Every finding on record at The Willows at Harrodsburg

Based on observation, interview, and facility policy review, the facility failed to serve food in a sanitary manner. Observation of the kitchen revealed dietary staff with unrestrained hair, which affected 42 of the 43 current residents in the facility that received food from the kitchen.The findings include:Review of the facility's policy titled, Hair Restraint Policy, reviewed date 07/09/2025, revealed, All Dining Service employees will be required to wear hair restraints as required by the 209 Federal Food Code; Hair Restraints 2-402.11 Effectiveness. Review of the policy provided by the facility titled, FDA Food Code 2009: Chapter 2 - Management & Personnel, revealed, Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, AND LINENS; AND UNWRAPPED SINGLE-SERVICE and SINGLE-USE ARTICLES.Observation during the initial tour of the kitchen on 01/20/2026 at 12:00 PM revealed Dietary Service Aide (DSA) 1 wearing a ballcap with approximately three inches of hair hanging loose on the entire back of her head. During an interview with DSA1 at the time of the observation, when asked what the policy instructed about hair restraints, she stated, Can I get back to you with that? Observation on 01/20/2026 at 12:19 PM revealed the Director of Food Service (DFS) was wearing a scarf, but the back of her hair was put up and not covered. During an interview with the DFS at the time of the observation, she stated, I forgot to put a hairnet on.During an interview with the Assistant Director of Food Service (ADFS) on 01/20/2026 at 1:03 PM, she stated, The policy says all hair is to be kept back with a hat, scarf, or hair net. During additional interview with the ADFS on 01/22/2026 at 2:37 PM, she stated hairs could potentially fall into food if it was not covered with a net. During an interview with the Culinary Support Staff on 01/22/2026 at 2:40 PM, he stated there could potentially be hair on a jacket that could fall into the resident's food if hair was not properly restrained.During an interview with the Divisional Vice-President on 01/23/2026 at 9:58 AM, she stated although the policy stated hair must be covered, it was permissible for two inches of the back of the hair to be uncovered.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to obtain dental services for 1 of 5 residents assessed for dental services, Resident (R) 43. Resident 43 was seen by dental services on 06/09/2025 with a recommendation to follow-up with an oral maxillofacial surgeon. However, the resident had not been seen by an oral surgeon.The findings include: Review of the facility's policy titled, Dental Services Including Repair, Replacement, review date 12/31/2023, revealed, The facility will ensure the delivery of emergency dental services to meet the resident needs. Emergency dental services will include services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that requires immediate attention by a dentist.Review of R43's admission Record revealed the facility admitted R43 on 03/11/2021 with diagnoses which included hemiplegia (the loss of ability to move) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left side, alcoholic cirrhosis of the liver with ascites (fluid build-up), and mild cognitive impairment of uncertain origin. Further review of R43's medical record revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 of 15, indicating moderate cognitive impairment. Review of R43's Progress Note dated 06/09/2025 and written by dental services, revealed R43 was seen by a Doctor of Dental Medicine (DDM). Per the note, the DDM recommended a referral to oral surgery.Observation of R43 on 01/20/2026 at 1:44 PM revealed he had several missing teeth. Further observation revealed most of the remaining teeth were broken off at the gum line.During an interview with R43 at the time of the observation, he stated the top teeth were very sensitive. He stated, I can't chew nothin. He further stated he had been eating soft food, mostly cottage cheese. He stated he loved steak, but he could not eat it because of his teeth. He stated he had trouble eating the roast and chicken the facility served.During an interview with Social Services Director (SSD) on 01/22/2026 at 1:08 PM, she stated Resident (R) 43 was seen by dental services, and they recommended R43 see an oral surgeon. She reviewed her notes and stated she contacted a family member (FM) 1, and he wanted to pursue the oral surgery. She stated the son told her he could take the resident any day but Wednesday. She stated dental services gave her a list of dentists that would be able to perform the surgery. She stated she then gave that list to a nurse at the 200 Hall, but she did not remember the name.During an interview with FM1 on 01/22/2026 at 1:25 PM, he stated he did not know much about the dental issue. He stated he only knew what his father told him, which was that all R43's teeth needed to be pulled. He stated R43's teeth had not been like that always. FM1 stated, before the stroke, R43 always took care of his teeth. FM1 then stated he thought his father had not taken care of his teeth since he was admitted to the facility. FM1 stated the facility called him about other things, whether R43 fell or any issue, but he did not recall staff mentioning anything about the teeth. FM1 stated he went to the doctor about R43's heart, but he had not heard anything from the facility about R43's teeth.During an interview with the Director of Health Services (DHS) on 01/22/2026 at 1:45 PM, she stated she knew R43 wanted to get his teeth removed, but she did not know how long it had been. She stated the nurses on the unit had attempted to contact FM1 about R43 several times, but they had not been successful. She stated the process for follow-up on dental services was the SSD would attempt to contact the Power of Attorney (POA). She stated the SSD would also ask the nurses to contact FM1. The DHS also stated the nurse usually handled issues with dental services.During additional interview with the DHS on 01/22/2026 at 2:12 PM, she stated she was unable to provide any documentation in the Nurse Progress Notes where the nurses had attempted to contact FM1 regarding the need for R43's further dental care.During an interview with the Divisional [NAME] President on 01/23/2026 at 9:58 AM, she stated she expected staff to follow the policy on dental care services.

Based on observation, interview, review of the glucometer (device used to measure blood glucose levels from finger stick) manufacturer's instructions, review of the germicidal wipe, used to clean and disinfect the glucometer, manufacturer's instructions, and review of the facility's policy, the facility failed to ensure its staff cleaned and disinfected the glucometer after use according to the manufacturer's instructions for 2 of 2 observations of using the shared glucometer on Resident (R) 4. The findings include:Review of the facility's policy titled, Infection Prevention and Control Program, review date 12/19/2025, revealed the purpose of the policy was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infections.Review of the manufacturer's instructions for the glucometer the facility used revealed the glucometer, with cleaning and disinfection, was to remain wet with the disinfectant for the appropriate contact time. It also revealed an approved disinfectant to use was Super Sani-Cloth Germicidal Disinfectant Wipe, Environmental Protection Agency (EPA) #9480-4.Review of the Super Sani-Cloth Germicidal Disinfectant Wipe container, with the Environmental Protection Agency (EPA) #9480-4, revealed its contact time was two minutes.Observation on 01/22/2026 at 9:38 AM revealed Licensed Practical Nurse (LPN) 4 checked the blood glucose level on R4, using a drop of blood from a finger stick and the shared glucometer. After the glucose check, LPN4 wiped the glucometer with a Super Sani-Cloth Disinfectant Wipe for 22 seconds (9:41:10 AM to 9:41:32 AM). She placed a paper towel on the cart and put the glucometer top of the paper towel, letting it air dry. Observation on 01/22/2026 at 3:53 PM revealed LPN4 performed another glucose check on R4. After the glucose check, she carried the glucometer to the cart with the glucose strips. She wiped the glucometer on all four sides with a Super Sani-Cloth Disinfectant Wipe for 48 seconds (3:55:40 PM to 3:56:28 PM). LPN4 then picked up another wipe and wiped the glucometer for an additional nine seconds (3:56:30 PM to 3:56:39 PM). She then placed the glucometer down on a paper towel.During an interview with LPN4, after the second observation, on 01/22/2026 at 4:00 PM, she stated she was taught to wipe the glucometer on all four sides. When questioned about the time the glucometer needed to stay wet, she stated she did not know.During an interview with the Director of Health Services/Infection Control Nurse on 01/22/2026 at 1:18 PM, she stated glucometers were cleaned with the wipes and then wrapped in the wipe for the time on the container. She further stated some residents had their own glucometer, but most residents did not and shared a glucometer.

Based on interview, record review, review of MapQuest, and review of the facility's policy, the facility failed to adequately supervise and ensure protection from accidents and injuries for 1 of 20 supplemental and sampled residents, Resident (R) 20. On 10/11/2024, R20 was assisted to bed with two Certified Resident Care Assistants (CRCA) using a mechanical lift. The resident was then re-positioned in bed with one CRCA, CRCA5. CRCA 5 rolled R20 away from her, which resulted in the resident being rolled off the bed and onto the floor. R20 sustained bilateral femur fractures. She was sent to the local emergency roiagnom on [DATE]. On 10/16/2024, R20 underwent surgical repair with Open Reduction and Internal Fixation (ORIF) of her bilateral femurs. The facility provided an acceptable Plan of Correction (POC) on 12/17/2024 alleging past noncompliance. The survey team validated the deficient practice was corrected on 11/06/2024, following the facility's implementation of the POC and before the start of the survey. The findings include: Review of the facility's policy titled, Fall Management Program Guidelines, effective 05/31/2017 and reviewed 12/31/2023, revealed the facility would put care plan interventions in place that addressed the resident's risk factors. Review of R20's Face Sheet revealed the facility admitted the resident on 10/31/2022 with diagnoses which included non-ST elevation myocardial infarction (heart attack); hemiplegia and hemiparesis following a cerebral infarction (stroke) affecting the left, dominant side; other paralytic syndrome following cerebral infarction, osteoarthritis in bilateral knees, and morbid (severe) obesity with a body mass index of 50-59. Review of R20's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/19/2024 and the last one done before the 10/11/2024 fall, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating intact cognition. This assessment also revealed R20 was nonambulatory and for mobility used a manual wheelchair which required two to wheel at least 150 feet in a corridor; to roll left and right required substantial/maximum assistance; from sitting to lying and lying to sitting required substantial/maximum assistance; and in a transfer from chair/bed to chair and chair to chair/bed, R20 was dependent, with the helper doing all of the effort. Review of R20's Comprehensive Care Plan (CCP), created on 11/09/2022, revealed the focus for the Care Guide stated she was non-weight bearing and required a mechanical lift. Further review of the care plan category: Falls included interventions, as of 10/11/2024, after the fall, to include assist of two for bed mobility. Prior to that she was one assist for bed mobility. Review of R20's Event Report, dated 10/11/2024, revealed on 10/11/2024 at 8:00 PM, R20 had a BIMS score of 12, which indicated moderate cognitive impairment. Per the report, R20 was assisted to bed via a mechanical lift and two CRCA staff members, CRCA5 and CRCA9. The report stated R20 was identified as someone who would benefit from a bariatric bed and mobility bars to aid with bed mobility, neither of which were in place previously. The report stated R20 was turned in bed and rolled out the other side, resulting in a fall. The report revealed R20 used the word sore when talking about her pain after the fall. Per the report, on 10/13/2024, R20 was asked to go to the hospital. The report stated R20 told staff she did not want to, but she felt it would be better to know if something was wrong with her knees. Per the report, R20 was sent to the local hospital for evaluation and subsequently sent to a larger hospital for further treatment. During an interview on 12/17/2024 at 2:20 PM with the Director of Health Services (DHS), she stated R20's BIMS score of 12, as listed on the 10/11/2024 Event Report was an error. She stated R20 had and continued to have a BIMS score of 15, indicating no cognitive impairment. Review of R20's Progress Note, dated 10/11/2024 at 12:29 AM (actual date was 10/12/2024) by Registered Nurse (RN) 5 revealed a CRCA reported to the staff nurse at 8:00 PM that during incontinence care and assisting R20 to get ready to go to sleep, the resident rolled out of bed onto the floor. Per the note, R20 was assessed and was observed with her head down by the foot of the bed and slightly under the edge of the bed, lying on her back. The note stated, during the physical assessment by RN5, she observed a laceration with a loose skin flap on the lateral side of R20's right great toe, and bleeding from the toe was stopped with pressure held. Per the note, the toe wound site was cleansed, steri-strips were applied to secure the flap, and it was covered with medical foam. The note stated R20 complained of pain, rated at seven out of 10 to bilateral knees, with pain on the left greater than the right. Per the note, as needed oral Tylenol (a pain reliever) was provided at 8:56 PM with R20's bedtime medications. The note stated R20's vital signs and neurological checks were stable. Further review revealed RN5 stated that she, as the staff nurse, educated the staff involved in the incident, CRCA5 and CRCA9 on a change in the plan of care for this resident and the importance of having two persons assisting with care in bed to avoid reoccurrence of the incident. Per the note, R20 remained safe with her needs met and the call bell within reach. The note stated staff would continue to monitor the resident. During an interview on 11/26/2024 at 11:50 AM with R20, she stated she did not think she would need to go to the hospital at first, but she was hurting worse and worse. Then, she stated, by Saturday, when the CRCAs tried to turn her, the pain had increased to more than she could handle, and she started to cry. She stated she told RN2 she wanted to go to the hospital, so she was sent to the local Emergency Department (ED). She stated she was told both of her femurs were fractured, and she had surgery to fix them at a larger hospital. During an interview on 11/26/2024 at 9:15 AM with CRCA9, she stated she was asked to help transfer R20 to bed using the mechanical lift. She stated once she had done that she left the room to finish a task she had started in another room. She stated she was called back to R20's room by RN5 because R20 had rolled onto the floor. She stated RN5 assessed R20, and she saw blood coming from R20's right toe. CRCA9 stated that she, along with other staff, assisted R20 back to bed with the mechanical lift. She stated R20 appeared to handle it well During an interview on 11/26/2024 at 10:04 PM with RN5, she stated on 10/11/2024 at approximately 8:00 PM, CRCA5 requested CRCA9 to assist in using a mechanical lift to place R20 in the bed. She stated once the task was complete, CRCA9 left the room, and CRCA5 started to provide incontinence care to R20. She stated R20 was care planned for one assist for bed mobility. She stated R20 rolled to the side of the bed, using the edge of the mattress to pull herself and rolled too far, falling off the side of the bed. RN5 stated she evaluated R20 and determined R20 had a skin tear to her toe, and first aid was applied. RN5 stated there was no deformity, redness, or edema, and R20 rated her pain at a 5 out of 10. RN5 stated she gave R20 Tylenol and documented the decreased pain, as manifested by the resident falling asleep. RN5 stated she was off for the next few days after that, and when she returned, she was surprised R20 had been admitted to the hospital. Review of R20's Progress Note, dated 10/13/2024 at 4:37 PM, revealed RN2 documented (a late entry on 10/14/2024 at 2:08 PM) R20 requested to go to the hospital due to pain in her legs, especially when moving, with the left more painful than the right. The note stated R20 was now crying when moving her left leg, and it was painful to palpation approximately two palms widths above the knee, but she was unable to determine if the left leg was shorter than the right leg due to R20's inability to move legs well. The note stated the APRN was notified by RN2, and Emergency Medical Services (EMS) accepted R20 for transport to the local hospital emergency department (ED, located eight miles from the facility per mapquest.com) for evaluation and treatment. Review of R20's hospital Discharge Summary, from the second and larger hospital, located approximately 33 miles from the facility per MapQuest.com, revealed R20 was admitted on [DATE], after an X-ray of her legs showed left and right femur comminuted (a fractured bone that had shattered into multiple pieces which could be caused by a serious fall) and displaced distal femur diaphysis fracture (the area of the femur just above the knee joint). The X-rays also showed surrounding soft tissue edema and vascular calcifications. The left and right knee radiology reports revealed severe tricompartmental joint space narrowing (indicated cartilage loss and severe osteoarthritis) and the femur fractures. Further review revealed on 10/16/2024, R20 had a surgical repair of her fractures with an open reduction and internal fixation (ORIF) of bilateral femurs. Per the record, R20 had no complications and was discharged back to the facility on [DATE] in stable condition. Review of R20's Progress Note, dated 10/19/2024 at 3:53 PM, revealed R20 was returned to the facility via private EMS, with an assist of four to transfer the resident from the stretcher to her bed. Per the note, R20's surgical dressings were clean, dry and intact. The note stated R20 rated her pain a six out of 10, and Tylenol was given per order. The note stated a follow-up was scheduled for 11/01/2024 with the orthopedic surgeon. During an interview on 11/27/2024 at 10:17 AM with RN2, she stated she worked with R20 during the day shift on 10/12/2024 and 10/13/2024. She stated, on 10/12/2024, R20's pain was a 7 out of 10, and RN2 provided Tylenol per order and topical Biofreeze. On 10/13/2024 at 4:37 PM, RN2 stated R20 was in tears and had increased pain. RN2 stated the Nurse Practitioner was notified, and an order was obtained to send R20 to the ED for evaluation and treatment. During an interview on 11/26/2024 at 2:59 PM with the Physician and the Nurse Practitioner, the Physician stated he was aware of R20's fall, and it had resulted in bilateral femur fractures. During an interview on 11/27/2024 at 1:47 PM with the Assistant Director of Health Services (ADHS) and the Director of Health Services (DHS), the DHS stated she expected an immediate intervention to be put in place after a fall. During an interview on 12/17/2024 at 2:24 PM with the Executive Director, when asked what she had the most concern with regarding this incident, she stated the occurrence of the fall and that the staff was educated on how to prevent one like it in the future. The facility provided an acceptable Plan of Correction on 12/17/2024 alleging past non-compliance of the deficient practice and a date of compliance of 11/06/2024 with corrective actions as follows verbatim: 1. Corrective actions for identified resident(s) affected by the deficient practice. a. On 10/11/24 at 8pm, The resident was immediately-assessed post incident by RN #1 (RN5). The RN #1 (RN5) noted no obvious injuries except a laceration to right great toe and treatment was initiated. The residents' pain level was monitored post incident and Tylenol was administered as needed. Tylenol was effective after each administration bringing pain level to baseline. Residents' average pain level is a 3 on a 0/10 scale due to chronic pain to bilateral knees related to diagnosis of osteoarthritis to bilateral knees and osteoporosis. The Physician was notified of the fall on 10/11/24 post incident. b. On 10/11/24, RN #1 (RN5) provided one on one education to CNA #1 (CRCA5) immediately by RN #1 (RN5) to ensure two assist with care in bed to avoid reoccurrence. c. On 10/13/24 at 4:37pm, RN#2 assessed resident and noted increased pain with movement and resident requested to be sent to ER. APRN was notified of the resident's condition. Resident was sent to ER. d. On 10/19/24 at 3:53pm, resident returned to facility with post-surgical intervention and resident expressed she was glad to be back home. Order for PT, OT and is non-weight bearing and follow up with ortho on 11/1/24. e. On 11/1/24, the resident returned from her ortho appointment with satisfactory condition post-surgical follow up. The resident remains non-weight bearing status. f. On 10/15/24, the IDT (Interdisciplinary Team) reviewed and revised the residents care plan to include 2 assist with bed mobility, per the RN#l (RN5) immediate intervention. 2. Identification of other residents who may be affected by the deficient practice and corrective actions that will be put in place to ensure the deficient practice does not reoccur. a. All residents requiring extensive to maximum assist with bed mobility could potentially be affected. b. A one-time audit of 100% health center residents was reviewed by [NAME] President of Clinical Operations and MDSC (Minimum Data Set Coordinator) on 10/23/24 reviewing the resident's most recent MDS section GG and ensuring care plan was appropriate for assist status. Any concerns that were identified were corrected immediately. 3. Measures put in place and systemic changes you will make to ensure that the deficient practice does not reoccur. a. On 10/14/24 education was initiated by DHS and ADHS regarding falls and care plans. Education was provided to licensed nursing staff and CRCAs. On 10/23/24 additional education from [NAME] President of Clinical Operations was provided to DHS, ADHS, MDS (MDSC), ED to include on rolling resident toward the care giver, ensuring profiles are completed on admission, following care plans, and notifying DHS or ADHS of all falls (injury or non-injury). This additional education was then provided to licensed nursing staff and CRCAs. Education concluded on 10/24/24. After 10/24/24, any newly hired staff will be educated through orientation by DHS and/or ADHS. Campus does not use agency staff. b. Starting on 10/24/24, as part of the facility's ongoing quality improvement plan the DHS, ADHS, SDC (Staff Development Coordinator), and/or clinical support will observe a total of 3 staff members completing bed mobility to ensure care plan/care profile is being followed weekly x 4 weeks, then 2 staff members weekly x 4 weeks, then 1 staff member weekly x 4 weeks, then 1 staff member monthly x 3 months. This will ensure staff members have retained the education provided on standards of care related to bed mobility. c. The findings of this audit will be presented to the Quality Assurance and Performance Improvement Committee (QAPI) consisting of the Executive Director, Director of Health Services, Assist director of health services, and medical director monthly. 4. Describe the Quality Assurance & Process Improvement Program that will be put into place. a. An Ad Hoc Quality Assurance meeting was held on 10/14/24 regarding the incident on 10/11/24 regarding resident fall with injury and the facility's corrective action, the facility QAPI Committee to review the findings of audits plan of correction to ensure the plan is effective. b. The findings of this audit will be presented to the QAPI committee consisting of ED, DHS, ADHS, MD (Medical Director), MDS will review monthly. The QAPI meetings will determine when compliance is achieved or if ongoing monitoring is required. The State Survey Agency (SSA) validated the facility's Plan of Correction for past noncompliance which determined the facility had corrected the deficient practice for F689 on 11/06/2024 as alleged. 1. Record review of R20's progress notes, incident report, discharge summary, internal investigation with witness statements, and the medication administration record (MAR), revealed R20 was immediately assessed post-incident by RN5, who noted no obvious injuries except a laceration to her right great toe and treatment was initiated. R20's pain level was monitored post incident, and oral Tylenol and Biofreeze were administered as needed. Tylenol was effective after each administration bringing R20's pain level to her baseline pain level of three. On 10/11/2024, immediately after the incident RN5 provided education to CRCA5 to ensure a two-person assist for R20 with care in bed to avoid recurrence. On 10/15/2024, the IDT reviewed and revised R20's care plan to include a two-person assist with bed mobility, per RN5's immediate intervention. 2. Record of two residents identified as potentially at risk to be affected were reviewed, R27 and R30. Record review for R27 revealed the current care plan and profile care guide was last reviewed on 11/27/2024, updated on bed mobility with assist x 1, with a start date of 10/23/2024; and transfers: assist x 2; mechanical lift. Further review revealed the resident profile and the care plan matched. Record review for R30 revealed the current care plan and profile care guide was last reviewed on 11/27/2024, updated on bed mobility with assist x 1, with a start date of 10/23/2024; and transfers with assist x 2; mechanical lift. Further review revealed the resident profile and the care plan matched. In interviews with CRCA3 on 12/18/2024 at 8:49 AM; CRCA13 on 12/17/2024 at 3:35 PM; and CRCA16 on 12/17/2024 at 3:27 PM, they stated they knew how to look at the profile care guide to verify the level of assist needed for residents and verbally described how they would always ensure they rolled the resident toward them and never away from them. Review of the letter dated 10/23/2024 revealed the Vice-President of Clinical Operations (VPCO) and the Minimum Data Set Coordinator (MDSC) conducted a one-time audit on 100 percent (%) of the facility's most recent MDS section on functional ability to ensure residents' care plans were appropriate to residents' assist status. The letter was signed by the VPCO and the MDSC. 3. Review of sign-in sheets for mandatory fall education performed by the DHS and ADHS that included fall policy and educations on following the care plan; profiles completed upon admission and following fall; notify DHS/ADHS regardless of injury; if one assist, roll resident toward staff and not away from staff, revealed all active nursing staff employees, licensed nurses and CRCAs, completed the education. Review of the provided employee list to check for education revealed 47 out of 47 active nursing staff employees received the previously listed fall education as of 10/24/2024. In an interview with the Executive Director on 12/17/2024 at 4:08 PM, she stated, on the provided employee list, the names that had a slash mark through them on the sign-off sheet were employees that were no longer employed at the facility. Review of the Audit Tool, dated October 2024, revealed the DHS, ADHS, Staff Development Coordinator (SDC), and/or Clinical support would observe a total of three staff members completing bed mobility. Further review revealed audits were performed on 10/24/2024 and 10/31/2024. Review of the Audit Tool, dated November 2024, revealed audits were performed on 11/07/2024, 11/14/2024, 11/21/2024 (2 staff members observed), and 11/28/2024 (2 staff members observed). Review of the Audit Tool, dated December 2024, revealed audits were performed on 12/5/2024 (2 staff members observed) and 12/12/2024 (2 staff members observed). The audit results indicated that all observed clinical staff members had no problems identified with providing correct bed mobility to residents. 4. Review of the meeting minutes of the Ad Hoc QAPI meeting on 10/14/2024 included the initiation of education, provided by the DHS and ADHS to all health center nursing staff on following the care plans, completing resident profiles upon admission and following resident profiles and a schedule of systemic monitoring for the assurance of retraining and education. The QAPI meeting on 11/05/2024 included the Executive Director (ED), DHS, Business Office Manager (BOM), MDS, Director of Social Services (DSS), Corporate Clinical Support (CCS), Pharmacist, Medical Director, and Nurse Practitioner and revealed the total falls, falls with major injury, trend versus target fall rate for 90 days prior, as well as root causes were reviewed. The QAPI meeting on 12/12/2024 included the ED, DHS, ADHS, MDS, DSS, CCS, Pharmacist, Medical Director, and Nurse Practitioner, and revealed a discussion of the investigation of R20's root cause of her fall; measures put in place to make her a two-person assist; notification to the DHS/ADHS for all falls, with or without injury; education, care plan, resident profile on admission; systemic monitoring; audit reviews; and falls tracking. In an interview with the Executive Director, DHS, MDS, BOM, and DSS on 12/18/2024 from 12:12 PM to 12:30 PM, they all stated they attended QAPI meetings, and they discussed R20's fall, the root cause, and staff would utilize a two person assist with R20 in bed mobility; the education of CRCA5 and all nursing staff on how to assist residents with bed mobility so that residents would roll toward the staff; audits would be done per schedule observing staff providing care with resident bed mobility, and these audits would be and were reviewed in the meetings.

Based on observation, interview, and review of the facility's policy, the facility failed to store and safely serve food. Observations on [DATE] at 9:49 AM and 11:12 AM revealed a case of bananas was left sitting directly on the floor, and staff continued to walk around the case. Observation on [DATE] at 2:30 PM revealed the medication room on the 200 Hall had one expired open case of TwoCal supplements with a use-by-date of [DATE]. The findings include: Review of the facility's Serve Safe policy titled, Food Storage, dated [DATE], revealed the best practice was to store food in designated clean food storage areas, away from walls, and at least six inches off the floor. Per the policy, food was to be stored away from dust and other possible contaminants. 1. Observation on [DATE] at 9:49 AM, during the initial kitchen tour, revealed a case of bananas on the floor, and staff was observed walking by and around the banana case. Additional observation on [DATE] at 11:12 PM, revealed the banana case remained on the floor, with staff walking by and around the case of bananas. In an interview with the Director of Food Services, Serve Safe Certified, on [DATE] at 10:57 AM, he stated the bananas were moved to the floor and not placed onto the rolling rack. He stated there was a potential for cross-contamination with the banana case on the floor. In an interview with the Director of Health Services (DHS) on [DATE] at 3:00 PM, she stated it was not acceptable to keep the banana case on the floor. In an interview with the Executive Director on [DATE] at 3:07 PM, she stated the bananas should be elevated off the floor. 30898 2. Observation on [DATE] at 2:30 PM of the 200 Hall medication storage room with Registered Nurse (RN) 2 revealed one opened case of TwoCal nutritional supplement. The case had a use by date of [DATE]. In interview on [DATE] at 2:30 PM, RN1 stated the open case with a use by date of [DATE] should not be used. She stated she was unaware of who was responsible for going through the supplements to ensure none were used past its use by date. However, she stated it was not the nurses. In interview on [DATE] at 3:15 PM, the Assistant Director of Health Services (ADHS) stated the nurses placed the stock in the medication storage rooms and were responsible to rotate the stock to ensure items did not expire. She stated she or the DHS periodically checked the stock in the medication room, and if they found expired items they would remove the items and educate staff. The ADHS stated she could not recall when she last audited for expired items in the medication rooms. She further stated the facility removed expired supplements so they were not used for residents. She also stated the facility did not want to use expired nutritional supplements as they would no longer be good to use, and no one liked anything expired. In interview on [DATE] at 4:20 PM, the DHS stated the nurses had their supplies in the medication room and conducted random checks for expiration dates. She stated she and the ADHS checked the medication rooms and got rid of anything they saw expired. The DHS also stated the medication rooms were audited the previous week, although she could not remember who conducted that audit. The DHS further stated the audit results were communicated verbally, and nothing was reported out of date. She further stated several nurses go into the medication rooms, and no one reported anything expired. In interview on [DATE] at 1:03 PM with the Executive Director, she stated her expectation was for all nutritional supplements to be used within their expiration dates, and if it was expired it should be removed by the person who identified it was expired. She stated if the supplement was needed immediately it could have been obtained by a new order or borrowing from a sister facility and would be received the same day. She stated checking expiration dates on supplements was very important for resident safety due to the supplements being consumed, and the facility would not want a resident to consume any expired supplements.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to have an effective system in place to implement infection control practices for 2 of 20 sampled and supplemental residents, Resident (R) 1 and R19 and 1 of 2 medication room refrigerators on the 300 Hall. Observations during the survey revealed 1) a nurse touched a resident's medication with bare hands; 2) there was not enhanced barrier precautions signage or a personal protective equipment (PPE) cart at Resident (R) 1's room; 3) R1's gastrostomy (g-tube) dressing change was completed by the nurse without enhanced barrier precautions (EBP) used; and 4) the 300 Hall medication room nutritional refrigerator had flu vaccine stored on the same shelf with nutritional supplements and yogurt. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program (IPCP), reviewed 12/31/2023, revealed the infection control program was designed to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections, following accepted national standards. Review of the facility's policy titled, Enhanced Barrier Precautions Standard Operating Procedure, dated 04/01/2024, revealed EBP would be in place during high-contact care activities for all residents with indwelling medical devices, which included feeding tubes. Per the polcy, PPE should be used even if blood and body fluid exposure was not anticipated. The policy revealed, at a minimum, staff should wear gloves and gowns during high-contact care activities. Review of the facility's Enhanced Barrier Precautions signage, from the United States (U.S.) Department of Health and Human Services CDC and posted at resident doorways, revealed providers and staff must wear a gown for high-contact resident care activities. Those activities included device care or use of a feeding tube and wound care of any skin opening requiring a dressing. 1. Review of Resident (R) 1's Face Sheet revealed the facility admitted the resident on 12/01/2015 and readmitted the resident on 04/15/2022. The resident's diagnoses included paralytic syndrome, dysphagia, and gastrostomy (feeding tube). Review of R1's Physician Orders, revealed an order for EBP, wearing a gown and gloves at a minimum during high-contact care activities, dated 07/29/2024. a. Observation of R1 on 11/24/2024 at 9:27 AM, 11/24/2024 at 11:26 AM, 11/25/2024 at 8:20 AM, 11/25/2024 at 8:49 AM, 11/25/2024 at 11:17 AM, 11/26/2024 at 10:57 AM, 11/26/2024 at 12:41 PM, 11/26/2024 at 2:58 PM, and 11/26/2024 at 4:17 PM, revealed the resident's room did not have signage posted for EBPs or a PPE cart at or in the resident's room. b. Observation on 11/26/2024 at 2:58 PM revealed Licensed Practical Nurse (LPN) 1 changed R1's feeding tube site dressing with the assistance of Certified Resident Care Assistant (CRCA) 6. While LPN1 performed the dressing change, CRCA6 assisted to position the resident and held the resident's left hand during the dressing change. Neither staff wore a gown during the change. In interview on 11/26/2024 at 3:18 PM, CRCA6 stated he was unsure if R1 needed EBP. He stated when a resident was in EBP there was a sign and cart outside the room. He stated he was not sure who was responsible to place the signs or carts, however he knew it was not the CRCAs. In interview on 11/26/2024 at 3:25 PM, LPN1 stated EBPs were required for the type of dressing change with bacteria in the wound. She stated she was not informed R1 was placed in EBP. She stated the EBP was to prevent spreading anything to others or to introduce bacteria to them. In interview on 11/27/2024 at 3:15 PM, the Assistant Director of Health Services (ADHS) stated she and the Director of Health Services (DHS) shared the duties as the facility's Infection Preventionist (IP). She stated the EBP signs stated what PPE was needed to wear and when. The ADHS also stated the nurses were responsible to place the EBP signs as she or the DHS might not be in the facility when the resident first came to the facility or needed the EBP. She stated without the sign, there was a risk to enter the resident's room and spread infection. She further stated if the resident was already in the facility, the nurse would receive the results that showed the need for EBP, and it would need implementing immediately. The ADHS stated the nurses were responsible to post the EBP signs and get the isolation cart prepared with supplies specific to the type of precaution the resident was in. The ADHS stated she was shocked R1 did not have the EBP sign or PPE cart as she personally placed those at his room. She also stated she completed weekly wound rounds, although she did not provide wound care to R1's feeding tube site in the last few weeks. She stated the purpose of the EBP was for resident safety and to prevent cross contamination from resident to resident. In interview on 11/27/2024 at 4:20 PM, the DHS stated she and the ADHS shared the responsibilities of the IP for the facility. She stated the nurses were responsible to place a resident in isolation precautions. She stated the nurses were responsible to place the precautions signage on the door and place the required PPE in the cart. The DHS also stated the morning clinical meeting conducted audits to look for everything to be in place. She stated EBPs were required only when working with what the precautions were related to. She stated the precautions cart should be in the resident's room, and there should be a sign on the resident's door or on top of the PPE cart. She further stated she did not notice R1 did not have the EBP sign or PPE cart. She stated he was in the EBP for the feeding tube, which had feedings, medications, and dressing changes. She also stated she placed the EBP sign on his door and placed the PPE cart inside his room yesterday (11/26/2024). She stated the purpose of the precautions was to reduce the spread of infection. 2. Observation on 11/26/2024 at 8:19 AM of Registered Nurse (RN) 4 during medication administration revealed the RN prepared a medication for R19. Observation revealed RN4 removed the medication from the pill pack with her bare hand and placed the medication in a medication cup. The nurse then put the medication package in the med cart drawer and was ready to administer the medication before the State Survey Agency (SSA) Surveyor stopped the RN. In interview on 11/26/2024 at 8:19 AM, RN4 stated she just sanitized her hands before preparing the medication. She stated it was possible for her hands to have something microscopic on them. She stated she was trained in orientation regarding medication administration with return demonstration. The nurse stated she should not give the medication to the resident as the resident could get germs from her. In continued interview on 11/27/2024 at 3:15 PM with the ADHS, she stated the nurse should wear gloves during medication administration and should not give the medication with bare hands. She stated she personally had not conducted any audits of medication administration and was unaware if the DHS completed those audits. She also stated nurses were trained on how to administer medications with return demonstration. The ADHS further stated the facility had not identified anyone handling medication pills with bare hands. She stated the purpose of not touching medication with bare hands was to prevent contamination. In continued interview on 11/27/2024 at 4:20 PM with the DHS, she stated although the nurses were not required to wear gloves to remove the pills from the packaging, they should pop the pills into a cup or tear the package and empty the medication into a cup, without touching the medication. She stated the medication should not be touched with bare hands to prevent the spread of germs. She stated she sporadically audited and watched administration and had not identified anyone removing medications with bare hands. She stated the medication touched by the nurse should be thrown away and not given. The DHS also stated medication administration education was provided annually. 3. Observation of the 300 Hall medication storage room on 11/27/2024 at 2:05 PM with RN7 revealed the medication room had a small medication refrigerator and a large nutritional refrigerator. Observation revealed a shelf on the large refrigerator door contained three cartons of Med Pass (a nutritional supplement), four bottles of Glucerna (a nutritional supplement), two yogurt containers, and three open boxes of flu vaccine, all on the same shelf together. In interview on 11/27/2024 at 2:05 PM, RN7 stated the flu vaccine should not be stored with the nutritional supplements and yogurt. She stated the flu vaccine was like a medication, and there was a potential for cross contamination to the other items on the shelf. In interview on 11/27/2024 at 2:30 PM, RN2 stated medications should not be mixed with food products in the refrigerator. She stated the refrigerator was opened a lot and could affect the temperature. She also stated she was not sure who was responsible for checking the refrigerators for medications mixed with food items. In continued interview on 11/27/2024 at 3:15 PM, the ADHS stated the flu vaccine should be stored in the medication rooms. She stated pharmacy checked the medication rooms, in addition to the facility's checks of the medication rooms. The ADHS stated the flu vaccine was stored in the large refrigerator, as it had more space for storage. She stated if the flu vaccine was stored on the same shelf as nutritional supplements and if the medication was opened, it could come into contact and contaminate the supplements. She stated she periodically checked the refrigerators and had not found any issues. In continued interview on 11/27/2024 at 4:20 PM, the DHS stated the large refrigerators in the medication rooms stored the nutritional supplements and the flu vaccines. She stated the facility had too many vaccines to store in the medication refrigerators. She stated she did not see an issue with storing the flu vaccine on the same shelf as the supplements; however, if there was cross contamination the facility would throw away what was contaminated. She stated it was possible the items could become damaged and leak. In interview on 12/17/2024 at 1:03 PM with the Executive Director, she stated she did not have a clinical background, but the expectation was orally ingested food supplements and injectable medications and biologicals should not be stored together due to the risk of cross contamination. She stated the expectation was for all employees to follow the facility's policies and procedures pertaining to Infection Prevention and Control which were based on the CDC guidelines. She stated all staff received annual education on Infection Prevention that included the use of proper PPE and hand hygiene.

Based on observation, interview, record review, review of the facility's Hospice Services Agreement, and review of the facility's policy, the facility failed to implement a comprehensive person-centered care plan for 1 of 3 residents sampled for Hospice care, Resident (R) 30. The findings include: Review of the facility's policy titled, Comprehensive Care Plan Guideline, dated 05/22/2018, revealed the facility would ensure appropriateness of services and communication that would meet the resident's needs, severity/stability of condition, impairment, disability, or disease in accordance with state and federal guidelines. Review of the facility's Hospice Services Agreement, dated 05/09/2019, revealed the services provided by the facility as specified in the Plan of Care for a Hospice Patient included, but were not limited to providing food, including individualized request and dietary supplements; and assisting with activities of daily living (ADL) such as mobility and ambulation, dressing, grooming, bathing, transferring, eating, and toileting. Review of R30's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 08/20/2024 with diagnoses including senile degeneration of brain, unspecified dementia, and anxiety. Review of R30's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 08/26/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status [BIMS] score of 10 out of 15, which indicated moderate cognition impairment. Further review revealed R30's functional ability was dependent for: shower, bath, upper/lower body dressing, personal hygiene, rolling side-to-side, and eating. The definition of dependent was the helper does ALL of the effort; the resident does none of the effort to complete the activity. Review of R30's Comprehensive Care Plan [CCP], dated 08/27/2024, revealed a focus of requiring assistance with partial bathing twice weekly, daily oral care, repositioning twice in the night, and assistance with restorative dining. The interventions included repositioning twice during night shift, providing extensive assistance with dining, and aid with self-care including bathing and oral care. R30's CCP did not indicate there was a problem with the resident refusing assistance with ADLs, repositioning, or restorative dining with meals. Observation on 11/24/2024 at 10:32 AM revealed R30's full breakfast tray sitting on the bedside table due to the resident not being able to feed herself and needing restorative dining services to help her to receive her daily nutritional meals. Observation on 11/25/2024 at 3:15 PM revealed R30 had not had a bath and was wearing the same clothing as seen on 11/24/2024. In an interview with R30 on 11/25/2024 at 9:10 AM, she stated she did not receive a partial bath or oral care on 11/24/2024. R30 stated staff did not reposition her at all on night shift. In an interview with R30's son, Family (F) 1 on 11/24/2024 at 11:15 AM, he stated the facility had not been providing R30 with bathing, oral care, repositioning on night shift, or staff assistance with restorative dining. F1 stated on last Thursday, 11/21/2024 at 9:00 AM, he hung R30 a clean shirt out for the aide to bathe her and change R30's clothes. F1 stated when he returned the next day on 11/22/2024 at 8:30 AM, R30 was not bathed and was still wearing the same dirty clothes from the previous day. In an interview with Social Services Hospice on 11/27/2024 at 4:15 PM, she stated the facility had not been providing bathing, oral care, or restorative dining to R30. The Social Services Hospice stated she visited the facility three times a week, and R30 had not been bathed or had oral care at all in the current month of November. The Social Services Hospice stated R30 had told her many times she had not eaten at different mealtimes due to not receiving staff assistance of at least one person. In an interview with the Director of Health Services (DHS) on 11/28/2024 at 2:30 PM, she stated staff did not follow R30's CCP because there were not always enough staff members to attend to all the residents who required a one person assist. The DHS stated she was not aware R30 refused assistance with bath, oral care, repositioning, or restorative dining. In an interview with the Executive Director on 11/28/2024 at 4:57 PM, she stated her expectation for staff following care plans for residents in the facility was to always receive the highest level of care. She stated the facility did not have enough staff to assist with residents who required one-on-one assistance. However, she stated she would be investigating why R30 did not receive bathing, repositioning, oral care, or restorative dining.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide the assistance of one at mealtime, partial bathing assistance, and oral care for 1 of 3 residents sampled for Hospice care, Resident 30 (R30). During an observation of meal service on 11/24/2024, the facility failed to assist R30 with restorative dining services. In addition, R30 did not receive bathing assistance or oral care as per R30's Comprehensive Care Plan (CCP). The findings include: Review of the facility's policy titled, Resident Rights Guidelines, dated 05/11/2017, revealed the facility would ensure the resident's rights were respected and protected and provide an environment in which they could be exercised. Review of the facility's policy titled, Comprehensive Care Plan [CCP] Guideline, dated 05/22/2018, revealed the facility would ensure appropriateness of services and communication that would meet the resident's needs, severity/stability of condition, impairment, disability, or disease in accordance with state and federal guidelines. Review of the facility's document Hospice Services Agreement, dated 05/09/2019, revealed the facility was to provide services as specified in the plan of care for a hospice patient including, but not limited to: providing food, including individualized request and dietary supplements; assisting with activities of daily living (ADL), such as mobility and ambulation, dressing, grooming, bathing, transferring, eating, and toileting. Review of R30's Face Sheet revealed the facility admitted the resident on 08/20/2024 with diagnoses that included senile degeneration of the brain, unspecified dementia, and anxiety. Review of R30's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 08/30/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of eight out of 15. This score indicated moderate cognitive impairment. Review of R30's CCP, dated 08/27/2024, revealed a focus that the resident required assistance with partial bathing twice weekly, daily oral care, and restorative dining. The interventions included to provide extensive assistance with dining, and to aid with self-care, including bathing and oral care. Observation on 11/24/2024 at 10:32 AM revealed R30's full breakfast tray was sitting on the bedside table. According to the CCP, R30 required restorative dining services to assist in eating meals. Observation on 11/25/2024 at 3:15 PM revealed R30 had not had a bath and was wearing the same clothing as she was observed wearing on 11/24/2024. In an interview on 11/25/2024 at 9:10 AM, R30 stated she did not receive a partial bath or oral care on 11/24/2024. In an interview on 11/24/2024 at 11:15 AM with Family Member (F) 1, he stated the facility had not been providing R30 with bathing, oral care, or restorative dining. F1 stated on 11/21/2024 at 9:00 AM, he hung a clean shirt out for R30 so the aide could bathe her and change the resident's clothes. F1 stated when he returned the next day on 11/22/2024 at 8:30 AM, R30 was not bathed and was still wearing the same dirty clothes from the previous day. He stated the family had a scheduled meeting with the Director of Health Services (DHS), Assistant Director of Health Services (ADHS), and the Social Services Director (SSD) on 11/27/2024 at 3:00 PM to discuss the issue. F1 requested the State Survey Agency (SSA) Surveyor be in attendance. Observation of the family conference on 11/27/2024 at 3:00 PM with R30's family, the DHS, the ADHS, the SSD, the SSA Surveyor, and the Federal Surveyor in attendance, revealed the family expressed they were not satisfied with the level of care provided to the resident. F1 stated the facility had failed to keep R30 free from moisture, had not provided fresh water at her bedside, and had not met her needs with bathing, repositioning, oral care, and restorative dining. During the family conference, the facility's staff in attendance took responsibility for failing to provide the standard of care for R30. F1, the DHS, the ADHS, and the SSD all agreed to meet via Zoom on Tuesdays, beginning 12/03/2024 at 1:00 PM, to discuss how the care for R30 was from the prior week. In an interview on 11/27/2024 at 4:37 PM, Hospice State Registered Nurse Aide (SRNA) 1 stated she provided bathing, oral care, and restorative dining to R30 when she was at the facility on Mondays, Wednesdays, and Fridays. SRNA1 stated there had been many times she had arrived at the facility and R30 had not received a bath or oral care, and her food was sitting on her bedside table, and it was cold. In an interview on 11/27/2024 at 4:15 PM, Social Services Hospice stated the facility had not been providing bathing, oral care, or restorative dining to R30. She stated she visited the facility three times a week, and R30 had not been bathed or had not received oral care during the month of November 2024. She stated R30's family had communicated with the facility's SSD on numerous occasions, and there had been no improvement in providing R30 with partial bathing, oral care, or restorative dining. The Social Services Hospice stated R30 had told her many times that she had not eaten at different meals because she had not been provided assistance. In an interview on 11/28/2024 at 2:30 PM, the DHS stated she was upset knowing R30 had not been receiving self-care and restorative dining. She stated she knew that R30 was not receiving self-care. She stated the lack of restorative dining services was a huge failure on the facility's behalf with staff not being able to attend to all the residents who required assistance. In an interview on 11/28/2024 at 4:57 PM, the Executive Director stated her expectation was for residents in the facility to always receive the highest level of care. She stated she was unsure where the ball was dropped with the care for R30. However, she stated she would be investigating why the resident did not receive bathing, oral care, or restorative dining. The Executive Director stated residents not receiving the proper care or services was not the facility's standard of practice.

Based on observation, interview, review of the facility's handout, review of the facility's policies, and review of the Centers for Disease Control and Prevention, Healthcare Providers Clean Hands Count for Healthcare Providers, 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 to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observations, in different areas of the facility, revealed undated oxygen tubing for three (3) residents; incorrect and the absence of wearing appropriate personal protective equipment (PPE); a contaminated rapid COVID-19 test resting on a clean surface; and the absence of hand hygiene when it was required. The findings include: Review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers, last reviewed 01/08/2021, revealed hand hygiene reduced the spread of potentially deadly germs to patients. 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; when hands were visibly soiled; after contact with blood, body fluids, or contaminated surfaces; and immediately after glove removal. Review of the facility's policy titled, Guidelines for Administration of Oxygen, revised 05/2018, revealed oxygen tubing must be dated for the date it was initiated. Additionally, oxygen tubing must be changed monthly and as needed (PRN). Review of the facility's policy titled, Infection Prevention and Control General Guidelines, revised 07/13/2020, revealed the purpose of the policy was to provide guidelines to prevent the spread of infection from one person to another. Review of the facility's policy titled, Standard Precautions Guidelines, revised 05/11/2016, revealed the purpose of the policy was to prevent the transmission of infectious organisms by the use of standard precautions. Further review of the policy revealed standard precautions would be used when caring for residents at all times regardless of their suspected or confirmed infection status. In addition to standard precautions, the policy stated staff would wear appropriate personal protective equipment (PPE) as a barrier to exposure. Review of the facility's policy titled, Guidelines for Droplet Precautions, revised 03/09/2020, revealed the purpose of the policy was to provide precautions when indicated for residents infected with diseases or microorganisms transmitted by droplets. Further review of the policy revealed droplet precautions would be used when caring for residents having confirmed or suspected COVID-19. In addition to standard precautions, the policy stated a mask should be worn within six (6) feet of the confirmed or suspected COVID-19 resident. Isolation precautions would remain in effect until discontinuation by the attending physician or when predetermined criteria had been met. Review of the facility's policy titled, Guidelines for COVID-19, revised 06/11/2021, revealed the facility should take steps to ensure all residents adhered to instructions for use of facemasks. Review of the facility's policy titled, Guidelines for Handwashing/Hand Hygiene, revision date 03/12/2020, revealed hand washing was the most important factor in preventing transmission of infections. Per the policy, all health care workers would utilize hand hygiene frequently and appropriately. Further review of the policy revealed health care workers would use hand hygiene after contact with excretions or secretions, [MEDICATION(S)] membranes, or specimens. Review of the facility's policy titled, COVID-19 Visitation Policy, revealed all visitors must comply with the core principals of infection control, including wearing a face mask. Per the policy, any visitor failing to meet any requirement of the COVID-19 Visitation Policy would be asked to leave the campus. Review of the facility's handout titled, Visit Dos and Don'ts, based on state and local guidelines, revealed visitors were expected to wear a mask over both nose and mouth when visiting residents. 1. Observation of the 200 Hall, on 07/27/2021 at approximately 2:30 PM, revealed oxygen tubing was not dated for three (3) residents receiving oxygen administration. Interview with Licensed Practical Nurse (LPN) #2, on 07/28/2021 at 3:20 PM, revealed she believed oxygen tubing was changed every Sunday night. She stated oxygen tubing was to be dated with the date it was changed. She stated it was important to date tubing so nurses knew when the tubing was last changed and as an infection prevention measure. Interview with the Minimum Data Set Coordinator (MDS)/Registered Nurse (RN) #2, on 07/28/2021 at 2:30 PM, revealed oxygen tubing was changed by the night shift nurses every Sunday night. She stated, per policy, oxygen tubing was to be dated with the date it was changed. She stated it was important to date tubing so nurses knew when the tubing was last changed and to control the spread of infection. Interview with the Assistant Director of Health Services (ADHS), on 07/28/2021 at 2:50 PM, revealed oxygen tubing was changed weekly on Sunday nights. Per policy, oxygen tubing was to be dated with the date it was changed. She stated changing oxygen tubing and dating it at the time it was changed was an important step to prevent the spread of disease. Interview with the Director of Health Services/Infection Preventionist (DHS/IP), on 07/28/2021 at 3:30 PM, revealed oxygen tubing was changed weekly on Sunday nights. Per policy, oxygen tubing was to be dated with the date it was changed. She stated this was important for infection prevention and control (IPC). 2. Observation of the 300 Hall, on 07/28/2021 at 11:45 AM, revealed RN #1 sitting at the nurses' station with her mask below the chin. The nurse was not eating, drinking, or on the phone at the time of observation. When RN #1 saw the State Survey Agency (SSA) Surveyor, she placed the mask appropriately over her chin and nose. Interview with RN #1, on 07/28/2021 at 11:50 AM, revealed she had been hired recently as a staff RN, this being her first day working on the floor. She stated she had completed her facility orientation prior to being scheduled on the floor and was, at the time of the interview, completing training and education modules. She stated she received infection prevention training upon hire, which included the use of PPE. RN #1 stated she was not aware that her mask was below her chin. She stated that per policy, masks were to be worn in the facility at all times. She stated wearing PPE appropriately was important for IPC. Interview with LPN #2, on 07/28/2021 at 3:20 PM, revealed per policy, masks were to be worn in the facility at all times. LPN #2 stated she received IPC training upon hire and had continued training through in-services and mandatory education modules related to IPC. She stated wearing PPE appropriately was important to prevent the spread of COVID-19. Interview with the Assistant Director of Health Services (ADHS), on 07/28/2021 at 2:50 PM, revealed every employee received infection prevention and control (IPC) training upon hire and were given continued training through in-services, daily huddles, and mandatory education modules related to IPC through the education portal. She stated wearing PPE appropriately was important to prevent the spread of COVID-19 and for resident safety. Interview with the Director of Health Services (DHS), on 07/28/2021 at 3:30 PM, revealed every employee had been trained regarding IPC and personal protective equipment (PPE). The DHS stated all employees received IPC and PPE training upon hire, through continuing education modules and in-services, and during daily huddles. She stated wearing PPE appropriately was important to prevent the spread of COVID-19 and other infectious diseases. 3. Additional observation of the 300 Hall nurses' station, on 07/28/2021 at 11:50 AM, revealed a contaminated COVID-19 rapid test sitting on a bedside table located in front of the nurses' station desk. LPN #1 picked up the contaminated COVID-19 rapid test off the table, without gloves, and proceeded to place it on a stack of papers, near a computer on the nurses' station desk. The nurse did not perform hand hygiene after handling the test. Interview with LPN #1, on 07/28/2021 at 11:56 AM, revealed that the contaminated test was her COVID-19 self-test. She stated she was waiting for the results of her self-test, done moments prior to the SSA Surveyor observation. Per the interview, it was facility procedure for employees to perform self-tests for COVID-19; however, staff was to test in a designated area and not in resident care areas. She stated there was a room dedicated to COVID-19 testing, which was monitored by the ADHS. Further interview revealed that employees were to report for COVID-19 testing on scheduled days, after they clocked in. LPN #1 stated she did not self-test when she clocked-in for work, and was testing now. When questioned if the test was considered contaminated, she replied, Well, it's my test. She stated that all test results must be verified before two (2) nurses. LPN #1 stated she received IPC training upon hire and throughout the year, with COVID-19 in-services provided by the ADHS and DHS. Furthermore, she stated she was trained to perform COVID-19 self-testing. Interview with Kentucky Medication Aide/Certified Resident Care Associate (KMA/CRCA) #2, on 07/28/2021 at 1:45 PM, revealed staff was trained to perform COVID-19 self-testing. She stated there was a dedicated room facilitated by the ADHS where staff was required to perform testing. Per the interview, KMA/CRCA #2 stated staff was trained to perform hand hygiene and wear gloves when performing their self-tests. Furthermore, she stated contaminated tests were placed on a paper towel, and the area was wiped with a Sani-cloth when the testing was completed. Further interview revealed that employees were to report for COVID-19 testing on scheduled days, after they clocked in. KMA/CRCA #2 stated she received IPC training upon hire and received IPC updates, specific to COVID-19, through in-service training. Interview with CRCA #3, on 07/28/2021 at 2:15 PM, revealed staff was required to perform COVID-19 self-testing in a dedicated room facilitated by the ADHS. Per the interview, CRCA #3 stated staff was trained to perform hand hygiene and wear gloves when performing their self-tests. Furthermore, she stated contaminated tests were placed on a paper towel, and environmental surfaces were wiped with a Sani-cloth when the testing was completed. Per the interview, contaminated tests were disposed of in a designated contaminated trash receptacle. Further interview revealed that employees were to report for COVID-19 testing on scheduled days, after they clocked in. CRCA #3 stated she received IPC training upon hire and IPC updates, specific to COVID-19, through in-service training. Interview with RN #2, on 07/28/2021 at 2:15 PM, revealed she received IPC training upon hire, and had received continued training through in-services, daily huddles, and mandatory education modules related to IPC through the education portal. Per the interview, RN #2 stated staff self-tested for COVID-19. RN #2 stated staff should clock-in and go to a designated COVID-19 testing room. RN #2 stated the room was equipped with testing supplies, PPE, and supplies for hand hygiene and for cleaning contaminated surfaces. According to RN #2, staff was required to follow IPC protocols, which included wearing gloves when handling contaminated test cards and following proper hand hygiene practices. Interview with the ADHS, on 07/28/2021 at 2:50 PM, revealed every employee received IPC training upon hire and were given continued training through in-services, daily huddles, and mandatory education modules related to IPC through the education portal. Per the interview, the ADHS stated staff self-tested with result verification by witnesses. The ADHS stated COVID-19 tests should be performed in the designated room, which was set up for employees to test. She stated she monitored the room and employee COVID-19 testing. She stated the room was equipped with testing supplies, PPE, and supplies for hand hygiene and for cleaning contaminated surfaces. She stated staff was trained to perform a COVID-19 self-test. Per the interview, she stated, if an employee did not want to self-test, she would perform the test on the employee. The ADHS stated that employees must wear gloves while performing a self-test. Additionally, staff was required to follow Standard Precautions for IPC, she reported, which included wearing gloves when handling contaminated test cards and following proper hand hygiene practices. Per the interview, the ADHS stated staff should not self-test in resident care areas. Interview with the DHS/IP, on 07/28/2021 at 3:30 PM, revealed all employees received IPC training upon hire and were given continued training through in-services. Per the interview, the DHS stated staff self-tested with witness verification. The DHS stated employee COVID-19 self-tests should be performed in the designated room, located on the second floor. The DHS stated the room was equipped with testing supplies, PPE, and supplies for hand hygiene and for cleaning contaminated surfaces. She stated staff was trained to perform a COVID-19 self-test. She stated that as the IP, she trained the trainer regarding self-testing protocols. further, she stated employees must wear gloves while performing a self-test. Additionally, she stated staff was required to follow Standard Precautions for IPC, which included wearing gloves when handling contaminated test cards and following proper hand hygiene practices. Per the interview, the DHS/IP revealed staff should not self-test in resident care areas. 4. Observation on the 300 Hall, on 07/28/2021 at 11:25 PM, revealed a visitor Resident #4's isolation room was not wearing a mask, gown, or gloves as required for the resident's Contact/Droplet Transmission-Based Precaution (TBP) status. LPN #2 was performing patient care and wearing the required PPE. The SSA Surveyor did not observe LPN #2 request to the family member to don appropriate PPE. Interview with KMA/CRCA #2, on 07/28/2021 at 1:45 PM, revealed visitors were required to wear appropriate PPE when visiting residents. She stated visitors received a handout titled, Visit Dos and Don'ts, based on state and local guidelines. She stated if a visitor was observed not adhering to facility policy regarding PPE, the visitor was educated. Interview with the ADHS, on 07/28/2021 at 2:50 PM, revealed it was the facility's policy that all visitors must comply with the core principles of infection control, including wearing a face mask. If a visitor did not comply with facility policy, she stated, the visitor was educated. It was the ADHS's expectation that all visitors follow the facility's handout, Visit Dos and Don'ts, based on state and local guidelines. She stated it important for the safety of residents, staff, and visitors. Interview with DHS/IP, on 07/28/2021 at 3:30 PM, revealed it was the facility's policy that all visitors must comply with the core principles of infection control, including wearing a face. Per the interview, the DHS/IP stated the facility requested that family and visitors use PPE appropriately. If a visitor had not complied with facility policy, the visitor was educated. Per the interview, Resident #4's family did not wear PPE while visiting, regardless of multiple efforts by staff to educate regarding IPC. When questioned about visitor non-compliance, the DHS/IP stated, visitors should wear appropriate PPE, but the facility could not force them, so they rely on education as needed. She stated further, We can't kick them out because they don't. The DHS/IP stated she expected all visitors to follow the facility's handout, Visit Dos and Don'ts, based on state and local guidelines. She stated this was important for the safety of residents, staff, and visitors. Interview with the Administrator, on 07/28/2021 at 3:56 PM, revealed it was the Administrator's expectation that all staff follow the facility's IPC policies. It was also the expectation of the Administrator that visitors were respectful and adhere to the rules detailed in the Visit Dos and Don'ts, handout. Furthermore, she stated she expected staff to educate any visitor not adhering to facility protocols to ensure the health and safety of everyone.

Based on observation, interviews, review of the facility's policies, review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers, review of the CDC's website on COVID-19 Self Testing, and review of the BinaxNOW Covid-19 Ag Card Instructions, it was determined the facility failed to conduct COVID-19 testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests. Observation at the 300 Hall nurses' station, on 07/28/2021 at 11:50 AM, revealed a contaminated COVID-19 rapid test sitting on a bedside table located in front of the nurses' station desk. A nurse picked up the contaminated COVID-19 rapid test off the table without wearing the appropriate PPE, such as gloves, and proceeded to place the contaminated specimen on a stack of papers, near a computer, on the nurses' station desk. The nurse did not perform hand hygiene after handling the contaminated test specimen. The findings include: Review of the facility's policy titled, Standard Precautions Guidelines, revised 05/11/2016, revealed the purpose of the policy was to prevent the transmission of infectious organisms by use of standard precautions. Further review of the policy revealed standard precautions would be used when caring for residents at all times regardless of their suspected or confirmed infection status. In addition to standard precautions, the policy stated staff would wear appropriate personal protective equipment (PPE) as a barrier to exposure. Review of the facility's policy titled, Guidelines for Handwashing/Hand Hygiene, revision date 03/12/2020, revealed hand washing was the most important factor in preventing transmission of infections. Per the policy, all health care workers would utilize hand hygiene frequently and appropriately. Further review of the policy revealed health care workers would use hand hygiene after contact with excretions or secretions, [MEDICATION(S)] membranes, or specimens. Review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers, last reviewed 01/08/2021, revealed hand hygiene reduced the spread of potentially deadly germs to patients. 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; when hands were visibly soiled; after contact with blood, body fluids, or contaminated surfaces; and immediately after glove removal. Review of the BinaxNOW Covid-19 Ag Card Instructions, revised 12/2020, for specimen collection and handling of test specimens revealed appropriate personal protection equipment (PPE), including gloves were to be worn when running each test and handling specimens to reduce the risk of biohazard exposure, which included: 1) treat specimens as well as used test kit components as potentially biohazardous materials; and, 2) wash hands thoroughly after handling. Review of the CDC's website (https://www.cdc.gov/coronavirus/2019-ncov/testing/self-testing) on COVID-19 Self Testing, last updated 08/02/2021, revealed, All instructions for performing the test must be followed. Furthermore, those who self-test should read the complete manufacturer's instructions before using the test. Instruction included that users should follow proper infection prevention and control (IPC) protocols, handle test kits appropriately, clean all surfaces that the specimen could have touched, and wash hands. Observation of the 300 Hall nurses' station, on 07/28/2021 at 11:50 AM, revealed a contaminated COVID-19 rapid test sitting on a bedside table located in front of the nurses' station desk. Licensed Practical Nurse (LPN) #1 picked up the contaminated COVID-19 rapid test off the table, without gloves, and proceeded to place it on a stack of papers, near a computer on the nurses' station desk. The nurse did not perform hand hygiene after handling the test. Interview with LPN #1, on 07/28/2021 at 11:56 AM, revealed that the contaminated test was her COVID-19 self-test. She stated that employees performed self-tests for COVID-19. She stated there was a room dedicated to COVID-19 testing, which was monitored by the ADHS. Further interview revealed employees were to report for COVID-19 testing on scheduled days, after they clocked in. LPN #1 stated she did not self-test when she clocked-in for work, and was testing now. When questioned if the test was considered contaminated, she replied, Well, it's my test. She stated that all test results must be verified before two (2) nurses. LPN #1 stated she received IPC training upon hire and throughout the year. She stated she received IPC regarding COVID-19 through in-services provided by the ADHS and DHS. Furthermore, she stated she was trained to perform COVID-19 self-testing. Interview with Kentucky Medication Aide/Certified Resident Care Associate (KMA/CRCA) #2, on 07/28/2021 at 1:45 PM, revealed staff was trained to perform COVID-19 self-testing. She stated there was a dedicated room facilitated by the ADHS where staff was required to perform testing. Per the interview, KMA/CRCA #2 stated staff was trained to perform hand hygiene and wear gloves when performing their self-test. Furthermore, she reported contaminated tests were placed on a paper towel, and the area was wiped with a Sani-cloth when the testing was completed. Further interview revealed employees were to report for COVID-19 testing on scheduled days, after they clocked in. KMA/CRCA #2 stated she received IPC training upon hire and received IPC updates, specific to COVID-19, through in-service training. Interview with CRCA #3, on 07/28/2021 at 2:15 PM, revealed staff was required to perform COVID-19 self-testing in a dedicated room facilitated by the ADHS. Per the interview, CRCA #3 stated staff was trained to perform hand hygiene and wear gloves when performing their self-tests. Furthermore, contaminated tests were placed on a paper towel, and environmental surfaces were wiped with a Sani-cloth when the testing was completed. Per the interview, contaminated tests were disposed of in a designated contaminated trash receptacle. Further interview revealed employees were to report for COVID-19 testing on scheduled days, after they clocked in. CRCA #3 stated she received IPC training upon hire and received IPC updates, specific to COVID-19, through in-service training. Interview with Registered Nurse (RN) #2, on 07/28/2021 at 2:15 PM, revealed she received IPC training upon hire and had received continued training through in-services, daily huddles, and mandatory education modules related to IPC through the education portal. Per the interview, RN #2 stated staff self-tested for COVID-19. Staff, she reported, should clock-in and go to a designated COVID-19 testing room. RN #2 stated the room was equipped with testing supplies, PPE, and supplies for hand hygiene and for cleaning contaminated surfaces. According to RN #2, staff was required to follow IPC protocols, which included wearing gloves when handling contaminated test cards and following proper hand hygiene practices. Interview with the ADHS, on 07/28/2021 at 2:50 PM, revealed every employee received IPC training upon hire and was given continued training through in-services, daily huddles, and mandatory education modules related to IPC through the education portal. Per the interview, the ADHS stated staff self-tested with result verification by witnesses. The ADHS stated the COVID-19 test should be performed in the designated room for employees to test. She stated she monitored the room and employee COVID-19 testing. The room was equipped with testing supplies, PPE, and supplies for hand hygiene and for cleaning contaminated surfaces. She stated staff was trained to perform a COVID-19 self-test. She stated if an employee did not want to self-test, she would perform the test on the employee. Further, she stated employees must wear gloves while performing a self-test. Additionally, staff was required to follow Standard Precautions for IPC, which included wearing gloves when handling contaminated test cards and following proper hand hygiene practices. Per the interview, the ADHS stated staff should not self-test in resident care areas. Interview with the DHS/IP, on 07/28/2021 at 3:30 PM, revealed all employees received IPC training upon hire and were given continued training through in-services. Per the interview, the DHS stated staff self-tested with witness verification. The DHS stated employee COVID-19 self-tests should be performed in the designated room, located on the second floor. The DHS stated the room was equipped with testing supplies, PPE, and supplies for hand hygiene and for cleaning contaminated surfaces. She stated staff was trained to perform a COVID-19 self-test. She stated that as IP, she trained the trainer regarding self-testing protocols. Further, she stated employees must wear gloves while performing a self-test. Additionally, she stated staff was required to follow Standard Precautions for IPC, which included wearing gloves when handling contaminated test cards and following proper hand hygiene practices. Per the interview, the DHS/IP stated staff should not self-test in resident care areas. Interview with the Administrator, on 07/28/2021 at 3:56 PM, revealed she expected all staff to follow the facility's IPC policies. The Administrator stated adhering to IPC protocols helped maintain the health and safety of all residents, staff, and visitors.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure a Registered Nurse (RN) was available eight (8) hours per day, seven (7) days per week. The facility failed to meet this requirement for four (4) twenty four (24) hour periods, for the review period 10/13/18 through 12/20/18. The findings include: Interview with the Administrator, on 12/20/18 at 9:12 AM, revealed the facility did not have a policy in place related to ensuring a Registered Nurse be on duty for eight (8) consecutive hours seven (7) days per week. Review of the facility policy titled Scheduling Standards, dated 06/14/18, revealed the purpose of the policy was to set standards for scheduling and establish bet practices across the company. Continued review revealed each schedule should be developed and planned to ensure adequate staffing levels to meet resident needs, to manage staff efficiently, to align the schedule with a census adjusted staffing budget, and to improve employee engagement and retention. Further review of the facility's policy revealed schedulers should build close working relations to enhance employee communications and to promptly identify any necessary schedule changes. Review of the facility's staffing schedules for (MONTH) (YEAR) revealed there was no RN on duty for eight (8) consecutive hours each day on the following four (4) dates: 10/13/18, 10/14/18, 10/27/18 and 10/28/18. Interview with the Director of Nursing (DON), on 12/20/18 at 2:51 PM, revealed in (MONTH) of (YEAR), the facility did have four (4) days the RN on schedule had a family emergency and did not report to the facility for duty. Per interview, staff could always call her if needed; however, it was just an oversight. Continued interview revealed the facility should have an RN on duty for eight (8) consecutive hours each day, seven (7) days a week. Interview with the Administrator, on 12/20/18 at 3:33 PM, revealed the facility did recognize the opportunity and will put a plan in place to ensure the facility had the appropriate RN coverage. Per interview, it was her expectation the facility would staff a RN eight (8) hours a day, seven (7) days a week, per the regulations.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to follow standard practice by crushing a medication on the facility's Medications Not To Be Crushed list for one (1) of eighteen (18) samples residents (Resident #24). Observation during a medication pass revealed staff crushed one (1) Aspirin 325 mg [MEDICATION NAME] coated (a polymer barrier applied on oral medication that prevents its dissolution or disintegration in the gastric environment) tablet and administered it to Resident #24. The findings include: Review of the facility's policy titled, Medication Administration - General Guidelines, revised 01/17, revealed tablet crushing or capsule opening was permitted if it was safe to do so. Continued review revealed long-acting or [MEDICATION NAME]-coated dosage forms should not be crushed and an alternative should be sought. Further review revealed staff should consult with the product literature or the Do Not Crush lists which the facility may have or with the pharmacist if there was a question about medications to be crushed. Per the facility's policy, liquid dosage forms may be a practical alternative in place of solid tablets, especially if tablets have a coating and will not crush finely. Review of the facility's documentation titled, Medications Not To Be Crushed, copyright 2002 American Society of Consultant Pharmacists, revealed [MEDICATION NAME]-coated Aspirin was documented on the list of Medications Not To Be Crushed due to the [MEDICATION NAME]-coated formulation. Continued review revealed alternate dosage forms for the product were available. Record review revealed Resident #24 was admitted by the facility on 11/09/18 with diagnoses, which included Cerebral Infarction, unspecified; Gastro-[MEDICAL CONDITION] reflux disease without esophagitis; Nondisplaced interochanteric fracture of right femur; Other lack of Coordination and muscle weakness. Review of the physician's orders [REDACTED]. Drug Class: Blood Formation, Coagulation, [MEDICAL CONDITION] | [MEDICAL CONDITION] Agents | Platelet-Aggregation Inhibitors. Form: tablet, delayed release (DR/EC). Crushed: No. The documentation further indicated the medication strength was to be three hundred twenty-five (325) mg and was to be administered orally once a day. Further review of the physician's orders [REDACTED]. Observation of a medication pass, on 12/19/18 at approximately 9:30 AM, revealed Licensed Practical Nurse (LPN) #2 crushed Resident #24's medications prior to administration. Continued observation revealed LPN #2 crushed (1) Aspirin 325 milligram [MEDICATION NAME] Coated tablet mixed it with pudding and administered the mixture to the resident. Interview with Licensed Practical Nurse (LPN) #2, on 12/19/18 at 2:21 PM, revealed she observed the medication card label for Resident #24's Aspirin and confirmed it to be [MEDICATION NAME] Coated. Continued interview revealed she was sure it should not have been (crushed) because it was [MEDICATION NAME] Coated; however, she stated she always crushes all of Resident #24's medications. Per interview, staff would need to obtain an order from the physician to crush [MEDICATION NAME] Coated medications for administration. Further interview with LPN #2, revealed she had not seen the document Medications Not To Be Crushed prior to today, unless it was in orientation. Telephone interview with the Pharmacist, on 12/20/18 at 1:28 PM, revealed the [MEDICATION NAME]-coated Aspirin should not be crushed due to the [MEDICATION NAME] Coating. Continued interview revealed a resident that received [MEDICATION NAME]-coated Aspirin that had been crushed would need to be observed for gastro-intestinal (GI) upset. Interview with the Director of Nursing (DON), on 12/20/18 at 2:58 PM, revealed LPN #2 should not have crushed the aspirin. Continued interview revealed the Medications Not To Be Crushed document is in a book on the medication cart and has been there as far as she knows. Further interview revealed it was her expectation that staff follow the facility's policies and protocols for medications administration. Interview with the Administrator, on 12/20/18 at 3:31 PM, revealed she expected nurses and all staff to follow the facility's policies and procedures regarding medication administration.

Based on observation, interview and review of facility policy, it was determined the facility failed to properly store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observation of food items stored in resident nourishment refrigerators were not properly labeled or dated and had no resident identification. The findings include: Review of the facility policy titled, Food Brought into Facility, dated [DATE], revealed the purpose of the policy was to ensure safe and sanitary storage, handling, and consumption of foods brought to residents by family and other visitors. Continued review revealed food brought to the facility by family members, friends or guests must be inspected by a staff member that has been properly trained to receive and inspect food. Further review revealed food and beverage items are to be properly labeled and the date marked on the item. Review of the sign posted on the nourishment refrigerator, located in the lounge area of the 100, 200 and 300 units, revealed directions to staff to date all food items with the resident's name and room number. Observation, on [DATE] at 11:19 AM, of the 300 Unit resident nourishment refrigerator, located in the medication preparation room, revealed an unidentified resident food item that was not labeled with the food item or resident name and was not dated. Observation, on [DATE] at 12:50 PM, of the 100 and 200 Unit resident nourishment refrigerator, located in the lounge area, revealed an unidentified resident food that was not labeled with the food item or resident name and was not dated. Observation of the freezer area revealed it contained two (2) boxed frozen dinners with no resident identification. Interview with Certified Resident Care Aide (CRCA) #3, on [DATE] at 2:23 PM, revealed she works the 100, 200, 300 Units. Continued interview revealed foods brought to the residents by their family should be stored in the nourishment refrigerators. Further interview revealed the items should have the resident's name or room number marked on the food. Interview with CRCA #4, on [DATE] at 2:34 PM, revealed she works the 200 and 300 Units. Continued interview revealed she writes the resident's name and room number on food items brought to the facility by the resident's family. Further interview revealed, expired foods should be thrown away. Interview with Licensed Practical Nurse #2, on [DATE] at 2:36 PM, revealed food items kept in the nourishment refrigerator should be marked with the residents name and dated. Continued interview revealed nursing staff were responsible to check the dates of the food items and to clean out expired food items weekly. Interview with Director of Food Service, on [DATE] at 2:41 PM, revealed nursing staff was responsible for resident food items brought to the facility by the family. Continued interview revealed the nursing staff was responsible for cleaning out of the nourishment refrigerator. Interview with Registered Nurse (RN) Director of Health Services, on [DATE] at 1:51 PM, revealed all food should be labeled with the residents' name and it should be dated per the facility's policy. Continued interview revealed, it was her expectation for the staff to store the resident's food per the facility's policy. Interview with Executive Director/Administrator, on [DATE] at 1:55 PM, revealed food kept in the nourishment refrigerators should be labeled, dated and with residents' name. Continued interview revealed, it was her expectation for staff to follow the facility's food safety requirements.

Based on observation, interview and review of facility's policy, it was determined the facility failed to store food under sanitary conditions as determined by observation of the unit nourishment refrigerator, cart storage shelf and stock drawers revealed out dated food products. The findings include: Review of the facility policy titled Food Labeling Guideline revised 12/2012, revealed refrigerated ready-to-eat potentially and hazardous food (RTE) must be dated so food was consumed within seven days. Review of the Kentucky Food Code 2005, Section 3-501.17 revealed for ready-to-eat foods, the date marked may not exceed the manufacturer's use-by date which was based on food safety. Observation, on 11/20/16 at 11:15 AM, revealed expired foods in the refrigerator included one (1) 2% milk dated 11/01/16, and three (3) Hormel Medication Pass Vanilla nectar thick liquid thirty-two (32) ounces dated 11/10/16. The storage cart contained eight (8) Hormel Medication Pass vanilla nectar thick liquid thirty-two (32) ounces dated 11/10/16 with dust like particles on the lids and eight (8) [MEDICATION NAME] 1.2 Cal closed system nutritional supplements dated 11/01/16. Continued observation of the nutritional supplements stored on the top of the refrigerator revealed twenty-one (21) cans of Glucerna Strawberry flavored with the expiration date of 11/01/16. Observation of the storage drawers revealed two (2) loose packages of Carnation Instant Breakfast No Sugar Added vanilla packages dated 08/14/16 and seven (7) loose chocolate packages dated 09/11/16. The drawer also contained an unopened box of Carnation Instant Breakfast No Sugar Added Chocolate dated 12/15/15, and seven (7) loose packages of single serve brown sugar all natural not dated. Interview, on 11/21/16 at 1:50 PM, with Dietary Manager revealed the unit placed an order for [REDACTED]. The nutritional supplements were ordered by nursing from an outside company and dietary did not stock those products. Interview, on 11/22/16 at 10:05 AM, with Licensed Practical Nurse (LPN) #3 revealed the Director of Nursing Services (DNS) placed the nourishment order and everyone assisted in putting up the nourishments. LPN #3 stated they tried to look for expired dates and rotate foods with first-in and first-out (FIFO) but it was not always done. Interview on 11/22/16 at 10:10 AM, with State Registered Nursing Assistant (SRNA) # 1 revealed the nourishment items were all rotated. The juices, if opened were dated and any expired foods should be thrown out. Interview, on 11/22/16 at 10:30 AM, with the Director of Health Services (DHS) revealed the nourishments should be rotated as new stock was put in the back and the oldest nourishments were brought forward. Nutritional supplements were ordered on-line from another company. Food items that were expired should be thrown away because they could become harmful to the resident if eaten. Interview, on 11/22/16 at 1:50 PM, with the Executive Director revealed her expectations for nursing staff would be to follow policy for First-in and First-out (FIFO) and check for expired dates. Residents should not be offered expired foods which could affect the resident.

Based on observation, interview and review of facility's policy, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as is possible. Observation during initial tour on 11/20/16, revealed the beauty shop was found to be unlocked and unattended with hair styling products, equipment, chemicals and grooming equipment accessible to residents. In addition, observations on 11/20/16 at 11:22 AM, revealed, the nurse responsible for passing medications walked away from the medication cart leaving the cart unlocked and unattended in the resident hall. The findings include: Review of the facility's Bill of Resident Rights Policy, not dated, revealed the facility would protect and promote each residents rights. Per policy, the facility would ensure each residents physical safety or the physical safety of other residents. 1. Review of the facility Cleaning Supplies and Chemicals Policy, revised December 2014, revealed chemicals should be stored as instructed on the labels of the products. The facility did not have a Wander List (list of residents who have the tendency to wander about the facility, and may have confusion), however, Unsampled Resident A, B, and C were observed sitting in the hallway in their wheelchairs near the beauty shop entrance on 11/20/16 at 9:20 AM. In addition, Unsampled Resident D was self propelling in wheelchair around the hallways of the facility throughout the survey. Observation, on 11/20/16 at 9:20 AM, during initial tour of the 100 Unit, revealed the beauty shop door was unlocked and unattended. Further observation of the contents within the beauty shop revealed one (1) curling iron, one (1) blow dryer and one (1) portable fan plugged into a electric power strip potentially in reach of residents. Also, there was hair styling products, and equipment cleaners also potentially in reach of residents. Hair styling products and equipment chemicals included: One (1) Pantene Pro-V Curly Hair Style Gel 8.5 ounce bottle, one (1) Pantene Pro-V Restoratives Frizz Control Anti-Humidity Hair Spray 33.8 ounce bottle, one (1) Matrix Biolace Pump Heat Protection Spray 10.0 ounce bottle, three (3) bottles of Old Spice After Shave Lotion 13.2 ounces, one (1) Pantene Pro-V Smooth Shampoo 21.1 ounce bottle, and three (3) Gillette Series Shave Foam 9 ounce cans. Continued observation, revealed the beauty shop remained unlocked and unattended until 11/20/16 at 12:11 PM, when staff was notified of the beauty shop door being unlocked by the surveyor. Review of Safety Data Sheets (SDS) for Pantene Hair Style Gel, dated March 2009, revealed ingestion of the product could cause nausea and vomiting, and eye contact may cause irritation and could result in irreversible damage. Review of Safety Data Sheets (SDS) for Pantene Anti-Humidity Hair Spray, dated June 2009, revealed flammable aerosol, caused eye and skin irritation. Avoid contact with eyes, skin and clothing. Keep away from heat, sparks, open flames and hot surfaces. Keep out of the reach of children and direct sunlight. Review of Safety Data Sheets (SDS) for Old Spice After Shave Lotion, dated November 2009, revealed ingestion of the product could cause nausea, vomiting, and diarrhea. Eye contact may cause irritation and redness. Review of Safety Data Sheets (SDS) for Pantene Pro-V Shampoo, dated September 2009, revealed ingestion of the product could cause nausea, vomiting, and diarrhea. Eye contact may cause irritation and redness. Review of Safety Data Sheets (SDS) for Gillette Series Shave Foam Conditioning, dated October 2011, revealed ingestion of the product could cause nausea, vomiting, and diarrhea. Eye contact may cause irritation and redness. Interview, on 11/20/16 at 2:35 PM, with the Life Enrichment Director, who assisted surveyor with the inventory of beauty shop products in reach of residents revealed the beauty shop was usually locked and should be locked. The Life Enrichment Director revealed it was used as an extra laundry room and that was probably why it was open. The Life Enrichment Director stated the beauty shop should be locked at all times. Interview, on 11/20/16 at 3:19 PM with State Registered Nursing Assistant (SRNA) #3, revealed chemicals or equipment left out in the beauty shop could be dangerous for residents. Further interview, revealed the beauty shop was usually locked. Interview, on 11/21/16 at 3:19 PM, with the Executive Director, revealed it was very important to keep the beauty shop locked. Further interview, revealed residents could drink the chemicals which could be harmful and the chemicals and equipment should always be put away and locked up when not in use. The Executive Director revealed it was the staff's responsibility to check the door to ensure it was locked. Interview, on 11/21/16 at 3:56 PM, with the Director of Nursing Services (DNS), revealed the supplies and equipment in the beauty shop should be locked up in a cabinet. The DNS stated, there could be possible issues with residents getting chemicals into eyes, or possibly ingesting chemicals. Further interview revealed curling irons could be turned on and could cause the residents' burns. The DNS stated, staff was responsible to check doors to make sure they remained locked and secured. 2. Review of the facility's Medication Storage in the Facility Policy, dated September 01, 2013, revealed medications and biologicals would be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Observation, on 11/20/16 at 11:22 AM, revealed Registered Nurse (RN) #1 walked away from the medication cart four (4) times while passing medications, leaving the medication cart unlocked and unattended on the resident hall. Unlocked medications were left accessible to residents and in the area. Interview, on 11/20/16 at 11:50 AM, with RN#1, revealed she was responsible for the medication cart while passing medications on the unit, and she should have locked the cart before walking away to protect residents from possible harm. Interview on 11/22/16 at 10:51 AM, with the Director of Health Services (DHS), revealed the nurse passing medications was responsible for ensuring the medication cart was locked prior to leaving the cart to pass medications to protect resident from potential harm. Continued interview revealed it was her expectation that nursing staff follow the facility's policy regarding medication storage. Interview on 11/22/16 at 2:19 PM, with the Executive Director (ED), revealed she expected the nurse passing medications to lock the medication cart prior to walking away to ensure resident and visitor safety. Continued interview revealed it was her expectation that nursing staff follow the facility's policy regarding medication storage.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure the personal privacy and confidentiality of each resident was protected. Observations on 11/20/16 at 11:50 AM, revealed confidential and clinical information was displayed on a computer screen on top of the medication cart located on the resident hall. The information was accessible to read, as the cart was left unattended by the nurse responsible for the cart. The findings include: Review of the facility's Bill of Resident Rights Policy, not dated, revealed the facility would protect and promote the right to privacy and confidentiality and the resident had the right to personal privacy and confidentiality of their personal and clinical records. Observation, on 11/20/16 at 11:22 AM, revealed Registered Nurse (RN) #1 walked away from the medication cart four (4) times while passing medications on the front hall, leaving confidential and clinical information displayed on a computer screen on top of the medication cart located on the resident hall. The information was accessible to read by residents and visitors in the area. Interview, on 11/20/16 at 11:50 AM, with RN #1, who was passing medications on the front hall, revealed she was responsible for maintaining privacy and confidentiality of clinical information when passing medications and she should have closed the computer screen or logged off the computer prior to walking away from the medication cart to protect the confidentiality of the resident's clinical information. Interview, on 11/22/16 at 10:51 AM, with the Director of Health Services (DHS) revealed the nurse passing medications was responsible for ensuring the computer located on the medication cart was logged off or closed prior to leaving the cart to ensure resident clinical information remained private and confidential. Continued interview revealed it was her expectation that nursing staff follow the facility's policy regarding Privacy and Confidentiality of clinical information. Interview, on 11/22/16 at 2:19 PM, with the Executive Director (ED) revealed she expected the nurse passing medications to log off the computer or close it prior to walking away to ensure resident privacy. Continued interview revealed it was her expectation that nursing staff follow the facility's policy regarding Privacy and Confidentiality of clinical information.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure the Advanced Directives and Code Status of each resident was incorparated into the comprehensive care plan to ensure staff was aware of the existing care instuctions for six (6) out of ten (10) sampled residents (Resident #1 #2, #3, #5, #8, and #9). The findings include: Review of the facility's Advanced Directive Policy, revised [DATE], revealed Advanced Directives would be reviewed with the resident and/or surrogate by the Director of Social Services or designee at the time of admission, with the annual comprehensive assessment, and as needed. Per policy, facility staff would obtain and follow the residents advanced directives regarding end of life care. Review of the facility's Bill of Resident Rights Policy, not dated, revealed residents had the right to formulate an advanced directive such as a living will or durable power of attorney for health care, recognized under state law relating to the provision of health care when the resident was no longer able to make decisions. Per policy, the resident had the right to be fully informed in advance about care and treatment and any changes in the care or treatment that may affect their well-being, and to participate in planning care and treatment or changes in care and treatment, unless the resident had been adjudged incompetent or found to be incapacitated under the law. 1. Review of Resident #1's Medical Record, revealed, the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed Resident #1's Cognitive Skills for Daily Decision Making score was 3, indicating the resident had moderate cognitive impairment. Review of Resident #1's Cardiopulmonary Resuscitation (CPR) Consent Form, dated [DATE], signed by the resident's legal court appointed guardian, revealed it was the resident's desire to be given CPR. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed, the resident had not been care planned for his/her Advanced Directive choice of Full Code. 2. Review of Resident #3's Medical Record, revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS, dated [DATE], revealed the facility assessed Resident #1's Brief Interview for Mental Status (BIMS) score was fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #3's Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order Form, dated [DATE], signed by the residents Health Care Surrogate (HCS) and Power of Attorney (POA), revealed, the undersigned person or surrogate who had been designated to make health care decisions in accordance with Kentucky Revised Statutes, hereby direct that in the event of cardiac or respiratory arrest that this Do Not Resuscitate (DNR) Order be honored. Review of Resident #3's(NAME)B. Haggin Memorial Hospital Extended Care Unit Resuscitation Order, dated [DATE], and signed by the residents Primary Care Physician, revealed Do Not Resuscitate. Review of Resident #3's Comprehensive Care Plan, dated [DATE], revealed no documented evidence of care planning related to his/her Advanced Directive choice of No Code or DNR. 3. Review of Resident #8's Medical Record, revealed the facility admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #8's Annual MDS, dated [DATE], revealed the facility assessed Resident #8's to have a BIMS score of three (03), indicating the resident was severely cognitively impaired. Review of Resident #8's Physicians Orders, dated [DATE], revealed the resident had a Code Status order of DNR, dated [DATE], signed by the Primary Care Physician. Review of Resident #8's Comprehensive Care Plan, dated [DATE], revealed no documented evidence the facility care planned for his/her Advanced Directive choice of No Code or DNR. 4. Review of the medical record revealed the facility admitted Resident #5 on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS Assessment, dated [DATE] revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15) indicating cognitive impairment. Review of Resident #5 Physician Orders, dated [DATE], revealed the resident had a Code Status order of DNR, dated [DATE], signed by the Primary Care Physician. Review of the Resident #5 Comprehensive Care Plan dated [DATE], revealed no documented evidence the facility care planned for his/her DNR code status. 5. Review of the medical record revealed the facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS score of nine (9) out of fifteen (15) indicating moderate cognitive impairment. Review of the Medical record revealed Resident #2 had a Living Will with Advanced Directived for DNR Code Status. Review of the Comprehensive Care Plan, dated [DATE] revealed no documented evidence the code status of DNR was addressed. 6. Review of the medical record revealed the facility admitted Resident #9 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated [DATE] revealed the facility assessed the resident as having a BIMS score of three (15) out of fifteen (15) which indicated the resident had no cognitive impairment. Review of the physician's orders [REDACTED].#9, on [DATE] at 1:30 PM, revealed he/she had Advanced Directives and desired to be a Full Code Status. Review of the Comprehensive Care Plan, dated [DATE] revealed no documented evidence the facility care planned the code status of Full Code for Resident #9. Interview, on [DATE] at 2:50 PM, with Licensed Practical Nurse (LPN) #2, revealed, the only way to be one hundred percent (100%) sure of a resident's code status was to look in the computer. Interview, on [DATE] at 2:55 PM, with LPN#3 revealed, there was no way to know a residents code status without looking it up in the computer. Interview, on [DATE], at 3:10 PM, with the MDS Coordinator (MDS) revealed staff must look in the computer to find out what a resident's code status or advanced directive was. Interview, on [DATE], at 10:51 AM, with the Director of Health Services (DHS), revealed the admission packet contained a checklist and code status and advanced directives were part of the process. Continued interview revealed, usually the Executive Director (ED), DHS, or the Admission Nurse would go over the whole admission packet including getting the order for code status. Once the code status was determined, it would be documented in the Admission note, an interim Care Plan would be created, and then it would be discussed in the first Care Plan Meeting. Further interview revealed, code status would be discussed with staff on all new residents after admission but, code status was not care planned. Additional interview revealed all staff should just know every resident's code status because it was a small facility. Interview, on [DATE] at 2:19 PM, with the Executive Director (ED) revealed she was not aware residents required Advanced Directive care planning on admission, that Advanced Directive care planning needed to be incorperated into the Comprehensive Care Plan after Admission, and needed routine periodic review. Continued interview revealed she expected staff to begin to initiate Advanced Directive Care Planning on admission and continue to routinely re-evaluate care planning thought out the residents' stay at the facility.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional standards, as evidenced by, observation on 11/21/16 at 11:00 AM, revealed the treatment cart on the back hall had expired biological's located in the cart. The findings include: Review of the facility's Medication Storage in the Facility Policy, dated September 01, 2013, revealed medications and biologicals would be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Per policy, outdated medications would immediately be removed from stock, disposed of according to procedures for medication disposal. Observation, on 11/21/16 at 11:00 AM, revealed the treatment cart on the back hall had seventeen (17) Melgisorb AG Dressing which were marked with an experation date of October 2015 and four (4) Maxorb Extra AG+ Silver Antimicrobial Dressing marked with an experation date of April 2016. Interview, on 11/21/16 at 11:20 AM, with Licensed Practical Nurse (LPN) #1, who was administering medications and treatments on the back hall, revealed the nurses were responsible for checking the medication and treatment supplies for expiration dates prior to administration to prevent possible harm to the residents. Per interview, she did not know why the expired biological's were still in the treatment cart. Continued interview revealed the outdated or expired medications or biologicals should have been sent back to the pharmacy. Interview, on 11/22/16 at 10:51 AM, with the Director of Health Services (DHS), revealed the nurses were responsible for checking the medication cart and treatment cart every day for expired medications and biologicals and disposing of them properly to ensure residents were protected from potential harm from outdated medications. Continued interview revealed it was her expectation that nursing staff follow the facility's policy regarding medication and biological storage. Interview on 11/22/16 at 2:19 PM, with the Executive Director (ED), revealed she expected the nurses to check the medication and treatment carts routinely for any expired or outdated products and dispose of them according to facility policy. Continued interview revealed it was her expectation that nursing staff follow the facility's policy regarding safe storage of medications and biologicals.

Based on observation, interview, and review of facility policies it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation of resident rooms on [DATE] revealed all resident rooms had a buildup of dirt and dust in corners of the floor, on the baseboards, and around door frames. All over bed tables in resident rooms also had a buildup of dust and debris at the base of the tables. In addition, the East and West Hallways had a buildup of dirt and dust in corners of the floor, and on the baseboards. The hand rail brackets on the hallways had a buildup of light brown residue, and there was a buildup of dirt and dust on the four (4) ceiling tiles, on the ceiling vent, and on the wall in the hallway outside the beauty shop. Also, the shower bed (equipment used to give resident showers in a lying position) had a buildup of hair and debris was noted under the shower bed pad. Additionally, the tube feeding pole in room 268 was noted to be soiled with a buildup of a light brown substance on the handle and base of the pole. Substandard Quality of Care was identified related to the facility's systemic failure. The findings include: Review of the facility's policy titled Cleaning Patient Rooms revised ,[DATE], revealed all patient rooms would be cleaned on a daily basis. Continued review revealed floors were to be mopped daily, starting with the farthest corner to prevent buildup. Review of the Extended Care Facility (ECF) Cleaning Schedule, revised [DATE], revealed deep cleaning of the resident rooms and care areas were to be completed every three (3) months. Review of the facility procedure for Enteral Feeding dated ,[DATE], revealed pump and pole would be cleaned nightly with changing of bags. Observation on [DATE] at 10:30 AM, on tour with the Maintenance Director, revealed all resident rooms (Rooms 243, 245, 247, 248, 249, 250, 251, 254, 255, 256, 257, 258, 259, 260, 263, 264, 265, 266, 267, 268, 269, 270, and 271) had a buildup of dirt and dust in corners of the floors and walls. In addition, there was a buildup of dirt and dust on the baseboards, and around door frames of every resident room. There was also a buildup of dust and debris on the base of the over bed tables in all resident rooms. Further observation during the same tour, revealed the East and West Hallways had a buildup of dirt and dust in corners of the floor and on the baseboards. The hand rails brackets on the East and West Hallways had a buildup of light brown residue. In addition, there was a buildup of dirt and dust on the four (4) ceiling tiles, on the ceiling vent, and on the wall outside the beauty shop. Continued observation during the same tour, revealed the shower bed stored inside the beauty shop had a buildup of hair, an alcohol pad, and a steri strip under the shower bed pad. Also, the tube feeding pole in room 268 was noted to have a dried buildup of a light brown substance on the handle and base of the pole. Interview with the Maintenance/Housekeeping Director, on [DATE] at 12:00 PM, revealed the facility had no system in place to monitor to ensure the cleaning schedule was completed or to monitor the overall cleanliness of the facility. He stated the housekeepers were responsible for the daily cleaning of resident rooms and hallways including the floor, door frames, baseboards, walls, over bed tables, and hand rail brackets. He stated the maintenance department was responsible to clean vents and change vent filters and clean the ceiling tiles. Interview with Housekeeper #1, on [DATE] at 11:15 AM, revealed the housekeepers floated between the hospital and the ECF, and she had noticed the dirt in the corners of the floor in resident rooms and they were to scrub the corners and baseboards when they had time, which was about every few weeks when staffing allowed. She further stated, the over bed tables were to be cleaned daily and disinfected. Housekeeper #1 stated, she reported to the Maintenance/Housekeeping Supervisor when there was areas she did not have time to clean. Interview with Housekeeper #2, on [DATE] at 1:55 PM, revealed the housekeepers were assigned to clean resident rooms, including over bed tables, halls, showers, dining room, nursing station, parlor and assist the hospital housekeeper daily. She further stated, no I can't always get everything done and I report this to the supervisor. Interview with State Registered Nurse Aide (SRNA #1), on [DATE] at 11:25 AM, revealed the shower beds should be cleaned immediately after use by whichever staff member used the bed. Interview with SRNA #4, on [DATE] at 11:40 AM, revealed the nurse aides were to wipe down the shower bed after each use with Saniwipes (germicidal disposable wipes). Interview with Licensed Practical Nurse (LPN) #4, on [DATE] at 12:20 PM, revealed the nurses were to clean the tube feeding poles when it was noticed they were soiled. Interview with LPN #5, on [DATE] at 12:30 PM, revealed the night shift staff and housekeeping were to wipe down tube feeding poles with a Saniwipe every night, and the nurses on any shift were to also clean them as needed for a spill. Interview with the Director of Nursing (DON), on [DATE] at 1:50 PM, revealed the nursing staff was responsible for the cleaning of the shower bed and tube feeding poles. However, observations revealed this was not being done. Continued interview with with the DON revealed the facility did not have a shower bed cleaning policy but the person using the shower bed was responsible to clean it after each resident use by spraying it down in the shower room and wiping with the Sanicloths for disinfecting. Continued interview, revealed the night shift nurse was responsible to clean the tube feeding poles when the tube feeding bags were changed every night. She stated the shower bed in the beauty shop and tube feeding pole in room 268 did not appear to have been cleaned for at least a week. The DON further revealed there was no system in place to ensure the shower beds and tube feeding poles were cleaned. Interview with the Administrator, on [DATE] at 6:05 PM, revealed she expected staff to follow the policies and procedures of the facility. She stated the facility was dirty and did not meet her expectations of clean. She further stated she had spoken with corporate about the problem, and was currently advertising for a floor tech. The Administrator further stated, the housekeeping and maintenance staff was contracted from the hospital since [DATE] when the facility bought the beds, and she had not followed up to ensure a monitoring system was in place. Further interview revealed the Hospital Maintenance/Housekeeping contract would be expired in a few months and when the contract expired, the facility would hire their own staff to address the issues.

Based on observation and interview it was determined the facility failed to ensure the resident environment remained free of accident hazards. Observation on 01/28/16, revealed doors to each resident room (twenty-three out of twenty-three rooms), shower room, and beauty shop had sharp jagged splintered edges. In addition, the sharp toilet bolts were exposed and uncovered at the base of the toilets in the bathrooms of Rooms 250 and 254. The facility failed to have an effective system to identify environmental hazards to minimize the likelihood of accidents. Substandard Quality of Care was identified related to the facility's systemic failure. The findings include: Interview with the Maintenance Director, on 01/28/16 at 12:00 PM and the Administrator, on 01/28/16 at 6:05 PM revealed they were unaware of any policies related to environmental hazards or maintenance/repairs of the facility. Observation on 01/28/16 at 10:30 AM, on tour with the Maintenance Director, revealed all resident room doors (Rooms 243, 245, 247, 248, 249, 250, 251, 254, 255, 256, 257, 258, 259, 260, 263, 264, 265, 266, 267, 268, 269, 270, and 271), shower room door, and the beauty shop door had sharp jagged splintered edges. Further observation, revealed the bathrooms of Rooms 250 and 254 had sharp toilet bolts to the base of the toilets which were exposed and uncovered. Interview with Housekeeper #1, on 01/29/16 at 11:15 AM, State Registered Nurse Aide (SRNA) #1, on 01/29/16 at 11:25 AM, and Licensed Practical Nurse (LPN) #1 on 01/29/16 at 12:40 PM, revealed they had not noticed the sharp jagged edges on the doors. Interview with the Maintenance Director, on 01/28/16 at 12:00 PM, and at 3:30 PM, revealed the facility had no system in place to monitor for repairs needed or environmental hazards such as sharp jagged edges on doors or missing bolt covers on toilet bases. He further stated he depended on staff to complete a Work Order for any repairs needed. Continued interview revealed the sharp, jagged edges of the doors could be a hazard to the residents as they could cause skin tears. He further stated the uncovered toilet bolts could cause severe injury if a resident stepped or fell on them. Interview with the Director of Nursing (DON), on 01/29/16 at 12:30 PM, revealed she had noticed sharp splintered edges on a couple of doors but did not remember which doors or when she had noticed them. She stated she had not submitted a Work Order for the doors, but the sharp edges of the doors could cause skin tears to residents. She stated she had not noticed any uncovered toilet bolts, but if a resident fell on the uncovered toilet bolts it could cause severe injury. She further stated she had seen maintenance on the floor working on things so she trusted the Maintenance Director was taking care of these areas. Per interview, she was not sure if the facility has a system to monitor and ensure repairs are completed. Interview with the Administrator, on 01/28/16 at 6:05 PM, revealed she was not aware of the sharp, jagged door edges, or uncovered toilet bolts until this survey. She stated she thought maintenance was monitoring for environmental concerns and making repairs as needed. She further stated in addition to Maintenance monitoring for repairs needed, she expected staff to submit Work Orders for any safety hazard they had identified. The Administrator revealed she would expect any environmental hazard to be reported to herself as well as the Maintenance Director. She stated the sharp jagged door edges and the uncovered toilet bolts were hazardous to the residents.

Based on interview and record review, it was determined the Immediate Jeopardy identified during the Abbreviated Survey concluded on 05/13/11 had been removed as of 05/24/11 related to Administration; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the development and implementation of the Plan of Correction (POC) as related to Administration. In addition based on interview and record review it was determined the Administration of the facility failed to ensure the facility's resources were utilized effectively and efficiently to ensure the delivery of the required care and services to the residents. This failure was evidenced by the repeat deficiencies identified during the Revisit Survey concluded on 06/03/11. The facility failed to meet the needs of each resident and assist them in maintaining or improving their status of health and well being. This lack of oversight to ensure that the residents' needs were met resulted in continued non-compliance from the Abbreviated Survey concluded on 05/13/11. The facility was cited at the Immediate Jeopardy (IJ) level on the Abbreviated Survey concluded on 05/13/11. The facility implemented their Allegation of Compliance (AOC) and Jeopardy was determined removed with deficient practice remaining in the areas of CFR 483.20 Resident Assessment, F-280 and CFR 483.25 Quality of Care, F-323. The findings include: 1. Immediate Jeopardy was identified on the Abbreviated Survey concluded on 05/13/11 for CFR 483.20 Resident Assessment, F-280 at a S/S of a "J". This was related to the facility's failure to revise Resident #1's Comprehensive Plan of Care to ensure safety related to the new intervention of an air mattress with bilateral half side rails which was implemented on 03/09/11. On 04/17/11 Resident #1 was found entrapped between the side rail and the air mattress. On 04/23/11 Resident #1 was diagnosed as having a broken femur. During the Revisit Survey concluded on 06/03/11, deficient practice was identified related to the facility's failure to revise residents' Plans of Care. Resident #5's Plan of Care was not revised to reflect physician's orders [REDACTED]. In addition, the Plan of Care was not revised to reflect the physician's orders [REDACTED]. Also, the Plan of Care was not revised to reflect the resident's fall sustained on 05/21/11 with interventions to prevent further occurrences. Interview on 06/03/11 at 12:00 PM with the ECF Coordinator and 5:30 PM with the ECF Coordinator, Chief Nursing Officer (CNO), and Hospital and ECF Administrator in training, revealed the Administrator had reviewed every draft of the AOC. Further interview revealed the facility reviewed all resident medical records and compared the Physicians' Orders with the Comprehensive Plans of Care and the Care Cards. However, interview revealed the facility focused on the areas of Activities of Daily Living (ADL) ability, mobility, and side rails for the AOC and did not ensure all aspects of the Care Plans were reviewed for needed revisions. (Refer to F-280) 2. Immediate Jeopardy was identified on the Abbreviated Survey concluded on 05/13/11 for CFR 483.25 Quality of Care, F-323 at a S/S of a "J". This was related to the facility failing to adequately assess for and identify potential hazards and environmental risks, and ensure adequate supervision to prevent accidents related to the use of an air mattress with bilateral side rails for Resident #1. Resident #1 was found with his/her arm and shoulder entrapped between the air mattress and the side rail with the resident's knees on the floor on 04/17/11. The resident was diagnosed as having a broken femur on 04/23/11. During the Revisit Survey concluded on 06/03/11, deficient practice was identified related to the facility failing to ensure adequate supervision and assistive devices to prevent accidents for Resident #5. Resident #5 sustained a fall on 05/21/11 while being transferred by the resident's daughter. Although interviews with staff revealed the daughter repeatedly transferred the resident without assistance; there was no documented evidence the daughter was educated on proper transfer technique either prior to the fall or after the fall. Interview on 06/03/11 at 5:30 PM with the Chief Nursing Officer (CNO)and the Extended Care Facility (ECF) Coordinator, and Hospital and ECF Administrator in training, revealed the resident's daughter repeatedly transferred the resident without assistance. Continued interview revealed the Care Plan interventions were reviewed with the resident's daughter including transfer technique during the Care Plan conferences held on 09/15/11 and 05/25/11. However, there was no documented evidence of the resident's daughter receiving education specifically on transfer technique before or after the fall on 05/21/11. (Refer to F-323)

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to accurately assess for safety related to the use of bilateral side rails with an air mattress, identify entrapment risks, and potential hazards for one (1) of three (3) sampled residents (Resident #1). Resident #1 was placed on an air mattress with bilateral side rails on 03/09/11. On 04/17/11, between the hours of 3:00 AM and 5:00 AM, Resident #1 was found at 5:00 AM with his/her arm and shoulder entrapped between the air mattress and the side rail. The resident was twisted and wrapped in his/her sheets and blankets with his/her knees on the floor. On 4/23/11, the resident's left knee was found to be swollen and the resident expressed pain with leg movement. X-rays revealed an oblique [MEDICAL CONDITION] portion of the left femur. Based upon the findings it was determined the facility failed to have an effective system in place to accurately assess residents for safety when utilizing half side rails with an air mattress. This failure has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 5/12/11, was determined to exist on 04/17/11, and is ongoing. The findings include: Review of the "Side Rail Policy and Procedure", undated, revealed each resident shall be assessed for the use of side rail(s) upon admission and ongoing assessment for the use of side rail(s) shall be conducted according to the resident's Resident Assessment Instrument (RAI). The policy further stated that each resident shall be assessed to determine the rationale for the use of side rails and whether or not the benefit(s) outweigh the risks for that resident, before the side rails shall be included in the comprehensive plan of care and the nurse assistant care plan. Review of the facility's "Resident Restraint Policy", effective 10/01/08, revealed any device applied to a resident solely for the purpose of position or enhancing resident function was not considered a restraint. Side rails must enable the resident to safely function within their environment and the resident must be able to voluntarily remove the device successfully three (3) times when asked. The Resident Restraint Policy revealed no information related to reassessing the use of a device after the resident had an accident (fall) which may be related to the use of that device. Review of the User Instruction Manual for the Alternate Mattress System stated on page 5, "Seven Zones of Bed Rail Entrapment": WARNING: Bed rail entrapment is a serious health risk that can result in serious injury or even death. (The company) recommends the use of bed rails if they were available. When using an Air Therapy system the caregiver is responsible for seeing that the mattress properly fits the bed frame. It is also the caregiver's ultimate decision whether or not to use bed rails with the patient. Interview, on 05/07/11 at 10:00 AM, with RN #1 the Extended Care Facility (ECF) Coordinator revealed the facility used one (1) standard size air mattress, the Alternate, that had been pre-approved and contracted for any resident of the facility who needed one. The ECF Coordinator stated a company representative installed the air mattresses with half side rails up. She explained whatever was up when the representative left the facility was what the facility implemented. The Coordinator stated side rails were not contraindicated for use with the air mattress; however, explained the facility did not assess a resident to determine the bed's appropriateness and safety before utilizing it for the resident. Review of Resident #1's clinical record revealed the facility admitted Resident #1 on 08/27/07, with [DIAGNOSES REDACTED]. Review of Resident #1's Side Rail assessment dated [DATE], revealed "resident does not use side rail to assist in turning but the benefit of having bilateral half side rails up outweighs the risk." On the 12/29/10, the quarterly update of the Side Rail Assessment, detailed that Resident #1 "uses upper half side rails for positioning and turning during changes." Review of the Nurse's Notes and physician's orders [REDACTED].#1's after the facility assessed and determined the resident had three (3) Stage I pressure sores to the coccyx, on 03/09/11. ECF Coordinator interview, on 05/07/11, revealed the facility implemented the use of half side rails with the air mattress because the air mattress representative did so upon demonstration. She stated the facility did not conduct an assessment to determine safety and appropriateness regarding Resident #1's use of the air mattress with half side rails engaged. Review of the 03/15/11 Side Rail Assessment, quarterly update, revealed Resident #1 "will occasionally use half side rails during personal care for turning and changing positions."; however, there was no documented detail what the determined benefits versus risks were for Resident #1. Rather the document detailed the answer "no" to, "Is there a risk to the resident if side rails are used? " and "Does the side rail alternatives/interventions create more risks than side rail use?" Review of the assessment revealed explanations of the risks verses benefits were only required with "yes" answers. Additionally, there was no documented evidence the facility had considered the use of the air mattress and the side rails as a contributing factor in determining appropriateness or risk versus benefit. While the assessment detailed the resident would use the half side rail during personal care for turning and repositioning, interview with State Registered Nurse Assistant (SRNA) #1, on 05/12/11 at 4:45 PM, revealed she had not observed Resident #1 use the side rail for mobility. The SRNA stated the resident required total care and the resident did not assist staff with care. Interview, on 05/11/11 at 12:20 PM with LPN #1, revealed "the resident can't use the side rail". Review of the Minimum Data Set (MDS) Assessment, dated 03/16/11, revealed the facility assessed the resident as severely impaired in cognitive skills for daily decision making and totally dependent for assistance with Activities of Daily Living (ADL's). Further review of the MDS revealed the facility assessed the resident as totally dependent upon staff with bed mobility and transfer, requiring two (2) staff for assistance. This assessment detailed side rails were not a restraint for Resident #1. Review of the Comprehensive Care Plan, dated 03/23/11, revealed Resident #1 was totally dependent on staff for all ADL's and required the assistance of two (2) staff persons for turning, positioning and transfers. Interview, on 05/06/11 at 3:10 PM with LPN #4, the MDS Assessment Coordinator, revealed "I don't believe the resident could move enough to get over to the side. I think she was repositioned improperly." She explained the facility would address the air mattress for the resident for care of skin breakdown. In additional interview the MDS nurse revealed the facility had no written assessment protocols to evaluate the safety needs of residents when they were put on an air mattress. Interview with the Extended Care Facility (ECF) Coordinator, who was responsible for verifying the accuracy of the MDS assessment, on 05/04/11 at 12:45 PM, revealed she did not believe Resident #1 could move in bed. However interview with SRNA #4, on 05/04/11 at 1:50 PM, revealed Resident #1 "moved around on the air mattress a lot." The SRNA stated the nurses didn't think the resident moved, but he/she did. The SRNA explained the resident moved his/her legs up and down and when the resident moved the leg his/her body would move and would squirm when he/she was in pain. SRNA #4 stated she told the nurses the resident moved a lot and she felt the air mattress was not safe for the resident because of how much the resident moved. Interview with SRNA #2, on 05/04/11 at 12:45 PM, revealed "we had to scoot her over three (3) times in four (4) hours one night". The SRNA explained the resident kept getting too close to the edge. SRNA #2 stated the resident does "wiggle" around and move quite a bit. Interview with LPN # 3, on 5/12/11 at 4:45 PM, revealed several times she observed Resident #1 move in bed to the side nearest the door (the side the resident was entrapped). The LPN stated "I don't know how he/she moved; I would just find him/her. I don't know how he/she got there. I would holler for an aide to help me get him/her back to the center. I can't say how often, not real often. But other people didn't get over like he/she did." Interview with LPN #2, on 05/04/11 at 2:00 PM, revealed "the resident moved easier on the air mattress. I think (he/she) slid out of the bed. (The resident) was on (his/her) side when it happened. I have seen the resident on (his/her) back over toward the edge of the bed a lot. I had to reposition (him/her). (Resident #1) did move (his/her) legs a lot; that could have caused (him/her) to scoot to the side. I can see that if the resident got over to the edge of the mattress (while lying) on (his/her) side, the resident could roll out over the side of the bed". Interview with LPN #7 revealed on 05/04/11 at 2:10 PM that Resident #1 "moves toward one side more". Interview with State Registered Nurse Assistant (SRNA) #2, on 05/04/11 at 12:45 PM, revealed she positioned Resident #1 on his/her side in the center of the bed on 04/17/11 at 3:00 AM. Review of Nurse's Notes's, dated 04/17/11 at 5:20 AM, written by Licensed Practical Nurse (LPN) #1, revealed upon entering Resident #1's room he found the resident wrapped up in the bed linen, on the floor leaning against the bed. The resident's right arm and shoulder was wedged between the air mattress and the side rail. The resident was resting on his/her knees (on the floor). The LPN immediately called for LPN #2 to assist and assess the resident for injuries before moving him/her. The side rail was let down and the LPNs placed the resident back in bed. The LPNs noted red areas to Resident #1's right abdomen and bilateral knees and great toes. The LPN stated in this nurse's note that the resident's mental status was difficult to evaluate due to his/her [DIAGNOSES REDACTED]. Review of the Nurse's Notes, dated 04/23/11, the resident was diagnosed with [REDACTED]. Observations at various times during the complaint investigation revealed the resident was laying on an air mattress in a low bed with raised half side rails on: 05/03/11 at 11:00 AM and 1:30 PM; 05/04/11 at 1:30 PM and 4:00 PM; 05/05/11 at 10:30 PM, 01:00 PM and 3:00 PM; 05/10/11 at 1:00 PM and 3:00 PM; 05/12/13 at 11:00 AM and 3:00 PM and 05/13/11 at 4:00 PM. Interview, on 05/07/11 at 10:00 AM with RN #1, the ECF Coordinator, revealed there was no documented evidence the facility assessed Resident #1 or any resident for safety and appropriateness before placing a resident on an air mattress with raised half side rails: She stated, "We have no specific form of assessment; only the nursing assessments during care." The Coordinator stated the facility's only assessment was the Side Rail Assessment form and all the residents half side rails were assessed as enablers for mobility. She stated the facility had no restraints.

Based on observation, interview, review of the facility's policies and procedures, and record review it was determined the facility failed to update the care plan related to the new intervention of an air mattress with bilateral half side rails for one (1) of three (3) sampled residents (Resident #1). On 03/09/11, the resident was ordered an air mattress for the treatment of [REDACTED]. On 04/17/11, Resident #1 was found entrapped between the side rail and the air mattress. Per the Nurse's Note, the resident was assessed to have redness to the abdomen, knees, and great toes. On 04/23/11, the resident complained of pain and an x-ray was ordered. The resident was diagnosed having a broken femur. Based on the above findings it was determined the facility' failure to update and revise the resident's care plan in order to ensure the resident's safety, contributed to unsafe conditions that had caused or were likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/12/11 and was determined to exist on 04/17/11, and is ongoing. The findings include: Review of the facility's Side Rail Policy and Procedure, under Procedure revealed, "1.) Each resident shall be assessed for the use of side rail(s) upon admission. 2.) Ongoing assessment for the use of side rail(s) shall be conducted according to the resident's (non PPS) RAI schedule. 3.) When it has been determined that the resident shall benefit from the use of a side rail(s), it shall be included in the comprehensive plan of care and the nurse assistant care plan. 4.) When the use of the side rail(s) meets the definition of a physical restraint then the Physical Restraint Policy and Procedure shall be implemented." Review of Resident #1's clinical record revealed the facility admitted Resident #1 on 08/20/07, with [DIAGNOSES REDACTED]. Review of the clinical record revealed physician orders, dated 03/09/11, for an air mattress for the treatment of [REDACTED]. Review of the User Instruction Manual for the Alternate Mattress System (the bed Resident #1 used) stated on page 5, "Seven Zones of Bed Rail Entrapment": WARNING: Bed rail entrapment is a serious health risk that can result in serious injury or even death. (The company) recommends the use of bed rails if they were available. When using an Air Therapy system the caregiver is responsible for seeing that the mattress properly fits the bed frame. It is also the caregiver's ultimate decision whether or not to use bed rails with the patient. Review of the 03/15/11, Side Rail Use assessment revealed the resident used the half side rails for positioning and turning. However, there was no evidence the facility assessed the use of the side rails with the air mattress. Review of the MDS assessment dated [DATE], revealed the facility assessed the resident as having both long and short term memory deficit and as being severely impaired in cognitive skills for daily decision making. Further review revealed the facility assessed Resident #1 to be totally dependent on staff's assistance for bed mobility and transfer, requiring the physical assistance of two (2) persons. The facility assessed the resident to have limited range of motion of the upper extremity on one side and impairment on both sides for the lower extremities. Review of the Comprehensive Plan of Care, dated 03/23/11, revealed the resident was to be transferred with a lift and the assistance of two (2) staff; 1/2 upper side rails for positioning and enable; and, an air mattress for the bed. However, there were no interventions on the care plan for increased monitoring for safety once the intervention of an air mattress with half side rails was added to the care plan for the treatment of [REDACTED]. Review of the Nurse's Notes, dated 04/17/11 at 5:00 AM, written by Licensed Practical Nurse (LPN) #1, revealed "upon entering the room noted resident to be wrapped up in bed linen on the floor leaning against bed. Resident appeared to be wedged by right upper arm and shoulder between the air mattress and side rail. Resident resting on knees. Immediately called for other nurse on duty to assist. Resident assessed prior to moving. Side rail let down as the other nurse stabilized the resident. Resident was then, with the assist of two (2) persons, placed back in bed. Red areas were noted on the right side of the abdomen, bilateral knees and bilateral great toes. Resident appeared to be absent of acute injury." Interview with the MDS Coordinator LPN #4, at 3:10 PM on 05/06/11 revealed she believed the Comprehensive Care Plan was appropriately updated on 03/09/11 when the intervention of a "New order for an air mattress to bed" for the treatment of [REDACTED]. However, the facility presented no documented evidence that they assessed the use of the side rails and air mattress for safety or added new interventions to the care plan to ensure the safety of the resident through increased monitoring and continuous assessment once he/she was placed on the air mattress with raised half side rails. Interview with the Extended Care Facility (ECF) Coordinator, Registered Nurse (RN) #1, on 05/05/11 at 3:00 PM revealed no one had assessed if residents with raised side rails were at risk for entrapment and there was no formal assessment or document for this purpose. The ECF Coordinator stated that the appropriateness of the air mattress was determined by the historical use of the one preapproved air mattress and by observation during routine care. Per interview the facility's process for protecting residents from side rail entrapment was to provide observation and monitoring during rounds and routine care.

Based on interview and record review, it was determined that Immediate Jeopardy identified during the Abbreviated Survey concluded on 05/13/11 had been removed on 05/24/11 related to revision of Care Plans; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the development and implementation of the Plan of Correction (POC) as related to revision of Care Plans. In addition, based on observation, interview, and record review during the Revisit Survey on 06/03/11, it was determined the facility failed to ensure Comprehensive Plans of Care were reviewed/revised for one (1) of six (6) sampled residents (Resident #5). Resident #5's Comprehensive Plan of Care was not revised to include physician's orders [REDACTED]. In addition, the Plan of Care was not revised to reflect the physician's orders [REDACTED]. Also, the Plan of Care was not revised to reflect the resident's fall sustained on 05/21/11 with interventions to prevent further occurrences. The findings include: Review of Resident #5's medical record revealed the facility admitted the resident on 08/31/10 with [DIAGNOSES REDACTED]. Review of the Resident Assessment Protocol Summary (RAPS) from the most recent Full Minimum Data Set (MDS) Assessment, dated 09/09/10 revealed the resident was at risk for falls, had a bed and chair alarm, and was assisted with transfers and bed mobility. Further review revealed the resident had impaired long term and short term memory loss and her/his needs were anticipated by nursing. Review of the physician's orders [REDACTED]. Further review revealed orders for the resident to be up with the assistance of two (2), and full weight bearing with a rolling walker and assistance of two (2). Review of a "Resident Falls Assessment" Form revealed the resident sustained [REDACTED]. The section which stated, "ways to prevent this fall from reoccurring" stated the daughter should request assistance to walk and transfer the resident. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as severely impaired in cognitive skills for daily decision making, as having verbal behaviors towards others, resisting care, and as requiring limited assistance of one person with transfers and ambulation, even though the physician's orders [REDACTED]. Review of the Comprehensive Plan of Care, last reviewed on 05/25/11 revealed the resident was at risk for falls related to medications, no safety awareness, and a history of behavior problems. There were several interventions noted; however, there was no intervention noted for a bed and chair alarm. In addition, the Plan of Care revealed interventions to transfer the resident with the assistance of two (2) and to ambulate the resident with the assistance of one (1) and a gait belt. There was no documented evidence the Plan of Care was revised to reflect the physician's orders [REDACTED]. Further review of the Comprehensive Plan of Care last reviewed on 05/25/11, revealed there was no indication the resident had sustained a fall on 05/21/11, and there were no interventions listed to ensure the daughter received assistance to walk and transfer the resident. Continued review revealed the Comprehensive Plan of Care, last reviewed on 05/25/11, revealed the resident had mood and behavior problems, and resisted care at times which was related to [DIAGNOSES REDACTED]and Mental Illness. The goal stated the resident would be safe with no injuries to self. However, there was no Plan of Care to address the resident's behavior related to the need for a wanderguard, and no indication the resident had a wanderguard in place. In addition, review of the Care Card (reference used for the aides related to care needs) revealed there was no indication the resident had interventions for a bed and chair alarm, or interventions for a wanderguard. In addition, the Care Card had interventions for the assistance of two (2) for transfers and the assistance of one (1) for ambulation, despite the physician's orders [REDACTED]. There was no documented evidence of interventions for two (2) to ambulate the resident with a rolling walker as per the physician's orders [REDACTED]. In addition, there were no interventions to ensure the daughter received assistance to walk or transfer the resident. Observation of Resident #5, on 06/02/11 at 3:45 PM, revealed the resident was in bed and a bed alarm was noted. Observation, on 06/03/11 at 11:30 AM, revealed the resident was in the diningroom in a wheelchair with an alarm and a wanderguard was attached to the wheelchair. Interview on 06/03/11 at 12:00 PM and 5:30 PM with the Extended Care Facility (ECF) Coordinator, revealed the bed/chair alarm and the wanderguard should have been on the Comprehensive Plan of Care because that was the main tool to refer to when implementing and evaluating the effectiveness of an intervention. She further stated, if the resident had a wanderguard in place, there should have been a Care Plan to address the resident's wandering behaviors. Continued interview revealed the Plan of Care should have been revised to include two (2) staff to ambulate the resident as physician's orders [REDACTED]. Further interview revealed the facility did not have a Policy related to Care Plans. Interview on 06/03/11 at 5:15 PM with the MDS Coordinator revealed she was responsible for completing MDS's, and developing Care Plans and both she and the staff nurses were responsible for revising Care Plans. Continued interview revealed she revised the Plan of Care during the Quarterly Assessment for Resident #5 in 05/11. She stated she reviewed physician's orders [REDACTED]. She further stated she did not know why she had missed the bed and chair alarm, as well as the wanderguard, when revising the Plan of Care and Care Card in 05/11. She stated she also should have included the gait belt and rolling walker on the Care Card. The MDS Coordinator stated she was unaware there was a physician's orders [REDACTED]. Continued interview revealed she would be responsible for updating the Plan of Care after a fall and remembered discussing the resident's fall at the morning meeting. She stated the daughter was aware the resident needed two (2) people to transfer the resident as well as a gait belt and walker for ambulation because the daughter visited three (3) to four (4) times a week; however, the daughter was not compliant and would transfer the resident herself. Non-compliance continued to exist at a S/S of an "D" as the facility had not completed the development, implementation, and evaluation of the Plan of Correction (POC) related to revision of Care Plans. Interview with the ECF, on 06/03/11 at 4:15 PM, revealed the QA Committee would review information to ensure the POC was implemented and evaluate the effectiveness of the POC to ensure compliance.

Based on observation, interview, review of the facility's policies, and record review it was determined the facility failed to adequately assess for safety related to the use of an air mattress with bilateral side rails, identify potential hazards and environmental risks, and ensure adequate supervision to prevent accidents for one (1) of three (3) sampled residents (Resident #1). On 04/17/11, Resident #1 was found with his/her arm and shoulder entrapped between the air mattress and the side rail with the resident's knees on the floor. On 04/23/11, the resident's left knee began to swell and the resident demonstrated signs of pain with leg movement. X-rays were ordered and a fracture of the left femur was identified. Based on the above findings it was determined the facility's failure to have an effective system in place to assess residents for safety when utilizing half side rails with an air mattress had caused, or was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on 05/12/11, and was determined to exist on 04/17/11, and is ongoing. The findings include: Review of the "Side Rail Policy and Procedure", undated, revealed "each resident shall be assessed upon admission and according to the Resident Assessment Instrument (RAI) to determine the rationale for the use of any type of side rail(s), to determine the benefit(s) of their use and to identify the risk factor(s) associated with side rail use that are specific to each resident. When it has been determined that the benefits of the use of side rails outweigh the risk factor(s), side rail(s) may be utilized by the resident." At that point, the use of the side rail(s) "shall be included in the comprehensive plan of care and the nurse assistant care plan." Review of the "Resident Restraint Policy", effective date 10/01/08, revealed no information related to reassessing the use of a restraint after the resident had an accident (fall) which may be related to the use of a restraint. Review of Resident #1's clinical record revealed the facility admitted Resident #1 on 08/20/07, with [DIAGNOSES REDACTED]. Review of Nurse's Notes on 03/09/11 revealed a status change to the resident's condition: "Resident has three (3) small Stage I areas on coccyx." The physician was notified and an order was received and carried out. Review of Physician's Telephone Orders dated 03/09/11, revealed an air mattress was ordered to prevent skin breakdown. Review of the Nurses's Note dated 03/10/11, revealed the resident had half side rails for assistance in turning and repositioning. There was no documented evidence in the resident's clinical record that the facility had assessed the resident for the use of bilateral half side rails with the physician ordered air mattress prior to the implementation of their use. Review of the quarterly Side Rail Assessment on 03/15/11 revealed the resident "will occasionally use half side rails for positioning and turning during changes." Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as severely impaired in cognitive skills for daily decision making and totally dependent for assistance with Activities of Daily Living (ADLs). The facility assessed the resident as totally dependent for bed mobility and transfer, requiring the physical assistance of two (2) persons, as well has having no history of falls, but identified as at high risk for falls. Review of the 03/16/11 MDS revealed that bed rails were not assessed as a restraint. Review of the Comprehensive Care Plan, revised on 03/23/11, revealed a falls care plan with interventions which included half upper side rails for positioning enabler, keep bed in lowest position and locked, to anticipate needs and check frequently, and seizure precautions. There was no evidence the facility had implemented interventions to address the use of side rails with an air mattress. Review of the Nurse's Notes written by Licensed Practical Nurse (LPN) #1, on 04/17/11 at 5:00 AM revealed "upon entering room noted resident to be wrapped up in bed linen and on floor leaning against bed. Resident appeared to be wedged by right upper arm and shoulder between air mattress and side rail. Resident resting on knees. Immediately called for other nurse on duty to assist. Resident assessed prior to moving. Side rail let down as other nurse stabilized resident. Resident then, with two (2) person assist, placed in bed. Noted red areas to right side of abdomen, bilateral knees with redness and bilateral great toes with redness. Resident appeared to be absent of acute injury." Review of the clinical record for Resident #1 revealed no documented evidence that any safety assessment was completed after the incident on 04/17/11. Further review of the Nurse's Notes revealed on 04/23/11 at 11:45 AM, revealed the charge nurse was called to evaluate the resident's left knee which was swollen with no warmth to the touch or bruising noted. The resident was able to extend his/her lower leg but grimaced and moaned with movement. The physician was notified and orders were received to x-ray the left knee. The x-ray report was called to the attending physician indicating a fracture to the left femur and orders were received to apply #16 knee immobilizer to the left knee and leg. Observations of Resident #1 on at various times during the complaint survey revealed the resident was now laying on a low bed with half side rails raised on: 05/03/11 at 11:00 AM; 05/04/11 at 10:00 AM and 1:00 PM; 05/05/11 at 10:30 AM and 1:30 PM; 05/10/11 at 11:00 AM; 05/12/11 at 3:00 PM and 05/13/11 at 3:00 PM. Interview on 05/11/11 at 12:20 PM with LPN #1, who found the resident on 04/17/11 at 5:00 AM, revealed "the resident can't use the side rail." The LPN further stated he believed the resident was positioned on his/her side to closely to the side of the bed and then "stretched" to move further and rolled over the side of the bed. He stated the resident was not reassessed for safety after being placed on the air mattress with the raised half side rails because it was not "charted" by the direct care staff that the resident sometimes stretched and moved. LPN #1 stated that he assumed everybody knew the resident "stretched" so he did not communicate this to change the resident's care plan. Interview with State Registered Nursing Assistant (SRNA) #4 on 05/04/11 at 1:50 PM, revealed she had seen Resident #1 move around on the air mattress a lot and was concerned for the resident's safety. She further stated she had informed the nurses that the resident moved a lot in bed but they did not believe it. Interview with SRNA #4 revealed that on the previous pressure reducing mattress, the Flexcare mattress, Resident #1 did not move around in bed as much as on the air mattress. Interview with LPN #2 on 05/05/11 at 1:10 PM revealed she often cared for Resident #1 and stated the resident moved his/her legs a lot in bed. She said she could understand if the resident's legs went over the mattress on the side, she could roll out of the bed. She further stated Resident #1 was unable to utilize the side rail for independent bed mobility. Interview on 05/06/11 at 2:10 PM, with SRNA #3 revealed Resident #1 could kick and move his/her legs and moved about in bed. She stated the resident often slid over to the side of the bed requiring repositioning. She said she had reported this to the nurses in the past. Interview with SRNA #3 further revealed Resident #1 was not able to use the side rail independently for bed mobility. Interview on 05/12/11 at 4:45 PM with LPN #3 revealed several times she had seen Resident #1 positioned too closely to the side of the bed. LPN #3 stated she did not see the resident move and did not know how he/she moved. She stated "I would just find him/her and I would holler for an aide to help me get him/her back to the center". The LPN stated "I can't say how often, not real often. But other people didn't get over like he/she did. I didn't see the resident move but I think an air mattress can move the resident." Interview with the Extended Care Facility (ECF) Coordinator, Registered Nurse (RN) #1, on 05/05/11 at 3:00 PM revealed no one had determined if residents with raised side rails were at risk for entrapment. She stated there was no formal assessment or document for this purpose. The facility's process for protecting residents from side rail entrapment was to provide observation and monitoring during rounds and routine care. Interview further revealed it was determined in the Side Rail Assessment if side rails were being used as enablers or restraints. She continued to state that they were not required to explain specific benefits and risks for a resident when side rails were being used for mobility and positioning. The ECF Coordinator stated that the appropriateness of the air mattress was determined by the historical use of the one preapproved air mattress and by observation during routine care.

Based on interview and record review, it was determined that Immediate Jeopardy identified during the Abbreviated Survey concluded on 05/13/11 had been removed as on 05/24/11 related to failure to prevent accidents; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the development and implementation of the Plan of Correction (POC) as related to prevention of accidents. In addition based on interview and record review, it was determined the facility failed to ensure adequate supervision and assistive devices to prevent accidents for one (1) of six (6) sampled residents (Resident #5). Resident #5 sustained a fall on 05/21/11 while being transferred by the resident's daughter. Interviews with staff revealed the daughter repeatedly transferred the resident without assistance; however, there was no documented evidence the daughter was educated on the proper transfer technique prior to the fall or after the fall to prevent reoccurrence. The findings include: Review of the facility's "Fall Prevention Protocol", dated 01/26/09, revealed the Extended Care Facility (ECF) Coordinator and nurse will implement interventions specifically goal oriented to prevent further falls. The Family or Power of Attorney would be notified of interventions for the resident. These interventions would be placed on the Care Plan and documented in the Nurse's Notes. Review of Resident #5's medical record revealed the facility admitted the resident on 08/31/10 with [DIAGNOSES REDACTED]. Review of the Resident Assessment Protocol Summary (RAPS) from the Admission Minimum Data Set (MDS) Assessment, dated 09/09/10 revealed the resident was at risk for falls, was assisted with transfers, and ambulated with a walker and assist of one (1) person. Review of the physician's orders [REDACTED]. Review of a "Resident Falls Assessment" Form revealed the resident sustained [REDACTED]. The section which stated, "ways to prevent this fall from reoccurring" stated the daughter should request assistance to walk and transfer the resident. Review of the Nurse's Notes dated 05/21/11 at 5:30 PM revealed the resident's daughter yelled at staff, "Moms in the floor". Further review revealed the resident's daughter stated "I lowered Mom to the floor". The resident was assessed with [REDACTED]. There was no bruising or pain noted and the Physician was faxed related to the fall at 5:45 PM. The Physician called back at 6:00 PM related to the incident and no new orders were received. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as severely impaired in cognitive skills for daily decision making, and as requiring limited assistance of one person with transfers and ambulation, even though the Physician ordered for the resident to be up with the assistance of two (2). Review of the Comprehensive Plan of Care, last reviewed on 05/25/11 revealed the resident was at risk for falls related to medications, no safety awareness, and a history of behavior problems. There were several interventions noted; however, there was no intervention noted for a bed and chair alarm. In addition, the Plan of Care revealed interventions to transfer the resident with the assistance of two (2) and to ambulate the resident with the assistance of one (1) and a gait belt. There was no documented evidence the Plan of Care was revised to reflect the physician's orders [REDACTED]. Further review of the Comprehensive Plan of Care last reviewed on 05/25/11, revealed there was no indication the resident had sustained a fall on 05/21/11, and there were no interventions listed to ensure the daughter received assistance to walk and transfer the resident. In addition, review of the Care Card (reference used for the aides related to care needs) revealed no interventions to ensure the daughter received assistance to walk or transfer the resident. Interview on 06/03/11 at 5:15 PM with the MDS Coordinator revealed both she and the staff nurses were responsible for revising the Care Plans. She stated she was also responsible for updating the Plan of Care after a fall and remembered discussing the resident's fall at the morning meeting. She further she should have indicated on the Care Plan the fall occurred on 05/21/11. Continued interview revealed the daughter was aware the resident needed two (2) people to transfer the resident as well as a gait belt and walker because the daughter visited three (3) to four (4) times a week; however, the daughter was non-compliant with asking for assistance. Interview on 06/03/11 at 5:30 PM with the Extended Care Facility (ECF) Coordinator, revealed after a fall, the facility completed investigations as to the time of day and causative factors in order to track and trend the falls. She stated, any nurse could update a Care Plan after a fall and the Plan of Care should have been revised to indicate a fall occurred on 05/21/11 with new interventions to prevent reoccurrence. She further stated the resident's daughter was a nurse and persisted on transferring the resident without assistance. However, she stated the Care Plan interventions were reviewed with the resident's daughter including transfer technique during the Care Plan conference on 09/15/10 and 05/25/11. Continued interview revealed Licensed Practical Nurse (LPN) #6 had spoken with the daughter after the fall on 05/21/11 and explained the daughter needed to ask for assistance prior to transferring the resident. However, there was no documented evidence of the daughter being educated specifically on transfer technique before or after the fall on 05/21/11. LPN #6 was unavailable for an interview. Non-compliance continued to exist at a S/S of an "D" as the facility had not completed the development, implementation, and evaluation of the Plan of Correction (POC) related to prevention of accidents. Interview with the ECF on 06/03/11 at 4:15 PM revealed the QA Committee would review information to ensure the POC was implemented and evaluate the effectiveness to ensure compliance.

Based on observation, interview, review of the facility's internal investigation, and the air mattress User's Operational Manual, it was determined the facility failed to ensure staff thoroughly assessed the proper use of side rails with an air mattresses; failed to ensure nursing staff completed assessments and updated care plans; and, failed to ensure policies and procedures were implemented related to side rail assessments, care plans and the use of air mattress with half side rails for one (1) of three (3) sampled residents (Resident #1). Resident #1 was placed on an air mattress on 03/09/11 and the use of half side rails continued. Review of the clinical record revealed no documented evidence the facility re-assessed the side rail risk factors during the quarterly side rail assessment on 03/15/11. Resident #1 was found entrapped between the side rail and air mattress, at 5:00 AM on 04/17/11. The resident was assessed to have no injury on 04/17/11; however, on 04/23/11 the resident was identified to have a fractured left femur. Based on the above findings, it was determined the facility's failures to implement their policies and procedures, complete thorough assessments, and revise care plans related to side rails had caused or was likely to cause, serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 05/12/11 and was determined to exist on 04/17/11 and is ongoing, related to Resident #1's use of half side rails with an air mattress. Immediate Jeopardy was identified at 483.20 Resident Assessments, F278 at a scope and severity of an "J" and F280 at a scope and severity of a "J"; 483.25 Quality of Care, F323 at a scope and severity of a "J"; and, 483.75 Administration, F490 at a scope and severity of a "J". Substandard Quality of Care was identified at 483.25 F323. The findings include: The facility failed to accurately assess the risks versus the benefits of the use of side rails with an air mattress. Resident #1 was placed on an air mattress on 03/09/11 and the use of half side rails continued. Review of the clinical record revealed no documented evidence the facility re-assessed the side rail risk factors during the quarterly side rail assessment on 03/15/11. Resident #1 was found entrapped between the side rail and air mattress, at 5:00 AM on 04/17/11. The resident was assessed to have no injury on 04/17/11; however, on 04/23/11 the resident was identified to have a fractured left femur. The facility's Administration failed to ensure an effective system was in place to accurately assess residents for the use of side rails with an air mattress to ensure resident safety. The facility failed to have an effective system to ensure the Comprehensive Plan of Care was reviewed and revised following the addition of an air mattress used on the resident's bed and failed to develop interventions to protect the resident from harm due to entrapment. The Administration failed to ensure facility staff followed the facility's policy related to the assessment and care planning of side rails. In Addition the Administration failed to ensure staff followed the User Instruction Manual for the Alternate Mattress System (the bed Resident #1 used) to determine the safety of the use of the mattress with half side rails even though it stated on page 5, "Seven Zones of Bed Rail Entrapment": WARNING: Bed rail entrapment is a serious health risk that can result in serious injury or even death. (The company) recommends the use of bed rails if they were available. When using an Air Therapy system the caregiver is responsible for seeing that the mattress properly fits the bed frame. (Refer to F278, F280, and F323) Interview with Extended Care Facility Coordinator, on 05/05/11 at 3:00 PM, revealed the facility had no system in place to determine if residents with side rails were at risk for entrapment and that it was an inherent process, done by observation and monitoring only, during routine care. Further Interview with the Extended Care Facility (ECF) Coordinator on 05/13/11 at 3:30 PM, revealed she provided oversight for resident care by attending the Standards of Care Meetings, which address changes in resident care, and by attending the Care Plan Meetings for each resident. The Administrator was on leave during the abbreviated survey and was unavailable for interview.

Based on interview and record review, it was determined that Immediate Jeopardy identified during the Abbreviated Survey concluded on 05/13/11 had been removed as on 05/24/11 related to accuracy of Assessment; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the development and implementation of the Plan of Correction (POC) as related to accuracy of Assessment. The findings include: Review of the acceptable Allegation of Compliance (AOC), received on 06/01/11 , revealed the facility reviewed and updated the Care Plans and Care Cards (reference for Nurse Aides) for all residents for proper designation of assistance levels on 05/18/11 through 05/20/11 and again on 05/23/11 to ensure the residents' ability to move, turn, and reposition was current. A new Positioning Tool was implemented on 05/17/11 for eleven (11) residents who were identified at risk for improper positioning related to skin integrity, and side rail reduction. The review of residents' Activities of Daily Living (ADL's) which included bed mobility, turning, and repositioning, transferring, locomotion, dressing, eating, toileting, personal hygiene and bathing was to be checked on Tuesday by the MDS Coordinator and Extended Care Facility (ECF) Coordinator and brought to the morning meeting for accuracy. Education for all aides and nursing team members was provided by the ECF Coordinator and Charge Nurse on completing accurate communication and documentation for all residents ADL's and changes for residents ADL status on 05/21/11 through 05/23/11. The ECF Coordinator was to perform daily audits of all Minimum Data Sets (MDS's), Care Plans and Care Cards to ensure the reviews were completed and accuracy was maintained until the Immediate Jeopardy was resolved. The Quality Assurance Committee met 05/23/11 to review and approve the Allegation of Compliance and attachments. Record review revealed the inservices and audits were completed as noted in the AOC, and the Positioning Tool was implemented and being utilized. Interview with the Charge Nurse, MDS Coordinator, Licensed Practical Nurse (LPN) #6, and Certified Nursing Assistants (CNA's) #5, #6, and #7 revealed they had recieved inservices as stated in the AOC and were aware of the information related to the inservice, and were utilizing the Positioning Tool. Interview with the Chief Nursing Officer (CNO), Performance Improvement Coordinator, and Extended Care Facility (ECF) Coordinator on 06/03/11 at 4:00 PM revealed the facility's Quality Assurance (QA) Committee which included the Medical Director met monthly and a Meeting was held 05/23/11. Continued interview revealed the Committee would continue to meet weekly until the IJ was resolved and then meet monthly to ensure compliance of accuracy of Assessments. However, non-compliance continued to exist at a S/S of an "D" as the facility had not completed the development, implementation, and evaluation of the Plan of Correction (POC) related to accuracy of Assessments. Interview with the ECF on 06/03/11 at 4:15 PM revealed the QA Committee would review information to ensure the POC was implemented and evaluate the effectiveness to ensure compliance.