Based on observation, interview, facility policy review, and review of manufacturer's instructions, the facility failed to ensure drugs and/or biologicals used in the facility were current for use and/or labeled with currently accepted professional principles, including the expiration date when applicable. Observation of a medication storage room revealed two Tuberculin vials stored in the refrigerator were opened but not labeled with a date as to calculate its discard date. Observation also revealed two vials of Tuberculin dated with a date that was beyond the 30 day manufacturer's required discard date. Additionally, observation revealed 60 COVID-19 test kits stored beyond the manufacturer's expiration date. The findings include: Review of the facility policy titled, Medication Storage, undated, revealed medications stored must be labeled accordingly and the facility should not use discontinued, outdated, or deteriorated drugs or biologicals. Observation on 04/23/2025 at 1:00 PM, of the medication storage room, revealed two multi-dose vials of house stock Aplisol tuberculin (used to detect tuberculosis infection) that was opened; however, not dated. Continued review revealed two additional multi-dose vials of house stock Aplisol tuberculin, one dated 03/15/2025 and the other 03/18/2025, which was past the manufacturer's 30 day required discard date. Further review revealed nine boxes of four (equaling 36 tests) Pilot COVID-19 at home test kits with an expiration date of 04/14/2025 and 24 Cordx COVID-19 ag at home test kits with an expiration date of 04/01/2025. During interview with Registered Nurse (RN) 1 on 04/23/2025 at 1:20 PM, she stated she was an agency nurse. RN 1 stated the tuberculin vials should be labeled with a date and initial immediately after opening. RN 1 reported a resident could have an adverse reaction (from the tuberculin that was undated or past the discard date) and the medication might not even be good anymore. She said the expired medications and test kits would need to be discarded based on the manufacturer's expiration date. The RN stated she did not know the recommendation from the manufacturer regarding how long a tuberculin vial was good for once it was opened. She stated she did not know who was responsible for monitoring the medication room for expired items. RN 1 further stated if the COVID tests were used, they could give a false result. During interview with Licensed Practical Nurse (LPN) 1, she stated the tuberculin vials should have been dated, timed and initialed as soon as they were opened and were only good for 30 days. She said residents could have an adverse reaction and the medication might not be as effective if it was used. LPN 1 reported the nurse who had been responsible for monitoring the medications had quit about two weeks ago. The LPN stated she did not know who was responsible for monitoring the medications now. She said staff should check expiration dates prior to using any medication or COVID test. LPN 1 further stated the COVID tests should have been discarded once they expired. During interview with the Director of Nursing (DON) on 04/24/2025 at 6:23 PM, she stated it was her first week working at the facility. She stated she would be responsible for checking expiration dates. The DON said she expected her staff to check expiration dates and dispose of any medication or test that was expired and dispose of those expired. She reported by using expired medications or COVID tests could result in a resident having a reaction or it could lead to a false test result, which might result in the result receiving treatment for something they did not actually have. The DON further stated expiration dates were there for a reason and should be followed. During interview with the Administrator on 04/24/2025 at 6:59 PM, he stated he expected staff to check expiration dates, date the medication vials once opened and discard the medication once it was past the deadline dates. He said something possibly could have happened to the residents (if the expired products were used). The Administrator explained the medication might not have been at full strength and might have became contaminated. He stated the COVID tests also needed to be monitored for their expiration dates. The Administrator reported if staff used an outdated test, it might not give an accurate indication of the results. He further stated his staff needed to be re-educated on the importance of expiration dates and when to discard medications.

Based on observation, interview, record review and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 13 sampled residents, (Resident (R)10). During observation on 04/24/2025 at 3:33 PM, Licensed Practical Nurse (LPN) 5 was observed to blow her nose; however, failed to perform hand hygiene after doing that. The LPN was then observed to touch R10's packaged medications and administer them to the resident. The findings include: Review of the facility policy titled, Hand Hygiene, undated, revealed it was to promote a simple and effective method for preventing the spread of infection. Per policy review, it included specific guidance for all staff to follow hand hygiene procedures after personal care activities that included blowing of the nose. Observation of LPN 5 on 04/24/2025 at 3:33 PM, revealed the LPN blew her nose at the medication cart, and tossed the used tissue into the waste can. Continued observation revealed LPN 5 then proceeded to touch the computer keyboard, open the medication drawer, and remove packaged medications from the drawer. Further observation revealed LPN 5 proceed to open the packaged medications to prepare to administer the medications to R10. In interview on 04/24/2025 at 3:40 PM, LPN 5 was asked by the State Survey Agency (SSA) Surveyor if she had hand sanitized her hands after blowing her nose. LPN 5 stated she had not sanitized her hands; however, probably should have and said was having allergies. The LPN further stated hand hygiene was important to stop the spread of germs. In interview on 04/24/2025 at 5:23 PM, the Director of Nursing (DON) stated she expected the nurse (LPN 5) to have performed hand hygiene after blowing her nose. The DON further stated the nurse should have performed the hand hygiene prior to touching anything to prevent potential contamination of everything, including the resident. She additionally stated the nurse should have performed hand hygiene to also prevent the spread of infection. In interview with the Administrator on 04/24/2025 at 6:46 PM, he stated he expected staff to appropriately perform hand hygiene to prevent the spread of germs.

Based on observation, interview, and review of the facility's Certified Nursing Assistant (CNA) job description and policy, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Observation and interview revealed an average call light response time of 15 - 20 minutes for three of 50 sampled residents, (Resident (R)15, R42, and R196). The findings include: Review of the facility policy titled, Activities of Daily Living (ADLs), undated, revealed the facility was to provide care, treatment, and services to residents as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Review of the facility policy titled, Answering the Call Light, undated, revealed the facility was to maintain a functional call light system and should make all reasonable efforts to ensure timely responses to the resident's requests and needs. Review of the facility policy titled, Staffing, dated 10/01/2021, revealed the facility was to provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the residents' care plans and the facility assessment. Review of the facility's job description titled, Certified Nursing Assistant, revised 03/2024, revealed the Certified Nursing Assistant's (CNA) personal nursing care responsibilities included ensuring (residents') call lights were within reach of residents and were answered promptly. During the Resident Council meeting held on 04/23/2025 at 1:18 PM, the residents unanimously stated most staff treated residents with dignity; however, certain staff were not friendly and could be mean or hateful. The residents stated sometimes they had to wait up to two hours for help after turning on their call lights. They further stated it was not uncommon to have to wait of 20-30 minutes to get help. Review of the residents who attended and actively participated in the Resident Council meeting medical records revealed Minimum Data Set (MDS) Assessments with Assessment Reference Dates (ARDs) ranging from 01/23/2025 to 03/28/2025 and Brief Interview for Mental Status (BIMS) scores ranging from 13 to 15, indicating intact cognitive function. 1. Record review revealed the facility admitted R42 on 03/28/2025, with diagnoses to include displaced trimalleolar fracture of left lower extremity, history of falls, and essential hypertension. Review of the MDS Assessment with an Assessment Reference Date (ARD) of 04/11/2025, revealed the facility assessed R42 to have a BIMS score of 15 out of 15, indicating intact cognitive function. Observation on 04/23/2025 at 5:18 PM revealed the call light R42 on as the State Survey Agency (SSA) Surveyor passed the resident's room. Observation at 5:22 PM, revealed Licensed Practical Nurse (LPN) 2 walked passed R42's room where the call light was on, and at 5:25 PM, LPN 2 and Registered Nurse (RN) 1 also walked past the resident's room where the call light was still on. Observation at 5:26 PM, revealed the Housekeeping Supervisor walked past R42's room where the call light remained on. Continued observation revealed at 5:31 PM, RN 1 knocked on R42's door and entered the room stating, you had your light on?. In interview on 04/23/2025 at 5:35 PM, R42 stated she was unsure how long she had waited after turning her call light on. She stated the reason the call light was on was because she needed help to get to the bathroom. 2. Review of the medical record facesheet for R15 revealed the facility admitted the resident on 03/05/2021, with diagnoses that included respiratory failure, generalized anxiety disorder, primary osteoarthritis, and hypothyroidism. Review of the MDS Assessment with an ARD of 03/13/2025, revealed the facility assessed R15 to have a BIMS score of nine out of 15, which indicated moderate cognitive impairment. In interview on 04/22/2025 at 1:00 PM, R15 stated her only complaint was that the wash cloths and bed pads were always locked up and she had to go find staff to get them when she needed them. She stated that made her feel in-human. R15 said, I'm an adult and shouldn't have to ask for a wash cloths when I want or need one. It's like they work with a skeleton crew. She stated when she turned her call light on, she had to wait for an hour for someone to come help her. R42 said it is always like that, because staff said it was because the facility was shorthanded. She reported there were usually only two or three aides for a day for the entire building, and the building was big and spread out. R42 stated the facility had new owners, had done a lot of cut backs, and fired some staff about six months ago. She further stated the staff were so overworked, working over 12 hours per day. 3. Review of the medical record facesheet for R196 revealed that the facility admitted the resident on 04/18/2025, with diagnoses that included stage 3A chronic kidney disease, type 2 diabetes, peripheral vascular disease, and moderate vascular dementia. Observation of R196 on 04/22/2025 at 2:55 PM, revealed resident lying on his right side on the bed, with yellow stains appearing to be dried urine on his briefs and bed pads and dried red stains by his foot wound which appeared to be blood on his bed sheets. In interview, at the time of observation, R196 stated his right leg was numb because no on had been in to help him change positions. The SSA Surveyor encouraged R196 to use his call light to request help, and the resident proceeded to press the call light button at that time. Further observation revealed staff responded to R196's call light 20 minutes later when the SSA Surveyor stepped into the hallway to find a staff member to help the resident. In interview on 04/23/2025 at 4:50 PM, CNA 2 stated she believed there was not enough staff to take care of the residents as they should be taken care of. In interview on 04/23/2025 at 5:00 PM, CNA 3 stated in her opinion there was no way there was enough staff to properly take care of the residents. In interview on 04/23/25 at 5:05 PM, the Housekeeping Supervisor stated when the (resident) census was down staff was decreased and residents had to wait longer for help. In interview with CNA 11 on 04/24/2025 at 9:35 AM, she stated anyone could answer a resident's call light and the lights should be answered within three minutes but no longer than 10 minutes. She said even if she was busy, she would stop and acknowledge the light and let the resident know that she would be right back to assist them. CNA 11 further stated a resident could try to get up alone and fall or even choke if their call light was not answered timely. In interview with CNA 12 on 04/24/25 at 10:00 AM, she stated anyone could answer a call light. She stated it should never take more than 10 minutes to answer a resident's call light and definitely should not be 20 minutes or an hour. CNA 12 said anything could happen to a resident during that the waiting time. She further stated she did not think the facility had enough staff, but she always got her job done and did not have to work over to finish it. In interview on 04/24/2025 at 6:23 PM, the Director of Nursing stated if someone walked by and saw a resident's call light on they should stop and respond. The DON said if the staff responding to the light could not take care of the resident's need, they should find someone that could. She stated 15-20 minutes response times were unacceptable. The DON reported elderly people's skin was frail, and they did not need to be left on the bed pan for too long. She stated there could be a lot of negative outcomes for not answering call lights in a timely manner. The DON further stated, You don't know why they (the residents) are calling and that can lead to lots of bad outcomes. She stated she stressed recognize and respond (to call lights). The DON explained that neglect was a big problem and never acceptable to her at all. She said staff are to be checking and changing residents more often. She stated that she expects her staff to conduct themselves professionally and respect other staff members. In interview on 04/24/2025 at 7:00 PM, the Administrator stated it was his expectation for answering call lights was as fast as they come on they should be answered. He stated the importance of answering call lights was discussed in morning meetings and said he answers call lights himself. The Administrator stated a 15-20 minute response time was unacceptable, and said, call lights are my biggest pet peeve. He stated he expected his staff to change residents and make sure they were dry, and did not expect his residents to be lying in urine and feces. The Administrator further stated a negative outcome for not answering call lights timely was a resident could fall, or have a crisis going on, and needed to be changed timely to prevent bed sores and urinary tract infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility failed to ensure a homelike environment for one (1) of eighteen (18) sampled residents (Resident #44). A chair was observed in Resident #44's room that was torn with the inside padding protruding out of the upholstery. The findings include: Interview with the Administrator on 02/12/2020 at 4:45 PM revealed that to his knowledge the facility did not have a policy addressing a homelike environment. Record review revealed the facility admitted Resident #44 on 06/07/2016 with diagnoses including Dementia, Huntington's Disease, Bipolar, and Anxiety. Review of Resident #44's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not done due to the resident being marked as rarely or never understood. Staff stated that the resident's cognition was severely impaired and Section C1000 was marked as never/rarely made decisions. Further review of the MDS revealed the resident required total assistance for all activities of daily living. Observation of Resident #44 on 02/11/2020 at 11:08 AM revealed the resident was resting in a low bed. The resident had his/her eyes open but did not respond to questions. An upholstered chair was observed in the corner of the resident's room. The arms of the chair were cushioned. The material on the arms of the chair was torn and the inside padding was protruding. Observation of Resident #44 on 02/12/2020 at 3:15 PM revealed the resident up in a geri-chair with eyes open. An interview was attempted but the resident was unable to answer any questions. Interview on 02/13/2020 at 3:50 PM with the Housekeeping Director revealed the chair should not have been left in the resident's room. The Housekeeping Director stated, Oh no, that needs to go. The Housekeeping Director along with the Maintenance Director took the chair out of the room. Interview on 02/13/2020 at 5:22 PM with the Director of Nursing (DON) revealed the facility tries to provide a homelike environment and many residents have brought their own furniture into the facility. She stated that she made rounds multiple times a day and had not noticed any furniture that was torn. Per the DON, she stated that she doubted the torn chair belonged to the resident as a lot of chairs had been left by discharged residents or families. She further revealed that they were trying to replace furniture as it was feasible. She stated that Resident #44 was totally dependent on staff for all activities of daily living and she had no concerns with the chair being a hazard to Resident #44; however, she did see that it could be a concern with other residents.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents (Resident #27) received respiratory care consistent with professional standards of practice. Resident #27 was observed to have their oxygen concentrator set to deliver three (3) liters per minute (LPM) during observation on 02/11/2020 and 02/13/2020. Review of the physician order revealed the resident's oxygen was ordered for two (2) LPM. Further observation on 02/13/2020 revealed the resident's oxygen tubing, attached to the resident's portable oxygen cylinder, was dated 12/14/2019. The findings include: Review of the facility policy, Oxygen Therapy/Administration, dated December 2019, revealed all disposable supplies should be discarded every fourteen (14) days. Observation of Resident #27 during the initial tour on 02/11/2020 at approximately 9:30 AM revealed the resident lying in bed and wearing oxygen via nasal cannula. Further observation of the oxygen concentrator revealed the setting was at three (3) LPM. Observation at 12:08 PM revealed the oxygen concentrator setting was at three (3) LPM. Observation of Resident #27 on 02/13/2020 at 9:25 AM revealed the oxygen concentrator was set on three (3) LPM. Review of the medical record revealed the facility admitted Resident #27 on 06/29/2018 with diagnoses of Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Unspecified Dementia with Behavioral Disturbance, and Peripheral Vascular Disease. Review of the Minimum Data Set (MDS) assessment, dated 12/07/2019, revealed a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident had moderate cognitive impairment. Review of the physician orders, dated 01/15/2020 through 02/13/2020, revealed an order dated 11/04/2019 for oxygen at two (2) LPM by nasal cannula. Further review of the physician orders revealed an order dated 11/04/2019 for oxygen cannula tubing to be changed every two (2) weeks on Friday during the night shift. Review of the Medication Administration Record (MAR) for Resident #27, dated January and February 2020, revealed a task for the nursing staff to assess oxygen administration at two (2) LPM by nasal cannula on day and night shift. Further review of the MAR dated February 2020 revealed nursing staff had documented that the oxygen was assessed on 02/11/2020 and 02/12/2020 for both shifts, and documented on night shift for 02/13/2020. Continued review of the MARs did not reveal a task for changing the oxygen tubing every two (2) weeks. Review of the comprehensive care plan for Resident #27 revealed an intervention for oxygen at two (2) LPM by nasal cannula dated 11/19/2019 to the problem area of Activities of Daily Living. Interview with Registered Nurse (RN) #1 on 02/13/2020 at 9:54 AM revealed nursing staff sign off the task on the MAR for oxygen. She stated that when they sign this task off they are assessing the respiratory status of the resident by auscultating breath sounds, checking the resident's oxygen saturation, and ensuring the oxygen is being delivered at the correct setting. The RN then accompanied the surveyor to the room of Resident #27 and observed the oxygen concentrator setting. She stated it was on three (3) LPM and needed to be set on two (2) LPM per the physician orders. The RN then adjusted the concentrator setting to two (2) LPM. The RN then observed the oxygen tubing on the portable oxygen tank on the wheelchair of the resident and stated the tubing was dated 12/14/2019. She removed the tubing immediately and stated the tubing is changed by the oxygen company contracted by the facility every couple of weeks. The resident then stated that the oxygen company had been in his/her room on 02/12/2020 and changed the tubing on the concentrator. Interview with the Director of Nursing on 02/13/2020 at 5:08 PM revealed when Nursing signs the MAR for oxygen therapy they are signing that the oxygen is being delivered at the correct setting and that the tubing and concentrator/oxygen tank are clean.

Based on observation, interview, and review of the facility policy it was determined the facility failed to ensure proper storage and labeling of medications on two (2) of four (4) medication carts. Observation on 02/13/2020 revealed an opened, undated Lantus insulin pen on Medication Cart 2 and an opened and undated Basaglar insulin pen on a treatment cart. Both medications were available for use. The findings include: Review of the facility policy, Insulin Vials (Dating and Storage), dated September 2019, revealed insulin would be stored in packaging and maintained in the refrigerator until opened. Once the insulin was opened, the insulin was to be dated with the opening date. Observation of the medication cart for Hall 200 on 02/13/2020 at 2:30 PM revealed an opened Lantus pen which was not dated as to when opened. Observation of a treatment cart on 02/13/2020 at 2:30 PM revealed an opened Basaglar insulin pen, also without a date as to when opened. Interview with Registered Nurse (RN) #1 on 02/13/2020 at 2:30 PM revealed she had not administered insulin from the Lantus insulin pen on Medication Cart 2. She stated the pens should be dated when opened and placed on the cart. Interview with Licensed Practical Nurse (LPN) #1 on 02/13/2020 at 2:30 PM revealed she had opened the Basaglar insulin pen that morning and had failed to date the pen. Interview with the Director of Nursing (DON) on 02/13/2020 at 5:17 PM revealed an insulin pen should have the information showing the type of insulin, resident's name, and date opened on the pen.

Based on observations, interview, record review, and facility policy review, the facility failed to ensure resident food preferences were honored for one (1) of eighteen (18) sampled residents (Resident #99) related to food dislikes and food/drink requests. The findings include: Review of the facility policy titled Diet History and Food Preferences, dated 02/11/2014, revealed, Food preferences will be noted on the tray ticket and honored at meal services when possible. Furthermore, the policy revealed that the Director of Food and Nutrition Services (or designee) and/or Registered Dietician or Dietetic Technician Registered will gather a diet history with food and beverage preferences within 72 hours for all admissions. The policy referred the reader to an attached form. The attached form was titled Diet History and Food Preferences. Record review revealed the facility admitted Resident #99 on 01/28/2020 with diagnoses of Gastroesophageal Reflux with Esophagitis, Gastroparesis, Dysphagia, Vomiting, and Anxiety. Interview with Resident #99 on 02/11/2020 at 3:59 PM revealed that he/she had notified staff of his/her dislike of eggs; however, the resident stated he/she was still receiving eggs on his/her tray every morning. In addition, Resident #99 stated he/she had requested orange juice on his/her tray for meals but the resident stated he/she was not receiving the orange juice. Further review of Resident #99's record revealed a physician's order for the resident to receive a regular diet with thin liquids. Record review revealed no noted contraindication for the resident to receive orange juice. Interview with the Dietary Manager (DM) on 02/12/2020 at 3:46 PM revealed she was aware of Resident #99's food preferences and of the resident's dislike of eggs. The Dietary Manager stated she was also aware of the resident's request to receive orange juice with meals. The Dietary Manager stated she had identified the above information when she obtained Resident #99's preferences on 01/29/2020, the day following his/her admission date. However, the Dietary Manager was unable to produce the Diet History and Food Preferences form. The DM revealed that she was aware that Resident #99 had received eggs on his/her tray on 02/12/2020. However, the DM stated she was unable to correct the meal ticket and was only able to add to the comments. In addition, the DM stated she did not know whom to contact to correct Resident #99's computerized meal ticket. Interview with the Administrator on 02/12/2020 at 4:00 PM and with the DM at 4:59 PM revealed the Administrator supplied the contact person for revising the computerized meal ticket for Resident #99 and the DM stated Resident #99's meal ticket had been revised to include the resident's food dislikes and requests. However, observation on 02/13/2020 at 8:35 AM of Resident #99's breakfast tray revealed the resident's tray card was incorrect. The card directed staff to provide the resident with 1/4 cup scrambled eggs and the tray card failed to include the resident's preference for orange juice. Interview with the DM on 02/13/2020 at 9:13 AM revealed Resident #99's tray card was incorrect because she did not reprint the ticket after it was corrected. The DM stated the meal tickets were printed approximately one (1) week in advance. The DM stated she ensured meal tickets were correct by checking them, as she is present for most meals; however, she stated neither she nor the cook had corrected Resident #99's tray card for 02/13/2020.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure accurate record documentation for one (1) of eighteen (18) sampled residents (Resident #7) related to the application of splints. Facility staff had documented that bilateral hand splints were applied to Resident #7's hands daily; however, staff interviews revealed the splints were not applied as documented. In addition, the order to place Resident #7's hand splints on hold was not transcribed to the Medication Administration Record (MAR). The findings include: Review of the facility policy titled Documentation and Charting, effective date September 2008, revealed that documentation of the record should be accurate and complete. Review of the facility policy titled Electronic Telephone/Verbal Orders, effective date July 2016, revealed orders were to be entered into the electronic medical record after receiving. Observations on 02/11/2020 at 12:27 PM and 02/12/2020 at 2:27 PM revealed the resident had bilateral wrist contractures and the resident was not wearing splints. Review of the record revealed the resident was admitted on [DATE] with diagnoses that included traumatic brain injury. Further review of the record revealed a Minimum Data Set (MDS) assessment dated [DATE] that assessed the resident to have severely impaired cognitive skills and to require extensive assistance from staff for activities of daily living. Review of the physician orders revealed bilateral hand splints were ordered on 08/20/2019 and were to be applied for one to two hours daily. Review of the MAR for month of February 2020 revealed License Practical Nurse (LPN) #1 had documented that the splints were applied as ordered on 02/01/2020, 02/02/2020, 02/06/2020, 02/08/2020, 02/09/2020, and 02/10/2020. Further review of the physician's orders, dated 02/01/2020, revealed an order to hold the splints because the resident was not tolerating the splint application. However, further review of the MAR revealed the physician's order to hold the splints had not been added to the MAR. Interview with State Registered Nurse Aide (SRNA) #2 on 02/12/2020 at 3:05 PM revealed that she had never seen the resident wearing the splints on his/her hands. Interview with LPN #1 on 02/13/2020 at 11:46 AM revealed that she had not applied the splints to Resident #7's hands. The LPN further stated that she should not have signed the Medication Record to show the splints had been applied. The LPN stated that she was not aware of an order to hold the splints. Interview with the Director of Nursing (DON) on 02/12/2020 at 2:00 PM, revealed that she had notified the physician that the resident was having issues with the splints, and received an order from the physician to place the splints on hold. Further interview with the DON on 02/14/2020 at 8:43 AM revealed newly received physician's orders should be noted by the nurse on duty and acted on. The DON stated she did not know why the nurse did not transcribe the order to hold the splints onto the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, and facility policy review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of infections for one (1) of eighteen (18) sampled residents (Resident #17). Observation on 02/11/2020 revealed while assisting Resident #17 with dinner, facility staff directly touched the resident's food with ungloved hands. The findings include: Review of the facility policy titled Feeding the Dependent Resident, with an implementation date of September 1988 and a reviewed/revised date of August 2012, revealed a procedure to feed slowly with fork or spoon filled only half full. Record review revealed the facility admitted Resident #17 on 05/21/2018 with diagnoses of Dementia with Behavioral Disturbance, Cognitive Communication Deficit, Adult Failure to Thrive, and Anxiety. Review of Resident #17's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Further review of the MDS revealed Resident #17 required the assistance of one staff person with eating. Observation during the evening meal on 02/11/2020 at 6:27 PM revealed State Registered Nurse Aide (SRNA) #5 was assisting Resident #17 with his/her meal. The SRNA was observed to pick up and handle the resident's food (grilled chicken sandwich) with her bare hands. At 6:30 PM, SRNA #5 was observed to pick up the resident's waffle fries with her bare ungloved hands. Interview with SRNA #5 on 02/13/2020 at 3:21 PM revealed that education and in-services were provided by the facility related to infection control and feeding of residents. Per SRNA #5, she has touched residents' food before with bare hands and remembered touching Resident #17's grilled chicken sandwich and waffle fries on 02/11/2020. SRNA #5 stated that she should not have touched the food and that it is a break in infection control practice/policy. Review of SRNA #5's annual competency evaluation dated 11/20/2019 revealed SRNA #5 met expectations regarding eating and infection control measures. The competency evaluation was signed by SRNA #5. The Director of Nursing (DON) signed the competency evaluation acknowledging that SRNA #5 was competent in performing the skills as defined. Interview with SRNA #2 on 02/13/2020 at 9:47 AM revealed that training and education was provided to staff upon hire and routinely throughout the year related to feeding of residents and infection control practices. Per SRNA #2, she utilizes eating utensils when assisting residents with eating and does not touch residents' food with her hands. Interview with SRNA #1 on 02/13/2020 at 10:33 AM revealed that she was educated to utilize gloves if she needed to touch resident food. Per SRNA #1, she utilized utensils when assisting a resident with eating and would not touch a resident's food without gloves. Interview with the Director of Nursing (DON)/Infection Control Nurse on 02/13/2020 at 4:43 PM revealed that she had not identified any concerns regarding staff touching resident food when assisting residents with eating. The DON stated touching resident food with bare hands is not acceptable. The DON stated if staff touched a resident's food with their bare hands it would be an infection control issue. The DON stated the facility had not provided staff education related to food handling.

Based on observation, interview, and review of the facility policy it was determined the facility failed to ensure infection control practices were maintained in the kitchen. On 02/11/2020, during the lunch and supper tray line, observations revealed a kitchen employee left the tray line and returned without changing gloves and performing hand hygiene. Further observation revealed a kitchen employee plated food and on three (3) occasions returned the food to the steam table pan. The findings include: Review of the facility policy, Use of Disposable Gloves for Food Handling, dated 03/27/2012, revealed gloves are to be discarded when damaged, torn, or soiled, or when interruptions occur. Review of the facility policy, Infection Control, dated 03/25/2012, did not reveal any guidance regarding plating of food. Observation of the tray line for the lunch meal on 02/11/2020 at 1:09 PM revealed the dietary cook shuffling through meal tickets with gloved hands to retrieve a ticket and then proceeding to plate the lunch meals. Further observation at 1:50 PM revealed the cook left the tray line to pick up a pan, went to the deep fryer, and placed food out of the fryer into the pan. The cook then returned to the tray line, set the pan on the steam table, and proceeded to plate the lunch without changing gloves and performing hand hygiene. Observation of the tray line for the supper meal on 02/11/2020 at 6:09 PM revealed the kitchen employee plated a chicken breast onto a bun and then took the chicken breast off the bun and put it back into the pan on the steam table. Further observation at 6:18 PM revealed the worker again placed a chicken breast on a bun and then removed it and returned it to the steam table pan. At 6:14 PM, observation revealed the kitchen worker served up broccoli into a bowl and then poured the broccoli back into the steam table pan. The worker was attempting to plate meals for residents as they were coming into the dining room. Interview with the Dietary Manager (DM) on 02/12/2020 at 3:36 PM revealed she had been in the position for five (5) months. She stated that once a kitchen employee who is working the tray line and plating the food leaves the tray, they should remove gloves, wash hands, and don clean gloves. She also stated the dietary cook should have removed gloves, washed hands, and donned clean gloves after leaving the tray to get the pan and bring new food to the steam table. The DM also stated that once the food is served from the steam table on to a plate it is not to be returned to the steam table. Interview with the Director of Nursing (DON) on 02/13/2020 at 5:03 PM revealed she also serves as the infection control nurse for the facility. She stated infection control in the kitchen is paramount. She further stated that if a worker leaves the tray they should remove gloves, wash hands, and put on clean gloves to resume plating food. She also stated you would never put food back into the steam table pans after being plated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy and procedure, it was determined the facility failed to ensure one (1) of nineteen (19) sampled residents received care, consistent with professional standards of practice; to promote healing, and to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable (Resident #26). Resoident #26 had orders to provide wound care to right and left buttock; however, there was no documented evidence the care was provided from 01/20/19 through 01/26/19. In addtion, observations revealed Resident #26 was on his/her back on 01/27/19, 01/28/19 and 01/29/19 was not being turned and repositioned every two (2) hours per facility policy. Observation of wound care on 01/29/19, revealed Resident #26 had developed a new facility acquired Stage II pressure ulcer at the top of the sacral area. The findings include: Interview with the Director of Nursing (DON) on 01/30/19 at 2:10 PM, revealed she was not aware of a facility policy related to the prevention of pressure ulcers. She stated she would expect the facility's goal to be to prevent new facility acquired pressure ulcers from occurring. Review of the facility policy titled, Wound Prevention and Management Program, last revised May 2017, revealed to Identify resident's at risk of developing pressure ulcers and conduct appropriate interventions to maintain intact skin. The goal is to maintain skin integrity and prevent tissue breakdown, unless avoidable and also increase the awareness of skin breakdown through education and monitoring systems. Skin assessments will be performed on each resident weekly, risk assessment should take place quarterly and with any significant changes or development of any new skin breakdown. Assess and inspect skin and bony prominence's and the sacral and perineal areas if the resident is incontinent. Identify and implement interventions based on the resident's risk for skin breakdown. Change position of resident every two (2) hours if bed bound. Record review revealed the facility admitted Resident #26 on 09/06/15 with diagnoses which included Type II Diabetes, Atherosclerotic Heart Disease, Heart Failure, and Acute and Chronic Respiratory Failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #26's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident was not interviewable. Further review of the MDS assessment, revealed the facility assessed the resident's bed mobility as extensive assist of one (1) person, at risk for developing pressure ulcers/injuries, and always incontinent of urine and bowel. Review of the Braden Scale for predicting pressure sore risk documentation, dated 12/03/18, revealed Resident #26 was at risk with a score of fifteen (15). Score key indicated an at risk score is fifteen (15) to eighteen (18). Review of a Weekly Skin Assessment, dated 01/02/19, revealed skin warm and dry, color with in normal limits, scar tissue to buttocks peeling off, cream applied; and oral mucosa pink and moist. Review of Resident #26's Comprehensive Care Plan for impaired skin integrity, dated,10/15/18 revealed, staff will inspect my skin during care for redness and irritation, staff to provide pressure relief mattress, staff to monitor and document change in skin appearance, weekly skin check per licensed staff, prefers to lay on back, and encourage and assist with repositioning. Review of the January 2019 Physician Orders and Treatment Administration Record (TAR), revealed to cleanse right and left buttocks with soapy water, apply Hydrogel, and cover with foam dressing. Further review of the January 2019 TAR revealed there was no documented evidence the treatment was completed on 01/20/19 through 01/26/19 (seven (7) days) and no indication the resident had refused the treatment. Interviews on 01/30/19 with Licensed Practical Nurse (LPN) #1 at 11:21 AM, and Registered Nurse (RN) #1 at 11:09 AM, revealed they must have have failed to sign their initials on the TAR. Observations on 01/27/19 at 2:40 PM, 3:45 PM, and 4:52 PM; and on 01/28/19 at 10:15 AM and 12:15 PM; and, on 01/29/19 at 9:12 AM and 2:34 PM, revealed Resident #26, was lying on his/her backside. Observation on 01/29/19 at 8:12 AM, of wound care for Resident #26, with Licensed Practical Nurse (LPN) #1, revealed upon entrance into the room, the resident was lying on his/her back, with the head of the bed elevated up forty-five (45) degrees. LPN #1, proceeded to provide wound care to a scab on the resident's upper left buttock. However, a new area was identified measuring 0.8 centimeter (cm) x 0.6 cm at the top of the sacral area. LPN #1 stated this is a new area, that I was not aware of, see the area above this new area, the one with the scab on it, that's the one I was to treat. She further stated I will have to call the MD to notify him of the new area at the center of the coccyx area/top. Interview with Certified Nurse Aide (CNA) #7 on 01/29/19 at 4:30 PM and CNA #8 on 01/29/19 at 5:01 PM, and CNA #3 at 5:08 PM, revealed Resident #26, does require turning and repositioning every two (2) hours, and is frequently incontinent of urine. The CNA's stated sometimes they get busy and just cannot make it in there every two (2) hours, to make sure the resident gets turned, and cleaned up. Interview with the Director of Nursing (DON) on 01/30/19 at 9:51 AM, revealed she would have expected the staff to have initiatled on the TAR, to show the treatment had been completed. She stated without the initials on the TAR, she could not verify the treatment had been completed as the physician had ordered. The DON also revealed there was a new open area identified on Resident #26's coccyx area, during wound care with the State Surveyor on 01/29/19. She stated staff were not aware of the newly identified area until the nurse went in to provide wound care of the first area, which was scabbed over. The DON revealed LPN #1 did what she was supposed to do, she called the MD, obtained a new order and made out a new skin assessment sheet. She stated when reviewing the resident list of diagnosis she did not see a diagnosis that would make the new pressure area avoidable. She further stated the resident chooses to stay in the bed all the time, therefore; the staff need to ensure the resident is turned, repositioned and incontinent care is provided at a minimum of every two (2) hours to help prevent the development of any new pressure ulcers.

Based on interview and review of the facility's policy and procedure, it was determined the facility failed to provide services by sufficient numbers of staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care on one (1) of How many halls Staff and resident interviews revealed there were not enough staff on 300 hall to ensure two (2) staff transferred residents with a hoyer lift per facility policy. The findings include: Interview with the Director of Nursing (DON) regarding a Staffing policy on 01/30/19 at 1:30 PM revealed the facility did not have a staffing policy. Review of the facility policy titled, Precautions-Lifting and Transferring Residents, last reviewed January 2018, revealed, All employees are expected to fully comply with the following procedure when lifting or moving residents. Never lift a resident by yourself. Never lift a maximum assist resident without a lift. Stop and call for help from a co-worker, then plan the lift or move together. Record review revealed the facility admitted Resident #11 on 05/21/18 with diagnoses which included Multiple Sclerosis, Anxiety Disorder and Depression. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 01/16/19 revealed the facility assessed Resident #11's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS revealed the resident has a functional status for transfers as extensive assist with two (2) persons. Review of Resident #11's Comprehensive Care Plan for Activities of Daily Living self care deficit due to diagnosis of Multiple Sclerosis with increased risk for contractures dated 07/30/18 revealed goals of I want to be able to transfer with sit to stand lift or slide board, I will participate in ADL's to my ability and My needs will be met by staff if I am unable to participate in care. Further review revealed Interventions for staff to assist me with ADL's as needed and for transfers, I require mechanical lift. Interview with Resident #11 on 01/28/19 at 10:41 AM revealed he/she had help today but last week and most weeks I was lifted by one CNA. Resident #11 stated he/she told administration and the DON that two (2) aides were needed on 300 hall since there were too many lift residents and there needs to be two (2) people to help lift. The resident also stated, I worry about them hurting themselves or hurting me and it scares me. If I was dropped I don't want to think about what it could do. Interview with CNA #5 on 01/28/19 at 1:53 PM revealed, it was impossible to do all the care that needed to be done by herself while working day shift on 300 hall. She stated 300 hall was the worse hall because lots of the residents required the hoyer lift and total care. She revealed she has used the lift by herself because there was no one to help and everyone was busy like her and it was impossible to do all the care. Interview on 01/28/19 at 3:58 PM with CNA #6 who works days and evenings, revealed when she works the 300 hall, she does the best she can do. She stated she always gets someone to help her if she uses the Hoyer lift but cannot always get personal care done for the residents. She also revealed the facility is always short staffed, and she does the best she can, but two (2) CNA's are needed on 300 hall. Interview with CNA #9 on 01/29/19 at 11:07 AM revealed she has left the facility in the past due to not enough staff and working on the 300 hall was too much for one (1) staff member. She stated you cannot care for six (6) residents who are Hoyer lifts and total care. She further stated sometimes someone gets left out and does not get out of bed. She revealed she could not work the 300 hall again. Interview with the DON on 01/30/19 at 4:30 PM revealed the budget plays a part in staffing. She stated the decision on staffing was dependent on the acuity of the residents and not the amount of residents. She also revealed if there are a large amount of heavy care like the 300 hall, then she will have the CNA from 500 hall assigned also to the 300 hall. She stated the Administrative team is strategically placed on the hallways so that they can help who needs help and she assures the resident are receiving care by talking and seeing the residents. She revealed she believes there are enough staff to meet the needs of the resident. She stated no staff are to use the Hoyer lift by themselves and the Hoyer lift should be a two person assist per the facility policy. She also revealed staff are educated on hire to use Hoyer lifts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to ensure a resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for three (3) of nineteen (19) sampled residents (Residents #55, #9, and #15). The facility failed to develop comprehenisve Care Plans to address Resident #55, #9, and #15 diagnoses of Dementia to ensure staff knew what care to provide if the resident had behaviors and to address the residents' activity needs. The findings include: Review of the facility policy, titled Behavior Dementia Care, last revised November 2018, revealed each resident must receive and the facility must provide the necessary behavioral health care and services to attain to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but not limited to, the prevention and treatment of mental and substance use disorders. Intervention's for dementia may vary as dementia is progressive. The plan of care will be developed and individualized by the interdisciplinary team which includes the resident/resident representative as possible. The plan of care will address activities based on level of intellectual functioning. The plan of care will be evaluated at a minimum of quarterly to ensure approaches remain appropriate. For a resident that is displaying behaviors it is important to determine of physical needs include but not limited to, hunger, thirst, pain, constipation, fatigue, full bladder, environment/room temperature; consistent staffing; report and document and document any specific triggers that result in distress; communication of individualized interventions via care plan and [NAME]; and, redirection of the resident from high stress environment. 1. Record review revealed the facility admitted Resident #55 on 08/15/16 with diagnoses which included Dementia, and Alzheimer's Disease. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #55's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was interviewable. Further review of the MDS, revealed Resident #55 had a diagnosis of Alzheimer's Disease and Non-Alzheimer's Dementia. Review Resident #55's Comprehensive Care Plans dated, 01/28/19, and Certified Nurse Aide (CNA)[NAME], revealed no documented evidence a Dementia care plan had been developed. Observation on 01/28/19 at 10:00 AM and 2:10 PM, revealed Resident #55 lying in bed. Interview with Resident #55 on 01/28/19 at 10:00 AM, revealed, he/she preferred staying in bed, watching television and reading magazines. 2. Record review revealed the facility admitted Resident #9 on 11/08/13 with diagnoses which included Dementia. Review of the Annual MDS assessment dated [DATE], revealed the facility assessed Resident #9's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Further review of the MDS, revealed Resident #9 had a diagnosis of Non-Alzheimer's Dementia. Review Resident #9's Comprehensive care plans dated, 01/25/19, and Certified Nurse Aide (CNA)[NAME], revealed no documented evidence a Dementia care plan had been developed. Observation on 01/28/19 at 10:00 AM and 2:20 PM, revealed Resident #9, sitting in a wheel chair, well groomed looking through a magazine. Interview with Resident #9 on 01/29/19 at 10:00 AM, revealed he/she sometimes attends activities. Resident #9 stated he/she prefers to stay in the room, and read the news paper or a good book. 3. Record review revealed the facility admitted Resident #15 on 11/18/16 with diagnoses which included Dementia with Lewy bodies and Unspecified Dementia without behavior's. Review of the quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #15's cognition as intact with a BIMS score of fourteen (14), which indicated the resident was interviewable. Further review of the MDS, revealed Resident #15 had a diagnosis of Non-Alzheimer's Dementia. Review Resident #15's Comprehensive care plans and Certified Nurse Aide (CNA)[NAME], revealed no documented evidence a Dementia care plan had been developed. Observation on 01/29/19 at 10:00 AM and 2:10 PM, revealed Resident #15 was well groomed and seated up in his/her wheelchair. Interview with Resident #15 on 01/29/19 at 10:00 AM, revealed he/she sometimes attends activities, if it is something he/she likes to do. Interview with Certified Nurse Aide (CNA) #7, on 01/29/19 at 4:58 PM, revealed she had no clue which residents had a diagnosis of Dementia or Alzheimer's disease, nor would she know what to do to help redirect a person with Dementia, if and when they became upset or needed re-directing. CNA #7 stated there is nothing specific on the CNA [NAME] that would give her guidance if a resident was having a sundowner's episode or if the resident became really confused. She revealed the CNA [NAME] is very generalized mainly to providing personal care for the resident, and lot of times they are not even filled out properly. She stated the CNA [NAME] is what we as CNA's go by when providing resident care, and they are very vague and generalized. Interview with CNA #3 on 01/29/19 at 5:08 PM, revealed when looking at the CNA [NAME] there is nothing that gives her a clue the resident has Dementia, or any guidance when they become confused on how to redirect them. CNA #3 stated the CNA [NAME] is very basic, and only really speaks to providing the basic care needs of the resident. Interview with CNA #8 on 01/29/19 at 5:21 PM, revealed she had only worked here for about seven (7) months, and floats all over the facility, and is not assigned a certain hall. She stated she as a floater, she really relied on the CNA [NAME] to give her guidance of how to provide care to each specific resident, and she felt the care plans provided very basic care needs for the resident, and there was no specific guidance for a resident with the diagnosis with Dementia. She revealed if a resident was to become confused or agitated she would only try to calm them down, and go tell the nurse. She stated there was no guidance on the CNA [NAME] to address a resident's Dementia. Interview with the MDS Coordinator on 01/29/19 at 3:41 PM, revealed, she was not aware of the new Dementia Regulation, that required a resident with the diagnosis of Dementia or Alzheimer's to have a Dementia care plan. She stated she had only been in this position about one (1) year, and no one had informed her of the new regulatory requirement. She stated she was the person responsible for creating the care plans upon admission and for ensuring changes are added to the care plan along with the Administrative nursing staff. Interview with the Director of Nursing (DON) on 01/30/19 at 11:37 AM, revealed she was not very familiar with the new regulation regarding F-744, and she would have to familiarize herself with the new regulation and give guidance to the MDS Coordinator, regarding developing a person-centered care plan related to the diagnosis of Dementia. She state she needed to ensure the nurse aide care plan/[NAME] was updated as well, to assist the aides in providing more person-centered care for a resident with Dementia.

Based on interview, record review, and facility policy and procedure review, it was determined the facility failed to ensure two (2) residents not in the selected sampled of nineteen (19) were free of any significant medication errors (Unsampled Residents #5 and #52). Interview with a Kentucky Medication Aide revealed Resident #5 missed a dose of Ativan and Resident #52 missed a dose of Sinemet on 01/27/19. The findings include: Review of the facility's policy and procedure, titled, Medication Administration-Unit Dose Cart System, revised 04/2018, revealed the objective was to administer medications as prescribed and to use the six (6) rights of medication administrator as follows: 1. Verify right resident by using two (2) resident identifiers 2. Verify the right ordered medication 3. Verify the right ordered dosage 4. Verify right ordered time for administration 5. Verify correct ordered route 6. Correctly document administration of ordered medication 1. Record review revealed the facility admitted Unsampled Resident #52, on 06/29/18 with diagnoses which included Anxiety, Parkinson's, Chronic Obstructive Pulmonary Disease, Dementia with behavioral disturbance, Peripheral Vascular Disease, Polyneuropathy and Insomnia. Review of Resident #52's January 2019 Physician Orders, revealed to administer Sinemet one tablet by mouth at 7:00 AM, 11:00 AM, and 5:30 PM. Review of Resident #52's January 2019 MAR revealed the 7:00 AM and 11:00 AM dose of Sinemet were signed off by KMA #1 on 01/27/19. However, interview with Kentucky Medication Aide (KMA) #1 on 01/29/19 at 8:34 AM revealed the dose of Sinemet that was supposed to be given at 7:00 AM was not given until 11:00 AM, and the 11:00 AM dose was not given until 1:00 PM. 2. Record review revealed the facility admitted Unsampled Resident #5, on 02/22/16 with diagnoses which included other Organic Psychotic disorders, Schizophrenia (paranoid type), Anemia, Hypothyroidism, Depression and Arthropathy. Review of Resident #5's January 2019 Physician Orders, revealed to administer Ativan one (1) milligram, one (1) tablet by mouth three (3) times a day (7:00 AM, 11:00 AM, and 7:00 PM) Review of Resident #5's January 2019 MAR, revealed the 7:00 AM and 11:00 AM doses of Ativan were administered by KMA #1 on 01/27/19. However, interview with KMA #1 on 01/29/19 at 8:34 AM revealed the 11:00 AM dose of Ativan was not administered to Resident #5 because it would have to have been given too close to the 7:00 AM dose. Interview with Resident #5's Physician, on 01/30/19 at 10:06 AM, revealed Resident #5 was paranoid schizophrenia and he was working closely with the resident's psychiatrist to keep him/her from having episodes of agitation and the resident missing the Ativan was disturbing to hear. The Physician stated he was not made aware of the missed medications. Interview with KMA #1, on 01/29/19 at 8:34 AM, revealed she should have told the charge nurse the medications were being administered past the one (1) hour time frame and would have to be given too close together in order to administer all scheduled doses. Interview with the Director of Nursing (DON), on 01/30/19 at 1:41 PM, revealed she expected the medications to be administered within the scheduled time frame and if the times were not being followed due to the medications being administered late, the charge nurse should have been notified to contact the physician. Interview with the Medical Director, on 01/31/19 at 3:30 PM, revealed the facility had not contacted her in regards to missed medications or medications being administered extremely late. Additionally, she stated it was not kosher for missed medications to be marked on the MAR as being administered.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs and biological's used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on two (2) vials of medication. Observation of medication cart check on 01/30/19 at 10:00 AM revealed two (2) vials of multiuse eyedrops not dated when opened. The findings include: Review of the facility's policy and procedure, titled Dispensing Multiple Dose Vials, last revised March 2009, revealed on dispensing of multiple dose vials, the person opening the vial would place the following information onto the vial: a. Date vial opened b. Initials of person opening vial e. Date of expiration: 1. Thirty (30) days of multi-dose vials with bacteriostat 2. As indicated by the manufacturer 3. Insulin- twenty-eight (28) days 4. Nitroglycerin (six) 6 months Observation of medication cart, on 01/30/19 at 10:00 AM, revealed one (1) Timolol eye drops and one (1) vial of Systane eye drops not dated when opened per facility policy. Interview with Kentucky Medication Aide (KMA) #1, on 01/30/18 at 10:15 AM, revealed the eye drops and any multi-dose vial was to be dated when opened. Interview with KMA #3, on 01/30/19 at 10:55 AM, revealed multi-dose medications should be dated when opened. Interview with the Director of Nursing (DON), on 01/30/19 at 1:41 PM, revealed she expected multi-dose vials to be dated when opened.

3. Record review revealed the facility admitted Resident #17 on 06/02/17 with diagnoses which included Unspecified psychosis, Major Depressive Disorder, History of Falling, Dementia, Type II Diabetes Mellitus, Myasthenia Gravis, Metabolic Encephalopathy, and Macular Degeneration. Observation of Resident #17's catheter care on 01/29/19 at 11:07 AM of catheter care provided by CNA #9 revealed the CNA did not clean the over bed table prior to placing her supplies for catheter care. Further observations revealed she did not place a barrier down prior to placing her supplies on the table and did not clean the table. after providing catheter care. Interview with CNA #9 on 01/29/19 at 11:30 AM revealed she should have cleaned the table and placed a barrier down prior to placing her supplies on the table. 4. Review of the facility policy titled, Trascheostomy Care for Disposable Inner Cannulas and Non-Disposable Inner Cannulas, last revised November 2018 revealed to perform hand hygiene, maintain standard precautions and discard soiled equipment when procedure completed. Record review revealed the facility admitted Resident #21 on 08/13/15 with diagnoses which included Osteoarthritis, Nutritional Anemia, Type II Diabetes Mellitus, Morbid Obesity, Schizoaffective Disorder, Major Depressive Disorder, Anxiety Disorder, Obstructive Sleep Apnea, Metabolic Encephalopathy, Essential Hypertension, Peripheral Venous Insufficiency, Acute/Chronic Respiratory Failure and Muscle Weakness. Observation of Resident #21's tracheostomy care by LPN #2 on 01/29/19 at 9:11 AM revealed the LPN removed a window fan from an over bed table, moved it to the resident's side and began care without cleaning the table and no barrier was placed on the over bed table prior to her placing her supplies for the procedure. Further observation revealed LPN #2 did not clean the table after the procedure. In addition, the nurse left the dirty inner cannula in the trash in the resident's room. Interview with LPN #2 on 01/29/19 at 9:20 AM revealed she should have cleaned the over bed table after the procedure and placed a clean barrier on the table prior to putting supplies on the table. She stated she should have removed the trash after she when she completed the procedure due to her placing the resident's inner cannula in the trash when it was removed. Interview with the DON on 01/30/19 at 2:15 PM revealed she expected staff doing tracheostomy care or any care that needed a place to put supplies to clean over bed table and use a barrier prior to putting supplies on table. She stated she expected the table to be cleaned again after the procedure and soiled trash etc. to be removed from the room and placed in the soiled utility room. Based on observation, interview, record review and review of the facility's policy and procedure it was determined the facility failed to ensure it must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to bed side tables not being cleaned before placing clean dressings for wound care on it and not being cleaned after care for four (4) of nineteen (19) sampled residents (Residents #26, #21, #54, and #17 . Observations on 01/29/19 of Resident #26's wound care, Residents #54's and #17's catheter care. and Resident 21's tracheostomy care. revealed staff failed to provide barriers prior to placing supplies on over bed tables, and clean bedside tables after providing care. In addition, the staff nurse left the soiled inner cannula from the tracheostomy in the trash and left the trash in the residents' room. The findings include: 1. Record review revealed the facility admitted Resident #26 on 09/06/15 with diagnoses which included Type II Diabetes, Atherosclerotic heart disease, heart failure, Acute and chronic respiratory failure. Observation on 01/29/19 at 8:12 AM, of wound care for Resident #26, with Licensed Practical Nurse (LPN) #1, revealed prior to LPN #1 providing wound care, LPN #1 tore a small brown paper towel, laid it on the resident's bedside table, and laid wound supply items on the brown paper towel. LPN #1 was observed to then provide wound care, and after providing wound care, removed the wet small brown paper towel and wound care items off the resident's bedside table, threw items in the trash, and placed the bedside table back in front of Resident #26 without cleaning the table. Interview on 01/29/19 at 8:10 AM with LPN #1, revealed she should have used a water proof barrier; other than a small torn piece of brown paper towel, and after using Resident #26's bedside table to provide wound care she should have ensured it was clean for the resident to use. She stated cleaning the table after use would have helped ensure table was free from the potential for germs, as the resident uses the table to eat his/her meals on. 2. Review of the facility policy, for Catheter Care and Maintenance dated 06/1988 and revised 04/18 revealed, it is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections. Record review revealed the facility admitted Resident #54 on 05/22/13 with diagnoses which included Neurogenic Bladder. Observation of catheter care provided for Resident #54 on 01/29/19 at 10:17 AM, revealed Certified Nurse Aide (CNA) #7, laid the water basin, cleaning supplies, and wash cloths on Resident #56's bedside table, and after providing catheter care for Resident #54, removed the basin and supplies. However, the CNA failed to clean and sanitize the bedside table prior to placing the bedside table back in front of the resident. Interview on 01/29/19 at 10:30 AM with Resident #54, revealed the staff rarely clean his/her bedside table, and he/she prefers to eat all meals at the bedside. Interview with CNA #7 on 01/29/19 at 10:04 AM , revealed she should have made sure the resident's table was cleaned/sanitized after use, as the resident uses the bedside table for meals and personal items, and not cleaning the table would be an infection control concern. Interview with the DON on 01/30/19 at 9:51 AM, revealed she expected LPN #1 to have placed a water proof barrier on the resident's bedside table, and prior to placing the table back in front of the resident for use, she would have expected LPN #1 and CNA #7 to have cleaned and sanitized the bedside table after use,. She stated the residents use the bedside table to place their personal items on and uses the table to eat their meals, so this was an infection control concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 12. Record review revealed the facility admitted Resident #26 on 09/06/15 with diagnoses which included Type two (2) Diabetes, Heart failure, and Acute and Chronic Respiratory Failure. Review of the quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #26's cognition as severely impaired with a BIMS score of seven (7), which indicated the resident was not interviewable. Review of the January 2019 Physician Orders and Treatment Administration Record (TAR), revealed to cleanse right and left buttocks with soapy water, apply Hydrogel, and cover with foam dressing. However, further review of the TAR revealed there was no documented evidence the treatment was completed on 01/20/19 through 01/26/19 (seven (7) days) and no indication the resident had refused the treatment. Observation on 01/29/19 at 8:12 AM, of wound care for Resident #26, with Licensed Practical Nurse (LPN) #1, revealed a 0.8 centimeter (cm) x 0.6 cm Stage II pressure ulcer. Interview on 01/30/19 at 11:21 AM, with Licensed Practical Nurse (LPN) #3, revealed the area on Resident #26's buttocks was discovered on 01/19/19, and she must have failed to sign her initials on the TAR. Interview on 01/30/19 at 11:09 AM, with Registered Nurse (RN) #1, revealed she was aware Resident #26 had an area on his/her buttocks, and she only works part-time. She stated if she failed to initial the TAR, she could not say for certain she completed the treatment. Interview with the Assistant Director of Nursing (ADON) on 01/19/19 at 9:37 AM, revealed, she would have expected the staff to have documented on the TAR when they completed the treatment for Resident #26, in order to indicate the treatment had been completed. She stated if there were no initials on the TAR, she would have to assume the treatment had not been completed. She further stated with the area scabbbed over, she knows the treatment had to have been completed. Interview with the Director of Nursing (DON), on 01/30/19 at 9:51 AM, revealed she would have expected the staff to have initiated on the TAR, to show the treatment had been completed. She stated the staff are aware they are required to document upon completing the treatment, and not before. She further, stated without the initials on the TAR, she could not verify the treatment had been completed as the physician had ordered. Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality for two (2) of nineteen (19) sampled residents (Residents #26 and #28) and nine (9) unsampled residents (Unsampled Residents #11, #35, #107, #4, #19, #5, #25, #52 and #3). Observation of a medication pass on 01/27/19 at 9:00 AM, 10:19 AM and 10:30 AM and interview with Kentucky Medication Aide (KMA) #1 revealed #11's, #35's, #107's, #4's, #19's, #5's, #25's, #52's and #3's 7:00 AM medications (fifty-eight medications) were administered past the one (1) hour window of time. Resident #26 and Unsampled Residents #5 and #52 did not receive their medications (three {3} medications) and one (1) medication was not administered prior to breakfast as ordered by the physician for Resident #28. In addition, Resident #26 had Physician Orders for staff to cleanse right and left buttocks with soapy water, apply Hydrogel, and cover with foam dressing; however, there was no documented evidence the treatment was completed on 01/20/19 through 01/26/19 (seven (7) days). The findings include: Review of the facility's policy and procedure, titled Medication Administration-Unit Dose Cart System, last revised April 2018, revealed the objective was to administer medications as prescribed and to use the six (6) rights of medication administrator as follows: 1. Verify right resident by using two (2) resident identifiers 2. Verify the right ordered medication 3. Verify the right ordered dosage 4. Verify right ordered time for administration 5. Verify correct ordered route 6. Correctly document administration of ordered medication Observation of medication administration passes, on 01/27/19 at 9:00 AM, 10:15 AM and 10:30 AM, revealed medications that were to be administered at 7:00 AM were being administered at 9:00 AM, 10:15 AM and 10:30 AM. Review of resident's Medication Administration Records (MAR's) revealed the medication pass times were as follows: Daily 6:00 AM or 7:00 AM Twice a day (BID) 7:00 AM and 7:00 PM Three times a day (TID) 7 AM, 11 AM and 7:00 PM Four times a day (QID) 7:00 AM, 11 AM, 7:00 PM and 1:00 AM 1. Record review revealed the facility admitted Unsampled Resident #3 on 03/21/18 with diagnoses which included Insomnia, Gastroesophageal Reflux, Chronic Constipation, Asthenia, Hypertension and Depressive Disorder. Review of a Brief Interview for Mental Status (BIMS) list, revealed Resident #3 with a (BIMS) score of three (3) indicating the resident was not interviewable. Review of Resident #3's Comprehensive Care Plan, last revised 01/18/19 revealed to administer the resident's medications as prescribed. Review of Resident #3's January 2019 Physician Orders, revealed the resident was ordered the following medications to be administered at 7:00 AM: Tylenol (pain reliever), Alendronate (bone loss), Artificial Tears (eye drops), Aspirin (pain reliever), Freshkote Eye Lubricant, Gabapentin (nerve pain), Miralax (laxative), and Senna Plus (stool softener). Review of Resident #3's January 2019 Medication Administration Record (MAR), revealed medications were signed off by Kentucky Medication Aide (KMA) #1 on 01/27/19 as being given within the 7:00 AM timeframe; however, observation of the medication pass on 01/27/19 at 10:30 AM revealed the 7:00 AM medications were not administered until 10:30 AM. 2. Record review revealed the facility admitted Unsampled Resident #11, on 01/07/12 with diagnoses which included contracture of the right shoulder, Neuromuscular dysfunction of the bladder and Benign Paroxysmal Vertigo. Review of a BIMS list, revealed Resident #11 with a (BIMS) score of fifteen (15) indicating the resident was interviewable. Review of Resident #11's Comprehensive Care Plan, last revised 10/30/18, revealed medications were to be administered as prescribed. Review of Resident #11's January 2019 Physician's Orders, revealed the resident was ordered the following medications to be administered at 7:00 AM per facility timing schedules: Colace (stool softener), Ferrous Sulfate (Iron supplement), Gabapentin (nerve pain), Modafinil (sleep disorder), Nexium (acid reducer), Nuedexta (involuntary outburst), Trileptal (aniteleptic), and Miralax (laxative). Review of Resident #11's January 2019 MAR revealed medications were signed off by KMA #1, on 01/27/19 as being given within the 7:00 AM timeframe; however, observation of the medication pass on 01/27/19 at 10:30 AM revealed the 7:00 AM medications were not administered until 10:19 AM. 3. Record review revealed the facility admitted Resident #28, on 11/02/18 with diagnoses which included Major Depressive disorder, acute and chronic respiratory failure, Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Kidney Disease (Stage 3) and Hyperlipidemia. Review of a BIMS list, revealed Resident #28 with a (BIMS) score of fifteen (15) indicating the resident was interviewable. Review of Resident #28's Comprehensive Care Plan, dated 12/18/18 revealed staff would administer medications as ordered and refer to the MAR. Review of Resident #28's January 2019 Physician's Orders, revealed the resident was ordered the following medications to be administered at 7:00 AM per facility timing schedules: Advair Diskus (inhaler), Artificial Tears (eye drops), Aspirin (pain reliever), Coreg (high blood pressure), Flonase (nasal spray), Januvia (anti-diabetic), Lisinopril (high blood pressure), Oxycontin (narcotic pain medication), Protonix (acid reflux) and Prednisone (steroid). One (1) medication was to be administered before breakfast (ac) at 6:00 AM which was Protonix (acid reducer), Review of Resident #28's January 2018 MAR, revealed medications were signed off by KMA #3 on 01/27/19 as being given within the 7:00 AM timeframe; however, observation of the medication pass on 01/27/19 at 9:00 AM revealed the 7:00 AM medications and the 6:00 AM Protonix was not administered until 9:00 AM after breakfast. 4. Record review revealed the facility admitted Unsampled Resident #35 on 08/04/14 with diagnoses which included Gastroesophageal Reflux, Arthropathy, Psoriasis, Major Depressive disorder, Anxiety, Multiple Sclerosis, Insomnia, Narcolepsy without Cataplexy, Trigeminal Neuralgia and Quadriplegia. Review of a BIMS list, revealed Resident #35 with a (BIMS) score of fifteen (15) indicating the resident was interviewable. Review of Resident #35's Comprehensive Care Plan, last revised 12/21/18 revealed medications were to be administered as prescribed. Review of Resident #35's January 2019 Physician Orders, dated 01/01/19 through 01/31/19, revealed the resident was ordered the following medications to be administered at 7:00 AM per facility timing schedules: Xanax (anti-anxiety), Baclofen (central nervous system suppressant), Tegretol (nerve pain), Periactin (antihistamine), Dantrolene (muscle relaxant), Bidex (mucus relief), Zanaflex (muscle relaxant), and Tecfidera (multiple sclerosis). Review of Resident #35's January 2019 MAR, revealed the 7:00 AM medications were signed off by KMA #1 on 01/27/19 after the last medication pass was observed at 10:30 AM. 5. Record review revealed the facility admitted Unsampled Resident #25, on 12/29/16 with diagnoses which included Hemiplegia and Hemiparesis of the right dominant side, Hypertension, Major Depressive disorder, restless leg syndrome, Hyperlipidemia and Insomnia. Review of a BIMS list, revealed Resident #25 with a (BIMS) score of thirteen (13) indicating the resident was interviewable. Review of Resident #25's Comprehensive Care Plan, last revised 01/24/19 revealed to administer medications as ordered. Review of Resident #25's January 2019 Physician's Orders, revealed the resident was ordered the following medications to be administered at 7:00 AM per facility timing schedules: Artificial Tears (eye drops), Baclofen (central nervous system suppressant), Cardizem (high blood pressure), Colace (stool softener), Gabapentin (nerve pain) and Norco (narcotic pain medication. Review of Resident #25's January 2019 MAR, revealed 7:00 AM medications were signed off by KMA #1 on 01/27/19 after the last medication pass was observed at 10:30 AM. 6. Record review revealed the facility admitted Unsampled Resident #52 on 06/29/18 with diagnoses which included Anxiety, Parkinson's, Chronic Obstructive Pulmonary Disease, Dementia with behavioral disturbance, Peripheral Vascular Disease, Polyneuropathy and Insomnia. Review of a BIMS list, revealed Resident #52 with a BIMS score of nine (9) indicating the resident was interviewable. Review of Resident #52's Comprehensive Care Plan, last revised 01/02/19 revealed to administer medications per Physician's Orders. Review of Resident #52's January 2019 Physician Orders, revealed the following medications ordered to be given at 7:00 AM per facility times: Artificial Tears (eye drops), Buspar (anti-anxiety), Sinemet (Parkinson's tremors), Cymbalta (antidepressant), Allegra (allergies), Flonase (nose spray), Gabapentin (nerve pain), Ocuflox (eye drop) and Prednisone (steroid). Review of Resident #52's January 2019 MAR, revealed 7:00 AM medications were signed off by KMA #1 on 01/27/19 after the last medication pass observed at 10:30 AM. 7. Record review revealed the facility admitted Unsampled Resident #19 on 10/31/18 with diagnoses which included Chronic Respiratory Failure with hypoxia and hypercapnia, Quadriplegia and Hypertension. Review of a BIMS list, revealed Resident #19 with a BIMS score of fifteen (15) indicating the resident was interviewable. Review of Resident #19's Comprehensive Care Plan, dated 11/05/18 revealed staff would administer medications as ordered. Review of Resident #19's January 2019 Physician's Orders, revealed the following medications to be administered at 7:00 AM per facility timing schedules: Gabapentin (nerve pain) and Mucinex (expectorant). Review of Resident #19's January 2019 MAR, revealed 7:00 AM medications were signed off by KMA #1 on 01/27/19 after the last medication pass was observed at 10:30 AM. 8. Record review revealed the facility admitted Unsampled Resident #5, on 02/22/16 with diagnoses which included other Organic Psychotic disorders, Schizophrenia (paranoid type), Anemia, Hypothyroidism, Depression and Arthropathy. Review of a BIMS list, revealed Resident #5 with a BIMS score of fifteen (15) indicating the resident was interviewable. Review of Resident #5's Comprehensive Care Plan, last revised 01/18/19, revealed medications were to be administered as prescribed. Review of Resident #5's January 2019 Physician Orders, revealed the following medications were ordered to be given at 7:00 AM: Aripiprozole (antipsychotic), Depakote (Bipolar disorder), Freshkote (eye drop), Keppra (seizure medication) and Ativan (anti-anxiety). Review of Resident #5's January 2019 MAR, revealed 7:00 AM medications were signed off by KMA #1 on 01/27/19 after the last medication pass was observed at 10:30 AM. 9. Record review revealed the facility admitted Unsampled Resident #107 on 01/25/19 with diagnoses which included unable to ambulate, Dehydration, Lung Cancer and Lumbar 1 back fracture. Review of a BIMS list, revealed Resident #107 with a BIMS score of ninety-nine (99) indicating the resident was not interviewable. Review of Resident #107's Comprehensive Care Plan, dated 01/28/19, revealed medications were to be administered as ordered by the physician. Review of Resident #107's January 2019 Physician Orders, revealed the following medications were ordered to be administered at 7:00 AM per facility timing schedules: Midodrine (low blood pressure). Review of Resident #107's January 2019 MAR, revealed 7:00 AM medications were signed off by KMA #1 on 01/27/19 after the last medication pass was observed at 10:30 AM. 10. Record review revealed the facility admitted Resident #26, on 09/06/15 with diagnoses which included Diabetes Type II, Obesity, Hypertension, Athrosclerosis, other disease of lung, acute and chronic, Encephalopathy and Symbolic Dysfunction. Review of a BIMS list, revealed Resident #26 with a BIMS score of seven (7) indicating the resident was not interviewable. Review of Resident #26's Comprehensive Care Plan, last revised 12/03/18 revealed to administer medications as ordered. Review of Resident #26's January 2019 Physician Orders, revealed the following medications were ordered to be administered at 7:00 AM per facility timing schedules: Dicyclomine (irritable bowel syndrome), Divalproex (seizure medication), Cymbalta (antidepressant), Review of Resident #26's January 2019 MAR, revealed 7:00 AM medications were signed off by KMA #1 on 01/27/19 after the last medication pass was observed at 10:30 AM. 11. Record review revealed the facility admitted Resident #4, on 03/17/18 with diagnoses which included Anxiety, Depression, Constipation and nasal congestion. Review of a BIMS list, revealed Resident #4 with a BIMS score of fourteen (14) indicating the resident was interviewable. Review of Resident #4's Comprehensive Care Plan, last revised 01/17/19 revealed to administer medications per physician orders. Review of Resident #4's January 2019 Physician Orders revealed the following medications were to be administered at 7:00 AM per facility timing schedules: Banophen (decongestant), Tums (antacid), Norco (narcotic pain medication), Ativan (antianxiety) Metformin (diabetic medication), Robaxin (Osteoarthritis) and Potassium Chloride (low potassium levels). Review of Resident #4's January 2019 MAR, revealed 7:00 AM medications were signed off by KMA #1 on 01/27/19 after the last medication pass observed at 10:30 AM. Interview with KMA #1, on 01/29/19 at 8:34 AM, revealed she did not administer Unsampled Residents #4, #35, #25, #52, #19, #5, and #107's 7:00 AM medications until after the last medication pass the State Surveyor observed at 10:30 AM on 01/27/19. She stated Resident #52's Sinemet due at 11:00 AM was missed because the 7:00 AM dose was being given at 11:00 AM and the 11:00 AM medications were given at 1:00 PM. She revealed Resident #5's Ativan was missed at 11:00 AM because it would have to have been given too close to the 7:00 AM dose. She also stated Resident #107's 11:00 AM dose of Midodrine was administered at 12:55 PM and Resident #26's Metformin missed at 7:30 AM because it was not administered until 12:00 PM. Further interview revealed Resident #4's 11:00 AM medications were administered at 2:00 PM. She stated she should have told the charge nurse the medications were being administered past the one (1) hour time frame. Interview with RN #1, on 01/29/19 at 11:15 AM, revealed if the KMA came to her for assistance with medication administration, she would have helped, however, that did not occur. Interview with Registered Nurses (RN)/Corporate Nurses #3 and #4, on 01/28/19 at 2:00 PM, revealed they did not have any answers as to how long the medications had been given late and staff needed to be educated again related to communicating with each other and with the physician related to late medication passes. Interview with the Assistant Director of Nursing (ADON), on 01/28/19 at 2:05 PM, revealed she thought the medications had been administered late this week only and KMA #1 was slow at times. Interview with the Director of Nursing (DON), on 01/30/19 at 1:41 AM, revealed medications should be administered within the allotted time frames and if for any reason they cannot be administered timely, the KMA should notify the charge nurse who in turn was to contact the physician for further instruction. Interview with the Medical Director, on 01/31/19 at 3:30 PM, revealed the facility had not contacted her in regards to missed medications or medications being administered extremely late. Additionally, she stated it was not kosher for missed medications to be marked on the MAR as being administered.