**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed the facility admitted Resident #10 on 03/02/18 with diagnoses which included Generalized Anxiety Disorder,and Major Depressive Disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #10's cognition as intact with a Brief Interview for Mental Status Score (BIMS) of fifteen (15) which indicated the resident was interviewable. Interview with Resident #10 on 03/20/19 at 8:57 AM revealed staff do not knock on door when they come in. During the resident interview on 03/20/19 at 9:09 AM, this surveyor observed the Activities Assistant walk into the room without knocking. Phone interview with the Activities Assistant on 03/21/19 at 10:24 AM revealed he should have knocked on the resident's door. He stated he was nervous since State was in the building but he usually knocked before entering the residents' rooms. Interview with the Activities Director on 03/21/19 at 10:19 AM revealed she expected all her employees to knock on the resident's door and ask for permission before entering the resident's room. Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure thirteen (13) of twenty-two (22) sampled residents was treated with respect, dignity and in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Observation of dining service on 03/19/19 and 03/20/19, revealed twelve (12) residents on the Reflections Unit were served milk in paper cartons. In addition, observation revealed staff failed to knock on Resident #10's door before entering his/her room. The findings include: Review of the facility policy, Attachment F: Resident Rights, not dated, revealed the resident has the right to be treated with consideration, respect and full recognition of his or her dignity and individuality, including privacy in treatment and in care for his or her personal needs. any policy or interview stating not one. 1. Observation of meal service on the Reflections Unit on 03/19/19 at 11:52 AM and 03/20/19 at 11:49 AM, revealed staff served twelve (12) of fifteen (15) residents milk in paper cartons and not in cups. Interview with Certified Nurse Aid (CNA) #1 on 03/21/19 at 1:25 PM, revealed they always serve the milk in the cartons to the residents and the residents don not seem to mind. Interview with Licensed Practical Nurse (LPN) #5 on 03/21/19 at 1:28 PM, revealed milk cartons are served to the residents because they may be more familiar to the Dementia population. She stated she felt it was because the residents grew up in school using milk cartons and she did not view it as a dignity issue. Interview with the Director of Nursing (DON) on 03/21/19 at 2:39 PM, revealed she was not sure why the residents' drinks were not served in cups, as they were in the main dining area. She stated she could understand why it may be considered a dignity issue, as drinking out of a glass or cup may be more home-like. The DON stated the dining experience should be home-like for all residents in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed the faclity admitted Resident #89, on 02/08/18 with diagnoses which included Hypertension, Non-Alzheimer's Dementia, Anxiety, Depression and Psychotic disorder. Review of a quarterly Mininimum Data Set (MDS) assessment, dated 03/08/19, revealed section N 0410 of the MDS indicated Resident #89 received seven (7) days of antipsychotic medication, however, review of section N0450 of the MDS assessment revealed the resident did not receive antipsychotic medications since admission/entry or reentry. Interview with MDS Coordinator #1 on 03/21/19 at 1:14 PM, revealed staff are trained on ADL coding upon hire and as needed. She stated no resident should require the assistance of two staff members with eating and Resident #11's coding as a 4/3 with eating was done in error. MDS Coordinator #1 stated Section N of Resident #89's MDS assessment was just an oversight, as the resident's Medication Administration Record (MAR) should be reviewed to accurately code if a resident received antipsychotics during the seven-day look-back period. Interview with MDS Coordinator #2 on 03/21/19 at 1:31 PM, revealed she should have followed up with the CNA's who coded Resident #11 required the assistance of two (2) staff with eating because it was coded inaccurately. MDS Coordinator #2 further stated she should have submitted a correction for the MDS assessment because no resident requires the assistance of two staff with eating. Interview with the Director of Nursing (DON) on 03/21/19 at 2:39 PM, It should only require one staff to feed a resident and the MDS assessment for Resident #11 must have been coded incorrectly. She furthre stated the CNA's get ADL training annually, upon hire and if they need additional training. The DON stated she would expect the MDS assessments to be coded accurately. Based on interview, record review and review of the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for two (2) of twenty-two (22) sampled residents (Residents #11 and #89). Staff failed to accurately code Resident #11's MDS assessment related to Activities of Daily Living (ADL) and Resident #89's MDS assessment related to antipsychotic medications. The findings include: Review of the Long-Term Care Facility RAI 3.0 User's Manual, on Coding instructions for Section G Functional Status, revealed total dependence (4) should be coded if full staff performance occurred every time during the entire 7-day look back period for Activities of Daily Living Self-Performance. Further review revealed the most support provided over all shifts, regardless of resident's self-performance classification, should be coded for ADL Support Provided. 1. Record review revealed the facility admitted Resident #11 to the facility on [DATE] with diagnoses, which included Alzheimer's Disease. Review of the MDS Section G-Functional Status, revealed the resident was coded as total dependence with full staff performance, requiring physical assistance of two plus staff for eating (4/3). However, interview with Certified Nurse Aid #1 on 03/21/19 at 1:25 PM, revealed the CNA's code resident care and staff assistance on the Kiosk during each shift. She stated staff are trained on ADL coding upon hire and as needed. CNA #1 stated Resident #11's requires the assistance of one (1) staff member for meals.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of twenty-two (22) sampled residents (Resident #90). Observations on 03/20/19, revealed staff failed to follow interventions to administer oxygen (O2) at 2 liters per minute (LPM) via nasal cannula for Resident #90. The findings include: Review of the facility's policy, Care Plans, dated 01/01/19, revealed the facility will ensure residents have a person-centered plan of care that supports the resident in making their own choices, having control of their daily lives and addresses their assessed needs. The care plan will address care needs identified through the comprehensive assessment, through implementation of the baseline care plan and describes services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The plan of care will be stated clearly and will identify the resident problems, measurable goals to be achieved, which include timetables to meet resident's needs, and the interventions to be followed by staff in providing the resident care. Record review revealed the facility admitted Resident #90 on 02/08/19 with diagnoses which included Chronic Obstructive Pulmonary Disease. Review of the admission Minimum Data Set (MDS) assessment, dated 02/15/19, revealed the facility assessed Resident #'90's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of Resident #90's Comprehensive Care Plan, dated 02/19/19, revealed an intervention for O2 per Physician's Orders via nasal cannula related to diagnosis of Chronic Obstructive Pulmonary Disease. Review of the Physician's Order, dated March 2019, revealed oxygen at 2 LPM continuously every shift and to monitor O2 saturation each shift, related to Chronic Obstructive Pulmonary Disease. However, observations on 03/20/19 at 8:58 AM and 2:07 PM, revealed Resident #90's oxygen concentrator was on three (3) LPM via nasal cannula. Interview with Resident #90 on 03/20/19 at 2:07 PM, revealed he/she does not touch the settings on the concentrator, only the nurses do. Interview with Licensed Practical Nurse #4 on 03/20/19 at 2:30 PM, revealed she checked Resident #90's oxygen setting for day shift and it was on two (2) liters at that time. She stated she would go correct the setting as the concentrator may have gotten bumped or possibly a family member may have changed the setting without staff's knowledge. LPN #4 checked Resident #90's oxygen saturation and it was ninety-six (96) percent. Interview with the Director of Nursing (DON) on 03/21/19 at 2:39 PM, revealed she expected the nurses to follow the residents care plan and physician's orders while providing care to each resident.

Based on observation, interview, record review and review of the facility's standards of practice, it was determined the facility failed to ensure the services provided or arranged by the facility meet professional standards of quality for one (1) of twenty-two (22) sampled residents (Resident #29) related to medications being left at bedside without nursing supervision. Observation on 03/19/19 revealed a medication cup containing five (5) pills was left unattended on Resident #29's bedside table. The findings include: Review of the facility policy, Safe Medication Administration, not dated, revealed nursing should stay with the patient until the medication is taken, provide help as necessary, and do not leave medications at the bedside without a health care provider's order. Record review revealed the facility readmitted Resident #29 on 03/04/19 with diagnoses which included Anxiety Disorder and Hypertension. Review of the admission Minimum Data Set (MDS) assessment, dated 10/04/18, revealed the facility assessed Resident #'29's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was interviewable. During initial tour of Resident #29's room, on 03/19/19 at 10:31 AM , revealed a medication cup containing five (5) pills on the resident's bedside table. Interview with Resident #29 on 03/19/19 at 10:31 AM, revealed the nurse came in and handed him/her the medications and left the room. Resident #29 stated he/she was feeling sick to his/her stomach and chose not to take them at that time and put them on the bedside table. Interview with Licensed Practical Nurse (LPN) #4 on 03/19/19 at 3:02 PM, revealed she placed the medication cup in Resident #29's hand and turned her back. She stated she thought the resident had taken the medications. LPN #4 further revealed she should have watched the resident take the medications instead of turning her back. She stated she completed a medication pass as part of her orientation and was checked off on the skill and it was facility policy to watch the residents take their medications and not leave them unattended. Interview with the Director of Nursing (DON) on 03/21/19 at 2:39 PM, revealed the nurse's should watch the residents take their medications before leaving the room. The DON stated staff do medication pass observations audits yearly for the nurses and it is also a skill check off done upon hire.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide oxygen (O2) therapy according to the Physician's Order and Care Plan for one (1) of one (1) sampled resident on oxygen (Resident #90). Observations on 03/20/19, revealed staff failed to ensure Resident #90, received O2 at two (2) liters per minute (LPM) per the Physician's Order and Care Plan. The findings include: Review of the facility's policy, Oxygen Therapy Concentrator Set-UP, dated 01/01/07, revealed the facility is to administer oxygen in a safe manner in accordance with accepted standards of practice and according to state and federal requirements and nursing should adjust the meter to prescribed rate. Record review revealed the facility admitted Resident #90 on 02/08/19 with diagnoses which included Chronic Obstructive Pulmonary Disease. Review of the admission Minimum Data Set (MDS) assessment, dated 02/15/19, revealed the facility assessed Resident #'90's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of Resident #90's Comprehensive Care Plan, dated 02/19/19, revealed an intervention for O2 per Physician's Orders via nasal cannula related to diagnosis of Chronic Obstructive Pulmonary Disease. Review of the Physician's Order, dated March 2019, revealed to oxygen at 2 LPM continuously every shift and to monitor O2 saturation each shift, related to Chronic Obstructive Pulmonary Disease. Review of the March 2019 Treatment Administration Record (TAR) revealed O2 at 2 LPM continuously every shift. Further review revealed the TAR had been initialed by Licensed Practical Nurse (LPN) #4 on 03/20/19 for day shift which meant O2 was observed in place at 2 LPM. Observations on 03/20/19 at 8:58 AM and 2:07 PM, revealed Resident #90's oxygen concentrator was on three (3) LPM via nasal cannula. Interview with Resident #90 on 03/20/19 at 2:07 PM, revealed he/she does not touch the settings on the concentrator, only the nurses do. Interview with Licensed Practical Nurse #4 on 03/20/19 at 2:30 PM, revealed she had checked Resident #90's oxygen setting for day shift and it was on two liters at that time. She stated she would go correct the setting and stated the concentrator may have gotten bumped or possibly a family member may have changed the setting without staffs knowledge. LPN #4 checked Resident #90's oxygen saturation and it was ninety-six (96) percent. Interview with the Director of Nursing (DON) on 03/21/19 at 2:39 PM, revealed the nurses check the oxygen settings once each shift and verify the check on the residents TAR. She stated the resident's daughter was in on that day and may have altered the setting. She revealed the nurses may need to start following behind the family to ensure nothing has been altered. The DON further stated she expected the nurses to follow the residents care plan and physician's orders while providing care to each resident.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for a total of five (5) medications on three (3) medication carts. Observation of three (3) of six (6) medication carts revealed four (4) insulin pens not dated when opened and one (1) outdated vial of insulin in the medication cart. The findings include: Review of the facility's policy, titled Medication Labels and Packaging, last revised 10/31/09, revealed if the efficacy of a drug was affected by opening a multi-dose vial/bottle, the vial or bottle should be dated and initialed when it was opened for the first time. Additional review revealed medications should be discarded by the expiration date unless indicated by the pharmacy and/or manufacturer's instructions to discard sooner. Observation of three (3) of six (6) medication carts, on 03/20/19 at 1:43 PM, revealed four (4) insulin pens not dated when opened and one (1) outdated vial of insulin in the medication carts. Interview with Licensed Practical Nurse (LPN) #4, on 03/20/19 at 2:25 PM and LPN #5 at 2:26 PM revealed multi-dose vial medications were to be dated when opened and insulin's should be discarded after thirty-one (31) days unless otherwise specified. Interview with Registered Nurse (RN) #1, on 03/20/19 at 2:49 PM, revealed multi-dose vials of medications were to be dated when opened and expired medications were to be removed from the medication cart. Interview with the Director of Nursing (DON), on 03/21/19 at 2:45 PM revealed she expected insulin to be dated when opened and expired medications to be removed from the medication cart.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure staff follow hand hygiene practices consistent with accepted standards of practice for one of twenty-two (22) sampled residents. Observation on while providing care.(Resident #51). related to not washing hands during G-tube care. The findings include: Review of the facility policy Hand Hygiene revealed the purpose is to decrease the risk of transmission of infection by appropriate hand hygiene. The policy revealed: Hand washing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues. Although antiseptics and other handwashing/hand hygiene agents do not sterilize the skin they can reduce microbial contamination depending on the type and the amount of contamination, the agent used, the presence of residual activity and the handwashing/hand hygiene technique followed. Hands should be washed when hands are visibly dirty or contaminated with proteinaceous material, are visibly soiled with blood or other body fluids, after going to the restroom, before eating, before performing a procedure, and after providing care to a resident. Record review revealed the facility readmitted Resident #51 on 01/21/19 with diagnoses which included Hemiplegia, Acquired Absence of other Specified Parts of Digestive Tract, Paralytic Ileus, and Gastro Esophageal Reflux Disease. Observation of Licensed Practical Nurse (LPN) #1 on 03/20/19 at 9:21 AM revealed he did not wash his hands prior to starting gastrostomy tube care and failed to wash his hands after he removed the old dressing. He then obtained a wash cloth and washed around the G-Tube site and placed the soiled wash cloth in sink, donned gloves and dried around site without washing his hands. He removed his gloves after placing the dressing and did not wash hands again. He removed trash from room, picked up dirty washcloth and left the room without donning gloves or washing hands. Interview with LPN #1 on 03/20/19 at 9:32 AM, revealed he would not do anything different. He revealed, that is the way I do it. Interview on 03/21/19 at 9:52 AM with LPN #1 revealed when he got back to the desk, he realized that he had not washed his hands prior to starting. He stated he should have washed his hands after removing the dressing, and after completing the procedure. He revealed he should have completed the care differently. Interview on 03/21/19 at 1:33 PM with the Staff Development Coordinator (SDC) revealed LPN #1 should have washed his hands when entering room, after removing soiled dressing, after placing clean dressing and after disposing of the trash. She stated hand washing education was provided at least quarterly and as often as needed.

Based on interview, record review, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to ensure the services provided or arranged by the facility, meet professional standards of quality for one (1) of twenty-two (22) sampled residents (Resident #12). On 01/22/18, the licensed nurse failed to check for gastrostomy tube (g-tube) placement prior to administering medications per Physician's Order. The findings include: Review of the KBN AOS #14 Patient Care Orders, last revised October 2010, revealed a Licensed Practical Nurse (LPN) will administer medications/treatment as authorized by a physician, or advanced practice registered nurse. Record review revealed the facility admitted Resident #12 on 01/16/16 with diagnoses which included unspecified convulsions, Parkinson's Disease, Hypokalemia, and Dysphagia and eating disorder. Review of Physician's Orders, dated 01/22/18, revealed g-tubes were to be checked before the administration of medication and flushed with sixty (60) milliliters (mls) of water before and after medication administration. However, observation on 02/20/18 at 11:40 AM, revealed LPN #2 did not check g-tube placement prior to administering medication or flushes. Interview with LPN #2, on 02/20/18 at 11:48 AM, revealed she was aware of the need to check for placement and residual of a g-tube prior to administering medications or flushes, however, she just forgot to do it. Interview with the Director of Nursing (DON), on 02/22/18 at 10:51 AM, revealed she expected the nursing staff to follow the Physician's Orders.

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to provide appropriate care and treatment to prevent complications of enteral feeding for one (1) of twenty-two (22) sampled residents (Resident #12). Resident #12 was to be administered medications per gastrostomy tube (g-tube); however, observation on 02/20/18 revealed the licensed nurse failed to check for placement prior to the administration of medication and flushes. The findings include: Review of the facility's policy and procedure, titled Medication via Feeding Tube dated 10/31/10, revealed the g-tube placement should be checked by verifying aspiration of gastric fluid and by auscultation of insufflate air. Record review revealed the facility admitted Resident #12 on 01/16/16 with diagnoses which included unspecified convulsions, Parkinson's Disease, Hypokalemia, Dysphagia and eating disorder. Review of a quarterly Minimum Data Set (MDS) Assessment, dated 12/06/17, revealed a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Further review of the MDS assessment revealed, in Section K the resident required a feeding tube for nutrition and medications. Review of the Comprehensive Care Plan, (no revision date), revealed the resident required assistance with water flushes and he/she would be free from aspiration through the review date. Review of Physician's Orders, dated 01/22/18, revealed g-tubes were to be checked before the administration of medication and flushed with sixty (60) milliliters (mls) of water before and after medication administration. Observation of a medication pass, on 02/20/18 at 11:40 AM, revealed Licensed Practical Nurse (LPN) #2 had prepared two (2) different medications into two (2) cups and two (2) cups of flushes for between administering of each medication. However, further observation revealed LPN#2 began to administer a flush of water to the G-tube without checking for placement first, and was stopped by the surveyor before she administered any flush or medication. Interview with LPN #2, on 02/20/18 at 11:48 AM, revealed she was aware of the facility's policy and the need to check for placement and residual of a g-tube prior to administering medications or flushes, however, she just forgot to do it. Interviews on 02/20/18 with LPN #1 at 2:00 PM and Registered Nurse (RN) #1 at 2:40 PM, revealed g-tube placement should be checked prior to administering medication or flushes. Interview with the Director of Nursing (DON), on 02/22/18 at 10:51 AM, revealed she expected nurses to check for placement of a g-tube prior to administering medications.

Based on observation, interview and review of the facility's policy and procedure, 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 for one (1) of twenty-two (22) sampled residents (Resident #27). Observation during a medication pass revealed the Licensed Nurse dropped a medication on top of the medication cart then proceeded to pick up the medication and administer it to Resident #27. The findings include: Review of the facility's policy and procedure titled, Administering Medications, not dated, revealed all medications were to be administered only as prescribed and infection control protocols were to be maintained at all times. Record review revealed the facility admitted Resident #27, on 07/23/16 with diagnoses which included Major Depressive Disorder, Anxiety, Hypertension and Heart Failure. Review of a quarterly Minimum Data Set (MDS) assessment, dated 01/04/18 revealed the facility assessed Resident #27's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable Observation of medication administration pass, on 02/21/18 at 8:20 AM revealed Medication Aide (MA) #1 dropped a pill (Celexa {antidepressant}), on top of the medication cart and then picked it up with bare hands and placed it in the medication cup with other medications to be administered to Resident #27. Interview with Medication Aide #1, on 02/21/18 at 8:20 AM, revealed she would not normally give a pill that had been dropped on top of the medication cart but would pull another one to administer. Interviews on 02/20/18 with Licensed Practical Nurses (LPN) #1 at 2:00 PM, LPN #2 at 2:33 PM, and Registered Nurse (RN) #1 a 2:40 PM; and, LPN #3 on 02/22/18 at 9:00 AM, revealed they would not administer a medication after it had been dropped on top of the medication cart, but would discard it and administer another one. Interview with the Director of Nursing (DON), on 02/22/18 at 10:51 AM, revealed she expected the nursing staff to discard the contaminated pill and get another one to administer.