Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 4 sampled residents, Resident (R) 34 and R120. The findings include: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, revised 01/30/2025, revealed staff would ensure the call light was within reach of the resident and secured as needed. Further review revealed the call system would be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Review of the facility's policy titled, Resident Rights, undated, revealed the resident had the right to a dignified existence and self-determination. Review of the facility's policy titled, Safe and Homelike Environment, undated, revealed the facility would provide a safe, clean, comfortable, and homelike environment. 1. Review of R34's admission Record revealed the facility admitted the resident on 12/05/2024 with diagnoses including acute lymphoblastic lymphoma (ALL), urine retention, and chronic obstructive pulmonary disease (COPD). Review of the R34's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 03/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15, which indicated the resident was cognitively intact. Further review revealed the resident required substantial to maximum assistance with bed mobility and was dependent on staff for transfers. Review of R34's Care Plan Report, with a revision date of 12/10/2024, revealed the resident required assistance from staff with activities of daily living (ADL). Observation on 04/22/2025 at 8:54 AM and again on 04/22/2025 at 11:22 AM revealed R34 was asleep in her bed. However, the call light was observed on the floor and out of the resident's reach. In an interview on 04/23/2025 at 9:32 AM, State Registered Nurse Aide (SRNA) 3 stated it was important residents' call lights were within their reach for safety purposes. She further stated if the call light was out of reach, residents felt unprotected. SRNA3 stated the call light should never be on the floor. In an interview with SRNA11 on 04/24/2025 at 9:54 AM, she stated residents' call lights should always be within their reach because it was a safety issue. She stated if a resident needed assistance, it was important for staff to be notified. In an interview with Licensed Practical Nurse (LPN) 1 on 04/24/2025 at 10:18 AM, she stated access to staff was important when residents needed help, and the call light should always be within their reach. 2. Review of R120's admission Record revealed the facility admitted the resident on 01/30/2025 with diagnoses including cerebral infarction (stroke) and Alzheimer's disease. Review of R120's admission MDS, with an ARD of 02/06/2025, revealed the resident had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Observation on 04/21/2025 at 1:42 PM revealed R120 in her room sitting up in the recliner. Observation on 04/22/2025 at 8:34 AM revealed R120 asleep in her recliner. In an interview with R120 on 04/21/2025 at 1:42 PM, she stated she slept in the recliner each night. She further stated she was not able to sleep in her bed because it was uncomfortable and small; and the facility was supposed to have it replaced. In an additional interview with R120 on 04/22/2025 at 1:31 PM, she stated again that the bed in her room was uncomfortable. She stated she spoke to someone at the facility about it, but no one had responded. R120 stated she was not sure who she spoke with, but thought it was about a week or so ago. R120 stated she preferred a bed rather than a recliner when she slept. In an interview with the Social Services Director (SSD) on 04/23/2025 at 3:41 PM, she stated she was notified of a problem with R120's bed about a week ago. She further stated she was not sure exactly what the issue was; but something about the bed being too narrow, and R120 slept in her recliner. The SSD stated she thought perhaps the resident was a little claustrophobic. She further stated it was her responsibility to make sure someone followed up with the resident. The SSD stated she had not followed up with R120 but should have. In an interview with R120's Representative on 04/24/2025 at 3:47 PM, she stated the resident had not slept in a recliner at home. She further stated she was not sure what the issue was with the bed at the facility, but R120 slept in a bed when she was at home. In an interview on 04/24/2025 at 4:29 PM, the Director of Nursing (DON) stated she expected all staff would answer call lights, and if the resident's need was not in their scope of practice, appropriate staff would be contacted. She further stated a call light should never be left on the floor or anywhere out of a resident's reach because they needed access to staff at all times. The DON stated they had several residents at the facility that preferred a recliner over a bed, and she was not aware of an issue with R120's bed. In an interview with the Administrator on 04/24/2025 at 5:06 PM, she stated it was her expectation call lights were placed on the bed within the resident's reach, and on the floor was not acceptable. She stated she had not received a grievance or complaint from R120, or her family related to the need for a different bed. She further stated that was an issue that should have been brought to her attention immediately and appropriately resolved.

Based on interview, record review, and review of the facility's documents, the facility failed to ensure residents and resident representatives were informed, using appropriate language, that binding arbitration agreements explicitly were not required as a condition of admission explicitly provided the residents or resident representatives the right to rescind the agreement within 30 days of signing it for 5 of 5 residents reviewed for arbitration agreements, Resident (R) 32, R58, R117, R127, and R131. Additionally, interview with three residents (R58, R127, R131) that signed agreements, including one as recently as 04/01/2025 (R131), did not recall the discussion of arbitration or signing of arbitration agreements. The findings include: Review of the facility's document Arbitration and Mediation agreement, not dated, revealed appropriate verbiage was not included on the form. The form did not indicate it was an optional form for the resident to complete; did not indicate it was not a requirement for the resident's admission; and did not indicate residents or representatives had 30 days to rescind the form after signing. In interviews with the five residents present for the Resident Council meeting on 04/22/2025 at 1:26 PM, they stated none of them recalled signing any arbitration agreement. After the State Survey Agency (SSA) Surveyor described the arbitration document as a form that should have been identified as not a requirement to sign for admission, they still did not recall signing any arbitration agreement. Review of R32's and R117's Arbitration and Mediation agreement revealed both forms were signed by responsible parties and did not include required verbiage indicating it was not a requirement for admission and could be rescinded within 30 days of signing. Review of R58's and R127's Arbitration and Mediation agreement revealed both residents had signed their own arbitration agreements, which did not include require verbiage indicating it was not a requirement for admission and could be rescinded within 30 days of signing. R58 signed her document on 08/15/2023, and R127 signed his document on 05/30/2024. Review of the facility's new electronic health records (EHR) revealed R131 was classified as a new admission. Per the record, the facility admitted R131 on 04/01/2025, and she signed her own arbitration agreement. In an interview with R131 on 04/23/2025 at 8:17 AM, she stated there's so many things, if it said to sign it, then I signed it. She stated she thought the forms in the admission packet were for insurance. She stated the word arbitration did not sound familiar to her, and an arbitration form was not explained to her in detail. In an interview with the Admissions Coordinator (AC) on 04/22/2025 at 3:36 PM, she stated she had been trained on presentation and completion of Arbitration and Mediation forms by the Administrator. The AC stated she went over and read the agreement to residents or the responsible party. She stated she shared that they had the option not to sign but was not aware residents or representatives had the right to rescind arbitration agreements within 30 days of signing. She stated the Arbitration and Mediation document was part of about 70 other pages she reviewed with residents or representatives as part of the admissions process. In an interview with the Administrator on 04/23/2025 at 1:16 PM, she stated when arbitration was first introduced it was mandatory for admission, which was overturned in 2022. She stated since, it had been explained to residents and representatives as voluntary. She stated in August 2024 it was turned over to attorneys to be made into a separate document. The Administrator stated the facility had not yet received a revised document. The Administrator stated some residents or representatives did refuse to sign, so they were clearly presenting the arbitration agreement as not a condition of admission. The Administrator stated that, even though the facility dealt with this every day and understood residents and representatives were not required to sign the form as a condition of admission, she could understand the importance of residents and families knowing it was not a condition of admission. The Administrator stated initial paperwork for admission took an hour and a half to two hours to complete, and quite often, even higher functioning residents were tired coming from hospitals and would ask if their family or power-of-attorney (POA) could complete paperwork for them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, facility document review, Centers for Disease Control and Prevention guidelines, and facility policy review, 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 6 of 34 sampled residents, Resident (R) 11, R34, R36, R119, R125, and R150. Observations revealed R11 and R34 had indwelling urinary catheter drainage bags resting on the floor; a gait belt was used on R36 without its prior disinfection; a blood pressure cuff was used on R125 and not disinfected after its use; R150's medications were placed on an unclean surface without using a barrier; R119's food was handled by a staff member with ungloved hands; and a dietary staff member's badge was resting in a resident's food. The findings include: Review of the facility's policy titled, Infection Surveillance, dated 01/01/2025 revealed its purpose was to identify infections and to monitor adherence to recommended infection prevention and control practices to reduce infections and prevent the spread of infections. Review of the facility's policy titled, Catheter Care, Urinary, revised 08/2022, revealed the catheter tubing and catheter drainage bag were kept off the floor. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 01/01/2025, revealed that reusable resident-care equipment will be cleaned and disinfected in accordance with current Centers for Disease Control and Prevention (CDC) recommendations. The policy stated, Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. The policy stated, Multiple-resident use equipment shall be cleaned and disinfected after each use. The policy stated, Use only Environmental Protection Agency (EPA)-registered disinfectants with kill claims for the common organisms found in the facility. Review of the CDC's Guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/2021, revealed reusable medical equipment should be cleaned and disinfected according to manufacturer's instructions or the facility's policies before and after use. Further review of the guidelines revealed staff should be trained in the correct steps for cleaning and disinfection of shared equipment. Review of the facility's [Facility] Employee Handbook, dated 01/01/2024, regarding employee identification badges, revealed, Staff must wear identification badges visibly above the waist and in front of the body. Badges may not be clipped onto sleeves. Staff must be aware of lanyards, metal clips, and pins during resident care. Breakaway lanyards are required for safety. 1. Observation on 04/21/2025 at 1:52 PM revealed the Physical Therapy/Occupational Therapy assistant (PTA/OTA) used a gait belt for R147 and then placed the gait belt around her neck without cleaning/disinfecting it. The PTA/OTA then used the same gait belt on R36, ambulated her to the Activities Room, removed the gait belt, and placed it back around her neck without cleaning/disinfecting it. The PTA/OTA then cleaned the handles on the walker that was used with R36 with hand sanitizer from the hall. During an interview with the PTA/OTA on 04/21/2025 at 2:03 PM, she stated she normally used a disinfectant spray to disinfect the gait belt, but she had left the spray downstairs in the office. She stated she cleaned the walker with sanitizer but was not sure what the policy stated. 2.a. Review of R34's admission Record revealed the facility admitted the resident on 12/05/2024 with diagnoses including acute lymphoblastic lymphoma (ALL), urinary retention, and chronic obstructive pulmonary disease (COPD). Review of R34's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15, which indicated the resident was cognitively intact. Further review revealed the resident was admitted with an indwelling urinary catheter. Review of a Physician's Order found in R34's electronic medical record (EMR) revealed an active order, dated 12/05/2024, that specified indwelling urinary catheter care every shift for neurogenic bladder. Review of the R34's Care Plan Report, revised 12/10/2024, revealed a problem of altered urinary elimination related to the use of an indwelling catheter with an increased risk for urinary tract infection (UTI) related to neurogenic bladder and urinary retention. Observation on 04/22/2025 at 8:54 AM revealed R34 asleep in bed; the urinary catheter was positioned on the far side of the resident's bed, and the drainage bag was located on the floor. Additional observation of R34 on 04/22/2025 at 11:22 AM again revealed the catheter positioned on the resident's bed with the drainage bag on the floor. b. Review of R11's admission Record revealed the facility admitted the resident on 01/21/2025 with diagnoses including Non-Hodgkin lymphoma, personal history of UTIs, and Alzheimer's disease. Review of R11's admission MDS, with an ARD of 01/28/2025, revealed the facility assessed the resident to have a BIMS score of three out of 15, which indicated the resident was severely cognitively impaired. Further review revealed the resident was admitted with an indwelling urinary catheter. Review of a Physician's Order found in R11's EMR revealed an active order, dated 04/02/2025, that specified indwelling urinary catheter care every shift and as needed. Review of the R11's Care Plan Report, dated 04/11/2025, revealed a problem of altered urinary elimination related to the use of an indwelling catheter. Observation on 04/22/2025 at 11:15 AM revealed R11 in her room seated in a recliner. R11 had an indwelling urinary catheter attached to the recliner with the drainage bag observed on the floor. In an interview with State Registered Nurse Aide (SRNA) 3 on 04/23/2025 at 9:32 AM, she stated she provided catheter care every time she changed R34 and as needed. She further stated the catheter drainage bags were positioned on the bed lower than the level of a resident's bladder, covered with a dignity bag, and not placed on the floor because of infection concerns. SRNA3 stated if she observed a catheter bag on the floor, she notified nursing so the resident could be assessed before the bag was changed. In an interview with SRNA4 on 04/23/2025 at 9:50 AM, she stated staff received frequent in-services related to infection control, and catheter care was sometimes one of the topics. SRNA4 stated a catheter was positioned low on the bed, but the collection bag was never placed on the floor because of bacteria and the risk for infection. In an interview on 04/23/2025 at 9:54 AM, SRNA11 stated she checked residents' catheters each time she rounded on them. She stated catheters should be lower than the level of the bladder so they drained properly, and the collection bag should be off the floor because of possible contamination and infection. In an interview with Licensed Practical Nurse (LPN) 5 on 04/24/2025 at 10:05 AM, she stated she typically rounded on residents between SRNA rounds, so they were seen at least every hour. She further stated catheter drainage bags should be below the resident and off the floor, so they were kept clean, which reduced the potential for infection. LPN5 stated in the past, on her rounds, she had observed catheter drainage bags on the floor, but they were replaced immediately. In an interview with LPN 1 on 04/24/2025 at 10:18 PM, she stated she expected catheter drainage bags to be protected with dignity covers for privacy and to be kept off the floor. Additionally, she stated if the drainage bags were on the floor, it put the resident at risk for infection. In an interview on 04/24/2025 at 12:34 PM, the Infection Preventionist (IP) stated infection control training and education began at orientation. He further stated the facility also held annual trainings that covered infection control as well as regular infection control and prevention in-services. The IP stated it was his expectation that catheter drainage bags were always kept off the floor because that presented an infection risk for the resident. In an interview on 04/24/2025 at 4:29 PM with the Director of Nursing (DON), the DON stated catheter drainage bags should always be kept off the floor due to the potential risk for infection to the resident. In an interview on 04/24/2025 at 5:06 PM, the Administrator stated she expected catheter drainage bags to be always kept off the floor because of the potential risk for infection. 3. Observation on 04/22/2025 at 9:00 AM revealed Kentucky Medication Aide (KMA) 1 used a blood pressure (BP) cuff on R125, then placed it back into the medication cart without cleaning/disinfecting it. In an interview on 04/22/2025 at 10:13 AM with KMA1, she stated BP cuffs should be cleaned between each resident with the purple top Sani-Wipes (an EPA registered disinfectant). In an interview on 04/22/2025 at 10:24 AM with Registered Nurse (RN) 1, she stated shared equipment should be cleaned between each use. She stated she used hand sanitizer to clean shared equipment, and she was unsure what the policy stated. In an interview on 04/23/2025 at 3:14 PM with SRNA7, she stated shared equipment was cleaned between each resident use with the purple top Sani-Wipes. She stated she would not use hand sanitizer and had not been taught that. 4. Observation on 04/22/2025 at 9:20 AM revealed KMA1 poured R150's medications onto the tablecloth in the dining room, without using a barrier, for R150 to self-administer medications. In continued interview on 04/22/2025 at 10:13 AM with KMA1, she stated she should have placed a barrier for medications placed on the tablecloth for R150 to self-administer. She stated tablecloths were normally cleaned daily, but she was unsure who changed them out. 5. Observation on 04/22/2025 at 12:20 PM revealed RN1 handled R119's chicken salad sandwich, breaking it in half, without wearing any gloves. In additional interview on 04/24/2025 at 8:40 AM with RN1, she stated she should have worn gloves while handling resident foods. She stated that was important to prevent contamination. In an interview on 04/24/2025 at 8:30 AM with the Infection Prevention/Wound Care Nurse (IP/WOCN), he stated shared equipment should be cleaned/disinfected before and between resident use with the purple top Sani-Wipes. He stated hand sanitizer should not be used as a disinfectant for shared equipment. He stated a barrier should always be used when pouring medications on a surface, and no direct contact with food is permitted. In an interview on 04/24/2025 at 4:29 PM with the Director of Nursing (DON), she stated shared equipment should be cleaned/disinfected between every use to decrease the spread of germs and diseases between residents. The DON stated hand sanitizer should never be used in place of Sani-Wipes. The DON stated staff should not be pouring medications on an uncleaned surface, and the medication cup should be handed to residents, or a clean barrier should be used. She stated gloves should be worn when handling resident food to prevent germs and cross contamination. In an interview on 04/24/2025 at 5:14 PM with the Administrator, she stated shared equipment should be cleaned/disinfected between each resident with Sani-Wipes, and hand sanitizer should never be used on equipment. She stated staff should not be handing foods without gloves on. She stated medications should never be poured onto an unsanitary surface for residents to self-administer for infection prevention and safety. 6. Observation on 04/23/2025 at 11:27 AM revealed the [NAME] leaning over a dish of mechanically soft beef to take a food temperature on an adjacent dish, with her identification badge resting in the mechanically soft beef. In an interview on 04/23/2025 at 2:20 PM, the [NAME] stated she wears her badge around her neck and keeps it tucked inside her apron during plating and temping [taking food temperatures]. She stated the facility policy required staff to keep badges on and connected to you and not hanging around food. She stated she had not received specific training on securing her badge during food service. She stated she understood the requirement to wear gloves or use utensils when handling food and understood the importance of preventing foreign objects from contacting food. She stated, Contaminated food must be removed from the line and placed in the dirty dish room. She stated she was unaware her badge had contacted food when she took food temperatures that morning. In an interview on 04/23/2025 at 2:28 PM, the Dietary Manager stated policy required staff to wear badges between the waist and shoulder, close to the body, on breakaway lanyards for safety. He stated no separate dietary-specific policy existed. He stated residents were a vulnerable population and emphasized the critical importance of preventing food contamination. He stated he expected staff to remove, discard, and replace any food contacted by a foreign object. In an interview on 04/24/2025 at 5:28 PM, the Administrator stated contaminated food constituted an infection control issue. She stated after the incident was reported, she reviewed the handbook and confirmed the requirement for breakaway lanyards. She stated she would obtain badge [NAME] for dietary staff. In continued interview on 04/24/2025 at 4:29 PM with the DON, she stated she expected all staff to follow facility policies and procedures related to infection control and prevention. She further stated she constantly walked the halls and monitored for compliance. In continued interview on 04/24/2025 at 5:14 PM with the Administrator, she stated she expected all staff to follow the facility's infection control policies to maintain a safe environment for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's abuse and Resident's Rights policies, it was determined the facility failed to protect residents from abuse for one (1) of forty-four (44) sampled residents (Resident #20). Resident #21 alerted State Registered Nursing Assistant (SRNA) #20 on the morning of 10/13/2023 that during the night when he/she had been sleeping, Resident #20, his/her roommate, struck him/her on the head with his/her iPad waking him/her up. The findings include: Review of the facility's Abuse Policy, dated 08/27/2019, revealed residents had the right to be free from abuse. Continued review revealed abuse was defined to include the willful infliction of injury with resulting physical harm, pain, or mental anguish. Review of the facility's Resident Rights policy revised 12/2016, revealed residents had the right to be treated with respect, kindness, and dignity, as well as the right to be free from abuse. 1. Review of Resident #21's Face Sheet revealed the facility admitted the resident on 09/13/2023, with diagnoses that included Parkinson's Disease, hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, and unspecified dementia without behavioral disturbance. Review of Resident #21's Care Plan (CP) revealed the facility developed a CP for potential mood problems, which was updated on 10/13/2023. Continued review of the CP revealed Resident #21's potential mood problem was updated related to a recent physical altercation. Review of Resident #21's admission Minimum Data Set (MDS) revealed the facility assessed the resident on 09/20/2023, with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) which indicated he/she had moderate cognitive impairment. Record review revealed all admission documentation was completed by Resident #21 upon admission to the facility. Further review of the Electronic Health Record (EHR) revealed psych notes for Resident #21 noting he/she had been seen by psych services on 10/18/2023, and the resident denied anxiety or fear regarding an incident and no concerns regarding mood or behavior were identified. 2. Review of Resident #20's Face Sheet revealed the facility admitted the resident on 04/01/2023, with diagnoses which included personal history of traumatic brain injury, other specified disorder of brain, and unspecified convulsions. Review of Resident #20's CP revealed the facility updated his/her CP beginning on 10/18/2023 to include: one (1) to (1) [1:1] supervision prior to and upon returning from his/her admission to a behavioral health unit; every fifteen (15) minute checks from 10/26/2023 until 10/29/2023. Further review reviewed Resident #20's Seroquel (an antipsychotic medication used to treat mental illness) was increased to 50 milligrams (mg) at hours of sleep (hs). Review of the facility's Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #20 to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen/(15). This score indicated the resident had severe cognitive impairment. Review of the facility's investigation revealed the facility assessed Resident #21 following an incident which occurred sometime during the night on 10/12/2023 and could not determine any injury had occurred. Resident #21 reported the incident to staff the following morning on 10/13/2023. Continued review of the investigation revealed other residents with a BIMS score of seven (7) or below were assessed with no additional concerns identified. Per review, residents with a BIMS of eight (8) or above were interviewed about abuse with no concerns identified. Additionally, the facility provided abuse education inservice to staff following the incident. Further review revealed the facility placed Resident #20 on 1:1 supervision; he/she was sent out for an psychiatric (psych) evaluation, and returned to the facility less than a week later. Review further revealed upon return, the facility placed Resident #20 in another room and on 1:1 supervision for seventy-two (72) hours, followed by every fifteen (15) minute checks for seventy-two (72) hours. In interview on 11/01/2023 at 3:15 PM, Resident #21 stated while he/she was asleep, Resident #20 struck him/her in the head with an iPad. Resident #21 stated after he/she was struck, he/she awakened, rolled over, and observed his/her roommate (Resident #20) with an iPad in hand, wheeling back to his/her side of room in a wheelchair (wc). When asked about the incident, Resident #21 stated he/she was upset at the time of the incident, and went to the hospital to get checked out. In continued interview Resident #21 shrugged when asked if he/she felt safe. the resident pointed to his/her (new) roommate behind privacy curtain. In interview on 11/07/2023 at 8:50 AM, Unit Manager (UM) #1 stated she removed Resident #21 from the room Resident #20 and he/she resided in, and placed Resident #20 on 1:1 supervision. She stated Resident #21 said Resident #20 had struck him/her with an iPad when he/she was sleeping. UM #1 stated she could not tell if Resident #21 was injured, as there was some swelling to the side of his/her head that had been present upon the resident's admission. She stated she thought the swelling might have been larger though. UM #1 further stated as Resident #21 said he/she had been struck in the head, had a headache and felt a little dizzy, and potentially had an injury, she sent him/her to the hospital for evaluation. The UM additionally stated Resident #21 returned the same day from hospital negative for concussion or any injury. In interview on 11/07/2023 at 9:53 AM, the Administrator stated she felt Resident #21 was a reliable reporting source, and believed Resident #21 had been struck by Resident #20. She stated in performing the investigation they were unable to determine what prompted or contributed to Resident #20 striking Resident #21. The Administrator further stated Resident #20 had not admitted to striking Resident #21 to any staff. She additionally stated with Resident #20's Traumatic Brain Injury (TBI) it was hard sometimes to figure out what the root cause of his/her emotions or behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policy, and the Police Report Number: 2023-00059001 it was determined the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or convenience and were not required to treat the resident's medical symptoms for one (1) of forty-four (44) sampled residents (Resident #2). On 03/30/2023, State Registered Nursing Assistant (SRNA) #3 (Agency Aide) provided Resident #2 a bath without assistance from other staff. Interview with SRNA #3, on 10/31/2023, revealed she was not briefed on how to provide care for Resident #2 when the resident became combative during the bed bath and tried to hit and scratch her. SRNA #3 stated she held the resident's hands to prevent the resident from hitting her. Resident #2 pulled back, and his/her hands slipped. The resident smacked himself/herself in the face which resulted in injuries that included a laceration to the resident's right eye. Refer to F656 The findings include: Review of the facility's policy titled, Restraint Free Environment dated 02/2023, revealed the facility was a restraint free facility which prohibited the use of restraints for discipline or convenience and limited restraints for circumstances which were medically necessary and warranted the use of restraints. The policy revealed holding down a resident in response to a behavioral symptom or during the provision of care if the resident was resistive or refusing care was considered a restraint. Further review revealed behavioral interventions were to be exhausted prior to the application of a physical restraint. Review of the facility's policy titled, Restraint Free Environment dated 02/2023, revealed holding down a resident in response to a behavioral symptom or during the provision of care if the resident was resistive or refusing care was considered a restraint. Review of Resident #2's Comprehensive Care Plan (CCP), initiated 05/19/2021, revealed the resident had a history of combative behaviors toward staff during care and when the resident became combative staff should step away and allow the resident time to calm down. However, further review revealed although the resident had behaviors, the CCP did not specify how many staff was required to assist the resident safely with a bath. Review of Resident #2's [NAME] Report (care plan used to address interventions for the State Registered Nurse Aide (SRNA)) with an as of date of 03/15/2023, revealed the resident required two (2) staff for bathing. Review of Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 03/24/2023, revealed the facility assessed the resident as totally dependent for bathing and required two (2) person physical assistance. However, on 03/30/2023, SRNA #3 (an agency aide) provided Resident #2 a bath without assistance from other staff. During an interview with SRNA #3, on 10/31/2023 at 1:53 PM, she stated she was not briefed on how to provide care for Resident #2. SRNA #3 stated the resident became combative during the bed bath and tried to hit and scratch her. During this interview, SRNA #3 stated she held the resident's hands to prevent the resident from hitting her; and in doing so, the resident pulled back, and his/her hands slipped and he/she smacked himself/herself in the face which resulted in injuries that included a laceration to the resident's right eye. Per Police Report Number: 2023-00059001, dated 03/30/2023, Resident #2 sustained injuries which included a small laceration with some bruising and swelling; injuries to the eye; red markings on the left side of the neck; a bruise on the resident's right hand, and bruising on the resident's chest. Review of Resident #2's Face Sheet, revealed the facility re-admitted the resident on 05/13/2022, with diagnoses that included dementia, Alzheimer's Disease and psychotic disorder with delusions due to known psychological condition. Review of Resident #2's Comprehensive Care Plan (CCP), initiated 05/19/2021, revealed the resident had a history of combative behaviors toward staff during care, as the resident would hit, slap, pinch, grab and attempt to bite. The goal stated the resident would have few episodes of physical and verbal behaviors, last revised on 10/03/2022. Further review of the CCP revealed interventions initiated on 05/19/2021 for this problem area that included: administer medication as ordered; monitor and document side effects and effectiveness; anticipate and meet the resident's needs; explain all procedures to the resident before starting and allow the resident time to adjust to changes; intervene as necessary to protect the rights and safety of others; approach and speak in a calm manner; divert attention and remove from the situation and take to alternate location as needed; monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, person involved, and situation, document behaviors and potential causes; praise any indication of the resident's progress/improvement in behaviors; make sure the resident is able to clearly hear when being talked to, and ensure he/she understands; and when the resident became combative, staff should step away and allow the resident time to calm down. The care plan noted, Provide assistance with daily care as indicated on the Point of Contact (POC) tasks schedules to find out what level of care the resident required. However, the CCP did not specify how many staff was required to assist the resident with a bath. Review of Resident #2's [NAME] Report, with an as of date of 03/15/2023, revealed the resident required a mechanical lift for all transfers, and required two (2) staff for bathing, dressing, and personal hygiene. For behaviors, staff was to intervene as necessary to protect the rights and safety of others; approach and speak to the resident in a calm manner; divert attention; remove from the situation and take to an alternate location as needed; make sure the resident heard when speaking to him/her; explain prior to proving care; praise any indication of progress and improvement in behavior; if the resident became agitated, intervene before agitation escalated; guide away from source of distress; engage calmly in conversation; and if response was aggressive, staff was to walk away calmly and approach later. Review of Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 03/24/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated severe cognitive impairment. Continued review revealed the facility assessed the resident as having physical and verbal behaviors directed toward staff present for four (4) to six (6) days during the assessment period. Additional review of the MDS Assessment, revealed the facility assessed the resident as rejecting care one (1) to three (3) days during this assessment period. Further review revealed the facility assessed the resident as requiring the physical assistance of two (2) staff for bed mobility, transfers, dressing, toileting, and personal hygiene and one (1) person physical assistance for eating. The facility assessed the resident as totally dependent for bathing requiring two (2) person physical assistance. Review of the Police Report Case Number 2023-00059001, revealed the police officer noted the following interview with SRNA #3, on 03/30/2023 at approximately noon. Per the document, SRNA #3 entered Resident #2's room to provide him/her a bed bath. SRNA #3 explained as she assisted the resident with the bed bath, the resident became combative, and she responded by grabbing his/her arms to prevent the resident from striking her. SRNA #3 explained, due to the resident's arms being wet from the bath, his/her arms slipped from SRNA #3's grip and the resident accidentally struck himself/herself in the face. SRNA #3 stated Resident #2 became combative again when she took the resident's gown off, for the bath Continued review of the Police Report Case Number: 2023-00059001, revealed the police officer documented the following interview with the Administrator on 03/30/2023 at approximately 1:51 PM. Per the document, the Administrator stated SRNA #3 informed her and Unit Manager/Licensed Practical Nurse (LPN) #2, while she gave Resident #2 a bed bath the resident became combative. The Administrator informed the police, that SRNA #3 stated she held the resident's arms to protect herself and as she did, Resident #2's hand slipped out of her grip. This caused the resident to strike himself/herself in the right eye, leaving a small laceration with some bruising and swelling. Additional review of Police Report No. 2023-00059001, revealed the Administrator reported to the police, on 03/30/2023 at approximately 1:51 PM, she believed SRNA #3 displayed poor judgement given her training as a Certified Nursing Assistant (CNA/SRNA) when dealing with Resident #2, but she did not believe she intentionally or willingly tried to harm the resident. It was also noted the Administrator informed the police, that Shower Aide (SA) #1 notified SRNA #3 about Resident #3 being combative during care. SRNA #3 told SA #1, This is not my first rodeo before going in to bathe the resident on her own. The Administrator also reported to police the facility had a communication system in place to advise staff who were not familiar with the resident and his/her history of being combative and it was preferred practice to have someone with them just in case. Review of Police Report Case Number 2023-00059001, revealed the police officer interviewed Registered Nurse (RN) #5, on 03/30/2023 (no time provided). Per the interview, the nurse stated SRNA #3 approached her and advised her she was giving Resident #2 a bath. At some point during the bath, Resident #2 became combative and SRNA #3 held his/her arms in an effort to stop him/her from injuring her. Due to Resident #2's arms being wet from the bath, his/her arm slipped from SRNA #3's grip, which caused him/her to accidentally strike himself/herself in the face near his/her eye. Review of the Police Report revealed a follow up interview was conducted with SRNA #3, on 05/03/2023 at 10:00 AM. Per the document, SRNA #3 stated, while she gave Resident #2 a bed bath, the resident was laying down in the bed and she was on the side of the bed washing him/her. She stated, at no point did she ever get into the bed with the resident while the bed bath was given. She stated she did wash all over the resident's upper body, but she did not recall any force being applied to the resident's chest area which would have caused the bruises photographed by the daughters. SRNA #3 stated she did not see any other injuries or bruising to the resident's chest prior or during the bed bath. Further review revealed She did bring up seeing the bruising on the arm a second time as she did in the first phone conversation, I had with her. Review of the facility's staffing invoices, revealed SRNA #3 provided resident care on 03/23/2023, 03/24/2023, 03/28/2023, 03/29/2023 and 03/30/2023. Review of the sign-in sheet dated 03/23/2023, revealed SRNA #3 signed in at 7:03 AM. Review of the facility's binder which was provided to agency staff the first time they worked at the facility, revealed agency staff were to sign in only on their first visit, and by signing in they acknowledged they had received and understood the training packet and policies. Further review revealed SRNA #3 signed as completing the training packet on 03/23/2023. However, further review of the training revealed the facility failed to include restraint training in the packet. In an interview with State Registered Nursing Assistant (SRNA) #3, on 10/31/2023 at 1:53 PM, she stated she had worked at the facility on 03/30/2023 as an agency aide. She stated when she arrived on site, she was not briefed on how to provide care for her assigned residents, nor was she aware of where the [NAME] or CCP was located. SRNA #3 stated she was not told Resident #2 required the assist of two (2) persons for Activities of Daily Living (ADL) and baths, nor that the resident had a history of combative behavior. She stated Resident #2 became combative during the bed bath and tried to hit and scratch her. SRNA #3 stated she held the resident's hands to prevent the resident from hitting her. In doing so, the resident pulled back, and his/her hands slipped and he/she smacked himself/herself in the face which resulted in a laceration to the right eye. In an interview with Shower Aide (SA) #1, on 11/03/2023 at 9:35 AM, she stated she was present on 03/30/2023 and informed SRNA #3, Resident #2 required two (2) staff for assistance with a bath. SA #1 stated, SRNA #3 told her she could do it by herself. The SA stated she told SRNA #3 this was not a good idea because Resident #2 was combative, but SRNA #3 replied, she could handle it. SA #1 stated later in the day she went to find SRNA #3 to assist with Resident #2's bed bath and was informed she (SRNA #3) had already completed the resident's bath. The SA stated she went about her day, and she did not end up seeing Resident #2 that day. In an interview with SRNA #10, on 11/02/2023 at 10:10 AM, he stated Resident #2 had lots of major behaviors and made noises, screamed, and hissed at staff. He stated Resident #2 got physically violent, would hit, pinch and spit at staff. The SRNA stated he witnessed Resident #2 grab a staff member's breast and twist her nipple hard and it was difficult to get the resident to let go. He also stated, staff worked hard to redirect the resident's behaviors, but it rarely worked and there was staff who worked at the facility who did not want to interact with the resident because of his/her behaviors. During continued interview, SRNA #10 stated, management informed staff they always needed two (2) staff members in the room with Resident #2. He stated he helped bathe the resident and he knew him/her well. Further, SRNA #10 stated, according to the Interdisciplinary Team (IDT), when staff provided care for Resident #2, staff was to explain everything they did for the resident and to report all behaviors to the Charge Nurse. He stated, with Resident #2, it was all hands-on deck. In an interview with Licensed Practical Nurse (LPN) #2, on 11/02/2023 at 1:06 PM, she stated SRNA #3 informed her she gave Resident #2 a bed bath and the resident became combative. She stated SRNA #3 told her she tried to hold the resident's hands to prevent being hit and in the process the resident hit himself/herself. LPN #2 stated she had not worked with SRNA #3 prior to 03/30/2023, and she recalled the aide worked for agency. Continued interview revealed LPN #2 stated when an agency staff reported to the facility, they were expected to sign in the binder at the front desk and complete any in-services prior to going to the floor. LPN #2 further stated the facility was a no restraint facility, which meant staff did not restrain residents in any way. She explained if a restraint was needed for emergency purposes, it had to be discussed with management and an order by the physician was required. LPN #2 stated, if SRNA #3 physically held the resident's hands in place or down that would be a physical restraint and could result in physical or psychosocial harm to the resident. In an interview conducted with Registered Nurse (RN) #5, on 11/02/2023 at 2:40 PM, she stated SRNA #3 had not reported to her she held the resident's hands in place to stop him/her from hitting her and if she had, she would have been concerned about the resident being restrained. She stated if SRNA#3 stated she held the resident's arms, she would have immediately reported the information to management. During continued interview with RN #5, she stated the facility had a no restraint policy and holding a resident's hands down violated the policy. During an interview with the Advanced Practice Registered Nurse (APRN), on 11/03/2023 at 2:32 PM, she stated Resident #2 had a history of self-harm and had a history of flinging his/her arms and she assessed his/her injuries on 03/30/2023 to be self-inflicted. She further stated it should be noted in the resident's medical file he/she had a history of self-inflicted injuries. The APRN stated, Resident #2's behaviors were not under control at the time and the facility altered his/her medication quite often. Review of the Medical Director's Progress Note, dated 03/30/2023 at 8:00 PM, revealed the APRN saw the resident and determined Resident #2 had bruising and an open area to the right temple above the right eye, bruising to the right arm, right hand and chest. Per the Note, the APRN reported to him the resident became combative during a bed bath and hit himself/herself. In an interview with the Medical Director (MD), on 11/03/2023 at 2:45 PM, he stated Resident #2 was easily agitated and flailed his/her arms, and that could be very dangerous when it happened in the shower. He stated the resident could be confused and felt like he/she was being raped if staff did not explain what care they were providing for him/her. The Medical Director stated if the resident had his/her hands held down, that could or could not be considered a restraint, as it depended on how the resident reacted. Continued interview with the MD, revealed a resident could be fine one moment and then in the next minute combative, upset and throwing things at staff. The MD further stated, residents with dementia and Alzheimer's, may not remember you and that made caring for them hard. During further interview he stated staff was to follow the care plan and the policies and procedures of the facility in order to provide optimal care for the residents. During an interview with the Director of Nursing (DON), on 11/08/2023 at 10:00 AM, she stated the facility did not use restraints. She further stated it was not okay for staff to hold a resident's hands in place to prevent the staff member from being hit. Per interview, holding the residents down in such a manner would be considered a restraint. She further stated, staff had been directed, if a resident became combative during care, staff was to wait and return later to allow the resident to calm down. Per interview, Resident #2's Care Plan had an intervention to step away if the resident was combative and the [NAME] noted two (2) staff was to assist the resident with a bath. The DON stated all staff was expected to follow the Care Plan and [NAME] while providing care including agency staff. Further, she stated all agency staff was to check in with the nurse to get report prior to starting their shift. The DON stated it was her expectation for agency staff to be fully trained by their agency prior to working at the facility. During an interview with the Administrator, on 11/08/2023 at 12:20 PM, she stated on 03/30/2023, when she arrived at the facility and saw Resident #2, it looked like (he/she) had been in a fight. She further stated she did not know what happened to the resident and did not make any assumptions, but the APRN saw the resident on 03/30/2023 and determined the injuries were self-inflicted. The Administrator stated the resident had a history of self-harm/self-injuries, and was identified as requiring two (2) person assist for care. She stated SRNA #3 showed poor judgement by providing care for the resident alone. The Administrator stated staff should not hold a resident's hand to prevent the resident from hitting them. She stated holding the resident's hands down would be considered a restraint, if the resident could not lift his/her hands. During interview with the Administrator, on 11/08/2023 at 12:20 PM, she stated SRNA #3 should have had two (2) care givers in the room while she provided care for Resident #2 and if the resident became combative during care the aide should have made sure the resident was safe, stepped away and asked for assistance, giving the resident time to calm down. The Administrator further stated, she expected all staff who worked at the facility to be aware of the policies and procedures and follow them. During further interview with the Administrator, on 11/08/2023 at 12:20 PM, she explained when agency staff was used at the facility, on their first visit they were to sign in the binder at the front desk which had a training packet they were to complete. She stated the training packet included several policies, and it was the expectation agency staff were fully trained by their agency prior to reporting the facility for work.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain clinical records that are accurately documented for one (1) of twenty-four (24) sampled residents (Resident #8). Review of Resident #8's Physician Orders revealed an order to Cleanse Stage 4 pressure wounds to right ischium and sacrum with normal saline, pat dry, apply alginate calcium with silver, cover with an abdominal (ABD) pad (wound dressing) and secure with pinc (zinc oxide-based adhesive tape) tape two (2) times daily, with a start date of 01/22/2020. However, review of the Treatment Administration Record revealed no documented evidence of treatment being signed out as administered from 01/22/2020 until 02/06/2020. The findings include: Interview with the facility's Director of Nursing, on 02/06/2020 at 4:32 PM, revealed maintaining accurate resident records is a standard of practice and there is no policy related to the accuracy of resident records. Review of Resident #8's clinical record revealed the facility admitted the resident on 09/22/2015 with diagnosis to include Cerebral Infarction, Major Depressive Disorder, and Cerebrovascular Disease. Review of Resident #8's Quarterly Minimum Data Set (MDS) Assessment, dated 11/01/19, revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #8's Order Summary Report, dated February 2020, revealed an active Physician's order, with a start date of 01/22/2020, to cleanse the stage 4 pressure wounds to the right ischium and sacrum with normal saline, pat dry, apply alginate calcium with silver, cover with ABD pad and secure with pinc tape two (2) times daily at 10:00AM and 10:00 PM. Review of Resident #8's Treatment Administration Record (TAR), for 01/22/2020, revealed the treatment to cleanse the stage 4 wounds to the right ischium and sacrum with normal saline, pat dry, apply alginate calcium with silver, cover with ABD pad and secure with pinc tape two (2) times daily. Continued review of the TAR revealed no documented evidence the treatments had been performed from 01/22/2020 at 10:00 PM until 02/06/2020 at 10:00 AM. Interview with Resident #8, on 02/06/2020 at 3:05 PM, revealed staff do come and change his/her dressing twice a day, morning and night, unless he/she refuses. Interview with LPN #1, on 02/06/2020 at 3:33 PM, revealed the blanks in the TAR means the nurse failed to sign out that the treatment was completed. It does not mean the treatment was not performed; just that it was not documented in the computer in the electronic Treatment Record. Interview with the Director of Nursing (DON), on 02/06/2020, at 4:33 PM, revealed the wound care and dressing changes should be signed off in the TAR to validate the treatment had been performed per the Physician's order. Continued interview revealed it was her expectation that the resident's clinical record including the TAR to be accurate and complete. Interview with the Administrator, on 02/06/2020, at 4:44 PM, revealed it was her expectation that the resident's medical record was to be complete and accurate. She stated the importance of signing out the treatment record was to ensure the treatment had been completed per the Physician's order.

Based on observation, interview and review of facility's policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observations on 02/05/2020 of the nourishment rooms on the 100 and 200 unit revealed numerous snacks undated in the nourishment drawers. The findings include: Review of the facility's policy, titled Dry storage dated 2013, revealed to store, prepare and serve food in accordance with Federal, state and local sanitary codes. Continued review revealed foods would be labeled as to content and dated. Further review revealed stock will be rotated on a first in first out (FIFO) basis. Observations of the 200 unit resident nourishment room, on 02/05/2020 at 9:00 am revealed snacks not dated for four (4) ginger bread cookies, eight (8) strawberry delight cookies, one (1) oatmeal creme cookie and two (2) peanut butter crackles. Observation of the 100 unit resident nourishment room, on 02/05/2020 at 9:10 AM, revealed snacks not dated for five (5) marshmallow pies, one (1) ginger bread cookie, one (1) fudge brownie cookie and one (1) package of peanut butter crackers. Interview with the 100/200 Unit Manager, on 02/06/2020 at 3:15 PM, revealed State Registered Nurse Aide (SRNA) #2 usually passes the 10:00 AM and 2:00 PM snacks. Continued interview revealed SRNA #2 should not return undated snacks to the nourishment room. Further interview revealed there was a potential for infection control concerns, and the snacks not appetizing to the residents. Interview SRNA #2, on 02/06/2020 at 3:37 PM, revealed she passes the 10:00 AM and 3:00 PM snacks to the residents for the 100 and 200 units. Continued interview revealed, should a resident refuse their snack, she places it in the nourishment room. Further interview revealed should she find any left over and undated snacks in the nourishment room, she throws them out and informs the kitchen. She stated undated snacks should not be available for the residents. Interview with SRNA #1, on 02/06/2020 at 3:22 PM, revealed snacks were available for residents at night in the nourishment room. Continued interview revealed snacks were not usually left in the nourishment room drawers. He stated snacks that were undated should be thrown out due to the potential to grow bacteria and not taste good. Per interview, he returns extra snacks on the cart to Dietary. Interview with Dietary Aide #1, on 02/06/2020 at 3:53 PM, revealed she had not been notified that there were any undated snacks in the nourishment room. Continued interview revealed snacks should be dated and rotated daily. She stated should a snack not be dated, it needs to be thrown away. Interview with [NAME] #1, on 02/06/2020 at 3:51 PM, revealed there has been no staff from the 100 unit or the 200 unit inform her that there were snacks in their nourishment room that were undated. Per interview, if there are items that are not dated, they should be discarded. Interview with Dietary Manager, on 02/06/2020 at 3:55 PM, revealed the facility policy was that every food item should be labeled and dated prior to being sent to the nourishment rooms. Continued interview revealed the Dietary Aide is responsible to supply the nourishment room and rotate the nourishments. Further interview revealed the Dietary Aides are not responsible to rotate any snacks in the nourishment room drawers. The Dietary Aide brings the snacks to the nourishment room in dated boxes. The SRNA passes snacks to the residents three (3) times a day. Per interview, she believes the SRNAs are putting the extra snacks from the snack cart into the nourishment room drawers without a date on the snack. Per interview, items should be label and dated because there was a potential for food borne illness if the nourishments not dated or expired. Interview with the Director of Nursing (DON), on 02/06/2020 at 03:58 PM, revealed all food items should be labeled and dated with an expiration date. Continued interview revealed food items without an expiration date can expire, and not taste good. Further interview revealed there was a potential for bacteria to grow in food, which contain high levels of sugar. Interview with Administrator, on 02/06/2020 at 4:05 PM, revealed all food items should be dated. Per interview, the food should be dated when taken out of the box. Continued interview revealed the expectation was that the food items would be labeled and dated as well as rotated with the first come first served. Per interview, bacteria can potentially grow in expired food items.

Based on observation, interview, record review, and review of the facility's Policies, it was determined the facility failed to ensure confidentiality of the Electronic Medication Administration Record (E-MAR) for one (1) of twenty-six (26) sampled residents (Resident #86). Observation on 02/12/19, on the Reflections Community/400 Unit, revealed Kentucky Medication Aide (KMA) #1 left the medication cart unattended with Resident #86's E-MAR open on the computer display screen, allowing the resident's personal and medical information to be visible to others on the unit. The findings include: Review of the facility's Policy titled, Confidentiality of Information and Personal Privacy, revised 10/2017, revealed the facility was required by law to maintain the privacy and confidentiality of resident protected health information. Further, the facility would protect and safeguard resident confidentiality and personal privacy. Continued review of the Policy, revealed the resident's clinical information, including computer-stored medical and/or personal information would be handled in accordance with resident rights and privacy policies. Review of the facility's Policy, titled Resident Rights, revised 12/2016, revealed the unauthorized release, access or disclosure of resident information was prohibited by law. Review of Resident #86's medical record revealed the facility admitted the resident on 02/02/17 with diagnoses to include Unspecified Dementia without Behavioral Disturbance, Alzheimer's Disease, Chronic Obstructive Pulmonary Disease (COPD), and Asthma. Observation during initial tour of the facility, on 02/12/19 at 8:30 AM, revealed Kentucky Medication Aide (KMA) #1 was standing at the medication cart located just outside of the medication room, preparing medications and reviewing the E-MAR from the computer display screen. Further observation revealed KMA #1 closed and locked the medication cart and left the medication cart unattended without logging off or closing down the computer screen. This left the computer display screen, with Resident #86's demographic and medical information, clearly visible and accessible to the surveyor, other unit residents and staff members coming to and from the unit. Continued observation revealed KMA #1 returned to the medication cart at 8:32 AM, two (2) minutes later, following administration of Resident #86's medication. Interview with KMA #1, on 02/12/19 at 8:35 AM, revealed she had been employed with the facility for eight (8) years and was assigned to administer medications to all of the residents on the Reflections Community/400 Unit. Further interview revealed facility policy was to ensure the E-MAR was secured to prevent other residents, visitors/family members, and/or staff not providing care to residents from obtaining the resident's personal or medical information. Continued interview revealed this was a privacy and confidentiality issue and she was familiar with the Health Insurance Portability and Accountability Act of 1996 (HIPPA) that prohibited the unauthorized release of resident's protected health information. Additional interview with KMA #1, revealed she should have closed the computer screen that displayed Resident #86's information prior to leaving the medication cart due to information was visible to unauthorized staff members, other residents, and visitors/family members to the facility which was a HIPPA violation. She stated the computer screen which had been left open included Resident #86's information including: name, date of birth , date of admission to the facility, allergies, medications, diagnoses, medical provider, special needs (takes medication crushed with applesauce) and code status. Continued interview with KMA #1, revealed she was aware of state and federal regulations as well as facility policy regarding resident confidentiality and privacy and should have kept the resident's information private. Interview with Licensed Practical Nurse (LPN) #7, on 02/13/19 at 10:07, revealed she had been employed with the facility for five (5) years and served as the Charge Nurse for the Reflections Community/400 Unit on 02/12/19 and 02/13/19. Further interview revealed she was familiar with the HIPPA Act of 1996 and it was the facility's policy to keep all resident personal, financial and medical information private and confidential. Continued interview revealed during medication administration, staff were to lock the medication cart, log off and close the E-MAR prior to leaving or turning away from the medication cart to administer medications, in an effort to prevent the potential release or unauthorized access of personal or medical information. LPN #7 stated KMA #1 should have closed the E-MAR computer display, as she too was aware of the facility's privacy/confidentiality policy and HIPPA Act as the facility had provided several in-service trainings on this topic. Interview with Unit Manager (UM)#3, for the Reflections Community 300 and 400 Units on 02/14/19 at 2:46 PM, revealed she had been employed with the facility for five and one half (5.5) years. Further interview revealed she expected staff to adhere to the privacy and confidentiality policy and follow HIPPA practices at all times while providing resident care, including medication administration. Continued interview revealed she expected KMA #1 to close the computer display prior to leaving the medication cart unattended to prevent the potential release of personal or medical information to unauthorized persons including staff who were not assigned to provide care to the resident, visitors/family members, or other residents living on the unit or in the facility. UM #3 stated KMA #1 and other staff assigned to administer medications were aware of the importance of maintaining resident's privacy/confidentiality due to the number of in-service trainings and online educational materials provided to them on the topic. Interview with the Director of Nursing (DON), on 02/14/19 at 5:28 PM, revealed she had been employed with the facility for one and a half (1.5) years. Further interview revealed it was her expectation staff maintain the resident's privacy and confidentiality at all times. Continued interview revealed staff was to close the E-MAR prior to leaving the locked medication cart unattended in order to prevent the potential unauthorized access to resident personal or medical information. Additional interview revealed leaving the E-MAR display visible to staff not assigned to the resident, visitors/family members, vendors and/or other residents in the facility was a violation of privacy/confidentiality and HIPPA and was unacceptable behavior. Interview with the Administrator, on 02/14/19 at 6:13 PM, revealed she had been employed with the facility for two (2) years. Further interview revealed it was her expectation staff close the E-MAR prior to leaving the medication cart in an effort to prevent the potential unauthorized access to resident personal or medical information. Continued interview revealed leaving the E-MAR screen visible to staff not assigned to care for the resident, visitors/family members, vendors and other residents was a violation of resident rights, privacy and confidentiality and was a HIPPA violation. The Administrator stated it was unacceptable behavior to allow unauthorized access to facility resident's personal or medical information, as staff have been educated and in-serviced numerous times on this information. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement the Comprehensive Care Plan for one (1) of twenty six (26) sampled residents (Resident #108). Resident #108's Comprehensive Care Plan initiated 04/29/16, revealed interventions for pacemaker checks as ordered in coordination with the cardiologist office. However, there was no documented evidence the resident was receiving pacemaker checks. The findings include: Review of the Policy utilized by the facility, titled Care Planning-Interdisciplinary Team, from the Nursing Services Policy and Procedure Manual for Long Term Care 2001 Med-Pass, Inc., revised September 2013, revealed the Care Plan is based on the resident's comprehensive assessment and is developed by the Care Planning/Interdisciplinary Team. However, the Policy did not reference the need to implement the Care Plan. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #108's clinical record revealed the facility re-admitted the resident on 03/12/12, with diagnoses including History of Unspecified Osteoarthritis, and Major Depressive Disorder. Review of the Annual Minimum Data Set (MDS) Assessment, dated 01/25/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15) indicating severe cognitive impairment. Review of the Comprehensive Care Plan, initiated 04/29/16, revealed Resident #108 had a problem of pacemaker placement. The goal revealed the resident would have less risk for complications and would have maintenance through 05/2019. The interventions included the following: Pacemaker checks as ordered in coordination with cardiologist office; education to resident/ responsible party and care giver as needed; and report any irregular pulse rates to the Physician. Review of Resident #108's Consultation Report, dated 08/29/16, following pacemaker generator replacement, revealed instructions for surgical site care. Further review revealed instructions for pacemaker checks as ordered in conjunction with cardiologist office; report any irregular pulse rates to the Physician; and follow up with the Attending Cardiologist. Review of Resident #108's Cardiology Consult for the surgical follow-up office appointment, dated 09/29/16, revealed the pacemaker surgical site was well healed, and the resident could return to care of the local cardiologist. Additional review revealed the resident was pacemaker dependent with a history of underlying third degree heart block, congestive heart failure(CHF), and hypertension (HTN). Continued review revealed the resident had a prior history of ventricular fibrillation (Vfib) with two (2) shocks on 12/2015. Review of Chest x-ray interpretation dated 04/19/18, revealed the view included a pacemaker. Review of the Physician's Progress Notes, dated 05/13/18 and 09/19/18, revealed Resident #108 heart regularity and rate had been assessed by the Medical Director, and was documented as regular rate and rhythm, no murmurs, rugs, or [NAME] (MRG's) Review of the Chest X-ray, dated 11/03/18, revealed the resident had left sided dual pacemaker wires in place. However, review of the Pacemaker Check Tracking Log, revealed there were no entries to indicate Resident #108's pacemaker had been checked. Additional record review revealed no documented evidence pacemaker checks had been performed since generator replacement on 08/29/16, and no documented evidence contact had been made with the Attending Cardiologist's office. Review of the Monthly February 2019 Physician's Orders, revealed there was no documented evidence of orders related to Pacemaker Checks. Interview on 02/14/19 at 1:30 PM, with Licensed Practical Nurse (LPN) #1, who was assigned to Resident #108, revealed she was unaware the resident had a pacemaker, and was unaware of any orders for pacemaker checks. LPN #1 reviewed the medical record and stated there was no evidence pacemaker checks had been performed for this resident. Interview on 02/14/19 at 3:20 PM, with the Unit Coordinator (UC) for the 100 Unit, which was the unit in which Resident #108 resided, revealed he could find no documented evidence Resident #108's pacemaker had been checked since the generator replacement on 08/29/16. The UC revealed the nurse receiving the resident after a hospital visit or clinic visit concerning a pacemaker was to place the resident's name in the Pacemaker Check log, then make arrangements for the resident to have transportation to the cardiologist office for the pacemaker check at the time appointed by the office. The UC further revealed the receiving nurse should have written orders to reflect the resident's discharge summary when the resident returned to the facility on [DATE], following pacemaker generator replacement. The UC stated these orders would have then been reviewed by nursing administration. Interview on 02/14/19 at 9:45 AM, with the Advanced Practice Nurse Practitioner (APRN) who routinely provided care for Resident #108, revealed she was unaware this resident had an implanted pacemaker, and was also unaware pacemaker checks had not been completed since the generator was replaced on 08/29/16. Phone interview was conducted with the Pacemaker Device Nurse in Resident #108's Cardiologist's office, on 02/14/19 at 1:40 PM, regarding the protocol for pacemaker checks. The Nurse revealed, generally pacemaker checks were to be performed quarterly, semi-annually, or annually, depending on the manufacturer's recommendations. Interview with the Director of Nursing (DON), on 02/14/19 at 6:15 PM, revealed there should have been Physician's Orders to check Resident #108's pacemaker. Per interview, the Care Plan should have been implemented related to pacemaker checks. She stated she was unaware pacemaker checks had not been performed for Resident #108 since 2016. Interview with the Administrator, on 02/13/19 at 6:32 PM, revealed it was her expectation the Comprehensive Care Plan be implemented for the safety of the residents.

Based on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined that the facility failed to revise the Comprehensive Care Plan for three (3) of twenty six (26) sampled residents (Resident #52, #84, and #94). Resident #94 was identified to have discoloration and slight edema to the left great toe on 02/07/19, and X-rays results dated 02/08/19, revealed an acute fracture to the left second toe. However, there was no documented evidence the facility identified the root cause of the injury in order to revise the Comprehensive Care Plan (CCP) with specific interventions to prevent further accidents. In addition, Resident #52 was identified to have a large bruise across the left great toe on 10/08/18. However, there was no documented evidence the facility identified the root cause of the bruise or made an effort to identify hazards and risks in the environment in order to revise the CCP with specific interventions to prevent further accidents. Furthermore, Resident #84, had an unwitnessed fall from the bed on 11/19/18. However, the CCP was not revised to indicate the fall event on 11/19/18 nor was the CCP revised with a new targeted fall intervention based on the root cause of the accident. Subsequently, the resident had an additional unwitnessed fall from the bed on 11/21/18. After the 11/21/18 fall, the CCP was not revised to indicate the fall event nor was the CCP revised with adequate interventions to prevent further falls. (Refer to F-689) The findings include: Interview with the Minimum Data Set (MDS) Coordinator, on 02/14/19 at 6:47 PM, revealed the facility followed the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, as a guide for revising the Comprehensive Care Plan (CCP). Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. Review of the facility's Accidents (F323) Policy, dated May 2008, revealed the facility would provide an environment that was free from accident hazards and provide supervision and assistance to residents to prevent avoidable specific accidents. Additionally, all staff would be involved in the identification of hazards and risk in the environment, and a reasonable effort would be made to identify hazards and risk factors through environmental rounds. Continued review revealed the Interdisciplinary Team would Analyze and Evaluate hazards and risks and develop specific target interventions to reduce the potential for accidents. Per Policy, the specific interventions would be communicated to relevant staff and documented on the individual resident's Plan of Care. Further, the facility would monitor the interventions effectiveness and make modifications as indicated. Per Policy potential Resident/Environmentally based risk included: resident vulnerabilities; falls, and Assistive Device/Equipment Hazards; and devices for mobility and transfer. 1. Review of Resident #94's clinical record revealed the facility admitted the resident on 11/15/16 with diagnoses including Type II Diabetes, Major Depressive Disorder, Polyneuropathy, Hemiplegia affecting Right Dominate Side, Coronary Artery Disease, Heart Failure, Cerebral Vascular Accident (CVA), Muscle weakness, and Chronic Kidney Disease, Abnormal Posture. Review of Resident #94's Accidents Comprehensive Care Plan (CCP), with an onset date of 11/28/16, revealed the resident had the potential for accidents, falls or injury related to Debility, Neuropathy, CVA, and psychotropic medication use. The goal revealed the resident would have reduced risk for injury. The interventions included: educate about safety, ensure appropriate assistance was provided, and maintain environment free of clutter and safety hazards. Review of Resident #94's Quarterly Minimum Data Set (MDS) Assessment, dated 01/11/19, revealed the facility assessed the resident as having both short and long-term memory problems. The facility further assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, toileting and bathing; total assistance of two (2) staff for transfers; and total assistance of one (1) staff for locomotion. Continued review revealed the facility assessed the resident as not steady, as only able to stabilize with staff assistance during surface to surfaces transfers, and as having limitations in functional range of motion on one (1) side, upper and lower extremities. Per the MDS Assessment, the resident had no falls since the previous assessment. Review of Resident #94's Situation Background Assessment Recommendation (SBAR) Note, dated 02/07/19 at 7:15 PM, revealed the resident had a discoloration to the left lower extremity, lower shin and medial ankle which was a change in condition. Further review revealed the Physician was notified and new orders were received for an X-ray. Review of the X-ray results, dated 02/08/19; revealed an acute fracture in the base of the left proximal phalanx of the second toe with soft tissue edema. Review of Resident #94's Progress Note, dated 02/08/19 at 2:28 PM, revealed X-ray results were received and the Advanced Practice Registered Nurse (APRN) was notified and recommended the resident to see a specialist related to the fracture of the left second toe. Review of a subsequent Progress Note, dated 02/08/19 at 8:27 PM, revealed there was no edema or bruising present to the resident's left second toe; and the family spoke with the nurse and did not want the resident sent out to a specialist. There was no documented evidence of an Incident Report, witness statements, staff statements or an investigation in order to determine the root cause of the injury, in order to revise the Care Plan with appropriate interventions to prevent recurrence. Further review of the Accidents CCP, revealed there was no revision to the CCP to include the incident/accident on 02/07/19 or a new intervention to prevent further occurrence of an injury of the same nature. Interview with SRNA #16, on 02/14/19 at 4:26 PM, revealed she was assigned to Resident #94, on 02/07/19. She stated while she was assisting the resident she noticed a discoloration and swelling to the resident's left foot and reported it to the nurse. Per interview, the nurse assessed the resident's foot. Further interview, revealed when the resident was asked what happened, he/she stated he/she did not know. SRNA #16 stated she was not asked to write a statement. Interview with Licensed Practical Nurse (LPN) #6, on 02/14/19 at 5:27 PM, revealed Resident #94 required total assistance with all Activities of Daily Living (ADLs) and had been progressively getting weaker, was not a good historian and his/her cognition waxed and waned. Further interview revealed the resident required a hoyer lift (mechanical lift) for transfer. She stated, the resident's room was a tight fit and cluttered with assistive devices and furniture. Further interview revealed it was important to determine the root cause of the injury in order revise the CCP with specific interventions to ensure the resident's environment was safe and the accident did not occur again. Interview with the Unit 2 Manager, on 02/14/19 at 6:05 PM, revealed she assessed Resident # 94's left foot and also completed the SBAR on 02/07/19. She stated at the time of assessment there was no edema or discoloration to the left foot; and only darkened skin was noted to the resident's lower legs, which appeared to be vascular in nature. Further interview revealed the root cause of the injury was not determined at the time the change in the left lower extremity was initially identified, and there was no documented evidence of an Incident Report, investigation, staff or resident statements, or an assessment of the environment to determine the root cause of the injury. Per interview, an investigation should have been completed and the CCP should have been revised to indicate the injury and revised with necessary interventions to reduce the risk of further injury or accident. 2. Review of Resident #52's clinical record revealed the facility admitted the resident on 12/21/16 with diagnoses including Type II Diabetes, Unspecified Dementia, Major Depressive Disorder, Epilepsy, Hemiplegia affecting left dominant side, Chronic Atrial Fibrillation, Cerebral Vascular Accident (CVA), Polyarthritis, Osteoporosis, Abnormal Posture, and weakness. Review of the Quarterly MDS Assessment, dated 09/21/18, revealed the facility assessed the resident as having a BIMS score of one (1), out of fifteen (15), indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfers and toileting, and total assistance of one (1) staff for locomotion, bathing, dressing, and personal hygiene. According to the MDS Assessment, the resident was not steady, was only able to stabilize with staff assistance during surface-to-surface transfers and had no limitations in Range of Motion. Continued review revealed the facility assessed the resident as having no falls since the previous assessment, and as receiving seven (7) days of Anticoagulant medication. Review of Resident #52's Accidents CCP, with an onset date of 01/03/17, revealed the resident had the potential for accidents, falls or injuries related to CVA with Hemiplegia, Dementia, Seizure Disorder, Ataxia, Polyarthritis, Incontinence, Malaise, and Psychotropic medication use. The goal revealed the resident would have reduced risk for injury. The interventions included: educate staff about safety, ensure appropriate assistance; ensure resident's environment was free of clutter and safety hazards; and no tight foot wear per podiatry. Review of the resident's October 2018 Monthly Physician's Orders, revealed an order for Xarelto (anticoagulant) twenty (20) milligrams (mg) by mouth once daily. Review of the SBAR, dated 10/08/18 at 2:05 PM, revealed the resident had a bruise across the left great toe which was a change in condition. Additional review revealed the Advanced Practice Nurse Practitioner (ARNP) and Resident Representative was notified. Review of the Progress Note, dated 10/11/18 at 10:11 AM, revealed there was a large yellow-green healing bruise covering the resident's right great toe and the top of the first metatarsal, which was painful to touch. The subsequent Progress Note, dated 10/11/18 at 11:01 AM, revealed there was a bruise on top of the resident's left great toe and metatarsal area and a new order was received for an X-ray to to the area. Review of the X-ray results, dated 10/11/18, revealed there was no acute fracture or dislocation of the left toes. There was no documented evidence of an Incident Report, witness statement or staff statements, or an investigation related to the bruise on top of the resident's left great toe and metatarsal area, in order to determine the root cause of the injury. Additional review of Resident #52's Accidents CCP, revealed a problem of a bruise to the left great toe was added on 10/11/18. There was an intervention added on 10/11/18 for an X-ray to the left great toe. However, there was no documented evidence the CCP was revised with a targeted intervention to prevent further occurrence of an injury of the same nature. Interview with SRNA #15, on 02/14/19 at 4:26 PM, revealed she was assigned to Resident #52 on 10/08/18, and on that date she took the resident's protective boot and socks off and noted a red and purple bruise across the top of the left big toe that had not been there before. Per interview, she reported the bruise immediately to the nurse who assessed the resident's foot. Further interview revealed she asked the resident what happened and the resident stated he/she did not know. SRNA #15 revealed she was not asked to write a statement and was not interviewed after she reported the bruise to the nurse. Interview with Licensed Practical Nurse (LPN) #6, on 02/14/18 at 5:27 PM, revealed she was familiar with residents on the 200 hall, and had been working with Resident #52. Per interview, Resident #52 required total assistance with all ADLs and his/her legs and feet were positioned straight out when in the seated position. She stated there was the potential staff could bump Resident #52's feet on something during transfer. Per interview, it was important to determine the cause of an injury to ensure the CCP was revised with the necessary interventions for care and treatment. Interview with the Unit 2 Manager, on 02/14/19 at 6:05 PM, revealed all noticeable bruises were to be investigated by the nursing staff and the Interdisciplinary Team (IDT) to determine the root cause of the bruise/accident in order to revise the CCP with specific interventions to ensure the residents received quality care, and to ensure safety. Continued interview revealed the root cause of Resident #52's injury should have been determined and the CCP should have been revised with specific interventions to reduce the risk of the same incident again. Interview with the Director of Nursing (DON), on 02/14/19 at 6:59 PM, revealed any bruises or injuries should be assessed by the nurse and a root cause should be determined through record review, Incident Report, witness statements, and statements from residents and staff. Per interview, the information gathered through the investigation would lead to a Root Cause Analysis (RCA) which would lead to revision of the CCP with targeted interventions in an attempt to prevent reoccurrence. Continued interview revealed investigations should have been completed to determine the root cause of the bruise and injury to Resident #94's left foot, on 02/07/19 and Resident #52's bruise on 10/08/18. Further, nursing staff and the Interdisciplinary Team (IDT) should have revised the CCP with interventions to prevent recurrence of the accidents/injuries for Residents #94 and #52. 3. Review of Resident #84's clinical record revealed the facility admitted the resident on 11/18/14 with diagnoses including Unspecified Dementia, Major Depressive Disorder, Age related nuclear cataract, Pain in Right Shoulder, Postural kyphosis, Low back pain, Age related Osteoporosis, Chronic Kidney Disease Stage III, Difficulty walking, Abnormality of gait, Lack of coordination, Repeated falls, and History of Fractures. Review of Resident #84's Accidents CCP, with an onset date of 12/04/14, revealed the Resident had potential for accidents, falls or injury related to: weakness, decreased mobility, difficulty walking, medication use, and falls sustained on: 01/13/18, 03/10/18, 03/11/18, 04/15/18, 04/18/18, 07/28/18, 08/04/18, 08/11/18, 08/20/18, 10/05/18, 11/17/18, 12/08/18, 12/21/18, 12/20/18, and 01/12/19. The goal revealed the resident would have reduced risk for injury. The interventions included: ensure appropriate assistance provided with care and mobility; maintain resident environment free of clutter and safety hazards; encourage use of non-skid socks/shoes; and bolster (perimeter) mattress initiated 07/30/18. Review of the Quarterly MDS Assessment, dated 10/10/18, revealed the facility assessed the resident as having a BIMS score of nine (9) out of fifteen (15), indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as requiring limited assistance of one (1) person for bed mobility, walking in room and toileting; and extensive assistance of one (1) person for transfers, locomotion, dressing, and personal hygiene. Continued review revealed the facility assessed the resident as not steady, but able to stabilize balance without human assistance moving from seated to standing position, walking, turning and facing the opposite direction while walking, and surface to surface transfers (between bed and chair and wheelchair). Additional review revealed the facility assessed the resident as having two (2) or more falls with injury since the previous MDS assessment. Review of the Non Witness Statement, completed by SRNA #17, dated 11/18/18 at 11:00 PM, revealed the bathroom emergency light was on for Resident #84's room and the joining room. SRNA #17 went to see who was in the bathroom and saw Resident #84 on the floor by the bed. Additional review revealed the resident stated he/she rolled out of bed onto the floor. Review of the SBAR, dated 11/19/18 at 6:25 AM, revealed the resident's change in condition symptom was a fall. Further review revealed the resident was found on the floor on his/her buttock by the right side of bed and stated he/she rolled out and had no pain. Additional review revealed there was redness without bruising noted to the mid back and the resident had full Range of Motion in upper and lower extremities. Review of the Incident/Accident Report, dated 11/19/18, revealed the date of the incident/accident was 11/18/18 at 11:30 PM, in Resident #84's room. Continued review of the Report, revealed no bed rails were present and the bed height was down. The description section of the Report, revealed the resident was found on the right side of the bed between the bed and wheelchair, sitting on his/her buttocks. The Report further revealed there was no pain verbalized by the resident, no bruising or other obvious injury, and the resident had full Range of Motion to upper and lower extremities. According to the Report, there was redness to the resident's mid back. Review of Resident #84's Pre and Post Incident Investigation, completed by LPN #8, dated 11/19/18 at 11:30 PM, revealed the resident's call light was not on and the resident stated he/she rolled onto side and out of bed. The fall was unwitnessed, the room was well lit, the resident was wearing socks, and the resident was not incontinent or confused at the time of the fall. This Investigation revealed the root cause of the fall was identified as the resident rolled out of bed due to positioning. The intervention implemented based on the root cause was a perimeter-defined mattress. However, this intervention was already in place per the CCP, and was initiated 07/30/18, and there was no documented evidence of a revision of the CCP with additional interventions to prevent recurrence. Subsequently, Resident #84 had an additional fall event from the bed to the floor on 11/21/18. Review of the SBAR, dated 11/21/18 at 11:35 AM, revealed the resident slid in the floor when transferring from the bed to the wheelchair, and was found at the bedside on his/her buttock. Further review revealed the resident had no pain or injury, and the Physician and resident representative were notified of the fall event. Review of the Incident/Accident Report, dated 11/21/18, revealed the incident/accident occurred on 11/21/18 at 11:30 AM, in Resident #84's room. Further review revealed no bed rails were present, the bed height was down. Per the Report, the resident was transferring self from bed to wheelchair; and was found in the floor near the bed by housekeeping. Further review revealed the resident had no pain and there was no injury noted. Review of Resident #84's Pre and Post Incident Investigation, completed by LPN #9, dated 11/21/18 at 11:30 AM, revealed the fall was unwitnessed, the room was well lit and the resident was wearing tennis shoes. The resident was not incontinent or confused at the time of the fall. Further review revealed the root cause of the fall was: attempted to transfer self from bed to wheelchair without assistance. Per the Investigation, the intervention implemented based on the root cause was to encourage the resident to use the call light when he/she wanted to transfer, and encourage to ask for assistance. Also, the new intervention implemented included every fifteen (15) minute checks for seventy-two (72) hours/increased supervision. Further review of the Accident CCP, revealed the CCP was not revised to include the fall events on 11/19/18 or 11/21/19. Also, the CCP was not revised with interventions listed on the Pre and Post Incident Investigation forms based on the root cause for the fall event on 11/21/18. Interview with LPN #6, on 02/14/19 at 5:27 PM revealed she was assigned frequently to Resident #84 and the resident sustained numerous falls. She stated her role after a resident sustained a fall was to assess the resident for injury and develop and implement an intervention immediately after a fall event to reduce the risk for a fall event to re occur. She stated the CCP should be revised with new interventions to prevent recurrence after a fall. Further interview revealed interventions for Resident #84 to encourage him/her to use the call light and increase his/her supervision for only seventy-two (72) hours was not effective to reduce the risk for unwitnessed falls when this resident was known to self transfer without assistance. Interview on 02/14/19 at 6:05 PM, with Unit 2 Manager, revealed Resident #84 resided on Unit 2 and continued to sustain falls. She stated a root cause of a fall should be determined at the time of the fall and an immediate intervention should be developed and implemented to prevent further falls. Per interview, the morning meeting, with the Interdisciplinary team, which included all Unit Managers, the DON, the MDS nurse, the Administrator, and Therapy reviewed all fall events each weekday to ensure the best intervention was used for the resident related to the specific fall event. However, she stated she was uncertain why Resident #84's CCP was not revised to include the fall events on 11/19/18 and 11/21/18 with adequate targeted interventions to prevent further falls. Interview with the DON, on 02/14/19 at 6:59 PM, revealed she expected the root cause of a fall to be determined in order to develop, and implement a targeted intervention to add to the CCP to reduce the resident's risk for the same occurrence again. Continued interview revealed a daily clinical review meeting, during weekdays, reviewed the fall events to ensure a thorough investigation was completed and an appropriate intervention was implemented. Further interview revealed Resident #84's CCP should have been revised to indicate the fall events on 11/19/18 and 11/21/18, and should have been revised with new interventions to prevent further falls. She further acknowledged the intervention for a perimeter mattress was already in place prior to the fall on 11/19/18, and therefore was not an appropriate intervention to add to CCP after the fall on 11/19/18. The DON further acknowledged the fall investigations on 11/19/18 and 11/21/18 were not thorough and did not indicate an appropriate root cause, in order to revise the resident's CCP with a targeted intervention to prevent recurrence. Interview with MDS Coordinator, on 02/14/19 at 6:47 PM revealed she received copies of all Physician's Orders to review daily. Additionally she attended a morning meeting, and listened to reports includes, falls, any incident or accident, behaviors, etc. During the meeting, she would actively review the CCP and ensure targeted interventions had been added related to incidents discussed in the meeting. Further, it was important to have a timeline of accidents/injuries and falls on the CCP with specific interventions to prevent further injury and keep the residents safe and to provide personalized quality care to each resident. Interview with the Administrator, on 12/14/19 at 7:24 PM revealed she expected staff to complete a thorough investigation of all accidents and falls per facility policy and protocol in order to determine the root cause and revise the CCP with necessary interventions to reduce the risk of reoccurrence and to maintain a safe environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, it was determined the facility failed to ensure provision of treatment and care in accordance with professional standards of practice for one (1) of twenty six (26) sampled residents (Resident #108). Although Resident #108 had a pacemaker, there was no documented evidence the resident was receiving pacemaker checks. Interviews with facility staff revealed they were unaware the resident had a pacemaker. The findings include: Interview with the Director of Nursing (DON) on 02/14/19 at 6:15 PM, revealed the facility did not have a policy related to pacemaker checks. Review of Resident #108's medical record revealed the facility re-admitted the resident on 03/12/12, with diagnoses including History of Unspecified Osteoarthritis, and Major Depressive Disorder. Review of Resident #108's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15) indicating severe cognitive impairment. Review of Resident #108's Comprehensive Care Plan, initiated 04/29/16, revealed a problem of pacemaker placement. The goal stated the resident will have less risk for complications and will have maintenance through 05/2019. The interventions included: pacemaker checks as ordered in coordination with cardiologist office; education to resident/ responsible party and care giver as needed; and report any irregular pulse rates to Physician. Review of the Consultation Report dated 08/29/16, following pacemaker generator replacement, revealed instructions for surgical site care. Further review revealed instructions for pacemaker checks as ordered in conjunction with cardiologist office; report any irregular pulse rates to the Physician; and follow up with the Attending Cardiologist. Review of the Cardiology Consult for the surgical follow-up office appointment, dated 09/29/16, revealed the pacemaker surgical site was well healed, and the resident could return to care of the local cardiologist. Further review revealed the resident was pacemaker dependent with a history of underlying third degree heart block, congestive hearth failure(CHF), and hypertension (HTN). Additional review revealed the resident had a prior history of ventricular fibrillation (Vfib) with two (2) shocks on 12/2015. Review of Chest x-ray interpretation dated 04/19/18, revealed a pacemaker was seen. Review of the Physician's Progress Notes, dated 05/13/18 and 09/19/18, revealed the resident's heart regularity and rate had been assessed by the Medical Director, and was documented as regular rate and rhythm, no murmurs, rugs, or [NAME] (MRG's) Review of the Chest X-ray, dated 11/03/18, revealed left sided dual pacemaker wires in place. However, review of the Pacemaker Check Tracking Log, revealed no entries to indicate Resident #108's Pacemaker had been checked. Further record review revealed no documented evidence pacemaker checks had been performed since generator replacement on 08/29/16, and no documented evidence contact had been made with the Attending Cardiologist's office. Review of the Monthly February 2019 Physician's Orders, revealed no documented evidence of orders related to Pacemaker Checks. . Interview with Licensed Practical Nurse(LPN) #1, on 02/14/19 at 1:30 PM, revealed she was assigned to Resident #108. She stated she was unaware the resident had a pacemaker, and was unaware of any orders for pacemaker checks. LPN #1 reviewed the medical record in an attempt to locate any pertinent information related to pacemaker checks; however, she stated there was no evidence pacemaker checks had been performed for this resident. Interview with Registered Nurse (RN) #3/weekend supervisor, on 02/14/19 at 1:45 PM, revealed the need for pacemaker checks was communicated to staff by the Unit Coordinator (UC); however, RN #3 stated she was unaware of any communication regarding pacemaker checks for Resident #108. Interview on 02/14/19 at 3:20 PM, with the Unit Coordinator (UC) for the 100 Unit, which was the unit in which Resident #108 resided, revealed he could find no documented evidence Resident #108's pacemaker had been checked since generator replacement on 08/29/16. The UC stated the nurse receiving the resident after a hospital visit or clinic visit concerning a pacemaker was to place the resident's name in the Pacemaker Check log, then make arrangements for the resident to have transportation to the cardiologist office for the pacemaker check at the time appointed by the office. The UC stated the receiving nurse should have written orders to reflect the resident's discharge summary when the resident returned to the facility on [DATE], following pacemaker generator replacement. He stated these orders would have then been reviewed by nursing administration. The UC was unsure why Resident #108's pacemaker checks were missed. Interview on 02/14/19 at 9:45 AM, with the Advanced Practice Nurse Practitioner (APRN) who routinely provided care for Resident #108, revealed she was unaware the resident had an implanted pacemaker, and also unaware pacemaker checks had not been completed since the generator was replaced on 08/29/16. Phone interview was conducted with the Pacemaker Device Nurse in Resident #108's Cardiologist's office, on 02/14/19 at 1:40 PM, regarding protocol for pacemaker checks. The Nurse stated usually pacemaker checks were to be performed quarterly, semi-annually, or annually, depending on the manufacturer's recommendations. Interview with the Director of Nursing (DON), on 02/14/19 at 6:15 PM, revealed she had no knowledge of Physician's Orders to check Resident #108's pacemaker, nor of any pacemaker checks performed for Resident #108 since 2016. The DON acknowledged the resident's care plan indicated pacemaker checks were to be performed. The DON acknowledged there were no physician's orders in place to ensure pacemaker checks were completed. Interview with the Administrator on 02/13/19 at 6:32 PM, revealed it was her expectation for residents to receive quality care including pacemaker checks as necessary.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure the Consulting Pharmacist reports irregularities related to psychotropic medication to the Attending Physician, Medical Director and Director of Nursing (DON). In addition, the facility failed to ensure Consultant Pharmacy Communication to Physician Reports were acted upon for one (1) of twenty-six (26) sampled residents (Resident #94). Resident #94's Physician's Orders dated 07/12/18, revealed orders for Xanax 0.25 milligrams (mg) by mouth three (3) times daily PRN (as needed) for anxiety, with a discontinue date of 10/02/18. This active PRN (as needed) psychotropic medication was ordered for eighty-four (84) days, with no documented evidence of a rationale for extending the duration of the medication beyond fourteen (14) days. However, there was no documented evidence the Consultant Pharmacist reported the irregularity until 09/21/18, over two (2) months after the medication was ordered. In addition, although the Physician agreed to discontinue the medication per the Consultant Pharmacy Communication to Physician Report, dated 09/21/18, there was no documented evidence the facility acted upon the report until 10/02/18, when the medication was discontinued. The findings include: Review of the facility's Medication Monitoring and Management; Psychotropic Medication Use Policy, undated, revealed psychotropic was any medication that affects the brain activities associated with mental processes and behavior. Additional review revealed the facility would comply with Psychopharmacologic Dosage Guidelines created by the Center for Medicare and Medicaid Services (CMS), and the State Operations Manual. Continued review revealed PRN (as needed) psychotropic medications should be ordered for no more than fourteen (14) days. However, the physician documenting a rationale in the resident's medical record could extend psychotropic medications beyond fourteen (14) days. 1. Review of Resident #94's clinical record revealed the facility admitted the resident on 11/15/16 with diagnoses including Type II Diabetes, Major Depressive Disorder, Hemiplegia affecting right dominate side, Coronary Artery Disease, Heart Failure, Cerebral Vascular Accident (CVA), and Chronic Kidney Disease. Review of Resident #94's July 2018 Physician's Orders, revealed orders dated 07/12/18 for Xanax 0.25 milligrams (mg) (anti-anxiety medication) by mouth three (3) times daily PRN for anxiety with a discontinue date of 10/02/18. However, there was no documented evidence the Provider documented a rationale for extending this medication past fourteen (14) days. Review of the July 2018 Electronic Medication Administration Record (EMAR), revealed Resident #94 received Xanax 0.25 mg on 07/24/18 at 10:03 PM. Review of the August 2018 EMAR, revealed the resident received Xanax 0.25 mg on 08/12/18 at 8:35 PM, and 08/29/18 at 4:38 PM. Review of the September 2018 EMAR, revealed the resident received Xanax 0.25 mg on 09/14/18 at 8:48 AM. Review of the September 2018, Consultant Pharmacist Monthly Drug Regimen Review (MDRR) worksheet, revealed a notation which stated, Irregularities; see consultant report. Review of the Consultant Pharmacy Communication to Physician Report (Consultation Report), dated 09/21/18, revealed Resident #94 had an order for Xanax 0.25 mg three (3) times a day PRN for Anxiety. Further review revealed recommendations to discontinue PRN psychotropic use past fourteen (14) days. Per the Report, the Physician agreed to discontinue the medication. However, there was no documented evidence the facility acted upon this Consultant Pharmacy Communication to Physician Report, until 10/02/18, eleven (11) days later. Review of Resident #94's Physician's Orders dated 10/02/18, revealed orders to discontinue Xanax 0.25 mg three (3) times a day PRN. The State Agency Representative placed a call to Resident #94's Attending Physician/Medical Director, on 02/14/19 at 6:45 PM and 02/27/19 at 10:30 AM, with a message left to return the call; however, the Provider did not return the call. Post Survey phone interview with the facility's Consultant Pharmacist, on 02/27/19 at 11:00 AM, revealed she came to the facility once a month and reviewed medical records for medication interactions, and to ensure regulations were followed related to medications. Further interview revealed when auditing a resident's record who was receiving psychotropic medications, she would look at the duration the medication was prescribed to ensure the facility was in compliance with regulations specific to fourteen (14) days PRN psychotropic drug use. Continued interview revealed she expected the Physician to prescribe PRN psychotropic medications per regulations, with a fourteen (14) days stop date, or to document a rationale for extending use of the drug. Additional interview revealed she did not know why Resident #94's PRN psychotropic medication order was not identified during her monthly reviews before 09/21/18. However, per interview, she did not see any potential negative outcomes for the resident having an active PRN psychotropic medication order for eight-four (84) days. Interview with the Director of Nursing (DON), on 02/14/19 at 6:59 PM, revealed it was her expectation each resident would have a thorough MDRR completed each month by a pharmacist to ensure the residents were receiving appropriate medications for the correct dosage, and duration; and to ensure there were no drug interactions with the residents' medication regimen. The DON stated the Physician was to prescribe PRN psychotropic medications with a fourteen (14) day stop date or document rationale for extended use of the medication, as per regulation. Additional interview revealed she ensured the Consultant Pharmacist's recommendations were followed by completing audits monthly to compare the recommendations with the Physician's Orders. Per interview, if the Provider did not agree with the recommendation for a fourteen (14) day stop date for a PRN psychotropic medication, she checked to ensure the Physician had written a rationale. However, she stated her audit process missed Resident #94's PRN psychotropic medication which was ordered for eighty-four (84) days. Per interview, it was important to identify and report irregularities related to medications including PRN psychotropic medications to ensure residents were free of unnecessary medications due to the risk of adverse effects Interview with the Administrator, on 12/14/19 at 7:24 PM, revealed she expected the Consultant Pharmacist to conduct a thorough MDRR to include a review of all psychotropic medication. Per interview, the MDRR should include ensuring psychotropic PRN medications were prescribed for the right duration. She stated PRN psychotropic medications should not be ordered past fourteen (14) days. Further interview revealed she expected the facility policy and regulations to be followed related to PRN psychotropic medication duration to ensure residents received appropriate medication doses that were therapeutic and would not cause adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, it was determined the facility failed to to ensure each resident's drug regimen was free from unnecessary drugs for one (1) of twenty-six (26) sampled residents (Resident #94). Review of Resident #94's medical record revealed the resident had an active PRN (as needed) psychotropic medication ordered for eighty-four (84) days, with no documented evidence of a rationale for extending the duration of the medication beyond fourteen (14) days. Physician's Orders dated 07/12/18, revealed orders for Xanax 0.25 milligrams (mg) by mouth three (3) times daily PRN for anxiety, with a discontinue date of 10/02/18. The findings include: Review of the facility's Medication Monitoring and Management; Psychotropic Medication Use Policy, undated, revealed psychotropic was any medication that affects the brain activities associated with mental processes and behavior. Additional review revealed the facility would comply with Psychopharmacologic Dosage Guidelines created by the Center for Medicare and Medicaid Services (CMS), and the State Operations Manual. Continued review revealed PRN (as needed) psychotropic medications should be ordered for no more than fourteen (14) days. However, the physician documenting a rationale in the resident's medical record could extend psychotropic medications beyond fourteen (14) days. 1. Review of Resident #94's Medical Record revealed the facility admitted the resident on 11/15/16 with diagnoses including Type II Diabetes, Major Depressive Disorder, Hemiplegia affecting right dominate side, Coronary Artery Disease, Heart Failure, Cerebral Vascular Accident (CVA), and Chronic Kidney Disease. Review of Resident #94's Comprehensive Care Plan, dated 11/28/16, revealed the resident received multiple medications with risk for adverse effects. The goal stated the resident would have decreased adverse side effects. Interventions included: administer medications as ordered and monitor for adverse effects; pharmacy review/consult of medication regimen PRN; and notify Physician of significant side effects. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having both short and long term memory loss; as having no diagnosis of Anxiety, and as not receiving anti-anxiety medications during the last seven (7) days. Review of Resident #94's July 2018 Physician's Orders, revealed orders dated 07/12/18 for Xanax 0.25 milligrams (mg) by mouth three (3) times daily PRN for anxiety with a discontinue date of 10/02/18. However, there was no documented evidence the Provider documented a rationale for extending the medication past fourteen (14) days. Review of the July 2018 Electronic Medication Administration Record (EMAR), revealed the resident received Xanax 0.25 mg on 07/24/18 at 10:03 PM. Review of the August 2018 EMAR revealed the Resident received Xanax 0.25 mg on 08/12/18 at 8:35 PM, and 08/29/18 at 4:38 PM. Review of the September 2018 EMAR revealed the Resident received Xanax 0.25 mg on 09/14/18 at 8:48 AM. Review of the September 2018, Consultant Pharmacist Monthly Drug Regimen Review (MDRR) worksheet, revealed a notation stating Irregularities; see consultant report. Review of the Consultant Pharmacy Communication to Physician Report (Consultation Report), dated 09/21/18, revealed the resident had an order for Xanax 0.25 mg three (3) times a day PRN for Anxiety. Additional review revealed recommendations to discontinue PRN psychotropic use past fourteen (14) days. Further review revealed the Physician agreed to discontinue the medication. However, there was no documented evidence the medication was discontinued until 10/02/18. Review of Physician's Orders dated 10/02/18, revealed orders to discontinue Xanax 0.25 mg three (3) times a day PRN. The State Agency Representative placed a call to Resident #94's Attending Physician/Medical Director, on 02/14/19 at 6:45 PM and 02/27/19 at 10:30 AM, with a message left to return the call; however, there was no return call. Post survey phone nterview with the facility's Consultant Pharmacist, on 02/27/19 at 11:00 AM, revealed she came to the facility once a month and reviewed medical records for medication interactions. Further interview revealed when auditing a resident's record who was receiving psychotropic medications, she would look at the duration the medication was prescribed to ensure the facility was in compliance with regulations specific to fourteen (14) days PRN use. Additional interview revealed she expected the Physician to prescribe PRN psychotropic medications per regulations, with a fourteen (14) days stop date, or to document a rationale for extending use of the drug. Continued interview revealed she did not know why Resident #94's PRN psychotropic medication order was not identified during her monthly reviews before 09/21/18. However, she stated she did not see any potential negative outcomes for the resident having an active PRN psychotropic medication order for eight-four (84) days. Interview with the Director of Nursing (DON), on 02/14/19 at 6:59 PM, revealed it was her expectation each resident would receive medications for the correct duration of time to ensure they did not receive unnecessary medication. The DON stated the Physician was to prescribe PRN psychotropic medications with a fourteen (14) day stop date or document rationale for extended use of the medication, as per regulation. Additional interview revealed she ensured the Consultant Pharmacist's recommendations were followed by completing audits monthly to compare the recommendations with the Physician's Orders. Per interview, if the Provider did not agree with the recommendation for a fourteen (14) day stop date for a PRN psychotropic medication, she checked to ensure the Physician had written a rationale. However, she stated her audit process missed Resident #94's PRN psychotropic medication order for eighty-four(84) days. Per interview, it was important to identify and report irregularities related to medications including PRN psychotropic medications to ensure residents were free of unnecessary medications due to the risk of adverse effects. Interview with the Administrator, on 12/14/19 at 7:24 PM, revealed she expected all psychotropic medications to be prescribed at the right duration. Per interview, the use of PRN psychotropic medications past fourteen (14) days should never happen. Further interview revealed she expected facility policy, procedure and regulations to be maintained related to PRN psychotropic medication duration to ensure residents received appropriate medication doses that were therapeutic and would not cause adverse side effects. Additional interview revealed the facility reviewed psychotropic drug use in daily morning meetings with the Interdisciplinary Team (IDT). Additional interview revealed if a problem was identified with any area a Plan of Action was initiated, however the IDT had not identified concerns related to excessive duration of PRN psychotropic medications. Further interview revealed she was uncertain how the IDT missed the identified concerns, and their audits would need to be changed.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals for three (3) of six (6) Medication Carts. Observation on 02/12/19, revealed the Medication Cart for rooms 116-130 contained a loose, unlabeled white pill in the medication drawer. In addition, observation on 02/13/19, revealed two (2) Medication Carts on Unit 2, each had one (1) unlabeled loose pill in the drawer. The findings include: Review of the facility Policy titled, Administering Medications revised December 2012, revealed nursing staff were required to check medication labeling prior to administration of any medication. The policy did not have guidelines for routine cleaning or monitoring of the Medication Cart to ensure all medications were properly labeled. Observation on 02/12/19 at 2:58 PM, revealed the Medication Cart for rooms 116-130 contained a loose, unlabeled white pill in the medication drawer. Interview with Licensed Practical Nurse (LPN) #2, on 02/12/19 at 2:58 PM, revealed staff took turns cleaning the Medication Carts; however, there was no set schedule. She stated if loose pills were found, they were to be discarded because the medications were unlabeled and not safe to administer. She further stated unlabeled loose pills should not be on the Carts. Observation on 02/13/19 at 1:27 PM, revealed two (2) Medication Carts on Unit 2, each had one (1) unlabeled loose pill in the drawer. Interview with LPN #1, on 02/14/19 at 11:18 PM, revealed Medication Carts were cleaned at the end of each shift. She stated night shift did a more thorough check of Medication Carts. LPN #1 stated unlabeled, loose pills were discarded and not administered because the identity of the medication was unknown. Interview with the Unit Manager on 02/14/19 at 2:12 PM, revealed each nurse was responsible for keeping the Medication Carts in order. He stated the night shift nursing staff cleaned the Medication Carts. The Unit Manager stated loose pills were unlabeled and unsafe to administer. He stated any unlabeled, loose pills were always discarded. Interview with the Director of Nursing (DON), on 02/14/19 at 4:05 PM, revealed Medication Carts were to be cleaned weekly by the night shift nursing staff. The DON stated it was her expectation for for staff to discard any loose pills found in the Carts. She stated no unlabeled medications were administered to residents as this was a safety issue. Interview with the Administrator, on 02/14/19 at 4:05 PM, revealed she concurred with the Director of Nursing. Per interview, nursing staff was responsible for the proper upkeep of Medication Carts. She stated all medications were to be properly labeled and stored, and any unlabeled medications were to be discarded and not administered to residents to ensure resident safety.

Based on interview, record review, and review of facility Policies, it was determined the facility failed to establish an infection prevention and control program (IPCP) that included an annual review of its IPCP in order to update their program as necessary. The facility was unable to submit documented evidence its IPCP and infection control policies were reviewed annually. The findings include: Interview on 02/14/19 at 3:09 PM, with the Director of Nursing (DON)/ Infection Control Preventionist (ICP), revealed the facility relied on the Med-Pass publications titled Nursing Services Managing Infections Policy and Procedure Manual for Long-Term Care and the Nursing Services Infection Control Procedure Manual for Long-Term Care. Review of the Med Pass Nursing Services Infection Control Policy and Policy Procedure Manual for Long -Term Care used by the facility, revealed the last revision was July 2017. The Manual contained twenty- two (22) policies. Although each policy had an individual revision date, all revisions had occurred more than twelve (12) months ago. No annual review dates were present. The Policy titled Blood or Body Fluids Exposure was revised in July 2016, and no review dates were present after the 2016 revision date. Review of the Med Pass Nursing Services Managing Infections Policy and Procedure Manual for Long-Term Care used by the facility, revealed a revision date of April 2018; however, the infection control policies within the Manual had revision dates not consistent with annual review dates. The Manual contained twenty- one (21) policies. Two (2) policies in the Manual had revision dates less than twelve (12) months old. All other policies had revision dates more than twelve (12) months ago with no review dates present. The Policy titled Healthcare-Associated Infections, Identifying was last revised in September 2017 with no review date noted. The Policy titled, Isolation-Categories of Transmission-Based Precautions was revised in January 2012, with no annual review date. Review of the Facility Assessment Tool, dated 08/18/17, revealed the facility routinely cared for residents with infectious diseases to include Skin and Soft Tissue Infections, Respiratory Infections, Urinary Tract Infections (UTIs), infections with Multi-Drug Resistant Organisms, Septicemia, Viral Hepatitis, Influenza, and Clostridium Difficile (C Diff). Prevention and management of infections was noted as a service provided by the facility. Interview with the Director of Nursing (DON,) on 02/14/19 at 3:09 PM, revealed she served as the Infection Control Preventionist for the facility. The DON stated she did not have an annual infection control program and infection control policy review process in place, but she would need to initiate an annual review process in the upcoming year. Interview with the Administrator, on 02/14/19 at 4:07 PM, revealed the DON served as the Infection Control Preventionist for the facility. The Administrator stated the DON worked on a collaborative basis with her to ensure the facility managed infection issues in accordance with accepted standards. Per interview, review of the infection control program and infection control policies was important for keeping pace with current practice, and she would ensure annual reviews of the IPCP and infection control policies were completed in the future.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #86's clinical record revealed the facility admitted the resident on 02/02/17 with diagnoses to include Unspecified Dementia without Behavioral Disturbance, Alzheimer's disease, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #86's Annual MDS Assessment, dated 01/11/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status Score (BIMS) of three (3) out of fifteen (15), which indicated severe cognitive impairment. Observation on 02/13/19 at 08:40 AM, revealed KMA #1 administered medications as SRNAs prepared and delivered breakfast plates from the delivery cart to the resident tables. Further observation revealed KMA #1 was at the medication cart located just outside of the room, preparing resident medications (orange-colored liquid poured in to one medication cup and several various-colored tablets placed in another medication cup). Continued observation revealed KMA #1 walked across the dining room and up to the State Agency Representative with medication cups in hand. KMA #1 asked the State Agency Representative if she could administer medications to Resident #86. The State Agency Representative explained no advice could be provided during the survey process and suggested KMA #1 follow her usual routine or seek guidance from her Charge Nurse or Unit Manager. Additional observation revealed KMA #1 sat down at the dining table next to Resident #86, explained to resident the medications he/she was provided, and gave instructions to take the medications, in the presence of other residents at the dining table. KMA #1 continued to sit with Resident #86, until the medications were consumed. Interview with KMA #1, on 02/13/19 at 09:00 AM, revealed she had been employed with the facility for the last eight (8) years and worked full-time on day shift from 06:30 AM-03:00 PM. KMA #1 revealed she was familiar with Resident #86's care as she was assigned to the Reflections Community (unit on which resident resides) frequently. KMA #1 stated she was unsure as to whether or not she could administer resident medications during meal service, but she administered the medicines to prevent being late on the morning medication pass. Further interview with KMA #1, revealed she believed she could administer Resident 86's medications without penalty because the resident had not yet received his/her meal tray. Continued interview with the KMA, revealed she should have requested the resident accompany her to the resident's personal bedroom or other private area to take his/her medications because this was a privacy/dignity issue and violated the resident's rights. Additional interview revealed medications administered during meal service could deter the resident from eating. KMA #1 advised in the future medications would be administered to residents in a more private manner to maintain the resident's privacy and dignity and to prevent the potential for other residents, staff not providing care to the residents and visitors from learning about the resident's medications and medical conditions. Interview with LPN #7, on 02/13/19 at 10:07 AM, revealed she had been employed with the facility for five (5) years and served as the charge nurse for The Reflections Community on 02/13/19. LPN #7 stated she was familiar with Resident #86's care. Further interview revealed she was not sure of the facility's policy regarding medication administration during meal service. LPN #7 stated, We have a little more [NAME]-way with medication administration on this unit due to the nature of the cognitive status of the population we provide care for. However, she stated it was a dignity violation to administer medication in the dining room area while telling the resident about each of the medications in the presence of other residents and staff who were not providing care to the resident. Additional interview revealed she and other staff on The Reflections Community have and do administer resident medications during meal service because of the residents we provide care for. Interview with Registered Nurse (RN) #1, on 02/14/19 at 02:35 PM, revealed she had been employed with facility for two (2) years and was the Charge Nurse for the Reflections Community on 02/14/19. Further interview revealed she was familiar with Resident #86's care. RN #1 stated facility policy prevented staff from administering medications during meal service as this was a dignity issue and also violated the resident's rights to privacy and confidentiality. Continued interview revealed staff should always administer medications in a private setting, in either the resident's room or other private location. RN #1 continued by stating, If we administered medications at the dining room table and tell the resident the medications we are administering, anyone can hear that information. That is a confidentiality violation as well as a dignity issue. We are here to protect that information. It doesn't matter what unit the resident lives on or the resident's cognitive status, it remains the same for all the residents. Per interview, the policy and regulations were the same, and staff should not interfere with a resident's meal service to administer their medications. Interview with Unit Manager (UM)#3, of the Reflections Community 300 and 400 Units on 02/14/19 at 02:46 PM, revealed it was unacceptable to administer a resident's medication in a public area and staff was aware of this. Continued interview revealed medications were to be administered to residents in a private location to maintain residents' privacy and dignity. Additional interview revealed it was preferable to administer medications in a resident's personal bedroom or other private location with no exceptions unless a Physician's Order was written for medication to be given with food. UM #3 added, We want to maintain our residents' dignity and privacy, regardless of the resident's cognition. Per interview, the policy and the regulation was the same throughout the facility, regardless of the resident's condition or mental status. Interview with the Director of Nursing (DON), on 02/14/19 at 05:28 PM, revealed it was her expectation staff treat all residents with dignity and respect while maintaining their privacy and confidentiality. Continued interview revealed she expected staff to administer resident medication as per Physician's Orders and in a private location within the facility. The DON further stated medications were not to be administered during meal service times unless otherwise specified by a Physician's Order, adding this violated the resident's rights for an exceptional dining experience and a dignified existence. Additional interview revealed medication administration during the resident's meal service was a resident rights/dignity issue and was unacceptable. Interview with the Administrator, on 02/14/19 at 06:13 PM, revealed it was her expectation staff treat residents with dignity and respect and administer medications as ordered in a private location on the unit. Further interview revealed she expected staff to not interrupt the resident's dining experience when administering medications unless otherwise specified by a Physician's Order, as this was a respect and dignity issue. Continued interview revealed she expected staff to maintain all resident rights to dignity and privacy while providing quality of care to each of the residents residing in the facility. 3. Review of Resident #3's medical record revealed the facility admitted the resident on 09/22/15 with diagnoses to include Unspecified Dementia without Behavioral Disturbance, History of Falling, and Flaccid Hemiplegia Affecting Left Nondominant Side. The facility assessed Resident #3, in a 02/01/19 Quarterly Minimum Data Set (MDS) as having a Brief Interview for Mental Status (BIMS) of a thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Review of the [NAME] Reports, detailing wait times for call bells to be answered from 01/09/19 through 01/31/19, revealed multiple incidents of wait times in excess of fifteen (15) minutes for Resident #3 to include the following. 01/09/19 at 7:28 PM, Resident #3 waited 30 minutes and 9 seconds for staff to respond. 01/09/19 at 9:28 PM, Resident #3 waited 27 minutes and 43 seconds for staff to respond. 01/09/19 at 10:17 PM, Resident #3 waited 27 minutes and 18 seconds for staff to respond. 01/10/19 at 11:08 AM, Resident #3 waited 30 minutes and 7 seconds for staff to respond. 01/10/19 at 5:41 PM, Resident #3 waited 29 minutes and 36 seconds for staff to respond. 01/14/19 at 12:48 PM Resident #3 waited 30 minutes and 6 seconds for staff to respond. 01/14/19 at 9:26 PM Resident #3 waited 20 minutes and 46 seconds for staff to respond. 01/15/19 at 5:11 PM Resident #3 waited 30 minutes and 6 seconds for staff to respond. 01/15/19 at 6:47 PM Resident #3 waited 18 minutes and 19 seconds for staff to respond. 01/15/19 at 9:36 PM Resident #3 waited 26 minutes and 20 seconds for staff to respond. 01/19/19 at 10:59 PM Resident #3 waited 18 minutes and 34 seconds for staff to respond. 01/21/19 at 4:25 PM Resident #3 waited 24 minutes and 24 seconds for staff to respond. 01/22/19 at 8:12 PM Resident #3 waited 18 minutes and 29 seconds for staff to respond. 01/23/19 at 4:32 AM Resident #3 waited 30 minutes and 6 seconds for staff to respond. 01/23/19 at 7:18 AM Resident #3 waited 20 minutes for staff to respond. 01/23/19 at 11:01 AM Resident #3 waited 50 minutes and 47 seconds for staff to respond. 01/25/19 at 8:29 AM Resident #3 waited 26 minutes and 40 seconds for staff to respond. 01/25/19 at 9:56 PM Resident #3 waited 22 minutes and 38 seconds for staff to respond. 01/26/19 at 9:09 AM Resident #3 waited 29 minutes and 23 seconds for staff to respond. 01/27/19 at 7:26 PM Resident #3 waited 18 minutes and 58 seconds for staff to respond. 01/28/19 at 7:40 PM Resident #3 waited 19 minutes and 52 seconds for staff to respond. 01/31/19 at 7:13 PM Resident #3 waited 30 minutes and 7 seconds for staff to respond. 01/31/19 at 9:11 PM Resident #3 waited 30 minutes and 8 seconds for staff to respond. Interview with Resident #3, on 02/13/19 at 3:16 PM, revealed he/she was being treated for an active infection, and was felt somewhat confused related to the infection. When asked about call lights, Resident #3 stated Medical, very medical yesterday, but the resident was unable to answer questions related to the call light response times. Interview on 02/14/19 at 3:59 PM, with SRNA #12, revealed Resident #3 required total care, and had a touch-sensitive call light because of problems with his/her hands. SRNA #12 revealed Resident #3 would use his/her call light if he/she wanted a sip of water, and would not ring the call bell for much of anything else. SRNA #12 stated if she was busy with another resident, she couldn't always answer the call lights quickly. She stated a lot of times multiple call lights would ring at the same time, with four (4) or five (5) call lights sometimes going off at once. She stated she believed over half the residents on the 200 Unit required the assist of two (2) staff for Activities of Daily Living (ADLs). 4. Review of Resident #11's medical record revealed the facility admitted the resident on 02/25/13 with diagnoses to include Difficulty in Walking, Chronic Kidney Disease Stage 3, and Anxiety Disorder. The facility assessed Resident #11 in a Significant Change MDS assessment dated [DATE] as having a BIMS score of seven (7) out of fifteen (15), indicating severe cognitive impairment. Review of the [NAME] Report, detailing wait times from 01/09/19 through 01/31/19, revealed multiple incidents of wait times in excess of fifteen (15) minutes for Resident #1 to include the following: 01/10/19 at 5:15 PM Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/10/19 at 6:41 PM Resident #11 waited 18 minutes and 37 seconds for staff to respond. 01/10/19, at 10:05 PM, Resident #11 waited 30 minutes and 8 seconds for staff to respond. 01/11/19 at 2:33 AM, Resident #11 waited 30 minutes and 8 seconds for staff to respond. 01/11/19 at 9:48 AM, Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/11/19 at 11:52 AM, Resident #11 waited 30 minutes and 8 seconds for staff to respond. 01/11/19 at 12:22 PM, Resident #11 waited 1 hour, 30 minutes, and 24 seconds for staff to respond. 01/11/19 at 4:11 PM, Resident #11 waited 20 minutes and 30 seconds for staff to respond. 01/11/19 at 5:36 PM, Resident #11 waited 22 minutes and 25 seconds for staff to respond. 01/11/19 at 7:25 PM, Resident #11 waited 1 hour, 30 minutes, and 27 seconds for staff to respond. 01/11/19 at 9:48 PM, Resident #11 waited 23 minutes and 37 seconds for staff to respond. 01/12/19 at 2:49 PM, Resident #11 waited 27 minutes and 1 second for staff to respond. 01/12/19 at 5:14 PM, Resident #11 waited 18 minutes and 17 seconds for staff to respond. 01/13/19 at 2:01 PM, Resident #11 waited 16 minutes and 59 seconds for staff to respond. 01/14/19 at 7:56 AM, Resident #11 waited 30 minutes and 9 seconds for staff to respond. 01/14/19 at 10:28 PM, Resident #11 waited 25 minutes and 3 seconds for staff to respond. 01/15/19 at 9:03 AM, Resident #11 waited 26 minutes and 8 seconds for staff to respond. 01/15/19 at 10:10 AM, Resident #11 waited 25 minutes and 17 seconds for staff to respond. 01/15/19 at 5:04 PM, Resident #11 waited 47 minutes and 9 seconds for staff to respond. 01/15/19 at 6:38 PM , Resident #11 waited 30 minutes and 7 seconds for staff to respond. 01/15/19 at 7:49 PM, Resident#11 waited 19 minutes and 52 seconds for staff to respond. 01/15/19 at 9:46 PM, Resident #11 waited 21 minutes and 16 seconds for staff to respond. 01/16/19 at 2:34 AM, Resident #11 waited 19 minutes and 32 seconds for staff to respond. 01/16/19 at 5:34 AM, Resident #11 waited 46 minutes and 31 seconds for staff to respond. 01/16/19 at 9:11 AM, Resident #11 waited 17 minutes and 4 seconds for staff to respond. 01/16/19 at 11:45 AM, Resident #11 waited 26 minutes and 37 seconds for staff to respond. 01/17/19 at 3:36 AM, Resident #11 waited 26 minutes and 55 seconds for staff to respond. 01/17/19 at 7:13 AM, Resident #11 waited 25 minutes and 20 seconds for staff to respond. 01/17/19 at 6:39 PM, Resident #11 waited 16 minutes for staff to respond. 01/17/19 at 8:53 PM, Resident #11 waited 23 minutes and 58 seconds for staff to respond. 01/17/19 at 9:54 PM, Resident #11 waited 22 minutes and 49 seconds for staff to respond. 10/17/19 at 10:17 PM, Resident #11 waited 30 minutes and 5 seconds for staff to respond. 01/18/19 at 10:16 AM, Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/18/19 at 7:08 PM, Resident #11 waited 30 minutes and 8 seconds for staff to respond. 01/18/19 at 10:53 PM, Resident #11 waited 18 minutes and 21 seconds for staff to respond. 01/19/19 at 3:19 AM, Resident #11 waited 25 minutes and 44 seconds for staff to respond. 01/19/19 at 9:06 AM, Resident #11 waited 16 minutes and 28 seconds for staff to respond. 01/19/19 at 7:38 PM, Resident #11 waited 26 minutes and 34 seconds for staff to respond. 01/19/19 at 9:05 PM, Resident #11 waited 27 minutes and 52 seconds for staff to respond. 01/20/19 at 7:17 PM, Resident #11 waited 24 minutes and 21 seconds for staff to respond. 01/20/19 at 8:32 PM, Resident #11 waited 30 minutes and 5 seconds for staff to respond. 01/21/19 at 4:39 PM, Resident #11 waited 18 minutes and 51 seconds for staff to respond. 01/22/19 at 2:29 PM, Resident#11 waited 24 minutes and 9 seconds for staff to respond. 01/22/19 at 5:10 PM, Resident #11 waited 59 minutes and 56 seconds for staff to respond. 01/22/19 at 8:17 PM, Resident #11 waited 1 hour and 13 seconds for staff to respond. 01/22/19 at 9:44 PM, Resident #11 waited 16 minutes and 27 seconds for staff to respond. 01/21/19 at 2:57 PM, Resident #11 waited 30 minutes and 7 seconds for staff to respond. 01/21/19 at 4:00 PM, Resident #11 waited 30 minutes and 8 seconds for staff to respond. 01/21/19 at 9:08 PM, Resident #11 waited 52 minutes and 11 seconds for staff to respond. 01/24/19 at 7:57 AM, Resident #11 waited 30 minutes and 7 seconds for staff to respond. 01/24/17 at 10:07 AM, Resident #11 waited 23 minutes and 20 seconds for staff to respond. 01/24/19 at 1:24 PM, Resident #11 waited 1 hour and 11 seconds for staff to respond. 01/24/19 at 3:04 PM, Resident #11 waited 1 hour, 50 minutes and 11 seconds for staff to respond. 01/25/19 at 9:00 AM, Resident #11 waited 25 minutes and 29 seconds for staff to respond. 01/25/19 at 11:23 AM, Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/25/19 at 2:27 PM, Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/25/19 at 3:21 PM, Resident #11 waited 15 minutes and 58 seconds for staff to respond. 01/25/19 at 6:15 PM, Resident #11 waited 17 minutes and 1 second for staff to respond. 01/25/19 at 6:58 PM, Resident #11 waited 1 hour and 18 seconds for staff to respond. 01/26/19 at 4:59 AM, Resident #11 waited 26 minutes and 38 seconds for staff to respond. 01/27/19 at 1:57 AM, Resident #11 waited 17 minutes and 56 seconds for staff to respond. 01/28/19 at 5:30 PM, Resident #11 waited 30 minutes and 7 seconds for staff to respond. 01/29/19 at 2:11 AM, Resident #11 waited 22 minutes and 9 seconds for staff to respond. 01/29/19 at 5:01 AM, Resident #11 waited 30 minutes and 7 seconds for staff to respond. 01/29/19 at 5:02 PM, Resident #11 waited 30 minutes and 6 seconds for staff to respond. 01/30/19 at 9:58 AM, Resident #11 waited 22 minutes and 3 seconds for staff to respond. 01/30/19 at 5:06 PM, Resident#11 waited 16 minutes and 44 seconds for staff to respond. 01/30/19 at 6:01 PM, Resident #11 waited 17 minutes and 23 seconds for staff to respond. 01/31/19 at 5:08 AM, Resident #11 waited 23 minutes and 45 seconds for staff to respond. 01/31/19 at 7:02 AM, Resident #11 waited 15 minutes and 58 seconds for staff to respond. 01/31/19 at 2:48 PM, Resident #11 waited 22 minutes and 56 seconds for staff to respond. 01/31/19 at 6:32 PM, Resident #11 waited 19 minutes and 15 seconds for staff to respond. Interview on 02/14/19 at 3:36 PM, with SRNA #5, revealed Resident #11 had many request when using his/her call light. Per interview, the resident usually requested a new cup of water, incontinence care, blankets to be adjusted or the bed to be moved up or down. SRNA #5 further stated Resident #11 required the assist of two (2) staff for incontinence care as he/she was no longer able to be toileted due to a decline. Further interview revealed residents had to wait longer than fifteen (15) minutes at times for the call bell to be answered because staff were busy showering residents or performing incontinence care for residents. Interview on 02/13/19 at 4:02 PM with SRNA #1, revealed she worked on Unit 2, and there was usually between four (4) and five (5) aides on the unit, a charge nurse, and at least one (1) nurse and one (1) Kentucky Medication Associate (KMA) on day shift. SRNA #1 stated Resident #11 did ring his/her call light a lot, often to request incontinence care. Further interview revealed she tried to answer call lights in under twenty (20) minutes. She further stated Resident #11 had informed her it sometimes took thirty (30) minutes before staff could answer his/her call light. Continued interview revealed when a resident rang the call light, aides on the unit were alerted by pager, whether assigned to the resident or not. She stated, after ten (10) minutes the pager would alert the nurses working the medication carts. She revealed all resident on Unit 2 except one (1) resident required the assist of two (2) staff to provide care. 5. Review of Resident #50's medical record revealed the facility admitted the resident on 04/30/18 with diagnoses to include Adult Failure to Thrive, Difficulty in Walking, and History of Falling. The facility assessed Resident #50, in a 12/19/18 Significant Change MDS Assessment, as having a BIMS score of four (4) out of fifteen (15) , indicating severe cognitive impairment. Review of the [NAME] Report from 01/09/19 through 01/31/19, revealed multiple incidents of wait times in excess of fifteen (15) minutes for Resident #50 including: 01/10/19 at 11:53 AM, Resident #50 waited 55 minutes and 5 seconds for staff to respond. 01/10/19 at 1:26 PM, Resident #50 waited for 1 hour, 57 minutes and 18 seconds for staff to respond. 01/10/19 at 8:22 PM, Resident #50 waited for 21 minutes and 31 seconds for staff to respond. 01/11/19 at 11:13 AM, Resident #50 waited for 1 hour, 30 minutes and 19 seconds for staff to respond. 01/11/19 at 7:02 PM, Resident #50 waited 1 hour and 16 seconds for staff to respond. 01/12/19 at 7:21 PM, Resident #50 waited 25 minutes and 2 seconds for staff to respond. 01/14/19 at 7:59 AM, Resident #50 waited 47 minutes and 40 seconds for staff to respond. 01/14/19 at 5:28 PM, Resident #50 waited 1 hour, 15 minutes and 22 seconds for staff to respond. 01/14/19 at 9:02 PM, Resident #50 waited 19 minutes and 1 second for staff to respond. 01/15/19 at 9:15 PM, Resident #50 waited 23 minutes and 24 seconds for staff to respond. 01/16/19 at 1:09 PM, Resident #50 waited 23 minutes and 1 second for staff to respond. 01/16/19 at 1:36 PM, Resident #50 waited 22 minutes and 48 seconds for staff to respond. 01/17/19 at 9:40 AM, Resident #50 waited 23 minutes and 32 seconds for staff to respond. 01 /17/19 at 1:20 PM, Resident #50 waited 16 minutes and 18 seconds for staff to respond. 01/17/19 at 3:32 PM, Resident #50 waited 21 minutes and 8 seconds for staff to respond. 01/18/19 at 9:58 AM, Resident #50 waited 30 minutes and 6 seconds for staff to respond. 01/19/19 at 9:59 AM, Resident #50 waited 17 minutes and 3 seconds for staff to respond. 01/19/19 at 8:40 PM, Resident #50 waited 19 minutes and 26 seconds for staff to respond. 01/20/19 at 8:35 PM, Resident #50 waited 20 minutes and 45 seconds for staff to respond. 01/21/19 at 10:25 AM, Resident #50 waited 52 minutes and 49 seconds for staff to respond. 01/21/19 at 8:35 PM, Resident #50 waited 17 minutes and 36 seconds for staff to respond. 01/22/19 at 8:31 PM, Resident #50 waited 15 minutes and 16 seconds for staff to respond. 01/23/19 at 6:57 AM, Resident #50 waited 21 minutes and 27 seconds for staff to respond. 01/23/19 at 9:16 AM, Resident #50 waited 26 minutes and 47 seconds for staff to respond. 01/24/19 at 10:10 AM, Resident #50 waited 15 minutes and 57 seconds for staff to respond. 01/25/19 at 6:04 AM, Resident #50 waited 29 minutes and 6 seconds for staff to respond. 01/25/19 at 9:03 AM, Resident #50 waited 46 minutes and 17 seconds for staff to respond. 01/25/19 at 10:24 AM, Resident #50 waited 1 hour and 16 seconds for staff to respond. 01/25/19 at 8:22 PM, Resident #50 waited 28 minutes and 8 seconds for staff to respond. 01/26/19 at 12:06 AM, Resident #50 waited 21 minutes and 43 seconds for staff to respond. 01/27/19 at 3:17 AM, Resident #50 waited 17 minutes and 3 seconds for staff to respond. 01/29/19 at 6:33 AM, Resident #50 waited 17 minutes and 12 seconds for staff to respond. 01/29/19 at 8:56 PM, Resident #50 waited 21 minutes and 8 seconds for staff to respond. 01/30/10 at 4:01 AM, Resident #50 waited 1 hour and 13 seconds for staff to respond. 01/30/19 at 10:43 AM, Resident #50 waited 25 minutes and 56 seconds for staff to respond. 01/30/19 at 4:52 PM, Resident #50 waited 30 minutes and 5 seconds for staff to respond. 01/31/19 at 7:31 AM, Resident #50 waited 1 hour and 12 seconds for staff to respond. 01/31/19 at 8:16 PM, Resident #50 waited 24 minutes and 39 seconds for staff to respond. Interview on 02/14/19 at 4:16 PM, with Licensed Practical Nurse (LPN) #6, revealed she worked on Unit 2 on this date, but had worked on every unit. She stated the SRNAs carried pagers that would alert them of a call light needing to be answered. Per interview, if the SRNA did not answer the call light within a certain amount of minutes, the pager would alert the charge nurses and unit managers as they also carried pagers. Further interview revealed there was a display screen in front of the nurse's station that would also alert staff to which call lights needed to be answered. LPN #6 revealed she and other staff answered call lights as promptly as they could, but staff prioritized call lights, with bathroom call lights having a higher priority typically than room call lights. She revealed, although their system did provide a more homelike environment than having alarms and lights going off on the unit, it could make it difficulty for staff to know when residents need assistance. She stated it was her perception the weakness in the call light system contributed to long response times for answering call lights. Interview on 02/14/19 at 4:30 PM with the Unit Manager for Unit 2, revealed if SRNAs did not respond to call lights in ten (10) minutes after the pager went off, the charge nurse on the unit and the Unit Manager would be alerted of the call lights per their pagers. Per interview, if the call light was not answered in twenty (20) minutes, the DON was alerted of the call light by pager, and after a total of thirty (30) minutes of the call light not being answered, the Administrator was alerted. Further interview revealed she received a copy of the [NAME] Report every day in morning meeting, and had conducted many inservices when there were longer call light response times. She stated many residents on Unit 2 required two (2) person assist, and staff were usually in with another resident when call lights went off. Per interview, the SRNAs had a long call light form to complete with explanation when there were long response times, with the most common explanation that they were taking care of another resident, or forget to turn the call lights off. Further interview revealed call light response time was an ongoing problem. Interview on 02/14/19 at 1:50 PM with Director of Nursing, revealed, it was her expectation for the staff to answer the call bells as timely as possible. Per interview, when a resident pushed the call light, the SRNA was alerted per the pager, then five (5) minutes later if the call light was not answered, the charge nurse would be alerted by pager, then five (5) minutes later the Unit Manager would be alerted by pager. She further stated if the Unit Manager did not answer the call light, then five (5)minutes later the DON would be alerted of the call light through the pager, and then the Administrator. Per interview, this was all within a twenty (20) minute period. Per interview, the pager was unit specific and was programmed for the specific unit. She stated she printed off the [NAME] Reports five (5) days a week; and distributed them to the Unit Managers during the morning meeting. Further interview revealed the Unit Managers should be talking to the residents and the staff when there were concerns with call light response times and the Unit Managers should also be educating staff related to the need to ensure the the call light was answered timely. Further interview revealed all staff could answer call lights and and it was unacceptable for staff to be walking up and down the hallways past a resident who had pushed a call light , or sitting at the nurse's station and not answering a call light. Interview on 02/14/19 at 6:11 PM, with the Administrator, revealed it was her expectation call lights were answered as quickly as possible, with a guideline of within fifteen (15) minutes. She stated she did not have a pager, but received an email if call lights went off over thirty (30) minutes. She stated she had not received many emails related to the call lights, possibly due to a a glitch in the system. Continued interview revealed a [NAME] Report was run each day through the week and brought to the morning meetings, and each Unit Manager received a copy to review. She further stated the facility conducted call light audits in the past when there was a concern noted with call lights not being answered timely. Further interview revealed staff had received many inservices related to the need to answer call lights quickly. She revealed long wait times concerned her, and she was not aware of the volume of long wait times identified by the surveyor from the [NAME] Report in January 2019. She stated she attributed a lot of the problem to the system, as not everyone was aware of or answering call lights. She stated she did not feel there was a staffing issue, as staffing patterns were higher at the facility than at any facility she had previously worked. Based on observation, interview, and record review, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for six (6) of twenty-six (26) sampled residents (Resident #3, Resident #11, Resident #50, Resident #87, Resident #99, and Resident #108). Review of the Situational Awareness and Response Assistant ([NAME]) Reports, detailing wait times for call lights to be answered from 01/09/19 through 01/31/19, revealed residents consistently had to wait long periods of time for the call light to be answered, and in some cases up to fifty-nine (59) minutes. In addition, residents complained of having to wait long periods of time for the call lights to be answered. In addition, observation on 02/13/19, revealed Kentucky Medication Aide (KMA #1) administered medication to Resident #86 in the dining room during morning meal service. The findings include: Review of the facility's Policy, titled Resident Rights, revised August 2009, revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Further review of the Policy, revealed demeaning practices and standards of care that compromise dignity are prohibited. 1. Review of Resident #99's medical record revealed the facility originally admitted the resident on 04/24/13 with diagnoses including Major Depressive Disorder, Dementia without Behavioral Disturbance, Personality Disorder, Anxiety Disorder, Disc Degeneration, Urinary incontinence, Physical Debility, Rhabdomyolysis, Chronic Pain, Dysphagia, and Difficulty walking. Review of Resident #99's Quarterly Minimum Data Set (MDS) Assessment, dated 01/18/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating resident was cognitively intact. Observation on 02/13/19 at 10:15 AM, revealed Resident #99 was lying in bed asking for ice water. The resident had his/her call light on and stated he/she had been waiting for someone to answer the call light for twenty (20) minutes. Further observation revealed staff were walking up and down the hallway outside of the resident's room, and staff were sitting at the nurse's station while this residents call light was on. Interview with the resident at the time of observation revealed, they are ignoring me because I complain a lot. Per interview, he/she always had to wait a long time for the call light to be answered, and it usually took twenty (20) to thirty (30) minutes for the call light to be answered. After ten (10)minutes of observing staff failing to answer the resident's call light, the State Agency Representative went to the nurse's station to inform staff the resident was requesting ice water. Review of the Situational Awareness and Response Assistant ([NAME]) Reports, detailing wait times for call lights to be answered from 01/09/19 through 01/31/19, revealed an average wait time

Based on observation, interview, record review and review of facility Policy, it was determined the facility failed to ensure the residents environment remained as free of accidents and hazards and risks as is possible and residents receive adequate supervision and assistive devices to prevent accidents for four (4) of twenty six (26) sampled residents (Resident #52, #71, #84, and #94). On 02/12/19, Resident #71 was observed in the Beauty Shop, under a running hair dryer while oxygen was being administered at three (3) liters per minute per nasal cannula and a portable oxygen tank. Staff failed to ensure the resident's oxygen tank was removed from his/her wheelchair prior to the resident being escorted to the Beauty Shop. Although the Beautician was in the Beauty Shop and had curled the resident's hair and placed the resident under the hair dryer, she had not noticed the resident was receiving oxygen. In addition, on 02/07/19, Resident #94 was identified to have discoloration and slight edema to the left great toe, and X-rays results dated 02/08/19, revealed the resident had an acute fracture to the left second toe. However, there was no documented evidence the facility conducted an investigation in order to identify the root cause of the injury and to identify hazards and risks in the environment in order to implement a specific intervention to prevent further accidents. Also, on 10/08/18, Resident #52 was identified to have a large bruise across the left great toe. However, there was no documented evidence the facility conducted an investigation in order to identify the root cause of the bruise or made an effort to identify hazards and risks in the environment or implement a specific intervention to prevent further accidents. Furthermore, on 11/19/18, Resident #84, had an unwitnessed fall from the bed. A new targeted fall intervention based on the root cause of the accident, to prevent fall events of the same nature was not developed or implemented after the 11/19/18 fall. Subsequently, the resident had an additional unwitnessed fall from the bed on 11/21/18. The findings include: 1. Review of the facility's Policy titled, Oxygen Administration, undated, revealed the purpose of this procedure is to provide guidelines for safe oxygen administration. Step #4 stated, remove all potentially flammable items (lotions. Oils, alcohol, smoking articles, etc.) from immediate area where oxygen is to be administered. Review of the Manufacturer's Instructions for the facility Beauty Shop Hair Dryer, revealed a Warning which stated: to reduce risk of burns, electrocution, fire or injury to persons, use this hair dryer only for intended use as described in this manual. Do not use attachments not recommended by the manufacturer. There was no oxygen warning noted. Review of Resident #71's medical record revealed the facility admitted the resident on 05/08/16 with diagnoses of Type 2 Diabetes Mellitus, Low Back Pain, Nonrheumatic Mitral Valve Prolapse, Chronic Pulmonary Embolism, and Osteoarthritis of the Knee. Review of the Comprehensive Care Plan, dated 05/26/16, revealed the resident had a need for oxygen related to altered respiratory function. The goal stated the resident would maintain oxygen saturation greater than ninety percent (90%). The interventions included: administer oxygen as ordered and educate resident/staff visitors about use of oxygen therapy as needed. Review of Resident's #71 Minimum Data Set (MDS) Assessment, dated 01/04/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a three (3) out of fifteen (15) indicating severe cognitive impairment. Review of the February 2018 Monthly Physician's Orders, revealed orders for oxygen at three (3) liters per minute per nasal cannula. There was no documented evidence of Physician's Orders related to removal of the oxygen prior to the resident being escorted to the Beauty Shop. Observation on 02/12/19 at 10:21 AM, revealed Resident #71 was seated in the wheelchair under the hard plastic, helmet-type hair dryer in the Beauty Shop. Oxygen was infusing, per nasal cannula tubing and a portal oxygen tank at three (3) liters per minute. The Director of Nursing (DON) was immediately informed of the observation on 02/12/19 at 10:25 AM, by the State Survey Representative, and the DON had the oxygen tank removed from the Beauty Shop. Post exit phone interview with the facility Beautician, on 02/28/19 at 8:20 AM, revealed she had been a Beautician for twenty eight (28) years, and had been contracted with the facility since 2011. Per interview, she worked at the facility on Tuesdays and Wednesdays of each week. The Beautician stated she provided each unit with a list of resident who were to have their hair done that day, and called the unit when she was ready for the residents. Per interview, nursing staff was responsible for escorting residents to the salon. She stated oxygen was not allowed in the salon and there was a sign on the Beauty Shop door regarding no oxygen usage. Continued interview revealed when she signed her contract with the facility, she was educated on safety and hazards of oxygen usage in the salon. She further stated she had been educated by the facility every year during annual compliance training related to oxygen not being allowed in the salon, and also during the safety meetings. Further interview with the facility Beautician, revealed she did not know who escorted Resident #71 to the salon on 02/12/19. She stated she had stepped away to the restroom and when she returned she did not notice the resident's oxygen. She stated the resident had received a shower prior to coming to the salon and she did not have to wash the resident's hair, but just had to roll his/her hair. The Beautician stated she put Resident #71 under the dryer that day and still did not notice the oxygen. She further stated a resident with an oxygen tank on the wheelchair had never entered the Beauty Shop before this incident, and if this happened again she would have the resident escorted back to the unit for the nurse to remove the oxygen. Per interview, the facility educated her again related to oxygen not being allowed in the Beauty Shop, after the incident on 02/12/19, Interview with Licensed Practical Nurse (LPN) #2, on 02/14/19 at 8:31 AM, revealed she had worked at the facility since October of 2018 on day shift, and was familiar with Resident #71. Per interview, Resident #71 was to have oxygen on at three (3) liters continuously. Further interview revealed the resident went to the Beauty Shop once a week, and sometimes the Beautician would come get the resident or one of the nursing staff members would take the resident to the Beauty Shop. LPN #2 stated she was unaware of who transported Resident #71 to the Beauty Shop on Tuesday of this week. LPN #2 further stated she did not know the rules related to oxygen usage in the Beauty Shop, and did not recall being in-serviced regarding this. Continued interview revealed all employees needed to know how to use oxygen safely. Interview was conducted on 02/14/19 at 8:40 AM, with the Unit Manager (UM) of Unit 1, which was the unit where Resident #71 resided. He stated he had been employed at the facility since May 2018. Per interview Resident #71 was on palliative care, and had orders for oxygen per nasal cannula continuously. The UM further stated it was staff's responsibility to make sure the resident was accompanied to the Beauty Shop weekly; however, he was unaware of Beauty Shop rules regarding oxygen. The UM stated he was unaware of an order for the resident to be without his/her oxygen; however, he could see how the use of oxygen while sitting under the hair dryer could be cause for concern as oxygen was flammable. Interview with LPN #1 on 02/14/19 at 08:52 AM, revealed she had worked at the facility for about six (6) years and worked on Unit 1 as a charge nurse and was assigned to Resident #71. Per interview, Resident #71 was alert and oriented to self only and was ordered three (3) liters of oxygen continuous. LPN #1 further stated the resident went to the Beauty Shop every Tuesday, but oxygen was not permitted in the Beauty Shop as it could be a fire hazard. Continued interview revealed all staff were responsible for taking residents to the Beauty Shop, and the Beautician would call the unit and ask someone to bring the residents down. Per interview, sometimes a list was sent to the unit showing which residents were to go to the Beauty Shop that day. Further interview revealed the nurse would be responsible to remove the oxygen tank from Resident #71's wheelchair before the resident went to the Beauty Shop; however, she stated she was unaware of an order for the oxygen to be removed before the resident went to the beauty shop. LPN #1 stated she did not remember staff asking her to remove the oxygen tank from the resident's wheelchair on 02/12/19. LPN #1 further stated she was not aware that Resident #71 was in the Beauty Shop with oxygen in use until the DON brought it to her attention. LPN #1 further stated she was not aware of any training or in-service regarding oxygen usage in the Beauty Shop for nursing staff. Interview with State Registered Nurse Aide (SRNA) #11, on 02/14/19 at 9:05 AM, revealed she had worked at the facility since August 2018 and was assigned to Resident #71 on 02/12/19. Per interview, Resident #71 went to the Beauty Shop on Tuesdays after shower days. She stated any staff member could assist the resident to the Beauty Shop, but sometimes the resident's sitter would take him/her. Per interview, Resident #71 was ordered oxygen per nasal cannula, but was not supposed to go to the Beauty Shop with his/her oxygen on. SRNA #11 stated the nurses would take the oxygen off Resident #71's wheelchair prior to the resident being escorted to the Beauty Shop. SRNA #11 stated if a resident was in the Beauty Shop with oxygen on, it could blow up and cause harm to {her/him} and other residents. Continued interview revealed she knew there was a sign on the Beauty Shop door, stating, no oxygen in use in this area, because she paid attention to signs in the facility. However, SRNA #11 stated she had never been trained related to the need to take oxygen off of a resident's wheelchair before escorting them to the Beauty Shop and had not been educated related to oxygen not being permitted in the Beauty Shop. Interview with the Director of Nursing (DON), on 02/14/19 at 1:50 PM, revealed she had been employed at the facility a little over a year. The DON stated, usually the Beautician would call the unit and let staff know to bring a resident to the Beauty Shop. Per interview, it was the nurse's responsibility to remove the oxygen from the residents' wheelchair prior to staff escorting the residents to the Beauty Shop. Per interview, she was aware that sometimes Resident #71's sitter would escort the resident to the Beauty Shop; however, she was uncertain if the sitter knew the resident could not go to the Beauty Shop while on oxygen. The DON stated it was a major safety hazard for any resident to be in the Beauty Shop with oxygen in use because there was electronic gadgets in there that could cause combustion. Further interview revealed she was not sure if there was a Physician's Order for Resident #71 to be without oxygen long enough to go to the Beauty Shop. Additional interview revealed she was unsure if staff was in-serviced regarding the Beauty Shop rules; however, they needed to be aware of the dangers of allowing a resident to enter the Beauty Shop with oxygen in use. Interview with the Administrator, on 02/14/19 at 02:27 PM, revealed she had been employed at the facility in the role of Administrator for about two (2) years. She stated she was made aware of the oxygen incident in the Beauty Shop by the DON. She further stated Resident #71 should have had Physician's Orders in place indicating oxygen could be removed prior to Beauty Shop appointments and it was the nurse's responsibility to remove the oxygen prior to the resident being escorted to the salon. Further interview revealed oxygen use in inappropriate areas could be combustible and detrimental to residents and staff. The Administrator stated she in-serviced the Beautician that oxygen was not allowed in the Beauty Shop on 02/12/19, after the incident occurred with Resident #71. The Administrator further stated when she interviewed the Beautician related to the incident, she was told the resident's sitter escorted the resident to the Beauty Shop. Per interview, the sitter has not been back to the facility since this incident, but the sitter would be educated related to the need to ensure the nurse removed oxygen prior to a resident being escorted to the Beauty Shop. Continued interview revealed she had already started inservicing staff related to the need for the nurse to remove oxygen prior to a resident being escorted to the Beauty Shop, and that oxygen was not allowed in the Beauty Shop. She stated she would need to work closely with the Beautician to ensure procedure is followed. She further stated, our process is broken and we will get it fixed. Review of the facility's Accidents (F-323) Policy, dated May 2008, revealed the facility would provide an environment that was free from accident hazards and provide supervision and assistance to residents to prevent avoidable specific accidents. Additionally, all staff would be involved in the identification of hazards and risk in the environment, and a reasonable effort would be made to identify hazards and risk factors through environmental rounds. Continued review revealed the Interdisciplinary Team would Analyze and Evaluate hazards and risks and develop specific target interventions to reduce the potential for accidents. Per Policy, the specific interventions would be communicated to relevant staff and documented on the individual resident's Plan of Care. Further, the facility would monitor the interventions effectiveness and make modifications as indicated. Per Policy potential Resident/Environmentally based risk included: resident vulnerabilities; falls, and Assistive Device/Equipment Hazards; and devices for mobility and transfer. Review of the facility's Falls-Clinical Protocol Policy, dated 2001, revealed the facility staff would evaluate and document observations of falls events that occur while the resident was in the facility. Additional review revealed staff would re-evaluate the situation and reconsider possible reasons for the resident's falling and reconsider current interventions for individuals that continue to fall. Review of the facility's Falls and Fall Risk, Managing Policy, dated 2001, revealed staff would identify interventions related to the resident's specific risk and causes to prevent the resident from falling and to minimize complications from falling. Additionally, if falling recurs despite initial interventions, staff will implement different interventions or indicate why the current approach remains relevant. Further review revealed if underlying causes cannot be corrected, staff will try various interventions based on assessment of the nature of falling, until falling was reduced or stopped. Review of the facility's Assessing Falls and Their Causes Policy, dated 2001, revealed after a fall event, within twenty-four (24) hours of the fall event, causes to the incident should be identified and appropriate interventions taken to prevent future falls. 2. Review of Resident #94's medical record revealed the facility admitted the resident on 11/15/16 with diagnoses including Type II Diabetes, Major Depressive Disorder, Polyneuropathy, Hemiplegia affecting Right Dominate Side, Coronary Artery Disease, Heart Failure, Cerebral Vascular Accident (CVA), Muscle weakness, and Chronic Kidney Disease, Abnormal Posture. Review of the Accidents Comprehensive Care Plan (CCP), with an onset date of 11/28/16, revealed the resident had the potential for accidents, falls or injury related to Debility, Neuropathy, CVA, and psychotropic medication use. The goal stated the resident would have reduced risk for injury. Interventions included: educate about safety, ensure appropriate assistance was provided, and maintain environment free of clutter and safety hazards. Review of Resident #94's Quarterly Minimum Data Set (MDS) Assessment, dated 01/11/19, revealed the facility assessed the resident as having both short and long-term memory problems, and as having no mood or behavior issues. Additionally, the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, toileting and bathing; total assistance of two (2) staff for transfers; and total assistance of one (1) staff for locomotion. Further, the facility assessed the resident as not steady, as only able to stabilize with staff assistance during surface to surfaces transfers, and as having limitations in functional range of motion on one (1) side, upper and lower extremities. Further, per the MDS, the resident had no falls since the previous assessment. Review of Resident #94's Situation Background Assessment Recommendation (SBAR), dated 02/07/19 at 7:15 PM, revealed Resident #94 had a discoloration to the left lower extremity, lower shin and medial ankle which was a change in condition. Additional review revealed the Physician was notified and new orders were received for an X-ray. Review of the Progress Notes, dated 02/07/19 at 10:33 PM, revealed there was discoloration and slight edema noted to the left lower extremity and an X-ray was ordered. Review of Physician's Orders, dated 02/07/19, revealed orders for an X-ray to the left lower extremity, below the knee to bottom of foot related to discoloration and slight edema. Review of Resident #94's X-ray results, dated 02/08/19; revealed an acute fracture in the base of the left proximal phalanx of the second toe with soft tissue edema. Review of the Progress Note, dated 02/08/19 at 2:28 PM, revealed X-ray results were received and the Advanced Practice Registered Nurse (APRN) was notified and recommended the resident to see a specialist related to the fracture of the left second toe. Per the Note, the resident representative was notified. Review of a subsequent Progress Note, dated 02/08/19 at 8:27 PM, revealed there was no edema or bruising present to the resident's left second toe. Per the Note, the family spoke with the nurse and did not want the resident sent out to a specialist because they felt the fracture was old and not causing the resident any distress. Continued review of the medical record revealed there was no documented evidence of an Incident Report, witness statement, staff statements or an investigation in order to determine the root cause of the injury. Additional review of the Accidents CCP, revealed there was no revision to the CCP to include the incident/accident on 02/07/19 or a new intervention to prevent further occurrence of an injury of the same nature. (Refer to F-657) Interview with SRNA #16, on 02/14/19 at 4:26 PM, revealed Resident #94 required total assistance with Activities of Daily Living (ADLs). Additionally, the resident required two (2) staff to assist with transfers using a hoyer lift. Per interview, the resident had been leaning to the left recently, which was the resident's side not affected by the stroke. Continued interview revealed it was crowded in the resident's room. SRNA #16 stated this was due to the air mattress motor at the end of the bed, the wheelchair with leg and foot supports, the two (2) over bed tables requested by the family, the dresser, and the hoyer lift (mechanical lift). Per interview, the resident's roommate also had a wheelchair and recliner that crowded the room. SRNA #16 stated it was difficult to transfer the resident in the crowded room and the resident required two (2) staff for the transfer. Additionally, the SRNA #16 stated the resident's feet could be easily bumped on numerous things in the residents room during a transfer; however, she was careful with the resident's feet during transfers to ensure they were not bumped. Further interview with SRNA #16, revealed she was assigned to Resident #94, on 02/07/19. SRNA #16 stated while she was assisting the resident she noticed discoloration and swelling to the resident's left foot and reported it the nurse. Per interview, the nurse came and assessed the resident's foot. Additional interview, revealed when the resident was asked what happened, he/she stated he/she did not know. Per interview, she was not asked to write a statement. Interview with Licensed Practical Nurse (LPN) #6, on 02/14/19 at 5:27 PM, revealed Resident #94 required total assistance with all ADLs and had been progressively getting weaker, was not a good historian and his/her cognition waxed and waned. Additional interview revealed the resident required a hoyer lift for transfer. Per interview, the resident's room was a tight fit and cluttered with assistive devices and furniture. Further, a thorough investigation of accidents to determine the root cause of the injury was important. Per interview, the root cause of an injury assisted the staff with knowing what specific interventions could be implemented to ensure the resident's environment was safe and the accident did not occur again. Interview with Unit 2 Manager, on 02/14/19 at 6:05 PM, revealed she assessed Resident #94's left foot and completed the SBAR on 02/07/19. Per interview, there was no edema or discoloration to the left foot; and only darkened skin was noted to the resident's lower legs, which appeared to be vascular in nature. Additional interview revealed the root cause of the injury should have been determined at the time the change in the left lower extremity was initially identified. Further, an Incident Report, staff and resident statements, and an assessment of the resident, and the environment should have been documented and reviewed to determine the root cause of the injury. Per interview, an investigation related to the resident's injury should have been completed and a necessary intervention should have been implemented to reduce the risk of further injury or accident. 3. Review of Resident #52's medical record revealed the facility admitted the resident on 12/21/16 with diagnoses including Type II Diabetes, Unspecified Dementia, Major Depressive Disorder, Epilepsy, Hemiplegia affecting left dominant side, Chronic Atrial Fibrillation, Cerebral Vascular Accident (CVA), Polyarthritis, Osteoporosis, Abnormal Posture, and weakness. Review of the Quarterly MDS Assessment, dated 09/21/18, revealed the facility assessed the resident as having a BIMS score of one (1), out of fifteen (15), indicating severe cognitive impairment. Additional review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfers and toileting, and total assistance of one (1) staff for locomotion, bathing, dressing, and personal hygiene. Per the MDS, the resident was not steady, was only able to stabilize with staff assistance during surface-to-surface transfers and had no limitations in Range of Motion. Further review revealed the facility assessed the resident as having no falls since the previous assessment, and as receiving seven (7) days of Anticoagulant medication. Review of Resident #52's Accidents Comprehensive Care Plan (CCP), with an onset date of 01/03/17, revealed the resident had the potential for accidents, falls or injuries related to CVA with Hemiplegia, Dementia, Seizure Disorder, Ataxia, Polyarthritis, Incontinence, Malaise, and Psychotropic medication use. The goal stated the resident would have reduced risk for injury. Interventions included: educate staff about safety, ensure appropriate assistance; ensure resident's environment was free of clutter and safety hazards; and no tight foot wear per podiatry. Review of Resident #52's October 2018 Monthly Physician's Orders, revealed an order for Xarelto (anticoagulant) twenty (20) milligrams (mg) by mouth once daily. Review of the SBAR, dated 10/08/18 at 2:05 PM, revealed the resident had a bruise across the left great toe which was a change in condition. Further review revealed the Advanced Practice Nurse Practitioner (ARNP) and Resident Representative was notified. Review of Resident #52's Weekly Nursing Skin Assessment, dated 10/08/18, revealed the resident had a bruise to the left great toe. Additional review revealed the resident bruised easily, received anticoagulant medication and scheduled pain medication. Further review revealed the resident had no complaints of pain or discomfort. Review of the Progress Note, dated 10/11/18 at 10:11 AM, revealed there was a large yellow-green healing bruise covering the resident's right great toe and the top of the first metatarsal, which was painful to touch. Review of the Progress Note, dated 10/11/18 at 11:01 AM, revealed there was a bruise on top of the resident's left great toe and metatarsal area and a new order was received for an X-ray to to the area. Review of the Physician's Orders, dated 10/11/18, revealed orders for a two (2) view X-ray of the left great toe and metatarsal areas due to injury, bruising, and pain. This order was obtained three (3) days after the bruise was identified, on 10/08/18. Review of X-ray results, dated 10/11/18, revealed no acute fracture or dislocation of the left toes. Further review of the medical record revealed there was no documented evidence of an Incident Report, witness statement, staff statements, or an investigation related to the resident's bruise on top of the resident's left great toe and metatarsal area, in order to determine the root cause of the injury. Additional review of Resident #52's Accidents Comprehensive Care Plan (CCP), revealed a problem of a bruise to the left great toe was added on 10/11/18. An intervention was added on 10/11/18 for an X-ray to the left great toe. However, there was no documented evidence the CCP was revised with a targeted intervention to prevent further occurrence of an injury of the same nature. (Refer to F-657) Interview with SRNA #16, on 02/14/19 at 4:26 PM revealed she had worked at the facility for one (1) year and seven (7) months, and was very familiar with residents on 200 hall, where Resident #52 resided. Per interview, she used the Care Plan as a guide to deliver care to the residents. SRNA #16 stated Resident #52 required total assist with ADLs; two (2) staff to assist with transfers using a hoyer lift, and one (1) additional staff to guide the resident because his/her legs would stick straight out. Continued interview revealed it was crowded in the resident's room with the bed, high-back wheelchair with leg and foot supports, the over bed table, the dresser, the hoyer lift, and the resident and three (3) staff during transfers. She stated she was mindful and careful with the resident's feet during transfers to ensure they were not bumped on anything. Interview with SRNA #15, on 02/14/19 at 4:26 PM, revealed she was assigned to Resident #52 on 10/08/18. SRNA stated when she took the resident's protective boot and socks off when assisting him/her to bed; she saw a red and purple bruise across the top of the left big toe that had not been there before. She stated she reported the bruise immediately to the nurse who came to assess his/her foot. Additional interview revealed she asked the resident what happened and the resident stated he/she did not know. SRNA #15 stated she was not asked to write a statement and was not interviewed after she reported the bruise to the nurse. Further interview revealed it was important to know what caused an injury to a resident in order to implement interventions to prevent recurrence. Interview with Licensed Practical Nurse (LPN) #6, on 02/14/19 at 5:27 PM, revealed she worked as needed (PRN); however, was familiar with residents on the 200 hall, and had been working at the facility for over two (2) years. Per interview, she used the CCP as a reference for the level of care and interventions necessary for each resident. Additional interview revealed Resident #52 required total assistance with all ADLs and his/her legs and feet were positioned straight out when in the seated position. Per interview, there was the potential staff could bump Resident #52's feet on something during transfer. Continued interview revealed the root cause of any injury was determined by evaluating data from a Skin Assessment, Incident Report, staff statements, resident statements, and an assessment of the environment. Per interview, it was important to determine the cause of an injury to ensure the resident receives necessary care and treatment. Further, it was important to find the cause of injury to reduce the risk of recurrence by planning interventions around that specific situation. She stated all employees were responsibility to provide a safe environment and necessary supervision to keep the residents safe. Interview with Unit 2 Manager, on 02/14/19 at 6:05 PM, revealed she expected all noticeable bruises to be investigated by the nursing staff through assessment of the resident, staff and resident statements, and assessment of the environment. Continued interview revealed this documentation should be recorded on Incident Reports, SBARs, and Nursing Progress Notes. Additionally, the gathered information should be reviewed and used to determine the root cause of the bruise/accident. Per interview, as a Unit Manager, she conducted ongoing walking rounds to ensure the residents environment was safe and she also attended a daily morning interdisciplinary team (IDT) meeting which included all Unit Managers, the Director of Nursing (DON), the MDS Nurse, the Administrator, and the Therapy staff. She stated during the meeting, all accidents were reviewed to ensure a thorough investigation was completed and an appropriate intervention was implemented. Further, it was important to complete a thorough investigation of accidents in order to implement specific interventions to ensure the residents received quality care, and to ensure safety. Continued interview with the Unit 2 Manager, revealed she could not recall if Resident #52's injury/bruise was discussed in the morning meeting, and stated the information from morning meeting was not part of the medical record. Per interview, there should have been witness statements obtained on 10/08/18, when the SRNA reported the bruise to Resident #52's left great toe. Additionally, a root cause of the injury should have been determined and a specific intervention should have been implemented to reduce the risk of the same incident again. Continued interview revealed this was important for the well being and safety of the resident. Further, she stated she was not sure how the facility missed completing an investigation related to Resident #52's bruise. Per interview, all staff were responsible to ensure a safe environment and supervision as necessary was provided. Interview with the DON, on 02/14/19 at 6:59 PM, revealed any bruises or injuries should be assessed by the nurse and a root cause should be determined at the time of identification through assessment, and statements from the residents and staff. She stated when a new large bruise or other signs of injuries were noted, she expected an Incident Report to be completed. Per interview, she also expected witness statements to be obtained, and an SBAR to be completed. She further stated after the information was gathered, there should be a Root Cause Analysis (RCA) which would lead to targeted interventions added to the CCP in an attempt to prevent reoccurrence. The DON stated this process was important to determine what was working for the resident, what was an effective intervention, and to reduce the risk for the same occurrence again. Per the DON, the Nurses should have obtained statements and tried to determine the root cause of the bruise and injury to Resident #94's left foot, on 02/07/19 and Resident #52's bruise on 10/08/18. Further, nursing staff and the Int[TRUNCATED]

Based on interview, record review, and review of facility Policy, it was determined the facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program to include antibiotic use protocols and a system to monitor antibiotic use. The facility was unable to submit documented evidence of an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use in order to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The findings include: Interview on 02/14/19 at 3:09 PM, with the Director of Nursing (DON), revealed there were no formal policies or written protocols for antibiotic prescribing. Review of the Med-Pass Policy and Procedure Manual for Long-Term Care Managing Infections utilized by the facility, revealed it included a Policy titled, Antibiotic Stewardship with revision date of December 2016, and a Policy titled Antibiotic Stewardship - Orders for Antibiotics with revision date of December 2016. However, there was no documented evidence of written protocols for prescribing antibiotics. Review of the facility Monthly Infection Control Log kept by the DON/Infection Control Preventionist, revealed the Log tracked antibiotics used; however, the microorganisms were not listed to enable assessment of antibiotic prescribing. Review of the Facility Assessment Tool, dated 08/18/17, revealed the facility routinely cared for residents with infectious diseases to include the following: Skin and Soft Tissue Infections, Respiratory Infections, Urinary Tract Infections (UTIs), infections with Multi-Drug Resistant Organisms, Septicemia, Viral Hepatitis, Influenza, and Clostridium Difficile (C Diff). Further review revealed Prevention and management of infections was noted as a service provided by the facility. Interview on 02/14/19 at 3:09 PM, with the DON/Infection Control Preventionist, revealed the facility reviewed antibiotic usage in Infection Control Quality Assurance Meetings. She further stated she kept an Infection Control Log noting antibiotic usage; however, the Log did not include the microorganisms related to the infection in which the antibiotics were prescribed. Further interview revealed the facility had no written protocols for antibiotic use, nor a system to monitor antibiotic usage and resistance data. Interview with the Consultant Pharmacist, on 02/26/19 at 11:25 AM, revealed she attended the facility quarterly Quality Assurance Meeting. She stated she was unaware of any written protocols for antibiotic prescribing; however, she stated the DON/Infection Control Preventionist routinely communicated with her regarding antibiotic usage for the residents. Interview with the Administrator, on 02/14/19 at 4:07 PM, revealed she worked with the DON/Infection Control Preventionist to ensure the facility's use of antibiotics for residents was consistent with standards of practice. She stated the facility currently did not have written antibiotic prescribing protocols, but she would ensure they were developed in accordance with regulations.