Every finding on record at Rockcastle Regional Hospital and Respiratory Care

Based on observation, interview, and record review, the facility failed to provide visual privacy for two residents (Resident (R) 114 and R24) of thirty sampled residents during tracheostomy care. On 3/23/25 at 2:47 PM and again at 2:53 PM, a respiratory therapist suctioned the resident's tracheostomy with the door open and without pulling the privacy curtain. Visitors, staff, and other residents in the hallway could see into the room during the procedure. The findings include: A review of the facility's Routine Trach Care policy, revised in June 2021, instructs staff to provide privacy as part of the procedure. The LTC Resident's Rights to Privacy policy, revised in May 2017, states, The resident is granted the privacy of his/her body during provision of personal care and services. Staff failed to follow both policies and did not protect the resident's right to Privacy. A review of R43's Admission Face Sheet revealed the facility admitted R114 on 02/07/2025. A review of R114's admission Minimum Data Set with an Assessment Reference Date (ARD) of 02/13/2025 indicated that a Brief Interview for Mental Status (BIMS) wasn't conducted, indicating that R114 is rarely/never understood. A review of R24's Admission Face Sheet revealed the facility admitted R24 to the facility on [DATE]. A review of R24's admission Minimum Data Set with an Assessment Reference Date (ARD) of 01/02/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3/15, indicating that R24 had severe cognitive impairment. During an observation at 2:47 PM on 03/23/2025 Respiratory Therapist (RT) 1 suctioned R114's tracheostomy with the door open and without pulling the privacy curtain, failing to provide visual privacy during the procedure. During observation on 03/23/2025 at 2:53 PM, RT 1 suctioned R24's tracheostomy without closing the door or pulling the privacy curtain. R24 and his roommate had visitors in the room. RT 1 only pulled the privacy curtain after she saw the State Survey Agent (SSA) outside the doorway. During an interview on 03/23/2025 at 3 PM, RT 1 stated, It's just suctioning; it doesn't require privacy like a bed bath. During the interview on 03/23/2025 at 3:05 PM, Family Member 1 stated, R24 is provided trach care often with the door open and the curtain not pulled. Sometimes, I think people passing by the room looking in may embarrass him. During an interview on 03/25/2025 at 11:40 AM, the Respiratory Director stated, Privacy should be provided during patient care, which includes trach care. I would be embarrassed if the door was left open during care, and I know it is the same for our residents here. During an interview on 03/26/2025 at 11:20 AM, the Chief Nurse Officer stated, My expectation for staff is to respect our residents and provide them privacy during patient care by closing the door.

Based on observations and staff interviews, the facility failed to post the required Nurse Staffing Information (i.e., total number and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care) on the North, South, East, and [NAME] units for the following dates: 03/21/2025, 03/22/2025, 03/23/2025, and 03/24/2025. The findings include: A review of the facility ' s policy titled, Nurse Staffing Information, with a revision date of March 2021, revealed that the facility must post the total number, and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care daily at each station by the beginning of each shift. Observation, on 03/23/2025 at 3:45 PM, revealed that the Rockcastle Respiratory Care Center Nurse Staffing Information, postings on the North, South, East, and [NAME] units had not been updated since 03/20/2025. Observation, on 03/24/2025 at 3:00 PM, revealed that the Rockcastle Respiratory Care Center Nurse Staffing Information, posted for the same units had still not been updated or exchanged since 03/20/2025. During an interview with the Nursing Administrative Assistant on 03/25/2025, at 11:00 AM, she stated that she was responsible for updating the staffing postings and typically posted this information daily. She further explained that she prepared the postings for Friday, Saturday, Sunday, and Monday each Thursday afternoon, with the weekend updates expected to be managed by the assigned nurse or weekend manager. However, the Nursing Administrative Assistant admitted to failing to deliver the postings for March 21, 22, 23, and 24, 2025 on 03/20/2025 which resulted in the units not having the information to post. In an interview with the Chief Nurse Officer on March 26, 2025, at 11:20 AM, she stated that it was the Nursing Administrative Assistant's responsibility to update the staffing postings. The Chief Nurse Officer also mentioned that she was unaware the postings had not been updated daily to inform residents and visitors of daily staffing information.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure one (Resident (R )43) of 30 sampled residents had access to a functional and accessible communication system to request staff assistance. On 03/23/2025, Resident (R) 43 was not equipped with a functional and accessible communication system to request staff assistance compromising R43's safety and well-being. On 03/23/2025, R43 activated the call light system but did not receive assistance, as the call was manually deactivated at the central staff station. On 03/24/2025, the call light was positioned on the resident's ventilator machine, out of the resident ' s reach, preventing the resident from alerting staff when suctioning was needed. These failures delayed staff response to the resident's needs, potentially compromising the resident ' s safety and well-being. The findings include: A review of the facility policy, Organizational Top Ten Behavior Standards-Call Lights (undated), revealed that call lights were to be acknowledged by the third ring and answered with How may I help you? According to the policy, staff should respond with care, courtesy, and respect. A review of R43's Admission Face Sheet revealed R43's was admitted to the facility on [DATE]. A review of R43's admission Minimum Data Set with an Assessment Reference Date (ARD) of 03/05/2025 indicated a Brief Interview for Mental Status (BIMS) score of 14, indicating that R43 was cognitively intact. On 03/23/2025, at 2:18 PM, R 43 was observed making a gurgling sound from the tracheostomy and activated the call light to request assistance. At 2:21 PM, the unit secretary deactivated the call system without calling or checking on the resident. At 2:22 PM, the State Survey Agent (SSA) instructed R43 to press the call light again. At 2:25 PM, the State Registered Nurse Aide (SRNA) 1 entered the room. At that time, R43 reported she needed respiratory therapy for suctioning. During an interview at 2:18 PM on 03/23/2025, R43 stated, I turn my light on, and they just turn it off without checking on me. R43 also reported feeling afraid and said, Sometimes I feel like I'm drowning in my secretions. During an interview at 2:43 PM on 03/23/2025, Unit Secretary 1 stated that she frequently deactivated resident call lights from the central location without calling into the room. She added, If the resident needs something, they will push the call light again. During an observation on 03/24/2025 at 3:10 PM, R 43 was observed in bed searching for the call light. R43 had an audible gurgling sound from the tracheostomy area. The SSA discovered the call light button was on the ventilator machine out of the resident's reach. When the Licensed Practical Nurse entered the room, R43 stated, No one calls into my room or checks when I push my light. I didn't think it was working. During an interview at 3:16 PM on 03/24/2025 with Licensed Practical Nurse (LPN) 1, she confirmed that the call light was misplaced during patient care. LPN 1 further stated that R43 was new to the facility and may accidentally hit the light. She added that the unit secretary often deactivated the light without follow-up but acknowledged that the staff should check on the resident for safety when the call light was activated. During an interview on 03/24/2025 at 3:25 PM, R43 stated, I need my light to work because I get scared when no one comes. What if I needed respiratory therapy because I need suctioning? During an interview on 03/25/2025 at 9:35 AM, the Administrator acknowledged that the call lights were a known issue in the facility. The Administrator attributed part of the problem to the layout of the newly constructed resident unit and a shortage of staff wanting to work the unit due to the distance between rooms, which caused increased fatigue. He stated, however, that this was not an excuse and that both floor staff and management should respond to all call lights to ensure resident needs were met, including alleviating fears of choking and lack of timely assistance.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (1) of thirty-three (33) sampled residents received a preadmission screening (Resident #84). Resident #84 had a Level I Pre-Admission Screening and Resident Review (PASARR) on 02/09/18 that indicated the resident required a Level II Screening; however, the facility failed to ensure a Level II screening was completed. The findings include: Interview with the Chief Nursing Officer revealed the facility did not have a policy related to the PASARR. Observation and interview with Resident #84 on 08/29/18 at 2:30 PM revealed the resident had resided at the facility for a few months, but was hoping to go home soon. Review of Resident #84's medical record revealed the facility admitted the resident on 02/12/18 with [DIAGNOSES REDACTED]. Further review revealed a PASARR Level I was completed for the resident on 02/09/18, prior to admission, and indicated the resident should have a Level II PASARR due to a [DIAGNOSES REDACTED].#84. Interview on 08/30/18 at 3:26 PM with Social Service Worker #1 revealed the facility should have made a referral to the appropriate agency requesting that a Level II PASARR be completed prior to the 40th day of the resident's admission, but Social Service Worker #1 was unable to explain why the referral was not made. Interview on 08/30/18 at 4:45 PM with the Director of Social Services revealed all residents were screened for PASARR and if the resident triggered, a PASARR II should be conducted. He stated a [DIAGNOSES REDACTED].#84 had not had a Level II screening.

Based on interview, record review, and policy review, it was determined the facility failed to ensure that an alleged violation of verbal abuse was reported immediately to the administrator of the facility and to other officials in accordance with state law. The finding include: Review of the facility policy, Freedom from Abuse, revealed verbal abuse included the oral, written, or gestured communication within a resident's hearing distance, regardless of their age, ability to comprehend, or disability. Further review of the policy revealed that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made. According to the facility's policy, the allegation was to be reported to the Administrator (or designee) of the facility and to other state officials as required. Further review of the policy revealed that the person(s) observing an incident of resident abuse or suspecting resident abuse must report such incident immediately to their supervisor. Interview on 08/08/18 at 1:25 PM with the Associate Director of Social Work (ADSW) revealed the House Supervisor contacted her on 07/24/18 at 7:45 PM, regarding an incident that occurred with State Registered Nurse Aide (SRNA) #1 using foul language near a resident's room. The ADSW stated she was out of the facility at the time she was notified, but came immediately to the facility. Further interview revealed when she arrived at the facility, the Chief Nursing Officer (CNO) and the RN House Supervisor had already interviewed SRNA #1, who was no longer in the facility. The ADSW stated she immediately initiated an investigation. Further interview with the ADSW revealed that during the course of the investigation it was discovered that on 07/20/18 at approximately 7:00 AM, SRNA #2 had also witnessed SRNA #1 verbally abuse Resident #1. Interview with SRNA #2 on 08/08/18, at 3:15 PM revealed she was assisting SRNA #1 to turn and reposition Resident #1 on 07/20/18, at approximately 7:00 AM. Further interview revealed that SRNA #1 stated, I wish this [***] would turn over and also said damn three times. SRNA #2 stated she informed SRNA #1 to not use foul language, and reported the incident to the Unit Coordinator. Interview with the Unit Coordinator on 08/08/18, at 10:50 AM revealed on the morning of 07/20/18, SRNA #2 stated she was concerned that SRNA #1 used her cell phone frequently during the shift and that the SRNA cursed a lot. However, the Unit Coordinator stated SRNA #2 did not tell her that the foul language had been used in a resident's room or directed toward a resident. Therefore, the Unit Coordinator failed to report the incident to the Administrator (designee) or state officials as required. Interview with SRNA #1 on 08/09/18, at 2:15 PM revealed the SRNA denied using foul language in the resident's room or directed toward a resident. Interview with the CNO on 08/09/18, at 11:09 AM, revealed she was notified by the ADSW on 07/26/18 at 10:52 AM that during the course of an investigation it was discovered that an incident had occurred on 07/20/18 involving SRNA #1 allegedly using foul language in a resident's room. The CNO stated that once the allegation was reported by the ADSW, it was reported as required to state officials.

Based on interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to have evidence that all alleged violations of abuse were thoroughly investigated, and failed to protect residents from further potential abuse after an allegation of abuse was made for two (2) of three (3) sampled residents (Resident #1 and Resident #3.) On 12/21/17, Resident #1 reported that a staff member was rough with him/her during care. The facility conducted an investigation; however, there was no documented evidence that the facility conducted a thorough investigation which included interviewing other residents to determine patterns of abuse or other occurrences. In addition, on 11/27/17, Resident #3 reported that a staff member touched his/her breast while providing care. The facility conducted an investigation; however, there was no documented evidence that the facility conducted a thorough investigation which included interviewing other residents to determine patterns of abuse or other occurrences. The findings include: Review of the facility's policy and procedure titled Freedom from Abuse, last revised (MONTH) (YEAR), revealed the facility would ensure residents would be free from abuse and neglect. Further review revealed the facility would develop intervention strategies which included investigating allegations to prevent occurrences. Additional review of the facility's policy revealed the facility would conduct an investigation when an incident or suspected resident abuse occurred. Additionally, the policy stated the facility would conduct interviews with other residents as necessary to determine patterns of abuse or other occurrences. Record review revealed the facility admitted Resident #1 on 03/10/16 with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of six (6) indicating Resident #1 was not interviewable. Review of a facility report titled Report of Suspected Abuse/Neglect/Injury of Unknown Origin/Misappropriation of Property, dated 12/21/17, revealed Resident #1 reported that a staff member was rough with him/her during care. Review of a facility Abuse Investigation Summary, not dated, revealed the allegation reported by Resident #1 was investigated by the facility using the facility's Abuse Protocol. Additional review of the Abuse Investigation Summary revealed the allegation was unsubstantiated; however, there was no documented evidence that the facility conducted interviews with other residents to determine potential patterns or other occurrences. Interview with Social Worker #1 revealed she was the staff member who conducted the investigation. Further interview with Social Worker #1 revealed she did not conduct interviews with other residents per the facility's policy and procedure. Social Worker #1 stated she did not feel that conducting interviews with other residents was necessary because she felt the occurrence was isolated. Record review revealed the facility admitted Resident #3 on 06/24/15 with [DIAGNOSES REDACTED]. Review of a facility report titled Report of Suspected Abuse/Neglect/Injury of Unknown Origin/Misappropriation of Property, dated 11/27/17, revealed Resident #3 reported that a staff member touched his/her breast while providing care. Review of a facility Abuse Investigation Summary, not dated, revealed the allegation reported by Resident #3 was investigated by the facility using the facility's Abuse Protocol. Additional review of the Abuse Investigation Summary revealed the allegation was unsubstantiated; however, there was no documented evidence that the facility conducted interviews with other residents to determine potential patterns of abuse or other potential occurrences. Interview with Social Worker #3 revealed she was the staff member who conducted the investigation. Further interview with Social Worker #3 revealed she did not conduct interviews with other residents per the facility's policy and procedure. Social Worker #3 stated she did not feel that conducting interviews with other residents was necessary because she felt the occurrence was isolated. Interview with the Social Services Director on 01/02/18 revealed he was ultimately responsible for ensuring allegations of abuse and neglect were investigated appropriately. Further interview with the Social Services Director revealed he felt interviewing other residents was only necessary if actual abuse was suspected and he stated that he felt the allegations for Resident #1 and Resident #3 were isolated incidents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure an allegation of abuse was reported to state agencies for one (1) twenty-three (23) sampled residents (Resident #4). On 05/26/17, Resident #4 reported that he/she did not want State Registered Nursing Assistant (SRNA) #2 taking care of me. Resident #4 stated the SRNA smarted off to me about using the bedpan. The next day, 05/27/17, the resident's spouse also reported the incident. The resident's spouse reported the SRNA stated It would be a lot easier if you would get your ass up and get on the BSC (bedside commode). The allegation was not reported to the facility's Social Worker until 05/27/17, and the allegation was never reported to state agencies. The findings include: Review of a facility policy titled Freedom From Abuse, with a review date of September 2016, revealed all alleged abuse or neglect would be reported immediately to the supervisor, state agencies would be notified, and the administrator or designee would appoint a staff member to investigate the incident. Review of Resident #4's medical record revealed the facility admitted the resident on 05/09/17, with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident had intact cognition and was interviewable. The MDS also revealed the resident required the limited assistance of one (1) person for toileting. Interview with Resident #4 on 08/01/17, at 10:15 AM, revealed an SRNA had spoken to the resident rudely when the resident needed to use the bedpan. Resident #4 stated he/she reported the incidents to staff, but did not know the outcome of the report. Review of Resident #4's nurse's notes dated 05/26/17, at 11:30 AM, revealed Registered Nurse (RN) #9 documented that Resident #4 reported that he/she did not want SRNA #2 taking care of me. The resident stated SRNA #2 smarted off to me about using the bedpan. The nurse's note stated the RN apologized to the resident and explained that she would ensure that the resident's needs were met by someone else. The note further stated that the nurse spoke with the Unit Coordinator and SRNA #2 about the incident and the resident's needs were provided by others for the remainder of the shift. Further review of Resident #4's nurse's notes dated 05/27/17, at 1:53 PM, revealed Resident #4's spouse reported that the resident requested a bedpan the day before and a staff member stated, It would be a lot easier if you would get your ass up and get on the BSC (bedside commode). Interview conducted on 08/03/17, at 6:17 PM, with SRNA #2 revealed she cared for Resident #4 on 05/26/17, on the 6:00 PM to 6:00 AM shift. SRNA #2 stated she attempted to encourage Resident #4 to use the bedside commode and the resident refused. SRNA #2 stated at no time was she rude or said anything abusive to the resident. Interview conducted with the Acting Director of Nursing (DON) on 08/03/17, at 6:25 PM, revealed RN #9 was unavailable for interview because she was on vacation. Interview conducted with RN #4 on 08/03/17, at 6:35 PM, revealed Resident #4's spouse reported on 05/27/17, that the resident asked for assistance with a bedpan and a nursing assistant told the resident that the resident should get off the bedpan and use the bedside commode. The RN stated she had immediately notified Social Worker (SW) #1 of the allegation. According to the RN, the SW interviewed the resident and the resident's spouse, and the resident denied the allegation. Interview conducted with SW #1 on 08/03/17, at 7:00 PM, revealed she was notified on 05/27/17, of the allegation regarding Resident #4, and was not aware the resident had reported the day before that the SRNA smarted off, and did not want the SRNA caring for the resident anymore. The SW stated she and RN #4 interviewed Resident #4, and the resident stated the incident did not happen. SW #1 stated she spoke with the Director of Social Services (DSS) and they decided the allegation was unsubstantiated and did not require further investigation and reporting to state agencies because the resident had stated the incident had not occurred. Interview conducted with the DSS on 08/03/17, at 7:05 PM, revealed he was responsible for ensuring all allegations of abuse and neglect were investigated and reported to state agencies. The DSS stated the allegation should have been thoroughly investigated and reported to state agencies.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide care for one (1) of twenty-three (23) residents (Resident #4) in a manner that maintained respect and dignity. Observation of the noon meal on 08/01/17, revealed Resident #4 was eating his/her meal. The resident's meal tray was observed sitting beside a urinal (a portable device in which to urinate) that contained approximately one hundred (100) milliliters of yellow fluid. The findings include: Interview with the Acting Director of Nursing on 08/01/17, at 3:30 PM, revealed the facility utilized Mosby's Textbook for Nursing Assistants (7th Edition) to guide residents' care. A review of the textbook revealed staff was required to ensure a resident's overbed table was clean from all dirty equipment prior to placing a meal tray on the area. The textbook also revealed staff were required to empty a resident's urinal after use. Review of the medical record for Resident #4 revealed the facility admitted the resident on 05/09/17, with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #4 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident had intact cognition and was interviewable. The MDS also revealed the resident required limited assistance of one (1) person for eating and toileting. Observation of Resident #4 on 08/01/17, at 12:17 PM, revealed State Registered Nursing Assistant (SRNA) #3 placed the resident's noon meal tray on the resident's overbed table beside a urinal that contained approximately one hundred (100) milliliters of yellow fluid. The SRNA set up the resident's meal tray and left the room without removing the urinal. Interview with Resident #4 on 08/03/17, at 11:10 AM, revealed the urinal contained urine and it bothered the resident for the urinal to be left on his/her overbed table. Interview with SRNA #3 on 08/03/17, at 3:35 PM, revealed she was required to empty dirty urinals. SRNA #3 stated she should have removed Resident #3's urinal from the overbed table prior to placing the resident's meal tray on the table and stored the urinal in the resident's bathroom. Interview conducted with the Acting Unit Manager for the East Unit on 08/03/17, at 3:45 PM, revealed SRNA #3 should have emptied Resident #3's urinal and ensured the overbed table was clean before setting up the resident's meal tray.

Based on observation and interview the facility failed to maintain a sanitary and comfortable interior. Observations on 08/01/17 at 12:10 PM and 5:35 PM revealed three (3) of three (3) suction canisters in one (1) of two (2) day rooms (East day room) had dirty tubing connected to the canisters. The findings include: Review of the facility's policy titled Pulmonary Suctioning, Bronchial Hygiene, Chest Physical Therapy, revised August 2013, revealed all equipment and supplies should be appropriately disposed of or disinfected. Observations on 08/01/17 at 12:10 PM and 5:35 PM revealed dirty suction tubing (secretions inside the tubing) was connected to three (3) suction canisters in the East day room. Interview with Certified Respiratory Therapist (CRT) #1 on 08/01/17 at 3:05 PM, revealed all suction canisters in the day rooms were changed daily. CRT #1 stated new suctioning tubing should be used for each resident and the tubing should be discarded after use. Interview with CRT #2 on 08/01/17 at 5:39 PM, revealed suctioning tubing should be changed after each resident use and used tubing should be discarded. CRT #2 stated she did not know why dirty tubing was left on the suction canisters. CRT #2 stated, Someone just forgot to throw the tubing away. Interview with CRT #3 on 08/02/17 at 1:30 PM, revealed the suction canisters in the day room were changed every morning. CRT #3 stated each resident had new tubing for suctioning on the back of their wheelchairs. When the resident required suctioning, new tubing was used and then thrown away. Further interview with CRT #3 revealed respiratory personnel did not make rounds to check the canisters; however, if they observed dirty tubing left on a suction canister, staff should discard the tubing. CRT #3 stated she had not observed dirty tubing being left on the canisters. Interview with the Respiratory Director on 08/01/17 at 3:15 PM, revealed all residents should have their own tubing for suctioning. The Director stated each resident should receive new tubing when suctioned and the tubing should be thrown away after use. Further interview with the Respiratory Director revealed he had not identified any concerns with dirty tubing being left connected to suction canisters.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure Pneumococcal and/or Influenza vaccinations were offered to one (1) of twenty-three (23) sampled residents (Resident #10) to minimize the risk of residents acquiring, transmitting, or experiencing complications of Pneumonia and/or Influenza. The findings include: Review of the facility's policies on Influenza vaccine, dated December 2016, and Pneumococcal vaccine, dated December 2016, revealed all residents would be offered vaccinations that aided in preventing infectious diseases, unless the vaccine was medically contraindicated or the resident had already been vaccinated. Review of Resident #10's medical record revealed the facility admitted the resident on 01/01/17 with [DIAGNOSES REDACTED]. Review of Resident #10's immunization record revealed no documentation the resident received Pneumococcal or Influenza vaccinations. Further review of Resident #10's medical record revealed no evidence the facility offered Pneumococcal or Influenza vaccinations to the resident. Interview with the Unit Coordinator, Registered Nurse (RN) #6, on 08/03/17 at 3:10 PM revealed that all nurses were responsible to ensure immunization consents were obtained and vaccinations were given to residents. The Unit Coordinator stated she was not aware that Resident #10 did not receive Pneumococcal and/or Influenza vaccinations or that no consent was obtained for acceptance or refusal for vaccinations. Interview with the Infection/Safety Coordinator, RN #7, on 08/03/17 at 09:45 AM revealed she and the Unit Coordinators were responsible to ensure resident consent was obtained and nurses (RNs and LPNs) were responsible to administer vaccinations. She stated she reviewed residents' medical records to ensure vaccination consents were obtained and vaccinations were administered to residents; however, she stated she had not identified that staff did not obtain consent and did not administer Pneumococcal or Influenza vaccinations to Resident #10.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infections for one (1) of twenty-three (23) sampled residents (Resident #4). Observation of the noon meal on 08/01/17, revealed a urinal (a portable device in which to urinate) that contained approximately one hundred (100) milliliters of yellow fluid was on Resident #4's overbed table beside the resident's meal tray while the resident was eating. The findings include: Interview with the Acting Director of Nursing on 08/01/17, at 3:30 PM, revealed the facility utilized the procedures in the Mosby's Textbook for Nursing Assistants (7th Edition). A review of the textbook revealed staff were required to ensure a resident's overbed table was clean from all dirty equipment prior to placing a meal tray on the area and staff were required to empty a resident's urinal after resident use. Review of Resident #4's medical record revealed the facility admitted the resident on 05/09/17, with [DIAGNOSES REDACTED]. A review of Resident #4's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident had intact cognition and was interviewable. The MDS also revealed the resident required the limited assistance of one (1) person for eating and toileting. Observation of the noon meal service on 08/01/17, at 12:17 PM, revealed State Registered Nursing Assistant (SRNA) #3 was observed to place Resident #4's meal tray beside a urinal with approximately one hundred (100) milliliters of yellow fluid. An interview with Resident #4 on 08/03/17, at 11:10 AM, revealed the resident stated it was nasty for the urinal that contained urine to be near his food tray. An interview with SRNA #3 on 08/03/17, at 3:35 PM, revealed she was required to empty and remove dirty urinals and store them in the bathroom. SRNA #3 stated she should have ensured Resident #4's overbed table was clean prior to placing a meal tray on the table. Interview conducted with the Acting Unit Manager for the East Unit on 08/03/17, at 3:45 PM, revealed SRNA #3 should have emptied Resident #3's urinal and ensured the overbed table was clean before setting up the resident's meal tray. The Acting Unit Manager stated she had not identified any concerns related to infection control. An interview conducted with the Acting Director of Nursing (DON) on 08/03/17, at 4:10 PM, revealed SRNAs were taught how to set up a resident's meal tray and SRNA #2 should not have set up Resident #3's meal tray with a urinal on the table. The Acting DON stated she had not identified any concerns related to infection control.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure allegations of verbal abuse were reported immediately to Administration for two (2) of two (2) sampled residents (Resident #1 and Resident #2) to ensure the safety of residents. Review of a facility investigation revealed that on 08/14/16 at approximately 6:30 AM State Registered Nurse Aide (SRNA) #3 witnessed SRNA #4 curse and use profanity toward Resident #1 and Resident #2 while providing care during shift change. SRNA #3 failed to immediately report the allegation of abuse in accordance with the facility policy. The findings include: Review of the facility policy entitled Freedom from Abuse, dated September 2015, revealed verbal abuse is defined as the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Any alleged violations involving mistreatment, neglect, or abuse, including inquiries of an unknown source and misappropriation of the resident property must be reported to the employee's immediate supervisor, who will report such to the administrator immediately or it can be reported directly to the administrator. The person(s) observing an incident of resident abuse or suspecting resident abuse must report such incident immediately to their supervisor. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 09/09/13 with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unable to be interviewed due to severe cognitive impairment. Observations of Resident #1 on 08/29/16 at 11:00 AM revealed the resident lying in the bed with his/her eyes closed, with no bruising or signs of abuse noted. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 05/14/09 with [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unable to be interviewed due to severe cognitive impairment. Observations of Resident #2 on 08/29/16 at 12:34 PM revealed the resident was lying in bed with his/her eyes closed, with no bruising or signs of abuse noted. Review of the facility investigation dated 08/14/16 revealed SRNA #3 reported to SRNA #1 that she witnessed SRNA #4 using foul language to Resident #1 and Resident #2 on 08/14/16 during the morning shift change. She stated SRNA #4 told Resident #1, F--- you and your daughter and your nasty a-- grandson too, and said to Resident #2, Turn over you B-----. The investigation stated that SRNA #1 reported the incident to LPN #1 as soon as SRNA #3 told her about the incident and LPN #1 reported the allegation of abuse to the House Supervisor immediately, who then started a formal investigation. Interview with SRNA #3 on 08/29/16 at 1:57 PM revealed that she had been educated on types of abuse and reporting abuse, but did not feel she had received a thorough in-service. SRNA #3 stated she witnessed the incident at shift change, but did not report the incident until later in the day because it caught her off guard when SRNA #4 spoke to Resident #1 and Resident #2 that way. She further stated that she had never witnessed SRNA #4 act that way before. Interview with LPN #1 on 08/29/16 at 1:51 PM revealed that SRNA #1 reported the allegation of abuse to her while they were on their late morning break. She stated she then immediately reported it to the Charge Nurse. Interview with the Charge Nurse on 08/29/16 at 2:42 PM revealed that she was made aware of the allegation of abuse by LPN #1. She then reported it to the House Supervisor who initiated a formal investigation. Interview with the House Supervisor on 08/29/16 at 2:49 PM revealed that prior to this allegation of abuse, SRNA #4 had not had any complaints from staff, residents, or family members related to abuse. She further stated that all of the residents liked him and that he provided good care. Interview with the Director of Nursing (DON) on 08/29/16 at 3:30 revealed that all staff had abuse training prior to working in direct care with residents. She stated this included the types of abuse and when to report abuse. She further stated that it was her expectation that staff report any alleged or witnessed abuse immediately to their supervisor. Further interview revealed that SRNA #3 should not have waited as long as she did before reporting the abuse that she witnessed.

Based on observation, interview, record review, review of facility policy, and review of the Textbook for Long-Term Care Nursing Assistants, it was determined the facility failed to provide services that meet professional standards of quality for two (2) of twenty (20) sampled residents (Resident #2 and Resident #17) related to catheter care. A review of Mosby's Textbook for Long-Term Care Nursing Assistants revealed urinary catheters should be secured to the resident's inner thigh, or to a man's abdomen. However, the facility developed a care plan for Resident #2 and Resident #17 that stated the catheter may be secured if pulling is problematic, and failed to ensure the residents' catheters were secured. The findings include: Review of the facility policy, Resident Interdisciplinary Care Plan, with a revision date of August 2014 revealed an interdisciplinary care planning conference was held to identify residents' needs and to establish obtainable goals, and an appropriate plan of action was designed to ensure optimal levels of activity and independence for all residents. Review of Mosby's Textbook for Long-Term Care Nursing Assistants, Seventh Edition, revealed catheters should be secured to the inner thigh, or secured to a man's abdomen. The textbook stated this prevents excess catheter movement and friction at the insertion site. The catheter should be secured with a tube holder, tape, or other devices as the nurse directed. 1. Review of the medical record for Resident #2 revealed the facility admitted the resident on 01/30/15 with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 required the use of an indwelling urinary catheter. According to the resident's MDS, the resident was not interviewable. Review of the comprehensive care plan dated 09/22/15 for Resident #2 revealed the facility identified that the resident had an indwelling catheter; however, the care plan stated, May anchor Foley (urinary catheter) to leg with tape or tubing holder if pulling is problematic. Observation of Resident #2 on 10/28/15, at 1:21 PM, revealed the resident was lying on his/her back in bed with the urinary catheter tubing draped over the resident's left leg. The urinary catheter tubing was not secured to the resident to prevent pulling of the urinary catheter tubing. 2. Review of Resident #17's medical record revealed the facility admitted the resident on 04/01/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #17 required an indwelling urinary catheter. According to the resident's MDS, the resident was not interviewable. Review of Resident #17's Care Plan dated 05/13/15, revealed the facility identified the resident required the use of a urinary catheter with interventions to position catheter bag and tubing below the level of the bladder and may anchor Foley to leg with tape or tubing holder if pulling is problematic. Observation on 10/27/15 at 9:35 AM with RN #1 revealed Resident #17 was in bed. The resident's urinary catheter tubing was lying over the left leg and attached to a drainage bag; however, Resident #17's catheter tubing was not secured to the resident's leg. Interview with the Director of Nursing (DON) on 10/29/15 at 4:05 PM revealed she was aware residents' care plans and the facility's policy stated that the resident's catheter tubing may be anchored to the resident. She stated they were worded that way because some residents requested that the catheter not be anchored (there was no evidence Resident #2 or Resident #17 had requested that their urinary catheters not be secured). Furthermore, she stated that the facility used Mosby's Textbook for Long-Term Care Nursing Assistants, Seventh Edition, for reference with urinary catheter care, and nurses and Certified Nursing Assistants (CNAs) were responsible for ensuring that residents' urinary catheters were secured.

Based on observation, interview, record review, review of a facility policy, and the Mosby Textbook for Long-Term Care Nursing Assistants, it was determined the facility failed to ensure urinary catheter tubing was secured to prevent possible injury/trauma of the urinary tract for two (2) of twenty (20) sampled residents (Resident #2 and Resident #17). The Mosby Textbook for Long-Term Care Nursing Assistants utilized by the facility stated urinary catheters should be secured to prevent excess movement and friction; however, the facility policy and care plans for Residents #2 and #17 stated the catheters may be secured and failed to ensure that urinary catheters were secured for the residents. The findings include: Review of a facility policy titled Urinary Catheter Care, dated June 1994, revealed the catheter may be secured to inner thigh (females) or lateral leg or abdomen (males) to prevent strain/friction at insertion site, prevent excessive movement of the catheter, and ensure the free flow of urine. The policy stated the catheter may be taped with non-[MEDICATION NAME] tape or secured with an anchoring device. Further review of the policy revealed staff should keep enough slack in the catheter tubing to allow the patient to move about without the catheter pulling on the urethra. Review of Mosby's Textbook for Long-Term Care Nursing Assistants, Seventh Edition, revealed catheters should be secured to the inner thigh, or secured to a man's abdomen. The textbook stated this prevents excess catheter movement and friction at the insertion site. The catheter should be secured with a tube holder, tape, or other devices as the nurse directed. 1. Review of the medical record for Resident #2 revealed the facility admitted the resident on 01/30/15 and was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's comprehensive care plan dated 09/22/15 revealed the facility addressed the use of the urinary catheter with interventions that included positioning the catheter bag and tubing below the level of the bladder and may anchor Foley to leg with tape or tubing holder if pulling is problematic. Catheter care was observed to be performed by facility staff for Resident #1 on 10/28/15 at 1:21 PM. The catheter was attached to a bedside drainage bag; however, the tubing was not secured to the resident's leg. Interview with State Registered Nursing Assistant (SRNA) #1 on 10/29/15 at 3:47 PM revealed she was trained to anchor an indwelling urinary catheter to the resident when performing catheter care. She stated she tried to keep Resident #2's catheter anchored, but the resident pulled off the anchor. Furthermore, she stated that if she were performing catheter care on a resident and noticed that their catheter was not anchored, she would get a device from the supply room and ensure the catheter was anchored. Interview with Licensed Practical Nurse (LPN) #1 on 10/29/15 at 5:32 PM revealed that all nurses and nursing assistants were responsible for ensuring residents' indwelling urinary catheters were anchored to the resident's leg or abdomen. She stated that sometimes the anchor came off and they replaced them. Interview with the East Unit Coordinator on 10/28/15 at 6:37 PM revealed the facility's policy stated that they may or may not anchor urinary catheters. She stated they tried to keep anchors on all residents that required indwelling urinary catheters. Furthermore, she stated the nurse was responsible for ensuring catheter tubing was anchored to their leg when nurses completed rounds and assessments. She also stated that Resident #2 routinely removed his/her anchor, which was why the resident did not always have one. Interview with the Director of Nursing (DON) on 10/29/15 at 4:05 PM revealed the facility utilized the Mosby's Textbook for Long-Term Care Nursing Assistants, Seventh Edition, as a reference for urinary catheter care. She stated nurses and Certified Nursing Assistants (CNAs) were responsible for ensuring residents' urinary catheters were anchored. She also stated she was aware that the facility's policy and residents' care plans stated that the catheter tubing may be anchored to the resident. She stated it was worded in that manner because the facility had many residents that requested the catheter not be anchored (there was no evidence Resident #2 or Resident #17 had requested their urinary catheters not be anchored). 2. Review of Resident #17's medical record revealed the facility admitted the resident on 04/01/14 with [DIAGNOSES REDACTED]. Review of Resident #17's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident required an indwelling urinary catheter. According to the resident's MDS, the resident was not interviewable. Review of Resident #17's Comprehensive Care Plan dated 05/13/15 revealed the facility identified the resident had an indwelling urinary catheter and developed an intervention that stated, May anchor Foley to leg with tape or tubing holder if pulling is problematic. Observation of Resident #17 with Registered Nurse (RN) #1 on 10/27/15 at 9:35 AM, revealed the resident's indwelling urinary catheter tubing was attached to the drainage bag; however, the tubing was not secured to Resident #17's leg. RN #1 explained during an interview on 10/29/15 at 6:45 PM, that she did not think there was any documentation reflecting the last time anyone documented the urinary catheter was secured. Interview with State Registered Nurse Aide (SRNA) #2 revealed Resident #17's indwelling urinary catheter was usually secured to the resident's leg and did not remember if the anchor (device to secure the catheter tubing) came off the resident's leg during a bath. SRNA#2 stated she should have secured the catheter tubing to Resident #17's leg after the resident's bath. Interview with the Director of Nursing (DON) on 10/29/15 at 4:05 PM revealed she was aware residents' care plans and the facility's policy stated that the resident's catheter tubing may be anchored to the resident. She stated they were worded that way because some residents requested that the catheter not to be anchored (there was no evidence Resident #2 or Resident #17 had requested that their urinary catheters not be secured). Furthermore, she stated that the facility used Mosby's Textbook for Long-Term Care Nursing Assistants, Seventh Edition, for reference with urinary catheter care, and nurses and Certified Nursing Assistants (CNAs) were responsible for ensuring that residents' urinary catheters were secured.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate treatment and services were provided for one (1) unsampled resident (Resident A). Facility staff administered medications to Resident A through the resident's gastrostomy tube (feeding tube); however, staff failed to check the feeding tube to ensure it was properly placed prior to administering medications. The findings include: A review of the Medication Administration Policy (dated 07/01/01) revealed staff should inject a small amount of air with a syringe into the gastrostomy tube while listening to the resident's stomach with a stethoscope for gurgling sounds. Staff should then aspirate the stomach contents with a syringe prior to administering medications into the gastrostomy tube. Observation conducted during medication administration on 10/29/15, at 9:15 AM, revealed Licensed Practical Nurse (LPN) #4 flushed Resident A's feeding tube with 30 milliliters of water without checking the resident's gastrostomy tube for placement. LPN #4 then administered [MEDICATION NAME] (antipsychotic) 25 milligrams (mg); [MEDICATION NAME] (anti-ulcer) 20 mg; Aspirin ([MEDICATION NAME]) 81 mg; [MEDICATION NAME] (antidepressant) 20 mg; [MEDICATION NAME] (opioid pain medication) 10 mg; and [MEDICATION NAME] (antianxiety) 0.5 mg to Resident A through the resident's feeding tube. Observation revealed the LPN failed to check to ensure the resident's feeding tube was placed in the resident's stomach prior to flushing the resident's feeding tube with water and administering medications. Interview with LPN #4 on 10/29/15, at 4:05 PM revealed the LPN was aware she was responsible to check the feeding tube for placement immediately prior to administering medications. The LPN stated she had checked Resident A's gastrostomy tube for placement approximately one hour before and should have checked again prior to administering the resident's medications. Interview conducted with the Director of Nursing (DON) on 10/29/15, at 4:10 PM, revealed she expected staff to check feeding tube placement once every shift, and would only check again if something was found to be abnormal, such as a clogged tube. However, a review of the facility's policy revealed staff should check a resident's feeding tube placement prior to administering medications. The DON revealed nurses' competency for administering medication via a feeding tube was checked annually, and no problems had been identified.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure food was stored under sanitary conditions. Seventeen (17) food products stored in the meat walk-in freezer were not labeled with the open date. One (1) food product stored in the vegetable walk-in freezer was not labeled with the open date. Two (2) multi-serving containers of salad dressings and one (1) multi-serving container of barbecue sauce were not labeled with the open date in the walk-in refrigerator. The findings included: Review of the facility's policy titled, "Standards for Dating and Storage of Perishables Foods", dated 07/10/98, revised June 2011, revealed all perishable foods in multi-serving containers will be labeled with the date they are opened and used by date based on the date opened. Observation of of the walk-in meat freezer on 09/10/13 at 1:20 PM, during the initial kitchen tour, revealed one (1) package of frozen sausage crumbles, one (1) package of frozen hot dogs, one (1) package of frozen fish nuggets, one (1) package of frozen chicken patties, one (1) package of frozen buffalo chicken legs, one (1) package of frozen polish sausage links, one (1) package of frozen fujita chicken, five (5) packages of frozen chicken tenders, one (1) package of diced chicken, one (1) package of chicken nuggets, one (1) package of frozen meatballs, and one (1) package of frozen bone in chicken fillets opened and not labeled with open date. Observation of the walk-in vegetable freezer on 09/10/13 at 1:20 PM, during the initial kitchen tour, revealed one (1) package of frozen cinnamon sticks opened and not labeled with open date. Observation of of the reach-in refrigerator on 09/10/13 at 1:20 PM, during the initial kitchen tour, revealed two (2) multi-serving containers of salad dressing and one (1) multi-serving container of barbecue sauce opened and not labeled with open date. Interview with Dietary Aid #1 on 09/11/13 at 11:50 PM revealed that she had been trained to label items in the freezer and the refrigerator with the open date. Dietary Aid #1stated there would be no way to know exactly how long an item had been in the refrigerator or freezer if they were not labeled with an open date and had been opened by someone on another shift. Interview with the Dietary Manager (DM), on 09/12/13 at 2:30 PM, revealed she had three (3) new employees that had not been inserviced on the proper storage of perishable foods. The DM revealed one (1) of the new employees had been employed for approximately three (3) weeks, one (1) of the new employees have been employed for approximately ten (10) weeks, and the other new employee had been employed approximately nine (9) months. The DM revealed it was her responsibility to make certain food was stored properly and that employees were trained on properly storing food.

Based on observations, interview and record review, it was determined the facility failed to properly store a varicella vaccine in the medication freezer in the medication room on the 2 South Nursing Unit. The findings include: Review of the facility's policy titled "Rockcastle Regional Hospital and Respiratory Care Center, Inc. Policy and Procedure: Safe Storage of Medications", last revised September 2012, revealed medications and biological are stored safely, securely, and properly following manufacturer's recommendations, or in the absence of such recommendations, according to a pharmacist's instructions. It further revealed medications are stored under proper conditions of sanitation, temperature, light, moisture, and ventilation according to manufacturer's recommendations or in absence of such recommendations, according to a pharmacist's instructions. The policy noted medications are stored at appropriate temperatures as defined below: Refrigerator temperature 2 degrees C - 8 degree C (36 degree F - 46 degree F) Room temperature 15 degree C - 30 degree C (59 degree F - 86 degree F) Freezer temperature -4 degree F - 14 degree F The policy further revealed refrigerator and freezer temperature logs are maintained with each refrigerator. Temperatures are recorded daily in regular medication storage refrigerators and twice a day in vaccine storage refrigerators. In the event medication is stored in a refrigerator or freezer which has deviated from the recommended temperature range, action will be taken based upon manufactures; information and/or appropriate research. Medication will be delivered to medication storage areas in the facility by pharmacy staff. Medications not administered may be returned to pharmacy, returned to medication storage areas, or wasted as appropriate. Observation on 09/12/13 at 2:30 PM, during an inspection of the medication room refrigerator and freezer on the 2 South Nursing Unit, revealed there was no thermometer in the freezer, and there was one medication present, a varicella vaccine. A record review revealed there was no daily temperature log being maintained for the freezer. Interview, on 09/12/13 at 2:30 PM, with Registered Nurse (RN) #1 revealed the varicella vaccine had been delivered by the pharmacy to administer to a resident and the vaccine was not administered secondary to the resident's condition and it was returned to the 2 South Nursing Unit freezer. RN #1 stated she did not know why there was not a thermometer in the freezer or a temperature log for the freezer and that she would investigate the situation. Interview, on 09/12/13 at 3:00 PM, with the Director of Nursing revealed medications and biologicals were not routinely stored in the freezers on the nursing units. Medications and biologicals which needed to be stored at a freezing temperature were stored in the pharmacy and delivered to the nursing units when they were ordered to be administered. The varicella vaccine should have been returned to the pharmacy when it was not administered to the resident, instead of the nursing unit freezer.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to provide care that promoted the dignity and respect for one of two unsampled and eighteen sampled residents (Resident B). Resident B was observed to be in the group interview with an uncovered urinary catheter drainage bag that was uncovered, and visible to every resident and visitor in the building. Interview with Resident B revealed the resident felt embarrassed for others to see the urinary drainage bag. In addition, observation of the noon meal on 11/07/12 revealed several residents received their meals in Styrofoam containers; interviews obtained during a group interview revealed several residents did not like to receive their food in Styrofoam containers. The findings include: A review of the facility policy, Resident' Rights for Residents in Kentucky Long-Term Care Facilities (undated), revealed residents had the right to a dignified existence inside and outside the facility. 1. Observation of Resident B on 11/07/12 at 3:00 PM, during the group interview revealed the resident's indwelling catheter drainage bag was uncovered and visible to every resident or visitor present. Interview with Resident B on 11/07/12 at 3:00 PM, revealed the resident felt embarrassed to have his/her catheter drainage bag visible to everyone. Resident B said he/she often took trips into the community and the catheter drainage bag was visible on trips as well. The resident felt the catheter drainage bag should be covered as it was a "dignity issue," but had never told the facility the way he/she felt. Interview with the Infection Control Supervisor on 11/09/12 at 2:45 PM, revealed urinary drainage bags were not covered but should be kept off the floor, under the resident's wheelchair or on the opposite side of the bed, out of view of the hallway if a resident was in bed. The Infection Control Supervisor was unaware of any complaints related to catheter drainage bags being visible to others. 2. Observation of the noon meal on 11/07/12 at 11:50 AM, revealed several residents received drinks, desserts, and salads in Styrofoam dishes. Interview with six alert and oriented residents during the group interview on 11/07/12 at 3:00 PM, revealed Styrofoam plates were utilized on a regular basis for meals. The residents stated they did not like receiving their food on Styrofoam plates. Interview with the Dietary Manager (DM) on 11/08/12 at 9:30 AM, revealed there was not enough room for all the dishes in the kitchen and the facility utilized Styrofoam. The DM did not notify any supervisor of the issue. The DM stated, "I can see how residents who live here wouldn't want Styrofoam for meals."

Based on observation and interview it was determined the facility failed to ensure foods were palatable and at the proper temperatures during the evening meal on 11/07/12. The findings include: Interview with the Dietary Manager (DM) on 11/07/12 at 5:30 PM, revealed there was no policy related to the point of service temperatures for the meal service but the temperature of the milk should not exceed 45 degrees Fahrenheit. Interview with six alert and oriented residents on 11/07/12 at 3:00 PM, revealed food was sometimes cold when served to the residents that ate meals in their rooms. Observation of the evening meal on 11/07/12 at 5:30 PM, revealed the South Hall meal cart arrived on the floor at 5:05 PM, and the last tray was removed from the cart at 5:30 PM. A test tray had been placed on the meal cart at the request of the surveyor and was removed from the cart at the same time the last tray from the cart was served. The temperatures of the food from the test tray were obtained by the DM and revealed the temperature of the milk was 54.2 degrees Fahrenheit, and exceeded the maximum acceptable temperature of 45 degrees Fahrenheit. Interview with the DM on 11/07/12 at 5:30 PM, revealed the milk should be 45 degrees Fahrenheit and no hotter. A taste test of the milk was conducted by the DM and the surveyor at the time the milk was removed from the meal cart and revealed the milk tasted warm. The DM stated even though the milk was placed into a container of ice until served the milk was apparently left too long on the meal cart next to the hot food. The DM stated routine observations were not made of the meal passes; however, test tray temperatures were checked on the B Hall every Friday by the cooks and dessert staff and they had not identified any problems related to food temperatures.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure staff used appropriate hand washing technique during wound care treatment for one of eighteen sampled residents (Resident #2). Staff was observed to omit hand washing/sanitizing after each glove removal during the dressing change as required. The findings include: Review of the facility policy/procedure, "Hand Hygiene," dated as revised October 2011, revealed staff was required to decontaminate hands after removing gloves. Observation on 11/08/12 at 10:16 AM, revealed Registered Nurse (RN) #1 prepared to conduct wound care for Resident #2. The RN donned gloves, removed the old dressing, and cleansed the skin surrounding the wound. The RN removed the gloves and donned new gloves without washing/sanitizing her hands after glove removal. The RN cleaned the wound and obtained wound measurements, removed her gloves, and donned new gloves without washing/sanitizing her hands after glove removal. After donning new gloves, the RN placed ointment into the wound, packed the wound, and removed her gloves. The RN donned new gloves but failed to wash/sanitize her hands after glove removal and proceeded to apply a new protective dressing to the resident's wound. Interview with RN #1 on 11/08/12 at 10: 20 AM, revealed she only washes/sanitizes her hands between glove changes if the resident has a draining wound. According to RN #1, she thought the facility policy/procedure was to wash hands between glove changes but she had failed to do so. Interview on 11/08/12 at 10:33 AM, with the West Unit Supervisor revealed staff should wash/sanitize their hands after glove removal. According to the supervisor, washing/sanitizing hands after glove removal was a Centers for Disease Control and Prevention (CDC) guideline.