Every finding on record at Sayre Christian Village Nursing Home

Based on observation, interview, and review of the facility's policies, the facility failed to prepare, store, and serve food under sanitary conditions. Observation of the Dietary Manager on 05/11/2026 at 2:00 PM, 2:20 PM, and 4:47 PM, revealed he performed hand hygiene at the hand sink and turned off the faucet with his bare hands.Observation of the resident nourishment refrigerator on Unit 2 on 05/11/2026 at 4:40 PM, revealed three clear plastic pitchers filled three-quarters full of a brown liquid substance. Further observation revealed one clear pitcher dated 05/04/2026 not labeled, and the other two pitchers with no date or label.The findings include: Review of the facility's policy titled, Hand Hygiene, dated 2024, revealed the process for hand hygiene technique when using soap and water included to rinse hands with water, dry thoroughly with a single-use towel, and use a clean towel to turn off the faucet. Further review revealed all staff would perform proper hand hygiene procedures in all locations within the facility. Review of the facility's policy titled, Food Safety Requirements, dated 2026, revealed food service safety referred to handling, preparing, and storing food in ways that prevented foodborne illness. Continued review revealed to label, date, and monitor refrigerated food by its use-by-date and discard once reached. 1. Observation during the initial kitchen tour on 05/11/2026 at 2:00 PM revealed the Dietary Manager (DM) performed hand hygiene at the hand sink and turned off the faucet with his bare hand instead of turning it off with a clean cloth. Continued observation of the DM on 05/11/2026 at 2:20 PM revealed he turned off the faucet at the hand sink again with his bare hand. Observation on 05/11/2026 at 4:45 PM during a return visit to the kitchen to view the supper resident tray line revealed the DM turned off the faucet at the hand sink with his bare hand again. 2. Observation of the Unit 2 nourishment refrigerator on 05/11/2026 at 4:40 PM revealed tea in a clear pitcher three-quarters full, dated 05/04/2026, with no use-by-date and two clear pitchers one-half to three-quarters full of tea that were not labeled or dated, and the original date label had been removed. During an interview with the DM on 05/15/2026 at 10:21 AM, he stated he should turn off the faucet with a paper towel to prevent the potential for cross contamination. He stated the lead dietary aide checked the nourishment refrigerators. He stated the tea should have been discarded within three days, and the undated tea should have been thrown out. During an interview with the Director of Nursing (DON) on 05/15/2026 at 10:54 AM, she stated germs could be reintroduced to clean hands by touching the faucets directly. She stated the State Registered Nurse Aides were instructed not to put any tea pitchers into the nourishment refrigerator. During an interview with the Administrator on 05/15/2026 at 3:02 PM, she stated the DM should not touch the faucets after washing his hands because of the potential to reintroduce bacteria. She stated the tea should be thrown out due to potential for bacteria and decreased quality of the product.

Based on observation, interview, and review of the facility's policy, the facility failed to maintain an effective cleaning and disinfection program for shared resident-care equipment. This affected 2 out of the 3 facility's Hoyer sit-to-stand lifts, one on the 300 Unit and one on the 200 Unit.The findings include: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 01/01/2025, revealed cleaning was the removal of visible soil from objects and surfaces and normally was accomplished manually or mechanically using water with detergents or enzymatic products. Additionally, the policy stated each user was responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. Per the policy, multiple-resident use equipment shall be cleaned and disinfected after each use. Observation on 05/14/2026 at 8:37 AM of the 300 Unit and observation on 05/14/2026 at 10:36 AM in the equipment storage area on the 200 Unit revealed the Hoyer sit-to-stand lifts located in a side area contained finger/toenail clippings in the platform of the device in addition to an encrusted substance throughout the creases in the platform.During an interview on 05/14/2026 at 9:55 AM with State Registered Nurse Aide (SRNA) 3 in the 300 Unit hall, she stated shared resident equipment should be cleaned after each resident use. The State Survey Agency (SSA) Surveyor asked SRNA3 to observe the Hoyer sit-to-stand lift positioned in the hall of the 300 Unit. After viewing the lift, SRNA3 stated the sit-to-stand lift was supposed to be cleaned by the night shift. She stated she thought housekeeping was responsible for deep cleaning of the lifts. SRNA3 stated the lifts were used in the shower rooms, and residents were required to have their feet covered while in the shower room.During an interview on 05/14/2026 at 2:46 PM with SRNA4, she stated equipment like the sit-to-stand lifts were to be cleaned after each resident use, and it was important to keep residents safe from infection. During an interview on 05/14/2026 at 2:51 PM with SRNA5, she stated the Hoyer lift and sit-to-stand lifts were all supposed to be cleaned after each resident use to keep residents from infecting each other.During an interview on 05/14/2026 at 2:59 PM with SRNA6, she stated Hoyer sit-to-stand lifts were to be wiped down with purple top (disinfectant) wipes after each resident use. During an interview on 05/14/2026 at 8:02 AM with Licensed Practical Nurse (LPN) 2, she stated multi-use resident equipment was to be cleaned after every resident use. She stated the cleaning of multi-use resident items lessened the chance of infections being spread to other residents. During an interview on 05/14/2026 at 10:16 AM with LPN3, she stated items staff used on residents should be cleaned after being used on each resident to prevent the spread of infection.During an interview on 05/14/2026 at 2:40 PM with LPN1, she stated all shared resident equipment was to be cleaned after each resident use to decrease the spread of infection. During an interview on 05/14/2026 at 11:34 AM with the Unit Manager of the 300 Unit, she stated Hoyer sit-to-stand lifts were to be cleaned after each resident use. She stated housekeeping did perform deep cleaning on the Hoyer sit-to-stand lifts. She stated all multi-use resident items were to be cleaned after every use on surfaces used by residents, and the cleaning was done to reduce the spread of infection. During an interview on 05/14/2026 at 11:47 AM with the Infection Preventionist (IP), he stated Hoyer sit-to-stand lifts were to be cleaned after each resident use. He stated housekeeping did perform deep cleaning on the Hoyer sit-to-stand lifts. The SSA Surveyor showed the IP photos of the two Hoyer sit-to-stand lifts. The IP stated, Oh my, we need to address this right away. He stated the cleanliness of the lifts was an infection control issue. During an interview on 05/15/2026 at 10:47 AM with the Director of Nursing (DON), she stated the policy for cleaning shared resident equipment was to sanitize after each resident use. She stated the result of not cleaning Hoyer sit-to-stand lifts was the presence of all kinds of germs on the lifts. During an interview on 05/15/2026 at 2:54 PM with the Administrator, she stated it was her expectation for staff to clean shared resident equipment after each use. She stated if equipment was not cleaned that would cause infection control problems. She stated it would also create a cross-contamination problem.During an interview on 05/15/2026 at 8:28 AM with the Medical Director, he stated it was his expectation for staff to follow protocol for infection control.

Based on interview, record review, and review of the facility's policy, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. The facility failed to ensure the notice included the reason, date, and location for the transfer, as well as a statement of the residents' appeal rights and the contact information for the state Long-Term Care Ombudsman. The deficient practice was identified for 3 of 7 residents sampled for transfer and/or discharge, Resident (R) 1, R7, and R11. The findings include:Review of the facility's policy titled, Bed Hold Notice, reviewed/revised 03/05/2025, revealed it was the policy of the facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. 1. Review of R1's Face Sheet revealed the facility admitted the resident on 01/25/2022 with diagnoses of Alzheimer's disease, unspecified abnormalities of gait and mobility, and unspecified psychosis not due to a substance or known physiological condition.Review of R1's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/13/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of zero of 15, indicating she was severely cognitively impaired.Review of R1's Progress Notes revealed on 03/27/2026 at approximately 9:55 AM, R1 was sent to the local emergency room by ambulance. Per the note, R1 was not given a Notice of Bed Hold or Notice of Transfer before leaving the facility or upon return to the facility on [DATE]. During an interview with Family Representative 1 on 05/14/2026 at 2:24 PM, she stated the facility did call her to notify her the resident was being sent out to the emergency room. However, she stated she had never received a Notice of Bed Hold or Notice of Transfer from the facility by hand delivery or mail.2. Review of R7s Face Sheet revealed the facility admitted the resident on 01/25/2022 with diagnoses of schizoaffective disorder bipolar type, anemia, and other idiopathic peripheral autonomic neuropathy.Review of R7's quarterly MDS, with an ARD of 05/01/2026, revealed the facility assessed the resident to have a BIMS score of 13 of 15, indicating she was cognitively intact.Review of R7's Progress Notes revealed on 12/30/2025, R7 was transferred to the emergency room via ambulance. Per the note, R7 was not given a Notice of Bed Hold or Notice of Transfer before leaving the facility or upon return to the facility on [DATE]. During an interview with Family Representative 7 on 05/14/2026 at 2:41 PM, she stated the facility did call her to notify her the resident was being sent out to the hospital. However, she stated she did not receive a Notice of Bed Hold or Notice of Transfer from the facility by hand delivery or mail.3. Review of R11's Face Sheet revealed the facility admitted the resident on 10/23/2025 with diagnoses of unspecified severe protein and calorie malnutrition, paroxysmal atrial fibrillation, and anemia.Review of R11's quarterly MDS, with an ARD of 05/01/2026, revealed the facility assessed the resident to have a BIMS score of 11 of 15, indicating she had moderate cognitive impairment.Review of R11's Progress Notes revealed on 12/24/2025 and 02/11/2026, R11 was transferred to the emergency room via ambulance. Per the note, R11 was not given a Notice of Bed Hold or Notice of Transfer before leaving the facility. During an interview with Family Representative 11 on 05/14/2026 at 2:43 PM, she stated the facility did call her when R11 was transferred to the emergency room. However, she stated she did not receive a Notice of Bed Hold or Notice of Transfer from the facility by hand delivery or mail.During an interview with the Administrator on 05/14/2026 at 4:02 PM, she stated the facility had just hired a new Business Office Manager (BOM). She stated the previous BOM was terminated due to not performing her job duties to ensure the best standard of practice for the residents and their representatives. She stated she would take the time to make sure the new BOM would complete the Notice of Bed Hold and/or Notice of Transfer notices. She stated residents would receive the forms before transfer, and the family representatives would receive the forms in person or by mail.

Based on interview, record review, and review of the facility's policy, the facility failed to provide completed pre- and post-dialysis communication documentation for 1 of 1 dialysis residents, Resident (R) 5. Review of documentation for 12 dialysis visits for R5, from 04/17/2026 through 05/13/2026, revealed communication forms were either unavailable or incomplete.The findings include: Review of the facility's policy titled, Hemodialysis, revision date 08/23/2024, revealed the facility would provide the necessary care and treatment consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences to meet the special medical, nursing, mental, and psychosocial needs of the resident receiving hemodialysis. Further review revealed the facility would assure each resident received care and services consistent with professional standards of practice which included ongoing assessments before and after dialysis treatments and ongoing communication with the dialysis facility. Additional review revealed the licensed nurse would communicate to the dialysis center either telephonically or in written format such as a communication form. Review of R5's Face Sheet revealed the facility admitted the resident on 05/14/2025 with diagnoses to include end stage renal disease, stroke, and acute respiratory distress. Review of R5's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 05/15/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15, which indicated the resident was cognitively intact. Review of R5's Physician's Orders, dated 11/26/2025, revealed an active order for the resident to receive dialysis every Monday, Wednesday, and Friday related to renal failure. Review of R5's Care Plan, initiated on 05/15/2025, revealed a problem identified as needing dialysis related to end stage renal disease (ESRD). Goals included the resident would have no signs and symptoms of complications from dialysis. However, interventions did not include initiation, completion, and documentation of the Pre/Post Dialysis Communication Form. Review of the facility's blank document Dialysis Communication Form revealed sections titled Pre-Dialysis, Dialysis Center Information (dialysis center to complete prior to the resident's return), and Post-Dialysis. Further review revealed sections for medications administered prior to dialysis, pre-weight, if a meal or snack was sent, shunt/catheter location/status, and additional information were to be completed by the facility's staff and the dialysis center's staff. Review of R5's hemodialysis treatment records received from the dialysis center revealed R5 received 12 hemodialysis in-center treatments from 04/17/2026 through 05/13/2026. During an interview with R5 on 05/15/2026 at 10:00 AM, she stated she had dialysis on Monday, Wednesday, and Friday. She stated she did not want food to be sent with her since her treatment was not until late morning, and she was not hungry. She stated getting to and from dialysis was never an issue, and she thought the dressing to her arm stayed in place until the next day after treatment. During an interview with State Registered Nurse Aide (SRNA) 1 on 05/15/2026 at 10:50 AM, she stated before R5 went to dialysis she helped get R5 dressed and sometimes would be asked to get vital signs and weights. She stated if she did get vital signs and weights, she verbally reported that to the nurse, and they would record the results. The State Survey Agency (SSA) Surveyor requested, from the Unit Manager (UM), on 05/15/2026 at 9:32 AM, R5's medical chart or folder for the Pre/Post Dialysis Communication Forms. She stated there was really no folder/chart with the forms. However, copies of dialysis communication forms were given to the SSA Surveyor. Review of the hard copies given revealed they were incomplete of pre- and post-dialysis information. During continued interview with the UM at this time, she stated as a UM her expectations were for the nurses to assure the dialysis forms were completed prior to sending the resident to dialysis and after the resident returned post-dialysis. She stated if current conditions were not listed on the forms, resident safety could be affected. She stated R5 had a dialysis access to the right upper extremity, and the bruit and thrill should be checked pre- and post-dialysis to assure it was functioning, and there was no abnormal bleeding. She stated the nurse aides or the nurses should be getting weights pre-dialysis, and nurses should be adding it to the form. She stated nurses sometimes would call the dialysis center with report, but the UM was unable to provide documentation the calls had been placed. The UM stated R5 only wanted a Nepro (nutritional shake specialized for residents on dialysis) sent with her to dialysis as a snack. During an interview with the Director of Nursing (DON) on 05/15/2026 at 11:15 AM, she stated her expectations of staff was to ensure the dialysis communication forms were completed pre- and post-dialysis treatments to make sure accurate information was current. She stated staff should be sending a snack with the residents since they were going to be there for an extended time. She stated the access site should be assessed pre- and post-dialysis to assure it was correctly functioning. During an interview with the Administrator on 05/15/2026 at 3:43 PM, she stated the dialysis communication forms should be completed by the sending staff, the dialysis staff, and staff receiving the resident after dialysis treatment. She stated it was important so all staff knew the status of the resident and especially the amount of fluid removed in the dialysis center.

Based on observation, interview, and review of the facility's policy, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 sampled residents, Resident (R) 12 and R99.The findings include: Review of the facility's policy titled, Medication Storage, implemented date 01/2025, revealed medications would be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and be sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Additional review revealed the policy did not address labeling medications. Further review revealed external products, such as disinfectants and drugs for external use, were stored separately from internal and injectable medications. Observation on 05/13/2026 at 4:08 PM of the 200 Hall medication refrigerator revealed one canister labeled F-Magic Butt/Lidocaine Cream to apply topically to buttocks every shift as needed for redness, dated 04/23/2026. Further review revealed the canister was labeled with R99's name and an expiration date of 05/06/2026. Further observation revealed one canister labeled Magic Butt Paste, apply to affected areas twice a day for stage 2 sacral wound until healed, dated 04/22/2026. Further review revealed the canister was labeled with R12's name and an expiration date of 05/09/2026. In an interview with Licensed Practical Nurse (LPN) 8 on 05/13/2026 at the time of the observation, she stated the creams for R12 and R99 had expired and should not be in use. When asked why, she stated medication could be ineffective and had the potential not to heal as it should. In an interview with the Unit 100 Manager on 05/15/2026 at 9:32 AM, she stated if expired medications were given, they might not work. In an interview with the Director of Nursing (DON) on 05/15/2026 at 11:15 AM, she stated nursing staff should be checking medication refrigerators daily for expired medications and discarding them. She stated if the medication was expired, it might have a negative effect and not work. In an interview with the Administrator on 05/15/2026 at 3:43 PM, she stated expired medications should be discarded. She stated she expected staff to follow the facility's policies. She stated if a medication had expired, it might not be effective.

Based on observation, interview, record review, facility document review, Centers for Disease Control and Prevention guidelines, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 34 sampled residents, Resident (R) 11, R34, R36, R119, R125, and R150. Observations revealed R11 and R34 had indwelling urinary catheter drainage bags resting on the floor; a gait belt was used on R36 without its prior disinfection; a blood pressure cuff was used on R125 and not disinfected after its use; R150's medications were placed on an unclean surface without using a barrier; R119's food was handled by a staff member with ungloved hands; and a dietary staff member's badge was resting in a resident's food. The findings include: Review of the facility's policy titled, Infection Surveillance, dated 01/01/2025 revealed its purpose was to identify infections and to monitor adherence to recommended infection prevention and control practices to reduce infections and prevent the spread of infections. Review of the facility's policy titled, Catheter Care, Urinary, revised 08/2022, revealed the catheter tubing and catheter drainage bag were kept off the floor. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 01/01/2025, revealed that reusable resident-care equipment will be cleaned and disinfected in accordance with current Centers for Disease Control and Prevention (CDC) recommendations. The policy stated, Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. The policy stated, Multiple-resident use equipment shall be cleaned and disinfected after each use. The policy stated, Use only Environmental Protection Agency (EPA)-registered disinfectants with kill claims for the common organisms found in the facility. Review of the CDC's Guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/2021, revealed reusable medical equipment should be cleaned and disinfected according to manufacturer's instructions or the facility's policies before and after use. Further review of the guidelines revealed staff should be trained in the correct steps for cleaning and disinfection of shared equipment. Review of the facility's [Facility] Employee Handbook, dated 01/01/2024, regarding employee identification badges, revealed, Staff must wear identification badges visibly above the waist and in front of the body. Badges may not be clipped onto sleeves. Staff must be aware of lanyards, metal clips, and pins during resident care. Breakaway lanyards are required for safety. 1. Observation on 04/21/2025 at 1:52 PM revealed the Physical Therapy/Occupational Therapy assistant (PTA/OTA) used a gait belt for R147 and then placed the gait belt around her neck without cleaning/disinfecting it. The PTA/OTA then used the same gait belt on R36, ambulated her to the Activities Room, removed the gait belt, and placed it back around her neck without cleaning/disinfecting it. The PTA/OTA then cleaned the handles on the walker that was used with R36 with hand sanitizer from the hall. During an interview with the PTA/OTA on 04/21/2025 at 2:03 PM, she stated she normally used a disinfectant spray to disinfect the gait belt, but she had left the spray downstairs in the office. She stated she cleaned the walker with sanitizer but was not sure what the policy stated. 2.a. Review of R34's Admission Record revealed the facility admitted the resident on 12/05/2024 with diagnoses including acute lymphoblastic lymphoma (ALL), urinary retention, and chronic obstructive pulmonary disease (COPD). Review of R34's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15, which indicated the resident was cognitively intact. Further review revealed the resident was admitted with an indwelling urinary catheter. Review of a Physician's Order found in R34's electronic medical record (EMR) revealed an active order, dated 12/05/2024, that specified indwelling urinary catheter care every shift for neurogenic bladder. Review of the R34's Care Plan Report, revised 12/10/2024, revealed a problem of altered urinary elimination related to the use of an indwelling catheter with an increased risk for urinary tract infection (UTI) related to neurogenic bladder and urinary retention. Observation on 04/22/2025 at 8:54 AM revealed R34 asleep in bed; the urinary catheter was positioned on the far side of the resident's bed, and the drainage bag was located on the floor. Additional observation of R34 on 04/22/2025 at 11:22 AM again revealed the catheter positioned on the resident's bed with the drainage bag on the floor. b. Review of R11's Admission Record revealed the facility admitted the resident on 01/21/2025 with diagnoses including Non-Hodgkin lymphoma, personal history of UTIs, and Alzheimer's disease. Review of R11's admission MDS, with an ARD of 01/28/2025, revealed the facility assessed the resident to have a BIMS score of three out of 15, which indicated the resident was severely cognitively impaired. Further review revealed the resident was admitted with an indwelling urinary catheter. Review of a Physician's Order found in R11's EMR revealed an active order, dated 04/02/2025, that specified indwelling urinary catheter care every shift and as needed. Review of the R11's Care Plan Report, dated 04/11/2025, revealed a problem of altered urinary elimination related to the use of an indwelling catheter. Observation on 04/22/2025 at 11:15 AM revealed R11 in her room seated in a recliner. R11 had an indwelling urinary catheter attached to the recliner with the drainage bag observed on the floor. In an interview with State Registered Nurse Aide (SRNA) 3 on 04/23/2025 at 9:32 AM, she stated she provided catheter care every time she changed R34 and as needed. She further stated the catheter drainage bags were positioned on the bed lower than the level of a resident's bladder, covered with a dignity bag, and not placed on the floor because of infection concerns. SRNA3 stated if she observed a catheter bag on the floor, she notified nursing so the resident could be assessed before the bag was changed. In an interview with SRNA4 on 04/23/2025 at 9:50 AM, she stated staff received frequent in-services related to infection control, and catheter care was sometimes one of the topics. SRNA4 stated a catheter was positioned low on the bed, but the collection bag was never placed on the floor because of bacteria and the risk for infection. In an interview on 04/23/2025 at 9:54 AM, SRNA11 stated she checked residents' catheters each time she rounded on them. She stated catheters should be lower than the level of the bladder so they drained properly, and the collection bag should be off the floor because of possible contamination and infection. In an interview with Licensed Practical Nurse (LPN) 5 on 04/24/2025 at 10:05 AM, she stated she typically rounded on residents between SRNA rounds, so they were seen at least every hour. She further stated catheter drainage bags should be below the resident and off the floor, so they were kept clean, which reduced the potential for infection. LPN5 stated in the past, on her rounds, she had observed catheter drainage bags on the floor, but they were replaced immediately. In an interview with LPN 1 on 04/24/2025 at 10:18 PM, she stated she expected catheter drainage bags to be protected with dignity covers for privacy and to be kept off the floor. Additionally, she stated if the drainage bags were on the floor, it put the resident at risk for infection. In an interview on 04/24/2025 at 12:34 PM, the Infection Preventionist (IP) stated infection control training and education began at orientation. He further stated the facility also held annual trainings that covered infection control as well as regular infection control and prevention in-services. The IP stated it was his expectation that catheter drainage bags were always kept off the floor because that presented an infection risk for the resident. In an interview on 04/24/2025 at 4:29 PM with the Director of Nursing (DON), the DON stated catheter drainage bags should always be kept off the floor due to the potential risk for infection to the resident. In an interview on 04/24/2025 at 5:06 PM, the Administrator stated she expected catheter drainage bags to be always kept off the floor because of the potential risk for infection. 51155 3. Observation on 04/22/2025 at 9:00 AM revealed Kentucky Medication Aide (KMA) 1 used a blood pressure (BP) cuff on R125, then placed it back into the medication cart without cleaning/disinfecting it. In an interview on 04/22/2025 at 10:13 AM with KMA1, she stated BP cuffs should be cleaned between each resident with the purple top Sani-Wipes (an EPA registered disinfectant). In an interview on 04/22/2025 at 10:24 AM with Registered Nurse (RN) 1, she stated shared equipment should be cleaned between each use. She stated she used hand sanitizer to clean shared equipment, and she was unsure what the policy stated. In an interview on 04/23/2025 at 3:14 PM with SRNA7, she stated shared equipment was cleaned between each resident use with the purple top Sani-Wipes. She stated she would not use hand sanitizer and had not been taught that. 4. Observation on 04/22/2025 at 9:20 AM revealed KMA1 poured R150's medications onto the tablecloth in the dining room, without using a barrier, for R150 to self-administer medications. In continued interview on 04/22/2025 at 10:13 AM with KMA1, she stated she should have placed a barrier for medications placed on the tablecloth for R150 to self-administer. She stated tablecloths were normally cleaned daily, but she was unsure who changed them out. 5. Observation on 04/22/2025 at 12:20 PM revealed RN1 handled R119's chicken salad sandwich, breaking it in half, without wearing any gloves. In additional interview on 04/24/2025 at 8:40 AM with RN1, she stated she should have worn gloves while handling resident foods. She stated that was important to prevent contamination. In an interview on 04/24/2025 at 8:30 AM with the Infection Prevention/Wound Care Nurse (IP/WOCN), he stated shared equipment should be cleaned/disinfected before and between resident use with the purple top Sani-Wipes. He stated hand sanitizer should not be used as a disinfectant for shared equipment. He stated a barrier should always be used when pouring medications on a surface, and no direct contact with food is permitted. In an interview on 04/24/2025 at 4:29 PM with the Director of Nursing (DON), she stated shared equipment should be cleaned/disinfected between every use to decrease the spread of germs and diseases between residents. The DON stated hand sanitizer should never be used in place of Sani-Wipes. The DON stated staff should not be pouring medications on an uncleaned surface, and the medication cup should be handed to residents, or a clean barrier should be used. She stated gloves should be worn when handling resident food to prevent germs and cross contamination. In an interview on 04/24/2025 at 5:14 PM with the Administrator, she stated shared equipment should be cleaned/disinfected between each resident with Sani-Wipes, and hand sanitizer should never be used on equipment. She stated staff should not be handing foods without gloves on. She stated medications should never be poured onto an unsanitary surface for residents to self-administer for infection prevention and safety. 52361 6. Observation on 04/23/2025 at 11:27 AM revealed the [NAME] leaning over a dish of mechanically soft beef to take a food temperature on an adjacent dish, with her identification badge resting in the mechanically soft beef. In an interview on 04/23/2025 at 2:20 PM, the [NAME] stated she wears her badge around her neck and keeps it tucked inside her apron during plating and temping [taking food temperatures]. She stated the facility policy required staff to keep badges on and connected to you and not hanging around food. She stated she had not received specific training on securing her badge during food service. She stated she understood the requirement to wear gloves or use utensils when handling food and understood the importance of preventing foreign objects from contacting food. She stated, Contaminated food must be removed from the line and placed in the dirty dish room. She stated she was unaware her badge had contacted food when she took food temperatures that morning. In an interview on 04/23/2025 at 2:28 PM, the Dietary Manager stated policy required staff to wear badges between the waist and shoulder, close to the body, on breakaway lanyards for safety. He stated no separate dietary-specific policy existed. He stated residents were a vulnerable population and emphasized the critical importance of preventing food contamination. He stated he expected staff to remove, discard, and replace any food contacted by a foreign object. In an interview on 04/24/2025 at 5:28 PM, the Administrator stated contaminated food constituted an infection control issue. She stated after the incident was reported, she reviewed the handbook and confirmed the requirement for breakaway lanyards. She stated she would obtain badge [NAME] for dietary staff. In continued interview on 04/24/2025 at 4:29 PM with the DON, she stated she expected all staff to follow facility policies and procedures related to infection control and prevention. She further stated she constantly walked the halls and monitored for compliance. In continued interview on 04/24/2025 at 5:14 PM with the Administrator, she stated she expected all staff to follow the facility's infection control policies to maintain a safe environment for residents.

Based on interview, record review, and review of the facility's documents, the facility failed to ensure residents and resident representatives were informed, using appropriate language, that binding arbitration agreements explicitly were not required as a condition of admission explicitly provided the residents or resident representatives the right to rescind the agreement within 30 days of signing it for 5 of 5 residents reviewed for arbitration agreements, Resident (R) 32, R58, R117, R127, and R131. Additionally, interview with three residents (R58, R127, R131) that signed agreements, including one as recently as 04/01/2025 (R131), did not recall the discussion of arbitration or signing of arbitration agreements. The findings include: Review of the facility's document Arbitration and Mediation agreement, not dated, revealed appropriate verbiage was not included on the form. The form did not indicate it was an optional form for the resident to complete; did not indicate it was not a requirement for the resident's admission; and did not indicate residents or representatives had 30 days to rescind the form after signing. In interviews with the five residents present for the Resident Council meeting on 04/22/2025 at 1:26 PM, they stated none of them recalled signing any arbitration agreement. After the State Survey Agency (SSA) Surveyor described the arbitration document as a form that should have been identified as not a requirement to sign for admission, they still did not recall signing any arbitration agreement. Review of R32's and R117's Arbitration and Mediation agreement revealed both forms were signed by responsible parties and did not include required verbiage indicating it was not a requirement for admission and could be rescinded within 30 days of signing. Review of R58's and R127's Arbitration and Mediation agreement revealed both residents had signed their own arbitration agreements, which did not include require verbiage indicating it was not a requirement for admission and could be rescinded within 30 days of signing. R58 signed her document on 08/15/2023, and R127 signed his document on 05/30/2024. Review of the facility's new electronic health records (EHR) revealed R131 was classified as a new admission. Per the record, the facility admitted R131 on 04/01/2025, and she signed her own arbitration agreement. In an interview with R131 on 04/23/2025 at 8:17 AM, she stated there's so many things, if it said to sign it, then I signed it. She stated she thought the forms in the admission packet were for insurance. She stated the word arbitration did not sound familiar to her, and an arbitration form was not explained to her in detail. In an interview with the Admissions Coordinator (AC) on 04/22/2025 at 3:36 PM, she stated she had been trained on presentation and completion of Arbitration and Mediation forms by the Administrator. The AC stated she went over and read the agreement to residents or the responsible party. She stated she shared that they had the option not to sign but was not aware residents or representatives had the right to rescind arbitration agreements within 30 days of signing. She stated the Arbitration and Mediation document was part of about 70 other pages she reviewed with residents or representatives as part of the admissions process. In an interview with the Administrator on 04/23/2025 at 1:16 PM, she stated when arbitration was first introduced it was mandatory for admission, which was overturned in 2022. She stated since, it had been explained to residents and representatives as voluntary. She stated in August 2024 it was turned over to attorneys to be made into a separate document. The Administrator stated the facility had not yet received a revised document. The Administrator stated some residents or representatives did refuse to sign, so they were clearly presenting the arbitration agreement as not a condition of admission. The Administrator stated that, even though the facility dealt with this every day and understood residents and representatives were not required to sign the form as a condition of admission, she could understand the importance of residents and families knowing it was not a condition of admission. The Administrator stated initial paperwork for admission took an hour and a half to two hours to complete, and quite often, even higher functioning residents were tired coming from hospitals and would ask if their family or power-of-attorney (POA) could complete paperwork for them.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 4 sampled residents, Resident (R) 34 and R120. The findings include: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, revised 01/30/2025, revealed staff would ensure the call light was within reach of the resident and secured as needed. Further review revealed the call system would be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Review of the facility's policy titled, Resident Rights, undated, revealed the resident had the right to a dignified existence and self-determination. Review of the facility's policy titled, Safe and Homelike Environment, undated, revealed the facility would provide a safe, clean, comfortable, and homelike environment. 1. Review of R34's Admission Record revealed the facility admitted the resident on 12/05/2024 with diagnoses including acute lymphoblastic lymphoma (ALL), urine retention, and chronic obstructive pulmonary disease (COPD). Review of the R34's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 03/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15, which indicated the resident was cognitively intact. Further review revealed the resident required substantial to maximum assistance with bed mobility and was dependent on staff for transfers. Review of R34's Care Plan Report, with a revision date of 12/10/2024, revealed the resident required assistance from staff with activities of daily living (ADL). Observation on 04/22/2025 at 8:54 AM and again on 04/22/2025 at 11:22 AM revealed R34 was asleep in her bed. However, the call light was observed on the floor and out of the resident's reach. In an interview on 04/23/2025 at 9:32 AM, State Registered Nurse Aide (SRNA) 3 stated it was important residents' call lights were within their reach for safety purposes. She further stated if the call light was out of reach, residents felt unprotected. SRNA3 stated the call light should never be on the floor. In an interview with SRNA11 on 04/24/2025 at 9:54 AM, she stated residents' call lights should always be within their reach because it was a safety issue. She stated if a resident needed assistance, it was important for staff to be notified. In an interview with Licensed Practical Nurse (LPN) 1 on 04/24/2025 at 10:18 AM, she stated access to staff was important when residents needed help, and the call light should always be within their reach. 2. Review of R120's Admission Record revealed the facility admitted the resident on 01/30/2025 with diagnoses including cerebral infarction (stroke) and Alzheimer's disease. Review of R120's admission MDS, with an ARD of 02/06/2025, revealed the resident had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Observation on 04/21/2025 at 1:42 PM revealed R120 in her room sitting up in the recliner. Observation on 04/22/2025 at 8:34 AM revealed R120 asleep in her recliner. In an interview with R120 on 04/21/2025 at 1:42 PM, she stated she slept in the recliner each night. She further stated she was not able to sleep in her bed because it was uncomfortable and small; and the facility was supposed to have it replaced. In an additional interview with R120 on 04/22/2025 at 1:31 PM, she stated again that the bed in her room was uncomfortable. She stated she spoke to someone at the facility about it, but no one had responded. R120 stated she was not sure who she spoke with, but thought it was about a week or so ago. R120 stated she preferred a bed rather than a recliner when she slept. In an interview with the Social Services Director (SSD) on 04/23/2025 at 3:41 PM, she stated she was notified of a problem with R120's bed about a week ago. She further stated she was not sure exactly what the issue was; but something about the bed being too narrow, and R120 slept in her recliner. The SSD stated she thought perhaps the resident was a little claustrophobic. She further stated it was her responsibility to make sure someone followed up with the resident. The SSD stated she had not followed up with R120 but should have. In an interview with R120's Representative on 04/24/2025 at 3:47 PM, she stated the resident had not slept in a recliner at home. She further stated she was not sure what the issue was with the bed at the facility, but R120 slept in a bed when she was at home. In an interview on 04/24/2025 at 4:29 PM, the Director of Nursing (DON) stated she expected all staff would answer call lights, and if the resident's need was not in their scope of practice, appropriate staff would be contacted. She further stated a call light should never be left on the floor or anywhere out of a resident's reach because they needed access to staff at all times. The DON stated they had several residents at the facility that preferred a recliner over a bed, and she was not aware of an issue with R120's bed. In an interview with the Administrator on 04/24/2025 at 5:06 PM, she stated it was her expectation call lights were placed on the bed within the resident's reach, and on the floor was not acceptable. She stated she had not received a grievance or complaint from R120, or her family related to the need for a different bed. She further stated that was an issue that should have been brought to her attention immediately and appropriately resolved.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure residents were free of accident hazards as possible and failed to provide the necessary supervision and assistance to prevent accidents for one (1) of forty-four (44) sampled residents (Resident #2). Resident #2 was assessed to require the assistance of two (2) staff to assist with his/her baths and showers. However, the facility failed to ensure the resident's Comprehensive Care Plan (CCP) was reflective of the resident's assessed needs. On 03/30/2023, staff assisted the resident with a shower, without the assistance of staff, and the resident became combative causing the resident to sustain injuries which included a small laceration with some bruising and swelling; injuries to the eye; red markings on the left side of the neck; a bruise on the resident's right hand, and bruising on the resident's chest. The findings include: A review of the facility's policy titled, Accidents and Supervision, with the copyright 2022, revealed the residents' environment would remain free from accident hazards as was possible. Further review revealed each resident would receive adequate supervision and assistive devices to prevent accidents which included implementing interventions to reduce hazard(s) and risk(s) and monitoring for the effectiveness and modifying the interventions when necessary. Further review revealed implementation of interventions included assigning responsibility, providing training needed, communicating interventions to all staff, ensuring the interventions were put into action, and implementing specific interventions as part of the plan of care. Continued review of the policy revealed supervision was an intervention and a means of mitigating accident risk. Further, the facility would provide adequate supervision to prevent accidents. Review of Resident #2's Face Sheet revealed the facility admitted the resident on 05/13/2022, with diagnoses of dementia, Alzheimer's Disease, and psychotic disorder with delusions due to a known psychological condition. Review of Resident #2's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated the resident had severe cognitive impairment. Review of the MDS revealed the facility assessed Resident #2 as free of hallucinations, delusions and behaviors directed toward himself/herself. Continued review revealed the facility assessed Resident #2 with physical and verbal behaviors directed toward staff were present for four (4) to six (6) days during the assessment period. The review revealed the facility assessed Resident #2's behaviors as not placing him/her at risk for injury, and as not having interfered with his/her care and activities of self or others. Further review revealed the facility assessed Resident #2's behaviors as not having caused privacy issues for others and as not having disrupted care or the living environment of others. The facility assessed Resident #2 as having rejected care one (1) to three (3) days during the assessment period. In addition, the facility assessed Resident #2 as requiring the physical assistance of two (2) staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. However, a review of the resident's Comprehensive Care Plan revealed the facility failed to develop the resident's care plan to include having two (2) staff during bathing. A review of Resident #2's Comprehensive Care Plan (CCP) initiated on 05/17/2021, revealed new interventions implemented on 03/06/2023, which included assistance with ADLs, and for staff to offer the resident items to hold in his/her hands due to him/her becoming combative during care. A review of Resident #2's Kardex (SRNA care plan) dated 03/15/2023, revealed Resident #2 was assessed to require two (2) staff for bathing, dressing, and personal hygiene. A review of the facility's investigation of Shower Aide (SA) #1's statement dated 03/30/2023, revealed her first time working with State Registered Nurse Aide (SRNA) #3 was on 03/30/2023, and she told SRNA #3 she would help give Resident #2 his/her bed bath. Continued review revealed SA #1 noted SRNA #3 told her she would wait to complete the bed bath after lunch or would do it by herself. Further review revealed SA #1 noted she informed SRNA #3 that Resident #2 could be combative and should not have care provided by only one (1) staff member. In addition, the review revealed SA #1 documented SRNA #3 told her Resident #2 was not her first combative resident and stated she had been an SRNA for a long time. Review further revealed SA #1 noted later in the day that SRNA #3 told her she completed Resident #2's bed bath alone. Observation on 11/01/2023 at 1:00 PM, revealed staff used a mechanical lift to transfer Resident #2 and transport him/her to the shower room. Continued observation revealed upon entering the shower room Resident #2 looked around in confusion, and yelled out at staff a few times. Further, Resident #2 became upset when water hit his/her face, causing Resident #2 to yell out each time the water hit his/her face and feet. In addition, observation revealed Resident #2 was transferred back to his/her room without incident. In an interview with Shower Aide (SA) #1 on 11/03/2023 at 9:35 AM, she stated she was working on 03/30/2023, and her job was to help the nursing aides with showers. She stated she discussed giving Resident #2 a shower with SRNA #3. SA #1 stated she also informed SRNA #3 that Resident #2 required two (2) staff during care as the resident could become combative and had previously hurt staff members. Per interview, they discussed doing Resident #2's shower later; however, when SA #1 returned to help SRNA #3 the nurse aide had already completed the resident's bed bath alone which was against her advice, to complete the resident's shower together. SA #1 stated it was important to use two (2) staff members when a resident's care plan noted that, especially if the resident was combative. She stated using two (2) staff as per the resident's care plan ensured the resident and staff were not harmed and helped protect staff against false allegations. In an interview with SRNA #3, on 10/31/2023 at 1:53 PM, she stated 03/30/2023 was her first-time providing care to Resident #2; however, it had not been her first time working at the facility. She stated she was not briefed on 03/30/2023 when she was assigned to work with the resident. SRNA #3 stated she also did not know how to access the residents' Comprehensive Care Plans (CCP) or Kardex. She stated she had not reviewed Resident #2's care plan because she did not know how to find where it was located. Further, she stated she was not aware of the resident's intervention of placing something in the resident's hands to help prevent combative behavior. In a further interview with SRNA #3, on 10/31/2023, she stated she had not been informed Resident #2 was combative or required two (2) staff. She stated orientation was completed through her contract agency. SRNA #3 explained she had been an aide for five (5) years and knew how to care for residents. In an interview with Resident #2's family members #1 and #2, on 11/01/2023 at 10:07 AM, she stated the resident's family paid to have two (2) private sitters to sit with the resident at the facility. Further, they stated they wanted consistency of care for their family member, Resident #2. Family members #1 and #2 stated Resident #2 had experienced several injuries since being at the facility. In an interview with Licensed Practical Nurse (LPN) #2, on 11/02/2023 at 1:06 PM, she stated SRNA #3 told her she had given Resident #2 a bed bath and the resident became combative. LPN #2 stated SRNA #3 told her she tried to hold Resident #2's hands to prevent being hit by the resident; however, in the process, the resident hit himself/herself. She stated she had not worked with SRNA #3 prior to 03/30/2023, and she recalled the aide worked for a contract agency. LPN #2 stated the facility had not used agency staff for several months. She stated when an agency staff person reported to the facility for work, they had to sign in the binder at the desk and were to complete any in-services prior to going to the floor for work. The LPN stated when the agency staff got to the floor, they received their assignment sheet and got a rundown of their assigned residents. She stated that even if the aide from the previous shift was gone, the oncoming aide was expected to obtain the care information on their residents from the nurse. LPN #2 stated she did not expect SRNA's to know how to access residents' care plan information if it was their first time working in the building; however, she expected aides to ask their nurse about their residents' care needs. In an interview with Registered Nurse (RN) #5, on 11/02/2023 at 2:40 PM, she stated she had been the Charge Nurse on 03/30/2023, when SRNA #3 provided a bed bath for Resident #2 by herself. She stated SRNA #3 probably should not have been in Resident #2's room by herself, and she thought all staff knew which residents required two (2) staff for assistance. RN #5 stated SRNA #3 came out of Resident #2's room and told her the resident hit himself/herself in the face and was bleeding. She stated she went to check on Resident #2 and noted blood on the resident's shirt; however, did not recall blood being on the resident's face. The RN stated she had seen a cut near Resident #2's eye, and she placed a bandage to that area. She stated SRNA #3 did not tell her, she had held Resident #2's hands to prevent from being hit by him/her. In an ongoing interview with RN #5, she stated she was not aware of any bruises on Resident #2's chest, breast, or neck. She stated she had not completed a skin assessment on the resident because she believed SRNA #3 when she reported Resident #2 hit himself/herself. In an interview with RN #1, on 11/03/2023 at 12:55 PM, she stated Resident #2 was very sensitive to the touch, and he/she was a very sweet person until he/she was touched. She said something as simple as listening to Resident #2's lungs could set him/her off and agitate the resident. RN #1 stated on 03/30/2023 she had not worked; however, she was informed Resident #2 had a black eye when she returned to work. She stated Resident #2 always needed two (2) staff assistance, and especially when he/she had to be touched. The RN said Resident #2 became very combative during care. She stated Resident #2 had a history of pinching staff on their breast, the resident would grab hold of the staff member's breast and twist it hard. RN #1 stated she could always tell when staff were in the room with Resident #2 because she could hear the resident screaming and yelling even if the daughters were present. RN #1 stated Resident #2 did not like being touched by his/her daughters. In ongoing interview with RN #1, on 11/03/2023 at 12:55 PM, she stated if an aide had not followed a resident's care plan, she would redirect them and tell them what they were expected to do. She stated the facility had a write-up system, and she would talk to the Unit Manager, and the Unit Manager would address it. The RN stated if she was present the Unit Manager usually called her into the office, and they talked with the aide together. She further stated it was a requirement for staff to follow residents' care plans, because the care plan was created to show what care each resident needed. In addition, she also said if staff did not follow the care plan residents could be harmed. In an interview with the Minimum Data Set (MDS) Coordinator #1, on 10/07/2023 at 12:15 PM, she stated nurses were expected to look at the residents' Kardex to find out what level of ADL care the residents required, as the resident's ADL care would not have been documented as an intervention in the resident's Comprehensive Care Plan (CCP). The MDS Coordinator further stated the care plan would only be noted as to refer to the POC for ADL care. In an interview with MDS #2, on 11/09/2023 at 1:03 PM, she stated ADL care was noted on the care plan as follow the POC task schedule which was found on the residents' Kardex. She explained they documented the ADL care that way because it reflected real-time changes. MDS #2 stated a resident's level of care could change from day to day and the Unit Manager would update it through the POC more quickly than it would be updated by the MDS Coordinator. She stated doing it through the POC kept it current and would result in better care for the residents. She explained by doing it that way, the Charge Nurse (CN) could also make necessary updates to the care plans in real-time. She stated ADL level of care was not required on the resident's care plan if it was noted, refer to POC. MDS #2 stated the CCP was developed through assessments, and orders which came up during the day. Further, she stated the care plan was reviewed every time an MDS Assessment was completed. MDS #2 stated the contract agency staff did not attend orientation at the facility, she said all the aides knew how to use the facility's computer system, and if they did not the nurse assisted them. She further stated it was the expectation for nurses to use the Kardex to find out which residents were provided ADL care. However, In an interview with the Nurse Practitioner (NP), on 11/03/2023 at 2:32 PM, in reference to Resident #2, she said nursing staff called her and asked her to come on-site and evaluate the resident, related to bruises. She stated she wrote a report and whatever happened was noted in the report; however, the NP could not recall the information in the report. The NP asked if the State Survey Agency (SSA) Surveyor had the report. The SSA Surveyor read the entire subject of the report aloud for the NP. She then stated Resident #2 had a history of self-harm and had a history of flinging his/her arms and she assessed the injuries Resident #2 incurred as self-inflicted. Per the NP, the information regarding Resident #2's history of self-inflicted injuries should have been noted in the resident's medical file. She stated that based on her evaluation she thought it was possible Resident #2 caused the bruising himself/herself. Further, she stated the marks on Resident #2's neck looked like friction marks to her from the gown he/she wore, which happened perhaps when the resident was being changed. The NP stated the case was handled as an allegation of abuse and it was reported to the police and appropriate State Agencies. She further stated she had no knowledge of what Resident #2 looked like prior to her assessment as it had not been pertinent to her evaluation. In addition, the NP stated she recalled Resident #2's mood was calm when she first arrived; however, the resident's mood could change rather quickly. Review of the Medical Director's progress note dated 03/30/2023 at 8:00 PM, revealed he saw Resident #2 and determined the resident had an open area to the right temple above the right eye, and bruising to the right arm, right hand, and chest. The Medical Director noted the nurse reported to him Resident #2 became combative during a bed bath and hit himself/herself, and his/her injuries were self-inflicted. In an interview with the Medical Director on 11/03/2023 at 2:45 PM, he stated Resident #2 was easily agitated and flailed his/her arms which could have been very dangerous when it happened in the shower. Further, the Medical Director stated Resident #2 could have been confused and felt like he/she was being raped if staff did not explain the care that was being provided. The Medical Director said the facility had many interventions in place for Resident #2, and psychiatry continued to follow the resident with medication adjustments. He stated Resident #2 had a history of self-injury. The Medical Director explained a resident could be fine one (1) moment and then in the next minute be combative, upset, and throwing things at staff. The Medical Director said the purpose of residents' care plans was to provide optimal care for the residents, and staff were expected to follow their care plans when they provided care for them. He further stated he expected staff to follow the facility's policies and procedures as that was why the facility had them. During an interview with the Director of Nursing (DON), on 11/08/2023 at 10:00 AM, she stated SRNA #3 should have followed the CCP related to stepping away from the resident when he/she became combative during the bath as all staff were expected to follow the CCP and Kardex while providing care. Per interview, she stated Resident #2's Kardex and MDS Assessment indicated two (2) staff were to provide ADL care including a bath for Resident #2. She stated the resident's CCP should have been developed with the intervention for two (2) staff to provide a bath for Resident #2 due to his/her behaviors. In an interview with the Administrator, on 11/08/2023 at 12:20 PM, she stated Resident #2 required two (2) staff members for all ADL care, and SRNA #3 should not have provided care for the resident without another staff member to assist. She explained if the resident became combative, staff were to ensure the resident was safe and step away from the situation and try again later or get another staff member to assist. The Administrator stated Resident #2 was very strong when he/she got going. She stated Resident #2 could have hit himself/herself and caused the bruises to his/her chest. The Administrator stated Resident #2 was on an Aspirin regimen and that could also account for the bruising the resident had. She stated staff should always follow the residents' care plans because they directed staff on the specialized care each resident required. The Administrator stated if the care plan was not followed, residents could be harmed. She further stated she expected all staff to follow the facility's policies and procedures and that included agency staff when they were present for work.

Based on interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person centered care plan for each resident to meet a resident's nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (1) of forty-four (44) sampled residents (Resident #2). Resident #2's Comprehensive Care Plan (CCP), initiated 05/19/2021, revealed the facility failed to develop a CCP which specified how many staff members were required to safely assist the resident with a bath. Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 03/24/2023, revealed the facility assessed the resident as totally dependent for bathing requiring two (2) person physical assistance. On 03/30/2023, State Registered Nurse Aide (SRNA) #3 provided Resident #2 a bath without assistance from other staff. SRNA #3 stated she was not briefed on how to provide care for Resident #2 when the resident became combative. The SRNA, who was agency staff, stated she did not where to locate the resident's care plan to ensure she provided the resident's care needs. SRNA #3 stated she held the resident's hands to prevent the resident from hitting her. Resident #2 pulled back, and his/her hands slipped. The resident smacked himself/herself in the face which resulted in injuries that included a laceration to the resident's right eye. The findings include: Review of the facility's policy titled Comprehensive Care Plan, dated 02/2023, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident to address the needs determined through comprehensive assessments. The care plan would be developed within seven (7) days of the comprehensive Minimum Data Set Assessment. All triggered areas on the Minimum Data Set (MDS) would be considered in development of the care plan. Any behaviors of refusal of care would be documented on the care plan. The objectives would be utilized to monitor the resident's progress and alternative interventions would be documented as needed. Review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated October 2023, revealed the Comprehensive Care Plan was an interdisciplinary communication tool and must include measurable objectives and timeframe's and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental,and psychosocial wellbeing. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #2's Face Sheet, revealed the facility readmitted the resident on 05/13/2022, with diagnoses that included dementia, Alzheimer's and psychotic disorder with delusions due to known psychological condition. Review of Resident #2's Comprehensive Care Plan (CCP), initiated 05/19/2021, revealed the resident had a history of combative behaviors toward staff during care, as the resident would hit, slap, pinch, grab and attempt to bite. The goal stated the resident would have few episodes of physical and verbal behaviors, last revised on 10/03/2022. Interventions for this problem area included the following which were all initiated on 05/19/2021: explain all procedures to the resident before starting and allow the resident time to adjust to changes; intervene as necessary to protect the rights and safety of others; approach and speak in a calm manner; divert attention and remove from the situation and take to alternate location as needed; monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, person involved, and situation, document behaviors and potential causes; praise any indication of the resident's progress/improvement in behaviors; make sure resident able to clearly hear when being talked to, and ensure he/she understands; and when the resident became combative, staff should step away and allow the resident time to calm down. The care plan noted, Provide assistance with daily care as indicated on the Point of Contact (POC) tasks schedules to find out what level of care the resident required. However, the CCP did not specify how many staff were required to assist the resident with a bath. Review of Resident #2's Kardex Report with an as of date of 03/15/2023, revealed the resident required a mechanical lift for all transfers, and required two (2) staff for dressing, personal hygiene and bathing. For behaviors, staff was to intervene as necessary to protect the rights and safety of others; approach and speak to the resident in a calm manner; divert attention; remove from the situation and take to an alternate location as needed; make sure the resident heard when speaking to him/her; explain prior to proving care; and praise any indication of progress and improvement in behavior. Further review revealed if the resident became agitated, intervene before agitation escalated; guide away from source of distress; engage calmly in conversation; and if response was aggressive, staff was to walk away calmly and approach later. Review of Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 03/24/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated severe cognitive impairment. Continued review revealed the facility assessed Resident #2 as having physical and verbal behaviors directed toward staff present for four (4) to six (6) days during the assessment period. Additionally, the facility assessed Resident #2 as rejecting care one (1) to three (3) days during the assessment period. The facility further assessed the resident as requiring the physical assistance of two (2) staff for bed mobility, transfers, dressing, toileting, and personal hygiene and one (1) person physical assistance for eating. Per the MDS Assessment, the facility assessed the resident to be totally dependent for bathing requiring two (2) person physical assistance. During interview, on 10/31/2023 at 1:53 PM, State Registered Nursing Assistant (SRNA) #3 (Agency Aide) stated she stated she provided Resident #2 a bath on 03/30/2023 without assistance from other staff. SRNA #3,stated she did not know where to find the resident's care plan. She stated she held the resident's hands to prevent the resident from hitting her. Resident #2 pulled back, and his/her hands slipped. The resident smacked himself/herself in the face which resulted in injuries. Resident #2 sustained injuries which included a small laceration with some bruising and swelling; injuries to the eye; red markings on the left side of the neck; a bruise on the resident's right hand, and bruising on the resident's chest. In an interview with State Registered Nurse Aide (SRNA) #3, on 10/31/2023 at 1:53 PM, she stated she worked as an agency staff member at the facility on 03/30/2023. She stated when she arrived she was not provided information on how to find Resident #2's CCP or Kardex, and therefore did not review them. She further stated she did not ask for help or ask how care was to be provided to Resident #2. SRNA #3 stated she was unaware of the need for two (2) staff members in providing the resident with a bath. Additionally, SRNA #3 stated she was unaware of the need to step away when the resident became combative. She stated, instead, when the resident became combative during the bath, she held the resident's hands to prevent him/her from hitting her. She further stated, in doing so, the resident pulled back, and his/her hands slipped and he/she smacked himself/herself in the face which resulted in a laceration to the right eye. In an interview with Shower Aide (SA) #1, on 11/03/2023 at 9:35 AM, she stated she was present on 03/30/2023 and made sure she informed SRNA #3, Resident #2 required two (2) staff for assistance with a bath. SA #1 further stated, SRNA #3 told her she could do it by herself. SA #1 explained she told SRNA #3 this was not a good idea because Resident #2 was combative, but SRNA #3 replied, she could handle it. SA #1 further stated later in the day she went to find SRNA #3 to assist with Resident #2's bed bath and was informed she (SRNA #3) had already completed the resident's bath. SA #1 stated SRNA #3 did not mention the resident became combative or sustained injuries during the bath. In additional interview with SA #1, she stated the purpose of the care plan was to ensure the resident was provided proper care, as it was a guide to help ensure the resident and staff member were not hurt during care. In an interview with Licensed Practical Nurse (LPN) #2/Unit Manager, on 11/02/2023 at 1:06 PM, she stated SRNA #3 informed her while providing Resident #2's bed bath, the resident became combative. She stated SRNA #3 told her she tried to hold the resident's hands to prevent being hit and in the process the resident hit himself/herself. LPN #2 further stated if SRNA #3 physically held the resident's hands in place, the SRNA did not follow the CCP related to stepping away when the resident became combative. In further interview with LPN #2, she stated she would not expect an aide to know how to find the care plan or Kardex unless they frequently worked at the facility; however, she would expect the aide to ask the nurse for help. LPN #2 stated it was her expectation for aides to follow the CCP and Kardex, in order to provide personalized care for the residents. Per interview, the resident's Kardex stated two (2) staff was to assist the resident with a bath. She further stated residents could be hurt if staff did not follow the care plan. When interviewed related to if the CCP should have had interventions related to the need for two (2) staff to assist Resident #2 with a bath, she stated staff were to review the Kardex to find Activities of Daily Living (ADL) level of care. In an interview conducted with Registered Nurse (RN) #5, on 11/02/2023 at 2:40 PM, she stated she was the Charge Nurse assigned to Resident #2 on 03/30/2023. She stated, on 03/30/2023 SRNA #3 reported the resident hit himself/herself, but had not reported to her she held the resident's hands in place to stop him/her from hitting her. Per interview, she looked at the resident and saw the cut/scratch on the resident's eye and that was all that was noted. She said because of the resident's history of being combative, she did not think anything else of it. RN #5 stated she did not complete a skin assessment at that time because she was aware of the resident's history of combative behavior. In an interview with SRNA #10, on 11/02/2023 at 10:10 AM, he stated he often provided care to Resident #2 and was very familiar with the requirements for his/her Activities of Daily Living (ADL) care. He further stated the resident had a history of becoming very combative during care. SRNA #10 stated he only provided any type of care to Resident #2 with the assistance of another staff member and the resident should have been care planned for two (2) staff at all times, for his/her safety and for the safety of staff. He further stated, when Resident #2 became upset during care, it was best for the resident if care was halted and staff stepped away for a few minutes to let the resident calm down. In an interview with Registered Nurse (RN) #1, on 11/03/2023 at 12:55 PM, she explained Resident #2 always needed two (2) staff as the resident became very combative during care. RN #1 stated the resident had a history of pinching staff in their breast, the resident would grab hold of the staff member's breast and twist it, hard. She also stated she could always tell when staff were in the room with Resident #2 because you could hear the resident screaming and yelling even if the daughters were present. RN #1 stated Resident #2 did not even like being touched by his/her daughters. In an interview with RN #1, on 11/03/2023 at 12:55 PM, she stated the care plan provided the direction of care for each resident and should always be accurate and followed. RN #1 stated if the care plan was not followed by staff, the resident could be harmed and/or miss out on care required. She stated, although she knew her residents well, she checked the care plan and Kardex regularly to ensure she provided the appropriate level of care. She stated aides should do the same. In an interview with LPN #11, on 11/09/2023 at 3:06 PM, she stated residents with dementia required special care, and it was important to follow the care plan when providing care because the care plan was the specialized guide of care for the resident. LPN #11 stated the level of ADL care including how many staff were needed to provide a bath should be care planned. In an interview with LPN #12, on 11/09/2023 at 3:17 PM, she stated she learned about ADL level of care during report, and the information was passed on verbally. LPN #12 further stated, the ADL level of care was not usually on the care plan, but general stuff was on the care plan. In an interview with MDS Nurse #1, on 11/07/2023 at 12:15 PM, she stated she completed MDS Assessments and the Comprehensive Care Plan was generated from the MDS Assessments. Additionally, she stated the CCP was developed from new Physician's Orders, Incident Reports, Discharge Summaries and discussion with the Interdisciplinary Team (IDT). MDS Coordinator #1 stated department heads met every morning and discussed the residents. She explained she updated care plans either prior to or after the meetings. MDS Nurse #1 stated the Social Services Director (SSD), Dietary and the Activities Director (AD) updated their care plans as needed. In further interview with MDS Nurse #1, she stated Activities of Daily Living (ADL) level of care was not documented on the care plan. Instead, it was under ADL care it was noted, follow the Point of Care (POC) schedule for ADL care. Per interview, the aide care plan POC was where staff would find the required number of staff required to assist the resident with ADLs. In an interview with MDS Nurse #2, on 11/07/2023 12:47 PM, she stated she attended morning meetings on rotation with the other MDS Nurse. She stated the morning meeting involved all department heads, and they discussed the census, level of care changes, new admits, discharges, maintenance issues, and social services issues. MDS Nurse #2 stated the facility also had a clinical meeting which all nursing management attended. She stated they discussed all medical concerns for each resident such as falls, any previous day incidents, unit reports, new orders, and labs. She further stated Social Services, Dietary and Activities Director were present and discussed, behaviors, food and activities and updated their part of the care plan. During interview with MDS Nurse #2, on 11/07/2023 at 12:47 PM, she stated ADLs, transfers and mobility requirements for residents changed constantly and that was why the number of staff required to assist with ADLs was documented on the POC instead of the CCP. Per interview, ADL assistance did not have to be on the CCP if it was noted to be referenced on the POC. Further, she stated she believed Resident #2 was care planned for two (2) staff at all times during care. However, after the interview concluded she checked the resident's care plan and explained the resident was not care planned for two (2) staff during all ADL care. She stated this needed to be discussed with the clinical team. In additional interview with MDS Nurse #2, on 11/09/2023 at 1:03 PM, she stated agency staff did not attend facility orientation, but aides knew how to use the computer system and if they did not a nurse could assist them. She stated it was her expectation the aides and nurses would use the Kardex to find out how residents were to be provided ADL care, including agency aides. In an interview with the Medical Director (MD), on 11/03/2023 at 2:45 PM, he stated Resident #2 was easily agitated and flailed his/her arms. The MD further stated the facility was to use the appropriate interventions for Resident #2. The MD stated the purpose of the care plan was to provide optimal care for the residents, and he expected all staff to follow the care plan. During an interview with the Director of Nursing (DON), on 11/08/2023 at 10:00 AM, she stated SRNA #3 should have followed the CCP related to stepping away from the resident when he/she became combative during the bath as all staff were expected to follow the CCP and Kardex while providing care. Per interview, she stated Resident #2's Kardex and MDS Assessment indicated two (2) staff were to provide ADL care including a bath for Resident #2. She stated the resident's CCP should have been developed with the intervention for two (2) staff to provide a bath for Resident #2 due to his/her behaviors. In an interview with the Administrator on 11/08/2023 at 12:20 PM, she stated SRNA #3 should have had another staff member present in the room when providing a bath for Resident #2. Further, when the resident became combative, SRNA #3 should have stepped out and allowed the resident to calm down, as care planned. She further stated Resident #2 was care planned as a two (2) staff assistance on 03/30/2023, after SRNA #3 provided a bed bath by herself. The Administrator stated when agency staff was used, there was a binder at the front desk and agency staff was required to sign in on the first visit. She stated signing in the binder acknowledged they received and understood the facility's training. Additionally, the Administrator stated the expectation was all agency staff were educated by their agency prior to working at the facility.

Based on interview, record review, and review of the facility's abuse and Resident's Rights policies, it was determined the facility failed to protect residents from abuse for one (1) of forty-four (44) sampled residents (Resident #20). Resident #21 alerted State Registered Nursing Assistant (SRNA) #20 on the morning of 10/13/2023 that during the night when he/she had been sleeping, Resident #20, his/her roommate, struck him/her on the head with his/her iPad waking him/her up. The findings include: Review of the facility's Abuse Policy, dated 08/27/2019, revealed residents had the right to be free from abuse. Continued review revealed abuse was defined to include the willful infliction of injury with resulting physical harm, pain, or mental anguish. Review of the facility's Resident Rights policy revised 12/2016, revealed residents had the right to be treated with respect, kindness, and dignity, as well as the right to be free from abuse. 1. Review of Resident #21's Face Sheet revealed the facility admitted the resident on 09/13/2023, with diagnoses that included Parkinson's Disease, hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, and unspecified dementia without behavioral disturbance. Review of Resident #21's Care Plan (CP) revealed the facility developed a CP for potential mood problems, which was updated on 10/13/2023. Continued review of the CP revealed Resident #21's potential mood problem was updated related to a recent physical altercation. Review of Resident #21's Admission Minimum Data Set (MDS) revealed the facility assessed the resident on 09/20/2023, with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) which indicated he/she had moderate cognitive impairment. Record review revealed all admission documentation was completed by Resident #21 upon admission to the facility. Further review of the Electronic Health Record (EHR) revealed psych notes for Resident #21 noting he/she had been seen by psych services on 10/18/2023, and the resident denied anxiety or fear regarding an incident and no concerns regarding mood or behavior were identified. 2. Review of Resident #20's Face Sheet revealed the facility admitted the resident on 04/01/2023, with diagnoses which included personal history of traumatic brain injury, other specified disorder of brain, and unspecified convulsions. Review of Resident #20's CP revealed the facility updated his/her CP beginning on 10/18/2023 to include: one (1) to (1) [1:1] supervision prior to and upon returning from his/her admission to a behavioral health unit; every fifteen (15) minute checks from 10/26/2023 until 10/29/2023. Further review reviewed Resident #20's Seroquel (an antipsychotic medication used to treat mental illness) was increased to 50 milligrams (mg) at hours of sleep (hs). Review of the facility's Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #20 to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen/(15). This score indicated the resident had severe cognitive impairment. Review of the facility's investigation revealed the facility assessed Resident #21 following an incident which occurred sometime during the night on 10/12/2023 and could not determine any injury had occurred. Resident #21 reported the incident to staff the following morning on 10/13/2023. Continued review of the investigation revealed other residents with a BIMS score of seven (7) or below were assessed with no additional concerns identified. Per review, residents with a BIMS of eight (8) or above were interviewed about abuse with no concerns identified. Additionally, the facility provided abuse education inservice to staff following the incident. Further review revealed the facility placed Resident #20 on 1:1 supervision; he/she was sent out for an psychiatric (psych) evaluation, and returned to the facility less than a week later. Review further revealed upon return, the facility placed Resident #20 in another room and on 1:1 supervision for seventy-two (72) hours, followed by every fifteen (15) minute checks for seventy-two (72) hours. In interview on 11/01/2023 at 3:15 PM, Resident #21 stated while he/she was asleep, Resident #20 struck him/her in the head with an iPad. Resident #21 stated after he/she was struck, he/she awakened, rolled over, and observed his/her roommate (Resident #20) with an iPad in hand, wheeling back to his/her side of room in a wheelchair (wc). When asked about the incident, Resident #21 stated he/she was upset at the time of the incident, and went to the hospital to get checked out. In continued interview Resident #21 shrugged when asked if he/she felt safe. the resident pointed to his/her (new) roommate behind privacy curtain. In interview on 11/07/2023 at 8:50 AM, Unit Manager (UM) #1 stated she removed Resident #21 from the room Resident #20 and he/she resided in, and placed Resident #20 on 1:1 supervision. She stated Resident #21 said Resident #20 had struck him/her with an iPad when he/she was sleeping. UM #1 stated she could not tell if Resident #21 was injured, as there was some swelling to the side of his/her head that had been present upon the resident's admission. She stated she thought the swelling might have been larger though. UM #1 further stated as Resident #21 said he/she had been struck in the head, had a headache and felt a little dizzy, and potentially had an injury, she sent him/her to the hospital for evaluation. The UM additionally stated Resident #21 returned the same day from hospital negative for concussion or any injury. In interview on 11/07/2023 at 9:53 AM, the Administrator stated she felt Resident #21 was a reliable reporting source, and believed Resident #21 had been struck by Resident #20. She stated in performing the investigation they were unable to determine what prompted or contributed to Resident #20 striking Resident #21. The Administrator further stated Resident #20 had not admitted to striking Resident #21 to any staff. She additionally stated with Resident #20's Traumatic Brain Injury (TBI) it was hard sometimes to figure out what the root cause of his/her emotions or behaviors.

Based on interview, record review, review of the facility's policy, and the Police Report Number: 2023-00059001 it was determined the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or convenience and were not required to treat the resident's medical symptoms for one (1) of forty-four (44) sampled residents (Resident #2). On 03/30/2023, State Registered Nursing Assistant (SRNA) #3 (Agency Aide) provided Resident #2 a bath without assistance from other staff. Interview with SRNA #3, on 10/31/2023, revealed she was not briefed on how to provide care for Resident #2 when the resident became combative during the bed bath and tried to hit and scratch her. SRNA #3 stated she held the resident's hands to prevent the resident from hitting her. Resident #2 pulled back, and his/her hands slipped. The resident smacked himself/herself in the face which resulted in injuries that included a laceration to the resident's right eye. Refer to F656 The findings include: Review of the facility's policy titled, Restraint Free Environment dated 02/2023, revealed the facility was a restraint free facility which prohibited the use of restraints for discipline or convenience and limited restraints for circumstances which were medically necessary and warranted the use of restraints. The policy revealed holding down a resident in response to a behavioral symptom or during the provision of care if the resident was resistive or refusing care was considered a restraint. Further review revealed behavioral interventions were to be exhausted prior to the application of a physical restraint. Review of the facility's policy titled, Restraint Free Environment dated 02/2023, revealed holding down a resident in response to a behavioral symptom or during the provision of care if the resident was resistive or refusing care was considered a restraint. Review of Resident #2's Comprehensive Care Plan (CCP), initiated 05/19/2021, revealed the resident had a history of combative behaviors toward staff during care and when the resident became combative staff should step away and allow the resident time to calm down. However, further review revealed although the resident had behaviors, the CCP did not specify how many staff was required to assist the resident safely with a bath. Review of Resident #2's Kardex Report (care plan used to address interventions for the State Registered Nurse Aide (SRNA)) with an as of date of 03/15/2023, revealed the resident required two (2) staff for bathing. Review of Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 03/24/2023, revealed the facility assessed the resident as totally dependent for bathing and required two (2) person physical assistance. However, on 03/30/2023, SRNA #3 (an agency aide) provided Resident #2 a bath without assistance from other staff. During an interview with SRNA #3, on 10/31/2023 at 1:53 PM, she stated she was not briefed on how to provide care for Resident #2. SRNA #3 stated the resident became combative during the bed bath and tried to hit and scratch her. During this interview, SRNA #3 stated she held the resident's hands to prevent the resident from hitting her; and in doing so, the resident pulled back, and his/her hands slipped and he/she smacked himself/herself in the face which resulted in injuries that included a laceration to the resident's right eye. Per Police Report Number: 2023-00059001, dated 03/30/2023, Resident #2 sustained injuries which included a small laceration with some bruising and swelling; injuries to the eye; red markings on the left side of the neck; a bruise on the resident's right hand, and bruising on the resident's chest. Review of Resident #2's Face Sheet, revealed the facility readmitted the resident on 05/13/2022, with diagnoses that included dementia, Alzheimer's Disease and psychotic disorder with delusions due to known psychological condition. Review of Resident #2's Comprehensive Care Plan (CCP), initiated 05/19/2021, revealed the resident had a history of combative behaviors toward staff during care, as the resident would hit, slap, pinch, grab and attempt to bite. The goal stated the resident would have few episodes of physical and verbal behaviors, last revised on 10/03/2022. Further review of the CCP revealed interventions initiated on 05/19/2021 for this problem area that included: administer medication as ordered; monitor and document side effects and effectiveness; anticipate and meet the resident's needs; explain all procedures to the resident before starting and allow the resident time to adjust to changes; intervene as necessary to protect the rights and safety of others; approach and speak in a calm manner; divert attention and remove from the situation and take to alternate location as needed; monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, person involved, and situation, document behaviors and potential causes; praise any indication of the resident's progress/improvement in behaviors; make sure the resident is able to clearly hear when being talked to, and ensure he/she understands; and when the resident became combative, staff should step away and allow the resident time to calm down. The care plan noted, Provide assistance with daily care as indicated on the Point of Contact (POC) tasks schedules to find out what level of care the resident required. However, the CCP did not specify how many staff was required to assist the resident with a bath. Review of Resident #2's Kardex Report, with an as of date of 03/15/2023, revealed the resident required a mechanical lift for all transfers, and required two (2) staff for bathing, dressing, and personal hygiene. For behaviors, staff was to intervene as necessary to protect the rights and safety of others; approach and speak to the resident in a calm manner; divert attention; remove from the situation and take to an alternate location as needed; make sure the resident heard when speaking to him/her; explain prior to proving care; praise any indication of progress and improvement in behavior; if the resident became agitated, intervene before agitation escalated; guide away from source of distress; engage calmly in conversation; and if response was aggressive, staff was to walk away calmly and approach later. Review of Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 03/24/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated severe cognitive impairment. Continued review revealed the facility assessed the resident as having physical and verbal behaviors directed toward staff present for four (4) to six (6) days during the assessment period. Additional review of the MDS Assessment, revealed the facility assessed the resident as rejecting care one (1) to three (3) days during this assessment period. Further review revealed the facility assessed the resident as requiring the physical assistance of two (2) staff for bed mobility, transfers, dressing, toileting, and personal hygiene and one (1) person physical assistance for eating. The facility assessed the resident as totally dependent for bathing requiring two (2) person physical assistance. Review of the Police Report Case Number 2023-00059001, revealed the police officer noted the following interview with SRNA #3, on 03/30/2023 at approximately noon. Per the document, SRNA #3 entered Resident #2's room to provide him/her a bed bath. SRNA #3 explained as she assisted the resident with the bed bath, the resident became combative, and she responded by grabbing his/her arms to prevent the resident from striking her. SRNA #3 explained, due to the resident's arms being wet from the bath, his/her arms slipped from SRNA #3's grip and the resident accidentally struck himself/herself in the face. SRNA #3 stated Resident #2 became combative again when she took the resident's gown off, for the bath Continued review of the Police Report Case Number: 2023-00059001, revealed the police officer documented the following interview with the Administrator on 03/30/2023 at approximately 1:51 PM. Per the document, the Administrator stated SRNA #3 informed her and Unit Manager/Licensed Practical Nurse (LPN) #2, while she gave Resident #2 a bed bath the resident became combative. The Administrator informed the police, that SRNA #3 stated she held the resident's arms to protect herself and as she did, Resident #2's hand slipped out of her grip. This caused the resident to strike himself/herself in the right eye, leaving a small laceration with some bruising and swelling. Additional review of Police Report No. 2023-00059001, revealed the Administrator reported to the police, on 03/30/2023 at approximately 1:51 PM, she believed SRNA #3 displayed poor judgement given her training as a Certified Nursing Assistant (CNA/SRNA) when dealing with Resident #2, but she did not believe she intentionally or willingly tried to harm the resident. It was also noted the Administrator informed the police, that Shower Aide (SA) #1 notified SRNA #3 about Resident #3 being combative during care. SRNA #3 told SA #1, This is not my first rodeo before going in to bathe the resident on her own. The Administrator also reported to police the facility had a communication system in place to advise staff who were not familiar with the resident and his/her history of being combative and it was preferred practice to have someone with them just in case. Review of Police Report Case Number 2023-00059001, revealed the police officer interviewed Registered Nurse (RN) #5, on 03/30/2023 (no time provided). Per the interview, the nurse stated SRNA #3 approached her and advised her she was giving Resident #2 a bath. At some point during the bath, Resident #2 became combative and SRNA #3 held his/her arms in an effort to stop him/her from injuring her. Due to Resident #2's arms being wet from the bath, his/her arm slipped from SRNA #3's grip, which caused him/her to accidentally strike himself/herself in the face near his/her eye. Review of the Police Report revealed a follow up interview was conducted with SRNA #3, on 05/03/2023 at 10:00 AM. Per the document, SRNA #3 stated, while she gave Resident #2 a bed bath, the resident was laying down in the bed and she was on the side of the bed washing him/her. She stated, at no point did she ever get into the bed with the resident while the bed bath was given. She stated she did wash all over the resident's upper body, but she did not recall any force being applied to the resident's chest area which would have caused the bruises photographed by the daughters. SRNA #3 stated she did not see any other injuries or bruising to the resident's chest prior or during the bed bath. Further review revealed She did bring up seeing the bruising on the arm a second time as she did in the first phone conversation, I had with her. Review of the facility's staffing invoices, revealed SRNA #3 provided resident care on 03/23/2023, 03/24/2023, 03/28/2023, 03/29/2023 and 03/30/2023. Review of the sign-in sheet dated 03/23/2023, revealed SRNA #3 signed in at 7:03 AM. Review of the facility's binder which was provided to agency staff the first time they worked at the facility, revealed agency staff were to sign in only on their first visit, and by signing in they acknowledged they had received and understood the training packet and policies. Further review revealed SRNA #3 signed as completing the training packet on 03/23/2023. However, further review of the training revealed the facility failed to include restraint training in the packet. In an interview with State Registered Nursing Assistant (SRNA) #3, on 10/31/2023 at 1:53 PM, she stated she had worked at the facility on 03/30/2023 as an agency aide. She stated when she arrived on site, she was not briefed on how to provide care for her assigned residents, nor was she aware of where the Kardex or CCP was located. SRNA #3 stated she was not told Resident #2 required the assist of two (2) persons for Activities of Daily Living (ADL) and baths, nor that the resident had a history of combative behavior. She stated Resident #2 became combative during the bed bath and tried to hit and scratch her. SRNA #3 stated she held the resident's hands to prevent the resident from hitting her. In doing so, the resident pulled back, and his/her hands slipped and he/she smacked himself/herself in the face which resulted in a laceration to the right eye. In an interview with Shower Aide (SA) #1, on 11/03/2023 at 9:35 AM, she stated she was present on 03/30/2023 and informed SRNA #3, Resident #2 required two (2) staff for assistance with a bath. SA #1 stated, SRNA #3 told her she could do it by herself. The SA stated she told SRNA #3 this was not a good idea because Resident #2 was combative, but SRNA #3 replied, she could handle it. SA #1 stated later in the day she went to find SRNA #3 to assist with Resident #2's bed bath and was informed she (SRNA #3) had already completed the resident's bath. The SA stated she went about her day, and she did not end up seeing Resident #2 that day. In an interview with SRNA #10, on 11/02/2023 at 10:10 AM, he stated Resident #2 had lots of major behaviors and made noises, screamed, and hissed at staff. He stated Resident #2 got physically violent, would hit, pinch and spit at staff. The SRNA stated he witnessed Resident #2 grab a staff member's breast and twist her nipple hard and it was difficult to get the resident to let go. He also stated, staff worked hard to redirect the resident's behaviors, but it rarely worked and there was staff who worked at the facility who did not want to interact with the resident because of his/her behaviors. During continued interview, SRNA #10 stated, management informed staff they always needed two (2) staff members in the room with Resident #2. He stated he helped bathe the resident and he knew him/her well. Further, SRNA #10 stated, according to the Interdisciplinary Team (IDT), when staff provided care for Resident #2, staff was to explain everything they did for the resident and to report all behaviors to the Charge Nurse. He stated, with Resident #2, it was all hands-on deck. In an interview with Licensed Practical Nurse (LPN) #2, on 11/02/2023 at 1:06 PM, she stated SRNA #3 informed her she gave Resident #2 a bed bath and the resident became combative. She stated SRNA #3 told her she tried to hold the resident's hands to prevent being hit and in the process the resident hit himself/herself. LPN #2 stated she had not worked with SRNA #3 prior to 03/30/2023, and she recalled the aide worked for agency. Continued interview revealed LPN #2 stated when an agency staff reported to the facility, they were expected to sign in the binder at the front desk and complete any in-services prior to going to the floor. LPN #2 further stated the facility was a no restraint facility, which meant staff did not restrain residents in any way. She explained if a restraint was needed for emergency purposes, it had to be discussed with management and an order by the physician was required. LPN #2 stated, if SRNA #3 physically held the resident's hands in place or down that would be a physical restraint and could result in physical or psychosocial harm to the resident. In an interview conducted with Registered Nurse (RN) #5, on 11/02/2023 at 2:40 PM, she stated SRNA #3 had not reported to her she held the resident's hands in place to stop him/her from hitting her and if she had, she would have been concerned about the resident being restrained. She stated if SRNA#3 stated she held the resident's arms, she would have immediately reported the information to management. During continued interview with RN #5, she stated the facility had a no restraint policy and holding a resident's hands down violated the policy. During an interview with the Advanced Practice Registered Nurse (APRN), on 11/03/2023 at 2:32 PM, she stated Resident #2 had a history of self-harm and had a history of flinging his/her arms and she assessed his/her injuries on 03/30/2023 to be self-inflicted. She further stated it should be noted in the resident's medical file he/she had a history of self-inflicted injuries. The APRN stated, Resident #2's behaviors were not under control at the time and the facility altered his/her medication quite often. Review of the Medical Director's Progress Note, dated 03/30/2023 at 8:00 PM, revealed the APRN saw the resident and determined Resident #2 had bruising and an open area to the right temple above the right eye, bruising to the right arm, right hand and chest. Per the Note, the APRN reported to him the resident became combative during a bed bath and hit himself/herself. In an interview with the Medical Director (MD), on 11/03/2023 at 2:45 PM, he stated Resident #2 was easily agitated and flailed his/her arms, and that could be very dangerous when it happened in the shower. He stated the resident could be confused and felt like he/she was being raped if staff did not explain what care they were providing for him/her. The Medical Director stated if the resident had his/her hands held down, that could or could not be considered a restraint, as it depended on how the resident reacted. Continued interview with the MD, revealed a resident could be fine one moment and then in the next minute combative, upset and throwing things at staff. The MD further stated, residents with dementia and Alzheimer's, may not remember you and that made caring for them hard. During further interview he stated staff was to follow the care plan and the policies and procedures of the facility in order to provide optimal care for the residents. During an interview with the Director of Nursing (DON), on 11/08/2023 at 10:00 AM, she stated the facility did not use restraints. She further stated it was not okay for staff to hold a resident's hands in place to prevent the staff member from being hit. Per interview, holding the residents down in such a manner would be considered a restraint. She further stated, staff had been directed, if a resident became combative during care, staff was to wait and return later to allow the resident to calm down. Per interview, Resident #2's Care Plan had an intervention to step away if the resident was combative and the Kardex noted two (2) staff was to assist the resident with a bath. The DON stated all staff was expected to follow the Care Plan and Kardex while providing care including agency staff. Further, she stated all agency staff was to check in with the nurse to get report prior to starting their shift. The DON stated it was her expectation for agency staff to be fully trained by their agency prior to working at the facility. During an interview with the Administrator, on 11/08/2023 at 12:20 PM, she stated on 03/30/2023, when she arrived at the facility and saw Resident #2, it looked like (he/she) had been in a fight. She further stated she did not know what happened to the resident and did not make any assumptions, but the APRN saw the resident on 03/30/2023 and determined the injuries were self-inflicted. The Administrator stated the resident had a history of self-harm/self-injuries, and was identified as requiring two (2) person assist for care. She stated SRNA #3 showed poor judgement by providing care for the resident alone. The Administrator stated staff should not hold a resident's hand to prevent the resident from hitting them. She stated holding the resident's hands down would be considered a restraint, if the resident could not lift his/her hands. During interview with the Administrator, on 11/08/2023 at 12:20 PM, she stated SRNA #3 should have had two (2) care givers in the room while she provided care for Resident #2 and if the resident became combative during care the aide should have made sure the resident was safe, stepped away and asked for assistance, giving the resident time to calm down. The Administrator further stated, she expected all staff who worked at the facility to be aware of the policies and procedures and follow them. During further interview with the Administrator, on 11/08/2023 at 12:20 PM, she explained when agency staff was used at the facility, on their first visit they were to sign in the binder at the front desk which had a training packet they were to complete. She stated the training packet included several policies, and it was the expectation agency staff were fully trained by their agency prior to reporting the facility for work.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19; and, failed to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the CDC, and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observations, on 01/24/2022, revealed the self-screening body temperature kiosk station in the lobby was not working. In addition, Receptionist #1 did not advise the State Survey Agency (SSA) Surveyors, upon facility entrance, that staff and visitors were required to wear an N95 face mask due to a COVID-19 outbreak in the facility. Observations, on 01/24/2022 and 01/26/2022, revealed staff failed to either not wear personal protective equipment (PPE) correctly or not wear the required PPE at all. On 01/24/2022, Receptionist #1 failed to correctly wear an N95 mask. Also, on 01/24/2022, Lab Technician #1 performed COVID-19 tests without wearing an N95 mask, face shield or goggles, or a gown. On 01/26/2022, State Registered Nurse Aide (SRNA) #7 failed to correctly wear an N95 mask and failed to doff (take off) PPE before exiting a room with a COVID-19 positive resident. Observations, on 01/24/2022, revealed two (2) resident rooms where residents were on transmission-based precautions (TBP); one (1) resident was because of COVID-19, and one (1) resident because of suspected [CONDITION(S)] infection (C diff, a very contagious infection of the intestines). There was no signage on the door of either room explaining the type of TBP and what PPE was required to be worn to enter the room. Observations, on 01/24/2022, 01/25/2022, and 01/26/2022, revealed contaminated linen and waste being disposed of improperly. Observations, on 01/25/2022, revealed Registered Nurse (RN) #1 and SRNA #1 failed to perform hand hygiene when entering and exiting residents' rooms. In addition, observation, on 01/26/2022, revealed RN #2 failed to perform hand hygiene when performing a blood glucose test. Observation, on 01/25/2022, revealed LPN #2 failed to disinfect a portable vital sign machine when used between residents. In addition, observation, on 01/26/2022, revealed RN #2 failed to properly disinfect a blood glucose monitor (glucometer) after use on a resident. The findings include: Review of the Kentucky Long-Term Care Facility COVID-19 County Indicator map, dated 01/20/2022, revealed all counties in the state were classified as high for community COVID-19 activity. Review of the CDC's guideline, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/2021, revealed facilities should implement source control measures, such as an approved N95 or a well-fitting face mask. Furthermore, per the guideline, facilities located in counties with substantial or high COVID-19 transmission rates should implement the use of an N95 for all health care professionals during all resident care encounters if COVID-19 transmission was identified. In addition, N95 masks used to care for residents with COVID-19 or on droplet precautions should be removed and discarded after the resident encounter, and staff should don (put on) a new N95 mask. Review of the CDC's guideline, Clean Hands Count for Healthcare Providers, reviewed 01/08/2021, revealed hand hygiene reduced the spread of infection and disease to patients. Alcohol-based hand rub (ABHR) and washing hands with soap and water were the two (2) methods for hand hygiene. Further examination revealed the clinical indications for the use of hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, when staff had visibly soiled hands, and before preparing or handling medications. Review of the CDC's Injection Safety guideline, Infection Prevention During Blood Glucose Monitoring and Insulin Administration, no date, revealed staff should not share blood glucose meters between residents whenever possible. According to the manufacturer's instructions, the device should be cleaned and disinfected after each use if they were shared. Furthermore, gloves that had touched potentially blood-contaminated objects or fingerstick wounds should be removed before touching clean surfaces. Staff should perform hand hygiene immediately after removing gloves and before touching surfaces or other medical supplies intended for use on other persons. Review of the facility's policy titled, Visitation and Infection Control, not dated, revealed the facility followed the Kentucky Department of Public Health (KDPH) and the CDC's recommendations to prevent the transmission of infectious diseases. Per the policy, the facility implemented standard precautions consistent with federal regulations. An additional review revealed employees were educated on proper hand hygiene techniques according to CDC guidelines. Staff should perform hand hygiene before and after contact with residents, contaminated surfaces, and after removing PPE. Further review of the policy revealed the facility would post signs on the door or wall outside of a TBP room that clearly described the type of precautions needed and the required PPE. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 08/2014, revealed the facility considered hand hygiene as the primary means to prevent the spread of disease and infections. The policy stated that all personnel were trained and regularly in-serviced on hand hygiene techniques. Further review revealed the clinical indications for the use of hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, before and after assisting residents with meals, and before preparing or handling medications. Furthermore, all facility personnel shall follow hand washing/hand hygiene procedures to help prevent the development and transmission of communicable diseases and infections. Review of the facility's policy titled, Personal Protective Equipment - Using Face Masks, revised 09/2010, revealed after one (1) use staff should discard the face mask. The mask should be placed into the designated waste receptacle inside the room to prevent the spread of infection through the air. Review of the facility's policy titled, Personal Protective Equipment - Using Gloves, revised 09/2010, revealed gloves were worn once and discarded into a designated waste receptacle inside the room to prevent the spread of infection. Review of the facility's policy titled, COVID-19 Vaccination Policy and Procedure, revised 11/12/2021, revealed all staff would wear face masks while in the facility to protect residents against COVID-19. Per the policy, face masks must cover the mouth and nose completely; be secured to the head with ear loops or elastic bands that go behind the head; and, fit snugly over the nose, mouth, and chin with no large gaps on the outside of the face. Review of the facility's document titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 07/2014, revealed resident-care equipment, including reusable items and durable medical equipment (DME), would be cleaned and disinfected per current CDC infection prevention and control recommendations. Further review revealed staff should disinfect blood pressure cuffs after each use. In addition, the policy stated reusable items, such as stethoscopes and DME, were cleaned and disinfected before reuse on another resident. Review of the facility's document, Visitor Screening and Attestation Form, not dated, revealed that staff and visitors must agree to have their temperature measured upon arrival to the facility. Furthermore, the vistor or staff member must agree to wear a face mask while in the facility. 1. Observation, upon entry to the facility, on 01/24/2022 at 1:45 PM, revealed staff and visitors performed self-screening. The body temperature kiosk station was not working correctly. State Survey Agency (SSA) Surveyors proceeded to the reception desk, where they were asked to fill out a COVID-19 screen questionnaire and sign a COVID-19 attestation form. SSA Surveyors requested that their temperatures be taken because this was a requirement mandated by the screening questionnaire. Receptionist #1 did not inform SSA Surveyors that staff and visitors must wear an N95 while in the facility. Interview with the Administrator, on 01/24/2022 at 2:05 PM, revealed N95 masks were required because one (1) resident and one (1) staff member had tested positive for COVID-19 that morning, and the facility was now in a COVID-19 outbreak situation. She stated the facility followed the CDC, State, and County IPC guidelines. On 01/24/2022 at 1:50 PM, observations revealed Receptionist #1 sitting at a desk in the front lobby. Continued observation revealed Receptionist #1 was wearing a surgical mask under an N95 mask. The N95 mask was attached to the surgical mask and not secured around the ears. Interview with Receptionist #1, on 01/24/2022 at approximately 1:55 PM, revealed she changed her surgical mask daily. Further discussion revealed she was not aware she was wearing the N95 mask improperly. She stated she had received infection prevention and control (IPC) training, including hand hygiene and PPE usage. 2. Observation, on 01/24/2022 at 2:00 PM, revealed a COVID-19 testing station set up in the lobby. Lab Technician #1 was performing COVID-19 tests wearing a surgical mask. Continued observations throughout the day revealed the lab technician did not wear an N95 mask, face shield or goggles, or a gown while performing COVID-19 tests. Interview with Lab Technician #1, on 01/24/2022 at approximately 2:00 PM, revealed she worked for an outside firm that the facility contracted with to do COVID-19 testing for staff. She stated the contracted facility trained her. She stated she was trained to wear a surgical mask and gloves when testing, remove gloves, and use ABHR after each test. Interview with SRNA/Kentucky Medication Aide (KMA) #3, on 01/26/2022 at 2:22 PM, revealed the contracted lab technicians had been testing staff two (2) times weekly because of the high county positivity rate for COVID-19. Additionally, SRNA/KMA #3 revealed the lab technician only wore a mask and gloves when testing staff. 3. Observation on the 100 Hall, on 01/24/2022 at 2:15 PM, revealed there was a PPE storage bag hanging on the door of room [ROOM NUMBER]. However, there was no signage on the outside of the door explaining the type of transmission-based precautions (TBP) being used or a sign alerting staff of the correct PPE needed to enter the room. According to the Administrator, room [ROOM NUMBER] was a COVID-19 isolation room under droplet/contact precautions. Continued observation, on 01/24/2022 at 2:23 PM, revealed room [ROOM NUMBER] was under contact precautions for the resident having a suspected infection with [CONDITION(S)] (C. diff.), according to the Unit Manager. A PPE storage bag was hanging on the door; however, no signage was posted outside the room alerting staff of the specific TBP precaution in use or instructions for PPE required for entry. Interview with Licensed Practical Nurse (LPN) #1/Unit Manager, on 01/24/2022 at 2:40 PM, revealed that a TBP room should have signage outside the door alerting staff and visitors to see a nurse before entering the room. She stated the Unit Manager was responsible for ensuring rooms had the appropriate signage. Further observation revealed LPN #1 placed a sign on the doors, which read, See Nurse Before Entering. However, she did not put signage specific to TBP or instructions regarding PPE usage on the doors. 4. Observations in the conference room, on 01/24/2022, 01/25/2022, and 01/26/2022, revealed the same portable cart with COVID-19 testing supplies on the cart. A clear plastic bag was tied to the handle of the cart. Per observation, trash inside the bag consisted of used COVID-19 testing supplies, contaminated gloves, and used COVID-19 tests. There was nothing on the bag that indicated it contained biohazardous waste. Observation of the 300 Hall, on 01/24/2022 at 2:40 PM, revealed a yellow bag filled with linen and marked, Infectious Linen. This bag was left on the top of the red-biohazard trash can inside room [ROOM NUMBER], the TBP room with the resident with a suspected C. Diff. infection. Observation of the 100 Hall, on 01/26/2022 at 9:35 AM, revealed a linen-filled yellow bag marked Infectious Linen on the floor in the hall, outside of the COVID-19 isolation room, room [ROOM NUMBER]. Signage on room [ROOM NUMBER] stated, Droplet/Contact Precautions. Continued observation of the 100 Hall, on 01/26/2022 at 12:15 PM, revealed room [ROOM NUMBER]'s red biohazard container was overfilled with contaminated waste, preventing closure of the lid. SRNA #7 was observed removing biohazard trash from room [ROOM NUMBER] in clear trash bags, which she then disposed of into a regular waste receptacle in the dirty utility room. Interview with SRNA #7, on 01/26/2022 at approximately 3:30 PM, revealed she did come out of the COVID-19 isolation room. She stated she carried the biohazard trash in clear plastic bags, and placed them into the regular trash bin. SRNA #7 stated she noted the red biohazard receptacle in room [ROOM NUMBER] was overflowing with trash, so she bagged the waste in clear plastic bags and took them out. She stated she should have emptied the red biohazard receptacle. She further stated she should have emptied the contaminated waste in the biohazard bin and not the regular trash. She stated she had received education on IPC practices and procedures and got updates on IPC and COVID-19 almost daily. Interview with RN #3/Unit Coordinator, on 01/31/2022 at 9:30 AM, revealed staff was trained that if trash cans were full, the contents should be bagged and taken to the dirty utility room. Further, if it was contaminated waste in a red bag, it should be disposed of in the red barrel. She stated contaminated linen was placed in a yellow bag and placed in the hamper. Then, when housekeeping staff did the daily cleaning of the room, they took the yellow bag to the laundry room. Interview with the Environmental Services (EVS) Supervisor, on 01/31/2022 at 10:49 AM, revealed both nursing and housekeeping staff were trained to put contaminated linen, from a TBP room, into a yellow bag marked, Infectious Linen, and place the bag in a specially marked bin in the dirty utility room. The EVS Supervisor stated both nursing and housekeeping staff should take infectious linen to the soiled utility room. She stated both nursing and housekeeping staff were responsible for emptying the trash from a TBP room and disposing it into a red biohazard bin. 5. Observation of RN #1, on 01/25/2022 at approximately 9:30 AM, revealed she exited a resident's room without performing hand hygiene. Interview with RN #1, on 01/25/2022 at 9:45 AM, revealed she was unaware that she failed to perform hand hygiene after she exited a resident's room. She stated she should have performed hand hygiene immediately upon exit. She stated it was important to prevent the spread of infectious diseases. Observation of SRNA #1, on 01/25/2022 at 9:50 AM, revealed she exited a resident's room holding a breakfast tray. She placed the tray on the serving cart and failed to perform hand hygiene. Per observation, SRNA #1 then rolled the cart down the hall, stopped, and entered another resident's room, without performing hand hygiene. Per observation, SRNA #1 also failed to perform hand hygiene when exiting this resident's room. Then, she proceeded to wheel the serving cart to the kitchen. Interview with SRNA #1, on 01/25/2022 at 9:58 AM, revealed staff was trained to perform hand hygiene between resident care, use gloves, and then perform hand hygiene after removing PPE. Additionally, she stated she had received IPC education. During the interview, SRNA #1 stated she had used her own bottle of ABHR when exiting both residents' rooms; however, this was not observed by the SSA Surveyor. Interview with LPN #3, on 01/25/2022 at 9:40 AM, revealed the facility's policy was to perform hand hygiene before and after resident care and after touching a contaminated surface, such as a used meal tray. She stated further that when serving or picking up trays, staff used ABHR after each tray, and after the third tray, staff must wash hands with soap and water. She stated it was important to prevent the spread of infectious disease. Interview with RN #3/Unit Coordinator, on 01/31/2022 at 9:30 AM, revealed staff received handwashing and hand hygiene education upon hire and during in-services. She stated staff was proactive about watching their peers for compliance. Further interview revealed Unit Managers were tasked with assuring staff compliance with IPC policies and procedures. Per the interview, the staff was trained, when delivering meal trays, to use ABHR after each tray, and after the third tray, staff must wash their hands with soap and water. Furthermore, she stated staff should always perform hand hygiene when entering and exiting a resident's room, after touching a resident, or after contact with a contaminated surface. She stated it was important to prevent the spread of communicable diseases, especially during a COVID-19 outbreak. 6. Observation, on 01/25/2022 at 12:10 PM, revealed LPN #2 obtained vital signs on two (2) residents using a portable vital sign machine. However, LPN #2 failed to clean and disinfect the equipment between residents. Interview with SRNA #4, on 01/25/2022 at 12:20 PM, revealed, between use on residents, all shared equipment had to be cleaned and sanitized with purple top wipes, letting the equipment dry for two (2) minutes after disinfection. Interview with RN #3/Unit Coordinator, on 01/31/2022 at 9:30 AM, revealed the facility's policy stated that all shared equipment was cleaned and disinfected between use on residents. Additionally, she stated all staff had been trained on IPC policies. 7. Observation, on 01/26/2022 at 12:25 PM, of Registered Nurse (RN) #2, revealed he performed a blood glucose monitoring test. RN #2 failed to remove his gloves and perform hand hygiene after completing the test. Furthermore, he opened the door to the Medication Room. Per observation, he placed the contaminated blood glucose monitor (BGM)/glucometer on the top of a medication cart without first putting a barrier on top of the cart. He then removed his gloves, but did not perform hand hygiene. Per the observation, there were no disinfectant wipes in the Medication Room, so RN #2 left the room. When he returned, he used one (1) wipe to clean and disinfect the BGM and then placed it on a paper towel, which he put on the contaminated medication cart. Interview with RN #2, on 01/26/2022 at 12:40 PM, revealed he did not realize he failed to remove his gloves and perform hand hygiene. Furthermore, he stated he was unsure of the correct steps for cleaning and disinfecting the BGM. He stated proper hand hygiene was essential to prevent the spread of infection. RN #2 further noted following appropriate cleaning and disinfection techniques protected the surface from contamination and therefore decreased the chance for cross-contamination. 8. Observation of SRNA #7, on 01/26/2022 at approximately 3:30 PM, revealed she failed to doff (take off) PPE before she exited a Droplet/Contact TBP room with a COVID-19 positive resident. Per observation, SRNA #7 was wearing booties and two (2) N95 masks, one on top of the other. The first N95 mask did not cover her nose or mouth. The second N95 mask was off the face and hanging down around her neck as she exited the isolation room. Interview with SRNA #7, on 01/26/2022 at approximately 3:30 PM, revealed she received education on IPC practices and procedures, including instructions to properly don and doff PPE. SRNA #7 stated she exited the COVID-19 isolation without properly doffing her PPE. She stated she did not get a new N95 mask after providing care to a COVID-19 positive resident. SRNA #7 stated she usually wore a surgical mask over her N95 mask and disposed of the surgical mask before exiting the room. She stated she was being extra cautious by wearing two (2) N95 masks, but she got overheated and had to pull one down when in the room to breathe. Interviews with SRNA/KMA #4, on 01/24/2022 at 12:20 PM; RN #2, on 01/26/2022 at 12:25 PM; SRNA/KMA #3, on 01/26/2022 at 2:22 PM; and RN #3/Unit Coordinator, on 01/31/2022 at 9:30 AM, revealed a surgical mask was worn over an N95 mask when entering a room with a COVID-19 positive resident. They stated the surgical mask was discarded upon exit, but staff wore the same N95 mask all day. They stated the N95 mask was replaced if it was visibly soiled; then, staff discarded the N95 mask at the end of the day and received a new N95 mask at the beginning of his/her next shift. Interview with the Infection Preventionist (IP), on 01/31/2022 at 2:00 PM, revealed she expected staff to use proper hand hygiene techniques routinely, before and after resident care and before and after each medication administration. Continued interview revealed it was her expectation that staff don and doff the appropriate PPE for the level of care given. In addition, she stated the staff was expected to wear face masks according to CDC recommendations. Finally, she stated it was her expectation that all nursing staff followed IPC guidelines to decrease the chance of the spread of infections and to keep residents and staff safe. Interview with the Interim DON, on 01/31/2022 at 2:00 PM, revealed it was her expectation that all staff followed IPC procedures to prevent the spread of infection. She stated the facility followed the CDC, State, and County IPC guidelines. Additionally, the DON stated that following the correct IPC policies and procedures was essential to prevent the spread of infectious disease and to ensure the safety of the residents and staff. She stated further that there was no shortage of PPE, and staff knew to contact the EVS Supervisor for additional supplies. Additional interview with the Administrator, on 01/31/2022 at 2:00 PM, revealed it was her expectation that all IPC guidelines were to be continuously maintained in the facility to decrease the potential spread of infection. The Administrator stated the facility had an abundance of PPE in storage to handle any outbreak that might occur. She stated the facility had received generous donations and could get supplies from the State and Local Health Departments.

Based on observation, interview and review of facility's policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observations on [DATE] of the nourishment rooms on the 100 and 200 unit revealed numerous snacks undated in the nourishment drawers. The findings include: Review of the facility's policy, titled Dry storage dated 2013, revealed to store, prepare and serve food in accordance with Federal, state and local sanitary codes. Continued review revealed foods would be labeled as to content and dated. Further review revealed stock will be rotated on a first in first out (FIFO) basis. Observations of the 200 unit resident nourishment room, on [DATE] at 9:00 am revealed snacks not dated for four (4) ginger bread cookies, eight (8) strawberry delight cookies, one (1) oatmeal creme cookie and two (2) peanut butter crackles. Observation of the 100 unit resident nourishment room, on [DATE] at 9:10 AM, revealed snacks not dated for five (5) marshmallow pies, one (1) ginger bread cookie, one (1) fudge brownie cookie and one (1) package of peanut butter crackers. Interview with the ,[DATE] Unit Manager, on [DATE] at 3:15 PM, revealed State Registered Nurse Aide (SRNA) #2 usually passes the 10:00 AM and 2:00 PM snacks. Continued interview revealed SRNA #2 should not return undated snacks to the nourishment room. Further interview revealed there was a potential for infection control concerns, and the snacks not appetizing to the residents. Interview SRNA #2, on [DATE] at 3:37 PM, revealed she passes the 10:00 AM and 3:00 PM snacks to the residents for the 100 and 200 units. Continued interview revealed, should a resident refuse their snack, she places it in the nourishment room. Further interview revealed should she find any left over and undated snacks in the nourishment room, she throws them out and informs the kitchen. She stated undated snacks should not be available for the residents. Interview with SRNA #1, on [DATE] at 3:22 PM, revealed snacks were available for residents at night in the nourishment room. Continued interview revealed snacks were not usually left in the nourishment room drawers. He stated snacks that were undated should be thrown out due to the potential to grow bacteria and not taste good. Per interview, he returns extra snacks on the cart to Dietary. Interview with Dietary Aide #1, on [DATE] at 3:53 PM, revealed she had not been notified that there were any undated snacks in the nourishment room. Continued interview revealed snacks should be dated and rotated daily. She stated should a snack not be dated, it needs to be thrown away. Interview with Cook #1, on [DATE] at 3:51 PM, revealed there has been no staff from the 100 unit or the 200 unit inform her that there were snacks in their nourishment room that were undated. Per interview, if there are items that are not dated, they should be discarded. Interview with Dietary Manager, on [DATE] at 3:55 PM, revealed the facility policy was that every food item should be labeled and dated prior to being sent to the nourishment rooms. Continued interview revealed the Dietary Aide is responsible to supply the nourishment room and rotate the nourishments. Further interview revealed the Dietary Aides are not responsible to rotate any snacks in the nourishment room drawers. The Dietary Aide brings the snacks to the nourishment room in dated boxes. The SRNA passes snacks to the residents three (3) times a day. Per interview, she believes the SRNAs are putting the extra snacks from the snack cart into the nourishment room drawers without a date on the snack. Per interview, items should be label and dated because there was a potential for food borne illness if the nourishments not dated or expired. Interview with the Director of Nursing (DON), on [DATE] at 03:58 PM, revealed all food items should be labeled and dated with an expiration date. Continued interview revealed food items without an expiration date can expire, and not taste good. Further interview revealed there was a potential for bacteria to grow in food, which contain high levels of sugar. Interview with Administrator, on [DATE] at 4:05 PM, revealed all food items should be dated. Per interview, the food should be dated when taken out of the box. Continued interview revealed the expectation was that the food items would be labeled and dated as well as rotated with the first come first served. Per interview, bacteria can potentially grow in expired food items.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain clinical records that are accurately documented for one (1) of twenty-four (24) sampled residents (Resident #8). Review of Resident #8's Physician order [REDACTED]. However, review of the Treatment Administration Record revealed no documented evidence of treatment being signed out as administered from 01/22/2020 until 02/06/2020. The findings include: Interview with the facility's Director of Nursing, on 02/06/2020 at 4:32 PM, revealed maintaining accurate resident records is a standard of practice and there is no policy related to the accuracy of resident records. Review of Resident #8's clinical record revealed the facility admitted the resident on 09/22/2015 with [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly Minimum Data Set (MDS) Assessment, dated 11/01/19, revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #8's Order Summary Report, dated (MONTH) 2020, revealed an active physician's orders [REDACTED]. Review of Resident #8's Treatment Administration Record (TAR), for 01/22/2020, revealed the treatment to cleanse the stage 4 wounds to the right ischium and sacrum with normal saline, pat dry, apply alginate calcium with silver, cover with ABD pad and secure with pinc tape two (2) times daily. Continued review of the TAR revealed no documented evidence the treatments had been performed from 01/22/2020 at 10:00 PM until 02/06/2020 at 10:00 AM. Interview with Resident #8, on 02/06/2020 at 3:05 PM, revealed staff do come and change his/her dressing twice a day, morning and night, unless he/she refuses. Interview with LPN #1, on 02/06/2020 at 3:33 PM, revealed the blanks in the TAR means the nurse failed to sign out that the treatment was completed. It does not mean the treatment was not performed; just that it was not documented in the computer in the electronic Treatment Record. Interview with the Director of Nursing (DON), on 02/06/2020, at 4:33 PM, revealed the wound care and dressing changes should be signed off in the TAR to validate the treatment had been performed per the physician's orders [REDACTED]. Interview with the Administrator, on 02/06/2020, at 4:44 PM, revealed it was her expectation that the resident's medical record was to be complete and accurate. She stated the importance of signing out the treatment record was to ensure the treatment had been completed per the physician's orders [REDACTED].>

Based on interview, record review, and review of facility's policy, it was determined the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two (2) hours after the allegation is made, to the State Agency for one (1) of five (5) sampled residents (Resident #1). Although the facility was notified of an allegation of abuse on 08/15/19 at approximately 8:30 AM, the facility failed to notify State Agencies within the two (2) hour timeframe in accordance with facility Policy and Regulation. Record review revealed State Agencies were not notified of the allegation until 08/16/19 at 2:14 PM. The findings include: Review of the facility Abuse Investigation and Reporting Policy, revised (MONTH) (YEAR), revealed an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. Review of the Facility's Initial Report, dated 08/16/19, revealed on 08/15/19 at 8:30 AM, a staff member was attending a meeting to discuss work performance issue, after becoming angry in this meeting she subsequently reported allegations of abuse by another staff. She stated she had overheard State Registered Nursing Assistant (SRNA) #1 tell Resident #1 to just pee in your damn depends and that SRNA #2 was a witness. She further stated she reported the incident to Licensed Practical Nurse (LPN) #1. The fax Transaction Report revealed this Initial Report was faxed to State Agencies on 08/16/19 at 2:14 PM. Review of the Facility's five (5) day report, dated 08/22/19, revealed after the Administrator and Social Services Director conducted an investigation it was determined the allegations were not substantiated, as both SRNA #1 denies and SRNA #2 stated she never witnessed SRNA #1 state this to Resident #1. It was determined the allegations were that of a disgruntled employee after she became upset over a job performance issue. Resident #1 was assessed and had no apparent injury and was non-interviewable. Review of Resident #1's clinical record revealed the facility admitted the resident on 04/25/18 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of four (4) out of fifteen (15), indicating the resident was severely cognitively impaired. Continued review revealed the facility assessed the resident as having behaviors. Review of Resident #1's Comprehensive Care Plan, revealed resident was incontinent of bowel and bladder and required assistance of two (2) for all activities of daily living. Interview with SRNA #1, on 08/28/19 at 3:14 PM, revealed she had been working at the facility since (MONTH) (YEAR) and she worked the 400 unit where Resident #1 resided. SRNA #1 denied ever stating to any resident to just pee in your damn depends, she stated she would never say that to a resident and she had been working in this field for over twenty eight (28) years. She further stated she did not understand why the staff member would make up this story other than the fact she had reported to her supervisor about some work performance issues. Interview with SRNA #2, on 08/28/19 at 3:00 PM, revealed she was notified of the allegation of abuse, on 08/15/19 at approximately 10:00 AM, by the Administrator when she was being interviewed and asked to provide a witness statement. She revealed she never witnessed SRNA #1 state those things to Resident #1 and in fact SRNA #1 was an excellent employee and was very kind and [MEDICATION NAME] about her job. Interview with LPN #1, on 8/29/19 at 9:15 AM, revealed she was the nurse on duty assigned to Resident #1 at the time of the alleged incident. She stated no one had ever reported that SRNA #1 told Resident #1 to just pee in the damn depends. She further stated that SRNA #1 provided excellent care to all the residents and the family members compliment the care she provided on a daily basis. Interview with the Administrator, on 08/29/19 at 10:49 PM, revealed the facility found out about the allegation involving Resident #1 and SRNA #1 on the morning of 08/15/19 during a meeting they were having with another staff member who was being counseled over poor job performance. The staff member got defensive during the meeting and subsequently reported an allegation of abuse. She stated they quickly were able to determine this allegation was false. She further stated on 08/16/19 when the ombudsman came into the facility reporting this allegation of abuse along with other concerns is when she notified the State Agencies within two hours of the ombudsman coming into the facility; however, she was informed of this allegation of abuse on 08/15/19 when she met with the staff member who made the allegations during a meeting. The Administrator stated the allegation was not reported immediately because they were able to determine the allegations were false and unsubstantiated. She further stated as soon as the allegation was made and investigation was initiated; however the State Agencies were not notified until the following day after the Ombudsman came in and made them aware of what allegations she had received. Per interview, the allegation of abuse was a late report and according to facility policy should have been reported within two (2) hours.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program to include antibiotic use protocols and a system to monitor antibiotic use. The facility was unable to submit documented evidence of an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use in order to optimize the treatment of [REDACTED]. The findings include: Interview on 02/14/19 at 3:09 PM, with the Director of Nursing (DON), revealed there were no formal policies or written protocols for antibiotic prescribing. Review of the Med-Pass Policy and Procedure Manual for Long-Term Care Managing Infections utilized by the facility, revealed it included a Policy titled, Antibiotic Stewardship with revision date of (MONTH) (YEAR), and a Policy titled Antibiotic Stewardship - Orders for Antibiotics with revision date of (MONTH) (YEAR). However, there was no documented evidence of written protocols for prescribing antibiotics. Review of the facility Monthly Infection Control Log kept by the DON/Infection Control Preventionist, revealed the Log tracked antibiotics used; however, the microorganisms were not listed to enable assessment of antibiotic prescribing. Review of the Facility Assessment Tool, dated 08/18/17, revealed the facility routinely cared for residents with infectious diseases to include the following: Skin and Soft Tissue Infections, Respiratory Infections, Urinary Tract Infections (UTIs), infections with Multi-Drug Resistant Organisms, [MEDICAL CONDITION], [MEDICAL CONDITIONS], Influenza, and [MEDICAL CONDITION] (C Diff). Further review revealed Prevention and management of infections was noted as a service provided by the facility. Interview on 02/14/19 at 3:09 PM, with the DON/Infection Control Preventionist, revealed the facility reviewed antibiotic usage in Infection Control Quality Assurance Meetings. She further stated she kept an Infection Control Log noting antibiotic usage; however, the Log did not include the microorganisms related to the infection in which the antibiotics were prescribed. Further interview revealed the facility had no written protocols for antibiotic use, nor a system to monitor antibiotic usage and resistance data. Interview with the Consultant Pharmacist, on 02/26/19 at 11:25 AM, revealed she attended the facility quarterly Quality Assurance Meeting. She stated she was unaware of any written protocols for antibiotic prescribing; however, she stated the DON/Infection Control Preventionist routinely communicated with her regarding antibiotic usage for the residents. Interview with the Administrator, on 02/14/19 at 4:07 PM, revealed she worked with the DON/Infection Control Preventionist to ensure the facility's use of antibiotics for residents was consistent with standards of practice. She stated the facility currently did not have written antibiotic prescribing protocols, but she would ensure they were developed in accordance with regulations.

Based on observation, interview, and record review, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for six (6) of twenty-six (26) sampled residents (Resident #3, Resident #11, Resident #50, Resident #87, Resident #99, and Resident #108). Review of the Situational Awareness and Response Assistant (SARA) Reports, detailing wait times for call lights to be answered from 01/09/19 through 01/31/19, revealed residents consistently had to wait long periods of time for the call light to be answered, and in some cases up to fifty-nine (59) minutes. In addition, residents complained of having to wait long periods of time for the call lights to be answered. In addition, observation on 02/13/19, revealed Kentucky Medication Aide (KMA #1) administered medication to Resident #86 in the dining room during morning meal service. The findings include: Review of the facility's Policy, titled Resident Rights, revised (MONTH) 2009, revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Further review of the Policy, revealed demeaning practices and standards of care that compromise dignity are prohibited. 1. Review of Resident #99's medical record revealed the facility originally admitted the resident on 04/24/13 with [DIAGNOSES REDACTED]. Review of Resident #99's Quarterly Minimum Data Set (MDS) Assessment, dated 01/18/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating resident was cognitively intact. Observation on 02/13/19 at 10:15 AM, revealed Resident #99 was lying in bed asking for ice water. The resident had his/her call light on and stated he/she had been waiting for someone to answer the call light for twenty (20) minutes. Further observation revealed staff were walking up and down the hallway outside of the resident's room, and staff were sitting at the nurse's station while this residents call light was on. Interview with the resident at the time of observation revealed, they are ignoring me because I complain a lot. Per interview, he/she always had to wait a long time for the call light to be answered, and it usually took twenty (20) to thirty (30) minutes for the call light to be answered. After ten (10)minutes of observing staff failing to answer the resident's call light, the State Agency Representative went to the nurse's station to inform staff the resident was requesting ice water. Review of the Situational Awareness and Response Assistant (SARA) Reports, detailing wait times for call lights to be answered from 01/09/19 through 01/31/19, revealed an average wait time of greater than twenty (20) minutes for Resident #99. Further review of the SARA Report revealed the longest wait times were on 0/31/2019 at 6:06 PM with a response time of thirty four (34) minutes; 01/31/2019 at 2:58 PM with a response time of thirty five (35) minutes seven (7) seconds; 01/31/19 at 11:25 AM, with response time of thirty five (35) minutes and six (6) seconds; 01/30/19 at 7:06 PM with response time of thirty five (35) minutes two (2) seconds; and 01/28/19 at 12:45 PM with response time of thirty five (35) minutes and nine (9) seconds. Interview on 02/14/19 at 10:16 AM, with the Social Service Director, revealed Resident #99 told her he/she would turn on the call light, and when staff would come to his/her room, he/the resident would tell them he/she did not remember what he/she needed. Per interview, Resident #99 told the SSD he/she did this deliberately because he/she wanted to get staff in trouble. The SSD stated Resident #99 was care planned for two (2) staff members to provide care related to resident making accusatory statements, which could be the reason the resident had longer call light response times. Further interview revealed if the SSD received a complaint related to call light response times she would review the SARA Reports; however, she did not remember receiving grievances regarding residents complaining of the call light response times. Continued interview revealed it would be best if the call lights were answered in less than ten (10) minutes, but the call lights were answered as soon a possible. Continued interview revealed the nursing staff had pagers they carried and there was a board in front of the unit 1 nurse's station which would light up to show which resident had pushed the call light. Interview on 02/14/19 at 10:34 AM, with Licensed Practical Nurse (LPN) #1, revealed Resident #99 was care planned for two (2) staff members to provide care due to being accusatory of staff. Per interview, Resident #99 did sometimes complain about the call light being on for ten (10) minutes or longer. LPN #1 stated the call light alerted the State Registered Nurse Aides (SRNAs) pagers first, and then in ten (10) minutes if the call light was not answered, the pager alerted the nurse. Per interview, after twenty (20) minutes of the call light going off, the pager would then alert the Director of Nursing (DON). LPN #1 stated sometimes staff were very busy serving meals or assisting residents to lye down after meals and it may take longer than fifteen (15) minutes for the call lights to be answered. Interview on 02/14/19 at 10:50 AM, with the Unit Manager (UC) for Unit 1, revealed he had been the UC since (MONTH) (YEAR). He stated the facility had a soundless silent call bell system. Per interview, when a call bell was initiated, it signaled the SRNAs on the floor, and the pagers were unit specific. Per interview, after twenty (20) to thirty (30) minutes, if the call light was not answered, the pager system would alert the UM. Further interview revealed during the morning meeting Monday through Friday, the DON gave the Unit Managers a list of residents who had to wait over fifteen (15) minutes for the call light to be answered the day before. He stated he had received complaints from Resident #99 regarding the call light not being answered in a timely fashion. The UM checked the SARA Report for to see how long it took staff to answer Resident #99's call light during observation of the resident asking for water on 02/13/19, and noted the wait time was twenty two (22) minutes at 10:15 AM. He stated it was his expectation for to answer call lights in a timely manner. 2. Review of Resident #87's medical record revealed the facility admitted the resident on 08/19/15 and readmitted the resident on 4/12/16 with [DIAGNOSES REDACTED]. Review of Resident #87's Annual Minimum Data Set (MDS) Assessment, dated 07/13/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) Score of thirteen (13) out of fifteen (15) indicating intact cognition. Further review of the MDS Assessment, revealed the facility assessed the resident as requiring one (1) person assistance with toileting, and as frequently incontinent of bowel and bladder. Review of the SARA Report, detailing wait times for call lights to be answered from 01/09/19 through 01/31/19, revealed Resident #87 experienced thirty-eight (38) occurrences of wait time for staff assistance greater than fifteen (15) minutes. Further review revealed ten (10) of the thirty- eight (38) occurrences were thirty (30) minutes or longer in length. Record review comparison between the (MONTH) 2019 SARA Report and (MONTH) 2019 Bowel and Bladder Report, revealed two (2) episodes of prolonged call light response with recorded episodes of incontinence. The referenced events were 01/12/19 at 4:35 AM with a call light response time of 20 minutes and 39 seconds; and 01/27/19 at 6:32 PM with a call light response time of 24 minutes and 42 seconds. Interview on 02/12/19 at 11:05 AM, with Resident #87, revealed he/ she utilized a bed pan for each void and bowel movement due to complaints of discomfort resulting from the hoyer lift (mechanical lift) sling, thus preventing the resident from utilizing the toilet. Resident #87 stated he/ she had experienced episodes of incontinence as a direct result of staff's failure to answer call lights timely. Resident #87 further stated he/she felt the facility was short staffed, but clarified since he/she could not provide the usual number of staff on the hall because he/she usually stayed in his/her room. Resident #87 did not feel there was a particular time of day in which the wait time was longer, but did mention wait times were anticipated to be longer when meal trays were being passed, and when staff were assisting residents with meals. Interview on 02/13/19 at 4:20 PM, with SRNA #6, revealed the pagers the SRNAs carried alerted them to call lights needing to be answered and they could also check the board at the nurse's station which would light up and show which resident had the call light on. SRNA #6 stated the usual time to answer call lights was between ten (10) and fifteen (15) minutes, but it sometimes took up to twenty (20) minutes when they were busy. 3. Review of Resident #3's medical record revealed the facility admitted the resident on 09/22/15 with [DIAGNOSES REDACTED]. The facility assessed Resident #3, in a 02/01/19 Quarterly Minimum Data Set (MDS) as having a Brief Interview for Mental Status (BIMS) of a thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Review of the SARA Reports, detailing wait times for call bells to be answered from 01/09/19 through 01/31/19, revealed multiple incidents of wait times in excess of fifteen (15) minutes for Resident #3 to include the following. 01/09/19 at 7:28 PM, Resident #3 waited 30 minutes and 9 seconds for staff to respond. 01/09/19 at 9:28 PM, Resident #3 waited 27 minutes and 43 seconds for staff to respond. 01/09/19 at 10:17 PM, Resident #3 waited 27 minutes and 18 seconds for staff to respond. 01/10/19 at 11:08 AM, Resident #3 waited 30 minutes and 7 seconds for staff to respond. 01/10/19 at 5:41 PM, Resident #3 waited 29 minutes and 36 seconds for staff to respond. 01/14/19 at 12:48 PM Resident #3 waited 30 minutes and 6 seconds for staff to respond. 01/14/19 at 9:26 PM Resident #3 waited 20 minutes and 46 seconds for staff to respond. 01/15/19 at 5:11 PM Resident #3 waited 30 minutes and 6 seconds for staff to respond. 01/15/19 at 6:47 PM Resident #3 waited 18 minutes and 19 seconds for staff to respond. 01/15/19 at 9:36 PM Resident #3 waited 26 minutes and 20 seconds for staff to respond. 01/19/19 at 10:59 PM Resident #3 waited 18 minutes and 34 seconds for staff to respond. 01/21/19 at 4:25 PM Resident #3 waited 24 minutes and 24 seconds for staff to respond. 01/22/19 at 8:12 PM Resident #3 waited 18 minutes and 29 seconds for staff to respond. 01/23/19 at 4:32 AM Resident #3 waited 30 minutes and 6 seconds for staff to respond. 01/23/19 at 7:18 AM Resident #3 waited 20 minutes for staff to respond. 01/23/19 at 11:01 AM Resident #3 waited 50 minutes and 47 seconds for staff to respond. 01/25/19 at 8:29 AM Resident #3 waited 26 minutes and 40 seconds for staff to respond. 01/25/19 at 9:56 PM Resident #3 waited 22 minutes and 38 seconds for staff to respond. 01/26/19 at 9:09 AM Resident #3 waited 29 minutes and 23 seconds for staff to respond. 01/27/19 at 7:26 PM Resident #3 waited 18 minutes and 58 seconds for staff to respond. 01/28/19 at 7:40 PM Resident #3 waited 19 minutes and 52 seconds for staff to respond. 01/31/19 at 7:13 PM Resident #3 waited 30 minutes and 7 seconds for staff to respond. 01/31/19 at 9:11 PM Resident #3 waited 30 minutes and 8 seconds for staff to respond. Interview with Resident #3, on 02/13/19 at 3:16 PM, revealed he/she was being treated for [REDACTED]. When asked about call lights, Resident #3 stated Medical, very medical yesterday, but the resident was unable to answer questions related to the call light response times. Interview on 02/14/19 at 3:59 PM, with SRNA #12, revealed Resident #3 required total care, and had a touch-sensitive call light because of problems with his/her hands. SRNA #12 revealed Resident #3 would use his/her call light if he/she wanted a sip of water, and would not ring the call bell for much of anything else. SRNA #12 stated if she was busy with another resident, she couldn't always answer the call lights quickly. She stated a lot of times multiple call lights would ring at the same time, with four (4) or five (5) call lights sometimes going off at once. She stated she believed over half the residents on the 200 Unit required the assist of two (2) staff for Activities of Daily Living (ADLs). 4. Review of Resident #11's medical record revealed the facility admitted the resident on 02/25/13 with [DIAGNOSES REDACTED]. The facility assessed Resident #11 in a Significant Change MDS assessment dated [DATE] as having a BIMS score of seven (7) out of fifteen (15), indicating severe cognitive impairment. Review of the SARA Report, detailing wait times from 01/09/19 through 01/31/19, revealed multiple incidents of wait times in excess of fifteen (15) minutes for Resident #1 to include the following: 01/10/19 at 5:15 PM Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/10/19 at 6:41 PM Resident #11 waited 18 minutes and 37 seconds for staff to respond. 01/10/19, at 10:05 PM, Resident #11 waited 30 minutes and 8 seconds for staff to respond. 01/11/19 at 2:33 AM, Resident #11 waited 30 minutes and 8 seconds for staff to respond. 01/11/19 at 9:48 AM, Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/11/19 at 11:52 AM, Resident #11 waited 30 minutes and 8 seconds for staff to respond. 01/11/19 at 12:22 PM, Resident #11 waited 1 hour, 30 minutes, and 24 seconds for staff to respond. 01/11/19 at 4:11 PM, Resident #11 waited 20 minutes and 30 seconds for staff to respond. 01/11/19 at 5:36 PM, Resident #11 waited 22 minutes and 25 seconds for staff to respond. 01/11/19 at 7:25 PM, Resident #11 waited 1 hour, 30 minutes, and 27 seconds for staff to respond. 01/11/19 at 9:48 PM, Resident #11 waited 23 minutes and 37 seconds for staff to respond. 01/12/19 at 2:49 PM, Resident #11 waited 27 minutes and 1 second for staff to respond. 01/12/19 at 5:14 PM, Resident #11 waited 18 minutes and 17 seconds for staff to respond. 01/13/19 at 2:01 PM, Resident #11 waited 16 minutes and 59 seconds for staff to respond. 01/14/19 at 7:56 AM, Resident #11 waited 30 minutes and 9 seconds for staff to respond. 01/14/19 at 10:28 PM, Resident #11 waited 25 minutes and 3 seconds for staff to respond. 01/15/19 at 9:03 AM, Resident #11 waited 26 minutes and 8 seconds for staff to respond. 01/15/19 at 10:10 AM, Resident #11 waited 25 minutes and 17 seconds for staff to respond. 01/15/19 at 5:04 PM, Resident #11 waited 47 minutes and 9 seconds for staff to respond. 01/15/19 at 6:38 PM , Resident #11 waited 30 minutes and 7 seconds for staff to respond. 01/15/19 at 7:49 PM, Resident#11 waited 19 minutes and 52 seconds for staff to respond. 01/15/19 at 9:46 PM, Resident #11 waited 21 minutes and 16 seconds for staff to respond. 01/16/19 at 2:34 AM, Resident #11 waited 19 minutes and 32 seconds for staff to respond. 01/16/19 at 5:34 AM, Resident #11 waited 46 minutes and 31 seconds for staff to respond. 01/16/19 at 9:11 AM, Resident #11 waited 17 minutes and 4 seconds for staff to respond. 01/16/19 at 11:45 AM, Resident #11 waited 26 minutes and 37 seconds for staff to respond. 01/17/19 at 3:36 AM, Resident #11 waited 26 minutes and 55 seconds for staff to respond. 01/17/19 at 7:13 AM, Resident #11 waited 25 minutes and 20 seconds for staff to respond. 01/17/19 at 6:39 PM, Resident #11 waited 16 minutes for staff to respond. 01/17/19 at 8:53 PM, Resident #11 waited 23 minutes and 58 seconds for staff to respond. 01/17/19 at 9:54 PM, Resident #11 waited 22 minutes and 49 seconds for staff to respond. 10/17/19 at 10:17 PM, Resident #11 waited 30 minutes and 5 seconds for staff to respond. 01/18/19 at 10:16 AM, Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/18/19 at 7:08 PM, Resident #11 waited 30 minutes and 8 seconds for staff to respond. 01/18/19 at 10:53 PM, Resident #11 waited 18 minutes and 21 seconds for staff to respond. 01/19/19 at 3:19 AM, Resident #11 waited 25 minutes and 44 seconds for staff to respond. 01/19/19 at 9:06 AM, Resident #11 waited 16 minutes and 28 seconds for staff to respond. 01/19/19 at 7:38 PM, Resident #11 waited 26 minutes and 34 seconds for staff to respond. 01/19/19 at 9:05 PM, Resident #11 waited 27 minutes and 52 seconds for staff to respond. 01/20/19 at 7:17 PM, Resident #11 waited 24 minutes and 21 seconds for staff to respond. 01/20/19 at 8:32 PM, Resident #11 waited 30 minutes and 5 seconds for staff to respond. 01/21/19 at 4:39 PM, Resident #11 waited 18 minutes and 51 seconds for staff to respond. 01/22/19 at 2:29 PM, Resident#11 waited 24 minutes and 9 seconds for staff to respond. 01/22/19 at 5:10 PM, Resident #11 waited 59 minutes and 56 seconds for staff to respond. 01/22/19 at 8:17 PM, Resident #11 waited 1 hour and 13 seconds for staff to respond. 01/22/19 at 9:44 PM, Resident #11 waited 16 minutes and 27 seconds for staff to respond. 01/21/19 at 2:57 PM, Resident #11 waited 30 minutes and 7 seconds for staff to respond. 01/21/19 at 4:00 PM, Resident #11 waited 30 minutes and 8 seconds for staff to respond. 01/21/19 at 9:08 PM, Resident #11 waited 52 minutes and 11 seconds for staff to respond. 01/24/19 at 7:57 AM, Resident #11 waited 30 minutes and 7 seconds for staff to respond. 01/24/17 at 10:07 AM, Resident #11 waited 23 minutes and 20 seconds for staff to respond. 01/24/19 at 1:24 PM, Resident #11 waited 1 hour and 11 seconds for staff to respond. 01/24/19 at 3:04 PM, Resident #11 waited 1 hour, 50 minutes and 11 seconds for staff to respond. 01/25/19 at 9:00 AM, Resident #11 waited 25 minutes and 29 seconds for staff to respond. 01/25/19 at 11:23 AM, Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/25/19 at 2:27 PM, Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/25/19 at 3:21 PM, Resident #11 waited 15 minutes and 58 seconds for staff to respond. 01/25/19 at 6:15 PM, Resident #11 waited 17 minutes and 1 second for staff to respond. 01/25/19 at 6:58 PM, Resident #11 waited 1 hour and 18 seconds for staff to respond. 01/26/19 at 4:59 AM, Resident #11 waited 26 minutes and 38 seconds for staff to respond. 01/27/19 at 1:57 AM, Resident #11 waited 17 minutes and 56 seconds for staff to respond. 01/28/19 at 5:30 PM, Resident #11 waited 30 minutes and 7 seconds for staff to respond. 01/29/19 at 2:11 AM, Resident #11 waited 22 minutes and 9 seconds for staff to respond. 01/29/19 at 5:01 AM, Resident #11 waited 30 minutes and 7 seconds for staff to respond. 01/29/19 at 5:02 PM, Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/30/19 at 9:58 AM, Resident #11 waited 22 minutes and 3 seconds for staff to respond. 01/30/19 at 5:06 PM, Resident#11 waited 16 minutes and 44 seconds for staff to respond. 01/30/19 at 6:01 PM, Resident #11 waited 17 minutes and 23 seconds for staff to respond. 01/31/19 at 5:08 AM, Resident #11 waited 23 minutes and 45 seconds for staff to respond. 01/31/19 at 7:02 AM, Resident #11 waited 15 minutes and 58 seconds for staff to respond. 01/31/19 at 2:48 PM, Resident #11 waited 22 minutes and 56 seconds for staff to respond. 01/31/19 at 6:32 PM, Resident #11 waited 19 minutes and 15 seconds for staff to respond. Interview on 02/14/19 at 3:36 PM, with SRNA #5, revealed Resident #11 had many request when using his/her call light. Per interview, the resident usually requested a new cup of water, incontinence care, blankets to be adjusted or the bed to be moved up or down. SRNA #5 further stated Resident #11 required the assist of two (2) staff for incontinence care as he/she was no longer able to be toileted due to a decline. Further interview revealed residents had to wait longer than fifteen (15) minutes at times for the call bell to be answered because staff were busy showering residents or performing incontinence care for residents. Interview on 02/13/19 at 4:02 PM with SRNA #1, revealed she worked on Unit 2, and there was usually between four (4) and five (5) aides on the unit, a charge nurse, and at least one (1) nurse and one (1) Kentucky Medication Associate (KMA) on day shift. SRNA #1 stated Resident #11 did ring his/her call light a lot, often to request incontinence care. Further interview revealed she tried to answer call lights in under twenty (20) minutes. She further stated Resident #11 had informed her it sometimes took thirty (30) minutes before staff could answer his/her call light. Continued interview revealed when a resident rang the call light, aides on the unit were alerted by pager, whether assigned to the resident or not. She stated, after ten (10) minutes the pager would alert the nurses working the medication carts. She revealed all resident on Unit 2 except one (1) resident required the assist of two (2) staff to provide care. 5. Review of Resident #50's medical record revealed the facility admitted the resident on 04/30/18 with [DIAGNOSES REDACTED]. The facility assessed Resident #50, in a 12/19/18 Significant Change MDS Assessment, as having a BIMS score of four (4) out of fifteen (15) , indicating severe cognitive impairment. Review of the SARA Report from 01/09/19 through 01/31/19, revealed multiple incidents of wait times in excess of fifteen (15) minutes for Resident #50 including: 01/10/19 at 11:53 AM, Resident #50 waited 55 minutes and 5 seconds for staff to respond. 01/10/19 at 1:26 PM, Resident #50 waited for 1 hour, 57 minutes and 18 seconds for staff to respond. 01/10/19 at 8:22 PM, Resident #50 waited for 21 minutes and 31 seconds for staff to respond. 01/11/19 at 11:13 AM, Resident #50 waited for 1 hour, 30 minutes and 19 seconds for staff to respond. 01/11/19 at 7:02 PM, Resident #50 waited 1 hour and 16 seconds for staff to respond. 01/12/19 at 7:21 PM, Resident #50 waited 25 minutes and 2 seconds for staff to respond. 01/14/19 at 7:59 AM, Resident #50 waited 47 minutes and 40 seconds for staff to respond. 01/14/19 at 5:28 PM, Resident #50 waited 1 hour, 15 minutes and 22 seconds for staff to respond. 01/14/19 at 9:02 PM, Resident #50 waited 19 minutes and 1 second for staff to respond. 01/15/19 at 9:15 PM, Resident #50 waited 23 minutes and 24 seconds for staff to respond. 01/16/19 at 1:09 PM, Resident #50 waited 23 minutes and 1 second for staff to respond. 01/16/19 at 1:36 PM, Resident #50 waited 22 minutes and 48 seconds for staff to respond. 01/17/19 at 9:40 AM, Resident #50 waited 23 minutes and 32 seconds for staff to respond. 01 /17/19 at 1:20 PM, Resident #50 waited 16 minutes and 18 seconds for staff to respond. 01/17/19 at 3:32 PM, Resident #50 waited 21 minutes and 8 seconds for staff to respond. 01/18/19 at 9:58 AM, Resident #50 waited 30 minutes and 6 seconds for staff to respond. 01/19/19 at 9:59 AM, Resident #50 waited 17 minutes and 3 seconds for staff to respond. 01/19/19 at 8:40 PM, Resident #50 waited 19 minutes and 26 seconds for staff to respond. 01/20/19 at 8:35 PM, Resident #50 waited 20 minutes and 45 seconds for staff to respond. 01/21/19 at 10:25 AM, Resident #50 waited 52 minutes and 49 seconds for staff to respond. 01/21/19 at 8:35 PM, Resident #50 waited 17 minutes and 36 seconds for staff to respond. 01/22/19 at 8:31 PM, Resident #50 waited 15 minutes and 16 seconds for staff to respond. 01/23/19 at 6:57 AM, Resident #50 waited 21 minutes and 27 seconds for staff to respond. 01/23/19 at 9:16 AM, Resident #50 waited 26 minutes and 47 seconds for staff to respond. 01/24/19 at 10:10 AM, Resident #50 waited 15 minutes and 57 seconds for staff to respond. 01/25/19 at 6:04 AM, Resident #50 waited 29 minutes and 6 seconds for staff to respond. 01/25/19 at 9:03 AM, Resident #50 waited 46 minutes and 17 seconds for staff to respond. 01/25/19 at 10:24 AM, Resident #50 waited 1 hour and 16 seconds for staff to respond. 01/25/19 at 8:22 PM, Resident #50 waited 28 minutes and 8 seconds for staff to respond. 01/26/19 at 12:06 AM, Resident #50 waited 21 minutes and 43 seconds for staff to respond. 01/27/19 at 3:17 AM, Resident #50 waited 17 minutes and 3 seconds for staff to respond. 01/29/19 at 6:33 AM, Resident #50 waited 17 minutes and 12 seconds for staff to respond. 01/29/19 at 8:56 PM, Resident #50 waited 21 minutes and 8 seconds for staff to respond. 01/30/10 at 4:01 AM, Resident #50 waited 1 hour and 13 seconds for staff to respond. 01/30/19 at 10:43 AM, Resident #50 waited 25 minutes and 56 seconds for staff to respond. 01/30/19 at 4:52 PM, Resident #50 waited 30 minutes and 5 seconds for staff to respond. 01/31/19 at 7:31 AM, Resident #50 waited 1 hour and 12 seconds for staff to respond. 01/31/19 at 8:16 PM, Resident #50 waited 24 minutes and 39 seconds for staff to respond. Interview on 02/14/19 at 4:16 PM, with Licensed Practical Nurse (LPN) #6, revealed she worked on Unit 2 on this date, but had worked on every unit. She stated the SRNAs carried pagers that would alert them of a call light needing to be answered. Per interview, if the SRNA did not answer the call light within a certain amount of minutes, the pager would alert the charge nurses and unit managers as they also carried pagers. Further interview revealed there was a display screen in front of the nurse's station that would also alert staff to which call lights needed to be answered. LPN #6 revealed she and other staff answered call lights as promptly as they could, but staff prioritized call lights, with bathroom call lights having a higher priority typically than room call lights. She revealed, although their system did provide a more homelike environment than having alarms and lights going off on the unit, it could make it difficulty for staff to know when residents need assistance. She stated it was her perception the weakness in the call light system contributed to long response times for answering call lights. Interview on 02/14/19 at 4:30 PM with the Unit Manager for Unit 2, revealed if SRNAs did not respond to call lights in ten (10) minutes after the pager went off, the charge nurse on the unit and the Unit Manager would be alerted of the call lights per their pagers. Per interview, if the call light was not answered in twenty (20) minutes, the DON was alerted of the call light by pager, and after a total of thirty (30) minutes of the call light not being answered, the Administrator was alerted. Further interview revealed she received a copy of the SARA Report every day in morning meeting, and had conducted many inservices when there were longer call light response times. She stated many residents on Unit 2 required two (2) person assist, and staff were usually in with another resident when call lights went off. Per interview, the SRNAs had a long call light form to complete with explanation when there were long response times, with the most common explanation that they were taking care of another resident, or forget to turn the call lights off. Further interview revealed call light response time was an ongoing problem. Interview on 02/14/19 at 1:50 PM with Director of Nursing, revealed, it was her expectation for the staff to answer the call bells as timely as possible. Per interview, when a resident pushed the call light, the SRNA was alerted per the pager, then five (5) minutes later if the call light was not answered, the charge nurse would be alerted by pager, then five (5) minutes later the Unit Manager would be alerted by pager. She further stated if the Unit Manager did not answer the call light, then five (5)minutes later the DON would be alerted of the call light through the pager, and then the Administrator. Per interview, this was all within a twenty (20) minute period. Per interview, the pager was unit specific and was programmed for the specific unit. She stated she printed off the SARA Reports five (5) days a week; and distributed them to the Unit Managers during the morning meeting. Further interview revealed the Unit Managers should be talking to the residents and the staff when there were concerns with call light response times and the Unit Managers should also be educating staff related to the need to ensure the the call light was answered timely. Further interview revealed all staff could answer call lights and and it was unacceptable for staff to be walking up and down the hallways past a resident who had pushed a call light , or sitting at the nurse's station and not answering a call light. Interview on 02/14/19 at 6:11 PM, with the Administrator, revealed it was her expectation call lights were answered as quickly as possible, with a guideline of within fifteen (15) minutes. She stated she did not have a pager, but received an email if call lights went off over thirty (30) minutes. She stated she had not received many emails related to the call lights, possibly due to a a glitch in the system. Continued interview revealed a SARA Report was run each day through the week and brought to the morning meetings, and each Unit Manager received a copy to review. She further stated the facility conducted call light audits in the past when there was a concern noted with call lights not being answered timely. Further interview revealed staff had received many inservices related to the need to answer call lights quickly. She revealed long wait times concerned her, and she was not aware of the volume of long wait times identified by the surveyor from the SARA Report in (MONTH) 2019. She stated she attributed a lot of the problem to the system, as not everyone was aware of or answering call lights. She stated she did not feel there was a staffing issue, as staffing patterns were higher at the facility than at any facility she had previously worked. 6. Review of Resident #86's clinical record revealed the facility admitted the resident on 02/02/17 with [DIAGNOSES REDACTED]. Review of Resident #86's Annual MDS Assessment, dated 01/11/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status Score (BIMS) of three (3) out of fifteen (15), which indicated severe cognitive impairment. Observation on 02/13/19 at 08:40 AM, revealed KMA #1 administered medications as SRNAs prepared and delivered breakfast plates from the delivery cart to the resident tables. Further observation revealed KMA #1 was at the medication cart located just outside of the room, preparing resident medications (orange-colored liquid poured in to one medication cup and several various-colored tablets placed in another medication cup). Continued observation revealed KMA #1 walked across the dining room and up to the State Agency Representative with medication cups in hand. KMA #1 asked the State Agen

Based on observation, interview, record review and review of facility Policy, it was determined the facility failed to ensure the residents environment remained as free of accidents and hazards and risks as is possible and residents receive adequate supervision and assistive devices to prevent accidents for four (4) of twenty six (26) sampled residents (Resident #52, #71, #84, and #94). On 02/12/19, Resident #71 was observed in the Beauty Shop, under a running hair dryer while oxygen was being administered at three (3) liters per minute per nasal cannula and a portable oxygen tank. Staff failed to ensure the resident's oxygen tank was removed from his/her wheelchair prior to the resident being escorted to the Beauty Shop. Although the Beautician was in the Beauty Shop and had curled the resident's hair and placed the resident under the hair dryer, she had not noticed the resident was receiving oxygen. In addition, on 02/07/19, Resident #94 was identified to have discoloration and slight [MEDICAL CONDITION] to the left great toe, and X-rays results dated 02/08/19, revealed the resident had an acute fracture to the left second toe. However, there was no documented evidence the facility conducted an investigation in order to identify the root cause of the injury and to identify hazards and risks in the environment in order to implement a specific intervention to prevent further accidents. Also, on 10/08/18, Resident #52 was identified to have a large bruise across the left great toe. However, there was no documented evidence the facility conducted an investigation in order to identify the root cause of the bruise or made an effort to identify hazards and risks in the environment or implement a specific intervention to prevent further accidents. Furthermore, on 11/19/18, Resident #84, had an unwitnessed fall from the bed. A new targeted fall intervention based on the root cause of the accident, to prevent fall events of the same nature was not developed or implemented after the 11/19/18 fall. Subsequently, the resident had an additional unwitnessed fall from the bed on 11/21/18. The findings include: 1. Review of the facility's Policy titled, Oxygen Administration, undated, revealed the purpose of this procedure is to provide guidelines for safe oxygen administration. Step #4 stated, remove all potentially flammable items (lotions. Oils, alcohol, smoking articles, etc.) from immediate area where oxygen is to be administered. Review of the Manufacturer's Instructions for the facility Beauty Shop Hair Dryer, revealed a Warning which stated: to reduce risk of burns, electrocution, fire or injury to persons, use this hair dryer only for intended use as described in this manual. Do not use attachments not recommended by the manufacturer. There was no oxygen warning noted. Review of Resident #71's medical record revealed the facility admitted the resident on 05/08/16 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 05/26/16, revealed the resident had a need for oxygen related to altered respiratory function. The goal stated the resident would maintain oxygen saturation greater than ninety percent (90%). The interventions included: administer oxygen as ordered and educate resident/staff visitors about use of oxygen therapy as needed. Review of Resident's #71 Minimum Data Set (MDS) Assessment, dated 01/04/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a three (3) out of fifteen (15) indicating severe cognitive impairment. Review of the (MONTH) (YEAR) Monthly physician's orders [REDACTED]. There was no documented evidence of physician's orders [REDACTED]. Observation on 02/12/19 at 10:21 AM, revealed Resident #71 was seated in the wheelchair under the hard plastic, helmet-type hair dryer in the Beauty Shop. Oxygen was infusing, per nasal cannula tubing and a portal oxygen tank at three (3) liters per minute. The Director of Nursing (DON) was immediately informed of the observation on 02/12/19 at 10:25 AM, by the State Survey Representative, and the DON had the oxygen tank removed from the Beauty Shop. Post exit phone interview with the facility Beautician, on 02/28/19 at 8:20 AM, revealed she had been a Beautician for twenty eight (28) years, and had been contracted with the facility since 2011. Per interview, she worked at the facility on Tuesdays and Wednesdays of each week. The Beautician stated she provided each unit with a list of resident who were to have their hair done that day, and called the unit when she was ready for the residents. Per interview, nursing staff was responsible for escorting residents to the salon. She stated oxygen was not allowed in the salon and there was a sign on the Beauty Shop door regarding no oxygen usage. Continued interview revealed when she signed her contract with the facility, she was educated on safety and hazards of oxygen usage in the salon. She further stated she had been educated by the facility every year during annual compliance training related to oxygen not being allowed in the salon, and also during the safety meetings. Further interview with the facility Beautician, revealed she did not know who escorted Resident #71 to the salon on 02/12/19. She stated she had stepped away to the restroom and when she returned she did not notice the resident's oxygen. She stated the resident had received a shower prior to coming to the salon and she did not have to wash the resident's hair, but just had to roll his/her hair. The Beautician stated she put Resident #71 under the dryer that day and still did not notice the oxygen. She further stated a resident with an oxygen tank on the wheelchair had never entered the Beauty Shop before this incident, and if this happened again she would have the resident escorted back to the unit for the nurse to remove the oxygen. Per interview, the facility educated her again related to oxygen not being allowed in the Beauty Shop, after the incident on 02/12/19, Interview with Licensed Practical Nurse (LPN) #2, on 02/14/19 at 8:31 AM, revealed she had worked at the facility since (MONTH) of (YEAR) on day shift, and was familiar with Resident #71. Per interview, Resident #71 was to have oxygen on at three (3) liters continuously. Further interview revealed the resident went to the Beauty Shop once a week, and sometimes the Beautician would come get the resident or one of the nursing staff members would take the resident to the Beauty Shop. LPN #2 stated she was unaware of who transported Resident #71 to the Beauty Shop on Tuesday of this week. LPN #2 further stated she did not know the rules related to oxygen usage in the Beauty Shop, and did not recall being in-serviced regarding this. Continued interview revealed all employees needed to know how to use oxygen safely. Interview was conducted on 02/14/19 at 8:40 AM, with the Unit Manager (UM) of Unit 1, which was the unit where Resident #71 resided. He stated he had been employed at the facility since (MONTH) (YEAR). Per interview Resident #71 was on palliative care, and had orders for oxygen per nasal cannula continuously. The UM further stated it was staff's responsibility to make sure the resident was accompanied to the Beauty Shop weekly; however, he was unaware of Beauty Shop rules regarding oxygen. The UM stated he was unaware of an order for [REDACTED]. Interview with LPN #1 on 02/14/19 at 08:52 AM, revealed she had worked at the facility for about six (6) years and worked on Unit 1 as a charge nurse and was assigned to Resident #71. Per interview, Resident #71 was alert and oriented to self only and was ordered three (3) liters of oxygen continuous. LPN #1 further stated the resident went to the Beauty Shop every Tuesday, but oxygen was not permitted in the Beauty Shop as it could be a fire hazard. Continued interview revealed all staff were responsible for taking residents to the Beauty Shop, and the Beautician would call the unit and ask someone to bring the residents down. Per interview, sometimes a list was sent to the unit showing which residents were to go to the Beauty Shop that day. Further interview revealed the nurse would be responsible to remove the oxygen tank from Resident #71's wheelchair before the resident went to the Beauty Shop; however, she stated she was unaware of an order for [REDACTED].#1 stated she did not remember staff asking her to remove the oxygen tank from the resident's wheelchair on 02/12/19. LPN #1 further stated she was not aware that Resident #71 was in the Beauty Shop with oxygen in use until the DON brought it to her attention. LPN #1 further stated she was not aware of any training or in-service regarding oxygen usage in the Beauty Shop for nursing staff. Interview with State Registered Nurse Aide (SRNA) #11, on 02/14/19 at 9:05 AM, revealed she had worked at the facility since (MONTH) (YEAR) and was assigned to Resident #71 on 02/12/19. Per interview, Resident #71 went to the Beauty Shop on Tuesdays after shower days. She stated any staff member could assist the resident to the Beauty Shop, but sometimes the resident's sitter would take him/her. Per interview, Resident #71 was ordered oxygen per nasal cannula, but was not supposed to go to the Beauty Shop with his/her oxygen on. SRNA #11 stated the nurses would take the oxygen off Resident #71's wheelchair prior to the resident being escorted to the Beauty Shop. SRNA #11 stated if a resident was in the Beauty Shop with oxygen on, it could blow up and cause harm to {her/him} and other residents. Continued interview revealed she knew there was a sign on the Beauty Shop door, stating, no oxygen in use in this area, because she paid attention to signs in the facility. However, SRNA #11 stated she had never been trained related to the need to take oxygen off of a resident's wheelchair before escorting them to the Beauty Shop and had not been educated related to oxygen not being permitted in the Beauty Shop. Interview with the Director of Nursing (DON), on 02/14/19 at 1:50 PM, revealed she had been employed at the facility a little over a year. The DON stated, usually the Beautician would call the unit and let staff know to bring a resident to the Beauty Shop. Per interview, it was the nurse's responsibility to remove the oxygen from the residents' wheelchair prior to staff escorting the residents to the Beauty Shop. Per interview, she was aware that sometimes Resident #71's sitter would escort the resident to the Beauty Shop; however, she was uncertain if the sitter knew the resident could not go to the Beauty Shop while on oxygen. The DON stated it was a major safety hazard for any resident to be in the Beauty Shop with oxygen in use because there was electronic gadgets in there that could cause combustion. Further interview revealed she was not sure if there was a physician's orders [REDACTED]. Additional interview revealed she was unsure if staff was in-serviced regarding the Beauty Shop rules; however, they needed to be aware of the dangers of allowing a resident to enter the Beauty Shop with oxygen in use. Interview with the Administrator, on 02/14/19 at 02:27 PM, revealed she had been employed at the facility in the role of Administrator for about two (2) years. She stated she was made aware of the oxygen incident in the Beauty Shop by the DON. She further stated Resident #71 should have had physician's orders [REDACTED]. Further interview revealed oxygen use in inappropriate areas could be combustible and detrimental to residents and staff. The Administrator stated she in-serviced the Beautician that oxygen was not allowed in the Beauty Shop on 02/12/19, after the incident occurred with Resident #71. The Administrator further stated when she interviewed the Beautician related to the incident, she was told the resident's sitter escorted the resident to the Beauty Shop. Per interview, the sitter has not been back to the facility since this incident, but the sitter would be educated related to the need to ensure the nurse removed oxygen prior to a resident being escorted to the Beauty Shop. Continued interview revealed she had already started inservicing staff related to the need for the nurse to remove oxygen prior to a resident being escorted to the Beauty Shop, and that oxygen was not allowed in the Beauty Shop. She stated she would need to work closely with the Beautician to ensure procedure is followed. She further stated, our process is broken and we will get it fixed. Review of the facility's Accidents (F-323) Policy, dated (MONTH) 2008, revealed the facility would provide an environment that was free from accident hazards and provide supervision and assistance to residents to prevent avoidable specific accidents. Additionally, all staff would be involved in the identification of hazards and risk in the environment, and a reasonable effort would be made to identify hazards and risk factors through environmental rounds. Continued review revealed the Interdisciplinary Team would Analyze and Evaluate hazards and risks and develop specific target interventions to reduce the potential for accidents. Per Policy, the specific interventions would be communicated to relevant staff and documented on the individual resident's Plan of Care. Further, the facility would monitor the interventions effectiveness and make modifications as indicated. Per Policy potential Resident/Environmentally based risk included: resident vulnerabilities; falls, and Assistive Device/Equipment Hazards; and devices for mobility and transfer. Review of the facility's Falls-Clinical Protocol Policy, dated 2001, revealed the facility staff would evaluate and document observations of falls events that occur while the resident was in the facility. Additional review revealed staff would re-evaluate the situation and reconsider possible reasons for the resident's falling and reconsider current interventions for individuals that continue to fall. Review of the facility's Falls and Fall Risk, Managing Policy, dated 2001, revealed staff would identify interventions related to the resident's specific risk and causes to prevent the resident from falling and to minimize complications from falling. Additionally, if falling recurs despite initial interventions, staff will implement different interventions or indicate why the current approach remains relevant. Further review revealed if underlying causes cannot be corrected, staff will try various interventions based on assessment of the nature of falling, until falling was reduced or stopped. Review of the facility's Assessing Falls and Their Causes Policy, dated 2001, revealed after a fall event, within twenty-four (24) hours of the fall event, causes to the incident should be identified and appropriate interventions taken to prevent future falls. 2. Review of Resident #94's medical record revealed the facility admitted the resident on 11/15/16 with [DIAGNOSES REDACTED]. Review of the Accidents Comprehensive Care Plan (CCP), with an onset date of 11/28/16, revealed the resident had the potential for accidents, falls or injury related to Debility, [MEDICAL CONDITIONS], and [MEDICAL CONDITION] medication use. The goal stated the resident would have reduced risk for injury. Interventions included: educate about safety, ensure appropriate assistance was provided, and maintain environment free of clutter and safety hazards. Review of Resident #94's Quarterly Minimum Data Set (MDS) Assessment, dated 01/11/19, revealed the facility assessed the resident as having both short and long-term memory problems, and as having no mood or behavior issues. Additionally, the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, toileting and bathing; total assistance of two (2) staff for transfers; and total assistance of one (1) staff for locomotion. Further, the facility assessed the resident as not steady, as only able to stabilize with staff assistance during surface to surfaces transfers, and as having limitations in functional range of motion on one (1) side, upper and lower extremities. Further, per the MDS, the resident had no falls since the previous assessment. Review of Resident #94's Situation Background Assessment Recommendation (SBAR), dated 02/07/19 at 7:15 PM, revealed Resident #94 had a discoloration to the left lower extremity, lower shin and medial ankle which was a change in condition. Additional review revealed the Physician was notified and new orders were received for an X-ray. Review of the Progress Notes, dated 02/07/19 at 10:33 PM, revealed there was discoloration and slight [MEDICAL CONDITION] noted to the left lower extremity and an X-ray was ordered. Review of physician's orders [REDACTED]. Review of Resident #94's X-ray results, dated 02/08/19; revealed an acute fracture in the base of the left proximal phalanx of the second toe with soft tissue [MEDICAL CONDITION]. Review of the Progress Note, dated 02/08/19 at 2:28 PM, revealed X-ray results were received and the Advanced Practice Registered Nurse (APRN) was notified and recommended the resident to see a specialist related to the [MEDICAL CONDITION] second toe. Per the Note, the resident representative was notified. Review of a subsequent Progress Note, dated 02/08/19 at 8:27 PM, revealed there was no [MEDICAL CONDITION] or bruising present to the resident's left second toe. Per the Note, the family spoke with the nurse and did not want the resident sent out to a specialist because they felt the fracture was old and not causing the resident any distress. Continued review of the medical record revealed there was no documented evidence of an Incident Report, witness statement, staff statements or an investigation in order to determine the root cause of the injury. Additional review of the Accidents CCP, revealed there was no revision to the CCP to include the incident/accident on 02/07/19 or a new intervention to prevent further occurrence of an injury of the same nature. (Refer to F-657) Interview with SRNA #16, on 02/14/19 at 4:26 PM, revealed Resident #94 required total assistance with Activities of Daily Living (ADLs). Additionally, the resident required two (2) staff to assist with transfers using a hoyer lift. Per interview, the resident had been leaning to the left recently, which was the resident's side not affected by the stroke. Continued interview revealed it was crowded in the resident's room. SRNA #16 stated this was due to the air mattress motor at the end of the bed, the wheelchair with leg and foot supports, the two (2) over bed tables requested by the family, the dresser, and the hoyer lift (mechanical lift). Per interview, the resident's roommate also had a wheelchair and recliner that crowded the room. SRNA #16 stated it was difficult to transfer the resident in the crowded room and the resident required two (2) staff for the transfer. Additionally, the SRNA #16 stated the resident's feet could be easily bumped on numerous things in the residents room during a transfer; however, she was careful with the resident's feet during transfers to ensure they were not bumped. Further interview with SRNA #16, revealed she was assigned to Resident #94, on 02/07/19. SRNA #16 stated while she was assisting the resident she noticed discoloration and swelling to the resident's left foot and reported it the nurse. Per interview, the nurse came and assessed the resident's foot. Additional interview, revealed when the resident was asked what happened, he/she stated he/she did not know. Per interview, she was not asked to write a statement. Interview with Licensed Practical Nurse (LPN) #6, on 02/14/19 at 5:27 PM, revealed Resident #94 required total assistance with all ADLs and had been progressively getting weaker, was not a good historian and his/her cognition waxed and waned. Additional interview revealed the resident required a hoyer lift for transfer. Per interview, the resident's room was a tight fit and cluttered with assistive devices and furniture. Further, a thorough investigation of accidents to determine the root cause of the injury was important. Per interview, the root cause of an injury assisted the staff with knowing what specific interventions could be implemented to ensure the resident's environment was safe and the accident did not occur again. Interview with Unit 2 Manager, on 02/14/19 at 6:05 PM, revealed she assessed Resident #94's left foot and completed the SBAR on 02/07/19. Per interview, there was no [MEDICAL CONDITION] or discoloration to the left foot; and only darkened skin was noted to the resident's lower legs, which appeared to be vascular in nature. Additional interview revealed the root cause of the injury should have been determined at the time the change in the left lower extremity was initially identified. Further, an Incident Report, staff and resident statements, and an assessment of the resident, and the environment should have been documented and reviewed to determine the root cause of the injury. Per interview, an investigation related to the resident's injury should have been completed and a necessary intervention should have been implemented to reduce the risk of further injury or accident. 3. Review of Resident #52's medical record revealed the facility admitted the resident on 12/21/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 09/21/18, revealed the facility assessed the resident as having a BIMS score of one (1), out of fifteen (15), indicating severe cognitive impairment. Additional review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfers and toileting, and total assistance of one (1) staff for locomotion, bathing, dressing, and personal hygiene. Per the MDS, the resident was not steady, was only able to stabilize with staff assistance during surface-to-surface transfers and had no limitations in Range of Motion. Further review revealed the facility assessed the resident as having no falls since the previous assessment, and as receiving seven (7) days of Anticoagulant medication. Review of Resident #52's Accidents Comprehensive Care Plan (CCP), with an onset date of 01/03/17, revealed the resident had the potential for accidents, falls or injuries related [MEDICAL CONDITIONS], Dementia, [MEDICAL CONDITION] Disorder, Ataxia, Polyarthritis, Incontinence, Malaise, and [MEDICAL CONDITION] medication use. The goal stated the resident would have reduced risk for injury. Interventions included: educate staff about safety, ensure appropriate assistance; ensure resident's environment was free of clutter and safety hazards; and no tight foot wear per podiatry. Review of Resident #52's (MONTH) (YEAR) Monthly physician's orders [REDACTED]. Review of the SBAR, dated 10/08/18 at 2:05 PM, revealed the resident had a bruise across the left great toe which was a change in condition. Further review revealed the Advanced Practice Nurse Practitioner (ARNP) and Resident Representative was notified. Review of Resident #52's Weekly Nursing Skin Assessment, dated 10/08/18, revealed the resident had a bruise to the left great toe. Additional review revealed the resident bruised easily, received anticoagulant medication and scheduled pain medication. Further review revealed the resident had no complaints of pain or discomfort. Review of the Progress Note, dated 10/11/18 at 10:11 AM, revealed there was a large yellow-green healing bruise covering the resident's right great toe and the top of the first metatarsal, which was painful to touch. Review of the Progress Note, dated 10/11/18 at 11:01 AM, revealed there was a bruise on top of the resident's left great toe and metatarsal area and a new order was received for an X-ray to to the area. Review of the physician's orders [REDACTED]. This order was obtained three (3) days after the bruise was identified, on 10/08/18. Review of X-ray results, dated 10/11/18, revealed no acute fracture or dislocation of the left toes. Further review of the medical record revealed there was no documented evidence of an Incident Report, witness statement, staff statements, or an investigation related to the resident's bruise on top of the resident's left great toe and metatarsal area, in order to determine the root cause of the injury. Additional review of Resident #52's Accidents Comprehensive Care Plan (CCP), revealed a problem of a bruise to the left great toe was added on 10/11/18. An intervention was added on 10/11/18 for an X-ray to the left great toe. However, there was no documented evidence the CCP was revised with a targeted intervention to prevent further occurrence of an injury of the same nature. (Refer to F-657) Interview with SRNA #16, on 02/14/19 at 4:26 PM revealed she had worked at the facility for one (1) year and seven (7) months, and was very familiar with residents on 200 hall, where Resident #52 resided. Per interview, she used the Care Plan as a guide to deliver care to the residents. SRNA #16 stated Resident #52 required total assist with ADLs; two (2) staff to assist with transfers using a hoyer lift, and one (1) additional staff to guide the resident because his/her legs would stick straight out. Continued interview revealed it was crowded in the resident's room with the bed, high-back wheelchair with leg and foot supports, the over bed table, the dresser, the hoyer lift, and the resident and three (3) staff during transfers. She stated she was mindful and careful with the resident's feet during transfers to ensure they were not bumped on anything. Interview with SRNA #15, on 02/14/19 at 4:26 PM, revealed she was assigned to Resident #52 on 10/08/18. SRNA stated when she took the resident's protective boot and socks off when assisting him/her to bed; she saw a red and purple bruise across the top of the left big toe that had not been there before. She stated she reported the bruise immediately to the nurse who came to assess his/her foot. Additional interview revealed she asked the resident what happened and the resident stated he/she did not know. SRNA #15 stated she was not asked to write a statement and was not interviewed after she reported the bruise to the nurse. Further interview revealed it was important to know what caused an injury to a resident in order to implement interventions to prevent recurrence. Interview with Licensed Practical Nurse (LPN) #6, on 02/14/19 at 5:27 PM, revealed she worked as needed (PRN); however, was familiar with residents on the 200 hall, and had been working at the facility for over two (2) years. Per interview, she used the CCP as a reference for the level of care and interventions necessary for each resident. Additional interview revealed Resident #52 required total assistance with all ADLs and his/her legs and feet were positioned straight out when in the seated position. Per interview, there was the potential staff could bump Resident #52's feet on something during transfer. Continued interview revealed the root cause of any injury was determined by evaluating data from a Skin Assessment, Incident Report, staff statements, resident statements, and an assessment of the environment. Per interview, it was important to determine the cause of an injury to ensure the resident receives necessary care and treatment. Further, it was important to find the cause of injury to reduce the risk of recurrence by planning interventions around that specific situation. She stated all employees were responsibility to provide a safe environment and necessary supervision to keep the residents safe. Interview with Unit 2 Manager, on 02/14/19 at 6:05 PM, revealed she expected all noticeable bruises to be investigated by the nursing staff through assessment of the resident, staff and resident statements, and assessment of the environment. Continued interview revealed this documentation should be recorded on Incident Reports, SBARs, and Nursing Progress Notes. Additionally, the gathered information should be reviewed and used to determine the root cause of the bruise/accident. Per interview, as a Unit Manager, she conducted ongoing walking rounds to ensure the residents environment was safe and she also attended a daily morning interdisciplinary team (IDT) meeting which included all Unit Managers, the Director of Nursing (DON), the MDS Nurse, the Administrator, and the Therapy staff. She stated during the meeting, all accidents were reviewed to ensure a thorough investigation was completed and an appropriate intervention was implemented. Further, it was important to complete a thorough investigation of accidents in order to implement specific interventions to ensure the residents received quality care, and to ensure safety. Continued interview with the Unit 2 Manager, revealed she could not recall if Resident #52's injury/bruise was discussed in the morning meeting, and stated the information from morning meeting was not part of the medical record. Per interview, there should have been witness statements obtained on 10/08/18, when the SRNA reported the bruise to Resident #52's left great toe. Additionally, a root cause of the injury should have been determined and a specific intervention should have been implemented to reduce the risk of the same incident again. Continued interview revealed this was important for the well being and safety of the resident. Further, she stated she was not sure how the facility missed completing an investigation related to Resident #52's bruise. Per interview, all staff were responsible to ensure a safe environment and supervision as necessary was provided. Interview with the DON, on 02/14/19 at 6:59 PM, revealed any bruises or injuries should be assessed by the nurse and a root cause should be determined at the time of identification through assessment, and statements from the residents and staff. She stated when a new large bruise or other signs of injuries were noted, she expected an Incident Report to be completed. Per interview, she also expected witness statements to be obtained, and an SBAR to be completed. She further stated after the information was gathered, there should be a Root Cause Analysis (RCA) which would lead to targeted interventions added to the CCP in an attempt to prevent reoccurrence. The DON stated this process was important to determine what was working for the resident, what was an effective intervention, and to reduce the risk for the same occurrence again. Per the DON, the Nurses should have obtained statements and tried to determine the root cause of the bruise and injury to Resident #94's left foot, on 02/07/19 and Resident #52's bruise on 10/08/18. Further, nursing staff and the Inte (TRUNCATED)

Based on observation, interview, record review, and review of the facility's Policies, it was determined the facility failed to ensure confidentiality of the Electronic Medication Administration Record [REDACTED]. Observation on 02/12/19, on the Reflections Community/400 Unit, revealed Kentucky Medication Aide (KMA) #1 left the medication cart unattended with Resident #86's E-MAR open on the computer display screen, allowing the resident's personal and medical information to be visible to others on the unit. The findings include: Review of the facility's Policy titled, Confidentiality of Information and Personal Privacy, revised 10/2017, revealed the facility was required by law to maintain the privacy and confidentiality of resident protected health information. Further, the facility would protect and safeguard resident confidentiality and personal privacy. Continued review of the Policy, revealed the resident's clinical information, including computer-stored medical and/or personal information would be handled in accordance with resident rights and privacy policies. Review of the facility's Policy, titled Resident Rights, revised 12/2016, revealed the unauthorized release, access or disclosure of resident information was prohibited by law. Review of Resident #86's medical record revealed the facility admitted the resident on 02/02/17 with [DIAGNOSES REDACTED]. Observation during initial tour of the facility, on 02/12/19 at 8:30 AM, revealed Kentucky Medication Aide (KMA) #1 was standing at the medication cart located just outside of the medication room, preparing medications and reviewing the E-MAR from the computer display screen. Further observation revealed KMA #1 closed and locked the medication cart and left the medication cart unattended without logging off or closing down the computer screen. This left the computer display screen, with Resident #86's demographic and medical information, clearly visible and accessible to the surveyor, other unit residents and staff members coming to and from the unit. Continued observation revealed KMA #1 returned to the medication cart at 8:32 AM, two (2) minutes later, following administration of Resident #86's medication. Interview with KMA #1, on 02/12/19 at 8:35 AM, revealed she had been employed with the facility for eight (8) years and was assigned to administer medications to all of the residents on the Reflections Community/400 Unit. Further interview revealed facility policy was to ensure the E-MAR was secured to prevent other residents, visitors/family members, and/or staff not providing care to residents from obtaining the resident's personal or medical information. Continued interview revealed this was a privacy and confidentiality issue and she was familiar with the Health Insurance Portability and Accountability Act of 1996 (HIPPA) that prohibited the unauthorized release of resident's protected health information. Additional interview with KMA #1, revealed she should have closed the computer screen that displayed Resident #86's information prior to leaving the medication cart due to information was visible to unauthorized staff members, other residents, and visitors/family members to the facility which was a HIPPA violation. She stated the computer screen which had been left open included Resident #86's information including: name, date of birth, date of admission to the facility, allergies [REDACTED]. Continued interview with KMA #1, revealed she was aware of state and federal regulations as well as facility policy regarding resident confidentiality and privacy and should have kept the resident's information private. Interview with Licensed Practical Nurse (LPN) #7, on 02/13/19 at 10:07, revealed she had been employed with the facility for five (5) years and served as the Charge Nurse for the Reflections Community/400 Unit on 02/12/19 and 02/13/19. Further interview revealed she was familiar with the HIPPA Act of 1996 and it was the facility's policy to keep all resident personal, financial and medical information private and confidential. Continued interview revealed during medication administration, staff were to lock the medication cart, log off and close the E-MAR prior to leaving or turning away from the medication cart to administer medications, in an effort to prevent the potential release or unauthorized access of personal or medical information. LPN #7 stated KMA #1 should have closed the E-MAR computer display, as she too was aware of the facility's privacy/confidentiality policy and HIPPA Act as the facility had provided several in-service trainings on this topic. Interview with Unit Manager (UM)#3, for the Reflections Community 300 and 400 Units on 02/14/19 at 2:46 PM, revealed she had been employed with the facility for five and one half (5.5) years. Further interview revealed she expected staff to adhere to the privacy and confidentiality policy and follow HIPPA practices at all times while providing resident care, including medication administration. Continued interview revealed she expected KMA #1 to close the computer display prior to leaving the medication cart unattended to prevent the potential release of personal or medical information to unauthorized persons including staff who were not assigned to provide care to the resident, visitors/family members, or other residents living on the unit or in the facility. UM #3 stated KMA #1 and other staff assigned to administer medications were aware of the importance of maintaining resident's privacy/confidentiality due to the number of in-service trainings and online educational materials provided to them on the topic. Interview with the Director of Nursing (DON), on 02/14/19 at 5:28 PM, revealed she had been employed with the facility for one and a half (1.5) years. Further interview revealed it was her expectation staff maintain the resident's privacy and confidentiality at all times. Continued interview revealed staff was to close the E-MAR prior to leaving the locked medication cart unattended in order to prevent the potential unauthorized access to resident personal or medical information. Additional interview revealed leaving the E-MAR display visible to staff not assigned to the resident, visitors/family members, vendors and/or other residents in the facility was a violation of privacy/confidentiality and HIPPA and was unacceptable behavior. Interview with the Administrator, on 02/14/19 at 6:13 PM, revealed she had been employed with the facility for two (2) years. Further interview revealed it was her expectation staff close the E-MAR prior to leaving the medication cart in an effort to prevent the potential unauthorized access to resident personal or medical information. Continued interview revealed leaving the E-MAR screen visible to staff not assigned to care for the resident, visitors/family members, vendors and other residents was a violation of resident rights, privacy and confidentiality and was a HIPPA violation. The Administrator stated it was unacceptable behavior to allow unauthorized access to facility resident's personal or medical information, as staff have been educated and in-serviced numerous times on this information.