Every finding on record at Oakmont Manor

Based on observation and interview, the facility failed to dispose of refuse in a sanitary manner for 2 of 2 dumpsters observed. This deficient practice had the potential to affect all residents who resided in the facility.The findings include:During an interview on 04/22/2026 at 3:20 PM, the Administrator stated the facility did not have a policy regarding dumpsters.Observation of the facility's dumpsters with the Dietary Manager on 04/20/2026 at 9:55 AM revealed the dumpsters were approximately 100 feet from the facility. Two dumpsters with lids and sliding side doors sat adjacent to each other, surrounded by a concrete brick wall that wrapped around them but did not enclose them. Facing the dumpsters, the left dumpster's right-side door was fully opened. Inside the left dumpster, several bags of trash rested at the bottom, below the level of the side door. During a concurrent interview, the Dietary Manager stated all staff was responsible for making sure the doors were closed. She stated she had educated staff on that before.Observation of the dumpsters on 04/22/2026 at 1:05 PM revealed the right dumpster's right-side door was fully opened. No staff was using the dumpster at that time. Bags of trash filled the dumpster a little less than halfway, just below the opened side door.During an interview on 04/22/2026 at 2:28 PM, the Regional Food and Nutrition Services Manager stated all staff who took out trash were responsible for shutting the doors after use. She stated the dietary department in-serviced their employees on this and assumed every department did the same. She stated there was no written documentation of in-services on dumpsters.During an interview on 04/22/2026 at 2:33 PM, the Dietary Manager stated they educated staff on closing dumpsters, but there was no specific training documentation on dumpsters they could provide.During an interview on 04/22/2026 at 3:06 PM, the Interim Maintenance Director stated the maintenance department was responsible for dumpsters behind the building, as well as the housekeeping department. He stated the facility's dumpsters were expected to be closed at all times.During an interview on 04/22/2026 at 3:10 PM, the Housekeeping Manager stated all staff was responsible for the dumpsters. The Housekeeping Manager stated all staff knew the doors must be closed because critters, raccoons specifically, had gotten into the dumpsters in the past.During an interview on 04/22/2026 at 3:16 PM, the Director of Nursing (DON) stated staff was responsible for taking the trash out to the dumpsters and closing the doors afterward. She stated she expected the dumpsters to be closed when they were not in use.During an interview on 04/22/2026 at 3:20 PM, the Administrator stated the facility's expectation was to make sure all refuse was disposed of and the dumpsters were shut and closed afterward. He stated he expected each department to be responsible for making sure they were closed.

Based on observation, interview, and review of a food safety article, the facility failed to serve food in a sanitary manner as determined by observation of the lunch service on 04/29/2025 and 04/30/2025 when the Dietary staff touched the clear plastic square bowls inside the rims with bare fingers as they turned the bowls over for service. This had the potential to affect all 84 current residents. The findings include: Review of the State Safe Food handling article Server Tips, Hands Off, dated 2025, https://www.statefoodsafety.com/Resources/Resources/server-tip-hands-off#:~:text=More%20importantly%20than%20the%20money,will%20be%20used%20by%20guests, revealed bare hand contact on dishes and utensils was an issue because bare hands spread germs. Observation on 04/29/2025 at 11:30 AM of the resident lunch tray line revealed the cook picked up and held the acrylic four ounce serving bowls with fingers touching the underside of the last bowl in the stack with her bare hand and fingers. . Observation on 04/30/2025 at 11:30 AM of the resident lunch tray line revealed Dietary Aide 2 picked up and held the acrylic four ounce serving bowls with fingers touching the underside of the last bowl with her bare hand and underneath the top two bowls. In an interview with the Dietary Manager on 05/01/2025 at 10:10 AM, she stated staff should handle the plastic clear square bowls by the bottoms and not put fingers over the rims because there was an infection control concern. In an interview with [NAME] 1 on 05/01/2025 at 9:30 AM, she stated she pulled the clear plastic square bowls off the shelf and turned them over by placing her hand on the bottom and turning over with her other hand. She stated it was not correct to touch the inside of the bowl with fingers to prevent the spread of germs from the fingers. In an interview with Dietary Aide 2 on 05/01/2025 at 9:45 AM, she stated it was correct not to touch the inside of the plate and the clear plastic square bowls to prevent the bacteria from fingers to cross contaminate. In an interview with the Registered Nurse (RN) Director of Nursing (DON) on 05/02/2025 at 9:37 AM, she stated she expected staff to prevent cross contamination by not putting fingers into the top of the bowl. She stated if a dish was contaminated by bare fingers or hands, it should be removed from the tray line. In an interview with the Administrator on 05/02/2025 at 12:12 PM, he stated his expectation was for staff to handle dishware in a sanitary manner and to perform hand washing prior to handling clean dishware.

Based on observation, interview, and review of the facility's policies, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observation on 04/29/2025 revealed Dietary Aide 1 coughed multiple times over the residents' trays on the lunch tray line for the D Unit cart. Dietary Aide 1 coughed into her elbow. However, she did not step back from the tray line, sanitize, or wash her hands. The deficient practice had the potential to affect all residents on the D Unit, with a census of 20. The findings include: Review of the facility's policy titled, Personal Hygiene and Health Reporting, dated 2019, revealed the food and nutrition services employees would be trained on appropriate personal hygiene and health reporting. Review of the facility's policy titled, Hand Washing, dated 2019, revealed employees would wash hands as frequently as needed throughout the day using proper hand washing procedures. Per the policy, hands should be washed after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking. Observation during the D Unit lunch tray line on 04/29/2025 at 11:30 AM to 11:55 AM, revealed Dietary Aide 1 was coughing into her elbow on the tray line and did not step away or wash/sanitize her hands. In an interview with Dietary Aide 1 on 05/01/2025 at 4:22 PM, she stated she had allergies. She stated she was taught to couch into her arm at the elbow (she demonstrated by coughing into her upper arm). She stated, on 04/30/2025, she went to an urgent treatment center for testing, and it was verified she just had allergies. She stated she was trained by the Dietary Manager to cough into her elbow and upper arm. In an interview with the Dietary Manager on 05/02/2025 at 9:12 AM, she stated Dietary Aide 1 should have stepped away from the line and covered her cough into the arm. She stated, if a staff member, such as Dietary Aide 1, continued to cough, they should be removed from the line. In an interview with the Registered Nurse (RN) Infection Preventionist (IP) Assistant Director of Nursing (ADON) 1 on 05/01/2025 at 2:44 PM, she stated staff was to cough into the elbow, using cough etiquette. She stated Dietary Aide 1 should have sanitized her hands between coughs. She stated if Dietary Aide 1 choked, she should step away from the line, take a drink of water, and sanitize hands. She stated if Dietary Aide 1 continued to cough, she needed to step away and wear a mask. She stated she expected Dietary Aide 1 to report to her on the day she felt sick at work. In an interview with the Registered Nurse (RN) Director of Nursing (DON) on 05/02/2025 at 9:34 AM, she stated her expectation was to discard the tray and get another one. She stated Dietary Aide 1 should have taken the day off, wore a mask, or gone to the medical doctor. In an interview with the Administrator on 05/02/2025 at 11:54 AM, he stated coughing on the tray line posed a risk for contamination. He stated Dietary Aide 1 should have let another staff member take over her position on the tray line. He stated if Dietary staff felt sick, they should step away, have other staff take over their position, and report to the IP Nurse.

Based on observation, interview, record review, review of the manufacturer's guidelines, review of a journal article, and review of the facility's policy, the facility failed to provide the services to prevent possible complications of enteral feeding including but not limited to diarrhea, vomiting, and dehydration, for 1 of 3 residents investigated for tube feeding care, sampled Resident (R) 83. Observations on [DATE] at 11:30 AM and 1:30 PM, revealed R83's tube feeding was hung and spiked, with the tubing primed. However, the facility's staff failed to document the time the tube feeding was hung. The findings include: Review of the facility's policy titled, Tube Feedings, not dated, revealed the tube feeding formula could hang for 24 to 48 hours, depending on the manufacturer's recommendation. Review of the formula company's recommendation guidelines, dated ,d+[DATE], revealed, for hang time, the referenced journal article was Enteral Nutrition Practice Recommendations Task Force, Enteral Nutrition Practice Recommendations, dated 2009, Journal of Parental Enteral Nutrition 2009; 33:,d+[DATE]. The article stated the open system should be changed every 24 hours. Review of the journal article Safety of Enteral Nutrition Practices: Overcoming the Contamination Challenges, Indian J Crit Care Med, 2020 Aug; 24(8):,d+[DATE], revealed most closed containers were discarded after 24 hours due to current manufacturer recommendations to change enteral feeding sets every 24 hours and to spike each closed container only once. Per the article, besides the feed, even the feeding delivery sets could be a source of contamination. Hence, they also needed to be replaced every 24 hours. Review of R83's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses of diabetes mellitus type 2, cachexia, and depression. Review of R83's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15, which indicated R83 had moderate cognitive impairment. Review of R83's Physician's Orders, revealed an order with a date/start date of [DATE]. The order stated to administer, every night from 8:00 PM to 6:00 AM, enteral nutrition via pump of diabetic source AC 1.2 at 39 milliliters per hour (ml/hr) per the resident's percutaneous endoscopic gastrostomy (PEG) tube continuously, (10 hours nightly). Observation on [DATE] at 11:30 AM and 1:23 PM revealed R83 had a closed system tube feeding diabetic source 1.2 spiked and primed at the bed side. The tube feeding label was dated for [DATE] with start time of 8:00 PM and end time of 6:00 AM. However, the observation revealed the time the tube feeding was hung was not documented on the label. In an interview with R83's spouse on [DATE] at 1:30 PM, he stated the tube feeding ran at night. In an interview with Licensed Practical Nurse (LPN) 4 at [DATE] on 11:45 AM, she stated the tube feeding was thrown away after the run time, and the tube feeding was labeled and dated with the start time. She stated the tube feeding bottle was not spiked or primed until hung. She stated the tube feeding bottle should not be spiked or the tube feeding hung or primed until ready for use. She stated, with tube feeding, there was a potential for bacteria to enter the system; therefore, the tube feeding could only hang for 24 hours. In an interview with LPN2 on [DATE] at 8:30 AM, she stated the tube feeding was hung when the time started. She stated the tube feeding was hung for 48 hours. She stated, if the tube feeding was hung early, it could become cross contaminated, and the tube feeding in the set could dry in the tube. In an interview with LPN1, who was also the F Unit Coordinator, on [DATE] at 8:36 AM, she stated R83's tube feeding was scheduled for 10 hours. She stated the tube feeding was hung right before the beginning time, according to the physician's orders. She stated the nurses could not hang it early because they could forget to turn it on at the start time. She also stated, if hung early, the tube feeding in the tube would crust or dry and become unsanitary, and it should be thrown away. She stated R83's tube feeding should not have been left hanging, but thrown away. She stated the formula could become spoiled if allowed to hang so long prior to usage. In an interview with Registered Nurse (RN) Infection Preventionist (IP) Assistant Director of Nursing (ADON) 1 on [DATE] at 2:44 PM, she stated the tube feeding only hung for 24 hours. She stated, once the tube feeding was spiked, the closed system became an open system, and the clock started the 24 hour count down. She stated, if the tube feeding was left hanging greater than 24 hours, it could become cross contaminated with medications and potentially with bacteria. She stated, once the time had expired, the tube feeding and tubing should be removed and discarded. In an interview with LPN6 on [DATE] at 10:21 AM, she stated the tube feeding should be hung when it was due to start, following the physician's orders. She stated after 24 hours the nurse should discard the tube feeding. She stated, if it was changed in the middle of the night or the tube feeding ran out, the nurse could hang another to use again for that night. She stated, on [DATE], it had not been 24 hours. She stated she did not remember the time she changed the tube feeding. She stated R83's order changed from continuous tube feeding to continuous for 10 hours. In an interview with RN1 on [DATE] at 10:48 AM, she stated the tube feeding was hung at the start time. She stated the tube feeding was discarded at the end time and could not be reused for the next start time due to cross contamination. In an interview with RN2 on [DATE] at 10:49 AM, she stated if R83's tube feeding did not run out prior to the stop time, the tube feeding should be taken down and thrown away. She stated the tube feeding could not be left for the next start time because it could become spoiled. In an interview with the Registered Nurse (RN) Director of Nursing (DON) on [DATE] at 9:26 AM, she stated when the tube feeding was hung at the start time, the tube was still capped at the end time, and did not hang greater then 24 hours, bacteria proliferation was not an issue. In an interview with the Administrator on [DATE] at 12:18 PM, he stated his expectation was the tube feeding hang for the scheduled time and not to spike ahead of time. He stated the tube feeding should be taken down when the time was completed.

Based on observation, interview, and review of the facility's current Spring/Summer cycle extension menus, the facility failed to ensure the puree diets were followed as determined by observations of the dinner tray line on 04/29/2025 and the lunch tray line on 04/30/2025 for 2 of 2 residents sampled for puree diets, Resident (R) 3 and R5. The findings include: 1. Review of the puree extension dinner menu for Tuesday, 04/29/2025 (Tuesday, week 1 dinner) revealed puree chicken salad croissant, tomato juice, puree cottage cheese, puree crackers, and puree fruit plate would be served. However, observation of the dinner meal on 04/29/2025 at 4:45 PM revealed, for Resident (R) 3 and R5, who received puree diets, the facility failed to provide a vegetable portion (tomato juice), bread portion (croissant), puree crackers and puree fruit plate, (or appropriate alternate items) per the puree diet extension. 2. Review of the puree extension lunch menu for Wednesday, 04/30/2025 (Wednesday, week 1 lunch) revealed puree cheesesteak, puree bun, puree tater tots, puree green beans, and puree fruit cocktail would be served. However, observation of a test tray on 04/30/2025 at 12:35 PM, which R3 and R5 received, revealed the puree lunch consisted of puree cheesesteak, puree bread, puree mashed potato, puree green beans, milk, iced tea, and regular Jello with no fruit pieces. The facility failed to provide puree tater tots and puree fruit cocktail. During an interview with morning [NAME] 1 on 05/01/2025 at 9:45 AM, the [NAME] stated, I puree all menu items separately: protein, starch, vegetable, bread, and dessert. When asked about Jello that was on the menu, the [NAME] stated, I would provide puree Jello or provide other puree if the extension calls for it. During an interview with morning Dietary Aide 1 on 05/01/2025 at 9:55 AM, she stated, I would puree separate items: meat, bread, mashed potatoes, green beans. When asked about puree dessert, she stated, Prep position takes care of dessert. During an interview with Dietary Aide 2 on 05/01/2025 at 10:00 AM, she stated, I puree whatever dessert is on the menu. When asked about Jello for puree diets, she stated, Plain Jello is provided without fruit. When asked about how she knew what to provide for a puree diet, the Prep Aide stated, I follow the diet sheets. During an interview with the Foodservice Director on 05/01/2025 at 10:10 AM, when asked about the correct diet for puree, she stated, Residents should not have received Jello; the pureed fruit was missed. Puree should include a separate protein, starch, vegetable, bread, and dessert. During an interview with the Registered Dietitian (RD) on 05/01/2025 at 10:35 AM, she stated Menus are provided from an outside source, and the dietitian is responsible for nutrition adequacy. During an interview with the Executive Director on 05/02/2025 at 12:35 PM, he stated he had no involvement with cycle menus, and the . dietitian follows the recipe book. When asked about menus that failed to meet nutritional requirements, he stated, We are to follow the extension or to provide an equivalent.

Based on interview, record review, and review of the facility's competency check lists titled, Using the Care Plan and Care Plan Goals and Objectives, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of four (4) sampled residents (Resident #1). The facility assessed and care planned Resident #1 for the extensive assistance of two (2) staff and the use of a mechanical lift for transferring. However, on 07/14/2021, State Registered Nurse Aide (SRNA) #5 transferred Resident #1 using the stand pivot method by herself. During the transfer, Resident #1 sustained a tibia/fibula fracture (a fracture in the lower leg). Resident #1 was transferred to the hospital for evaluation and treatment of the fractured leg. The findings include: Interview with the Director of Nursing (DON), on 11/11/2021 at 10:31 AM, revealed the facility did not have a specific care plan policy, but used the competency checklist to guide the staff. Review of the facility's document titled, Care Plan Goals and Objectives, dated 08/01/2013, revealed goals and objectives were entered on the resident's care plan so that all disciplines had access to such information. Review of the facility's document titled, Using the Care Plan, dated 08/01/2013, revealed care plans would be used in developing the resident's daily care routines and would be available to the staff member responsible for providing care. Review of Resident #1's clinical record revealed the facility admitted the resident, on 07/12/2019, with diagnoses that included Osteoarthritis, Chronic Pain Syndrome, Vitamin Deficiency, and Peripheral Vascular Disease. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 05/12/2021, and the Quarterly MDS Assessment, dated 08/06/2021, revealed the facility assessed Resident #1 to require the extensive assist of two (2) plus (+) staff for transfers. In addition, the Brief Interview for Mental Status (BIMS) examination score revealed the facility assessed Resident #1 with a score of fifteen (15) of fifteen (15) out of fifteen (15), which indicated he/she was cognitively intact. Review of Resident #1's Comprehensive Care Plan, dated 03/05/2021, revealed Resident #1 had a focus of limited physical mobility with a goal of remaining free of complications related to immobility and fall related injuries. The intervention was for staff to use a mechanical lift for transfers. Review of the Long-Term Care Facility-Self Reported Incident Form, 5 Day Follow Up/Final Report, dated 07/20/2021, and signed by the Administrator, revealed, on 07/14/2021, SRNA #5 transferred Resident #1 from the bed to the geri-chair without using the mechanical lift, resulting in a tibia/fibula fracture to the resident. Per the report, it stated the facility concluded the cause of Resident #1's injury was that SRNA #5 failed to follow Resident #1's care plan/Kardex for transferring the resident, which required use of the mechanical lift. Review of the X-ray report and review of the Nurses Notes, dated 07/14/2021, revealed the X-ray results indicated Distal tibia/fibula fractures with malalignments. Mild soft tissue swelling, joint space narrowing and that the resident report a pain level of eight (8) out of ten (10). The Nurses Notes also indicated the resident was ordered pain medication and nursing to schedule appointment with Orthopedics. Interview with Resident #1, on 11/09/2021 at 3:47 PM, revealed he/she had told SRNA #5 that staff used a lift when they would get him/her up. Resident #1 stated SRNA #5 told him/her that she was going to get him/her up using the stand pivot method. Resident #1 continued by stating his/her right foot got twisted when he/she was being lowered into the chair. Further interview revealed he/she told SRNA #5 that it hurt his/her right foot. Telephone interview with SRNA #5, on 11/09/2021 at 2:37 PM, revealed on 07/14/2021, she was pulled from her usual hall and assigned to Resident #1. Continued interview revealed shortly before shift change at 2:00 PM, she was requested (unable to remember requestor) to get Resident #1 up for a visitor. Further interview revealed she used a stand pivot method to transfer Resident #1 to the chair. Additionally, she stated she did not use the Kardex (SRNA Care Plan) nor did she have time to look up on the Kiosk, which had the care plan, on how to transfer Resident #1. Further interview revealed she acknowledged sometime in June 2021 she had received the facility presented skills check offs and mechanical lift education. SRNA #5 stated she had been suspended, on 07/14/2021, and she subsequently quit. SRNA #5 stated that Resident #1 did not complain of pain after getting him/her into the wheelchair. Interview with the Director of Nursing (DON), on 11/11/2021 at 10:31 AM, revealed all care plans were reviewed for appropriate interventions and revised as needed. Interview with the Administrator, on 11/11/2021 at 11:45 AM, revealed the incident with Resident #1 occurred prior to her arriving at the facility, and she would not be able to speak to specifics of the event nor the investigation. She stated that staff should be familiar with resident care and there were multiple avenues to acquire that knowledge, such as asking the nurse and looking at the care plan. The facility developed a Plan of Correction, which was initiated on 07/14/2021 and completed on 09/14/2021, alleging compliance on 09/15/2021: 1. Resident #1 was immediately assessed by Licensed Practical Nurse (LPN) #2, who performed range of motion. Resident #1 complained of pain in the right foot. Pain medication was administered, ice was applied by LPN #2, the resident was repositioned for comfort, an x-ray was ordered, and then the resident was sent to the emergency room (ER). 2. MDS Nurse/LPN #3, on 07/15/2021, reviewed the Care Plan/Kardex's for all residents for the level of assistance required for transfer. The Business Office Manager, on 07/15/2021, interviewed all interviewable residents with a BIMS' score of eight (8) or above regarding resident care. This was completed by the Assistant Director of Nursing (ADON), on 07/14/2021 and 07/15/2021. 3. Education was initiated on 07/14/2021 and continued through 07/24/2021 for all staff on utilizing and checking the Care Plan/Kardex prior to providing care. Pocket assignments were initiated for all SRNA's, and all were educated on the pocket assignment by the DON and ADON. The education included discussion about the assignment sheet; SRNA Kardex Protocol, with an emphasis on the expectation that the Kardex instructions must be followed; and, on the Resident Protection Policy. The education included that SRNA's must turn in the pocket assignments to the Charge Nurse or DON daily, and they were to be kept on the SRNA's person during their shift. 4. The facility had a Quality Assurance (QA) Meeting, on 07/19/2021, which consisted of the DON, ADON, Administrator, and MDS Nurse and others to discuss the incident and corrective action plan, and they developed and assigned audits. The DON and ADON began auditing daily, starting 07/15/2021 through 09/14/2021, to ensure pocket assignments were being utilized and being turned into the Charge Nurse or DON daily. Nursing began daily walking round audits to ensure all staff were utilizing pocket care plans during care and residents were receiving the assistance they were assessed to require during transfer and ADL care. 5. The facility had a QA Meeting, on 09/20/2021, to discuss the incident, the corrective action, and the auditing. The State Survey Agency validated the Plan of Correction as follows: 1. Review of the Progress Notes for Resident #1 revealed LPN #2 immediately assessed Resident #1, administered pain medication, and notified the Physician to obtain an x-ray. Continued review revealed after the x-ray results, Resident #1 was sent to the ER. Interview, on 11/30/2021 at 3:45 PM, with LPN #2 revealed she assessed the resident and when there was pain with range of motion, she knew the resident needed to get an x-ray. She stated she assessed the resident for pain, administered pain medication, repositioned the right foot, and applied ice. 2. Review of the facility's documents revealed a list of all residents and a check mark by the name for each resident that the Care Plan/Kardex was reviewed by MDS Nurse/LPN #3. Review of the facility's document with a list of all the residents with a BIMS of 8 or greater, revealed initials by the Business Office Manager that she conducted interviews with twenty-four (24) residents on 07/15/2021. Review of the facility's document with all residents with a BIMS of less than eight (8) revealed it was initialed off by the ADON that skin assessments had been completed on thirty-two (32) residents on 07/14/2021 and 07/15/2021. Interview, on 11/30/2021 at 4:45 PM, with the ADON revealed she ensured all residents were interviewed or had skin assessments performed and ensured the Care Plan/Kardex review was completed. 3. Review of the facility's documentation revealed all staff was educated between 07/14/2021 and 07/24/2021 on utilizing and checking the Care Plan/Kardex prior to providing care. Pocket assignments were initiated for all SRNA's, and all were educated on the pocket assignment by the DON and ADON to be kept on their bodies their entire shift. The education included discussion about the assignment sheet and SRNA Kardex Protocol, with an emphasis on the expectation that the Kardex instructions must be followed. Additional documentation revealed all staff was educated on the Resident Protection Policy. The education included the SRNA's must turn in the pocket assignments to the Charge Nurse or DON daily. Observation on 12/07/2021 at 10:00 AM to 10:30 AM revealed SRNA #13 and SRNA #14 were performing transfers, while weighing Residents #5 and #6, from wheelchair to chair and back to the wheelchair. Observation of SRNA #13 and SRNA #14 revealed they used the pocket guides for transfers with one assist. However two staff were always present. Interviews on 12/07/2021 SRNA #7 at 10:49 AM, LPN #4 at 10:53 AM, Kentucky Medication Assistant (KMA) #6 at 10:58 AM, LPN #5 at 11:00 AM, SRNA #8 at 11:14 AM, SRNA #9 at 11:22 AM, SRNA #10 at 2:30 PM, SRNA #11 at 2:35 PM and SRNA #12 at 2:42 PM revealed they received training from the DON and/or ADON regarding the Resident Protection Policy and the use of mechanical lifts. They reported the training included a video on how to lift the resident properly with two assists, the training included how to change the battery, placement of the sling, and attaching the sling and that a post test was provided requiring a 100% pass score. Interviews further revealed they received training at the same time by the ADON/DON regarding transfers. They were also updated on the comprehensive care plan, SRNA pocket care plan/daily guide and Kardex daily. Care plan changes were made immediately and communicated to all staff. The education also included using the Report Sheet to update the next shift of any changes. Interview with the DON and ADON, on 11/30/2021 at 4:40 PM, revealed they conducted education as stated in the Plan of Correction for all staff, starting 07/14/2021 and continuing through 07/24/2021, until 100% of the facility staff had received the education. The facility did not utilize agency staff. Further interview revealed this education would be a part of the new hire orientation. Continued interview with the ADON on 12/07/2021 at 3:00 PM revealed training and testing by the ADON and DON consisted of use of the Pocket guides, Hoyer (2 staff required) Lifts, and mechanics of the lift. Including ensuring that staff was aware of the requirement to turn in their pocket guides to the nursing staff at the end of the shift. 4. Review of the facility's documents revealed audits were being performed daily, from 07/14/2021 through 09/14/2021, to ensure SRNA's were carrying their pocket assignments and that they were being turned in at the end of each shift to the Charge Nurse or DON. Further review of the facility's documents revealed Nurses were conducting walking rounds five (5) times daily to ensure staff was using the pocket care plans. Interviews with the DON, ADON, and MDS Nurse/LPN #3, on 11/30/2021 at 4:50 PM, revealed they were all involved in the auditing to ensure compliance with utilization of the Care Plan/Kardex and the pocket assignments and observations of staff utilizing the pocket guides while providing care. Continue interview with the ADON on 12/07/2021 at 3:00 PM revealed the audits for pocket guides and visual checks for mechanical lifts were ongoing. Physical Therapy, ADON with other nurses made visual checks on staff during mechanical lifts. They audited the pocket guides and turned them in at the end of shift. They were collected by the nurses. The pocket guides were reviewed during Quality Assurance (QA) meetings. 5. Review of the Quality Assurance (QA) Committee Minutes, dated 09/20/2021, revealed the QA Committee reviewed the audits as indicated in the plan of correction. Continued review of the Meeting Minutes revealed the Committee reviewed the process and determined they were in compliance. Interviews with the DON, ADON, and MDS Nurse/LPN #3, on 11/30/2021 at 4:50 PM, revealed they were all part of the QA team and were responsible for conducting audits and reporting to the QA Committee to ensure compliance with the required assistance being provided for all transfers and for the staff utilization of the care plan, Kardex, and pocket guides for reference before transferring a resident. Continued review of the QA Committee minutes revealed the minutes noted the facility had seen improvement in transfers of residents with mechanical lifts and use of the pocket guides. Interview with Administrator on 12/07/2021 at 3:30 PM revealed she was not the Administrator at the time of the incident. However, she was a member of the QA Committee involved in reviewing the ongoing audits. She stated they were continuing to monitor the Pocket care plans for changes, and if they were being filled out and turned in at the end of the shift by the staff. She stated the nurses, DON, and the ADON continued to spot check the use of Hoyer lifts with residents for safety.

Based on interview, record review, and review of the facility's competency, Total Mechanical Lift Competency Checklist, undated, it was determined the facility failed to ensure each resident received adequate assistive devices to prevent an accident with injury for one (1) of four (4) sampled residents (Resident #1). The facility's care plan for Resident #1 required the extensive assistance of two (2) staff and the use of a mechanical lift for transferring. However, on 07/14/2021, State Registered Nurse Aide (SRNA) #5 transferred Resident #1 using the stand pivot method by herself. During the transfer, Resident #1's legs became tangled. Resident #1 sustained a tibia/fibula fracture (a fracture in the lower leg). Resident #1 was transferred to the hospital for evaluation and treatment of the fractured leg. The findings include: Interview with the Director of Nursing (DON), on 11/11/2021 at 10:31 AM, revealed the facility did not have a specific mechanical lift policy. The DON stated the facility used the competency checklist to guide and educate staff on its use. Review of the Mechanical Lift Competency Checklist, not dated, revealed two (2) staff were required to operate the lift. Also, there were step-by-step instructions on how to use the lift. Review of Resident #1's clinical record revealed the facility admitted the resident, on 07/12/2019, with diagnoses that included Osteoarthritis, Chronic Pain Syndrome, Vitamin Deficiency, and Peripheral Vascular Disease. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 05/12/2021, and the Quarterly MDS Assessment, dated 08/06/2021, revealed the facility assessed Resident #1 to require the extensive assistance of two (2) plus (+) staff for transfers. In addition, the Brief Interview for Mental Status (BIMS) score revealed Resident #1 was assessed a score of fifteen (15) of fifteen (15), which indicated he/she was cognitively intact. Review of Resident #1's Comprehensive Care Plan, dated 03/05/2021, revealed Resident #1 had an intervention of to use a mechanical lift for transfers. The focus was limited physical mobility with a goal of Resident #1 remaining free of complications related to immobility and fall related injuries. Review of the Long-Term Care Facility-Self Reported Incident Form, 5 Day Follow Up/Final Report, dated 07/20/2021, and signed by the Administrator, revealed, on 07/14/2021, SRNA #5 transferred Resident #1 from the bed to the geri-chair. This transfer resulted in a tibia/fibula fracture to the resident. The report stated Resident #1 told facility staff that the mechanical lift was not used during the transfer. Per the report, it stated the facility concluded the cause of Resident #1's injury was that SRNA #5 failed to follow Resident #1's care plan/Kardex for transferring the resident. Review of the x-ray report and review of the Nurses' Notes, dated 07/14/2021, revealed the resident sustained Distal tibia/fibula fractures with alignments. Mild soft tissue swelling, joint space narrowing and that the resident reported a pain level of eight (8) out of ten (10). The Nurses' Notes also indicated the resident was ordered pain medication and nursing would schedule an appointment with Orthopedics. Interview with Resident #1, on 11/09/2021 at 3:47 PM, revealed he/she had told SRNA #5 that staff used a lift when they would get him/her up. Resident #1 stated the SRNA told him/her that she was going to get him/her up using the stand pivot method. Resident #1 stated his/her right foot got twisted when he/she was being lowered into the chair. Further, Resident #1 stated he/she told SRNA #5 that using the stand pivot method for the transfer had hurt his/her right foot. Telephone interview with SRNA #5, on 11/09/2021 at 2:37 PM, revealed on 07/14/2021, she was pulled from her usual hall and was assigned to Resident #1. Continued interview revealed shortly before shift change, at 2:00 PM, she was requested (unable to remember the requestor) to get Resident #1 up for a visitor. Further interview revealed she used a stand pivot method to transfer Resident #1 to the chair. Additionally, she stated she did not use the Kardex (SRNA Care Plan), nor did she have time to look up the care plan on the Kiosk on how to transfer Resident #1. Further interview revealed she acknowledged sometime in the summer of 2021 she had received the skills check offs and mechanical lift education. SRNA #5 stated she was suspended, on 07/14/2021, and she subsequently quit. The SRNA stated that Resident #1 did not complain of pain after getting him/her into the wheelchair. Review of the mechanical lift education and sign-in sheets revealed SRNA #5 had received the education, on 07/01/2021, approximately thirteen (13) days prior to the incident with Resident #1. Interview with SRNA #3, on 11/09/2021 at 2:35 PM, revealed she had received skills education in the summer of 2021, and mechanical lift education was included. Interview with Resident #4, on 11/09/2021 at 4:01 PM, revealed his/her mobility needs had been declining because of joint pain and arthritis. He/she stated staff now used a mechanical lift to get him/her up to a chair or back to bed. Resident #4 stated there were always (2) staff to operate the lift. Interview with the Director of Nursing (DON), on 11/11/2021 at 10:31 AM, revealed she did not think the facility had a specific mechanical lift policy, but she would bring it to the State Survey Agency (SSA) Surveyor if available. She also stated the information on the Mechanical Lift Competency Checklist was used as the facility's policy. She stated education on mechanical lifts was presented during competency/skills day in June 2021, as well as July 2021. Interview with the Administrator, on 11/11/2021 at 11:45 AM, revealed the incident with Resident #1 occurred prior to her arriving at the facility. She stated that staff should be familiar with resident care, and there were multiple avenues to acquire that knowledge, such as asking the nurse and looking at the care plan. The facility developed a Plan of Correction, which was initiated on 07/14/2021 and completed on 09/14/2021, alleging compliance on 09/15/2021: 1. Resident #1 was immediately assessed by Licensed Practical Nurse (LPN) #2, who performed range of motion. Resident #1 complained of pain in the right foot. Pain medication was administered, ice was applied by LPN #2, the resident was repositioned for comfort, an x-ray was ordered, and then the resident was sent to the emergency room (ER). 2. MDS Nurse/LPN #3, on 07/15/2021, reviewed the Care Plan/Kardex's for all residents for the level of assistance required for transfer. The Business Office Manager, on 07/15/2021, interviewed all interviewable residents with a BIMS' score of eight (8) or above regarding resident care and getting the transfer assistance needed. Skin assessments for all resident with a BIMS of less than eight (8) received skin assessments by the Assistant Director of Nursing (ADON), on 07/14/2021 and 07/15/2021. 3. Education was initiated on 07/14/2021 and continued through 07/24/2021 for all staff on utilizing and checking the Care Plan/Kardex prior to providing care. Pocket assignments were initiated for all SRNA's, and all were educated on the pocket assignment by the DON and ADON. The education included discussion about the assignment sheet; SRNA Kardex Protocol, with an emphasis on the expectation that the Kardex instructions must be followed; and on the Resident Protection Policy. The education included that SRNA's must turn in the pocket assignments to the Charge Nurse or DON daily, and they were to be kept on the SRNA's person during their shift. 4. The facility had a Quality Assurance (QA) Meeting, on 07/19/2021, which consisted of the DON, ADON, Administrator, and MDS Nurse and others to discuss the incident and corrective action plan. They also developed and assigned audits. The DON and ADON began auditing daily, starting 07/15/2021 through 09/14/2021, to ensure pocket assignments were being utilized and being turned into the Charge Nurse or DON daily. Nursing began daily walking round audits to ensure all staff were utilizing pocket care plans during care and residents were receiving the assistance they were assessed to receive during transfer and ADL care. 5. The facility had a QA Meeting, on 09/20/2021, to discuss the incident, the corrective action, and the auditing. The State Survey Agency validated the Plan of Correction as follows: 1. Review of the Progress Notes for Resident #1 revealed LPN #2 immediately assessed Resident #1, administered pain medication, and notified the Physician to obtain an x-ray. Continued review revealed after the x-ray results, Resident #1 was sent to the ER. Interview, on 11/30/2021 at 3:45 PM, with LPN #2 revealed she assessed the resident and when there was pain with range of motion, she knew the resident needed to get an x-ray. She stated she assessed the resident for pain, administered pain medication, repositioned the right foot, and applied ice. 2. Review of the facility's documents revealed a list of all residents and a check mark by the name for each resident that the Care Plan/Kardex was reviewed by MDS Nurse/LPN #3. Review of the facility's document, with a list of all the residents with a BIMS' score of 8 or greater, revealed initials by the Business Office Manager that she conducted interviews with twenty-four (24) residents on 07/15/2021. Review of the facility's document, with all residents with a BIMS of less than eight (8), revealed it was initialed off by the ADON that skin assessments had been completed on thirty-two (32) residents on 07/14/2021 and 07/15/2021. Interview, on 11/30/2021 at 4:45 PM, with the ADON revealed she ensured all residents were interviewed or had skin assessments performed and ensured the Care Plan/Kardex review was completed. 3. Review of the facility's documentation revealed all staff was educated between 07/14/2021 and 07/24/2021 on utilizing and checking the Care Plan/Kardex prior to providing care. Pocket assignments were initiated for all SRNA's, and all were educated on the pocket assignment by the DON and ADON to be kept on their bodies their entire shift. The education included discussion about the assignment sheet and SRNA Kardex Protocol, with an emphasis on the expectation that the Kardex instructions must be followed. Additional documentation revealed all staff was educated on the Resident Protection Policy. The education included the SRNA's must turn in the pocket assignments to the Charge Nurse or DON daily. Observation on 12/07/2021 at 10:00 AM to 10:30 AM revealed SRNA #13 and SRNA #14 were performing transfers, while weighing Residents #5 and #6, from their wheelchair to chair and back to the wheelchair. Observation of SRNA #13 and SRNA #14 revealed they used the pocket guides for transfers with one assist. However, two (2) staff were always present. Interviews on 12/07/2021 with SRNA #7 at 10:49 AM, LPN #4 at 10:53 AM, Kentucky Medication Assistant (KMA) #6 at 10:58 AM, LPN #5 at 11:00 AM, SRNA #8 at 11:14 AM, SRNA #9 at 11:22 AM, SRNA #10 at 2:30 PM, SRNA #11 at 2:35 PM and SRNA #12 at 2:42 PM, all revealed they received training from the DON and/or ADON regarding the Resident Protection Policy and the use of mechanical lifts. They reported the training included video on how to lift the resident properly with two assists; how to change the battery, placement of the sling, and attaching the sling. A post test was provided requiring a 100% pass score. Interviews further revealed they received training at the same time by the ADON/DON regarding transfers; updates were to be put on the comprehensive care plan, and the SRNA pocket care plan/daily guide and Kardex daily. Care plan changes were made immediately and communicated to all staff. The education also included using the Report Sheet to update the next shift of any changes. Interview with the DON and ADON, on 11/30/2021 at 4:40 PM, revealed they conducted education as stated in the Plan of Correction for all staff, starting 07/14/2021 and continuing through 07/24/2021, until 100% of the facility staff had received the education. The facility did not utilize agency staff. Further interview revealed this education would be a part of the new hire orientation. Continued interview with the ADON on 12/07/2021 at 3:00 PM revealed training and testing by the ADON and DON consisted of use of the Pocket guides, Hoyer (2 staff required) lifts, and mechanics of the lift. Including ensuring that staff was aware of the requirement to turn in their pocket guides to the nursing staff at the end of the shift. 4. Review of the facility's documents revealed audits were being performed daily, from 07/14/2021 through 09/14/2021, to ensure SRNA's were carrying their pocket assignments and that they were being turned in at the end of each shift to the Charge Nurse or DON. Further review of the facility's documents revealed nurses were conducting walking rounds five (5) times daily to ensure staff was using the pocket care plans. Interviews with the DON, ADON, and MDS Nurse/LPN #3, on 11/30/2021 at 4:50 PM, revealed they were all involved in the auditing to ensure compliance with utilization of the Care Plan/Kardex and the pocket assignments and observations of staff utilizing the pocket guides while providing care. Continued interview with the ADON, on 12/07/2021 at 3:00 PM, revealed the audits for pocket guides and visual checks for mechanical lifts were ongoing. Physical Therapy, the ADON with other nurses made visual checks of staff during mechanical lift use contained to be audited. The audits included that the pocket guides were turned in at the end of shift and collected by the nurses. The pocket guides were reviewed during Quality Assurance (QA) meetings. 5. Review of the Quality Assurance (QA) Committee Minutes, dated 09/20/2021, revealed the QA Committee reviewed the audits as indicated in the plan of correction. Continued review of the Meeting Minutes revealed the Committee reviewed the process and determined they were in compliance. Interviews with the DON, ADON, and MDS Nurse/LPN #3, on 11/30/2021 at 4:50 PM, revealed they were all part of the QA team and were responsible for conducting audits. They also reported the findings to the QA Committee to ensure compliance that the required assistance was being provided for all transfers. They also ensured the staff utilization of the care plan, Kardex, and pocket guides for reference before transferring a resident. Continued review of the QA Committee minutes revealed the minutes noted the facility had seen improvement in transfers of residents with mechanical lifts and use of the pocket guides. Interview with Administrator on 12/07/2021 at 3:30 PM revealed she was not present as the Administrator at the time; however, she was a member of the QA Committee involved in reviewing the ongoing audits. She stated they were continuing to monitor the Pocket care plans for changes, and if they were being filled out and turned in at the end of the shift by the staff. She stated the nurses, DON, and the ADON continue to spot check the use of Hoyer lifts with residents for safety.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to store food under sanitary conditions for one (1) of five (5) resident refrigerators on unit [NAME] Observation on [DATE], revealed a shared refrigerator in room G4 on the G unit with food in the freezer compartment not labeled or dated. The Findings Include: Review of the facility's policy, titled Personal Refrigerator Policy, dated [DATE], revealed it was the policy of the facility that residents may utilize personal refrigerators. Further review revealed the food must be labeled with the resident's name and be dated with the date of when it was placed in the refrigerator. Per policy, food will be discarded two (2) days after placed in the refrigerator. Continued review of the policy revealed the resident/responsible party would be educated to the above procedure and safe food handling practices upon admission. Per the policy, Environmental Services will check personal refrigerators daily for appropriate temperature and cleanliness and will clean personal refrigerators no less than weekly and on an as needed basis. Review of the Admission Manual, undated, revealed food may be brought in by family/visitors and must be placed in an airtight container. Further review revealed the food must be labeled with resident name and date of when the item was placed in the refrigerator. Continued review revealed food would be discarded two (2) days after placed in the refrigerator. Per the Admission Manual, the resident/resident representative will be educated to the above procedure and safe food handling practices upon admission. Further review of the Admission Manual, revealed the Safe Food Handling acknowledgement document was provided to resident/resident representative as part of the admission packet. Observation of the G Hall Room G 4 personal refrigerator, on [DATE] at 10:51 AM, revealed a food storage container in the freezer, which contained a red pasta like item. Continued observation revealed the container had no label with resident's name and was not dated. Further observation revealed white ice/frost in the bottom of the inside of the container, with the food inside the container. The temperature of the refrigerator was observed to be thirty-six (36) degrees Fahrenheit. Observation of the G Hall Room G 4 personal refrigerator, on [DATE] at 11:16 AM, revealed the food storage container remained in the freezer. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 11:16 AM, revealed housekeeping was responsible to check personal refrigerators and defrost them. Continued interview revealed the aides checked dates and temperatures on the freezers at night. LPN #2 removed the food storage container and indicated the food looked like it was lasagna and rice, and stated the food should have been labeled and dated. Further interview revealed she did not know how long the food had been in the freezer and would not want someone to eat the food because it had no date on it and no way to know if the food was good. Interview on [DATE] at 08:41 AM, with Environmental Services staff revealed the resident's family or the nurse should date the food containers. Continued interview revealed environmental services checked the refrigerator temperatures daily and cleaned personal refrigerators once a week. Further interview revealed environmental services also checked the food item and stated the food was good for two (2) days from the date on the food container. Interview with an Environmental Services Staff/Housekeeping Aide, on [DATE] at 2:25 PM, revealed the facility's policy regarding refrigerators in residents rooms was that food items were dated and good for two (2) days. Further interview revealed housekeeping checked personal refrigerator temperatures daily, and stated the correct temperature for the refrigerators was thirty-two (32) degrees Fahrenheit to Forty-six (46) degrees Fahrenheit. She stated they were to defrost freezers as they ice. Continued interview revealed when housekeeping checked refrigerators daily if food was outdated they were supposed to throw it away. Per interview, the Environmental Services Staff/Housekeeper stated she missed checking that freezer that day. Per interview, she stated she saw the container with the food after it was removed from the freezer and it had no date or label. Further interview revealed the food did not look like something a resident should eat with the frost and that it looked like it had been in there a while. Per interview, with no date on the container there was no way to know how long it had been in the freezer and if a resident ate something expired; it could make the resident sick. Interview with the Director of Nursing (DON), on [DATE] at 2:33 PM, revealed the policy on personal refrigerators was in the admission packet, which included information on food storage. Per interview, if nurses take food from family and put it in the personal refrigerators, they should label and date the food. She stated if family brings it and sneaks it in, nursing would not know. Further interview revealed personal refrigerator temperatures were checked daily, by Housekeeping and they discard every day any out of date food. Further interview revealed if nursing or anyone gets in a personal refrigerator and food was out of date, they could discard outdated food as well. Per interview, if you do not know the date the food was placed in the refrigerator, it should be discarded. Continued interview revealed she would have to double check, but believed food was good for three (3) days. Per interview, the leftover food in Room G4 personal freezer should have been labeled, dated and discarded after three (3) days. Continued interview revealed if a resident consumed expired food, depending on what type of food it was, it could cause upset stomach. Interview with the Administrator, on [DATE] at 2:48 PM, revealed the facility educated residents and families on admission, on safe food handling and the information is in the resident admission packets to include how food is stored, sealed, dated, labeled with name and how soon food should be thrown out. Continued interview revealed food storage in personal refrigerators was monitored daily by the housekeeping staff, who checked refrigerator temperatures and checked for expired items. Per interview, if family had not notified staff that they brought food into the facility and is was not dated, or had no name, housekeeping should take it to nursing to be discarded. Further interview revealed if a food item had no name or date and they do not know who it belonged to, there would be no way to verify the integrity of the food. Per interview, if food was expired it could be a safety issue. Continued interview revealed it was the expectation that staff follow the facility's policy as it was written and communicate as needed.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure the accuracy of SectionKof the Minimum Data Set (MDS) Assessment for one (1) of eighteen (18) sampled residents (Resident #39). Resident #39's Quarterly MDS assessment dated [DATE], revealed the resident was coded to reflect the resident was on a prescribed weight loss program; however, interview and record review revealed the MDS Assessment was coded incorrectly. The findings include: Interview with the Director of Nursing (DON, on 01/17/19 at 5:00 PM, revealed the facility utilized the the Resident Assessment Instrument (RAI) Version 3.0 User Manual as a guide for completing the MDS Assessments. Review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, dated (MONTH) (YEAR), Chapter 3, revealed the intent of Section K was to assess the many conditions that could affect the resident's ability to maintain adequate nutrition and hydration. Nurse assessors should collaborate with the dietician and dietary staff to ensure that items in this section have been assessed and calculated accurately. Under section K0300, it states to code 1-yes, if the expressed goal of the diet was inducing weight loss. Review of Resident #39's medical record revealed the facility readmitted the resident on 06/13/18 with [DIAGNOSES REDACTED]. Review of Resident #39's Summary Report for active orders revealed the resident was ordered Fortified cereal in the morning as a supplement with a start date of 09/11/18, and the order was active. Further review revealed orders for House Supplement sixty (60) millimeters (ml) two (2) times a day with a start date of 09/10/18 and an end date of 12/12/18. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Section K0300 was coded 1- yes, indicating the resident had a weight loss of five percent (5%) or more in the last month or loss of ten percent (10%) or more in the last six (6) months, and indicating the resident was on a physician prescribed weight loss regimen. Further review of Resident #39's medical record revealed no documented evidence the resident was prescribed a weight loss plan. Review of the resident's weights revealed a weight of 177 pounds on 07/11/18; and a weight of 147 pounds on 12/12/18. This revealed the resident had a severe weight loss of 24.29 % in six (6) months. Interview on 01/17/19 at 3:59 PM, with the Dietary Manager, revealed she was responsible for completing section K of the MDS Assessments. She stated when completing the MDS Assessments she would check resident weights for triggers of loss or gain. She further stated if a resident was receiving [MEDICATION NAME], she would mark prescribed weight loss regimen. Further interview revealed the MDS Coordinator or MDS Nurse checked behind her to ensure her section was correct before transmission. Interview on 01/17/19 4:06 PM, with the MDS coordinator, revealed she was responsible for ensuring all disciplines completed their sections of the MDS Assessments, and was also responsible for checking the MDS Assessments for accuracy, prior to transmission. Further interview revealed all disciplines responsible for completing the MDS Assessments had been trained in completing the Assessments accurately. After reviewing Resident #39's MDS Assessment, she stated the resident should not have been coded as on a prescribed weight loss regimen, and the Assessment was not completed accurately. Interview with the DON, on 01/17/19 at 5:00 PM, revealed it was expected the disciplines complete the MDS Assessments accurately by following the (RAI) Version 3.0 User Manual. Further interview revealed prior to completing the MDS Assessment, it was expected information be gathered for each section through observation of the resident, record review, and resident and staff interview. Continued interview revealed Resident #39's MDS Assessment was completed inaccurately as the resident was not on a prescribed weight loss program. Per interview, the Physician and interdisciplinary team were making efforts to prevent further weight loss for this resident through nutritional interventions. Interview with the Administrator, on 01/17/19 at 5:20 PM, revealed it was important for the MDS Assessment to be accurate because this Assessment drives the Comprehensive Care Plan. Per interview, there would need to be a physician's orders [REDACTED].#39.

Based on observation, interview, and review of the facility's Policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of eighteen (18) sampled residents (Resident #52). Observation of pericare care/incontinence care for Resident #52, on 01/15/19, revealed staff failed to perform good hand hygiene prior to, during and following pericare/incontinence care. The findings include: Review of the facility's Policy, titled, Hand Hygiene/Hand Washing, dated, (MONTH) 2002, revealed the facility considered hand washing/hand hygiene the most important single procedure for preventing healthcare associated infections. Further policy review revealed staff should follow proper hand hygiene procedures to decrease the risk of transmission of infections to residents, staff and visitors. Continued review of the facility's Policy, revealed the facility would implement an infection control and prevention program. Review of the facility's Policy, titled, Perineal Care for Incontinent Resident, undated, revealed the facility would provide perineal care to the incontinent resident every two (2) hours and as needed. Prior to providing incontinence care, staff were to perform hand hygiene by washing hands with soap and water or by applying an alcohol-based hand rub. Continued review of the facility's Policy, revealed staff would remove soiled gloves, perform proper hand hygiene and apply clean gloves after incontinence care and prior to repositioning resident's clean bed linens, call light and bed position. Review of Resident #52's clinical record revealed the facility readmitted the resident on 11/21/18 with [DIAGNOSES REDACTED]. Observation of perineal care provided to Resident #52 on 01/15/19 at 3:00 PM, by State Registered Nursing Assistant (SRNA) #3 and SRNA #4, revealed SRNA #3 and SRNA #4 entered the resident's room, and set up incontinence care supplies at bedside. Further observation revealed SRNA #3 and SRNA #4 failed to wash hands, prior to providing resident care. The SRNAs donned gloves and turned the resident onto his/her left side and tucked the urine soaked brief with the urine saturated chucks pad underneath the resident's buttocks. SRNA #3 held the resident in position as SRNA #4 provided pericare and cleansed the perineal area from front to back with a soapy washcloth. SRNA #4 then rinsed the pubic and perineal area with clean water and patted the areas dry with a clean washcloth. SRNA #3 then rolled the resident onto his/her right side, towards SRNA #4 and pulled the soiled brief and urine soaked chucks pad out from underneath the resident. SRNA #3 then tucked a clean adult brief under the resident's buttocks as SRNA #4 assisted to reposition the resident back on to the left side. SRNA #3 then pulled the clean brief out from underneath the resident and without washing hands or changing gloves, applied Balmex ointment to reddened areas on the resident's buttocks. Further observation revealed SRNA #4 fastened the clean brief at both left and right tabs. SRNA #3 and SRNA #4 then, with the same soiled gloves, dressed the resident in slacks, and both SRNAs adjusted the resident's bed linens and side rails. SRNA #3 adjusted the call light with the same soiled gloves used to provide perineal care. SRNA #3, and SRNA #4 then without removing soiled gloves or washing hands, cranked the resident's head of bed in to the desired position and hung the resident's gait belt on a hook located on the back of the resident's bedroom door. SRNA #3 failed to remove his soiled gloves and wash hands prior to exiting Resident #52's room. Interview on 01/15/19 at 3:20 PM, with SRNA #4, revealed she had received infection control and prevention and hand hygiene/hand washing training upon hire approximately five (5) months ago and several times since then. She stated she should have washed her hands and donned clean gloves prior to providing pericare care to Resident #52 as this was an infection control issue and could potentially spread germs, infection or disease to the resident. Further interview with SRNA #4, revealed she should have removed her soiled gloves, washed her hands and applied clean gloves before dressing the resident, repositioning the resident's bed linens, and touching objects in the environment. Further interview with SRNA #4, revealed in the future she needed to be more diligent and wash her hands frequently during perineal care. Interview on 01/15/19 at 3:35 PM, with SRNA #3, revealed he had received infection control and prevention training upon hire nearly four (4) years ago and had received several updates since that time. SRNA #3 stated he was familiar with and had received training on proper hand washing/hand hygiene and all staff were frequently in-serviced on new/revised material related to infection control and prevention practices. SRNA #3 stated he should have washed his hands and applied clean gloves prior to providing incontinence care to Resident #52. Further interview revealed he should have washed his hands and applied clean gloves after providing the resident's incontinence care and prior to applying the Balmex cream to the resident's buttocks, but could not explain why he failed to do so. Continued interview revealed he should have removed his soiled gloves, washed his hands and applied clean gloves prior to applying the resident's clean brief following perineal care. Additional interview revealed the SRNA was aware he should have removed his soiled gloves and washed his hands prior to dressing the resident, readjusting the bed linens and repositioning the resident's call light. SRNA #3 stated he was aware of the importance of proper hand washing and glove use in the prevention of the spread of germs, infection and potential diseases to residents, staff, and visitors, and he should have washed his hands prior to exiting Resident #52's room. SRNA #3 further stated he needed to be more aware of the need to wash hands when providing direct care to his residents in the future. Interview with Registered Nurse (RN #1), on 01/17/19 at 2:49 PM, revealed she had received training on proper hand washing/hand hygiene techniques and infection control and prevention practices upon hire approximately fifteen (15) months ago and at least four (4) or five (5) times since her date of hire. RN #1 revealed she participated in in-service trainings provided by the facility where staff performed skills and competency check-offs and hand washing was a competency the SRNAs were required to return demonstrate. RN #1 stated she would expect the SRNAs to wash their hands prior to providing perineal care to the residents. RN #1 further stated she also expect the direct care staff to remove soiled gloves, wash hands and apply clean gloves after removing a soiled brief, and prior to applying a clean brief or cream to a resident. Further interview with RN #1, revealed she expected direct care staff to remove their soiled gloves, wash their hands and apply clean gloves after applying a clean brief and cream to a resident and before repositioning the resident in bed, readjusting the bed linens, call light or head of bed. RN #1 further stated she would expect staff to wash their hands prior to exiting the resident's room. Additional interview with RN #1 revealed it was important to utilize proper hand hygiene and glove use to prevent urinary tract infections and any type of cross-contamination. RN #1 stated, It's important that we wash our hands during any direct resident care; we want to protect our residents from illness. Interview on 01/17/19 at 4:50 PM, with the Director of Nursing (DON, revealed it was her expectation staff wash their hands before donning clean gloves, prior to providing peri care/incontinence care. Further interview with the DON, revealed she expected staff to remove their soiled gloves, wash their hands and apply clean gloves prior to applying a clean brief or cream on a resident following perineal care. Continued interview revealed she expected staff to remove soiled gloves, wash their hands and apply clean gloves prior to readjusting the resident's bed linens, call light, side rails and other objects in the resident's room following perineal care. She further stated staff were to wash hands after providing care and before exiting the room. Additional interview with the DON, revealed it was her expectation staff utilize proper hand hygiene and infection control and prevention practices. Interview on 01/17/19 at 5:23 PM, with the Administrator, revealed he expected all staff to utilize proper hand hygiene and infection control and prevention practices. Further interview revealed hand washing and proper use of gloves was expected during perineal care of incontinent residents.

Based on interview, record review, review of the facility's Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for one (1) of twenty-one (21) sampled residents (Resident #27). Review of Resident #27's Quarterly Minimum Data Set (MDS) Assessment, dated 10/30/17, revealed the facility assessed the resident to be feeling down, depressed, or hopeless nearly every day during the fourteen (14) day assessment period; however, the resident's Comprehensive Care Plan was not implemented related to interventions for mood/depression and behavior health consults as needed (psycho-geriatric team, psychiatrist, etc). The findings include: Review of the facility's policy titled, Care Plan Goals and Objectives, dated 08/01/13, revealed care plans should have incorporated goals and objectives that lead to the resident's highest obtainable level of independence. Continued review of the policy revealed care plan goals and objectives were defined as the desired outcome for a specific resident problem; and were derived from information contained in the resident's comprehensive assessment and were resident oriented, behaviorally stated, measurable and contained timetables to meet the resident's needs in accordance with the comprehensive assessment. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #27's medical record revealed the facility admitted the resident on 06/30/16 and readmitted the resident on 07/18/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/30/17, revealed the facility assessed Resident #27 to have a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), indicating the resident was moderately cognitively impaired. Continued review of the MDS, revealed the resident the facility assessed the resident to have a problem of feeling down, depressed, or hopeless and feeling tired or having little energy for twelve (12) to fourteen (14) days (nearly every day) of the fourteen (14) day assessment period. Review of the Comprehensive Care Plan for Resident #27, undated, revealed a focus of Mood Problem related to [MEDICAL CONDITION] and anxious behaviors with the goal stating the resident would have improved sleep pattern by reporting adequate rest and also the resident would have improved mood state as measured by decreased anxious behaviors. The interventions included: administer medications as ordered; allow time to talk and encourage the resident to express feelings; behavior health consults as needed (psycho-geriatric team, psychiatrist, etc.), observe for mood patterns and signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols; provide the resident with a program of activities that is meaningful and of interest, and encourage and provide opportunities for exercise, physical activity. Observation and interview, on 12/19/17 at 10:58 AM, with Resident #27, revealed the resident became tearful and began to cry stating he/she did not have anything to live for. Further interview revealed the resident stated he/she did not have anyone who cared for or loved him/her. Resident #27 further stated he/she had two (2) sons, but they never came to see him/her. Per interview, the resident's roommate did not talk to him/her either. Continued observation revealed the resident continued to cry and stated his/her spouse had built their house; however, his/her son now had his/her home. Further interview revealed the resident had seen a psychiatrist before, but had not seen him recently. Interview, on 12/20/17 at 10:26 AM, with the facility's Director of Social Services, revealed she completed the Resident Mood Interview section of Resident #27's Quarterly MDS Assessment on 10/30/17; however, had not recognized the resident was having symptoms of depression. When reviewing the MDS, the Director of Social Services stated, per the MDS, the resident experienced symptoms of depression most days during the assessment period for the MDS. Review of Resident #27's consultation record provided by the facility, revealed the resident's last appointment with his/her psychiatrist was 04/11/17. Continued review revealed the psychiatrist recommended the resident to return PRN (as needed) Review of the Activity Log dated (MONTH) (YEAR), revealed Resident #27 attended seven (7) facility activities for the month. Review of Activity Log dated (MONTH) (YEAR), revealed the resident attended eight (8) activities for the month. Review of the Activity Log dated (MONTH) (YEAR), revealed the resident attended nine (9) activities for the month. Review of the Activity Log dated (MONTH) (YEAR) revealed the resident attended three (3) activities for the month. Review of the Activity Log dated (MONTH) (YEAR), revealed the resident had only attended one (1) activity up to the date of 12/20/17, indicating a decline in activities participation. Interview, on 12/20/17 at 11:01 AM with Activity Assistants #1 and #2, revealed in the past few months, Resident #27 had not participated in facility activities as he/she once did. Continued interview revealed when they offered activities to the resident, he/she would tell them he/she did not feel like going and when asked what was wrong, the resident stated he/she wanted his/her family to visit and be more involved in his/her life. The Activity Assistants stated they could tell the resident's feelings were hurt when speaking to him/her about the family not coming to see him/her. The Activity Assistants further stated back around the end of (MONTH) (YEAR) to the first of (MONTH) (YEAR), they had both mentioned the resident was feeling down and out to the facility's Director of Social Services. Continued interview with the Activity Assistants revealed with review of the Activity Logs, the logs showed a significant decrease in participation in activities for (MONTH) and (MONTH) (YEAR) as compared to the prior months dating back to (MONTH) (YEAR). Interview, on 12/20/17 at 1:45 PM, with State Registered Nurse Aide (SRNA) #1, revealed even though he would not consider himself Resident #27's regular aide, he did answer the resident's call light and/or if he was down the resident's hall, he would stop and talk to him/her. Continued interview revealed he had spoken to the resident this past Friday or Monday around breakfast time and the resident's eyes were glossy and were tearing up and appeared to maybe be getting ready to cry. Further interview revealed he asked the resident what was wrong and the resident stated he/she had not eaten since dinner the evening prior. SRNA #1 stated he did not ask the resident any other questions. Interview, on 12/20/17 at 1:50 PM, with SRNA #3, revealed she was one of Resident #27's permanent aides. Continued interview revealed the resident was usually in a good mood; however, once in a blue moon, the resident would get upset and sad because of staff having to assist him/her so much and because the resident wanted his/her family to visit more often. Interview, on 12/20/17 at 1:57 PM, with SRNA #2, revealed she was Resident #27's permanent aide during the day shift. Continued interview revealed the resident had told her that he/she was depressed because his/her family did not come see him/her even though they lived close to the facility. Further interview revealed when the resident did tell her that he/she was depressed, she would reassure the resident everyone at the facility cared for him/her and they were there to help him/her. SRNA #2 stated a couple days ago, she observed the resident crying, and when she asked the resident why he/she was crying, the resident replied that he/she did not have anyone. The SRNA further stated she reported this to the nurse, specifically Licensed Practical Nurse (LPN) #1; however, there was no place for her to document that she reported this to the nurse. Continued interview revealed Resident #27 used to participate in facility activities; however, over the past few months the resident had quit attending activities. Further interview revealed the resident also used to go to the dining room to eat meals with his/her peers; however, the resident had quit going to the dining room as well. The SRNA stated she has encouraged the resident to get out of his/her room and even though the resident could self-propel in his/her wheelchair, she would offer to assist the resident. SRNA #2 further stated she felt the resident was in a depressive state, although she had not received any behavior health training from the facility. Interview, on 12/20/17 at 2:11 PM, with LPN #1, revealed one minute she could go into Resident #27's room and the resident would exhibit signs and symptoms of depression and then later the resident would be fine. Continued interview revealed SRNA #2 was really good with Resident #27 when the resident was upset and crying and the SRNA would listen to the resident and reassure him/her the facility staff cared about him/her; however, if that did not work, the SRNA would come report to her. Additional interview revealed when staff reported to her that the resident was crying over family, she would only record this in the resident's Behavior/Intervention Flow Record if she went and observed the resident herself and thought it was depression. Further interview with LPN #1, revealed the staff did not report to her that Resident #27 was tearful on this past Friday or Monday. Per interview, today when the Director of Social Services and the Business Manager was in the resident's room, was the first time she had seen the resident tearful. The LPN stated as the charge nurse, it was her expectation the facility staff would notify her if the resident was observed to be tearful. She stated, if the resident was crying over his/her family, then she would expect that to be reported to her, and she should notify the facility's Director of Social Services and the resident's Physician. LPN #1 further stated she had noticed the resident had stopped going to the main dining room for meals and she had also noticed the resident's activity participation had decreased. Continued interview revealed she had encouraged the resident to attend activities and to just get out of his/her room for socialization. Continued interview, on 12/21/17 at 8:58 AM, with the facility's Director of Social Services, revealed since the last interview with the State Agency (SA) Representative, she had spoken with Resident #27 and the resident stated he/she was feeling down about his/her sons not coming to see him/her. Further interview revealed she asked the resident if he/she would like to see the Psychiatrist he/she had seen in the past and the resident stated he/she did and an appointment had been made. The Director of Social Services stated the resident had seen a psychiatrist while being a resident of the facility; however, the resident's son quit taking him/her. The Director of Social Services stated as the social worker, she should have made a referral to psychiatric services or the resident's primary care Physician in (MONTH) of (YEAR), when she completed the resident's MDS mood assessment on 10/31/17, to ensure the resident's psychosocial well-being, as per the Care Plan. Interview, on 12/21/17 at 9:58 AM, with the facility's Director of Nursing, revealed she felt like Resident #27's care plan addressed mood. She stated when the Director of Social Services completed the Quarterly MDS Assessment for Resident #27 in (MONTH) (YEAR), the assessment indicated the resident had increased depression, and interventions should have been implemented such as one (1) on one (1) activities, psychosocial support and mental health consults, non-pharmacological interventions, or as a last resort pharmacological change or adjustments to ensure the resident's psychosocial well-being, as per the Care Plan. Interview, on 12/21/17 at 10:14 AM, with the facility Administrator, revealed it was her expectation the Director of Social Services would have addressed Resident #27's depression, and informed the Interdisciplinary Team in order to update the Care Plan or implement current Care Plan interventions related to depression. Per interview, this was important for the quality of life and well-being of the resident.

Based on interview, record review, review of the facility's Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for one (1) of twenty-one (21) sampled residents (Resident #27). Review of Resident #27's Quarterly Minimum Data Set (MDS) Assessment, dated 10/30/17, revealed the facility assessed the resident to be feeling down, depressed, or hopeless nearly every day during the fourteen (14) day assessment period; however, the resident's Comprehensive Care Plan was not implemented related to interventions for mood/depression and behavior health consults as needed (psycho-geriatric team, psychiatrist, etc). The findings include: Review of the facility's policy titled, Care Plan Goals and Objectives, dated 08/01/13, revealed care plans should have incorporated goals and objectives that lead to the resident's highest obtainable level of independence. Continued review of the policy revealed care plan goals and objectives were defined as the desired outcome for a specific resident problem; and were derived from information contained in the resident's comprehensive assessment and were resident oriented, behaviorally stated, measurable and contained timetables to meet the resident's needs in accordance with the comprehensive assessment. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #27's medical record revealed the facility admitted the resident on 06/30/16 and readmitted the resident on 07/18/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/30/17, revealed the facility assessed Resident #27 to have a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), indicating the resident was moderately cognitively impaired. Continued review of the MDS, revealed the resident the facility assessed the resident to have a problem of feeling down, depressed, or hopeless and feeling tired or having little energy for twelve (12) to fourteen (14) days (nearly every day) of the fourteen (14) day assessment period. Review of the Comprehensive Care Plan for Resident #27, undated, revealed a focus of Mood Problem related to [MEDICAL CONDITION] and anxious behaviors with the goal stating the resident would have improved sleep pattern by reporting adequate rest and also the resident would have improved mood state as measured by decreased anxious behaviors. The interventions included: administer medications as ordered; allow time to talk and encourage the resident to express feelings; behavior health consults as needed (psycho-geriatric team, psychiatrist, etc.), observe for mood patterns and signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols; provide the resident with a program of activities that is meaningful and of interest, and encourage and provide opportunities for exercise, physical activity. Observation and interview, on 12/19/17 at 10:58 AM, with Resident #27, revealed the resident became tearful and began to cry stating he/she did not have anything to live for. Further interview revealed the resident stated he/she did not have anyone who cared for or loved him/her. Resident #27 further stated he/she had two (2) sons, but they never came to see him/her. Per interview, the resident's roommate did not talk to him/her either. Continued observation revealed the resident continued to cry and stated his/her spouse had built their house; however, his/her son now had his/her home. Further interview revealed the resident had seen a psychiatrist before, but had not seen him recently. Interview, on 12/20/17 at 10:26 AM, with the facility's Director of Social Services, revealed she completed the Resident Mood Interview section of Resident #27's Quarterly MDS Assessment on 10/30/17; however, had not recognized the resident was having symptoms of depression. When reviewing the MDS, the Director of Social Services stated, per the MDS, the resident experienced symptoms of depression most days during the assessment period for the MDS. Review of Resident #27's consultation record provided by the facility, revealed the resident's last appointment with his/her psychiatrist was 04/11/17. Continued review revealed the psychiatrist recommended the resident to return PRN (as needed) Review of the Activity Log dated August 2017, revealed Resident #27 attended seven (7) facility activities for the month. Review of Activity Log dated September 2017, revealed the resident attended eight (8) activities for the month. Review of the Activity Log dated October 2017, revealed the resident attended nine (9) activities for the month. Review of the Activity Log dated November 2017 revealed the resident attended three (3) activities for the month. Review of the Activity Log dated December 2017, revealed the resident had only attended one (1) activity up to the date of 12/20/17, indicating a decline in activities participation. Interview, on 12/20/17 at 11:01 AM with Activity Assistants #1 and #2, revealed in the past few months, Resident #27 had not participated in facility activities as he/she once did. Continued interview revealed when they offered activities to the resident, he/she would tell them he/she did not feel like going and when asked what was wrong, the resident stated he/she wanted his/her family to visit and be more involved in his/her life. The Activity Assistants stated they could tell the resident's feelings were hurt when speaking to him/her about the family not coming to see him/her. The Activity Assistants further stated back around the end of November 2017 to the first of December 2017, they had both mentioned the resident was feeling down and out to the facility's Director of Social Services. Continued interview with the Activity Assistants revealed with review of the Activity Logs, the logs showed a significant decrease in participation in activities for November and December 2017 as compared to the prior months dating back to August 2017. Interview, on 12/20/17 at 1:45 PM, with State Registered Nurse Aide (SRNA) #1, revealed even though he would not consider himself Resident #27's regular aide, he did answer the resident's call light and/or if he was down the resident's hall, he would stop and talk to him/her. Continued interview revealed he had spoken to the resident this past Friday or Monday around breakfast time and the resident's eyes were glossy and were tearing up and appeared to maybe be getting ready to cry. Further interview revealed he asked the resident what was wrong and the resident stated he/she had not eaten since dinner the evening prior. SRNA #1 stated he did not ask the resident any other questions. Interview, on 12/20/17 at 1:50 PM, with SRNA #3, revealed she was one of Resident #27's permanent aides. Continued interview revealed the resident was usually in a good mood; however, once in a blue moon, the resident would get upset and sad because of staff having to assist him/her so much and because the resident wanted his/her family to visit more often. Interview, on 12/20/17 at 1:57 PM, with SRNA #2, revealed she was Resident #27's permanent aide during the day shift. Continued interview revealed the resident had told her that he/she was depressed because his/her family did not come see him/her even though they lived close to the facility. Further interview revealed when the resident did tell her that he/she was depressed, she would reassure the resident everyone at the facility cared for him/her and they were there to help him/her. SRNA #2 stated a couple days ago, she observed the resident crying, and when she asked the resident why he/she was crying, the resident replied that he/she did not have anyone. The SRNA further stated she reported this to the nurse, specifically Licensed Practical Nurse (LPN) #1; however, there was no place for her to document that she reported this to the nurse. Continued interview revealed Resident #27 used to participate in facility activities; however, over the past few months the resident had quit attending activities. Further interview revealed the resident also used to go to the dining room to eat meals with his/her peers; however, the resident had quit going to the dining room as well. The SRNA stated she has encouraged the resident to get out of his/her room and even though the resident could self-propel in his/her wheelchair, she would offer to assist the resident. SRNA #2 further stated she felt the resident was in a depressive state, although she had not received any behavior health training from the facility. Interview, on 12/20/17 at 2:11 PM, with LPN #1, revealed one minute she could go into Resident #27's room and the resident would exhibit signs and symptoms of depression and then later the resident would be fine. Continued interview revealed SRNA #2 was really good with Resident #27 when the resident was upset and crying and the SRNA would listen to the resident and reassure him/her the facility staff cared about him/her; however, if that did not work, the SRNA would come report to her. Additional interview revealed when staff reported to her that the resident was crying over family, she would only record this in the resident's Behavior/Intervention Flow Record if she went and observed the resident herself and thought it was depression. Further interview with LPN #1, revealed the staff did not report to her that Resident #27 was tearful on this past Friday or Monday. Per interview, today when the Director of Social Services and the Business Manager was in the resident's room, was the first time she had seen the resident tearful. The LPN stated as the charge nurse, it was her expectation the facility staff would notify her if the resident was observed to be tearful. She stated, if the resident was crying over his/her family, then she would expect that to be reported to her, and she should notify the facility's Director of Social Services and the resident's Physician. LPN #1 further stated she had noticed the resident had stopped going to the main dining room for meals and she had also noticed the resident's activity participation had decreased. Continued interview revealed she had encouraged the resident to attend activities and to just get out of his/her room for socialization. Continued interview, on 12/21/17 at 8:58 AM, with the facility's Director of Social Services, revealed since the last interview with the State Agency (SA) Representative, she had spoken with Resident #27 and the resident stated he/she was feeling down about his/her sons not coming to see him/her. Further interview revealed she asked the resident if he/she would like to see the Psychiatrist he/she had seen in the past and the resident stated he/she did and an appointment had been made. The Director of Social Services stated the resident had seen a psychiatrist while being a resident of the facility; however, the resident's son quit taking him/her. The Director of Social Services stated as the social worker, she should have made a referral to psychiatric services or the resident's primary care Physician in October of 2017, when she completed the resident's MDS mood assessment on 10/31/17, to ensure the resident's psychosocial well-being, as per the Care Plan. Interview, on 12/21/17 at 9:58 AM, with the facility's Director of Nursing, revealed she felt like Resident #27's care plan addressed mood. She stated when the Director of Social Services completed the Quarterly MDS Assessment for Resident #27 in October 2017, the assessment indicated the resident had increased depression, and interventions should have been implemented such as one (1) on one (1) activities, psychosocial support and mental health consults, non-pharmacological interventions, or as a last resort pharmacological change or adjustments to ensure the resident's psychosocial well-being, as per the Care Plan. Interview, on 12/21/17 at 10:14 AM, with the facility Administrator, revealed it was her expectation the Director of Social Services would have addressed Resident #27's depression, and informed the Interdisciplinary Team in order to update the Care Plan or implement current Care Plan interventions related to depression. Per interview, this was important for the quality of life and well-being of the resident.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of twenty-one (21) sampled residents (Resident #27). Observation and interview on 12/19/17, revealed Resident #27 was tearful, crying, and expressing feelings of hopelessness. Review of the resident's Quarterly Minimum Data Set (MDS) Assessment, dated 10/30/17, revealed the facility assessed the resident as feeling down, depressed, or hopeless nearly every day during the fourteen (14) day assessment period; however, there was no documented evidence the resident was provided with behavioral/mental health services after the Assessment. The findings include: Review of the facility's Policy titled, Referrals-Social Services dated 08/01/13, revealed social services personnel shall coordinate most resident referrals with outside agencies and document the referral in the resident's medical record. Continued review of the Policy, revealed social services would help arrange transportation to outside agencies, clinic appointments, etc., as appropriate. Review of Resident #27's medical record revealed the facility admitted the resident on 06/30/16 and readmitted the resident on 07/18/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/30/17, revealed the facility assessed Resident #27 as having a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), indicating moderate cognitive impairment. Continued review of the MDS Assessment, revealed the facility assessed the resident as feeling down, depressed, or hopeless and feeling tired or having little energy for twelve (12) to fourteen (14) days of the fourteen (14) day assessment period. Review of Resident #27's Comprehensive Care Plan, undated, revealed a focus of Mood Problem due to [MEDICAL CONDITION] and anxious behaviors. The goal stated the resident would have improved sleep pattern and would have improved mood state as measured by decreased anxious behaviors. The interventions included: administer medications as ordered; allow time to talk and encourage the resident to express feelings; observe for mood patterns and signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols; provide the resident with a program of activities that is meaningful and of interest, and encourage and provide opportunities for exercise, physical activity. There was also an intervention for behavior health consults as needed with psycho-geriatric team, psychiatrist, etc. Observation and interview, on 12/19/17 at 10:58 AM, with Resident #27, revealed the resident became tearful and began to cry. The resident stated he/she did not have anything to live for, and did not have anyone who cared for him/her or loved him/her. Resident #27 further revealed he/she had two (2) sons, but they never came to visit. Per interview, his/her roommate did not talk to him/her either. Additional observation revealed the resident continued to cry and stated his/her spouse had built their house; however, his/her son now had her home. The resident stated she/he had seen a psychiatrist in the past, but no longer saw the psychiatrist. Interview, on 12/20/17 at 10:26 AM, with the facility's Director of Social Services, revealed she was unaware Resident #27 was depressed. She stated she completed the Resident Mood Interview section of Resident #27's Quarterly MDS Assessment on 10/30/17. The Director of Social Services reviewed the MDS assessment dated [DATE] during the interview, and stated, per the MDS, the resident experienced depression most all the days of the assessment period. Review of Resident #27's Consultation Record, provided by the facility, revealed the resident's last appointment with the psychiatrist was 04/11/17. Per the Consultation, the psychiatrist recommended the resident to return PRN (as needed). Further review of Resident #27's medical record revealed no documented evidence of any behavioral health referrals after the 10/31/17 MDS Assessment was completed. Observation, on 12/20/17 at 10:54 AM, revealed the facility's Director of Social Services and the facility's Business Office Manager (former Director of Social Services) talking to Resident #27. Further observation revealed the resident stated to both of them, he/she had no one who would come see him/her and all he/she had was the ceiling and the clock. Review of the Activity Log dated August 2017, revealed Resident #27 attended seven (7) facility activities. Review of the Activity Log dated September 2017, revealed the resident attended eight (8) activities. Review of the Activity Log dated October 2017, revealed the resident attended nine (9) activities. Review of the Activity Log dated November 2017, revealed the resident attended three (3) activities. Review of the Activity Log dated December 2017, revealed the resident only attended one (1) activity up to the date of 12/20/17, revealing a decline in activities participation. Interview, on 12/20/17 at 11:01 AM, with Activity Assistants #1 and #2, revealed in the past few months, Resident #27 had not participated in as many facility activities. Further interview revealed when they offered activities to the resident, he/she would tell them he/she did not feel like going and when asked what was wrong, the resident stated he/she wanted his/her family to visit and be more involved in his/her life. The Activity Assistants revealed they could tell the resident's feelings were hurt when speaking to him/her about the family not coming to see him/her. The Activity Assistants further revealed back around the end of November 2017 to the first of December 2017, they had both mentioned the resident was feeling down and out to the facility's Director of Social Services. Additional interview with the Activity Assistants, revealed when looking at the Activity Logs, the logs showed a significant decrease in participation in activities in November and December 2017, compared to the prior months dating back to August 2017. Interview, on 12/20/17 at 1:45 PM, with State Registered Nurse Aide (SRNA) # 1, revealed even though he would not consider himself Resident #27's regular aide, he did answer the resident's call light and would stop and talk to him/her. Per interview, he had spoken to the resident this past Friday or Monday around breakfast time and the resident's eyes were glossy and were tearing up and it appeared the resident may have been getting ready to cry. Further interview revealed he asked Resident #27 what was wrong and the resident stated he/she had not eaten since dinner the evening prior. SRNA #1 revealed he did not ask the resident any further questions. Interview, on 12/20/17, at 1:50 PM, with SRNA #3, revealed she was one of Resident #27's permanent aides and the resident was usually in a good mood. However, she stated once in a blue moon, the resident would get upset and sad because of staff having to assist him/her so much and because the resident wanted his/her family to visit more often. Interview, on 12/20/17 at 1:57 PM, with SRNA #2, revealed she was Resident #27's permanent aide on the day shift. She stated the resident had told her he/she was depressed because his/her family did not come see him/her even though they lived close to the facility. Continued interview revealed when the resident did tell her that he/she was depressed, she would reassure the resident everyone at the facility cared for him/her and they were there to help him/her. Per interview, a few days ago, she observed the resident crying, and when she asked the resident why he/she was crying, the resident replied, he/she did not have anyone. SRNA #2 further stated she reported this to the nurse, specifically Licensed Practical Nurse (LPN) #1; however, there was no place for her to document what she reported. Further interview revealed Resident #27 used to participate in facility activities; however, over the past few months the resident had quit attending activities. She stated the resident also used to go to the dining room to eat meals with his/her peers; however, the resident had quit going to the dining room as well. The SRNA further stated she had encouraged the resident to get out of his/her room and even though the resident could self-propel in his/her wheelchair, she would offer to assist the resident. Additional interview revealed she had not received any behavior health training from the facility. Interview, on 12/20/17 at 2:11 PM, with LPN #1, revealed one minute she could go into Resident #27's room and the resident would exhibit signs and symptoms of depression and then later the resident seemed to be fine. Per interview, SRNA #2 was really good with Resident #27 when the resident was upset and crying and the SRNA would listen to the resident and reassure him/her the facility staff cared about him/her; however, if that did not work, the SRNA would come report to her. Further interview revealed when staff reported to her that the resident was crying over family, she would only record that in the resident's Behavior/Intervention Flow Record if she went and observed the resident herself and thought it was depression. Additional interview with LPN #1, revealed the staff did not report to her that Resident #27 was tearful on this past Friday or Monday. Per interview, today when the Director of Social Services and the Business Manager was in the resident's room, was the first time she had seen the resident tearful. The LPN revealed, as the charge nurse, it was her expectation the facility staff would notify her if the resident was observed to be tearful. She further stated, if the resident was crying over his/her family, then she would expect that to be reported to her, and she should then notify the facility's Director of Social Services and the resident's Physician. LPN #1 stated she had noticed the resident had stopped going to the main dining room for meals and she had also noticed the resident's activity participation had decreased. Per interview, she had encouraged the resident to attend activities and to just get out of his/her room for socialization. Review of Resident #27's Behavior/Intervention Monthly Flow Record, for the months of October 2017, November 2017, and December 2017, revealed the facility indicated the resident's depression was identified as a behavior. Further review of the Record for the three (3) months, revealed the facility nursing staff documented no observed behaviors of Depression. Further interview, on 12/21/17 at 8:58 AM, with the facility's Director of Social Services, revealed since the last interview with the State Agency (SA) Representative, she had spoken with Resident #27 and the resident stated he/she was feeling down about his/her sons not coming to see him/her. She stated she asked the resident if he/she would like to see the Psychiatrist he/she had once seen and the resident stated he/she did, and an appointment had been made. The Director of Social Services further stated the resident had seen a psychiatrist while being a resident of the facility; however, the resident's son quit taking him/her. Further interview revealed as the social worker, she should have made a referral to psychiatric services or the resident's primary care Physician in October of 2017 when she completed the resident's MDS mood assessment on 10/31/17, for the resident's psychosocial well-being. Interview, on 12/21/17 at 9:09 AM, with the facility's Business Office Manager, revealed as the former Director of Social Services, he had been training the current Director of Social Services. Continued interview revealed when Resident #27 was assessed to have depression for nearly every day of the assessment period in October 2017, the Director of Social Services should have notified the resident's primary care Physician for a mental health consult. Interview, on 12/21/17 at 9:58 AM, with the facility's Director of Nursing, revealed when the Director of Social Services completed the Quarterly MDS Assessment for Resident #27, and the assessment indicated the resident had increased depression, the Physician and Interdisciplinary Team (IDT) should have been notified for treatment and intervention. Per interview, interventions should have been implemented such as one (1) on one (1) activities, psychosocial support/ mental health services, non-pharmacological interventions, or as a last resort pharmacological change or adjustments to ensure the resident's psychosocial well-being. Interview, on 12/21/17 at 9:33 AM, with Resident #27's Attending Physician, revealed he was aware the resident had increased depression and was tearful daily. However, he stated he was not sure if the resident was really crying or if it was a behavior related to his/her [DIAGNOSES REDACTED]. Interview, on 12/21/17 at 10:14 AM, with the facility Administrator, revealed it was her expectation the Director of Social Services would have addressed Resident #27's depression, and informed the Interdisciplinary Team (IDT) in order to implement interventions including mental health services. Continued interview revealed it was important for the resident's depression to be addressed for the resident's quality of life and well-being.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of twenty-one (21) sampled residents (Resident #27). Observation and interview on 12/19/17, revealed Resident #27 was tearful, crying, and expressing feelings of hopelessness. Review of the resident's Quarterly Minimum Data Set (MDS) Assessment, dated 10/30/17, revealed the facility assessed the resident as feeling down, depressed, or hopeless nearly every day during the fourteen (14) day assessment period; however, there was no documented evidence the resident was provided with mental health services after the Assessment. The findings include: Review of the facility's Policy titled, Referrals-Social Services dated 08/01/13, revealed social services personnel shall coordinate most resident referrals with outside agencies and document the referral in the resident's medical record. Continued review of the Policy, revealed social services would help arrange transportation to outside agencies, clinic appointments, etc., as appropriate. Review of Resident #27's medical record revealed the facility admitted the resident on 06/30/16 and readmitted the resident on 07/18/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/30/17, revealed the facility assessed Resident #27 as having a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), indicating moderate cognitive impairment. Continued review of the MDS Assessment, revealed the facility assessed the resident as feeling down, depressed, or hopeless and feeling tired or having little energy for twelve (12) to fourteen (14) days of the fourteen (14) day assessment period. Review of Resident #27's Comprehensive Care Plan, undated, revealed a focus of Mood Problem due to [MEDICAL CONDITION] and anxious behaviors. The goal stated the resident would have improved sleep pattern and would have improved mood state as measured by decreased anxious behaviors. The interventions included: administer medications as ordered; allow time to talk and encourage the resident to express feelings; observe for mood patterns and signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols; provide the resident with a program of activities that is meaningful and of interest, and encourage and provide opportunities for exercise, physical activity. There was also an intervention for behavior health consults as needed with psycho-geriatric team, psychiatrist, etc. Observation and interview, on 12/19/17 at 10:58 AM, with Resident #27, revealed the resident became tearful and began to cry. The resident stated he/she did not have anything to live for, and did not have anyone who cared for him/her or loved him/her. Resident #27 further revealed he/she had two (2) sons, but they never came to visit. Per interview, his/her roommate did not talk to him/her either. Additional observation revealed the resident continued to cry and stated his/her spouse had built their house; however, his/her son now had her home. The resident stated she/he had seen a psychiatrist in the past, but no longer saw the psychiatrist. Interview, on 12/20/17 at 10:26 AM, with the facility's Director of Social Services, revealed she was unaware Resident #27 was depressed. She stated she completed the Resident Mood Interview section of Resident #27's Quarterly MDS Assessment on 10/30/17. The Director of Social Services reviewed the MDS assessment dated [DATE] during the interview, and stated, per the MDS, the resident experienced depression most all the days of the assessment period. Review of Resident #27's Consultation Record, provided by the facility, revealed the resident's last appointment with the psychiatrist was 04/11/17. Per the Consultation, the psychiatrist recommended the resident to return PRN (as needed). Further review of Resident #27's medical record revealed no documented evidence of any behavioral health referrals after the 10/31/17 MDS Assessment was completed. Observation, on 12/20/17 at 10:54 AM, revealed the facility's Director of Social Services and the facility's Business Office Manager (former Director of Social Services) talking to Resident #27. Further observation revealed the resident stated to both of them, he/she had no one who would come see him/her and all he/she had was the ceiling and the clock. Review of the Activity Log dated (MONTH) (YEAR), revealed Resident #27 attended seven (7) facility activities. Review of the Activity Log dated (MONTH) (YEAR), revealed the resident attended eight (8) activities. Review of the Activity Log dated (MONTH) (YEAR), revealed the resident attended nine (9) activities. Review of the Activity Log dated (MONTH) (YEAR), revealed the resident attended three (3) activities. Review of the Activity Log dated (MONTH) (YEAR), revealed the resident only attended one (1) activity up to the date of 12/20/17, revealing a decline in activities participation. Interview, on 12/20/17 at 11:01 AM, with Activity Assistants #1 and #2, revealed in the past few months, Resident #27 had not participated in as many facility activities. Further interview revealed when they offered activities to the resident, he/she would tell them he/she did not feel like going and when asked what was wrong, the resident stated he/she wanted his/her family to visit and be more involved in his/her life. The Activity Assistants revealed they could tell the resident's feelings were hurt when speaking to him/her about the family not coming to see him/her. The Activity Assistants further revealed back around the end of (MONTH) (YEAR) to the first of (MONTH) (YEAR), they had both mentioned the resident was feeling down and out to the facility's Director of Social Services. Additional interview with the Activity Assistants, revealed when looking at the Activity Logs, the logs showed a significant decrease in participation in activities in (MONTH) and (MONTH) (YEAR), compared to the prior months dating back to (MONTH) (YEAR). Interview, on 12/20/17 at 1:45 PM, with State Registered Nurse Aide (SRNA) # 1, revealed even though he would not consider himself Resident #27's regular aide, he did answer the resident's call light and would stop and talk to him/her. Per interview, he had spoken to the resident this past Friday or Monday around breakfast time and the resident's eyes were glossy and were tearing up and it appeared the resident may have been getting ready to cry. Further interview revealed he asked Resident #27 what was wrong and the resident stated he/she had not eaten since dinner the evening prior. SRNA #1 revealed he did not ask the resident any further questions. Interview, on 12/20/17, at 1:50 PM, with SRNA #3, revealed she was one of Resident #27's permanent aides and the resident was usually in a good mood. However, she stated once in a blue moon, the resident would get upset and sad because of staff having to assist him/her so much and because the resident wanted his/her family to visit more often. Interview, on 12/20/17 at 1:57 PM, with SRNA #2, revealed she was Resident #27's permanent aide on the day shift. She stated the resident had told her he/she was depressed because his/her family did not come see him/her even though they lived close to the facility. Continued interview revealed when the resident did tell her that he/she was depressed, she would reassure the resident everyone at the facility cared for him/her and they were there to help him/her. Per interview, a few days ago, she observed the resident crying, and when she asked the resident why he/she was crying, the resident replied, he/she did not have anyone. SRNA #2 further stated she reported this to the nurse, specifically Licensed Practical Nurse (LPN) #1; however, there was no place for her to document what she reported. Further interview revealed Resident #27 used to participate in facility activities; however, over the past few months the resident had quit attending activities. She stated the resident also used to go to the dining room to eat meals with his/her peers; however, the resident had quit going to the dining room as well. The SRNA further stated she had encouraged the resident to get out of his/her room and even though the resident could self-propel in his/her wheelchair, she would offer to assist the resident. Additional interview revealed she had not received any behavior health training from the facility. Interview, on 12/20/17 at 2:11 PM, with LPN #1, revealed one minute she could go into Resident #27's room and the resident would exhibit signs and symptoms of depression and then later the resident seemed to be fine. Per interview, SRNA #2 was really good with Resident #27 when the resident was upset and crying and the SRNA would listen to the resident and reassure him/her the facility staff cared about him/her; however, if that did not work, the SRNA would come report to her. Further interview revealed when staff reported to her that the resident was crying over family, she would only record that in the resident's Behavior/Intervention Flow Record if she went and observed the resident herself and thought it was depression. Additional interview with LPN #1, revealed the staff did not report to her that Resident #27 was tearful on this past Friday or Monday. Per interview, today when the Director of Social Services and the Business Manager was in the resident's room, was the first time she had seen the resident tearful. The LPN revealed, as the charge nurse, it was her expectation the facility staff would notify her if the resident was observed to be tearful. She further stated, if the resident was crying over his/her family, then she would expect that to be reported to her, and she should then notify the facility's Director of Social Services and the resident's Physician. LPN #1 stated she had noticed the resident had stopped going to the main dining room for meals and she had also noticed the resident's activity participation had decreased. Per interview, she had encouraged the resident to attend activities and to just get out of his/her room for socialization. Review of Resident #27's Behavior/Intervention Monthly Flow Record, for the months of (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), revealed the facility indicated the resident's depression was identified as a behavior. Further review of the Record for the three (3) months, revealed the facility nursing staff documented no observed behaviors of Depression. Further interview, on 12/21/17 at 8:58 AM, with the facility's Director of Social Services, revealed since the last interview with the State Agency (SA) Representative, she had spoken with Resident #27 and the resident stated he/she was feeling down about his/her sons not coming to see him/her. She stated she asked the resident if he/she would like to see the Psychiatrist he/she had once seen and the resident stated he/she did, and an appointment had been made. The Director of Social Services further stated the resident had seen a psychiatrist while being a resident of the facility; however, the resident's son quit taking him/her. Further interview revealed as the social worker, she should have made a referral to psychiatric services or the resident's primary care Physician in (MONTH) of (YEAR) when she completed the resident's MDS mood assessment on 10/31/17, for the resident's psychosocial well-being. Interview, on 12/21/17 at 9:09 AM, with the facility's Business Office Manager, revealed as the former Director of Social Services, he had been training the current Director of Social Services. Continued interview revealed when Resident #27 was assessed to have depression for nearly every day of the assessment period in (MONTH) (YEAR), the Director of Social Services should have notified the resident's primary care Physician for a mental health consult. Interview, on 12/21/17 at 9:58 AM, with the facility's Director of Nursing, revealed when the Director of Social Services completed the Quarterly MDS Assessment for Resident #27, and the assessment indicated the resident had increased depression, the Physician and Interdisciplinary Team (IDT) should have been notified for treatment and intervention. Per interview, interventions should have been implemented such as one (1) on one (1) activities, psychosocial support/ mental health services, non-pharmacological interventions, or as a last resort pharmacological change or adjustments to ensure the resident's psychosocial well-being. Interview, on 12/21/17 at 9:33 AM, with Resident #27's Attending Physician, revealed he was aware the resident had increased depression and was tearful daily. However, he stated he was not sure if the resident was really crying or if it was a behavior related to his/her [DIAGNOSES REDACTED]. Interview, on 12/21/17 at 10:14 AM, with the facility Administrator, revealed it was her expectation the Director of Social Services would have addressed Resident #27's depression, and informed the Interdisciplinary Team (IDT) in order to implement interventions including mental health services. Continued interview revealed it was important for the resident's depression to be addressed for the resident's quality of life and well-being.

Based on observation, interview and record review, it was determined the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles. Observation on 12/19/17 of the Lodge Unit refrigerator, revealed one (1) vial of Influenza Vaccine which was open, with no date indicating the date the vial had been opened and no initials of the person who opened the vial. In addition, there was one (1) bottle of [MEDICATION NAME] Purified Protein Derivative which was open with the box dated 12/14/17, but without the vial dated or initialed. The findings include: Review of the facility Policy titled, HA 3 Vials and [MEDICATION NAME] of Injectable Medications, undated, revealed vials should have the date opened and the initials of the first person to use the vial recorded on multi-dose vials on the vial label or an accessory label affixed for that purpose. Observation on 12/19/17 at 10:00 AM, of the Lodge Unit refrigerator, revealed one (1) vial of Influenza Vaccine NDC 3332-117-10 with expiration date of June 30, 2018 which was open, with no date indicating the date the vial had been opened and no initials of the person who opened the vial. In addition, there was one (1) bottle of [MEDICATION NAME] Purified Protein Derivative which was open with the box dated 12/14/17, but without the vial dated or initialed. Interview with Licensed Practical Nurse (LPN) #3 on the Lodge Unit, on 12/19/17 at 10:15 AM, revealed it was facility policy for multi-dose vials to be dated after being opened and if found in the refrigerator undated, it would need to be discarded. Per interview, this was because the nurse administering the medication would not know when the medication would expire if there was no open date on the vial. Interview with LPN #4, on the Lodge Unit, on 12/20/17 at 2:55 PM, revealed it was facility policy for multi-dose vials to be dated and initialed after being opened and if found in the refrigerator undated and not initialed, the vial would need to be discarded. Per interview, the open date was important because multi-dose vials would expire a certain amount of days after opened. Interview with the Director of Nursing (DON), on 12/20/17 at 2:30 PM, revealed it was her expectation for all nursing staff to follow policy regarding storage and labeling of medications and biologicals. She further stated staff should date and initial the multi-dose vials when they were opened. Continued interview revealed it was important to follow policy to ensure safety of the residents in regards to medication administration. Interview with the facility Administrator, on 12/20/17 at 2:45 PM, revealed it was important for all nursing staff to follow policy regarding storage and labeling of medications and biologicals for the safety of the residents. She further stated the staff should date and initial the multi-dose vials when they were opened. Continued interview revealed it was important for staff to be knowledgeable and educated regarding storage and labeling of biologicals.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure residents were free from misappropriation for one (1) of four (4) sampled residents (Resident #1). The facility hired State Registered Nurse Aide (SRNA) #1 on 11/01/16, although the background screening which was completed by the facility indicated the SRNA was ineligible for work in a Long Term Care setting by the Ohio Nurse Aide Registry. Resident #1's wallet was misappropriated on 10/08/17, resulting in loss of property in the form of photographs which could not be replaced. Per the facility Investigation, SRNA #1 was terminated due to possible misappropriation of the Resident #1's wallet. Then findings include: Review of the facility Prevention Policy, undated, revealed the facility did not condone any form of resident abuse, with the goal of maintaining an abuse free environment. Review of the facility Background Investigations Policy, undated, revealed if personnel background checks revealed any conviction of abuse, neglect, or exploitation, the applicant will not be employed. Review of SRNA #1's Personnel File, revealed the Ohio Nurse Aide Registry check with an original approval date of 03/25/03, found her guilty of abuse, neglect, or misappropriation; not in good standing; and not eligible for work in a Long Term Care Facility in any capacity. Continued review of the Personnel File, revealed SRNA #1 was hired at the facility on 11/01/16, even though the facility application revealed she had documented the incident which led to her ineligibility for hire. Review of Resident #1's medical record revealed the facility admitted the resident on 06/12/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Review of the facility Long Term Care Facility Report, dated 10/17/17, revealed on 10/16/17 Resident #1 placed his/her wallet in the pocket of a pair of clean pants and laid his/her clothes out prior to taking a shower. Per the Report, Resident #1's SRNA gathered up the clean closet and took them to the shower room, then went to get the resident and returned to the shower room. When Resident #1 put his/her clean pants on, he/she noticed the wallet was not in the pants pocket. Further review revealed staff searched the resident's room, shower room, and laundry and were unable to locate the wallet. Per the Report, cameras in the hallway revealed one employee entered the shower room from the time the clothes were placed in the shower room to when Resident #1 ended the shower (SRNA #1). Continued review of the Report, revealed the employee had left for the day on 10/16/17, and the Administrator met with the employee at 6:00 AM on 10/17/17 and questioned her about the missing wallet. Per the Report SRNA #1 was terminated. Interview with Resident #1 on 11/06/17 at 12:30 PM, revealed he/she last saw his/her wallet in the shower room next door (next to the resident's room) on 10/16/17 before noon, when he/she was assisted by State Registered Nurse Aide (SRNA) #4. Resident #1 revealed his/her wallet was in his/her pants which were placed in the shower room by SRNA #4. Resident #1 further revealed he/she noticed the wallet missing after the shower, and although staff looked for it they couldn't find it. He/she revealed the facility replaced missing money, and were in the process of replacing missing social security and insurance cards. Resident #1 stated the only thing he/she really missed was a photo of his/her spouse when the spouse was nineteen (19) years old that couldn't be replaced. Per interview, Resident #1 was alright with the way the facility handled everything. Resident #1 pointed out drawers beneath the wardrobe in his/her room in which he/she could lock up valuables. Interview with SRNA #4, on 11/07/17 at 8:21 AM, revealed Resident #1 was scheduled for a shower on 10/16/17 and he took the resident's clothing into the shower room first, and noticed something heavy in Resident #1's pants, but did not know whether it was a wallet or a belt buckle, and did not actually see anything. He revealed he placed Resident #1's clothing on the sink. He further stated he immediately went back to the resident's room and took him/her in the shower. SRNA #4 revealed when he was helping Resident #1 dress after the shower, Resident #1 stated his/her wallet was missing. SRNA #4 revealed he thoroughly searched the shower room, to include hampers, trash, sink and cabinets, but couldn't find it. SRNA #4 further stated he alerted staff of the missing wallet as soon as he took Resident #1 back to his/her room. Per interview, an investigation was started and he gave a statement, and he checked with laundry throughout the day hoping the wallet would turn up, but it didn't. SRNA #4 revealed SRNA #6 was in the shower room briefly using the mirror and having trouble with her contacts, but he was unaware if anyone else came into the shower room during the resident's shower. Interview with SRNA #6, on 11/07/17 at 8:37 AM, revealed she entered the shower room on 10/16/17 to see how long SRNA #4 would be, and had something in her eye which was bothering her so she checked her eye in the mirror. She revealed SRNA #4 said he wouldn't be too much longer, so she took the resident she had escorted, who was outside of the shower room, back to his/her room to wait. She revealed SRNA #4 was in the shower room with Resident #1 about fifteen (15) minutes, then she went in to give a shower to another resident. Interview with the Administrator, on 11/06/17 at 3:21 PM, revealed in reviewing video footage for 10/16/17, they determined SRNA #4 and SRNA #6 were in the shower room. Per interview, the footage also revealed SRNA #1 was in and out of the shower room after SRNA #4 put Resident #1's clothing in the shower room and during the time SRNA #4 was assisting Resident #1 with a shower. She revealed, based on their investigation, they believed SRNA #1 had taken Resident #1's wallet, but had no proof and during her interview with SRNA #1, SRNA #1 denied taking Resident #1's wallet. She revealed SRNA #1 was terminated as a result of the investigation. The video footage was no longer available for review at the time of the investigation. Interview with SRNA #1, on 11/06/17 at 4:05 PM, revealed she went into the shower room on 10/16/17 as an unsampled resident had asked her to see if a cell phone had been left in the shower room. She revealed the cell phone was not in the shower room, and she later found it in a pocket behind the unsampled resident's wheelchair. Per interview, she left the facility at 2:00 PM on 10/16/17, as she did every day and as there was no cell phone service where she lived, she did not receive messages from the facility until the following morning on her way in to work. She stated she had several missed calls from the facility, and upon calling the facility found she needed to speak to the Administrator on arrival. Per interview, upon arrival to the facility she was pulled into the Quality Assurance (QA) Nurses' office to wait until the Administrator arrived. Per interview, when the Administrator arrived she accused her of taking Resident #1's wallet, which she denied. SRNA #1 further revealed she was not allowed to return to work and was terminated as a result of the allegation. Interview on 11/13/17 at 9:23 AM, with the Administrative Assistant, revealed she submitted paperwork for background checks online, to include Ohio and Virginia Nurse Aide Registries as well as KARES (Kentucky Applicant Registry and Employee Screening), a screening tool that can check national registries if utilized to do so. Per interview, if an applicant was listed as No under the auto match category during online search through KARES, such as with Ohio, she was either required to provide further information or do the search manually, which she did. She further stated she submitted all of her printed documentation, to include KARES and the Ohio Nurse Aide Registry, to the appropriate department head and the Administrator, who were responsible for the hiring decision. Interview with the Director of Nursing (DON), on 11/13/17 at 9:33 AM, revealed she was responsible for interviewing anyone to be hired in a nursing capacity. She stated, in addition to determining appropriateness through interview, she reviewed KARES which gives a red light or green light, indicating eligibility to hire. Per interview, she believed KARES to be a national background check and was the final word whether or not an applicant was eligible for hire. She stated she did not realize the Ohio Nurse Aide Registry was not included as part of the KARES background check. Per interview, she had been through KARES trainings and misunderstood how KARES was being used at her facility. Additional interview revealed if KARES had indicated SRNA #1 was ineligible for employment, she never would have been hired, and going forward she would be examining the Nurse Aide Registry Checks from nearby states. Further interview with the Administrator, on 11/13/17 at 9:42 AM, revealed she was responsible for reviewing applicants for hire once Department Heads had interviewed and expressed an interest in hiring. Per interview, she looked to KARES for the determination whether or not an applicant was eligible, and did not realize it did not automatically check the Ohio Nurse Aide Registry. Continued interview revealed she was under the understanding KARES was a national background check, and had she known SRNA #1 was ineligible for hire, she would not have hired her.

Based on interview and record review, it was determined the facility failed to implement written policies and procedures related to screening potential employees for a history of abuse, neglect or mistreatment of [REDACTED].#1. SRNA #1 was hired by the facility on 11/01/16, although the SRNA was determined to be ineligible for work in a Long Term Care setting by the Ohio Nurse Aide Registry. On 10/08/17, Resident #1 complained of his/her wallet missing after receiving a shower and per the facility Investigation, SRNA #1 was terminated for possible misappropriation. The findings include: Review of the facility Background Investigations Policy, undated, revealed if personnel background checks revealed any conviction of abuse, neglect, or exploitation, the applicant would not be employed. Review of SRNA #1's Employee File, revealed the Ohio Nurse Aide Registry check with an original approval date of 03/25/03, found her guilty of abuse, neglect, or misappropriation; not in good standing; and not eligible for work in a Long Term Care Facility in any capacity. Review of SRNA #1's facility application, revealed she had documented the incident which led to her ineligibility prior to hire. Further review of the SRNA #1's Employee File, revealed she was hired at the facility on 11/01/16. Review of Resident #1's medical record revealed the facility admitted the resident on 06/12/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), indicating the resident was cognitively intact. Interview with Resident #1, on 11/06/17 at 12:30 PM, revealed his/her wallet was determined to be missing on 10/16/17, after his/her shower. He/she stated he/she remembered last seeing his/her wallet in the shower room next door to his/her room on 10/16/17, before noon when he/she was assisted with a shower by SRNA #4. Resident #1 revealed the wallet was in his/her pants which were placed in the shower room by SRNA #4. Resident #1 stated he/she noticed the wallet missing after the shower, and although staff searched, they couldn't find it. Interview with SRNA #4, on 11/07/17 at 8:21 AM, revealed on 10/16/17, he took Resident #1's clothing into the shower room and noticed something heavy in Resident #1's pants, but did not know whether it was a wallet or a belt buckle, and did not actually see anything. He stated he placed Resident #1's clothing on the sink and immediately went back and assisted Resident #1 to the shower room for his/her shower. SRNA #4 revealed after the shower when helping Resident #1 dress, Resident #1 stated his/her wallet was missing. Per interview, SRNA #4 thoroughly searched the shower room including the hampers, trash, sink and cabinets, but couldn't find the wallet. SRNA #4 stated he alerted staff the wallet was missing as soon as he took Resident #1 back to his/her room. SRNA #4 stated an investigation was started and he gave a statement, and he also checked with laundry throughout the day hoping the wallet would turn up, but it didn't. SRNA #4 stated SRNA #6 was in the shower room briefly using the mirror and having trouble with her contacts, but he was unaware if there was anyone else in the shower room during the resident's shower. Interview with SRNA #6, on 11/07/17 at 8:37 AM, revealed she went into the shower room on 10/16/17 to see how long SRNA #4 would be, and also to check her eye in the mirror because it was bothering her. Per interview, SRNA #4 stated he wouldn't be too much longer, so she took the resident she had escorted, who was outside of the shower room, back to his/her room to wait. Further interview revealed SRNA #4 was in the shower room with Resident #1 about fifteen (15) minutes, then she went in to give a shower to another resident. Interview with the Administrator, on 11/06/17 at 3:21 PM, revealed in reviewing video footage for 10/16/17, they determined SRNA #4 and SRNA #6 were in the shower room, and also SRNA #1 was in and out of the shower room during the time SRNA #4 placed Resident #1's clothing in the shower room and also while SRNA #4 was assisting Resident #1 with the shower. She stated, based on their investigation, they believed SRNA #1 had taken Resident #1's wallet, but had no proof and during her interview with SRNA #1, SRNA #1 denied taking Resident #1's wallet. Per interview, SRNA #1 was terminated as a result of the investigation. Interview with SRNA #1, on 11/06/17 at 4:05 PM, revealed she was pulled into the Quality Assurance (QA) Nurse's office upon entering the facility for work the morning of 10/17/17 and was asked to wait there until the Administrator arrived. She stated when the Administrator arrived, she accused her of taking Resident #1's wallet. SRNA #1 stated she denied taking the wallet, but was not allowed return to work and was terminated as a result of the investigation. SRNA #1 revealed she discussed an incident in which she was accused of misappropriation in Ohio prior to hire during an interview with the facility. Interview with the Administrative Assistant, on 11/13/17 at 9:23 AM, revealed she submitted paperwork for background checks online, to include Ohio and Virginia Nurse Aide Registries as well as KARES (Kentucky Applicant Registry and Employee Screening), a screening tool that can check national registries if utilized to do so. The Administrative Assistant revealed, if an applicant was listed as No under the auto match category during online search through KARES, such as with Ohio, she was either required to provide further information or do the search manually. She revealed she submitted all of her printed documentation, to include KARES and the Ohio Nurse Aide Registry, to the appropriate department head and the Administrator, who were responsible for the hiring decision. Interview with the Director of Nursing (DON) on 11/13/17 at 9:33 AM, revealed she was responsible for interviewing anyone to be hired in a nursing capacity. She revealed, in addition to determining appropriateness through interview, she reviewed KARES which gives a red light or green light, indicating eligibility to hire. She stated she believed KARES to be a national background check and was the final word whether or not an applicant was eligible for hire. Per interview, she did not realize the Ohio Nurse Aide Registry was not included as part of the KARES background check. She revealed she had been through KARES trainings and misunderstood how KARES was being used at her facility. Further interview revealed if KARES had indicated SRNA #1 was ineligible for employment, she never would have been hired, and going forward she would be examining the Nurse Aide Registry Checks from nearby states. Follow up interview with the Administrator, on 11/13/17 at 9:42 AM, revealed she was responsible for reviewing applicants for hire once Department Heads had interviewed and expressed an interest in hiring. She revealed, like the DON, she looked to KARES for the determination whether or not an applicant was eligible, and did not realize it did not automatically check the Ohio Nurse Aide Registry. Further interview revealed she was under the understanding KARES was a national background check, and had she known SRNA #1 was ineligible for hire, she would not have hired her.

Based on observation, interview and review of the facility's Storage Area's, Maintenance Policy, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as possible. Observation, on facility tour on 01/25/16, revealed the chemical storage cabinet in the shower rooms on Unit A and Unit F Halls were unlocked with hazardous chemicals inside. In addition, observation on 01/26/16, on the Unit F Hall, revealed a housekeeping cart was left unattended and unlocked with numerous hazardous chemicals inside. The findings include: Review of the facility's Storage Area's, Maintenance Policy, dated 08/01/13, revealed materials including chemical toxins that may pose a safety hazard to vulnerable residents shall be monitored and/or stored safely. 1. Observation, on facility tour on 01/25/16 at 7:05 PM, revealed the chemical storage cabinet in the shower room on the Unit F hall was unlocked with Whirlbath Lemon - Kleen Germicidal Cleaner inside. Review of the Material Data Safety Sheet (MSDS) for Whirlbath Lemon - Kleen Germicidal Cleaner, revealed the chemical could cause skin and eye irritation and ingestion which could be harmful. Interview on 01/25/16 at 7:07 PM, with Licensed Practical Nurse (LPN) #4, revealed the chemical storage cabinet in the shower room should be locked at all times, that's why it has a keypad on it. 2. Observation on facility tour, on 01/25/16 at 7:30 PM, revealed the chemical storage cabinet in the shower room on the Unit A Hall was unlocked with hazardous chemicals inside which included one (1) bottle of Hydrogen Peroxide, one (1) bottle of Skin Bracer Men's After Shave, one (1) bottle of Glide Spray Buff Spray, and two (2) containers of Microdot Bleach Wipes. Review of the MSDS, for Hydrogen Peroxide, revealed very hazardous in case of skin contact and/or eye contact. Review of the MSDS for the Skin Bracer Men's After Shave, revealed skin and eye irritation on direct contact and may be harmful if swallowed in large quantities. Review of the MSDS for Glide Spray Buff Spray, revealed obtain medical attention immediately after contact with the chemical. And review of the MSDS for the Microdot Bleach Wipes revealed, harmful if swallowed. Interview with State Registered Nursing Assistant (SRNA) #1, on 01/25/16 at 7:40 PM, revealed the cabinet in which the chemicals were stored should have been locked and would be harmful if a resident came into contact with the chemicals. SRNA #1 stated, it was the facility's staff responsibility to ensure this cabinet was locked when not in use. Interview with LPN #4, on 01/25/16 at 7:45 PM, revealed the chemicals should be locked in the cabinet when not in use to keep the chemicals out of reach of the residents. 3. Observation on 01/26/16 at 11:10 AM, revealed a housekeeping cart was left unattended and unlocked on the Unit F Hall with the following hazardous chemicals inside: Malodor Neutralizer, Mint Bowl Cleaner, Virex II 256, Soft Scrub, Bleach Water, Clorox 4 in 1, Vanish, Glance Spray, Steel One, Tilex Spray, Provon Antimicrobial Wash. Review of the MSDS for the Maoldor Neutralizer: fatal if swallowed and enters the airways. Review of the MSDS for the Mint Bowl Cleaner: A) could cause damage to the respiratory tract and nasal passages, causing burning, choking, coughing, headache, and irreversible damage to the respiratory tract; B) liquid and vapors could cause severe irritation and burning of the skin and eyes. Repeated exposure may cause skin damage, severe eye irritation and burns including blindness; C) could cause burns to the mouth, esophagus, and stomach; Review of the MSDS for the Virex II 256: could cause skin and eye burns. Harmful or fatal if swallowed. Review of the MSDS for the Soft Scrub: causes severe skin burns and eye damage and could cause damage to organs through prolonged or repeated exposure. Review of the MSDS for the Bleach: causes severe skin burns and eye damage. Review of the MSDS for the Clorox 4 in 1: causes eye irritation and may cause cancer. Review of the MSDS for the Vanish: causes eye irritation and may cause skin irritation. Inhalation or ingestion of large quantities may cause irritation to the nose, throat, and gastrointestinal tract. Review of the MSDS for the Glance Spray: may be mildly irritating to the eyes and skin. Review of the MSDS for the Steel One Cleaner: may be fatal if swallowed and enters the airways. Review of the MSDS for the Tilex: may cause skin corrosion or irritation and serious eye damage or irritation. Review of the MSDS for the Provon Antimicrobial Wash: may cause eye irritation. Interview, on 01/26/16 at 11:15 AM, with Housekeeper #1, revealed the housekeeping cart lock was broken and there was no way to lock the cart when it was unattended. Further interview, revealed she would make the Housekeeping Manager aware that the cart lock was broken. She revealed, she was aware the cart needed to be locked for resident safety. Interview, on 01/28/16 at 9:39 AM, with the Director of Environmental Health and Safety Services, revealed all chemical storage cabinets should be shut and locked when not in use to protect the residents. Further interview, revealed he had already placed new locks on the housekeeping cart to ensure all chemicals were secured for resident safety. Interview, on 01/28/16 at 9:45 AM, with the Director of Nursing (DON), revealed all chemicals in the shower rooms were to be locked and secured at all times to protect residents. Further interview, revealed she had already inserviced staff on keeping chemicals stored properly and it was her expectation that all staff follow the facility's chemical storage policy. Interview, on 01/28/16 at 11:00 AM, with the Administrator, revealed she had maintenance place new exterior keypad locks on all the shower room doors and the Environmental Health and Safety Director placed new locks on all housekeeping carts to ensure resident safety after hearing of the chemicals not being properly secured, and it was her expectation that all chemicals be locked and secured at all times.

Based on observation, interview, and review of the facility's Confidentiality of Information policy, it was determined the facility failed to keep clinical records private and confidential. Observation on initial tour, on 01/25/16, revealed four (4) notebooks for Halls A,B,C,and F containing State Registered Nurse Assistant (SRNA) Resident Care Plans, Nutritional Intake Flowsheets, and Bowel and Bladder Flowsheets were left unattended on a table in the Alcove on Unit C Hallway. Additional observation on 01/26/16, revealed a resident's Medical Record was left open and unattended in the Alcove on Unit C Hallway. Further observation on 01/27/16, revealed a resident's Medication Administration Record [REDACTED]. The findings include: Review of the facility's Confidentiality of Information policy dated 08/01/2013, revealed the facility would safeguard all resident records, whether medical, financial, or social in nature, to protect the confidentiality of the information. 1. Observation on initial tour, on 01/25/16 at 7:00 PM, revealed four (4) notebooks for Halls A,B,C and F containing resident information including; SRNA Care Plans, Nutritional Intake Flowsheets, and Bowel and Bladder Flowsheets were left unattended on a table in the Alcove on Unit C Hallway. Interview, on 01/25/16 PM at 7:05 PM, with Licensed Practical Nurse (LPN) #4, revealed all notebooks containing resident information should be kept behind the nurse's station. 2. Observation, on 01/26/16 at 10:50 AM, revealed a residents Medical Record was left open and unattended in the alcove on Unit C Hallway. Interview, on 01/26/16 at 10:50 AM, with the Quality Assurance (QA) Nurse, revealed, resident information should not be left unattended in the alcove area. Further interview, revealed all medical records and notebooks containing resident care plans and other pertinent health information about residents should be secured behind the nurse's station when not in use. Interview, on 01/26/16 at 10:55 AM, with the Dietician, revealed she had been working on resident's medical records in the Alcove on Unit C Hall and had stepped away to talk with another resident. She stated she was unaware she could not leave medical records and other pertinent health information unattended in the alcove area. Further interview, revealed she would place the medical record and other pertinent health information behind the nurse's station in the future. 3. Observation on 01/27/16 at 9:00 AM, revealed a residents Medication Administration Record [REDACTED]. Interview, on 01/27/16 at 9:10 AM, with LPN #2, revealed he should not have walked away and left the MAR indicated [REDACTED]. He further stated, he should have closed the MAR before leaving the medication cart to protect the residents confidential information. Interview, on 01/28/16 at 9:45 AM, with the Director of Nursing (DON), revealed all staff should follow the facility's policy and keep all medical records and notebooks containing resident information behind the nurse's station. Interview, on 01/28/16 at 11:00 AM, with the Administrator, revealed resident medical records and other pertinent health information should not be left unattended in common areas where residents and or visitors could have access to them. She further stated, all medical records should be secured behind the nurses station when not in use. Additional interview, revealed she expected all staff to follow the facility's Confidentiality of Information policy.

Based on interview, record review, review of facility policy, and review of the Resident Assessment Instrument, User Manual Version 3.0, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for three (3) of ten (10) sampled residents (Resident #1, Resident #5, and Resident #10) related to skin issues and urinary tract infections (UTIs). The findings include: Review of the facility's policy titled Attestation to accuracy of the Resident Assessment, dated 08/01/13, revealed all personnel who completed any part of the Resident Assessment MDS must sign and certify the accuracy of that portion of the assessment. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument, User Manual Version 3.0, Section I, Item UTI, revealed the UTI had a look-back period of thirty (30) days for active disease. Further review revealed code only if all the following are met: Physician, Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist, or authorized licensed staff as permitted by state law diagnosed a UTI in the last thirty (30) days, sign or symptom attributed to UTI, significant laboratory findings, and current medication or treatment for [REDACTED]. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 01/01/11 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set assessment with an assessment reference date (ARD) of 07/03/15 revealed items M0100A, M0210, M0300B, M1200E, and M1200I were coded to say that Resident #1 did not have a pressure sore and was not receiving treatment. However, continued review of the medical record revealed a Physician's Telephone Order dated 07/02/15 to clean the left great toe with normal saline, pat it dry with gauze, apply [MEDICATION NAME] (a wound care dressing), and change the dressing every three (3) days. Review of the Weekly Progress Note dated 07/02/15 under measurement/description revealed the size of the ulcer was 0.5 by 0.5 centimeters, and documentation that stated the area remained open with a scant amount of drainage noted and to continue the [MEDICATION NAME]. Review of the Wound Care Summary dated 05/26/15 revealed the wound developed/was discovered on 05/26/15 and the [DIAGNOSES REDACTED]. Interview with the Licensed Practical Nurse (LPN) MDS Coordinator on 09/15/15 at 3:50 PM revealed she believed the area on the toe was due to a Podiatrist visit, and not due to pressure. She stated she did fail to code M1200 correctly that Resident #1 had application of a dressing to the feet. Interview with the Director of Nursing (DON) on 09/17/15 at 3:15 PM revealed the facility had a quality of care meeting every Thursday. She stated during the meeting each department was given a copy of the wound sheet and they discussed the progress of the wound. She stated the LPN MDS Coordinator attended the meetings weekly. The DON stated she expected the MDS Coordinators to review the physicians orders, the treatment sheets, and wound care sheets when doing a MDS to assure accuracy. She stated she did not know how the MDS Coordinator missed coding the pressure ulcer for Resident #1. 2. Review of Resident #5's medical record revealed the facility admitted the resident on 05/12/14 with [DIAGNOSES REDACTED]. Review of the Quarterly/14-day Medicare Required Prospective Payment System (PPS) assessment with an ARD of 09/09/15 revealed item I2300 UTI was not checked, indicating that Resident #5 did not have a UTI in the past 30 days. Continued review of the assessment revealed the facility assessed Resident #5's Brief Interview for Mental Status (BIMS) score as 15 indicating the resident was interviewable. Continued review of the medical record revealed a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of the C&S report dated 09/05/15 revealed Escherichia coli (E. coli) greater than 100,000 colony forming units per milliliter (CFU/ml). During an interview with Resident #5 on 09/16/15 at 2:30 PM, the resident stated he/she was aware of the UTI due to having pain during urination. Interview on 09/17/15 at 10:05 AM with the LPN MDS Coordinator revealed she had not coded the UTI because she could not find documentation of any symptoms of a UTI in the nurse's notes. She stated an elevated temperature could be a sign of a UTI but she had not counted the elevated temperature because she could not find a baseline temperature documented. She stated to be counted as an elevated temperature per the facility's policy the temperature had to be two (2) points Fahrenheit over the baseline temperature. She stated she had not interviewed the resident about the symptoms when completing the MDS. The LPN MDS Coordinator stated the resident had all four (4) criteria and the UTI should have been coded on the MDS. 3. Review of the medical record revealed the facility readmitted Resident #10 on 06/26/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed in section C0500, the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 9, revealing the resident had moderate cognitive impairment. Further review of the Quarterly MDS, dated [DATE], revealed section I Active Diagnoses, section , was coded to reflect the resident had a UTI within the last 30 days, the ARD plus 29 days. Review of the nurse's notes dated 07/22/15, revealed a Urinalysis (UA) and Culture and Sensitivity (C&S) via a straight cath was obtained with large amounts of sediment and trace amounts of visible blood. Continued review of the nurse's notes dated 07/23/15, revealed Resident #10 complained of dysuria and frequency and the lab report was pending. Review of the final lab report status dated 07/24/15, revealed a culture of Proteus Mirabilis (gram negative anaerobic rod shaped bacterium) greater than 100,000. Review of the Physician/Prescriber Sign and Return Order Sheet dated 07/24/15 revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview on 09/17/15 at 9:48 AM with the Registered Nurse (RN) MDS Coordinator revealed she signed the MDS to reflect the MDS was completed within the period of the ARD. Continued interview revealed each person that completed their portion must sign and certify the MDS was accurate. Further interview revealed the MDS was not accurate because the UTI did not fall within the 30-day look-back period. Interview on 09/17/15 at 10:15 AM with the LPN MDS Coordinator revealed she coded the MDS for the UTI and did not look at the correct date. Continued interview revealed she should not have coded the MDS for the UTI, because it was not within the 30-day look-back period. Further interview revealed she signed the MDS and it was not an accurate assessment. Interview on 09/17/15 at 3:15 PM with the DON revealed she expected the MDS Coordinators to code based on an accurate assessment of the resident, use the four (4) criteria of the UTI, and ensure the [DIAGNOSES REDACTED].

Based on interview and record review, it was determined the facility failed to ensure the physician was notified of a change in status for two (2) of nine (9) sampled residents (Residents #1 and #3). Residents #1 and #3 did not have adequate bowel elimination, as defined by the facility's bowel protocol, for periods ranging from four (4) to twenty (20) days. There was no documented evidence the facility's Bowel Care Protocol was implemented, including the notification of the resident's physician when the resident failed to have bowel movements. Although interview and record review revealed Resident #1 did not have regular bowel movements, there was no evidence the resident's physician was notified regarding the resident's lack of bowel movements. Resident #1 was admitted to the hospital on [DATE], with [DIAGNOSES REDACTED]. The findings include: Review of the facility's Bowel Care Protocol (BCP), which was not dated, revealed a resident must have at least one (1) large or two (2) medium bowel movements every three (3) days to be considered adequate. According to the facility's Bowel Care Protocol, if three (3) days elapsed without adequate bowel elimination bowel movements, the following steps should be taken, beginning with Step 1, then 2 and so forth: 1. Milk of Magnesia (M.O.M.) 30 ml po, if no results in 24 hours, 2. [MEDICATION NAME] Suppository 10 mg rectally, if no results in 12 hours, 3. Fleets Enema, 4. If no results, or inadequate results, with Fleets Enema, 1000 ml soap suds enema x 2, if still inadequate results, notify Physician. Review of the facility's Changes in a Resident's Condition or Status Policy revealed the Physician was to be notified of changes in the resident's condition and/or status. 1. Review of the clinical record revealed Resident #1 was admitted with [DIAGNOSES REDACTED]. Review of the Bowel Information Tracking Logs for September and October of 2010 revealed no documented evidence Resident #1 had a bowel movement for the eleven (11) day period between [DATE] and [DATE]. Continued review revealed the resident had a medium bowel movement on [DATE], a small bowel movement on [DATE], and a small bowel movement on [DATE]. Application of the facility's bowel protocol to Resident #1's bowel record revealed the resident did not have an adequate bowel movement for twenty (20) days, from [DATE] to [DATE]. Continued review revealed no evidence the resident's physician was notified of the resident's lack of bowel movements. Interview with the attending physician on [DATE] at 4:45 PM revealed he had never received a call from the facility related to the resident's constipation or lack of bowel movements. Review of the Nurse's Notes dated [DATE] at 1:00 AM, and signed by Registered Nurse (RN) #1, revealed Resident #1 complained of constipation and received [MEDICATION NAME] earlier in the shift. Continued review revealed the resident told the nurse he/she would need an enema if the [MEDICATION NAME] did not work. Review of Nurse's Notes for the remainder of the shift revealed no indication of the results following the [MEDICATION NAME], no evidence the physician was notified, and no report of an enema being offered to the resident. Interview with Registered Nurse (RN) #1 on [DATE] at 3:45 PM revealed she recalled Resident #1 complained, "one night" of constipation and needed an enema. The nurse stated she called the doctor, who said she could give an enema, which she attempted to administer. The RN explained the resident refused the enema and said, "I don't want it, it wouldn't help anyway." Continued interview revealed RN #1 recalled finding a container of [MEDICATION NAME] suppositories on the resident's bedside table. She stated she locked the medication in the medication cart and advised the resident she would obtain a physician's orders [REDACTED]. Review of the Nurse's Notes dated [DATE] at 5:00 PM revealed Resident #1 complained of "pain in stomach, just not feeling well, nausea, chills." Continued review revealed the resident had a temperature of 101.1 degrees Farenheit and the spouse requested the resident be sent to the hospital. Further review of the Nurse's Notes revealed the resident was sent to the hospital, by ambulance, at 5:15 PM. Further review revealed a call was received from the hospital at 11:30 PM, informing the facility the resident had been admitted with abdominal pain and constipation. During interview, on [DATE] at 9:30 AM, Resident #1 reported a long history of constipation which required the use of five (5) to six (6) [MEDICATION NAME] tablets (a stool softener) twice a day. The resident reported the use of a "Fleets" suppository "at least twice a week." Further interview revealed Resident #1 reported he/she "begged them every day" to get an order for [REDACTED]. They let me lay there and almost die. If it wasn't for my (spouse), I would have died . Now here I lie." Interview with the spouse of Resident #1 on [DATE] at 2:30 PM revealed Resident #1 was admitted to the hospital on [DATE]. Continued interview revealed the spouse had spoken to the resident's surgeon after Resident #1 underwent surgery on [DATE]. The spouse reported being told by the surgeon the resident's bowel had burst. In addition, the spouse stated he/she was told the resident was so impacted, the bowel was dead and the resident required placement of a [MEDICAL CONDITION]. Further interview revealed the spouse had spoken to the resident's attending physician, who had cared for the resident at the nursing home, and the physician reported he had never been called by facility staff about the resident's lack of a bowel movement. The spouse further stated different nurses at the facility said they would call the doctor, but they never did. During interview on [DATE] at 4:45 PM, the attending physician for Resident #1 stated he had spoken to the surgeon, who reported the resident had a fecal impaction on admission to the hospital, with perforation of the bowel after admission to the hospital requiring surgical intervention. 2. Review of Resident #3's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the August-[DATE] Monthly Physicians Orders revealed an order for [REDACTED]. Review of the [DATE] Bowel Information Tracking Log revealed no documented evidence of a BM from [DATE]-31 (3 days). Review of the September, October and [DATE] Bowel Information Tracking Logs revealed no documented evidence of adequate BMs, as defined by the facility's bowel protocol, from [DATE]-[DATE] (18 days), [DATE]-17 (10 days), and [DATE]-22 (4 days). Further review revealed no documented evidence of adequate BMs from [DATE]-[DATE] (11 days) and [DATE]-23 (16 days). Review of the August-[DATE] Nurses Notes revealed no documented evidence that the Physician was notified of the resident's condition or status regarding bowel elimination. Interview on [DATE] at 10:30 PM with Licensed Practical Nurse #1 revealed the Bowel Care Protocol was not followed. Resident #3 should have received [MEDICATION NAME], and Fleets enema several times. She stated she was unable to find documentation the Physician was notified of the change in bowel elimination.

Based on interview and record review it was determined the facility failed to ensure necessary care and services were provided for the residents' physical well-beings for four (4) of nine (9) sampled residents (Residents #1, #3, #4, and #7). Resident #1 did not have adequate bowel elimination, per facility protocol, for twenty (20) days. As a result, Resident #1 was admitted to the hospital with [REDACTED]. There was no documented evidence Resident #3, #4 and #7 experienced bowel movements for periods ranging from four (4) to eighteen (18) days. There was no documented evidence the facility followed its Bowel Care Protocol regarding the administration of medications and notification of the physician for residents who did not have regular bowel movements. The findings include: Review of the facility's Bowel Care Protocol (BCP), which was not dated, revealed a resident must have at least one (1) large or two (2) medium bowel movements every three (3) days to be considered adequate. According to the facility's Bowel Care Protocol, if a resident has gone three (3) days without adequate bowel elimination one large or two medium bowel movements the nurse should implement treatment as follows: 1. Milk of Magnesia 30 milliliters (ml) by mouth (po), and if no results in 24 hours, 2. [MEDICATION NAME] Suppository 10 milligrams (mg) rectally, and if no results in 12 hours, 3. Fleets Enema. 4. If no results, or inadequate results, with Fleets Enema, 1000 ml soap suds enema x 2, and if still inadequate results, notify Physician. 1. Review of Resident #1's closed record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as being able to complete the Brief Interview for Mental Status satisfactorily and did not require further assessment of cognitive status. Review of the Functional Status portion of the MDS revealed the facility assessed the resident as being totally dependent on staff for toileting. In addition, the facility assessed the resident as not having constipation. However, review of the Nursing Assessment Quarterly Summary dated 10/06/10, revealed bowel constipation was present. Review of the Bowel and Bladder Evaluation section of the Admission Nursing assessment dated [DATE], revealed Resident #1 was assessed as being continent of bowel. However, the facility failed to identify the presence of constipation, the use of laxatives and/or enemas, and the date of the resident's last bowel movement as components of the assessment. Review of admission physician's orders [REDACTED]. In addition, a physician's telephone order for [MEDICATION NAME] (a laxative), to be given daily as needed, was received on 10/05/10. Review of the Bowel Information Tracking Log for September 2010 revealed no documented evidence Resident #1 had a bowel movement between 09/24/10 and 09/30/10. Review of the Bowel Information Tracking Log for October 2010 revealed the resident had a small bowel movement on 10/04/10, eleven (11) days after admission to the facility. Continued review revealed the resident had a medium bowel movement on 10/07/10, a small bowel movement on 10/10/10, and a small bowel movement on 10/13/10. The resident was noted to have had a large bowel movement on 10/14/10. According to the log, Resident #1 failed to have an adequate bowel movement for twenty (20) days, from 09/24/10 to 10/14/10, as identified by the facility's policy. Review of the Medication Administration Record (MAR) revealed the resident could be administered [MEDICATION NAME] (laxative) every day, as needed for constipation, however the resident received the [MEDICATION NAME] on 10/05/10 at 11:45 AM, and 10/08/10 at 1:00 PM only. Continued review of the MAR revealed the resident could be given [MEDICATION NAME] every day as needed for constipation, and [MEDICATION NAME] at bedtime as needed for constipation. Further review revealed there was no documented evidence the [MEDICATION NAME] was given throughout the resident's stay; and there was no documented evidence a [MEDICATION NAME] suppository, a "Fleets" enema, or a soap suds enema were ever given. Review of the Nurses Notes dated 10/06/10 at 1:00 AM, and signed by Registered Nurse (RN) #1, revealed Resident #1 complained of constipation and received [MEDICATION NAME] earlier in the shift. Continued review revealed the resident told the nurse an enema may be needed if the [MEDICATION NAME] didn't work. Review of subsequent Nurses Notes for the shift and for the following days revealed no further reference to the resident's complaint, results following the [MEDICATION NAME], the administration of an enema, or notification of the physician regarding the resident's lack of adequate bowel movements. Interview with RN #1 on 11/24/10 at 3:45 PM revealed she recalled Resident #1 complained "one night" of constipation and needed an enema. The nurse stated she called the doctor, who said she could give an enema. She further stated she attempted to administer the enema to the resident, who then refused it by saying "I don't want it, it wouldn't help anyway." RN #1 stated she told the resident she would get a physician's orders [REDACTED]. RN #1 was unable to recall Resident #1 ever having a bowel movement, during the resident's stay at the facility. Interview with Certified Nursing Assistant (CNA) #2 on 11/24/10 at 9:40 AM and CNA #1 on 11/24/10 at 10:10 AM, revealed they had provided care to this resident but could not recall Resident #1 voicing concerns related to being constipated. Neither of the CNAs could recall the resident having a bowel movement during his/her stay at the facility. Interview, on 11/24/10 at 12:40 PM with Licensed Practical Nurse (LPN) #1, who provided care to this resident, revealed she did not recall if Resident #1 had any complaints related to constipation or not having a bowel movement. LPN #1 indicated she did not recall the resident requesting a suppository. Interview, on 11/14/10 at 4:55 PM, with the Unit Manager (UM), where Resident #1 resided, revealed the Bowel Protocol should be initiated for any resident who did not have a bowel movement in three (3) days. She stated the administration of PRN (as needed) medications should be documented on the MAR. The UM explained she reviewed the bowel logs three (3) times a week but had not identified a problem with Resident #1, or the lack of bowel movements. After reviewing the Bowel Tracking Information Log with the surveyor, the Unit Manager expressed surprise the resident had gone so long without a documented bowel movement. She further stated she did not recall Resident #1 complaining of constipation or asking for an order for [REDACTED]. Review of the Physical Therapy Progress Report dated 10/07/10 revealed after therapeutic exercises Resident #1 "began to cry with abdominal pain from lack of bowel movement." Interview with the Therapy Assistant on 11/24/10 at 11:10 AM revealed she only saw Resident #1 twice. She recalled the resident said she was really constipated and stated, "my stomach is killing me, I'm constipated." During a follow-up interview on 11/24/10 at 4:00 PM, the Therapy Assistant stated she did not recall reporting the resident's complaints to nursing staff. Review of the Nurse's Notes dated 10/16/10, at 5:00 PM revealed Resident #1 complained of "pain in stomach, just not feeling well, nausea, chills." Continued review revealed the resident had a temperature of 101.1 degrees Farenheit. The spouse requested the resident be sent to the hospital. The Nurse's Notes revealed the resident was sent to the hospital, by ambulance, at 5:15 PM. The Note indicated a call was received from the hospital at 11:30 PM, informing the facility the resident had been admitted with abdominal pain and constipation. Review of the hospital record revealed Resident #1 was admitted to the Intensive Care Unit on 10/16/10 with [DIAGNOSES REDACTED]. Review of emergency room records revealed the resident complained of abdominal pain rated with a severity of eight (8) on a scale of ten (10). Review of the abdominal x-ray dated 10/16/10, revealed a "markedly large amount of stool in the rectosigmoid portion of the colon most consistent with severe constipation/impaction." Review of the Computerized Tomography (CT) scan of the abdomen dated 10/16/10 revealed "severe impaction of the rectosigmoid with stool." The hospital's History and Physical (H&P) dated 10/17/10, was reviewed and revealed the physician assessed the resident to have severe constipation. The resident was noted to have been anxious, with abdominal pain and sluggish bowel sounds. A rectal exam revealed hard stool in the rectum. At the time of dictation of the H&P, the resident had received two (2) Fleets enemas with results of two (2) moderate bowel movements. Review of the Surgical Consult dated 10/18/10 revealed Resident #1 had a "severe stool impaction." Aggressive laxative therapy was initiated. The Surgical Consult dated 10/19/10 revealed Resident #1 had a bowel-to-bladder fistula (a connection between the intestine and the bladder which allowed fecal material to spill into the bladder). In addition, the resident was diagnosed with [REDACTED]. Review of the Infectious Disease consult dated 10/18/10, revealed Resident #1 was assessed to have severe constipation, severe abdominal pain "worrisome for perforated bowel", [MEDICAL CONDITION]. The Operative Report dated 10/21/10 was reviewed and revealed Resident #1 underwent an Exploratory Laparotomy. Continued review revealed feculent peritonitis (inflammation due to contamination with feces) was present throughout the abdomen. Two (2) liters of purulent (pus-filled) fluid was suctioned out. A Colovesical (bowel-to-bladder) fistula was identified, with the bladder containing fecal material as well. A colectomy with [MEDICAL CONDITION] was performed, the fistula was repaired, and a supra-pubic urinary catheter was placed. During interview on 11/24/10 at 4:45 PM, the attending physician for Resident #1 stated he had spoken to the surgeon, who reported the resident had a fecal impaction with perforation of the bowel. The attending physician denied having received a call from the facility related to the resident's constipation or lack of bowel movements. An interview was conducted with Resident #1, on 11/23/10 at 9:30 AM, at the nursing home he/she resides at this time. During the interview the resident expressed having a long history of constipation which required the use of five (5) to six (6) [MEDICATION NAME] tablets (a stool softener) twice daily. In addition, the resident reported the use of "Fleets" suppository "at least twice a week." The resident expressed having a history on going four (4) days without a bowel movement. The resident stated, "I knew I had to stay on it, that's why I took so much [MEDICATION NAME]." Further interview revealed Resident #1 reported he/she "begged them (facility staff) every day" to get an order for [REDACTED]. They let me lay there and almost die. Interview with Resident #1's spouse, on 11/23/10 at 2:30 PM, revealed Resident #1 was admitted to the hospital on [DATE]. The spouse indicated he/she had spoken to the resident's surgeon after Resident #1's surgery and was told the resident's bowel had burst. According to the spouse, the surgeon further reported the resident was so impacted, the bowel was dead and the resident required a [MEDICAL CONDITION]. Further interview revealed the spouse had spoken to the resident's attending physician, who had cared for the resident at the nursing home, and the physician reported no one had ever called him about the resident's lack of a bowel movement. 2. Review of Resident #3's clinical record revealed [DIAGNOSES REDACTED]. Review of the August-November 2010 Monthly Physicians Orders revealed an order for [REDACTED]. Review of the August 2010 Bowel Information Tracking Log revealed no documented evidence of a Bowel Movement (BM) from August 29-31 (3 days). Review of the Medication Administration Record (MAR) revealed no documented evidence the prescribed medications were provided to the resident. Review of the September and October 2010 Bowel Information Tracking Logs revealed no documented evidence of adequate BMs, as described by the facility's policy, from September 15-October 2 (18 days), October 8-17 (10 days), and October 19-22 (4 days) and review of the September and October 2010 MAR revealed no documented evidence that the prescribed medications were given. Review of the October and November 2010 Bowel Information Tracking Logs revealed no documented evidence of adequate BM's from October 26-November 5 (11 days) and November 8-23 (16 days). Review of the October and November MAR revealed [MEDICATION NAME] was given on 11/04/10 and 11/06/10. There was no documented evidence any other bowel medications were administered. Interview on 11/24/10 at 10:30 PM with Licensed Practical Nurse #1 revealed Bowel Care protocol was not followed. The nurse stated according to the Bowel Care Protocol, Resident #3 should have received [MEDICATION NAME], and Fleets enema several times. LPN #1 stated the Certified Medication Technicians (CMT) examine the bowel logs daily, give the [MEDICATION NAME] when needed and notify the nurse when it was given. She further stated she was unable to find documentation regarding the Physician being notified of the change in bowel elimination for Resident #3. 3. Review of the clinical record revealed Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Admission Minimum Data Set (MDS) assessment dated [DATE], and Admission MDS assessment dated [DATE] revealed the facility assessed the resident as having constipation. Review of the Comprehensive Plan of Care dated 09/16/10, revealed the resident was at risk for constipation due to decreased mobility and "routine" use of pain medications. The Plan of Care revealed interventions which included: administering medications as ordered, monitoring bowel movement (BM) each shift, and reporting if no BM every two (2) to three (3) days. Review of a Computed Tomography (CT) Scan report, dated 09/07/10 revealed findings which included probable constipation and fecal impaction. Review of the August, September, October, and November 2010 Monthly Physician order [REDACTED]. Continued review revealed orders for [MEDICATION NAME] (synthetic sugar laxative for constipation) thirty (30) milliliters by mouth every four (4) hours PRN (as needed), [MEDICATION NAME] ten (10) milligram rectal suppository every day PRN and Enema disposable Fleet type (saline laxative for constipation) once daily PRN. Review of Resident #4's August, September, October and November 2010 Bowel Information Tracking Logs revealed no documented evidence of adequate (per the facility's policy) bowel elimination from 08/13/10 through 08/19/10, seven (7) days; from 08/31/10 through 09/06/10, seven (7) days; 09/23/10 through 09/29/10 seven (7) days; 09/30/10 through 10/06/10, seven (7) days; and 10/27/10 through 11/02/10, seven (7) days. review of the resident's medical record revealed [REDACTED]. 4. Review of Resident #7's clinical record revealed [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #7 as having moderate impairment in cognitive skills and requiring extensive assistance with most Activities of Daily Living. Further review of the resident's MDS Assessment revealed the facility assessed the resident as having no constipation. Review of the Comprehensive Plan of Care dated 10/15/10 revealed the resident had Impaired Bowel Elimination with Occasional Constipation. The interventions included; administering medication as ordered; monitoring bowel movement (BM) each shift, and reporting if no BM every two (2) to three (3) days. Review of the October and November 2010 Monthly Physician order [REDACTED]. [MEDICATION NAME] (a laxative) twenty (20) milliliters by mouth as needed for constipation and [MEDICATION NAME] ten (10) milligram rectal suppository once a day as needed for constipation. Review of Resident #7's October 2010 and November 2010 Bowel Information Tracking Logs revealed no documented evidence of adequate (as noted in in the facility's policy) bowel elimination from 10/10/10 through 10/14/10, five (5) days; 10/16/10 through 10/19/10, four (4) days; 10/21/10 through 10/26/10, six (6) days; 10/28/10 through 11/03/10 seven (7) days; 11/06/10 through 11/10/10, five (5) days; and 11/17/10 through 11/21/10, five (5) days. review of the resident's medical record revealed [REDACTED]. Further review revealed the facility failed to follow the Plan of Care related to administering as needed (PRN) medications as ordered and reporting if the resident had no bowel movement every two (2) to three (3) days. Interview with LPN #2 on 11/24/10 at 11:20 AM revealed if a resident did not have a bowel movement in three (3) days, the Bowel Protocol should be initiated. She stated she would not count a small bowel movement as adequate for most residents. She further stated the physician should be notified if there were no results after implementing the bowel protocol. Continued interview revealed all PRN medications administered, and results obtained after administering the medications, should be documented on the MAR.

Based on interview and record review it was determined the facility failed to identify the failure to implement the facility's Bowel Care Protocol to ensure regular bowel movements for four (4) of nine (9) sampled residents (Residents #1, #3, #4 and #7). Residents #1, #3, #4, and #7 did not have adequate bowel movements, as defined per facility policy, for periods ranging from four (4) to twenty (20) days. Record review revealed the facility failed to follow their Bowel Care Protocol regarding the administration of medications and notification of physicians. The Quality Assurance Committee had not identified the system failure, and had not initiated corrective action to correct the deficiency. Resident #1 was hosptalized on [DATE], after failure to implement the Bowel Care Protocol, or notify the resident's physician regarding the lack of bowel movements by the resident. The resident was admitted with [DIAGNOSES REDACTED]. The resident under surgical intervention and placement of a [MEDICAL CONDITION]. The findings include: Review of the facility's Bowel Care Protocol (undated) revealed a resident must have at least one (1) large or two (2) medium bowel movements every three (3) days to be considered adequate. 1. Resident #1 was admitted to the facility on [DATE]. Review of Bowel Information Tracking Logs for September and October of 2010 revealed no evidence Resident #1 had a bowel movement for eleven (11) days, from 09/24/10 to 10/04/10. The tracking log indicated the resident had a medium bowel movement on 10/07/10, a small bowel movement on 10/10/10, and a small bowel movement on 10/13/10. In addition, application of the Bowel Protocol to the tracking logs revealed the resident did not have an adequate bowel movement for twenty (20) days, from 09/24/10 to 10/14/10. There was no evidence the physician was notified regarding the resident's lack of bowel movements nor interventions implemented to ensure the resident had regular bowel movements. Review of hospital records, including an abdominal x-ray dated 10/16/10, and a Computerized Tomography (CT) scan, dated 10/16/10, revealed Resident #1 had a large amount of stool in the rectosigmoid portion of the colon, consistent with fecal impaction. In addition, hospital records indicated the resident underwent [REDACTED]. 2. Resident #3 was admitted to the facility on [DATE]. review of the resident's medical record revealed [REDACTED]. During November, 2010, there was no evidence of an adequate bowel movement between October 26 and November 5 (11 days), and November 8 and November 23 (16 days). Review of the MAR for September and October of 2010 revealed no documented evidence the Bowel Care Protocol was followed with interventions implemented to ensure regular bowel movements. In addition, there was no evidence the physician was notified related to the resident's bowel status. 3. Record review revealed Resident #4 was admitted to the facility on [DATE]. Review of Resident #4's medical record revealed no documented evidence of adequate bowel elimination from 08/13/10 through 08/19/10, five (5) days; from 08/31/10 through 09/06/10, six (6) days, 09/23/10 through 09/29/10, seven (7) days; 10/01/10 through 10/06/10, six (6) days; and 10/28/10 through 11/02/10, six (6) days. There was no evidence the facility followed the Bowel Care Protocol, including medication administered to ensure regular bowel movents, nor notification of the resident's physician regarding the lack of bowel movements. 4. Record review revealed Resident #7 was admitted to the facility on [DATE]. review of the resident's medical record revealed [REDACTED]., five (5) days. there was no evidence facility staff implemented the Bowel Care Protocol for Resident #7. Interview with the Unit Manager where Residents #1, #3, and #7 reside, on 11/24/10 at 11:55 AM, revealed in addition to the Bowel Information Tracking Log, the facility utilized an additional form she referred to as the Bowel Log. She stated she reviewed the Bowel Log three (3) times a week, on Mondays, Wednesdays, and Fridays, but had not identified any concerns with the Bowel Care Protocol implementation. She further stated this log was an internal record and not part of the medical record. She described the Bowel Log as a communication tool between the Certified Medical Technicians (CMTs) and the nurses. Continued interview with the Unit Manager (UM) revealed she considered one (1) medium bowel movement in three (3) days to be adequate. Upon reviewing the Bowel Care Protocol with the UM, she stated she had not been aware one (1) medium bowel movement was not adequate, per the facility's protocol. The UM was unaware Resident #1 had not had an adequate bowel movement for twenty (20) days. Interview with the CQI/QA Coordinator on 11/24/10 at 12:45 PM, revealed the committee met monthly to develop action plans for identified problems. She stated weekly meetings were held to check the progress of the plan. She explained since the introduction of the Minimum Data Set 3.0 Version on 10/01/10, the matrix was used to identify triggered areas for follow-up by the QA Committee. Continued interview revealed any areas on the matrix that fell in the 75th percentile were reviewed by the committee. The CQI/QA Coordinator explained that bowel management had not triggered for further review, and was not being tracked by the Committee.