, R2, R4, R6, R8, R10, R22, R37, R38, R54, R56, and R60. Seven residents had a Health Care Decision Making form on file, with six indicating they had advance directives. However, review of the documentation did not meet the requirements for advance directives. The findings include:Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, not dated, revealed the facility would support and facilitate a resident's right to formulate an advance directive. The policy stated if requested, the facility would provide the resident or resident's representative information about the right to formulate an advance directive, and if a resident had an advance directive on admission, copies would be placed in the chart.Review of the facility's admission Packet revealed a form, Health Care Decision Making, that asked if residents had an advance directive, and if so, asked what documentation it consist of, with possibilities being a living will, a health care surrogate, durable power of attorney for health care, court appointed guardian for person, court appointed guardian for property, or other. There was also a question at the end asking if residents wanted to proceed further with Social Services (SS). In the body of the form, it stated facility staff would not act as a witness to signing any forms or documents concerning health care decision making and would not notarize such documents. 1. Review of R1's admission Record revealed the facility admitted the resident on 08/05/2021 with diagnoses to include congestive heart failure (CHF), hypertensive heart disease with heart failure, and dependence on supplemental oxygen. R1's responsible party completed a Health Care Decision Making form on 08/09/2021 indicating R1 did not have an advance directive. However, R1's document does not answer the question of whether or not the resident wanted to proceed further with SS.2. Review of R2's admission Record revealed the facility admitted the resident on 10/20/2022 with diagnoses to include demyelinating disease of central nervous system, posterior reversible encephalopathy syndrome, and acute and chronic respiratory failure. No Health Care Decision Making form was on file. Further review revealed guardianship documentation on file. However, that documentation did not delineate responsibility for health care decision making. 3. Review of R4's admission Record revealed the facility admitted the resident on 09/29/2025 with diagnoses to include chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and stage 4 chronic kidney disease. Further review revealed a Health Care Decision Making form completed by R4's responsible party on 09/30/2025 that indicated the resident had an advance directive, specifically a durable power of attorney for healthcare. However, review of the document revealed a general power of attorney on file, which did not address health care decision making.4. Review of R6's admission Record revealed the facility admitted the resident on 03/25/2025 with diagnoses to include COPD, hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left dominant side, and chronic respiratory failure. A Health Care Decision Making form completed by R6's responsible party on 03/25/2025 indicated the resident had an advance directive and did not want to proceed further with SS. However, review of R6's document revealed a general power of attorney on file which did not address health care decision making. 5. Review of R8's admission Record revealed the facility admitted the resident on 05/08/2024 with diagnoses to include atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive heart disease with heart failure, and acute kidney failure unspecified. A Health Care Decision Making form completed on 05/09/2024 indicated R8 had an advance directive, a durable power of attorney for health care, and did not want to proceed further with SS. However, review of the document revealed only a general power of attorney on file which did not address health care decision making. 6. Review of R10's admission Record revealed the facility admitted the resident on 06/11/2025 with diagnoses to include acute respiratory failure with hypoxia, COPD, and acute kidney failure unspecified. A Health Care Decision Making form completed on 01/09/2024 indicated the resident had an advance directive, a durable power of attorney for health care, and did not want to proceed further with SS. However, no further documentation was on file. 7. Review of R22's admission Record revealed the facility admitted the resident on 01/09/2024 with diagnoses to include heart failure unspecified, hypertensive heart disease with heart failure, and unspecified atrial fibrillation. There was no Health Care Decision Making form, and a general power of attorney was on file which did not address health care decision making. 8. Review of R37's admission Record revealed the facility admitted the resident on 12/11/2025 with diagnoses to include metabolic encephalopathy, acute respiratory failure with hypoxia, and repeated falls. A Health Care Decision Making form dated 12/11/2025 indicated the resident had an advance directive, specifically a durable power of attorney for health care, and did not want to proceed further with SS. However, continued review revealed only a general power of attorney on file which did not address health care decision making. 9. Review of R38's admission Record revealed the facility admitted the resident on 06/20/2022 with diagnoses to include metabolic encephalopathy, COPD, and end stage renal disease. No Health Care Decision Making form was on file, nor any advance directive. 10. Review of R54's admission Record revealed the facility admitted the resident on 01/15/2025 with diagnoses to include cerebral infarction unspecified, dysphagia following cerebral infarction, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. No Health Care Decision Making form was on file, nor any advance directive. 11. Review of R56's admission Record revealed the facility admitted the resident on 03/25/2025 with diagnoses to include metabolic encephalopathy, quadriplegia unspecified, and chronic combined systolic and diastolic heart failure. No Health Care Decision Making form was on file. An order for emergency guardianship was on file; however, this did not address advance directives. 12. Review of R60's admission Record revealed the facility admitted the resident on 04/05/2024 with diagnoses to include unspecified atrial fibrillation, expressive language disorder, and essential (primary) hypertension. A Health Care Decision Making form dated 04/05/2024 indicated the resident had an advance directive and did not want to proceed further with SS. However, there was only a general power of attorney on file which did not address health care decision making. During an interview with the Admissions Coordinator (AC) on 03/05/2026 at 2:20 PM, she stated she had been in that position for five years and had limited training with the prior AC. She stated she reviewed with residents and/or resident representatives on admission the Health Care Decision Making form that asked if they had an advance directive. She stated an advance directive was a choice that a resident made regarding whether or not they wanted any lifesaving or life prolonging care, and was usually a living will, a health care surrogate, or a power of attorney for health care. The AC stated when she went over the admission packet, she asked if residents had advance directives, and if they say no, she asked if they would be interested and documented that on the question and whether they wanted to proceed further with SS. She stated if they had an advance directive, she asked for a copy, and followed up with residents and families in order to get a copy. She stated no one had ever expressed an interest in following up with SS regarding advance directives, but if they did she would pass that on to the social worker. The AC stated it was important for the facility to have advance directive paperwork in case something was to happen, so the facility would know what a resident wished and staff was able to follow those wishes, which would be especially important for residents with no power-of-attorney (POA). During an interview on 03/05/2026 at 4:01 PM with the Social Services Director (SSD), she stated she had been in her position almost 10 years, and no resident or the resident's representative had expressed an interest in an advance directive. She stated if anyone did, she would provide them with information on living wills. After review of some of the residents identified as having an advance directive in medical records but not having appropriate paperwork on file or having non-appropriate paperwork, she stated it looked like residents or families were not educated on the purpose and elements of an advance directive. She stated resident wishes regarding code status and advance directives were discussed during the quarterly care plan meetings. During an interview with the Director of Nursing (DON) on 03/06/2026 at 12:17 PM, she stated she expected everyone's advance directives to be followed, and if at any time a resident wanted to talk about advance directives or change them, the facility got the appropriate people to assist them. She stated her expectation when residents were admitted was that staff discussed the differences in each level of resuscitation, and what they expected of the facility's staff and what the facility's expected of them. She stated, if there was confusion about what an advance directive was, staff should discuss that with them. During an interview with the Administrator on 03/06/2026 at 11:36 AM, he stated when a resident was admitted , advance directives were discussed with the resident or the resident's representative. He stated, if a resident had an advance directive, the facility's staff asked for a copy. He stated, if a resident did not have an advance directive and was interested, the facility's staff offered them assistance. He stated the facility's social worker had resources to help facilitate obtaining an advance directive. He stated resident wishes for code status as well as advance directives were reviewed quarterly at their care plan meeting. He stated when discrepancies were brought up between what was documented on the Health Care Decision Making form and what was actually on file, he thought there might be some confusion on what constituted an advance directive. He stated, if the resident's representative or family brought in what they thought was an advance directive but it was not, the expectation was that SS would work with them to explore how they would like to proceed. He stated advance directives were important so that the facility followed the wishes of residents.

Based on observation, interview, and review of the facility's policies, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles and include the appropriate expiration date when applicable for 3 out of 8 medications carts, the Wisteria Unit medication cart 1 and medication cart 2 and the Lakeview Unit medication cart 1.Observations on [DATE] revealed three expired and/or undated eye drops in the Wisteria Unit's medication cart 1; seven expired and/or undated eye drops in the Wisteria Unit's medication cart 2; and one expired eye drop in the Lakeview Unit's medication cart 1.The findings include:Review of policy titled Storage of Medication Requiring Refrigeration not dated, revealed The facility will ensure that all drugs and biologicals used will be labeled in accordance with professional standards, including expiration dates (when applicable) and with appropriate accessary and precautionary instructions (such as shake well, take with meals, do not crush, special storage instructions).Review of policy titled Medication Storage not dated, revealed Unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.Observation on [DATE] at 8:46 AM of the Wisteria Unit's medication cart 1 revealed one bottle of Systane (an eye lubricant) eye drops for Resident (R) 7 was opened and dated [DATE]; one bottle of Lumigan (generic bimatoprost, a prescription medication used to lower high eye pressure) eye drops for R105 was opened and dated [DATE]; and one bottle of Refresh (an eye lubricant) eye drops for R105 was opened and not dated. Observation on [DATE] at 8:55 AM of the Wisteria Unit's medication cart two revealed one bottle gentamycin (an antibiotic) prescription eye drops for R86 was opened and dated [DATE]; one bottle of Systane eye drops for R86 was opened and not dated; one bottle of Systane eye drops for R125 was opened and dated [DATE]; one bottle of polyvinyl alcohol (an eye lubricant) eye drops for R114 was opened and dated [DATE]; one bottle of bimatoprost eye drops for R130 was opened and not dated; one bottle of tobramycin (an antibiotic) prescription eye drops for R60 was opened and dated [DATE]; one bottle of tobramycin eye drops for R60 was opened and dated [DATE]; and one tube of erythromycin (an antibiotic) prescription eye ointment for R60 was opened and not dated. Observation on [DATE] at 9:16 AM of the Lakeview Unit's medication cart 1 revealed one bottle of brimonidine (used to lower high eye pressure eye drops for R14 was opened and dated [DATE]. During an interview on [DATE] at 9:00 AM with Kentucky Medication Aide (KMA) 2, she stated her process was to date and initial medications when they are opened. She stated she looked for the date to ensure it was not expired so she knew when to dispose of the medications. She stated she was not sure when the eye drops were to be discarded and would find out. She then returned and stated the Director of Nursing (DON) told her she thought 30 days from opening. She stated she had not worked the Wisteria Unit recently and had not had to access or administer any drops this shift. During an interview on [DATE] at 2:59 PM with the Pharmacy Consultant, she stated eye drops should be dated when they were opened, and most were to be discarded 28 to 30 days after opening. She stated she did not have a list of eye drops and when to discard them. During an interview on [DATE] at 10:04 AM with the Assistant Director of Nursing (ADON), she stated eye drops should be dated when they were opened, and they were usually good for about a month. She stated it was her expectation that all dates were being checked prior to administration by the nurses and KMAs. She stated she would expect them to notify pharmacy if needed for clarification. She stated if mediations were not dated or dated prior to 30 days, then the medication should be discarded and reordered if the resident still needed it. She stated if a medication was expired then it might not be as potent or work correctly which could worsen a resident's condition. During an interview on [DATE] at 9:17 AM with the DON, she stated she believed eye drops were to be discarded after 30 days, but she would call the pharmacy to confirm and get back to me. During an additional interview with the DON on [DATE] at 11:28 AM, she stated she called their pharmacy consultant who stated all eye drops should be discarded after 30 days of opening date unless the expiration date was extended by the manufacturer. During an additional interview with the DON on [DATE] at 12:19 PM, she stated eye drops should be dated correctly so the staff knew they were still effective. She stated the nurses and KMAs on the floor should be checking for dates daily, if not weekly, and always prior to administering medications. During an interview on [DATE] at 11:26 AM with the Administrator, he stated it was his expectation that medications were stored according to policy and discarded appropriately to achieve positive outcomes for the residents.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices for 6 out of 10 sampled residents, Resident (R) 11, R18, R38, R113, R122, and R133, who were cared for by staff who had not performed the required hand hygiene. The findings include:Review of the Centers for Disease Control and Prevention (CDC) guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care was completed. According to the guidelines, staff should ensure the proper selection and use of PPE based on the nature of the patient interaction and potential for exposure to blood, body fluids, and/or infectious materials. Review of the facility's policy, Infection Prevention and Control Program, revised 05/2025, revealed the purpose of the policy was to ensure the facility provided a safe and comfortable environment to prevent infections, according to accepted national standards and guidelines. According to the policy, hand hygiene was a component of standard precautions and was required to prevent the transmission of infectious organisms during the provision of resident care. The policy stated staff was to use personal protective equipment (PPE) according to facility policy. Additionally, the policy stated staff received infection control education and training related to their job duties.1 a. Observation on 03/04/2026 at 9:30 AM revealed Nurse Aide State Registered ([NAME]) 5 exited room [ROOM NUMBER] wearing gloves and holding a plastic trash bag containing soiled briefs. NASR5 opened the laundry cart and disposed of the bag inside. He then removed his contaminated gloves and did not perform hand hygiene before he donned a new pair of gloves and entered R113's room. NASR5 was subsequently observed exiting the resident's room and again did not perform hand hygiene. He removed his gloves, donned a new pair of gloves and entered R122's room.b. Observation on 03/04/2026 at 11:50 AM revealed NASR5 exited R11's room after transferring the resident with a mechanical lift into his Broda (as specialized wheelchair) chair. NASR5 was observed wearing gloves as he exited the room. During an interview with NASR5 on 03/03/2026 at 11:58 AM, he stated PPE should be removed inside the resident's room and hand hygiene should be performed prior to exiting to prevent the spread of the infection between residents. NASR5 further stated he could not explain why he failed to remove his gloves inside the resident's room or perform hand hygiene after providing resident care, before and after donning and doffing (putting on and taking off) PPE, and before entering another resident's room to provide care during his rounds. The [NAME] stated he had received education and training on hand hygiene and PPE use.2. Observation on 03/04/2026 at 9:40 AM revealed NASR1 passing ice and water to residents. NASR1 filled a cup obtained from R38's room by holding it over the open ice chest. She placed the scoop inside the chest, entered R38's room, and placed the cup on the resident's bedside table. NASR1 exited the room and did not perform hand hygiene. She entered R18's and R133's room. Again, she filled both cups while holding them over the ice. The scoop was placed on top of the ice. NASR1 delivered R18 and R133 their ice cups. She exited the room, did not perform hand hygiene, and proceeded to the next resident's room.During an interview with NASR1 on 03/04/2026 at 9:40 AM, when asked by the State Survey Agency (SSA) Surveyor why it was important to place the ice scoop in its holder and not back on top of the ice, she stated, I didn't put it on the ice. However, when the SSA Surveyor asked NASR1 to open the ice chest, the scoop was observed resting directly on top of the ice. NASR1 further stated she performed hand hygiene between residents while passing ice. The [NAME] was unable to explain the importance of performing hand hygiene between resident contacts or the need to store the scoop in the designated holder. Furthermore, after the question was asked, the nurse aide did not respond to the question and ended the interview. During an interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) on 03/06/2026 at 9:39 AM, she stated staff should perform hand hygiene when entering and exiting resident rooms and before and after providing resident care. She stated hand hygiene should also be performed after removing gloves, and gloves were not a substitute for proper hand hygiene. The ADON/IP further stated staff should use PPE equipment when indicated and remove the equipment prior to leaving the resident's room. Additionally, she stated proper handling of ice was important to prevent contamination. She stated the ice scoop should not be stored inside the ice container and cups should not be filled while held directly over the ice bin. She stated these practices were necessary to prevent contamination of the ice supply and reduce the risk of spreading germs that could impact the residents' health and safety. The ADON/IP stated it was her expectation for staff to follow all infection control policies. She stated it was important to prevent the spread of microorganisms between the residents staff, and the environment and helped to protect the health and safety of the residents.During an interview with the Director of Nursing (DON) on 03/06/2026 at 12:08 PM, she stated it was her expectation that staff followed infection control policies and procedures when providing resident care. She stated staff was expected to perform hand hygiene before and after resident contact and after removing gloves. She further stated PPE should be worn when indicated and removed prior to leaving the residents' rooms. The DON stated staff should not wear contaminated gloves in the hallway, and the wearing of gloves did not replace the need for hand hygiene. Additionally, the DON stated staff should maintain sanitary practices when passing ice. She stated the ice scoop should be stored in the designated holder and not placed inside the ice bin. She further stated cups should not be held over the ice container while being filled. She stated following those practices were necessary to prevent contamination of the ice supply and reduce the potential spread of germs to residents. Furthermore, the DON stated it was her expectation that staff followed infection control policies and procedures when providing resident care. She stated following infection control practices was important to prevent the spread of infection and protect the health and safety of residents and staff.During an interview with the Administrator on 03/06/2026 at 11:27 AM, he stated it was his expectation that nursing staff followed the facility's infection control policies and procedures when providing resident care. He stated following CDC guidelines and the facility's policies helped reduce the risk of infection transmission.During a telephone interview with the Medical Director on 03/06/2026 at 12:53 PM, she stated it was her expectation that staff followed the facility's infection control policies and adhered to CDC guidelines when providing care for residents. She stated following these practices, including proper hand hygiene and use of personal protective equipment, was important to prevent the spread of infection and protect the health and safety of the residents.

Based on observation, interview, record review, review of the facility's job description, and review of the facility's policies, the facility failed to provide adequate supervision and an environment free of accident and hazards for 3 of 5 sampled residents, Resident (R) 10, R82, and R60. Review of R82's electronic medical record (EMR) revealed on 05/19/2025 R82 was left unsupervised in the bathroom and fell. Review of R10's EMR revealed on 09/15/2025 R10 was sitting in a chair in the television area and fell while attempting to self-transfer. The resident sustained a fractured nose, abrasion to the right eyebrow, and complained of pain in the right shoulder.Observation on 03/03/2026 of R60 revealed a medication cup containing crushed medication mixed in pudding, with a spoon inside, was left on the bedside table in front of R60, who was awake and sitting in her wheelchair.The findings include:Review of the facility's policy titled, Fall Prevention Program, undated, revealed each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risks to minimize the likelihood of falls. The policy listed the definition of fall as an unintentional change of position. Further review revealed the facility utilized a standardized risk assessment to determine fall risk, and the nurse would refer to high, or low/moderate risk when determining primary interventions. Per the policy, if a resident was identified as high risk, the resident would be placed on the Fall Prevention Program, which identified the risk on the care plan, and an indicator of the high fall risk (a star or colored sticker) would be placed on the resident's name plate and wheelchair. Further review revealed when a resident fell, the facility would assess, complete the post fall assessment, and complete an incident report. Further review revealed the facility should notify the physician and family, review the care plan and update as indicated, document all assessments/actions, and obtain witness statements in case of injury.Review of the facility's policy titled, Conducting Internal Incident/Accident Investigations, undated, revealed the policy was to establish procedures to conduct investigations of internal incidents and accidents. Per the policy, the procedure was to include in the investigation, the root cause analysis, which included care plan interventions and corrective action. Further review revealed there would be a Quality Improvement Review with a review of the Quality Assurance and Performance Improvement (QAPI) process to identify trends and opportunities for improvement.Review of the facility's policy titled, Safe Resident Handling/Transfers, undated, revealed all residents required safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. Furthermore, the policy stated staff would perform resident transfers, in accordance with the minimum degree of assistance indicated on the care plan. The provision of more assistance than specified is the only permissible deviation from the resident care plan pertaining to transfer practice. Review of the facility's undated policy titled, Accidents and Supervision, revealed the facility was responsible for maintaining an environment as free of accident hazards as possible and providing adequate supervision to prevent accidents. The policy further indicated staff was responsible for observing and identifying potential hazards.1. Review of the admission Record, found in R82's electronic medical record (EMR), revealed the facility admitted the resident on 10/22/2024 with diagnoses of other intervertebral disc degeneration lumbar region with discogenic back pain only, extrapyramidal and movement disorder unspecified, and cardiomegaly. Review of the quarterly Minimum Data Set [MDS], found in R82's EMR and with an Assessment Reference Date (ARD) of 12/9/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15, indicating the resident was cognitively intact. Review of the Comprehensive Care Plan [CCP], found in R82's EMR and dated 12/06/2024, revealed the resident was dependent on two staff members to move between surfaces and as necessary. It also stated the resident was to be supervised when toileting. Review of the facility provided job description titled, Certified Nursing Assistant, dated 2023, revealed major duties and responsibilities were assisting residents with or performing activities of daily living for the residents in accordance with care plans and established policies and procedures and assisting nursing staff in carrying out toileting program activities. Review of the Morse Fall Scale evaluation done before the fall, dated 04/15/2025, revealed R82 scored 75.0, indicating she was at high risk for falling.Review of the Morse Fall Scale evaluation done after the fall on 05/19/2025 and dated 05/19/2025, revealed R82 scored 80.0, indicating she was at high risk for falling. During an interview with Nurse Aide State Registered ([NAME]) 7 on 03/05/2026 at 3:48 PM, she stated she transferred R82 to the bathroom commode by herself on 05/19/2025. She stated she was told the resident was a one-person assist. She stated she placed R82 on the bathroom commode, told the resident to pull the call light when she was done using the restroom, and then proceeded to leave the resident on the bathroom commode as she went to the nurse's station to tell a co-worker something. She stated she was gone for only two minutes, and when she returned to the bathroom, R82 was on the floor beside the commode in the bathroom. She stated R82 stated, I guess I thought I could do it by myself, but I guess not. During an interview with the MDS Coordinator on 03/05/2026 at 10:07 AM, she stated R82 was now a two-person assist but she was unsure of the date that became effective. She stated the night of the fall, on 05/19/2025, she was the Unit Nurse that evening. She stated she re-educated staff about R82 being a two-person assist due to weakness in her legs. During an interview with the Director of Nursing (DON) on 03/05/2026 at 3:58 PM, she stated R82 required two staff members to assist her due to false accusation she made against staff members. She stated through fall incident reports she had been informed of two reports of one aide transferring the resident. She stated currently all staff was fully aware the resident was a two-person assist with transfers. 2. Review of the admission Record, found in R10's EMR, revealed the facility admitted the resident on 06/11/2025 with diagnoses to include acute respiratory failure, dementia, and anxiety.Review of the quarterly MDS, found in R10's EMR and with an ARD of 01/22/2026, revealed the facility assessed the resident to have a BIMS score of seven out of 15, which indicated the resident was severely cognitively impaired. Review of R10's Morse Fall Scale, dated 09/14/2025 (prior to fall) and 09/16/2025 (post fall) revealed both scored 55, indicating a high risk for falling.Review of R10's CCP, with an initiation date of 06/11/2025, identified R10 as a risk for falls related to gait and balance and a revision date of 06/18/2025 with the goal of being free of minor injuries. Further review of the CCP revealed interventions of assistance to toilet and to bed and bed in low position, with the date initiated on 09/16/2025. Further review revealed no interventions were added for supervision while in the common area or up in a chair. Additional review of the CCP revealed R10 had a focus of Activities of Daily Living (ADL) deficit with initiation date of 06/11/2025 and the goal of improvement of function for transfers to bed and chair. Further review revealed interventions were initiated on 06/11/2025 for two staff to move resident between surfaces with a revision date of 06/22/2025. No updates were located for after the fall on 09/15/2025. Further review revealed a focus of R10 as having impaired cognition and impaired thought processes with the goal of being able to communicate basic needs on a daily basis. Interventions included to cue, to reorient, and to supervise the resident as needed with initiation date of 09/11/2025. However, the CCP was not updated after the fall on 09/15/2025.Review of the facility's document Unwitnessed Fall, dated 09/15/2025 at 8:20 PM, revealed a nurse heard the resident (R10) yelling for help, and upon observation, the nurse found R10 face down in front of a chair in the common area. Injuries documented included a moderate amount of bleeding from the nose, a new laceration over the right eyebrow, and the nose swollen and bruised. Further review revealed R10 had right shoulder pain, and vital signs were obtained. The document stated the resident's predisposing factors included gait imbalance, incontinence, confusion, and impaired memory. Also, the document stated the predisposing situation factors included transferring without assistance and improper footwear.Review of the facility's document Fall Investigation, dated 09/15/2025 at 8:20 PM, revealed R10 had an unwitnessed fall from a Broda chair while in the common area and sustained a closed fracture to the nose with abrasion and bruising to the face and was transferred to the emergency room. Further review revealed the Quality Assurance Performance Improvement (QAPI) Root Cause Analysis determined R10 was getting up without assistance due to confusion from short- and long-term memory loss with weakness and limited mobility. Further review revealed the action plan included more frequent hourly checks and resident up in chair at the nurses' area when awake. The document stated the care plan was updated on 09/16/2025 when R10 returned from the hospital with the intervention of to offer to assist to toilet and to bed. However, the care plan was not updated with more frequent hourly checks.Review of R10's Progress Note, dated 09/15/2025 at 9:23 PM and written by Licensed Practical Nurse (LPN) 10, revealed she heard R10 yelling for help, and upon observation, she found R10 face down in front of her chair in the TV area. The note stated the resident's nose was swollen and bleeding, there was a new skin abrasion over the right eyebrow, and R10 complained of increased pain to right shoulder. Review of R10's Progress Note, dated 09/16/2025 at 1:40 AM and written by LPN10, revealed R10 returned from the hospital with a diagnosed closed fracture of the nasal bone. Observation on 03/03/2026 at 10:00 AM revealed R10 in bed. An attempt was made to interview the resident, but she was not interviewable. The bed was in low position, and the call light was within reach. During an interview with Nurse Aide State Registered ([NAME]) 10 at 11:20 AM on 03/05/2026, she stated the facility did have a lot of falls but there had not been an increase in falls. She stated she was not familiar with R10.During an interview with NASR12 at 8:23 AM on 03/05/2026, she stated her [NAME] tasks included meeting the care needs of residents. She stated she had received training for fall prevention. When asked if a resident was a fall risk how would she know, she stated staff normally had it on the Group/Assignment sheet, and the on-coming staff did walking rounds with the off-going staff. She stated she looked at the care plan sometimes but not always.During an interview with LPN4 on 03/05/2026 at 11:10 AM, she stated the facility did have more falls than they should, but she could not pinpoint a specific reason. She stated she did not recall R10 sustaining a fall, but she was not familiar with the resident. She stated she had received fall prevention training and in services. During an interview with LPN10 (nurse providing care for R10 the date of the incident) on 03/06/2026 at 11:11 AM, she stated she had picked up an extra shift and was in the middle of administering medications down the hallway. She stated she heard R10 yell, and when she got there, R10 was face down and bleeding from the nose. She stated she contacted the provider and the family, and the resident was sent to the local emergency room (ER). When asked if she had any training for assessing a resident for risk of falls, she stated, I don't think so. She stated she did receive training after the incident from the Director of Nursing (DON) because the DON at that time was the Staff Development Coordinator (SDC). When asked if R10 had experienced other falls, she stated she did not think so. In an interview with the Minimum Data Set (MDS) Coordinator on 03/06/2026 at 10:26 AM, she stated one of her tasks included to view the progress notes and orders to identify anything new and to place that information on the care plan. She stated she usually would view every 48 hours to assure interventions were placed. She stated a care plan guided the care of a resident, and that was why it was so important.During an interview with the Director of Nursing (DON) on 03/06/2026 at 12:08 PM, she stated she had been DON for about three weeks and was Staff Development Coordinator (SDC) at the time of R10's fall. She stated she was not that familiar with the event. She stated it was her expectation that staff looked at care plans each and every day, so they knew how to provide the correct care to residents. She stated if they were not doing that, they might not be the safest person to be providing care to residents. She stated that it would be a concern not only for R10 but for all the residents. During an interview with the Administrator on 03/06/2026 at 11:26 AM, he stated his tasks included providing oversight of the facility. When asked if that included the clinical side of the operation, he stated yes. He stated all the department heads were present in the daily stand-up meetings to identify and discuss concerns. When asked if resident falls was a topic discussed he stated yes. He stated the process was for nurses to follow up with newly identified problems from the fall and place new interventions to the care plan to help prevent another fall. He stated a care plan's purpose was so staff would know what care to provide to keep residents safe and have a positive outcome. The Administrator stated falls had been discussed in the quality improvement meetings, and there had been improvements. He stated his expectations were for all staff to follow the facility's policies and procedures.Review of the facility's undated policy titled, Medication Storage, revealed medications were required to remain under the direct observation of the staff member administering them during medication administration or be secured in the medication cart or designated medication storage area.Review of the facility's undated policy titled, Medication Administration, revealed medications must be administered in accordance with physician orders, and staff must observe a resident's consumption of the medication.3. Review of the admission Record found in R60's EMR, revealed the facility admitted the resident on 04/05/2024 with diagnoses to include unspecified atrial fibrillation, expressive language disorder, and gout.Review of the quarterly MDS, found in R60's EMR and with an ARD of 04/05/2024, revealed the facility assessed the resident to have a BIMS score of six out of 15, indicating the resident had severe cognitive impairment. Review of the Comprehensive Care Plan [CCP], dated 02/09/2026, found in R60's EMR, revealed the resident was not assessed to self-administer her medications. Review of the Medication Administration Record [MAR], dated 03/2026, found in R60's EMR, revealed the resident was scheduled to receive the following medications during the 9:00 AM medication administration and were documented as given at 9:00 AM by Kentucky Medication Aide (KMA) 3: amlodipine besylate tablet 2.5 milligrams (mg), give one tablet by mouth one time a day for hypertension; aspirin oral capsule 81 mg, give one tablet by mouth one time a day related to atrial fibrillation; cholecalciferol tablet 1000 units (u), give two tablets by mouth one time a day for vitamin D deficiency; docusate sodium oral tablet 100 mg, give one tablet by mouth one time a day for constipation; methenamine hippurate oral tablet 1 gram (g), give one tablet by mouth one time a day for urinary tract infection prevention; metoprolol tartrate oral tablet 25 mg, give one tablet by mouth one time a day related to atrial fibrillation; and acetaminophen oral tablet 500 mg, give two tablets by mouth three times a day for chronic pain.Observation of R60 on 03/03/2026 at 9:45 AM revealed she was seated in her wheelchair in front of her bedside table. She was holding a baby doll in her lap. There was a medication cup containing multiple crushed medications mixed in pudding, with a spoon inside the cup, left unattended on the bedside table in front of R60. The resident was unable to be interviewed due to impaired cognition.During an interview with KMA3 on 03/03/2026 at 9:49 AM, she stated the medication cup was from last night. She stated she did not remove it when she entered the room earlier to administer morning medications to R60 because she wasn't thinking. KMA3 quickly disposed of the cup, and as she did, she retrieved an empty medication cup from the trash. She stated this was the cup she used to administer R60's morning medication. The cup did not contain any pudding or pill residue. KMA3 stated it was important to remove medications after administration for resident safety and to prevent another resident from accessing or ingesting the medication. During an interview with Licensed Practical Nurse (LPN) 5 on 03/03/2026 at 9:55 AM, she stated she had not been in R60's room that morning and did not observe the medication cup on the bedside table because she had not completed her rounding on all her residents. LPN5 stated medications should be removed and disposed of to prevent accidental ingestion by another resident. She stated R60 could not self-administer her medications. She stated it was important to stay with R60 to ensure the resident received all her ordered medications.During an interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) on 03/06/2026 at 9:39 AM, she stated medications should not be left at the bedside due to the risk of residents or others taking medications incorrectly or failing to take prescribed medications. The ADON/IP stated if medications were observed unattended, staff should address the issue immediately.During continued interview with the DON on 03/06/2026 at 12:08 PM, she stated medications should not be left unattended at the resident's bedside. She stated if she observed a medication cup with pills at the bedside, she would immediately investigate the situation by speaking with the nurse or KMA involved. She stated medications should never be left unattended because another resident could take the medications or the intended resident might not take the medications creating a safety risk. Additionally, she stated leaving medications unattended at the bedside could result in the resident not receiving the medications as ordered. The DON stated it was her expectation that nursing staff administered medications as ordered and ensured unused medications would be disposed of to maintain resident safety.During an interview with the Administrator on 03/06/2026 at 11:27 AM, he stated medications should not be left unattended at the resident's bedside due to the potential risk of accidental ingestion or misuse. He stated it was his expectation that nursing staff administered medications as ordered and ensured unused medications would be disposed of to maintain resident safety.During a telephone interview with the Medical Director on 03/06/2026 at 12:53 PM, she stated it was her expectation that licensed clinical staff administered medication as ordered. The Medical Director stated medication should not be left at the bedside unless the resident was care planned to self-administer. She stated it was important for staff to follow the facility's policies to ensure resident safety and prevent avoidable accidents.During an additional interview with the Administrator on 03/05/2026 at 2:01 PM, he stated he expected leadership to make sure care plans were correct in point click care (the facility's software). He stated the MDS Coordinator reviewed the care plans daily, and when the care plan was correct it should be communicated to floor staff so residents could get the proper care. He stated when care plans were not correct or floor staff chose not to follow the resident's individual care plan, it could have a negative impact on the residents. He stated his expectation was for all staff to always follow a resident's care plan.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with physician orders and professional standards of practice for 2 out of 3 sampled residents, Resident (R) 11 and R93.1. Observation on 03/03/2026 revealed R11's oxygen was set at 4.5 liters per minute (LPM) when his physician order was for continuous oxygen at 4.0 LPM. Further observation on 03/03/2026 and 03/05/2026 revealed the resident was not wearing his oxygen tubing and not receiving oxygen, and staff did not return to R11's room to place the oxygen back on the resident. 2. Observation on 03/03/2025 revealed R93's oxygen was set at 2 LPM and observation on 03/04/2026 revealed R93's oxygen was set at 3.5 LPM when her physician order was for continuous oxygen for 14 hours or more at 3.0 LPM via nasal cannula.The findings include:Review of the facility's undated policy titled, Oxygen Administration, revealed the purpose of the policy was to ensure oxygen was administered to residents who required it in accordance with professional standards of practice, physician orders, and the care plan. The policy stated staff was expected to set and maintain the oxygen equipment at the prescribed flow rate ordered by the physician. Further review of the policy revealed staff was to maintain infection control measures.Review of the facility's undated policy titled, Oxygen Concentrator, revealed the purpose of the policy was to establish responsibilities for the care and use of the concentrators. The policy stated the nurse should [NAME] the physician's orders for the prescribed oxygen flow rate.1. Review of the admission Record found in R11's electronic medical record (EMR), revealed the facility admitted the resident on 07/04/2024 with diagnoses to include chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypercapnia, and myocardial infarction.Review of the quarterly Minimum Data Set [MDS], found in R60's EMR with an Assessment Reference Date (ARD) of 07/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating the resident was cognitively intact.Review of the Comprehensive Care Plan [CCP], dated 12/25/2025 and found in R11's EMR, revealed a focus for COPD with interventions to include oxygen at 5 liters per minute (LPM) via nasal cannula.Review of the Order Review Report, dated 03/2026 and found in R11's EMR, revealed an order dated 10/23/2025 for oxygen at 4 LPM via nasal cannula every day and night shift related to chronic obstructive pulmonary disease in chronic respiratory failure with hypercapnia.Observation of R11 on 03/03/2026 10:58 AM revealed he was sitting up in bed with the head of the bed elevated and was not wearing oxygen. The oxygen concentrator was on, and the flow rate was set at 4.5 LPM. The nasal cannula and tubing were on the floor and were out of reach of the resident. Observation on 03/05/2026 at 10:58 AM, revealed R11 was seated in his chair. The resident's oxygen tubing had been removed during transfer from the bed to the chair per the resident. The resident's nasal cannula remained on the bed and was not within reach of the resident. The oxygen concentrator was placed behind the resident's chair and out of view. Staff did not return to the room during the observation period to replace the oxygen on the resident. During an interview with R11 on 03/05/2026 at 10:58 AM, he stated his oxygen flow rate was supposed to be 4 liters per minute. He stated he could not adjust the set due to limited mobility. He further stated he was unsure how often staff checked the oxygen concentrator to ensure the correct flow rate. R11 stated staff transferred him from his bed to his Broda chair and removed his oxygen during the transfer. During an interview with Licensed Practical Nurse (LPN) 3 on 03/05/2026 at 11:00 AM, she stated R11 was on continuous oxygen and should be wearing his nasal cannula. She stated it was important for staff to ensure residents wear their oxygen and maintain the correct flow as prescribed to maintain oxygen levels to prevent shortness of breath. 2. Review of the admission Record found in R93's EMR, revealed the facility admitted the resident on 01/22/2025 with diagnoses to include unspecified atrial fibrillation, expressive language disorder, and gout.Review of the annual MDS, found in R93's EMR with an ARD of 02/01/2026, revealed the facility assessed the resident to have a BIMS score of 10 out of 15, indicating the resident was moderately impaired. Review of the CCP, dated 02/09/2026, found in R93's EMR, revealed a focus for COPD with an intervention initiated on 01/22/2025 to include oxygen at 2 LPM via nasal cannula.Review of the Order Review Report, dated 03/2026 and found in R93's EMR, revealed an order dated 01/26/2026 for oxygen at 3 LPM via nasal cannula every day and night shift related to COPD.Observation of R93 on 03/03/2025 at 2:43 PM revealed she was lying in bed with the head of the bed slightly elevated and wearing a nasal cannula which delivered oxygen from her oxygen concentrator. Observation of the oxygen concentrator revealed the flow rate was set at 2 LPM. Additional observation of R93 in her room on 03/04/2026 at 10:52 AM revealed R93's oxygen was set at 3.5 LPM.During an interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), on 03/06/2026 at 9:39 AM, she stated nurses were responsible to ensure oxygen was administered according to physician orders. She stated staff should verify the oxygen concentrator was set to the ordered liters per minute during resident assessments. She further stated staff was instructed to read the oxygen flow meter at eye level and ensure the center of the ball aligned with the ordered liter flow. The ADON/IP stated following oxygen orders was important to ensure residents received the correct oxygen therapy and to prevent respiratory distress.During an interview with the Director of Nursing (DON) on 03/06/2026 at 12:08 PM, she stated staff should follow physician orders for oxygen therapy. She stated staff was educated on the proper use of oxygen equipment to ensure residents received the ordered oxygen therapy. The DON stated it was her expectation that nursing staff administered medications as ordered, including oxygen therapy. She stated it was important to ensure the resident received the prescribed oxygen for their overall health and well-being. During an interview with the Administrator on 03/06/2026 at 11:27 AM, he stated it was his expectation that nursing staff administered medications as ordered to maintain resident safety.During a telephone interview with the Medical Director on 03/06/2026 at 12:53 PM, she stated it was her expectation that licensed clinical staff administered medication as ordered. She stated administering oxygen as ordered was important to ensure the resident received adequate oxygenation to prevent respiratory distress and decreased oxygen saturation or a complication related to excess oxygen.

Based on interview, record review, and review of the facility's policy, the facility failed to provide residents who required dialysis services an ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for 1 of 1 sampled resident who received dialysis services, Resident (R) 38.Record review revealed R38 received hemodialysis three times a week on Monday, Wednesday, and Friday. However, the facility provided incomplete documentation for pre-and-post dialysis assessments on the following dates: 02/04/2026, 02/05/2026, 02/16/2026, 02/23/2026, and 02/25/2026. Also, the facility did not provide ongoing assessment and monitoring for the months of January 2026 or March 2026.The findings include:Review of the facility's undated policy titled, Hemodialysis, revealed the facility would ensure each resident's care and services included an ongoing assessment and oversight of the resident before, during, and after treatments, including monitoring for complications and ongoing communication and collaboration with the dialysis facility. Review of the admission Record found in R38's electronic medical record (EMR), revealed the facility admitted the resident on 10/02/2020 with diagnoses to include dependence on renal dialysis, type 2 diabetes mellitus, and metabolic encephalopathy.Review of the quarterly Minimum Data Set [MDS], found in R38's EMR with an Assessment Reference Date (ARD) of 10/02/2020, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15, indicating the resident was cognitively intact.Review of the Comprehensive Care Plan [CCP], dated 03/05/2025, found in R38's EMR, revealed a focus initiated on 05/12/2025 which identified the resident required hemodialysis related to renal failure. The CCP included goals to ensure the resident would have no complications from dialysis.Review of the Order Review Report, dated 03/2026, found in R38's EMR, revealed an order, dated 01/28/2026, for dialysis three times weekly on Monday, Wednesday, and Friday. Further review revealed an order to monitor the insertion site related to mild bleeding from the site post dialysis and an order for a renal, regular texture diet with liquid protein supplement of 30 milliliters twice a day, dated 01/28/2026.Review of R38's Windsor Care Dialysis Communication Form [DCF], no date, and found in R38's Dialysis Folder, revealed multiple prefilled DCFs with the resident's name, physician, current renal diet order, fluid restriction of 1500 milliliters (mL), and pre-signed by Licensed Practical Nurse (LPN) 4. Further review of the resident's dialysis communication folder revealed no additional dialysis communication forms or documentation for dialysis treatments during 01/2026, 02/2026, or 03/2026 beyond the dates listed above.At the request of the State Survey Agency (SSA) Surveyor, the facility was asked to provide dialysis communication documentation for the months of 01/2026, 02/2026, and 03/2026. The facility provided dialysis communication forms for the following dates: 02/05/2026, 02/06/2026, 02/16/2026, 02/23/2026, and 02/25/2026. The facility also provided nursing notes corresponding to dialysis treatments dated 02/16/2026, 02/18/2026, and 02/23/2026. However, no additional dialysis communication documentation was provided for the requested months.Review of R38's DCF, dated 02/04/2026, revealed several sections of the facility's information were left blank. Vital signs were taken on 02/04/2026 at 6:00 AM. The date and time of the resident's last meal was not documented. Documentation indicated the resident's current diet order was a regular diet. The section titled Important information for dialysis nurse to know contained no entries. Additionally, the section for facility nurse name/signature, phone number, and extension was not completed. Review of the dialysis communication section revealed it was dated 02/05/2026 at 10:30 AM. The result section contained no documentation. The dialysis nurse signature, phone number, and extension were not documented. Review of R38's DCF, undated, revealed several sections of the facility's information were left blank. Vital signs were taken on 02/05/2026; however, no time was documented. Review of the dialysis communication section revealed it was dated 02/06/2026 at 6:45 AM. The position of the resident when vital signs were taken was not documented. The oxygen saturation (SpO2) was left blank. The time of discharge was not documented. The results section contained no documentation. The dialysis nurse's name was signed but no contact information was provided. Review of R38's DCF, dated 02/16/2026, revealed several sections of the facility's information were left blank. Vital signs were taken on 02/16/2026 at 5:00 AM; however, the pulse, respirations, and SpO2 fields were blank. Documentation indicated the resident's current diet order was a regular diet. The section titled Important information for dialysis nurse to know contained no entries. Additionally, the section for facility nurse name/signature, phone number, and extension was not completed. Review of the dialysis communication section revealed it was dated 02/16/2026 at 6:30 AM. The SpO2 was left blank. The results section contained no documentation. The dialysis nurse's name was signed but no contact information was provided. Review of R38's DCF, dated 02/23/2026, revealed the resident received her last meal at 5:30 AM, and it was documented as a regular diet. The section titled Important information for dialysis nurse to know contained no entries. Additionally, the section for facility nurse name/signature, phone number, and extension was not completed. Review of the dialysis communication section revealed it was dated 02/23/2026 at 6:30 AM. It was noted R38 did not receive a meal or snack during treatment. The results section contained no documentation. Further documentation requested the facility remove R38's bandage prior to sending the resident to dialysis, as the bandage prevented access to the site. The note further indicated the resident should eat prior to leaving for dialysis because once the fistula was accessed, the resident could not move her right arm. It was also documented that sending the resident's meals tray with her was not appropriate. The dialysis nurse's name was signed but no contact information was provided. Review of R38's DCF, dated 02/25/2026, revealed several sections of the facility's information were left blank. Vital signs were taken on 02/25/2026 at 5:30 AM. Documentation indicated the resident's current diet order was a regular with thin liquids. The section titled Important information for dialysis nurse to know contained no entries. Additionally, the facility phone number, and extension fields were not completed. Review of the dialysis communication section revealed the entire section was left blank. During an interview with Licensed Practical Nurse (LPN) 4 on 03/05/2026 at 9:50 AM, she stated dialysis communication forms were kept at the nurse's station in a binder. She stated the binder accompanied the resident when the resident was transported to and from the dialysis clinic. LPN4 stated the dialysis communication form should be completed prior to the resident leaving the facility. She stated the form should include complete documentation. She further stated the nurse completing the form should document the nurse's name, signature, and contact information on the form. LPN4 stated the dialysis clinic nurse was expected to complete the dialysis portion of the form and return the form with the resident. She stated the dialysis clinic staff should document information including dialysis treatment details and any issues that occurred during dialysis.During the continued interview with LPN4 on 03/05/2026 at 9:50 AM, she stated the resident should be monitored for complications after returning from dialysis and any complications should be documented. She stated a nurse's note should also be entered into the resident's medical record following the resident's return from dialysis. LPN4 stated she did not know why dialysis communication forms in Resident 38's dialysis binder had been copied and pre-filled with her name. She stated information should not be pre-filled on the dialysis communication form because the resident's condition and clinical information could change, and the form should reflect the resident's current and most up-to-date information at the time the resident was sent to dialysis.During an interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), on 03/06/2026 at 9:39 AM, she stated the facility's process for residents receiving dialysis treatment included use of a dialysis communication form that was sent with the resident to the dialysis center. She stated the form contained sections for both the facility and dialysis staff to complete. She stated the facility's portion of the form should be completed prior to the resident leaving the facility, and the dialysis clinic was expected to complete its portion before the resident returned. The ADON/IP further stated the nurse was expected to document a nursing note upon the resident's return from the dialysis clinic and contact the dialysis provider if any information was missingDuring an interview with the Director of Nursing (DON) on 03/06/2026 at 12:08 PM, she stated the facility used a dialysis communication form that accompanied the resident to the dialysis clinic. She stated the facility's nurse was expected to complete the facility's portion on the form prior to the resident leaving for dialysis, and the dialysis clinic was expected to complete the dialysis communication section and return the form with the resident. The DON stated nurses should review the dialysis communication form upon the resident's return and document a nurse's note regarding the dialysis treatment. She further stated if the form was incomplete or information was missing, nursing staff was expected to contact the dialysis provider to obtain the missing information.During an interview with the Administrator on 03/06/2026 at 11:27 AM, he stated it was his expectation that nursing staff followed the facility's policies and procedures when providing resident care. The Administrator stated staff members were expected to carry out their assigned responsibilities so residents received appropriate care to ensure the residents' safety and well-being.During a telephone interview with the Medical Director on 03/06/2026 at 12:53 PM, she stated it was her expectation that licensed clinical staff followed the facility's policies and procedures when providing resident care. She stated it was important to ensure residents received appropriate medical care and treatment and to protect the residents' health and overall well-being.

Based on interview, record review, review of the facility's investigation, and review of the facility's policies, the facility failed to ensure its staff practiced safe transfer techniques, utilizing a mechanical lift, to prevent injuries for 1 of 5 sampled residents, Resident (R) 1.On 04/02/2025, R1 was transferred from the bed to a chair by two State Registered Nurse Aides (SRNA) using a mechanical lift. SRNA4 was operating the lift, while SRNA1 was holding onto the lift pad during maneuvering. SRNA4 moved the lift from the bed to the chair, positioned the lift device under the chair, and failed to extend the legs, necessary for balancing the device. SRNA1 pulled on the lift pad to position R1 into the chair resulting in unbalanced weight distribution that caused the lift to tilt. The bar attachment struck R1 on the back of her head causing a laceration. R1 was transferred by ambulance to a local emergency room on [DATE] and required staples to close the wound.Based on review of the facility's plan of correction (PoC) and validation through observation, interview, and record review, the facility provided mandatory education and training regarding safe use of the mechanical lift. The State Survey Agency (SSA) validated the deficient practice was corrected on 04/16/2025, following completion of the mandatory employee education and training and before the start of the survey. Therefore, the deficient practice was past noncompliance.The findings include:Review of the facility's policy titled, Safe Resident Handling/Transfers, not dated, revealed the policy of the facility was to ensure residents were handled and transferred safely to prevent or minimize the risk of injury and provide and promote a safe, secure, and comfortable experience, while keeping employees safe in accordance with current standards and guidelines. Per the policy, two facility staff members would participate in the transfer process and be provided staff education and/or training and would be observed demonstrating competence at the time of hire, annually, and as needed. Review of the facility's policy titled, Accidents and Supervision, dated 11/01/2018, revealed the environment would remain as free of accident hazards as possible, and each resident would receive adequate supervision and assistive devices to prevent accidents. Review of R1's admission Record revealed the facility admitted R1 on 11/28/2018 with diagnoses of hemiplegia and hemiparesis following a stroke, dementia, dysphagia, and aphasia. Further review revealed R1 was discharged from the facility on 06/28/2025 due to death. Review of R1's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/11/2025, revealed the facility assessed the resident's Brief Interview for Mental Status [BIMS] score could not be completed due to R1 being severely cognitively impaired. Review of Functional Abilities revealed R1 had limitations in range-of-motion in both lower extremities and was dependent in all self-care and mobility areas. Review of R1's Order Entry revealed a physician's order for a mechanical lift for transfers entered on 08/09/2022. Review of R1's Care Plan Report revealed a focus of having an Activities of Daily Living (ADL) self-care performance deficit related to diagnoses. Interventions included dependent with mechanical lift with two staff for transfers and required extensive staff assist of two for transferring.Review of R1's Health Status Note, dated 04/02/2025 at 8:36 AM, revealed two aides were transferring the resident using a Hoyer lift (mechanical lift) when it began to tip over. Per the note, while trying to keep it from falling, the lift bar hit R1 on the back of the head. The note stated the incident resulted in a laceration to the back of R1's head that required manual pressure be applied to control bleeding. Per the note, 911 was called, and the resident was transported to the hospital by ambulance and notifications were made. Review of R1's Health Status Note, dated 04/02/2025 at 12:53 PM, revealed the resident returned to the facility from the emergency room (ER) via ambulance with one staple in place to the laceration on the head with instructions for care and precautions. Review of R1's ER After Visit Summary, dated 04/02/2025 revealed a visit to the local ER for evaluation of fall resulted in an computed tomography (CT) scan of the brain and neck related to head trauma, a scalp laceration that was repaired with staple closure, and a diagnosis of a scalp hematoma, which was a collection of blood outside of the blood vessels under the skin, caused by trauma. Per the summary, R1 received an oral medication for pain and was administered a tetanus shot prior to discharge back to the facility with follow-up instructions.Review of R1's Incident Report, completed by Licensed Practical Nurse (LPN) 2, revealed LPN2 was standing outside of R1's door when a State Registered Nurse Aide (SRNA) was heard calling for help. LPN2 visualized R1 in the Hoyer lift sling in a chair with blood coming from the back of the head. LPN2 assessed R1 for further injuries, only noted the laceration to the back of the head, and pressure was applied to control bleeding. The report stated the assessment revealed R1 remained oriented to baseline, neurological check was normal, and a raised area of bleeding, known as a hematoma, was evident on the head. Per the report, notifications were made to the physician, family, and Director of Nursing (DON), and R1 was transferred to the ER. Further review revealed the two SRNAs involved, SRNA1 and SRNA4, described the incident as: one SRNA was holding the handles of the Hoyer pad that held R1 and pulled on it causing the Hoyer lift device to tilt to one side, the other SRNA attempted to catch the lift to keep it from falling over, and the action caused the bar of the device to hit R1 on the back of the head. Further review of the document revealed there were no predisposing environmental factors. The report stated R1 had predisposing physiological factors of history of falls and weakness/fainted and a predisposing situation factor of transferring with staff assistance.Review of the handwritten Witness Statement, dated 04/02/2025 and signed by SRNA1, revealed SRNA1, along with SRNA4, was placing R1 in the chair using the lift. SRNA1 was holding onto the lift pad straps and pulling R1 into position into the chair, and the lift started to tip over. Per the statement, SRNA4 attempted to keep the lift from falling over causing the lift device to come down and hit R1 in the head. Review of the handwritten Witness Statement, dated 04/02/2025 and signed by SRNA4, revealed SRNA1 and SRNA4 were getting R1 up with the Hoyer lift when SRNA1 pulled the lift pad back to position the resident in the chair while SRNA4 had hold of the device handles. Per the statement, the device started to tip, and SRNA4 attempted to catch it. Further review revealed Licensed Practical Nurse (LPN) 2 was outside the room and entered to help get R1 detached from the device. The statement revealed R1 was bleeding from the head and pressure was applied to control bleeding.Review of the handwritten Statement, dated 04/02/2025 and signed by former Director of Nursing (DON) 1, revealed SRNA1 and SRNA4 were using the Hoyer lift for R1. Per the statement, SRNA1 reported holding the handles of the lift pad, and when it was pulled back, the lift started to tip over to the right. The statement revealed SRNA4 tried to keep the lift from falling over, and the bar of the lift came down and hit R1 in the back of the head causing a laceration and raised hematoma.Review of SRNA1's employee file revealed a Validation Checklist Mechanical Lift document dated 04/02/2025 with satisfactory completion for all listed procedures. Review of SRNA4's employee file revealed a Resignation/Termination Form, dated 04/02/2025, with the last day worked and termination of 04/02/2025, which was handwritten. The form stated the discharge was due to failure to use proper lifting techniques; non-compliance with safe body mechanics training, and unsafe work conduct, procedures, habits, practices, or methods. The form was signed and dated 04/02/2025 by Director of Nursing (DON) 1. Further review revealed an Employee Disciplinary Action form, dated 04/02/2025, with a handwritten note which stated, Failure to use Hoyer lift properly. Also, another handwritten text stated, Did not spread legs of Hoyer lift causing it to tip sideways and injured a resident. The form was signed by DON1, SRNA4, and the Administrator, all dated for 04/02/2025.In an interview with the Complainant on 10/21/2025 at 9:44 AM, she stated someone from the facility notified her on 04/02/2025 that while using the mechanical lift device, R1 had fallen and was being taken to the hospital. The Complainant stated when she arrived at the hospital, she was told the legs on the mechanical lift had not been extended, the lift fell, and R1 hit her head, which resulted in a laceration to the back of the head that required at least one staple. In an interview with SRNA1 on 10/21/2025 at 10:50 AM, she stated she had been one of two SRNAs that were present during the Hoyer lift accident involving R1 on 04/02/2025. SRNA1 stated she and SRNA4 were using a Hoyer lift to transfer R1 to a chair, and SRNA4 was the operator of the controls, steering the machine, and she was holding onto the pad and the resident. She stated once R1 was positioned over the chair, she pulled on the lift pad to make sure R1 was directly over the seat, and the machine started to tilt. She stated SRNA4 attempted to stabilize it with her hands, but a part of the bar at the top of the machine ended up striking R1 on the back of the head. SRNA1 stated she was yelling, and a nurse that was outside the door came in, provided assistance unhooking R1 and getting her in the chair, identified bleeding from the head, held pressure and called for an ambulance. She stated, after R1 had been taken to the emergency room, she was questioned by DON1 and wrote a statement of the incident. She stated, later that same day she had to complete education on safe transferring and use of the Hoyer lift. She stated she had to do a return demonstration as a competency validation.In an interview with SRNA4 on 10/21/2025 at 2:17 PM, she stated she was one of two SRNAs that was present during the Hoyer accident involving R1 on 04/02/2025. SRNA4 stated she was the operator of the machine, and SRNA1 was the second person, holding onto the sling pad holding R1. SRNA4 stated once R1 was positioned over the chair, SRNA1 pulled on the sling pad, and the machine started to tilt. She stated the attachment connecting the sling to the machine hit R1 in the head. She stated a nurse standing outside the door came in and helped stabilize the machine, helped get R1 into the chair, and held pressure on R1's head wound. SRNA4 stated, after R1 had been taken to the hospital, DON1 asked her to write a statement about the event. SRNA4 stated she explained to DON1 that R1 was being transferred from the bed to a Geri chair, and after moving the Hoyer to the chair, the legs of the machine could not be extended, so they were not extended at the time of the incident. SRNA4 stated later the same day as the incident, she was called into DON1's office and was fired. In an interview with Maintenance staff on 10/22/2025 at 10:00 AM, he stated all mechanical lift devices were checked on a monthly basis for preventative maintenance. He stated monthly inspection of the device included checking all moving parts and the battery. He stated that included ensuring the controllers worked, the machine moved up and down properly, the brakes were working, and the legs extended and retracted appropriately. He stated he had been informed of the accident with the Hoyer lift by the Administrator, and he did an inspection of the lift and could not find any problem with the mechanics of the machine. He stated he informed the Administrator of his findings. In an interview with DON1 on 10/22/2025 at 10:55 AM, she stated she had been notified of the incident by a staff nurse and did the investigation. DON1 stated after R1 had been taken to the hospital, she questioned the staff involved, had them demonstrate to her what they had done, and then had them write out statements. She stated after the demonstration and interviews, it was determined one of the two SRNAs had positioned the Hoyer device under the chair in a way that did not allow the legs to be extended, which was necessary for proper operation. However, she stated SRNA4 continued with the use of the device, and when SRNA 1 pulled on the lift pad to position the resident, the machine became unbalanced and tilted. She stated that resulted in a head injury to R1. She stated the incident was determined to be an isolated incident caused by an employee not following procedure.In an interview with the Administrator on 10/22/2025 at 9:40 AM, he stated he was notified by DON1 of an incident with a Hoyer lift that resulted in an injury to a resident. He stated DON1 questioned both SRNAs involved, had them demonstrate exactly what happened, and they wrote statements. The Administrator stated after the demonstration and interviews with both SRNAs, it was determined it had been an isolated incident due to not following safety and transferring policy and not using the Hoyer lift appropriately resulting in one of the two SRNAs being terminated the same day. He stated management staff met to discuss the situation and had maintenance inspect the lift. The facility provided an acceptable plan of correction (PoC) on 10/21/2025 alleging past non-compliance of the deficient practice and a date of compliance of 04/16/2025, with corrective actions and validation as follows:Review of the facility's folder Mechanical Lift Education revealed a document, Staff In-Service Attendance Record, with the subject Mech [Mechanical] Lift Safety Safe Resident Handling & Transfers, dated 04/02/2025, with the handwritten instructor's name and Staff Development. There were three sign-in sheets with a total of 78 signatures over the three pages. A printed handout, Patient Lifts Safety Guide, was 16 pages of pictures and wording that described the parts of a lift device, selecting sling size, preparing the environment, placing patient in the sling, lifting the patient, sling care, caregiver safety tips, and a blank copy of the validation checklist for mechanical lifts. Observation by the State Survey Agency (SSA) Surveyor on 10/21/2025 at 3:21 PM revealed SRNA1 and SRNA2 used a Hoyer lift device for transfer of R4 from a specialty chair to the bed. Staff donned appropriate personal protective equipment (PPE) prior to entering the room, the lift pad was under R4 in the chair, the device was placed appropriately beside the resident, wheels were locked, and the legs of the lift were extended, and the sling was connected to the device appropriately. SRNA1 operated the lift controls to raise R4 from the chair, while SRNA2 kept a hand on the sling and R4. SRNA1 unlocked the wheels and maneuvered the device over the bed while SRNA2 maintained both hands on R4 to steady and control movement. Once R4 was positioned over the bed in the proper location, SRNA1 locked the wheels and operated the lift controls to lower R4 while SRNA2 continued hands on guiding of R4 during lowering. Once staff had placed R4 safely back to bed, removal of the sling and final positioning was performed. In a continued interview with the Complainant on 10/21/2025 at 9:44 AM, the Complainant stated she had received communication from DON1 and the Administrator, after the incident, and had been informed that one of the two staff had been fired, and all staff had been trained on the correct way to use the lift device.In an interview with Registered Nurse (RN) 2/Staff Development Specialist (SDS) on 10/21/2025 at 1:38 PM, she stated she had been in the position of staff education for about two weeks when the incident occurred. RN2 stated the Manager for the unit and DON1 came to her and told her they needed immediate education concerning the use of Hoyer lifts, instructed her on what material to gather, and what needed to be done. RN2 stated she had an empty room set up with a Hoyer lift and a mannequin, and clinical staff were brought in small groups and given the packet of instructions along with the facility's policy on transferring. She stated all clinical staff on all shifts were required to sign-in on a roster, verbalize proper steps, and completed the return demonstration to be considered compliant, before they could work their next shift. She stated completion of the education was ongoing for about two weeks before all staff were compliant. RN2 stated all new hire clinical staff received the same Hoyer lift training during orientation and again annually during skills day.In the interviews with nine staff on 10/22/2025, they all stated they received verbal instruction with a demonstration and a return demonstration required for proper use of a mechanical lift to include two staff to operate, legs must be extended, use the appropriate sling size, and ensure the resident was secured. The staff members interviewed were RN3 at 11:20 AM, SRNA5 at 11:29 AM, SRNA7 at 11:40 AM, LPN4 at 1:51 PM, SRNA/Kentucky Medication Aide (KMA) 9 at 2:07 PM, LPN3 at 2:15 PM, LPN5 at 2:24 PM, SRNA11 at 2:40 PM, and SRNA15 at 2:51 PM.In a continued interview with DON1 on 10/22/2025 at 10:55 AM, she stated the facility decided to do mandatory education for all clinical personal that operated the Hoyer lift. DON1 stated a training packet of information on proper use was put together, and training was started the same day as the incident and was required by all clinical staff before the start of their next shift. She stated she believed the incident had been discussed at Quality Assurance Performance Improvement (QAPI) meetings, but she did not recall the specifics. Review of the QAPI meeting minutes, dated 04/10/2025, revealed there had been training for all clinical staff on mechanical lifts due to a resident injury sustained during its use. Further review revealed all lift devices had been checked for proper functioning after the resident injury. Review of the QAPI meeting minutes, dated 05/08/2025, revealed the in-service for the clinical staff on the use of mechanical lifts was 100 percent complete.In a continued interview with the Administrator on 10/22/2025 at 9:40 AM, he stated, after the incident with R1, management staff determined mandatory education for anyone using the lift would begin immediately and be required before working their next shift. The Administrator stated a Quality Assurance Performance Improvement (QAPI) committee meeting was held on 04/10/2025. He stated, at that meeting, the incident was discussed, findings were given, and mandatory education had been started the day of the incident. He stated discussion on need for an action plan was determined not to be required due to the committee members' agreement that the incident was isolated, the employee had been terminated, and all clinical staff were required to attend education of the lift. He stated at the following month's QAPI meeting, an update was given that 100% compliance of the mandatory education had been completed, and the committee agreed that no further actions would be necessary.

Based on interview, record review, and review of the facility's investigation, the facility failed to immediately notify the resident's representative (s) when there was an identified injury, an accident, or a significant change in the resident's physical status, for 1 of 1 sampled resident, Resident (R) 2. The findings include:Review of R2's admission Record revealed the facility admitted the resident on 02/28/2022 with diagnoses to include chronic lymphocytic leukemia (CLL) and chronic kidney disease. A diagnosis of contracture left hand was added on 11/26/2023.Review of R2's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 08/19/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status [BIMS] score of six out of 15, indicating severe cognitive impairment. R2 was further assessed as dependent on staff for most Activities of Daily Living (ADL), as well as dependent on staff for ambulation. Review of the facility's investigation into R2's bruising revealed a statement, dated 09/19/2025, from the Sterling Unit Manager Registered Nurse (RN) 3, who reported she observed R2's bruising on 09/05/2025. The statement revealed the RN determined the bruise on R2's chest was located between and slightly above her breasts in the mid-upper sternal region and was about the size of an orange, with a dark purple center and some yellowing beginning on the upper portion of the bruise. The RN noted R2 had her hands clutched together in a fist against this area, which was consistent with the location of the bruising. Further review revealed a statement from the former Director of Nursing (DON), dated 09/19/2025, which stated she had been notified by the Sterling Unit nurse on 09/05/2025 that R2 had a bruise to her chest. The DON stated her assessment of R2's determined location and size of bruising was consistent with where R2 frequently clasped her hands tightly against her chest, and with R2's diagnosis of CLL and higher platelet count in her most recent blood work, R2 would bruise more easily. Further review of the DON's statement revealed the DON stated that based on her investigation, she was convinced bruising occurred due to R2 clasping her hands against her chest. She also stated her findings were discussed in the stand down meeting on 09/05/2025. The DON's statement concluded by noting she became ill and had to leave work early and had been unable to follow-up with the nurse that reported the bruising to her. Review of the facility's document Weekly Skin Observation, dated 09/08/2025, described the bruising to R2's chest as old bruising across the upper chest, appearing to have been there for several days based on the greenish, yellowish, purplish color of bruising. It stated the bruising was not a new skin injury. Review of the facility's Initial Report, dated 09/16/2025, revealed on 09/09/2025 bruising was observed to the center of R2's chest and reported to the family. Per the report, R2 denied anyone causing the bruise and was unaware of how it occurred. The report stated the bruise was reported as not suspicious or of unknown origin, with the report being initiated due to Adult Protective Services (APS) visiting the facility on 09/16/2025 to investigate the injury to R2. In an interview with R2's Family Member (F) 2 on 10/21/2025 at 11:25 AM, he stated bruising to R2 was in the process of healing prior to the family being made aware of it. He stated he felt like someone had dropped the ball somewhere in not reporting that to him, but he did not suspect R2 had been mistreated. In an interview with the Administrator on 10/22/2025 at 9:32 AM, he stated bruising to R2 was discussed initially in their 3:00 PM stand-down meeting on Friday 09/05/2025 when a nurse brought it to the DON's attention. He stated the DON investigated the bruising, but prior to a report being initiated, the DON fell ill. He stated on 09/11/2025, R2's daughter came in asking about the bruising and why they had not been informed of the bruising until 09/09/2025. The Administrator stated he had a conference call with R2's two daughters and son, and he informed them what the facility thought had caused the bruising. The Administrator stated the family told him they did not think anything abusive happened but were upset they did not get contacted on Friday when the bruising was discovered.

4. Review of R30's admission Record revealed the facility admitted the resident on 10/07/2021 with diagnoses of acute on chronic diastolic heart failure, chronic respiratory failure with hypercapnia, and COPD. Review of R30's Nurse's Note, dated 09/11/2024, revealed R30 had a decreased blood oxygen saturation of 78% on 5 Liters (L) per minute of oxygen and was sent to the emergency room (ER). Review of R30's Transfer to Hospital Summary, dated 10/16/2024, revealed the facility transferred the resident to the hospital on that date for a blood oxygen saturation of 75% on 4 Liters (L) per minute nasal cannula oxygen, wet lung sounds, and lethargy. Review of R30's Health Status Note, dated 12/01/2024, revealed R30's oxygen saturation dropped to 71% after getting a nebulizer treatment. The note stated R30 was sent to the hospital. Review of R30's eInteract Transfer Form, dated 02/17/2025, revealed R30 was transferred to the hospital because her oxygen saturation was 85% on 4 Liters (L) per minute nasal cannula. Review of R30's medical record revealed there was no written documented form/notice showing the facility notified the resident/family of the reason, date, and location for the transfer, as well as a statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman. In an interview on 03/11/2025 at 7:47 PM, R30's Representative F5 stated he was notified over the phone by the facility that they were sending R30 to the hospital but did not receive paperwork from the facility. 2. Review of R44's admission Record revealed the facility admitted the resident on 03/16/2023 with diagnoses including quadriplegia, uropathy, and congestive heart failure (CHF). Review of R44's Notice of Resident Transfer or Discharge, dated 06/10/2024, revealed the facility transferred R44 to the hospital for a fall with injury. Further review revealed the facility failed to provide evidence they provided F44's representative with written information related to R44's transfer. During interview with Family Member (F) 1 on 03/13/2025 at 10:27 AM, she stated she was notified of R44's transfer to the hospital, but never received written information detailing the reason for the resident's transfer. 3. Review of R62's admission Record revealed the facility admitted the resident on 12/01/2023 with diagnoses of neuropathy, chronic obstructive pulmonary disease (COPD), and acute respiratory failure with hypoxia. Review of R62's Nurse's Note, dated 12/09/2024, revealed R62 had signs and symptoms of cough, wheezing and crackle lung sounds, and a complaint of shortness of breath. Further review revealed R62 was transferred to a local hospital emergency room for evaluation, and a family member was called and verbally informed of the situation. Review of R62's Nurse's Note, dated 12/13/2024, revealed R62 returned to the facility from the hospital admission. Review of R62's medical record revealed there was no written documented form/notice showing the facility notified the resident/family of the reason, date, and location for the transfer, as well as a statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman. 5. Review of R91's admission Record revealed the facility admitted the resident on 11/04/2024 with a diagnosis of dysphagia following a stroke. Review of the facility's document Census revealed R91 was sent to the hospital on [DATE] and 11/23/2024. However, the facility failed to provide evidence R91 and/or R91's responsible party received written information about her transfer to the hospital for both events. 6. Review of R94's admission Record revealed the facility admitted the resident on 03/01/2024 with diagnoses of metabolic encephalopathy, depression, and dementia. Review of the facility's document Census revealed R94 was sent to the hospital on [DATE] and 04/04/2024. However, there was no documentation by the facility stating written information was sent to R94's responsible party. 7. Review of R66's admission Record revealed the facility admitted the resident on 10/22/2024 with diagnoses of depression, dementia, and congestive heart failure (CHF). Review of the facility's document Census revealed R66 was sent to the hospital on [DATE] and 11/01/2024. However, there was no documentation by the facility for either transfer which stated or revealed written information was sent to R66's responsible party. Review of R66's Progress Note, dated 10/26/2024, revealed R66 was transported by ambulance to the hospital at 12:25 PM. Per the note, R66's family was notified and updated on R66's status, but again there was no written documentation. 8. Review of R68's admission Record revealed the facility admitted R68 on 04/29/2021 with a diagnosis of quadriplegia. Review of the facility's document Census revealed R68 was sent to the hospital on [DATE] and 12/25/2024. However, there was no documentation by the facility for either transfer which stated or revealed written information was sent to R68's responsible party. During interview with the Business Office Manager (BOM) on 03/12/2025 at 3:28 PM, she stated she did not send out written information to the family when a resident was transferred to the hospital. She stated she did not know this was a requirement. During interview with the Director of Nursing (DON) on 03/13/2025 at 10:55 AM, she stated her process for assuring the staff was following the facility policy was to monitor staff periodically. During interview with the Administrator on 03/12/2025 at 5:50 PM, he stated, No copy of the notification [transfer/discharge] because they went with them [the residents]. He stated when there was a transfer/discharge, the packet was sent with the resident/emergency medical service. He stated a copy was not kept for the resident's chart, and a second packet was not made and sent to the resident's representative. He stated residents' representatives were called and updated. Based on interview, record review, and review of the facility's documents and policy, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. The facility further failed to ensure the notice included the reason, date, and location for the transfer, as well as a statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman. The deficient practice was identified for 8 out of 10 residents reviewed for transfer and/or discharge, Resident (R) 30, R35, R44, R62, R66, R68, R91, and R94. The findings include: Review of the facility's Transfer and Discharge (including AMA) policy, not dated, revealed, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. 1. Review of R35's admission Record revealed the facility admitted R35 on 08/22/2023 with diagnoses including hemiplegia and hemiparesis following a stroke, moderate protein-calorie malnutrition, and chronic kidney disease, stage three. Review of R35's hospital discharge summary, located in the medical record, revealed the resident was hospitalized from [DATE] to 02/18/2025 at a local hospital. During interview with Licensed Practical Nurse (LPN) 5 on 03/12/2025 at 11:47 AM, she stated she only sent a bed hold form with the resident and called the family to notify them when a resident transferred to the hospital. During telephone interview with R35's son on 03/12/2025 at 2:58 PM, he stated he did not receive written information when his father was transferred to the hospital.

4. Review of R30's admission Record revealed the facility admitted the resident on 10/07/2021 with diagnoses of acute on chronic diastolic heart failure, chronic respiratory failure with hypercapnia, and COPD. Review of R30's Nurse's Note, dated 09/11/2024, revealed R30 had a decreased oxygen saturation of 78% on 5 Liters (L) per minute of oxygen and was sent to the emergency room (ER). Review of R30's Transfer to Hospital Summary, dated 10/16/2024, revealed the facility transferred the resident to the hospital on that date for oxygen saturation of 75% on 4 Liters (L) per minute via nasal cannula, wet lung sounds, and lethargy. Review of R30's Health Status Note, from 12/01/2024, revealed R30's oxygen saturation dropped to 71% after getting a nebulizer treatment which failed to stabilize R30's oxygen saturation. R30 was sent to the hospital. Review of R30's eInteract Transfer Form, dated 02/17/2025, revealed R30 was transferred to the hospital because her oxygen saturation was 85% on 4 Liters (L) per minute via nasal cannula. Review of R30's Bed Hold Agreement, dated 09/11/2024 and 10/16/2024, revealed an illegible signature to verify the facility obtained verbal consent to hold the resident's bed. Further review revealed no evidence the form was sent to the resident or the resident's representative. The form was not fully completed, and the basic per diem rate and the maximum number of days the State Plan paid for the resident were not filled in. Review of R30's Bed Hold Agreement, dated 12/02/2024 and 02/18/2025, revealed the Business Office Manager (BOM) signed to verify she obtained verbal consent to hold the resident's bed. Further review revealed no evidence the form was sent to the resident or the resident's representative. In an interview on 03/11/2025 at 7:47 PM, R30's Representative/Family Member (F) 5 stated he did not receive paperwork from the facility related to the facility's bed hold policy, but the facility did notify him over the phone that they were sending R30 to the hospital and verbally confirmed his wishes related to holding the resident's bed on each of the occasions that R30 was hospitalized .Based on interview, record review, and review of the facility's documents and policy, the facility failed to provide written information or notice at the time of transfer to the resident or resident representative which specified the duration of the bed-hold during which the resident was permitted to return and resume residence in the nursing facility and the reserve bed payment for 8 out of 10 residents reviewed for hospitalizations, Residents (R) 30, R35, R44, R62, R66, R68, R91, and R94. The findings include: Review of the facility's Bed Hold Notice policy, not dated, revealed, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. 1. Review of R35's admission Record revealed the facility admitted R35 on 08/22/2023 with diagnoses including hemiplegia and hemiparesis following a stroke, moderate protein-calorie malnutrition, and chronic kidney disease, stage three. Review of R35's hospital discharge summary, located in the medical record, revealed the resident was hospitalized from [DATE] to 2/18/2025 at a local hospital. During interview with Licensed Practical Nurse (LPN) 5 on 03/12/2025 at 11:47 AM, she stated she sent a bed hold form with the resident and called the family when a resident was transferred to the hospital. During telephone interview with R35's son on 03/12/2025 at 2:58 PM, he stated he did not receive written information when his father was transferred to the hospital. 2. Review of R44's admission Record revealed the facility admitted the resident on 03/16/2023 with diagnoses including quadriplegia, uropathy, and congestive heart failure (CHF). Review of R44's Notice of Resident Transfer or Discharge, dated 06/10/2024, revealed the facility transferred R44 to the hospital for a fall with injury. Review of R44's Bed Hold Notice, dated 06/11/2024, revealed the Business Office Manager (BOM) signed to verify she obtained verbal consent from Family Member (F) 1 to hold the resident's bed. Further review revealed no evidence the form was sent to F1. In an interview with F1 on 03/13/2025 at 10:27 AM, she stated she was notified of the resident's transfer to the hospital via telephone, but she never received a written copy of R44's bed hold notice. 3. Review of R62's admission Record revealed the facility admitted the resident on 12/01/2023 with diagnoses of neuropathy, chronic obstructive pulmonary disease (COPD), and acute respiratory failure with hypoxia. Review of R62's Nurse's Note, dated 12/09/2024, revealed the resident had signs and symptoms of cough, wheezing and crackle lung sounds, and a complaint of shortness of breath. Further review revealed R62 was transferred to a local hospital emergency room for evaluation, and the facility called the family member and verbally informed them of the situation. Review of R62's Nurse's Note, dated 12/13/2024, revealed R62 returned to the facility from the hospital admission. Review of the facility's document Bed Hold Notice for R62, revealed F2 was notified by phone on 12/16/2024, and the document was signed by facility staff with the notation via phone. In an interview with F2 on 03/12/2025 at 8:48 AM, she stated the facility notified her of R62 being sent to the hospital due to respiratory symptoms in 12/2024, and she was later notified of the facility's policy on the bed hold but believed that call was received after R62 had returned to the facility. F2 stated she did not recall receiving a written copy of the bed hold in the mail or in person from the facility. 5. Review of R91's admission Record revealed the facility admitted the resident on 11/04/2024 with a diagnosis of dysphagia following a stroke. Review of the facility's document Census revealed R91 was sent to the hospital on [DATE] and 11/23/2024. Review of R91's Bed Hold Notice, dated 11/05/2024 and 11/25/2024, revealed R91's representative was made aware of the bed hold notice by facility staff via telephone. 6. Review of R94's admission Record revealed the facility admitted the resident on 03/01/2024 with diagnoses of metabolic encephalopathy, depression, and dementia. Review of the facility's document Census revealed R94 was sent to the hospital on [DATE] and 04/04/2024. The State Survey Agency (SSA) Surveyor requested a copy of R94's Bed Hold Notice, on 03/12/2025 at 3:30 PM, but it was not produced by the facility. Furthermore, there was no documentation by the facility stating any written information was sent to R94's responsible party related to the hospital admissions. 7. Review of R66's admission Record revealed the facility admitted the resident on 10/22/2024 with diagnoses of dementia, congestive heart failure, and chronic kidney disease. Review of the facility's document Census revealed R66 was sent to the hospital on [DATE] and 11/01/2024. Review of R66's Progress Note, dated 10/26/2024, revealed R66's family was notified and updated on the resident's status. Review of R66's Bed Hold Notice, dated 10/28/2024 and 11/01/2024, revealed R66's representative was made aware of the bed hold notice by the facility staff via phone. However, there was no documentation by the facility for either transfer stating written information was sent to R66's responsible party. 8. Review of R68's admission Record revealed the facility admitted R68 on 04/29/2021 with a diagnosis of quadriplegia. Review of the facility's document Census revealed R68 was sent to the hospital on [DATE] and 12/25/2024. Review of R68's Bed Hold Notice, dated 08/26/2024 and 12/26/2024, revealed R68's representative was notified by facility staff and made aware of the bed hold notice via telephone. However, there was no documentation by the facility for either transfer stating written information was sent to R68's responsible party. During interview with the BOM on 03/12/2025 at 3:28 PM, she stated she did not send out written information to the family when a resident was transferred to the hospital. She stated she did not know this was a requirement. During interview with the Administrator on 03/12/2025 at 5:50 PM, he stated resident representatives were called and updated on the resident's status and informed verbally about the bed hold.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to establish or maintain an effective infection prevention and control program, which was essential for providing a safe, sanitary, and comfortable environment while preventing the development and spread of infectious diseases for 5 of 50 sampled residents, Resident (R) 30, R17, R74, F90, and R325. 1. Observation on 03/11/2025 and 03/12/2025 revealed R30's oxygen nasal cannula tubing was dated 02/18/2025, and the humidification water bottle was undated. 2. Observation on 03/11/2025 revealed State Registered Nurse Aide (SRNA) 3 and SRNA5 were seen not hand sanitizing between passing lunch trays for R17, R74, and R90. Further observation on 03/12/2025 revealed SRNA13 touched R90's food with no gloves on and hand hygiene not performed. 3. Observation on 03/12/2025 revealed SRNA8 and SRNA7 entered R325's room, who was on droplet precautions, performed resident care, then exited the room with the used, uncleaned gait belt, and SRNA7 put it in her pant pocket. 4. Observation on 03/12/2025 of R30's wound care revealed Licensed Practical Nurse ( LPN) 1 did not sanitize hands between changing gloves. 5. Observation on 03/13/2025 at 9:45 AM of laundry services revealed gowns were not worn in the laundry while staff handled dirty or soiled linens. The findings include: Review of the facility's policy titled, Hand Hygiene, not dated, revealed all staff would perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applied to all staff working in all locations within the facility. Per the policy's attachment, hand hygiene via either with soap and water or with alcohol based hand rub should be performed before and after applying personal protective equipment (PPE) such as gloves, before and after handling clean or soiled dressings, linens, etc., and during resident care when moving from a contaminated body site to a clean body site. Additional review revealed the use of gloves did not replace hand hygiene, and if the task required gloves, perform hand hygiene prior to donning (putting on) gloves and immediately after removing gloves. Review of the facility's policy titled, Oxygen Administration, revealed staff should change tubing weekly and as needed if it became soiled or contaminated for infection prevention purposes. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, undated, revealed resident care equipment can be a source of indirect transmission of pathogens. The policy also stated that each user is responsible for routine cleaning and disinfection of multi resident items after each use, particularly before use for another resident. Review of the facility's policy titled, Personal Protective Equipment [PPE], undated, revealed, This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. The policy also stated, All staff who have contact with resident and/or their environments must wear PPE equipment as appropriate during resident care and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. Review of the facility's policy titled, Laundry, undated, revealed staff shall consider all previously worn clothing and used linens as potentially contaminated, and laundry staff will be in-serviced to handling linens and laundry on a regular basis. 1. Observation of R30 on 03/11/2025 at 9:32 AM and 03/12/2025 at 11:59 AM revealed she had on oxygen being administered via nasal cannula. Further observation of R30's oxygen concentrator revealed it was hooked to a humidification bottle that was full of water. There was no date on the bottle. The oxygen tubing was dated 02/18/2025. Observation could not be done on 03/13/2025 because R30 was hospitalized on [DATE]. Review of R30's Treatment Administration Record revealed that in January 2025 and February 2025 oxygen tubing was changed weekly on Tuesdays, except for 02/18/2025, which was not marked off. Review of the month of March had both Tuesdays marked for the changing of the tubing. In an interview on 03/12/2025 at 2:35 PM with LPN1, she stated oxygen tubing and the humidification water bottle for administration of oxygen via nasal cannula were changed weekly, on Tuesday evenings. She stated both should be dated the date they were changed. She stated they should be changed to prevent infections. In an interview on 03/13/2025 at 8:11 AM with the Infection Prevention (IP) Nurse, she stated oxygen tubing was changed weekly, and the humidification bottles should be changed when empty or when the oxygen tubing to administer oxygen via nasal cannula was changed. She stated both were to be labeled with the date they were changed. The IP Nurse stated oxygen tubing that was not changed was a source of infection because of bacterial growth. In an interview on 03/13/2025 at 8:18 AM with the Director of Nursing (DON), she stated oxygen tubing and the humidification water bottle should be changed weekly. She stated some individuals that were on continuous high levels of oxygen might need their humidification water bottle changed more frequently, as it might run dry more frequently. She stated that an issue that could result from oxygen tubing dated 2/18/2025 observed on 03/12/2025 and 03/13/2025 still in use would be the user could get a respiratory infection. In an interview on 03/13/2025 at 8:35 AM with the Administrator, he stated oxygen tubing and humidification water bottles needed to be changed weekly or if soiled. He stated both should be dated when changed. He stated an issue that could result from oxygen tubing being used longer than a week could be an infection. 2. On 03/11/2025 at 12:23 PM during observation of the lunch service, two State Registered Nurse Aides (SRNA) 3 and SRNA5, were seen not hand sanitizing between distributing trays for R17, R74, and R90. Further observation on 03/12/2025 at 12:22 PM revealed SRNA13 touched R90's food with no gloves on and hand hygiene not performed. In interviews with both SRNA3 and SRNA5 on 03/11/2025 at 12:40 PM and 12:35 PM respectively, both stated hand hygiene should be performed between each delivered tray, either using alcohol-based hand gel or washing hands with soap and water. In an interview on 03/13/2025 at 8:11 AM with the IP Nurse, she stated staff should hand sanitize between each tray with the alcohol-based hand gel and wash their hands with soap and water after every third tray delivered. She stated if a resident's food was touched, the staff member should wear gloves. In an interview on 03/13/2025 at 8:18 AM with the DON, she stated staff should hand sanitize between each resident's tray with alcohol-based hand gel and wash their hands with soap and water after every third tray delivered or when soiled. In an interview on 03/13/2025 at 8:35 AM with the Administrator, he stated his expectation was that staff should keep their hands clean and not touch the food when distributing meal trays to the residents. He stated if a staff member needed to touch a resident's food, they should wear gloves. He stated hand hygiene should be performed between each tray and when visibly soiled. 3. Observation on 03/12/2025 at 9:21 AM revealed SRNA8 and SRNA7 entered R325's room, who was on droplet precautions, performed resident care, then exited the room with the used, uncleaned gait belt placed in SRNA7's pant pocket. Review of R325's Admission Record revealed the facility admitted R325 on 03/11/2025 with a diagnosis of influenza. Review of the facility's list of Residents on Isolation Precautions, provided by the facility, listed 19 residents, including R325, who was on Droplet Precautions for influenza. During an interview on 03/11/2025 at 12:13 PM with SRNA3, she stated she carried her gait belt around her waist, and each SRNA had their own. She stated she did not clean her gait belt between each resident use. During an interview on 03/11/2025 at 12:15 PM with SRNA4, she stated she had her own gait belt, and she washed it at her house after her shifts. She stated during her shift, between resident use, she used an antibacterial spray provided by the janitor. She stated gait belts were part of their uniform, and they must keep them on person while working. During an interview on 03/11/2025 at 12:17 PM with SRNA5, she stated she sanitized her gait belt with sani-wipes (a disinfectant) between each use. She stated the wipes were kept at the nurses' stations, and it was important not to spread germs. During an interview on 03/12/2025 at 9:21 AM with SRNA8, she stated she had used her gait belt on R325 while in the room and placed it in her pocket when she was finished using it, prior to cleaning it. She stated she was going to clean it with sani-wipes that were at the nurses' station. She stated once she cleaned it, she usually placed it back into her pocket. During an interview on 03/12/2025 at 9:21 AM with SRNA7, she stated she kept her gait belt around her waist, and it was important not to place a dirty shared equipment and a clean shared equipment in the same place to prevent the spread of infection. During an interview on 03/12/2025 at 10:05 AM with the IP Nurse, she stated we've done a lot of verbal and hands on education regarding cleaning shared equipment because the facility had gone through this on the last survey. She stated SRNAs were expected to keep gait belts on them, and they were expected to clean them with sani-wipes after each use. She stated this was important so infections were not transmitted from one person to another. 4. Observation on 03/12/2025 at 12:05 PM of R30's wound care performed by LPN1 revealed she hand sanitized and put on gloves prior to cleaning R30's pressure ulcer with normal saline. LPN1 then removed her gloves and placed on a new pair without performing hand hygiene. She rubbed the zinc cream onto R30's pressure ulcer with her gloved hand and then removed the gloves. Once again, she did not perform hand hygiene prior to placing on a new pair of gloves. Instead, she began to rub the zinc cream on various open sores on R30's hip, abdomen, and shoulder without changing gloves between sites and without washing her hands. In an interview with LPN1 on 03/12/2025 at 12:23 PM, she stated hand hygiene should be done prior to, during, and throughout wound care. When asked if hand hygiene should be performed between each glove change, LPN1 stated yes. LPN1 stated she should have used hand sanitizer each time she changed her gloves, but there was not any in the room, so she did not. LPN1 stated she should have changed gloves when placing zinc cream on different parts of R30's body to prevent contamination of the wounds. In an interview with Unit Manager/Registered Nurse (RN) 1 on 03/12/2025 at 1:59 PM, she stated staff should hand sanitize and change gloves before and after resident care. In an interview on 03/13/2025 at 8:11 AM with the IP Nurse, she stated it was her expectation that staff hand sanitized or washed their hands before and after putting on or taking off gloves. In an interview on 03/13/2025 at 8:18 AM with the DON, she stated her expectation was that hands should be washed or alcohol-based hand gel should be used every time a staff member changed gloves, in addition to prior to and after resident care. In an interview on 03/13/2025 at 8:35 AM with the Administrator, he stated hand hygiene should be performed between glove changes. 51155 5. Observation on 03/13/2025 at 9:45 AM of laundry services revealed gowns were not worn while handling dirty or soiled linens. During an interview on 03/12/2025 at 9:45 AM with the Environmental Supervisor, he stated exam gloves were used while handling dirty laundry, but gowns were only used for laundry from COVID rooms. He stated gowns were not worn otherwise. He stated he did not know what the facility policy stated regarding PPE and dirty linens. During an interview on 03/12/2025 at 9:45 AM with the Laundry and Housekeeping Supervisor, she stated only gloves were worn when handling soiled/dirty laundry, and gowns were only worn when linens were from a COVID positive room. She stated she was not aware of what the facility policy stated regarding PPE and dirty linens. During an interview on 03/13/2025 at 10:45 AM with the DON, she stated it was her expectation that staff follow policies and procedure to keep infections down. During an interview on 03/13/2025 at 4:23 PM with the Administrator, he stated his expectation was that staff properly cleaned shared equipment between resident use to prevent infection and any kind of cross contamination.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to develop and/or implement a Comprehensive Care Plan (CCP) to ensure it met the residents' medical, nursing, mental, and psychosocial needs as identified on his/her comprehensive assessment and other assessments for 2 of 26 sampled residents, Resident (R) 30 and R31. Review of R30's Comprehensive Care Plan [CCP] revealed staff failed to follow the interventions based on the physician's orders for the administration of oxygen. Review of R31's CCP revealed the facility failed to develop a care plan for R31's dialysis catheter. The findings include: Review of the facility's Comprehensive Care Plans policy, not dated, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Further review revealed the facility would notify qualified staff responsible for implementing the care plan when interventions were added to the care plan or when changes were made. Review of the facility's policy titled, Oxygen Administration, not dated, revealed oxygen was to be administered under orders of a physician, except in the case of an emergency. In such case, oxygen was administered and orders for oxygen were obtained as soon as practicable when the situation was under control. 1. Review of R31's Admission Record revealed the facility admitted R31 on 08/02/2018 with diagnoses to include end stage renal disease (ESRD), heart failure, and diabetes. Review of R31's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/31/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating intact cognition. Review of R31's CCP, last reviewed 02/20/2025, revealed R31 did not have a plan on how to care for his dialysis catheter. During interview with R31 on 03/11/2025 at 10:35 AM, he stated he was on dialysis. He further stated he had a port in the right upper chest. R31 also stated it was supposed to be removed the 10th of next month. Observation at the time of the interview revealed a dialysis catheter was sutured into his upper right chest with two lines from the port. The site had approximately 1.5 inch of redness surrounding the port. There was approximately 0.25 inch of dried blood where the catheter entered the skin. During interview with Registered Nurse (RN) 1 on 03/11/2025 at 10:46 AM, she stated R31 had a port, and it was to be removed on 04/10/2025. She further stated staff was just monitoring for infection. She stated staff was not accessing or doing anything with the port. During interview with the Director of Nursing (DON), on 03/13/2025 at 10:55 AM, she stated she expected staff to develop care plans for dialysis catheters. She further stated dialysis catheters needed to be monitored to make sure there was no drainage. 50442 2. Review of R30's Admission Record revealed the facility admitted R30 on 10/07/2021 with diagnoses of acute on chronic diastolic heart failure, chronic respiratory failure with hypercapnia, and chronic obstructive pulmonary disease (COPD). Review of R30's quarterly MDS, with an ARD of 02/17/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating intact cognition. Further review revealed the resident was assessed as needing continuous oxygen therapy. Review of R30's Physician's Orders, dated 12/04/2024, revealed orders for oxygen at four (4) Liters (L) per minute per nasal cannula (NC) continuously. Review of R30's CCP, dated 03/18/2023, revealed R30 had oxygen therapy related to respiratory illness as a focus. The goal of the focus was that R30 would have no signs and symptoms of poor oxygen absorption through the review date of 05/18/2025. One intervention for the care plan focus area was oxygen would be administered at 4 L per minute via nasal cannula. Observation on 03/11/2025 at 9:32 AM revealed R30's oxygen concentrator was set on 5 Liters (L) per minute per nasal cannula (NC), and on 03/12/2025 at 11:59 AM, R30's oxygen concentrator was set on 4.5 L per minute per NC. During interview with Family Member (F) 5 on 03/12/2025 at 11:59 AM, he stated R30 was continuously sent out to the hospital for her oxygen due to exacerbation of her COPD and heart failure. He stated the hospital would fix R30's oxygen level overnight and send her back to the facility. He stated then, it would happen all over again. During interview on 03/12/2025 at 1:44 PM with Kentucky Medication Aide (KMA) 1, she stated R30 wore her oxygen but would not wear her bipap (a device that delivered a continuous positive airway pressure for inhalation and exhalation). KMA1 stated, when R30's oxygen saturation level got low, she would wear the bipap until her carbon dioxide levels decreased, and she became more alert. She stated, however, then R30 would remove the bipap again. During interview with Licensed Practical Nurse (LPN) 1 on 03/12/2025 at 2:35 PM, she stated R30 would wear her oxygen administered by a nasal cannula but would often pull it out of her nose. She stated R30's multiple hospitalization s stemmed from her chronic heart failure (CHF) and COPD exacerbations due to improper oxygenation. She stated she made sure the oxygen concentrator matched R30's orders each shift. She stated if it was not set at the right level (too high) this would increase R30's carbon dioxide levels, and residents like R30 often would say they were short of breath or they would become lethargic. LPN1 stated if the concentrator was set on the wrong amount, she would check the resident's oxygen saturation and change the concentrator back to correct setting. During interview with Unit Manager/RN1 on 03/12/2025 at 1:59 PM, she stated R30 would wear her oxygen provided by her nasal cannula and refused to wear her bipap. RN1 stated staff should check the oxygen concentrator settings and compare it to the order and care plan each shift. She stated if a resident was not on the appropriate administration rate for oxygen as specified in the orders and care plan, she would correct and find out why the concentrator was set higher/lower. She stated if the oxygen administration rate was set higher than ordered, R30's carbon dioxide went up, and she became lethargic and confused. She stated R30 had multiple hospitalization s due to refusing to wear her bipap and having hypercapnia (high carbon dioxide levels) and hypoxia (low oxygen levels). During interview with the DON on 03/13/2025 at 8:18 AM, she stated it was her expectation that staff checked the oxygen orders and the resident's care plan against the oxygen concentrator settings a minimum of each shift. She stated she hoped staff glanced at the concentrator each time they entered a resident's room. The DON stated administration of too much oxygen to a resident with COPD (like R30) caused carbon dioxide to build up which caused hypoxia. She stated she expected staff to follow the CCP for each resident. During interview with the Administrator on 03/13/2025 at 8:35 AM, he stated staff should check the oxygen concentrator each time they went into a resident's room or at a minimum each shift. He stated there could be a problem with too much oxygen being administered to a resident by causing hypercapnia in a resident with COPD. He stated staff should follow the CCPs.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents requiring respiratory care were provided such care consistent with professional standards of practice for 1 out of 3 residents sampled for respiratory care, Resident (R) 30. Observation on 03/11/2025 at 9:32 AM revealed R30's oxygen concentrator was set on 5 Liters (L) per minute via nasal cannula (NC), and on 03/12/2025 at 11:59 AM, R30's oxygen concentrator was set on 4.5 L per minute via NC. However, review of R30's Physician's Orders revealed R30 had orders for oxygen to be administrated continuously at 4 L per minute via NC. The findings include: Review of the facility's policy titled, Oxygen Administration, not dated, revealed oxygen was to be administered under orders of a physician, except in the case of an emergency. In such case, oxygen was administered and orders for oxygen were obtained as soon as practicable when the situation was under control. Review of R30's electronic medical record (EMR) Admission Record revealed the facility admitted R30 on 10/07/2021 with diagnoses of acute on chronic diastolic heart failure, chronic respiratory failure with hypercapnia, and chronic obstructive pulmonary disease (COPD). Review of R30's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/17/2025, revealed the facility assessed R30 to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating intact cognition. Further review revealed the resident was assessed as needing continuous oxygen therapy. Review of R30's Physician's Orders, dated 12/04/2024, revealed orders for oxygen at four (4) Liters (L) per minute per nasal cannula (NC) continuously. Review of R30's Comprehensive Care Plan [CCP], dated 03/18/2023, revealed R30 had oxygen therapy related to respiratory illness as a focus. The goal of the focus was that R30 would have no signs and symptoms of poor oxygen absorption through the review date of 05/18/2025. One intervention for the care plan focus area was oxygen would be administered at 4 L per minute via NC. Observation on 03/11/2025 at 9:32 AM revealed R30's oxygen concentrator was set on 5 Liters (L) per minute via NC, and on 03/12/2025 at 11:59 AM, R30's oxygen concentrator was set on 4.5 L per minute per NC. The State Survey Agency (SSA) Surveyor was unable to observe R30's oxygen concentrator on 03/13/2025 because R30 was hospitalized for low oxygen saturations on the evening of 03/12/2025. In an interview with Family Member (F) 5 on 03/12/2025 at 7:47 PM, he stated R30 was continuously sent out to the hospital for her oxygen issues (exacerbation of her COPD and heart failure), and the hospital would fix her overnight and send her back to the facility. F5 stated it would then happen again. In an interview on 03/12/2025 at 1:44 PM with Kentucky Medication Aide (KMA) 1, she stated R30 wore her oxygen but would not wear her bipap (a device that delivered a continuous positive airway pressure for inhalation and exhalation). KMA1 stated, when R30's oxygen saturation level got low, she would wear the bipap until her carbon dioxide levels diminished, and she became more alert. However, then she would remove the bipap. In an interview with Licensed Practical Nurse (LPN) 1 on 03/12/2025 at 2:35 PM, she stated R30 would wear her oxygen administered by a nasal cannula but would often pull it out of her nose. LPN1 stated she had even found R30 with it on her forehead. She stated she would put the oxygen back on correctly and educate R30 that her oxygen levels would drop if she continued to take off her oxygen. LPN1 stated R30 refused to wear the bipap. She stated most nights R30 would only wear the bipap for a maximum of two to three hours if at all. She stated when R30's carbon dioxide levels went up, R30 became lethargic, and staff would then be able to put on the bipap to help get rid of the increased carbon dioxide. She stated when R30 roused up, she would take the bipap back off. LPN1 stated R30's multiple hospitalization s stemmed from her chronic congestive heart failure (CHF) and COPD exacerbations due to improper oxygenation. LPN1 stated she made sure the oxygen concentrator matched R30's orders each shift. She stated if the oxygen concentrator was not set at the right level (too high) this would increase R30's carbon dioxide levels, and residents like R30 often would say they were short of breath or they would become lethargic. LPN1 stated if the concentrator was set on the wrong amount of oxygen delivered, she would check the resident's oxygen saturation and change the concentrator back to the correct setting. In an interview with Unit Manager/Registered Nurse (RN) 1 on 03/12/2025 at 1:59 PM, she stated R30 would wear her oxygen provided by her nasal cannula, but refused to wear her bipap. RN1 stated staff should check the oxygen concentrator settings and compare it to the order each shift. RN1 stated if a resident was not on the appropriate administration rate for oxygen as specified in the orders, she would correct and find out why the concentrator was set higher/lower. She stated if the oxygen administration rate was set higher than ordered, R30's carbon dioxide increased, and she became lethargic and confused. She stated R30 had multiple hospitalization s due to refusing to wear her bipap and having hypercapnia and hypoxia. RN1 stated she tried to teach and instruct R30 on the importance of wearing her bipap, but R30 still refused to wear it. In an interview with the Medical Director on 03/12/2025 at 6:46 PM, he stated it was his expectation that staff followed his orders for oxygen administration. He stated R30 should wear her oxygen continuously, delivered through her NC, while she was awake and her bipap while she was sleeping. He stated if R30's oxygen saturations fell , it was OK for the nurse to increase the oxygen up to 5 L per minute, but once R30 was stabilized, the nurse should call him and have the order changed. In an interview with the Director of Nursing (DON) on 03/13/2025 at 8:18 AM, she stated it was her expectation that staff checked the oxygen orders against the oxygen concentrator settings at a minimum of each shift. She stated she hoped staff glanced at the concentrator settings each time they entered a resident's room. The DON stated administration of too much oxygen to a resident with COPD (like R30) caused carbon dioxide to build up which caused hypoxia. She stated she expected staff to follow the Physician's Orders and the CCP for each resident. In an interview with the Administrator on 03/13/2025 at 8:35 AM, he stated staff should check the oxygen concentrator each time they went into a resident's room or at a minimum each shift. He stated there could be a problem with too much oxygen being administered to a resident with COPD because the resident could experience hypercapnia. He stated staff should follow the Physician's Orders and the CCPs.

Based on observation, interview, review of the facility's documents, and review of the facility's plan of correction (PoC), dated 05/27/2024, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) process. The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on indicators of the outcomes of care and quality of life that were achieved and sustained for 1 of 50 sampled residents, Resident (R) 325. Observation on 03/12/2025 at 9:21 AM revealed State Registered Nurse Aide (SRNA) 8 and SRNA7 entered R325's room, who was on droplet precautions, performed resident care, then exited the room with a used, uncleaned gait belt placed in SRNA7's pant pocket. Review of the previous survey, dated 04/30/2024 to 05/03/2024, revealed a repeat issue was found with equipment not being cleaned between resident use. Refer to F880 The findings include: Review of the facility's acceptable PoC, for the Standard Recertification/Abbreviated/Extended Survey, concluded on 05/03/2024, revealed the facility was to implement the PoC to ensure the facility achieved substantial compliance by 06/12/2024. However, the facility had a repeat deficiency following the latest survey, concluded on 03/13/2025. Further review of the facility's PoC, for the survey with an exit date of 05/03/2024, revealed the Director of Nursing (DON) visually monitored two different employees per day to confirm equipment cleaning between residents. Furthermore, the PoC stated these observations would be completed three times per week for four weeks then monthly for two months. Review of the facility's Plan of Correction Monitoring Tool revealed the facility would perform weekly audits for two employees, three times per week for four weeks then weekly for two months. The review of audits performed by the Director of Nursing (DON) revealed audits were completed as directed by the PoC from 06/04/2024 to 08/28/2024. Review of the facility's Staff In-Service Attendance Record discussing cleaning and disinfecting shared equipment was dated 05/09/2024, 05/10/2024, 05/17/2024, 05/24/2024, and 05/29/2024. Observation on 03/12/2025 at 9:21 AM revealed SRNA8 and SRNA7 entered R325's room, who was on droplet precautions, performed resident care, then exited the room with a used, uncleaned gait belt placed in SRNA7's pant pocket. During an interview on 03/12/2025 at 9:21 AM with SRNA8, she stated she had used the gait belt while in the resident's room and was going to clean it with sani-wipes (a disinfectant wipe) that were at the nurses' station. She stated that once the gait belt was cleaned, she placed it back into her pocket. SRNA8 stated it was important to clean and store dirty/clean shared equipment properly to stop the spread of infection. During an interview on 03/12/2025 at 9:21 AM with SRNA7, she stated she kept her gait belt around her waist, and it was important not to place a dirty shared equipment and a clean shared equipment in the same place to prevent the spread of infection. During an interview on 03/12/2025 at 10:05 AM with the Infection Prevention (IP) Nurse, she stated we've done a lot of verbal and hands on education regarding cleaning shared equipment because the facility went through this on the last survey. She stated SRNAs were expected to keep gait belts on them, and they were expected to clean them with sani-wipes after each use. She stated that was important so infections were not transmitted from one person to another. During an interview on 03/13/2025 at 10:45 AM with the Director of Nursing (DON), she stated audits related to F880, from the last survey, were performed for at least three months. She stated she no longer performed audits of cleaning shared equipment and hand hygiene. She stated it was her expectation that staff follow policies and procedures to keep infections down. She stated it was her expectation that all the appropriate people attended QAPI meetings for QAPI to be successful. During an interview on 03/13/2025 at 4:23 PM with the Administrator, he stated quality assurance meetings were held every day. He stated during those meetings, if a process was not successful, then adjustments were made to improve it. The Administrator stated he maintained oversight of QAPI. He stated shared equipment should be cleaned and disinfected to prevent infection and any kind of cross contamination.

Based on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of medication package inserts, and review of the facility's policy, it was determined the facility failed to ensure drugs, biologicals, and vaccines were stored per currently accepted professional principles and failed to ensure appropriate environmental controls were used to preserve their integrity. This deficient practice was found in three of four medication storage rooms. Observations of the facility's treatment carts revealed improper storage of medications was found in three of four treatment carts affecting nine residents, Resident (R) 30, R31, R34, R37, R43, R46, R58, R68, and R94. Observation of the Lakeview and Sterling Units' medication refrigerators revealed one influenza vaccine was improperly stored in the door of the medication refrigerators. Observation of the Sterling Unit's medication refrigerator revealed the medication refrigerator's temperature was not maintained between 36 and 46 degrees Fahrenheit (F). The temperature of the refrigerator was at 50 degrees F. Observation of the Lakeview Unit's medication cart revealed multiple boxes of medication for R43 were remained in the cart after the resident was discharged . Observation of the Bluegrass Unit's medication storage room revealed the medication cart was unlocked and the room was unattended. Observation of the Lakeview Unit revealed nursing staff kept the keys to the Medication Room and the refrigerator, which held the controlled substance lock box, in a drawer at the nurse's station. The nursing station was unattended. Observation of the Sterling Unit's Verification of Controlled Substances Count sheets revealed the medication nurse did not sign the sheet at the beginning of the 7:00 AM shift. Observation of the Lakeview, Sterling, and Wisteria Units' treatment carts revealed staff failed to date, discard, and store medications and insulin according to professional standards and in a sanitary manner. The findings include: Review of the Centers for Disease Control and Prevention's (CDC) document, Vaccine Storage and Handling, updated 09/29/2021, revealed vaccines exposed to storage temperatures outside the recommended ranges might have decreased efficacy (result), creating limited protection. Per the document, vaccine temperatures should be monitored and documented at least twice daily if the refrigerator did not have a temperature monitoring device, which read minimum and maximum temperatures. Further review revealed best practices for storage of vaccines was to ensure that vaccines were not stored on the top shelf, floor, or door of the refrigerator as the temperature in these areas might differ significantly from the temperature in the body of the unit. Review of the facility's policy titled, Storage of Medications, no date, revealed drugs and biologicals were stored safely, following manufacturer's recommendations. Further review revealed the medication supply was accessible only to licensed nursing personal and staff members lawfully authorized to administer medications. Medications requiring refrigeration would be stored in a refrigerator in the medication room. Per the policy, outdated, contaminated, or deteriorated (cracked, soiled, or without closers) medications were removed from stock. Furthermore, nursing staff was responsible for maintaining medication storage. In addition, the policy stated compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals were locked when not in use. Per the policy, medication storage conditions were monitored monthly. Review of the facility's policy titled, LTC Facility's Pharmacy Services and Procedures Manual, revised 01/01/2022, revealed the facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with the potential for abuse or diversion. The policy stated the full form of declining inventory, using the controlled substance declining inventory record, should include the resident name, prescription number, medication name, strength, dosage form, dosage with total quantity received, the date and time of administration, the quantity remaining, and the name/signature of the person administering the medication. Per the policy, the facility should ensure the incoming and outgoing nurses counted all Schedule II controlled substances and any other medications with the risk of abuse or diversion at the change of each shift or at least once daily. The policy stated, after the count, the nurses should document the results on the controlled substance account verification sheet. Review of Drugs.com product insert (https://www.drugs.com/) for insulin glargine and insulin lispro, revealed opened (in-use) vials and injection pens, stored at room temperature, should be discarded after 28 days. Review of Drugs.com product insert (https://www.drugs.com/) for Levemir revealed opened (in-use) vials and injection pens, stored at room temperature, should be discarded after 42 days. 1. a. Observation of the Lakeview Unit's medication refrigerator on 04/30/2024 at 9:48 AM, revealed one vial of unopened influenza vaccine was stored improperly in the door of the medication refrigerator. During an interview with Kentucky Medication Aide (KMA) 1 on 04/30/2024 at 9:48 AM, she stated she was unaware staff should not store medications and vaccines in the refrigerator door. She stated the facility provided education on medication storage upon hire, which included checking for expiration dates, dating medications when opened, and discarding any expired medication. She stated the nurse or KMA on the medication cart was responsible to check for expired medications and discard. She stated nursing staff should check the refrigerator to ensure medications were stored properly. KMA1 stated it was important to store medication according to the insert to ensure they remained effective and for the safety of the resident. b. Observation of the Sterling Unit's medication refrigerator on 05/02/2024 at 8:20 AM and 05/02/2024 at 3:15 PM, revealed one vial of unopened influenza vaccine was stored improperly in the door of the medication refrigerator. During an interview with Licensed Practical Nurse (LPN) 5 on 05/02/2024 at 8:25 AM, she stated she was unaware staff should not store medications and vaccines in the refrigerator door. She stated the facility provided education on medication storage upon hire, which included checking for expiration dates, dating medications when opened, and discarding any expired medication. LPN5 stated, if medications were not stored properly, they might not work. 2. Observation of the Sterling Unit's medication refrigerator on 05/02/2024 at 3:15 PM, revealed the temperature inside the refrigerator was 50 degrees F. During an interview with LPN2 on 04/30/2024 at 3:30 PM, she stated the freezer compartment had accumulated ice, and she had turned the temperature up to a higher degree to defrost the freezer. She stated she did not think to move the medications to another refrigerator. LPN2 stated the night shift maintained the temperature log for the refrigerator. She stated that temperatures needed to be checked once daily and should be around 40 degrees F. LPN2 stated the nurse or KMA assigned to the medication carts was responsible for maintaining the cart and the refrigerator. She stated she was not aware of routine medication cart or refrigerator audits. She stated monitoring refrigerators was important to ensure residents' safety. During an interview with LPN1 on 04/30/2024 at 9:38 AM, she stated there was no set time for checking the refrigerator temperatures, but it needed to be done every day on night shift. She stated the temperature should be around 40 degrees F. During continued interview with KMA1 on 04/30/2024 at 9:48 AM, she stated medication refrigerators were checked once daily on night shift. She stated she was unsure of the appropriate temperature range for medication and vaccine storage. She stated it was important to store medications and vaccines at the correct temperature range to maintain their effectiveness. During continued interview with LPN5 on 05/02/2024 at 8:25 AM, she revealed medication refrigerator temperatures were monitored twice daily by the nurse or KMA responsible for the medication cart. LPN5 stated medications must be stored at the proper temperature to ensure their effectiveness. 3. Observation of the Lakeview Unit's medication cart on 04/30/2024 at 8:20 AM, revealed multiple boxes of medication for R43 remained in the cart after the resident had been discharged . The discontinued medications included one box of Vitamin C 500 milligrams (mg), one box of Vitamin D 5000 units (u), one box of loratadine (an antihistamine) 10 mg, one box of omeprazole (a proton pump inhibitor given for heartburn) 40 mg, one box of magnesium 400 mg, one box of potassium 10 milliequivalents, one box of baclofen (a muscle relaxant) 5 mg, one box of Jardiance (a hypoglycemic) 10 mg, and one box of senna (a laxative) 8.6 mg. During an interview with KMA1 on 04/30/2024 at 8:20 AM, she stated R43 was discharged from the hospital on 04/26/2024 and returned to the facility on [DATE] with new medication orders. She stated the facility's policy stated medication for a resident discharged to a hospital should be held for 48 hours. KMA1 stated according to the facility policy, R43's medication should have been taken from the medication cart on 04/29/2024 and sent back to the pharmacy when R43 did not return to the facility within 48 hours. 4. a. Observation of the Bluegrass Unit's medication storage room on 04/30/2024 at 9:40 AM, revealed the medication cart was unlocked, and the room was unattended. During an interview with LPN1 on 04/30/2024 at 9:40 AM, she stated she forgot to lock the cart when she left the medication storage room. She stated medication carts were to be locked when not attended. b. Observation of the Lakeview Unit's medication storage room on 05/02/2024 at 2:30 PM, revealed when KMA4 was searching for the key to the medication refrigerator, which stored the refrigerated narcotic lock box, KMA4 found the keys stored in the top drawer of the desk at the nurse's station. The nurse's station was unattended at the time. Further observation revealed the key to the medication storage room and the key to the refrigerator were on the keychain, allowing anyone possessing the keys to enter the medication storage room, unlock the refrigerator, and access the narcotic box. During an interview with KMA4 on 05/02/2024 at 2:30 PM, she stated the medication cart should be locked inside the medication room, and the nurse or KMA in charge of the medication cart should have access to the keys. She stated this was important to prevent unauthorized staff in the medication rooms. During an interview with LPN5 on 05/02/2024 at 8:20 AM, she stated the medication cart should be locked inside the medication room, and the nurse or KMA in charge of the medication cart should be responsible for the keys to prevent access to medication storage. During an interview with LPN10 on 05/03/2024 at 1:15 PM, she stated the nurse in charge of the medication cart should lock it when it was unattended or while it was stored inside the medication room. She further stated the nurse or KMA in charge of the medication cart should be responsible for the keys to prevent unauthorized access to medication storage. 5. Observation of the narcotic count sheets for both Sterling Unit's medication carts on 05/03/2024 at 9:45 AM, revealed the medication day shift nurse did not sign the Verification of Controlled Substances Count sheet at the beginning of the 7:00 AM shift. Further review revealed there was no verification of the number of controlled substance cards on either cart. Observation of the narcotic count revealed the count was correct. During an interview with LPN11 on 05/03/2024 at 9:45 AM, she stated that it was the facility's policy to sign the controlled drug count record at every shift change to verify that all controlled drugs had been counted and reconciled with the quantity on hand. She stated she did the count with the night shift nurse at shift change but failed to document it on the control sheets. She emphasized the importance of following the facility's policy to ensure the proper reconciliation of controlled narcotics. 6. a. Observation of the Lakeview Unit's treatment cart on 05/03/2024 at 2:40 PM, revealed R43's insulin was not stored in the original packaging received from the pharmacy or in a manner to prevent cross contamination from contact with other pens, medications, or supplies. Furthermore, nursing staff failed to date opened insulin and discard according to product instructions. One vial of R43's Novolog 100 units/milliliter was observed with no opened date. The top of the original packaging was torn off exposing the insulin to light. During an interview with LPN2 on 05/03/2024 at 2:55 PM, she stated all medications should be dated when opened. She stated insulin should be placed in its original packaging to protect the solution from light, and medication that had expired should be discarded appropriately. She stated she was not sure when insulin pens should be discarded after opening. She stated medications should be stored in a manner to prevent cross contamination. b. Observations of the Wisteria Unit's treatment cart on 05/03/2024 at 3:05 PM, revealed multiple residents' insulin pens were not stored in the original packaging received from the pharmacy or in a manner to prevent cross contamination from contact with other pens, medications, or supplies. Furthermore, nursing staff failed to date insulin pens and discard according to product instructions. Observations included: 1) R34's Basaglar (insulin glargine) kwik pen was not stored in its original packaging and was undated; 2) two of R46's Humalog 100 unit insulin pens were not in their original packaging and had opened dates of 04/12 and 04/27 without the year; 3) R58's Humalog 100 unit insulin, dated 04/15, and insulin glargine, dated 04/12, were not in their original packaging; 4) R37's Levemir insulin 100 unit flex pen was not in its original packaging and not dated; 5) R30's Lispro insulin 100 unit pen was not in its original packaging; and 6) R68's Lispro insulin 100 unit pen was not in its original packaging. During an interview with LPN9 on 05/03/2024 at 3:05 PM, she stated all medication should be dated when opened. She stated insulin should be placed in its original packaging to protect the solution from light, and medication that had expired should be discarded appropriately. She stated she was not sure when insulin pens or vials should be discarded after opening but thought it was around 28 days. She stated medications should be stored in a manner to prevent cross contamination. LPN9 stated proper medication storage was important for the safety of the residents and staff. c. Observations of the Sterling Unit's treatment cart on 05/03/2024 at 3:45 PM, revealed: 1) one bag of albuterol inhaler was opened without a date. The remaining 10 vials were unprotected from light, and there was no resident's name on the packaging; 2) one opened bottle of hydrogen peroxide with no opened date; 3) one opened bottle of hydrogen peroxide with an opened date of 12/20; 4) R94's insulin Lispro 100 unit pen was not in the original packaging, and two vials of R94's insulin glargine were opened. One had an opened date of 03/20, and the other was dated 04/27. Both were outside their packaging, which protected them from light; and 5) one package of R31's ipratropium albuterol 3 milliliter vials was opened, with no date, exposing the vials to light. During an interview with LPN5 on 05/03/2024 at 3:45 PM, she stated, per the facility's policy, medication should be stored in its original packaging, and all medication should be dated when opened. If the medication had expired or was past its opened date, she stated, it should be discarded. She stated she was not sure when insulin pens should be discarded after opening. She stated medications should be stored in a manner to prevent cross contamination. She stated following policy was important for the safety of the residents. During an interview with the facility's Pharmacist on 05/03/2024 at 4:53 PM, she stated controlled substances sheets were audited by the Pharmacy to ensure staff was reconciling controlled medication. She stated she had experienced no issues with the facility's audits. She further stated medication and vaccines should be stored according to manufacturer's instructions to protect the safety of the residents. She stated most insulin pens were good for 28 days after opening. She stated most pens and vials should be discarded 28 days after opening. During an interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) on 05/03/2024 at 11:00 AM, she stated vaccines were stored in one refrigerator in the Lakeview Unit's medication storage room. She stated she was unaware there was influenza vaccine in the refrigerator in the Sterling Unit's medication room. She stated all medication should be stored according to accepted standards, and expired medication should be discarded appropriately. The ADON/IP stated Unit Managers (UM) were responsible for auditing medication storage. She stated it was done routinely, but she did not have documentation of any audits. She stated it was important for the safety of the residents. During an interview with the Director of Nursing (DON) on 05/03/2024 at 11:25 AM, she stated she expected the nurses to discard expired medications. She stated nursing staff was educated on medication administration and storage during their orientation upon hire. She stated it was her expectation that medications and vaccines were stored according to currently accepted professional standards and under the appropriate environmental controls to protect the efficacy of the medication and vaccines for the safety of the residents. Furthermore, the DON stated it was her expectation the nursing staff and KMAs followed the facility's policy regarding documentation of controlled medication counts. She stated medication carts should be locked when unattended to prevent unauthorized access to medications. During an interview with the Administrator on 05/03/2024 at 2:22 PM, he stated everyone must follow the facility's policies. He stated it was important for the safety of residents.

Based on observation, interview, and review of the facility's policy, the facility failed to store food under sanitary conditions for three of four nourishment unit refrigerators as determined by observations during survey of ice packs stored in two unit nourishment freezers, and one unit nourishment refrigerator with no thermometer, and no temperature log for April 2024. The findings include: Review of the facility's policy titled, Monitoring of Cooler/Freezer Temperature, dated 2024, revealed logs for recording temperatures for each refrigerator or freezer would be posted in a visible location outside the freezer or refrigerator unit. Further review revealed temperatures would be checked and logged at least twice per day by designated personnel, and thermometers shall be placed inside each cooler/freezer and calibrated at least once per week. Continued review revealed all refrigerator storage must be maintained at or below 41 degrees Fahrenheit (F), and all frozen storage must be maintained at or below -4 degrees F. Observation of the Sterling Unit nourishment refrigerator on 04/30/2024 at 11:46 AM, revealed six ice packs located in the freezer door. Observation of the Lakeview Unit nourishment refrigerator on 04/30/2024 at 11:56 AM, revealed no temperature log and no thermometer for the month of April 2024. Observation of the Bluegrass Unit nourishment refrigerator on 04/30/2024 at 12:56 PM, revealed five ice packs located in the freezer door. In an interview with Licensed Practical Nurse (LPN) 10 on 05/03/2024 at 1:13 PM, she stated it was important to check the refrigerator temperatures to know if the food was stored at an appropriate temperature. She further stated the ice packs stored in the freezer presented a potential for cross contamination, and the ice packs should be stored in the medication storage room. In an interview with LPN8 on 05/03/2024 at 1:37 PM, she stated the AM or PM nurse checked the nourishment refrigerator. She further stated the therapy department stored ice packs in the nourishment freezer to use with residents in rehabilitation. In an interview with the Director of Rehabilitation on 05/03/2024 at 1:44 PM, she stated nursing used ice packs for residents, and therapy had not used ice packs in about two years. She further stated there was potential for cross contamination when stored in the nourishment refrigerator. In an interview with the Director of Nursing (DON) on 05/03/2024 at 3:55 PM, she stated there should be a thermometer and a temperature log to record temperatures. She further stated the ice packs should not be stored in the nourishment freezer with food items due to cross contamination. In an interview with the Administrator on 05/03/2024 at 4:41 PM, he stated his expectation was for the nourishment refrigerators to be used to keep food cold. He further stated the ice packs should not be stored in the unit nourishment refrigerator.

Based on interview, record review, review of the facility's investigation, and review of the facility's policy, the facility failed to ensure alleged violations of abuse were thoroughly investigated for 5 of 11 sampled residents that were reviewed in 7 allegations of resident-to-resident abuse, Resident (R) 27, 168, 368, 94, and 87. The facility failed to provide documented evidence of an investigation in three facility-reported allegations of abuse. These investigations involved R27 and R168, that occurred on 06/30/2023; R368 and R94, that occurred on 07/11/2023; and R368 and R87, that occurred on 09/10/2023. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 10/31/2022, revealed, as part of the identification process, the facility was responsible for taking all necessary actions as a result of the investigation, to include analyzing the occurrence to determine why it occurred, and the changes needed to prevent further occurrences. 1. Review of R27's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include unspecified dementia without behavioral disturbance, adjustment disorder with mixed disturbance of emotions and conduct, and major depressive disorder. Review of R27's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/05/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment. Review of R27's Progress Note, dated 06/30/2023 at 6:00 AM and signed by Licensed Practical Nurse (LPN) 4, revealed R27 and R168 were sitting at the nurse's station. Per the note, R27 reported R168 started yelling at R27 and grabbed R27 by her hair, so R27 grabbed R168 back. LPN4 stated there were no injuries noted. Review of R27's Progress Note, dated 06/30/2023 at 3:51 PM and signed by LPN4, revealed staff witnessed no contact between R27 and R168, with residents redirected to their rooms, 15 minute checks initiated, and the physician and responsible party contacted. Review of R168's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include unspecified dementia with other behavioral disturbance, restlessness and agitation, and anxiety disorder unspecified. Review of R168's quarterly MDS, with an ARD of 05/13/2023, revealed the facility assessed the resident as severely cognitively impaired, and the resident was not able to be interviewed. Review of R168's Progress Note, dated 06/30/2023 at 3:56 PM and signed by LPN4, revealed staff witnessed no contact between R27 and R168, with residents redirected to their rooms, 15 minute checks initiated, and the physician and responsible party contacted. Review of the facility's investigation into the 06/30/2023 incident between R27 and R168, revealed the State Survey Agency (SSA) Surveyor was provided a folder with a handful of pages. One page was the Long Term Care Facility Self-Reported Incident Form, dated 06/30/2023, comprising the facility's initial and final report. This report indicated R27 grabbed R168's hair because R168 was yelling at R27 and touched R27's arm. The other pages in the folder were fax sheets maintained as evidence all appropriate parties, to include the SSA, were notified in the required time frames. The facility's investigation listed three staff as involved in the incident, although only LPN4 could be reached during the investigation. In an interview with LPN4 on 05/02/2024 at 8:00 AM, she stated she had limited recollection of the event. LPN4 stated she remembered hearing yelling, running down the hall, and seeing R27 and R168 seated next to each other in their wheelchairs, yelling at each other, and pulling each other's hair. She stated it was their routine to sit and talk by the nurse's station, and she did not know what triggered the incident. She stated she could not tell what they were yelling about, but it did not look like they were trying to hurt each other. LPN4 stated staff separated both residents, she assessed them, and they were placed on 15 minute checks. She stated she remembered staff kept a closer eye on both of them, although they quickly resumed their routine of sitting together and talking, with no evidence either of them remembered the incident. In an interview with the Administrator on 05/02/2024 at 1:53 PM, when asked to compare this investigation with another investigation, he stated the other investigation had more information, to include statements from witnesses and staff who worked. He stated for a thorough investigation, he would expect staff to try to determine what occurred and to include skin assessments if physical contact occurred or might have occurred unwitnessed. He stated, based on information obtained in a thorough investigation, interventions would be put into place to ensure it did not reoccur. 46710 2. Review of R368's Admission Record revealed the facility admitted the resident on 03/28/2022 with diagnoses including post-traumatic stress disorder (PTSD). Further review revealed the resident's later diagnoses included unspecified dementia with behavioral disturbance, anxiety disorder, and bipolar disorder. Review of R368's significant change MDS, with an ARD of 09/12/2023, revealed the facility assessed the resident to have a BIMS score of 12 out of 15, indicating the resident was moderately cognitively impaired. Further review revealed the facility assessed the resident as having verbal behaviors directed at others for one to three days of the look-back period, but noted the behaviors did not have a significant impact on the resident or other's safety or care activities. Review of R94's Admission Record revealed the facility admitted the resident on 03/10/2023 with diagnoses including metabolic encephalopathy (altered consciousness due to brain dysfunction), dementia with agitation, and anxiety disorder. Review of R94's quarterly MDS, with an ARD of 06/11/2023, revealed the facility assessed the resident to have a BIMS score of six out of 15, indicating severe cognitive impairment. Further review revealed the facility assessed R94 as free of aggressive behavior during the look-back period. Review of the facility's document Incident Note, dated 07/11/2023, revealed a Nurse Aide-State Registered ([NAME]) reported to LPN 10 that R368 hit another resident on the side of the head. Further review revealed staff immediately separated both residents and initiated 15 minute checks. Review of the facility's investigation file, dated 07/11/2023, revealed fax confirmation pages and one page of notes from the Social Services Director (SSD) of interviews with other residents. Further review revealed no residents interviewed were witnesses to the altercation, rather these were statements that the residents interviewed felt safe in the facility. Continued review revealed the facility failed to provide documented evidence of witness interviews, staff statements, or attempts to determine a root cause of the altercation. In an interview on 05/03/2024 at 2:58 PM, the SSD stated her role in abuse allegation investigations was to interview residents with BIMS scores of eight or higher to determine if they experienced any abuse. She further stated it was the role of nursing management to interview staff and complete other parts of the investigation. 3. Review of R87's Admission Record revealed the facility admitted the resident on 12/15/2022 with diagnoses including idiopathic (of unknown cause) hydrocephalus (excess fluid in the brain), severe protein calorie malnutrition, and anxiety disorder. Further review revealed subsequent diagnoses included unspecified dementia. Review of R87s quarterly MDS, with an ARD of 07/21/2023, revealed the facility assessed the resident to have a BIMS score of six out of 15, indicating severe cognitive impairment. Further review revealed the facility assessed the resident as free from aggressive behaviors towards others during the look-back period. Review of the facility's document Health Status Note, dated 09/10/2023, revealed R87 was sitting by the nurse's station when another resident (R368) came out of his room, verbally abused R87, and then kicked her twice. Review of the facility's investigation file, dated 09/10/2023, revealed fax confirmation pages, a half page typed summary of resident information, and a summary of the incident. Further review revealed no witness statements, no list of staff and residents present, and no evidence of evaluation of other residents. In an interview on 05/02/2024 at 10:02 AM, R87 stated she recalled a while back when a male resident got mad and kicked her in the leg, but she did not know why. In further interview, R87 stated staff kept the man away from her after the altercation. In an interview on 05/03/2024 at 9:54 AM, Kentucky Medication Aide (KMA) 2 stated, on 09/10/2023, she came out of the medication room and heard R368 call R87 a whore and kick her. KMA 2 further stated she heard R87 say Oh! and she and another staff member separated the residents. KMA 2 stated she did not see any injuries on R87. In another interview on 05/03/2024 at 5:24 PM, the Administrator stated the person who was the Administrator when the resident-to-resident altercations occurred was no longer with the facility. He further stated the files did not contain enough information to be considered a thorough investigation. In continued interview, the Administrator stated his expectations going forward would be for an investigation into an allegation of abuse include witness statements, a root cause analysis, resident assessments, and staff re-education as necessary.

Based on observation, interview, record review, and review of the facility's documents and policy, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM for 3 of 3 residents sampled for ROM (Resident (R) 1, 37 and 79). Multiple staff interviews revealed the facility currently had no restorative nursing program (RNP). The findings include: Review of the facility's policy titled, Restorative Nursing Programs, undated, revealed it [was] the policy of [the] facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. The RNP [referred] to nursing interventions that [promoted] the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively [focused] on achieving and maintaining optimal physical, mental, and psychosocial functioning. Nursing personnel [were] trained on basic, or maintenance nursing care that [did] not require the use of a qualified therapist or licensed nurse oversight. This training may [have] included, but [was] not limited to: a. maintaining proper positioning and body alignment, b. encouraging and assisting residents, as needed, in turning and position changes, c. encouraging residents to remain active and assisting with any exercises according to the plan of care, d. promoting independence in activities of daily living (ADLs), performing tasks for residents only as needed to ensure completion of tasks, e. assisting residents in adjustment to their disabilities and use of any assistive devices, f. assisting residents with range of motion [ROM] exercises, performing passive ROM for residents who lack active ROM ability, and g. promoting continence with various toileting and/or bowel and bladder training activities. Further review of the facility's policy titled, Restorative Nursing Programs, undated, revealed all residents [would] receive maintenance nursing services as described above, as needed, by certified nursing assistants. The Restorative Nurse and restorative aides (RA) [would] receive additional training on restorative nursing program activities upon hire and as needed. The Restorative Nurse [was] responsible for maintaining a current list of residents who [required] restorative nursing services, and for ensuring that all elements of each resident's program [were] implemented. A resident's Restorative Nursing plan [would] include: a. the problem, need, or strength the restorative tasks are to addressed, b. the type of activities to be performed, c. frequency of activities, d. duration of activities, and e. measurable goal[s] and target date. The discharging therapist, Restorative Nurse, or designated licensed nurse [would] communicate to the appropriate RA, the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan. RAs [would] implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form. The Restorative Nurse, or designated licensed nurse, [would] provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly. Review of the facility's document Daily Staffing, dated 05/03/2024, revealed the facility staffed its' four residential units with 13 nurses, and 22 nurse aides ([NAME]) and certified medication aides (KMA). Additionally, the Daily Staffing document indicated two places for Restorative staff names to be added, indicating they were working that day in the facility. However, no names were written on the two blank lines for two Restorative staff members' names. 1. Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2024, revealed the facility assessed R1 to have functional limitation in ROM impairment on both sides of her upper extremities (shoulders, elbows, wrists, hands). Observation on 05/02/2024 at 8:35 AM, revealed R1 was in her bed in her room at the facility. R1's room was dark. Nurse Aide-State Registered ([NAME]) 13 knocked on R1's door, entered the room, and said good morning to R1. During an interview with the Director of Rehabilitation (DOR) on 05/02/2024 at 9:27 AM, she stated R1 was not currently in therapy and was at baseline, with no therapy goals to achieve. 2. Review of R37's quarterly MDS, with an ARD of 02/06/2024, indicated R37 had functional limitation in ROM impairment on one side of her lower extremity (hip, knee, ankle, foot). Observation on 05/02/2024 at 9:31 AM, revealed R37 was in her bed in her room at the facility eating breakfast. During an interview with R37 on 05/01/2024 at 9:57 AM, she stated she did not know what staff was doing to help her with her limited ROM. During continued interview with the DOR on 05/02/2024 at 9:27 AM, she stated R37 was not in therapy, and R37 was last on the therapy caseload in February 2024. The DOR stated therapy worked with R37 on getting out of bed, changing from sitting to standing, lower body dressing, and wheelchair propulsion. The DOR stated when residents were discharged from therapy, nursing was notified. 3. Review of R79's quarterly MDS, with an ARD of 04/16/2024, revealed the facility assessed R79 to have functional limitation in ROM impairment on both sides of her upper extremities (shoulders, elbows, wrists, hands) and in her hips, knees, ankles, and feet. Observation on 05/03/2024 at 9:05 AM, revealed R79 lying on her back in bed in her room at the facility. R79's head was tilted toward her left side. During an interview with NASR11 on 05/02/2024 at 10:32 AM, she stated, We do ROM with ADLs. [The residents] get ROM when we dress them. NASR11 stated, It hurts [R79] to sit up for a long time, and she wants to go back to bed. During an interview with NASR13 on 05/02/2024 at 4:20 PM, she stated she repositioned R79's leg that was contracted with a pillow. NASR13 stated she had tried to use a neck pillow for R79, but when she did, R79 let her know the neck pillow was uncomfortable. During continued interview with the DOR on 05/02/2024 at 9:27 AM, she stated R79 was not in therapy. The DOR stated she had tried multiple times to get R79's insurance to cover therapy, but they kept denying her coverage because she was at baseline. During an interview with NASR9 on 05/03/2024 at 9:55 AM, she stated she did ROM with residents every time she changed [their brief]. NASR9 stated she would like to have some direction, and it would be helpful to have some guidance on what specific ROM activities to do for each resident. During an interview with NASR3 on 05/03/2024 at 10:30 AM, she stated she recalled at one time the facility had restorative aides (RAs), and those RAs had a list of residents the physical therapy department had referred [to the RNP]. She stated the RAs would do ROM activities and put residents' braces on them. NASR3 stated, We had one aide who would do restorative all the time, and I missed them. NASR3 stated she did not know what had happened to the RA, and the program kind of disappeared. NASR3 stated the facility did not really tell us we had to do restorative, but [the residents] need it, so we do it. NASR3 stated she had not received any specific training on restorative, but I just know [how to do restorative care with residents], and we do what we think we need to do for certain residents. NASR3 stated if she were new to the facility, she would not know how to do restorative care for each resident and she would like to have pictures or diagrams that showed what we should be doing for each resident. During an interview with the Assistant Director of Nursing on 05/02/2024 at 3:24 PM, she stated, At this time restorative is only done with ADLs, and we are hoping to get our restorative program back. During an interview with the Regional Nurse Consultant on 05/02/2024 at 10:45 AM, she stated the facility, since COVID, had not been able to start the RNP again, and ROM was done with donning (putting on) and doffing (taking off) of residents' clothing and other ADLs. During an interview with the Director of Nursing (DON) on 05/03/2024 at 5:45 PM, she stated the facility had a RNP at the facility before she became DON, and she RNP being at the facility was dependent on whether they could get the needed staff. The DON stated the RNP was important to prevent residents from getting contractures and to prevent a decline in residents' ROM abilities. During an interview with the Administrator on 05/03/2024 at 2:14 PM, he stated they have the FTE [full-time equivalent] for a restorative aide. He stated a wage increase had been put through, but the facility currently did not have the staff for an RNP.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the manufacturers' directions for use for the glucometer (blood glucose monitoring device) and disinfectant wipes, and review of the facility's policies, the facility failed to identify and correct problems related to infection prevention practices for 5 out of 57 sampled residents, Resident (R) 31, R37, R43, R49, and R318. Three additional observations of the Bluegrass Unit (BGU) revealed violations of infection control standards. 1. Observation of R37 and R43 revealed staff failed to clean the glucometer (shared equipment) before and after use according to the Environmental Protection Agency (EPA) registered disinfectant manufacturer's instructions. In addition, for both residents, appropriate hand hygiene was not performed. 2. Observation of R318 and R31 revealed staff failed to clean and disinfect a mechanical lift (shared equipment) after use on the residents. 3. Observation on R49 during medication administration revealed the resident was given a medication that had contact with the medication cart surface and the staff's bare hands. 4. Observation of the BGU's portable vital sign machine (shared equipment) revealed it was visibly dirty on the base and the screen. 5. Observation of the BGU's clean linen storage room revealed the facility did not properly store residents' briefs and supplies off the floor in a sanitary manner. 6. Observation of the BGU's medication cart revealed staff did not dispose of disinfecting wipes when they expired. The findings include: Review of the CDC's Guidelines, provided by the facility, titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated [DATE], revealed that reusable or shared medical equipment should be cleaned and disinfected according to manufacturer's instructions or the facility's policies before use on another patient. The guidelines stated facilities were to adhere to the manufacturer's instructions for reprocessing. The guidelines stated facilities should maintain separation between clean and soiled equipment to prevent cross-contamination. Further review of the guidelines revealed staff should be trained in the correct steps for cleaning and disinfection of shared equipment. Review of the facility's policy titled, Routine Cleaning and Disinfection, dated 2023, revealed the purpose of the policy was to ensure routine cleaning and disinfection to provide a safe environment to prevent the development and transmission of infections. Per the policy, routine surface cleaning and disinfection according to manufacturer's recommendations would be conducted with a detailed focus on visibly soiled surfaces. Additionally, staff should adhere to standard precautions when cleaning any soiled material that had the potential to contain a contaminated substance, to include hand hygiene. Review of the facility's policy titled, Glucometer Disinfection, dated 2023, revealed the purpose of the procedure was to provide guidelines for the disinfection of blood glucose sampling devices to prevent transmission of bloodborne diseases to residents and employees. Per the policy, the facility would ensure blood glucometers would be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The policy stated the glucometer would be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that was effective against HIV Hepatitis C and Hepatitis B virus. Review of the cleaning and disinfecting instructions for the Assure Prism Blood Glucose Monitoring System, no date, revealed to minimize the risk of transmitting bloodborne pathogens, the exterior of the glucometer should be cleaned of all dirt, blood, and bodily fluids before performing the disinfection procedure, which would prevent the transmission of bloodborne pathogens. Per the instructions, the exterior of the glucometer should remain wet for the appropriate contact time according to the disinfectant's instructions. Review of the cleaning and disinfecting instructions for the MicroDot Bleach Wipes, undated, revealed to preclean prior to disinfecting the surface. Further review revealed the user was to unfold a clean wipe to thoroughly wet the surface and allow the treated surface to remain wet for a full three minutes to ensure complete disinfection of all pathogens, and then allow the treated surface to air dry. Review of the cleaning and disinfecting instructions for the Sani-Cloth Germicidal Disposable Wipe, undated, revealed to clean and disinfect non-porous surfaces, the user would use one or more wipes as necessary to wet surfaces sufficiently and clean the surface. Further review revealed the user was to unfold a clean wipe to thoroughly wet the surface and allow the treated surface to remain wet for a full two minutes to ensure complete disinfection of all pathogens, and then allow the treated surface to air dry. Review of the cleaning and disinfecting instructions for the One Step Cleaner and Disinfecting Wipe, undated, revealed the item must stay wet for the required one minute dwell time and then air dry to achieve disinfection. 1. a. Observation of Licensed Practical Nurse (LPN) 3 on [DATE] at 8:35 AM, revealed LPN3 performed blood glucose monitoring on R37. The glucometer was stored in a plastic container with other residents' glucose injector pens (not inside the original packaging from the pharmacy), lancets, and test strips. LPN3 did not disinfect the glucometer prior to use and placed it on the treatment cart without a barrier. She took her supplies into R37's room, placing the glucometer and supplies on the bedside table without a barrier. After performing the fingerstick, she put the contaminated glucometer back on the bedside table. LPN3 did not perform hand hygiene (HH) upon leaving the room. She then placed the contaminated glucometer on top of paperwork on the cart and without performing HH, she donned (put on) a new pair of gloves. Using a MicroDot bleach wipe, LPN3 wiped the glucometer, placed it again on the paperwork to dry. She did not wrap the glucometer to stay wet for the required 3 minute dwell time. During an interview with LPN3 on [DATE] at 8:55 AM, she stated she received infection control training upon hire to include hand hygiene (HH), use of personal protective equipment (PPE), and transmission-based precautions (TBP). She stated the facility educated staff regarding infection prevention and control practices (IPCP) annually and during frequent in-service trainings. LPN3 stated staff should use HH before and after resident care and after removing PPE, including gloves. She stated staff should wash hands with soap and water if they came in contact with bodily fluid. Furthermore, LPN3 stated staff should remind each other of IPCP if they saw another co-worker breach protocols or fail to perform hand hygiene. In continued interview with LPN3 on [DATE] at 8:55 AM, LPN3 stated she did not know the dwell time for the MicroDot Bleach Wipes. She stated she thought the dwell time was the same as the dry time. She stated she used two glucometers so that one could dry while the other glucometer was being used. She stated she cleaned the glucometer before and after each use using one wipe and allowed it to dry thoroughly. LPN3 stated all nurses who performed blood glucose monitoring (BGM) received training and had to pass a return demonstration competency given by the Assistant Director of Nursing/Infection Preventionist (ADON/IP). b. Observation of LPN5 on [DATE] at 4:15 PM, revealed LPN5 performed blood glucose monitoring on R43. LPN5 took R43's supplies into her room, placing the glucometer and supplies directly on top of R43's bedside table. After performing the fingerstick, LPN5 put the contaminated glucometer back on R43's bedside table. She doffed (took off) her gloves but did not perform HH upon leaving the room. She placed the contaminated glucometer on a tissue barrier on the treatment cart. She performed HH and donned gloves. Using a One Step Cleaner and Disinfecting Wipe, LPN5 wiped the glucometer and placed it on the same tissue to dry. During an interview with LPN5 on [DATE] at 4:28 PM, she stated the facility educated staff regarding IPCP upon hire and annually. LPN5 stated that staff should perform HH before and after resident care and after removing PPE. She stated HH should be performed after removing gloves. Continued interview revealed LPN5 stated the dwell time for One Step Cleaner and Disinfecting Wipes was round about two minutes. She stated she thought the dwell time was the time it took for the glucometer to dry. LPN5 stated she received blood glucose monitoring (BGM) training from the ADON/IP. 2. a. Observation of Nurse Aide-State Registered ([NAME]) 1 on [DATE] at 9:15 AM, revealed the [NAME] removed a mechanical lift out of R318's room. She took it down the hall and stored it in the Library at the end of the BGU. NASR1 did not clean and disinfect the lift after use on R318. During an interview with NASR1 on [DATE] at 9:24 AM, she stated that the mechanical lift should be cleaned and disinfected after each use and before being stored. She stated the lift was cleaned prior to using it on R318. She stated she was going to clean the lift before using it on the next resident. However, she stated she should have cleaned it immediately before storing it in a public area. NASR1 stated it was important to clean and disinfect shared equipment to prevent the spread of disease. During an interview with NASR4 on [DATE] at 10:01 AM, she stated she received IPCP training upon hire and during monthly in-services. She stated all shared equipment was cleaned after each use. She stated staff cleaned mechanical lifts and portable vital sign equipment between residents to prevent cross-contamination. b. Observation on [DATE] at 4:30 PM revealed NASR9 failed to disinfect the mechanical lift after use with R31, placing the lift in the hallway and entering another resident's room. In an interview with NASR9 on [DATE] at 4:39 PM, she stated she should have disinfected the lift before beginning another resident's care task because another staff member could have used the lift, not realizing it was not clean. She further stated this would have created a risk for cross contamination. 3. a. Observation on the BGU of the Clean Linen storage room on [DATE] at 9:30 AM, revealed residents' supplies including shampoo, lotions, and two briefs, were on the floor and not stored on the shelves. There was also one large bottle of perineal-care wash and one large bottle of body wash stored directly on the floor with visible dust and dirt on it. b. Observation on the BGU on [DATE] at 9:40 AM, revealed the portable vital sign machine in the nurses' station had visible dust and dirt on the base. The screen was covered with multiple fingerprints. During an interview with LPN1 on [DATE] at 9:48 AM, she stated shared equipment should be cleaned between residents. She stated this included lifts and vital sign equipment. She stated she received infection control training upon hire to include HH and the use of PPE. She stated all staff was trained in IPCP upon hire and periodically throughout the year. LPN1 stated all supplies should be kept off the floor and placed on shelves to prevent cross contamination. During an interview with LPN10 on [DATE] at 11:25 AM, she stated shared equipment should be cleaned and disinfected after each use. She stated staff should store all supplies off the floor to prevent contamination. During an interview with the ADON/IP on [DATE] at 9:00 AM, she stated nursing staff ensured supplies and equipment were cleaned and stored correctly according to the facility's policy. The ADON/IP stated staff cleaned mechanical lifts and portable vital sign machines with disinfecting wipes between residents. She stated nursing leadership did daily rounds and looked for any infection control issues. She stated, if an issue was identified, it was brought to the attention of staff, and if necessary, in-service training was provided. 4. Observation of the BGU Medication Storage room on [DATE] at 9:38 AM, revealed a container of Jantex Disinfecting Alcohol Wipes (75%) on top of the medication cart, which had an expiration date of ,d+[DATE]. During an interview with LPN1 on [DATE] at 9:48 AM, she stated she used the wipes to clean the glucometers. She was unsure if the 75% alcohol solution was the appropriate product to use for cleaning and disinfecting of glucometers. She stated further that expired products should be discarded to ensure the effectiveness of the product. During an interview with the ADON/IP on [DATE] at 10:55 AM, she stated expired products should be discarded when expired. She stated nursing staff was responsible for checking the medication carts daily to ensure there were no expired supplies. She also stated it was important to check the expiration dates to ensure the product's efficacy to prevent the spread of infection and disease. 5. Observation of Kentucky Medication Aide (KMA) 2 on [DATE] at 11:35 AM, revealed she was preparing to give a medication to R49. The medication was Gabapentin (given for nerve pain) 100 milligrams oral, to be given whole with a glass of water. Per the observation, KMA2 placed the capsule in a medication cup, which turned the medication cup over, and the capsule landed on the surface of the medication cart. KMA2 picked up the capsule with bare hands and placed it back in the medication cup prior to administering it. During an interview with with KMA 2 on [DATE] at 11:40 AM, after medication administration, she stated she should not have touched the medication with bare hands, adding it could cause contamination, and she knew better. During an interview with the ADON/IP on [DATE] at 11:05 AM, she stated the facility followed CDC guidelines and recommendations related to infection control. She stated, in addition to having the role of IP, she was also the ADON. She stated while she did not keep documentation, she, and nursing leadership (Unit Managers (UM)) monitored staff nurses to ensure they were following the facility's policy and at a minimum, standard precautions. She stated alcohol wipes were not used to clean and disinfect glucometers. She stated nurses should use the MicroDot Bleach Wipes or Sani Wipes according to the manufacturer's instructions. She stated it was her expectation that all staff followed the facility's infection control policies and procedures. The IP/ADON stated it was important to prevent the spread of infection. During an interview with the Director of Nursing (DON) on [DATE] at 11:25 AM, she stated the facility followed IPCP guidelines as per the CDC. She stated she reviewed infection surveillance reports and assisted the ADON/IP and UMs in maintaining a safe environment for the staff and residents. Furthermore, the DON stated she expected all staff members to be responsible for infection control and follow the facility's infection control policies and procedures. She stated having an infection control and prevention program was essential to prevent the spread of infectious and communicable diseases. During an interview with the Administrator on [DATE] at approximately 4:00 PM, he stated infection prevention and control education was provided upon hire for all staff, and it was based on job duties. He stated the facility followed the CDC's recommendations and guidelines related to IPCP, HH, and TBPs. The Administrator stated it was his expectation that all staff followed the CDC guidelines and facility policies. Additionally, the Administrator stated everyone was responsible for infection control and providing a safe environment for the residents and staff. During an interview with the Medical Director on [DATE] at 11:29 AM, she stated it was her expectation that the facility followed infection control guidelines and policies to prevent the spread of infection and to ensure the safety of residents and staff. 45990 46710

Based on observation, interview, record review, and review of the facility's documents and policies, the facility failed to protect residents from abuse for 3 of 11 sampled residents investigated for abuse (Resident (R) 87, 94, and 101). On [DATE], R368 struck R94 on the side of the head. On [DATE], R168 kicked R87 in the leg. On [DATE], R94 kicked R101 in the right knee. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, reviewed/revised on [DATE], indicated it was the policy of [the] facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 1. Review of R368's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses including post-traumatic stress disorder (PTSD). Further review revealed the resident's later diagnoses included unspecified dementia with behavioral disturbance, anxiety disorder, and bipolar disorder. Review of R368's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating the resident was moderately cognitively impaired. Further review revealed the facility assessed the resident as having verbal behaviors directed at others for one to three days of the look-back period, but noted the behaviors did not have a significant impact on the resident or other's safety or care activities. Review of R368's Care Plan, dated [DATE], after the altercation, revealed the facility identified R368 as physically aggressive toward other residents and included interventions such as one-on-one supervision, administering medications as ordered, distracting the resident with favorite candies and conversation about his daughters, and intervening before resident agitation escalated. Review of R94's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses including metabolic encephalopathy (altered consciousness due to brain dysfunction), dementia with agitation, and anxiety disorder. Review of R94's quarterly MDS with an ARD of [DATE], revealed the facility assessed the resident with a BIMS score of six out of 15, indicating severe cognitive impairment. Further review revealed the facility assessed R94 as free of aggressive behavior during the look-back period. Review of R94's Care Plan, dated [DATE], revealed the facility identified R94 as having a behavior problem, including yelling at other residents. Further review revealed the interventions included intervening as necessary to protect the rights of others, redirecting the resident to an alternate location, reminiscing with the resident about fishing, and offering a snack. Continued review revealed the facility added a care plan section following an altercation with another resident (R368) on [DATE], and included interventions such as 15 minute checks, intervening before agitation escalated, and offering diversional activities, such as television. Review of the facility's document Incident Note, dated [DATE], revealed a Nurse Aide-State Registered ([NAME]) reported to Licensed Practical Nurse (LPN) 10 that R368 hit another resident on the side of the head. Further review revealed staff immediately separated both residents and initiated 15 minute checks. Review of the facility's investigation file, dated [DATE], revealed fax confirmation pages and one page of notes from the Social Services Director (SSD) of interviews with other residents. Further review revealed no residents interviewed were witnesses to the altercation, rather these were statements that the residents interviewed felt safe in the facility. Continued review revealed the facility failed to provide documented evidence of witness interviews, staff statements, or attempts to determine a root cause of the altercation. Review of the facility's document Health Status Note, dated [DATE], revealed R368 died in the facility under hospice care. Observation on [DATE] at 1:50 PM revealed R94 sitting in his wheelchair in the unit television room, quietly muttering to himself. Further observation revealed R94 did not disturb other residents nearby. Interview attempted with R94 on [DATE] at 1:53 PM. However, the resident did not respond to the State Survey Agency (SSA) Surveyor's questions. In an interview on [DATE] at 1:30 PM, NASR17 stated she was working at the facility on [DATE]. She further stated she was coming out of another resident's room when she saw R368 and R94 in the hallway together, and R368 hit R94 on the side of the head. NASR17 stated she immediately separated the residents and took R368 back to his room and notified the nurse. Per interview, NASR17 stated she was not sure what caused the altercation. In an interview on [DATE] at 1:01 PM, LPN 10 stated she recalled seeing R94 in the hallway outside R368's room, yelling. LPN 10 stated R368 thought R94 was trying to come into his room, so he went out into the hallway and punched R94 in the side of the head. LPN 10 stated she was not in the hallway when the altercation occurred, but saw the red mark behind R94's right ear. Per interview, LPN 10 notified the Director of Nursing (DON) and the physician and started 15 minute neurological checks to ensure R94 was okay. In an interview on [DATE] at 2:28 PM, the SSD stated her role in investigating allegations of abuse was to interview residents and fax in the reports when the Administrator finished the investigation. In further interview, the SSD stated R368 was triggered by loud noises and R94 was known to yell out, so she believed this was the cause of their altercation. In an interview on [DATE] at 3:59 PM, the DON stated she was not the DON at the time of the altercation between R368 and R94 and was not aware of the specifics of the allegation. In further interview, the DON stated it was her expectation that staff de-escalated agitated residents, kept residents safe, and reported any altercations immediately. In an interview on [DATE] at 5:24 PM, the Administrator stated he did not work for the facility at the time of the altercation between R368 and R94, but he expected staff to be aware of residents who were easily agitated and protect vulnerable residents who might be in their vicinity. He further stated staff should implement resident specific interventions to meet the resident's psychosocial needs to prevent resident-to-resident altercations. 2. Review of R87's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses including idiopathic (of unknown cause) hydrocephalus (excess fluid in the brain), severe protein calorie malnutrition, and anxiety disorder. Further review revealed subsequent diagnoses included unspecified dementia. Review of R87s quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of six out of 15, indicating severe cognitive impairment. Further review revealed the facility assessed the resident as free from aggressive behaviors toward others during the look-back period. Review of R87's Care Plan, dated [DATE], revealed the facility assessed the resident as wandering throughout the facility and having impaired cognitive function. Further review revealed the facility included interventions such as supervising the resident as needed and distracting the resident from wandering by offering food and conversation. Review of the facility's document Health Status Note, dated [DATE], revealed R87 was sitting by the nurse's station when another resident (R368) came out of his room, verbally abused R87, and then kicked her twice. Review of the facility's investigation file, dated [DATE], revealed fax confirmation pages and a half page typed summary of resident information and a summary of the incident. Further review revealed no witness statements, no list of staff and residents present, and no evidence of evaluation of other residents. In an interview on [DATE] at 10:02 AM, R87 stated she recalled a while back when a male resident got mad and kicked R87 in the leg, but she did not know why. In further interview, R87 stated staff kept the man away from her after the altercation. In an interview on [DATE] at 9:54 AM, Kentucky Medication Aide (KMA) 2 stated, on [DATE], she came out of the medication room and heard R368 call R87 a whore and kick her. KMA 2 further stated she heard R87 say Oh!, and she and another staff member separated the residents. KMA 2 stated she did not see any injuries on R87. In an interview on [DATE] at 10:38 AM, [NAME] 11 stated she was behind the nurse's desk when R368 kicked R87, and she ran to separate the residents because R368 became agitated so quickly when there were loud noises. [NAME] 11 stated she did not recall any specific noises that might have triggered R368, but she knew the increased activity at the nurse's station would not help the resident calm down, so she directed him back to his room. In an interview on [DATE] at 2:58 PM, the SSD stated she recalled interviewing R368 after the altercation with R87, and R368 did not remember the incident and could not provide a reason for kicking R87. The SSD stated R87 stated in an interview the day after the incident that she (R87) did not recall the event either. The SSD stated neither resident displayed psychosocial changes after the incident. In an interview on [DATE] at 3:59 PM, the DON stated she was not the DON at the time of the altercation between R368 and R87 and was not aware of the specifics of the allegation. The DON stated it was her expectation that staff de-escalated agitated residents, kept residents safe, and reported any altercations immediately. In an interview on [DATE] at 5:24 PM, the Administrator stated he did not work for the facility at the time of the altercation between R368 and R87, but he expected staff to be aware of residents who were easily agitated and protect vulnerable residents who might be in their vicinity. He further stated staff should implement resident specific interventions to meet the resident's psychosocial needs to prevent resident-to-resident altercations. 3. Review of R94's Admission Record revealed the facility admitted R94 on [DATE] with diagnoses that included unspecified psychosis not due to a substance or known physiological condition; age-related physical debility; major depressive disorder, recurrent; and dementia .with agitation. Further review revealed R94 resided in the facility's Sterling Place unit. Review of R94's annual MDS, with an ARD of [DATE], revealed R94 the facility assessed the resident to have a BIMS score of six out of 15, which indicated the resident was severely cognitively impaired. Review of R101's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses that included Alzheimer's disease with late onset; unspecified hearing loss, bilateral; and other abnormalities of gait and mobility. Further review revealed R101 resided in the facility's Wisteria unit. Review of R101's quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of six out of 15, which indicated the resident was severely cognitively impaired. Observation on [DATE] at 2:25 PM, revealed R101 ambulated from within her room at the facility to the room's door to greet the State Survey Agency (SSA) Surveyor. During an interview on [DATE] at 2:30 PM, R101 stated she felt safe in the facility, and there was never a time when she did not feel safe. When R101 was asked about being kicked in the knee by another resident last year, R101 could not recall the event and stated she had trouble with her hearing. Observation on [DATE] at 4:25 PM, revealed R94 was seated in his wheelchair near the nurse's station of the unit where R101 lived. R94 was able to self-propel himself throughout the unit and did so. During an interview on [DATE] at 4:30 PM, when R94 was asked if he kicked R101 last fall, R94 stated he did not kick her, and I do not remember that. Review of the document Long Term Care Facility - Self-Reported Incident Form Part B: Description of Incident, signed by LPN14 on [DATE], revealed [R94] kicked [R101] in the right knee. No injuries. Immediately seperated [sic] residents. Review of the document Long Term Care Facility - Self-Reported Incident Form Part C, signed by the Assistant Director of Nursing (ADON) on [DATE], revealed the summary of the investigation was, Upon investigation it was determined that [R94] rolled in w/c [wheelchair] behind [R101] and hit her in the back of the leg, facility determined physical altercation occurred. No injuries [were] noted. No redness noted. Residents were immediately separated and [R94 was] on 15 minute checks [meaning staff were to check on R94 every 15 minutes]. Review of the document Resident Abuse Report/Investigation Form, undated, indicated the date of the incident between R94 and R101 was [DATE] at 5:40 PM. The location of the [DATE] incident was in the facility's Wisteria hallway, which was the hallway where R101 resided. The Form indicated [NAME] 19 witnessed and reported the incident and described the incident as R94 kicked R101 [on the] back of [her] right knee. The Form indicated the immediate action taken to protect the resident by NASR19 was separation of residents. R94 [was taken] back to his unit [and] placed on 15 minute checks. During an interview on [DATE] at 2:03 PM, NASR19 stated she recalled seeing R94 kick R101 one day last October. NASR19 stated, When he kicked her, he had behavior issues. [R101] walked in front of [R94], and he just kicked her. [NAME] 19 stated when R94 kicked R101 she immediately had R101 go sit down on the couch. [NAME] 19 stated the nurse came and checked her out, and there was not even a mark on her leg. During an interview on [DATE] at 4:12 PM, LPN14 stated abuse prevention included supervision of residents and being aware where they are, especially those who have the potential to be involved in resident-to-resident altercations. She stated staff had to know all the time where R94 was, and when LPN14 saw R94 getting close to people he needed to be redirected because R94 could get loud and combative. LPN14 stated she did not see R94 kick R101, but R94 and R101 were immediately separated, and R94 was put on one-to-one supervision, meaning a nursing staff member would continuously supervise R94. LPN14 also stated she and another nurse did skin assessments on non-interviewable residents and had no concerns. During an interview on [DATE] at 5:45 PM, the Director of Nursing (DON) stated she expected all staff to report any resident-to-resident altercations to their supervisor. Regarding R94, the DON stated, He is a wanderer and should be watched closely. During an interview on [DATE] at 1:53 PM, the Administrator stated he expected a full assessment of residents after resident-to-resident incidents. He also expected staff who were working at the time, along with any witnesses, to be interviewed to try to determine pertinent background information. Further interview revealed the Administrator stated the facility then wanted to put interventions in place to ensure [resident-to-resident] abuse did not happen again. 46710

Based on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to ensure residents received adequate supervision to prevent accidents. The facility failed to ensure hot liquids were at a safe temperature and were served in an appropriate container for one (1) of three (3) sampled residents reviewed for accident hazards out of a total of twenty-seven (27) sampled residents (Resident #1). Resident #1, who the facility assessed as requiring supervision (oversight, encouragement, or cueing) and support from staff for set up help only with eating, was served a cup of coffee in a Styrofoam cup with a lid on 08/24/19; instead of the correct hot beverage plastic drinking cup. Subsequently, Resident #1 spilled hot coffee resulting in a second degree burn to the right thigh. The findings include: Review of the facility's Policy titled, Accidents and Supervision dated 11/01/18, revealed the resident environment should remain as free of accident hazards as possible and each resident should receive adequate supervision to prevent accidents. This includes identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks and communicating the interventions to all relevant staff; and monitoring for effectiveness and modifying interventions when necessary. Accident refers to an unexpected or unintentional incident which results in injury or illness to a resident. A Policy related to food/fluid temperatures at point of service was requested; however, not submitted for review. Interview with the Director of Nursing (DON), on 08/29/19 at 3:00 PM, revealed the facility did not have a policy related to resident safety with hot beverages, nor did the facility complete assessments/evaluations on residents related to resident safety with hot liquids prior to 08/24/19. Review of Resident #1's medical record revealed the facility admitted the resident on 09/29/17 with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan (CCP), revised 07/26/19, revealed the resident had a self-care deficit problem due to limited physical mobility related to general weakness. The goal stated the resident would maintain level of mobility. There were several interventions including extensive assist of one (1) staff for bed mobility, transfers, locomotion in wheelchair, toileting and personal hygiene. Further review revealed the resident fed self after tray prep with supervision as needed. Review of the Nutritional Assessment, dated 08/05/19, completed by the Registered Dietician, revealed the resident received a regular diet with thin liquids and had no problems with chewing or swallowing. Further review revealed the resident fed self after set up help. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 08/07/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a six (6) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring supervision (oversight, encouragement, or cueing) and support from staff for set up help only with eating. Review of the Incident Report, completed by Licensed Practical Nurse (LPN) #1, revealed on 08/24/19 at 10:30 AM, Resident #1 was served coffee in his/her room and spilled the coffee, sustaining a right thigh burn. Per the Report, there were no witnesses to the event. Further review of the Report, revealed the Physician was immediately notified and orders were received for [MEDICATION NAME] Cream. The family was notified on 08/24/19 at 3:36 PM. Review of the CCP initiated 08/24/19, revealed the resident sustained [REDACTED]. There were several interventions including administer medications and treatments as ordered; air mattress; assess right leg for infection; and monitor nutritional status. Review of the physician's orders [REDACTED]. Review of the Nurse's Note, dated 08/24/19 at 11:10 AM, written by the DON, revealed she spoke with Resident #1's Daughter and explained treatment was in place related to the burn and informed her the resident could be sent to the emergency room (ER) if she desired. Per the Note, the Daughter declined sending the resident to the ER. Review of the Nurse's Note, dated 08/24/19 at 3:47 PM, written by LPN #1, revealed the resident was served coffee from the kitchen, spilled coffee on his/her right thigh and sustained a burn. Per the Note, the DON and Administrator were notified. Additional review of the Note, revealed the Physician was notified and orders were received for [MEDICATION NAME] Cream to areas. The subsequent Nurse's Note dated 08/24/19 at 8:56 PM, revealed treatment was completed to the burn on the resident's right upper side of the leg and clear fluid was draining from large blisters. Per the Note, the resident denied pain. Review of the Doctor's Progress Notes, dated 08/26/19 at 4:00 PM, revealed Resident #1 sustained an accidental burn to the right thigh and had a large bullous blister and excoriation. Review of the Resident Investigation Form, signed by the Administrator on 08/26/19, revealed on 08/24/19 at 10:30 AM, Resident #1 received coffee from the kitchen and sustained a burn to the left thigh. The Physician was notified and an order was received for [MEDICATION NAME] twice a day. Per the Investigation Form, staff was educated on not serving hot beverages in Styrofoam cups and the need to serve hot beverage in regular coffee cups with lids. Further review of the Investigation Form, revealed temperatures were lowered on the coffee pot in the kitchen; and each unit would have a thermometer to test the temperatures of hot liquids. Review of the Long Term Care Facility-Self Reported Form Five (5) Day Follow Up/Final Report, signed by the DON, on 08/28/19, revealed per employee interviews, Resident #1 was served coffee from a Styrofoam cup with a lid. The employee placed the cup on the resident's tray and exited the room. The employee heard the resident yell out and entered the room at which time the resident stated, my pants are wet. Per the Report, the employee stated she removed the resident's pants and noted the resident spilled coffee, at which time she went to get the nurse. Additional review of the Report, revealed education was started on 08/24/19 regarding serving hot beverages; the facility devised the Hot Liquid Safety Policy and began education on Policy on 08/27/19; hot beverage audits on temperatures began on 08/24/19 and would continue in dietary department; and two (2) employees were terminated who were directly involved with the incident (State Registered Nurse Aide (SRNA) #1 and SRNA #2). Review of the Attached written Statement by SRNA #2, undated, revealed Resident #1 asked for a cup of coffee and she went to the kitchen to get the coffee. Per the Statement, a brand new girl handed her a cup of coffee in a Styrofoam cup with a plastic lid and the lid on the cup was sealed. Review of the Wound Physician's Note, dated 08/27/29, revealed the resident was seen at bedside at the facility for a burn to the right lateral thigh which measured 22 centimeters (cm) length x 5.5 cm width x not measurable depth with light serous exudate, 100 % percent dermis, and fluid filled blister. The Note stated the resident sustained [REDACTED]. and appeared to be at least a second degree burn. Per the Note, treatment options were discussed with resident and Daughter. According to the Note, the Wound Physician recommended sending the resident to the burn unit at the University Hospital for further evaluation, but the resident was palliative care and the resident and Daughter did not want this. Per the Note, the resident's and Daughter's wishes would be respected. Recommendations were to off load the wound, vitamin C 500 milligrams (mg) twice daily, multivitamin once daily, zinc sulfate 220 mg once daily, and silver [MEDICATION NAME] apply twice daily with Gauze Island for fourteen (14) days. Observation of meal service on 08/27/19 at 12:45 PM, revealed all residents were served in dining area with plastic cups with safety lids applied. There was no visual confirmation of Styrofoam cups being dispensed by the kitchen for hot soups or beverages. Observation of the Breakfast meal on the Wisteria Unit where Resident #1 resided, on 08/29/19 at 8:45 AM, revealed all resident trays were delivered with no presence of Styrofoam cups. Resident #1 was observed to have the meal tray set up by staff and his/her coffee was dispensed in a plastic cup with a lid. LPN #1 cued the resident to eat and supervised the resident while he/she was drinking coffee. Observation on 08/29/19 at 1:30 PM, of Resident #1's burn wound, and dressing change performed by LPN #2, revealed the wound to the resident's right thigh appeared as skin excoriation and decompressed blisters with redness of the entire area, with signs of new dermal formations present. The nurse cleansed the wound with Normal Saline and 4 x 4 gauze, and applied Silvadine cream to the entire burn area, and applied the dressing as per the physician's orders [REDACTED].#1 denied any pain during the procedure. Interview was attempted with Resident #1, on 08/27/19 at 10:30 AM, and the resident stated he/she could not recall how he/she acquired the wound to his/her hip and upper thigh. He/she denied having any pain from the wound. Interview with Resident #1's Daughter, on 08/27/19 at 11:00 AM, revealed she received a telephone call on 08/24/19 from the facility explaining Resident #1 sustained a burn to his/her right leg from spilling a cup of coffee which had been given to the resident in a Syrofoam cup. Continued interview revealed she requested Resident #1 not be transferred to the ER and that all treatment be carried out at the facility as the family wanted to keep the resident comfortable and an extensive hospitalization may cause the resident to decline. Continued interview revealed Resident #1 did not remember the exact details of how the burn occurred when family inquired as to how the incident happened. Interview with SRNA #1, on 08/28/19 at 8:16 AM, revealed on 08/24/19 after breakfast between 9:00 AM and 10:00 AM, she witnessed Resident #1 ring the call bell and ask for coffee. SRNA #1 stated she walked to to the Kitchen with SRNA #2 who was new and on orientation. SRNA #1 stated SRNA #2 came out of the kitchen carrying a Styrofoam cup with a lid on the cup. Per interview, the temperature of the coffee was not checked at the time by the SRNAs because dietary staff checked coffee temperatures. Continued interview revealed she witnessed SRNA #2 set the coffee on the resident's table beside the chair where the resident was sitting, and then SRNA #1 and SRNA #2 continued resident care with other residents on the unit. Per interview, shortly thereafter, Resident #1 began to scream, and when she entered the resident's room, the resident had spilled the coffee and LPN #1 was notified. SRNA #1 could not recall if the coffee cup had lost its integrity or if the lid was still on the cup upon finding the resident had spilled his/her coffee. Further interview revealed after the incident she was informed by kitchen staff that coffee had to be delivered in plastic cups and not Styrofoam cups, but she had never been educated related to this prior to the incident with Resident #1. Per interview, SRNA #1 had seen residents being served hot drinks in Styrofoam cups in the past. Interview with SRNA #2, on 08/28/19 at 8:30 AM, revealed she was in the orientation period as she was a new hire and was assigned to Resident #1 on 08/24/19. SRNA #2 stated she was orienting with SRNA #1 when Resident #1 asked her for a cup of coffee. Per interview, she went to the dining room and informed kitchen staff and SRNA #3 handed her the cup of coffee in a Styrofoam cup with the lid from the kitchen door. She stated she took the coffee to the resident's room and placed the cup on the table by the chair where the resident was sitting. Continued interview revealed a short time later, while conducting rounds, Resident #1 was heard screaming out, and upon entering the resident's room Resident #1's pants were wet and the resident complained his/her leg was hurting. SRNA #2 stated the coffee had spilled on the resident's leg, but she could not recall if the cup had lost its integrity causing the coffee to spill out or if the lid was still on the cup. SRNA #2 stated at this point Resident #1's nurse, LPN #1 was called into the room along with the weekend Supervisor/Registered Nurse #1. Further interview revealed she had not been educated related to the need to use plastic cups and not Styrofoam cups for hot beverages, prior to the incident on 08/24/19. Interview with SRNA #3, on 08/28/19 at 9:45 AM, revealed SRNAs were not allowed to go into the kitchen and she did not recall going into the kitchen on 08/24/19 and obtaining a cup of coffee to hand SRNA #2. Per interview, she had been trained in the past that Styrofoam cups were not to be used to serve hot liquids. Interview with LPN #1, on 08/29/19 at 1:30 PM, revealed on 08/24/19 she was working on the Wisteria unit and was assigned to Resident #1. Per interview, on that date during midmorning she was called to Resident #1's room by SRNA #1 and SRNA #2 who stated the resident spilled coffee on himself/herself. She stated when she entered the room, she noted the Styrofoam cup was upright on the table by the chair and the cup had a safety lid in place, but the lid was loose. Further interview revealed she assessed the resident and noticed there was a red area on the resident's right thigh, and she immediately notified the Physician who ordered [MEDICATION NAME] treatment. LPN #1 stated she then notified the resident's Daughter of what happened, and the Daughter stated she did not want the resident sent to the Hospital ER as the resident had a recent referral for a palliative care consult. Further interview with LPN #1, revealed the weekend Supervisor/RN #1 went to the kitchen to investigate as to why the resident had been served coffee from the kitchen in a Styrofoam cup. Additional interview revealed Resident #1 was independent with eating and could drink hot beverages independently in plastic lids with cups. LPN #1 stated she felt the burn could have been prevented if staff had not served the resident coffee in a Styrofoam cup as the hot liquid plastic cups were better designed to be safe. LPN #1 stated she had been informed not to put hot liquids in Styrofoam prior to the incident, but did not know if it was a formal inservice. Interview with the Weekend Supervisor/RN #1, on 08/29/19 at 2:15 PM, revealed on 08/24/19, she responded to an incident where Resident #1 spilled hot coffee on himself/herself from a Styrofoam cup. She stated she and the DON immediately initiated an investigation and concluded Resident #1 was given a Styrofoam cup of coffee with a lid, and shortly afterward spilled coffee on his/her right leg. Per interview, the investigation revealed SRNA #2 gave the cup of coffee to the resident; however, it was not clear as to who prepared the coffee in the kitchen for the resident and handed the cup of coffee to SRNA #2. Continued Interview revealed Resident #1's family did not want the resident sent to the ER and the burn was treated in the facility with [MEDICATION NAME]. RN #1 stated education was provided to all staff after the incident related to hot coffee was not to be served in Styrofoam cups, and she further stated she had received education related to this prior to the incident. Interview with Dietary Aide # 1, on 08/29/19 at 10:30 AM, revealed even though only dietary staff was to be in the kitchen, certain SRNAs did not abide by that policy. Per interview, SRNA #3 was in the kitchen on 08/24/19 midmorning while kitchen staff was in the process of preparing lunch; however, she did not notice if SRNA #3 poured a cup of coffee during that time. She further stated she did not recall anyone asking dietary staff for a cup of coffee for Resident #1 on 08/24/19 during midmorning. Further interview revealed the Coffee temperature was 150 degrees Fahrenheit (F) in the pot on the morning of 08/24/19 when it was tested earlier at breakfast. Additional interview revealed dietary staff knew not to serve hot beverages in Styrofoam cups. Per interview, hot coffee was to be served in plastic cups with a lid and there was no shortage of plastic cups on 08/24/19. Review of the facility's Temperature Log, dated 08/24/19 at breakfast, revealed the coffee temperature was one hundred fifty (150) degrees Fahrenheit (F) for the morning serving. Interview with the Dietary Manager on 08/28/19 at 10:45, revealed 150 degrees F was an acceptable temperature for coffee in the pot and it would cool once poured into a cup. Further interview revealed hot coffee had to be served in plastic cups with a lid. She stated this was because the plastic hot liquid cups could not be eroded, warped, or broken. Further interview revealed the kitchen never ran out of the plastic hot liquid cups. Continued interview revealed all nursing and dietary staff was specifically trained on this facility practice. Further interview revealed she had witnessed SRNAs to come into the kitchen and help themselves; however, only dietary staff should be in the kitchen. Continued interview revealed accurate coffee temperatures were obtained and recorded on the morning of 08/24/19 with coffee temperatures consistent with normal preparation. Interview with SRNA #4, on 08/28/19 at 11:45 AM, revealed she was not working on 08/24/19; however, was frequently assigned to Resident #1. Per interview, Resident # 1 required meals to be set up, and some verbal cueing, but was capable of feeding self and capable of handling glasses and cups and drinking independently. Per interview, Resident #1 frequently drank coffee independently in his/her room. Further interview revealed she learned upon hire that in no circumstance was a resident to receive a hot liquid drink in a Styrofoam cup. Interview with LPN #2, on 08/29/19 at 2:00 PM, revealed she was frequently assigned to Resident #1 and the resident could feed himself/herself and often drank coffee independently in his/her room. LPN #2 stated all hot drinks were to be covered with safety lids. Further, she had been informed prior to and after 08/24/19, to not put hot drinks in Styrofoam cups as the plastic hot beverage cups were safer. Interview on 08/29/19 at 1:45 PM, with Unit Supervisor/RN #2, who was the Supervisor of the Wisteria Unit where Resident #1 resided, revealed Resident #1 required meal setup and cues to eat. Per interview, the resident liked to drink coffee independently and had never had an incident in the past to her knowledge until the incident on 08/24/19 when he/she spilled the coffee. Unit Supervisor/RN #2 stated under no circumstances was staff permitted to give hot liquids in Styrofoam cups as they were not as safe as the plastic cups that were to be used for hot beverages. Interview with the Staff Development Coordinator, on 08/29/19 at 2:30 PM, revealed she was new to the position and had been in her current role only a few months. She stated to her knowledge there had been no formal staff education in the past related to the need to use hot beverage plastic cups instead of Styrofoam cups for hot beverages. However, she stated after the incident on 08/24/19, with Resident #1 sustaining the burn from the hot coffee, education was being provided for all staff. The State Agency Representative phoned Resident #1's Attending Physician on 08/29/19 at 2:45 PM, and a message was left with no return phone call. Interview with the DON, on 08/29/19 at 3:00 PM, revealed on 08/24/19 she received a phone call related to the incident where Resident #1 spilled hot coffee and sustained a burn. Per interview, the Physician was immediately notified of the burn and orders were received for [MEDICATION NAME] treatment which the facility immediately retrieved from a nearby pharmacy. The DON stated the resident's family was asked several times if hospitalization was desired; however, the family was adamant they did not want the resident sent to the Hospital ER. Additional interview with the DON, revealed she initiated an investigation on 08/24/19 and started interviewing staff as to how the resident received a Styrofoam cup. Per interview, SRNA # 2 admitted to giving the resident the hot coffee in the Styrofoam cup; however, no staff member admitted to dispensing the coffee from the kitchen or giving SRNA #2 the cup of coffee for Resident #1 on the morning of 08/24/19. Continued interview revealed, it had always been a rule to not serve hot beverages in Styrofoam cups. She stated hot liquids were to be served in plastic hot liquid cups with a safety lid; however, she was unaware if staff had been educated during inservices related to this rule. Further, the DON stated new policies and education were being instituted in an attempt to prevent further accidents from hot beverages. Post survey phone interview with the Administrator, on 09/11/19 at 3:05 PM, revealed there was no written policy in effect related to serving hot beverages nor was there an assessment tool in place for screening residents at risk [MEDICAL CONDITION] to hot beverages prior to 8/24/19 when Resident #1 sustained the burn. Per interview, staff had been informed in the past they needed to be sure to use the hot beverage plastic cups for hot liquids such as coffee instead of the Syrofoam cups because the safety lids worked better on the plastic cups. However, further interview revealed there was no documented evidence of formal education presented to staff related to this prior to 08/24/19. She stated this information was just passed along from staff members to other staff members in the past, but after the accident occurred related to Resident #1 sustaining a burn, formal education began in an attempt to prevent recurrence. The Administrator stated, Honestly, it feels like it was unfortunate accident, as the wrong style of cup was used.

Based on observation, interview and record review, it was determined the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of their individuality for four (4) sampled residents (Residents #2, #16, #18 and #19) and two (2) unsampled residents (Unsampled Residents C and D). Group Interview, on 06/25/13 at 3:00 PM, revealed some residents complained there were bathroom lines, after lunch, on the Wisteria Unit and that some of the residents cried and fussed when in line. Interviews with Residents #2, #16, #18, and #19 and Unsampled Residents C and D revealed they preferred to use the bathrooms in their own rooms, but were taken to the common bathroom, beside the nurse station, to be toileted. They stated they sometimes had to wait a long time and as a resulted soiled themselves making them feel bad. The findings include: Interview, on 06/28/13 at 6:05 PM, with the Director on Nursing (DON) revealed it was the residents choice to determine what bathroom they preferred to use, the common bathroom or the bathroom in their room. She further stated staff should not line up residents to use a bathroom, unless the resident stated they wanted to use the common bathroom. At the Group Interview, on 06/25/13 at 3:00 PM, Resident #16 and Unsampled Resident H revealed there were bathroom lines, after lunch, on Wisteria and some of the residents cried and fussed when in the line. Residents at the group interview reported they thought all residents had bathrooms in their rooms. Record review of the April 15, 2013 "Windsor Care Resident Council Minutes" under "New Business" revealed residents reported the lines for the bathroom were starting to get long. The residents did not appreciate the lines for the bathroom and felt they were undignified. Review of the documented responds from the facility revealed the bathroom lines were to be immediately discontinued and the facility apologized for any emotional distress felt by the residents. Further review of the meeting minutes revealed the facility put out a "ward" conference to staff related to the bathroom lines. However, observation on 06/27/13 from 9:15 AM until 9:30 AM revealed residents lined up in the hall waiting to use the common bathroom on the Wisteria Unit. 1. Review of Unsampled Resident C's medical record revealed the facility admitted the resident on 02/25/11 with [DIAGNOSES REDACTED]. Further record review revealed Resident C was assessed by the facility as having a Brief Interview of Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating the resident was moderately impaired in cognition. Interview, on 06/27/13 at 9:50 AM, with Unsampled Resident C revealed he/she was toileted in the community bathroom. Resident C reported he/she could not walk, thus he/she depended on staff to assist him/her with toileting. Resident C further stated he/she had waited in line for more than thirty (30) minutes. Resident C added that many residents had to wait in line to be toileted and had waited longer than he/she had. Resident C stated he/she has been told by staff that he/she should wear briefs. Resident C revealed he/she had urinated on self while waiting to be toileted. Resident C added this made him/her fell like "hell" or "dirty" when he/she had peed on self. 2. Review of Resident #2's medical record revealed the resident was admitted by the facility on 11/10/11 with [DIAGNOSES REDACTED]. Review of the 10/30/12 admission Minimum Data Set (MDS) Assessment revealed the facility assessed the resident as being cognitively intact. In addition, the resident was assessed as required extensive assistance of two (2) staff for toileting. Interview, on 06/27/13 at 9:15 AM, with Resident #2 revealed the resident was regularly toileted in the community bathroom. Resident #2 stated he/she had to wait in line for an hour to an hour and a half before he/she could be toileted. Resident #2 stated it made him/her feel bad to have to wait in line and reported he/she would like to be toileted in his/her bathroom versus the community bathroom. Resident #2 was observed to have a bathroom in his/her room and it appeared to be in working condition as evidenced by flushing the toilet. Observation, on 06/27/13 from 9:15 AM until 9:30 AM, revealed Resident #2 was in line, at the community bathroom, waiting to be toileted. Resident #2 was observed sitting in his/her wheelchair, for fifteen (15) minutes, behind two (2) other residents. Resident #2 stated,"I have to go to the restroom". 3. Record review revealed the facility admitted Resident #19 on 08/28/12 with [DIAGNOSES REDACTED]. Review of the latest Quarterly MDS Assessment revealed the facility assessed the resident as being moderately impaired in cognition. Observations, on 06/27/13 from 9:15 AM until 9:30 AM, revealed Resident #19 waited in line in the hallway outside of the common bathroom to be toileted. Observation, on 06/28/13, at 3:50 PM, of Resident #19's room revealed a toilet chair to the left side of the bed against the wall and a shared toilet area located in the room. Further observation of the toilet chair revealed personal items piled on top of the toilet chair against the wall. Interview, on 06/28/13 at 3:50 PM, with Resident #19 revealed he/she had to wait in line to use the bathroom and had accidents of urine while waiting. Resident #19 also revealed the accidents made him/her feel bad. 4. Review of Resident #18's medical record revealed the facility admitted the resident on 04/11/13 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 04/15/13, revealed the facility assessed Resident #18 as having a BIMS score of eight (8) out of fifteen (15) indicating moderate impairment in cognition. Interview with Resident #18, on 06/28/13 at approximately 1:45 PM, revealed Resident #18 was toileted in the community bathroom. Resident #18 stated he/she did not know how long he/she had to wait for the bathroom, but reported it had been about thirty (30) minutes or so and added, "You are lucky to get in then". Resident #18 revealed he/she had problems with his/her bladder, but reported it was better now that he/she had been placed on bladder control medication. Resident #18 reported he/she had urinated on self while waiting to be toileted. Resident #18 stated, "it did not make him/her feel good to wait in line". Resident #18 reported he/she felt terrible when he/she was unable to hold his/her bladder while he/she waited in line. 5. Review of Unsampled Resident D's medical record revealed the facility admitted the resident on 03/11/13 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 03/15/13, revealed the facility assessed Unsampled Resident D as having a BIMS score of eight (8) out of fifteen (15) indicating the resident was moderately impaired in cognition. Interview, on 06/27/13 at 11:00 AM, with Unsampled Resident D revealed he/she was regularly toileted in the community bathroom. Resident D reported he/she had to wait in line for an hour or longer. Resident D added that often times, residents were still behind him/her after he/she had been toileted. Resident D stated there were no set times in which the line for toileting occurred, "it happened throughout the day", reported Resident D. Resident D stated he/she depended on staff to toilet him/her and had urinated on self while waiting to be toileted. Resident D reported he/she would rather go to his/her own bathroom for toileting. Resident D revealed it made him/her feel "awful" to have to wait in line to be toileted. Observation, on 06/27/13 at 10:58 AM, revealed unsampled Resident D had a private bathroom and it appeared to be working as evidenced by a flushed toilet. 6. Record review of Resident #16's medical record revealed the facility admitted the resident on 11/29/07 with [DIAGNOSES REDACTED]. Review of the 05/09/13 Quarterly Minimum Data Set (MDS) Assessment revealed the facility assessed the resident as being moderately cognitively impaired. Interview, on 06/28/13 at 1:40 PM, with Resident #16 revealed he/she had seen residents lined up to be taken to the bathroom by the nurse station and thought the residents had to wait awhile, but could not recall how many residents were lined up. Interview, on 06/28/13 at 2:43 PM, with Certified Nursing Assistant (CNA) #7 revealed residents on the Wisteria Unit lined up to use the common bathroom, by the nursing station, after they ate. The CNA stated, on Wisteria, they typically had two (2) CNAs assist residents who were in the bathroom line and two (2) CNAs who would answer room call lights after meals. She stated there were a bunch of residents who lined up to use the public restroom after eating, but the residents were used to doing that. She stated, she thought residents preferred the public bathroom because it was bigger and was not aware of any resident complaints. The CNA revealed it took awhile to get all the residents through the line, but it was easier taking them to the public bathroom. She stated some residents had accidents when waiting to use the public bathroom and got upset, but they tried to get to them as fast as they could. Interview with CNA #8, on 06/28/13 at 3:30 PM, revealed the residents on Wisteria line themselves up at the public bathroom across from the nurse station after meals. The CNA stated she was unsure why residents didn't use the bathroom in his/her room, but the public bathroom was bigger and it was difficult to get two (2) people and a wheelchair in the bathroom in the residents' rooms. CNA #8 revealed she didn't ask the resident's what bathroom they preferred to use. She stated one time a resident had soiled themselves waiting in the line, the resident had diarrhea, but it didn't seem to bother him/her. Interview, on 06/28/13 at 3:43 PM, with CNA #9, who worked on Wisteria, revealed after meals or activities residents put themselves over to the public bathroom because they would rather use the hall bathroom because it was bigger. CNA #9 stated it didn't seem to bother the residents to use the bathroom. The CNA further stated with residents who required two (2) assist to use the bathroom, they took them to the bigger bathroom to make it easier. She stated if the residents complained about using the hall bathroom they would take them to his/her own bathroom. She further stated they usually had two (2) CNAs who assisted the residents in the bathroom line and two (2) CNAs who assisted the residents to his/her own bathroom. The CNA stated she had not seen any residents who had accidents when waiting to use the public bathroom. Interview, on 06/28/13 at 2:30 PM, with CNA #10 revealed she was aware of the lines that formed outside of the community bathroom. CNA #10 stated she was not sure why the residents stood in line, but reported residents had always formed the lines since she has worked the unit beginning in January 2013. CNA #10 revealed she knew the residents had waited approximately ten (10) minutes before being toileted, but expressed residents had not waited longer than thirty (30) minutes. CNA #10 revealed residents had soiled themselves while waiting to be toileted. CNA #10 reported she had asked residents if they preferred to be toileted in their rooms and residents had indicated they would like to. Interview, on 06/28/13 at 3:00 PM, with CNA #6 revealed staff tried to get to every resident as fast as they could but had noticed that some residents voided on themselves while waiting to be toileted. Interview with Licensed Practical Nurse (LPN) #5, on 06/28/13 at 3:10 PM, revealed the residents on Wisteria, would line up to use the public bathroom when they needed to go; it was mostly the alert and oriented residents. She stated that is just how they had done it, the bathroom was bigger and most of them liked to use it. She further stated she was unaware of any resident complaints about using the public bathroom. LPN #5 stated when residents lined up to use the public bathrooms they had two (2) CNAs assist them and two (2) CNAs answered room call lights. The LPN further stated she did observe a resident soiled in the line, but it was awhile ago and the resident had a weak bladder. Interview with Social Worker (SW) #1, on 06/27/13 at 11:25 AM, revealed they had lined up the residents after meals to use the bathroom in the hall because it was quicker. SW #1 stated residents had voiced concern to her about why they were being lined up to use the bathroom in the hall instead of their room. The SW further stated she had informed the residents staff was hoping to get to them quicker. She stated it was the residents' right to choose where they wanted to be toileted unless there was a medical reason for it and it could be a dignity issue if the residents preferred to use the bathroom in their room and had to wait in line. SW #1 stated she had spoken to the DON because it was a nursing issue. Continued interview with the DON, on 06/28/13 at 6:05 PM, revealed the Social Worker did discuss resident complaints about bathroom lines and the DON did an investigation of the bathroom lines and talked to staff and residents but had no documentation of her investigation. She stated she had felt the situation had improved since she had put out education. She further stated residents had chosen to line up to use the public bathroom because it was bigger and wanted to go there. The DON stated the expectation was residents had the right to use the bathrooms in their rooms if they wanted. The DON further stated it was a dignity issue if residents were taken to the public bathroom but the residents preferred to use the bathroom in their own rooms. The DON further stated it would be a dignity issue if a resident had an event in which they soiled themselves while waiting to be toileted by staff and the event was upsetting to the resident.