Every finding on record at The Terrace Nursing and Rehabilitation Center

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to electronically transmit the discharge assessment within 14 days for one (1) resident, Resident (R) 19. R19's discharge date was 11/14/2024, but R19's Minimum Data Set (MDS) was not transmitted until 03/02/2025. The findings include: Review of the Resident Assessment Instrument (RAI) Manual, dated 10/2024, revealed the MDS completion date must be no later than seven (7) days from the Event Date for a Death in Facility Assessment. Further review of the RAI Manual revealed the MDS should be transmitted within 14 days of the Event Date for Death in a Facility. Review of the facility's policy, MDS Completion and Submission Timeframes, dated 08/01/2013, revealed the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. Review of R19's Face Sheet revealed the facility admitted the resident on 10/29/2024 with diagnoses which included malignant neoplasm of the spinal cord, diabetes, and chronic kidney disease. Review of R19's electronic medical record (EMR) revealed the last documented MDS, with an ARD of 11/14/2024, showed Death in Facility, and was signed by the MDS Coordinator on 11/14/2024 as verified the assessment was complete. However, the MDS was listed as Exported but not Accepted, which indicated the MDS had not been transmitted and accepted per the RAI guidelines. In an interview, on 03/03/2025 at 3:30 PM, MDS Nurse 1 stated the facility followed the RAI Manual for guidelines and timeframes of submitting the MDS. She further stated R19's Death in Facility MDS should have been transmitted within 14 days of R19's discharge date of [DATE]. In an interview, on 03/03/2025 at 3:35 PM, the [NAME] President of Clinical Reimbursement stated the facility follows the RAI Guidelines for submission of MDSs and discharge assessments should be transmitted within 14 days of completion. She further stated R19's discharge MDS had been overlooked and was transmitted on 03/02/2025.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan (CCP) for one (1) of sixteen (16) sampled residents, (Resident #3). On [DATE] at 10:25 AM, State Registered Nurse Aide (SRNA) #12 failed to follow the intervention in place on Resident #3's CCP that stated Resident #3 was a two (2) person assist for bed mobility for bottom to top and side to side changes, and as a result, SRNA #12 caused Resident #3 to roll out of the bed and on to the floor. The findings include: Review of the facility policy titled, Care Plans - Comprehensive, dated ,d+[DATE], revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological, cultural and trauma-informed needs would be developed for each resident. Review of the Policy Interpretation and Implementation section, item one (1) revealed, the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), would develop and maintain a comprehensive care plan for each resident that identified the highest level of functioning the resident might be expected to attain. Further review revealed each resident's comprehensive care plan was designed to incorporate identified problem areas; would incorporate risk factors associated with identified problems; would reflect treatment goals, timetables and objectives in measurable outcomes; and aid in preventing or reducing declines in the resident's functional status and/or functional levels; and would reflect currently recognized standards of practice for problem areas and conditions. Review of Resident #3 Admission Record revealed the facility had admitted the resident on [DATE] with diagnoses to include of Alzheimer's, Vascular Dementia, Dysphagia, Diabetes, Obesity and Incomplete Paraplegia. Resident #3 expired at the facility on [DATE]. Review of Resident #3's Quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15), indicating severe cognitive impairment. Continued review of the MDS revealed Resident #3 had been assessed as requiring extensive assistance of two (2) staff for bed mobility and extensive assistance of two (2) staff for toileting. Review of Resident #2's Fall Risk assessment dated [DATE] revealed the resident had been assessed as a high fall risk. Review of Resident #3's Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) initiated on [DATE] revealed Resident #3 had ADL deficits related to impaired cognition, impaired physical functioning, weakness, paraplegia, dementia, fibromyalgia, chronic pain, depression and behaviors with a goal to include the resident would have ADL care needs met daily as measured by, he/she being observed as clean, well-groomed and odor free through next review. Interventions for bed mobility initiated on [DATE] revealed Resident #3 was an assist of two (2) staff for being moved bottom to top in the bed and an assist of two (2) for being moved side to side in the bed. Review of Resident #3's Incident Note dated [DATE] at 12:25 AM, entered by LPN #3, revealed Nursing staff was in Resident #3's room to provide morning ADLs and turned Resident #3 in the bed, facing the doorway. Resident #3 moved his/her legs off the side of the bed, propelling his/her body off the side of the bed. Resident #3 landed on the floor, on his/her buttocks, at the bedside, with his/her neck against the nightstand, and his/her arms were outstretched at each side, and his/her legs were outstretched towards the bathroom door. Further review of the note revealed Resident #3 was assessed and had no complaints of pain or injury. Continued review revealed neurological checks were initiated and found to be within normal limits, hand grips and speech were also found to be within normal limits, and his/her pupils were equal and reactive. Additional review revealed a rotation was observed to the left lower extremity. Ongoing review revealed one (1) of Resident #3's responsible parties and the Advance Practice Registered Nurse (APRN) were notified, and Resident #3 was transported to the hospital emergency department by Emergency Medical Services (EMS) for evaluation. Review of the facility Root Cause Analysis (RCA) Interdisciplinary Team (IDT) Note dated [DATE] at 1:34 PM, entered by LPN #1, revealed Resident #3 sustained a witnessed fall on [DATE] at 10:25 AM. continued review revealed the RCA had been documented as nursing staff were in the resident's room to provide ADL's and when staff turned the resident in bed, facing the doorway, the resident moved his/her legs off the side of bed, propelling his/her body off the side of bed, causing the resident to land on the floor on his/her buttocks. Resident #3 was documented as stating his/her arm hurt, and the physician and family were notified. Review of the facility document titled, State Registered Nurse Assignment (SRNA) Group dated [DATE] for Day Shift, 6:30 AM to 6:30 PM, revealed SRNA #11, SRNA #12, SRNA #13 and SRNA #15 were all assigned to resident care on the 300 Hall where Resident #3 was located. SRNA #12 was assigned to care for Resident #3. Review of Resident #3's Emergency Department (ED) Provider Notes dated [DATE], revealed Resident #3 had presented to the ED after a fall at the nursing home. Continued review revealed a Computed Tomagraphy (CT) of the head without contrast, CT of the Cervical Spine without contrast, Chest X-ray, X-rays of the right and left forearms, right and left humerus, right and left hip were completed without evidence of bleed or fracture. Resident #3 was transported back to the facility. During an interview on [DATE] at 10:11 AM with LPN #3 one of the aides let her know Resident #3 had fallen out of bed. LPN #3 stated Resident #3 was a very heavy person and was difficult to roll in the bed. She stated State Registered Nurse Aide (SRNA) #12 was caring for Resident #12 the day the resident fell out of the bed, and she stated SRNA #12 told her the resident's leg had flopped over the side of the bed, which caused Resident #3 to roll out of the bed. LPN #3 stated she did not think there was another SRNA in the room with SRNA #12 at the time of the incident. LPN #3 stated she sent Resident #3 to the hospital for evaluation because one of his/her legs appeared to be turned out and a looked like it was a different length from the other leg. LPN #3 further stated it was odd the way Resident #3 landed, he/she was sitting straight up on the floor, with his/her back against the bedside table, and his/her arms at either side and legs straight out. LPN #3 stated she did not notice and injuries at the time of her assessment of the resident. LPN #3 stated Resident #3 was two (2) staff assist for mobility and that would have been visible on the Kardex. LPN #3 further stated, Resident #3 had been a long-time resident of the facility, and his/her care had not recently changed and SRNA #12 was not a new aide, and she should have been familiar with Resident #3's plan of care. The State Survey Agency attempted to call SRNA #12 on [DATE] at 10:19 AM and [DATE] at 1:30 PM. The SSA left messages for SRNA #12 for a return call. All attempts to reach SRNA #12 were unsuccessful. During an interview on [DATE] at 11:20 AM, with SRNA #11, he stated he was on duty the day of the incident involving Resident #3, but did not assist SRNA #12 with care. He stated he was informed of the incident after the fact, and he stated he did not know how many staff were providing care to Resident #3 when the fall happened. SRNA #11 stated if he needed to know how a resident needed to be transferred, or the number of staff required to assist a resident with mobility, he would ask a nurse. SRNA #11 stated he did not know what a Kardex was and had not been educated on the use of the Kardex. During a phone interview on [DATE] at 12:47 PM, with SRNA #13, she stated she did not assist with the care of Resident #3 the day of the fall but helped get him/her on the gurney after the fall occurred. SRNA #13 stated she did not know how many staff were in the room caring for Resident #3 at the time of the fall. She stated if she needed information on how a resident transferred or the number of staff assistance needed, she could find that information on the Kardex. SRNA #13 further stated she thought Resident #3 was a two person assist for mobility. During a phone interview on [DATE] at 1:04 PM, with SRNA #15, she stated she was not on the unit when Resident #3 fell , nor did she care for Resident #3 the day he/she fell out of bed. SRNA #15 stated information regarding resident transfer and mobility assist was on the Kardex, and she was not positive but believed Resident #3 required a two person assist for mobility. During an interview on [DATE] at 1:40 PM, with the Assistant Director of Nursing (ADON), the Director of Nursing (DON) and the Administrator, they stated the incident involving Resident #3's fall out of bed happened on a weekend and none of them were at the facility at the time the incident occurred. They all agreed SRNA #12 was in Resident #3's room waiting for assistance and began providing care before help arrived . They further stated SRNA #12 knew Resident #3 was a two (2) person staff assist for care, and providing care to the resident without assistance of another staff member created an increased safety risk to the resident. The DON stated the Kardex was available to every SRNA on the charting Kiosks and the SRNA's had to check it off as completed during their shift. The ADON, DON and Administrator all stated they expected the SRNA to review the Kardex at the beginning of each shift and follow the residents car plan to ensure the safety of the resident. They further stated they expected staff to follow all the facility's policy's.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide supervision to each resident to prevent avoidable accidents for one (1) of sixteen (16) sampled residents, (Resident #3). On [DATE] at 10:25 AM, State Registered Nurse Aide (SRNA) #12 failed to follow the intervention in place on Resident #3's Comprehensive Care Plan (CCP) that stated Resident #3 was a two (2) person assist for bed mobility for bottom to top and side to side changes, and as a result, SRNA #12 caused Resident #3 to roll out of the bed and onto the floor. The findings include: Review of the facility policy titled, Falls and Fall Risk, Management, dated [DATE], revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try to minimize complications from falling. Continued review revealed the staff, with input from the Attending Physician, would identify appropriate interventions to reduce the risk of falls. Review of the facility policy titled, Care Plans - Comprehensive, dated ,d+[DATE], revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological, cultural and trauma-informed needs would be developed for each resident. Review of the Policy Interpretation and Implementation section, item one (1) revealed, the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), would develop and maintain a comprehensive care plan for each resident that identified the highest level of functioning the resident might be expected to attain. Further review revealed each resident's comprehensive care plan was designed to incorporate identified problem areas; would incorporate risk factors associated with identified problems; would reflect treatment goals, timetables and objectives in measurable outcomes; and aid in preventing or reducing declines in the resident's functional status and/or functional levels; and would reflect currently recognized standards of practice for problem areas and conditions. Review of Resident #3 Admission Record revealed the facility had admitted the resident on [DATE] with diagnoses to include of Alzheimer's, Vascular Dementia, Dysphagia, Diabetes, Obesity and Incomplete Paraplegia. Resident #3 expired at the facility on [DATE]. Review of Resident #3's Quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15), indicating severe cognitive impairment. Continued review of the MDS revealed Resident #3 had been assessed as requiring extensive assistance of two (2) staff for bed mobility and extensive assistance of two (2) staff for toileting. Review of Resident #2's Fall Risk assessment dated [DATE] revealed he/she had been assessed as a high fall risk. Review of Resident #3's Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) initiated on [DATE] revealed Resident #3 had ADL deficits related to impaired cognition, impaired physical functioning, weakness, paraplegia, dementia, fibromyalgia, chronic pain, depression and behaviors with a goal to include the resident would have ADL care needs met daily as measured by, he/she being observed as clean, well-groomed and odor free through next review. Interventions for bed mobility initiated on [DATE] revealed Resident #3 was an assist of two (2) staff for being moved bottom to top in the bed and an assist of two (2) for being moved side to side in the bed. Review of Resident #3's Incident Note dated [DATE] at 12:25 AM, entered by LPN #3, revealed Nursing staff was in Resident #3's room to provide morning ADLs and turned Resident #3 in the bed, facing the doorway. Resident #3 moved his/her legs off the side of the bed, propelling his/her body off the side of the bed. Resident #3 landed on the floor, on his/her buttocks, at the bedside, with his/her neck against the nightstand, and his/her arms were outstretched at each side, and his/her legs were outstretched towards the bathroom door. Further review of the note revealed Resident #3 was assessed and had no complaints of pain or injury. Continued review revealed neurological checks were initiated and found to be within normal limits, hand grips and speech were also found to be within normal limits, and his/her pupils were equal and reactive. Additional review revealed a rotation was observed to the left lower extremity. Ongoing review revealed one (1) of Resident #3's responsible parties and the Advance Practice Registered Nurse (APRN) were notified, and Resident #3 was transported to the hospital emergency department by Emergency Medical Services (EMS) for evaluation. Review of the facility Root Cause Analysis (RCA) Interdisciplinary Team (IDT) Note dated [DATE] at 1:34 PM, entered by LPN #1, revealed Resident #3 sustained a witnessed fall on [DATE] at 10:25 AM. continued review revealed the RCA had been documented as nursing staff were in the resident's room to provide ADL's and when staff turned the resident in bed, facing the doorway, the resident moved his/her legs off the side of bed, propelling his/her body off the side of bed, causing the resident to land on the floor on his/her buttocks. Resident #3 was documented as stating his/her arm hurt, and the physician and family were notified. Review of the facility document titled, State Registered Nurse Assignment (SRNA) Group dated [DATE] for Day Shift, 6:30 AM to 6:30 PM, revealed SRNA #11, SRNA #12, SRNA #13 and SRNA #15 were all assigned to resident care on the 300 Hall where Resident #3 was located. Continued review revealed SRNA #12 had been assigned to care for Resident #3. Review of Resident #3's Emergency Department (ED) Provider Notes dated [DATE], revealed Resident #3 had presented to the ED after a fall at the nursing home. Continued review revealed a Computed Tomagraphy (CT) of the head without contrast, CT of the Cervical Spine without contrast, Chest X-ray, X-rays of the right and left forearms, right and left humerus, right and left hip were completed without evidence of bleed or fracture. Resident #3 was transported back to the facility. During an interview on [DATE] at 10:11 AM with LPN #3 one of the aides let her know Resident #3 had fallen out of bed. LPN #3 stated Resident #3 was a very heavy person and was difficult to roll in the bed. She stated State Registered Nurse Aide (SRNA) #12 was caring for Resident #12 the day the resident fell out of the bed, and she stated SRNA #12 told her the resident's leg had flopped over the side of the bed, which caused Resident #3 to roll out of the bed. LPN #3 stated she did not think there was another SRNA in the room with SRNA #12 at the time of the incident. LPN #3 stated she sent Resident #3 to the hospital for evaluation because one of his/her legs appeared to be turned out and a looked like it was a different length from the other leg. LPN #3 further stated it was odd the way Resident #3 landed, he/she was sitting straight up on the floor, with his/her back against the bedside table, and his/her arms at either side and legs straight out. LPN #3 stated she did not notice and injuries at the time of her assessment of the resident. LPN #3 stated Resident #3 was two (2) staff assist for mobility and that would have been visible on the Kardex. LPN #3 further stated, Resident #3 had been a long-time resident of the facility, and his/her care had not recently changed and SRNA #12 was not a new aide, and she should have been familiar with Resident #3's plan of care. The State Survey Agency attempted to call SRNA #12 on [DATE] at 10:19 AM and [DATE] at 1:30 PM. The SSA left messages for SRNA #12 for a return call. All attempts to reach SRNA #12 were unsuccessful. During an interview on [DATE] at 11:20 AM, with SRNA #11, he stated he was on duty the day of the incident involving Resident #3 but did not assist SRNA #12 with care. He stated he was informed of the incident after the fact, and he stated he did not know how many staff were providing care to Resident #3 when the fall happened. SRNA #11 stated if he needed to know how a resident needed to be transferred, or the number of staff required to assist a resident with mobility, he would ask a nurse. SRNA #11 stated he did not know what a Kardex was and had not been educated on the use of the Kardex. During a phone interview on [DATE] at 12:47 PM, with SRNA #13, she stated she did not assist with the care of Resident #3 the day of the fall but helped get him/her on the gurney after the fall occurred. SRNA #13 stated she did not know how many staff were in the room caring for Resident #3 at the time of the fall. She stated if she needed information on how a resident transferred or the number of staff assistance needed, she could find that information on the Kardex. SRNA #13 further stated she thought Resident #3 was a two person assist for mobility. During a phone interview on [DATE] at 1:04 PM, with SRNA #15, she stated she was not on the unit when Resident #3 fell , nor did she care for Resident #3 the day he/she fell out of bed. SRNA #15 stated information regarding resident transfer and mobility assist was on the Kardex, and she was not positive but believed Resident #3 required a two person assist for mobility. During an interview on [DATE] at 1:40 PM, with the Assistant Director of Nursing (ADON), the Director of Nursing (DON) and the Administrator, they stated the incident involving Resident #3's fall out of bed happened on a weekend and none of them were at the facility at the time the incident occurred. They all agreed SRNA #12 was in Resident #3's room waiting for assistance and began providing care before help arrived . They further stated SRNA #12 knew Resident #3 was a two (2) person staff assist for care, and providing care to the resident without assistance of another staff member created an increased safety risk to the resident. The DON stated the Kardex was available to every SRNA on the charting Kiosks and the SRNA's had to check it off as completed during their shift. The ADON, DON and Administrator all stated they expected the SRNA to review the Kardex at the beginning of each shift and follow the residents car plan to ensure the safety of the resident. They all further stated they expected staff to follow the facility's policy and protect residents from falls.

Based on observation, interview, record review, facility policy review, and a review of the Minimum Data Set (MDS) reference manual, the facility failed to ensure a comprehensive MDS was completed within fourteen days after a significant change in status for one (1) of six (6) sampled residents (Resident #2). The facility failed to conduct a significant change MDS when Resident #2 was discharged from hospice (end of life care) program, and admitted into a Palliative Care program. The findings include: A review of the Long Term Care Resident Assessment Instrument User's Manual (MDS 3.0), dated October 2016, revealed a significant change in status assessment must be performed when a terminally ill resident enrolls in a hospice program and when a resident discontinues the hospice service and remains a resident at the facility. The manual also revealed the assessment reference date must be no later than 14 days from the date the resident was enrolled or discontinued from the hospice program. A review of the facility's policy titled, Change in a Resident's Condition dated 08/01/2013 revealed if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current Omnibus Budget Reconciliation ACT (OBRA) regulations governing resident assessments and as outlined in the MDS Resident Assessment Instrument (RAI) Instruction Manual. Review of Resident #2's medical record revealed resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimal Data Set (MDS) Assessments revealed the resident had a quarterly assessment on 11/16/2020, and on 2/15/2021. However, there was no evidence a significant change assessment was completed for Resident #2 after the resident was discharged from Hospice, and enrolled into Palliative Care on 2/17/2021. An interview with the MDS Coordinator, on 04/21/2021 at 2:15 PM, revealed she was responsible for completing MDS assessments for the residents. The MDS Coordinator stated normally if a resident is discharged from a hospice program, she had to complete a significant change assessment. The MDS Coordinator further stated she did not have a reason as to why it was not completed; however, stated it should have been completed. An interview conducted with the Director of Nursing (DON) on 04/21/2021, at 3:01 PM, revealed that he/she didn't know if a significant change in status assessment was required when a resident was discharged from a hospice program, and admitted into a palliative care program. An interview conducted with the Administrator on 04/22/2021 at 1:15 PM revealed the MDS nurse is included in the morning meeting, and the orders are verbally communicated, and the orders are given to the MDS nurse. Per the Administrator, the MDS nurse would have received the order when Resident #2 was discharged from Hospice and admitted to Palliative Care.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to provide outside visitation for three (3) of four (4) sampled residents (Residents #2, #3, and #4). The findings include: Review of the facility policy titled COVID-19 Policy and Procedure, updated 09/22/2020, revealed a safe outdoor space should be created for outdoor visitation and all visits should be held outdoors whenever possible. Interview with the facility Administrator on 10/12/2020 at 5:00 PM revealed the facility was using the Centers for Medicare and Medicaid Services (CMS) guidance as well as recommendations from the Centers for Disease Control and Prevention (CDC) and Kentucky Association of Health Care Facilities (KAHCF) when considering visitors in the facility. Review of the CMS guidance on Nursing Home Visitation - COVID-19 dated 09/17/2020 revealed nursing homes should accommodate and support inside visitation if there have been no new COVID-19 cases in the last fourteen days and the county positivity rate is less than or equal to ten percent. Per the guidance, We note that county positivity rate does not need to be considered for outdoor visitation. Further review of the guidance revealed the following information under outside visitation: While taking a person-centered approach and adhering to the core principles of COVID-19 infection prevention, outdoor visitation is preferred and can also be conducted in a manner that reduces the risk of transmission. Outdoor visits pose a lower risk of transmission due to increased space and airflow. Therefore, all visits should be held outdoors whenever practicable. Aside from weather considerations (e.g., inclement weather, excessively hot or cold temperatures, poor air quality), an individual resident's health status (e.g., medical condition(s), COVID-19 status), or a facility's outbreak status, outdoor visitation should be facilitated routinely . Interview with Resident #2 revealed he/she was unaware of any type of outdoor visitation and had not been offered outdoor visits with family. Review of Resident #2's medical record revealed he/she had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Interview with Resident #3 revealed he/she only got to do a window visitation once with his/her family. Resident #3 further revealed he/she was unaware of any type of outdoor visitation. Review of Resident #3's medical record revealed he/she had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Interview with Resident #4 revealed he/she had not been outside for visits. Resident #4 further revealed he/she would love to see his/her family. Review of Resident #4's medical record revealed he/she had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Observations on 10/12/2020 at 11:05 AM and 1:20 PM revealed no outside visitation. The positivity rate for Madison County on 10/12/2020 was 17.4%. Interview with the Director of Nursing on 10/12/2020 at 12:40 PM revealed the last COVID-19 positive resident was on 08/25/2020. An interview with the Administrator on 10/12/2020 at 5:00 PM revealed the facility was only conducting window visits and [MEDICATION NAME] care visits due to the county positivity rate of 17.4% and had not been cleared for outside visitation by Corporate due to the county positivity rate. She further revealed no outdoor visitation was occurring and had not been offered in several weeks.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the comprehensive plan of care for two (2) of twenty-three (23) sampled residents (Residents #55 and #73) related to securing indwelling urinary catheters. Resident #55 and Resident #73 both had interventions on their comprehensive plans of care to secure the residents' urinary catheters (to prevent trauma). However, observation of indwelling catheter care for Resident #73 on 01/23/19 and Resident #55 on 01/24/19, revealed the indwelling urinary catheters were not secured. The findings include: Review of the facility's policy titled, Care Plans-Comprehensive, dated 08/01/13, revealed daily care and documentation would be consistent with the resident's care plan. 1. A review of Resident #55's medical record revealed the facility admitted the resident on 11/21/18, with [DIAGNOSES REDACTED]. The medical record revealed Resident #55 was admitted to the facility with a suprapubic urinary catheter. A review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status Score (BIMS) of nine (9) which indicated moderately impaired cognitive status and was therefore interviewable. A review of Resident #55's comprehensive care plan dated 11/22/18, revealed staff were required to keep the resident's indwelling urinary catheter tubing secured. Observation of suprapubic urinary catheter care for Resident #55 on 01/24/19 at 8:51 AM, revealed the resident's catheter was not secured, and Kentucky Medication Aide (KMA) #1 did not secure the catheter after providing suprapubic catheter care. An interview with KMA #1 on 01/24/19 at 9:00 AM, revealed she was required to check residents' comprehensive plans of care daily or anytime they were unsure what care was required by a resident. The KMA stated she was aware Resident #55's catheter was required to be secured. The KMA stated she should have secured the resident's catheter and was not sure why she had not. 2. Review of the medical record for Resident #73 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C: Cognitive Patterns, revealed Resident #73 was unable to complete the Brief Interview for Mental Status (BIMS). Further review of the MDS Assessment, Section H: Bladder and Bowel, revealed the resident had an indwelling urinary catheter. Review of the Comprehensive Plan of Care for Resident #73 dated 07/23/18, revealed the resident had an indwelling urinary catheter intervention to keep the catheter bag and tubing below the level of the bladder and secured. Observation of indwelling urinary catheter care for Resident #73 was conducted on 01/23/19 at 9:42 AM. State Registered Nursing Assistant (SRNA) #2 was observed to provide care. The observation revealed Resident #73's indwelling urinary catheter was not secured prior to the catheter care being conducted. SRNA #2 also failed to secure the indwelling urinary catheter after the care was completed. Interview with SRNA #2 on 01/24/19 at 2:26 PM, revealed she was required to check residents' plans of care every shift before performing care. The SRNA further revealed Resident #73 should have had his/her indwelling urinary catheter secured as the care plan stated and she had just overlooked securing the indwelling urinary catheter. Interview with the Director of Nursing (DON) on 01/24/19 at 2:04 PM, revealed she made rounds throughout the facility daily to ensure residents were receiving the care they required as directed by the residents' comprehensive plans of care. The DON stated she would randomly ask staff to give her a report on the care required by residents. The DON stated she had not identified any concerns with residents not receiving the care as directed in their comprehensive plans of care.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of twenty-three (23) sampled residents (Residents #55 and #73) received appropriate treatment and services for an indwelling urinary catheter. Observation of indwelling urinary catheter care for Resident #55 on 01/25/19 and Resident #77 on 01/24/19, revealed staff failed to secure the indwelling urinary catheters to prevent trauma as required by the facility's policy. The findings include: Review of the facility's policy titled, Catheter Associated Urinary Tract Infection Prevention, undated, revealed the facility's policy was to secure urinary catheter tubing to prevent movement. 1. Review of the medical record for Resident #55 revealed the facility admitted the resident on 11/21/18, with [DIAGNOSES REDACTED]. The medical record revealed Resident #55 was admitted to the facility with a suprapubic urinary catheter. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated moderately impaired cognitive status and the resident was therefore interviewable. Review of the comprehensive care plan for Resident #55 dated 11/22/18, revealed staff were required to keep the resident's catheter tubing secured. Observation of suprapubic urinary catheter care for Resident #55 on 01/24/19 at 8:51 AM, revealed the resident's catheter was not secured, and Kentucky Medication Aide (KMA) #1 did not secure the catheter after providing suprapubic catheter care. An interview with KMA #1 on 01/24/19 at 9:00 AM, revealed the KMA was aware Resident #55's catheter was required to be secured. The KMA stated she should have secured the resident's catheter and was not sure why she had not. Interview with the Director of Nursing (DON) on 01/24/19 at 2:04 PM, revealed she made rounds throughout the facility daily to ensure residents were receiving the care they required. The DON stated staff were required to secure all indwelling urinary catheters with butterfly clips, tape, or leg straps. The DON revealed she had not identified any residents' urinary catheters not being secured. 2. Review of the medical record for Resident #73 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C: Cognitive Patterns, revealed Resident #73 was unable to complete the Brief Interview for Mental Status (BIMS). Further review of the MDS Assessment, Section H: Bladder and Bowel, revealed the resident had an indwelling urinary catheter. Review of the Comprehensive Plan of Care for Resident #73 dated 07/23/18, revealed the resident had a urinary catheter intervention to keep the catheter bag and tubing below the level of the bladder and secured. Observation of indwelling urinary catheter care for Resident #73 was conducted on 01/23/19 at 9:42 AM. State Registered Nursing Assistant (SRNA) #2 was observed to provide care. The observation revealed Resident #73's indwelling urinary catheter was not secured prior to the catheter care being conducted. SRNA #2 also failed to secure the indwelling urinary catheter after the care was completed. Interview with SRNA #2 on 01/24/19 at 2:26 PM, revealed she had been trained by the facility to secure indwelling urinary catheters to the resident's leg to prevent trauma or injury. The SRNA stated she had just overlooked securing the indwelling urinary catheter, but she should have secured it. Interview with the Director of Nursing (DON) on 01/24/19 at 2:03 PM, revealed she monitored care by making rounds every morning and checking on all the residents. The DON further revealed all indwelling urinary catheters should be secured and if a security device has fallen off it should promptly be resecured. The DON further revealed she had not identified any concerns with indwelling urinary catheters not being secured.

Based on interview, record review, and facility policy review, it was determined that the facility failed to develop and operationalize policies and procedures for screening new employees for protection of residents and prevention of abuse. Review of three (3) of five (5) personnel files revealed the facility failed to conduct checks of previous and/or current employers to screen for a history of abuse, neglect, or mistreating residents. The findings include: The facility policy titled Prevention, dated February 2004, revealed the facility would conduct background investigations to prevent hiring personnel who had been found guilty by a court of law of abusing, neglecting, or mistreating individuals, or who had a finding of such action entered into the Nurse Aide Registry. However, the policy did not address attempting to obtain information from previous/current employers to screen for a history of abuse, neglect, or mistreating residents. 1. Review of Nursing Assistant #1's personnel file revealed the facility hired the employee on 10/12/17; however, there was no documented evidence the facility conducted a background check of the employee's previous/current employers. 2. Review of State Registered Nursing Assistant #1's personnel file revealed the facility hired the employee on 11/02/17. There was no documented evidence the facility completed a background check of the employee's previous/current employers. 3. Review of State Registered Nursing Assistant #2's personnel file revealed the facility hired the employee on 11/02/17; however, there was no evidence the facility screened the employee's previous/current employers. Interview conducted on 11/21/17 at 4:45 PM with the Administrator revealed Human Resources staff was responsible for screening potential new employees. The Administrator stated the facility should have checked with previous/current employers prior to hiring an employee and was not aware the screening was not being completed.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to maintain an effective infection control program to provide a safe and sanitary environment to minimize the development and transmission of disease and infection for two (1) of twenty (20) sampled residents (Resident #1). Observations on 11/19/17 during the evening meal revealed a State Registered Nurse Aide (SRNA) was observed to pick up Resident #1's fall mat twice from the floor and then proceed to feed Resident #1 without performing hand hygiene. The SRNA was then observed to retrieve a tray lid from the floor, and again continued to feed Resident #1 without performing hand hygiene. In addition, the SRNA's hair was observed to drop into the peaches that was on the resident's tray, and the SRNA continued to feed the peaches to the resident. The findings include: Review of the facility's Hand Hygiene policy (undated) revealed facility staff would perform handwashing after hands were visibly soiled. However, the policy did not address performing hand hygiene if hands were not visibly soiled. Observations on 11/19/17 at 4:33 PM during the supper meal service revealed SRNA #1 delivered the supper meal tray to Resident #1. The SRNA was observed to pick up Resident #1's fall mat twice from the floor, and then proceed to set up the meal tray and feed Resident #1 without washing/sanitizing her hands. SRNA #1 then retrieved a tray lid from the floor, and continued to feed Resident #1 without washing/sanitizing her hands. Additional observation revealed SRNA #1's hair was observed to drop into the resident's peaches and the SRNA continued to feed the peaches to the resident. Interview with SRNA #1 on 11/19/17 at 5:42 PM revealed she should have washed/sanitized her hands before handling Resident #1's meal tray and feeding the resident. Further interview revealed she was not aware her hair had dropped into Resident #1's peaches. Interview with Licensed Practical Nurse (LPN) #1, who is also the Unit Coordinator, on 11/19/17 at 5:44 PM revealed SRNA #1 should have washed/sanitized her hands after touching the resident's fall mat and before proceeding to feed the resident. Further interview revealed she performed random rounds to ensure appropriate infection control measures were being performed, and had not identified any concerns with handwashing. Interview with the Director of Nursing (DON) on 11/21/17 at 5:18 PM revealed staff were expected to perform appropriate hand hygiene at all times. Further interview revealed she conducted random rounds to ensure staff were washing/sanitizing their hands as required. Additional interview revealed she had not identified any problems with staff not performing hand hygiene when necessary.

Based on observation, interview, record review, facility policy review, and facility abuse investigation review, it was determined the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse were reported immediately to the administrator of the facility and to state agencies for one (1) of three (3) sampled residents (Resident #1). Interviews conducted with Resident #1, Resident #2, and Resident #1's family member revealed they had reported to Registered Nurse (RN) #2 on 11/07/15, that State Registered Nursing Assistant #1 had thrown Resident #1 on the bed and had injured the resident's foot. Resident #1's family member did not want SRNA #1 to provide care for Resident #1 in the future. However, interview conducted with the Administrator on 11/16/15, revealed she had not investigated the allegation because Resident #1 always complained of pain with any movement, and she had not considered the incident to be an allegation of abuse, therefore no investigation had been completed, SRNA #1 was allowed to continue working, and state agencies had not been notified of the incident. The findings include: Review of the facility's Abuse Policy, dated 08/01/13, revealed the Administrator must be notified immediately of any suspected abuse or incidents of abuse. The policy also revealed any individual observing an incident of abuse must immediately report the incident. The policy revealed all reports of resident abuse, neglect, and injuries of unknown origin would be promptly and thoroughly investigated by facility management and would be reported to state agencies as required. Review of the medical record for Resident #1 revealed the facility admitted the resident on 08/04/14, with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set (MDS) assessment for Resident #1 dated 10/23/15, revealed Resident #1 was assessed by the facility to have a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident was interviewable. The MDS also revealed the resident required the total assistance of two staff persons for bed mobility and transfers. Review of the medical record for Resident #2 revealed the facility admitted the resident on 08/03/15, with [DIAGNOSES REDACTED]. Review of an admission MDS assessment for Resident #2 dated 08/10/15, revealed Resident #2 was assessed by the facility to have a BIMS score of 11 which indicated the resident was interviewable. Observation of Resident #1 on 11/16/15, at 1:30 PM, revealed SRNA #4 and SRNA #5 were observed to turn and reposition the resident in bed. The resident was observed to moan as the SRNAs moved the resident. Interview conducted with Resident #1 on 11/16/15, at 12:00 PM, revealed SRNA #1 was not allowed back in my room because he hurt my foot when he turned me. The resident stated SRNA #1 had not been back in the resident's room since. Resident #1 could not recall SRNA #1 yelling. Interview conducted with Resident #2 (Resident #1's roommate) on 11/16/15, at 12:05 PM, revealed Resident #1 asked to be pulled up in bed and that big boy came in here and said what in the hell do you want? Resident #2 stated SRNA #1 then picked him/her up and threw him/her on the bed. Resident #2 stated Resident #1 yelled out you hurt my foot. The resident stated SRNA #1 then went to get help. Resident #2 stated he/she told RN #1 what had happened. Interview conducted with SRNA #1 on 11/16/15 at 12:15 PM, revealed he was providing care for Resident #1 on 11/07/15, and at approximately 12:35 AM both he and RN #1 went into Resident #1's room to reposition the resident in bed. He denied that he yelled at the resident, or that he threw the resident in the bed. The SRNA stated the resident always complained of pain when turning him/her in bed. The SRNA stated he was required to immediately report any allegations of abuse or neglect. Interview conducted with RN #1 on 11/16/15, at 2:05 PM, revealed she had helped SRNA #1 to turn and reposition Resident #1 on 11/07/15, at approximately 12:30 AM. The RN stated Resident #1 always complained of pain with any movement. RN #1 stated Resident #1 had complained that they were hurting him/her when they were moving the resident. The RN stated the resident complained of his/her left foot being hurt while they were moving him/her. The RN stated she had assessed the resident's foot and had not identified any injury. RN #1 stated Resident #2 told her SRNA #1 had thrown Resident #1 on the bed and hurt his/her foot, and had yelled at Resident #1. RN #1 stated she told Resident #2 that she had helped to turn Resident #1 and they had not hurt the resident's foot, nor had SRNA #1 yelled at Resident #1. The RN stated she then reported the allegations to RN #2 who was the house supervisor. Interview conducted with Resident #1's family member on 11/16/15, at 2:55 PM, revealed he came to the facility on [DATE], and was unsure of the time. The family member stated Resident #1 and Resident #2 both told the same story that SRNA #1 had thrown Resident #1 on the bed, hurt his/her foot, and then yelled at the resident. The family member stated he/she reported the incident to RN #2 and told her he/she did not want SRNA #1 back in Resident #1's room again. The family member stated he/she was told not to pay any attention to Resident #2 because the resident was just confused. Interview with RN #2 on 11/16/15, at 3:10 PM, revealed RN #1 had reported the allegations by Resident #1 and Resident #2 to her on 11/07/15. The RN stated she then went in to talk to Resident #1 and Resident #2. The RN stated Resident #2 reported to her that he/she had been awake all night watching to ensure SRNA #1 did not hurt Resident #1 again. RN #2 stated Resident #2 was very angry and agitated. The RN stated Resident #1 did not appear to be in any increased pain. The RN stated Resident #1's family member came in and after the family talked with Resident #1 asked for SRNA #1 not to provide care for Resident #1 because the resident had told him/her SRNA #1 threw the resident on the bed, yelled at him/her, and hurt his/her left foot. RN #2 stated she notified the Administrator to report Resident #1's family member's concerns and was instructed by the Administrator to not let SRNA #1 provide care for Resident #1 and Resident #2. The RN stated the Administrator told her the family member was aware the resident experienced pain when he/she was moved. Interview with the Director of Nursing (DON) on 11/16/15, at 5:25 PM, revealed no investigation had been completed because this was a normal behavior for Resident #1. The DON stated Resident #1 always complained of pain with any movement. The DON stated both SRNA #1 and RN #1 were in the room when the alleged incident occurred. Interview conducted with the Administrator on 11/16/15, at 5:45 PM, revealed she was notified on 11/07/15, by RN #2 regarding Resident #2 having increased agitation requiring physician and family notification. The Administrator stated she was not notified of Resident #2's allegations and was told of Resident #1's family member not wanting SRNA #1 to provide care for the resident. The Administrator stated she was unaware of any allegations of abuse, but should have been. An investigation was required to be completed for any allegation and state agencies were to be notified. The Administrator stated RN #2 had taken witness statements but had not forwarded them to her, nor were any other residents or staff interviewed.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to provide care in accordance with the Comprehensive Plan of Care for one (1) of twenty (20) sampled residents (Resident #9). Resident #9's Comprehensive Care Plan contained care plan interventions that included oxygen as ordered; however, observations on 06/30/15 and 07/01/15 revealed oxygen was not in use for Resident #9. The findings include: Review of the facility's policy titled Using the Care Plan, dated 08/01/13, revealed daily care and documentation must be consistent with the resident's care plan. Further review revealed changes in the resident's condition must be reported to the Nurse Assessment Coordinator so that a review of the resident's assessment and care plans can be made. Review of Resident #9's medical record revealed the facility admitted Resident #9 on 06/17/14 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #9 was unable to be interviewed due to being severely cognitively impaired. Further review of the MDS revealed Resident #9 required the use of oxygen. Review of the Comprehensive Care Plan, updated on 06/12/15, revealed Resident #9 was at risk for altered cardiac output and required the use of oxygen. Review of the physician orders [REDACTED]. Observations of Resident #9 on 06/30/15 at 11:20 AM, 3:05 PM, 4:05 PM, and 5:45 PM, and 07/01/15 at 8:55 AM, 10:10 AM, and 10:55 AM, revealed Resident #9 was sitting in a wheelchair in different areas of the facility without oxygen in use by the resident. Interview with Unit Coordinator #1 on 07/02/15 at 1:40 PM revealed she was responsible for updating the care plans when new orders were written. She further revealed staff does QA (Quality Assurance) on oxygen when a resident has an order for [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1 on 07/02/15 at 1:50 PM revealed she had noticed Resident #9 had not been wearing his/her oxygen but had assumed the oxygen was ordered on an as needed basis. She further stated she had not seen Resident #9 in any respiratory distress. Interview with the MDS Coordinator on 07/02/15 at 2:00 PM revealed she was responsible for developing the care plans and updating the care plans as needed. However, she was not responsible for ensuring staff followed the care plans. Interview with the Director of Nursing (DON) on 07/02/15 at 3:45 PM revealed staff has morning meetings to discuss new orders and to update the care plans. She further stated no problems had been identified concerning following the care plans.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents' food preferences were honored for residents that had identified food dislikes for one (1) of twenty (20) sampled residents (Resident #1). Resident #1 disliked cheese; however, on 06/30/15 during the 2:00 PM snack service, Resident #1 was observed to have a bologna and cheese sandwich. The findings include: Review of the facility's policy titled Food Preference/Diet History Record, dated 2013, revealed upon a resident's admission to the facility, the Dietary Manager (DM) would identify a resident's food preferences, food likes, and food dislikes. The policy stated, Obtained information should be used to develop client tray cards for meal service and should be updated as necessary. Review of Resident #1's meal tray card revealed that one of the resident's dislikes was cheese. Review of the medical record for Resident #1 revealed the facility admitted the resident on 08/04/14 with [DIAGNOSES REDACTED]. Further review of the record revealed a Minimum Data Set (MDS) Assessment with a reference date of 06/22/15. The MDS revealed the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of 9. Observation of Resident #1 on 06/30/15 at 2:30 PM revealed Resident #1 received a bologna and cheese sandwich for a 2:00 PM snack. The sandwich was lying on the overbed table unopened. Interview conducted with Resident #1 on 06/30/15 at 2:30 PM revealed, I do not like cheese. Resident #1 stated he/she had informed staff several times of the dislike, but stated staff continued to send cheese. Interview conducted with the Dietary Manager (DM) on 07/02/15 at 3:35 PM, revealed Resident #1 should not have received a bologna sandwich with cheese on it. Interview conducted with the Registered Dietitian (RD) on 07/02/15 at 3:45 PM revealed that the resident had many dislikes and was very hard to please. The RD stated the resident should not have received a bologna sandwich with cheese due to the resident's dislike of cheese.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of twenty (20) sampled residents (Resident #1) received services with reasonable accommodations for individual needs. Observation on 06/30/15 during the evening meal revealed Resident #1's meal tray was served on the overbed table; however, the table was too high for the resident to see the food on the tray and the resident had difficulty feeding himself/herself. The findings include: Interview with Director of Nursing (DON) on 07/01/15 at 3:15 PM revealed there was no policy pertaining to meal tray setup. Medical record review for Resident #1 revealed the facility admitted the resident on 08/04/14 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 9, indicating the resident had moderate cognitive impairment. Further review of the MDS revealed the facility assessed the resident to require extensive assistance with all ADLs except eating, in which the resident was independent requiring assistance with setup only. Observation on 06/30/15 at 5:20 PM revealed student Nurse Aide (NA) #7 carried Resident #1's dinner tray to his/her room, set it up on the overbed table, and raised the head of the bed for Resident #1 to a 45-degree angle. Resident #1 had a wedge between his/her knees that caused the knees to be elevated off the bed. NA #7 positioned the overbed table above Resident #1's knees and lowered it as far is it would go. The table was positioned right above the resident's knees with the overbed table at eye level with Resident #1. The privacy curtain was pulled between Resident #1 and his/her roommate, and Certified Nursing Assistant (CNA) #4 was feeding Resident #1's roommate. Observations further revealed Resident #1 attempted to feed himself/herself, but had difficulty reaching the food and did not eat anything from the tray. Interview with Resident #1 on 06/30/15 at 5:25 PM revealed staff set his/her tray up high all the time. Resident #1 stated if the staff would help him/her eat, he thought he/she would eat more. Resident #1 stated he/she could not see or reach all of the food on the tray due to the table being so high. Interview with NA #7 on 07/02/15 at 3:25 PM revealed she served Resident #1 the evening meal tray on 06/30/15 and thought the resident would probably have had difficulty reaching all of the food. NA #7 stated she should have gotten a Certified Nurse Aide to assist in repositioning Resident #1 in bed more. NA #7 said she was a student nurse aide and that a Certified Nurse Aide was supposed to supervise her at all times. NA #7 stated the CNA that was supervising her that day was feeding Resident #1's roommate during the evening meal service. Interview with CNA #4 on 07/02/15 at 2:45 PM revealed the over bed table should have been lower for Resident #1 to easily reach and see the food. CNA #4 further stated that she did not check on NA #7 to make sure the tray was set up correctly, but that a CNA should have since NA #7 was a student. Interview with Registered Nurse (RN) #2 on 07/02/15 at 3:00 PM revealed she was the nurse assigned to Resident #1 during the evening meal on 06/30/15. RN #2 stated the overbed table should have been lower so that Resident #1 could reach the food better. RN #2 stated a CNA should have been supervising NA #7 when setting up trays. Interview with the Director of Nursing (DON) on 07/01/15 at 3:15 PM revealed that Resident #1's overbed table probably should not have been that high and that somebody should have been looking at NA #7's work.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty (20) sampled residents (Resident #9) received oxygen therapy according to physician orders [REDACTED]. Resident #9 had physician's orders [REDACTED]. However, during several observations on 06/30/15 and 07/01/15, Resident #9 was out of his/her room, without oxygen being administered. The findings include: Interview with the Director of Nursing (DON) on 07/02/15 at 3:45 PM revealed the facility did not have a policy concerning the use of oxygen. Review of Resident #9's medical record revealed the facility admitted Resident #9 on 06/17/14 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #9 was unable to be interviewed due to severe cognitive impairment. Further review of the MDS revealed Resident #9 required the use of oxygen. Review of the Comprehensive Care Plan, updated on 06/12/15, revealed Resident #9 was at risk for altered cardiac output and had interventions for the use of oxygen. Review of the physician's orders [REDACTED].#9 was to have oxygen at 2 liters per minute (LPM) via nasal cannula to maintain oxygen saturation levels above 90 percent. Review of the oxygen saturation levels that were performed monthly, revealed Resident #9's oxygen saturation level was maintained above 90 percent as ordered. Observations of Resident #9 on 06/30/15 at 11:20 AM, 3:05 PM, 4:05 PM, and 5:45 PM, and 07/01/15 at 8:55 AM, 10:10 AM, and 10:55 AM) revealed Resident #9 was sitting in a wheelchair in different areas of the facility without receiving oxygen. Interview with Unit Coordinator #1 on 07/02/15 at 1:40 PM revealed she had noticed Resident #9 without the oxygen on while in the wheelchair, but assumed the oxygen was ordered as needed. She further revealed no problems had been identified with residents not receiving oxygen as ordered. Interview with Licensed Practical Nurse (LPN) #1 on 07/02/15 at 1:50 PM revealed she had noticed Resident #9 had not been wearing his/her oxygen but had assumed the oxygen was ordered on an as needed basis. She further stated she had not seen Resident #9 in any respiratory distress. Interview with the Director of Nursing (DON) on 07/02/15 at 3:45 PM revealed staff had morning meetings to discuss new orders and to update the care plans. She further stated no problems had been identified concerning residents receiving oxygen as ordered.

Based on observation, interview, and facility policy review, it was determined the facility failed to establish and maintain an effective infection control program designed to provide a safe and sanitary environment to prevent the transmission of disease and infection for two (2) unsampled residents (Residents B and C) of twenty (20) sampled and three (3) unsampled residents. Observation during medication administration/blood glucose monitoring on 07/02/15, revealed staff failed to change their gloves and wash/sanitize their hands after cleansing the blood glucose monitoring device, and proceeded to perform blood glucose monitoring for Resident B and Resident C. The findings include: Review of the facility's policy titled Cleaning Your Meter, undated, revealed the policy did not address wearing gloves or hand washing while disinfecting the blood glucose monitoring device. Review of the facility's policy titled Hand Hygiene, undated, revealed staff was required to wash/sanitize their hands before any invasive procedure. Observation of Licensed Practical Nurse (LPN) #3 on 07/02/15 at 11:15 AM revealed the LPN washed/sanitized her hands, applied gloves, and then cleaned the blood glucose monitoring device with a bleach wipe. LPN #3 proceeded to perform blood glucose monitoring for Resident B without changing gloves or washing/sanitizing her hands. The LPN then cleaned the blood glucose monitoring device without changing gloves or washing/sanitizing her hands. Observation of LPN #3 on 07/02/15 at 11:30 AM revealed LPN #3 washed/sanitized her hands, applied gloves, and performed blood glucose monitoring for Resident C. The LPN then cleansed the blood glucose monitoring device without changing her gloves or washing/sanitizing her hands. The LPN was observed to discard her gloves and wash/sanitize her hands after the device was cleansed. Interview conducted with LPN #3 on 07/02/15 at 11:40 AM, revealed she was aware she should have changed her gloves and washed/sanitized her hands prior to cleansing the blood glucose monitoring device and after performing blood glucose testing. The LPN stated she had attended in-services by the facility on blood glucose testing and cleansing of the blood glucose monitoring device, but was nervous and forgot to change gloves and wash her hands. Interview conducted with the Director of Nursing (DON) on 07/02/15 at 2:50 PM revealed she made rounds several times throughout the day to ensure residents were being provided the care they required. The DON stated she attended morning meeting where resident care was discussed. The DON stated random medication administration observations, which included blood glucose monitoring, were completed, and no concerns had been identified regarding blood glucose monitoring. The DON stated staff was required to change gloves and wash/sanitize their hands after cleansing a blood glucose monitoring device, and after performing blood glucose testing.

Based on observation, interview, record review, and facility investigation review it was determined the facility failed to accommodate the individual needs for one (1) of three (3) sampled residents (Resident #1). The facility failed to ensure Resident #1's dentures were in use on 05/10/15, and the resident ate the evening meal without his/her dentures. The findings include: Interview with the Administrator on 05/26/15 at 5:24 PM revealed the facility did not have policies related to grooming, showering/bathing, oral care, or dentures. The Administrator also stated the facility does not have an Activities of Daily Living (ADL) policy. Medical record review revealed the facility admitted Resident #1 on 04/16/14 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. Further review of the annual assessment revealed the facility had assessed the resident to require extensive assistance with hygiene and also required setup help with eating. Review of the comprehensive care plan, dated 04/24/14, revealed assistance was to be provided with oral hygiene including denture care every morning and every night. Review of the Nurse Assistance Care Plan, dated 05/2015, revealed oral care was to be provided with assistance. Review of the physician assessment completed on 05/05/15 revealed Resident #1 was edentulous and his/her dentures fit well. Observations made on 05/26/15 at 1:00 PM revealed Resident #1 was in the facility dining area feeding himself/herself lunch and was found to be wearing dentures. Review of the facility investigation, dated 05/10/15, revealed the facility had determined on 05/10/15 that Resident #1 had eaten the evening meal without dentures being in place. Further review of the investigation revealed after a grievance was made to facility staff, Resident #1's dentures were made available for the resident for use. Review of the facility's On the spot In-Service, Dentures policy, dated 05/11/15, revealed, If a resident wears dentures, you must clean them and put them in every day. The dentures must be in before meals. Interview with State Registered Nurse Aide (SRNA) #4 on 05/26/15 at 5:57 PM revealed she had been caring for Resident #1 on 05/10/15 and was unaware the resident's dentures were not in place during the evening meal until the grievance was made. Further interview revealed the SRNA had been trained to make sure their dentures are in before they eat. Interview with Registered Nurse (RN) #4, who was also the facility House Supervisor, on 05/26/15 at 5:41 PM revealed Resident #1's family member was upset due to the resident's dentures not being in place during the evening meal. Further interview revealed the family member had voiced concern that the resident's dentures were taken out prior to the evening meal and were not replaced until a grievance was made to staff after the resident had eaten. The RN stated the dentures were replaced after the facility was made aware. Interview with Family Member #1 on 05/26/15 at 9:22 AM revealed she had taken out the resident's dentures to clean and soak them prior to supper. The family member stated when leaving the facility, she had informed nursing staff that she had removed the resident's dentures for cleaning. When she returned to the facility after the evening meal, the resident was still not wearing his/her dentures. The Family Member stated she was scared when she learned the resident ate without dentures and no one apparently noticed. The Family Member stated she was concerned because the resident could have choked to death. Interview with the Director of Nursing (DON) on 05/26/15 at 2:30 PM revealed Resident #1's dentures should have been in place prior to the evening meal on 05/10/15. Interview with the Administrator on 05/26/15 at 6:10 PM revealed the facility was not aware the resident's dentures were not in place until after a family member voiced the concern. The Administrator stated the resident should have had dentures in place.

Based on interview, record review, and policy review, the facility failed to ensure the medical record for one of nineteen sampled residents (Resident #3) contained documentation that the resident received the pneumococcal vaccine. Interview revealed staff had administered an influenza vaccine to Resident #3; however, staff failed to document the vaccination in the resident's medical record. The findings include: A review of the facility's policy, Immunizations: Influenza (FLU) Vaccination of Residents, Staff, and Volunteers (dated 2007) revealed all residents of the facility should receive the influenza vaccine annually, unless there is a documented contraindication. The policy also revealed the administration of the influenza vaccine, including injection site, should be documented in the medical record (medication sheet, nurse's notes, immunization record, or progress sheet). A review of the medical record for Resident #3 on 02/21/12, revealed the resident had a standing order from his/her physician to obtain an influenza vaccine yearly. The medical record further revealed consent for influenza vaccine was obtained from the resident's guardian on 01/05/12. However, a review of documentation in the medical record revealed no documentation that the influenza vaccine had been given. An interview conducted with Licensed Practical Nurse #6 on 02/23/12, at 12:55 PM, revealed she administered the influenza vaccine to Resident #3 on 01/06/12, but forgot to document the administration in the resident's medical record, stating, "I got side-tracked."

Based on observation, interview, and record review, it was determined the facility failed to establish and maintain an effective infection control program to prevent the development and transmission of disease and infection for three (3) of twenty-one (21) sampled residents (residents #7, #20, and #21). Observation of medication administration on December 14, 2010, revealed staff administered subcutaneous injections to resident #20 and resident #21 without donning gloves. Observation of wound care for resident #7 on December 15, 2010, revealed staff failed to change gloves when going from a soiled area to a clean area. The findings include: 1. During medication administration conducted on December 14, 2010, at 4:00 p.m., observation revealed Licensed Practice Nurse (LPN) #2 administered [MEDICATION NAME] R Insulin subcutaneously to resident #20 without donning gloves. Additional observation conducted on December 14, 2010, at 4:30 p.m., revealed LPN #2 administered [MEDICATION NAME] Insulin subcutaneously to resident #21 without donning gloves. In an interview conducted on December 14, 2010, at 4:35 p.m., LPN #2 revealed he/she did not wear gloves to administer subcutaneous injections of insulin and did not feel it was necessary to wear gloves. The LPN further stated he/she had not been trained by the facility to don gloves prior to the administration of subcutaneous injections. An interview conducted on December 15, 2010, at 12:20 p.m., with LPN #1 revealed he/she wore gloves to administer subcutaneous injections due to the risk of contact with blood and further stated the injection site could bleed during/after a subcutaneous injection. In an interview conducted on December 15, 2010, at 1:20 p.m., with the Director of Staff Development/Continuous Quality Improvement (DSD/CQI), the DSD/CQI stated staff would be at risk of exposure to blood/body fluids when administering an injection without the use of gloves. The DSD/CQI further revealed nurses were trained to don gloves prior to performing a venipuncture or intravenous catheters; however, the nurses were not trained to don gloves to administer a subcutaneous injection. In an interview conducted on December 15, 2010, at 9:55 a.m., with the Director of Nursing (DON), the DON stated the facility's policy did not require that gloves be worn to administer subcutaneous injections. Review of the facility's policy on Subcutaneous Medication Administration (not dated) stated that staff was required to don gloves to administer a subcutaneous injection. However, review of the facility's policy on Standard Precautions (2007) revealed gloves should be worn whenever exposure to blood or non-intact skin was planned or anticipated. The policy further stated all residents' blood, body fluids, excretions, and secretions other than sweat would be considered potentially infectious and gloves should be worn when providing care. 2. A review of the medical record for resident #7 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Observation of skin assessment and wound care with Licensed Practical Nurse (LPN) #1 on December 15, 2010, at 1:30 p.m., revealed the LPN assessed resident #7 to have a Stage 4 decubiti to the left buttock, and a Stage 3 and a Stage 4 decubitus to the right buttock. Observation revealed LPN #1 used clean gloves to cleanse stool from the left buttock of resident #7 with a Prevail Adult Washcloth, and the LPN then placed a clean dressing on the wound, without washing/sanitizing hands or changing gloves (going from a soiled area to a clean area). A review of the facility's policy for Hand Hygiene revealed handwashing should be conducted when hands were visibly dirty or contaminated with proteinaceous material, were visibly soiled with blood or other body fluids, and in case of a resident with a spore-forming organism. The policy further revealed hand hygiene should be performed with either a non-microbial soap and water or antimicrobial soap and water. The policy further stated if hands were not visibly soiled, the staff was to use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those listed in handwashing.

Based on interview and record review, it was determined the facility failed to ensure the pneumococcal and flu vaccines were provided for one (1) of twenty-one (21) sampled residents (resident #3). The facility further failed to provide evidence the resident/responsible party had been informed of the health risks related to the immunizations. The findings include: A review of the medical record revealed resident #3 was readmitted to the facility on [DATE]. A review of the readmission physician's orders [REDACTED]. A review of the immunization record for resident #3 revealed the flu/pneumococcal vaccines were offered to the resident on October 11, 2009. The immunization record noted the resident refused the vaccines. However, there was no evidence the facility had offered the resident or responsible party (R/P) information regarding the risks/benefits of the flu/pneumococcal vaccines. A review of the facility's Immunization policy/procedure (dated 2007) revealed the vaccines would be offered/administered to all current and newly admitted residents. The policy/procedure noted informed consent regarding risks/benefits of vaccination was required to be provided to the resident or R/P prior to the vaccination. An interview conducted with LPN #4 on December 15, 2010, at 3:10 p.m., revealed the LPN was responsible for completing the admission process for resident #3 when the resident was readmitted to the facility on [DATE]. LPN #4 stated the admitting nurse was responsible to provide/discuss the risks/benefits related to the flu and pneumococcal vaccines to the resident or the resident's R/P when a resident was readmitted to the facility. The LPN stated he/she did not provide the information related to the risks/benefits of the vaccines to resident #3 or the resident's R/P.

Based on observation, interview, and record review, it was determined the facility failed to review and revise the comprehensive care plan for one (1) of twenty-one (21) sampled residents. Resident #13 sustained a fall on December 6, 2010, and the care plan was not revised with interventions to prevent additional falls for the resident. The findings include: Review of the medical record for resident #13 revealed the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Incident/Accident Follow-up Assessment Form for resident #13 revealed the resident had sustained a fall on December 6, 2010. The causative factor was determined to be that the resident didn't realize he/she was too close to the edge of the bed and had fallen off the bed. A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had been assessed as being at risk for falls, and a care plan had been implemented to address the resident being at risk for falls. However, the comprehensive care plan had not been updated with new interventions to prevent additional falls for this resident after the fall on December 6, 2010. Observation of resident #13 on December 15, 2010, at 3:50 p.m., revealed the resident to be lying on a bed of medium to lower height. The bed was in the lowest position. An interview conducted with the Unit Coordinator (UC) for the South Wing of the facility on December 15, 2010, at 5:30 p.m., revealed the care plan for resident #13 should have been updated with new interventions after the fall the resident sustained [REDACTED]. The UC further reported it was the responsibility of the MDS Coordinator or her/his designee to update the resident's care plan with the interventions discussed at the meeting. An interview conducted with the MDS Licensed Practical Nurse (LPN) on December 15, 2010, at 5:45 p.m., revealed the MDS Coordinator was currently on sick leave. The MDS LPN further stated he/she had attended the Medicare Quality Improvement Meeting on December 7, 2010, in which the fall resident #13 received on December 6, 2010, was discussed. The MDS LPN stated he/she was responsible for updating the care plan but had failed to update the care plan. The MDS LPN reported the care plan should have been updated the same day the meeting was held.