Based on observation, interview, record review, and review of the facility's policies, the facility failed to implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 29 sampled residents, Resident (R)23 and R82. R23 and R82 were not provided Activities of Daily Living (ADL) care per their care plan. Reference F677 The findings include: Review of the facility's policy titled, Quality of Care - Care Planning, dated 10/2022, revealed the facility would provide resident/patient centered care aiming to provide individualized Comprehensive/Interdisciplinary Care Plans for each resident. A care plan was developed to identify strengths or possible barriers to guide the resident in reaching their maximum functional level while encompassing a holistic approach including medical, nursing, psycho-social, nutritional, activities, therapy, spiritual, and educational interventions. Per the policy, the ultimate objective was to assist the resident in meeting their personal goals with optimal functional level and a more fulfilled/enhanced quality of life. Review of the facility's policy titled, Resident Rights & Facility Responsibilities, not dated, revealed the resident had a right to choose schedules of health care services consistent with her plan of care. 1. Review of R82's Face Sheet revealed the facility admitted R82 on 09/01/2022 with diagnoses which included malignant neoplasm of unspecified part of left bronchus of lung, polyneuropathy, and heart failure. Review of R82's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 10/01/2024, revealed the facility assessed R82's cognition as intact with a Brief Interview for Mental Status [BIMS] score of 15, which indicated the resident was interviewable. Review of R82's Comprehensive Care Plan for Activities of Daily Living, dated 11/20/2024, revealed the resident required extensive assistance with bathing. Continued review revealed R82 was care planned to adjust ADLs as needs dictated. Review of R82's Shower/Bath Schedule revealed showers were scheduled for Tuesday and Friday. However, review of R82's Documentation Survey Report v2, dated 09/2024, 10/2024, and 11/2024, revealed R82 only received three showers/baths in September 2024, three showers/baths in October 2024, and three showers/baths in November 2024. Observation of R82 on 12/03/2024 at 12:30 PM revealed the resident was lying in bed; her hair was not combed. During interview with R82 at the time of the observation, she stated she did not always receive showers when she needed them. During interview with State Trained Nursing Assistant (STNA) 12 on 12/04/2024 at 3:55 PM, she stated if a resident refused a shower, she let the nurse know. However, she stated she did not say anything about asking the resident if she would like the shower later or if she would pass it on to the next shift. During interview with STNA8 on 12/06/2024 at 3:06 PM, she stated if a resident refused a shower, she encouraged them to take one and let them know they might not get a shower because they were scheduled twice a week. She stated she then told the nurse. During interview with Licensed Practical Nurse (LPN) 9 on 12/06/2024 at 3:09 PM, she stated when she was informed a resident refused a shower, she talked to the resident and called the family to let them know. During interview with the Director of Nursing (DON) on 12/05/2024 at 2:11 PM, she stated residents received two showers a week, and that was documented in the electronic medical record (EMR). The DON stated when residents refused a shower initially, staff offered again. Also, if residents refused again, a shower or bath was not given, but it was added to the schedule and given another day. 2. Review of R23's, Face Sheet revealed the facility admitted the resident on 05/16/2023 with diagnoses including type 2 diabetes, osteoarthritis, and other diseases of the musculoskeletal system and connective tissue. Review of R23's quarterly MDS, with an ARD of 11/21/2024, revealed the resident had a BIMS score of 10 out of 15, which indicated the resident was moderately cognitively impaired. Additional review of the MDS revealed no rejections of care, functional range of motion (ROM) was limited due to impairment on one side, and dependent for bath and shower care. Review of R23's, Comprehensive Care Plan, dated of 05/16/2023, revealed the resident had an ADL self-care performance deficit related to impaired mobility, impaired balance, pain, and musculoskeletal impairment, and ADLs would be met as evidenced by neat, clean appearance, being free of body odor, and dressed in clothing appropriate for the season. Further review revealed interventions for extensive assistance with one staff member for bathing and assistance with ADLs as needed. Additional review of R23's care plan revealed the resident was assessed for altered cardiopulmonary status and risk for skin impairment with interventions that included assist with toilet and hygiene as needed, keep skin clean and dry, and shower/bath per schedule and as needed. Review of R23's Shower/Bath Schedule revealed R23 was scheduled a bath or shower on Monday and Thursday of each week for the months of October, November, and December of 2024. Review of R23's Shower Sheets, from 11/07/2024 to 12/05/2024 revealed the resident received only one bath/shower each week. Observation and interview of R23 on 12/04/2024 at 9:45 AM revealed the resident was in bed, and her hair was greasy and uncombed. R23 stated she did not remember when she last had her hair washed or received a bed bath. She further stated baths were not offered regularly, and she just wanted to get her hair washed. R23 stated, It makes me feel better when I'm clean and my hair is clean. R23 also stated she preferred a bed bath. In an interview with STNA16 on 12/05/2024 at 2:47 PM, he stated if residents refused their scheduled shower time, he reapproached the resident the same day and provided education and encouragement. He stated they did not always have time for make-up showers the following day. STNA16 stated the nurses and Kentucky Medication Aides (KMA) informed him if there were changes made to a resident's care. He further stated he also looked at the care plan because resident care information was required on their care plan. In additional observation and interview with R23 on 12/06/2024 at 1:57 PM, she stated she did not refuse showers or baths when offered. She further stated she received a bath yesterday, her hair was washed, and she felt so much better. Observation of R23 revealed she smiled as she spoke, and her hair was clean and combed. In an interview on 12/06/2024 at 2:09 PM with the Wound Care Certified Nurse (WOCN), she stated she had worked one year as WOCN and prior to that was a floor nurse at the facility for 10 years. She stated residents received two showers or baths a week with their hair washed if desired. However, the WOCN stated residents had complained that showers were not always received. She further stated a resident's ADL care plan was how staff determined a resident's needs. The WOCN stated it was important care plans were updated as needed so care was current, and it was important to follow the care plan so resident needs were met. In additional interview with the DON on 12/06/2024 at 2:16 PM, she stated she expected staff to follow the resident's care plan for ADL care because it was important they received correct care, and it was necessary for the overall well-being of the resident. During an interview with the Administrator on 12/06/2024 at 3:18 PM, she stated she expected residents to receive their showers and baths per their plan of care and that all ADL care was provided based on care planned needs. The Administrator stated it was important staff followed a resident's care plan so proper care was provided.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 2 of 29 sampled residents, Resident (R) 23 and R82. R82 reported showers were not given as needed. Review of R82's electronic medical record (EMR) revealed showers/baths were to be given two days a week, but R82 only received three showers/baths in September 2024, three showers/baths in October 2024, and three showers/baths in November 2024. R23 stated she preferred bed baths, but they were not offered regularly. Review of R23's EMR revealed showers/baths were to be given two days a week, but from 11/07/2024 to 12/05/2024, R23 received only one bath/shower each week. The findings include: Review of the facility's policy titled, Bathing and General Hygiene, revised 03/2021, revealed the facility wanted to give patients as much choice as possible in relation to bathing and their general hygiene. Further review revealed residents' hair was washed each week, and refused scheduled baths were reported to the Charge Nurse by the State Tested Nurse Assistant (STNA). Per the policy, the resident's refusal was documented in the medical record. Review of the facility's policy titled, Activities of Daily Living [ADL] Care, revised 08/2024, revealed staff would ensure residents who were unable to carry out ADLs received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of R82's Face Sheet revealed the facility admitted R82 on 09/01/2022 with diagnoses which included malignant neoplasm of unspecified part of left bronchus of lung, polyneuropathy, and heart failure. Review of R82's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 10/01/2024, revealed the facility assessed R82's cognition as intact with a Brief Interview for Mental Status [BIMS] score of 15, which indicated the resident was interviewable. Review of R82's Shower/Bath Schedule revealed showers were scheduled for Tuesday and Friday. Review of R82's Documentation Survey Report v2, dated September 2024, revealed R82 did not receive a shower on Tuesday, 09/03/2024; refused a shower on Friday, 09/06/2024; received a shower on Tuesday, 09/10/2024; refused a shower on Friday, 09/13/2024; received a shower on Tuesday, 09/17/2024; refused a shower on Friday 09/20/2024; received a bed bath on Tuesday, 09/24/2024; and did not receive a shower on Friday, 09/27/2024. Review of R82's Documentation Survey Report v2, dated October 2024, revealed R82 received a bed bath on Tuesday 10/01/2024; received a shower on Friday 10/04/2024; refused a shower on Tuesday, 10/08/2024; and did not receive a shower on Friday, 10/11/2024. Continued review revealed on Tuesday, 10/15/2024, R82 did not receive a shower; on Friday 10/18/2024, R82 received a shower; on Tuesday, 10/22/2024, R82 did not receive a shower; and on Friday, 10/25/2024, R82 refused a shower. Review of R82's Documentation Survey Report v2, dated November 2024, revealed R82 received a shower on Friday, 11/01/2024; R82 refused a shower on Tuesday, 11/05/2024; R82 did not receive a shower on Friday, 11/08/2024; R82 did not receive a shower on Tuesday, 11/12/2024; R82 received a bed bath on Friday, 11/15/2024; R82 refused a shower on Tuesday 11/19/2024; R82 received a bed bath on 11/22/2024; and R82 did not receive a shower on Tuesday, 11/26/2024 or on Friday, 11/29/2024. Observation of R82 on 12/03/2024 at 12:30 PM revealed the resident was lying in bed; her hair was not combed. During interview with R82 at the time of the observation, she stated she did not always receive showers when she needed them. 2. Review of R23's Face Sheet revealed the facility admitted the resident on 05/16/2023 with diagnoses including type 2 diabetes, osteoarthritis, and other diseases of the musculoskeletal system and connective tissue. Review of R23's quarterly MDS, with an ARD of 11/21/2024, revealed the resident had a BIMS score of 10 out of 15, which indicated the resident was moderately cognitively impaired. Additional review of the MDS revealed no rejections of care, functional range of motion (ROM) was limited due to impairment on one side, and dependent for bath and shower care. Review of R23's Shower/Bath Schedule revealed R23 was scheduled a bath/shower on Monday and Thursday of each week for the months of October, November, and December of 2024. Review of R23's Point of Care [POC] documentation for 10/2024 revealed no bath or shower was documented for Monday, 10/07/2024, or Thursday, 10/31/2024. Additionally, Monday, 10/14/2024, was documented as not given due to resident refusal. Review of R23's POC documentation for 11/2024 revealed the resident had not received a bath or shower on Monday, 11/04/2024, Monday, 11/11/2024, or Monday, 11/25/2024, and those dates were documented as resident refusal. Review of R23's POC documentation for 12/01/2024 to 12/05/2024 revealed no documented bath or shower for Monday, 12/02/2024. Review of R23's Shower Sheets, from 11/07/2024 to 12/05/2024, revealed the resident received only one bath/shower each week. Review of R23's Progress Notes, from 10/01/2024 to 12/05/2024, revealed one entry, dated 12/05/2024, related to shower/bath documentation. Further review revealed that entry stated staff approached the resident twice on 12/05/2024 about a shower, and it was given after lunch. Observation and interview of R23 on 12/04/2024 at 9:45 AM revealed the resident in bed, and her hair was greasy and uncombed. R23 stated she did not remember when she last had her hair washed or received a bed bath. She further stated baths were not offered regularly, and she just wanted to get her hair washed. R23 stated, It makes me feel better when I'm clean and my hair is clean. R23 also stated she preferred a bed bath. In additional observation and interview with R23 on 12/06/2024 at 1:57 PM, she stated she did not refuse showers or baths when offered. She further stated she received a bath yesterday, her hair was washed, and she felt so much better. Observation of R23 revealed she smiled as she spoke, and her hair was clean and combed. During interview with STNA12 on 12/04/2024 at 3:55 PM, she stated if a resident refused a shower, she let the nurse know. However, she did not say anything about asking the resident if the resident would like the shower later or if STNA12 would pass it on to the next shift. In an interview with STNA16 on 12/05/2024 at 2:47 PM, he stated if residents refused their scheduled shower time, he reapproached the resident the same day and provided education and encouragement. He further stated there was not always enough time for make-up showers the following day. In an interview with STNA14 on 12/05/2024 at 9:53 PM, she stated residents typically received showers twice a week, and they had scheduled shower days. In an interview with STNA17 on 12/06/2024 at 1:46 PM, she stated residents were showered or bathed twice a week. She further stated after completion, the shower or bath was documented in the resident's EMR under POC and in the shower binder at the nurse's station. STNA17 stated sometimes showers were missed because staff was too busy. Additionally, she stated if a resident refused a shower or bath, she returned later in the day and asked again; if the resident refused again, she notified the nurse. STNA17 also stated she explained to residents their showers were important and helped them feel better. During interview with STNA8 on 12/06/2024 at 3:06 PM, she stated if a resident refused a shower, she encouraged the resident and let the resident know he/she might not get a shower because showers were scheduled twice a week. STNA8 stated she informed the nurse of the refusal. During additional interview with STNA14 on 12/06/2024 at 3:14 PM, she stated if a resident refused a shower, she tried to encourage the resident or offer to do the shower later. She stated she tried twice, or if the resident was agitated, she let the nurse know. During interview with Licensed Practical Nurse (LPN) 9 on 12/06/2024 at 3:09 PM, she stated when she was informed a resident refused a shower, she talked to the resident and called the family to let them know of the refusal. In an interview on 12/06/2024 at 2:09 PM with the Wound Care Certified Nurse (WOCN), she stated she had worked one year as WOCN and prior to that was a floor nurse at the facility for 10 years. She stated residents received two showers or baths a week with their hair washed if desired. The WOCN stated nursing aides usually reapproached residents later the same day if a resident refused their bath or shower. She further stated if the resident continued to refuse, the aide notified the nurse, and the resident was educated on the shower schedule and the need for personal hygiene. The WOCN stated residents had complained that showers were not always received. She further stated when she worked as a floor nurse and a shower was missed, she asked the resident if they refused, and if not, she then spoke to staff and determined the reason it was skipped. In an interview with the Director of Nursing (DON) on 12/05/2024 at 2:11 PM, she stated residents received two showers a week, and that was documented in the EMR under POC. She further stated there were quite a few residents that refused regularly, and when that occurred, refusals were put on their care plan, and families were made aware. The DON stated when residents refused a shower initially, staff offered again; if the resident refused again, a shower or bath was not given, and it was added to the schedule and given another day. In additional interview with the DON on 12/06/2024 at 2:16 PM, she stated neither staff nor residents had notified her that showers and baths were missed. She further stated residents frequently refused showers, and aides did not always document properly. She stated she thought the problem was a combination of both of those things. During an interview with the Administrator on 12/06/2024 at 3:18 PM, she stated she was not aware of missed showers. She stated she expected residents to receive their showers and baths as scheduled, as needed, and when they chose. She further stated she expected residents who refused were offered a shower later, and staff documented that information in the resident's EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) signage, and review of the facility's policies, the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 29 sampled residents, Resident (R)10, R231, and R26. Observation on 12/04/2024 revealed R10 was in Enhanced Barrier Precautions (EBP), but State Trained Nurse Aide (STNA) 11 and STNA12 changed R10's brief and the bed linen without wearing a gown. Observation on 12/04/2024 revealed STNA11 and STNA12 used a gait belt to transfer R10 to a wheelchair, and then they then attempted to use the same gait belt to transfer her roommate, R231. Observations on 12/03/2024 and 12/05/2024 revealed R26's wound vacuum (vac) tubing was on the floor. The findings include: Review of the facility's policy titled, Infection Control Transmission Based Precaution, revised 04/2024, revealed when possible, dedicate the use of non-critical resident-care equipment items such as a stethoscope, sphygmomanometer, or bedside commode to a single resident to avoid sharing between residents. Per the policy, if the use of common items was unavoidable, then adequately clean and disinfect them before use for another resident. Further review revealed for residents on EBPs, a gown and gloves was required when performing high contact activities with residents. Review of the facility's policy titled, Standard Precautions, revised 09/2024, revealed for staff to wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during procedures and resident care activities that were likely to generate splashes or sprays of blood, body fluids, secretions or excretions, or cause soiling of clothing. Per the policy, staff should ensure that reusable equipment was not used for the care of another resident until it had been appropriately cleaned and reprocessed. Review of the facility's signage for Enhanced Barrier Precautions, undated and with the CDC logo on the bottom right of the sign, revealed Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting. 1. Observation on 12/04/2024 at 2:04 PM revealed an EBP sign on the right wall. There was also a magnetic STOP sign on the left side of the bathroom door. The sign stated, ENHANCED BARRIER PRECAUTIONS, room [ROOM NUMBER]-1 BED DOOR. R10 was in the bed by the door. Continued observation revealed STNA11 and STNA12 changed R10's brief, and both staff members were wearing gloves but no gown. Further, after they cleaned and dressed R10, they put a gait belt around her waist. They then held R10 under each arm and held the gait belt with the other arm. They transferred R10 to the wheelchair and removed the gait belt. Then, STNA12 placed the gait belt on R10's dresser. 2. Continued observation revealed R231 requested to get in her wheelchair. STNA12 picked up the gait belt off R10's dresser and attempted to put it on R231. Before that happened, the State Survey Agency (SSA) Surveyor asked STNA11 and STNA12 to step into the hall. During immediate interview with STNA12 in the hall, she stated she had been trained in infection control, but they did not go over what to do with the gait belt. She stated each resident did not have their own belt; they used the gait belt they had with them to transfer each resident without cleaning the belt between residents. On 12/04/2024 at 2:23 PM Licensed Practical Nurse (LPN) 4 came to the SSA Surveyor, STNA11, and STNA12. LPN4 asked if she could help. During immediate interview with LPN4, she stated she was last trained in cleaning a gait belt years ago when she was an STNA. She stated the computer training she received at this facility did not include gait belt use on residents. During interview with STNA11 after interview with LPN4, she stated she had not been trained to clean the gait belt after use. She stated each resident did not have their own gait belt. During interview with the Director of Nursing (DON) on 12/04/2024 at 2:40 PM after she arrived on the unit, she stated staff had been trained in EBPs. She stated STNA11 and STNA12 should have put on a gown prior to changing R10. She further stated there was no reason to clean gait belts between residents unless they were visibly soiled. She also stated if they were visibly soiled, they were put in a bag and sent to the laundry. During interview with the Assistant Director of Nursing (ADON) on 12/04/2024 at 2:45 PM, she stated the same gait belts were used on each resident unless they were visibly soiled. She further stated if a gait belt was used on a resident who was in EBP, it would depend on what reason they were in EBP to determine if the same gait belt could be used on another resident who was not in EBP. She stated she made rounds to monitor staff to see if they were maintaining infection control. She stated she did not document the findings. During interview with the Administrator on 12/06/2024 at 2:58 PM, she stated she had not been made aware of staff using the same gait belt on residents without cleaning the belt. She stated she expected staff to maintain infection control precautions. 3. Observation on 12/03/2024 at 12:35 PM revealed R26 in the first-floor dining room at lunch in her wheelchair. R26's wound vac was secured to the back of her wheelchair, and the wound vac tubing was observed on the floor. Observation on 12/05/2024 at 8:42 AM revealed STNA14 asked STNA3 (also a Kentucky Medication Aide (KMA)) how R26's wound vac should be positioned prior to transport in the wheelchair, and R26 was in her room with the wound vac attached to the back of her wheelchair. The wound vac tubing was again observed on the floor. In an interview with STNA14 on 12/05/2024 at 9:53 AM, she stated earlier in the morning she asked STNA3 how wound vac tubing should be positioned when residents were transported because she was unsure of its placement. STNA14 further stated when residents with a wound vac were transported, the tubing was positioned high enough, so it was kept off the floor because of the risk for infection. In an interview with STNA3 on 12/05/2024 at 10:05 AM, she stated if a resident's wound vac tubing was found on the floor, it needed replacement tubing because of potential infection control concerns. In an interview with STNA17 on 12/06/2024 at 1:46 PM, she stated R26's wound vac was managed by nursing, but she knew the tubing was kept off the floor because of the risk for infection. She further stated if she found tubing on the floor or the machine beeped, she notified the nurse immediately. In an interview with the Wound Care Certified Nurse (WOCN) on 12/06/2024 at 2:09 PM, she stated she had worked for a year as WOCN and prior to that she was a floor nurse at the facility for 10 years. The WOCN stated nursing aides notified nursing if there was an issue with a wound vac. She further stated nursing typically contacted her for concerns with a wound vac, but they addressed issues as well. The WOCN stated the wound vac canister was changed weekly and as needed and the wound vac itself (with tubing) was changed three days a week and as needed. The WOCN stated tubing was kept off the floor because of the risk for infection. She further stated when a resident with a wound vac was transported in a wheelchair, the device (in its bag) was attached to the back of the wheelchair, and the tubing wrapped around the straps of the bag. The WOCN stated if she observed wound vac tubing on the floor, it was corrected immediately through staff education, and the tubing was replaced. In additional interview on 12/06/2024 at 2:16 PM with the DON, she stated she expected staff to follow infection protocols, and wound vac tubing was kept off the floor. She further stated if tubing was observed on the floor, it was cleaned/changed immediately, and staff was reeducated on proper infection control processes. In an interview on 12/06/2024 at 2:29 PM with the Infection Preventionist (IP), she stated nursing aides received education regarding wound vacs. She stated education included if a wound vac or the tubing was leaking, beeping, came off, or fell on the floor, they notified nursing right away. The IP stated when residents with wound vacs were transferred, the wound vac case was attached to the back upper portion of the wheelchair, and the tubing was wrapped around the case and kept off the floor. She further stated, if noncompliance was noticed by her, it was corrected immediately, and education was provided to staff. The IP stated anytime tubing was found on the floor, it was changed because of infection concerns. In an interview with the Administrator on 12/06/2024 at 3:18 PM, she stated tubing of any kind, including wound vac tubing, was never left on the floor. The Administrator stated she made rounds throughout the day, and any identified noncompliance was corrected and addressed immediately with staff through reeducation. She further stated staff education was important, so they understood the potential infection concerns with tubing left on the floor.

Based on observation, interview, record review, review of the facility's policy, review of the Facility Assessment Tool, and review of the Payroll-Based Journal Staffing Data Report, the facility failed to have sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted each residents' rights, physical, mental, and psychosocial well-being. During interviews with seven interviewable residents, Residents (R) 6, R34, R69, R82, R101, R108, and R116, they all stated they had concerns and care issues as a result of low staffing with wait times from 30 to 45 minutes for assistance. During interviews with Resident Representatives for R81 and R52, they stated they had concerns with low staffing. The findings include: The facility did not provide a policy regarding staffing. Review of the undated policy titled, [Facility] Federal Residents Rights and Facility Responsibilities, indicated the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. Review of the facility's policy titled, Facility Assessment Tool, revised 07/2024, indicated staffing for licensed nurses, medication aides, and nurse aides were based on the current census and resident acuity in the facility. Further review revealed no evidence the tool contained the number of licensed nurses, medication aides, and nurse aides the facility needed each shift based on the resident acuity and resident census. Review of the Payroll-Based Journal (PBJ) Staffing Data Report, with the due date of submission, 08/14/2024, revealed the facility triggered for excessively low weekend staffing during the third Fiscal Quarter, from April 1st to June 30th, 2024. 1. Review of R108's Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/14/2024, revealed R108 had a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated R108 was cognitively intact. In an interview on 12/03/2024 at 10:44 AM with R108, she stated her biggest complaint was with the STNAs on evening and night shifts, from 7:00 PM to 7:00 AM, not answering the call lights when she needed help. She stated she had waited an hour to get help in going to the bathroom. She stated, I try to hold my bowel movement until I receive help but there are times I have to hold it, and it causes me to become constipated. I have gotten hemorrhoids from holding my bowels. I have left side paralysis and need assistance in going to the restroom. She stated the morning staff was better about assisting her. Observation on 12/03/2024 at 10:59 AM revealed R108 was talking with her daughter on the phone, and her daughter was concerned that staff at the front desk did not answer the phone. Her daughter stated she had tried calling for the last two days, and no one had answered the phone when she tried calling either in the morning or at night. 2. Review of R6's quarterly MDS, with an ARD of 11/12/2024, revealed R6 had a BIMS score of 10 out of 15, which indicated the resident was moderately cognitively impaired. In an interview on 12/03/2024 at 9:30 AM with R6, she stated, They ain't got a nurse when you need one, stating she had to holler, holler, and holler to get help. R6 stated the issue had been happening for a while, and it happened more on the weekends. 3. Review of R34's quarterly MDS, with an ARD of 09/13/2024, revealed R34 had a BIMS score of 15 out of 15, indicating R34 was cognitively intact. In an interview on 12/03/2024 at 9:45 AM with R34, she stated, Facility is short of help on dayshift. She stated when she used her call light it took 30 plus minutes for it to get answered by staff. 4. Review of R69's admission MDS, with an ARD of 09/09/2024, revealed R69 had a BIMS score of 15 out of 15, indicating R69 was cognitively intact. In an interview on 12/03/2024 at 10:27 AM with R69, he stated his big concern was the staffing at nights and on the weekends. He stated the facility was short staffed. R69 stated he had complained to management, but they just smiled at him and nodded in agreement, but nothing was ever changed. 5. Review of R82's quarterly MDS, with an ARD of 10/01/2024, revealed R82 had a BIMS score of 15 out of 15, indicating R82 was cognitively intact. In an interview on 12/03/2024 at 12:27 PM with R82, she stated she had to wait an hour to go to the bathroom because of staff not coming to help. 6. Review of R101's quarterly MDS, with an ARD of 08/01/2023, revealed R101 had a BIMS score of 14 out of 15, which indicated R101 was cognitively intact. In an interview on 12/03/2024 at 9:50 AM with R101, he stated it took 45 minutes for his call light to get answered. He stated he called out this morning at 6:30 AM to get up and ready for the day, and no one came to his room until 7:15 AM. 7. Review of R116's MDS, with an ARD of 08/26/2024, revealed R116 had a BIMS score of 15 out of 15, which indicated R116 was cognitively intact. In an interview on 12/03/2024 at 9:45 AM with R116, he stated his concern was staffing on the weekends. He stated it took a long time to get help. 8. In an interview on 12/03/2024 at 2:25 PM with R81's Representative, she stated when she called the facility after 8:00 PM no one answered the phone. She also stated she had three different numbers to call, and she did not get an answer for any of them. 9. In an interview on 12/03/2024 at 2:38 PM with R52's Representative, she stated low staffing was an issue. She stated it took hours to get a response when the call light was used. She also stated there was one STNA and one nurse for a floor at times. In an interview on 12/04/2024 at 10:11 AM with STNA9, she stated they worked short staffed on most days. She stated they were usually short staffed due to call-ins, and weekends were worse. She stated on good days she would be responsible for approximately 16 residents, and on bad days she would be responsible for 20 plus residents. In an interview on 12/06/2024 at 8:53 AM with Kentucky Medication Aide (KMA) 1, she stated low staffing was a problem, and it could be difficult to get all her work done by the end of the shift. During an interview on 12/05/2024 at 9:50 AM with the Staffing Coordinator and Director of Nursing (DON), the Staffing Coordinator stated she started in April 2024. They both stated staffing was based on the residents' acuity and how many residents needed assistance with care. They both stated they discussed acuity in the building with the Assistant Director of Nursing (ADON) and the Administrator. They both stated they used the sheet from the day prior to look at the acuity and census in order to determine the staff needed for the following day, and if call-ins occurred, they would all jump in and help. In an interview on 12/06/2024 at 2:57 PM with the Administrator, she stated she was aware of staffing issues in April, May, and June 2024, and short staffing was triggered by the Payroll Based Journal (PBJ). She stated she was not at the facility during that period but was working to develop better staffing to cover the weekends.

Based on observation, interview, review of medication package inserts, and review of the facility's policy, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles and include the expiration date when applicable for 6 of 6 sampled medication carts. Review of the six medication carts revealed four opened bottles of eyedrops without a date on the container, one bottle of expired potassium chloride tablets, one opened Advair inhaler without a date on the container, three expired bottles of nasal spray, 10 opened bottles of nasal spray without a date on the container, and one opened/used vial of lidocaine that was undated. The findings include: Review of the facility's policy titled, Medication Storage, revised 12/2021, revealed medications and biologicals should not be retained longer than recommended by the manufacturer or supplier. Further review revealed once any medication or biological package was opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Per the policy, facility staff should record the date opened on the medication container when the medication had a shortened expiration date once opened. Review of the manufacturer's package insert prescribing information for fluticasone propionate (a corticosteroid nasal spray for allergies) revealed the medication should be discarded after 120 sprays. Further review revealed the dosage for adult patients was one to two sprays per nostril twice daily. Review of the manufacturer's package insert prescribing information for azelastine hydrochloride (a nasal spray for allergies) revealed the medication should be discarded after 120 sprays. Further review revealed the dosage for adult patients was one to two sprays per nostril twice daily. Review of the manufacturer's package insert prescribing information for Advair Diskus (inhaled glucocorticoid used to treat asthma or chronic obstructive pulmonary disease (COPD)) revealed the medication should be discarded after 120 uses. Further review revealed the dosage for adult patients was one inhalation twice daily. Review of the manufacturer's package insert prescribing information for latanoprost ophthalmic solution (an eye drop used to treat glaucoma) revealed the medication should be discarded six weeks after opening. Observation on 12/05/2024 at 8:31 AM of the 1200 Hall medication cart revealed one opened undated box of fluticasone propionate nasal spray. Observation on 12/05/2024 at 12:46 PM of the 1100 Hall medication cart revealed one bottle of potassium chloride tablets with an expiration date of 11/2024; one bottle of saline nasal spray with an expiration date of 10/2024; one bottle of calcitonin nasal spray (used to treat osteoporosis) with an expiration date of 12/01/2024; two bottles of fluticasone propionate that contained opened dates on the packaging, but not on the medication containers; and one bottle of opened fluticasone propionate nasal spray that was not dated on either the container or the packaging. Observation on 12/05/2024 at 12:56 PM of the 2200 Hall medication cart revealed one bottle of fluticasone propionate nasal spray with an expiration date of 10/14/2024 and one bottle of latanoprost eye drops that contained an opened date on the packaging, but not on the medication bottle. Observation on 12/05/2024 at 1:02 PM of the 2300 Hall medication cart revealed one opened, undated vial of lidocaine and one opened, undated bottle of fluticasone propionate nasal spray. Observation on 12/05/2024 at 1:02 PM of the 2100 Hall medication cart revealed one opened, undated bottle of fluticasone propionate nasal spray; one opened, undated bottle of azelastine nasal spray; and the following eye drops that contained an opened date on the packaging, but not on the medication containers: one bottle of dorzolamide timolol eye drops (used to treat glaucoma), one bottle of moxifloxacin eye drops (used to treat eye infections), and one bottle of polymyxin eye drops (used to treat eye infections). Observation on 12/05/2024 at 1:14 PM of the 1300 Hall medication cart revealed the following that contained an opened date on the packaging, but not on the medication containers: one Advair Diskus inhaler, one bottle of azelastine nasal spray, and three bottles of fluticasone propionate nasal spray. In an interview on 12/05/2024 at 8:31 AM with State Tested Nurse Aide (STNA) 3, who was also a Kentucky Medication Aide (KMA), she stated medications were dated as soon as they were opened on both the package and the medication container. STNA3 stated it was important medications were dated when opened because outdated medications lost their effectiveness over time and were potentially harmful to residents. She further stated, when she found undated or expired medications, they were discarded and reordered. In an interview on 12/05/2024 at 12:46 PM with STNA15, who was also a KMA, she stated medications were dated on both the packaging and the medication container when opened. She further stated if expired medications were found in the cart, she gave them to the nurse in charge. STNA15 stated expired or outdated medications were less effective after the expired dated and were potentially harmful if given to residents. In an interview with the Pharmacy Technician on 12/05/2024 at 1:41 PM, she stated they checked carts at the facility at least monthly for expired medications. She further stated any expired medications were removed from the cart, reordered, and taken back to the pharmacy. In an interview with Licensed Practical Nurse (LPN) 4 on 12/05/2024 at 1:46 PM, she stated when she opened a medication, she dated the box with both the opened date and the discard date because medications lost effectiveness over time. LPN4 stated she did not always date both the packaging and the container because the container was typically in the original packaging. She further stated she had not previously found medications separated from their original packing in her medication cart, but it made sense to date both in case the packaging was misplaced or discarded. LPN4 stated nurses on the floor checked carts for expired and undated medications. In an interview with the Director of Nursing (DON) on 12/06/2024 at 2:34 PM, she stated nurses checked carts for expired medications, and pharmacy performed audits on the medication carts at least once a month. The DON stated medications should be dated when opened, but stated an opened date on the packaging alone was sufficient because the prescription number on the packaging correlated with the prescription number on the container. When asked what staff would do if a medication was found undated without packaging, she stated that was something she had not witnessed, but if that occurred the opened date would be unknown. She further stated expired medications were discarded because of potential adverse effects to residents. In an interview on 12/06/2024 at 3:18 PM with the Administrator, she stated she expected opened medications were labeled and dated both on the packaging and the medication container. She further stated nurses on the carts checked for expired medications, and pharmacy checked the carts at least once a month. The Administrator stated if medications were not properly labeled, they could be administered to the wrong resident, and if not properly dated, were less effective and potentially harmful. The Administrator stated she monitored for compliance through spot checks of the medication carts. She further stated, if issues were identified with outdated or undated medications, those medications were discarded and reordered, and staff received immediate education.

Based on observation, interview, record review and review of facility Policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance of his or her quality of life for one (1) of twenty-six (26) sampled residents (Resident #65). Interview with Resident #65 on 09/24/19, revealed State Registered Nurse Aide (SRNA) #10 told the resident that he/she was wetting his/her pants and vomiting purposefully and it made SRNA #10 mad (date unknown). Further, Resident #65 complained SRNA #10 was sometimes rude and accused him/her of frequently ringing the call light and always ringing the call light at the end of the shift when she needed to leave to get her kids on the school bus. The findings include: Review of the Resident Rights document, undated submitted by the facility for review, revealed each resident shall be treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and care for his personal needs. Review of the Resident #65's clinical record revealed the facility admitted the resident on 03/04/19 and re-admitted the resident on 08/22/19 with diagnoses including: Major Depressive Disorder, Anxiety Disorder, Enterocolitis due to Clostridium Difficile, Type 2 Diabetes Mellitus, Bladder Disorder, Hydronephrosis with Renal and Ureteral Calculous Obstruction, Urinary Tract Infection, and Gastro-Esophageal Reflux Disease. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/28/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident had no cognitive impairment. Interview with Resident #65, on 09/24/19 at 12:51 PM, revealed he/she had been nauseated off and on for quite a while. Further interview revealed at therapy earlier today the resident was unable to complete his/her therapy due to nausea. Continued interview revealed Resident #65 felt his/her care was good except for one (1) staff member who was rude. Per interview, State Registered Nurse Aide (SRNA) #10 told Resident #65 about a week ago, that he/she was wetting his/her pants and vomiting purposefully and it made SRNA #10 mad. Resident #65 further stated SRNA #10 was not always rude, but if it was a busy day or if he/she needed frequent assistance, SRNA, #10 was not nice. Continued interview with Resident #65, revealed SRNA #10 told him/her in the past, he/she had been ringing the call light too often. Resident #65 was unable to recall a specific date; however, he/she stated one morning right before the shift change, SRNA told him/her that he/she always rang the call bell right before shift change and she (SRNA #10) needed to hurry to finish up, so she could leave in time to get her kids on the school bus. Further interview revealed Resident #65 did not report the incident because it was partially his/her fault for ringing the call bell too often. Continued interview revealed Resident #65 had not seen SRNA #10 in the last few days and he/she was happy when he/she rang the call light and it was not SRNA #10 who answered. Resident #65 stated he/she did not feel SRNA #10 was abusive towards him/her, but she re-iterated SRNA was rude at times. Post survey phone interview with SRNA #10, on 10/04/19 at 5:50 PM, revealed she denied mistreating Resident #65 and stated she did not recall telling the resident he/she was incontinent or vomiting on purpose, and if she did mention anything like that, it would have been in a joking manner. She stated she did remember an incident with Resident #65 when she jokingly told the resident he/she would often ring the call light right before shift change. Further interview revealed she did not remember if she mentioned anything about the need to put her children on the school bus, but she may have said something while providing care. Continued interview revealed Resident #65 did call for assistance often at 7:00 AM, at the end of SRNA #10's shift. SRNA #10 stated when Resident #65 rang the call light one particular day recently the resident stated, I thought I had waited long enough for the shift to end. Oh, I thought you might have gone. SRNA #10 stated she and Resident #65 had no issues and perhaps her statements to the resident were taken the wrong way due to her tone of voice. Interview on 09/27/19 at 12:52 PM, with Licensed Practical Nurse (LPN)/Unit Manager, who worked the unit in which Resident #65 resided, revealed it was her expectation each resident was treated kindly. She stated she had not heard any complaints with SRNA #10's name mentioned. Further interview revealed if a staff member accused Resident #65 of vomiting or of urinary incontinence purposefully that would be a dignity issue. Further, if a staff member spoke to a resident and made them feel as if they should not use their call light when needed, that would be a dignity issue which would need to be reported to the Director of Nursing (DON) and the Administrator. Continued interview revealed Resident #65 had not reported any negative incidents. Interview with the Director of Nursing (DON), on 09/27/19 at 1:09 PM, revealed if an employee was suspected of abuse or if a staff member did not treat a resident with dignity, the staff member would need to immediately clock out. The DON stated she was unaware of the allegations related to SRNA #10 telling Resident #65 he/she was vomiting and incontinent on purpose; and telling the resident he/she rang the call bell frequently and right before shift change until the State Agency Representative brought it to the attention of the Administrator. The DON stated SRNA #10 had not worked the floor after it was reported. Continued interview revealed it was her expectation all residents were treated in a kind and compassionate manner. Per interview, staff was not to disagree with a resident and was to honor their requests. Interview with the Administrator, on 09/27/19 at 1:28 PM, revealed staff was to always act in an an appropriate manner and have work place behavior. Per interview, it would be inappropriate for a staff member to tell Resident #65 he/she was purposefully vomiting and being incontinent. Further, if a staff member was providing care at the end of a shift, it would be expected for them to complete the care to the resident and not complain to the resident. Continued interview revealed the facility provided customer service training for staff and they should be aware of how to talk to a resident. Further interview revealed after the Administrator was informed of the allegations related to Resident #65, SRNA #10 was questioned and denied saying anything inappropriate to Resident #65. Continued interview revealed there had been no issues with SRNA #10's behavior in the past; however, after she learned of the allegations, SRNA #10 was re-educated concerning customer service.

Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, it was determined the facility failed to ensure services were provided as outlined in the Comprehensive Care Plan for one (1) of twenty-nine (29) sampled residents (Resident #72). Resident #72's Comprehensive Care Plan had an intervention for two (2) to assist with transfers; however, on 12/10/18, one (1) staff member assisted the resident to transfer, and the resident sustained a fall. 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 Resident #72's medical record revealed the facility admitted the resident on 11/17/16 with diagnoses including Transient Cerebral Ischemic Attack, Cerebral Infarction, Syncope, and Hemiplegia affecting right dominant side. Review of the Annual Minimum Data Set (MDS) Assessment, dated 11/06/18, revealed the facility assessed Resident #72 as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Additional review of the MDS Assessment, revealed the facility assessed the resident as requiring two (2) person physical assistance for transfers to and from: bed, chair, wheelchair, and standing position. Review of Resident #72's Care Assessment Area (CAA), dated 11/06/18, revealed the resident had balance problems during transitions and had a prior history of falls. Further review revealed Resident #72's had a diagnosis of stroke with right sided weakness, and had a history of previous strokes which may contribute to his/her decreased mobility and increase his/her need for staff assistance. Review of the Comprehensive Care Plan, undated, revealed Resident #72 had an Activities of Daily Living (ADL) self-care performance deficit related to Impaired Mobility, Cerebral Vascular Accident, and Hemiplegia. The goal revealed the resident would maintain current level of function with ADLs through the review date. The interventions included: extensive assistance times two (2) staff for bed mobility and extensive assistance times two (2) staff for all transfers. Review of the Nurse's Notes, dated 12/10/18 at 5:56 AM, revealed Resident #72's was being transferred to the wheelchair by a State Registered Nurse Aide (SRNA), when the resident had to be lowered to the floor. Further review of the Note, revealed the resident had no injuries from the fall. Review of the Interdisciplinary Team Follow Up Note, dated 12/10/18, revealed a Nurse Aide was attempting to transfer Resident #72 from the bed to the wheelchair, when the resident's leg got caught underneath him/her and the resident started to fall. Per the Note, Resident #72 was lowered to the ground. Continued review revealed staff was to utilize assist times two (2) (staff) with all transfers. Interview with Resident #72, on 12/13/18 at 11:00 AM, revealed in the past he/she had always been transferred by two (2) staff members. Further interview revealed on the morning of 12/10/18, he/she was being transferred to the wheelchair by only one (1) SRNA, when he/she started to fall and had to be lowered to the floor. The State Agency Representative attempted a phone interview on 12/13/18 at 2:00 PM, with with SRNA #8, who was the SRNA who transferred Resident #72 independently on 12/10/18. Although a message was left to return the call; the SRNA did not return the call. Interview with the Director of Nursing (DON) and the Administrator, on 12/13/18 at 5:00 PM, revealed they investigated the root cause of Resident #72's fall, and identified the resident would tell staff when he/she required the assistance of two (2) persons, and the resident would let staff know when he/she was too weak to transfer with just one (1) person. Further interview revealed Resident #72 was transferred with the assist of one (1) staff on 12/10/18 and sustained a fall. Additional interview revealed it was important staff followed the care plan to help ensure patient safety.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident receives adequate supervision to prevent accidents for one (1) of five (5) residents sampled residents reviewed for falls out of a total sample of twenty-nine (29) residents (Resident #72). Resident #72's Minimum Data Set (MDS) Assessment, dated 11/06/18, revealed the resident required assist of two (2) staff for transfers; and the resident's Comprehensive Care Plan had an intervention for two (2) persons for transfer. However on 12/10/18, the resident was transferred with the assist of one (1) staff and sustained a fall. The findings include: Review of the facility's Fall and Accident Management Policy, dated 05/2016 revealed the facility will identify patients at risk of falls and other accidents. Further review revealed interventions will be implemented and evaluated to reduce the risk of injuries, falls or other accidents. Review of Resident #72's medical record revealed the facility admitted the resident on 11/17/16 with diagnoses of Transient Cerebral Ischemic Attack, Cerebral Infarction, Syncope, and Hemiplegia affecting right dominant side. Review of Resident #72's Annual Minimum Data Set (MDS) Assessment, dated 11/06/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS Assessment, revealed the facility assessed the resident as requiring two (2) person physical assistance for transfers to and from: bed, chair, wheelchair, and standing position. Review of Resident #72's Comprehensive Care Plan, undated, revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to Impaired Mobility, Cerebral Vascular Accident, and Hemiplegia. The goal stated the resident would maintain current level of function with ADLs through the review date. The interventions listed included: extensive assistance times two (2) staff for bed mobility and extensive assistance times two (2) staff for all transfers. Review of Resident #72's Nurse's Notes, dated 12/10/18 at 5:56 AM, revealed the resident was being transferred to the wheelchair by a State Registered Nurse Aide (SRNA), when the resident had to be lowered to the floor. According to the Note, the resident had no injuries from the fall. Review of the Interdisciplinary Team Follow Up Note, dated 12/10/18, revealed a Nurse Aide was attempting to transfer Resident #72 from the bed to the wheelchair, when the resident's leg caught underneath him/her and the resident started to fall. Per the Note, the resident was lowered to the ground. Further review revealed staff was to utilize assist times two (2) (staff) with all transfers. Interview with Resident #72, on 12/13/18 at 11:00 AM, revealed in the past he/she had always been transferred by two (2) staff. Further interview revealed on the morning of 12/10/18, he/she was being transferred to the wheelchair by only one (1) SRNA, when he/she had to be lowered to the floor. The State Agency Representative attempted a phone interview on 12/13/18 at 2:00 PM, with with SRNA #8, who was the SRNA who transferred the resident independently on 12/10/18. A message was left to return the call; however, the SRNA did not return the call. Interview with the Director of Nursing (DON) and the Administrator, on 12/13/18 at 5:00 PM, revealed in investigating the root cause of Resident #72's fall, it was identified the resident would tell staff when he/she required the assistance of two (2) persons, and the resident would let staff know when he/she was too weak to transfer with just one (1) person. Per interview, the resident was transferred with the assist of one (1) staff on 12/10/18 and sustained a fall. Continued interview revealed staff were to follow the Care Plans related to transfers.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. Observation on 12/13/18 on the HC2 hall for the 2200 rooms, revealed two (2) tablets of Amantadine 100 milligram (anti-viral medication) was left unattended on top of the medication cart. The findings include: Review of the Medication Storage Policy, dated 08/2018, revealed medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Observation on 12/13/18 at 10:00 AM, revealed two (2) tablets of Amantadine 100 milligram tablets on top of the HC2 medication cart for the 2200 rooms, in the central common area with residents present. Continued observation revealed there was no nurse or staff present in the vicinity of the medication cart. Interview on 12/13/18 at 10:05 AM, with Licensed Practical Nurse (LPN) #3, who was assigned to the 2300 hallway revealed the medication cart belonged to LPN #2. During this interview, LPN #2 walked up the hall to the medication cart with the Amantadine tablets which had the unsecured Amantadine tablets. Interview with LPN #2 on 12/13/18 at 10:07 PM, revealed she pulled the Amantadine in error and set the medication on top of the cart, then got distracted with another resident and left the medications unsecured. Interview with the Assistant Director of Nursing (ADON) on 12/13/18 at 4:30 PM, revealed it was her expectation all medications be secured in the locked medication cart or locked medication storage area. Per interview, medications should never be left unattended. She further stated a resident could have consumed the Amantadine medication which could have resulted in adverse consequences. Interview with the Director of Nursing and the Administrator, on 12/13/18 at 5:00 PM, revealed it was their expectation medications be stored appropriately. Per interview, staff should follow the policies and procedures regarding medication storage. Continued interview revealed there should never be a time medications were left unattended. Further interview revealed there could be a possible negative outcome if a resident consumed the medication that was left on top of the medication cart.

Based on observation, interview and review of facility Policy, it was determined the facility failed to ensure dietary sanitation. Review of the Dish Machine Worksheets on 12/12/18 at 8:44 AM, during kitchen tour, revealed the dish machine temperatures were not consistently documented for the wash and rinse cycles before starting the dish machine at each meal for 10/2018, 11/2018, and 12/2018, as per Policy. The findings include: Review of the facility Policy titled Dish Machine Temperature Checks dated 06/2015, revealed the dietary employee or janitor will check the temperatures of the the dish machine wash and rinse cycle and record the temperatures on the dish machine worksheet before starting the dish machine at each meal. Continued review revealed instructions for the staff to check temperatures BEFORE running the dishes through the dish machine. Review of the facility Dish Machine Worksheets dated 10/2018, revealed the breakfast dish machine temperatures for wash and rinse were not recorded for 10/01/18, 10/02/18, 10/03/18, 10/04/18, 10/05/18, 10/06/18, and 10/07/18. On 10/11/18, the breakfast dish machine wash temperature was not recorded. On 10/16/18, the dish machine wash and rinse temperatures were not recorded at lunch or dinner. The dates of 10/17/18 and 10/18/18 were not listed on the dish machine worksheet and there was no documentation of the temperatures for wash or rinse cycles for those dates. On 10/20/18, the dish machine wash temperature was not recorded at breakfast. On 10/21/18, the dish machine wash temperature was not recorded at dinner. On 10/29/18 and 10/31/18, the dish machine temperatures for wash and rinse were not recorded at breakfast. On 10/30/18, there was no documentation of the dish machine temperatures for the wash or rinse cycles. Review of the Dish Machine Worksheets dated 11/2018, revealed the dates of 11/01/18 and 11/02/18 were not listed on the dish machine worksheet and there was no documentation of the dish machine temperatures at meals for the wash or rinse cycles. On 11/03/18 and 11/04/18, the dish machine wash and rinse temperatures were not recorded at the breakfast meal. On 11/05/18, 11/06/18, 11/07/18, 11/08/18, 11/09/18, 11/10/18 and 11/11/18, there was no documentation of the dish machine wash and rinse temperatures at meals. On 11/12/18, the wash temperature at breakfast was not recorded. On 11/13/18 and 11/14/18, the dish machine wash and rinse temperatures were not recorded at dinner. The breakfast dish machine temperatures were not recorded for 11/16/18, 11/17/18, 11/19/18, 11/20/18, and 11/21/18. On 11/22/18, the lunch and dinner dish machine temperatures were not recorded. The dish machine wash and rinse temperatures at breakfast on 11/26/18 was not recorded. The dish machine temperatures for 11/27/18 and 11/28/18 were not recorded at breakfast, lunch and dinner. The dish machine temperatures for 11/30/18 were not recorded at breakfast and lunch. Review of the Dish Machine Worksheets dated 12/2018, revealed on 12/01/18 and 12/02/18 dish machine wash and rinse temperatures were not recorded at any meal. In addition, there was no documentation of the dish machine temperatures at meals for the wash or rinse cycles for 12/06/18, 12/08/18 and 12/11/18. Interview on 12/12/18 at 4:48 PM, with the Chef, revealed the staff were responsible to record all dish machine temperatures every day at all meals. Continued interview revealed it was important to ensure the dish machine temperatures were high enough to kill bacteria, and sanitize the dishware for the residents' protection. Interview on 12/13/18 at 8:53 AM, with [NAME] #1, revealed staff were to document dish machine temperatures and let maintenance know or tell the Chef if the machine was not reaching high enough temperatures. Per interview, the high temperatures kill the bacteria, and sanitize the dishes. Interview on 12/13/18 at 8:56 AM, with Prep [NAME] #1, revealed it was important to obtain and document the dish machine temperatures to ensure the dishware was sanitized. Interview on 12/13/18 at 8:58 AM, with Dietary Aide #1, revealed it was important to obtain and record dish machine temperatures to ensure temperatures were high enough to sanitize the dishware. Interview on 12/13/18 at 5:10 PM, with the Director of Nursing (DON), revealed it was her expectation for dietary staff to follow dietary policies. Interview on 12/13/18 at 11:59 AM, with the Administrator, revealed it was his expectation for staff to obtain and record temperatures of the Dish Machine as per Policy to ensure dietary sanitation.