Every finding on record at Owensboro Health Muhlenberg Community Hospital Lon

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 37 of the facility's 37 residents who consumed food from the kitchen. Observation of the kitchen revealed food items were not sealed and/or covered to prevent contamination. Food items were labeled with a use-by date but had not been discarded after expiration. Review of the facility policy titled, Food and Supply Storage, revised 04/2025, revealed all food supplies used in food preparation should be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. All foods past the use by date should be discarded. Additionally, all unused portions and opened packages were to be covered, labeled and dated, and freezer food items were to be wrapped tightly to prevent cross-contamination. Observation during initial tour of the kitchen on 03/17/2026, revealed the following:a. Observation of the Walk-In Freezer, on 03/17/2026 at 11:35 AM, revealed one box of chicken patties in original box/container with flaps and plastic packaging inside the box, uncovered, and exposed to potential cross-contamination. b. Observation of the Walk-In Refrigerator, on 03/17/2026 at 11:45 AM, revealed approximately 12-14 American cheese slices out of its original container, stored in a plastic container and labeled with a use by date, but was outdated. A box/container of bacon, and hamburger patties with the box flaps opened and the plastic packaging inside uncovered with exposure to potential contamination. c. Observation of the Cook's freezer, on 03/17/2026 at 11:55 AM, revealed one box of frozen biscuits, in the original box/container, flaps opened and plastic packaging inside was uncovered allowing potential cross-contamination. d. Observation of small refrigerator located near steam table area, on 03/17/2026 at 12:00 PM, revealed approximately 12-14 American cheese slices stored in a plastic container but was unsealed allowing exposure to air contaminants. In an interview with the Director of Food Services, on 03/18/2026 4:30 PM, she stated her expectations for the kitchen staff regarding food safety had been to ensure all foods that were stored in the refrigerators and/or freezers would be sealed and covered to protect residents from being served food that had been potentially contaminated. She stated any food items that had a label with a use-by date should be discarded to ensure residents had not been served outdated food. She further stated there was a potential for residents to become sick or be exposed to bacteria if served contaminated or outdated foods. Additionally, she stated all staff were educated immediately after kitchen tour had ended to ensure proper food storage safety practices would be implemented. In an interview with the Administrator, on 03/19/2026 5:45 PM, she stated all dietary staff were expected to ensure any food products served from the kitchen were safe for the residents. She further stated expectations of food safety were defined in the facility's policy and procedures, guidelines, and the facility should be in compliance with those requirements.

Based on observation, interview, record review, and policy review, the facility failed to maintain a comprehensive care plan that is reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 4 out of 4 sampled residents.The findings include: Record review revealed Resident (R)8 was admitted on [DATE] with diagnoses including congestive heart failure, Type 2 Diabetes Mellitus, coronary artery disease, and chronic obstructive pulmonary disease. Additional diagnoses include class 3 severe obesity, sleep apnea, ischemic congestive cardiomyopathy, and atrial flutter. Further review revealed an order for Eliquis 5 mg, oral, 2 times daily, started on 10/17/2025. Review of the most recent MDS for R8, accepted on 03/14/2025, revealed that the resident was reported as being on an anticoagulant. Review of the Comprehensive Care Plan for R8 revealed no care planning regarding the for risk of bleeding related to taking an anticoagulant. The Care Plan was further reviewed by the MDS Coordinator, and it was confirmed that there was no Care Plan initiated regarding risk for bleeding. The MDS Coordinator then presented the facility form labeled, Care Plan Addendum with the problem Risk for bleeding r/t anticoagulant therapy that she stated should have been added to R8's Care Plan. Observation of R3 on 03/17/2026 at 9:25 AM revealed upper left and right bedrails in use. Review of the Comprehensive Care Plan for R3 revealed no care planning in regard to the use of bedrails. Review of the facility's policy labeled, Careplans Comprehensive, last revised 01/2025, revealed the comprehensive care plan is based on a thorough assessment that included, but is not limited to, the MDS. Additionally, the policy stated, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The policy also stated, The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies. Review of the facility's policy labeled, Safety: Use of Bed/Bedrails/Alarms, effective 01/2025, revealed, Bedrail/Alarm use or non-use shall be accompanied by a care plan. In an interview with the MDS Coordinator on 03/19/2026 at 12:00 PM, she stated she is responsible for reviewing and updating Comprehensive Care Plans. She further stated that there should be a care plan in place addressing a resident's risk for bleeding related to the use of anticoagulants. In an interview with RN1 on 03/19/2026 at 12:45 PM, she stated R24 frequently refuses her medications. Additionally, she stated R24 has been in the facility long-term and frequently gives staff a hard time by refusing medications and treatment. Review of the Medication Administration Records for R24 from 12/13/2025 to 03/18/2026 revealed R24 refused 1,501 of 2,120 (approximately 71%) of the medications that were ordered and scheduled during that timeframe. These included antihypertensive and anticonvulsant medications, amongst others. Review of the Comprehensive Care Plan for R24 revealed no care planning related to her refusal of medications. In an interview with RN1 on 03/19/2026 at 3:07 PM, she stated refusal of care is not a problem she ever sees care planned. In an interview with the Director of Nursing (DON) on 03/19/2026 at 3:10 PM, she stated she is not aware of a care plan for refusal of care. She further stated the provider is made aware under circumstances of refusal but is unaware of a care plan that should be put in place. In an interview with RN1 on 03/19/2026 at 3:33 PM, she stated staff do not frequently notify providers regarding R24's refusal of medications and care because it is a chronic problem. She further stated that providers have been made aware of R24's frequent refusal of treatment over time. Record review for R24 revealed a provider note from 01/13/2026 that states, still continues to refuse medications often. Rude, verbally and physically abusive towards staff at times. Further record review revealed a provider note on 02/04/2026 that stated, non-compliance - refusing medications. In an interview with the DON on 03/19/2026 at 5:51 PM, she stated if a care plan is not updated and maintained as current, something could fall through and could be detrimental to a resident's care. She further stated bedrails and risk for bleeding should be addressed in the care plan and she stated again that she is not aware that refusal of care should be care planned as a problem. In an interview with the administrator on 03/19/2026 at 6:01 PM, she stated she expected staff to review and update care plans regularly and should be updated with any change in condition. She further stated bedrails should be addressed in a care plan and was unsure whether risk for bleeding should be included because she didn't recall seeing that before. Falls Notes 03/18/2026 10:51 AM Resident #7 stated that she fell a few weeks back and cracked her right hip, and reports falling many times. 03/19/2026 9:40 AM Physical Therapist Assistant (PTA) 10 stated that Resident #7 is not assessed by PT for the use of bed rails. 03/19/2026 9:46 AM RN1 stated that Resident #7 is a special low bed due to falls and that the family POA refused a bed alarm. 03/19/2026 2:48 PM Resident #7's Care plan review does not reflect the use of bed rails. 03/19/2026 3:00 PM MDS coordinator stated that she reviewed the progress notes when completing quarterly MDS assessments and completed the Care plan. She stated that she completes all care plans. The MDS coordinator did not state that medication refusal should be a part of the care plan.

Based on record review, policy review, and interviews, the facility failed to have follow-up procedures that must be in place to provide the information to the individual directly at the appropriate time for advance directives for one of the three residents sampled. A record review of Resident (R) 28's electronic chart on 03/18/2026 at 9:00 AM revealed the resident had an order for Do Not Resuscitate (DNR) as of 02/26/2026 and had advanced directive in parentheses behind the DNR located just beneath the resident's picture. A policy review of the documents titled Advance Directives & Medical Orders for Scope of Treatment (MOST), 600-024, revised date of 12/2025, on 03/18/2026 at 10:00 AM, revealed that the policy did not have direction on follow-up assessments for an advance directive. An interview with Resident #28's Daughter, Family #2 and power of attorney (POA) on 03/18/2026 at 9:37 AM, she revealed that she is her mother's POA but had not brought a copy to the facility. She denied that the facility had asked for the advance directive. During a review of Resident #28's durable power of attorney (DPOA) document on 03/18/2026 at 11:07 AM, it was revealed that the DPOA did not give medical decision-making rights to the POA. The DPOA conferred the ability to handle financial matters for the resident to include paying for healthcare. An interview with Social Services (SS) on 03/18/2026 at 2:10 PM, she stated that they have contacted the family regarding the advance directive and made the POA aware that they did not have medical decision-making rights per the DPOA papers scanned into the hospital. In an interview with Registered Nurse (RN)1 on 03/19/2026 at 2:03 PM, it was revealed that advance directive paperwork is either obtained at the time of admission or, if it is brought in later, a copy is left for Social Services if Social Services are not available. RN1 stated that they revisit the advance directives when needed, such as a change of condition, but does not know of a regular time frame in which the advance directives are revisited. An Interview on 03/19/2026 at 2:14 PM with SS revealed that she is the person who received the advance directives to review when they are brought to the hospital. She was not aware of regular follow-ups of advance directives. An interview with the DON on 03/29/2026 at 5:51 PM, she revealed that she was unaware whether the advance directives were to be followed up on after the admission assessment. The DON reported that a negative outcome could be that the facility would go against a resident's wishes. In an interview with the facility administrator on 03/19/2026 at 6:01, she reviewed the process of obtaining an advance directive; it is first assessed at admission if the resident has an advance directive, needs more information, or does not wish to provide an advance directive. If the resident had an advance directive, the nurse would communicate with social services to provide additional information. If they do not have the advance directive with them, they will follow up to obtain the advance directive. The administrator, upon reviewing the policy Advance Directives & Medical Orders for Scope of Treatment (MOST), 600-024 revised date 12/2025. Could not identify where it stated that they would need to follow up with the resident or responsible party to update the advanced directive. The administrator stated that a negative outcome could be resuscitation against a resident's wishes.

Based on interview, record review, and review of the Facility Assessment, it was determined the facility failed to ensure the services of a Registered Nurse (RN) were utilized for at least eight consecutive hours a day, seven days a week. The facility failed to provide eight consecutive hours of RN coverage for 13 days between 07/01/2024 and 09/30/2024. This failure affected all persons residing in the facility on those 13 days, as the residents did not receive the required minimum nursing services. The findings include: Review of the Facility Assessment Staffing Plan, dated 07/2024 and revised 11/2024, revealed the facility received a one-star rating on staffing due to a high number of days without an RN on site daily. The facility had an RN house supervisor available 24 hours a day in the attached acute hospital. Due to her supervising in the attached acute hospital and not being assigned eight consecutive hours to the long-term care facility, the RN house supervisor's hours were not reflected on the Payroll Based Journal (PBJ) report. Review of the facility's PBJ Staffing Data Report, dated 07/01/2024 through 09/30/2024, revealed there was no RN coverage for eight consecutive hours for the following 13 dates: 07/06/2024, 07/07/2024, 07/27/2027, 08/03/2024, 08/04/2024, 08/24/2024, 08/25/2024, 09/07/2024, 09/14/2024, 09/21/2024, 09/22/2024, 09/28/2024 and 09/29/2024. Interview with Certified Nursing Assistant (CNA) 6, on 01/07/2025 at 11:50 AM, revealed no evidence of RN coverage eight consecutive hours each day of the week, as she stated the facility had a Licensed Practical Nurse (LPN) who managed the units on weekdays and weekend shifts. Interview with CNA4, on 01/07/2025 at 11:59 AM, revealed no evidence of RN coverage eight consecutive hours, seven days a week, as she stated the facility had an LPN that worked as the unit manager on the floor weekdays and weekends, and she did not think they have an RN at night either. In interview with RN2 on 01/09/2025 at 2:00 PM, she stated she thought the facility had RN coverage on the weekends and she was not aware that an RN had to be in the facility all seven days per week, including weekends. In an interview with RN3 on 01/09/2025 at 2:14 PM, she stated she was aware the facility had to have RN coverage. RN3 stated that they tried to have RN coverage on the weekends but there was not always an RN working in the facility on the weekend, although the attached hospital had a house supervisor who was available. In an interview with LPN1 on 01/09/2025 at 2:38 PM, she stated the facility did not have an RN on the weekends and she was not aware that the facility was required to have RN weekend coverage. In an interview with the Director of Nursing (DON) on 01/07/2025 at 12:10 PM, she stated she had been the DON for about a year. She stated the facility does not have an RN on most weekends, but there is an RN that works every third weekend. The DON stated that there was an RN manager in the attached hospital who covers the long-term care unit; however. the hospital RN did not work eight consecutive hours on the weekends when the facility has no other RN coverage. In a follow up interview with the DON on 01/09/2025 at 4:20 PM, she stated she was aware that the facility should have an RN working seven days a week, eight consecutive hours a day, and confirmed the hospital house supervisor could not be counted.

Based on observation, interview, and review of facility policy, the facility failed to store food in accordance with professional standards for food service safety. Refrigerated foods were not dated, labeled, and/or discarded in a timely manner. These failures had the potential to affect 34 of 34 residents in the facility who consumed food from the kitchen. The findings include: Review of the facility policy titled, Food Safety Management System, revised [DATE], revealed leftover foods must be properly labeled and date marked. The policy also stated that leftover foods must be discarded if required by local, state, or provincial health department regulation, but failed to identify specific discard dates. Observation during the initial kitchen tour on [DATE] at 12:03 PM, with the Dietary Supervisor, revealed the cold prep cooler contained a small container of a red jelly-like substance that was not labeled or dated which the Dietary Supervisor identified as cranberry sauce, and a large container of pineapple chunks that was not labeled or dated. Additional observation revealed a large container of vanilla pudding, two containers of chopped pears, and two containers of fruit cocktail that were dated [DATE] - [DATE], as well as a large full container of applesauce, and a container of sliced cucumbers that were dated [DATE] - [DATE]. In an interview with the Dietary Supervisor on [DATE] at 12:15 PM, she stated she expected staff to label and date all food items before placing them in the coolers. She stated leftovers were to be dated for three days out (from the original use date) and the items were to then be discarded in three days. She stated the evening shift dietary aide was responsible for checking the cold prep cooler and was supposed to remove any expired items. In an interview with the Administrator on [DATE] at 5:10 PM, she stated she expected the dietary staff to follow their policies for labeling and dating food items. She stated there could be consequences if residents were served expired or outdated foods.

Based on observation, interview, and facility policy review, it was determined the facility failed to store food in accordance with professional standards for food service safety. The facility census was forty (40) and thirty-nine (39) residents received meals from the kitchen and had the potential to be affected. Observation, during initial tour of the kitchen, revealed opened food items that were not labeled or dated. The findings include: Review of the facility's policy, Food Receiving and Storage, dated 02/2022, revealed, foods would be received and stored in a manner that complies with safe food handling practices. All food stored in the refrigerator or freezer would be covered labeled and dated with a use by date. Observation of the facility's kitchen on 11/14/2023 at 6:40 PM, revealed there was a container of four (4) biscuits and a container of bacon not dated or labeled in the walk-in cooler. During an interview with the Certified Dietary Supervisor on 11/14/2023 at 6:45 PM, she stated she expected all opened food items located in the refrigerator or freezer to be labeled and dated. She stated items not dated or labeled should have been removed and discarded, as there was a potential for food borne illness if such items were used.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure that an alleged allegations of physical abuse was reported to the State Agency and local law authorities immediately, but no later than two (2) hours after the allegations were made for one (1) of twelve (12) sampled residents ( Resident #15). During a Resident Council Meeting on 11/15/2023 at 2:06 PM, Resident #15 stated he/she reported an allegation of abuse last week to the Nursing Supervisor/ However, the allegation was not reported to the Abuse Coordinator until 11/15/2023. Additionally, the facility failed to notify the State Survey Agency (SSA) of the allegation. The findings include: Review of the facility's policy, Abuse and Abuse Prevention, revised 05/2023, revealed all residents would be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, would be reported immediately to the administrator or designee. All owners, operators, employees, managers, agents, or contractors should report to the state agency and one or more law enforcement entities. any reasonable suspicion of a crime against an individual who was a resident of or was receiving care from the facility. Review of Resident #15's Demographics revealed the facility admitted the resident on 05/03/2018 with diagnoses which included Depression, Hemiplegia/Hemiparesis and Anxiety. Review of Resident #15's Quarterly Minimum Data Set (MDS) Assessment, dated 08/22/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Review of the Facility Investigation dated 11/17/2023, completed by the Nursing Supervisor (NS), revealed she was made aware by the Wound Care nurse on 11/15/2023 that Resident #15 stated Certified Nursing Assistant (CNA) #2 had grabbed him/her by the left arm leaving a bruise on 11/12/2023. The NS assessed Resident #15's left arm and did not find any bruising or redness but did note a small bruise to the left hand. Further, the NS interviewed Resident #15 when he/she indicated the bruise was from CNA #2 turning him/her and grabbing him/her by the arm during a bath on 11/12/2023. The NS interviewed CNA #2 on 11/15/2023 and the CNA denied the allegation and was not working on 11/12/2023. The findings of the facility investigation were that the complaint did not support evidence of abuse. The resident stated bruising was from grabbing the left arm, not hand, on 11/12/2023. There was no evidence of any injury to the arm. There was bruising between the digits but did not appear to be a bruise from being grabbed. CNA #2 did not work on 11/12/2023 which was the night the alleged incident occurred. Review of a facility witness statement dated 11/15/2023, and completed by the Wound Care (WC) Nurse, revealed a Certified Nursing Assistant (CNA) had reported to her that Resident #15 had a small bruise on the left hand, between the thumb and first digit. The WC nurse assessed Resident #15's left hand finding a small circular bruise. The WC nurse stated Resident #15 stated that CNA #2 had pulled his/her arm. The WC nurse reported the allegation to the Director of Nursing (DON). Review of a facility witness statement dated 11/15/2023, and completed by the Nursing Supervisor, revealed Resident #15 stated CNA #2 had put a bruise on his/her left hand while CNA #2 rolled him/her over to give a bath on 11/12/2023. Review of a facility witness statement dated 11/15/2023, and completed by Certified Nursing Assistant (CNA) #2, revealed she was not working the night the allegation was made. Further review of the statement revealed she always used the blue pads to turn residents, never by their body parts because she knew their skin was tender and fragile. During an observation on 11/15/2023 at 2:10 PM revealed Resident #15 had a quarter sized green-yellow bruise to his/her left hand. During a Resident Council Meeting on 11/15/2023 at 2:00 PM, Resident #15 stated CNA #2 was rolling him/her over during a bed bath causing a bruise on the top of his/her left hand on 11/12/2023. During an interview with Resident #15 on 11/16/2023 at 2:30 PM, he/she stated CNA #2 grabbed his/her left hand on 11/12/2023 while turning him/her in the bed during a bath. Resident #15 stated CNA #2 pulled him/her toward her by his/her hand. He/she stated this was not reported immediately but the Wound Care (WC) Nurse noticed the bruise during his/her weekly skin assessment and that is when he/she reported the incident. Resident #15 stated he/she had a stroke and was dependent on the staff for transfers and care due to his/her paralysis. During an interview with Certified Nursing Assistant (CNA) #2 on 11/15/2023 at 3:27 PM, she stated she was not working during the time of the alleged abuse incident. She stated she was made aware of the allegation on 11/15/2023 when the nursing supervisor called her and she then came into the facility and wrote a statement. CNA #2 stated she would notify the nurse or nursing supervisor immediately of abuse. She stated she regularly provided care to Resident #15 and the resident never voiced any concerns during care. CNA #2 further stated she received training on abuse at least annually which was done online. She stated she knew exactly what to do and would never abuse an elderly person. During an interview with the WC nurse on 11/15/2023 at 2:51 PM, she stated a CNA had reported to her that Resident #15 showed her a bruise on his/her hand and alleged someone had pulled his/her arm on 11/12/2023. The WC nurse assessed Resident #15 on 11/13/2023 and determined the bruise did not appear new as it was small and green to yellow in color. She stated Resident #15 alleged CNA #2 had pulled his/her arm on 11/12/2023 causing the bruise. The WC nurse stated she reported the alleged incident on 11/14/2023 around noon to the Director of Nursing (DON). She further stated abuse should be reported immediately to the DON, nursing supervisor or the Administrator. During an interview with the Nursing Supervisor on 11/15/2023 at 2:59 PM, she stated the wound care nurse reported the allegation of abuse to the DON on 11/14/2023. She stated she had left work early on 11/14/2023 so she initiated the investigation on 11/15/2023. The Nursing Supervisor stated the facility did not follow their abuse policy and the allegation should have been reported immediately. During an interview with the Director of Nursing (DON) on 11/16/2023 at 9:45 AM, she stated she had been out of town and the nursing supervisor made her aware of the abuse allegation this morning. She stated the Nursing Supervisor started an investigation on 11/15/2023 and she expected abuse to be reported to her or any administration staff immediately. The DON stated she would not allow staff to mistreat the residents. During an additional interview with the DON on 11/17/2023 at 11:00 AM, she stated she should not have to report Resident #15's allegation of abuse to an outside agency because she did not feel like it was abuse. She stated she was responsible for reporting abuse to the state agency. The DON stated she expected staff to report any abuse allegation to her immediately or the employee could be terminated. Further, she stated if not reported, it could potentially cause serious harm to the resident and the resident could show psychological issues. During an interview with the Administrator on 11/17/2023 at 4:33 PM, she stated she expected all abuse allegations to be reported immediately and an investigation should be initiated at that time to protect residents. She further stated she expected any alleged abuse to be reported to the State Agency.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for one (1) of twelve (12) sampled residents (Resident #24). Observations and record review revealed Resident #24 was being treated for a wound however, there was no documented evidence a care plan had been implemented to include wound care. The findings include: Review of the facility's policy. Careplan's Comprehensive, revised 02/2023, revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs would be developed for each resident. Review of Resident #24's Demographics revealed the facility admitted the resident on 08/03/2022 with diagnoses which included Alzheimer's Disease with Behavioral Disturbances, Diabetes Mellitus Type II, and Thrombocytopenia. Review of Resident #24's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #24 as having a Brief Interview for Mental Status (BIMS) of ninety-nine (99) indicating the resident chose not to participate in the assessment. Review of a Nurse Progress Note dated 11/07/2023 and documented by the Wound Care (WC) Nurse, revealed Resident #24 had an area to his/her right outer foot that was a hard knot with reddish/purple discoloration and did not seem to cause the resident pain. The WC nurse reported to the Advanced Practice Registered Nurse (APRN). Review of a Nurse Progress Note dated 11/08/2023 and documented by the WC Nurse, revealed she had completed a skin assessment on Resident #24 and noted the resident's right outer foot had a ruptured and the WC nurse painted the area with a Betadine swab. Review of a Nurse Progress Note dated 11/12/2023 and documented by Licensed Practical Nurse (LPN) #1 revealed Resident #24 had some break through right foot and great toe pain noted. Repositioned resident for comfort and Betadine swab applied the to area. Review of a Nurse Progress Note dated 11/16/2023 and completed by the WC Nurse revealed Resident #24 had an open blister area to right outer foot, painted with Betadine, allowed to dry and Covaderm placed. Review of Order Report dated 11/10/2023 by the APRN, revealed an order to apply Betadine swab to Resident #24's right outer foot blister daily for seven (7) days. During observation of Resident #24's wound care performed on 11/16/2023 at 1:55 PM by the WC Nurse revealed Resident #24 had a wound that was approximately quarter sized, with dark brown well-defined edges on his/her right foot. Further observation of the wound revealed the area had a purple center located on his/her right foot distal to the fifth digit and no drainage present. Resident #24 tolerated the procedure without any complaints. During an interview with the WC Nurse on 11/16/2023 at 1:55 PM, she stated Resident #24's wound initially appeared as a blister approximately eight (8) days ago. The WC Nurse stated the resident was assessed by the medical doctor and the Advanced Practice Registered Nurse (APRN) who gave orders for wound care to begin. She stated Resident #24's wound had actually began to heal however, the resident had bumped his/her foot on his/her wheelchair yesterday ultimately irritating the wound again. The WC Nurse stated any licensed nurse could implement a care plan. During an additional interview with the WC Nurse on 11/17/2023 at 9:45 AM, she stated she should have implemented a care plan for wound care for Resident #24. She stated she was responsible for implementing the care plan but had gotten busy, was working as a nurse on the floor and had just forgotten to do one. The WC Nurse further stated if a care plan was not implemented or interventions were not revised, it could cause a delay in a resident's care needs. She stated it could potentially cause an infection or the resident could not receive the care they may need. During an interview with the Director of Nursing (DON) on 11/16/2023 at 1:38 PM, she stated any nurse could implement a care plan or add an intervention. She stated Resident #24 did not have a care plan in place for his/her wound and whoever started the wound care should have been the one to do so. The DON stated she expected staff to ensure care plans were implemented and interventions revised to reflect resident care because if that was not done, staff would not know how to care for the residents. During an interview with the Administrator on 11/17/2023 at 4:33 PM, she stated she expected care plans to be individualized, associated with assessments, be reassessed and have an ongoing update to reflect the resident's individual needs. She further stated a care plan should be revised or implemented with any significant change.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise each resident's Comprehensive Person Centered Care Plan for one (1) of twelve (12) sampled residents (Resident #33). Resident #33 had a significant weight loss of nineteen percent (19%) from 07/02/2023 to 11/10/2023, with no revisions made to his/her plan of care. The findings include: Review of facility the policy's policy, Care Plans - Comprehensive, dated 02/2022, revealed, an individualized comprehensive care plan that included measurable objectives and timetables to meet the residents medical nursing mental and psychological needs would be developed for each resident. Assessments of residents were ongoing and care plans were revised as information about the resident and the residents condition change. The care plan Interdisciplinary Team (IDT), and or clinical staff were responsible for the review and updating of care plans when there had been a significant change in the residents' condition, when the desired outcomes were not met, when the resident had been readmitted to the facility from a hospital stay, and at least quarterly. Review of Resident #33's electronic medical record (EMR) revealed the facility admitted the resident on 07/26/2022 with diagnosis which included Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), and Atrial Fibrillation. Review of Resident #33's Quarterly Minimum Data Set, dated dated dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ten (10) of fifteen (15) indicating moderate cognitive impairment. Further review of the MDS Assessment, Section K, revealed the facility identified the resident as having experienced a significant weight loss. Review of Resident #33's Care Plan, initiated on 08/01/2023, revealed Resident #33 had nutrition risk factors related to weight loss or gain, functional decline in activities of daily living (ADL's), and received a therapeutic diet. Resident #33's goal stated that weight would be maintained at one hundred seventy-three (173) pounds (lbs.), plus or minus eight (8) lbs. Interventions included, assist dietary in obtaining providing food and beverage likes, accurately monitor and record daily intake of food and fluids, consult with physician regarding removing dietary restrictions as allowed by medical condition, weigh resident weekly or as ordered by the physician, evaluate medications for possible appetite suppression, food drug interactions, and or nausea, set up tray, open cartons, cut up food, and provide a consistent carbohydrate diet. During an interview with Certified Nursing Assistant (CNA) #6 on 11/17/2023 at 11:53 AM, she stated Resident #33 sometimes received a supplement (Boost) on the meal tray and sometimes they got one from the nourishment room. She stated Resident #33 did not usually drink the supplement and that the nurses were aware. CNA #6 stated Resident #33 required set up assistance with meals and typically ate in his/her room. She stated resident care plans were in binders at the nurses' station and if something new was added the Director of Nursing (DON) told staff. During an interview with the Registered Dietitian (RD) #1 on 11/17/2023 at 3:40 PM, she stated she ran up on Resident #33's weight loss while doing the Quarterly MDS assessment in October. She stated she gave no additional recommendations as Resident #33 already had two different supplements ordered. RD #1 stated she did not know what the facilities process for updating care plans was but she would expect supplements to be on the care plan. In an interview with the Director of Nursing (DON) on 11/17/2023 at 4:09 PM, she stated it was the responsibility of the nurses to initiate and revise the care plan. She stated Resident #14's care plan should have been revised with changes in medication in June. The DON stated she expected staff to review and revise the care plan when changes occurred. In an interview with the Administrator on 11/17/2023 at 4:30 PM, she stated she expected care plans to be developed, implemented, and reviewed and revised, based on the residents' needs. She stated the care plans should have been revised when the residents had a change or return from a hospital stay.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain acceptable parameters of nutritional status, including usual body weight for one (1) of four (4) sampled residents for weight loss of a total sample size of twelve (12) (Resident 33). Resident #33 had a significant weight loss of nineteen percent (19%) from 07/02/2023 to 11/10/2023. The findings include: Review of the facility's policy, Weight Protocol, Nutritional Risk, dated 02/2022, revealed the long-term care unit strived to maintain each resident at the appropriate weight for that resident and that all residents were screened for nutritional risk. An accurate weight of all residents should be obtained on admission and be weighed according to the physicians' orders but at a minimum monthly. The physician and the multidisciplinary care team would address unintended weight loss or gain in order that all residents were assessed for nutritional risk. Further review revealed the residents current weight would be compared to the previous weight obtained and a significant weight variant would indicate the need for reweigh a significant weight loss or gain was defined as a five percent (5%) or greater difference within thirty (30) days a seven and one half percent (7.5%) or greater difference within ninety (90) days or a ten percent (10%) or greater within one hundred eighty (180) days. If it was determined that a significant weight loss or gain had occurred it should be reported immediately to the charge nurse, clinical care coordinator, and or the Resident Assessment Instrument (RAI) Coordinator to initiate a change of status. The physician should be notified and appropriate orders received to address the issue. Consultation with the dietitian should be included. Review of Resident #33's electronic medical record (EMR) revealed the facility admitted the resident on 07/26/2022 with diagnosis which included Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), and Atrial Fibrillation. Review of Resident #33's Quarterly Minimum Data Set Assessment, dated 10/10/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of ten (10) of fifteen (15) indicating moderate cognitive impairment. Further review of the assessment revealed the facility assessed Resident #33 as requiring set up help with eating, required a therapeutic diet, and identified the resident as having experienced a significant weight loss. Review of Resident #33's Care Plan, initiated on 08/01/2023, revealed Resident #33 had nutrition risk factors related to weight loss or gain, functional decline in activities of daily living (ADL's), and received therapeutic diet. Resident #33 goal stated that weight would be maintained at one hundred seventy-three (173) pounds (lbs.), plus or minus eight (8) lbs., and that resident would consume greater than seventy-five (75%) percent of meals. Review of Resident #33's EMR weight record revealed Resident #33 weighed one hundred eighty-two (182) pounds on 07/02/2023 and one hundred forty-seven pounds (147) on 11/10/2023, which represented a loss of nineteen percent (19%). In an interview with Certified Nursing Assistant (CNA) #6 on 11/17/2023 at 11:53 AM, she stated she had only worked at the facility a few months and had provided care for Resident #33. She stated Resident #33's appetite was not great and she reported to the nurse when a resident did not eat. CNA #6 stated weekly weights were obtained on the weekends and if a difference of five pounds, the nurse would have them reweigh the resident. In an interview with Licensed Practical Nurse (LPN) #3 on 11/17/2023 at 2:40 PM, she stated when residents were identified as a weight loss, they were typically placed on weekly weights she stated she was unsure if Resident #33 received supplements but thought that he/she was at risk for weight loss. In an interview with Registered Dietitian (RD) #2 on 11/17/2023 at 3:01 PM, she stated she worked remotely and was contracted through the facility. She stated she attended weekly meetings following the MDS schedule. RD #2 stated Resident #33 received supplements three times a day, but she was unaware of who administered the supplements. During an interview with Registered Nurse (RN) #1 on 11/17/2023 at 3:23 PM, she stated if residents had a change in their eating habits the nursing assistants would typically report that, and she would inform the Advanced Practice Registered Nurse (APRN). She stated Resident #33 had a decreased appetite since returning from the hospital in July. She stated he/she received supplements on the meal tray. During an interview with the Registered Dietitian (RD) #1 on 11/17/2023 at 3:40 PM, she stated she was a contract employee and had worked on and off for the facility since June 2023. She stated she ran up on Resident #33's weight loss while doing the quarterly MDS assessment. She stated she believed she notified the clinical team and that she gave no additional recommendations as Resident #33 had supplements ordered. During an interview with the Nursing Supervisor (NS) on 11/17/2023 at 4:00 PM, she stated she was part of the Inter-Disciplinary Team (IDT), and they had care conference weekly and as needed. She stated weekly weights were obtained on weekends and that every resident gets weighed weekly unless daily weights were ordered. The Nursing Supervisor stated she was unsure why Resident #33's weight loss was not discovered earlier. During an interview with the Director of Nursing (DON) on 11/17/2023 at 4:09 PM, she stated some residents were at risk for weight loss when they got sick. She stated Resident #33 was hospitalized in July and had been declining since that time. The DON stated Resident #33 was weighed weekly and that the RD reviewed the weights in the electronic record. She stated we (the family) knew Resident #33 was losing weight and refusing the supplements. The DON further stated they had failed to document the refusals. She stated Resident #33's intake varied and that he/she had snacks in his/her room that the family had provided. During an interview with the Administrator, on 11/17 2023 at 4:30 PM, she stated she expected the IDT to collaborate on a weekly basis. She stated the facility was using a contracted RD and that she attended the care conferences weekly. The Administrator stated she expected staff to follow the facility policy on weights and monitor the resident's for weight loss.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents were assessed for the capability to safely self-administer their medications. Observation and interview, on 10/10/2022 at 9:30 AM, revealed staff left medications in Resident #32's room unattended for him/her to self-administer. Record review revealed no documented assessments completed for the resident to self-administer medications. The findings include: Review of the facility's policy titled, Self-Administration of Medications, revised 01/2022, revealed if medications were ordered by the practitioner for a medication to be kept at bedside, there may be self-administration of medications by non-hospital staff such as patients or family members. These medications should be limited to: Antacids, Topical Anesthetic Throat Spray, Rescue Inhalers, Vaseline Lip Therapy, and Topical Over-the-Counter products. The nursing staff would train, supervise and document the competency of the patient and/or family member before allowing self-administration of an ordered medication in the facility to assure safe, accurate use of the medication. Review of Resident #32's medical record revealed the facility admitted the resident on 09/01/2020 with diagnoses which included Anemia, Hypertension, and Arthritis. Further review revealed there was no documented evidence the resident has been assessed to self-administer medications. Review of Resident #32's Annual Minimum Data Set (MDS) assessment, dated 09/19/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) which indicated the resident was cognitively intact and interviewable. Review of Resident #32's Current Scheduled Medications, dated October 2022, revealed the resident was ordered to receive Lopressor (50) milligrams (mg) two (2) times daily, Mucinex twelve (12) hour six hundred (600) mg two times daily, Diovan one hundred and sixty (160) mg daily, Zyrtec ten (10) mg daily, and Colace one hundred (100) mg daily. Observation on 10/10/2022 at 9:30 AM, during initial tour, revealed the surveyor observed five (5) medications in a calibrated dose cup inside a clear-lidded denture cup in Resident #32's room. Interview with Resident #32, on 10/10/2022 at 9:30 AM, revealed staff placed the medications inside the denture cup because the resident was not ready to take the medications at that time. Interview with Registered Nurse (RN) #2, on 10/10/2022 at 9:40 AM, revealed she was pretty sure Resident #32 was assessed to self-administer medications. She stated she had planned to return to Resident #32's room, but had not yet made it. Additionally, RN #2 stated the resident wanted to use the restroom before taking the medications observed by the surveyor inside the denture cup. Observation on 10/10/2022 at 9:42 AM, revealed RN #2 entered Resident #32's room and watched the resident take the medications observed inside the denture cup by the surveyor at 9:30 AM. Interview with the Wound Care Nurse, on 10/12/2022 at 9:48 AM, who was observed during medication administration task by the surveyor, indicated there were no residents in the facility who self-administered their medications. She further stated medications should not be left unattended in a resident's room. Interview with RN #1, on 10/12/2022 at 10:18 AM, revealed there were no residents in the facility who self-administered their medications. She stated medications should not be left unattended in a resident's room. Interview with the Director of Nursing (DON), on 10/12/2022 at 4:21 PM, revealed the facility currently did not have any residents who were assessed as capable of self-administering their medications. She further stated she expected no medications be left at the resident's bedside.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent infection for one (1) of three (3) sampled (Resident #35). Observation on 10/11/2022 at 3:14 PM, revealed State Registered Nurse Aide (SRNA) #1 failed to change her gloves and perform hand hygiene between dirty and clean tasks, while providing incontinence care to Resident #35. The findings include: Review of the facility's policy titled, Hand hygiene, dated 08/19/2022, revealed, Hand hygiene was a general term used by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to refer to handwashing, antiseptic handwashing, antiseptic hand rubbing, and surgical hand asepsis. Further review revealed in order to protect a patient from health care-associated infection, hand hygiene should be performed routinely and thoroughly. The use of an alcohol-based hand rub was appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings (if hands aren't visibly soiled); after removing gloves; and after contact with inanimate objects in the patient's environment. Review of Resident #35's medical record revealed the facility admitted the resident on 09/09/2022 with diagnoses which included diagnoses of Alzheimer's Disease and Non-Alzheimer's Dementia. Review of Resident #35's Admission Minimum Data Set (MDS) assessment, dated 09/16/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), which indicated the resident was severely cognitively impaired. Further review of the assessment revealed the resident was totally dependent on staff for toilet use, and was incontinent of bladder and bowel. Review of Resident #35's Comprehensive Care Plan, dated 09/19/2022, revealed the resident was a high risk for infection, with interventions to include directing staff to utilize proper hand-washing techniques and personal protective equipment as indicated. Further review of the care plan revealed the resident was incontinent of bladder and bowel, with interventions which included directing staff to turn, dry, and cleanse the resident every two (2) hours and as needed. Review of Resident #35's, Current Scheduled Medications, dated 10/10/2022, revealed an order directing staff to administer Cipro five hundred (500) milligram (mg) by mouth every twelve (12) hours to treat a urinary tract infection. Observation on 10/11/2022 at 3:14 PM, revealed State Registered Nurse Aide (SRNA) #1 was providing incontinence care to Resident #35. SRNA #1, with gloved hands, unsecured the resident's soiled incontinence brief and pushed the brief down through the resident's legs. SRNA #1 then used a basin of water to wet and apply soap to a clean washcloth. She cleansed the resident's right and left groin area, then separated the genital area with one gloved hand and then cleansed in a downward motion. Without changing her gloves, she obtained a clean washcloth, wet it in the same basin of water, and rinsed the resident's perineal area. SRNA #1, with the same gloved hands, turned the resident to the right side and removed the soiled brief. With the same gloved hands, SRNA #1 wet a washcloth and applied soap in the same water basin. SRNA #1 wiped front to back and a small amount of bowel movement was observed on the washcloth. She repeated front to back with a new cloth, until no bowel movement was observed on the washcloth. With the same gloved hands, SRNA #1 used a clean washcloth to rinse the area and then obtained a clean towel to pat the area dry. Without changing her gloves, she applied a clean brief, placed a positioning wedge behind the resident's back and obtained a pillow from a shelf and placed it between the resident's legs. SRNA #1 then touched the bedrail controls and adjusted the height of the bed prior to removing her soiled gloves. Interview with SRNA #1, 10/11/2022 at 3:14 PM following the incontinence care observation, SRNA #1 stated the facility policy did not specify when gloves should be changed, but that soiled gloves should be changed while providing care. Interview with SRNA #2, on 10/12/2022 at 3:30 PM, revealed gloves should be changed before a clean brief was applied during incontinence care. Interview with SRNA #4, on 10/12/2022 at 3:34, revealed when providing incontinence care, gloves should be changed before applying a clean brief and when completed, before offering water, and before ensuring everything was in the resident's reach. Additional interview on 10/12/2022 at 3:41 PM, with SRNA #1, revealed gloves should be changed between cleansing the resident's front and the back areas. She further stated she did not change the gloves during incontinence care provided to Resident #35. Interview with the Nurse Educator, on 10/12/2022 at 3:50 PM, revealed gloves were to be changed when the staff finished cleaning the resident and when the gloves were soiled. The Nurse Educator further stated the standard of practice was to change gloves when going from a dirty task to a clean task. Interview with the Registered Nurse Infection Preventionist (RN IP), on 10/12/2022 at 4:00 PM, revealed gloves should be changed anytime the gloves were soiled. She further stated when staff were performing incontinent they should dispose of soiled gloves, perform hand hygiene, reapply new gloves, prior to applying a clean brief. The RN IP stated gloves were contaminated if used to separate the resident's genital area during care due to potential mucus, urine, or bowel movement. Additionally, she stated gloves should be changed when moving from a dirty task to a clean task. Interview with the Director of Nursing (DON), on 10/12/2022 at 4:24 PM, revealed she expected gloves to be changed during incontinence care, especially if bowel movement was involved. The DON indicated everything that was touched was contaminated.

Based on observation, interview, and facility policy review, 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. The State Surveyor entered the main entrance of the facility on 10/26/2020, to conduct a Focused Infection Control Survey (FICS). The Staff Member posted at the Main Entrance of the facility took the Surveyor's temperature; however, failed to assess the Surveyor for COVID-19 exposure and/or symptoms as indicated per facility's policy. The findings include: Review of the facility policy titled, COVID 19 Response: Visitor Policy for OHMCHLTC, dated 04/20/2020, revealed prior to visitation, visitors were screened for signs/symptoms (s/s) of COVID 19 and must have temperature taken, wear face mask, perform hand hygiene, social distance, and all visitation spaces were disinfected and cleaned prior to and after visit session. Questions for all Fever Screening Stations: Do you have any of these symptoms that are not caused by another condition, fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, recent loss or taste or smell, sore throat, congestion, nausea or vomiting, diarrhea within the past fourteen (14) days, and have you had contact with anyone that you know had COVID-19 or COVID like symptoms? Have you had a positive COVID-19 test for [MEDICAL CONDITION] in the past ten (10) days? Within the past 14 days, has public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19? Observation on 10/26/2020 at 12:00 PM, revealed the Surveyor entered the main entrance of the facility to conduct a FICS of the facility's Long Term Care (LTC) Unit. Upon entering the facility, the surveyor's temperature was taken by the Staff Member; however, the staff member failed to ask the surveyor questions related to COVID-19 exposure and/or symptoms per facility policy. In addition. further observations revealed the assigned Staff Member took temperatures' on other persons entering the facility but failed to perform COVID-19 questions as indicated per the facility's policy. Interview with the Staff Member, on 10/26/2020 at 12:35 PM, revealed the facility's policy was for everyone that entered the facility to have their temperature taken and to be asked questions related to COVID-19 signs/symptoms and exposure. The Staff Member stated in addition to taking temperatures of everyone, she should have also asked each person questions related to COVID-19 symptoms and exposure. Interview revealed there was a laminated document at the facility's main entrance screening post of COVID-19 signs/symptoms and criteria used in the screening process. The Staff Member was unable to provide an explanation as to why she failed to ask questions related to COVID-19 screening when the surveyor and others entered the facility. Interview with the Director of Health Information Management, on 10/28/2020 at 10:00 AM, revealed she was appointed to ensure Screener's were at the facility's main entrance. She stated a document was posted at each screening post to ensure proper screening of all persons entering the facility which included staff. She revealed she expected each screener to utilize the screening tool provided and follow the facility's policy to screen everyone entering the facility related to COVID-19. Interview with the Administrator, on 10/28/2020 at 12:40 PM, revealed she expected each staff member to assess for COVID-19 signs/symptoms and exposure at screening post. The Administrator stated everyone should have temperature taken and asked COVID-19 questions about signs, symptoms and exposure at each entrance into the facility.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observation of the kitchen, on [DATE], revealed food stored in the walk-in freezer was open to air and unsealed, there was expired food and food not dated in the walk-in refrigerator, and spilled food on the floor in the dry pantry area. Review of the Census and Condition, dated [DATE], revealed one (1) of thirty-seven (37) residents received their food from the kitchen. The findings include: Review of facility policy titled, Food Receiving and Storage, dated (MONTH) (YEAR), revealed food services or other designated staff will maintain clean food storage areas at all times and all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Observation of the kitchen's walk in freezer on [DATE] at 9:54 AM, revealed an opened box of garlic bread and an opened box of french toast with both food items open to air and not sealed. Observation of the kitchen's walk-in refrigerator on [DATE] at 10:00 AM, revealed an opened container of potato salad with an expired date of [DATE] and a container of ground up ham with no date labeled on the container. Observation of the dried goods/pantry area on [DATE] at 10:28 AM, revealed a spilled pile of corn meal on the floor. Interview with the Dietary Manager on [DATE] at 10:21 AM and 10:28 AM, revealed he expected all foods in the refrigerators and freezers to be sealed completely, labeled and dated. He stated he expected outdated or expired foods to be discarded when they pass their use by or expiration dates. He also revealed he expected staff to clean up spills immediately and it was not acceptable for staff to leave spills such as the corn meal on the pantry floor.

Based on interview, and review of the Skilled Nursing Facility Beneficiary Protections Notifications it was determined the facility failed to ensure they issued the appropriate and required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to residents/beneficiaries when Medicare covered services were ending for one (1) of three (3) Medicare Discharges reviewed (Resident #A). Review of Resident #A's Medicare Discharge, revealed the facility did not issue a SNFABN CMS Form . The findings include: Interview with the Social Services Director on 08/08/18 at 12:17 PM, revealed the facility did not have a specific policy related to beneficiary protection notices and they follow the Federal Regulations. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review completed by the facility revealed the facility discharged Resident #A from Medicare Part 'A' services with the last covered day being 06/24/18; however, the resident still had benefit days that were not exhausted. Further review of this Skilled Nursing Facility Beneficiary Protection Notification Review, revealed the facility did not provide a SNFABN form CMS- to this resident. Interview with the Social Services Director on 08/08/18 at 12:17 PM, revealed she expected the Advanced Beneficiary Notices to be completed per requirements. She stated the one that was not completed for Resident #A should have been completed and it was just missed.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide written notification of the notice of transfer to the resident, the resident's representative, and the representative of the Office of the State Long-Term Care (LTC) Ombudsman for one (1) of seventeen (17) sampled residents (Resident #7). The findings include: Review of the facility policy titled, Bed-hold/Leave of Absence (LOA), last reviewed (MONTH) (YEAR), revealed residents may have a Leave of Absence (LOA) from the facility for a required short-term stay at an acute care facility. Should the resident require a LOA from the facility for an overnight stay or longer, with the intent of returning to the facility, the resident's bed will be held upon a request from the resident and/or responsible party. All documentation regardless if a pass or LOA, a consent to hold the bed/release the bed will be included in the resident's medical record. Record review revealed the facility admitted Resident #7 on 05/02/17 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 05/16/18, no time, revealed Resident #7 was transferred to an acute care facility on 05/16/18 with a [DIAGNOSES REDACTED]. Resident #7's Representative was notified via telephone of the orders received to transfer Resident #7 to an acute care facility with understanding voiced by the resident representative. However, further review revealed there was no documented evidence the facility notified the resident, resident representative, and LTC Ombudsman in writing of the the transfer. Interview with Licensed Practical Nurse (LPN) #1 on 08/09/18 at 10:36 AM, revealed he was unable to locate any documentation concerning a bed-hold or written notification that the LTC Ombudsman had been notified of Resident's #7's transfer to an acute care facility. Interview with the Social Service (SS) Director, on 08/09/18 at 4:12 PM revealed Resident #7's Representative was verbally informed of the transfer and the number of available bed-hold days at the time of the transfer. The SS Director stated no written documentation was issued to Resident #7's Representative nor was the Office of the State LTC Ombudsman notified of Resident #7's transfer to an acute care facility. The SS Director revealed she thought since Resident #7 would be returning to the facility upon discharge from the acute care facility that the LTC Ombudsman did not need to be notified. She also stated since the Resident Representative had been notified verbally, a written notification was not issued.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide written notice to the resident and resident's representative at the time of transfer for hospitalization that specified the duration of the bed-hold policy for one (1) of thirteen (13) sampled residents (Resident #7) and one (1) of three (3) closed records (Resident #37). The findings include: Review of the facility policy titled, Bed-hold/Leave of Absence (LOA), last reviewed (MONTH) (YEAR), revealed should a resident require a leave from the facility for an overnight stay or longer, with the intent of returning to the facility, the resident's bed will be held upon request of the resident and/or the resident's responsible party. All documentation, regardless of a pass or LOA, a consent to hold the bed/release the bed, will be included in the resident's medical record. 1. Record review revealed the facility admitted Resident #37 on 07/16/18 with [DIAGNOSES REDACTED]. Further review of this resident's record, revealed a discharge tracking record, dated 07/26/18 which indicated Resident #37 was transferred to an acute care hospital on [DATE]; however, there was no documented evidence in the medical record of a Bed Hold offered to this resident or resident's representative. Interview with Social Services Director on 08/09/18 at 10:32 AM, revealed she expected the facility to follow the facility policy on bed holds. She stated to her knowledge Resident #37 was not offered a bed hold when he/she transferred out to an acute care hospital. She stated she believes there is not an exact staff person who has sole responsible for ensuring a Bed Hold is offered. Interview with facility Administrator on 08/09/18 at 10:43 AM, revealed she would expect their facility bed hold policy to be in place, completed and enforced as per the policy. 2. Record review revealed the facility admitted Resident #7 on 05/02/17 with [DIAGNOSES REDACTED]. Resident #7 was transferred to an acute care facility on 05/16/18 with a [DIAGNOSES REDACTED]. Review of Nurse's Notes dated 05/16/18, no time revealed Resident #7's Representative was notified via telephone of the new orders received to transfer Resident #7 to an acute care facility with understanding voiced by the resident representative. However, further review revealed there was no documented evidence the facility notified the resident or resident representative in writing of the duration of the bed-hold policy. Interview with Licensed Practical Nurse (LPN) #1 on 08/09/18 at 10:36 AM, revealed he was unable to locate any written documentation concerning Resident #7's bed-hold notice. Interview with the Social Services (SS) Director, on 08/09/18 at 11:05 AM revealed the facility did not issue a written bed-hold notice at the time Resident #7 was transferred, or immediately after, to an acute care facility. The SS Director stated she verbally informed Resident #7's Representative of the number of available Medicaid bed-hold days and since the Resident Representative had been notified verbally, a written notification was not issued.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure the comprehensive care plan interventions were followed for one (1) of thirteen (13) residents (Resident #13). Resident #13 was care planned for a bed alarm when in bed; however, on 06/14/18, staff failed to ensure the bed alarm was turned on and Resident #13 attempted an unassisted transfer from bed and fell sustaining a laceration to the left eye and hematoma to side of left eye. The findings include: Review of the facility policy titled Care Plans Comprehensive, last reviewed (MONTH) (YEAR), revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care planning/interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Record review revealed the facility admitted Resident #13 on 05/29/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 06/05/18 revealed the facility assessed Resident #13's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required extensive assist of two (2) staff for transfers, extensive assist of one (1) to two (2) with walking, required the use of a walker or wheelchair for mobility, and balance during transition and walking was not steady only able to stabilize with human assistance. The MDS further indicated the resident had one (1) fall in the month prior to admission and one (1) fall after admission but prior to the MDS assessment. Review of the Comprehensive Care Plan for Falls/Safety, dated 05/28/18 revealed an intervention for bed check (alarm) intact (bed or chair). However, review of the facility Risk Event Worksheets dated 06/14/18 and interviews on 08/09/18 with Certified Nurse Aide (CNA) #3 at 9:19 AM and Licensed Practical Nurse (LPN) #1 at 9:51 AM revealed Resident #13 had a fall on 06/14/18 at 2:52 PM, due to the resident attempting a self-transfer from the bed. The bed alarm did not sound and the resident fell at bedside causing a laceration over the left eye as well as a hematoma (a mass of usually clotted blood that forms in tissue as a result of a broken blood vessel) to the side of the left eye. The facility determined the bed alarm had been turned off while resident was up and out of the room and staff failed to turn alarm back on. Interviews on 08/09/18 with Certified Nurse Assistant (CNA) #1 at 8:59 AM and CNA #2 at 9:13 AM revealed Resident #13 was assisted to bed after lunch on 06/14/18 at approximately 1:00 PM and rounds were completed every two (2) hours. The CNA's stated the bed alarm was checked on the last round at approximately 2:30 PM, and the alarm was turned on. The CNA's revealed they were trained to use the silence button on the alarm, rather than turning the alarm off, when assisting the resident to the bathroom or when getting him/her out of bed so that when the resident is assisted back to bed, the pressure applied to the alarm pad automatically reactivated the alarm. CNA #1 stated the resident had family visiting at the time of the last round and she believed the family turned off the alarm and failed to turn it back on before they left, as this often happens with family visits. Further interview with Certified Nurse Aide (CNA) #3 at 08/09/18 at 9:19 AM revealed CNA #3 came on shift between 2:45 PM and 3:00 PM. She stated the bed alarm was turned off, but she did not know why the alarm was not on because she had just started her shift Interview with the Director of Nursing (DON) on 08/09/18 at 3:00 PM revealed she expected staff to follow and carry out the interventions listed on the resident's care plan.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (1) of thirteen (13) sampled residents (Resident #13). Resident #13 was assessed and care planned as a high fall risk with an order for [REDACTED]. The findings include: Review of the facility policy titled, Fall Assessment, Reduction, and Monitoring, last reviewed (MONTH) (YEAR), revealed a fall reduction program is clearly established and understood by the staff as well as the residents and/or families. A key to successful fall reduction program is education and re-education of staff, residents and families. Interventions are established to provide guidelines for the staff and families working with the residents. Record review revealed the facility admitted Resident #13 on 05/29/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 06/05/18 revealed the facility assessed Resident #13's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required extensive assist of two (2) staff for transfers, extensive assist of one (1) to two (2) with walking, required the use of a walker or wheelchair for mobility, and balance during transition and walking was not steady only able to stabilize with human assistance. The MDS further indicated the resident had one (1) fall in the month prior to admission and one (1) fall after admission but prior to the MDS assessment. Review of the facility Fall Assessment for Resident #13 dated 05/29/18 revealed a score of thirty (30) indicating resident was a fall risk. Noted on the assessment; A score of twelve (12) or more indicates a high risk for fall and requires safety measures in place to lessen the likelihood of fall. A list of measures in place included Bed check in use. Review of the Comprehensive Care plan Falls/Safety dated 05/28/18 revealed Resident #13 was at high risk for injury related to history of falls, use of psychoactive medications, use of diuretic, impaired cognitive ability, and unsteady gait with an intervention for bed check intact (bed or chair {alarm}). Review of the Physician Orders for June, (YEAR), revealed the bedcheck (bed alarm) was ordered on [DATE]. Review of the facility Risk Event Worksheets dated 06/14/18 revealed Resident #13 had two (2) falls on this date. The first fall, at 9:20 AM, was a result of resident's attempt to self-transfer from the wheelchair to the sofa in the sunroom. The chair alarm sounded and resident ultimately sat in the floor, and there was no injury. However, at 2:52 PM, the resident attempted a second self-transfer from the bed. The bed alarm did not sound and the resident fell at bedside causing a laceration over the left eye as well as a hematoma to the side of the left eye. Bilateral bedside floor mats were initiated as a result of the second fall. Interview with Certified Nurse Assistant (CNA) #1 on 08/09/18 at 8:59 AM revealed she provided care for Resident #13 on 06/14/18. CNA #1 stated the resident was assisted to bed after lunch at approximately 1:00 PM and rounds were completed every two (2) hours. The CNA revealed she checked the bed alarm on the last round at approximately 2:30 PM, and the alarm was turned on. She stated she was trained to use the silence button on the alarm, rather than turning the alarm off, when assisting the resident to the bathroom or when getting him/her out of bed so that when the resident is assisted back to bed, the pressure applied to the alarm pad automatically reactivated the alarm. The CNA further stated the resident had family visiting at that time of the last round and she believes the family turned off the alarm and failed to turn it back on before they left, as this often happens with family visits. Telephone interview with CNA #2 on 08/09/18 at 9:13 AM revealed she worked day shift on 06/14/18. The CNA stated Resident #13 was assisted back to bed after lunch at approximately 1:15 PM and routine rounds were made to check on residents to see if they need anything, and she made the last round at approximately 2:15 PM. The CNA revealed the bed alarm was turned on at the time of the last round. She stated CNA's were instructed to use the silence button on the alarms when residents were assisted to the bathroom or out of bed so that when the pad was reactivated with pressure, the alarm was on and would sound when pressure was relieved. Interview with CNA #3 at 08/09/18 at 9:19 AM revealed she came on shift between 2:45 PM and 3:00 PM 06/14/18. She stated she was in the nurse's station right beside Resident #13's room when she heard a noise from the resident's room. CNA #3 revealed she immediately went to the resident's room and found him/her laying on the floor beside the bed. The CNA further stated the resident had a laceration to her head. She stated LPN #1 and RN #1 were in the room as well. CNA #3 revealed the nurses assessed the resident for injuries, treated the laceration to stop the bleeding, and all three (3) of them assisted the resident back to bed. The CNA stated the bed alarm was turned off at the time of the fall and family was not present at that time. Interview with Licensed Practical Nurse (LPN) #1 on 08/09/18 at 9:51 AM revealed she was charting and heard a loud noise. She stated she went to the sound and found the resident on the floor at the foot of the bed with a laceration on the forehead. The LPN revealed a full assessment was completed then the resident was assisted back to bed. She further stated the bed alarm was not sounding. The LPN stated steri-strips were placed over the laceration, and sutures were not required. LPN #1 revealed the Physician saw the resident that evening and completed a full assessment with no new orders received. The LPN further stated that the resident's family visits often, but did not know if family visited on 06/14/18. However, the LPN stated she knows of more than one occasion, the family has visited and turned the bed alarm off before assisting the resident to the bathroom and does not turn the alarm back on. Interview with Registered Nurse (RN) #1 on 08/09/18 at 10:33 AM revealed she did not recall the particulars surrounding the resident's second fall on 06/14/18. RN #1 stated education was provided to the resident and family on admission in regards to bed and chair alarms use. She revealed she did not recall re-educating the resident's family regarding the bed alarm. The RN further stated there had not been any specific intervention put in place for checking the bed alarm after family leaves from a visit. Telephone interview with the Resident's Representative (RR) on 08/09/18 at 10:17 AM revealed she does not visit until later in the afternoons, about 4:30 PM or later. The RR stated the resident had two (2) sisters that visited every two (2) to three (3) days, and it would not surprise me if they turned the alarm off during a visit and did not turn it back on when they left. RR stated that when she visited, if she assisted her mother to the bathroom and turned the alarm off, she made sure she turned it back on when the resident was assisted back to bed. Interview with the Director of Nursing (DON) on 08/09/18 at 11:22 AM revealed I'm sure there has been education to the family regarding the reason for the alarms and the safety of the resident for the family members. The DON stated it was a possibility that the family turned the alarm off on the day of the resident's fall with injury. The DON revealed there is not a written intervention to check the alarm after the family leaves and there was not an intervention put into place to prevent a fall when the alarm had been turned off by the family. The DON further stated the immediate action after the 06/14/18 fall was bedside floor mats, however, there was no immediate corrective action to assure the bed alarm was turned on after family visits.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions. Review of the facility Census and Condition, dated 09/20/16, revealed thirty-eight (38) of thirty-eight (38) residents received their meals from the kitchen. Observation of the kitchen revealed numerous food items not sealed and open to the air in the walk in refrigerator and walk in freezer. Further observation revealed the walk in refrigerator and walk in freezer floors were dirty with food particles and trash on the floors; and there was a ice build-up on several boxes in the walk-in freezer. In addition, Dietary Aide #1 was observed touching and handling food with non-gloved hands while preparing food for herself. Observation of the dry goods storage area revealed trash and food scattered across the floor along with boxes and packs of soda being stored on the floor. Multiple push carts had crumbs and food build up on the shelves. Two (2) of three (3) red sanitary buckets were empty with no sanitization solution present. The findings include: Review of the facility's policy titled, Food Safety Standards and Requirements, revised 08/17/16, revealed dry food which is opened or removed from the original packaging, should be stored properly covered in food grade containers and clearly labeled. Further review of this policy, revealed clearly labeled sanitizer of the proper concentration must be available and used to sanitize all food contact services of stationary equipment ie .work counters/tables and sanitizer test strips must be used to ensure proper concentration. It also states, sanitizing solution must be checked throughout the day and wiping cloths used for cleaning up food spills must be stored in sanitizing solution between uses. Review of the facility's policy titled, Food Safety Standards and Requirements, revised 03/13/15, revealed all ready to eat food must not be touched with bare hands and disposable gloves or cleaned, sanitized utensils must be used properly to handle food. 1. Observations of the kitchen during the initial tour, on 07/05/17 at 10:55 AM, revealed: A. The walk -in freezer contained an open box with an open bag of chicken patties open to air, an open box with an open bag of pepperoni open to air, and an open box with an open bag of sausage patties open to air. B. The walk-in refrigerator contained an open bag of hamburger patties open to air, an open bag of fajita bread open to air, and an open container of sour cream not dated when opened. In addition, there was a long handled spoon laying on top of a a five gallon bucket of sliced pickles with pickle juice all over the spoon, on the lid of the five gallon bucket, and on the floor surrounding the five gallon bucket. C. The freezer in the tray line area had an ice build-up mixed with food particles. D. The ice cream freezer had an ice build-up in the freezer and on the sealing edge which prevented the freezer from being closed properly. E. The kitchen floor and dry goods storage area had food and trash scattered about on the floors. In addition, there were cereal boxes and soda being stored on the floor in the dry goods storage area. F. Multiple push carts throughout the kitchen had crumbs and food build-up on them. G. The can opener had a build-up of old food on the blade and the metal turner. Also, Dietary Aide #1 was observed making herself a meal from the trayline and was handling the food with her bare hands. H. Two (2) of three (3) red sanitary buckets were empty with no sanitization solution present. 2. In addition, observation of the walk-in freezer, on 07/07/17 at 11:53 AM, revealed an open box with a bag of frozen omelets open to air with dripping water going into the open bag of omelets. It also revealed an open box with and open bag of fish fillets open to air. Interview with Dietary Cook #1, on 07/07/17 at 12:19 PM, revealed she expected staff to ensure all foods in the refrigerators and freezers were sealed completely. She stated it is an expectation that all kitchen staff clean as they go and the duty of all staff to ensure the kitchen area is as clean as possible. She revealed having a long handled spoon in the walk-in refrigerator for staff to reuse to obtain pickles was inappropriate and staff were to get a new/clean spoon for each use. She stated sanitary buckets are supposed to be in use at each work station and not having them in use was unacceptable. Interview with Dietary Line Supervisor #1, on 07/05/17 at 11:20 AM, revealed she expected staff to ensure all foods in the refrigerators and freezers were sealed completely to protect the food. She stated it is an expectation that all kitchen staff clean as they go and there should never be a build up of food on the push carts. She revealed having a long handled spoon in the walk-in refrigerator for staff to reuse to obtain pickles was unacceptable and staff were to get a clean spoon for each time pickles were needed for use. She stated sanitary buckets are supposed to be in use at each work station and it was unacceptable to not have them in use. Interview with the Director of Dietary Services, on 07/06/17 at 3:05 PM, revealed he expected staff to clean as they go and to also follow the weekly cleaning schedule. He stated it was unacceptable to have food build up on the push carts and it was unacceptable to have a dirty can opener. He revealed staff are to clean the can openers after each use. He stated all staff were trained on the storage of food items and it was unacceptable to store food in unsealed bags or containers and it was also inappropriate to store food items in direct contact with the floor. He further stated the person who opens food items was responsible to ensure labeling, dating, sealing and food was stored properly. He revealed any handling of ready to eat food without gloves was prohibited. He stated the red sanitary buckets should always be in use and it was unacceptable to not have them in use.

Based on observation, interview, record review, review of Kentucky Administration Regulation (KAR) - 900 KAR 2:010 and review of the facility's policies, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as possible. On 05/14/16, Resident #1's Spouse verbalized to two (2) staff members (Licensed Practical Nurse {LPN} #1 and State Registered Nurse Aide {SRNA} #1, on separate occasions that he/she wanted to harm a dietary staff member and showed these two (2) staff members he/she was carrying a concealed firearm. LPN #1 and SRNA #1 told SRNA #2 of the incidents. However, LPN #1, SRNA #1, and SRNA #2 left the facility at the end of their shift at 7:00 PM without reporting the incident, leaving the Resident's Spouse still in the facility. On 05/15/16, (the next day) at 8:30 AM, LPN #1, SRNA #1 and SRNA #2 reported the incidents to Registered Nurse (RN) #1. However, RN #1 did not report the incidents to administration until 11:00 AM on 05/15/16, two and one half hours {2.5} after she had been made aware of the incident. The facility's failure to ensure the residents' environment was free from accident hazards has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/20/16 and determined to exist on 05/14/16. The facility was notified of the Immediate Jeopardy on 05/20/16. An acceptable Allegation of Compliance (AoC) was received on 05/20/16, which alleged removal of the Immediate Jeopardy on 05/18/16. The State Survey Agency validated, on 05/20/16, that the Immediate Jeopardy was removed on 05/20/16. The scope and severity was lowered to an F while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Security Management Plan, approved January 2008, revealed the Security Management Plan defines the processes through which the facility provides a system of safeguards to protect the physical property of the facility to achieve relative security for all people interacting within the organization and its environment. The policy further states, Critical Events should be reported to senior administrators of the facility immediately upon discovery. Review of the facility's policy titled Incident/Accident Reporting, last revised October 2015, revealed all staff should complete a full report of any incident/accident occurring and an incident is any event that disrupts or occurs outside of normal procedure. The policy further stated the incident report must be completed prior to the end of the shift in which the incident occurred or was discovered. Record review revealed the facility admitted Resident #1 on 07/22/15 with diagnoses, which included Dementia with Lewy Bodies, Hypertension, Major Depressive Disorder, Anxiety Disorder and Type 2 Diabetes Mellitus. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/22/16, revealed the facility assessed Resident #1's cognition as severely impaired, as the resident was unable to complete a Brief Interview for Mental Status (BIMS) score. Review of the facility's Final Investigation Timeline Report, dated 05/20/16, revealed on 05/14/16 at approximately 6:20 PM, Resident #1's Spouse displayed to two (2) different staff members that he/she was carrying a concealed weapon (gun). Prior to the visual display, the Resident's Spouse stated he/she was angry with the Dietary Manager and would be willing to fight him to get what he/she wanted or he/she could take care of him by other means (implication to use the gun). The staff that was aware of the Spouse carrying the concealed weapon was very upset; however, they did not share this information with anyone else on this date. On 05/15/16 at approximately 8:30 AM, LPN #1, SRNA #1, and SRNA #2 informed the Charge Nurse/Registered Nurse {RN} #1, of the incident from the prior day. At 11:00 AM, RN #1 called the facility's Administrator to report the incident. Interview with Dietary Clerk #1, on 05/19/16 at 1:00 PM, revealed Resident #1's Spouse had called dietary on 05/14/16 at suppertime, complaining about the gravy being thicker than normal, and wanted something to make it thinner. She stated she explained they could not thin Resident #1's gravy because the resident had a physician's orders [REDACTED]. She stated Resident #1's Spouse would not listen to her and was very loud, cursing, and belligerent. Dietary Clerk #1 stated she gave the phone to the Dietary Manager to speak to Resident #1's Spouse. Interview with the Dietary Manager, on 05/19/16 at 10:45 AM, revealed on 05/14/16 during suppertime, Dietary Clerk #1 had received a call from Resident #1's Spouse and he/she was being very belligerent about Resident #1's diet and she had handed him the phone to speak with him/her. He stated Resident #1's Spouse was very belligerent and loud and would not listen to his explanation of why Resident #1 could not have thin gravy. During further interview, he stated he offered to make some fresh gravy for Resident #1, explaining that he could not thin the gravy because Resident #1 required a nectar consistency, per the physician's orders [REDACTED].#1's Spouse continued to be belligerent and would not listen to the explanation and eventually hung up the phone He stated he made some fresh gravy and had it sent up to Resident #1's room. The Dietary Manager stated he had never seen Resident #1's Spouse or spoken to Resident #1's Spouse prior to their phone conversation. He stated he did not hear back from Resident #1's Spouse after he got off the phone with him/her and figured the situation was resolved once the fresh gravy had been delivered to Resident #1's room. Interview with SRNA #1 on 05/19/16 at 8:10 AM revealed she was working on Resident #1's unit on 05/14/16 during the twelve (12) hour day shift. She stated Resident #1's Spouse visits daily and had come to visit around suppertime. SRNA #1 stated Resident #1's Spouse was cursing loudly about the head of the kitchen and Resident #1's diet. She stated Resident #1 had a diet change the previous day because he/she had a stroke and the doctor had ordered him/her to have a diet change. During further interview, she stated she attempted to reassure Resident #1's Spouse about the diet change and attempted to calm him/her down. She stated she left Resident #1's Spouse to go attend to other residents. SRNA #1 stated a short time later, Resident #1's Spouse stopped her in the hallway and pulled his/her shirt up and exposed a concealed firearm and made threats toward the head of the kitchen. She stated she was shocked when she saw the firearm. SRNA #1 stated she was very intimidated by Resident #1's Spouse, so she did not report this incident. She stated after a short time she went and told LPN #1 what had happened, and at that time LPN #1 told her that she had a similar experience. Interview with LPN #1, on 05/19/16 at 8:40 AM, revealed she was working on Resident #1's unit on 05/14/16 during the twelve (12) hour day shift. She stated Resident #1's Spouse had come in to visit as he/she normally does around supper time and she had heard him/her. She stated Resident #1's Spouse started making threats toward the Dietary Manager and pulled his/her shirt up to show her that he/she had a concealed firearm. LPN #1 stated she immediately became fearful and tried not to say anything else to him/her because she was afraid she might make him/her angrier. She stated she left the vicinity and shortly after that, she and SRNA #1 spoke and determined they both had witnessed Resident #1's spouse make threats toward a dietary staff member and they both were shown Resident #1's Spouse's concealed firearm. LPN #1 stated she and SRNA #1 told SRNA #2 about Resident #1's Spouse making threats and showing them his/her concealed firearm. She stated at that time all three (3) of them were scared and they did not report the incidents to anyone. LPN #1 stated when they left the facility at the end of their shift Resident #1's Spouse was still in the facility and they were worried he/she may do something, but they were scared that if they reported it and he/she was confronted he/she may hurt someone. She also stated she knew it was wrong not to have reported it immediately after it happened as it could have put others in danger by not reporting it immediately. LPN #1 stated the next morning on 05/15/16 at approximately 8:30 AM, she along with SRNA #1 and SRNA #2 informed RN #1 of the incidents. Further interview with SRNA #1, on 05/19/16 at 8:10 AM revealed that she and LPN #1 told SRNA #2 about Resident #1's Spouse making threats and showing them his/her concealed firearm. She stated neither she, LPN #1 nor SRNA #2 reported this to anyone prior to leaving at the end of their shift. SRNA #1 also stated they had conversed during the evening by phone and realized they should have reported this to someone as they believed Resident #1's Spouse could hurt someone and his/her threats seemed credible, but they were afraid of him/her. She stated the next morning on 05/15/16 at approximately 8:30 AM, she along with LPN #1 and SRNA #2 informed RN #1 of the incident. SRNA #1 stated she knew the incidents should have been reported immediately on 05/14/16. She stated if she could do it over again, she would have reported it immediately after it occurred on 05/14/16, as she believed it was a safety issue for all residents, visitors, and staff by not reporting the incident to administration immediately. SRNA #1 stated she was scared for everyone. Interview with SRNA #2, on 05/19/16 at 9:20 AM, revealed she was working on Resident #1's unit on 05/14/16 during the twelve-hour day shift. She stated around supper time that day, LPN #1 and SRNA #1 told her that Resident #1's Spouse had been cursing and making threats; and, had showed both LPN #1 and SRNA #1 he/she had a concealed firearm. She stated all three (3) of them were very intimidated by him/her and scared to have someone confront him/her, fearing that he/she may act out and hurt someone. SRNA #2 stated they left at the end of their shift and did not report the incidents to anyone, but they were scared for everyone at the facility because of the threats Resident #1's Spouse verbalized and because he/she had a concealed firearm with him/her. She stated she knew now that it was wrong not to report it to administration immediately and she felt very bad about it. SRNA #2 stated the next morning on 05/15/16 at approximately 8:30 AM, she along with SRNA #1 and LPN #1 informed RN #1 of the incidents. Interview with RN #1, on 05/19/16 at 3:45 PM, revealed she had been the Charge Nurse on Resident #1's unit on day shift on 05/14/16 and was unaware of any incident regarding Resident #1's Spouse making threats and showing a concealed firearm to staff during that shift on 05/14/16. She stated LPN #1, SRNA #1, and SRNA #2 informed her on 05/15/16 around 8:30 AM of the incidents that took place on 05/14/16. RN #1 further stated she went around the facility to check all residents after learning this information and ensured all the doors were secured. RN #1 stated she notified the Administrator at approximately 11:00 AM of the incidents that occurred the day before on 05/14/16. She also stated she should have promptly notified the Administrator after she learned of the incidents. RN #1 stated she would have expected LPN #1, SRNA #1 and SRNA #2 to have notified her of the incidents right after they occurred and not wait until a day later to report something this serious. Interview with the Director of Nursing, on 05/19/16 at 9:40 AM, revealed she would have expected LPN #1, SRNA #1 and SRNA #2 to immediately report the incidents that occurred on 05/14/16. She stated it was unacceptable to have not reported these events immediately. The DON stated she would also have expected RN #1 to report the incidents immediately once she was made aware of them on 05/15/16. She stated she expected all staff to follow facility policies and procedures. Interview with the Administrator, on 05/19/16 at 9:50 AM, revealed SRNA #1 and SRNA #2 should have immediately reported the incidents that occurred on 05/14/16 to their Charge Nurse and to administration. She stated it was unacceptable to have not reported these immediately. The Administrator stated she would also have expected RN #1 to report the incidents more timely once she was made aware of them on 05/15/16. She stated she expected all staff to follow the facility's policy and procedures. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Administrator, on 05/15/16 directly after she was made aware of the incidents, contacted Resident #1's daughter-in-law to inform Resident #1's Spouse that he/she was not allowed to return to the facility until further investigation into the incidents that occurred on 05/14/16. The Administrator also informed RN #1, who was the Charge Nurse on 05/15/16 that Resident #1's Spouse was not allowed to return to the facility and to call security and notify the house supervisor if there was any trouble. 2. The Administrator arrived at the facility at 1:00 PM on 05/15/16 and notified the facility's Safety Officer of the incident. The Safety Officer notified the local police of the incidents that occurred on 05/14/16. 3. At 3:00 PM on 05/15/16, the Safety Officer made the decision to change the facility's entrance codes and lock the facility down completely and all visitors would have to use the emergency room (ER) entrance where they would have to sign in, detail who they were and who they were visiting. 4. The Administrator at approximately 3:00 PM on 05/15/16 met with Resident #1's Son and he (the son) assured the Administrator that Resident #1's Spouse had agreed not to return to the facility. 5. On 05/15/16 at approximately 3:30 PM, the Administrator began interviewing RN #1, LPN #1, SRNA #1 and SRNA #2 in depth in regards to the incidents that occurred on 05/14/16. 6. At approximately 4:00 PM on 05/15/16, the Administrator then began one on one education with all staff present related to appropriate notification for any security issue. 7. On 05/16/16, the Administrator continued to meet with additional staff and provided one on one education to staff who had not been given the one on one education thus far. 8. On 05/16/16, the Safety Officer met with facility's leadership members and reviewed the facility's Active Shooter policy and Safety Management plan. They discussed the need of immediacy of reporting the type of situation that occurred on 05/14/16 with Resident #1's Spouse and staff failing to report the incidents immediately. 9. On 05/17/16 at approximately 9:30 AM, the facility's Administrator met with the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO) to discuss the results of the investigation. They made the decision to terminate Resident #1's Spouse's visitation rights indefinitely based on the seriousness of the incidents and with guidance from Kentucky Administration Regulation 900 KAR 2:010 - Access and Hours of Visitation. The facility sent a certified letter to Resident #1's Spouse explaining the termination of visitation rights. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview with Resident #1's daughter-in-law (RN #2) on 05/19/16 at 3:15 PM, revealed at approximately 11:30 AM on 05/15/16 the Administrator did contact her to inform her to notify Resident #1's Spouse that he/she was not allowed to return to the facility until further investigation into the incidents that occurred on 05/14/16. Interview with RN #1, on 05/19/16 at 3:45 PM, revealed the Administrator did inform her that Resident #1's Spouse was not allowed to return to the facility, and if he/she did, or there was any trouble to contact security and the house supervisor. 2. Interview with the Safety Officer, on 05/18/16 at 2:05 PM, revealed the Administrator contacted him at approximately 1:00 PM on 05/15/16 and informed him of the incidents that occurred on 05/14/16 and he notified the police department shortly after he received the information from the Administrator. Review of the Police Department Report, revealed the police department was notified by the facility on 05/15/16 at 2:10 PM. 3. Interview with the Safety Officer on 05/19/16 at 2:05 PM, revealed he made the decision to change the facility's door entrance codes to new codes and lock the facility down with having only one (1) entrance available for visitors so the facility could monitor exactly who was visiting. The Safety Officer discontinued the lock down on 05/16/16 at 6:30 PM, because the police had cleared the facility. he 4. Interview with Resident #1's Daughter-in-law (RN #2) on 05/19/16 at 3:15 PM revealed the Administrator did meet with her husband, Resident #1's Son at approximately 3:00 PM on 05/15/16 in regards to Resident #1's Spouse agreeing to not attempt to visit the facility. 5. Interview with RN #1, on 05/19/16 at 3:45 PM, revealed the Administrator met with her during the afternoon of 05/15/16 and interviewed her in regards to the incident that LPN #1, SRNA #1, and SRNA #2 had reported to her at 8:30 AM on 05/15/16. Interview with LPN #1, on 05/19/16 at 8:40 AM, revealed the Administrator interviewed her on 05/15/16 about the incidents that occurred on 05/14/16. Interview with SRNA #1, on 05/19/16 at 8:10 AM, revealed the Administrator met with her on 05/15/16 and interviewed her in regards to the incidents that occurred with Resident #1's Spouse on 05/14/16. Interview with SRNA #2, on 05/19/16 at 9:20 AM, revealed the Administrator met with her on 05/15/16 and interviewed her about the incidents that occurred on 05/14/16 with Resident #1's Spouse. 6. Interview with RN #1, on 05/19/16 at 3:45 PM, revealed the Administrator provided one on one education for all staff that was working during the afternoon of 05/15/16. Interview with LPN #1, on 05/19/16 at 8:40 AM, revealed the Administrator started providing one on one education to all staff that were present on 05/15/16. Interview with SRNA #1, on 05/19/16 at 8:10 AM, revealed the Administrator met with staff individually and provided one on one education on 05/15/16. Interview with SRNA #2, on 05/19/16 at 9:20 AM, revealed the Administrator met staff on 05/15/16 and provided one on one education to all staff that was at the facility. 7. Interview with SRNA #4, on 05/20/16 at 1:05 PM, revealed she received one on one education with the Administrator on 05/16/16, about the importance of promptly notifying administration about serious incidents, safety and security issues. She further stated all staff was getting the education provided by the Administrator. Interview with Housekeeper #1, on 05/20/16 at 1:11 PM, revealed she received one on one education from the Administrator on 05/16/16 related to reporting serious incidents and prompt notification was necessary regarding safety and security issues. Interview with Dietary Clerk #1, on 05/19/16 at 1:00 PM, revealed she had been provided one on one education from the Administrator related to promptly notifying administration anytime there was a serious incident that jeopardizes safety and security issues. 8. Interview with the Safety Officer on 05/20/16 at 1:16 PM revealed he held the meeting with the Leadership Team and Department Directors on 05/16/16 at 3:00 PM. He stated he provided the Leadership Team with a review of the facility's, Active Shooter , and Safety Management plan. Review of the attendee list and review of the content of the meeting that was provided revealed the meeting took place on 05/16/16 at 3:00 PM with Department Directors and the Leadership Team. 9. Interview with the Administrator, on 05/19/16 at 9:50 AM, revealed she met with the CEO and the CNO on 05/17/16 at approximately 9:30 AM and they discussed the findings of the investigation. She stated due to the seriousness of Resident #1's Spouse's actions and behaviors, they felt that for the safety of the facility and all residents, visitors and staff they would need to terminate Resident #1's Spouse's visitation rights. She further stated they referred to the Kentucky Administration Regulation (KAR) - 900 KAR 2:010 related to Access Hours and Hours of Visitation. Review of a copy of the certified letter sent to Resident #1's Spouse, dated 05/17/16, revealed it was addressed to Resident #1's Spouse and it explained the termination of his/her visitation rights.

Based on observations, interviews, record reviews and facility policy and procedure, it was determined the facility failed to notify the physician of changes in status for two residents, (#2 & #4)), in the selected sample of ten (10) residents. The facility failed to notify the physician of the deterioration of Resident #2's skin tear, which resulted in an unstageable pressure wound. On 10/24/10, Resident #2 sustained a skin tear to the posterior left lower leg. The physician was notified per a fax from the nurse and an order for [REDACTED].#4's brown area on the second toe of the left foot, which measured 0.5 centimeters (cm) x 0.3 cm, and a nickle-sized dark purple discoloration with surrounding light purple discoloration, which was discovered during a skin assessment on 04/21/11. The findings include: A review of the facility's policy "Skin Impairment," revised 02/01/11, revealed the physician shall be notified for awareness of the skin impairment and confirmation of the treatment plan and any non-healing/declining skin impairment or area of concern may referred to the Long Term Care skin team for more in-depth evaluation and recommendations. The policy did not address a defined time frame for physician notification related to deterioration of the wound status or the need for an alternate treatment. 1. A record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition to be severely impaired, incontinent of bowel and had an indwelling urinary catheter. The facility assessed the resident as being totally dependent for mobility and activities of daily living and at risk to develop pressure ulcers. A review of a physician's fax form, dated 10/24/10 at 12:00 PM, revealed notification of two minor skin tears, with current actions as follows: areas cleansed with normal saline, Vaseline Petroleum applied, covered with 2 x 2 gauze and wrapped with Kerlix. Change daily and as needed (prn). The fax was sent by Licensed Practical Nurse (LPN) #4. A review of a physician's orders [REDACTED]. A review of the "Long Term Care Wound Observation" documentation, dated 10/24/10 at 5:40 PM, revealed Registered Nurse (RN) #5 documented a skin tear on the posterior left lower leg, with a small amount of serosanguinous drainage and redness in the center. No measurement was documented. A review of a nurse's note, dated 10/24/10 at 7:13 PM, revealed LPN #4 documented two skin tears on the left lower leg were reported by a nurse aide during morning care. One was on the left posterior lower extremity and one was on the inner right side. The areas were cleansed with normal saline, Vaseline applied, covered with 2 x 2 gauze and wrapped with Kerlix. On 10/28/10 at 11:45 AM, RN #2 documented an observation of the skin tear and noted blood-tinged drainage with a small amount of green drainage. There was no documented evidence of physician notification. On 11/04/10 at 2:23 PM, Licensed Practical Nurse (LPN) #6 documented an observation of the skin tear and noted blood-tinged drainage. There was no documented evidence of physician notification. On 11/11/10 at 3:05 PM, LPN #6 documented an observation of the skin tear and noted yellow/green drainage. There was no documented evidence of physician notification. On 11/15/10 at 10:30 AM, LPN #3 (Wound Nurse), documented the skin tear with minimal green drainage and the skin flap was missing. There was dark pink tissue in the center with pink surrounding edges. The treatment was changed to clean the wound with normal saline, apply Visco paste loosely, cover with Kerlix, secure with paper tape and change every five days and as needed (prn). A notification of the change in treatment was faxed to the attending physician on 11/15/10 by LPN #3; however, there was no documented evidence of a physician's orders [REDACTED]. Documentation on the November and December 2010 TARs revealed the treatment ordered for every five days and as needed (prn) was completed on 11/25/10, 11/30/10, 12/05/10, 12/10/10, 12/15/10 and 12/20/10. A review of nurse's notes, dated 12/20/10 at 3:24 PM, revealed LPN #3 (Wound Nurse), documented that "upon dressing change to the left lower leg, the wound showed great decline, and was no longer a skin tear but an unstageable pressure ulcer." She described the tissue in the wound base as consisting of 100% yellow slough against a bony prominence. She measured the wound as 12.7 cm x 2.0 cm and was unable to determine the depth due to the yellow slough. On 12/20/10, no time indicated, an order from the attending physician revealed to consult with the Wound Care physician. The nurse revealed the physician (Wound Care Specialist) was notified for consultation. An observation, on 04/20/11 at 2:00 PM, revealed wound care was provided and wound measurements were completed by LPN #3, (Wound Nurse). She was accompanied by other members of the Wound Care Team which included the Director Of Nursing (DON), the Clinical Care Coordinator and the Registered Dietician. The wound on the back of the left lower leg measured 10.6 cm long x 0.5 cm wide, with a depth of 0.8 cm. LPN #3, (Wound Nurse) stated the wound started out as a skin tear and progressed to an unstageable wound. She was unable to provide an explanation of how or why this occurred. An interview with LPN #3 (Wound Nurse), on 04/21/11 at 9:55 AM, revealed the wound initially presented as a skin tear and the treatment was changed because the skin tear was not healing. She stated the wound became worse after the new treatment was initiated. Further interview at 3:45 PM, revealed the new treatment was tried for a while to see if it would work. She was off for a couple of days in December, and when she returned to work, the wound had changed drastically. She stated she did weekly wound assessments and the nurses on the unit did the weekly skin assessments. If the nurses noticed a change in the wound status, they should notify the physician for a treatment change or contact her. Continued interview at 6:30 PM, revealed if there was no documentation, then she did not have any communication with the physician. She stated blood-tinged or yellow/green drainage was something the physician should be notified about, but she was unable to explain why physician notification did not occur. She stated the physician should be notified whenever a wound changes for the worse. An interview with RN #2 (Charge Nurse), on 04/22/11 at 10:00 AM, revealed she did admission skin assessments and wound care occasionally. She stated she expected the nurses to notify her to collaborate on skin concerns and that any nurse could contact a physician with concerns. She stated that the nurse doing a skin assessment should remove the dressings to assess the wounds, and if the wound declined, the physician should be notified. An interview with Resident #2's physician, on 04/21/11 at 2:00 PM, revealed she usually consulted with a wound surgeon regarding wounds. She stated she was notified about the resident's skin tear on 10/24/10 and about a change in treatment on 11/15/10, but did not recall any other communication with staff, related to the skin tear, until contacted on 12/20/10. She gave the order to refer the resident for consult with the wound surgeon related to his/her wounds. The resident's physician stated she expected to be notified if the wound became worse. Further interview, on 04/22/11 at 11:10 AM, revealed if she had been notified of the worsening of the skin tear sooner, she would have taken action and consulted with the wound surgeon sooner and also referred the resident to Physical Therapy for a wound management program. The physician stated the green drainage may have indicated the presence of infection, but this could only be confirmed by a culture. An interview with the DON, on 04/22/11 at 3:20 PM, revealed nurses on the unit did weekly skin assessments and looked at the wounds depending on the treatment. She stated the nurses usually did not take off dressings because the Wound Nurse did wound treatments daily and the Wound Team did weekly rounds on Wednesday. She stated when a nurse observed a change in a wound, she expected the physician to be notified. An interview with the Administrator, on 04/22/11 at 2:15 PM, revealed the staff did not follow the facility's process related to monitoring the skin tear and notification of the physician in order to prevent the decline in the wound. 2. A record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Reviews of the annual Minimum Data Set (MDS), dated [DATE], and the quarterly MDS, dated [DATE], revealed the facility assessed the resident to be cognitively intact and required total assistance with bed mobility. A review of the comprehensive care plan for "At Risk for Impaired Skin Integrity," dated 12/10/10, revealed no information related to physician notification. A review of the "Skin Assessments", dated 03/01/11, 03/08/11, 03/15/11, 03/22/11, 03/29/11 04/05/11, 04/12/11, and 04/19/11, revealed no documentation related to the resident's second toe on the left foot or the bruising on the left outer ankle. An observation of a skin assessment, on 04/21/11 at 1:30 PM, revealed Resident #4 had a brown area on the second toe of the left foot. The area measured 0.5 centimeters (cm) in length x 0.3 cm width. The brown area was dry, with redness around the perimeter. The resident's outer left ankle had a "nickle-sized" bruise that appeared dark purple in color, with generalized bruising above the nickle-sized area, which was light purple in color. An interview with Licensed Practical Nurse (LPN) #6, on 04/21/11 at 1:30 PM, revealed she completed the resident's skin assessment on 04/19/11; however she did not notice the brown area on the second toe of the resident's left foot. She was unable to provide any information about the bruising on the resident's left ankle. She revealed the bruising should be documented with an investigation report completed. The area on the left second toe was not "open", and should be documented to monitor the area. Further interview with LPN #6, on 04/22/11 at 11:20 AM, revealed she did not document the skin assessment performed on 04/21/11 due to the fact she assessed the resident's skin on 04/19/11 and did not know she was supposed to document the 04/21/11 information. She revealed she informed Registered Nurse (RN) #1 about the area on the resident's left second toe and the bruising on the outer ankle. LPN #6 stated, "We do not call the physician unless we find something major. I did not notify the physician because the area was minor." She revealed the area on the resident's toe looked like there was a scab on it and the scab was ready to fall off. An interview with RN #1, on 04/22/11 at 11:40 AM, revealed she had not received any report of skin breakdown or bruising related to Resident #4. She revealed it would be the responsibility of the nurse taking care of the resident to document and notify the physician. An interview with the Director of Nursing (DON), on 04/22/11 at 2:40 PM, revealed the area on the resident's left second toe should be measured and documented as a "brown scabbed area that was unstageable." She revealed the bruising should be measured and documented on an investigation report to determine the cause of the bruise. The DON indicated she expected the nurse to notify the physician of both skin issues.

Based on observations, interviews, record reviews and review of facility policy and procedure, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practical physical, mental and psychological well-being, in accordance with the comprehensive assessment and plan of care for two residents (#2 & #4), in the selected sample of ten (10) residents. The facility failed to ensure staff assessed the progression of a skin tear, which occurred on 10/24/10, to an unstageable wound on 12/20/10. The skin tear was located on the posterior side of Resident #2's left lower leg and deteriorated to an unstageable wound by 12/20/10. On 12/20/10, the wound measured 12.7 cm x 2.0 cm and the depth of the wound was unable to be determined, due to the yellow slough. Additionally, Resident #4 had a brown area on the second toe of the left foot, which measured 0.5 centimeters (cm) x 0.3 cm, and a nickle-sized dark purple discoloration with surrounding light purple discoloration, which was not discovered until observation of a skin assessment on 04/21/11. The nurse had completed a skin assessment on 04/19/11. The findings include: A review of the facility's policy and procedure for "Pressure Ulcer Assessment, Prevention and Treatment," dated 10/10, revealed a weekly head to toe physical assessment of the resident's skin was to be completed by licensed personnel, with skin impairment referred to the Skin Team. A review of the facility's policy and procedure for "Skin Impairment," dated 02/01/11, revealed basic treatment for [REDACTED]. The policy did not address a defined time frame for notifying the physician about deterioration of the wound status or the need for an alternate treatment. 1. Resident #2's clinical record included Pressure Ulcers (coccyx, both hips, right upper back and left lower leg), [MEDICAL CONDITION], Cardiopulmonary Disease ([MEDICAL CONDITION]), Dementia and History of [MEDICAL CONDITION] (MRSA). The quarterly Minimum Data Set (MDS), dated [DATE], was reviewed and revealed the facility assessed the resident as being severely impaired related to cognition, incontinent of bowel and having an indwelling urinary catheter. The facility noted the resident was totally dependent for mobility and activities of daily living as well as being at risk to develop pressure ulcers. The comprehensive care plan, revised 02/21/11, for "Risk for Impaired Skin Integrity," was reviewed and revealed interventions related to the resident's "High Risk" to develop a pressure ulcer included to perform a head to toe skin assessment weekly, be alert to changes in skin condition daily, use a lift sheet for repositioning, manage friction and shear daily by using a lift sheet, floating heels, keeping the head of the bed elevated no more than 30 degrees, use mechanical lift and an alternating air mattress on the bed. The care plan did not address physician notification. A review of a physician's fax form, dated 10/24/10 at 12:00 PM, revealed notification of two minor skin tears, facility's current actions included: areas cleansed with normal saline, Vaseline Petroleum applied, covered with 2 x 2 gauze and wrapped with Kerlix. Change daily and as needed (prn). The fax was sent by Licensed Practical Nurse (LPN) #4. The physician's orders [REDACTED]. The "Long Term Care Wound Observation" documentation, dated 10/24/10 at 5:40 PM, was reviewed and revealed that Registered Nurse (RN) #5 noted a skin tear on the posterior left lower leg, with a small amount of serosanguinous drainage and redness in the center. However, no measurement was noted. Nurse's note, dated 10/24/10 at 7:13 PM, were reviewed and revealed LPN #4 had documented two skin tears on the resident's left lower leg were reported by a nurse aide during morning care. The note indicated that one, skin tear, was on the left posterior lower extremity and the other one was on the inner right side. The nurse noted the areas were cleansed with normal saline, Vaseline applied, covered with 2 x 2 gauze and wrapped with Kerlix. The nurse noted family was notified and a fax form was completed. A review of the Treatment Administration Record (TAR), dated October 2010, revealed daily treatment was provided from 10/24/10 through 10/31/10. Review revealed that on 10/28/10 at 11:45 AM, RN #2 documented an observation of the skin tear and noted blood-tinged drainage with a small amount of green drainage. However, there was no documented evidence the residents's physician was notified. Review revealed that on 11/04/10 at 2:23 PM, Licensed Practical Nurse (LPN) #6 documented an observation of the skin tear and noted blood-tinged drainage. However, there no documented evidence of physician notification. Review revealed that on 11/11/10 at 3:05 PM, LPN #6 documented an observation of the resident's skin tear and noted yellow/green drainage. However, there was no documented evidence the resident's physician was notified. On 11/15/10 at 10:30 AM, LPN #3 (Wound Nurse), documented the following regarding the skin tear: skin tear with minimal green drainage and the skin flap was missing. There was dark pink tissue in the center with pink surrounding edges. The treatment was changed to clean the wound with normal saline, apply Visco paste loosely, cover with Kerlix, secure with paper tape and change every five days and as needed (prn). A notification of the change in treatment was faxed to the attending physician on 11/15/10 by LPN #3. However, review of the TAR, dated November 2010, revealed there was no documented evidence of the change in treatment until 11/25/10. Documentation on the TAR revealed the treatment ordered for every five days and as needed (prn) was completed on 11/25/10 and 11/30/10. Additional review of the TAR, dated December 2010, revealed treatments were completed as ordered (every five days), on 12/05/10, 12/10/10, 12/15/10 and 12/20/10. Review of weekly skin assessments, dated 11/25/10 through 12/16/10, revealed there was no documented evidence related to the skin tear on the resident's posterior left lower leg. A nurse's notes, dated 12/20/10 at 3:24 PM, revealed LPN #3 (Wound Nurse), revealed that "upon dressing change to the left lower leg, the wound showed great decline, and was no longer a skin tear but an unstageable pressure ulcer." She described the tissue in the wound base as consisting of 100% yellow slough against a bony prominence. The nurse measured the wound as 12.7 cm x 2.0 cm and noted she was unable to determine the depth due to the yellow slough. On 12/20/10, no time indicated, an order from the attending physician revealed to consult with the Wound Care physician. The nurse revealed the physician (Wound Care Specialist) was notified for consultation. A review of the Wound Care physician's consultation, dated 12/21/10, described the wound on the posterior left calf as a long, irregular-shaped, deep stage III decubitus ulcer which measured 16 cm in length x 1 cm in width. The physician made a recommendation for a new treatment to be completed twice daily. He revealed due to the resident's advanced age, the likelihood that the [MEDICAL CONDITION] would heal was remote. An observation, 04/20/11 at 2:00 PM, revealed wound care was provided and wound measurements were completed by LPN #3, (Wound Nurse). She was accompanied by other members of the Wound Care Team which included the Director Of Nursing (DON), the Clinical Care Coordinator and the Registered Dietician. The wound on the back of the left lower leg measured 10.6 cm long x 0.5 cm wide, with a depth of 0.8 cm. LPN #3, (Wound Nurse) stated the wound started out as a skin tear and progressed to an unstageable wound. She was unable to give an explanation of how or why this occurred. An interview with LPN #3 (Wound Nurse), on 04/21/11 at 9:55 AM, revealed the wound initially presented as a skin tear and treatment was changed but to the skin tear was not healing. LPN #3 stated a new treatment was initiated on 11/15/10 and continued for awhile to see if it worked; however, the wound continued to worsen over time. She revealed she was off from work for two days in December 2010, and by the time she returned, the wound had changed drastically. The LPN stated she did the weekly wound assessments and the unit nurses conduct the weekly skin assessments. She sated if the nurses noticed any changes in wound status, they should notify the physician immediately for a treatment change or contact her if they needed to do so. Continued interview with LPN #3 at 6:30 PM, revealed if it was not documented, then there was no communication with the physician. She indicated when a wound was identified to contain blood-tinged or yellow/green drainage, the physician should be notified. She stated the physician should be notified whenever a wound changes for the worse and was not able to explain why the physician was not notified. An interview with LPN #4, on 04/21/11 at 4:00 PM, revealed she did weekly skin assessments and occasionally did wound care on weekends. She stated if she observed a change in a wound, she notified the Charge Nurse or the Wound Nurse. An interview with LPN #2, on 04/22/11 at 9:15 AM, revealed she did weekly skin assessments and wound care if the Wound Nurse was off. She stated she reviewed the previous weekly assessment in order to be familiar with any area noted. If she noted any changes, she would get another nurse to observe the area and document the change. If this occurred during the week (Monday through Friday), she notified the Wound Nurse. If occurred on the weekend, she notified the Charge Nurse, documented on the shift report and the treatment book. She stated she did not remove any dressings unless they were saturated. They were usually changed prn and she acknowledged that they were intact. An interview with LPN #1, on 04/22/11 at 10:30 AM, revealed she was trained during orientation to do skin assessments and assessed for anything out of the ordinary. If she noted anything, she went to the Wound Nurse. She used the treatment book to verify any new areas and for comparison of old areas and if she noted a significant change in a wound she notified the physician. LPN #1 indicated she changed an existing dressing if there was drainage noted, or it was due to be changed and the Wound Nurse was not there. During an interview with RN #2 (Charge Nurse), on 04/22/11 at 10:00 AM, revealed she conducted admission skin assessments and wound care occasionally. She stated she expected the nurses to notify her to collaborate on skin concerns and any nurse could contact a physician with concerns. She stated nurses conducting skin assessments should remove the dressings to assess wounds, and if the wound was declining, the physician should be notified. Interviews with Certified Nurse Aides (CNAs) #1, #2, #3, #4 and #5, on 04/22/11 at 9:30 AM, revealed they were trained to observe residents for any skin injury or unusual changes and to immediately report to the Unit Nurse or the Charge Nurse. However, they could provide no explanation related to the decline of the skin tear on Resident #2's lower left leg. During an interview with the DON, on 04/22/11 at 3:20 PM, she indicated nurses on the unit did weekly skin assessments and looked at the wounds depending on the treatment. She stated the nurses usually did not take off dressings because the Wound Nurse did wound treatments daily and the Wound Team did weekly rounds on Wednesdays, but if the nurses observed a change in a wound she expected the physician to be notified. During an interview with Resident #2's physician, on 04/21/11 at 2:00 PM, she indicated she usually consulted with a wound surgeon regarding wounds. She stated she was notified about the resident's skin tear on 10/24/10 and about a change in treatment on 11/15/10, but did not recall any other communication with staff, related to the skin tear, until contacted on 12/20/10. The physician indicated she ordered a referral for a consult with the wound surgeon related to the resident's wounds. She stated she expected to be notified if the wound became worse. Further interview, on 04/22/11 at 11:10 AM, revealed if she had been notified of the worsening of the skin tear sooner, she would have taken action and consulted with the wound surgeon sooner and also referred the resident to Physical Therapy for a wound management program. The physician stated the green drainage may have indicated the presence of infection, but this could only be confirmed by a culture. An interview with the Wound Care physician, on 04/22/11 at 11:45 AM, revealed the wound was related to pressure and he did not recognize the wound was related to a deteriorating skin tear. An interview with the Administrator, on 04/22/11 at 2:15 PM, revealed the staff did not follow the facility's process related to monitoring the skin tear and notification of the physician in order to prevent the decline in the wound. 2. Review of Resident #4's record revealed an admitted 02/02/09 with [DIAGNOSES REDACTED]. Reviews of the annual Minimum Data Set (MDS), dated [DATE], and the quarterly MDS, dated [DATE], revealed the facility assessed the resident to be cognitively intact and required total assistance with bed mobility. A review of the "Skin Assessments", dated 03/01/11, 03/08/11, 03/15/11, 03/22/11, 03/29/11 04/05/11, 04/12/11, and 04/19/11, revealed no documentation related to the Resident #4's second toe on the left foot or the bruising on the left outer ankle. During an observation of a skin assessment, on 04/21/11 at 1:30 PM, revealed Resident #4 had a brown area on the second toe of the left foot. The area measured 0.5 centimeters (cm) in length x 0.3 cm width. The brown area noted to have been dry, with redness around the perimeter. The resident's outer left ankle was noted to have a "nickle-sized" bruise which appeared dark purple in color, with generalized bruising above the nickle-sized area, which was noted to be light purple in color. During an interview with Licensed Practical Nurse (LPN) #6, on 04/21/11 at 1:30 PM, revealed she completed the resident's skin assessment on 04/19/11, and did not notice the brown area on the second toe of the left foot. LPN #6 was unaware of bruising on the resident's left ankle. She revealed the bruising should have been documented with an investigation report completed. The area on the left second toe was not "open", and should have been documented to monitor the area. Further interview with LPN #6, on 04/22/11 at 11:20 AM, revealed she did not document the skin assessment performed on 04/21/11, because she had assessed the resident's skin on 04/19/11. She indicated she informed Registered Nurse (RN) #1 about the resident's area on the left second toe and the bruising on the outer ankle. LPN #6 stated, "We do not call the physician unless we find something major. I did not fax the physician because the area was minor." She stated, "The area on the resident's toe looked like a scab, ready to fall off." During an interview with RN #1, on 04/22/11 at 11:40 AM, she stated she had not received any report of skin breakdown or bruising related to Resident #4. The RN indicated was the responsibility of the nurse taking care of the resident to document and notify the physician. Interviews with Certified Nurse Aides (CNAs) #2 and #3, on 04/21/11 at 4:55 PM, revealed all of the CNAs rotated areas and did not always work the same unit. Each of them stated they had not noticed any bruising on the resident's ankle or any areas on the resident's toes until it was pointed out by the surveyor. An interview with the Director of Nursing (DON), on 04/22/11 at 2:40 PM, revealed the area on the resident's left second toe should be measured and documented as a "brown scabbed area that was unstageable." She revealed the bruising should have been measured and documented on an investigation report to determine the cause of the bruise. She expected the nurse to notify the physician of both skin issues.