Every finding on record at River Valley Nursing Home

Based on observation, interview, and review of the facility's policies, the facility failed to follow infection prevention and control directives to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident sampled for utilizing a catheter bag, Resident (64), and for 2 of 3 residents sampled for using gait belts, R28 and R32.The findings include:Review of the facility's policy titled, Infection Prevention and Control Program, dated 07/07/2026, revealed all staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. Per the policy, direct care staff shall demonstrate competence in resident care procedures established by the facility.Review of the facility's policy titled, Catheter Care, dated 07/01/2026, revealed catheter drainage bags would be clipped to the wheelchair/bedframe when in use. Per the policy, if the catheter drainage bag fell (and became contaminated) due to resident movement or tampering, change the drainage bag per physician's orders.Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 2026, revealed, Multiple-resident use equipment shall be cleaned and disinfected after each use.Review of the facility's policy titled, Resident Rights, dated 03/05/2026, revealed the resident had a right to a safe, clean, comfortable and homelike environment. This right included, but was not limited, to receiving treatment and supports for safe daily living.1. a. Observation on 07/22/2026 at 8:56 AM revealed the Physical Therapy Assistant (PTA) removed the gait belt from a resident (R50) and placed it over the parallel bars in the therapy room. Further observation at 9:03 AM revealed the PTA removed that gait belt from the parallel bars and placed it on R28. The PTA then stood R28 up in front of the wheelchair and did arm exercises. During an interview with the PTA on 07/22/2026 at 10:14 AM, she stated she was supposed to clean the gait belt after she used the gait belt on R50 and before she put it on R28. She stated she had it in the back of her mind to clean it but did not. The PTA stated the cleaning wipes were under the sink in the therapy room. She stated the importance of cleaning the gait belt was to prevent the spread of infection. The PTA stated she had received training in infection control in 2026. She stated she was taught about cleaning equipment after use on a resident.b. Observation on 07/22/2026 at 9:16 AM revealed the Therapy Director (TD) removed a gait belt from the end of the parallel bars and placed it on R32. Further observation at 9:44 AM revealed the TD removed the gait belt from R32 and placed it on the end of the parallel bars without cleaning the belt. During an interview with the TD on 07/22/2026 at 10:21 AM, she stated she was supposed to clean the belt after she removed the belt from R32. The TD stated she was nervous and just forgot to clean the belt. She stated she had received training in infection control about cleaning shared equipment after resident use. During an interview with the Infection Preventionist on 07/23/2026 at 10:21 AM, she stated gait belts should be cleaned after resident use and before use on another resident. Review of R64's admission Record revealed the facility admitted the resident to the facility on [DATE]. The resident's admitting diagnoses included cerebral palsy, unspecified; major depressive disorder recurrent, moderate; and gastro-esophageal reflux without esophagitis.Review of R64's quarterly Minimum Data Set [MDS], dated 04/23/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of three out of 15. The score indicated R64 had severe cognitive impairment.Review of R64's Care Plan [CP], initiation date 07/17/2026 and target date 09/16/2026, revealed the resident was to be free from signs/symptoms of infection. The CP revealed R64 was receiving antibiotic therapy treatment for a urinary tract infection (UTI)/bacteremia (having bacteria in the bloodstream).Review of R64's Physician Orders, revealed an order, dated 07/15/2026 by the Medical Director, to change the indwelling urinary catheter as needed and change the catheter graduate every Friday. Further review revealed the order also listed contact precautions because of a blood infection with extended-spectrum beta-lactamase (ESBL, an enzyme found in certain bacteria that made an infection harder to treat) and enhanced barrier precautions (EBP) related to the indwelling urinary catheter. The order stated to please ensure the resident's wheelchair was cleaned every night shift.2. Observation on 07/22/2026 at 4:12 PM revealed R64 was sitting in a wheelchair at the front desk talking on the telephone. R64's legs were extended straight out from the wheelchair, and the dignity cover with a catheter drainage bag was in contact with the floor. During an interview on 07/23/2026 at 10:04 AM with State Registered Nurse Aide (SRNA) 1, she stated drainage bags for catheters were supposed to be attached under the wheelchair of the resident. She also stated catheter drainage bags or tubing touching the floor could be a source of infection for the resident.During an interview on 07/23/2026 at 10:09 AM with SRNA2, she stated catheter bags were supposed to be hooked under the wheelchair. She stated she had not taken care of a resident with a wheelchair and with a catheter drainage bag. She also stated if she cared for a resident in a wheelchair with a catheter drainage bag, she would hook the catheter under the wheelchair, making sure the bag did not touch the ground. She stated the bag could pick up germs from the floor if the bag touched the floor.During an interview on 07/23/2026 at 11:00 AM with the Infection Preventionist (IP), she stated indwelling catheter bags should not come in contact with the floor because it created a potential source of infection for the resident. She stated her expectation for staff would be to ensure the catheter bag attached to the wheelchair did not come in contact with the ground. She stated if a drainage bag touched the floor, the bag was to be replaced immediately. She stated staff received yearly education on infection control.During an interview on 07/23/2026 at 12:53 PM with the Director of Nursing (DON), she stated she talked with the nurse this morning, and the nurse felt a catheter drainage bag had touched the floor. The DON stated she had the nurse change the drainage bag. The DON stated she questioned staff probably 30 minutes ago and asked the staff members where they put catheter bags when the residents were in wheelchairs. She stated all of the staff members answered appropriately. She stated the facility had a few residents with indwelling catheters. She stated she walked through the building looking for potential breaks in infection control because the catheter bag on the floor was an infection control issue. She stated she asked all staff members, and she did not have to educate anybody. She stated they all knew where the drainage bags were supposed to be attached. The DON stated it was her expectation for catheter drainage bags not to touch the floor when residents were in their wheelchairs.During an interview on 07/23/2026 at 2:31 PM with the Administrator, she stated she was upset about hearing a resident's catheter bag was on the floor. She stated every morning staff reviewed infection control issues, and the facility only had three residents with catheters. She stated catheter bags resting on the ground would pose an issue for infection control. She stated it was her expectation staff would be aware of that and would ensure it did not happen.During an additional interview on 07/22/2026 at 2:42 PM with the Administrator, she stated all staff should follow the facility's infection control policies.

Based on observation, interview, and review of the facility's policy, the facility failed to label medications (eye drops) in accordance with currently accepted professional principles, including the expiration date, for 1 of 4 medication carts, Medication Cart B1.The findings include:Review of the facility's policy titled, Medication Storage, dated [DATE], revealed there were no instructions on dating medication with an opened date once used initially.Observation on [DATE] at 9:11 AM of Medication Cart B1 in the medication room of the B Unit revealed five boxes of eye drops were opened and not dated. They included iVizia (preservative free artificial tears), brimonidine (used to lower eye pressure), ketotifen (used to treat eye allergies), latanoprost (used to lower eye pressure), and Refresh artificial tears.During an interview on [DATE] at 9:13 AM with Licensed Practical Nurse (LPN) 3 in the B Unit medication storage room, she stated all medications opened in the medication cart should be dated after opening. She stated dates were put on the medication to know how long the medication could be used before it was expired. She stated night shift nurses were expected to audit the medication carts to find undated and opened medications.During an interview on [DATE] at 9:50 AM with Kentucky Medication Aide (KMA) 1 in the hallway of the A Unit, she stated the residents' eye drop medications were supposed to be dated once opened. She stated it was required because certain medications had a short expiration date once they were opened.During an interview on [DATE] at 12:53 PM with the Director of Nursing (DON), she stated LPN3 had informed her about the eye drops in the B1 Medication Cart that were not dated after being opened. The DON stated eye drops were supposed to be dated after opening to ensure they did not expire and then were used. During an interview on [DATE] at 2:31 PM with the Administrator in her office, she stated the DON audited the carts weekly for undated and expired medication. She stated the pharmacy did monthly medication cart audits. She stated it was her expectation for medications to be dated when opened to ensure the medication was not expired when given.

Based on interview, record review, and review of the facility's policies, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and and psychosocial needs for 1 of 17 sampled residents, Resident (R) 34. R34 was identified as exhibiting exit-seeking behaviors on 05/25/2025, and a Wander Guard device was placed on 05/26/2025. However, R34 was not care planned for wandering. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, 2025, revealed the facility would develop and implement comprehensive person-centered care plans for each resident to meet the resident's medical, nursing, and mental and psychosocial needs, and all services would meet professional standards of quality. Review of the facility's policy titled, Elopement and Wandering Residents, 2024, revealed residents identified with wandering behaviors or risk for elopement would receive adequate supervision in accordance with their person-centered plan of care. Review of R34's admission Record revealed the facility admitted the resident on 09/09/2024 with diagnoses to include schizophrenia unspecified; unspecified psychosis not due to a substance or known physiological condition; and insomnia, unspecified. Review of R34's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/19/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of five of 15, indicating severe cognitive impairment. No behaviors were noted on the MDS at that time. Review of R34's Nurse Progress Note, dated 05/25/2025 at 11:18 AM, revealed R34 attempted to exit a door by the nurses' station, and she indicated, when approached by staff, she wanted to go outside. Review of R34's Elopement Evaluation, dated 05/25/2025 at 11:20 AM, revealed the resident wanders aimlessly or non-goal-directed. Review of R34's Physician's Orders, dated 05/26/2025, revealed an order for the placement of a Wander Guard (a wireless system that protected memory care residents from elopement with bracelets and door controllers). Review of R34's Nurse Progress Note, dated 05/26/2025 at 11:31 AM, revealed a Wander Guard was applied to R34's left ankle. Review of R34's Nurse Progress Note, dated 05/30/2025 at 12:57 PM, revealed R34 ambulated in the hallway by herself and sat in the lobby at times. Per the note, R34 continued to wander at times, and a code alert (Wander Guard) was in place. Review of R34's Comprehensive Care Plan, last revised 06/24/2025, revealed no care plan for wandering behaviors or indicating placement of a Wander Guard. In an interview on 06/26/2025 at 9:22 AM with the Minimum Data Set (MDS) Coordinator and Director of Nursing (DON), the DON stated before she became DON, she was the MDS Coordinator. She stated when the replacement MDS Coordinator left in late 2023, she worked in that position in addition to being DON. She stated the facility was actively looking for a new MDS Coordinator. The DON stated whoever entered the order for the Wander Guard, was supposed to do an elopement assessment and develop the care plan around those issues. She stated she was not sure how R34's care plan was missed, describing it as an oversight that had since been corrected once brought to her attention. She stated not just one person, but several people reviewed the care planning process, but R34's just got overlooked somehow. The DON also stated it was important for resident information to be on the care plan so every staff member knew what they were supposed to do, a guide to follow in providing care. In an interview on 06/26/2025 at 9:48 AM with the Administrator, she stated she did not have involvement in the care planning process. She stated her expectation was for care plans to be comprehensive and resident centered. She stated accurate care plans were important so staff knew how to provide appropriate care for each resident.

Based on observation, interview, record review, review of the manufacturer's medication prescribing information, and review of the facility's policy, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 sampled residents, Resident (R) 17. The findings include: Review of the facility's policy titled, Medication Administration, undated, revealed medications were administered by licensed nurses or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Further review revealed medications should be administered as ordered in accordance with manufacturer's specifications. Review of R17's admission Record revealed the facility admitted the resident on 09/11/2024 with diagnoses including chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD), and type 2 diabetes. Review of R17's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact. Review of R17's Physician's Orders revealed an active order, dated 06/11/2025, for Trelegy Ellipta inhaler one puff once daily for COPD. Further review revealed instructions for mouth to be rinsed after use to avoid oral thrush. Review of R17's electronic medication administration record (eMAR) revealed documented daily administration of Trelegy Ellipta inhaler that began on 06/11/2025 per physician order. Review of the manufacturer's prescribing information for Trelegy Ellipta, revised 12/2022, revealed instructions located under warnings/precautions that stated mouth should be rinsed with water without swallowing after inhalation, so the risk of oral thrush was reduced. Further review revealed Trelegy Ellipta contained the active ingredient, fluticasone furoate (corticosteroid). Observation on 06/25/2025 at 9:34 AM revealed R17 was administered Trelegy Ellipta inhaler; however, staff did not ensure the resident rinsed her mouth after administration per the manufacturer's specifications. In an interview with Kentucky Medication Aide (KMA) 1 on 06/25/2025 at 3:21 PM, she stated prior to administration of inhalers, she performed hand hygiene and donned clean gloves. KMA1 stated following administration of an inhaler, the resident rinsed with water if indicated so oral infections such as thrush were prevented. KMA1 stated she failed to ensure R17 rinsed her mouth after her inhaler was used this morning. In an interview with KMA2 on 06/26/2025 at 9:17 AM, she stated R17 received a daily inhaler, Trelegy Ellipta, and the resident administered it herself. KMA2 stated inhalers often led to thrush, and it was important R17 rinsed with water after use so oral infections were prevented. In an interview with the contracted Pharmacist on 06/26/2025 at 10:18 AM, he stated rinsing the mouth with water after use was generally recommended for inhalers that contained steroids. He further stated if a resident failed to rinse after use, left over residue from the inhaler potentially led to thrush or other oral infections. In an interview on 06/26/2025 at 10:52 AM with Licensed Practical Nurse (LPN) 4, she stated when residents received inhalers, it was important staff ensured they rinsed with water after use because inhalers left a powder residue that could cause oral infections. In an interview with the Director of Nursing (DON) on 06/26/2025 at 12:25 PM, she stated she expected staff practiced what they had learned when they administered medications and that included staff stayed at the bedside, knew why medication was given, ensured resident swallowed medication, and medication was given at the right time. She further stated the facility's policy for medication administration was used as a guideline for administering medications. The DON stated it was her expectation staff educated residents regarding proper use of inhalers, so they knew to rinse their mouth with water after use. The DON stated it was important residents rinsed after an inhaler was used so oral infections such as thrush were prevented. In an interview with the Administrator on 06/26/2025 at 12:31 PM, she stated she expected medications prescribed to residents were administered as ordered and directed. She further stated if staff had questions, they referenced the medication administration policy or called the physician for clarification. The Administrator stated the facility's policy related to medication administration stated manufacturer's specifications were followed. She further stated she knew it was important staff ensured residents rinsed their mouth following inhaler use but was unsure why it should be done.

Based on interview, record review, and review of the facility's policy, the facility failed to provide eight consecutive hours of Registered Nurse (RN) coverage for 12 out of 92 days from 03/01/2024 through 05/31/2024 and 27 out of 92 days from 06/01/2024 through 08/31/2024. The findings include: Review of the facility's policy titled, Nursing Services and Sufficient Staff, dated February 2023, revealed except when waived, the facility must use the services of an RN for at least eight consecutive hours a day, seven days a week. Further review revealed the Director of Nursing (DON) could serve as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. Review of the facility's daily schedules of the 92 day period from 03/01/2024 through 05/31/2024 revealed a lack of evidence of an RN on duty for 12 dates. These dates were 03/09/2024, 03/10/2024, 03/23/2024, 03/24/2024, 03/30/2024, 04/07/2024, 04/21/2024, 05/04/2024, 05/18/2024, 05/19/2024, 05/25/2024, and 05/26/2024. Further review of the facility's daily schedules of the 92 day period from 06/01/2024 through 08/31/2024 revealed the facility did not have an (RN) scheduled to work on 27 dates. These dates were 06/01/2024, 06/02/2024, 06/08/2024, 06/09/2024, 06/15/2024, 06/16/2024, 06/22/2024, 06/23/2024, 06/29/2024, 06/30/2024, 07/06/2024, 07/07/2024, 07/13/2024, 07/14/2024, 07/20/2024, 07/21/2024, 07/27/2024, 07/28/2024, 08/03/2024, 08/04/2024, 08/10/2024, 08/11/2024, 08/17/2024, 08/18/2024, 08/24/2024, 08/25/2024, and 08/31/2024. Review of the Payroll Based Journal (PBJ) Staffing Data Report, run on 08/30/2024, triggered no RN hours for four or more days within the second quarter (April through June 2024). During an interview with Certified Nursing Aide (CNA) 6 on 09/05/2024 at 12:10 PM, she stated she did not usually complete her assignments. She stated staff had a lot of bed baths and must cut corners to make sure everyone was clean and dry. She stated she felt staff must skip over nail care and shaves because staff did not have time to do them. She stated staff tried to pass things on to the next shift. During an interview with CNA5 on 09/05/2024 at 7:05 PM, she stated the facility had been very short staffed. She stated the facility used agency nurses but sometimes staffing was still short. She further stated she had worked several shifts with only one other nurse caring for the entire building. During an interview with the Director of Nursing (DON) on 09/05/2024 at 3:55 PM, she stated most of the staff call-ins for being absent happened on the weekends. She stated, at that time, the facility utilized agency staff or asked facility staff already on duty to stay over to help. She stated management staff would come in if needed. She further stated she talked to staff about their workloads and areas they needed help from other shifts. She stated staff discussed staffing and retention weekly and then again monthly in Quality Assurance and Performance Improvement (QAPI) meetings. She stated the facility had plenty of staff now but could use an RN on night shift. During an interview with the Administrator on 09/05/2024 at 4:10 PM, she stated the facility did not have an RN staffing waiver. She stated she had accommodated staffing by asking facility staff to come in, using agency staffing, or the DON to cover as needed. She further stated they had utilized the DON to fulfill the RN requirements Monday-Friday when the patient census was below 60. She further stated the facility had recently lost an RN staff member and was in the process of hiring another RN now.

Based on observation, interview, record review, review of the manufacturer's instructions for use, and review of the facility's policies, the facility failed to maintain infection control precautions for the following: 1) enhanced barrier precautions (EBP) for 1 out of 14 sampled residents on EBPs, Resident (R) 6; 2) cleaning the mechanical lift after use for 1 of 1 observation of mechanical lift use, R37; and 3) cleaning glucometers (device used to measure blood glucose levels) for 2 of 2 observations of glucometer use, R17 and R151. The findings include: 1. Review of the facility's policy titled, Clinical Standard & Guideline Enhanced Barrier Precautions, last revised 12/19/2023, revealed it was the policy to ensure that additional and appropriate Personal Protective Equipment (PPE) was utilized, when indicated, to prevent the spread of multidrug-resistant organisms also known as MDROs. EBPs were defined as the use of PPE, gowns and gloves, during high-contact resident care activities that generated opportunities for transfer of MDROs in the form of blood or body fluids, onto the hands and/or clothing of the rendering caregiver. Per the policy, EBP was to be used when Contact Precautions did not otherwise apply and where there was a diagnosis of a MDRO or a colonized MDRO. Observation on 09/05/2024 at 10:59 AM revealed an EBP sign on R6's door directing staff to wear gloves and gown when providing high contact resident care, such as bathing/showers. Further observation revealed Certified Nursing Aide (CNA) 3 gave a bed bath to R6 without wearing a gown. During interview with CNA3 on 09/05/2024 at 11:22 AM, she stated she thought the other resident in the room was on EBP which was why she did not wear a gown. However, review of R6's annual Minimum Data Set assessment, with an assessment reference date (ARD) of 04/18/2024, revealed R6 was diagnosed as having an MDRO infection. During interview with the Infection Preventionist on 09/06/2024 at 1:29 PM, she stated she did not do any specific audits on the rooms where residents were on EBP. She stated she expected staff to follow what was posted on the EBP sign. 2. Review of the facility's policy titled, Safe Resident Handling/Transfers, not dated, revealed all residents required safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assisted them. Per the policy, while manual lifting techniques might be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts were a safer alternative and should be used. Per the policy, the lift would be cleaned and disinfected after each resident use. Review of the facility's Inservice on Hand Hygiene & PPE, Bloodborne Pathogens, Cleaning Glucometer, Dressing Changes, Isolation Precautions, COVID Policy/Vaccination, Cleaning Multiple Use Items, dated 01/18/2024, stated, Cleaning of multi-resident use equipment, examples of multi-resident use equipment: scales and Hoyer [mechanical] lift handles. Clean multi-resident use equipment between each resident use with a bleach-based wipe, bleach solution of 1:10 dilution or other product designated that meets regulation. Observation on 09/06/2024 at 10:22 AM revealed CNA11 and CNA12 put R37 back to bed using a mechanical lift, and then they changed R37's brief. CNA11 left the room with the lift, went down the hall, put the lift in the shower room, and shut the door without cleaning/disinfecting the lift. During interview with CNA11 on 09/06/2024 at 10:35 AM, she stated she should have cleaned the lift after she used the lift. 3. Review of the manufacturer's instructions for use of the Assure Prism glucometers, revised 04/2021, revealed the manufacturer had validated Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, CaviWipes1, and PDI Super Sani-Cloth Germicidal Disposable Wipe for disinfecting the glucometer. Observation on 09/06/2024 at 11:28 AM revealed Licensed Practical Nurse (LPN) 4 removed the glucometer from the compartment with R151's name (each resident had their own glucometer). She performed a blood glucose check on R151. After the check, she put the glucometer back in the drawer without cleaning the glucometer. She then went to R17's room, removed the glucometer from the compartment with R17's name, and performed a glucose check on R17. After the check, she used an alcohol pad to clean the glucometer. She cleaned the glucometer from 11:32:10 to 11:32:20 with the alcohol wipe and then put the glucometer back in the drawer. During interview with LPN4 at 11:36 AM, she stated she should clean the glucometer for a few seconds with an alcohol wipe. She did not state she was taught to clean the glucometer, and her name was not listed on the infection control education dated 01/18/2024. During interview with LPN2 on 09/03/2024 at 2:14 PM, she stated the cleaning process for glucometers was to use bleach wipes and allow to air dry for three minutes. She stated this was done after every use. During interview with the Director of Nursing on 09/06/2024 at 1:38 PM, she stated she expected the staff to clean the glucometers according to the manufacturer's directions. She stated she had not been auditing the glucometer checks.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 19 sampled residents, Resident (R) 14. R14 was ordered to have a fentanyl patch (synthetic opioid pain reliever delivered transdermally) placed every 72 hours. On [DATE] a new fentanyl patch was placed on R14. On [DATE] it was due to be changed, the prescription had expired, and the medication was not available. R14 did not have a new fentanyl patch placed until [DATE], 48 hours past due. The findings include: Review of the facility's policy titled, Medication Orders: Controlled Substance Prescriptions, dated ,d+[DATE], revealed before a controlled drug could be dispensed, the pharmacy must be in receipt of a prescription. The policy revealed partial fill requests for controlled level II drugs should be made allowing for appropriate time for the pharmacy to obtain the prescription and to assure an adequate supply was on hand. The policy stated the pharmacy contacted the prescriber for direction when delivery of a medication would be delayed or was not or would not be available. Review of the facility's policy titled, Preparation and General Guidelines: Controlled Substances, dated ,d+[DATE], revealed all controlled medications were reordered when a minimum of a five-day supply remained to allow time for acquisition and transmittal of the required original written prescription to the provider pharmacy, if necessary. Review R14's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses of Alzheimer's disease, osteoarthritis with pathological fracture, and vertebral disc degeneration with collapsed vertebra. Review of R14's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated severe cognitive impairment. The MDS also assessed the R12 to have a high-risk drug class use, which included opioids. Review of R14's Orders revealed a fentanyl transdermal patch 75 micrograms per hour (mcg/hr) to be applied to the skin every 72 hours with a start date of [DATE] and an end date of [DATE]. Further review revealed a new order for the same medication and instructions was placed on [DATE] with an end date of [DATE]. Review of R14's Medication Administration Record (MAR) identified a fentanyl patch was applied on [DATE], with the next patch applied on [DATE] at 12:00 PM by Licensed Practical Nurse (LPN) 2. Further review revealed Norco 7XXX,d+[DATE] milligram (mg) tablet (opioid pain reliever used to treat moderate to severe pain) was given as scheduled twice a day every day on all days in ,d+[DATE]. Additional review revealed Tylenol Extra Strength 500 mg (a non-narcotic pain reliever), two tablets were given three times a day as scheduled on [DATE], [DATE], and [DATE]. Review of R14's Nursing Progress Note, dated [DATE], revealed a fentanyl patch was replaced as ordered. Review of R14's Nursing Progress Note, dated [DATE] at 1:52 PM, revealed LPN6 notified the Nurse Practitioner (NP) of the need for a new prescription for fentanyl and noted the NP had sent the prescription to the pharmacy. Review of R14's Nursing Progress Note, dated [DATE], revealed at 10:00 AM Registered Nurse (RN) 1 called the pharmacy to confirm the order for fentanyl was received. Per the note, the pharmacy informed RN1 the medication would be sent that day. Review of R14's Nursing Progress Note, dated [DATE] revealed at 4:10 PM RN1 called the pharmacy to get the estimated time of arrival of the fentanyl patch and was informed it would leave the pharmacy by 6:00 PM. Review of R14's Nursing Progress Note, dated [DATE] revealed at 6:00 PM RN1 documented R14 did not complain of pain and did not exhibit any signs or symptoms of withdrawal. Review of R14's Nursing Progress Note, dated [DATE] revealed LPN 2 observed the fentanyl patch that was applied last date was loose, it was removed, and a new fentanyl patch was placed and covered with Tegaderm (a transparent medical dressing). Review of a pharmacy document labeled Prescription History, dated [DATE] for R14 identified prescription 21270848 was entered on [DATE] at 1:34 PM, reviewed at 4:11 PM, label printed at 7:39 PM, and was placed in tote for delivery to the facility on [DATE] at 11:25 PM. Further review of the document identified the delivery information for who was assigned the delivery, who received the delivery, but the delivery date had no information documented. Review of the pharmacy Packing Slip, dated [DATE] for prescription 21270848 identified one fentanyl patch was delivered to the facility and signed as being accepted by LPN7. Further review of the document revealed the section titled refused control was blank, and LPN7 signed her name and dated it [DATE]. Review of a pharmacy document labeled Prescription History, dated [DATE] for R14 identified prescription 21271802 was entered on [DATE] at 1:32 PM, reviewed at 1:47 PM, label printed at 2:13 PM, and placed in tote for delivery to facility on [DATE] at 5:17 PM. Further review of the document identified the delivery information for who was assigned the delivery, who received the delivery, but the delivery date had no information documented. Review of the pharmacy Packing Slip, dated [DATE] for prescription 21271802 identified five fentanyl patches were delivered to the facility and signed as being accepted by LPN7. Further review of the document revealed the section titled refused control was blank, and LPN7 signed her name and dated it [DATE]. Observation on [DATE] at 9:04 AM of the fentanyl patch placed on R14's right shoulder revealed the patch was dated [DATE] and was initialed by the nurse that placed it, which corresponded to documentation on R14's MAR. In an interview with family member (F) 1 of R14 on [DATE] at 1:39 PM, she stated R14 had been using fentanyl patches for chronic back pain for at least [AGE] years. F1 stated she kept track of when the patch was due to be changed and visited several times a week, always checking the patch. F1 stated she checked the patch on R14 and noted it was due to be changed the same day and mentioned to the nurse on duty, name she did not recall, and was told she would take care of it. F1 stated she returned the following day for a visit, and when she checked, the same patch was still in place, and it was now 24 hours past when it was due to be changed. F1 stated she did not recall when it was finally replaced, but she was told by facility staff that it was delayed because of delivery from the pharmacy. She stated she was told, when it finally arrived, it had the wrong label on it and could not be administered. She stated, to the best of her memory, it was five days between when the last patch was placed and R14 had a new one placed. F1 stated she believed R14 was having withdrawal symptoms as evidenced by her observation of R14's sweating and lack of appetite. She stated R14 was having pain but could not verbalize distinct symptoms other than those previously mentioned. In an interview with LPN7 on [DATE] at 1:47 PM, she stated she recalled R14's family member was upset that R14's fentanyl patch had not been changed when it was due. She stated she recalled calling a provider to request a new prescription, and she asked for the administration due dates to be changed due to the fentanyl patch being off-schedule because of late administration. She stated she believed the future doses should be rescheduled from the point the new patches were delivered. LPN7 stated a fentanyl patch was delivered on her shift by the pharmacy, she checked the label and reported that the name was for a different resident. So, she stated she completed the pharmacy return information at the bottom of the delivery form and signed for the patch to be returned. LPN7 stated the following night shift the pharmacy made another delivery of the fentanyl patches, the label was correct, she signed for acceptance of the patches, and placed a new fentanyl patch on R14 that night. LPN7 stated she could not recall if she placed the patch on [DATE] or [DATE] due to confusion sometimes with night shift starting on one date and ending on another date. She also stated she could not remember what she documented or where she documented it. In an interview with LPN2 on [DATE] at 6:49 PM, she stated she was not working when the situation occurred but did receive in report that R14's fentanyl patch was on order and waiting to be delivered. She stated there was a lapse in replacing it. LPN 2 stated the process for reordering a narcotic medication was to first determine if the resident had refills remaining or if a new prescription was required. LPN2 stated if a resident was out of refills a new prescription was needed. She stated, in that case, the nurse contacted the NP, and the NP placed an order in the electronic chart. However, she stated a second, different NP who handled controlled medication prescriptions was contacted to send the prescription to the pharmacy. LPN2 stated she did not recall there being any other incidents of R14 not receiving her fentanyl patches as ordered since that occurrence, and she did not recall R14 having any signs or symptoms of withdrawal while caring for her. In an interview with LPN6 on [DATE] at 8:00 PM, she stated she had worked previously as a Unit Manager at the facility and, in that role, would do audits of the medication carts and would call pharmacy when a refill of a medication was needed, would verify orders of medications, and checked on delivery estimated arrivals. LPN6 stated the facility's policy at that time was that all controlled substances required a new prescription every time the last one ran out, and they could only write for a small number of refills. LPN6 stated she recalled R14 but did not recall the incident involving the fentanyl patch not being placed when due or any issue with labeling or delivery. In an interview with RN1 on [DATE] at 11:47 AM, she stated she was told in report from the night shift nurse that R14's fentanyl patch was late because pharmacy had delivered it, but something was wrong with the label, it had to be returned, and staff was waiting for re-delivery. RN1 stated a family member came to the desk irate after finding out a new patch had not been placed, and she personally called the pharmacy several times regarding the prescription and delivery of the fentanyl patch. RN1 stated the family member informed the pharmacy the medication was time sensitive. RN1 stated during that time she monitored R14 very closely, obtained frequent vital signs, and assessed for any signs or symptoms of withdrawal. She stated she kept the family informed every time she placed a call to the pharmacy. RN1 stated R14 never exhibited any signs or symptoms of withdrawal, complained of pain, or exhibited any non-verbal signs of pain. She stated she administered other narcotic pain medication that was scheduled along with scheduled Tylenol. RN1 stated the fentanyl patch was never delivered on her shift, but when she returned for her next shift R14 had received a new fentanyl patch. In an interview with the Consultant Pharmacist on [DATE] at 4:06 PM, he stated he was not actively involved in the process of filling medications or receiving refill orders, but the process for filling narcotic prescriptions at the facility was the provider entered the order into the electronic medication system, and typically the nurse caring for the resident was the one who notified pharmacy of a request for refill. The Consultant Pharmacist stated the pharmacy did two deliveries daily through the week and on weekends did a nighttime delivery only. The Consultant Pharmacist stated that in situations where a medication was needed more urgently the nurse could call the pharmacy, speak with a pharmacist, would be given an access code, and could pull the medication from the Pyxis system, if the medication was stocked. He stated if the medication was not stocked, the facility must wait for delivery and contact the prescribing provider to get any further direction. The Consultant Pharmacist stated he did not have computer access at the current time and was unable to look at the record for R14 to give specific details. However, he stated in a typical situation, a fentanyl patch could have continued to have residual delivery of the medication if left on past 72 hours, but he was unable to quantify due to unknown variances. In an interview with the Clinical Director of Pharmacy Services on [DATE] at 9:48 AM, she stated at the request of the State Survey Agency (SSA) Surveyor she pulled the requested pharmacy documents. She stated her review revealed a delivery of one fentanyl patch was sent out on [DATE] on the late night run and was delivered to the facility sometime after midnight. She stated this delivery was signed and accepted. Then, she stated an additional five fentanyl patches, which made the order complete, was sent out for delivery on [DATE], and was received and accepted by the facility. The Clinical Director of Pharmacy Services stated the pharmacy had no records with documentation that a fentanyl patch was returned due to a label error. She stated, if that had occurred, it would have been discussed and investigated through the pharmacy's quality assurance program and would have been discussed with the facility's administration and the prescribing provider. She stated fentanyl patch withdrawal would typically start within two to three days of not receiving a new patch. She stated the withdrawal usually presented with anxiety as a first symptom, and it would be difficult to determine the amount of fentanyl that would continue to be excreted by a patch if left on past the ordered 72 hours. In an interview with the Director of Nursing (DON) on [DATE] at 10:33 AM, she stated she was not aware of any incident concerning R14 until the SSA Surveyor requested pharmacy documents. The DON stated she reviewed the records and could not provide any answers regarding the incident, but the expectation was for all medication administration to occur on time, when they were due, and they should be charted appropriately on the MAR. The DON stated refills and prescriptions should be initiated when the nurse administered the last dose of a medication to prevent a resident from running completely out and not receiving the next scheduled dose. The DON stated the pharmacy delivered medications twice a day through the week and once on a night run on the weekends. She stated the facility had never had any issues with obtaining medications when needed. She stated the facility would add the incident to the Quality Assurance Performance Improvement (QAPI) meeting for discussion and investigation to prevent further occurrences. In an interview with the Administrator on [DATE] at 10:46 AM, she stated she was not aware of the reported incident until today when informed by the SSA Surveyor. The Administrator stated that now the incident had been discovered, there would be discussion of it in QAPI, with the Medical Director, and she would be meeting with the DON to determine if more audits of MAR's and charts needed to occur. The Administrator stated the situation would be investigated and would determine what education should be provided to nursing staff and direct education to the LPN involved.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were not discharged from the facility unless the resident's needs could not be met in the facility, for one (1) of eight (8) sampled residents (Resident #1). The facility transferred Resident #1 to a hospital for emergency services, in November 2020. Resident #1 was admitted to the hospital and the facility did not allow the resident to return to the facility, in February 2021, despite the resident's condition having improved to the point that his/her needs could be met in the facility. The findings include: Review of the facility's policy titled, Transfer or Discharge Policy Statement, not dated, revealed a resident would not be transferred or discharged from the facility unless the transfer was necessary for the resident's welfare, and the resident's needs could not be met in the facility. Record review revealed the facility admitted Resident #1, on 08/19/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was admitted as a full code (would receive all resuscitative interventions). Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 08/25/2020, revealed the facility assessed the resident as severely cognitively impaired. The facility also assessed the resident to have an indwelling catheter and a feeding tube, requiring extensive physical assistance of staff for most activities of daily living. Review of Resident #1's Progress Note, dated 11/14/2020 at 11:38 AM, revealed the resident was unresponsive to verbal and tactile stimuli. Continued review revealed staff contacted the resident's Power-of-Attorney (POA) and offered comfort measures for the resident; however, the POA opted for Resident #1 to be hospitalized . Review of Resident #1's Progress Note, dated 02/08/2021, revealed the Care Coordinator from the hospital where Resident #1 was a patient, informed the Director of Nursing (DON) that Resident #1 was no longer requiring [CONDITION(S)] services, and the resident's POA would like for him/her to return to the facility. Per the note, the DON responded, in addition to having no beds available at that time, that the facility would not accept Resident #1 back due to high risk for re-hospitalization , and the facility would be unable to meet Resident #1's healthcare needs. Review of Resident #1's Progress Note, dated 02/16/2021, revealed the regional Ombudsman spoke with the Administrator and the DON regarding the potential for Resident #1 to return to the facility. Continued review revealed Resident #1 had the right to return, as no discharge had been issued, and he/she was no longer on [CONDITION(S)]. In addition, per the note, the resident's condition and needs, as well as regional limitations (transportation providers in the area were unable to transport residents on stretchers for non-emergent appointments) were discussed. Review of Resident #1's Notice of Transfer or Discharge, dated 02/16/2021, revealed the discharge was necessary for the resident's welfare, and the resident's needs could not be met in the facility, with 03/17/2021 as the date of discharge. The discharge notice did not specify what the needs were that could not be met by the facility. Interview with the Care Coordinator of the hospital where Resident #1 was a patient, on 03/11/2021 at 10:35 AM, revealed Resident #1 came to the hospital on 12/31/2020. She stated she sent the facility a referral on 01/06/2021. Further interview revealed she spoke with the DON who said Resident #1 could not return to the facility as he/she was on [CONDITION(S)] on 01/12/2021. The Care Coordinator stated Resident #1 had recovered and no longer required [CONDITION(S)] the week after 02/04/2021, at which point she resent a referral to the facility for Resident #1. Per interview, she stated she spoke with the DON, on 02/11/2021, at which time there were no available beds. In addition, the Care Coordinator stated the DON told her the facility would not take Resident #1 back due to concerns for re-hospitalization . The Care Coordinator stated she got the Ombudsman and others involved at that time. Interview with the DON, on 03/10/2021 at 2:03 PM, revealed, given the severity of Resident #1's condition, his/her return to the facility was not anticipated. She stated the facility could not take Resident #1 back on [CONDITION(S)], as he/she required stretcher services during transportation, and all non-emergent resources in the area could not transport residents by stretcher. In addition, she stated if Resident #1 had any appointments or acute care needs, the facility could not meet them, as Resident #1 required stretcher services for transportation. Per interview, she stated she was uncertain when Resident #1's last [CONDITION(S)] treatment was, as she was still waiting on records from the hospital. The DON stated there was nothing in Resident #1's medical record regarding the facility being unable to meet Resident #1's needs, and she expected, for any future discharges, there would be thorough documentation to support the discharge. Interview with the Administrator, on 03/10/2021 at 9:49 AM, and again, on 03/11/2021 at 11:50 AM, revealed Resident #1 was admitted to the facility, on 08/19/2020, and transferred out to the hospital, on 10/12/2020 for [CONDITION(S)]. Then, she stated Resident #1 returned to the facility, on 11/06/2020, and was hospitalized again, on 11/15/2020, for [CONDITION(S)]. The Administrator stated due to the extensive medical needs of Resident #1, coupled with transport time to the hospital and the inability of the facility to arrange non-emergent transport for residents requiring stretcher services, she felt Resident #1's needs could be better met at a facility closer to the services Resident #1 might require. In addition, the Administrator stated this information was not in Resident #1's medical record, as she was previously unaware the medical record would need to support that the facility could not meet a resident's needs prior to indicating that as a reason for discharge. The Administrator stated she expected, going forward, staff to meet with residents or responsible parties and have documentation in the medical record whenever there were concerns the facility was not able to meet a resident's needs.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the resident's representatives, in writing, and in a language and manner they could understand for one (1) of eight (8) sampled residents (Resident #1), of the discharge and the reasons for the move. The facility transferred Resident #1 to a hospital, on 11/14/2020; however, the facility did not provide a notice of discharge until 02/16/2021, more than thirty (30) days after he/she was out of the facility. The findings include: Review of the facility's policy titled, Transfer or Discharge Policy Statement, not dated, revealed the resident's representative would be given a thirty (30) day advance notice of an impending discharge, a copy of the notice would be sent to the Office of the Long-Term Care Ombudsman, and reasons for the notice would be documented in the resident's medical record. Further review of the policy revealed the resident's representative would be notified in writing of the reason for the discharge; the location to which the resident was being discharged ; the name, address, email, and telephone number of the agency responsible for protection and advocacy of residents with a mental disorder or related disabilities; and a statement of the resident's rights to appeal the discharge. Per policy, the appeal request information would include the name, address, email and telephone number of the entity that received such requests; information on how to obtain, complete, and submit an appeal form; and how to get assistance with the appeal process. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility, on 08/19/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no documentation in the record of the reasons for Resident #1's discharge. Review of Resident #1's Progress Note, dated 11/14/2020 at 11:38 AM, revealed the resident was unresponsive to verbal and tactile stimuli. Continued review revealed staff contacted the resident's POA (Power of Attorney), and staff offered comfort care measures for the resident. However, the POA decided to have Resident #1 sent to the hospital. Review of Resident #1's Progress Note, dated 02/08/2021, revealed the Care Coordinator, from the hospital where Resident #1 was a patient, informed the Director of Nursing (DON) that Resident #1's POA would like the resident to return to the facility. Per the note, the DON told the Care Coordinator in addition to having no beds available at that time, the facility would not accept Resident #1 back due to his/her high risk for re-hospitalization , and the facility would be unable to meet Resident #1's healthcare needs. Review of Resident #1's Notice of Transfer or Discharge form, signed on 02/16/2021 by the Administrator, revealed Resident #1 would be discharged from the facility, on 03/17/2021, twenty-nine (29, not thirty (30) as required) days later, to the home of Resident #1's Power-of-Attorney (POA), who was unable to meet Resident #1's care needs. Continued review revealed the State Long-Term Care appeal agency was listed incorrectly as the Office of Inspector General, instead of the Secretary of the Cabinet for Health and Family Services. Further, the form listed the agency responsible for protection and advocacy for the mentally ill, but their mailing address, email address, and telephone information were incorrect. Per review, a copy of the notice was not sent to the Office of the State Long-Term Care Ombudsman. In addition, the notice did not include a statement of the resident's appeal rights to include name, address, telephone number of the entity which received such requests, how to obtain an appeal form, assistance in completing the form, and submitting the appeal hearing request. Interview with the DON, on 03/10/2021 at 9:49 AM and again at 2:03 PM, revealed she initially did not know a discharge notice needed to be issued to Resident #1 because he/she had been out of the facility for more than thirty (30) days. She stated she understood the discharge notice provided to the POA of Resident #1 did not have the required information. She stated it was not the intention to transfer Resident #1 to the POA's address, but the Administrator completed the form, and had not completed one previously, and made the error. The DON stated the form was not sent to the Ombudsman because the facility was waiting to get a signed form back from the POA, prior to sending it to the Ombudsman. Per interview, the DON stated she expected discharge documentation to be completed timely and correctly. Interview with the Administrator, on 03/10/2021 at 9:49 AM, and again, on 03/11/2021 at 11:50 AM, revealed she had not previously completed a notice of discharge, and the facility did not routinely issue notices of discharge. She stated the form, Notice of Transfer or Discharge, the facility was using was outdated and did not include all the required information. She also stated she had put in some incorrect information. Continued interview revealed she had miscalculated, when documenting 03/17/2021 as the discharge date , and realized it should have been 03/18/2021, which would have been thirty (30) days. Per interview, she stated the plan was never to discharge Resident #1 to the home of the POA, but she filled out the form incorrectly, putting the address where she sent the form. She further revealed she did not realize that the information that was needed included documenting the specific needs, from the resident's medical records, that could not be met at the facility. In addition, she stated she did not know which state agency was responsible for appeals regarding discharges or which agency was responsible for the protection and advocacy of individuals with a mental disorder or related disabilities.

Based on interview, record review, and review of the facility's Admission Notebook, it was determined the facility failed to ensure, when a resident transferred to a hospital, the resident's representative received proper notice of the bed hold for two (2) of eight sampled residents (Residents #1 and #4). The facility transferred Resident #1 to a hospital, on 11/14/2020; and, no Bed Hold Approval Letter was issued to the resident's responsible party. The facility transferred Resident #4 to a hospital, on 02/05/2021; and, no Bed Hold Approval Letter was issued to the resident or to the resident's responsible party. The findings include: Review of the facility's Admissions Notebook, not dated, revealed a blank Bed Hold Approval Letter indicating Medicaid would pay for fourteen (14) days per calendar year for a bed hold while a resident was hospitalized . Further review revealed there was a blank space for the facility's rate for a bed hold following fourteen (14) days, and a place for notification and a signature whether or not the resident or responsible party agreed to a bed hold. 1. Review of Resident #1's medical record revealed the facility admitted Resident #1, on 08/19/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #1 was admitted as a full code. Record review revealed the facility assessed Resident #1, on an Admission Minimum Data Set (MDS), dated [DATE], as severely cognitively impaired. Continued review revealed the facility assessed the resident to have an indwelling catheter, a feeding tube and requiring extensive physical assistance of staff for most activities of daily living. Review of Resident #1's Progress Note, dated 11/14/2020 at 11:38 AM, revealed the resident was unresponsive to verbal and tactile stimuli. Per the note, staff contacted the POA and offered comfort care measures for the resident; however, the POA chose to have Resident #1 sent to the hospital. Review of Resident #1's electronic medical record (EMR) revealed documentation that Resident #1's Power-of-Attorney (POA) was contacted regarding the facility's bed hold procedure, on 11/16/2020. However, there was no documentation regarding whether or not the POA opted for a bed hold, nor was there a place for a signature. Further review revealed a note indicating the POA did not understand why he would have to pay for a bed hold as Resident #1 had Medicaid. 2. Review of Resident #4's medical record revealed the facility admitted the resident on 01/26/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's EMR revealed bed hold documentation, dated 02/05/2021, in which Resident #4's POA was contacted and agreed to a bed hold, following the resident's hospitalization due to an in-facility fall, with displaced fractures noted on x-ray. Interview with the Director of Nursing (DON), on 03/10/2021 at 2:03 PM, revealed she was unaware a written notice of a bed hold needed to be printed or signed but stated she would expect this to be done in the future. Interview with the Administrator, on 03/10/2021 at 9:49 AM, and again, on 03/11/2021 at 11:50 AM, revealed she spoke with Resident #1's POA regarding a bed hold, but Resident #1's POA did not want to discuss a bed hold. She stated she routinely spoke with responsible parties, when a resident was transferred to a hospital, regarding the bed hold. However, she stated the documentation was in the resident's EMR, with nothing printed out, signed, or provided to the resident or his/her responsible party. Per interview, she stated she was not aware she needed to have Resident #1's POA sign anything but had since become aware of the need to have a printed and signed bed hold agreement, whenever a resident was transferred to a hospital. The Administrator stated, in the future, she would ensure bed hold agreements were printed and signed, and residents or responsible parties would be provided a copy of the documentation.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were allowed to return to the facility after hospitalization , either to their own rooms or to the first available room for one (1) of eight (8) sampled residents (Resident #1). The facility transferred Resident #1 to the hospital on 11/14/2020. The hospital planned to discharge the resident back to the facility, in February 2021. However, the facility refused to readmit Resident #1 to the facility at that time. The findings include: Review of the facility's policy titled, Readmission to the Facility Policy Statement, not dated, revealed residents who had been discharged to the hospital would be given priority in readmission to the facility. The policy stated residents whose bed hold period exceeded the period allowed by the state would be readmitted to the facility upon the first availability of a bed in a semi-private room, if the resident required and was eligible for nursing facility services, met the facility admission criteria, and was not discharged for any reason outlined in the Transfer or Discharge Notice Policy. Review of Resident #1's discharge documentation revealed no documented evidence that Resident #1 met the criteria for discharge from the facility. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility, on 08/19/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Progress Note, dated 11/14/2020 at 11:38 AM, revealed the resident was unresponsive to verbal and tactile stimuli. Per the note, staff contacted Resident #1's Power-of-Attorney (POA), and staff offered comfort care measures for the resident. However, Resident #1's POA decided to have him/her hospitalized . Review of Resident #1's Progress Note, dated 02/08/2021, revealed the Care Coordinator, from Resident #1's hospital, told the Director of Nursing (DON), Resident #1's POA wished for Resident #1 to return to the facility, and Resident #1 would be eligible to do so the following week. Per the note, the DON responded to the Care Coordinator that in addition to having no beds available at that time, the facility would not accept Resident #1 back due to his/her high risk for re-hospitalization , and the facility would be unable to meet Resident #1's healthcare needs. Interview with the DON, on 03/10/2021 at 9:49 AM, and again at 2:03 PM, revealed she was not aware the facility was required to issue a discharge notice, as Resident #1 had been out of the facility for more than thirty (30) days. She stated there were concerns regarding the facility's ability to meet the resident's needs, in terms of response and transportation time to the nearest hospital because of Resident #1's multiple comorbidities. She also expressed concerns as to the lack of resources for transporting Resident #1 to any required non-emergent appointments because transportation providers in the area were unable to transport residents in stretchers. Continued interview with the DON revealed there were no beds available in mid-February, and Resident #2 (spouse of Resident #1) did not want to isolate, which would be required, if on readmission, he/she shared a room with Resident #1. However, the DON stated the facility had decided Resident #1 could return to the facility, and a bed would be available for him/her to return, during the week of 03/15/2021. Interview with the Administrator, on 03/10/2021 at 9:49 AM, and again, on 03/11/2021 at 11:50 AM, revealed she was not knowledgeable about the discharge process, and she had not realized the refusal to readmit Resident #1 neither had the supporting documentation nor the requirements for discharge. The Administrator stated the plan was to not readmit Resident #1 because she believed Resident #1's needs could be better met elsewhere. Continued interview with the Administrator revealed the facility did not have any open beds, with any empty beds currently having bed holds, from 02/21/2021 through 03/11/2021. The Administrator stated she expected, if there was no valid discharge in place, the resident would be allowed to return to the facility to the first available bed. The policy stated residents whose bed hold period exceeded the period allowed by the state would be readmitted to the facility upon the first availability of a bed in a semi-private room, if the resident required and was eligible for nursing facility services, met the facility admission criteria, and was not discharged for any reason outlined in the Transfer or Discharge Notice Policy.

Based on interview, and review of the facility's Policy, it was determined the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State in which [MEDICATION NAME]; and was eligible for certification as a therapeutic recreation specialist or as an activity professional by a recognized accrediting body; or had two (2) years of experience in a social or recreational program within the last five (5) years, one of which was full-time in a therapeutic activities program; or was a qualified occupational therapist or occupational therapy assistant; or had completed a training course approved by the State. Interview with the Activity Director, and the Administrator in Training (AIT), revealed the Activity Director did not yet have the qualifications to work as an Activity Director in a Long-Term Care Facility. The findings include: Review of the Activity Program Staffing Policy, undated, revealed the Activity Director shall at least complete or delegate the completion of the activities component of the comprehensive assessment; contribute or ensure the contribution of activity goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident; monitor and evaluate the resident's responses to activities and revise the approaches as appropriate; and develop, implement, supervise and evaluate the activity programs. Interview on 06/16/2020 at 2:20 PM, with the Activity Director, revealed she had been employed at the facility five (5) years, and had worked in the role of Activity Director for one (1) year and nine (9) months. Per interview, before assuming the role of the Activity Director, she worked as a Certified Nursing Assistant/Certified Medical Assistant (CNA/CMA). The Activity Director stated she was currently in an on-line two (2) year program to certify as an Activity Director, and had completed one (1) year of the two (2) year program; however, she could not recall the name of the program. In addition, she stated she thought the requirement for the role was to certify within one (1) year of taking the position, and she had not met that requirement. Continued interview with the Activity Director, revealed her duties included planning and implementing the facility's monthly activities calendar. She stated, since the COVID 19 pandemic, it had been challenging to practice social distancing while coordinating activities for all residents; however, activities such as bingo, crafts, puzzles, church, etc. occurred one (1) person to a table six (6) feet apart. Per interview, on Mondays, she helped coordinate face time, video conferencing, and window visits between residents and their families. She stated all staff is required to wear mask interacting with residents. Interview on 6/16/2020 at 2:40 PM, with the Administrator in Training (AIT), revealed the Activity Director had been in that position since October of 2018. She stated she was aware the Activity Director did not have the licensure or certification required in order to be in the role of Activity Director. Per interview, it was her expectation the Activity Director would meet the educational requirements within the next three (3) months.

Based on interview, and review of Long Term Care (LTC) licensure regulations, it was determined the facility failed to ensure the Governing Body hired an Administrator who is licensed by the state where licensing is required. The findings include: Review of KY statute 216A.030, Effective [DATE], Supervision and license requirement for Long Term Care Facilities, revealed no licensed long-term Care facility shall operate except under the supervision of a long-term care Administrator unless approved by the board through administrative regulation, and no person shall be a long-term care Administrator unless he or she is the holder of a long-term care administrator's license. Review of the Job Description for the Administrator in Training, undated, revealed this position is a program that provides a career track to become a Licensed Administrator. He/she reports to the Administrator and the Governing Body. Review of the Kentucky Board of Licensure for Long-Term Care Administrators, as of [DATE], revealed the facility's Administrator in Training (AIT) held a Temporary Long-Term Care Administrator license from [DATE] until it expired on [DATE]. Interview with the Administrator in Training (AIT), on [DATE] at 2:40 PM, revealed she has been in her position since 2018. She stated she finished her Administrator in Training (AIT) in [DATE], under the guidance of the previous Administrator. Per interview, since 2018, she had functioned under the guidance of a contracted licensed Long-Term Care Administrator. She further stated she tested for the Long Term Care Administrator's license in 2018, but did not pass the exam. Per interview, she planned to take the test in 2019; however, she was unable to do so due to personal reasons. She further stated the test was offered two (2) to three (3) times a year, but she had not re-applied to take the test. Continued interview with the Administrator in Training, revealed she had frequent communication with the contracted Administrator, sometimes once or twice a week, but the contracted Administrator had not been on site this year. A follow-up interview with the Administration in Training (AIT) via email on [DATE] at 11:54 AM, revealed she planned to take the test for the Long Term Care Administrator's license once the COVID restrictions were lifted. Telephonic interview with the contracted Administrator, on [DATE] at 2:38 PM, revealed River Valley Nursing Home employed her as a contracted Administrator to provide assistance and consultation to the Administrator in Training (AIT) in the Spring of 2018, until the AIT successfully passed her long-term care certification. She stated the Administrator in Training (AIT) completed the required six (6) months of training under the prior Administrator, but failed her certification exam several times. She further stated perhaps the COVID pandemic disrupted the AIT's retesting plan. Additional interview with the contracted Administrator, revealed she provided phone and video conferencing communication to the Administrator in Training (AIT) frequently, but admitted it had not been as frequent lately due to COVID. Per interview, she had not been at the facility this year. She stated the AIT performed the job well independently. Telephonic interview again, on [DATE] at 1:16 PM, with the contracted Administrator, revealed before the COVID outbreak, she was on-site as needed and attended the quarterly QA meetings. Additionally, she verbalized this set up was not a concern during the last annual survey. Post exit telephonic interview, with the Corporate Owner of the facility, on [DATE] at 2:38 PM, revealed it was his expectation that the Administrator in Training (AIT) would take the licensure test the next time it was offered and pass the test in order to become licensed. He stated it was also his expectation that there was weekly communication between the AIT and the contracted Administrator as indicated. When questioned how he ensured the meetings between the contracted Administrator and the AIT were occurring, he stated the AIT reported to him each time she had meetings with the contracted Administrator. Additional interview with the Corporate Owner, revealed the facility had glowing reports with each survey. Likewise, he stated he lived in the community and had contact and relationships with the residents' families via Facebook, phone calls, etc. and there had been no recent issues or concerns. The Corporate Owner verified he was not licensed as a LTC Administrator.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure residents were free from abuse for two (2) of three (3) sampled residents (Resident #1 and Resident #2). On 11/19/19, staff witnessed Resident #1 and Resident #2 in a physical altercation. Staff interviews revealed Resident #2 was deliberately hitting Resident #1, causing Resident #1 to sustain a skin tear. The findings include: Review of the facility's River Valley Nursing Home Policy Procedure, Policy, revised 11/2016, revealed the residents of River Valley Nursing Home have the right to be free from physical and mental abuse. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Review of the facility's Investigation, dated 11/19/19, signed by the Social Service Director, revealed Resident #2 hit Resident #1 on the arm and both residents were offered a room change. Both residents stated they were not afraid of each other and had just been getting on each others nerves lately. Local law enforcement was contacted and the Power of Attorney (POA) for both residents was contacted. Review of the Long Term Care -Self Reported Form Five (5) Day Follow Up/Report, dated 11/24/29, revealed Resident #1 and Resident #2 had a physical altercation. Further review revealed Resident #1 allegedly grabbed Resident #2's face. Resident #2 responded by hitting Resident #1 on the arm. Continued review revealed the residents were immediately separated, placed on thirty (30) minute checks, and offered a room change. However, both residents refused a room change. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 04/25/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/16/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15) indicating moderate cognitive impairment. Review of Resident #1's Progress Note, dated 11/19/19 at 5:39 PM, written by the Director of Nursing (DON), revealed she was called to Resident #1's room by Certified Nurse Aide (CNA) #1, who stated Resident #1 and Resident #2 had been in a physical altercation. Resident #1 and Resident #2 were immediately separated and Resident #1 received a treatment for [REDACTED]. Per the Note, the DON offered Resident #1 a room change, as Resident #1 and Resident #2 shared a room. Resident #1 refused a room change. Further review of the Note, revealed notifications were made to Resident #1's Power of Attorney (POA) and the Primary Care Provider. Resident #1's care plan was updated to reflect the altercation and every thirty (30) minute checks were initiated and continued for seventy two (72) hours. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 04/25/19 with [DIAGNOSES REDACTED]. Review of Resident #2' Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of eleven (11) out of fifteen (15) indicating moderate cognitive impairment. Review of Resident #2's Progress Note, dated 11/19/19 at 5:39 PM, written by the DON, revealed she was called to Resident #2's room by CNA #1 who stated Resident #1 and Resident #2 had been in a physical altercation. Resident #1 and Resident #2 were immediately separated, and she offered Resident #2 a room change, as Resident #1 and Resident #2 shared a room. However, Resident #2 refused a room change. Notifications were made to Resident #2's POA and the Primary Care Provider. Resident #2's care plan was updated to reflect the altercation and every thirty (30) minute checks were initiated and continued for seventy two (72) hours. Interview on 12/11/19 at 1:40 PM, with Resident #1 and Resident #2, revealed they recalled having a disagreement on 11/19/19. During the interview, they both stated they did not remember the cause of the disagreement, but did remember the disagreement becoming physical. Resident #1 stated, That sometimes happens when you've been married a long time. Further interview revealed they were both offered a room change after the disagreement and both residents refused a room change. Resident #1 and Resident #2 stated there had been no further disagreements. Interview on 12/11/19 at 2:55 PM with CNA #1, revealed she had been employed at the facility for approximately three (3) months. She stated if a resident struck another resident, it would be considered physical abuse if it was willful. Per interview, on 11/19/19, she heard Resident #1 and Resident #2 bickering throughout the day. She stated because of this she performed more frequent checks on the residents to ensure safety. Further interview revealed while she was passing dinner trays at approximately 5:15 PM on 11/19/19, she heard Resident #1 yelling at Resident #2, and heard smacking noises coming from their room. Per interview, upon entering the room shared by Resident #1 and Resident #2, who were married, she witnessed Resident #2 deliberately striking Resident #1 in the arm and shoulder area. CNA #1 stated she removed Resident #1 from the room and transported him/her to the nurse's station as he/she had a skin tear to his/her left forearm from the altercation. Per interview, once Resident #1 returned to the room with Resident #2, thirty (30) minute checks were initiated for both residents. CNA #1 stated there had been no further altercations between Resident #1 and Resident #2. Interview on 12/11/19 at 3:12 PM, with Registered Nurse (RN) #1, revealed she had been employed at the facility for approximately three (3) months. She stated she was aware Resident #1 and Resident #2 had been having small disagreements throughout the day on 11/19/19. She further stated because of this, she directed CNA #1 to perform more frequent checks on the residents. Continued interview revealed sometime after 5:00 PM, CNA #1 brought Resident #1 to the nurse's station to have his/her arm assessed due to a skin tear. Per interview, she was told by CNA #1 the skin tear occurred as a result of a physical altercation between Resident #1 and Resident #2. Additional interview with RN #1, revealed she assessed the Resident #1, and notified the Primary Care Physician of the altercation between the residents and of Resident #1's injury. RN #1 stated she also notified the DON and the POA for both residents. Per interview, she offered both residents a room change and both parties refused. Further interview revealed thirty (30) minute checks were initiated when Resident #1 returned to the room with Resident #2. Per interview, there had been no further incidents between the residents. RN #1 stated if a resident deliberately struck another resident it would be considered abuse, and the altercation between Resident #1 and Resident #2 would be considered physical abuse. Interview on 12/11/19 at 4:37 PM, with the DON, revealed RN #1 informed her of the physical altercation between Resident #1 and Resident #2 on 11/19/19. The DON stated staff immediately separated the residents, ensured the safety of the residents involved and other residents, and notified Resident #1 and Resident #2's POA, as well as the Medical Provider. She further stated thirty (30) minute checks were initiated after the altercation. The DON stated it was her expectation residents were free from abuse. Further interview revealed the physical altercation between Resident #1 and Resident #2 was considered abuse as it was willful and deliberate. Interview on 12/11/19 at 4:45 PM with the Administrator revealed it was her expectation residents were free from abuse as per policy. However, further interview revealed physical abuse did occur during the altercation between Resident #1 and Resident #2.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure background checks were completed for one (1) of six (6) sampled employees, Employee #4. The findings include: Review of the facility's policy titled, River Valley Nursing Home Policy and Procedure with revision date 11/2016, revealed all potential employees will undergo background studies. On 12/04/18 at 8:40 AM, review of six (6) sampled Human Resource files for documentation of background studies revealed one (1) of six (6) employee files with no documentation of an abuse background check, Employee #4. Brief interview with the Administrator, on 12/04/18 at 8:40 AM, revealed she could not locate any documentation for an abuse background check for Employee #4, hired on 11/30/17. The background checks were an integral part of abuse prevention for the facility and were required for all staff. Follow up interview with the Administrator on 12/04/18 at 11:56 AM, revealed documentation of a background check for Employee #4 could not be located. Employee #4 was hired on 11/30/17. She stated she was unsure how the background check was missed at the time of hire; however, a Kentucky Care Giver Background check for Employee #4 was completed on 12/04/18 (date of the survey) and no findings were noted.

Based on interview, record review, and review of facility policy, it was determined the facility failed to implement the facility's policy related to abuse. The facility failed to ensure employees underwent background studies at the time of employment as required by policy, failed to immediately report potential abuse allegations to appropriate state agencies as required by policy, failed to suspend staff alleged to have committed resident abuse during an investigation as required by policy, failed to interview all staff involved in the allegation as required by facility policy, failed to document in the Medical Record the physical examinations of residents examined after receipt of the abuse allegation, and failed to interview the resident's representative and the resident's physician about the abuse allegation according to facility policy. The findings include: Review of the facility's policy titled, River Valley Nursing Home Policy and Procedure with revision date 11/2016, revealed the facility was required to perform background studies on all potential staff, provide abuse education at hire and annually, and to report all allegations or suspicions of abuse immediately to the Nursing Supervisor and Administrator. Review of facility policy titled, River Valley Nursing Home, Subject: Vulnerable Adult Reporting and Investigation Procedure with revision date 11/2016, revealed staff must immediately report any suspicion of abuse to the nurse or immediate supervisor. The appropriate state agency was to be notified immediately with a follow up five (5) day investigative report. Staff were to receive Vulnerable Adult education upon hire and annually thereafter. Employees potentially or suspected to be involved in resident abuse were to be suspended during investigation of an allegation. Staff were to be appointed to complete an investigation. The family, roommate, and physician were to be interviewed per facility policy. The policy further required any unexplained injuries including bruises to be recorded in the Medical Record. Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score was ninety nine (99) on the Minimum Data Set (MDS) based on the BIMS score report provided by the facility at the time of the abbreviated survey. Resident #2 frequently exhibited resistance to care and required staff interventions to accomplish activities of daily living. Interview with the Administrator on 12/04/18 at 9:51 AM, revealed she became aware of the abuse allegation for Resident #2 on 11/05/18, when State Registered Nursing Assistant (SRNA) #5 left a note for her detailing an abuse concern. The Administrator stated either she or the DON were responsible for investigation of abuse allegations. The Administrator further stated she took the lead on abuse investigations. Upon continued interview the Administrator stated she was responsible for external reporting as required by facility policy titled, River Valley Nursing Home, Subject: Vulnerable Adult Reporting and Investigation Procedure. She stated she did not report the allegation nor did she file a final investigative report as required by facility policy and Centers for Medicare and Medicaid Services (CMS) regulations because she could not substantiate the allegation. The policy stated the appropriate state agency would be notified immediately for any potential abuse or neglect that may have occurred. The policy further required a final investigative report to be submitted within five (5) working days. Interview with SRNA #5 on 12/04/18 at 10:26 AM, revealed she notified the Administrator of the abuse allegation sometime in early November. Although she could not recall the date, she stated the alleged event occurred the end of October, (YEAR). SRNA #5 was interviewed by telephone by the Administrator and the Director of Nursing (DON) after the note was received. She stated she shared the name of the perpetrator (SRNA #2) during the interview based on what she was told at the time she was made aware of the allegation. SRNA #5 received no follow up from the Administrator relative to resolution of the allegation and was unaware of any suspensions related to the alleged event. Interview with SRNA #2, the alleged perpetrator, on 12/03/18 at 12:56 PM, revealed she was questioned about the abuse allegation with Resident #2 by the Administrator at an unknown time in November. Although SRNA #2 denied the allegation, she state she was not suspended during the investigation. Interview with the Director of Nursing (DON) on 12/04/18 at 9:24 AM, revealed the Administrator served as the investigator for this abuse allegation. The DON stated she assisted in some of the staff interviews. She further stated the alleged perpetrator should have been taken off the work schedule until the Administrator figure(d) out what was going on. Upon continued interview the DON stated no staff were suspended, even though required by facility policy, because she was unsure of the alleged perpetrator's identity. Although she interviewed SRNA #2 she stated she was not aware she was the alleged perpetrator nor was she aware of anyone else being the alleged perpetrator. The DON stated she checked ten (10) residents for injury after the abuse allegation; however, she only kept a list of the names of the residents examined. No Progress Notes in the Medical Record were made available for review. Although facility policy required suspension of alleged perpetrators during the investigation, the Administrator, upon continued interview, stated she never suspended any staff because she could not substantiate the allegation. She stated she was aware the allegation was against SRNA #2 from her interviews with SRNAs #5 and #6. This was not consistent with the facility policy requiring suspension of alleged perpetrators during the investigation to ensure the safety and well-being of the alleged victim. Continued interview with the Administrator on 12/04/18 at 8:40 AM, revealed she also could not locate any documentation for an abuse background check for Employee #4, hired on 11/30/17. The background checks were an integral part of abuse prevention for the facility and were required for all staff by facility policy titled River Valley Nursing Home Policy and Procedure with revision date 11/2016. Upon follow up interview with the Administrator on 12/04/18 at 11:56 PM, documentation of a background check for Employee #4 could not be located. Employee #4 was hired on 11/30/17. She stated she was unsure how the background check was missed at the time of hire; however, a Kentucky Care Giver Background check for Employee #4 was completed on 12/04/18 (date of the survey) and no findings were noted. This was an important part of abuse prevention for the facility. On 12/04/18 at 8:40 AM, review of six (6) sampled Human Resource files for documentation of background studies revealed one (1) of six (6) employee files with no documentation of an abuse background check, Employee #4. Review of the facility Monthly Grievance Log for (MONTH) and (MONTH) (YEAR), revealed no care or abuse concerns were received. Review of facility report titled, River Valley - SNF, Incidents by Incident Type dated 10/01/18 through 11/30/18, revealed no incident report for the abuse allegation was completed. Review of the Administrator's Investigative Notes revealed a three (3)page document. Page One (1) was a copy of the handwritten note written by SRNA #5, Page Two (2) was four sentences written by the Administrator, and Page Three (3) included the names of twelve (12) residents interviewed and the three (3) questions the residents were asked. The Investigative Notes from the Administrator revealed the handwritten note from SRNA #5. The note stated Resident #2 was found by an unnamed nursing assistant with her hands tied together with the resident's apron (kept in her top dresser drawer). The note further detailed the event as happening on 10/27/18 or 10/28/18 on day shift. The note revealed upon entering the resident's room, SRNA #6 found Resident #2 with his/her hands tied. SRNA #5 stated in the note she was made aware of the allegation by SRNA #6. Continued review of the investigative file revealed four (4) SRNAs were interviewed on 11/05/18. Continued review revealed there was no documentation the individual conversations were in the investigative notes, rather a summary sentence stated there were no witnesses or knowledge of the allegation by the four (4) SRNAs. Twelve (12) residents were asked if they felt safe, had needs met timely, and were treated with dignity and respect. Again, only a summary sentence was included stating none of the residents had concerns. Although the last three (3) abuse investigative files for the facility were requested upon entry to the facility on [DATE], only one file from (MONTH) (YEAR) was provided. The investigative file for this event was not provided until additional requests were made on 12/04/18 at 9:51 AM. The Investigative Notes contained no documentation of reports to external agencies as required by facility policy. The file also lacked documentation of interviews with staff on all shifts who had contact during the period of the alleged incident required by the facility policy. The resident was alleged to have bruises on his/her wrists; however, no documentation of a physical examination of the resident following the abuse allegation was produced. Facility policy required examination of residents with unexplained injuries including bruises. Results of the physical examination were to be recorded in the resident's electronic medical record per facility policy. Review of the Medical Record for Resident #2 revealed the resident last received an evaluation from a mental health provider on 04/30/18. Resident #2 was stable at baseline with a recommendation to continue the current regimen. No further psychological evaluations were in the Medical Record. The facility could not provide any Progress Notes related to the allegation of abuse, examination for injury, and/or notifications of the physician, resident representative, or external agencies. Review of the Care Plan with admission date of [DATE] revealed a focus area for resistance to care and a goal for Resident #2 to cooperate with care through the next review date of 09/25/18. Interventions included education of family, resident, and caregivers of possible outcomes of non-compliance, encouragement of resident participation in care, and consistency of care, timing of Activities of Daily Living (ADLs), caregivers, and routine as much as possible. In addition, the resident was to be offered choices during care provision. The revision date was 09/25/18. There were no Care Plan interventions found related to the abuse allegation. Review of the Medication Administration Record [REDACTED]. The order start date was 05/18/18. On 12/04/18 at 8:40 AM, review of six (6) sampled Human Resource files for documentation of background studies revealed one (1) of six (6) employee files with no documentation of an abuse background check, Employee #4. The Kentucky Care Giver Background check for Employee #4, hired on 11/30/17, was not conducted until 12/04/18, the date of the survey.

Based on interview, record review and review of the facility's investigation, it was determined the facility was aware of an abuse allegation on 11/05/18 when a State Registered Nursing Assistant (SRNA) left a note for the Administrator with an abuse allegation involving Resident #2. The facility failed to report the allegation to the State Survey Agency within two (2) hours after knowledge of the allegation. The State Survey Agency was never notified of the allegation until an anonymous complaint was received on 11/29/18. The findings include: Review of facility policy titled, River Valley Nursing Home Policy and Procedure with revision date 11/2016, revealed the River Valley Nursing Home reporting procedure for abuse should be followed. Further review of facility policy titled, River Valley Nursing Home, Subject: Vulnerable Adult Reporting and Investigation Procedure with revision date 11/2016, revealed all allegations of abuse incidents were to be immediately reported to the state agency. In addition, a final investigative report to the appropriate state agency was required within five (5) working days. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score was ninety nine (99) on the Minimum Data Set (MDS) based on the BIMS score report provided by the facility. Resident #2 frequently exhibited resistance to care and required staff interventions to accomplish activities of daily living. The resident received medication each morning to facilitate the provision of daily morning care for the resident. Review of the facility's abuse investigative file for Resident #2 revealed no documentation of any required external reporting. Review of the Electronic Medical Record for Resident #2 did not reveal any external reporting of the abuse allegation. Review of the investigative notes produced by the Administrator revealed four (4) staff members were interviewed about the event on 11/05/18. No interview notes were produced only a handwritten summary statement stating SRNAs #2, #3, #6, and #7 had no knowledge of the allegation and there were no witness(es) to the event. Although SRNA #5, who left the note stated she was interviewed, there was no documentation to support that interview. SRNA #7 stated she was never interviewed however, she was included in the summary statement noted above. On 11/05/18 at 9:00 AM the Administrator stated the DON assessed Resident #2; however, no Medical Record documentation was available to support the assessment. Three (3) other staff first names are listed as having no knowledge of the event with no details of the interviews. On 11/06/18 at 3:00 PM, a handwritten note by the Administrator stated staff education was provided by the Administrator about the abuse policy, when to report abuse, and to report it to. The third page of the investigative notes contains twelve (12) names of residents who were asked if they felt safe, had needs met in a timely matter, and felt care was delivered with respect and dignity. No interview notes were produced. A summary sentence stated there were no concerns regarding care and all feel safe working at the facility. There was no documented evidence in the notes to indicate the facility report the allegation of abuse to the State Agency. Interview with SRNA #5 on 12/04/18 at 10:26 AM, revealed she came in early, on an unknown date, to cover an absence on Hall A where Resident #2 resided. She stated she was providing personal care to Resident #2 when another SRNA (SRNA #7) told her other nursing assistants were tying up Resident #2's hands when performing personal care. She stated although she did not know specifically who SRNA #7 was talking about she left a note for the Administrator before she left that shift because she knew it needed to be reported immediately. SRNA #5 stated the Administrator and the Director of Nursing interviewed her by telephone on an unknown date after her note was received. Interview with the Director of Nursing (DON) on 12/04/18 at 9:24 AM, revealed she became aware of the abuse allegation when SRNA #5 left a note for the Administrator on 11/05/18. The DON stated she made no reports to outside agencies nor, to her knowledge, did anyone else. The Director of Nursing was aware of the reporting requirements in the facility policy. However, she stated external reports were generally done by the Administrator unless the Administrator was not available. Interview with the Administrator on 12/04/18 at 9:51 AM, revealed she was aware of the allegation on 11/05/18 when SRNA #5 left her a note about abuse allegations involving Resident #2. The Administrator stated she was aware of the policy reporting requirements. She further stated she never reported the allegation externally because she could not substantiate the allegation.

Based on interview, record review, and review of facility policy, it was determined the facility failed to conduct a thorough investigation of an abuse allegation. On 11/05/18 the facility was notified by staff of an alleged abuse event with Resident #2. The facility failed to conduct an investigation that included observation of the alleged victim's interactions between staff and the resident, conduct interviews to include the resident's representative, all possible witnesses, and the practitioner. In addition, the facility did not ensure further abuse would not occur during the investigation. The findings include: Review of facility policy titled, River Valley Nursing Home Policy and Procedure with revision date 11/2016, revealed the facility Director of Nursing (DON) or designee was responsible for ensuring alleged abuse violations were thoroughly investigated and ensure the prevention of further potential abuse while the investigation was in progress. Review of facility policy titled, River Valley Nursing Home Subject: Vulnerable Adult Reporting and Investigation Procedure, with revision date 11/2016, revealed the facility would review abuse allegations, review the resident's Medical Record, interview the person reporting the event and witnesses to the event as well as staff members on all shifts with potential to have contact with the resident during the allegation period. In addition, the facility investigator should have interviewed the physician, roommate, family members, and visitors, if indicated. Other residents who received care from the alleged perpetrator were to be interviewed by the facility investigator. Unexplained injuries including bruises were to be included and documented in the Electronic Medical Record (EMR). The policy further required the potential or suspected employee to be suspended during the investigation. Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score was ninety nine (99) on the Minimum Data Set (MDS) based on the BIMS score report provided by the facility at the time of the Abbreviated Survey. Resident #2 frequently exhibited resistance to care and required staff interventions to accomplish activities of daily living (ADLs). Interview with State Registered Nursing Assistant (SRNA) #5 on 12/04/18 at 10:26 AM, revealed she came in early on an unknown date to help on Hall A. On the occasion she came in early to assist on Hall A she was providing personal care to Resident #2 when SRNA #7 entered the room. She stated, SRNA #7 told her other nursing assistants (SRNAs) were tying up the resident's hands when providing personal care. She thought this occurred sometime in late October. She stated SRNA #7 gave her the names of SRNAs #2 and #3. She stated at the time she was giving care to Resident #2 she did not notice any bruising. She further stated she notified Licensed Practical Nurses (LPNs) #3 and #4, night shift nurses, who were on the unit at the time. She further stated she wrote the note to the Administrator advising her of the allegation and left it in the Administrator's office before she left the facility. She stated the Administrator and Director of Nursing interviewed her by telephone. She told them she had no further information other than what she left in the note. Interview with SRNA #7 on 12/04/18 at 11:19 AM, revealed she routinely cared for Resident #2. She stated the resident was not hard to care for but he/she could scratch and hit you during care. She further stated the resident responded well to verbal cues given slowly. SRNA #7 stated she did not observe Resident #2 with his/her wrists tied together; however, she heard staff talking about it. She first heard about it from SRNA #6 who stated she had reported the event. She recalled SRNA #2 was identified as the perpetrator. SRNA #7 did not observe any bruises to the wrists of Resident #2. She verbalized that no one at the facility ever interviewed her about the allegation and to her knowledge, no one was ever suspended. Interview with LPN #3 on 12/04/18 at 11:45 AM, revealed she usually worked on Hall B. She stated she was unaware of any concerns or allegations of abuse for Resident #2. She stated she was aware she should report all abuse allegations but denied SRNA #5 ever told her about Resident #2 having his/her wrists tied during personal care. She stated no one at the facility ever discussed the allegation with her or interviewed her. Interview with LPN #4 on 12/04/18 at 10:01 PM, revealed she heard Resident #2 was tied up with a bib while staff delivered personal care. She stated this was a couple months ago. LPN #4 stated she did not recall who told her about the event. She further stated she did not report it to the Administrator or DON because she thought they were already aware of the allegation. She stated she never noticed any bruises on Resident #2. Upon continued interview, LPN #4 revealed neither the Director of Nursing nor the Administrator had ever discussed or interviewed her regarding this abuse allegation. Interview on 12/03/18 at 12:56 PM, with SRNA #2 revealed she had been employed since (MONTH) (YEAR). She had previously been employed by the facility for four (4) years but left to work for Hospice. She stated she rarely worked on Hall A where Resident #2 lived. She recalled taking care of the resident only once. SRNA #2 stated Resident #2 was difficult to care for because he/she lashed out at staff during care, particularly bathing. Upon continued interview she stated she never recalled working on Hall A with SRNA #3, alleged to have witnessed the abuse event. She stated she normally worked with SRNA #3 only on Hall B which is not the hall where Resident #2 resided. SRNA #2 further stated Resident #2 was never restrained. She denied any knowledge of Resident #2 having his/her hands tied together or to the bed. SRNA #2 stated if she were to be aware of any event like that she would immediately report to her direct supervisor. Upon continued interview, SRNA #2 verbalized the only restraint device she used in the facility were wheelchair seatbelts. She further stated Resident #2 did not use a wheelchair seat belt. SRNA #2 stated the Administrator asked her about the allegation on one (1) occasion. She was never suspended and never received any follow up communication from the Administrator. Interview on 12/03/18 at 1:18 PM with SRNA #3 revealed she worked on Hall B and rarely worked on Hall A. However, she did recall one (1) occasion when she worked on Hall A with SRNA #2. She denied witnessing any event where Resident #2's wrists were tied together. She further stated Resident #2 never had restraints applied. SRNA #3 stated she was questioned by the Administrator and Director of Nursing (DON) on one occasion. Following that interview she received no other communication about the alleged event. Interview with SRNA #4 on 12/03/18 at 1:59 PM, revealed she was interviewed by the Administrator regarding an allegation of abuse with Resident #2 sometime in the last month. She stated she never observed Resident #2's wrists being tied. Review of the Administrator's investigative notes does not reveal any detailed notes regarding the interview. Only a general statement with three (3) first names stating no knowledge or witness to the allegation. SRNA #4 was assigned to Resident #2 on the date of the interview and stated she routinely cared for the resident. She verbalized the residents was difficult to care for during personal care; however, she never observed restraints in use including tying the resident's wrists. Interview with SRNA #6 on 12/04/18 at 10:16 AM, revealed she became aware of the allegation Resident #2's wrists were being tied up using an apron belonging to the resident when other staff told her about it. She was unsure who told her other than she thought it might have been SRNA #3. She stated she never witnessed the alleged event; however, she recalled SRNA #5 leaving a note for the Administrator when she heard SRNA #6 talking about the allegation. SRNA #6 stated she routinely cared for Resident #2 and never noticed any bruises on the resident. After stating she was unsure about who told her about the wrist restraints she stated she thought SRNA #3 told her she observed SRNA #2 use the resident's apron to tie her hands during care. She stated the Administrator and the Director of Nursing interviewed her one (1) time about the event and wanted to know if she saw anything. No further follow up occurred. Review of the investigative notes produced by the Administrator revealed four (4) staff members were interviewed about the event on 11/05/18. No interview notes were produced only a handwritten summary statement stating SRNAs #2, #3, #6, and #7 had no knowledge of the allegation and there were no witness(es) to the event. Although SRNA #5, who left the note stated she was interviewed, there was no documentation to support that interview. SRNA #7 stated she was never interviewed however, she was included in the summary statement noted above. On 11/05/18 at 9:00 AM the Administrator stated the DON assessed Resident #2; however, no Medical Record documentation was available to support the assessment. Three (3) other staff first names are listed as having no knowledge of the event with no details of the interviews. On 11/06/18 at 3:00 PM, a handwritten note by the Administrator stated staff education was provided by the Administrator about the abuse policy, when to report abuse, and to report it to. The third page of the investigative notes contains twelve (12) names of residents who were asked if they felt safe, had needs met in a timely matter, and felt care was delivered with respect and dignity. No interview notes were produced. A summary sentence stated there were no concerns regarding care and all feel safe working at the facility. Review of the Medical Record for Resident #2 revealed no documentation in the Progress Notes regarding physical examination of the resident at the time the allegation was made (11/05/28). No Progress Notes were located indicating the Resident Representative or the physician were interviewed and notified about the allegation. No psychological assessments were present beyond the last note from 04/30/18. Review of River Valley - Incidents by Incident Type dated 10/01/18 through 11/30/18 revealed no reports for alleged abuse were included on the report. Review of the Sign In Sheet for the Nurse/SRNA/KMA Meeting held on 11/06/18 revealed nineteen (19) staff members attended. The meeting summary notes revealed twenty (20) bullet points for various topics including if an incident happens that you are not sure about like an abuse allegation you must report it immediately:. There was no reference to facility policy and no additional sign in sheets to document education for the remainder of staff members. Review of the Human Resource - Employee Listing with report date 12/03/18, revealed one hundred five (105) staff members. Nineteen (19) attended the inservice on 11/06/18 that included a reminder to report abuse allegations. Interview with the Director of Nursing (DON) on 12/04/18 at 9:24 AM, revealed the Administrator performed abuse allegation interviews. Her role as DON was to sit in on the interviews. She was aware the Administrator received a note from a staff member regarding the abuse allegation with Resident #2. She stated as DON, in accordance with facility policy, she was responsible for taking nursing staff, alleged to be perpetrators, off the schedule during abuse investigations. She further stated no one was suspended during this investigation because the perpetrator was unknown. She stated upon interview, SRNA #6 did not reveal any names of alleged perpetrators although SRNA #6 did reveal the alleged perpetrator's name to the State Representative during her interview. SRNA #2 was interviewed about the allegation but the DON stated she was unaware the SRNA was an alleged perpetrator. The DON stated she checked Resident #2's wrists for signs of injury; however, this was a week after the alleged event. She did not note any bruises. She further stated she checked approximately ten (10) other residents for injuries and found none. No notations were made in the Medical Record but she stated she kept a list of the residents. (The list was never produced for the State Representative.) Interview with the Administrator on 12/04/18 at 9:51 AM, revealed she expected all staff to immediately report suspicion or knowledge of abuse. She stated she and the Director of Nursing (DON) were responsible for conducting abuse investigations and she was responsible for external reporting of abuse allegations. She stated she did not produce the abuse investigative file for Resident #2 requested on 12/03/18 at 11:15 AM because she only had her notes and had not created a file. On 11/05/18 the Administrator stated a note was left for her from SRNA #5 stating Resident #2 was being tied up during care. She stated the alleged perpetrator was SRNA #6. She interviewed four (4) nursing assistants (SRNAs #3, #6, #7 and presumably SRNA #2 although the investigative notes from the Administrator have the wrong initial for SRNA #2's last name.) The Administrator did not produce any detailed interview notes, only a summary sentence for all four (4) interviews was created stating none were witnesses nor did they have knowledge of the allegation. There was no documentation of an interview with SRNA #5 who left the note nor of the two (2) LPN's whom SRNA #5 stated she reported the event to prior to leaving the note. She did not discuss the allegation with the family or the resident's physician. She said did not suspend anyone during the investigation even though the Administrator stated SRNA #5 told her SRNA# 6 was tying up Resident #2 with an apron. The Administrator also stated the alleged perpetrator could have been SRNA #2. Although facility policy required suspension during the investigation and SRNAs #2 and #6 were identified as possible perpetrators, no one was suspended during the investigation. In addition, SRNA #7 stated the Administrator and DON never interviewed her about the allegation. The summary sentence in the Administrator's notes includes SRNA #7 name as interviewed; however, there were no detailed notes to establish whether an interview was ever conducted. The Administrator stated she did not complete a final five (5) day investigative report nor make any reports to external agencies because she could not substantiate the allegation.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to store, prepare, and distribute food under sanitary conditions. Observation and interview with dietary staff on [DATE], revealed they were unaware of the proper measurement of bleach to water when filling the sanitizer buckets in the kitchen. Also, observation of the kitchen on [DATE] and [DATE], revealed the sanitizer bucket containing sanitizer was positioned between the open case of potatoes and the open case of onions. In addition, observation on [DATE] of the kitchen, revealed clear containers labeled flour and cornmeal which were not dated; one (1) open package of 6.0 ounce garden rice seasoning mix; which was not dated with the open date; a small open package of brown sugar which was not dated with the open date; three (3) cans of Ensure (nutritional supplement) with an expiration date of [DATE]; two (2) cases of Ensure Plus with the expiration date of [DATE]; one (1) case of Ensure Plus with the expiration date of [DATE]; six (6) bottles of Ensure Original with an expiration date of [DATE]; and fountain Power Aide with an expiration date of [DATE]. Additionally, observation on [DATE], of the B unit nourishment refrigerator and cabinets, revealed ten (10) soft chew cookies which were not dated; eight (8) sugar free cookies which were not dated; and two (2) vanilla sugar free pudding cups with manufacturer's 'Best by Date of [DATE]. Furthermore, observation on [DATE], of the A unit nourishment refrigerator and cabinets, revealed a box of six (6) Swiss Miss milk chocolate packages dated [DATE]; six (6) vanilla sugar free cookies which were not dated; seventeen (17) soft chew cookies which were not dated; and one (1) 12.7 ounce bottle of London Pub malt vinegar which was sealed and not opened, and not dated. The findings include: Review of facility River Valley Nursing Home Policy and Procedure dated ,[DATE], revealed cleaning supplies will be stored separately from food items. All opened foods are to be labeled, dated and sealed before returning to proper storage areas and discarded after three (3) days. Further review revealed all foods and beverages was to be dated with the date of storage and the date to be discarded. Review of the Clorox Bleach Safety Data Sheet, dated [DATE], revealed bleach can cause severe skin burns, eye damage and when mixed with an acid liberates a toxic gas. The bleach should be stored away from food. Review of the Clorox Bleach Label sanitizer instructions, revealed use two (2) teaspoons of bleach per gallon of water. Wipe the surface and let stand for two (2) minutes and allow to air dry. 1. Observation upon entering the kitchen through the dish room, on [DATE] at 2:09 PM, revealed Diet Aide #1 was preparing the sanitizer for the sanitizer bucket. Interview on [DATE] at 2:09 PM, with Diet Aide #1, revealed she did not have a way to test the Clorox; however, she stated she checked the bleach water by how it felt, not slimy and how it smells. Continued tour of the kitchen, revealed under a preparation sink on the shelf, there was an open case of Idaho potatoes to the left of the sanitizer bucket, and an open case of white onions, to the right of the bucket. Observation on [DATE] at 11:25 AM, during the kitchen lunch tray line, revealed, the sanitizer bucket remained between the open case of Idaho potatoes and open case of white onions under the preparation sink. The Sanitizer bucket was filled with ,[DATE] of sanitizer. The State Agency Representative informed the Dietary Manager and the sanitizer bucket was immediately removed. Interview on [DATE] at 9:35 AM, with Cook #1, revealed she used bleach to sanitize the carts and the food preparation table. She further explained she tested the bleach by touch and the bleach needed to feel slick to the touch. She further stated she measured half a cup of bleach and filled the sanitizer bucket ,[DATE] full of water. Continued interview revealed she wiped the bleach over the preparation area and then immediately wiped off the bleach. Interview on [DATE] at 09:50 AM, with Dietary aide #1, revealed the sanitizer buckets were usually kept on the cart by the three (3) compartment sink or on the counter and were not to be placed near any food to prevent cross contamination. Interview on [DATE] at 10:11 AM, with Diet Aide #3, revealed she filled the sanitizer bucket ,[DATE] full to almost full of water and then poured bleach into the bucket. She stated she tested the bleach by feel and smell. Per interview, she wiped the kitchen surfaces with the bleach water and allowed the surfaces to air dry. Further interview revealed the sanitizer bucket was not to be kept near open food such as potatoes and onions or on the same shelf as food, as there could be a problem with cross contamination of the sanitizer to the food. Interview on [DATE] at 10:22 AM, with the Dietary Manager, revealed the bleach was to be measured and staff was to use one (1) tablespoon of bleach to one (1)gallon of water when filling the sanitizer bucket. Per interview, it was important to use the correct amount of bleach with water for the sanitizer in order to ensure food production surfaces were effectively sanitized. Further interview revealed there was the danger of cross contamination if the sanitizer bucket was stored near food items. 2. Observation on [DATE] at 2:09 PM, during initial kitchen tour, revealed clear containers labeled flour and cornmeal which were not dated; one (1) open package of 6.0 ounce garden rice seasoning mix; which was not dated with the open date; and a small open package of brown sugar which was not dated with the open date; above the preparation sink on the shelves. Continued tour of the kitchen revealed three (3) cans of Ensure nutritional supplement with an expiration date of [DATE] on the open shelving located near the clean area of the dish room. Further observation during the initial tour of the kitchen, revealed expired nutritional supplements in the dry storage including two (2) cases Ensure Plus with the expiration date of [DATE]; one (1) case of Ensure Plus with the expiration date of [DATE]; and six (6) bottles of Ensure Original with an expiration date of [DATE]. In addition, the fountain Power Aide located near the dry storage had an expiration date of [DATE]. Interview on [DATE] at 9:50 AM, with Diet Aide #1, revealed she was responsible for putting up the stock and rotating food First in and First Out (FIFO) in dry storage. Per interview, the resident who needed the nutritional supplements was discharged and the outdated nutritional supplements were not removed from the shelf. Interview on [DATE] at 10:00 AM, Dietary Aide #2, revealed she helped to bring stock from dry storage. Per interview, all foods were to be labeled and dated after opening. She stated she checked for dates when she pulled food products for the cook and if any out dated food was found, it was thrown away and the Dietary Manager was notified. Interview on [DATE] at 2:24 PM, with Cook #2, revealed all food items, on the shelves in the kitchen should be labeled and dated with the open date. Per interview, food could go bad and bacteria could grow which could make residents sick if food was consumed past the expiration date. Interview on [DATE] at 10:22 AM, with the Dietary Manager, revealed it was her expectation for Diet Aide #1 to put up the stock and rotate the food by date. Further interview revealed Diet Aide #1 should have found the out dated food items and nutritional supplements and ensured they were discarded. Per interview, all foods should be labeled and dated with the open date by the staff member who opened the food item. Further interview revealed food which was not dated when opened, could be used past the expiration date which could lead to foodborne illnesses. 3. Observation on [DATE] at 3:45 PM, of the B unit nourishment refrigerator and cabinets, revealed ten (10) soft chew cookies which were not dated; eight (8) sugar free cookies which were not dated; and two (2) vanilla sugar free pudding cups with manufacturer's 'Best by Date of [DATE]. Observation on [DATE] at 3:55 PM, of the A unit nourishment refrigerator and cabinets, revealed a box of six (6) Swiss Miss milk chocolate packages dated [DATE]; six (6) vanilla sugar free cookies which were not dated; seventeen (17) soft chew cookies which were not dated; and one (1) 12.7 ounce bottle of London Pub malt vinegar which was sealed and not opened, and not dated. Interview on [DATE] at 9:50 AM, with Diet Aide #1, revealed it was the responsibility of 2nd shift to stock the nourishments on the units. Interview on [DATE] at 10:22 AM, with the Dietary Manager, revealed the evening cook took care of the nourishment areas. Per interview, all foods in the nourishment areas should be labeled and dated and discarded if expired. Interview on [DATE] at 2:24 PM, with Cook #2, revealed she took snacks to the nourishment areas on the units. Per interview, the snacks should be checked for dates and rotated. Cook #2 stated the expired pudding found on the shelf could have been provided by a family member and should have been thrown away. Interview on [DATE] at 10:35 AM, with the Director of Nursing (DON), revealed revealed it was her expectation the kitchen be cleaned with bleach sanitizer which had been mixed properly to ensure the sanitizer was effective in killing germs and bacteria on kitchen surfaces. Further interview revealed it was her expectation for all food products in the kitchen and nourishment areas on the units to be labeled and dated and expired food discarded. Per interview, outdated food should not be served to residents. Interview on [DATE] at 12:12 PM, with the Administrator, revealed it was her expectation for staff to follow the policy and procedure for sanitization to kill bacteria and prevent cross contamination. Further interview revealed it was her expectation for all foods to be labeled as per policy, and expired foods be discarded for the safety of the residents.

Based on interview and record review, it was determined the facility failed to ensure the Governing Body appoints an Administrator who is licensed by the state where licensing is required. The findings include: Review of the Job Description for the Administrator in Training, revised [DATE], revealed she was required to report to the Administrator and the Governing Body, with the Administrator or preceptor evaluating her work weekly. Review of the Kentucky Board of Licensure for Long-Term Care Administrators, as of [DATE], revealed the facility Administrator in Training held a Temporary Long-Term Care Administrator license from [DATE] until it expired on [DATE]. Interview on [DATE] at 9:05 AM, with the Administrator, revealed she had been working at the facility in the capacity of Administrator for eighteen (18) months, since [DATE]. She stated she took over after the previous Administrator retired. She further stated, after the previous Administrator retired, he provided her with almost-daily supervision in the form of telephone calls and electronic correspondence, and was available to answer any questions she had. Further interview revealed for the past three (3) months she had been receiving supervision in the form of phone calls and electronic correspondence multiple times a week from another licensed Administrator, who had been to the facility on more than one (1) occasion. She stated she filed an application to test for an Administrators license and was scheduled for testing on [DATE]. Regarding a governing body, she stated the facility had an owner. Interview on [DATE] at 1:02 PM, with the facility Owner, revealed he hired the Administrator in Training and was aware of the requirement for facility Administrators to hold a current license. The Owner stated when the prior Administrator retired, he (Owner) retained his license and maintained communication with the Administrator in Training. He further stated he felt what they were doing was satisfactory, having an Administrator in Training receiving any needed support from a licensed Administrator until she could get her Administrator's license. Continued interview revealed resident care was of utmost importance, and the facility would do whatever was needed to ensure regulatory requirements were met. Interview with the Medical Director, on [DATE] at 1:10 PM, revealed as Medical Director, most of his interactions were with the Director of Nursing. Further interview revealed he had been very impressed by the Administrator in Training, describing her as well-established in the community. However, he stated it was his expectation for the facility to follow licensure requirements.