**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R90's Resident Face Sheet revealed the facility admitted the resident on 08/02/2021 with diagnoses including colitis (inflammation of the large intestine), unspecified dementia, and hemiplegia (paralysis of one side) following a cerebral vascular accident (stroke). Review of R90's quarterly MDS, with an ARD of 01/24/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Review of R90's Progress Note, dated 02/20/2025, revealed the facility transferred R90 to the hospital on that date due to continued complaint of pain of the left hip following a fall reported on 06/22/2024. Further review revealed the facility documented they sent all appropriate paperwork to the resident and her representative. Review of R90's medical record revealed no evidence R90 received a completed Notice of Transfer or Discharge form, with notification of appeal rights or that the appeal rights were discussed with the resident. During interview with R90 on 03/06/2025 at 11:45 AM, she stated she did not recognize the blank Notice of Transfer or Discharge form the SSA Surveyor showed her. 3. Review of R110's Resident Face Sheet revealed the facility admitted the resident on 10/31/2024 with diagnoses including cerebral infarction (stroke), aphasia (difficulty speaking, writing, or understanding written words), and congestive heart failure. Review of R110's quarterly MDS, with an ARD of 02/28/2025, revealed the facility assessed the resident to have a BIMS score of 5 out of 15, indicating the resident had severe cognitive impairment. Review of R110's Progress Note, dated 03/03/2025, revealed the facility transferred R110 to the hospital on that date due to a critically low potassium level. Further review revealed the facility documented they sent all appropriate paperwork to the resident and her representative. Review of R110's medical record revealed no evidence R110, or his Resident Representative (RR) received a completed Notice of Transfer or Discharge form or that the transfer or discharge notice, with notification of appeal rights, was discussed with the resident or RR. R110 was not interviewable due to mental cognition. Interview by telephone was attempted with R110's wife on 03/06/2025 at 3:28 PM. However, she did not answer the call, and no voicemail was available. R110's wife did not return the SSA Surveyor's call. 4. Review of R25's Resident Face Sheet revealed the facility admitted the resident on 07/05/2023 with diagnoses of depression, anxiety disorder, and dementia. Review of the facility's document Census, revealed R25 was sent to the hospital on [DATE]. However, there was no documentation by the facility stating a completed Notice of Transfer or Discharge form was sent to R25's responsible party. During interview with R25's RR on 03/04/2025 at 4:23 PM, she stated the facility did not mail or provide her with a Notification of Transfer or Discharge form when R25 was sent to the hospital on [DATE]. During interview with Licensed Practical Nurse (LPN) 1 on 03/06/2025 at 1:30 PM, he stated he had never seen a Notice of Transfer or Discharge form nor provided it to any resident transferred to the hospital. During interview on 03/06/2025 at 11:52 AM, Registered Nurse (RN) 3 stated she had never seen the form, Notice of Transfer or Discharge, and had not provided that form to any resident she transferred to the hospital. She further stated the only paperwork she completed when she sent a resident to the hospital was a transfer form of clinical information for the receiving facility and a bed hold policy form for the resident. During interview with RN6 on 03/06/2025 at 1:30 PM, she stated she had never seen a Notice of Transfer or Discharge form nor provided it to any resident transferred to the hospital. She stated the only paperwork she completed was the inter-hospital transfer form with relevant clinical information and a bed hold policy form. During interview on 03/06/2025 at 2:30 PM, the A Hall Unit Manager (AHUM) stated her expectations for nurses sending residents to the hospital was that they would complete a bed hold policy form to give to the resident and a transfer communication form to provide to Emergency Medical Services (EMS) and the receiving facility. During interview with the Business Office Manager (BOM) on 03/06/2025 at 10:46 AM, she stated she was responsible for sending residents and their representatives the bed hold agreement but did not send the Notice of Transfer or Discharge form outlining the resident's appeal rights. During interview with the Administrative/Corporate Consultant on 03/06/2025 at 10:51 AM, she stated that the facility was required to send a Notice of Transfer or Discharge form with residents transferred or discharged to the hospital. Per interview, this form included the resident's rights and the contact information for state agencies in case the facility did not readmit them. Additionally, the Administrative Consultant stated she could not provide evidence that the facility had given the correct form to residents who were transferred or discharged to the hospital. During interview with the acting Director of Nursing (DON) on 03/06/2025 at 3:57 PM, she stated she initially believed the facility needed to provide the bed hold form to the resident and the inter-hospital transfer form to the receiving facility. However, she stated after speaking with the Administrative/Corporate Consultant, she was made aware of the Notice of Transfer or Discharge form, which informed residents of their appeal rights, which was also required. She stated staff education on utilizing the Notice of Transfer or Discharge form for all transfers had begun and would continue. During interview with the Administrator on 03/06/2025 at 5:06 PM, she stated the facility's practice regarding resident transfer notices prior to today were the resident was provided with a bed hold agreement, and the receiving facility was sent pertinent clinical information on an inter-hospital transfer form. She stated she had been advised by the Administrative/Corporate Consultant earlier that staff was required to discuss and complete the Notice of Transfer or Discharge form with the resident or resident's representative. She further stated she would implement the correct procedure moving forward. Based on interview, record review, and facility document and policy review, the facility failed to notify the resident and/or the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. The facility further failed to ensure the notice included the reason, date, and location for the transfer, as well as a statement of the resident's appeal rights, and the contact information for the state Long-Term Care Ombudsman. The deficient practice was identified for 4 of 5 residents investigated for hospitalizations, Resident (R) 25, R47, R90, and R110. The findings include: Review of the facility's policy titled, Transfer/Discharge Notice, dated 02/03/2025, revealed the facility was to ensure appropriate notices and documentation were provided for all transfers. Further review revealed the facility was to respect residents' rights while complying with federal and state regulations related to transfers. Review of the facility's blank document Notice of Transfer or Discharge, not dated, revealed the form contained spaces for staff to fill in relevant resident information, as well as the reasons for transfer/discharge, contact information for the state agency responsible for appeals, and contact information for the state ombudsman. 1. Review of R47's Resident Face Sheet revealed the facility admitted the resident on 12/18/2024 with diagnoses including acute and chronic respiratory failure, dependence on renal dialysis, and type 2 diabetes. Review of R47's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of R47's Progress Note, dated 02/20/2025, revealed the facility transferred R47 to the hospital on that date due to a critically elevated potassium level. Further review revealed the facility documented they sent all appropriate paperwork to the resident and her representative. Review of R47's medical record revealed no evidence she received the Notice of Transfer or Discharge form. During interview on 03/06/2025 at 1:37 PM, R47 stated she did not recognize the blank transfer form the State Survey Agency (SSA) Surveyor showed her. She further stated her husband handled all her paperwork. Interview was attempted with R47's husband via telephone on 03/06/2025 at 1:44 PM. However, he did not answer either of the two numbers listed, no voicemail was available, and he did not return the SSA Surveyor's call.

Based on observation, interview, review of a Centers for Medicare and Medicaid Services (CMS) memorandum, review of a Centers for Disease Control and Prevention (CDC) document, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 40 residents reviewed for infection control, Resident (R) 68 and R45. The facility also failed to conduct an annual review of their IPCP. Observation of R68's wound care revealed Registered Nurse (RN) 1 failed to wear a gown while performing it, and the resident's door did not have an Enhanced Barrier Sign (EBP) sign posted. Observation of R45's room revealed it had a Contact Precautions sign posted, but State Registered Nurse Aide (SRNA) 3 pushed a mechanical lift out of the room and entered another resident's room without performing hand hygiene prior to exiting R45's room and before entering the other resident's room. The findings include: Review of the facility's policy titled, Infection Control, effective date 01/23/2024, revealed the facility's policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. However, there was no documentation the policy was reviewed or updated annually. Review of the facility's policy titled, Enhanced Barrier Precautions Policy, last revised 03/25/2024, revealed if a resident was placed on Enhanced Barrier Precautions (EBP), appropriate signage was placed at the room entrance so that personnel and visitors were aware of the need for and the type of precautions. Review of the Centers for Medicare and Medicaid Services (CMS) memorandum from its Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, QSO-24-08-NH, dated 03/20/2024, revealed EBP were used in conjunction with standard precautions and expanded the use of personal protective equipment (PPE) to donning (putting on) of gown and gloves during high-contact resident care activities such as wound care. Review of the Centers for Disease Control and Prevention (CDC) document C. diff: Facts for Clinicians | C. diff | CDC, dated 03/05/2024, revealed clostridium difficile (C. diff, a bacteria that caused severe diarrhea) spores could transfer to residents from the hands of healthcare personnel who had touched a contaminated surface or item; an alcohol based hand sanitizer was not effective against C. diff; and washing hands with soap and water was required for hand hygiene. 1. Observation of R68's door on 03/03/2025 at 4:48 PM revealed there was no EBP sign on the door. Observation on 03/03/2025 at 4:50 PM revealed RN1 performed wound care to R68's left hip. RN1 was not wearing a gown. While cleaning the wound, RN1 laid her arm on the bed. During interview with RN1 right after the wound care, she stated she forgot all about the gown. She further stated it was important to wear a gown during wound care to prevent the spread of germs. During interview with the Assistant Director of Nursing (ADON) on 03/05/2025 at 3:33 PM, she stated when a resident had a wound, the staff was to wear a gown and gloves. She stated nurses put precaution signs on the residents' doors. She stated she performed rounds to assure staff was wearing the appropriate PPE. When questioned what could occur if a staff member did not wear a gown and performed wound care, she stated she could not answer to that. During interview with the Director of Nursing (DON) on 03/05/2025 at 3:24 PM, she stated she was the interim DON. She further stated she had been at the facility for about two months. She stated she had a meeting with the staff at different times, educating staff on infection control. She stated at those meetings she educated on EBP, what it was needed for and what the precaution signs stated. When questioned about the incident, she stated RN1 might have been nervous because a State Survey Agency (SSA) Surveyor was observing. She further stated because there was not an EBP sign on the door, that could have contributed to the problem. She stated, after the incident, a sign was placed on the door, and RN1 was reeducated on EBP. She further stated if a staff member was not wearing a gown while providing wound care, it could have caused a spread of infection. During interview with the Administrator on 03/06/2025 at 10:44 AM, she stated, I guess the infection control policies should be updated yearly. She further stated corporate updated the policies and sent them to her by e-mail. She stated she then educated the staff on the policy updates. She stated she was on the floor often, monitoring staff to assure they were following the IPCP. She stated if she saw a staff member not following the policy, she educated immediately and might send the staff for training. She also stated if staff did not follow the IPCP, that could contribute to the spread of an infection. During interview with the corporate [NAME] President of Clinical Operations on 03/06/2025 at 3:14 PM, she stated the clinical department was responsible to assure the policies were up-to-date and accurate. She stated the [NAME] Presidents of each department and the Chief Nursing Officer met as a team and reviewed the policies. She stated the compliance department put policies in a Web based program, and the old policies were archived. 2. Review of R47's Resident Face Sheet revealed the facility admitted the resident on 02/03/2025 with diagnoses including clostridium difficile (C. diff). Review of R47's Comprehensive Care Plan (CCP) revealed the facility identified the resident required contact precautions for C. diff; however, the care plan did not specify interventions related to hand hygiene. Observation on 03/05/2025 at 8:51 AM revealed R45's room had a Contact Precautions with Special Enteric Guidance sign posted on the door. The sign instructed staff to wash hands with soap and water before leaving the room. Continued observation on 03/05/2025 at 8:51 AM revealed SRNA3 pushed a mechanical lift out of R45's room but failed to perform hand hygiene prior to exiting. Further observation revealed SRNA3 exited R45's room and entered R130's room without performing hand hygiene. During interview on 03/05/2025 at 8:59 AM, SRNA3 stated she failed to wash her hands with soap and water after removing the mechanical lift from R45's room. During interview on 03/06/2025 at 3:57 PM, the interim DON stated she expected staff to wash their hands with soap and water prior to exiting a room in contact precautions with enteric instructions due to clostridium difficile. She further stated she had reeducated SRNA3 that she needed to perform hand hygiene with soap and water, even if she had not performed incontinence care for R47 because clostridium difficile spores live on surfaces in the resident's room. In an interview on 03/06/2025 at 5:06 PM, the Administrator stated she expected staff to wash their hands with soap and water prior to exiting a room when the resident had clostridium difficile. She further stated proper hand hygiene was important to prevent the spread of the bacteria.

Based on interview and review of the facility's policy, the facility failed to ensure residents had the right to receive mail delivered to the facility on Saturdays. This affected all 125 current residents in the facility. During a group interview on 03/05/2025 the Resident Council members stated they did not receive mail on Saturdays. In an interview with the Assistant Business Office Manager (ABOM) and the Administrator on 03/06/2025, it was confirmed that mail delivered from the Post Office to the facility on Saturday after 5:00 PM was not sorted or delivered by staff until the following Monday. The findings include: Review of the facility's policy titled, Resident Rights, revised 01/31/2025, revealed the facility was responsible to ensure residents were treated with respect and dignity. Furthermore, the policy stated the facility ensured the residents' right to privacy in sending and receiving mail. During an interview with Resident (R) 3, R28, R43, R61, R64, R75, R82, and R107 on 03/05/2025 at 11:00 AM, at the Resident Council meeting, the State Survey Agency (SSA) Surveyor interviewed residents as to whether they received mail at the facility, including on Saturdays. All eight residents present stated they did not receive mail on Saturdays, except for special package deliveries from delivery services. R61 stated mail was delivered from the Post Office on Saturdays. However, R61 stated if mail was delivered to the facility after 4:30 PM, it would not be sorted and delivered to the residents. R61 further stated during the week, the Social Services Director (SSD) sorted the mail, and he (R61) then distributed it to the residents. However, R61 stated the SSD and other front office staff were unavailable to sort mail on weekends, which prevented him from delivering it. During an interview with the ABOM on 03/06/2025 on 5:13 PM, she stated mail was delivered from the Post Office on Saturdays. She stated there had been times when the mail had not been delivered to the facility on a Saturday. The ABOM stated she had contacted the Post Office and discussed the issue with the local Postmaster. She further stated if mail was delivered after 5:00 PM, there was no one in the Business Office who was able to sort resident mail from facility mail. She stated the facility should possibly consider ensuring mail delivery on Saturday because it was the residents' right to receive communication from outside the facility. During an interview with the Administrator on 03/06/2025 at 5:13 PM, she stated mail was delivered from the Post Office most Saturdays. However, she stated there had been instances where no mail delivery occurred. She stated the facility was one of the last stops on the postal carrier's route, resulting in mail arriving after 5:00 PM on Saturdays. She stated she did not have front office staff available after 5:00 PM on Saturdays. The Administrator stated she would contact the local Postmaster to discuss their concerns. The Administrator stated it was the residents' right to receive mail on Saturdays. She stated it was essential for their well-being and quality of life.

Based on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of the website www.drugs.com, review of medication package inserts, and review of the facility's policy, the facility failed to ensure drugs, biologicals, and vaccines were stored per currently accepted professional principles and failed to ensure appropriate environmental controls were used to preserve their integrity. This deficient practice was found in 3 out of 3 medication refrigerators, and 2 out of 5 medications carts, affecting 25 residents, Resident (R) 17, R11, R17, R19, R21, R23, R25, R36, R37, R38, R45, R46, R47, R52, R58, R61, R62, R68, R79, R92, R98, R117, R229, R230, and R231. Observation of the A, B, and D Hall Units' medication refrigerators revealed multiple vials of Flucelvax and Fluzone (influenza vaccines) and Spikevax (COVID-19 vaccine), multiple multidose vials of Tubersol purified protein derivative (PPD) (diagnostic tuberculin skin test), and resident medications were stored in the medication refrigerators, outside of the recommended temperature parameters. Additionally, all three of the units' medication refrigerators were overcrowded, limiting proper airflow. Observation of D Hall Unit's Medication Cart revealed staff failed to discard expired medication. Observation of the B Hall Unit's Medication Cart revealed staff failed to date opened medications, failed to properly store insulin, failed to discard items with compromised packaging, and failed to dispose of expired medications or medications with specific expired dates after opening. The findings include: Review of the CDC's document, Vaccine Storage and Handling, updated 03/29/2024, revealed proper vaccine storage and handling played critical roles in efforts to prevent vaccine-preventable diseases. Per the document, vaccines exposed to storage temperatures outside the recommended ranges could have decreased efficacy, creating limited protection; and exposure to temperatures 32 degrees Fahrenheit (F) or colder could destroy its potency. Review of the facility's policy titled, Medication Storage, dated January 2025, revealed medications and biologicals must be stored according to the manufacturers' guidelines or pharmacy recommendations to ensure their integrity and to facilitate safe and effective administration. Per the policy, those medications that required refrigeration or must be kept at temperatures between 36 to 46 degrees F should be placed in a refrigerator equipped with a thermometer for monitoring purposes. The policy state the temperatures of any refrigerator storing vaccines should be checked and recorded twice daily. Per the policy, outdated, contaminated, or deteriorated (cracked, soiled, or without closers) medications were removed from stock. Review of the A, B, and D Hall Unit's Medication Temperature Logs, for March 2025, revealed all documented temperatures were between 36 to 46 degrees F. Review of PPD's package insert/product label revealed it was used as an aid in the detection of infection with mycobacterium. Further review revealed a multi-dose vial of PPD, which had been opened and used, should be discarded after 30 days. Review of Fluzone's package insert/product label revealed Fluzone was a vaccine indicated for active immunization for the prevention of influenza. Further review revealed Fluzone should be stored between use at temperatures between 35 to 46 degrees F, and it should be discarded if the vaccine was frozen. Additionally, product labeling indicated not to use after the expiration date. Review of the website www.drugs.com revealed Flucelvax was a vaccine indicated for active immunization for the prevention of influenza. Further review revealed Flucelvax should be stored between use at temperatures between 35 to 46 degrees F, and it should be discarded if the vaccine was frozen. Additionally, product labeling indicated not to use after the expiration date. Review of the website www.drugs.com revealed Spikevax was a vaccine indicated for active immunization to prevent COVID-19. Further review revealed Spikevax should be stored frozen between minus 58 to 5 degrees F. Continued review revealed after thawing, Spikevax could be stored refrigerated between 36 to 46 degrees F for up to 60 days or up to the expiration date printed on the carton, whichever came first. According to the manufacturer's instructions, Spikevax should not refreeze once thawed. Review of the website www.drugs.com for insulins revealed opened (in-use) vials and injection pens, stored at room temperature, should be discarded after 28 days. Further review revealed unopened insulin lispro injections should be stored in the refrigerator at 36 to 46 degrees F until the first use. The unopened multidose vials and prefilled pen would be good until the expiration date on the package if they remained refrigerated until use. 1. Observation of the D Hall Unit's Medication Storage Room on 03/05/2025 at 8:45 AM, revealed a small medication storage refrigerator was on the floor between the shelving system. The temperature reading of the thermometer inside of the refrigerator was at 32 degrees F. Additionally, the refrigerator was over-packed with very little room for proper airflow. Medications and biologicals found in the refrigerator at below acceptable levels included: seven intravenous (IV) bags of R38's daptomycin (antibiotic) 500 milligram (mg)/50 milliliter (mL); five IV bags of R38's cefepime (antibiotic) 2 gm (grams)/50 mL, one IV bag of R23's cefepime 1 gm/50 mL, seven IV bags of R21's cefazolin (antibiotic) 2 gm/50 mL; R98's Ozempic pen (semaglutide); one vial of Risperdal (anti-psychotic) 12 mg; one house stock multidose vial of Fluzone 0.5 mL with an expiration date of 06/2025; two vials of insulin glargine 100 units (u) for R21 and R25; one house stock multidose vial of PPD; three of R52's Trulicity 0.75 mg/0.5 mL pens (dulaglutide); R23's Wegovy 0.5 mg/0.5 mL pen (semaglutide); R17's Wegovy 0.25mg/0.5mL pen; 12 IV bags of R92's daptomycin 300 mg/100 mL; and 13 IV bags of R23's cefepime 1 g/50 mL. 2. Observation of D Hall Unit's Medication (Cart 1) on 03/05/2025 at 9:00 AM, revealed 24 famotidine (stomach acid reducer) 20 mg tablets and 18 pravastatin (statin) 40 mg tablets for R37 with an expiration date 03/01/2025. Additionally, R58's fluoxetine (anti-depressant) 20 mg tablets had expired on 03/01/2025. During interview with the D Hall Unit Manager (DHUM) on 03/05/2025 at 9:10 AM, she stated the refrigerator was checked at least daily, and temperatures were recorded on the Medication Refrigerator Temperature Log by Central Supply during the week and by nursing staff on weekends. The DHUM further stated the nursing staff was responsible for ensuring medications were labeled according to the facility process, which was to record the date opened on the medication package when the medication had been opened. Furthermore, she stated if an item was found to be expired, not labeled, or stored improperly, the nursing staff was responsible to discard the medication according to policy. The DHUM further stated the importance of that was to ensure the safety of all residents. During interview with the Administrative/Corporate Consultant (CC) on 03/05/2025 at 9:23 AM, she stated the Medication Storage Room for D Hall shared space in a small room with the facility's computer server and wiring equipment. The CC further stated expired medications should not be kept in the medication cart. She stated nursing staff should adhere to facility policy regarding the removal of expired medications, as this was important for resident safety. Additionally, the CC stated medications past their expiration date lost their effectiveness. 3. Observation of B Hall Unit's Medication Cart 1 on 03/05/2025 at 9:25 AM revealed one packaged Zofran (for nausea) tablet without a resident label in the top drawer of the cart. Additionally, the following medications or items were found to be without an opened date, improperly stored, or expired: one open bottle of Sprite cola, half full, in the bottom of the medication cart; one bottle of ProHeal concentrated liquid protein was found with an uncovered drilled hole in the protective cap, causing the product to spill out onto the sides of the bottle; three opened packages of albuterol nebulizer solution 2.5 mg/0.5 mL (bronchodilator) not in the original pharmacy packaging and not protected from light; R46's iprat/albuterol 0.5 3(2.5) mg/3 mL (bronchodilator) inside a foil package that was not dated, opened, and exposed to light; R36's bottle of generic mouthwash was opened with the date of 8/12/2022; and R68's Bion Tears (ocular lubricant) with an opened date of 01/21/2025. During interview with the B Hall Unit Manager (BHUM) on 03/05/2025 at 9:25 AM, he stated the nursing staff was responsible for ensuring medication were dated when opened. The BHUM stated that expired, incorrectly labeled, or improperly stored items should be discarded. He stated the medication storage refrigerator was checked daily, with temperatures recorded on the Medication Refrigerator Temperature Log by Central Supply during the week and by nursing staff on weekends. He stated those measures were vital for ensuring medication potency and resident safety. 4. Observation of B Hall Unit's Medication Storage Refrigerator on 03/06/2025 at 9:15 AM revealed a small refrigerator that had very little room for proper airflow. The temperature reading of the thermometer inside of the refrigerator was 50 degrees F. Further observation revealed medications and biologicals inside the refrigerator included: one house stock multidose vial of PPD stored in the door of the refrigerator; R79's Ozempic 4 mg/3 mL, Ozempic 2 mg/3 mL, and Ozempic 8 mg/3 mL pens; one vial of R36's Semglee (insulin glargine) 100 units/mL; R11's Trulicity 0.75/0.5 mL pen, Lantus 1.5/0.5 pen, and a vial of insulin lispro 100 units/mL; two of R7's Trulicity 0.75/0.5 mL pens, and one vial of R19's Lantus 100 units/mL. 5. Observation of A Hall Unit's medication storage room on 03/06/2025 at 9:15 AM revealed two milk crates full of expired or discontinued residents' medications. These crates were unlabeled and available for use. During interview with the CC on 03/06/2025 at 9:15 AM, she stated during an audit of the A Hall Unit's Medication Cart on 03/05/2025, she pulled the medications from the cart. She stated according to facility policy, medication carts and storage areas were monitored on a regular basis. She further stated the pharmacy picked up expired and discontinued medications regularly. 6. Observation of A Hall Unit's Medication Storage Refrigerator, revealed it was a small refrigerator located on the floor that had very little room for proper airflow. The temperature reading of the thermometer inside of the refrigerator was 28 degrees F. Medications and biologicals inside the refrigerator included: one vial of R47's insulin glargine 100 units/mL; one vial of R61's insulin lispro 100 units/mL; three bags of R229's IV daptomycin 700 mg/100 mL; six bags of R92's daptomycin 300 mg/114 mL; R230's acidophilus (probiotic); one vial of R21's insulin glargine 100 units/mL; one vial of R62's Novolog (insulin aspart) 100 units/mL; R98's Ozempic 0.25/0.5 pen; two vials of R117's Risperdal 12 mg; R45's hydrocortisone 25 mg suppository (for hemorrhoids); one tube of lidocaine for R231; R17's Wegovy 0.5 mg/0.5 mL pen; one multidose vial Fluzone (house stock); three multidose vials of PPD (house stock); 16 vials of Flucelvax with an expiration date of 06/02/2025 (house stock); eight vials of Flucelvax with an expiration date of 06/13/2025; and 30 vials of Spikevax 2024-2025 (house stock). During interview with Licensed Practical Nurse (LPN) 2 on 03/06/2025 at 9:59 AM, she stated medication storage refrigerators should be kept between 36 to 46 degrees F. LPN2 stated she did not know why the refrigerator was at 28 degrees F. She stated nursing staff only checked the medication refrigerator temperatures on weekends. During interview with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 03/06/2025 at 3:32 PM, she stated it was the responsibility of the nurse to monitor the medication storage refrigerators like any other medication. She stated the facility should follow manufacturer's guidelines for proper temperature storage. She stated it was important because prolonged exposure outside of the correct medication temperature range could affect efficacy. She further stated medications and vaccines could not be stored in the refrigerator door as temperatures could fluctuate from the inside of the refrigerator. Additionally, the IP/SDC stated medications should be stored in such a way as to ensure proper airflow to ensure consistent temperatures. She stated all medications should be dated when opened. According to the IP/SDC, she stated each medication cart had a cheat sheet that listed frequently used medications and insulins, along with their storage requirements. The IP/SDC she expected that the nursing staff be familiar with the cheat sheet. During continued interview with the IP/SDC on 03/06/2025 at 3:32 PM, she stated that Central Supply monitored the refrigerators throughout the week, while nurses were responsible for conducting checks on weekends. She stated staff members were expected to verify that temperatures remained within the acceptable range. When the State Survey Agency (SSA) Surveyor inquired about the frequency of nursing leadership audits for the medication carts and refrigerators, the IP/SDC stated, I have taken medications out of the cart. I have not found anything in the refrigerators, but I have only checked twice. The IP/SDC stated all medications should be dated when opened, and staff must adhere to the facility's policies concerning medication storage. She stated expired medications could pose a risk if administered, raising safety concerns. She further stated it was important to follow physician's orders and monitor medication storage to maintain the health and well-being of the residents. During interview with the acting Director of Nursing (DON) on 03/06/2025 at 3:57 PM, she stated she expected the nurses to discard expired medications. She stated nursing staff was educated on medication administration and storage during their orientation upon hire. The DON stated it was her expectation that medications and vaccines were stored according to currently accepted professional standards and under the appropriate environmental controls to protect the efficacy of the medication and vaccines for the safety of the residents. During interview with the Administrator on 03/06/2025 at 5:06 PM, she stated it was her expectation that medications and vaccines were stored according to the facility's policy to protect the efficacy of medications and vaccines for the safety of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #69's medical record revealed the facility admitted the resident on 12/18/19 with diagnoses including Dementia with Behavioral Disturbances, and Insomnia. Review of the Quarterly MDS Assessment, dated 10/19/19, revealed the facility assessed the resident as having a BIMS score of zero (0) out of fifteen (15) indicating the resident was unable to complete the interview. Further review of the MDS Assessment, revealed the facility assessed the resident as independent with bed mobility. Continued review of the MDS Assessment, revealed the facility assessed the resident as requiring the assist of one (1) staff for transfers and ambulation; and requiring limited assist of two (2) staff for toileting. Testing of the call light in Resident #69's room (room [ROOM NUMBER]) on 12/17/19 at 10:15 AM, on the locked unit, revealed adequate communication and signaling to display the light directly above the resident's room door. Observation of Resident #69, on 12/17/19 at 10:30 AM, revealed the resident was resting in bed. Further observation revealed the resident's call light was not in plain view, and after searching for the call light, it was found on top of the overhead light above the resident's bed out of reach of the resident. A metallic clip was attached to the call line which would allow placement and securement to the resident's bed linens. Observation of staff on 12/17/19 at 10:45 AM, revealed they were conducting rounds in and out of Resident #69's room. Further observation on 12/17/19 at 11:00 AM, revealed after staff rounds, Resident #69's call light remained in the previous location on the overhead light out of reach, while the resident was resting in bed. The Surveyor attempted an interview with Resident #69, on 12/18/19 at 2:00 PM; however, the interview was unsuccessful due to the resident's cognitive status. Observation on 12/19/19 at 9:00 AM, revealed Resident #69 was in bed with eyes closed. Further observation revealed the resident's call light was directly behind the resident's bed in the floor inaccessible to the resident. Interview with SRNA #1 on 12/19/18 at 2:00 PM, revealed the SRNAs shared responsibility of the residents on the locked unit and she was familiar with Resident #69. Per interview, Resident #69 was actively encouraged to utilize the call system, and at times was capable of using and making specific requests. Further interview revealed having call lights in reach of residents was a facility expectation, and was crucial in the prevention of accidents. Per interview, call lights should always be in reach of the residents in order for them to be able to communicate with staff, and receive the required assistance. Further interview revealed residents who could not reach or find call lights were prone to falls or other potential accidents, especially if the call light cord was lying on the floor. Interview with SRNA #2, on 12/19/18 at 2:15 PM, revealed Resident #69 sometimes used his/her call light. SRNA #2 stated it was the facility's expectation that call lights be in reach of the residents. Per interview, call lights were not to be in the floor as the cord could cause a resident to trip. Further interview revealed call lights should be checked during scheduled rounds for placement and any time care was provided. Interview with SRNA #3, on 12/19/18 at 3:00 PM, revealed call lights should be accessible and visible to the residents. Further Interview revealed the facility provided training and education on call light placement and all staff was responsible for answering and maintaining call lights in resident rooms. Interview with LPN #1, on 12/19/18 at 3:30 PM, revealed she was assigned to Resident #69. Per interview, all residents were to have call lights in reach and accessible for use. She stated when residents were in bed resting, call lights should be pinned to the bed sheet in reach of the resident and not obstructed by sheets or blankets. Per interview, if a resident was sitting in a chair, the call light needed to be placed in view of the resident and in reach. Further interview revealed residents could not receive proper assistance if they could not find or reach their call lights. In addition, she stated there was the potential for falls or accidents if residents could not reach the call lights. Additional interview revealed all staff was responsible for checking call lights to ensure they were in reach prior to exiting any residents' room. Interview with the Director of Nursing, on 12/19/18 at 5:00 PM, revealed it was her expectation for call lights to be in reach, visible, and accessible to residents. Per interview, there was the potential for accidents such as falls if call lights were out of reach, and residents could not call for assistance. Further interview revealed any time a staff member was in a resident's room, they should check to ensure the call light was in reach prior to exiting the room. Interview with the Administrator, on 12/19/18 at 5:15 PM, revealed call lights should be in reach and in plain sight while residents were in their rooms or in the bathrooms. Per interview, if call lights were out of reach, this could prohibit residents from receiving prompt care and assistance, which may lead to falls or other accidents. The Administrator further stated it was her expectation for all staff to be answering and monitoring call lights in resident rooms. Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident receives services in the facility with reasonable accommodation of resident needs for two (2) of twenty-eight (28) sampled residents (Residents #25 and Resident #69). Observation on 12/17/19 and 12/19/19, revealed Resident #25 and Resident #69's call lights were out of reach and inaccessible to the residents. The findings include: Review of the facility's Kentucky Resident Handbook and admission Information Signature Healthcare: KY revised 03/14/2019, revealed the facility will provide general nursing care and treatment to all residents in a non-discriminatory manner as required by federal and state law. Further review revealed this is without regard to race, gender, religion, national origin, veteran status, sexual preference, disability, age, or any other legally protected status. Review of the facility's Answering Call Lights: Guideline Steps Policy, undated, revealed staff are to leave the call light on until the resident's needs are met. The staff are to identify themselves to the resident by their name and address the resident by name. Continued review revealed the staff are to listen to the resident's request, and do what the resident has requested if permitted. If assistance is needed when entering the room, summon help by using the call signal. However, the Policy did not address the need to ensure the call light was in reach of the resident. Observation and inspection of the facility call system on 12/17/19 at 10:15 AM, revealed the call light consisted of a long white cord with a singular push button activation. 1. Review of Resident #25's clinical record revealed the facility admitted the resident on 11/30/18 and readmitted the resident on 03/13/19 with diagnoses which included Seizures, History of Traumatic Brain Injury, Dysphagia, Contractures of the Right and Left Knee, Contracture of the Right and Left Ankle, and Difficulty in Walking. Review of the Quarterly MDS Assessment, dated 12/09/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of nine (9) out of fifteen (15) indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assist of two (2) persons for bed mobility and toileting; requiring total assist of two (2) persons for transfers; and as did not ambulate. Observation of Resident #25 on 12/17/19 at 11:12 AM, revealed he/she was sitting in the wheelchair which was positioned to the left side of the bed. The resident was wearing a support type glove to the right hand. Further, the call light was in the center of the bed and was not accessible to the resident. Interview with Resident #25 on 12/17/19 at 11:12 AM, revealed staff often placed his/her call light out of reach. Resident #25 stated in order to receive care, he/she had to call out into the hall to get assistance. Continued interview revealed the resident was unable to use his/her right hand with the glove support, but staff would often wheel him/her to his/her room and leave him/her in the wheelchair to the left of the bed. Per interview, he/she was unable to use the call light from that position. During this interview, State Registered Nurse Aide (SRNA) #1 entered the room and explained she was not aware the resident was back in his/her room. SRNA #1 did not identify the call light was out of the resident's reach, and did not ensure it was in reach prior to exiting the room. Further interview with Resident #25, after SRNA #1 left the room, revealed he/she wanted to go to bed, and could not use his/her call light. Resident #25 then called out to staff in the hall that he/she wanted to go to bed. Licensed Practical Nurse (LPN) #1 immediately arrived in the room, moved the resident to the right side of the bed, and placed the call light where he/she could reach it with his/her left hand. Resident #25 was then agreeable to sitting up in the wheelchair for the lunch meal. Continued observation revealed maintenance came into the room and hooked up a longer call light cord at the request of LPN #1. Interview with SRNA #1 on 12/19/19 at 10:13 AM, revealed the call lights should be within reach of the residents while they were in their rooms or in the restrooms. Further interview revealed she did recall on 12/17/19, Resident #25 was in his/her room and sitting in the wheelchair which was positioned on the left side of the bed. Per interview, she should have ensured Resident #25 was positioned on the right side of the bed while in the wheelchair in order for him/her to be able to use his/her left hand to reach the call light since he/she could not use his/her right hand due to pain. Per interview, on that date she should have ensured the call light was in reach prior to exiting the room. Interview with LPN #1, on 12/19/19 at 1:19 PM, revealed on 12/17/19, she did notice Resident #25 was unable to use his/her call bell when he/she had to call out for staff. Per interview, the resident's call light was not within reach when she checked on him/her on that date, and she had a longer cord put on the call light. Further interview revealed if a resident did not have access to his/her call light, that could be a safety issue. Interview on 12/19/19 at 10:42 AM, with the Unit Manager for the unit in which Resident #25 resided, revealed Resident #25 would not be able to use his/her right hand with the Edema Glove on, and the call light should not be placed to his/her right side. Per interview, the facility did address the issue on 12/17/19 by placing a longer call light cord in the room and on that date staff was instructed to position the call light on the resident's left side at all times.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to submit the Minimum Data Set (MDS) Assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for one (1) of twenty-eight (28) sampled resident's (Resident #1). Review of the CMS Submission Final Validation Report, dated 12/12/19, revealed the facility failed to submit Resident #1's Annual MDS Assessment with an Assessment Reference Date of 09/26/19, within the required timeframe. The findings include: Review of the facility's MDS Assessment Completion Policy, revised February 2016, revealed the facility will conduct and submit resident assessments in accordance with the Resident Assessment Instrument (RAI) Manual including federal and state submission timeframes. Review of the RAI 3.0 User's Manual, Version 1.16, dated October 2018, Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Entry and Death in Facility tracking records, information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). Review of Resident #1's medical record revealed the facility admitted the resident on 11/30/18 with diagnoses including Myocardial Infarction, Chronic Obstructive Pulmonary Disease (COPD), Cerebral Infarction, Generalized Anxiety Disorder, Dysphagia, Use of Anticoagulants, Benign Prostatic Hyperplasia (BPH), Acute Respiratory Failure, and Non-traumatic Acute Subdural Hemorrhage. Resident #1's Annual MDS Assessment, revealed an Assessment Reference Date (ARD) date of 09/26/19. Review of the CMS Submission Final Validation Report, dated 12/12/19, revealed the Annual MDS Assessment ARD date was 09/26/19; and the Comprehensive Care Plan (CCP) and Care Area Assessments (CAA) were completed on 10/18/19. However, per the Report, the Assessment was transmitted on 12/12/19, which was more than fourteen (14) days after the CCP was completed. Interview with the MDS Director, on 12/19/19 at 5:00 PM, revealed all sections of Resident #1's Annual MDS Assessment were completed on 10/18/19, when the MDS transmission was supposed to take place. However, further interview revealed MDS Nurse #1 failed to sign the MDS Assessment or she may have signed and the electronic signature did not stay on the document and therefore the Assessment was not transmitted. Further interview with the MDS Director, revealed the process to ensure MDS Assessments were transmitted timely was to run a Monthly Final Validation Report; however, this error was not caught until 12/12/19. Per interview, once the error was identified, the MDS Assessment was transmitted on 12/12/19 to CMS. Post Survey phone interview, on 01/06/19 at 2:34 PM, with MDS Nurse #1, revealed she worked at the facility PRN (as needed), and would fill in if needed to complete MDS Assessments. Continued interview revealed she did not transmit MDS Assessments, as the transmission was the responsibility of the MDS Coordinator. Per interview, her job was to complete the MDS Assessment, CAA and CCP. Further interview revealed prior to the transmission of the MDS Assessment, she signed the CAAS, CCP, and MDS Assessment. However, she stated there were some issues when the facility switched to the new Electronic Medical Record system, as they were having problems with the signatures on the MDS Assessments holding. Interview with the Director of Nursing (DON), on 12/19/19 at 5:30 PM, revealed she did not monitor MDS transmissions. Further interview revealed she was not familiar with the MDS transmission process and did not provide supervision to the MDS Director. Per interview, the MDS Director was supervised directly by the Administrator, and there was also a Regional MDS Coordinator who the facility utilized as a resource for the MDS Director. Interview with the Administrator, on 12/19/19 at 5:43 PM, revealed it was discovered by the MDS Director on 12/12/19, after she ran a CMS Submission Final Validation Report, that MDS Nurse #1's signature was missing from Resident #1's Annual MDS Assessment. Per interview, the document did not transmit on 10/18/19 due to the missing signature. The Administrator stated this may have been due to a problem with the new Electronic Medical Record system. Further, when the error was discovered on 12/12/19, the MDS Assessment was transmitted on that date. Continued interview revealed it was the Administrator's expectation that all MDS Assessments be transmitted timely as per the RAI Manual.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. Observation of the Medication Cart One (1) D Wing, on 12/18/19, revealed one (1) vial of Lantus Insulin, with an open date of 11/08/19 and an expiration date of 12/06/19; and one (1) vial of Humalog U-100 Insulin, with an open date of 11/09/19 and an expiration date of 12/07/19. The findings include: Review of the facility Medication Storage Policy, revised 09/2018, revealed medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Continued review revealed, Insulin products should be stored in the refrigerator until opened. Note the date on the label of Insulin vials when first used. Further review revealed medications labeled for individual residents were stored separately from floor stock medications, and outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secured closures were immediately removed from stock. Review of the facility Medication Administration Subcutaneous Insulin Policy, revised 05/2016, revealed when obtaining insulin, check expiration date. Observation of the Medication Cart One (1) D Wing, on 12/18/19 at 9:45 AM, revealed the following items were in the cart and accessible for use: one (1) vial of Lantus Insulin, with an open date of 11/08/19 and an expiration date of 12/06/19 and one (1) vial of Humalog U-100 Insulin, with an open date of 11/09/19 and an expiration date of 12/07/19. Interview with Licensed Practical Nurse (LPN) #5, on 12/18/19 at 9:55 AM, revealed expired medications should be pulled from the medication cart. She further stated vials of Insulin should be dated with the open date, as Insulin was only good for twenty-eight (28) days after opened. She further stated the nurses should check the Insulin vials prior to administration for expiration date. Interview with LPN #2, on 12/19/19 at 1:11 PM, revealed it was the responsibility of all nurses to check the Insulins on the medication cart, and to remove any expired Insulin. She further stated she checked the Insulin open date before she administered the medication to ensure it was not expired. She further stated Insulin was only good for twenty-eight (28) days once opened, and then needed to be discarded. Per interview, if expired Insulin was administered the medication may not be effective which could affect the resident's blood glucose levels. Interview on 12/19/19 at 1:17 PM, with Registered Nurse (RN) #2, revealed Insulin should be marked with the open date immediately when opened, because the medication expired twenty-eight (28) days after it was opened. Per interview, nurses should always check the date of expiration prior to administering Insulin because if expired Insulin was administered, it may not be effective. Interview with the Director of Nursing (DON), on 12/19/19, at 1:30 PM, revealed Insulin vials were to be dated when opened and discarded twenty-eight (28) days after opened. Per interview, the facility had been conducting audits of medication carts on Mondays and Fridays and she ensured those were completed. Per interview, it was her expectation for staff to follow the facility's policies. Interview with the Administrator, on 12/19/19, at 2:33 PM, revealed it was her expectation that Insulin medications be dated when opened, stored properly, and discarded when expired. Per interview, the facility had been conducting audits of the medication carts twice a week to ensure proper storage of medication; however, since expired Insulins were found in the medication carts, the audits needed to be completed more frequently. Per interview, it was her expectation for staff to follow the facility's policies.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of twenty-eight (28) sampled residents (Resident #59). Observation on 12/17/19, during initial tour of D-Wing and subsequent observations on 12/17/19, revealed Resident #59's suprapubic catheter urinary drainage bag was lying on the floor. The findings include: Review of the facility's Policy, titled Infection Control, revised 10/2018, revealed the intended purpose of the facility's infection control policies was to facilitate maintaining a safe, sanitary and comfortable environment and to assist in the prevention and management of the transmission of diseases and infections. Further review revealed the facility's infection control policies objectives was to prevent, detect, investigate and control infections in the facility. Continued review revealed all personnel would be trained on the infection control policies and practices upon hire and periodically thereafter. Review of the facility's Policy, titled Urinary Catheter Care, revised 10/2018, revealed the purpose of the procedure was to prevent catheter-associated urinary tract infections. Further review revealed urinary catheter drainage bags were to remain positioned at a level lower than the bladder to ensure prevention of urine back-flow into catheter tubing and in to the urinary bladder, which could lead to urinary tract infections. Continued policy review revealed urinary drainage bags and catheter tubing were to remain off the floor and secured to inner thigh with leg strap to reduce friction and movement at insertion site that could cause pain, tearing or dislodgement of tubing from the resident. Review of Resident #59's clinical record revealed the facility admitted the resident on 11/22/16 with diagnoses including Dementia, Cerebral Infarction, Renal and Perinephric Abscess, Type II Diabetes Mellitus, Urethral Fistula, Urinary Retention, Urogenital Implants, End-Stage Renal Disease and Dependence on Renal Dialysis, and Indwelling Suprapubic Catheter Review of Resident #59's Annual Minimum Data Set (MDS) Assessment, dated 10/11/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as having an indwelling suprapubic catheter and as always incontinent of bowels. Observation during initial tour of D-Wing, on 12/17/19 at 10:14 AM, revealed Resident #59 was in bed with eyes closed. The resident's suprapubic catheter urinary drainage bag was hanging from the lower bed rail and lying on the floor near the foot of the bed. Observation on 12/17/19 at 10:23 AM, revealed Resident #59 was sitting up in bed with eyes closed and his/her urinary drainage bag was hanging on the bed rail and touching the floor. Interview with Licensed Practical Nurse/Unit Manager of D-Wing, on 12/17/19 at 11:12 AM, revealed Resident #59 had an indwelling suprapubic catheter and received catheter care every shift as per Physician's Orders. Observation on 12/17/19 at 11:25 AM, revealed Resident #59 was lying in bed, and his/her urinary drainage bag remained on the floor. Interview with Resident #59, on 12/17/19 at 11:30 AM, revealed he/she was unaware of any current or past urinary tract infections. Continued interview revealed Resident #59 attended dialysis off-site, three (3) times each week on Monday, Wednesday and Friday. Interview was conducted, on 12/17/19 at 12:45 PM, with State Registered Nurse Assistant (SRNA) #9, who was currently assigned to Resident #59, and was also assigned to the resident during the observations of the resident having the urinary drainage bag on the floor. SRNA #9 stated she was routinely assigned to the resident and was familiar with his/her care. Further interview revealed she should have ensured the resident's urinary drainage bag was positioned at a level below the resident's bladder, but in a manner that prevented the bag from touching the floor. Continued interview revealed if the urinary drainage bag was touching the floor, the likelihood for urinary infections would be increased due to potential for cross-contamination from bacteria, germs or other microorganisms present on the floor. Observation on 12/17/19 at 1:00 PM, revealed Resident #59's urinary drainage bag remained on the floor while the resident was in bed eating lunch independently following tray set up provided by staff. Interview on 12/17/19 at 1:10 PM, with Licensed Practical Nurse (LPN) #4, who was assigned to Resident #59, revealed urinary drainage bags were never to be on the floor. LPN #4 stated the urinary drainage bags were to remain at a position below the resident's bladder, secured to to the resident with a leg strap (if Foley) or dry dressing (with Suprapubic) and placed in a manner to allow for proper urine flow. Further interview revealed the urinary drainage bags should not be on the floor, as there was microorganisms, bacteria and other germs on the floor that could potentially enter the urinary drainage bag and cause infection or illness to the resident. LPN #4 stated the indwelling catheter urinary drainage bag should be removed and replaced if observed on the floor. Interview on 12/18/19 at 9:30 AM with Unit Manager #1, revealed indwelling catheter urinary drainage bags should be positioned below the resident's bladder and off the floor in order to prevent the potential for urinary tract infections through cross contamination of bacteria and other germs that may be on floor. Interview on 12/19/19 at 2:45 PM, with the Staff Development Coordinator (SDC), revealed she was responsible for ensuring licensed nursing staff and SRNAs received Infection Control and Prevention education and training, including competency check-offs with return demonstration by both newly hired staff and those currently employed with the facility. Further interview revealed it was her expectation staff position the suprapubic catheter urinary drainage bags properly and off the floor in order to prevent potential cross contamination which could cause illness or infection. Continued interview revealed the SDC performed random audits on each unit weekly to ensure staff performed skills efficiently and effectively. Per interview, infection control as it related to handwashing/hand hygiene, gloving technique, transporting clean and soiled linens, and urinary catheter care were all topics covered by the random audits that she and other department heads performed. Additional interview revealed the SDC had not identified any concerns regarding catheter care or urinary drainage bags being on the floor, and therefore had not performed any recent staff in-servicing related to this. Interview on 12/19/19 at 4:10 PM, with the Director of Nursing (DON), revealed she expected staff to follow facility policy and practices related to infection control and prevention. Further interview revealed the DON expected staff to position the resident's suprapubic catheter urinary drainage bag below the level of the bladder and secure the bag as to not allow the bag to touch the floor which could cause cross contamination, and lead to infections and illness. Interview on 12/19/19 at 4:30 PM, with the Administrator, revealed it was her expectation for staff to follow facility policy and practices related to infection control and prevention at all times. Further interview revealed staff were expected to properly secure and position the indwelling catheter urinary drainage bags in order to prevent the bags from touching the floor, and causing the potential for cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management for one (1) out of four (4) sampled residents (Resident #342). Resident #342 was prescribed Neurontin for pain; however, the facility failed to administer the medications on 11/13/18 and 11/14/18. The findings include: Review of the facility's policy Medication Administration General Guidelines dated 05/16, revealed medications were administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices. Further review revealed medications were administered in accordance with written orders of the prescriber. Review of the facility's policy Pain Management At-A-Glance undated, revealed for resident's exhibiting pain that was not relieved to a satisfactory level as indicated in the care plan by current medication/comfort measure, staff were to ensure that ordered medications were available for use, or obtained in a timely manner. Review of Resident #342's medical record revealed the facility admitted the resident on 11/09/18, with diagnoses to include Coronary Atherosclerosis, Acute Non-traumatic Kidney Injury, Anasarca, Hypothermia, Diabetes Mellitus, Decline in Functional Status, Asthenia, Hypertension, and Degenerative Myelopathy. Review of Resident #342 admission care plan, dated 11/09/18, revealed the facility identified the resident had right hip pain related to diseases of the spinal cord, and developed an intervention to administer pain medication as ordered by the physician. Review of the Physician Order Sheet for Resident #342 revealed an order dated 11/09/18, to administer Neurontin 300 milligram (mg) one (1) capsule four times daily at 12:00 PM, 6:00 PM, 12:01 AM, and 6:00 AM for pain. Review of the Medication Administration Record (MAR) dated 11/01/18 to 11/30/18, revealed Resident #342 did not receive the 12:00 PM or 6:00 PM scheduled 300 mg dose of Neurontin on 11/13/18. Further review of the MAR revealed Resident #342 did not receive his/her 12:01 AM or 6:00 AM scheduled 300 mg dose of Neurontin on 11/14/18. Observation of the Unit A medication cart, on 11/13/18 at 11:27 AM, revealed Neurontin 300 mg capsule for Resident #342 was not available. Observation of the Unit A medication cart, on 11/14/18 at 11:30 AM, revealed Neurontin 300 mg capsule for Resident #342 continues to be unavailable. Interview with Resident #342, on 11/14/18 10:10 AM, revealed he/she was stiff on 11/13/18 but not in a lot of pain. Continue interview revealed, on 11/14/18, Resident #342 was having sharp pain then dull pain to the right lower back that he/she rated to be an eight (8) out of ten (10), ten (10), with being the most pain ever felt. Resident #342 stated, that he/she struggled to get through some exercises this morning due to the pain. Resident #342 stated, he/she was given Tylenol, but it did nothing for the pain. Interview with Licensed Practical Nurse (LPN) #3, on 11/14/18 at 2:36 PM, revealed she would count to see how many days were left of a resident's narcotic prescription, and would then reorder the medication accordingly. Continued interview revealed, Resident # 342 was discharged from the hospital on [DATE] with a prescription for 12 capsules of Neurontin 300 mg. She further stated Resident #342's physician had not written a new prescription once the resident was admitted by the facility and as a result, the resident ran out of medication on 11/13/18. Further interview revealed the facility should not allow a resident to run out of their pain medication. She stated, if a resident ran out of pain medication they could have increased pain, which could also cause them to refuse therapy, and therapy was the reason most residents were on Unit A. Interview with Registered Nurse (RN) #1, on 11/14/18 at 2:20 PM, revealed she uses the number scale to assess residents with pain, for residents with dementia she stated behaviors and expressions were used to assess for pain. She further stated, nurses use the computer to chart a follow up on effectiveness of pain medications administered. Continued interview revealed, she would audit the medications and order any needed medications two days before the resident was scheduled to run out. She further stated, when narcotics need to be ordered, staff call the resident's physician and inform them that a prescription was needed. Per interview, staff then inform the facility's pharmacy service to send a prescription request form to the resident's physician. Further interview revealed, if a resident ran out of pain medication, the resident could have withdrawal symptoms and increased pain. Interview with the Assistant Director of Nursing, on 11/14/18 at 3:34 PM, revealed it was her expectation that medications would be reordered when the nurse passing medications notices they are getting low. She further stated if a resident did not have their pain medication when it was due, the resident's pain could increase. Continued interview revealed it was the nurse's responsibility to make sure resident's do not run out of medication. Interview with the Director of Nursing, on 11/14/18 at 3:49 PM, revealed she receives a report fourteen (14) days before a controlled medication needs to be reordered. Continued interview revealed nurses were able to call the pharmacy to order medications and nurses were able to click reorder on the facility computer. Further interview revealed, her expectation was that the residents would not run out of their medications. She further stated, it was the nurse's responsibility to make sure residents did not run out of medication. She stated if a resident did run out of pain medication they could die, they could be in pain, or their blood pressure could go up. Interview with the Administrator, on 11/14/18 at 3:56 PM, revealed her expectation was for nursing to put together some way of monitoring resident medications, and medications should be ordered promptly. Continued interview revealed the resident could be in pain if their pain medication was not available.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observations revealed the medication storage rooms to contain opened medications without labels or expiration dates. Further observation revealed the medication refrigerator in two of the medication storage rooms had refrigerator temperatures missing on the temperature log. The findings include: Review of the facility's policy titled, Medication Administration General Guidelines, dated 05/2016, revealed medications are administered as prescribed in accordance with manufacturer's specifications, and good nursing principles and practices. Per policy, the nurse shall place a date opened sticker on the medication if one is not provided by the dispensing pharmacy. Continued review revealed the date medication was opened should be enter on the sticker. Further review revealed, once opened, certain products or package types such as multi-dose vials and ophthalmic drops have specified shortened end-of-use dating to ensure medication purity and potency. Review of the Food and Drug Administrations insert, regarding Tuberculosis Purified Protein Derivative- TUBERSOL, revealed the medication should be stored at thirty-five to forty-six (35-46) degrees Fahrenheit, and protected from light. Further review revealed a vial of TUBERSOL which has been entered (opened) and in use for thirty (30) days should be discarded. Observation, on 11/13/18 at 1:00 PM, of the A Wing Medication Storage Room refrigerator revealed two (2) Tuberculin Purified Protein Derivative 5TU/0.1mL vials opened and undated. Further observation revealed missing medication refrigerator temperatures for the month of November on the dates of the 2nd, 8th and the 9th. Observation, on 11/13/18 at 1:20 PM, of the Reflection Wing Medication Storage Room refrigerator revealed an opened and expired Tuberculin Purified Protein Derivative 5TU/0.1mL vial dated 09/30/18 available for resident use. Interview with LPN #1, on 11/14/18 at 3:00 PM, revealed Tuberculin Solution should be dated when it was first opened. She stated it was also nursing's responsibility to check the opened date before administering the medication to make sure the medication was not expired. If the medication was not dated correctly then it could be expired and no longer any good. She further stated that night shift was responsible for monitoring and recording refrigerator temperatures, and if the fridge was too hot or too cold then the medication would not usable. Interview with LPN #2, on 11/14/18 at 3:10 PM, revealed she would date the Tuberculin Solution as soon as it was opened. Continued interview revealed if it was not date then the medication could be expired and no longer useful. She also stated it was night shifts responsibility to monitor refrigerator temperatures, and without proper temperature control medications would not be any good. Interview with the A Wing Unit Manager, on 11/14/18 at 3:50 PM, revealed it was the responsibility of whomever opened the vial of Tuberculin Solution to date the vial. She stated it was her responsibility to go through the medication refrigerators and monitor the medications. She stated it was night shifts responsibility to monitor the refrigerator temperatures, and the importance of doing so was to make sure the refrigerator was within the normal ranges to make sure medications were at the correct temperatures. Further interview revealed, if the medication were not maintained at the correct temperatures they would not work. Interview with the Assistant Director of Nursing (ADON), on 11/14/18 at 3:55 PM, revealed it was her expectation for medications to be labeled when they were opened and the facility's policy be followed by staff. She stated the importance of labeling medications was to note when the medication expired and thus knowing it was still effective. Further interview revealed it was her expectation for refrigerator temperatures to be monitored and that it was the unit manager's responsibility that it was completed. She further stated the importance of monitoring temperatures was to make sure medications were kept within the correct temperature ranges and nothing ruins. Interview with the Director of Nursing (DON,) on 11/14/18 at 4:00 PM, revealed it was her expectation that staff date vials when they were opened. She stated it was night shift nurses and the unit manager's responsibility to monitor the refrigerator temperatures, and that they should be monitored regularly. Further interview revealed it was important to monitor refrigerator temperatures due to the fact that incorrect temperatures could ruin medications. Interview with the facility's Administrator, on 11/14/18 at 4:10 PM, revealed it was her expectation for medications to be labeled when they were opened and stored properly in the refrigerator, also medications should be disposed of properly when they had expired. It was her expectation that temperatures were to be monitored regularly on the refrigerators. The unit managers were responsible for making sure the temperatures were being recorded accurately.

Based on observation, interview, and review of the facility's Policy and Plan of Correction (POC) for the Abbreviated/Partial Extended and Standard Survey dated 11/16/17, it was determined the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) that developed and implemented effective plans of action to correct quality deficiencies. This was evidenced by the repeat deficiency from the Abbreviated/Partial Extended and Standard Survey, conducted on 11/12/18, related to the facility's failure to ensure proper storage of drugs and biological's at 42 CFR 483.45 Pharmacy Services, F-761. (Refer to F-761) Findings include: Review of the facility's Quality Assurance and Performance Improvement (QAPI) Guideline undated revealed the QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments. When fully implemented, the QAPI program should address all systems of care and management practices, and should always include clinical care, quality of life, and resident choice. Continued review revealed, the Governing Body should foster a culture where QAPI is a priority by ensuring that policies are developed to sustain QAPI despite changes in personnel and turnover. Their responsibilities include, setting expectations around safety, quality, rights, choice and respect by balancing safety with resident-centered rights and choice. The Governing Body ensures staff accountability. The facility puts systems in place to monitor care and services, drawing data from multiple sources. The facility conducts Performance Improvement Projects to examine and improve care or services in areas that the facility identifies as needing attention. Further review revealed, the facility uses a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the was services are organized or delivered. Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. During this Revisit Survey, it was identified the facility failed to ensure proper storage of drugs and biologicals. This was a repeat deficiency for the facility which was cited 11/16/17 for medication cart and/or rooms which contained multi-dose vials of medications which had been opened with no open date. Review of the facility's Plan of correction (POC), with a compliance date of 12/24/17, revealed on 11/14/17 all unit medication storage refrigerators in this facility were audited by the Unit Managers and Nurses to identify any opened or undated medication. Per review of the POC, on 11/15/17, all medication carts in the facility were audited by the unit managers and nurses to identify any open or undated medications. Additionally, review of the POC, revealed the Staff Development Coordinator provided education to all Kentucky Medication Aide (KMA's) and nurses regarding when medications were opened they would be immediately dated. Continued review of the POC revealed beginning 11/15/17 the DON, Unit Managers and nurses would complete audits daily for seven (7) days , then two (2) times per week ongoing on Tuesdays and Fridays. Per review of the POC, any issues would be immediately corrected by the DON, Staff Development Coordinator, Unit Managers, or licensed staff with ongoing education provided as needed. Further review of the POC revealed, the results of the audits as well as the education would be presented to the monthly QAPI Committee for review and recommendation. Interview with facility staff revealed the facility implemented the POC related to proper storage of drug and biologicals; however, observation during the Standard Survey on 11/13/18, revealed monitoring was ineffective in ensuring overall compliance with labeling and storage of medications and biologicals. Observation, on 11/13/18 at 1:00 PM, of the A Wing Medication Storage Room refrigerator revealed two (2) Tuberculin Purified Protein Derivative 5TU/0.1mL vials opened and undated. Furthermore, observation on 11/13/18 at 1:20 PM, revealed the Reflections Wing medication storage room refrigerator to have an opened Tuberculin Purified Protein Derivative 5TU/0.1mL vial, with an open date of 09/30/18 marked on the vial, accessible for use. Interview with the A Wing Unit Manager, on 11/14/18 at 3:50 PM, revealed it was the responsibility of whomever opened the vial of Tuberculin Solution to date the vial. She stated it was her responsibility to go through the medication refrigerators and monitor the medications. Interview with the Assistant Director of Nursing (ADON), on 11/14/18 at 3:55 PM, revealed it was her expectation for medications to be labeled when they were opened and the facility's policy be followed by staff. She stated the importance of labeling the medications with the date opened, was to note when the medication expired and thus knowing it was still effective when administered to the facility's residents. Interview with the Director of Nursing (DON,) on 11/14/18 at 4:00 PM, revealed it was her expectation that staff date vials when they were opened to know when the medication had expired. Continued interview revealed, the medication should be discarded if it was open with no date on the label. Interview with the facility's Administrator, on 11/14/18 at 4:30 PM, revealed it was her expectation for medications to be labeled when they were opened and stored properly in the refrigerator, also medications should be disposed of properly when they had expired. Per interview, education and audits were completed per the Plan of Correction, with a compliance date of 12/24/17. Continued interview revealed, staff continued to perform spot checks on the unit's medication storage room refrigerators. Per interview, the unit managers were responsible to spot check the medications monthly and the spot checks had been completed up until this week. Continued interview revealed, she felt this was not a failure in QAPI. Further interview revealed she felt the issue was the A wing unit refrigerator was too small and it was difficult to see things in the refrigerator and it was missed. She stated, there was so much in the refrigerator, such as the flu vaccines, it was crammed in there. Per interview, a larger refrigerator may help with this issue.