Every finding on record at Woodland Oaks

Based on observation, interview, and facility policy review, the facility failed to ensure all drugs were labeled in accordance with professional standards in 5 out of 6 treatment carts and 2 out of 6 medication carts. Observation on 04/16/2025 revealed that five treatment carts and two medication carts had many multi-use patient specific lotions, powders, creams, eye drops, nasal sprays, and inhalers that were not dated after being opened. The findings include: Review of the facility's policy titled, Medication Storage in the Facility, dated November 2021, revealed when the original seal of a manufacturer's container or vial was initially broken, the container or vial would be dated, if applicable, for medications requiring a shortened expiration date. Per the policy, the nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration if applicable. Examples of medications with shortened expiration dates included insulins and inhalers. Observation on 04/16/2025 at 7:25 AM of the medication cart from the 300 Hallway revealed it contained a bottle of artificial tears, an albuterol inhaler, and another bottle of eye drops that were not dated as to when they were opened. Observation on 04/16/2025 at 7:44 AM of the treatment cart from the 100/200 Hallway revealed 15 bottles of powders of various types, three tubes of nystatin cream, and seven bottles of lotions of various types which were all opened but not dated with the date they were opened. Observation on 04/16/2025 at 8:03 AM of the treatment cart from the 500 Hallway revealed that 11 tubes of various types of creams (including diclofenac, Aspercreme, hydrocortisone, and zinc), three bottles of Cetaphil and Aveno lotions, and two bottles of Biofreeze were not labeled with the date they were opened. Observation on 04/16/2025 at 8:17 AM of the treatment cart from the 400 Hallway revealed that 22 bottles of various powders were not dated with an opened date and 15 creams were not dated as to when they were opened. Observation on 04/16/2025 at 8:23 AM of the treatment cart on the Rehabilitation Hallway revealed that one tube of opened cream (zinc) and two containers of powder (nystatin) were not labeled with an opened date. Observation on 04/16/2025 at 8:40 AM of the treatment cart on the 300 Hallway revealed nine bottles of solutions (Dekins, betadine, peroxide, and Silvadene) were opened but unlabeled as to when they had been opened. Also, 21 various types of lotions and creams were opened and not dated with the opened date. Observation on 04/16/2025 at 8:55 AM of the medication cart on the 200 Hallway revealed there was one inhaler that was not labeled with when it was opened. In an interview with Licensed Practical Nurse (LPN) 5 on 04/16/2025 at 7:34 AM, she stated if a multi-use vial of medication was not dated as to when it was opened, it could be outdated and no longer effective. In an interview with LPN2 on 04/16/2025 at 8:03 AM, she stated if medications were not dated when opened, they could be bad (expired) and not effective for the treatment of the condition they were used for. In an interview with the Wound Nurse on 04/16/2025 at 8:30 AM, she stated it was the facility's policy to date any multi-use medication when opened to make sure it was discarded prior to expiration. In an interview with the Assistant Director of Nursing (ADON) 1 on 04/17/2025 at 8:10 AM, she stated she expected staff to date multi-use bottles/tubes/inhalers when opened. She stated the date the medication was opened should be written both on the container containing the medication and any box or bag that the medication container was stored in. She stated, if the bottle was not dated but the bag or box was dated with the opened date, boxes could get mixed up or thrown away, and staff would not know when the medication expired. She stated if there was no date on either the container or the box/bag it was stored in, staff would not know when it expired. She stated the issue with not knowing the expiration date was that an expired medication could be given, and it might not be as effective. In an interview with ADON2 on 04/17/2025 at 9:20 AM, she stated staff was trained to date multi-use medications upon opening. She stated the date should be written on the pharmacy label on the medication container. She stated if the container was stored in a box or a bag, the date should also be written on those too. She stated the reason for dating the medications when they were opened was to help staff know how long the medication could be kept. In an interview with the Director of Nursing (DON) on 04/17/2025 at 1:51 PM, she stated staff should date both the bottle and the box for a medication to ensure the opened date was still known if something happened to the box. She stated if the medication and/or the box was not dated, staff risked not knowing if the medication was still good and able to be used. In an interview with the Medical Director for the facility on 04/17/2025 at 2:20 PM, she stated it was her expectation that staff date multi-use medications when opened to prevent use of expired medications. In an interview with the Administrator on 04/17/2025 at 2:42 PM, she stated she was unsure if it was the facility's practice/policy to date multi-use containers of medications with the date they were opened.

Based on observation, interview, record review, review of the manufacturer's directions for use, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and helped prevent the development and transmission of communicable diseases and infections for three (3) of three (3) sampled residents reviewed for infection control, Resident (R) 6, R8, and R19. Observation on 04/15/2025 and 04/16/2025 revealed Licensed Practical Nurse (LPN) 3 did not perform appropriate hand hygiene and don (put on) gloves when required during medication administration for R6, R8, and R19. Additional observation on 04/16/2025 revealed LPN3 did not disinfect shared equipment when required; did not disinfect R19's glucometer as directed before and after use; did not use a barrier for R19's glucometer; and touched the medication cart and other residents' insulin pens while wearing soiled gloves. The findings include: Review of the facility's policy titled, Infection Prevention Program Overview, not dated, revealed it was the goal of the infection prevention program to decrease the risk of infection in residents and personnel, monitor for occurrence of infection, implement appropriate control measures, identify and correct problems relating to infection prevention practices, and maintain compliance with state and federal regulations relating to infection prevention. Further review revealed the scope of the infection prevention program was comprised of surveillance of infections with implementation of control measures and prevention of infections, outbreak investigations, policy and procedure review/revision, staff education, quality assurance, and consultation. Review of the facility's policy titled, Preparation and General Guidelines-Medication Administration and General Guidelines, dated 11/2021, revealed hand washing and hygiene should be performed by the person administering the medication before beginning medication administration; prior to handling any medications (gloves were worn with direct contact); after coming into direct contact with the resident; before and after administering ophthalmic, topical, vaginal, rectal, and parenteral preparations; or via enteral tubes. Review of the Assure Prism Multi Blood Glucose Monitoring System Cleaning and Disinfecting Procedure, revised 08/2015, revealed the meter should be cleaned and disinfected after each use on a resident. It stated the cleaning procedure was needed to clean dirt, blood, and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The directions stated the disinfection procedure was needed to prevent the transmission of blood borne pathogens. Further review of the procedure revealed that cleaning and disinfection could be performed by using Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Super Sani Cloth Germicidal Disposable Wipes, or CaviWipes1. Further review stated the contact time for Clorox Germicidal Wipes (those used by the facility) was two minutes. Further review of the directions provided a step-by-step on how to clean the glucometer. 1. Review of R6's Face Sheet located in his Electronic Medical Record (EMR) revealed the facility admitted the resident on 12/07/2020 with medical diagnoses of diabetes mellitus with mild diabetic retinopathy, dysphagia following a cerebral infarction, and vascular dementia. Observation on 04/15/2025 at 8:05 AM of medication administration revealed LPN3 was popping the medications from the medication cards into her ungloved hand and then placing them into R6's medication cup. In an interview with LPN3 on 04/15/2025 at 8:05 AM, she stated she washed her hands prior to popping the pills out of the blister packages on the medication cards, and her hands were clean. She stated she did not pop them directly into the cup because there was not enough room in the drawer to do so. 2. Review of R19's Face Sheet located in her EMR revealed the facility admitted the resident on 05/15/2017 with the medical diagnoses of cirrhosis of the liver, hypertension, and fibromyalgia. Review of R19's Physician Orders located in her EMR revealed that she received 1 spray per nostril of fluticasone propionate, 50 mcg per spray, once daily and Systane Restore eye drops, 1 per eye, once per day. a. Observation on 04/16/2025 at 8:15 AM of medication administration revealed LPN3 placed a pulse oximeter onto the finger of R19 and did not clean the pulse oximeter, a piece of shared equipment, prior to or after use. Further observation revealed LPN3 placed the pulse oximeter onto R19's bed prior to use and then on her bedside table after use. LPN3 placed the pulse oximeter into its case without cleaning it and placed the case back onto the medication cart. b. Observation on 04/16/2025 at 8:20 AM of medication administration revealed LPN3 did not perform hand hygiene or don gloves prior to administration of R19's nose spray and eye drops. Further observation revealed she did not perform hand hygiene between the administration of the nose spray and the eye drops. LPN3 was then noted to don gloves but did not perform hand hygiene prior to putting on the gloves to take R19's finger stick blood glucose (FSBG). She also did not use a barrier for R19's personal glucometer, but instead placed it directly onto the bedside table. Further observation revealed LPN3 did not clean the glucometer prior to use or after use. She placed the uncleaned glucometer back into the storage box and put the box in R19's nightstand. LPN3 then realized she forgot the value of the FSBG and then took the uncleaned glucometer out of the storage box with ungloved hands to review the FSBG value. LPN3 was also observed obtaining the insulin pen from the medication cart wearing the gloves she wore when she performed the FSBG for R19. She was observed touching the bagged insulin pens of other residents with the dirty gloves and touching the medication cart handle, lock, and computer keyboard all while wearing those soiled gloves. 3. Review of R8's Face Sheet located in her EMR revealed the facility admitted the resident on 02/19/2013 with the medical diagnoses of osteoarthritis of the knee, hypertension, and cerebral palsy. Review of R8's Physician Orders, located in her EMR revealed she had an order for Lubricating Eye Drops, 0.5%, 1 drop per eye, once per day. Observation on 04/16/2025 at 8:35 AM of medication administration revealed LPN3 did not perform hand hygiene prior to entering R8's room nor did she don gloves to administer her eye drops. In additional interview with LPN3 on 04/15/2025 at 8:20 AM, she stated hand hygiene should be performed between residents, alcohol gel for each resident and hand washing for every third resident. She stated she was unsure when to clean and disinfect R19's personal glucometer, stating that she never cleaned it. She stated shared equipment such as the pulse oximeter needed to be cleaned after each resident. She stated she was unsure how long the contact time was for the Clorox Germicidal Wipes when using it to clean personal glucometers or shared equipment. When asked if a barrier was needed when using a resident's personal glucometer, she stated she should have used one but did not. She stated she placed the clean pulse oximeter into her scrub pocket prior to use on a resident, so it did not need a barrier. LPN3 stated she should have performed hand hygiene and placed on gloves prior to administering eye drops or nasal spray and changed her gloves and hand sanitized between the nasal spray and the eye drops. In additional interview with LPN3 on 04/15/2025 at 11:30 AM, she stated the residents' personal glucometers should be cleaned after each use, and the contact time for the wipes the facility used (Clorox Germicidal Wipes) was three minutes. In an interview with Registered Nurse (RN) 2 on 04/16/2025 at 10:47 AM, she stated pills were never to be popped out of their blister packs into an ungloved hand due to infection control practices. She stated, if the pill must be touched, it must be with a gloved hand. She stated staff should wear gloves when preparing and administering any type of medication, including pills, and gloves should be changed between medication types (eye drops to nose spray to pills to injections). She stated when gloves were changed, hand hygiene should be performed. She stated staff should never wear used gloves in the hallway, and gloves should always be worn when performing finger sticks for obtaining blood glucose values. She stated hand hygiene was to be performed before and after resident care of any type. She stated shared equipment, such as a pulse oximeter, was to be cleaned after use on each resident. She stated personal glucometers should also be cleaned after each use. She stated both personal equipment and shared equipment should be placed on a barrier during use to keep them and the area clean. In an interview with the Assistant Director of Nursing (ADON) 1 on 04/17/2025 at 8:10 AM, she stated a nurse should never pop pills into their ungloved hand. She stated gloves should be worn when preparing medications, and the medication should be popped directly into a medication cup, which was placed on a barrier during medication preparation and administration. She stated the eye drops or nasal spray containers should be placed in a medication cup as a barrier when taking them into a resident's room. She stated gloves should be changed with each new type of medication and between each resident, but staff did not need to perform hand hygiene between glove changes. She stated after every third resident, staff should wash their hands instead of hand sanitizing with alcohol-based hand gel. She stated staff should never wear used gloves into the hallway and should never touch the medication cart or medications with soiled gloves. She stated shared equipment should be cleaned after each resident use. She stated barriers should be placed for shared and single use equipment when placing them on surfaces. In an interview on 04/16/2025 at 9:27 AM with ADON2, who was also the Infection Preventionist and the Staff Educator, she stated when preparing or administering medications staff should never pop pills out into ungloved hands because of contamination. She stated staff should hand sanitize between residents when providing care such as administering medications. She stated gloves should always be worn when administering nose spray, eye drops, injections, when giving oral chemotherapy, when applying patches such as a fentanyl patch, and when applying cardiac medication pastes. She stated when staff was done with resident care, they should discard their gloves prior to exiting the room and never wear them in the hallway or when touching the medication cart. She stated staff did not need to change gloves between medications such as eye drops and nose sprays. She stated hand hygiene should always be done before and after any resident care, prior to and after performing a procedure, and whenever staff encountered bodily fluids. She stated shared equipment as well as personal equipment like glucometers, should be cleaned/disinfected after each use. She stated glucometers were to be wiped down with the Clorox Germicidal Wipes and kept wet for three minutes. She stated staff should never touch the glucometers without gloves, and glucometers should be placed onto a barrier prior to use as should shared equipment. She stated when staff did not wear gloves or perform hand hygiene they put themselves and the residents at risk for contracting an illness and spreading infections. In an interview with the Director of Nursing (DON) on 04/17/2025 at 1:51 PM, she stated staff should never touch pills with ungloved hands nor should staff touch resident food or perform personal care without gloves due to infection issues. She stated staff should wear gloves when administering eye drops, nose sprays, or giving injections. She stated shared equipment should be cleaned after each use/each resident, and personal glucometers should also be cleaned/disinfected after each use. She stated the contact time for the disinfectant was three minutes. She stated glucometers and the pulse oximeter should be placed on a barrier when in a resident's room to keep them clean. She stated staff should never touch a glucometer with ungloved hands. She stated hand hygiene should be done before and after any action when a staff member touched a resident or their surroundings. She stated staff should perform hand hygiene between glove changes and should never wear soiled gloves from a resident's room into the hallway. She stated her expectation was that between each medication type administered, gloves should be changed. In an interview with the Medical Director on 04/17/2025 at 2:20 PM, she stated staff should perform hand hygiene after they performed care or touched a resident's food or belongings. She stated nurses should not be popping medications into their ungloved hands, and she wanted them to wear gloves when they administered nasal sprays, eye drops, or injections. She stated shared equipment should be cleaned after each resident, and personal glucometers should be cleaned after each use. In an interview with the Administrator on 04/17/2025 at 2:42 PM, she stated hand hygiene should be performed when providing care such as meal setup, incontinence care, or when staff encountered bodily fluids. She stated she expected staff not to pop pills into their ungloved hand prior to administration because it was an infection prevention issue. She stated staff should wear gloves when administering nasal sprays, eye drops, and injections but did not need to wear gloves when giving pills. She stated staff should perform hand hygiene when changing gloves and should remove gloves and hand sanitize after performing a finger stick blood glucose (FSBG). She stated staff should never wear used gloves into the hallway or touch the medication cart with soiled gloves. She stated multi-use equipment should be cleaned after each use/between residents.

Based on interview, record review, and review of the facility's policies, the facility failed to document a resident's concern for lost, missing, or stolen items for 1 of 21 sampled residents, Resident (R) 363. In interviews with the Complainant and the facility's staff, they stated R363's dentures were lost, missing, or stolen. However, the facility failed to document the missing, lost, or stolen item on the grievance log, provide a facility investigation, and offer a replacement for the missing, lost, or stolen dentures. The findings include: Review of the facility's policy titled, Reporting Abuse to Facility Management, undated, revealed each resident had the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation. Review of the facility's policy titled, Grievance Policy, effective 01/27/2025, revealed the Administrator was responsible to ensure the investigation of grievances and complaints. Per the policy, the Administrator could designate the Social Services Director or a different designee who would serve as the Grievance Coordinator. Review of R363's Face Sheet, from the residents's closed electronic medical record (EMR), revealed the facility admitted the resident on 03/08/2024 with diagnoses of cellulitis of the left lower limb, injury of the head, and chronic kidney disease. Review of R363's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/09/2024, from the residents's closed EMR, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of nine of 15, indicating she was moderately impaired. Review of 363's Comprehensive Care Plan (CCP), created on 03/09/2024, from the residents's closed EMR, revealed R363's oral/dental status was resident wears full dentures. Review of the facility's Grievance Logs, dated April 2024, revealed the missing dentures were not documented as missing, lost, or stolen. Review of R363's Progress Note, dated 04/06/2024, written by the Social Services Director (SSD), and located in R363's closed EMR, revealed the resident's Guardian was informed that a dental company had been contacted by the SSD and required more information to schedule an appointment for R363. Per the note, the Guardian stated, She would call [the dental company] on Monday. Review of the Administrator's typed note, located in R363's closed EMR and dated 04/15/2024, revealed she [the Administrator] spoke with the Complainant about the lost dentures and stated the resident thought he threw them away. The note stated she informed the Complainant she had looked in the laundry room and kitchen. The typed note further revealed the Administrator would continue to look for the dentures, and she gave the Complainant information on denture services in the area. During an interview with the Complainant on 04/15/2025 at 6:34 PM, she stated once she got R363 home and noticed his dentures were missing, she contacted the facility and spoke with the SSD. The Complainant stated the SSD told her she would look for the dentures and give her a call back with any information if they were found or not. The Complainant stated the SSD did call her back and told the Complainant she could not find the missing dentures. The Complainant stated that at no time did the SSD imply the facility was going to replace the resident's missing dentures. The Complainant stated that after two weeks of no communication from the facility, she received a call from the SSD stating she needed to call a dental company to provide more information to schedule an appointment. The Complainant stated she did not bother calling the facility back because she had already taken the resident to an appointment, and the dentures were in the process of being made. The Complainant stated she paid $800 for the replacement dentures for R363. During an interview with State Registered Nurse Aide (SRNA) 7 on 04/17/2025 at 1:40 PM, she stated she had never received any education on receiving grievances from residents. During an interview with Licensed Practical Nurse (LPN) 9 on 04/17/2025 at 1:41 PM, she stated there was a paper residents could fill out or a form a facility staff could complete and give to the SSD for grievances. LPN9 stated she could also tell her unit manager, and the unit manager would write the grievance on their report sheet to pass to the next nurse on duty if an item was not found on her shift. During an interview with LPN10 on 04/17/2025 at 1:44 PM, she stated she would tell a nurse on duty if a resident had a grievance to report. LPN10 stated she thought there was a piece of paper a staff member could fill out concerning a grievance. LPN10 stated she might have seen the grievance form before, but she was unsure. During an interview with the Social Services Director (SSD) on 04/17/2025 at 2:49 PM, she stated all grievances were taken seriously and were investigated. The SSD stated once a grievance was filed, she tried to locate the missing item. She stated if the item was not found, the facility would replace the missing item. The SSD stated she did not think to complete the grievance form and conduct an investigation for the missing dentures because she told the Complainant the resident had thrown them away. The SSD stated she called the dental company to get the resident an appointment to replace the dentures. The SSD stated, during the phone call with the dental company, she did not have all the resident's information. The SSD stated she then called the Complainant to explain to her she needed to call the dental company to provide more information, so the resident could be scheduled for an appointment for the dentures. The SSD stated, after this communication with the Complainant, she had not had any further ones. During an interview with the Director of Nursing (DON) on 04/17/2025 at 3:52 PM, she stated the Grievance Compliance Officer for the facility was the SSD. She stated if items like dentures were missing, staff would look through the trash, as she had found many residents took their dentures out of their mouths after dinner, wrapped them in a napkin, and placed them on the food tray. The DON stated when residents placed their wrapped dentures on their food tray, if the SRNA's picked up the food trays and did not notice the wrapped dentures, the dentures mistakenly went in the trash. The DON stated staff working in resident care had been educated only to tell the Administrator, SSD, or DON of any compliant or grievance they received from a resident. The DON stated when she received a grievance, she investigated as thoroughly as possible. She stated she had the SSD contact the family to get any information about the grievance, and she scheduled a follow-up appointment to make sure the grievance was resolved. During an interview with the Administrator on 04/17/2025 at 3:21 PM, she stated any resident could file a grievance. The Administrator stated the grievance forms were located at the nurse's station. However, she stated staff was accustomed to going to the SSD, Assistant Director of Nursing, or DON to discuss a grievance filed by a resident. The Administrator stated if an item was reported missing, she, the SSD, and all facility staff tried to locate the item. She stated if the item could not be located, the facility would replace the item. The Administrator stated once a grievance had been filed, she had five working days to revisit the grievance and provide a resolution.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure that services provided met professional nursing standards for 2 of 3 sampled residents, Residents (R) 6 and R19. On 04/15/2025 at 8:05 AM, Licensed Practical Nurse (LPN) 3 was observed during medication administration to give the medication cup containing each resident's medication to R6 and R19, but she did not to stay and watch the residents take their medications. The findings include: Review of the facility's policy titled, Preparation and General Guidelines: Medication Administration, dated November 2021, revealed residents could self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Further review revealed the resident was always observed after administration to ensure the dose was completely ingested. Review of Resident (R) 6's Face Sheet located in his Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with medical diagnoses of diabetes mellitus with mild diabetic retinopathy, dysphagia following a cerebral infarction, and vascular dementia. Review of R19's Face Sheet located in her EMR revealed the facility admitted the resident on 05/15/2017 with the medical diagnoses of cirrhosis of the liver, hypertension, and fibromyalgia. Observation of medication administration on 04/15/2025 at 8:05 AM revealed Licensed Practical Nurse (LPN) 3 delivered a cup of pills to R6. LPN3 then left the room prior to R6 taking his medications. She returned to her medication cart, located in the hall at the door of R6's room. LPN3 stood with her back to R6 while he was taking his medications, not observing him take the pills. LPN3 began preparing medications for the next resident, R19. LPN3 would periodically ask R6 if he was finished taking his medications while continuing to prepare medications for R19. In an interview with LPN3 on 04/15/2025 at 8:05 AM, when asked if she observed residents take their medications, she stated she would observe any confused resident or resident that she was unfamiliar with take their medications. She further stated she did not need to observe R6 because she knew he would take it without her needing to observe him. Further observation of medication administration on 04/15/2025 at 8:15 AM revealed LPN3 brought R19's medications into R19's room. She gave R19's nose spray, eye drops, took a finger stick blood glucose, and administered R19's insulin. However, LPN3 did not stay afterwards to observe R19 take her pill form medications. Instead, LPN3 returned to the hallway to the medication cart and began preparing medications for the next resident. In an interview on 04/16/2025 at 10:47 AM with Registered Nurse (RN) 2/Unit Manager she stated during medication administration her expectation was that staff observed and aided the resident in taking their medications. In an interview on 04/17/2025 at 9:17 AM with Assistant Director of Nursing (ADON) 2, who was also the Infection Preventionist and Staff Educator, she stated it was not acceptable for a nurse to leave pills in the room with a resident and go to the medication cart or in the hallway while the resident was taking their pills. She stated residents should be observed to ensure they took their medications. In an interview on 04/17/2025 at 1:51 PM with the Director of Nursing (DON), she stated it was not acceptable for nursing staff to not observe residents take their medications. She stated residents possibly could not take the medications, spill them, or another resident could take them. In an interview on 04/17/2025 at 2:42 PM with the Administrator, she stated it was her expectation that during medication administration, the nurse remained in the room with the resident to ensure the medication was taken.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Center for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observations and interviews during the survey revealed the staff failed to appropriately disinfect reusable resident medical equipment in use for six (6) out of eleven (11) sampled residents. The findings include: Review of the facility's policy, COVID-19 Policy and Procedure, undated, revealed medical equipment was properly cleaned and disinfected with limited sharing between residents and areas of the facility. Electronic devices were to be cleaned in between each resident use in compliance with the manufacturer's instructions and disinfected utilizing an Environmental Protection Agency (EPA) certified agent that was effective against [DIAGNOSES REDACTED]-CoV-2 (COVID-19). Per policy, if use of common equipment or items was unavoidable, the items should be adequately cleaned and/or disinfected before use on another resident. Review of the facility's policy, Environmental Infection Control Policy, undated, revealed all non-dedicated, non-disposable medical equipment used for resident care should be cleaned and disinfected utilizing EPA approved products. Review of the facility's policy, Infection Prevention Manual for Long Term Care Housekeeping Services, undated, revealed its purpose was to promote a safe and sanitary environment which was maintained by a contract service, by employees of the facility, or a combination of both. Per policy, review of choice of cleaning agents for use in patient care areas revealed a hospital-grade disinfectant/detergent registered by the EPA shall be used, and except for [MEDICATION NAME] alcohol (70-90%), antiseptic agents intended for use on skin should not be used for surface cleaning. However, review of the approved EPA hospital-grade disinfectant/detergent revealed [MEDICATION NAME] alcohol (product name Klercide 70/30) required a contact time of five (5) minutes; Virex, per the manufacturer's directions for use, required a contact time of three (3) to five (5) minutes; and Lysol wipes, per the manufacturer's directions for use, required a contact time of four (4) minutes. Review of the facility's policy, Infection Prevention Manual for Long Term Care Resident Care Equipment, undated, revealed if use of common equipment or items was unavoidable, the items should be adequately cleaned and/or disinfected before use on another resident. Review of a sterile alcohol prep pad sample, provided by the Director of Nursing (DON), and purportedly used by staff to clean shared medical equipment, revealed the pad contained 70% [MEDICATION NAME] alcohol. However, the package instructions stated intended use was for the preparation of skin prior to injection only. Observation, on 01/12/2021 at 3:53 PM, revealed State Registered Nurse Aide (SRNA) #2 left room [ROOM NUMBER] and entered room [ROOM NUMBER] without sanitizing the rolling blood pressure (BP) cuff. Then, SRNA #2 moved from A Bed, after taking that resident's BP to B Bed, and taking that resident's BP, without sanitizing the BP cuff between uses. Observation, on 01/12/2021 at 4:39 PM, revealed SRNA #2 came out of room [ROOM NUMBER] with the rolling BP cuff and entered room [ROOM NUMBER]. Further observation revealed room [ROOM NUMBER] contained two (2) residents. Interview with SRNA #2 revealed she did not disinfect the equipment appropriately. According to the facility's policy and the product label for Klercide 70/30, the contact time for disinfection was five (5) minutes, and she stated she used an alcohol pad, waiting thirty (30) seconds for it to dry between BP cuff uses. Furthermore, the alcohol prep pad package instructions stated the wipe was to be used for skin preparation prior to injection only. Observation, on 01/12/2021 at 4:45 PM, revealed SRNA #2 left room [ROOM NUMBER] and proceeded to enter room [ROOM NUMBER] with the rolling BP cuff. SRNA #2 was stopped for interview prior to entering room [ROOM NUMBER]. Interview with SRNA #2, on 01/12/2021 at 4:47 PM, revealed she had worked at the facility for three (3) months and had received Infection Control training during orientation. During the interview, SRNA #2 stated the rolling BP cuff was taken into multiple resident rooms, and all items used were to be cleaned with bleach wipes with a five (5) minute dry time, or alcohol wipes with a one (1) minute dry time. Further interview revealed bleach wipes were kept at the nurse's station or utility room, and alcohol wipes were kept in the supply closet. During the interview, SRNA #2 stated she cleaned the BP cuff between residents and stated she used an alcohol pad, waiting thirty (30) seconds for it to dry. However, the policy stated a hospital-grade EPA approved product must be used for surface cleaning, and the product with [MEDICATION NAME] alcohol 70% used at the facility was Klercide, with a contact time for disinfection of five (5) minutes. Furthermore, the package instructions for alcohol prep pads or wipes stated their only use was for skin preparation prior to injection. Interview with Licensed Practical Nurse (LPN) #1, on 01/12/2021 at 4:00 PM, revealed shared equipment was cleaned with bleach wipes and left to dry five (5) to seven (7) minutes. Interview with SRNA #1, on 01/12/2021 at 4:25 PM, revealed she had worked at the facility for one (1) year. SRNA #1 stated staff shared one (1) rolling BP cuff per hallway. Further interview revealed staff was to clean the BP cuff and other equipment with bleach wipes between residents. Continued interview revealed bleach wipes were kept in the utility room. Interview with SRNA #5, on 01/13/2021 at 8:50 AM, revealed shared equipment was to be cleaned between residents. During the interview, SRNA #5 stated she used Lysol wipes to clean equipment, which were obtained from the cleaning person or at the nurse's station. SRNA #5 stated she tried to clean equipment between residents. Interview with Resident #6, on 01/13/2021 at 9:00 AM, revealed staff used alcohol prep wipes to clean shared equipment. During the interview, Resident #6 stated the staff clean equipment like the thermometer and the BP cuff with those little alcohol wipes. Interview with LPN #2, on 01/13/2021 at 9:10 AM, revealed she had worked at the facility for fifteen (15) years. LPN #2 stated shared equipment was to be cleaned with bleach wipes between residents. Interview with SRNA #6, on 01/13/2021 at 9:25 AM, revealed she had worked at the facility for twelve (12) years. SRNA #6 revealed that shared equipment was to be cleaned between residents with bleach wipes. Interview with the Director of Nursing (DON), on 01/13/2021 at 11:28 AM, revealed shared equipment was to be cleaned with Virex or bleach wipes using a three (3) to five (5) minute dry time. Additional interview revealed staff was educated on the correct cleaning process for shared equipment. During the interview, the DON stated an alcohol prep wipe was not appropriate to use for cleaning and disinfecting equipment. Additionally, the DON stated it was her expectation staff use bleach wipes or Virex with appropriate dry times between each resident, per the facility's policy. Interview with the Administrator, on 01/13/2021 at 1:22 PM, revealed staff monitoring and audits were conducted related to infection control practices. Further interview revealed face to face education was used to communicate standards of practice and COVID infection control policies. During the interview, the Administrator stated it was his expectation all staff follow the policies and procedures related to infection control practices.

Based on interview, record review, review of the facility's investigation, and review of the facility's policy, it was determined the facility failed to protect one (1) of six (6) residents from abuse (Resident #3). On 09/13/2020, at approximately 7:45 PM, Resident #2 struck Resident #3 with a long metal shoe horn resulting in three (3) skin tears that required medical attention to Resident #3's left forearm. The findings include: Review of the facility policy, titled Reporting Abuse to Facility Management, dated 11/02/2017 revealed each resident had the right to be free from abuse. Additionally abuse was defined as the willful infliction of injury with resulting physical harm. Further, willful was defined as an individual acting in a deliberate way; not that the individual must have intended to inflict injury or harm. 1. Review of Resident #2'medical record revealed the facility admitted the resident on 04/29/2017 and readmitted the resident on 02/11/2020, with [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS) Assessment, dated 07/15/2020 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (03) indicating severe cognitive loss. Further review revealed the resident had no Physical behavior symptoms directed towards others. Review of the Incident Report for Resident # 2's, dated 09/13/2020 at 7:45 PM revealed a loud noise was heard coming from Resident # 2's room. Per Incident Report, staff entered the resident's room to find the resident with their arms raised, ready to strike Resident # 3 (his/her roommate), who was sitting at the foot of Resident # 2's bed, with long metal object. Further review revealed Resident #2 stated he/she hit Resident # 3 because he/she was shaking the bed. Observations of Resident #2, on 09/22/2020 at 12:45 PM, revealed the resident was in his/her room in a wheelchair sitting at a bedside table eating. Additionally, the Resident stated everyone was nice at the facility and he/she had not had any negative encounters or concerns with staying at the facility. 2. Review of Resident #3's medical record revealed the facility admitted the resident on 06/06/2016, with [DIAGNOSES REDACTED]. Review of Resident # 3's MDS Assessment, dated 08/26/2020, revealed the facility assessed the resident as severe short term and long term cognitive impairments. Further review revealed the resident had Physical behavioral symptoms directed towards others. Review of the Incident Report for Resident #3's, dated 09/13/2020 at 7:45 PM revealed a loud noise was heard coming from Resident #3's room. Per Incident Report, staff entered the resident's room to find the resident sitting at the foot of Resident #2 (roommates) bed, in his/her wheelchair and Resident #2 was striking Resident #3 with a long metal object. Further review revealed Resident #2 and Resident #3 were separated and the long metal object was confiscated. Continued review of Incident Report for Resident #3, dated 09/13/2020 at 7:45 PM revealed the resident had three (3) skin tears noted to his/her left forearm. Per report, the areas were cleansed and a dry dressing was applied. Observations of Resident #3, on 09/22/2020 at 12:30 PM, revealed the resident was in his/her room sitting in a wheelchair. The resident's eyes were closed and the resident did not respond to State Inspector. Additional observations of Resident #3, on 09/23/2020 at 12:20 PM revealed the resident sitting in a wheelchair in his/her room eating lunch at the bedside table. The resident did not respond to the State Inspectors. Review of the Long Term Care Facility-Self Reported Incident Form-Initial Report, received by the Office of Inspector General (OIG), on 09/14/2020 at 1:42 PM, revealed a resident to resident altercation occurred on 09/13/2020 at 8:00 PM. Per Report, employees heard a loud sound and approached Resident #2's room, where he/she was observed holding long handled shoehorn above his head. Additionally, Resident #3 was observed to have a skin tear noted to his/her left forearm. Continued review revealed Resident #2 admitted to striking Resident # 3 on the arm because he/she was on his/her side of the room. Further, the residents were immediately separated; the alleged perpetrator (Resident #2) was given a private room and was placed on fifteen (15) minute checks. Interview with State Registered Nursing Assistant (SRNA) #3, on 09/21/2020 at 4:00 PM, revealed on 09/13/2020 at approximately 8:00 PM, she heard a noise come from Resident #2's room. Per interview, when she entered the room, Resident #3 was holding onto Resident #2's bed and Resident #2 had a long handled shoehorn over his/her bed . Further, Resident #2 stated he/she struck Resident #3 with the shoehorn because he/she was holding the bed. Interview with Social Services Director, on 09/23/2020 at 2:50 PM, revealed on the morning of 09/14/2020 she and the Director of Nursing (DON) discussed the incident on 09/13/2020 involving Resident #2 and Resident #3 and she followed up with both residents to ensure there were no psychosocial changes. Per interview, Resident #3 was unaffected, and could not answer questions related to the incident. Additionally, Resident #2 did not recall the incident happening. Per interview, she collaborated with the DON and the Administrator and discussed interventions for both residents and the five (5) day follow up report. Further, it was important for the facility abuse policy to be known and followed by all staff to ensure abuse was identified and reported to keep residents safe. Interview with the Director of Nursing (DON), on 09/24/2020 at 9:15 AM revealed she had worked in the facility for one (1) year. Additional interview revealed she expect the facility policy related to Abuse to be followed by all staff. Per interview, residents should be free from abuse. Further, it was important for to follow the Abuse policy to ensure residents remained safe and free from abuse. Interview with Administrator, on 09/24/2020 at 10:00 AM revealed, he had worked in the facility for one (1) year. Per interview, residents had the right to be free from abuse. Additional interview revealed abuse was the willful intent to injury with physical harm. Continued interview revealed he expected staff to be educated and knowledgeable of and maintain the facility Abuse policy (s). Further, it was important to ensure resident safety.

Based on interview, record review, review of the facility's investigation, review of the facility's policies, and review of the Kentucky Revised Statues (KRS), it was determined the facility failed to ensure all alleged violations involving abuse or neglect were reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse, to the State Survey Agency in accordance with state law through established procedures for one (1) of six (6) sampled residents (Resident #3). On 09/13/2020, at approximately 7:45 PM, Resident #2 and Resident #3 had an altercation in their room. The facility initiated an abuse investigation; however they failed to report the allegation of abuse to the State Agency per the facility's policy and state law. The findings include: Review of the facility's policy, titled Reporting Abuse to State Agencies and Other Entities/Individuals, dated 11/03/2017, revealed all suspected violations of abuse would be reported to appropriate state agencies and other entities or individuals as required by law. Additionally, all alleged violations would be reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury. Further, inquiries concerning the reporting of abuse to State Agencies would be referred to the Administrator. Review of KRS Chapter 209.030, revealed an oral or written report was to be made immediately to State Agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. Review of Resident # 3's medical record revealed the facility admitted the resident, on 06/06/2016, with [DIAGNOSES REDACTED]. Review of Resident # 3's Minimum Data Set (MDS) Assessment, dated 08/26/2020, revealed the facility assessed the resident as severe short term and long term cognitive impairments. Further review revealed the resident had physical behavioral symptoms directed towards others. Review of the Long-Term Care Facility-Self Reported Incident Form-Initial Report, received by the Office of Inspector General (OIG), on 09/14/2020 at 1:42 PM, revealed a resident to resident altercation occurred on 09/13/2020 at 8:00 PM. Per Report, employees heard a loud sound and approached Resident #2's room, where he/she was observed holding a long- handled shoehorn above his/her head. Additionally, per report, Resident #3 was observed to have a skin tear noted to his/her left forearm. Continued review revealed Resident #2 admitted to striking Resident #3 on the arm because he/she was on his/her side of the room. Further, per report, the residents were immediately separated; the alleged perpetrator (Resident #2) was given a private room and was placed on fifteen (15) minute checks. Review of the Director of Nursing's (DON) e-mail, dated 09/14/2020 at 1:42 PM, revealed confirmation the Initial Report of the allegation of abuse, to the State Agency was made sixteen (16) hours and forty-two (42) minutes after the allegation was identified in the facility, on 09/13/2020 at 8:00 PM. Interview with the Director of Nursing (DON), on 09/24/2020 at 9:15 AM, revealed she had worked in the facility for one (1) year. Per interview, she received a call, on 09/13/2020 at approximately 8:00 PM, from nursing staff who notified her of the allegation of abuse. However, the DON stated it was later in the evening, and she was not at the facility, so she did not report the allegation until the next business day, on 09/14/2020 at 1:42 PM. Additional interview revealed if there was an allegation of abuse, she expected State Agencies to be notified timely, as per facility policy. Further, she stated it was important for staff to follow the Abuse policy specific to timely reporting to ensure residents remained safe and free from abuse. Interview with the Administrator, on 09/24/2020 at 10:00 AM, revealed he had worked in the facility for one (1) year. Per interview, he expected the facility's policy related to reporting abuse to be maintained and followed. Additionally, he stated it was his responsibility to ensure all allegations of abuse were reported to State Agencies in a timely manner. Further, per the Administrator, when the facility was aware of the allegation, on 09/13/2020 at 8:00 PM, the Initial Self Reported Incident Form should have been sent to State Agencies, no later than two (2) hours after the facility was aware of the incident.

Based on observation, interview, record review, review of facility policy, and review of the facility Investigation, it was determined the facility failed to ensure each resident was free from physical restraints for purposes of discipline or convenience for one (1) of four (4) sampled residents (Resident #1). On 01/01/2020, State Registered Nursing Assistant (SRNA) #1 held Resident #1's arms/hands down to his/her chest while performing incontinence care between 4:00 AM and 5:00 AM, due to the resident being combative. On 01/01/2020 at approximately 8:45 AM, bruising was noted to the resident's arms and hands. (Refer to F-656) The findings include: Review of the facility Reporting Abuse to Facility Management Policy, dated 11/02/17, revealed physical abuse is defined as hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Injury of Unknown source is defined as an injury that meets both of the following conditions: 1) Any person did not observe the source of the injury or the resident could not explain the source of the injury; 2)The injury is suspicious because of the extent of the injury or the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Review of the facility Investigation, dated 01/06/2020, signed by the Administrator, revealed bruising was noted to Resident #1's arms/ hands on the morning of 01/01/2020. According to SRNA #1's Statement, Resident #1 was combative and SRNA #1 held the resident's hands down to his/her chest while performing check and change of the brief. Notifications included the Physician, Office of Inspector General (OIG), Ombudsman, Adult Protective Services (APS), and local law enforcement on 01/01/2020 between 8:45 AM and 9:45 AM. Further review of the Investigation, revealed medications were reviewed for causative factor of the bruising and labs were ordered on [DATE]. Skin Assessments were completed on all residents on 01/02/2020 by the Director of Nursing (DON), Assistant Director of Nursing (ADON), North Unit Coordinator and South Unit Coordinator with no concerns noted. Interviews with staff members were completed on 01/01/2020, 01/02/2020, and 01/03/2020. All interviewable residents were interviewed on 01/01/2020 and 01/02/2020 with no concerns noted. Review of Resident #1's skin assessment completed by the DON on 01/02/2020, revealed there were no other injuries or skin concerns that may have resulted from the incident on 01/01/2020. SRNA #1 clocked out at the end of the shift at 6:30 AM on 01/01/2020, and on 01/01/2020 at 2:00 PM SRNA #1 gave her statement. SRNA #1 did not work after the incident on 01/01/2020, pending the investigation. SRNA #1 was educated related to dementia care, and re-approaching dementia/combative residents upon returning to work. The facility determined the bruising was an injury of unknown origin. Review of Resident #1's medical record revealed the facility admitted the resident on 11/30/18 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 11/08/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of three (3) out of fifteen (15) indicating severe cognitive impairment. Review of section G revealed Resident #1 required one (1) person physical assist for all activities of daily living. Observation of Resident #1, on 01/21/2020 at 8:45 AM, and 01/23/2020 at 8:45 AM, revealed the resident was sitting in the chair looking over the newspaper and had no apparent bruising noted to the back of his/her hands or his/her arms. Interview with Resident #1, during these observations, revealed staff treated him/her very well. Resident #1 could not recall an incident where staff was holding his/her hands down. Interview on 01/21/2020 at 4:08 PM, with SRNA #1, who worked the night shift on the 100 unit, revealed on 01/01/2020 sometime between 4:00 AM and 5:00 AM, she had to awaken Resident #1 to perform incontinence care and change his/her brief prior to the end of his/her shift at 6:30 AM. Per interview, Resident #1 became combative and she held the resident's hands down over his/her chest while changing his/her brief. SRNA #1 stated Resident #1 continued to be combative and may have possibly hit his/her hands on the bed rails. She stated Resident #1 calmed down after she changed his/her brief. Continued interview with SRNA #1, revealed facility practice was to leave the resident when combative and re-approach the resident later; ask another SRNA to approach the resident; and inform the nurse of the resident's behavior. However, SRNA #1 stated she did not follow this protocol. SRNA #1 further stated she did not observe any bruising on Resident #1's hands or arms after she changed the resident's brief that morning. Interview on 01/21/2020 at 3:40 PM, with Licensed Practical Nurse (LPN) #1, revealed she was assigned to Resident #1 the evening of 12/31/19 through the morning of 01/01/2020 and was not notified of Resident #1's combative behavior with SRNA #1. She stated she did not notice the resident had bruising on the top of his/her hands or on his/her arms. Interview on 01/22/2020 at 1:25 PM with SRNA #5, revealed she worked the 100-unit on the day shift on 01/01/2020, but did not notice any apparent bruising to the resident's hands or arms that day. Per interview, if a resident was asleep, they should be given time to wake up prior to attempting to provide incontinence care. Per interview, if a resident was combative during care, they should be re-approached at a later time when the resident was calm, and the nurse should be notified. Interview on 01/22/2020 at 1:10 PM, with SRNA #3, revealed she worked the 100 unit on 01/01/2020 from 2:00 PM to 10:00 PM, but did not notice Resident #1 to have bruising during that time. She stated she did notice bruising to the resident's hands a few days later and it looked like he/she had bumped his/her hands on something. Per interview, if a resident was being combative, the nurse should be notified and the resident should be re-approached at a later time when the resident had calmed down. Interview on 01/21/2020 at 3:00 PM, with Social Services, revealed she followed up with Resident #1 on 01/02/2020, 01/03/2020, and 01/06/2020, after the bruising was noted and did not identify any agitation or any difference in behavior. Further interview revealed Resident #1's family requested the resident be allowed to sleep through the night, and the resident was now to wear a thicker brief at night. Interview on 01/22/ at 2:15 PM, with Registered Nurse (RN) #1/Unit Manager (UM) for the 100, 200, 300 units, revealed Resident #1's daughter notified her of bruising on Resident #1 hands on 01/01/2020 at 8:45 AM and she immediately started an investigation. RN #1/UM stated she contacted the DON, ADON, and the Physician. Per interview, there was bruising to the top of the resident's hands, and there was also bruising in a more defined shape to the resident's forearms near the wrists. Further interview with RN #1/UM, revealed she phoned SRNA #1 and told her she needed to come in for an interview prior to working her next shift. Per interview, SRNA #1 gave a statement on 01/01/2020, admitting she held Resident #1's hands down while she provided incontinence care. RN #1/UM stated SRNA #1 was not allowed to provide resident care after the Statement was obtained, but was suspended pending the investigation. Per interview, SRNA #1 should have explained care to be provided to Resident #1 and allowed him/her time to calm down prior to providing care. Further, SRNA #1 should not have held the resident's hands down during care. Interview on 01/21/2020 at 3:00 PM, and 01/22/2020 at 2:41 PM, with the DON, revealed Resident #1's family noticed bruising on the resident's hands and arms and notified RN #1/UM on 01/01/2020 at approximately 8:45 AM. Per interview, RN #1 then immediately notified the DON and an investigation was initiated. The DON stated a Statement was obtained from SRNA #1 on 01/01/2020, who admitted to holding the resident's hand and arms down while performing incontinence care as the resident was combative, and SRNA #1 was suspended pending the investigation. Additional interview revealed it was her expectation that when a resident becomes combative, staff leave the resident in a safe situation, then re-approach later, and inform the nurse of the resident's behavior. Further interview revealed staff interviews were obtained with interviewable residents, and a skin sweep was completed for non-interviewable residents with no concerns noted. Continued interview revealed there could be other possible reasons for the bruising to Resident #1's hands and arms as the resident could have hit himself/ herself on the bed rails. Interview on 01/21/2020 at 3:00 PM, with the Administrator, revealed he received a phone call from the DON on 01/01/2020 concerning bruising to Resident #1's hands. The Administrator stated the DON, the Administrator and the Police interviewed SRNA #1 on 01/02/2020. He stated during the interview, SRNA #1 admitted Resident #1 become combative on 01/01/2020 at the end of the shift and she held the resident's hands down to his/her chest to protect him/her from hitting the side rails and to finish incontinence care. Per interview, SRNA #1 should not have held Resident #1's hands/arms down in order to provide care, but should have re-approached him/her at a later time after the resident had calmed down. Further interview revealed SRNA #1 did not work after the shift in which the incident occurred, pending investigation. He stated the facility's Investigation concluded the bruising to the resident's hands and arms were from an injury of unknown source as the facility was unable to say for certain the bruising was from SRNA #1 holding the resident's upper extremities down during care.

Based on interview, record review, review of review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, and review of the facility Investigation, it was determined the facility failed to implement the Comprehensive Care Plan for one (1) of four (4) sampled residents (Resident #1). Resident #1 Comprehensive Care Plan, dated 08/16/19, revealed the resident exhibited Behaviors and had a history of [REDACTED]. However, interview with State Registered Nurse Aide (SRNA) #1, on 01/21/2020, revealed she awakened Resident #1 during the early morning hours on 01/01/2020 to provide incontinence care and held his/her hands down to his/her chest due to the resident being combative. On 01/01/2020 at approximately 8:45 AM, there was bruising noted to the resident's arms and hands. (Refer to F-604) The findings include: Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of the facility Investigation, dated 01/06/2020, revealed bruising was noted to Resident #1's arms/ hands on the morning of 01/01/2020. Per SRNA #1's Statement, Resident #1 was combative and SRNA #1 held the resident's hands down to his/her chest while performing check and change of the brief. Review of Resident #1's clinical record revealed the facility admitted the resident on 11/30/18 with [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 11/08/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of three (3) out of fifteen (15) indicating severe cognitive impairment. Review of section G revealed the resident required one (1) person physical assist for all activities of daily living. Interview with Resident #1, on 01/21/2020 at 8:45 AM, and 01/23/2020 at 8:45 AM, revealed staff treated him/her very well and he/she could not recall an incident where staff was holding his/her hands down. Interview on 01/21/2020 at 4:08 PM, with SRNA #1, who worked the night shift on the 100 unit, revealed on 01/01/2020, between 4:00 AM and 5:00 AM, she had to awaken Resident #1 to provide incontinence care and change his/her brief prior to the end of his/her shift at 6:30 AM. She stated Resident #1 became combative and she held the resident's hands down over his/her chest while changing his/her brief. SRNA #1 further stated Resident #1 continued to be combative and may have possibly hit his/her hands on the bed rails. Further interview with SRNA #1, revealed she did not follow Resident #1's Comprehensive Care Plan related to allowing the resident to adjust. She stated she should have left the resident when he/she became combative and re-approached him/her later. Interview on 01/21/2020 at 3:40 PM, with Licensed Practical Nurse (LPN) #1, revealed she was the nurse assigned to Resident #1 the evening of 12/31/19 through the morning of 01/01/2020 and SRNA #1 did not notify her of Resident #1 being combative during that shift. She stated Resident #1's Care Plan should have been implemented related to allowing the resident time to adjust after being awakened. She stated SRNA #1 should not have provided incontinence care while the resident was combative. Interview on 01/22/ at 2:15 PM, with Registered Nurse (RN) #1/Unit Manager (UM) for the 100, 200, 300 units, revealed Resident #1's daughter notified her of bruising on Resident #1 hands on 01/01/2020 at 8:45 AM. Per interview, she then assessed the resident and noted there was bruising to the top of the resident's hands, and there was also bruising in a more defined shape to the resident's forearms near the wrists. She stated she contacted the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Physician, and initiated an investigation. Further interview revealed SRNA #1 gave a statement on 01/01/2020, admitting she held Resident #1's hands down while she provided incontinence care during the early morning hours on 01/01/2020. Per interview, SRNA #1 should not have held the resident's hands down during care. She stated SRNA #1 should have explained care to be provided to Resident #1 and allowed him/her time to calm down and adjust prior to providing care, as per the Care Plan. Interview on 01/21/2020 at 3:00 PM, and 01/22/2020 at 2:41 PM, with the DON, revealed SRNA #1 admitted to holding Resident #1's hand and arms down while performing incontinence care as the resident was combative, during the early morning on 01/01/2020. The DON stated SRNA #1 was suspended pending the investigation. Additional interview revealed Resident #1's Care Plan should have been implemented related to interventions to allow the resident time to adjust. Per interview, SRNA #1 should have left the resident when he/she became combative and re-approached him/her later. Per interview, SRNA #1 should not have held the resident's hands/arms down while providing care. Interview on 01/21/2020 at 3:00 PM, with the Administrator, revealed it was his expectation staff implement the Care Plan for the safety of the residents. However, he stated SRNA #1 did not implement Resident #1's Care Plan when she provided incontinence care while the resident was being combative.

Based on observation, interview, record review, and review of facility Policy, 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 the development and transmission of communicable diseases and infections for one (1) of five (5) sampled Residents (Resident #5). Observation of wound treatment provided for Resident #5, on 1[DATE], revealed Registered Nurse (RN) #3 removed the soiled dressing and removed her soiled gloves, but failed to perform hand hygiene prior to applying the physician ordered treatment and clean dressing as per the facility policy. Further observation revealed RN #3 failed to perform hand hygiene at the completion of the treatment before exiting the resident's room. Continued observation revealed upon exiting the resident's room, RN #3 touched the Treatment Cart, the keypad to enter the soiled utility room, the door to exit the soiled utility room, and the keypad to enter the clean utility room prior to performing hand hygiene. The findings include: Review of the facility Wound Care/Treatment Guidelines Policy, undated, revealed the purpose was to provide wound care to promote healing. Continued review revealed the steps for wound care included: gather supplies to be placed on a clean surface; perform hand hygiene; explain procedure; don gloves; remove soiled dressing and place in bag; perform hand hygiene; put on clean gloves; clean the wound according to the order; provide treatment per order; dispose of waste; and perform hand hygiene. Review of the facility Hand Hygiene Policy, undated, revealed the purpose for hand hygiene is to decrease the risk of transmission of infection by appropriate hand hygiene. Further review revealed handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. Continued review revealed: I) Handwashing-wash Hands with either a non-antimicrobial soap and water or an antimicrobial soap and water when hands are visibly dirty or contaminated with proteinaceous material, are visibly soiled with blood or other body fluids, before eating, before performing an invasive procedure, and after providing care to a resident with a spore-forming organism (e.g.,[DIAGNOSES REDACTED]icile). II) Use an alcohol-based hand rub for routinely decontaminating hands if hands are not visibly soiled, in all clinical situations other than those listed under Handwashing above. Review of Resident #5's clinical record revealed the facility admitted the resident on 11/21/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 11/21/19, revealed Resident #5 was assessed by the facility as having a Brief Interview for Mental Status (BI[CONDITION]) score of five (5) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility assessed the resident as having one (1) Unstageable Pressure Ulcer. Review of the Comprehensive Care Plan, dated 11/21/19, revealed a focus of Pressure Sores/Skin Care, with a goal to prevent/heal wounds and prevent avoidable skin breakdown. Interventions included turn every two (2) hours and as needed, assess/measure ulcers weekly, notify physician of signs or symptoms of complication, and [MEDICATION NAME] to buttocks every shift. Per the Care Plan, an intervention was documented to cleanse wound with normal saline, apply [MEDICATION NAME] to wound bed, apply zinc to periwound, and cover with foam dressing due to unstageable coccyx wound. Review of the active physician's orders [REDACTED]. Observation on 1[DATE] at 9:15 AM, revealed RN #3 was performing wound care with the assistance of the South Unit Manager for Resident #5. Observation revealed RN #3 applied gloves and removed the soiled dressing. RN #3 then removed the soiled gloves and applied clean gloves and was not observed to perform hand hygiene prior to donning clean gloves, as per facility policy. Continued observation revealed RN #3 cleaned the wound with normal saline, then removed the soiled gloves and failed to perform hand hygiene, prior to opening the treatment cart to obtain a cotton tipped swab. RN #3 was then observed to apply gloves, and apply the foam dressing, with the [MEDICATION NAME]. RN #3 then applied the zinc to the areas around the wound/dressing. Continued observation revealed RN #3 removed the soiled gloves and tied the bag of soiled items, and exited the resident's room, without performing hand hygiene. Continued observation revealed RN #3 touched the Treatment Cart, the keypad to enter the soiled utility room, the door to exit the soiled utility room, and the keypad to enter the clean utility room prior to performing hand hygiene after the completion of the treatment. Interview with RN #3, on 1[DATE], at 9:25 AM, directly after the nurse performed the wound treatment for [REDACTED]. Further interview revealed hand hygiene was not necessary during wound care as long as dirty gloves were changed between steps when changing the dressing, and as long as hands were not visibly soiled. Interview with the South Unit Manager, on 1[DATE] at 1:24 PM, revealed after removal of Resident #5's soiled dressing, RN #3 should have removed gloves and performed hand hygiene prior to proceeding with the ordered treatment. Further interview revealed hand hygiene should have been performed anytime during the procedure after removing soiled gloves. Per interview, at the completion of the treatment, gloves should have been removed and items discarded and hand hygiene should have been performed prior to exiting the resident's room. Per interview, soiled items should have then been taken to the soiled utility area for disposal and then hand hygiene performed again. Continued interview revealed RN #3 should have performed hand hygiene prior to exiting the resident's room and touching the treatment cart and door keypads. Per interview, failure to perform hand hygiene could cause the spread of infections. Interview on 1[DATE] at 1:06 PM, with the Assistant Director of Nursing/Infection Control Nurse, revealed supplies should be gathered and hand hygiene should be performed at the beginning of a dressing change and gloves should be applied. Per interview, after the removal of a soiled dressing, hand hygiene should be performed and clean gloves applied, prior to applying the clean dressing. Further interview revealed failure to perform hand hygiene when moving from a soiled dressing to clean dressing could cause infection to the wound. Continued interview revealed hand hygiene should be performed at the completion of the treatment/dressing change, and again after items were disposed of in the soiled utility room. Per interview, failure to perform hand hygiene prior to exiting the resident's room and then touching the treatment cart and door keypads or other items could result in the spread of infections. Interview with the Director of Nursing (DON), on 1[DATE] at 11:32 AM, revealed staff received Handwashing and Infection Control inservices per facility schedule, which was annually. Further interview revealed hand hygiene should be performed after removal of a soiled dressing and prior to applying a clean dressing, prior to leaving the resident's room, and after disposal of soiled items in the soiled utility room. Per interview, hand sanitizer could be used, but handwashing was best. The DON stated failure to perform hand hygiene at appropriate times before, during and after a dressing change could cause the spread of germs. Interview with the Administrator, on 1[DATE] at 3:14 PM, revealed it was his expectation that employees follow facility policies related to handwashing, infection control, and wound care. Per interview, staff should perform hand hygiene as appropriate before and during a dressing change. Further interview revealed failure to wash hands after providing wound care and prior to exiting a resident's room and touching objects in the environment could cause the potential spread of bacteria or infection. Per interview, when leaving a soiled environment, there was opportunity to pass along bacteria.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to provide residents with necessary respiratory care and services in accordance with professional standards of practice for five (5) of twenty-eight (28) sampled residents (Residents #54, #60, #88, #301, and #302). Observation on 11/12/19, 11/13/19, and 11/14/19, revealed Resident #54, #60, #301, and #302's oxygen tubing and nasal cannula was not dated to indicate when it was last changed. In addition, observation on 11/12/19, revealed Resident #88's C-PAP (continuous positive airway pressure) tubing and mask was lying on his/her rolling walker and was not dated to indicate when it was last changed, nor was it in a protected bag while not in use. The findings include: Review of the facility Oxygen Use Policy, undated, revealed staff should promote resident safety in administering oxygen. Per Policy, the oxygen cannula or mask does require scheduled changing and should be changed when visibly soiled. Review of the Respiratory Company email to the facility Administrator, dated 11/14/19 at 4:21 PM, revealed the Company contracted with the facility to provide respiratory change outs, dating and placing a sticker on the associated supply once a month. 1. Review of Resident #54's medical record revealed the facility readmitted the resident on 06/27/19 with [DIAGNOSES REDACTED]. Observation of Resident #54, on 11/12/19 at 12:17 PM, and on 11/13/19 at 9:02 AM, revealed he/she was lying in bed with oxygen in use per nasal cannula at four (4) liters per minute via the oxygen concentrator. Further observation revealed the nasal cannula and oxygen tubing was not dated to indicate when it was last changed. 2. Review of Resident #60's medical record revealed the facility readmitted the resident on 11/28/17 with [DIAGNOSES REDACTED]. Observation on 11/12/19 at 12:37 PM, revealed Resident #60 was in bed with his/her eyes closed with oxygen in use per nasal cannula. The resident's oxygen was set at five (5) liters per minute via an oxygen concentrator with humidified water. Further observation revealed the nasal cannula and oxygen tubing was not dated to indicate when it was last changed. 3. Review of Resident #88's medical record revealed the facility admitted the resident on 05/16/18 with [DIAGNOSES REDACTED]. Review of Resident #88's medical record revealed Monthly (MONTH) 2019 Physician's Orders to apply C-PAP nightly and take off in the morning due to Sleep Apnea with the setting to be set at ten (10). Observation on 11/12/19 at 12:20 PM, revealed Resident #88's C-PAP tubing and mask was lying on his/her rolling walker and was not labeled nor was it in a protected bag while not in use. Resident #88 was not in his/her room. 4. Review of Resident #301's medical record revealed the facility admitted the resident on 11/03/19 with [DIAGNOSES REDACTED]. Observation on 11/14/19 at 2:10 PM, revealed Resident #301 had oxygen in use at two (2) liters per minute via nasal cannula; however, the nasal cannula and oxygen tubing was not dated to indicate when it was last changed. 5. Review of Resident #302's medical record revealed the facility admitted the resident on 09/26/19 with [DIAGNOSES REDACTED]. Observation of Resident #302, on 11/14/19 at 2:14 PM, revealed oxygen was in use per nasal cannula at two (2) liters per minute while the resident was seated in a chair in his/her room. Further observation revealed the oxygen tubing and cannula was not dated to indicate when it was last changed. Interview on 11/14/19 at 11:10 AM, with State Registered Nurse Aide (SRNA) #5, revealed she noticed dates on the oxygen tubing in the past; however, not consistently. Further interview revealed any oxygen tubing was to be labeled with the date it was last changed, but she was unaware of how often the tubing needed to be changed. Continued interview revealed at times she had to replace oxygen tubing due to contamination such as the tubing falling on the floor. Further interview revealed it was the responsibility of the nurse to routinely change the oxygen tubing and date the tubing. Interview on 11/14/19 at 2:15 PM, with SRNA #1 and SRNA #2, revealed the SRNAs changed the oxygen tubing and nasal cannulas once weekly, but did not date the tubing. Interview on 11/14/19 at 2:20 PM, with the Rehabilitation Unit Manager for the 500 unit, revealed the oxygen tubing, cannula, and nebulizer masks and tubing was to be changed every Saturday night, and should be dated when changed out. Interview with Licensed Practical Nurse (LPN) #2, on 11/14/19 at 2:44 PM, revealed oxygen equipment including oxygen tubing, masks, cannulas; C-PAP tubing and mask; and nebulizer tubing, mouth pieces and masks were changed out and marked with the dated it was changed out weekly by the nurses on night shift. Per interview, this was important to ensure these items were clean and did not harbor bacteria and organisms that could make a resident sick with an upper respiratory illness. Interview on 11/14/19 at 3:02 PM, with the South Unit Coordinator, revealed in the past, nurses were responsible to change out the oxygen tubing and respiratory equipment and date the items as they were changed out; however, there was now a respiratory service who changed the oxygen equipment including oxygen tubing, masks, cannulas; C-PAP tubing and mask; and nebulizer tubing, mouth pieces and masks monthly. Further interview revealed the SRNAs should alert the nurse if these items needed to be changed due to contamination and at that point the nurse should change it out and date it with their initials as per standard nursing practice. Further interview revealed oxygen tubing, nebulizer tubing or C-Pap tubing should be stored in plastic bags when not in use. Interview on 11/14/19 at 3:10 PM, with the SRNA Supervisor, revealed the SRNAs were allowed to change out oxygen tubing and inform the nurse. Further interview revealed she was not aware that oxygen or nebulizer tubing required labeling with the date in which it was changed. Interview on 11/14/19 at 3:15 PM, with the Staff Development Coordinator/ Infection Control Nurse, revealed oxygen equipment including oxygen tubing, masks, cannulas; C-PAP tubing and mask; and nebulizer tubing, mouth pieces and masks were to be changed by the respiratory company contracted with the facility. Further interview revealed if a resident's tubing was soiled, frail, or dropped on the floor it should be changed out by the facility nurse and a sticker applied with the nurse's initials and date. Further interview revealed education had not yet been provided to nursing staff regarding the change in the process as these respiratory tubing and devices used to be changed out by nursing staff weekly. Additional interview revealed it was important to ensure respiratory tubing and supplies were changed out at least monthly for infection control purposes. Interview on 11/14/19 at 3:24 PM, with the Director of Nursing (DON), revealed the nurses used to change out respiratory tubing and supplies weekly, but now there was a contracted Respiratory Company who did this monthly. Per interview, the nurses still changed out the respiratory tubing or equipment as needed if it was dropped, dirty or not working. Continued interview revealed when the Respiratory Company or facility nurses changed out these items, there should be a label with the date placed on the oxygen therapy tubing and other respiratory equipment in order for staff to know when these items had last been changed out. Per interview, if the oxygen tubing, masks, nebulizer tubings and C-Pap tubings and other respiratory equipment was not changed monthly, it could be a source of contamination as bacteria could develop causing infection and illness to residents. Interview on 11/14/19 at 4:00 PM, with the Administrator, revealed the facility contracted with a respiratory company to come in monthly to change tubing for oxygen and other respiratory equipment. Per interview, it was the nurse's responsibility at all other times to maintain and change out respiratory tubing and supplies as needed. Further, there should be a date when respiratory tubing and supplies were changed out in order to ensure it was changed out monthly.

Based on observation, interview, record review, review of facility Policy, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to meet professional standards of quality. Observation on 09/26/18 of the 200 Hallway medication cart, revealed an unidentified pill, which was loose in a cup, and not in the packaging. The findings include: Review of the facility Medication Ordering and Receiving from Pharmacy Policy, undated, revealed Medications are labeled in accordance with facility requirements, state, and federal laws. Each Prescription medication label includes resident's name; specific directions for use, including route of administration; medication name; strength of the medication; Prescriber's name; date dispensed; quantity of medication; expiration date of medication; prescription number; accessory labels; and initials of dispensing pharmacist. Review of the KBN, AOS #14, revised (MONTH) (YEAR), Roles of Nurses in the implementation of Patient Care Orders, revealed in accordance with Kentucky Revised Statutes (KRS) 314.021 (2), nurses are responsible and accountable for making decisions that are based upon the individual's educational preparation and current clinical competence in nursing and requires licensees to practice nursing with reasonable skill and safety. Further review revealed licensed nurses should administer medication and treatment as prescribed by the Physician, Physician Assistant, Dentist, or Advanced Practice Registered Nurse (ARNP). Observation on 09/26/18 at 9:30 AM, of the medication cart on the 200 Hallway with Certified Medication Aide (CMA) #1, revealed there was a single loose blue pill in a medication cup without packaging or identifying information. Interview with CMA #1, on 09/26/18 at 4:00 PM, revealed she did not leave the loose blue pill in the medication cart. CMA #1 stated medications left loose and not in the packaging in the medication cart would need to be disposed of and reported to the Director of Nursing (DON). Interview with CMA #3, on 09/26/18 at 4:24 PM, revealed if a resident refused or did not take a medication once the package was opened, the medication should be properly discarded and the reason the medication was not administered should be documented on the Medication Administration Record (MAR). Further interview revealed a loose pill left in the medication cart with no identifying packaging, should not be administered to a resident and the medication would need to be taken to the DON for further investigation. Interview with Registered Nurse (RN) #1, on 09/27/18 at 10:30 AM, revealed she left the loose blue pill in the cup in the the medication cart. Per interview, the medication was [MEDICATION NAME] (medication used to treat Prostatic [MEDICAL CONDITION]) and the medication belonged to Resident #93. RN #1 stated Resident #93 did not want to take the medication ([MEDICATION NAME]) at the time scheduled time, and she left the loose [MEDICATION NAME] pill in a cup for administration later when the resident was ready for the medication. Continued interview revealed RN #1 was aware this was not proper procedure. RN #1 further stated, as a standard of practice she would not administer a medication from the medication cart that was not labeled or in the package. Interview with the DON, on 09/26/18 at 10:00 AM, revealed through her investigation she discovered the unidentified blue pill left in the medication cart on the 200 Hallway belonged to Resident #93. The DON stated the pill was identified by the facility as [MEDICATION NAME] 5 milligrams (mg) which the resident was to receive each morning. Additional interview on 09/27/18 at 5:10 PM, with the DON, revealed it was her expectation the nurses and CMAs dispose of medication in the proper manner, if the resident refused the medication. Per interview, the nurses and CMAs were also to follow the facility policies, guidelines and practices for reporting a missed dose. The DON stated she would not expect staff to administer a medication which was left in the cart opened without a package or pharmacy label as this created the potential for a medication error. Interview with the Administrator, on 09/27/18 at 5:43 PM, revealed nursing staff should not leave a loose pill which was not in the package in the medication cart for later administration as this was not safe. Per interview, the nurses and CMAs were to follow physician's orders [REDACTED].

Based on observation, interview, record review, review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, review of the Manufacturer's Recommendations for Air Mattresses, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure services provided are delivered by qualified individuals who have the skills, experience and knowledge to provide care and services that meet the resident's needs for one (1) of five (5) sampled residents (Resident #15). Resident #15's Comprehensive Care Plan (CCP) revealed the resident had the potential for impaired skin integrity, initiated 01/07/15, and revised 09/26/18, which included an intervention for a weekly skin assessment by a licensed nurse. Observation of a skin assessment for Resident #15 on 09/27/18, revealed the resident had an identified reddened area over a bony prominence of the coccyx, and review of the current (MONTH) (YEAR) physician's orders [REDACTED]. In addition, Resident #15's CCP revealed an intervention to assist with turning and repositioning every two (2) hours and as needed; however, observation on 09/25/18, 09/26/18, and 09/27/18, revealed the resident was lying on his/her back, and had not been turned and repositioned every two (2) hours. Furthermore, Resident #15's CCP revealed an intervention for a pressure redistributing mattress, Low Air Loss (LAL). However, staff were not regulating or knowledgeable of the resident's appropriate Low Air Loss (LAL) mattress setting in order to ensure this was an effective treatment to prevent or to heal skin breakdown. The findings include: Interview with the Director of Nursing (DON), on 09/27/18 at 6:01 PM, revealed the facility did not have a policy related to following the Care Plan; however, used the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0 as a guide. Further interview revealed the facility did not have a policy specific to skin assessments or prevention of pressure ulcers, but used NPUAP guidelines. Continued interview revealed the facility did not have a policy related to Air Mattresses; however, followed the Manufacturer's Recommendations. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of the Pressure Injury Prevention Points, dated April, (YEAR), from the National Pressure Ulcer Advisory Panel (NPUAP) organization, revealed all individuals at risk for pressure injury should be provided inspection of the skin at least daily for signs of pressure injury, especially nonblanchable [DIAGNOSES REDACTED]. Additional review revealed these individuals should be provided assistance with turning and repositioning based on a frequency for turning according to the support surface in use. Continued review revealed the level of immobility, exposure to moisture, body size and weight of the individual should be considered when choosing a support surface. Further, an individual should continue to be repositioned when placed on any support surface. Review of the Operation Manual for the LAL Air Mattress utilized by the facility, revealed the intended use of the mattress series is to provide individualized comfort and to reduce the incidence of pressure ulcers. Additionally, the Weight Setting Selection should be adjusted by choosing the patient's corresponding weight setting using the plus and minus buttons. Continued review revealed recommendations to follow the Hand Check procedure to decide the appropriate pressure level. Further, the Hand Check procedure is used to see if a suitable pressure is selected by sliding one hand between the air mattress and the foam base or bed frame to feel the patient's buttocks. An acceptable range is approximately one (1) inch to one and a half (1.5) inches. Review of Resident #15's Electronic Medical Record (EMR) revealed the facility admitted the Resident on 03/02/16, with [DIAGNOSES REDACTED]. Review of Resident #15's Quarterly Minimum Data Set (MDS) Assessment, dated 07/09/18, revealed the facility assessed the resident as having severe cognitive impairment. Further review of the MDS Assessment revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility and toileting; and as frequently incontinent of bowel and bladder. Further, per the MDS Assessment, the Resident weighed one hundred and twenty nine (129) pounds and was at risk of developing pressure ulcers. Review of Resident #15's Order Summary Report, dated 01/01/18 through 09/30/18, revealed Active physician's orders [REDACTED]. Further review revealed Active physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR), dated (MONTH) (YEAR) through (MONTH) (YEAR), revealed Resident #15's coccyx treatment with foam dressing, was signed as administered daily per physician's orders [REDACTED]. Review of Resident #15's Weekly Skin Assessments, dated 06/15/18 through 09/21/18, revealed skin assessments were performed weekly; however, there was no documented evidence staff monitored the reddened area to the coccyx weekly, as per the CCP. The Skin assessment dated [DATE], revealed the coccyx area was described as red/blanchable with foam dressing, clean dry and intact. The Skin assessment dated [DATE], revealed the coccyx area was described as a pink blanchable area with treatment in place. However, these were the only Skin Assessments from 06/15/18 through 09/21/18, which documented the presence of discoloration to Resident #15's coccyx. Review of the Braden Scale for Predicting Pressure Sore Risk Assessment, dated 09/26/18, revealed Resident #15 was at mild risk for developing a pressure sore. The risk factors included: could not always communicate discomfort or the need to be turned; very limited mobility as evidence by being unable to make frequent or significant changes independently; occasionally moist; and potential for friction and shearing of the skin when moved. Review of the Comprehensive Care Plan (CCP), initiated 01/07/15, revised 09/26/18, revealed Resident #15 had the potential for impaired skin integrity related to debility and often staying in bed; refusing turning and re-positioning at times; history of Suspected Tissue Damage Injury to left heel; and red coccyx. The goal stated the resident was to have intact skin and the risk for impaired skin integrity was to be minimized through nursing interventions/education. Interventions included, but were not limited to: weekly skin assessments by licensed staff to monitor for any indication of skin breakdown initiated 01/07/15; turn and reposition every two (2) hours and PRN initiated 02/21/18; and pressure redistributing mattress (LAL mattress) initiated 04/19/18. Review of the State Registered Nursing Assistant (SRNA) Kardex (SRNA Care Plan) dated 09/28/18, revealed Resident #15 required turning and repositioning every two (2) hours and as needed (PRN). Additionally, per the Kardex, the resident required a pressure-redistributing mattress, LAL mattress. Further review of the Kardex, revealed the resident required skin observations. Observation on 09/25/18 at 2:27 PM; 09/25/18 at 4:21 PM; and 09/26/18 at 7:29 AM; revealed Resident #15 was lying in bed on his/her back in a semi-fowlers position, under the covers up to his/her chest, with his/her head on a single pillow. Further, the LAL mattress settings were: Static/Alternating button was set to Alternating pressure mode; Cycle Time Button was set to ten (10) minute cycle time of inflation; Weight Setting Button (used to adjust the pressure of the inflated cells based on the patient's weight) was set to four hundred fifty (450) pounds. Observation on 09/26/18 at 9:49 AM, revealed Resident #15 was lying in bed on his/her back in a semi-fowlers position, under the covers up to his/her chest, with his/her head on a single pillow. SRNA #1 entered the resident's room, pulled the privacy curtain, then closed the door. At 9:54 AM, SRNA #1 exited the resident's room with a clear plastic garbage bag with a blue brief in it. However, Resident #15 remained in the same position. Additional observation on 09/26/18 at 11:47 AM; 09/26/18 at 3:18 PM; and 09/27/18 at 8:10 AM; revealed Resident #15 was lying in bed on his/her back in a semi-fowlers position, under the covers up to his/her chest, with his/her head on a single pillow. Further, the LAL mattress settings were Static/Alternating button was set to Alternating pressure mode; Cycle Time Button was set to ten (10) minute cycle time of inflation; Weight Setting Button (used to adjust the pressure of the inflated cells based on the patient's weight) was set to four hundred fifty (450) pounds. Interview with the Quality Assurance (QA) Nurse/ Wound Nurse, on 09/27/18 at 9:20 AM, revealed she had worked in the facility as a Licensed Practical Nurse (LPN) for thirteen (13) years. Per interview, she was responsible for following Pressure Ulcers which were Stage II and higher. The QA Nurse stated Resident #15 was at risk for skin breakdown related to refusing to turn and reposition at times, immobility, and a history of skin breakdown. Continued interview revealed the Resident had preventative skin interventions in place including a non-sterile dressing to his/her coccyx, weekly skin assessments, a LAL mattress, and a turning and reposition program. The QA Nurse revealed, per Resident #15's turning and reposition program, the SRNAs assigned to the resident were to turn and reposition the resident every two (2) hours and as needed. Per interview, the nurses assigned to Resident #15 should be monitoring the hall during rounds for compliance and consistency to ensure the resident was turned and repositioned, as per the Care Plan. Continued interview with the QA Nurse/ Wound Nurse, on 09/27/18 at 9:20 AM, revealed direct care floor nurses were to assess residents' skin weekly, and any skin impairment should be monitored with a description of the skin concern documented in the EMR. Per interview, this was to ensure the medical record was accurate, the resident's condition was monitored sufficiently and the resident received necessary care and services related to skin integrity. Per interview, Resident #15's reddened area to the coccyx should have been documented with a description of the area weekly from the time the area was identified. Additional interview with the QA Nurse, revealed she was unaware of how LAL mattress settings were determined for each individual resident or how to ensure the LAL mattress was on the correct setting. She stated she thought the Physician or the company who delivered the Mattress determined the LAL mattress setting. Further interview revealed it was her expectation the CCP was followed related to skin assessments weekly, and LAL mattress. Per interview, the CCP weekly skin assessment intervention would include assessment and description of any areas of skin breakdown, and the LAL mattress intervention would include ensuring the correct setting for the individual resident, in order to provide quality care. Observation of Resident #15, on 09/27/18 at 9:40 AM, revealed the resident was lying in bed on his/her back in semi-fowlers position on a LAL Air Mattress. The QA Nurse initiated a skin assessment during this observation, and Resident #15 was noted to have a non-sterile adhesive dressing over his/her coccyx. Additional observation revealed when the dressing was removed from the resident's coccyx, there was an area of [DIAGNOSES REDACTED] approximately the size of a quarter, over the bony prominence of the coccyx. The QA Nurse palpated the area, which was noted to be blanchable. Interview with SRNA #1, on 09/27/18 at 9:44 AM, revealed he checked the Kardex/SRNA Care Plan on the kiosk in the hallways as a reference for providing care to the residents. Per interview, he reported any change in a residents' skin to the nurse. Further interview revealed Resident #15's preventative skin interventions included turning and repositioning every two (2) hours, LAL mattress, and per the nurse's direction pillows under the resident's feet. He stated he was frequently assigned to Resident #15 and the resident did not try to resist or refuse turning and repositioning. He further stated LAL mattress settings were based on the individual resident's weight; however, he had never been trained on LAL mattress setting so he never observed the settings or adjusted the settings. Continued interview revealed ensuring each resident's preventative skin interventions were in place was important to decrease a residents risk for skin breakdown, and provide good care. Interview with SRNA #2, on 09/27/18 at 9:51 AM, revealed he reviewed the resident's Kardex/SRNA Care Plan on the kiosk in the hallway for interventions related to providing care for residents. He stated this Kardex/SRNA Care Plan included skin prevention interventions for each resident. The State Agency (SA) Representative and SRNA #2 reviewed Resident #15's Kardex/SRNA Care Plan and noted interventions to turn and reposition the resident every two (2) hours, LAL mattress, and skin observation. Continued interview with SRNA #2, revealed he turned and repositioned Resident #15 every two (2) hours, without resistance or refusal. Further interview revealed he was unaware of how to determine the proper LAL mattress setting as he had never been training on monitoring or adjusting the settings. Interview with Registered Nurse (RN) #1, on 09/27/18 at 3:18 PM, revealed all areas of skin impairment should be consistently documented on the weekly skin assessments, especially reddened areas over bony prominence which required current Physician ordered treatment. RN #1 stated accurate and consistent weekly skin assessments of all areas of skin impairment was important to evaluate if the current treatment was effective and to identify deterioration of areas of skin breakdown. Continued interview with RN #1, revealed Resident #15 was to be turned and repositioned every two (2) hours. Per interview, she tried to ensure the resident was repositioned off his/her back, but the resident was known to wiggle onto his/her back after being turned and repositioned. However, she did state she expected the SRNAs to re-approach and re-position the resident when the resident would turn self on to his/her back. Per interview, she tried to ensure the Care Plans were followed related to turning and repositioning the residents by conducting rounds down the hallway, assisting SRNAs with resident care, and communicating with SRNAs. Further interview with RN #1, revealed she was aware LAL mattress settings were determined by the individual resident's weight, and if the settings were not accurate the mattress may not be as effective at treating and preventing skin breakdown. However, she stated she was unaware of how to ensure the mattress setting was accurate or where the appropriate setting would be documented in the medical record. She stated the nurses initialed on the TAR every shift to indicate the LAL mattress was in place and she knew to report obvious problems with LAL mattresses, or an alarm sounding on the LAL mattress to her supervisor or the mattress company. However, she stated she was unaware of any check, or monitoring for LAL mattress settings. Continued interview with RN #1 revealed all CCP skin interventions should be followed. Interview with the Minimum Data Set (MDS) Nurse, on 09/27/18 at 5:30 PM, revealed Resident #15 had a Care Plan intervention for weekly skin assessments and during a skin assessment the nurse was to assess and document all areas of skin impairment. Continued interview revealed accurate and consistent skin assessments were important because the assessments assisted and guided the interdisciplinary team in developing and providing necessary quality care to each resident. Per interview, the CCP was not followed related to weekly skin assessments if each area of skin impairment was not assessed. Additionally, she stated she expected preventative skin interventions to be implemented by direct care staff, including turning and repositioning residents every two (2) hours for Resident #15, as per the CCP. Further interview revealed there was an intervention on Resident #15's CCP for a LAL mattress and the company provided an initial set up including an assessment for each resident to determine the appropriate LAL mattress setting. However, per interview she was unaware of staff monitoring the LAL mattress to ensure it was effective in treating or preventing skin breakdown. Interview with the Director of Nursing (DON), on 09/27/18 at 6:01 PM, revealed Resident #15's skin assessments should have been completed weekly to include an accurate ongoing reflection of all skin impairment, as per the CCP. Additional interview revealed turning and repositioning was expected to be provided consistently for Resident #15, as per the individualized CCP and monitored for compliance by the nurse. Continued interview revealed Resident #15 had a Care Plan intervention for a LAL mattresses, and LAL mattresses should be provided to residents at correct settings per the manufacturer's recommendation by qualified staff. However, per interview, the facility staff did not monitor or regulate the LAL mattress settings in order to ensure the mattress was an effective intervention for treatment or prevention of skin breakdown, and relied on the LAL mattress company to maintain the settings. Further interview revealed it was her expectation the CCP interventions to prevent and heal skin breakdown be followed. Interview with the Senior Director of Clinical Services, on 09/27/18 at 5:40 PM, revealed she expected weekly skin assessments to accurately reflect the resident's skin and all skin impairment should be documented on the assessment, including reddened areas over bony prominences, as per the care plan. Additionally, she expected residents to be turned and repositioned, as per their individualized care plan. Continued interview revealed LAL mattress settings were determined by the manufacturer and were to be maintained by utilizing the Hand Check procedure. However, per interview, the individual resident's mattress settings were not documented anywhere in the facility and staff were not expected to monitor LAL mattress settings or perform the Hand Check procedure. Per interview, she did expect staff to alert the company if they noticed an obvious problem with the LAL mattress. Interview with the Administrator, on 09/27/18 at 5:50 PM, revealed CCP interventions such as skin assessments should accurately reflect a resident's current skin status to ensure new changes in skin integrity were identified and necessary care was provided to the resident. Additional interview revealed the CCP interventions related to turning and repositioning should be implemented. Continued interview revealed staff should provide CCP interventions, such as LAL mattresses, per manufacturer's recommendations. Further interview revealed in order to provide quality care to residents, the CCP needed to be implemented. Post Survey phone interview with the LAL mattress Representative, on 10/01/18 at 4:45 PM, revealed the distributors/providers for the LAL mattress was to provide initial set up and maintenance for LAL mattresses. Per interview, the recommendations for settings, in the User Manual, for the LAL mattresses were strictly based on weight. Further interview revealed the Physicians were to determine recommendations for the LAL mattress beyond the User Manual.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals. Observation on 09/26/18, of the South Medication Room refrigerator, revealed two (2) vials of [MEDICATION NAME] which were opened and not dated. Additional observation revealed a bottle of [MEDICATION NAME] Solution which was opened, but not marked with an open date. In addition, the [MEDICATION NAME] Solution had no pharmacy label to include the resident's name, prescription number, date, physician's name, caution statements, and directions. Furthermore, observation 09/26/18 of the 200 Hallway medication cart, revealed an unidentified pill, which was loose and not in the packaging. The findings include: Review of the facility Medication Storage in the Facility Policy, undated, revealed Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. Review of the facility Medication Ordering and Receiving from Pharmacy Policy, undated, revealed Medications are labeled in accordance with facility requirements, state, and federal laws. Each Prescription medication label includes, resident's name; specific directions for use, including route of administration; medication name; strength of the medication; Prescriber's name; date dispensed; quantity of medication; expiration date of medication; prescription number; accessory labels; and initials of dispensing pharmacist. 1. Review of the Mantoux [MEDICATION NAME] Skin Test Facilitator Guide: Centers for Disease Control and Prevention (CDC), (MONTH) 2003, revealed [MEDICATION NAME] vials ([MEDICATION NAME] is a sterile protein extract from cultures of tubercle bacillus, used in a test by [MEDICATION NAME] injection for infection with or immunity to [MEDICAL CONDITION]) are to include the date and initials of the person opening the vial. Vials open past thirty (30) days are to be disposed of and a new vial used. Observation on 09/26/18 at 9:00 AM, of the medication refrigerator in the south medication room, revealed two (2) vials of opened [MEDICATION NAME] with no date or initials on the vials. Additional Observation revealed a bottle of opened [MEDICATION NAME] Inhalant Solution 20% (twenty percent), six (6) grams per thirty (30) milliliters (medication used to dissolve mucous in the treatment of [REDACTED]. There was no date to indicate the open date of the [MEDICATION NAME] Inhalant Solution, and there was no pharmacy label to include the resident's name; dosage to be administered; prescription number; date; physician name; caution statements; and directions. Interview with Licensed Practical Nurse (LPN) #3, on 09/26/18 at 9:10 AM, revealed multi-dose medications such as [MEDICATION NAME] Inhalant Solution should be dated with the open date, and should have a pharmacy label to indicate the resident's name, prescription number, date issued, physician's name, caution statements, and directions. Further interview with LPN #3, revealed it was standard practice to date and initial [MEDICATION NAME] on the vial when opened. Per interview, [MEDICATION NAME] was good thirty-(30) days from the date it was opened. Continued interview revealed if [MEDICATION NAME] was not dated when opened, it was to be discarded because the expiration date would be unknown. 2. Observation on 09/26/18 at 9:30 AM, of the medication cart on the 200 Hallway with Certified Medication Aide (CMA) #1, revealed a single loose blue pill in a medication cup without packaging or identifying information. Interview with CMA #1 on 09/26/18 at 4:00 PM, revealed she was not the individual who left the loose blue pill in the medication cart. Additional interview revealed prior to administering a medication, she verified the right resident, right medication, right dose, right time and right route according to the Medication Administration Record [REDACTED]. Interview with CMA #3 on 09/26/18 at 4:24 PM, revealed if a resident did not take a medication once the package was opened, the medication should be properly discarded and the refusal should be indicated on the MAR. Additional interview revealed a loose pill left in the cart with no identifying packaging, should not be administered to a resident and the medication would need to be taken to the DON for further investigation. Interview with Registered Nurse (RN) #1, on 09/27/18 at 10:30 AM, revealed the blue pill left in the medication cart was [MEDICATION NAME] (medication used to treat Prostatic [MEDICAL CONDITION]) and the medication belonged to Resident #93. Per interview, Resident #93 did not want to take the medication ([MEDICATION NAME]) at the time scheduled time. RN #1 stated she left the loose [MEDICATION NAME] pill in a cup with no packaging for administration later when the resident was ready for the medication. Further interview revealed RN #1 was aware this was not proper procedure. RN #1 stated, as a standard of practice she would not administer a medication from the medication cart that was not labeled or in the package. Interview with the DON, on 09/26/18 at 10:00 AM, revealed after her investigation the unidentified blue pill left in the medication cart on the 200 Hallway belonged to Resident #93. Per interview, the pill was identified by the facility as [MEDICATION NAME] 5 milligrams (mg) which the resident was to receive each morning. Further interview on 09/27/18 at 5:10 PM, with the DON, revealed it was her expectation the nurses and CMAs dispose of medication in the proper manner, if the resident refused the medication. Per interview, the nurses and CMAs were to follow the facility policies, guidelines and practices for reporting a missed dose. The DON stated she would not expect staff to administer a medication which was left in the cart opened without a package or pharmacy label as this created the potential for a medication error which could cause an adverse reaction. Additional interview revealed she would expect an unlabled medication such as the [MEDICATION NAME] Inhalant Solution which was left in the medication refrigerator to be discarded and reported to her. Additional interview revealed [MEDICATION NAME] should be marked on the vial with the open date and the nurse's initials as it expired thirty (30) days after opening. Interview with the Administrator, on 09/27/18 at 5:43 PM, revealed no nurse or CMA should leave a loose pill in the medication cart for later administration. Further interview revealed the nurses and CMAs were to follow physician's orders [REDACTED]. Per interview, a multidose medication such as [MEDICATION NAME] should be marked with the open date as the medication expired thirty (30) days after opening. The Administrator stated all multidose medications were to be labeled according to the facilities policies and standards of practice.

Based on observation, interview, record review, and review if the facility's Policy, it was determined the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for one (1) of twenty-two (22) sampled residents (Resident #41). Resident #41 had an order for [REDACTED]. The findings include: Review of the facility's Physician Medication Orders Policy, dated 08/01/13, revealed the Charge Nurse or the Director of Nursing Services shall forward to pharmacy the order for all prescribed medications. Drug and biological orders must be recorded on the physician's orders [REDACTED]. Continued review of the Policy, revealed orders must be recorded immediately in the resident's chart by the person receiving the order and must include the date and time order. Review of Resident #41's medical record revealed the facility admitted the resident on 12/16/15, with [DIAGNOSES REDACTED]. Further review of Resident #41's medical record revealed the facility transferred Resident #41 to the hospital on [DATE] related to a Urinary Tract Infection and the resident was admitted to the hospital on that date. The facility readmitted Resident #41 on 07/14/18. Review of Resident #41's current Physician order [REDACTED]. Observation of Resident #41, on 09/26/18 at 9:30 AM, revealed the resident had a suprapubic catheter in place with drainage bag draining on the right side of the bed. Interview with Licensed Practical Nurse (LPN) #1, on 9/27/18 at 4:05 PM, revealed when a facility transferred or discharged a resident to the hospital, and the resident was admitted to the hospital, the nurse placed the resident's physician's orders [REDACTED]. Further interview revealed if a resident had a suprapubic catheter in place, there should be an active order for the catheter. Interview with LPN #2, on 9/27/17 at 5:01 PM, revealed when the facility transferred or discharged a resident to the hospital, and the resident was admitted to the hospital, the nurse obtained a bed hold and placed the resident's current orders on hold. Per interview, when the resident was readmitted to the facility, the orders were to be re-activated. LPN #2 stated previous orders which were on hold and any new orders were to be checked and verified by two (2) nurses per the doctor's approval. Further interview revealed if a resident had a suprapubic catheter in place on re-admission to the facility, there should be an active physician's orders [REDACTED].>Interview with the Director of Nursing (DON), Senior Clinical Service Director (SCSD) and the Administrator on 09/27/18 at 5:30 PM, revealed Resident #41 should have had an active order for a suprapubic catheter upon re-admission to the facility in order for there to be an , accurate representation of the resident. The SCSD stated the lack of an order for [REDACTED].

Based on observation, interview, record review and review of the facility's Policies, it was determined the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included expiration dates; and failed to ensure all drugs and biologicals were in locked compartments to permit only authorized personnel to have access. Observation on 12/11/17 from 4:54 PM to 5:00 PM, revealed the medication/treatment cart on North Hall 300 was unlocked and unsupervised with an Insulin Pen on top of the cart for six (6) minutes. In addition, the cart contained Insulin Pens which had not been dated when opened; blood glucose test strips which had not been dated when opened; and discontinued medication. The findings include: Review of the facility's Policy titled, Medication Storage In The Facility, undated, revealed medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. Continued review of the Policy, revealed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medications. Per Policy, Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Review of the facility's Policy titled, Disposal of Medications and Medication Related Supplies, undated, revealed when medications are discontinued by a prescriber, a resident is transferred or discharged and does not take medications with him/her, or in the event of a resident's death, the medications are marked as discontinued and destroyed (when appropriate), or if the packages are unopened, returned to the issuing pharmacy. Continued review revealed medications awaiting disposal or return are stored in a locked secure area designated for the purpose until destroyed or picked up by the pharmacy. Medications are removed from the medication cart immediately upon receipt of an order to discontinue (to avoid inadvertent administration). Discontinued medications not returned to the pharmacy are destroyed in accordance with the Medication Destruction policy. Observation of the North 300 Hall, on 12/11/17 at 4:54 PM, revealed a medication/treatment cart unattended, unlocked, with a glucometer (device used to measure the concentration of glucose in the blood) and a [MEDICATION NAME] Pen labeled with Resident #51's name and room number, on top of the cart. Continued observation revealed there was no staff, residents or visitors in the hall way at that time. Further observation revealed at 5:00 PM, six (6) minutes later, Registered Nurse (RN) #1 came out of a resident's room, and returned to the cart. Interview with RN #1, on 12/11/17 at 5:00 PM, revealed she had been employed at the facility since October 2017. She stated it was unusual for her to leave the cart unattended, unlocked and with medications on top of the cart. She further stated she had prepared Resident #51's Insulin and intended to come straight back to the cart to proceed with administration of the Insulin, but got distracted. She stated it was important to keep the medication cart locked at all times to ensure no one had access to the medications and for resident safety. Observation on 12/11/17 at 5:00 PM of the contents of the North 300 Hall medication/treatment cart which had been left unlocked and unattended included the following in the top drawer of the cart: [MEDICATION NAME] Pen labeled with Resident #51's name which was opened, but was not dated with open date; and Insulin Pen labeled with Resident #11's name which was opened, but was not dated with open date; and an opened bottle of blood glucose test strips with an expiration date of 05/16/19, and no opened-date marked on the bottle. Observation of the second drawer of the North 300 Hall medication/treatment cart, revealed it contained medications as follows: Resident #12's [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) sixteen (16) tablets in three (3) packages; Resident #26's [MEDICATION NAME] (medication used to treat enlarged prostate in men) 5 milligram (mg) ten (10) tablets; Resident #91's [MEDICATION NAME] (medication used to treat and prevent [MEDICAL CONDITION]) 70 mg four (4) tablets and two (2) tablets in another box; Resident #51's [MEDICATION NAME] 70 mg two (2) tablets; Resident #14's [MEDICATION NAME] 70 mg three (3) tablets; Resident #57's Aspirin (medication to treat mild pain and fever) 81 mg seventeen (17) tablets and also a full box, Calcium [MEDICATION NAME] 600 mg seventeen (17) tablets, [MEDICATION NAME] (antidepressant medication) 20 mg nineteen (19) tablets, [MEDICATION NAME] ([MEDICATION NAME] medication) 10 mg fifteen (15) tablets, [MEDICATION NAME] (medication used to treat overactive bladder) 5 mg seven (7) tablets, [MEDICATION NAME] (antidepressant medication) 15 mg 1/2 tabs (7.5 mg) sixteen (16) tablets, Tylenol (fever reducer and pain reliever) eleven tablets and a full box, [MEDICATION NAME] ([MEDICAL CONDITION] harmone) 125 micrograms (mcg) twenty-two (22) tablets, [MEDICATION NAME] (medication to treat acid reflux) 150 mg ten (10) tablets and Zinc 220 mg a full box. Observation of the third drawer of the of the North 300 Hall medication/treatment cart revealed [MEDICATION NAME] (medication to prevent asthma attacks) three (3) packets labeled with Resident #11's name; [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME] to open airways in the lungs) two (2) packets labeled with Resident #15's name and Resident #40 nebulizer inhalation medications. Observation of the bottom drawer of the of the North 300 Hall medication/treatment cart revealed a bottle of [MEDICATION NAME] skin cleanser, a spray bottle of DermaKlenz wound cleanser, and Clorox Disinfectant wipes. The other side of the med cart, which was up against the wall, was also unlocked, and held topical medications, i.e. ointments and DermaKlenz wound cleansers. Additional interview with RN #1 during observation of the contents of the medication cart, revealed all Insulins should be dated when opened to ensure they were not used past their , expiration date. She further stated the night shift nurse checked controls of the glucose test strips when new bottles were opened and should have dated the bottle when it was opened. RN #1 stated she would replace the bottle of glucose test strips because she didn't know when the bottle had been opened and the strips would expire in a certain amount of days after opened. Further interview with RN #1, revealed Resident #57's Zinc medication had been discontinued on 12/05/17 and should have been removed from the cart and put in the return box in the medication room. Continued interview revealed RN #1 knew the medication was discontinued because it was marked dc'd on the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON), on 12/13/17 11:31 AM, and 12/15/17 at 8:45 AM, revealed no medications should be left unattended on top of the medication cart and the medication cart should be kept locked at all times when unattended for safety and to prevent residents or visitors from getting into the medication cart. Continued interview revealed she expected Insulin Pens to be dated immediately when opened because Insulin expired after opened twenty-eight (28) days and needed to be discarded after 28 days. Further interview revealed any discontinued or expired medications should be removed from the medication cart as soon as they were discontinued and put in the pharmacy bin in the medication room for pickup. Continued interview revealed this was an important safety measure to avoid continuing to administer a medication that was discontinued. Additional interview revealed all nurses were trained in orientation on the medication policy, procedures, and proper handling and storage of medications. She further verified RN #1 was a fairly new nurse and had received education on the medication policies during orientation, Interview with the Administrator, on 12/15/17 at 2:00 PM, revealed medication carts should never be left unlocked; and medications should never be left on top of the cart unattended. Further interview revealed she expected the nurses to follow policy and date Insulin when it was opened, so the nurses would not administer the medication past the expiration date. Continued interview revealed she expected the nursing staff to follow policy when a medication was discontinued or if a resident expired and remove the medication immediately off the cart, to avoid inadvertent administration. Additional interview, revealed it was her expectation for staff to follow policies related to medication storage and handling for the safety of all the residents.

Based on observation and interview, it was determined the facility failed to provide a home like environment for two (2) of twenty-eight (28) sampled residents (Resident #22 and #94). Observation during initial tour on 12/11/17, revealed the bathroom ceiling for room [ROOM NUMBER], which was shared by Resident #22 and Resident #94 was stained over the toilet; and the sink counter appeared worn with missing paint. In addition, Resident #22 and Resident #94 complained to the State Survey Agency Representative that the shared bathroom for room [ROOM NUMBER], was leaking water which would drip on their heads when near the toilet; and also the sink counter needed repair. The findings include: Interview on 12/14/17 at 2:20 PM, with the Administrator, revealed the facility did not have a Policy related to maintenance of the environment. Observation on 12/11/17 at 3:28 PM, of the 501 bathroom, which was shared by Resident Resident #22 and Resident #94, revealed the appearance of a dry stain on the ceiling above the toilet around the intake vent. Further observation revealed the wooden sink counter edge had missing paint. Interview was conducted on 12/11/17 at 3:28 PM, with Resident #22, who the facility assessed in an Admission Minimum Data Set (MDS) Assessment as having a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15), indicating moderate cognitive impairment. Resident #22 stated when in the bathroom near the toilet, or on the toilet, water dripped onto his/her head. Per interview, the dripping was worse when it rained. The resident revealed the maintenance man had been notified about two (2) weeks ago about the leak in the bathroom ceiling. Resident #22 further revealed he/she did not like how the sink counter currently looked with missing paint where the protective soft foam had been placed and then removed. Interview was conducted on 12/13/17 at 8:53 AM, with Resident #94, who the facility assessed in an Annual MDS Assessment, dated 12/01/17, as having a BIMS score of twelve (12) out of fifteen (15), revealing the resident was cognitively intact. Resident #94 stated the tile on the bathroom ceiling above the toilet had a leak and would drip onto his/her head. The resident further revealed the sink counter in the bathroom looked awful. He/she further stated he/she had told several staff many times about the leak and the sink counter. Interview on 12/14/17 at 1:44 PM, with the Director of Maintenance, revealed he conducted ongoing walking rounds of the building and resident rooms on a monthly basis to identify any repairs needed and also checked the maintenance request books located at the nurses' station desk. He stated he then made repairs as soon as possible. Per interview, he did not document the identified problems nor did the facility have policies and procedures in place for maintenance of the environment. Further interview revealed after making rounds, he would write the repairs needed on a sticky note. He stated the Technology-Enhanced Learning in Science, (TELS) program was available to use for Work Orders, but he did not make use of the system because it took too much time. Continued interview with the Director of Maintenance, revealed Resident #22 told him verbally about the leak in the ceiling of bathroom [ROOM NUMBER] about two (2) weeks ago; however, he stated he was unaware the residents were getting rained on. He further stated Resident #94 told him he did not like the foam around the edge of the sink counter and he thought Resident #94 may have removed the foam from the sink counter. Per interview, the soft foam was placed around the sink for Resident #94's protection due to the [DIAGNOSES REDACTED]. Per interview, this caused condensation to collect around the ceiling tiles above the toilet, and with the flow of air the collected water could be pushed out into the ceiling tiles. Further interview revealed he had not yet fixed the leaky ceiling or the sink counter, but was working on the repairs. Interview on 12/14/17 at 2:00 PM, with State Registered Nursing Assistant (SRNA) #9, who was sometimes assigned to Resident #22 and Resident #94, revealed the residents had not complained to her about the leak in the ceiling or about the missing paint on the sink counter. Per interview, when there was a concern voiced by a resident or when there was needed repairs, staff could verbally tell maintenance staff, fill out a request slip at the nurses' station, call maintenance, or send an e-mail. Interview on 12/14/17 at 2:05 PM, with SRNA #10, who was assigned at times to Resident #22 and Resident #22, revealed the residents did not express any concerns about a leaking ceiling or a sink counter in need of repair. Interview on 12/14/17 at 2:15 PM ,with Registered Nurse (RN)/Unit Manager 500 hall #2, revealed staff would usually tell her about needed repairs. Per interview, staff could contact Maintenance about needed repairs by phone, or by use of the request slip located at the nurse's station. She stated she was unaware of the leak in the ceiling of the bathroom or the bathroom sink counter needing repair in room [ROOM NUMBER] and did not see any request in the requisition book for repairs. Interview on 12/14/17 at 2:20 PM, with the Administrator, revealed anytime a resident voiced a concern, maintenance staff was to follow up and make repairs immediately. Per interview, if staff was aware of any concerns, they were to complete a Work Order for repairs.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure transfer medication orders were transcribed correctly upon admission to the facility, for one (1) of three (3) sampled residents (Resident #2). The findings include: Review of the facility's policy titled admission orders [REDACTED]. Medical record review revealed the facility admitted Resident #2 on 08/12/16 with [DIAGNOSES REDACTED]. Review of the medication list from the transferring facility revealed Resident #2 was to be on the following medications: [REDACTED]. Review of Resident # 2's admission orders [REDACTED]. The orders were signed by Registered Nurse (RN) #1. Interview with RN #1, on 09/13/16 at 5:54 PM, revealed she acknowledged the medication [MEDICATION NAME] was omitted when the resident's admission orders [REDACTED]. She stated, I can only say it was human error and an oversight on my part. Interview with the Director of Nursing (DON), on 09/14/16 at 10:25 AM, revealed it was her expectation for medications from transferring facilities to be accurately transcribed onto the resident's admission orders [REDACTED] Interview with the Administrator, on 09/14/16 at 10:30 AM, revealed it was her expectation for admission orders [REDACTED]. She stated the medications should be reviewed with the Physician upon admission in order to avoid medication errors. Continued interview revealed when the facility identified the error in transcription, the Physician was notified and an order was received to discontinue the [MEDICATION NAME].

Based on observation, interview, and record review, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for one (1) of twenty-two (22) sampled residents (Resident #14) and one (1) unsampled resident (Unsampled Resident #A). Observation revealed staff failed to use appropriate hand hygiene during and after performing perineal/incontinence care. The findings include: 1. Review of Resident #14's medical record revealed the facility admitted the resident on 10/16/14 with [DIAGNOSES REDACTED]. Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) indicating severe cognitive impairment. Observation of Resident #14's perineal care, on 12/10/15 at 1:50 PM, revealed State Registered Nursing Assistant (SRNA) #2 provided perineal care, removed the soiled gloves, and failed to wash her hands prior to donning new gloves. After donning new gloves, SRNA #2 assisted the resident to roll to his/her side and cleansed the resident's buttocks and anal area. Further observation revealed SRNA #2 failed to remove the soiled gloves or wash her hands after cleaning the resident's buttocks and anal area and prior to touching the resident's bed linens. 2. Observation of perineal care for Unsampled Resident A on 12/10/15 at 2:20 PM, revealed after performing perineal care, SRNA #3 failed to remove her soiled gloves before touching the resident's bed linens. Further observation revealed after pulling up the resident's bed linens with the soiled gloves, SRNA #3 removed her soiled gloves, but failed to wash her hands prior to touching the resident's bed controls and call light. Interview with SRNA #3, on 12/10/15 at 4:30 PM, revealed she had been educated on the correct procedure for perineal care and handwashing at the facility. Further interview, revealed she should have washed her hands prior to touching environmental surfaces such as the resident's bed linens, bed controls and call light after providing perineal/incontinence care. Interview, with CQI (Continuous Quality Improvement) /Infection Control Registered Nurse on 12/10/15 at 3:10 PM, revealed staff was educated on the correct procedures for hand washing and perineal care. Further interview revealed staff should wash their hands anytime gloves were removed and before touching environmental surfaces. Interview, on 12/10/15 at 3:30 PM, with the Director of Nursing (DON), revealed staff was trained on the correct procedures for hand washing and perineal care upon hire, annually and when there was identified issues in the facility. Continued interview, revealed staff was to wash their hands anytime gloves were removed and before reapplying gloves, when going from dirty to clean, when finished with care, and before leaving a resident's room.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for two (2) of twenty-eight (28) sampled residents (Resident #8 and #5). Resident #8 sustained a significant weight loss of ten (10) pounds from 10/06/14 through 10/20/14, a 5.95 percent weight loss in less than a month; however, the resident's Comprehensive Care Plan was not revised to indicate the actual weight loss. Resident #5 sustained a significant weight loss of sixteen (16) pounds from May 2014 through October 2014; however, the Comprehensive Care Plan was not revised to indicate the actual weight loss. The findings include: Review of the facility's, "Weight Loss Protocol Nutrition at Risk (N.A.R.)", undated revealed the facility determined the candidates for the N.A.R. program as all new admissions and residents with unplanned weight loss. The N.A.R. Program was to consist of: weekly weights; interventions tailored to the resident's individual needs to support stable or increased weight; weekly review by the N.A.R. Committee with detailed progress notes looking at risk factors, causal factors, interventions and progress. 1. Review of Resident #8's medical record revealed the facility admitted the resident on 11/09/09, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having both short term and long term memory loss and to require extensive assistance with eating. Review of the "Monthly Weight" Sheet revealed Resident #8's weight was one hundred and seventy-four (174) pounds on 09/01/14, and one hundred and seventy-eight (178) pounds on 10/06/14. Further review of the "Monthly Weight" Sheet revealed on 10/20/14, Resident #8's weight was one hundred and sixty-eight (168) pounds which was a ten (10) pound or 5.95 percent weight loss in fourteen (14) days. Review of the Nutrition At Risk (NAR) Note dated 10/23/14, revealed Resident #8's current weight was one hundred and sixty-eight (168) pounds, and the Physician was notified of this on 10/20/14, with new orders were received for: weekly weights; a Hospice Consult; and discontinuation of the resident's [MEDICATION NAME] (a diuretic which is Potassium depleting) medication and the Potassium (a supplement to replace Potassium lost and prevent Potassium deficiency) medication. Continued review of the NAR Note revealed Resident #8's intake ranged from refused meal to one hundred percent (100%) consumed, and the resident received a snack which he/she had refused the last four (4) days. Review of the Comprehensive Care Plan, undated, in the current record, revealed the facility had care planned Resident #8 for the potential for altered nutrition related to a history of difficulty swallowing and advanced [MEDICAL CONDITION]. Continued review of the care plan revealed the goal was Resident #8 would have adequate nutritional status as evidenced by weight remaining stable. Further review of the Comprehensive Care Plan revealed however, no documented evidence it was updated and revised to include Resident #8's actual weight loss of 5.95 percent from 10/06/14 through 10/20/14. Interview with MDS Coordinator #2 on 10/23/14 at 4:15 PM, revealed the Dietary Manager (DM) would be responsible for updating and revising residents' Nutrition Care Plans for Admission, Quarterly, Annual, and Significant Change MDS Assessments. However, she stated the MDS Coordinators were responsible for updating and revising the Nutrition Care Plans between MDS Assessments. She stated the facility had a weekly Quality of Care (QOC) meeting which consisted of the Assistant Director of Nursing (ADON), the Assistant Administrator, the Administrator, the DM, and other disciplines. Per interview, during the QOC the staff present would review residents' weights and talk about possible interventions to prevent further weight loss. Continued interview revealed also during the meeting, they would decide if the Physician should be consulted for further orders. However, she stated the MDS Coordinators would not always attend these meetings and might not be notified of a resident's weight loss in order to update and revise the Comprehensive Care Plan. She revealed although the MDS Coordinators received a copy of the Physician's Orders in order to update the care plans, if the Physician's Orders did not specify the medication, supplement or interventions was related to a resident's weight loss the MDS Coordinators would transcribe the intervention to the Care Plan; however, would not necessarily know to revise the care plan to indicate actual weight loss for a resident had occurred. MDS Coordinator #2 verified Resident #8's current Comprehensive Care Plan included the potential for altered nutrition. She indicated she should have revised Resident #8's potential for altered nutrition care plan for the resident's actual weight loss after receiving the Physician's orders dated 10/20/14 which were for weekly weights and a Hospice Consult. 2. Review of the medical record revealed the facility admitted Resident #5 on 06/12/08, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #5 to have a Brief Interview for Mental Status (BIMS) score of eight (8) indicating moderate cognitive impairment. Continued review of the Quarterly MDS Assessment revealed under Section K, Nutrition the facility had assessed Resident #5 to have had a loss of five (5) percent or more in the last six (6) months and was not on a Physician prescribed weight loss regimen. Review of the "Monthly Weight" Sheet revealed Resident #5's weight was one hundred and thirty-five (135) pounds on 05/26/14, and on 10/20/14 the resident's weight was noted to be one hundred and nineteen (119) pounds, a sixteen (16) pound weight loss in a five (5) month period, and an 11.9 percent weight loss indicating significant weight loss. Review of the Dietary Consultant's Nutritional assessment dated [DATE], revealed the Registered Dietitian (RD) noted Resident #5 had a weight loss of five (5) pounds from 05/05/15 to 05/26/14, and had made recommendations for a high calorie nutritional supplement to attempt to stabilize the resident's weight. Review of the Nutritional Progress Notes dated 06/01/14 and 08/24/14, revealed the Dietary Manager (DM) noted Resident #5 continued to have weight loss, and made recommendations to the nursing staff. Review of the Physician's Orders revealed an order dated for [MEDICATION NAME] (an appetite stimulant) dated 08/27/14. Review of the Comprehensive Care Plan revealed the facility care planned Resident #5 to have altered nutrition related to no dentures, loss of some teeth, loss of appetite, family reporting the resident was a "picky" eater. Continued review of the altered nutrition care plan revealed the goal was for Resident #5 to maintain adequate nutritional status as evidenced by maintaining a stable weight. Further review of the Comprehensive Care Plan revealed the altered nutrition care plan was revised to include the [MEDICATION NAME] ordered on [DATE]; however, review revealed no documented evidence it was updated and revised to include Resident #5's actual weight loss from 05/26/14 through 10/20/14. Interview, on 10/23/14 at 1:40 PM, with Resident#5's daughter revealed Resident #5 would not eat the food she brought in for him/her and stated the resident was a very "picky" eater. Interview, on 10/23/14 at 3:50 PM, with the MDS Coordinator revealed MDS nurses were responsible for updating the care plan which pertained to nursing; however, the nutritional care plans were the responsibility of the DM. Continued interview revealed Resident #5's care plan should have been revised to reflect the resident's significant weight loss. Interview, on 10/22/14 at 4:54 PM, with the RD revealed she became the facility's new RD in mid-August of 2014. She stated she received referrals from the DM when a resident experienced a significant weight loss. She further stated the DM was responsible for revising the Comprehensive Care Plan and stated Resident #5's altered nutrition care plan should have been updated to reflect the resident's declining weight. Interview, on 10/23/14 at 4:25 PM, with the DM revealed she reviewed the weights weekly and discussed the weights in the weekly QA meeting. She stated Resident #5 had a five (5) percent weight loss in May 2014 and a referral was made to the RD. She stated from May 2014 to October 2014 Resident #5 also had a greater than ten (10) percent weight loss, which had been referred to the RD. She further stated she was responsible for revising residents' nutritional care plans, and should have updated Resident #5's care plan to reflect his/her significant weight loss. Interview, on 10/23/14 at 4:55 PM, with the ADON revealed for Resident #5 there were interventions in place by the Physician. The ADON stated the RD was new to the facility; however, the DM attended all of the QOC meetings as well as the morning meetings. She stated the DM communicated with the nursing staff when there were concerns with a resident's weight. Continued interview revealed the MDS nurses updated the care plan when there were new orders; however, the DM was responsible for revising the nutrition care plans. The ADON stated the DM should have revised Resident #5's care plan to reflect his/her significant weight loss.