Chestnut Ridge Health & Rehabilitation

Based on interview, record review and review of the facility's policy, the facility failed to ensure residents received a therapeutic diet per the physician's order for 1 of 7 residents sampled for diets out of the total sample of 21 residents, (Resident (R)86). The physician ordered a pureed diet for R86; however, on 04/25/2025, a Certified Nurse Assistant (CNA) gave the resident a peanut butter sandwich. R86 choked on the sandwich and subsequently lost his pulse. The Emergency Medical Services (EMS) transferred R86 to a hospital where R86 expired. Review of the official Kentucky Certificate of Death listed the immediate cause of death as, choking on a food bolus. Immediate Jeopardy was identified on 09/19/2025 and was determined to exist as of 04/25/2025 (the day R86 choked on the sandwich), in the area of 42 CFR 483.60, Food and Nutrition Services. The Administrator was notified of the Immediate Jeopardy on 09/19/2025 at 6:01 PM and provided a copy of the CMS IJ Template and was notified that the facility failed to have a system to ensure residents received physician ordered, therapeutic diets. The facility provided an acceptable plan for removal of the Immediate Jeopardy on 09/20/2025 at 9:58 AM. The survey team validated the Immediate Jeopardy was removed on 04/29/2025 following the facility's implementation of the plan of removal of the Immediate Jeopardy. The facility's alleged date of compliance was 08/01/2025. The Immediate Jeopardy was determined to be past non-compliance. Review of the facility's policy titled Specialized Diets dated 10/01/2021 revealed that attending physicians prescribe therapeutic diets to support resident treatment and the plan of care. The policy defined mechanically altered diets as foods modified in texture or consistency to facilitate oral intake and thickened liquids as dietary adjustments intended to prevent choking. Further, the policy stated that snacks will be compatible with therapeutic diets. No policy or standard was provided or obtained from the facility regarding what food items were acceptable for the different types of therapeutic diets. However, review of the National Dysphagia Diet Task Force (2002), Dysphagia Diet Level 1 revealed to avoid breads not pureed, and peanut butter, unless purred into another food item. Review of Resident (R) 86's admission Record revealed an admission date of 07/14/2015 with diagnoses including unspecified cerebrovascular disease, anoxic brain damage, dementia, dysphagia - oropharyngeal phase (difficulty in swallowing), generalized anxiety disorder, major depressive disorder, and disturbances of salivary secretion. A Quarterly Minimum Data Set (MDS) Assessment, dated 07/18/2024, identified the resident with a Brief Interview of Mental Status (BIMS) score of 8/15, consistent with severe cognitive impairment.Review of the facility's comprehensive care plan for R86 initiated on 09/26/2018, revealed R86 has altered nutrition related to multiple diagnoses such as dysphagia, bipolar disorder, anoxic brain damage, mood and impulse disorders, dementia, type II diabetes mellitus, and unspecified protein-calorie malnutrition. Interventions included a physician-ordered general pureed diet with nectar-thickened liquids (NTL), initiated on 11/23/2024, and nutritional supplements per physician order, initiated on 02/07/2023. A subsequent care plan initiated on 06/30/2021 revealed risk for aspiration (inhaling food, liquid or other foreign substances instead of swallowing), with interventions including dietician and therapy consultation as needed, and provision of a modified diet. Another care plan initiated on 10/26/2022 documented the resident's behavior of chewing on foreign objects, including his fingers and fingernails, with interventions including the provision of a snack, initiated on 04/05/2023.Review of the physician's orders located in the Electronic Medical Record (EMR) revealed several changes to the resident's diet. On 04/04/2023, the order reflected a general diet with regular consistency and thin liquids. On 04/10/2023, the order was changed to a general diet with regular texture and NTL. On 11/05/2024, the order was changed to a mechanical soft texture with thin liquids. On 11/08/2024, the order was changed to a regular diet, pureed texture with NTL, sugar-free condiments, and beverages. The Order Summary Report also reflected one-to-one (1:1) staff supervision from 6:30 PM-6:30 AM, and 15-minute checks during daytime hours related to behaviors. Review of the Speech Therapy records revealed a referral on 11/05/2024 following an incident where R86 had choked on a peanut butter sandwich. An evaluation revealed swallowing disorders involving the pharyngeal and esophageal phases. The Speech-Language Pathologist (SLP) recommended a mechanical soft diet with thin liquids and explicitly noted no peanut butter sandwiches. A Fiberoptic Endoscopic Evaluation Swallow (FEES) study performed on 11/08/2024 revealed a decline from prior studies, and the SLP recommended a pureed diet with NTL. Therapy Encounters notes between 11/05/2024 and 12/24/2024 documented ongoing treatment, repeated education of staff and the resident, and trials of mechanical soft food and thin liquids. Despite occasional therapeutic trials, the physician order as of 11/08/2024 remained a pureed diet with NTL.Review of the facility's Initial Incident Report dated 04/25/2025 revealed CNA 11 was the sole witness to an incident at 6:40 PM when R86 requested CNA 11 to give him a peanut butter sandwich, which was not part of his physician-ordered diet. R86 started to eat the sandwich. NEED TO SAY GOT CHOKED , ETC.The report revealed the resident experienced a change in condition, required the Heimlich maneuver and Cardio-Pulmonary Resuscitation (CPR), and was transferred to the hospital, where he expired later that evening. The Kentucky Certificate of Death listed the immediate cause of death as choking on a food bolus.Review of the facility's 5-Day Follow-Up Report dated 04/30/2025 confirmed the resident was provided a snack inconsistent with his prescribed diet. The report described unsuccessful attempts with the Heimlich maneuver, CPR initiation by staff, and transfer to the hospital by EMS. Review of staff attestations revealed CNA 11 stated she provided the peanut butter sandwich at the resident's request. Further review revealed CNA 11 acknowledged she was aware R86 was ordered a pureed diet, but she had observed him eating peanut butter sandwiches previously without difficulty. The statement confirmed the resident choked, became distressed, and CPR was initiated until EMS assumed care. Statements from Registered Nurse (RN) 1, Licensed Practical Nurse (LPN) 6 and LPN 7 confirmed their actions during the code, including attempts at the Heimlich maneuver, initiation of CPR, and coordination with EMS.In an interview with CNA 11 on 09/19/2025 at 3:13 PM, she stated she was assigned to provide 1:1 care for R86 on 04/25/2025. She stated a peanut butter sandwich, milk carton, and banana were already present on R86's bedside table. She stated she was aware that R86 was ordered a pureed diet. She stated she had previously observed him eating peanut butter sandwiches without difficulty. She stated she opened the sandwich for him, and after nearly finishing it, he began choking. She attempted the Heimlich maneuver and called for help. Two nurses entered and took over as she called 911. She stated the resident became unconscious, CPR was initiated, EMS arrived, and he was transported to the hospital.In an interview with CNA 12 on 09/19/2025 at 9:19 AM, she stated that the last time she had provided 1:1 care for the resident, approximately two weeks earlier, his diet was pureed with NTL. She stated all staff were aware the resident was restricted from peanut butter sandwiches and that alternative snacks such as pudding and applesauce were available. She stated she had never observed the resident eating a peanut butter sandwich or choking, although he frequently coughed even when not eating or drinking.In an interview with CNA 13 on 09/19/2025 at 3:35 PM, he stated he was aware of the resident's swallowing difficulties and his ordered pureed diet with NTL. He stated when he had previously provided 1:1 care for R86, the resident never requested food outside of his diet order, although he frequently asked for snacks. CNA 13 stated CNA 11 had multiple options to verify the resident's diet order, including reviewing the KARDEX (a nursing tool that serves as a care plan chart or template to manage and reference critical resident/patient information), checking the EMR, or asking the nurse, and that she (CNA11) failed to do so. In an interview with CNA 20, on 09/20/2025 at 2:15 PM, she stated she received training on diets at hire and annually thereafter. She stated staff were instructed to check diet orders when residents were admitted , returned from the hospital, or experienced a change in condition. CNA 20 stated that when a resident asked for food, staff were to check the diet, confirm with the nurse, and provide the snack only if it was consistent with the orders. She stated that peanut butter and jelly sandwiches were not part of a pureed diet.In an interview with the MDS Coordinator, on 09/19/2025 at 4:29 PM, he stated the sandwich provided to R86 was inconsistent with his diet order. He stated the 1:1 care sheet included diet information, and the diet orders were available in the KARDEX and care plans. He stated that it was important for all staff to be able to access diet orders to ensure residents' safety.In an interview with the Assistant Director of Nursing (ADON) on 09/19/2025 at 3:26 PM, she stated CNAs can find diet orders on the KARDEX, which includes all relevant diet and Activities of Daily Living (ADLs) information. She reported that if CNAs were uncertain, they were to ask the nurse.In an interview with the Director of Nursing (DON) on 09/19/2025 at 11:00 AM, she stated there had been a prior incident in November 2024 when the resident choked on a peanut butter sandwich, which required the Heimlich maneuver. She stated that following that incident, the physician referred the resident to Speech Therapy, which completed a swallow study and recommended a pureed diet with NTL. The DON stated CNA 11 was suspended immediately following the April 2025 incident and terminated effective 05/01/2025 for failing to follow diet orders. She confirmed the resident's ordered diet was accurately reflected in the KARDEX.In an interview with the Administrator on 09/19/2025 at 4:43 PM, she stated she was notified of the incident immediately and the CNA was removed from the care area. She stated her expectation was staff verified diet orders through the KARDEX and confirmed with a nurse when in doubt, to prevent errors and protect residents.The facility provided an acceptable plan for removal of the Immediate Jeopardy on 09/20/2025 at 11:03 AM.The survey team validated the Immediate Jeopardy was removed on 04/29/2025 following the facility's implementation of the plan of removal of the Immediate Jeopardy. The facility's alleged date of compliance is 08/01/2025. The deficient practice was determined to be past non-compliance.The Removal of Immediate Jeopardy/Past Non-compliance was validated with implementation of the following measures:The Immediate Jeopardy identified at F803, related to the facility's failure to follow R86's physician-ordered therapeutic diet, was removed on 04/29/2025. The facility's plan of removal, submitted and initiated on 04/25/2025, was reviewed and validated through interviews, observations, record review, and audit verification on 09/20/2025.On 04/25/2025, all mechanical soft and pureed snacks in the snack room and refrigerator were labeled by the Dietary Manager with the appropriate consistency. The Administrator reviewed all snacks and supplemental foods available outside of meal service to ensure compliance with current diet orders. Education was initiated immediately by the Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator for all licensed nurses, certified medication technicians, and certified nurse aides. Staff were instructed on the new process for labeled snacks, the requirement to verify diet orders through the Kardex, care plan, or physicians' order, and the inappropriateness of peanut butter on a pureed diet unless blended to proper consistency under IDDSI standards. All staff completed return demonstrations prior to working their next scheduled shifts, and competency validation was confirmed.A 100% audit of all resident diet orders and Kardex entries was completed on 04/25/2025 by the DON, MDS nurse, and Regional Nurse. On 04/26/2025, the ADON completed a 100% audit of all physician diet orders in Point-Click-Care against tray tickets to ensure accuracy. Ongoing monitoring was implemented, including nursing audits of 10 trays per week for four weeks, followed by 10 trays monthly for three months, and the Administrator audited snacks three times per week for four weeks, then decreased frequency over the following two months.The Administrator and DON confirmed that all new hires will receive training on therapeutic diets, Kardex review, and snack verification during orientation prior to assuming care responsibilities.The QAPI Committee held an ad hoc meeting on 04/28/2025 to review corrective actions, with a monthly follow-up scheduled for three months. The Medical Director was notified on 04/26/2025 of all corrective measures and ongoing monitoring efforts and agreed with the plan.Through interviews with staff, review of educational materials and attendance records, validation of snack labeling and tray card audits, and confirmation of QAPI oversight, the survey team determined the Immediate Jeopardy was removed on 04/29/2025, although the facility remained out of compliance at F803 until 08/01/2025, the facility's alleged date of compliance for the IJ tags (F656 and F803). Top of Form Bottom of Form

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, individualized care plan that accurately reflected the nutritional and dietary needs for 1 of 7 residents sampled for dietary needs out of the total sample of 21 residents, (Resident (R)86). The facility failed to develop and ensure R86's care plans accurately reflected the resident's risk for choking, the Speech Therapy (ST) recommendations, dietary consistency requirements, and safe snack provisions consistent with the resident's physician's orders and with interventions necessary to address the risk. On 04/25/2025, Certified Nurse Aide (CNA) 11 gave R86 a peanut butter sandwich, the resident choked on the sandwich, became unresponsive, and eventually expired at the hospital. The official Kentucky Certificate of Death noted R86's immediate cause of death as choking on a food bolus (when an aspirated material occludes the upper airways resulting in the inability to breathe). Immediate Jeopardy (IJ) was identified on 09/19/2025 and was determined to exist as of 04/25/2025 (the day R86 choked on the sandwich), in the area of 42 CFR 483.21, Comprehensive Person-Centered Care Planning. The Administrator was notified of the Immediate Jeopardy on 09/19/2025 at 6:01 PM and was provided a copy of the CMS IJ Template notifying the facility of its failure to ensure residents had the necessary care plans to address a resident's risk for choking. The facility provided an acceptable plan for removal of the Immediate Jeopardy on 09/20/2025 at 9:58 AM. On 09/20/2025, the State Survey Agency (SSA) team validated the IJ was removed on 04/29/2025, following the facility's implementation of the IJ removal plan. The facility's alleged date of compliance was 08/01/2025. The IJ was determined to be past. The findings include: No policy related to resident centered care plans was provided or obtained. Review of the facility's policy titled Specialized Diets dated 10/01/2021 revealed that attending physicians prescribe therapeutic diets to support resident treatment and the plan of care. The policy defined mechanically altered diets as foods modified in texture or consistency to facilitate oral intake and thickened liquids as dietary adjustments intended to prevent choking. Further, the policy stated that snacks will be compatible with therapeutic diets. No policy or standard was provided from the facility regarding what food items were acceptable for the different types of therapeutic diets. However, review of the National Dysphagia Diet Task Force (2002), Dysphagia Diet Level 1 revealed to avoid breads not pureed, and peanut butter, unless purred into another food item. Review of the facility's comprehensive care plan for Resident (R) 86 for altered nutrition, dated 09/26/2018, revealed no specific interventions directing staff to ensure all snacks provided outside of scheduled meals met the resident's ordered therapeutic diet. The care plan only stated for the diet per physician's orders, general pureed and nectar thick liquids (NTL). Review of the Speech Therapy records revealed a referral on 11/05/2024 following an incident where R86 choked on a peanut butter sandwich. An evaluation revealed swallowing disorders involving the pharyngeal and esophageal phases. The Speech-Language Pathologist (SLP) recommended a mechanical soft diet with thin liquids and explicitly noted no peanut butter sandwiches. A Fiberoptic Endoscopic Evaluation Swallow (FEES) study performed on 11/08/2024 revealed a decline from prior studies, and the SLP recommended a pureed diet with NTL (nectar thick liquids). Therapy Encounters notes between 11/05/2024 and 12/24/2024 documented ongoing treatment, repeated education of staff and the resident, and trials of mechanical soft food and thin liquids. However, despite occasional therapeutic trials, the care plan was not developed to include individualized interventions to include the SLP's recommendations. Review of the facility's Initial Incident Report dated 04/25/2025 revealed a Certified Nursing Assistant (CNA) was the sole witness to an incident at 6:40 PM when R86 requested the CNA to give him a peanut butter sandwich, which was not part of his physician-ordered diet. R86 started to eat the sandwich. The report revealed the resident experienced a change in condition [choked] and required the Heimlich maneuver and Cardio-Pulmonary Resuscitation (CPR). R86 was transferred to the hospital, where he expired later that evening. The official Kentucky Certificate of Death noted R86's immediate cause of death as choking on a food bolus (when an aspirated material occludes the upper airways resulting in the inability to breathe).Review of the facility's 5-Day Follow-Up Report dated 04/30/2025 confirmed the facility provided a snack [peanut butter sandwich] inconsistent with his prescribed diet. The report described unsuccessful attempts with the Heimlich maneuver, CPR initiation by staff, and transfer to the hospital by EMS. Review of staff attestations revealed CNA 11 stated she provided the peanut butter sandwich at the resident's request. Further review revealed CNA 11 acknowledged she was aware R86 was ordered a pureed diet, but she had observed him eating peanut butter sandwiches previously without difficulty. In an interview with CNA 11 on 09/19/2025 at 3:13 PM, she stated she was assigned to provide 1:1 care for R86 on 04/25/2025. She stated a peanut butter sandwich, milk carton, and banana were already present on R86's bedside table. She stated she was aware that R86 was ordered a pureed diet. She stated she had previously observed him eating peanut butter sandwiches without difficulty. She stated she opened the sandwich for him, and after nearly finishing it, he began choking. She attempted the Heimlich maneuver and called for help. Review of written statements from Registered Nurse (RN) 1, Licensed Practical Nurse (LPN) 6 and LPN 7 confirmed their actions during the code, including attempts at the Heimlich maneuver, initiation of CPR, and coordination with EMS.In an interview with CNA 12 on 09/19/2025 at 9:19 AM, she stated that the last time she had provided 1:1 care for the resident, approximately two weeks earlier. She stated R86's diet was pureed with NTL. She stated all staff were aware the resident was restricted from peanut butter sandwiches and that alternative snacks such as pudding and applesauce were available.In an interview with CNA 13 on 09/19/2025 at 3:35 PM, he stated he was aware of the resident's swallowing difficulties and his ordered pureed diet with NTL. CNA 13 stated CNA 11 had multiple options to verify the resident's diet order, including reviewing the KARDEX (a nursing tool that serves as a care plan chart or template to manage and reference critical resident/patient information), checking the EMR, or asking the nurse, and that she (CNA11) failed to do so.In an interview with Licensed Practical Nurse (LPN) 4 on 09/19/2025 at 4:33 PM, she stated she believed the Director of Nursing and someone else were responsible for developing care plans for the residents. She stated all staff help implement the care plans by doing the interventions for the residents. In an interview with the Dietary Manager on 09/20/2025 at 2:42 PM, he stated he started working in this facility on 08/01/2025, and on his first day of work in this facility, he ensured all snacks in the facility were labeled clearly with the type of modified diet consistency. Prior to his employment, all the snacks were in the refrigerators, but they were not labeled with the type of diet they fit into. After he began his employment, the Dietary Manager stated he labeled all the snacks himself, pureed, mechanical and regular for sandwiches, cookies, chips, peanut butter crackers, or any snack that was in the snack rooms. The Dietary Manager stated the labeling of snacks was supposed to already be in place, but someone had, .dropped the ball. In an interview with the MDS Coordinator on 09/19/2025 at 3:26 PM, he stated R86's care plans included all interventions regarding his diet orders. He stated he implemented care plans for residents based on physician's orders and multiple other factors. When asked why there were no interventions regarding the SLP's recommendations or the dietary manager's recommendations, he was not able to answer. The MDS Coordinator stated he and the Director of Nursing were responsible for developing care plans for the residents. In an interview of the Director of Nursing (DON) on 09/20/2025 at 2:52 PM, stated she and the MDS Coordinator were responsible for developing the residents' care plans.In an interview with the Administrator on 09/20/2025 at 3:02 PM, the Administrator confirmed that on 04/25/2025, care plans had not been developed to incorporate the dietary manager or the SLP's recommendations for modified diets, resulting in unsafe and inconsistent practice.The facility provided an acceptable plan for removal of the Immediate Jeopardy on 09/20/2025 at 11:03 AM.The survey team validated the Immediate Jeopardy was removed on 04/29/2025 following the facility's implementation of the plan of removal of the Immediate Jeopardy. The facility's alleged date of compliance is 08/01/2025. The deficient practice was determined to be past IJ.The Removal of Immediate Jeopardy Plan was validated with implementation of the following measures:On 04/25/2025, the Dietary Manager labeled all snacks/snack-room foods with correct consistency per residents' diet orders.On 04/25/2025, the DON, ADON, and SDC immediately educated all licensed nurses, CMTs, and CNAs regarding:Reviewing the care plan, KARDEX, and diet orders before providing snacks.IDDSI standards for puree and mechanical soft diets.Specific instruction that peanut butter was not allowed for puree diets unless blended with another food to meet puree consistency.Staff completed return demonstrations and will not work unsupervised until competency verified.Care plans for all residents on modified diets were immediately reviewed and updated by licensed staff to include:Speech therapist and dietary recommendations.Specific snack and supplemental food interventions.Cross-reference to diet order consistency requirements.Administrator initiated ongoing daily audits of snacks and care plans to ensure compliance.New staff will be educated during orientation and before working independently.

Based on interview, record review, and facility documentation, the facility failed to complete all pre-employment checks for 2 of 8 sampled new employees' files, (a Dietary Aide and Activities Assistant). The findings include:Review of the facility's policy Abuse,' revised 10/20/2022, revealed the facility was committed to developing and operationalizing policies for screening employees and protection of residents. Further, under the section labeled Screening, the policy stated the organization will screen potential employees for a history of abuse, neglect or mistreating residents. Additionally, multi-state registry checks and license verifications will be checked from every State registry established that the facility believed will include information on the individual.Review of the personnel file for the Dietary Aide (DA) revealed the facility hired the DA on 09/05/2025. Review of the personnel file for the Activities Assistant (AA) revealed the facility hired the (AA) on 09/11/2025. However, continued review revealed no documentation the facility completed the Kentucky (KY) Nurse Aide Abuse Registry check for either employee before they began working at the facility.In interview on 09/19/2025 at 3:14 PM, the Administrator stated the facility did not have anyone in the Human Resources (HR) position at the moment and she was filling in for the HR role for about a month. She stated the pre-employment checks were completed for every employee. The Administrator stated the facility completed license verifications for Certified Nurse Aides (CNAs) and nurses. She further stated the KY Nurse Aide Abuse Registry check was not completed for non-clinical staff as those staff did not have a license to verify. She also stated the pre-employment checks were completed to keep residents in the facility safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to provide necessary behavioral health services to thoroughly address the physical, mental, and psychosocial needs for one (1) of thirteen (13) sampled residents (Resident 6).
On 08/09/2023, Resident (R) 6, exhibited behaviors that initiated a Behavior Comprehensive Care Plan (CCP), on 08/10/2023, for staff to monitor and document R6's observed behaviors. Staff; however, were unable to recall the behavior that prompted the resident's care plan, and the behavior was not addressed in the Behavior Logbook or Behavior Charting. On 12/12/2023, the resident expressed to staff that R8 was calling him/her inappropriate names, and on 12/13/2023, the resident wrote a letter, in his/her notepad, indicating that if the facility did not address his/her concerns he/she would do something about R8. The resident's care plan was revised on 12/13/2023 for staff to ensure the resident felt safe and to ensure the needs of the resident were met. However, there was no documentation to support staff were educated on the resident's needs. Subsequently, on 12/14/2023, Resident (R) 6 threw coffee on R8 and R8 sustained a burn with an open blister on his/her upper chest.
The documentation provided by the Regional Nurse Consultant (RNC) revealed the resident was on the Behavioral Meeting caseload; however, no documentation was supplied to show evidence the facility monitored, discussed, or reviewed R6's behaviors, as per the Behavior Management Program policy.
(Cross Reference F656)
The findings include:
Review of the facility's policy titled, Behavior Management Program, undated, revealed it was the policy of the facility to assess those residents exhibiting challenging behaviors. Continued review revealed residents exhibiting significant behaviors were to be monitored through a team effort on a weekly basis, involving all applicable disciplines to best cater to the improvement of the resident's psychosocial status. Per policy review, the interdisciplinary team (IDT) members monitored residents with problematic behavior and consisted of but was not limited to the Director of Nursing (DON), Nursing management staff, Social Services staff, Psychiatrist, Psychologist, Attending Physician, Family, Administrator, and Activities. Continued review of the policy revealed the IDT was to appropriately determine clinical and psychosocial interventions to best address each resident's needs. Per review, any interventions and/or issues in need of review by the Psychiatrist were to be listed on the Psychiatrist referral form and addressed at the routine visit.
Further review of the facility's policy titled, Behavior Management Program, undated, for Special Elements, revealed the facility would complete the following: identification of the problematic behavior; assessment of new or worsening behavior symptoms; discuss with staff, Physician, and family members regarding the observance of the behavior and manifestation of the same to gain insight relative to the behavior and effective interventions. Continued review revealed the Special Elements also included: discussion with the facility's Psychiatrist/Psychologist regarding the resident's manifestation of behavior and/or evaluation if ordered by the attending Physician and the appropriateness of planned interventions. Review further revealed the Special Elements additionally included: initiation of the Behavior Management Logbook; educating staff members of specific interventions to be attempted for the individual resident exhibiting problematic behavior; weekly review of the resident's behavior, behavior management program and progress toward eliminating/controlling problematic behavior.
Review of Resident (R) 6's admission Record revealed the facility admitted R6 on 03/17/2021, with diagnoses that included malignant neoplasm of the larynx, acquired absence of larynx, Tracheostomy status, Schizoaffective disorder bipolar type, and Impulsiveness.
Review of R6's Social Service Progress Note, dated 08/09/2023, revealed the Social Services Director (SSD) documented, SSD was advised the resident was having behaviors today. Continued review revealed the SSD would schedule a care plan meeting with R6 and include the IDT and a local behavioral health services provider.
Review of R6's Comprehensive Care Plan (CCP) revealed the facility, on 08/10/2023, initiated a Behavior Care Plan with a focus on the resident's verbal aggression towards other residents. Interventions included to monitor and document R6's observed behaviors.
A review of R6's Quarterly Minimum Data Set (MDS) Assessment, dated 11/24/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) which indicated R6 had no cognitive impairment. Further review of the MDS, under Section E for Behaviors, revealed the resident was assessed to have no behaviors.
Review of the Nurses Progress Note related to Behavior Charting, dated 11/29/2023 at 3:20 AM, revealed R6 was throwing his/her drink on the floor, slamming the bedroom door, damaging the doorknob, having a tantrum, and refused his/her medication. However, there was no documentation to support the facility monitored the resident's behaviors after the incident, as per the resident's care plan. Additionally, there was no documentation to support the resident was referred to the Psychiatrist for her next routine visit, as stated in the facility's policy.
Review of the document titled, Behavior Meeting, dated 12/08/2023, revealed Advanced Practice Registered Nurse (APRN #1) attended the meeting. Continued review of the document revealed the Residents Reviewed section stated, Discussed resident seen on caseload today. Per the review, the residents' new behaviors were discussed, and they were added to the psychiatric (psych) caseload, and new orders were discussed. In addition, listed on the document in parenthesis were the names of five (5) residents; however, none of the residents discussed included R6.
Review of a letter provided by Resident (R)6, on 12/13/2023, revealed the resident had written the following on two (2) pieces of note paper: Dear [sic] Sate of Kentucky I want you to [sic] kenow about [sic] wanth [sic] goneing hear and [sic] there are some this system was ok at first[ sic] aulie they stare behind R8 [sic] asshloe talk about last night and say this that why he/she had bitch cancer you thank that take hell no not head [sic] hem in the hall way night. If you don't do [sic] someing about he/she I will stop [sic] he/she from [sic] takeing about [sic] peolepe and he/she [sic] wont [sic] stoping it well he/she will to [sic] beceuse had [sic] ut to hear with it now. He/She will be [sic] stop so [sic] [NAME] do hear now. Do you [sic] thank I [sic] caer so what?
R6's Comprehensive Care plan was updated on 12/13/2023 with new interventions for staff to ensure the resident felt safe and secure. Further review of the care plan revealed that trained staff would address the resident's needs.
Review of the Long-Term Care Facility- Self-Reported Incident Form, dated 12/14/2023, revealed on that date it was reported that R6 threw coffee on R8. Further review of the Form revealed a skin assessment was completed on R8, and the resident was observed to have a quarter-sized area on his/her chest.
Review of the Certified Nursing Assistant (CNA) Bath and Skin Report, dated 12/14/2023, revealed the Assistant Director of Nursing (ADON) assessed R8's skin after the coffee was thrown on him/her and documented R8 had an open blister on his/her upper chest.
Review of the resident's Physician Orders, dated 12/15/2023, revealed the resident was to have Triple Antibiotic External Ointment (Neomycin-Bacitraci-Polymyxin) applied to his/her upper chest topically one (1) time a day for an open blister. Further, review of the orders revealed staff was to monitor the blister/open area to the resident's upper chest for signs and symptoms of an infection every shift.
During an interview, on 12/15/2023 at 1:15 PM, R6 stated, by moving his/her lips, that he/she was angry earlier but was better now. R6 stated he/she threw coffee on R8 because he/she called him/her a bitch. R6 stated R8 had been calling him/her names for a long time.
During an interview, on 12/15/2023 at 8:30 AM, R8 stated last night he/she heard a knock at his/her door so he/she got out of bed, opened the door, and R6 threw coffee on him/her. R8 denied calling R6 names and denied talking with R6.
During an interview, on 12/16/2023 at 6:15 PM, Certified Nursing Assistant (CNA) 6 stated she had not received training from the facility before R6 threw coffee on R8 on how to manage R6's impulsive behaviors. However, the facility's Behavior Management Policy revealed staff would be educated on the resident's specific interventions, which included to monitor and document the resident's behaviors and ensure that the resident felt safe within the facility.
During an interview on 12/18/2023 at 1:24 PM, the State Survey Agency (SSA) Surveyor read the Social Services Director's (SSD) Progress Notes, documented on 08/09/2023, to the SSD. The SSD stated that though he documented the resident had behaviors on 08/09/2023, he was not sure what behaviors R6 displayed in his Note.
During an interview on 12/18/2023 at 12:10 PM, the Minimum Data Set (MDS) Coordinator stated she recalled discussing in the facility's morning meeting on Thursday 12/14/2023 that R8 called R6 a bitch. She stated R6 gave her a note the afternoon of 12/13/2023, and the note said something about R8 called him/her a bitch. The MDS stated she did not know if she told the facility's Administrator about the Note R6 showed her. She stated she told R6 to take the note to the State if you want, and further told the resident she did not want R6's note because there was nothing she was going to do with it. The MDS Coordinator stated the note was not addressed to her, it was addressed to the State and that R6 could write whatever he/she wanted to write. She further stated, we could not have prevented what happened, not even a little bit. However, review of the resident's care plan, dated 08/10/2023, revealed the resident's behaviors would be monitored and documented.
During an additional interview on 12/18/2023 at 2:20 PM, the MDS Coordinator stated she had removed the intervention to monitor R6's behaviors and document observed behaviors, and attempted interventions from the resident's care plan on that day. She stated she removed that information because the facility was not monitoring R6, and the facility did not have the monitoring tools that were requested by the State Survey Agency (SSA) Surveyor.
During an interview on 12/18/2023 at 2:30 PM, the Regional Nurse Consultant (RNC) stated the Behavior Meeting was held every other week on Fridays. She stated the resident behavior information that the facility used in the Behavior Meetings was the information staff talked about in each weekday morning meeting regarding resident behaviors. The RNC stated if someone told her a resident had a thumbs down day during the morning meeting, she would then relay that information in the Behavior Meeting. She stated any intervention from the behavior meeting was updated in the resident's care plan. She continued by stating she was unable to locate the facility's Behavior Meeting minutes for August 2023, which was the month the SSD documented R6 was having behaviors.
In an additional interview with the Regional Nurse Consultant (RNC), on 12/19/2023 at 10:20 AM, she stated the facility's nursing staff charted by exception which meant if a resident exhibited a problematic behavior, nursing should document the behavior in the resident's Progress Notes or behavior charting notes. The RNC stated if a Certified Nursing Assistant (CNA) observed behaviors in a resident they were to report it to the nurse, and the nurse was to document the behavior. The RNC further stated nursing staff knew to document residents' behaviors from the resident's care plan and from nursing huddles (meetings with nursing staff).
During an interview on 12/17/2023 at 12:22 PM, APRN #1 stated she provided psych med services for the facility and her last psychotherapy visit was on 12/08/2023. The APRN stated those visits were called behavior meetings, and were held at the facility every two (2) weeks on Fridays. The APRN stated if a resident had any agitation they talked about what needed to be done, and if it was an isolated incident they talked about what they needed to do. The APRN stated she saw the facility's residents for psych medications only. She stated she was very familiar with R6, and other medications R6 was taking. The APRN further stated she provided guidance to the facility's leaders and nurses on how to address R6's impulsivity when they talked about him/her in the behavior meetings. APRN #1 stated R6 got frustrated at times; however, was easily redirected. She stated, other than redirecting and talking to R6, there was no specific guidance on his/her outbursts that she provided to staff.
In further interview, with Advanced Practice Registered Nurse (APRN) 1, on 12/17/2023 at 12:22 PM, she stated she had not seen the facility's Behavior Management Program Policy, nor was she familiar with the Behavior Management Log Book. The APRN stated she was unaware if any individual monitoring records or Recommended Intervention Worksheet forms had been documented on R6, per the procedure of the facility's Behavior Management Program Policy. She stated the Assistant Director of Nursing (ADON) typically guided the behavior meeting, the Social Services Director (SSD), and the Director of Nursing (DON) also came in and discussed the residents. APRN 1 stated she usually told the ADON, the SSD, and the DON if she had seen the resident being discussed in the behavior meetings and informed them on how to proceed. She stated she was not aware of a formal guideline or protocol for the behavior meetings and stated the SSD kept track of the meetings. The APRN further stated she did not know R8 and was very surprised R6 threw coffee on him/her.
During an interview on 12/18/2023 at 1:50 PM, the DON stated any behaviors residents had since the last morning meeting were discussed. The DON stated if new interventions were added to a resident's care plan, she talked to nursing about the intervention and added it to her charting guide which she typed out for each resident who had a new behavior intervention. She stated if something new happened and a resident had a new care plan intervention, she let nursing know about it, so the facility could ensure the nurses were documenting the new intervention(s). The DON further stated if a nurse reported a behavior, then it was discussed in the next morning meeting.
During a telephonic interview on 12/19/2023 at 10:20 AM, the Administrator stated in the day-to-day life of the facility, people talked about other people. She stated she and the RNC heard about R8 calling R6 a bitch, on 12/12/2023 and discussed R6's concerns with both residents. According to the Administrator, R8 denied making any inappropriate comments to R6. The Administrator stated, however, she and the RNC were not aware of the Note R6 had shown to the MDS Coordinator nor were they aware the MDS Coordinator had removed the intervention from the resident's CCP to monitor R6's behaviors, document observed behaviors, and attempted interventions on 12/18/2023.
In an additional telephonic interview with the Regional Nurse Consultant (RNC), on 12/19/2023 at 10:25 AM, the RNC stated it would have been helpful to know about the Note R6 wrote and showed to the MDS Coordinator so the facility could have addressed any potential problems. The RNC stated if knowledge of the Note, on which R6 wrote R8's name and the word bitch and showed to the MDS Nurse, had been shared in the morning meeting on the 13th or 14th of December, the information would have been helpful to the facility so R6 could have been provided increased monitoring.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure residents' care plans were implemented to provide the proper care, monitoring and documentation to enable residents to have effective coping skills for one (1) of thirteen (13) sampled residents (Resident (R) 6).
On 12/14/2023, R6 threw coffee on R8 and R8 sustained an open blister/burn on his/her upper chest. Documentation provided by the facility revealed it failed to implement R6's comprehensive care plan to monitor the resident's behaviors and document observed behaviors, and attempted interventions after facility staff documented R6 was having behaviors on 08/09/2023. Staff learned on 12/13/2023 that R6 wrote a note on his/her notepad, which he/she showed to the Minimum Data Set (MDS) Coordinator, and the note indicated R8 called him/her a bitch.
Additionally, it was not validated R6's care plan was implemented as written, as there was no documentation noting the facility assessed R6's understanding of the situation or allowed time for the resident to express himself/herself and his/her feelings towards the situation.
The findings include:
Review of the facility's Careplan Policy, Effective Date: 09/01/2017, revealed it was the policy of the facility to ensure every resident had a Baseline Care Plan completed and implemented within forty-eight (48) hours of admission. Per policy review, the Baseline Care Plan was to be discontinued upon the completion of the resident's Comprehensive Care Plan (CCP). Review revealed the CCP would further expand on the resident's risks, goals and interventions using the Person-Centered Plan of Care approach for each resident, which included measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs. Continued review revealed those needs were to be defined from observation, interview, clinical medical record review and thorough assessments. Per review, the Minimum Data Set (MDS)/Care Plan Coordinator and/or ancillary MDS staff were to attend the facility's Morning/CQI meetings, where an in-depth review of the 24 Hour Report(s), completed in the prior Morning/CQI meeting were reviewed and discussed. Further review revealed during the facility's Morning/CQI meetings any new or changed orders, new admissions, readmissions, falls and other pertinent circumstances regarding the residents was discussed, and the care plans for those residents was revised and updated as necessary.
Review of R6's admission Record, revealed the facility admitted Resident #6 (R6) on 03/17/2021, with diagnoses that included Schizoaffective disorder bipolar type, Impulsiveness, malignant neoplasm of larynx, acquired absence of larynx, aphonia, and Tracheostomy status.
Continued record review revealed R6's Quarterly Minimum Data Set (MDS) Assessment, dated 11/24/2023, noted the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of 15, indicating he/she had no cognitive impairment.
Review of R6's CCP revealed on 08/10/2023, the facility initiated care plan interventions for the resident which focused on his/her verbal aggression towards other residents. Continued review revealed interventions included staff were to monitor R6's behaviors, document observed behaviors, and attempted interventions. Further review revealed additional interventions initiated on 08/10/2023 included staff were to assess R6's understanding of the situation and allow time for R6 to express self and feelings towards the situation.
During an interview, on 12/19/2023 at 10:20 AM, the Regional Nurse Consultant (RNC) stated the facility's staff charted by exception, which meant if a resident exhibited a problematic behavior, staff were to document the behavior in the resident's Progress Notes or behavior charting notes. The RNC stated if a Certified Nursing Assistant (CNA) observed behaviors in a resident they were to report that information to the nurse, and the nurse was to document the behavior. The RNC further stated staff knew to document resident behaviors from the resident's care plan and from nursing huddles, (morning meetings with nursing staff).
Review of the Progress Notes, dated 08/09/2023, revealed the Social Services Director (SSD) documented SSD advised that resident was having behaviors today. Continued review revealed the SSD would schedule a care plan (meeting) with R6, the interdisciplinary team (IDT) and a local behavioral health services provider.
During an interview, on 12/18/2023 at 1:24 PM, the Social Services Director (SSD) stated he was not sure what R6's behavior had been when he wrote the note.
During an interview on 12/18/2023 at 2:30 PM, the RNC stated the Behavior Meeting was held every other week on Fridays. She stated the resident behavior information which the facility used in the Behavior Meetings was the information about resident behaviors staff talked about in each weekday morning meeting. The RNC stated if someone told her a resident had a thumbs down day in the morning meeting, she relayed that information in the Behavior Meeting. She further stated any intervention from the bi-weekly behavior meeting was updated in the resident's care plan.
During an interview on 12/18/2023 at 1:50 PM, the DON stated any behaviors a resident had displayed since the last morning meeting was discussed. The DON stated if new interventions were added to a resident's care plan, she talked to nursing about the intervention and added it to her charting guide which she typed out for each resident who had a new behavior intervention. She stated if something new happened and a resident had a new care plan intervention, she let nursing know about the new intervention so the facility could ensure the nurses were documenting about the resident's new intervention. The DON further stated if a nurse reported a behavior then it was discussed in the next morning meeting.
During an interview on 12/18/2023 at 12:10 PM, the Minimum Data Set (MDS) Coordinator stated she recalled discussing in the facility's morning meeting on Thursday 12/14/2023, that R8 called R6 a bitch. She stated R6 gave her a note the afternoon of 12/13/2023, and said something about R8 called him/her a bitch. The MDS Coordinator stated she did not know if she told the facility's Administrator about the note R6 showed her. She stated she told R6 to take the note to State if you want, and she did not want R8's note because there was nothing she was going to do with it. The MDS Coordinator stated the note was not addressed to her, it was addressed to the State, and said R8 could write whatever he/she wanted to write. She further stated the facility could not have prevented what happened, not even a little bit.
Review of the Long Term Care Facility - Self-Reported Incident Form dated 12/14/2023, revealed documentation noting on 12/14/2023, it had been reported R6 threw coffee on R8. Continued review revealed the residents were immediately separated and R6 was placed on one-to-one (1:1) supervision until he/she could be sent out for psychiatric (psych) services.
Review of the CNA Bath and Skin Report, dated 12/14/2023, indicated the Assistant Director of Nursing (ADON) assessed R8's skin after the coffee was thrown on him/her and documented R8 had an open blister on his/her upper chest.
During a telephone interview, on 12/16/2023 at 2:14 PM, the MDS Coordinator stated it did not surprise her that Resident #6 threw coffee on Resident #8, because he/she had it out for R8 for some reason, but did not know why.
During an additional interview on 12/18/2023 at 2:20 PM, the MDS Coordinator stated she had removed the intervention to monitor R6's behaviors and document observed any behavior and attempted interventions from the resident's care plan on that day. She stated she removed that information because the facility was not monitoring R6, and the facility did not have the monitoring tools requested by the State Survey Agency (SSA) Surveyor.
During a telephone interview on 12/19/2023 at 12:10 PM, the MDS Coordinator stated she had not told any facility staff she had removed the interventions to monitor R6's behavior, document observed behavior, and any attempted interventions from the resident's care plan the day before. She stated she took out the monitoring because the facility could not meet the State Survey Agency's (SSA's) expectations. The MDS Coordinator stated staff observed and discussed R6, and that she did not know what the SSA was wanting the facility to do. She stated, if we did behavior monitoring all day long nobody would get the job of passing medications done. In further interview, the MDS Coordinator stated the residents at the facility had the right to be safe from injury at all times.
During an interview on 12/19/2023 at 10:20 AM, the Administrator stated in the day-to-day life of the facility, people talked about other people. She stated she and the RNC heard about R8 calling R6 a bitch, but were not aware of the note R6 had shown to the MDS Coordinator. The Administrator further stated she, the RNC and the DON also were not aware the MDS Coordinator had removed the intervention to monitor R6's behavior, document observed behavior, and attempted interventions from R6's care plan, the previous day.
During an additional interview on 12/19/2023 at 10:25 AM, the RNC stated it would have been helpful to know about the note R6 wrote and showed to the MDS Coordinator, so the facility could address any potential problems. The RNC further stated if knowledge of the note had been shared in morning meeting on the 13th or 14th of December, that information would have been helpful so the facility could have increased monitoring of R6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's investigation report, and review of the facility's policies, it was determined the facility failed to ensure a safe environment that was free from accidents and hazards to ensure resident safety and supervision for one (1) of thirty one (31) sampled residents (Resident #595).
On 10/07/2023 at approximately 1:00 PM, Resident #595, whom the facility assessed to lack safety awareness, was seen by the Regional Director of Operations for Food/Nutrition Services, outside, behind the facility, sitting in his/her wheelchair near the street unsupervised by facility staff. By the time staff inside the facility were alerted by the Regional Director of Operations for Food/Nutrition Services, the resident was found two (2) blocks away from the facility.
The findings include:
Review of the facility's policy titled, Standard Supervision and Monitoring, dated 05/17/2023, revealed the general purpose of the policy emphasized a proactive intervention to promote enhanced physical and psychosocial well-being. Further review of the policy revealed that when a resident had been assessed by the staff nurse or psychosocial staff to have stable physical and psychosocial needs that regular rounds would be maintained. In addition, per the policy, the staff member that had been assigned to care for the resident would visualize the resident at the start and end of the shift, during meal times, and at a minimum every two (2) hours between.
Review of the facility's policy titled, Elopement and Missing Resident Prevention, dated 04/20/2023, revealed the facility would provide adequate supervision to meet each resident's nursing and personal care needs. Further review revealed staff would be trained on elopement prevention upon hire and at a minimum annually.
Review of Resident #595's admission Record revealed the facility admitted the resident on 10/03/2023, with diagnoses of rhabdomyolysis (sore, weak muscles), hemiplegia affecting left nondominant side, convulsions, and alcohol abuse.
Record review revealed Resident #595 was homeless before he/she was hospitalized and later admitted to the facility. Resident #595 also had a guardian.
Review of Resident #595's admission Minimum Data Set (MDS) Assessment, dated 10/03/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS Assessment revealed Resident #595 required substantial to moderate assist for safe transfers, sit to stand, and bed mobility.
Review of Resident #595's admission Elopement Risk Assessment, dated 10/03/2023, revealed a score of three (3), which indicated the resident was at low risk for elopement. Further review revealed the resident had no history of elopement episodes for the past three (3) months, and the resident had readily accepted nursing home placement.
Review of Resident #595's Care Plan, dated 10/04/2023, revealed a focus of decreased safety awareness as the resident required assistance with Activities of Daily Living (ADL), transfers, and mobility related activities.
Observation of Resident #595 on 10/19/2023 at 8:59 AM, revealed the resident lying in bed with eyes closed. The resident was neat, clean, appropriately dressed, well groomed, and without odor.
Review of Resident #595's Nurse Progress Note, dated 10/07/2023 at 2:56 PM, entered by Registered Nurse (RN) #5, revealed the aides were looking for Resident #595, and the resident was located outside of the facility.
Review of Resident #595's Nurse Progress Note, dated 10/07/2023 at 2:57 PM, revealed the resident was back from the street, where he/she was found a few blocks away from the facility.
Review of the Facility's Investigation, dated 10/07/2023, revealed Resident #595 went to the front entrance door and requested the security guard let him/her outside. Per the report, the security guard opened the door allowing the resident to exit the facility.
Review of the typed summary of the Facility's investigation, not signed or dated, revealed on 10/07/2023 at approximately 1:15 PM, Licensed Practical Nurse (LPN) #11 was standing outside the facility with Resident #595 and could not get him/her to come back to the facility. Continued review revealed the resident was returned to the facility within thirty (30) minutes of leaving with the assistance of his/her sister/guardian, and staff. Further review revealed Resident #595 was mad because he/she had a legal guardian, and the resident felt he/she was able to make his/her own decisions.
During an interview with Resident #595's Guardian (sister) on 10/19/2023 at 2:26 PM, she stated she was appointed the resident's guardian in August or September of 2023. The guardian stated she had been unable to reach the resident by phone, went to the hotel where the resident was staying, and found him/her unconscious on the floor. She stated the resident was sent to the hospital, and upon discharge from the hospital, he/she was admitted to the facility. She stated she was at the facility visiting Resident #595 on 10/07/2023 around 11:00 AM to 12:00 PM, and she could not remember the resident stating he/she wanted to leave. The guardian stated she had left the facility to get Resident #595 some cigarettes when she received a call from the facility at 1:38 PM. She stated staff called her to inform her that Resident #595 was outside the facility a few blocks away, and refused to go back to the facility. The Guardian stated she went to Resident #595's location and talked Resident #595 into going back to the facility.
Review of Security Guard #5's witness statement, dated 10/07/2023, revealed she saw a male/female walking toward the front entrance door. Continued review revealed Security Guard #5 stood up and asked Resident #595 if he/she was a resident of the facility, and Resident #595 stated No, and continued to walk out the door.
During an interview on 10/19/2023 at 9:20 AM with Receptionist #1, she stated if a resident was leaving the facility for any reason, they must sign and date the Resident Sign In/Out Log located at the front desk. Receptionist #1 further stated she had a binder located at the front desk with photos of the residents that were identified as an elopement/risk. She stated, as of last week, she now had a second binder located at the front desk with photos of all residents in the facility. Receptionist #1 stated if anyone came to the window, and wanted out the front door, and she did not know them, she would call the nurse to come and identify the person prior to letting him/her exit the facility. She further stated she conducted orientation with new hires on the sign in/out process and the two (2) binders located at the front desk. Additionally, she stated she informed new hires if they did not know who the resident was, they needed to check at the nurses' station prior to opening the door and letting anyone exit the facility.
Review of the facility's Resident Sign In/Out Log dated 10/07/2023, revealed Resident #595 had not signed out prior to exiting the facility. Further review revealed Resident #595 had not signed out of the facility since being admitted on [DATE].
During an interview with Resident #595 on 10/19/2023 at 9:00 AM, the resident stated he/she had been appointed a new state guardian, and he/she had seen her two (2) weeks ago. The resident stated he/she did leave the facility the other day without staff knowledge. He/she stated the lady at the front office asked if he/she was a resident, and when he/she told the lady no, the lady at the front desk let the resident exit the front door. The resident stated he/she was able to walk some, but normally used his/her wheelchair for mobility. The resident further stated, I am grown, I can make my own decisions, and I do not need a guardian.
During an interview with the Business Office Manager (BOM) on 10/19/2023 at 9:39 AM, she stated she was responsible for updating the resident binder as needed, and the binders were kept at the front desk for the receptionist and the security guards to use to identify residents residing in the facility. The BOM stated the binders should be used to identify residents who were assessed as an elopement risk and to prohibit those residents from exiting the building unattended/unsupervised by staff.
The State Survey Agency (SSA) Surveyor attempted a phone interview with Security Guard #5, on 10/19/2023 at 10:18 AM, 11:25 AM, 4:43 PM, and again on 10/20/2023 at 11:27 AM. All attempts to contact Security Guard #5 by phone were unsuccessful.
During an interview with the Social Services Director (SSD) on 10/19/2023 at 9:46 AM, he stated he had completed the BIMS Assessment on Resident #595 on admission. He stated Resident #595's BIMS' score was thirteen (13), which indicated the resident was cognitively intact. The SSD stated Resident #595 did not mention he/she had a desire to leave the facility. He further stated he had contacted the guardian to obtain permission for Resident #595 to go outside and smoke with staff supervision but failed to obtain consent for the resident to leave the facility at will.
During an interview with the Regional Director of Operations of Food/Nutrition on 10/19/2023 at 10:52 PM, he stated on 10/07/2023 he was leaving the facility to go get supplies and noted a person outside in a wheelchair struggling to wheel the chair. The Regional Director of Operations (RDO) stated he stopped his car and asked the person if they needed assistance and if he/she was a resident of the facility, and the person stated No. The RDO stated he felt the person in the wheelchair was a resident. He stated he drove back to the front entrance of the facility, went to the nurses' station, and asked the staff at the nurses' station if there was a resident missing from the facility. He stated three (3) staff, (Certified Nursing Assistant [CNA] #33, CNA #24, and CNA #22) went outside with him to see what the person looked like, and the resident was no longer in the area where he/she was last seen. The RDO stated he saw the resident at the next block down the street and drove his car over to the resident.
Continued interview with the RDO on 10/19/2023 at 10:52 PM, he stated he asked the resident his/her name, and the resident stated again he/she was not a resident at the facility. The RDO stated he came back to CNAs #22, #24, and #33, who were outside near the facility next to the street, and gave them the resident's name. He stated the CNAs did not recognize the resident's name and went back into the facility and asked Licensed Practical Nurse (LPN) #11 if Resident #595 was a resident. He stated LPN #11 stated, Yes, that is our resident. The RDO stated he let the staff handle the situation from that point on.
During an interview with CNA #33 on 10/19/2023 at 1:09 PM, she stated she was at the nurses' station on 10/07/2023 when the RDO came to the nurses' station and informed them a person was outside in a wheelchair, and he thought the resident might reside at the facility. CNA #33 stated she, CNA #22, and CNA #24 went outside to the area where Resident #595 was last seen. CNA #33 stated Resident #595 was not there, the RDO found the resident two (2) blocks away, and he asked the resident for his/her name. CNA #33 stated when the RDO came to where the CNAs were standing and told them the name of the person in the wheelchair, she did not recognize the name and went back to the facility to check with a nurse (LPN#11). CNA #33 stated she gave LPN #11 the person's name, and LPN#11 stated it was Resident #595. CNA #33 stated she, CNA #22, and CNA #24 drove to the location where the resident was sitting in his/her wheelchair on the sidewalk, which was approximately two (2) blocks away from the facility. CNA #33 stated the resident refused to go back to the facility, and LPN #11 had to call the resident's guardian to assist with getting the resident back into the facility. She stated the guardian arrived and talked Resident #595 into getting into the car and returning to the facility.
During an interview with LPN #11, on 10/20/2023 at 4:50 PM, he stated on 10/07/2023 around 1:00 PM, CNA #33 yelled from the nurse's station, asking if they had a resident (Resident #595) in the facility. LPN #11 stated CNA #33 informed him the Regional Director of Operations had found the resident outside the fenced area of the facility. LPN #11 stated he ran to Resident #595's room and noticed he/she was not in the room, then went to the breakroom and other areas of the facility, but could not locate Resident #595. LPN #11 said he then went to the security guard who was at the front desk, described Resident #595, and asked if the resident had gone outside. LPN #11 stated the security guard said yes. LPN #11 stated at the same time CNA #33 was calling stating Resident #595 had been found. LPN #11 stated he drove to Resident #595. He stated while on the way, he called the Assistant Director of Nursing (ADON) and the resident's legal guardian to notify them the resident had been found outside the facility. LPN #11 stated the guardian arrived at the location where the Resident was sitting in his/her wheelchair and encouraged Resident #595 to return to the facility. LPN #11 stated the security guard at the desk should have called the nurses' station prior to letting anyone out of the facility to make sure he/she was not a resident trying to exit.
During an interview with Registered Nurse (RN) #5 on 10/20/2023 at 12:05 PM, he stated on 10/07/2023 sometime between 12:00 PM and 1:00 PM, one (1) of the CNAs (he could not identify) made him aware Resident #595 was out of the facility, unsupervised. RN #5 stated he was informed the security guard at the front desk had let Resident #595 out of the building. RN #5 stated he was assigned to care for Resident #595 on 10/07/2023 from 6:00 AM to 6:00 PM. The RN stated sometime between 10:00 AM to 11:00 AM he had taken medications to Resident #595 and had not seen him/her since that time. RN #5 stated Resident #595 had not stated he/she desired to leave the facility the last time he saw the resident. Continued interview revealed he was on break during the time the resident exited the building. RN #5 stated the security guard should not have allowed the resident to exit the building before checking with the nurse.
During an interview with Security Guard #2 on 10/20/2023 at 2:35 PM, he stated he worked at the front office on Saturdays and Sundays from 8:00 PM to 8:00 AM. He further stated there were two (2) books, a visitors' book and a resident book, located at the desk, and staff was to refer to the books prior to letting anyone outside the facility. Additionally, he stated there were two (2) sign in and sign out logs located at the desk, one (1) for visitors and one (1) for residents. He stated he was aware of the elopement book with pictures and the resident book, which were both located at the front desk.
During an interview with the ADON on 10/19/2023 at 11:00 AM, she stated she was contacted between approximately 1:00 PM to 2:00 PM on 10/07/2023 by LPN #11. She stated LPN #11 stated he was standing outside the facility with Resident #595 and could not get the resident to come back into the building. The ADON stated she instructed LPN #11 to stay with Resident #595 and continue to try to get the resident to come back to the facility. She stated she contacted the Director of Nursing (DON) and Administrator (ADM) on a three (3) way call and informed them Resident #595 was located outside the facility and was refusing to come back in. The ADON stated Resident #595 was placed on one-to-one (1:1) supervision which meant someone had their eyes on Resident #595 at all times. The ADON stated the security guard at the desk should have checked with the nursing staff prior to letting Resident #595 exit the facility. The ADON stated the facility's New Resident Binder identifying all residents in the facility was not added to the front desk for staff to use until after Resident #595 had exited the building.
During an interview with the Medical Director (MD) on 10/20/2023 at 10:58 AM, he stated he was made aware of the incident and could not remember who called him or when he was called. He stated by the time he had been notified, Resident #595 was already back in the facility. The MD stated this was an unfortunate incident. and He further stated from what he understood about the incident involving Resident #595, someone dropped the ball and placed the resident at increased risk of harm. He further stated any elopement/missing person could put a resident at high risk for harm, and it was his expectation the facility should keep residents 100% safe.
During an interview with the Administrator (ADM) on 10/20/2023 at 11:55 PM, she stated she was notified on 10/07/2023 of the incident with Resident #595. She further stated the resident was found quickly and was placed on one-to-one (1:1) supervision. She stated all staff, including the security guards, had been educated on not allowing persons to leave the facility without knowing their identity. The Administrator also stated the facility did not have a policy related to signing in/out of the facility. The Administrator stated all processes were put in place to quickly locate the resident when the incident occurred. She stated it was her expectation for all staff to follow the facility's process in regard to viewing the binders located at the front desk prior to allowing anyone outside the facility.

Based on interview, record review, and review of the Kentucky Pre-admission Screening and Resident Review (PASARR) Manual, it was determined the facility failed to complete a PASARR screening Level I identification of individuals with a mental disorder (MD) or intellectual disability (ID) that was completed prior to admission to a nursing facility for two (2) of sixty-one (61) sampled residents, Resident #73 and #55.
The findings include:
Review of the Kentucky PASARR Manual, revised April 2020, revealed the federal requirement for PASARR applied to all licensed long-term care nursing facilities that were participating in Medicaid programs, regardless of the individual's funding source. Per the manual, anyone seeking placement in a nursing facility (NF) participating in the Kentucky Medicaid Program would have a Level I screen completed prior to admission. The manual stated anyone identified by the screening as having a possible serious mental illness, intellectual disability, or related condition must also go through the Level II process or meet all requirements for a provisional admission before the individual could be admitted to the NF.
1. Review of Resident #73's admission Record revealed the facility admitted the resident, on 09/28/2022, with diagnoses of Encephalopathy, Pancreatitis, and Diabetes. Review of Resident #73's Quarterly Minimum Data Set (MDS) Assessment, dated 07/26/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15), which indicated severe cognitive impairment.
Review of Resident #73's PASARR screening, revealed the resident's PASARR I screen was completed on 09/30/2022 and not prior to admission. The PASARR I screen did not indicate to trigger a PASARR II screen by the information put in by the facility.
2. Review of Resident #55's admission Record revealed the facility admitted the resident on 05/30/2023, with diagnoses including Metabolic Encephalopathy, Heart Failure, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #55's admission MDS Assessment, dated 06/05/2023, revealed the facility assessed the resident to have a BIMS score of fourteen (14) of fifteen (15), which indicated the resident was cognitively intact.
Review of Resident #55's PASARR screening revealed the resident's PASARR I screen was completed on 05/31/2023 and not prior to admission. The PASARR I screen did not indicate a PASARR II screen was required at that time.
In an interview on 08/03/2023 at 10:10 AM, the Business Office Manager (BOM) stated she opened and put in basic information into KLOCS, the MDS Coordinator put in diagnoses codes, and the SSD puts in their part. However, the BOM stated she had been doing all the parts of inputting PASARR information for last six (6) to eight (8) months. She stated she received no extra training to do this. She stated she would consult the MDS Coordinator for diagnoses codes. She stated they pulled diagnoses codes from Point Click Care (PCC, a facility software program). The BOM stated staff completed the PASARR I after the resident was admitted to the facility.
In an interview with the Administrator on 08/07/2023 at 1:45 PM, she stated she was unaware of the process for completing the PASARR. She further stated the process was completed by the Admissions Coordinator/Business Office Manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Review of Resident #84's medical record revealed the facility admitted the resident on 05/03/32023, with diagnoses of Post-Traumatic Stress Disorder, Chronic Obstructive Pulmonary Disease, Anxiety, and Diabetes Mellitus type 2. Review of the admission MDS assessment dated [DATE] revealed the facility assessed Resident #84 as having a BIMS score of fifteen (15) out of fifteen (15) indicating he/she was cognitively intact. Continued MDS review of section I, revealed Resident #84 triggered for Post Traumatic Disorder (PTSD).
Review of Resident #84's Comprehensive Care Plan dated 05/16/2023 revealed no documented evidence of care plan formulated for the resident's PTSD. Continued review of the Comprehensive Care Plan revealed a list of diagnoses under Resident #84's potential nutrition problem dated 05/16/2023, which listed PTSD with the resident's other diagnoses.
In interview on 08/06/2023 at 9:42 AM, the DON stated she was not aware Resident #84 had a diagnosis of PTSD. The DON stated a care plan should have been developed and implemented for Resident #84's PTSD.
In interview on 08/06/2023 at 10:08 AM, the Administrator stated a care plan should have been developed for Resident #84 concerning his/her PTSD.
In interview on 08/07/2023 at 11:11 AM, the MDS Coordinator stated a comprehensive care plan should have been formulated for Resident #84's PTSD.
5. Review of Resident #15's medical record revealed the facility admitted the resident on 06/16/2023, with diagnoses which included Respiratory Failure, Liver Transplant, Seizures, Dependence on Renal Dialysis, Anemia, Muscle Weakness, and Cognitive Communication Deficit. Review of the admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fourteen (14) out of fifteen (15) which indicated the resident was cognitively intact. Continued review of the MDS under section G revealed the facility assessed Resident #15 required two (2) person assist for bed mobility and one (1) person physical assist with transfers.
Review of Resident #15's Comprehensive Care Plan dated 06/19/2023, revealed the resident was at risk for falls related to impaired balance and mobility, poor safety awareness due to cognitive decline, use of psychotropic medications, and visual impairment. Continued review revealed interventions which included bed in low position, call light within reach, and keep frequently used items close to the resident. Further review revealed an intervention, initiated on 06/29/2023, not to leave the resident up in the chair in the room alone.
However, observation on 07/13/2023 at 2:55 PM, revealed Resident #15 sitting in a reclining chair in his/her room alone, with his/her feet raised. Continued observation revealed Resident #15 was attempting to climb out of chair, and no staff were present near the resident's room. The State Survey Agency (SSA) Surveyor notified staff who went to Resident #15's room.
Review of Resident #15's Progress Notes revealed the resident slipped out of the wheelchair on 06/28/2023, when he/she was left alone in his/her room. Continued review of the Progress Notes revealed Resident #15 complained of right hip pain on 07/04/2023, at which time an x-ray of his/her right hip was ordered by the Physician. Review of the Progress Notes revealed an x-ray was obtained on 07/07/2023 (nine [9] days after the resident's fall), with a final x-ray report received on 07/08/2023, which revealed Resident #15 had a right hip fracture. Further review of the Progress Notes revealed no documented evidence of entries noted from 07/08/2023 until 07/10/2023, when Resident #15 was admitted to the hospital for the right hip fracture.
During an interview with CNA #21 on 07/16/2023 at 7:20 PM, she stated Resident #15 required total assist with transfers and was currently out to the hospital.
During an interview with the MDS Nurse on 08/07/2023 at 11:15 AM, she stated the nurse should implement an immediate intervention following a resident's fall and the Interdisciplinary Team (IDT) met at the next scheduled IDT meeting, which was usually held Monday through Friday, to discuss if the intervention was appropriate. She further stated she then placed the intervention on the resident's Comprehensive Care Plan.
6. Review of Resident #72's medical record revealed the facility admitted the resident on 05/01/2023, with diagnoses which included Major Depression, Anxiety, End Stage Renal Disease, and Altered Mental Status. Review of the admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of thirteen (13) out of fifteen (15) indicating he/she was cognitively intact. Continued review of the MDS, section G, revealed the facility assessed Resident #72 as a one (1) person physical assist for bed mobility and review of section J revealed the resident had a history of falls prior to admission.
Review of the facility's baseline care plan for Resident #72 dated 05/01/2023, revealed the facility identified and care planned the resident for his/her risk for falls; however, the facility did not initiate the comprehensive fall care plan until 06/20/2023.
Review of the baseline care plan dated 05/02/2023 for Resident #72 revealed the facility identified the resident's risk for falls; however, did not initiate a comprehensive fall care plan for him/her until 06/20/2023. Review of base line care plan dated 05/02/2023, the section H safety risks Resident #72 was identified fell at home, had a history of falls prior to admission, and within the last two (2) to six (6) months. Continued review revealed bed in lowest position was listed under specify other safety devices. Further review revealed under the comments documentation noting: Resident #72 was only oriented to self; could not comprehend where he/she was; his/her gait was weak and unsteady; he/she attempted unassisted transfers; and he/she used the call light.
Review of Resident #72's Comprehensive Care Plan dated 06/20/2023 revealed a focus for the resident as at risk for falls related to decreased safety awareness, incontinence of bowel, and incontinence of bladder. Review of the goal dated 06/20/203, revealed Resident #72 was to have a safe environment maintained through the next review target date of 11/07/2023. Further review revealed interventions dated 06/23/2023 for a reacher (grabber) for safety with frequently used items within reach, and on 07/07/2023 for bilateral (enabler) side bars added to bed to assist resident to lay in center of bed.
Review of Nurse Progress Note dated 07/06/2023 at 10:00 AM, revealed LPN #2 was notified Resident #72 had been found lying on the floor. Continued review revealed Resident #72 was assessed and found to be bleeding from a gash on his/her left leg below the knee. Further review revealed the medical doctor was notified and gave an order to send to Resident #72 to the emergency room (ER). In addition, the resident's family and management were notified.
In interview on 08/06/2023 at 10:10 AM, the Director of Nursing (DON) stated the baseline care plan was in place and was in place for the twenty-one (21) days until the comprehensive care plan.
In interview on 08/06/2023 at 10:08 AM, the Administrator stated Resident #72 was a high risk for falls and had interventions on his/her baseline care plan.
In interview on 08/07/2023 at 11:14 AM the MDS Coordinator stated the comprehensive care plan took twenty-one (21) days to be developed. The MDS Coordinator stated the fall comprehensive care plan should have been formulated for Resident #72 within the twenty-one (21) day period.
7. Review of Resident #6's medical record revealed the facility admitted the resident on 06/20/2023, with diagnoses including Hypertension, Parkinson's Disease, Anxiety, and Depression. Review of Resident #6's admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) indicating the resident had intact cognition. Continued MDS review, Section G functional status, revealed the facility assessed the resident to require assistance of two (2) persons for transfers.
Review of Resident #6's Comprehensive Care Plan dated 06/21/2023, revealed the facility care planned the resident to require assistance with Activities of Daily Living (ADLs) related to Disease Process and Limited Mobility. Continued review revealed interventions which included extensive assistance by two (2) staff to move between surfaces.
Observation on 07/23/2023 at 9:20 AM, revealed Resident #6 suspended in a lift sling from a mechanical lift and being transferred from the bed to the chair by CNA #21. Per observation, CNA #21 had no other staff member present in the room to assist her. Continued observation revealed Registered Nurse (RN) #3 was standing in the hallway outside Resident #6's room at a medication cart. CNA #21 was observed to go to the doorway of the Resident #6's room to ask RN #3 to assist her with the mechanical lift transfer, leaving the resident suspended in the lift sling alone. Observation further revealed RN #3 told the CNA she would help her after she gave the resident's medication.
In interview on 07/23/2023 at 9:24 AM, CNA #21 stated that day there were only four (4) CNAs for the whole building, in addition to the CNA sitting 1:1 with a resident. She stated there were two (2) CNA call ins, and no other CNAs were available to assist her at the time of Resident #6's transfer. The CNA stated she knew she should have two (2) staff for all lift transfers and as per the resident's care plan. She stated that day however, she had twenty-four (24) residents to care for by herself on the hall and Resident #6 needed to be gotten up and into his/her wheelchair to attend church services. CNA #21 stated the DON told her before Resident #6 was to be gotten up for church services if he/she wanted to go to church. The CNA further stated Resident #6 could have fallen from the lift, or the lift could have tipped over or the straps have broken, which could have caused the resident injury.
In interview on 07/23/2023 9:27 AM, RN #3 stated she was passing medications for the entire hall and was attempting to give the medication she had already prepared for a resident before she assisted CNA #21. She stated two (2) staff should always perform lift transfers so one (1) person could move the lift while the second person assisted the resident so the lift did not move, the sling did not break, or the resident fall out of the sling and cause injury to the resident.
In interview on 08/05/2023 at 10:50 AM, Resident #6 stated he/she was very afraid when being in the lift with only the one (1) staff person using it on 07/23/2023. Resident #6 stated he/she had hurt his/her left shoulder and hip after experiencing a fall from a lift at another facility. The resident further stated he/she had been a nurse and knew there should always be two (2) staff with all lift transfers for resident safety.
8. Review of Resident #51's medical record revealed the facility admitted the resident on 04/07/2023, with diagnoses including Hypertension, Malnutrition, Depression and Anxiety. Review of Resident #51's admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of ninety-nine (99), which indicated the resident chose not to participate, or four (4) or more items were coded as zero (0). Further review of the MDS, Section G, functional status revealed the facility assessed the resident as requiring two (2) person assist for bed mobility and transfers, and review of the MDS, section J revealed Resident #51 had a history of falls.
Review of Resident #51's Comprehensive Care Plan, dated 04/23/2023, revealed the resident was care planned for a risk for falls with interventions including: two (2) staff for ADL care for safety; bolsters to left side of bed; one-to-one (1:1) supervision for safety due to frequent falls; call light within reach at all times, therapy to assess for locking tray table for geri chair; low bed related to decreased safety awareness; full size mattress to right side of bed; and the resident to be taken to activities to help keep him/her engaged in other forms of stimulation.
Review of Resident #51's medical record revealed Resident #51 sustained ten (10) falls after admission to the facility on [DATE], which were as follows:
a). On 04/13/2023, Resident #51 was found lying on the floor in his/her room and the facility determined the resident sustained a fall which resulted in a laceration and hematoma over the resident's right eye and a laceration over his/her left eye. Resident #51 was sent to the hospital and underwent a left frontotemporoparietal craniotomy (brain surgery) for evacuation of a right-sided acute on chronic subdural hematoma (brain surgery) for evacuation of a right-sided acute on chronic subdural hematoma (bleed between the covering of the brain {dura}and the surface of the brain). Review revealed Resident #51 was hospitalized from [DATE] to 04/20/2023.
b). On 04/22/2023, Resident #51 was found lying on the floor beside the bed with blood noted from the head beside him/her and he/she was transported to the hospital emergency room (ER). On 04/25/2023, the IDT implemented an intervention for Resident #51 to have his/her bed in the low position with a fall mat on the floor. However, review of the resident's care plan revealed the facility implemented a full size mattress beside the bed on 04/23/2023.
c). On 04/26/2023, Resident #51 was found lying on the floor with feces on him/her, on the bed, mat, and floor. The IDT implemented an intervention on 04/27/2023, to toilet the resident every two (2) hours.
d). On 05/11/2023, Resident #51 was found lying on the floor and was sent to the ER. On 05/12/2023, the IDT implemented an intervention for therapy to do wheelchair modifications. However, care plan review revealed the facility failed to develop the falls care plan further with this intervention.
e). On 05/20/2023, Resident #51 was found lying face down on the floor with blood on his/her face and gown, and the resident stated he/she tripped on the mattress beside the bed. Resident #51 was transferred to the ER, and returned on 05/21/2023, with sutures in place to the right eyelid. On 05/23/2023, the IDT placed the resident on 1:1 supervision while in bed. The facility continued the mattress beside the bed as an intervention, even though Resident #51 tripped over it.
f). On 05/29/2023, Resident #51 was found sitting on the floor mat beside his/her bed and the facility placed him/her on 1:1 supervision at all times.
g). On 06/11/2023, Resident #51 was found lying on the floor with a laceration to his/her head and was sent to the ER for treatment with admission overnight. Review revealed no documented evidence of an IDT note or of an intervention implemented and added to his/her care plan.
h). On 06/21/2023, a staff member witnessed Resident #51 fall to the floor and hit his/her head. Resident #51 was sent to the ER and admitted overnight. Review revealed no documented evidence of an IDT note or of an intervention implemented and added to his/her care plan.
i). On 07/01/2023, Resident #51 sustained a fall from his/her chair to the floor, and was sent to the ER. The resident returned to the facility on [DATE]. On 07/03/2023, the IDT implemented an intervention to take the resident to activities to be engaged in other forms of stimulation.
j). On 07/08/2023, Resident #51 fell and hit his/her nose on the table while staff were providing 1:1 care. On 07/10/2023, the IDT implemented an intervention for two (2) staff members to assist with the resident's ADLs.
Observation, on 07/12/2023 at 6:20 PM, revealed Resident #51 sitting at the nurse's station in his/her chair with a lap tray across the tray physically restraining the resident. CNA #11 was assigned to be sitting 1:1 with Resident #51; however, the CNA was observed walking around the nurse's station and chatting with other staff.
Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents' comprehensive person-centered care plans were developed and implemented that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs for nine (9) of sixty-one (61) sampled residents, Residents #6, #15, #11, #51, #72, #84, #242, #243, and #244.
1. The facility failed to thoroughly develop and implement a comprehensive care plan for dialysis for Residents #242, #243, #244 and #11.
(a) The facility failed to ensure Resident #242 received his/her dialysis treatment on 04/23/2022 and on 04/26/2022, as per the resident's care plan. Therefore, upon arrival at the dialysis clinic on 04/28/2022, Resident #242 presented slumped over, unresponsive, with his/her body twitching, and required transport to the emergency room (ER).
(b) The Physician ordered in-house dialysis treatments for Resident #243 three (3) times a week on Monday-Wednesday-Friday at the in-house clinic. However, the facility failed to develop Resident #243's care plan to include the in-house dialysis clinic's schedule for the resident's dialysis on Mondays, Wednesdays, and Fridays. Therefore, review of Resident #243's Nurse Progress Note dated 07/14/2023 at 3:55 PM, revealed the resident had received no dialysis since Monday, 07/10/2023, prior to his/her admission to the facility.
(c) The facility admitted Resident #244 on 02/23/2022, without an outpatient dialysis clinic order for him/her to receive his/her dialysis treatments. The facility failed to develop and implement Resident #244's care plan to include his/her dialysis orders, days of dialysis, his/her access site location; the dialysis center where he/she was to go with the dialysis time and transport company listed. Therefore, Resident #244 was sent back to the acute care hospital on [DATE] to receive his/her dialysis treatment and did not return to the facility.
(d) The facility failed to develop Resident #11's care plan to include the dialysis center, the time, frequency, days of the week for treatment, and transport method. Additionally, the facility failed to implement Resident #11's care plan to ensure it communicated with the dialysis center regarding the resident's treatment.
2. The facility failed to thoroughly develop and implement the comprehensive care plan with necessary fall interventions for Residents #6, #15, #51, and #72.
(a) The facility failed to implement Resident #6's care plan on 07/23/2023, when Certified Nursing Assistant (CNA) #21 transferred the resident via mechanical lift alone, and left the resident suspended in the lift sling to try to get assistance from Registered Nurse (RN) #3. Resident #6 stated he/she was afraid when left alone in the lift sling.
(b) On 06/28/2023, Resident #15 sustained a fall which resulted in a hip fracture, and on 06/29/2023, the facility implemented an intervention not to leave the resident sitting in a chair alone in his/her room. However, observation on 07/13/2023 at 2:55 PM, revealed Resident #15 sitting in a reclining chair with his/her feet elevated in his/her room alone, and attempting to climb out of chair with no staff near the resident's room.
(c) The facility failed to develop and implement Resident #51's fall risk care plan as necessary. Resident #51 therefore sustained ten (10) falls after admission to the facility on [DATE] through 07/08/2023, seven (7) of which resulted in injury and the resident being transferred to the emergency room (ER).
(d) The facility failed to develop and implement Resident #72's care plan related to his/her history of falls. Resident #72 sustained a fall from his/her bed on 07/06/2023 at 10:00 AM, resulting in a gash to his/her leg requiring transport to the ER where the resident's gash was closed with sutures.
3. The facility admitted Resident #84 with a diagnosis of Post Traumatic Stress Disorder (PTSD); however, failed to develop and implement a care plan for the resident's PTSD diagnosis and ensure staff were knowledgeable of his/her diagnosis.
The facility's failure to ensure residents' comprehensive person-centered care plans were developed and implemented to include measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs is likely to cause serious injury, serious harm, serious impairment, or death to residents.
Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/21/2023 and determined to exist on 02/25/2022 in the area of 42 CFR 483.21(b)(1) Quality of Care F656 at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/21/2023, and the IJ is ongoing.
The findings include:
Review of the facility's policy titled, Care Plan Policy, revised 11/24/2022, revealed it was the facility's policy to ensure every resident had a Baseline Care Plan completed and implemented within forty-eight (48) hours of admission to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events most likely to occur right after admission. Continued review revealed the Baseline Care Plan was to be updated with changes in risk factors, goals and interventions until the Comprehensive Care Plan was completed, then discontinued. Review revealed the Comprehensive Care Plan further expanded on the resident's risks, goals, and interventions using the Person-Centered Plan of Care approach for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental, and psychosocial needs. Further review revealed the resident's needs were to be defined from observation, interviews, clinical medical record review and thorough assessments and Care Area Assessments (CAAs). Review further revealed the facility's Interdisciplinary Team (IDT), in conjunction with the resident, resident's family, or representative as appropriate along with a hands on caregiver, such as a Certified Nursing Assistant were to discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident.
1. Review of Resident #242's medical record revealed the facility admitted the resident on 04/21/2022, with diagnoses which included: Hypotension, End Stage Renal Disease (ESRD), and Pain in Leg. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #242 to have a Brief Interview for Mental Status score of eleven (11) out of fifteen (15), indicating he/she was moderately cognitively impaired.
Review of Resident #242's baseline care plan initiated on 04/22/2022, revealed a potential for complications related to ESRD and dialysis treatment three (3) times a week on Tuesday, Thursday, Saturday, resident to be picked up at 2:00 PM; however, the facility listed no dialysis company on the baseline care plan. Continued review revealed the care plan interventions included: protect the resident's shunt (dialysis access) site from injury; avoid constriction on affected arm, such as a blood pressure (BP) cuff, carrying purse, constrictive clothing; however, the facility did not list the site of the dialysis access on the care plan. Further review of the care plan revealed additional interventions: to monitor/record/report to Physician/Medical Director (MD) as needed (PRN) for signs and symptoms related to renal disease, including fluid overload, itching, BP changes, confusion, altered mental status, fatigue, hair/skin/nail texture changes, nausea/vomiting, and restless leg syndrome. In addition, the further interventions included to make transportation arrangements for dialysis; however, the facility listed no transport company on the care plan.
Review of Resident #242's records from the outpatient dialysis center revealed he/she did not receive a dialysis treatment on Saturday, 04/23/2022 or on Tuesday, 04/26/2022, as per the resident's care plan. Continued review revealed on Thursday, 04/28/2022, Resident #242 was transported from the facility to the dialysis clinic's lobby; however, was sent to the local hospital Emergency Department (ED) from the lobby. Further review revealed Resident #242 had presented to the dialysis clinic lobby slumped over and unresponsive, with his/her body twitching.
Review of Resident #242's facility medical record revealed no documented evidence of the resident's missed dialysis treatments on 04/23/2022 and 04/26/2022. Continued review revealed manual BPs were taken with the BP cuff on 04/23/2022 at 12:56 AM, 04/23/2022 at 10:40 AM, 04/26/2022 at 1:39 AM, 04/27/2022 at 8:08 AM, and 04/28/2022 at 2:02 AM on Resident #242's affected arm with the shunt site, even though the resident's care plan interventions specified this was not to be done.
In an interview with the former Assistant Director of Nursing (ADON) on 07/13/2023 at 12:11 PM, she stated when Resident #242 was accepted by the facility the transport for dialysis should have already been set up by the facility prior to the resident being admitted , and this was stated in his/her care plan. She stated Resident #242's missed treatment on 04/23/2022 was on a weekend (Saturday), and the facility could not get transport because it was not set up prior to the resident coming to the facility.
2. Review of Resident #243's admission Record revealed the facility admitted the resident, on 07/11/2023, with diagnoses of ESRD, Diabetes, and Abnormal Findings of Blood Chemistry. Record review revealed the facility discharged Resident #243 on 07/14/2023, therefore, the resident's BIMS score was not assessed due to his/her short stay in the facility.
Review of Resident #243's baseline care plan initiated on 07/11/2023, revealed care plan interventions to monitor/document/report PRN (as needed) the following signs and/or symptoms: edema, weight gain of over two (2) pounds a day, neck vein distension, difficulty breathing (dyspnea), increased heart rate (tachycardia), elevated blood pressure (hypertension), peripheral pulses, level of consciousness, and breath sounds for crackles. Continued review revealed additional interventions included: to check and change dressing daily at the dialysis access site and document; and do not draw blood or take BP in arm with graft (dialysis access, however, no site was listed). Further review revealed the interventions also included monitor/document/report PRN for signs and/or symptoms of renal insufficiency: changes in level of consciousness; changes in skin turgor; oral mucosa; and changes in heart and lung sounds. Review further revealed however, the facility documented no dialysis clinic, frequency of dialysis treatments, or days of dialysis treatment on Resident #243's care plan.
Continued review of Resident 243's medical record revealed the facility ordered in-house dialysis treatments for the resident on 07/12/2023, a Wednesday. Review further revealed the order was for Resident #243 to have dialysis treatments three (3) times a week on Monday-Wednesday-Friday at the in-house clinic.
However, the facility failed to develop Resident #243's care plan to include the in-house dialysis clinic's schedule of dialyzing the resident on Monday-Wednesday-Friday.
Review of Resident #243's Nurse Progress Note dated 07/14/2023 at 3:55 PM, revealed the resident had received no dialysis since Monday, 07/10/2023, prior to his/her admission to the facility.
In an interview on 07/25/2023 at 9:30 AM, with Licensed Practical Nurse (LPN) #2, she stated it was not communicated to her that Resident #243 had a dialysis order in place. She stated if Resident #243 had an order for dialysis on 07/12/2023 and she had known, she would have taken the resident to dialysis. She stated she relied on the resident's care plan to inform her on how to care for the resident.
3. Review of Resident #244's admission Record revealed the facility admitted the resident on 02/23/2022, with diagnoses of Chronic Kidney Disease Stage 4, Diabetes, and Hypertension. Continued review revealed Resident #244 had a tunnel catheter in the right upper chest for dialysis access. Further review revealed Resident #244 was discharged on 02/25/2022, and therefore, a BIMS score was not assessed to determine the resident's cognition.
Continued review of Resident #244's medical record revealed the facility admitted the resident on 02/23/2022, without an outpatient dialysis clinic order for him/her to receive his/her dialysis treatments.
Review of Resident #244's baseline care plan initiated on 02/25/2022, revealed a potential for complications related to end stage renal disease and dialysis treatments three (3) times a week; however, there was no documented evidence of the resident's dialysis orders or days listed. Continued review revealed other interventions included: to make transport arrangements for dialysis; protect shunt site from injury; and avoid constriction on affected arm, such as with BP cuff, carrying purse, constrictive clothing. Further review revealed however, no documented evidence of Resident #244's access site listed. In addition, review further revealed no documented evidence of a dialysis center listed, the time listed, or a transport company listed.
Further review of Resident #244's medical record revealed the resident was sent back to the acute care hospital on [DATE] to receive his/her dialysis treatment and did not return to the facility.
Review of Resident #244's Nurse Progress Note dated 02/25/2022 at 11:11 AM, documented by the former ADON, revealed the resident was being transported to a local ED because the resident needed to have dialysis. Further review of the Note revealed upon Resident #244's return to the facility, a dialysis center needed to be assigned to establish a regular dialysis schedule; however, the resident did not return to the facility.
In interview on 07/23/2023 at 8:05 AM, LPN 11 stated for HD residents nurses got their vital signs and made sure their medications were given. She stated they checked the resident's access site for infection and swelling, and monitored the residents for swelling. LPN #11 stated for fluid overload the nurse would talk to the doctor and send the resident out if their dialysis was missed. She stated they used a monitoring form and filled it out on residents' HD days, monitoring the access site and weights prior HD. The LPN further stated nurses used residents' care plans and orders for dialysis information about their access site and how to care for the resident.
4. Review of the facility's policy titled, Community Hemodialysis (HD), effective and last revised date 07/25/2019, revealed a dialysis communication sheet was to return with the resident after the dialysis session to communicate to the facility information regarding the dialysis session.
Review of Resident #11's medical record revealed the facility admitted the resident on 10/26/2022, with diagnoses of ESRD, Diabetes, and Hypertension. Review of Resident #11's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), indicating he/she was cognitively intact.
Review of Resident #11's Comprehensive Care Plan revealed care plan interventions initiated on 10/27/2022 to: communicate with dialysis center regarding medication, diet, and lab results; protect shunt (dialysis access) site from injury; avoid constrictio [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, it was determined the facility failed to have an effective system in place to ensure adequate supervision and monitoring to prevent falls and accident hazards for four (4) of sixty-one (61) sampled residents, Residents #6, #15, #51, and #72.
Observation on 07/23/2023, revealed Resident #6 being transferred by a mechanical lift with the assistance of one (1) staff member. The facility assessed Resident #6 to require extensive assistance of two (2) staff to move between surfaces on 06/21/2023.
Record review revealed Resident #15 had a fall on 06/28/2023 and was diagnosed with a right hip fracture on 07/07/2023. Review revealed Resident #15 was noted to be rolling to the edge of the bed on 07/28/2023. Further record review revealed Resident #15 fell from his/her bed on 07/28/2023.
Record review revealed Resident #51 sustained ten (10) falls after his/her admission to the facility on [DATE] through 07/08/2023.
Review of medical record Resident #72 revealed the facility assessed the resident as a high risk for falls. On 07/06/2023, Resident #72 rolled out of bed and fell to the floor sustaining an injury which required eleven (11) sutures to his/her leg.
The facility's failure to to have an effective system in place to ensure adequate supervision and monitoring to prevent falls and accident hazards is likely to cause serious injury, harm, impairment, or death to a resident.
Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/21/2023 and determined to exist on 02/25/2022 in the area of 42 CFR 483.25(d)(1)(2) Quality of Care F689 at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/21/2023, and the IJ is ongoing.
The findings include:
Review of the facility policy titled, Incident, Accidents and Falls revised 01/30/2022, last reviewed 02/01/2023, dated revealed it was the facility's policy to ensure any incident/accident to include falls was reported immediately to the nurse or appropriate person designated to be in charge. Continued review revealed after the resident had received immediate attention and their safety was established, a written report was to be entered into Risk Management. Further review revealed the facility was to ensure incidents and accidents involving residents were identified, reported, investigated, and resolved.
1. Review of the facility policy titled, Mechanical Lift Transfer Usage Guideline dated 01/09/2023, revealed to avoid slinging the resident lift only high enough to clear the bed or chair to facilitate a transfer. Continued review revealed one (1) person was to always maintain control of the resident in the sling while the second person did not move once the mechanical lift was in the correct position.
Review of Resident #6's medical record revealed the facility admitted the resident on 06/20/2023, with diagnoses including Hypertension, Parkinson's Disease, Anxiety, and Depression. Review of Resident #6's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating he/she was cognitively intact. Further MDS review, Section G functional status, revealed the facility assessed Resident #6 as a two (2) person assist for transfers.
Observation on 07/23/2023 at 9:20 AM, revealed Resident #6 suspended in a lift sling from a mechanical lift being transferred from the bed to the chair by Certified Nurse Assistant (CNA) #21. Continued observation revealed no other staff member present in the room; however, Registered Nurse #3 was standing in the hallway outside Resident #6's room at the medication cart. Observation revealed CNA #21 went to the doorway of the resident's room to ask RN #3 to assist with the mechanical lift transfer, leaving Resident #6 suspended in the lift sling. Further observation revealed RN #3 informed CNA #21 she would assist after she passed the resident's medication.
In interview with Resident #6 on 08/05/2023 at 10:50 AM, the resident stated he/she was very afraid while in the lift with only the one (1) person using it on 07/23/2023. The resident stated he/she had fallen from a lift at another facility and hurt his/her left shoulder and hip. Resident #6 stated he/she had been a nurse and was aware there should always be two (2) staff with all lift transfers for resident safety.
In interview with CNA #21 on 07/23/2023 at 9:24 AM, she stated there were only four (4) CNAs for the building in addition to the CNA sitting one-to-one (1:1) with another resident. The CNA stated there had been two (2) call ins, and there were no other CNAs available to assist her at the time of Resident #6's transfer. She stated she was aware she should have two (2) staff for all lift transfers; however, she had twenty-four (24) residents to care for by herself on the hall and Resident #6 needed to be assisted into his/her wheelchair to attend church services. CNA #21 stated the Director of Nursing (DON) had previously told her Resident #6 was to get up for church services if he/she desired to go to church. She further stated Resident #6 could have fallen from the lift, the lift could have tipped over or the straps could have broken, causing the resident injury.
In interview RN #3 she stated she had to pass medications for the entire hall and was attempting to give the medication she had already got ready for a resident before assisting the CNA. She further stated two (2) staff should always perform lift transfers so one person could move the lift while the second person assisted the resident so the lift doesn't move, the sling break, or the resident fall out of the sling and cause injury to the resident.
2. Review of Resident #51's medical record revealed the facility admitted the resident on 04/07/2023, with diagnoses including Hypertension, Malnutrition, Depression and Anxiety. Review of the admission MDS assessment dated [DATE], revealed the facility assessed Resident #51 as having a BIMS score of ninety-nine (99), which indicated the resident chose not to participate, or four (4) or more items were coded zero (0). Continued MDS review, Section G functional status revealed the facility assessed Resident #51 to require two (2) person assist for bed mobility and transfers and review of section J revealed the resident had a history of falls.
Review of Resident #51's Comprehensive Care Plan revealed the facility care planned the resident for his/her risk for falls. Continued review revealed interventions which included one-to-one (1:1) supervision for safety due to frequent falls; two (2) staff for Activities of Daily Living (ADL) care for safety; and call light within reach at all times. Further review revealed additional intervention included: bolsters to left side of bed; full size mattress to right side of bed; low bed related to decreased safety awareness; and the resident to be taken to activities to help keep him/her engaged in other forms of stimulation.
Review of Resident #51's medical record revealed the resident experienced a history of ten (10) falls since admission to the facility on [DATE] which included:
a) On 04/13/2023, Resident #51 was found in room with a laceration and hematoma over his/her right eye and laceration over his/her left eye and the facility determined he/she had fallen. Resident #51 was sent to the hospital and underwent a left frontotemporoparietal craniotomy (brain surgery) for evacuation of a right-sided acute on chronic subdural hematoma (bleed between the covering of the brain [dura] and the surface of the brain). The resident was admitted to the hospital from [DATE] to 04/20/2023.
b) On 04/22/2023, Resident #51 was found lying on the floor beside the bed with blood noted coming from his/her head beside him/her and around the room. Resident #51 required transport to the hospital emergency room (ER) due to his/her sutures pulling loose from his/her head trauma on 04/14/2023. On 04/25/2023, the Interdisciplinary Team (IDT) implemented an intervention for Resident #51 to have his/her bed in the low position with a fall mat to the floor by the bed.
c) On 04/26/2023, Resident #51 was found on the floor with feces on his/her bed, mat, floor and the resident. The IDT implemented an intervention on 04/27/2023 to toilet the resident every two (2) hours. However, review of the care plan revealed no documented evidence of the intervention for toileting the resident every two (2) hours.
d) On 05/11/2023, Resident #51 was found lying on the floor and was sent to the ER. On 05/12/2023, the IDT determined therapy would make wheelchair modifications to the resident's wheelchair.
e) On 05/20/2023, Resident #51 was found lying face down on the floor, behind his/her closed door, with blood noted on his/her face and gown. Resident #51 stated he/she tripped on the mattress beside the bed. Resident #51 required transfer to the ER where he/she required sutures to his/her right eyelid. The resident returned to the facility on [DATE]. The IDT met on 05/23/2023 and implemented 1:1 supervision of Resident #51 while he/she was in bed.
f) On 05/29/2023, Resident #51 was found sitting on the floor mat beside the bed and was placed 1:1 supervision at all times.
g) On 06/11/2023, Resident #51 was found lying on the floor with a laceration to his/her head and was sent to the ER for treatment and was admitted overnight. Review revealed no documented evidence of an IDT note or intervention noted on the care plan.
h) On 06/21/2023, Resident #51 fell to the floor and hit his/her head which was witnessed by a staff member. Resident #51 was sent to the ER and was admitted overnight. Review revealed no documented evidence of an IDT note and the intervention on the Care Plan was to send to the ER.
i) On 07/01/2023, Resident #51 fell from his/her chair to the floor and was sent to the ER. The resident returned to the facility on [DATE]. On 07/03/2023, the IDT implemented an intervention to take the resident to activities to be engaged in other forms of stimulation.
j) On 07/08/2023, Resident #51 fell on his/her hands and knees and hit his/her nose on the table. On 07/10/2023, the IDT implemented an intervention for two (2) staff members to assist with Resident #51's ADLs.
Observation, on 07/12/2023 at 6:20 PM, revealed Resident #51 sitting at the nurse's station in his/her chair with a lap tray physically restraining the resident while CNA #11 walked around the nurse's station and chatted with other staff.
In interview with CNA #8 on 07/12/2023 at 10:20 AM, she stated she had been sitting with Resident #51 to provide a break for the CNA taking care of the resident at 2:30 PM yesterday (07/11/2023) and the other CNA left for the day without notifying her. She stated Resident #51 kept trying to reach out of bed and she turned around to turn on the television, and, when she turned back around, the resident was coming up out of the bed like he/she was going to choke her. CNA #8 stated Resident #51 then got fidgety with his/her gastrostomy tube (G-tube) and pulled it out and had to be sent to the hospital. She further stated she had sat with Resident #51 in the past and the resident tried to get out of bed which had not been locked.
During interview with LPN #7 on 07/12/2023 at 10:35 AM, she stated Resident #51 had been pretty much 1:1 since he/she had been at the facility. The LPN stated Resident #51 had behaviors since admission, was ambulatory on admission, and continued to be ambulatory; however, needed assistance as he/she was now unsteady on his/her feet. She stated Resident #51 had a psychiatric evaluation and medication changes which worked temporarily, but we can't chemically restrain the resident.
During interview with Resident #51's family member on 07/27/2023 at 10:42 AM, she stated the resident had a traumatic brain injury in January 2023 and she felt the facility did not have resources to take care of the resident. She stated Resident #51 was wasting away and had been self ambulatory upon admission but now the resident can't stand and cannot walk now. The family member stated Resident #51 had declined since admission to the facility and had to have a craniotomy related to a fall the very first week he/she was a resident in the facility. She further stated she was unsure how Resident #51 kept falling if he/she was on 1:1 supervision.
3. Review of Resident #15's medical record revealed the facility admitted the resident on 06/16/2023, with diagnoses which included Respiratory Failure, Liver Transplant, Seizures, Dependence on Renal Dialysis, Anemia, Muscle Weakness, and Cognitive Communication Deficit. Review of the admission MDS assessment dated [DATE], revealed the facility assessed Resident #15 to have a BIMS score of fourteen (14) out of fourteen (14) which indicated the resident was cognitively intact. Continued review of the MDS, section G revealed the facility assessed Resident #15 to require two (2) person assist for bed mobility and one (1) person physical assist with transfers.
Review of Resident #15's Comprehensive Care Plan dated 06/19/2023, revealed the facility care planned the resident as at risk for falls related to impaired balance and mobility, poor safety awareness due to cognitive decline, use of psychotropic medications, and visual impairment. Continued review revealed interventions which included bed in low position, call light within reach, and keep frequently used items close to the resident. Further review revealed an intervention initiated on 06/29/2023, not to leave Resident #15 up in the chair in the room alone.
Observation on 07/13/2023 at 2:55 PM, revealed Resident #15 sitting in a reclining chair with feet raised, attempting to climb out of chair in his/her room alone with no staff present near the resident's room. Staff were notified and went to the resident's room.
Review of Resident #15's Progress Notes revealed the resident fell on [DATE], then complained of right hip pain on 07/04/2023 at which time an x-ray of the right hip was ordered by the Physician. Continued review of the Progress Notes revealed an x-ray was obtained on 07/07/2023, with a final x-ray report on 07/08/2023, which revealed a right hip fracture. Review of the Progress Notes revealed no documented evidence of entries noted from 07/08/2023 until 07/10/2023. Further review reveale Resident #15 was transported to the hospital on [DATE] and admitted for a right hip fracture.
Additional review of Resident #15's Progress Notes revealed the resident returned from the hospital on [DATE]; however, was readmitted to the hospital on [DATE], for oxygen saturation levels of seventy-eight percent (78%) and facial edema. Review of the Progress Notes revealed Resident #15 continued to be in the hospital until 07/24/2023.
Review of the 07/31/2023 Hospital History and Physical Note revealed the diagnosis for Resident #15 had been Sepsis with acute on chronic Encephalopathy due to Pneumonia.
Interview with CNA #21, on 07/16/2023 at 7:20 PM, revealed Resident #15 required total assist with transfers and was currently out to the hospital.
4. Review of Resident #72's medical record revealed the facility admitted the resident on 05/01/2023, with diagnoses including Major Depression, Anxiety, End Stage Renal Disease, and Altered Mental Status. Review of the admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of thirteen (13) out of fifteen (15) indicating he/she was cognitively intact. Continued MDS review of section G, revealed the facility assessed Resident #72 as a one (1) person physical assist for bed mobility. Further MDS review of section J revealed the resident had a history of falls prior to admission.
Review of the facility's fall risk assessments dated 05/01/2023 and 07/06/2023, revealed the facility assessed Resident #72 with a score of thirteen (13) which indicated he/she was a high fall risk.
Review of the baseline care plan dated 05/02/2023 for Resident #72 revealed the facility identified the resident's risk for falls; however, did not initiate a comprehensive fall care plan for him/her until 06/20/2023. Review of Resident #72's base line care plan dated 05/02/2023, was a safety risk, was identified fell at home, had a history of falls prior to admission, and within the last two (2) to six (6) months. Continued review revealed listed under specify other safety devices-bed in lowest position was noted. Further review revealed under comments it was noted Resident #72 was only oriented to self, could not comprehend where he/she was and could not use a call light. In addition, it was noted Resident #72 attempted unassisted transfers, and his/her gait was weak and unsteady.
Review of Nurse Progress Note dated 07/06/2023 at 10:00 AM, revealed LPN #2 was notified Resident #72 had been found lying on the floor. Continued review revealed Resident #72 was assessed and found to be bleeding from a gash on his/her left leg below the knee. Further review revealed the medical doctor was notified and gave an order to send to Resident #72 to the emergency room (ER). In addition, the resident's family and management were notified.
Interviews with LPN #2 were attempted on 08/01/2023, 08/02/2023, and 08/03/2023; however, were unsuccessful.
Review of the Emergency Department history and physical dated 07/06/2023 revealed Resident #72 presented to the ER after a fall out of bed that morning. Continued review revealed Resident #72 had an open laceration to the left proximal tibia (upper part of the shinbone next to the knee). Review revealed the bone was exposed, and the description of the repair noted as a laceration eight (8) centimeters (CM) in length on the left lower extremity, anterior, lateral, lower leg. Further review revealed the repair included skin closure with eleven (11) sutures in a single layer. In addition, review revealed Resident #72 tolerated the procedure well.
Review of the Nurse Progress Note dated 07/07/2023 at 10:34 AM, documented by the DON, revealed Resident #72's fall was reviewed in the facility's Interdisciplinary Team (IDT) meeting. Continued review revealed the Note stated Resident #72 was lying to close to the edge of the bed and rolled out of bed while sleeping. Further review revealed Resident #72 needed assistance with moving to the center of the bed, and side rails were to be added to his/her bed for bed positioning.
In interview with Resident #72's spouse and family member on 08/03/2023 at 2:38 PM, they stated Resident #72 had rolled out of bed and hit his/her leg on the floor. Resident #72's sister-in-law stated she had requested bed rails ever since the resident's admission because he/she had a history of falls from the bed at home.
In interview on 08/04/2023 at 2:05 PM, Resident #72 stated he/she rolled out of bed and had a hard fall to the floor. Resident #72 stated there had been nothing in the way of the side on the side of the bed and the floor. The resident further stated he/she had not rolled out of bed since the side rails were added.
In interview on 08/06/2023 at 9:42 AM, the DON stated Resident #72 had been independent in his/her room and since admission he/she had lain too close to the edge of the bed. The DON stated Resident #72 was assessed as a high fall risk. She further stated Resident #72 appeared as less of a risk for falls after receiving dialysis and therapy; however, the resident had not been reassessed for falls.
In interview on 08/06/2023 at 10:08 AM, the Administrator stated Resident #72 was a high risk for falls and had interventions on his/her baseline care plan which covered his/her fall risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure a resident whp was incontinent of bladder received appropriate treatment and service realted to incontinence care for one (1) of sixty-one (61) sampled residents, Resident #40.
Tha findings include:
Review of the facility's policy, Activities of Daily Living Incontinence Care, revised 01/25/2021, revealed it was the policy of the facility to ensure residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with daily routine care. Further review of frequency depended on the individual's emptying of the bladder and/or routine two (2) hour checks as well as care planning.
Review of Resident #40's medical record revealed the facility admitted the resident on 12/11/2022, with diagnoses which included Hemiplegia, Morbid Obesity, Osteoarthritis, Polyneuropathy, and Weakness. Review of Resident #40's admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15) which indicated he/she was cognitively intact. Continued review of the MDS under section G revealed the facility assessed Resident #40 to require extensive assistance of two (2) persons for bed mobility, transfers, dressing, and one (1) person assist for eating and personal hygiene.
Review of Resident #40's Comprehensive Care Plan, dated 01/09/2023, revealed the resident had an alteration in elimination due to bowel incontinence and a potential for complications associated with urinary incontinence with interventions which included ask/encourage the resident to use the call system to report the need to toilet as needed and to provide incontinence care/peri care after incontinence episodes as needed. Further review revealed the resident had an alteration in comfort related to Osteoarthritis, Cluster Headache Syndrome, Low Back Pain, Muscle Spasms and Neuropathy with interventions which included pain medication per order and observe for effectiveness.
Observation, on 07/16/2023 at 6:58 PM, revealed Resident #40 put on the call light to ask for incontinence care. Observation revealed the call light was answered by Certified Nursing Assistant (CNA) #21 at 7:10 PM. The CNA was in the resident's room for approximately thirty (30) seconds, then returned to the hallway and continued picking up dinner trays.
During an interview with Resident #40, on 07/16/2023 at 7:32 PM, he/she stated he/she had asked for incontinence care and CNA #21 told him/her that no one had been changed on the hall yet and he/she would have to wait until he got time to change Resident #40. He/she further stated he/she had not received incontinence care since 2:30 PM and he/she often doesn't receive every two (2) hour incontinence care as he/she as expected. He/she continued to state he/she was embarrassed and worried about skin breakdown because of lack of incontinence care.
During an interview with CNA #21, on 07/16/2023 at 7:35 PM, he stated he was the only CNA on the hall taking care of thirty plus (30+) residents because another CNA was running late and it happened a lot that he was the only CNA for the hall.
During an interview with the Director of Nursing, on 08/07/2023 at 9:56 AM, she stated she expected all nursing staff to follow the facility's policy. She further stated she was aware staff occasionally called in but she and the scheduler worked very hard to make sure the facility had sufficient staff at all times. She stated she expected residents that required assistance with incontinence care, recieved the assistance they needed.
During an interview with the Administration, on 08/07/2023 at 1:45 PM, she stated it was her expectation that staff follow the facility policies. She further stated the Director of Nursing was reponsible for the nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents, who required dialysis/hemodialysis received such services, consistent with professional standards of practice for four (4) of nineteen (19) sampled residents who received dialysis (Residents #242, #243, #244, and #11). In addition, the facility failed to ensure communication sheets, used to communicate information on the resident, were completed for each dialysis treatment.
1. The facility failded to secure and set-up Resident #243's dialysis treatments prior to admission to the facility on [DATE]. The facility failed to ensure Resident #243 received his/her dialysis treatment on 07/12/2023. The resident was discharged on 07/14/2023, and transported to the hospital for acute care dialysis.
2. The facility failed to ensure Resident #242 received his/her dialysis treatments on 04/23/2022, 04/26/2022, and on 04/28/2022. On 04/28/2022, when Resident #242 arrived to his/her dialysis appointment, the resident presented in the dialysis lobby slumped over, unresponsive, with his/her body twitching. The resident was immediately sent to the hospital for emergent care. Review of Resident #242's diagnoses when he/she presented to the hospital were Acute Metabolic Encephalopathy, from Uremia; Sepsis; End Stage Renal Disease; Hyperkalemia (high potassium); and Adult Neglect, concern for lack of hemodialysis for one (1) week.
3. The facility admitted Resident #244 on 02/23/2022. However, the facility failed to set up the resident's dialysis treatments prior to admission. On 02/25/2022, Resident #244 was readmitted to the hospital for acute care dialysis.
4. The facility failed to ensure Resident #11, who received out of facility dialysis on Tuesdays, Thursdays, and Saturday's, had communication sheets between the facility and the dialysis center, which were required for each treatment. The communication sheets were not completed from 05/17/2023 to 07/11/2023.
The facility's failure to have an ongoing assessment of the resident before and after dialysis treatments, including monitoring the resident's condition for complications; and the failure to conduct ongoing communication and collaboration with the dialysis facility regarding residents' dialysis care and services; and failure to ensure residents had dialiysis appointments and failure to ensure residents were transported to their dialysis appointments is likely to cause serious injury, serious harm, serious impairment, or death to residents.
Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/21/2023 and determined to exist on 02/25/2022 in the area of 42 CFR 483.25(l) Quality of Care F698 Dialysis, at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/21/2023, and the IJ is ongoing.
The findings include:
Review of the facility's policy titled, Community Hemodialysis (HD), effective and last revised date of 07/25/2019, revealed all residents admitted to the facility with the need for hemodialysis were to have coordination of services between the facility and the hemodialysis unit prior to admission. Per the policy, dialysis services were to be set up with the dialysis center by the hospital or community agency prior to the resident's admission to the facility. Continued review revealed when the dialysis schedule was determined, the facility would set up the transportation arrangements. The policy revealed a schedule would be provided to the nursing units for the resident's dialysis days, including the time and day of the week that the resident was to attend dialysis. Review revealed the facility was to obtain orders from the Physician for the resident's dialysis days, which was to be written on the Physician order sheet. In addition, a dialysis communication sheet was to return with the resident after the dialysis session to communicate to the facility information regarding the dialysis session. Further review revealed the facility was to continue to monitor the resident after dialysis for any signs and symptoms of disequilibrium syndrome (a serious and rare complication of dialysis that involves a range of neurological symptoms), nausea, vomiting, or bleeding from the dialysis access site. The policy review revealed changes in the resident's condition were to be documented and reported to the Physician.
Review of the In-House Dialysis Company's policy titled, Patient Selection Criteria for Staff Assisted Home Hemodialysis in the Skilled Nursing Facility, dated 10/26/2021, revealed their clinical team reviewed patient (resident) records to ensure the patient could be safely dialyzed in a group environment, and the patient was not at risk of becoming unstable during treatment. Per the policy, the patient's services intake team was the central hub for all referral activity, returning patients, and admission related updates. Continued review revealed the admission items needed for acceptance were dialysis treatment records, lab reports within seven (7) days; a nephrology note including renal diagnosis, history and physical, face sheet with insurance information, hepatitis B surface antigen results within thirty (30) days, and chest x-ray or Purified Protein Derivative (PPD) test within 90 (ninety) days. The policy stated the patient services team would work with the facility to proactively reach out to hospitals to collect the necessary documents. Per the policy, it was helpful for the facility that wanted to admit the patient/resident to share relevant case worker contact information so the in-house clinic could support the facility's efforts to collect paperwork and admit residents/patients as quickly as possible.
1. Review of Resident #242's admission Record revealed the facility admitted the resident, on 04/21/2022, with diagnoses of End Stage Renal Disease (ESRD), Pain in Leg, and Hypotension. Review of Resident #242's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15), indicating moderate cognitive impairment.
Review of Resident #242's Nursing Progress Note, dated 04/21/2022 at 9:04 PM, revealed the resident was total care for bed mobility and total care with transfers. Review of Resident #242's Nursing Progress Note, dated 04/23/2022 at 11:53 PM, revealed the resident had an arteriovenous (AV) fistula (a vascular access for hemodialysis) in the left upper arm. Further review of the 04/23/2022 Progress Note revealed the resident received hemodialysis three (3) times a week.
Review of Resident #242's care plan initiated on 04/22/2022, revealed a potential for complications related to dialysis because of ESRD, with intervention which included dialysis treatment three (3) times a week on Tuesday, Thursday, Saturday at the dialysis clinic, pick up 2:00 PM, with no transport company listed, and make transportation arrangements for dialysis.
Continued review of Resident #242's facility medical record revealed no documented evidence of the resident having a nursing assessment, progress note, or documentation of Physician/MD/NP notification of the missed HD treatment for 04/26/2022. Further review revealed a nursing assessment was performed on 04/23/2022; however, there was no documentation noting Resident #242 missing his/her HD or documented evidence of the Physician, Medical Director, or NP being notified of that information or of progress notes concerning the missed dialysis treatment.
Review of the freestanding dialysis clinic progress notes dated 04/26/2022, revealed the clinic notified the NP of Resident #242's missed dialysis treatment. Continued review of the notes revealed on 04/28/2022, Resident #242 presented to the dialysis clinic lobby from the facility slumped over and unresponsive, with his/her body twitching. Further review revealed Emergency Medical Services (EMS) was called, and EMS transported the resident to the local Emergency Department (ED).
Review of the EMS Run Sheet/Report dated 04/28/2022, revealed the EMS personnel arrived at the dialysis center and found Resident #242 seated in wheelchair. Per the report, Resident #242 was lethargic, difficult to arouse, and non-verbal when awakened. Continued review revealed the dialysis center staff told EMS staff the resident was discharged from the hospital on the previous Saturday and received his/her most recent dialysis treatment at that time. Per the report, EMS staff were informed Resident #242 was transferred to the facility from the hospital and had not been transported to dialysis until that day (04/28/2022), and upon arrival presented lethargic and non-verbal. Review revealed dialysis center staff, informed EMS staff, the skilled longterm care facility had requested Resident #242 receive only one (1) hour of the normal three (3) and a half hours of his/her dialysis treatment for every treatment because of scheduling convenience. Further review revealed the EMS assessment revealed no visible or palpable signs of trauma; all vital signs within normal limits; and blood glucose checked and was 105 mg/dl (normal).
Review of Resident #242's hospital records of the History and Physical (H&P) dated 04/28/2022 at 10:30 PM, revealed the resident had admission diagnoses of Acute Metabolic Encephalopathy, likely multifactorial, Sepsis, ESRD, Hyperkalemia, Hyperthermia, Malnutrition, Decubitus Ulcer, and Adult Neglect. Continued revealed Resident #242 had a negative head Computed Tomography (CT) scan; had been febrile with a temperature of 100.7 degrees Fahrenheit; had a heart rate greater than ninety (90) beats per minute; and his/her chest X-ray noted possible inflammatory infiltrate. Per review, intravenous (IV) Vancomycin and Zosyn started (antibiotics) were initiated, and for the resident's ESRD dialysis was scheduled on a Tuesday, Thursday, Saturday schedule, and he/she received HD today in the ED. Review revealed cooling blankets were ordered for treatment of Resident #242's hyperthermia; and the resident's potassium level of 6.5 (normal range was 3.5-5) was noted as related to lack of receiving HD. Further review revealed Resident #242 had a basic metabolic index (BMI) of 17.5 (underweight), appeared cachectic (wasting away), and nutrition was consulted. Review further revealed Resident #242's Stage 3 Decubitus Ulcer which was noted on his/her last admission, appeared to have increased in size. In addition, review revealed documentation noting there was concern for neglect given the patient's nutrition status, lack of HD for one (1) week, and Stage 3 Decubitus Ulcer; and Hypertension.
In an interview on 07/11/2023 at 3:23 PM, the Social Worker, from the out of facility freestanding dialysis center, stated Resident #242 had been a no call/no show on 04/23/2022 for his/her dialysis treatment. She stated, on 04/26/2022, the resident was sent back to the facility from the dialysis center without receiving a dialysis treatment. According to the Social Worker, the resident's transportation arrived after 3:00 PM and would only pick up the resident at 5:00 PM or earlier. She stated Resident #242 would not have been able to get a full dialysis treatment as ordered due to the transportation issue.
In an interview with the former Assistant Director of Nursing (ADON) on 07/13/2023 at 12:11 PM, she stated when Resident #242 was accepted by the facility the transport should have been set up for dialysis by the facility prior to the resident coming. She said it was the responsibility of the facility. She stated Resident #242's missed treatment on 04/23/2022 (Saturday) happened on a weekend, and the facility could not get transport because it had not been scheduled yet. She stated the referrals went to the Business Office Manager (BOM) and then to the Director of Nursing (DON), prior to the resident's admission. The former ADON stated if the facility decided to accept the resident, facility staff corresponded with the liaison (facilitator of communication of information between the hospital or outside facility and the facility). She stated then the BOM set up dialysis transport for the resident.
In an interview on 07/25/2023 at 8:38 AM, with the Director of Nursing (DON), she stated the facility did not have the Physician/Medical Director (MD) communication book sheets from April 2022 because the facility had changed medical providers since then. The DON further stated the scheduler and not the BOM set up transport for dialysis residents to the dialysis clinic.
2. Review of Resident #243's facility admission Record revealed the facility admitted the resident from a hospital, on 07/11/2023, with diagnoses of ESRD, Diabetes, and Abnormal Findings of Blood Chemistry. Review further revealed Resident #243 was discharged from the facility on 07/14/2023; prior to the facility being able to assess the resident's BIMS score for cognition.
Review of an email to the facility's Liaison #1 from the in-house dialysis clinic, dated 07/10/2023 at 12:51 PM, revealed Resident #243's name was on the in-house dialysis clinic's waitlist.
Review of the hospital record Dialysis Notes for Resident #243, dated 07/10/2023 at 7:00 AM, revealed dialysis was in progress. Continued review of the Dialysis Notes at 10:00 AM on 07/10/2023, revealed Resident #243's dialysis session was completed. Further review of Resident 243's hospital record revealed laboratory results dated [DATE] at 6:46 AM, revealed a Potassium level of 5.3 millimoles per liter (mmol/L, normal value 3.5-5.1 mmol/L), BUN 83 milligram per deciliter (mg/dL, normal value 8 to 26 mg/dL), and Creatinine-Blood 6.01 mg/dL (normal 0.73 to 1.18 mg/dL).
Review of Resident #243's care plan, initiated by the facility on 07/11/2023, revealed care plan interventions which included to monitor/document/report as needed (PRN) signs and/or symptoms of renal insufficiency such as: changes in level of consciousness; changes in skin turgor or oral mucosa; and changes in heart and lung sounds. Continued review revealed additional interventions included: check and change dressing daily at dialysis access site and document; and do not draw blood or take Blood Pressure (BP) in the arm with graft; however, no site was listed. Review further revealed no documented evidence of dialysis clinic, frequency of treatment, or days of treatment listed in the care plan.
Continued review of Resident #243's facility medical record revealed a Physician's order dated 07/12/2023, for the resident to receive in house dialysis three (3) times per week, on Monday-Wednesday-Friday.
Review of a Nurse Progress Note for Resident #243, dated 07/14/2023 at 3:55 PM, documented by Registered Nurse (RN) #3, revealed the resident had received no dialysis since Monday (07/10/2023), and the Physician had been notified. Per review of the Note, Resident #243 was transported to a local Emergency Department (RD) via medical transport. Continued review revealed facility staff accompanied Resident #243 to the ED, and the resident was alert and oriented when transported and displayed no signs and/or symptoms of distress or discomfort.
Additional review of the 07/14/2023 Nurse Progress Note documented by RN #3 revealed the documentation had been struck through (a line drawn through the text) by RN #3 on 07/22/2023 at 3:52 PM.
The State Survey Agency (SSA) Surveyor attempted a telephone interview with RN #3 on 07/25/2023 at 3:07 PM; however, no answer was received. The SSA Surveyor left RN #3 a message requesting a return call.
In an interview on 07/25/2023 at 4:01 PM with Registered Nurse (RN) #3, she stated she had only taken care of Resident #243 once. She stated on 07/14/2023, she was told in report that Resident #243 was an Hemodialysis (HD) patient, and was told by the ADON the resident needed to go to the hospital. RN #3 stated the ADON said it was something about Resident #243's HD and that the resident had missed a few days of his/her HD. She stated she struck through her Nurse Progress Note from that date because it had not been an accurate note. The RN stated she made a mistake by charting an assumption on the time frame. According to RN #3, she had just been employed at the facility within the last month. She stated she received education on dialysis; however, every facility was different regarding residents' weights, such as if staff at the facility weighed the resident or if the staff at the dialysis clinic weighed the resident. RN #3 further stated if a resident missed a dialysis treatment, the resident usually was sent to the ED to get the missed treatment.
Review of Resident #243's facility medical record revealed the resident had one (1) nursing assessment completed on 07/11/2023, while residing in the facility. Further review revealed for 07/12/2023, there was no documented evidence of a Nurse Progress Note, assessment of Resident #243, or documentation of notification to the Physician or Nurse Practitioner (NP) of the missed dialysis treatment on 07/12/2023.
In an interview with the Unit Manager (UM) on 07/27/2023 at 2:05 PM, she stated she put the change of condition note in for Resident #243, dated 07/14/2023, due to the resident having behaviors and needing dialysis. She further stated she was unsure about Resident #243's missing HD treatment on 07/12/2023.
In an interview on 07/19/2023 at 2:10 PM, with the in-house dialysis RN, she stated Resident #243 was never accepted by the in-house dialysis clinic when the SSA Surveyor requested the resident's missed HD documentation. The RN stated Resident #243 had been on the in-house dialysis clinic's pending list, and the Medical Director had not yet accepted Resident #243. She stated before acceptance, the DON and Medical Director of the in-house dialysis clinic met and determined, by doing a medical review, whether the patient/resident would be accepted into the dialysis clinic. She reiterated that Resident #243 had not been accepted into the in-house dialysis clinic.
In an interview on 07/25/2023 at 9:30 AM, with Licensed Practical Nurse (LPN) #2, she stated it was not communicated to her that Resident #243 had an HD order placed. She stated if she had known the resident had a dialysis treatment due on 07/12/2023, she would have taken Resident #243 to dialysis.
In an interview on 07/25/2023 at 9:49 AM, with the Staff Development Coordinator (SDC), she stated she placed the order on 07/12/2023 for Resident #243 to have dialysis three (3) times per week on Monday, Wednesday, and Friday, and for it to be done by the in-house dialysis clinic. She stated she put the order in during the Interdisciplinary (IDT) meeting because Resident #243 was a new admission and needed dialysis orders. She stated the members of the IDT were Therapy, Nursing, the Social Services Direct, the Activity Director, the Minimum Data Set (MDS) Coordinator, the Dietary Director, and the Staff Development Coordinator (SDC). She stated the IDT clinical meeting was held every Monday through Friday. However, there was no documented evidence the order was followed-up.
In an interview with the Director of Nursing (DON), on 07/19/2023 at 2:26 PM, she stated there was a Pending Outpatient list for residents until a dialysis chair became open, and there was currently one (1) resident on that list, Resident #243.
In an additional interview on 07/25/2023 at 9:55 AM with the DON, she stated it was her understanding the in-house dialysis clinic had approved Resident #243. She stated she was not aware the resident was on a waiting list. The DON stated two (2) facility residents that were on dialysis were in the hospital, and she did not understand why the in-house dialysis clinic could not put Resident #243 in one (1) of those dialysis chairs. The DON stated there would not be anything in the Physician/MD communication book about a missed dialysis treatment on 07/12/2023 for Resident #243, because staff should have completed a change of condition form. She stated the change of condition form for 07/12/2023 was not entered. She stated Nurse Practitioner (NP) #3 was aware of the missed dialysis for Resident #243, but there was no documented evidence the facility notified NP #3. The DON stated for in-house dialysis, the facility must have approval by Liaison #1, who coordinated treatments between the facility and the in-house dialysis clinic.
In an interview on 07/25/2023 at 2:42 PM, with NP #3 she stated she worked on Tuesdays and Thursdays; however, had been on call 07/12/2023 (Wednesday). She stated she did not recall receiving a call about Resident #243. The NP stated if a resident missed dialysis, she expected a nursing assessment and stat (immediate) labs (laboratory work) drawn on the resident. She stated she would want the nurse to monitor for lethargy; vital signs, especially low or high blood pressure; increased confusion; seizure activity; and high potassium, blood urea nitrogen (BUN), creatinine, and sodium. NP #3 stated she always ordered lab work on new admissions; however, had covered for another NP at another facility on Thursday, 07/13/2023, so she had not seen Resident #243. She further stated Resident #243 had been seen by the Medical Director on 07/14/2023.
In an interview on 07/25/2023 at 3:17 PM with the facility's Liaison #1, he stated for dialysis residents he sent all the information to the in-house dialysis clinic. He stated he and the facility would get an approval email and then admit the resident. He stated he received an email that said Resident #243 was accepted. When the SSA Surveyor asked for the email and previous emails dealing with that subject, or the email thread, he stated there was only an email with Resident #243's approval for the waitlist.
In an interview on 07/25/2023 at 4:33 PM, with Liaison #2, she stated Resident #243 did come from her account, she had sent information to the in-house dialysis clinic, and they went through an authorization saying Resident #243 was good to go. She stated she received an email from the in-house dialysis clinic saying Resident #243 was approved for the waitlist, and they had seventeen (17) chairs. She stated when she gave this information to the facility's Admissions office, she was told the facility was good to accept the resident.
In an interview on 07/25/2023 at 4:08 PM, with the Admissions Coordinator, she stated for outpatient dialysis the hospital set up the HD center or clinic for the resident, and the facility set up the transport. She stated once that was verified the facility could admit the resident. The Admissions Coordinator stated for in-house dialysis the facility sent information to the in-house dialysis clinic for approval for a chair, and the clinic was supposed to open more chairs on 07/10/2023. She stated she messaged the Administrator who responded that the in-house dialysis clinic was not opening more chairs. She stated the hospital had been holding Resident #243 for acceptance to the facility. She stated the DON spoke to the in-house dialysis clinic, who stated since the facility had two (2) residents at the hospital, the in-house dialysis clinic would accept Resident #243. The Admissions Coordinator stated she told the hospital the facility could accept Resident #243. However, the facility provided no documented evidence to corroborate the Admissions Coordinator's statement.
In an interview with the in-house Dialysis Clinic Manager (DCM) on 07/26/2023 at 3:47 PM, she stated the clinical liaisons were updated regularly, and the facility was previously told the in-house dialysis clinic was at full capacity. The DCM stated an email was sent on 07/10/2023 at 12:51 PM, that informed the facility that Resident #243 had been waitlisted. She stated the clinic advised the facility not to admit the resident for their (in-house clinic) dialysis. The DCM stated they did allow one (1) extra spot because of the closure of two (2) other nearby facilities in June 2023. She stated the in-house dialysis clinic's RN had access to the facility's charting, and the RN noted Resident #243 was residing in the facility and had not had his/her HD. The DCM stated the facility then brought Resident #243 to them for HD on 07/14/2023; however, the in-house dialysis clinic did not have specific dialysis orders as they had not accepted Resident #243 at that point. The DCM stated the facility could admit a resident on dialysis that had not been accepted by the in-house dialysis clinic; however, the resident would have to go to an outpatient dialysis clinic to receive treatment.
In an interview on 07/25/2023 at 2:56 PM, with the Medical Director, he stated the facility had many residents on dialysis with multiple co-morbidities. The Medical Director stated he would not send a resident to the hospital unless he/she missed multiple dialysis days. He stated he or the NP should be notified if a resident missed their dialysis. He further stated he had only been the facility's Medical Director for a month, but if resident rwuiring dialysis di not recieve the dialysis as ordered it could greatly affect the resident's renal staus.
3. Review of Resident #244's admission Record revealed the facility admitted the resident on 02/23/2022, with diagnoses of Chronic Kidney Disease Stage 4, Hypertension, and Diabetes. The resident was only in the facility for a short time, and a BIMS score was not assessed.
Review of the facility's Nursing admission assessment dated [DATE], revealed Resident #244 received hemodialysis and had a tunnel catheter (dialysis access) in the right upper chest. Per review of the Assessment, Resident #244 received dialysis treatments on Monday-Wednesday-Friday, and the resident's last treatment was on Wednesday, 02/23/2022.
Continued review of Resident #244's medical record revealed the facility admitted Resident #244 without an outpatient dialysis clinic order to receive his/her HD. Review revealed Resident #244 was sent back to the acute care hospital two (2) days later (on 02/25/2022) to receive his/her HD. Per the record, Resident #244 did not return to the facility.
Review of Resident #244's care plan dated 02/25/2022, revealed the resident had a potential for complications related to dialysis related to ESRD and dialysis treatments three (3) times a week. Continued review revealed interventions which included: make transport arrangements for dialysis; protect shunt (dialysis access) site from injury; and avoid constriction on affected arm, such as BP cuff, carrying purse, constrictive clothing. However, further review revealed no documented evidence of a dialysis clinic listed, times listed, or a transport company listed.
Review of the Nurse's Note dated 02/25/2022 at 11:11 AM, documented by the former ADON, revealed Resident #244 was being transported to a local ED. Continued review revealed the former ADON notified the ED nurse that Resident #244 needed to have dialysis, and upon return to the facility, a dialysis center needed to be assigned on a regular schedule.
In an interview with the former Assistant Director of Nursing (ADON) on 07/13/2023 at 12:11 PM, she stated she could not remember anything about Resident #244.
4. Review of Resident #11's admission Record revealed the facility admitted the resident on 10/26/2022, with diagnoses of ESRD, Diabetes, and Hypertension. Review of Resident #11's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating no cognitive impairment.
Continued review of Resident #11's Point-Click-Care (PCC, software used by the facility) Physician's order, dated 06/28/2023, revealed the resident received out of facility dialysis on Tuesday, Thursday, and Saturday. Further review, on 07/11/2023 at 2:56 PM, revealed the communication sheets between the dialysis center and the facility, provided by the facility, showed the last communication sheet was dated 05/17/2023.
Review of Resident #11's care plan revealed interventions initiated on 10/27/2022, which included: to communicate with dialysis center regarding medication, diet, and lab results; protect shunt (dialysis) site from injury; avoid constriction on affected arm, such as BP cuff, carrying purse, constrictive clothing; avoid any possible injury to the arm with the fistula; and monitor for bleeding of the right upper chest and left upper arm fistula.
In an interview with Licensed Practical Nurse (LPN) #12 on 07/23/2023 at 8:15 AM, she stated she just started working at the facility a month ago and had not received any education on dialysis. She stated she knew to watch a resident's vital signs and change the resident's access bandage after HD. However, she stated she was not sure about ongoing monitoring or what to do if a resident missed HD. LPN #12 stated some residents got weighed every morning; however she was not sure about how residents receiving HD were to be weighed. She further stated the care plans and orders told staff how to care for residents.
In an interview with the DON on 07/19/2023 at 2:26 PM, she stated the hospital had the responsibility to set-up HD for residents. She stated if not, the facility made sure transportation for the dialysis treatments was set up prior to the resident coming to the facility. The DON stated the facility did not accept a resident until HD and the transport was set up. The DON stated sometimes the hospital set up transport also, and sometimes it was the facility that set it up. She stated the HD schedule was posted at the nurse's station, and it was also written in the Physician's orders. According to the DON, the communication sheet utilized did not have an area for monitoring residents after their HD. However, she stated Physician's orders stated to monitor the fistula and remove the bandage over the fistula after four (4) hours. The DON stated the process for when a resident missed an HD treatment was for the Physician, Medical Director, or NP to be notified to send the resident to the ED to get dialysis, and for the resident to be monitored for fluid overload, shortness of air, and respiratory failure. She stated the Admissions Liaison talked to the hospital about admitting a resident that required dialysis. The DON stated the resident's hospital Discharge Summary was where dialysis orders were located, such as the chair time and the days of the week for the dialysis treatment. The DON stated the facility currently had no transportation issues regarding dialysis. She stated there was a Pending Outpatient list for residents until a dialysis chair became open.
In an additional interview with the DON on 08/01/2023 at 3:54 PM, she stated she would expect HD to be set up prior to a resident being admitted to the facility. She stated she expected the facility to set up transportation for HD treatments. The DON stated she would expect communication to occur between the dialysis center and the facility. She stated the facility's process for if the communication sheet was not completed, was the facility would contact the dialysis center and get the sheet sent over. She stated the staff at the facility were to monitor for fluid overload and shortness of air of residents. The DON stated she expected a nursing assessment to be completed to monitor a resident when he/she missed an HD treatment, and she expected a post-HD nursing assessment to be completed to monitor for complications. According to the DON, intake and output were monitored for dialysis patients for those with fluid restrictions, she expected a weight pre/post treatment, and the facility had orders to monitor for complications of the access site twice a day. In addition, she further stated employees received education regarding HD in their orientation and she realized the importance for residents with renal problems to recieve the routine schedule dialysis to ensure their renal function did not decline.
In an interview with the Administrator on 08/01/2023 at 3:40 PM, she stated she expected HD to be set up prior to a resident being admitted to the facility. She stated expected the facility to set up transportation for residents' HD treatments.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice. The facility also failed to account for the resident's experiences and preferences in order to eliminate or mitigate triggers that might cause re-traumatization of the resident for one (1) of sixty-one (61) sampled residents (Resident #84).
The findings include:
Review of the facility's policy titled, Trauma/PTSD Informed Care Guidance (Post-Traumatic Stress Disorder/PTSD), dated 01/09/2023, revealed the facility was committed to being a Trauma-Informed organization and recognized that many individuals might have experienced trauma. Continued review revealed this included people we serve, all staff and other persons who entered the building. Further review revealed it was the intent for staff to be informed about the effects and difficulties of psychological trauma and work in an environment which was sensitive to, and facilitated recovery from that trauma.
Record review revealed the facility admitted Resident #84 on 05/03/2023, with diagnoses of Post-Traumatic Stress Disorder, Anxiety, and Diabetes Mellitus Type 2. Review of the admission Minimum Data Set (MDS) Assessment, dated 05/09/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) which indicated Resident #84 was cognitively intact. Further review of the MDS, Section I revealed Resident #84 triggered for Post Traumatic Stress Disorder.
Review of the Physician's Order, dated 06/20/2023, revealed an order for Risperadol (antipsychotic used to treat PTSD) oral tablet 2 milligram (mg) give one (1) tablet by mouth at bedtime for PTSD. Review of the medication administration documentation dated 05/03/2023, 06/01/2023 and 07/01/2023 revealed the resident had received Risperadol 2 mg at bedtime for PTSD as ordered.
Review of the History and Physical documentation for Resident #84 noted by the Advanced Practice Registered Nurse (APRN) dated 05/05/2023, 05/08/2023, 05/15/2023, 05/22/2023, and 06/12/2023 revealed PTSD was listed under active medical problems. Review of the History and Physical, dated 07/13/2023, for Resident #84 noted by his/her Physician revealed PTSD was listed under the active medical problems. Continued review of the 07/13/2023 History and Physical revealed under the assessment plan for PTSD to continue the resident on Risperadol.
Review of the Comprehensive Care Plan, dated 05/16/2023, revealed no care plan was formulated for Resident #84's PTSD. Continued review of the Comprehensive Care Plan revealed a list of diagnoses under potential nutrition problem dated 05/16/2023, which listed PTSD with the other diagnoses.
However, even though Resident #84 had a documented diagnosis of PTSD and was receiving a medication to treat it, the facility failed to identify possible triggers which could cause him/her trauma, and failed to develop and implement a care plan to address the resident's PTSD. Therefore, staff were unaware of the resident's PTSD diagnosis and lacked training in trauma informed care.
In an interview on 08/04/2023 at 4:15 PM, Licensed Practical Nurse (LPN) #13 stated she had training on trauma informed care while employed in acute care. However, the LPN had not had trauma informed care training at this facility and stated she was not aware Resident #84 had PTSD.
In an interview on 08/04/2023 on 4:28 PM, Certified Nurse Aide (CNA) #22 stated she had no trauma informed care training and did not know of any residents with trauma.
In an interview on 08/05/2023 at 11:00 AM, Restorative/Certified Nurse Assistant (CNA) #8 stated she was just trained on trauma informed care on Sunday.
In an interview on 08/05/2023 at 3:04 PM, Nurse Practitioner (NP) #3 stated she was one (1) of three (3) NPs providing care for residents in the facility. The NP stated she did not know Resident #84 had a history of the PTSD as she had not provided his/her care. After reviewing the resident's History and Physical, NP #3 stated Resident #84 had diagnoses of PTSD and Anxiety. NP #3 stated Resident #84 also continued on the Risperadol for the PTSD, which appeared to be working.
In an interview on 08/06/2023 at 9:42 AM, the Director of Nursing (DON) stated there had been training on trauma informed care with staff. She further stated she was not aware Resident #84 had a diagnosis of PTSD.

Based on observation, interview, review of facility records and policy, it was determined the facility failed to ensure there were adequate, competent staff to ensure the safety of its residents. Observation on 08/07/2023 revealed three (3) Certified Nursing Assistants (CNAs) called off for day shift leaving one (1) CNA on the two hundred (200) hall.
The findings include:
Review of the facility's Staffing Guideline, revised on 05/11/2021, revealed during critical staffing periods there might be times when an incentive would be provided to nursing staff to work additional shifts outside their normal schedule.
Review of the facility's Standard Staffing Supervision Monitoring Guideline Policy and Procedure, last reviewed 06/20/2023, revealed staff assignments were based on residents' needs as far as their acuity and their assessment results, and their person-centered care planning. Continued review revealed the requirement for meeting residents' needs to include physical, emotional, psychosocial, social, and spiritual, was to be accomplished by provision of as much hands on care as necessary. Further review revealed supportive services to include staff from various departments in the facility and/or outside resources/vendor services were to be provided when indicated.
Review of the facility's assessment titled, Facility Assessment Tool, dated 02/28/2023, revealed the purpose of the facility assessment was to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. Per review of the Tool, the assessment was to be used to make decisions about the facility's direct care staff needs, as well as the facility's capabilities to provide services to residents in the facility. Continued review revealed the intent of the assessment was for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services residents required. Continued review revealed Administrator, Director of Nursing (DON) and a former Medical Director were involved in completing the assessment. Review of the facility's assessment, Part 1: Our Resident Profile, revealed the number of residents the facility was licensed to provide care for, and the average daily census questions were not answered and were left incomplete. Further review of the facility's assessment, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, revealed the total number of licensed nurses needed to provide direct care were (was) five (5) daily, and the total number of Nurse Aides needed daily were (was) eleven (11).
Review of the Resident Census and Conditions of Residents, Form CMS 672, (the form completed by the facility which represented the current condition of its residents and their needs) received from the facility on 07/11/2023, revealed the facility had a census of eighty-seven (87) residents. Per review of the form, thirty (30) residents needed one (1) to two (2) direct care staff to assist them with bathing, and fifty-seven (57) residents were totally dependent on staff for bathing. Continued review revealed seventy-seven (77) residents needed assistance of one (1) to two (2) staff for dressing and ten (10) residents were totally dependent upon direct care staff for dressing. Further review revealed seventy-two (72) residents needed one (1) to two (2) staff to assist with transfers and fifteen (15) residents depended totally upon staff to transfer them between surfaces, such as the resident's bed and his/her wheelchair. The data also revealed seventy-three (73) residents needed the assistance of one (1) to two (2) staff for toileting and fourteen (14) residents depended totally upon the facility's direct care staff for all their toileting needs. Additional review revealed fifty-three (53) residents were on a scheduled program for urinary toileting, and forty-two (42) residents were on a scheduled program for bowel toileting.
Review of the facility's Payroll Based Journal (PBJ) Staffing Report on 08/07/2023 at 8:41 AM, revealed the facility received a One-Star Rating, which indicated providers whose audits showed significant inaccuracies between hours reported and verified or those who fail to submit data by the PBJ reporting deadlines would have a One-Star rating on the staffing domain, which would result in a drop by one (1) star in their overall Five-Star rating.
During an interview on 07/19/2023 at 2:13 PM, Certified Nursing Assistant (CNA) #16 stated sometimes staff called themselves off work, and there would be no one to replace them. CNA #16 stated that concerned her because her residents complained about not receiving their medications and not being treated well. She stated every time staff tried to address the issue nothing gets done. CNA #16 further stated staff who were supposed to be in the building were sometimes gone from 10:00 PM to 1:00 AM with no explanation as to why, when they returned, just as if they were gone on a long break.
CNA #17 stated during interview on 07/19/2023 at 3:07 PM, that people would be on the schedule to work; however, would just not come to work. The CNA further stated at times there would only be three (3) aides for the whole building and that was not enough.
During an interview on 07/25/2023 at 3:22 PM, Licensed Practical Nurse (LPN) #14 stated she worked at the facility on 05/08/2022; however, lasted only four (4) months because she had to remove herself from the facility due to it being so hectic. She stated during that time the facility seemed disorganized, and there were agency nurses who seemed to not know what they were doing regarding sending residents out to the hospital, reordering medications, charting, and performing resident assessments. LPN #14 stated she had to do lots of education about things she thought a nurse should already know. She stated a lot of staff would regularly show up to work around 8:30 AM to 9:00 AM for day shift which was supposed to begin at 6:00 AM, and that left a hole on the unit. She further stated an interim DON tried to nip this in the bud, but the interim DON left the facility, and staff continuing to show up late to work was an ongoing issue.
During an interview on 07/23/2023 at 5:06 PM, LPN #13 stated nurses left the building at night for hours during their shift.
The DON stated during an interview on 07/26/2023 at 1:40 PM, that CNA #11 did the nursing staff scheduling in the staffing coordinator's absence. CNA #11 had the scheduling book in the room where he was providing one on one (1:1) supervision to Resident #51 and CNA #11 was looking at the schedules in Resident #51's room, but he was not making phone calls.
Observation, on 07/26/2023 at 4:05 PM, revealed Resident #51, who was assigned to be supervised (1:1) at all times related to his/her past unsupervised accidents and injuries, was alone in his/her room. The State Survey Agency (SSA) Surveyor, for the resident's safety, walked towards the nurses' station to find staff to supervise Resident #51. Continued observation at 4:07 PM revealed CNA #11 coming out of the facility's employee break room. Interview with CNA #11 at the time of observation revealed he stated he had to drop something off in the breakroom and could not find anyone to supervise Resident #51 while he did that. CNA #11 further stated he was only maybe gone thirty (30) seconds from Resident #51's room.
Review of the facility's Daily Census revealed the resident census on 07/28/2023 was eighty-six (86) residents.
On 07/28/2023 at 8:55 PM, LPN #13 stated during interview there was one (1) aide staffed to supervise one (1) resident, and there were only three (3) other nursing aides on duty from 6:30 PM until 10:30 PM to care for the facility's other residents. LPN #13 stated there were only two (2) nurses scheduled from 10:30 PM until 6:30 AM, and that made her feel overwhelmed. She stated she dreaded coming to work at the facility because they were always short staffed of either nurses or aides every time she came to work. LPN #13 stated, every time it is one or the other. These people are suffering. It is not right. Residents are not getting the care they need. She stated she would report the problems to the DON and the Administrator; however, it did not change anything. LPN #13 stated she had worked night shift at the facility for about one (1) year and had just been introduced to the DON for the first time last week. She further stated she had never seen the Administrator, and she had never seen any leadership rounding in the facility during the night.
In interview, on 07/28/2023 at 9:20 PM, LPN #13 stated they had two (2) CNAs call in for night shift. LPN #13 again stated it was overwhelming working for the facility as it was always short staffed of nurses or CNAs. LPN #13 stated again she reported the issue to the DON and stated she also reported it to the Assistant Director of Nursing (ADON); however, reiterated that things never changed.
Review of the Daily Staffing Sheet, dated 07/28/2023, revealed only three (3) Certified Nursing Assistants (CNAs) were assigned to care for the facility's (86) residents from 6:30 PM until 10:30 PM that evening.
Observation and concurrent interview with LPN #11 on 08/06/2023 at 9:53 AM, revealed two (2) Registered Nurses (RNs) called off for dayshift. In interview with LPN #11, he stated that two (2) nurses called off for today on dayshift; which included the nurse that was originally scheduled to work the 400 Hall, and the backup on-call nurse (Supervisor). LPN #11 stated they were both Registered Nurses (RNs), and this resulted in the 400 Hall not having any nursing coverage. Observation further revealed LPN #11 was noted to be covering both the 300 and the 400 Hallways.
Observation on 08/06/2023 at 10:30 AM, revealed no one came to relieve LPN #11 of his duties on the 400 Hall, and he continued to cover both the 300 and 400 Halls. Observation revealed the DON was present in the facility; however, she had not checked with staff, LPN #11, nor the CNA that was covering the 300 Hall. LPN #11 continued to cover both the 300 and 400 Halls without any assistance. Further observation revealed at 11:10 AM, the DON had not come to check the 300 or 400 Halls to see if LPN #11 or other staff needed assistance.
Observation on 08/06/2023 at 2:15 PM, revealed the DON was performing treatments on the 400 Hall for residents because there was no staff nurse available to work the 400 Hall that day. Further observation revealed LPN #11 returned to the 300 Hall to care for the residents residing on that hall.
Observation on 08/07/2023 at 8:51 AM, revealed three (3) CNAs called off for dayshift leaving one (1) CNA on the 200 Hall. Continued observation revealed the DON noted sitting at the nurses's station making calls on her phone attempting to contact other staff to come in and work.
During an interview with LPN #11 on 08/06/2023 at 9:53 AM, LPN #11 stated that he was instructed to just come do the accuchecks and other nurse duties until coverage arrived. LPN #11 further stated this was the first time in a very long time they had two (2) different nurses call in for today on dayshift; which was the nurse that was originally scheduled to work the 400 Hall, and the backup On-Call nurse (Supervisor). LPN #11 stated that he had a CNA on the 300 Hall watching residents while he was over here on the 400 Hall, and that he had not finished his morning medication pass on the 300 Hall before he was directed by the DON to go to the 400 Hall. He said he was able to complete his accuchecks on the 300 Hall before beginning to cover the 400 hallway, as well.
In an additional interview with LPN #11 on 08/07/2023 at 2:01 PM, he stated weekend staffing was not usually an issue, with maybe one (1) call in a weekend. He stated nurse staffing was usually good; however, CNAs were the ones that called in mostly on weekends. The LPN stated he did not know about the call in issue for the 400 Hall on 08/06/2023 until around 8:00 AM, and he got to the 400 Hall around 8:30 AM. He further stated only the Certified Medication Technician (CMT) working the 400 Hall volunteered to help him, with duties on the 400 Hall, that were within her scope of practice.
In interview on 08/07/2023 at 10:23 AM, the Director of Nursing (DON), she stated the facility's staff coverage process was when a call-in occurred she contacted the staffing scheduler who assisted with calling in other staff. The DON stated she might offer to pay out bonuses to staff members who were willing to pick up a shift. She stated if no one picked up the shift then she went to the on-call staff member for that day, who was usually someone from management for coverage. The DON stated for this week the Staff Development Coordinator (SDC) was on vacation and the next person in line was the ADON, who had been absent from work the past two (2) days and who had recently submitted his resignation, and the DON said she did not anticipate the ADON's return at this point. She stated if the on-call staff or ADON were not available then she (the DON) would have to come in and cover the shift. The DON stated she was not aware LPN #11 was having issues with getting glucose checks done on time while he attempted to cover both the 300 and 400 Hall by himself. She further stated once she became aware of his situation she then came and assisted him as much as she could.
In interview on 08/07/2023 at 3:00 PM, the Administrator stated the facility had a weekend on-call nurse, as necessary (PRN) staff, and offered staff bonus pay incentives to address weekend staffing issues, to get staff to come to work as ways to address the weekend staffing issues. She further stated staffing needs were based on the resident census, and the facility was okay as long as there were at least two (2) RN's and a CMT in the facility. The Administrator further stated if no one else was available to work, the DON would have to come in and work the floor.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were secured in locked compartments under proper temperature controls. The facility also failed to ensure only authorized personnel to have access to the drugs and biologicals.
Observation of one (1) treatment cart located on the 400 Hall, on 08/06/2023 at 11:10 AM, revealed the treatment cart was unlocked and unattended.
The findings include:
Review of the facility's policy, Medication Administration Policy Guideline, revised 05/17/2021, revealed during routine administrations, the medication and/or treatment cart was to be kept in the doorway of the resident's room, with the open drawers facing inward and all other sides closed. Continued review revealed the cart must be fully visible to the personnel administering medications/treatments, and all outward sides must be inaccessible to residents or others passing by the cart.
Observation of a treatment cart located on the 400 Hall on 08/06/2023 at 11:10 AM, revealed the cart was unlocked and unattended with the closed drawers facing toward the hallway. During the observation, no residents were observed in the hallway and no one passed by the medication cart.
In an interview on 08/07/2023 at 2:01 PM, Licensed Practical Nurse (LPN) #11 stated he was responsible for the contents of the treatment cart. He stated it was important to always keep the treatment carts locked when it was unattended so no one walking by could access them. LPN #11 further stated he should have locked the treatment cart prior to walking away from it.
In an interview on 08/07/2023 at 10:23 AM, the Director of Nursing (DON) stated the assigned staff was responsible for ensuring the safe keeping of carts, including locking them, when on duty.

Based on observation, interview, and review of the facility's menus, it was determined the facility failed to follow its menus. Observation revealed the menus were not always followed as posted. In addition, portion sizes were not always used according to the guidance on the production sheets.
The findings include:
Review of the facility's guide titled, Portion Control Chart, undated, revealed the color for the scoop and disher (type of ladle) for accurate portion servings. Scoops number and color were noted as follows: #8 scoop was gray; #12 scoop was green; #16 was blue; and, the #24 scoop was green. Scoop numbers and portion size were noted as: #8 scoop equaled four (4) ounces; #12 scoop equaled two and two thirds (2 and 2/3) ounces; the #16 scoop equaled two (2) ounces; and the #24 scoop equaled one and one-third (1 and 1/3) ounces.
Observation of the breakfast tray line on 07/25/2023 at 8:35 AM, revealed scoops used were as follows: the #12 green scoop (2 and 2/3 ounces) was used for pureed sausage instead of the #24 red scoop (1 and 1/3 ounces) per the production sheet; the #16 blue scoop (2 ounces) was used for the pureed eggs instead of the #12 green scoop (2 and 2/3 ounces) per the production sheet.
Observation of the breakfast tray line on 07/26/2023, at 8:15 AM, revealed scoops were used as follows: the #12 green scoop (2 and 2/3 ounces) was used for scrambled eggs instead of the #16 blue scoop (2 ounces) per the production sheet; the #16 blue scoop (2 ounces) was used for the pureed sausage instead of the #24 green scoop (1 and 1/3 ounces) per the production sheet; the #12 green scoop was used for the cooked pureed cereal (2 and 2/3 ounces) instead of the #8 gray scoop (4 ounces) per the production sheet.
Observation of the supper tray line on 08/01/2023 at 6:50 PM, revealed the food on the tray line appeared with a hash like appearance, with mixed vegetables, and applesauce for dessert. However, review of the menu, week 1, for the week of 08/01/2023, revealed the supper meal listed beef and potato bake, seasoned mixed vegetables, and honey bun cake for dessert.
Further observation of the tray line revealed scoops were used as follows: the #12 green scoop (2 and 2/3 ounces) was used for the pureed meat instead of the #8 gray scoop (four (4) ounces) per the production sheet; the #12 scoop (2 and 2/3 ounces) for pureed vegetable instead of the #8 gray scoop for four (4 ounces) per the production sheet; and a black ladle, unknown serving ounce, used for the main entrée that appeared hash like instead of the #8 gray scoop (two (2) ounces), and for double portions, two (2) #8 gray scoops (eight 8 ounces) per the production sheet.
During an interview with the Activities Director, on 07/24/2023 at 4:27 PM, she stated she was assisting with cooking in the kitchen for all meals, including breakfast. She stated she looked at the menu and had a history of working as a food service manager.
During an interview with the Registered Dietitian/Licensed Dietitian (RD/LD), on 08/03/2023 at 1:31 PM, she stated the Portion Control Chart was posted at the tray line and in a book in the kitchen.
During an interview with [NAME] #3, on 08/05/2023 at 10:05 AM, she stated dietary staff showed her which scoops to use. [NAME] #3 stated if she did not know, she would ask.
During an interview with Cook/Dietary Aide #4, on 08/05/2023 at 2:33 PM, he stated he did not currently cook. However, the menu listed the scoop and portion size for the food and the guide listed the scoops by color.
During an interview with [NAME] #5, on 08/05/2023 at 2:46 PM, she stated she knew the portion sizes and the size of the scoop by color. She stated the scoop guide and the portions were listed on the menu.
During an interview with the Dietary Supervisor, on 08/07/2023 at 9:43 AM, she stated it was important to follow the menus and to use the food available. She stated if other foods were used, then the foods listed on the menu were substituted and noted on the substitution log. She stated the scoops were used according to the menu spreadsheet and scoop sizes were posted in the kitchen. The Dietary Supervisor stated it was important to provide the correct portion size because if the proper portion was not used, the facility could run out of food.
During an interview with the Director of Nursing (DON), on 08/06/2023 at 9:42 AM, she stated it was important for staff to use the correct serving sizes for calories and prevent residents' possible weight loss.
During an interview with the Administrator, on 08/06/2023 at 10:08 AM, she stated staff should always follow the menus and use the correct serving sizes and provide for the needs of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's mealtimes it was determined the facility failed to serve meals at regular times comparable to normal mealtimes in the community for eight (8) of twenty-seven (27) sampled residents (Residents #4, #40, #46, #55, #56, #71, #75, and #86) on the 400 Unit.
Observations, during the survey, revealed breakfast, lunch and dinner meals were served two (2) hours after the posted mealtimes, on the 400 Unit. The residents did not receive dinner trays until 9:00 PM on 07/30/2023. In addition, interviews revealed the residents did not receive or were offered food from the always available menu.
The findings include:
Review of the facility's posted mealtimes titled, Mealtimes, not dated revealed Breakfast Dining room service was 7:00 AM; Lunch Dining room service was 12:00 PM; and, Dinner Dining room service was 5:00 PM. The breakdown of trays to the units, after the dining room was served, was to the 100 Unit Autumn; 200 Unit Evergreen; 300 Unit Lakeview; and then the 400 Unit Maple.
Review of the facility's posted menu titled, Menu Always Available, undated, revealed for breakfast: sausage/bacon, eggs (hard boiled, scrambled, over easy). lunch and dinner: hamburger and French fries; hotdog and French fries; chicken salad sandwich and chips; tuna salad and chips; peanut butter and jelly; ham and cheese sandwich and chips; bologna, cheese and chips; chicken noodle and tomato soup with a grilled cheese sandwich; and house salad and dressing.
Review of the facility's, Quality Assurance Tracking, (a grievance form) dated 07/31/2023, revealed it listed five (5) residents on the 400 Unit that had not received their dinner trays on 07/30/2023 until 9:00 PM (Residents #4, #46, #55, #56, and #71)
1. Observation of Resident #55 on 08/01/2023 at 6:55 PM revealed his/her supper tray was sitting on the bedside table untouched. In interview with Resident #55, on 08/01/2023 at 6:55 PM, when asked about supper and if he/she wanted something else to eat, Resident #55 stated No.
Record review revealed the facility admitted Resident #55 on 05/30/2023, with diagnoses that included Diabetes Type 2, Bipolar Disorder and Major Depression. Review of the admission Minimum Data Set (MDS) Assessment, dated 06/05/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) which indicated the resident was cognitively intact.
2. During interview with Residents #75 and #40, on 08/01/2023 at 6:50 PM, the residents stated the food looked like dog food and they did not receive a meal substitution. The residents stated if they asked for a substitution, they were offered sandwiches at night and staff told them that salads were not available. Residents #75 and #40 stated even if they asked for a salad, they were told salads were not available and did not always receive the substitution requested. The residents stated they did not receive a meal tray on 07/30/2023 for dinner. They stated they ate the snacks their families had provided.
Record review revealed the facility admitted Resident #75, on 11/06/2022, with diagnoses that included Major Depression, Bipolar Disorder, and Anxiety. Review of the Quarterly MDS Assessment, dated 08/01/2023 revealed the facility assessed the resident as having a BIMS score of thirteen (13) out of fifteen (15) which indicated the resident was cognitively intact.
3. Record review revealed the facility readmitted Resident #40, on 07/10/2023 with diagnoses that included Anxiety, Major Depression, and Cerebral Vascular Accident (CVA/stroke) with right and left side Hemiplegia. Review of the Quarterly MDS Assessment, dated 07/14/2023, revealed the facility assessed the resident as having a BIMS score of fourteen (14) out of fifteen (15) which indicated the resident was cognitively intact.
4. Record review revealed the facility admitted Resident #71, on 01/25/2023 with diagnoses that included Protein-calorie Malnutrition, Depression, Anemia, and Anxiety. Review of the admission MDS Assessment, dated 05/23/2023, revealed the facility assessed the resident as having a BIMS score of ten (10) out of fifteen (15) which indicated the resident had moderate cognitive impairment; however, was interviewable.
In an interview on 08/01/2023 at 8:27 AM, Resident #71 stated sometimes he/she did not get his/her dinner trays. The resident stated neither he/she or his/her roommate got their dinner meal tray on Sunday night (07/30/2023). Resident #71 stated some of the food he/she got, he/she could not eat because it just did not taste good.
Observation on 08/01/2023 at 7:00 PM on the 400 Unit revealed staff gave Resident #71 a sandwich, and his/her dinner meal tray revealed it sitting on the bed side table not eaten. During interview with Resident #71, at the time of observation, the resident stated he/she had wanted a sandwich.
Observation on 08/03/2023 at 1:49 PM, of Resident 71's lunch meal tray revealed the meal was uneaten. In an interview, at the time of observation, Resident #71 stated he/she had his/her sister bring lunch in to him/her because the resident did not want the alternative which was peanut butter and jelly, and he/she did not like that.
Observation on 08/01/2023 at 6:47 PM, revealed the dinner menu posted noted beef and potato bake, mixed vegetables, bread, and pudding/dessert. Continued observation revealed the dinner meal food being served appeared to be a hash/goulash, mixed vegetables, bread, and pudding. Further observation revealed all residents residing on the 400 hall were served dinner meal trays except one (1) resident whose family had brought food in for that resident. In an interview with Resident #71, at the time of observation, revealed he/she stated he/she did not want the dinner meal being served and had received an alternate meal of peanut butter and jelly sandwich and pudding dessert instead.
5. Record review revealed the facility admitted Resident #46 on 03/21/2023, with admitting diagnoses of End Stage Renal Disease, Hypertension, and Diabetes Mellitus. Review of Resident #46's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), which indicated he/she was cognitively intact and interviewable.
In an interview on 08/01/2023 at 8:35 AM, Resident 46 stated there had been multiple times when he/she had not received his/her meal tray and had to go find someone to fix him/her and his/her roommate (Resident 71) something to eat. The resident stated it was usually the dinner meal that did not get served to them.
In an additional interview on 08/03/2023 at 1:52 PM, Resident 46 stated he/she just tried to eat what was given to him/her because residents did not have a chance to ask for an alternative before they (staff members) took off before they could ask. Resident 46 stated he/she had not had a dinner tray delivered at least five (5) different times since he/she had been here. The resident further stated, They have been bringing them since you all have been here.
6. Record review revealed the facility admitted Resident #86 on 05/24/2023, with admitting diagnoses of Chronic Kidney Disease, Hepatitis C, and Hypertensive Emergency. Review of Resident #86's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fourteen (14) out of fifteen (15), which indicated he/she was cognitively intact and interviewable.
In an interview on 08/02/2023 at 1:38 PM, Resident 86 stated he/she had experienced not receiving his/her meal trays in the past.
7. Review of Resident #4's admission Record revealed the facility admitted the resident on 11/08/2022, with diagnoses which included Metabolic Encephalopathy, Unspecified Protein-Calorie Malnutrition, Diabetes, Morbid Obesity, and Chronic Pain Syndrome. Review of Resident #4's admission Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Continued review of the MDS revealed the resident was assessed to require the assistance of two (2) persons physical assist for bed mobility and transfers and one (1) person physical assist for dressing and eating.
Review of the facility's Grievance Log revealed the resident did not receive his/her dinner tray on 07/30/2023 until 9:00 PM.
Observation, on 07/16/2023 at 6:51 PM, revealed Resident #4's dinner tray was sitting on the overbed table with resident sleeping and room light turned off. Continued observation revealed CNA #21 woke Resident #4 up at 7:43 PM and took the resident's food to be reheated. Staff were observed assisting the resident to eat at 8:05 PM.
During an interview with Resident #4, on 07/12/2023 at 9:23 AM, he/she stated his/her dinner tray had been brought into his/her room on 07/11/2023 at 6:30 PM with a hot dog and potato wedges and staff were not available to assist him/her with eating until 10:00 PM. The resident further stated this occurred frequently as his/her tray arrived to his/her room at about 6:30 PM, which was the time of shift change. The resident stated night shift staff told him/her they had to complete a round and get everyone into bed before assisting the resident with his/her meal.
During an interview with CNA #21, on 07/16/2023 at 7:35 PM, he stated he was the only CNA on the hall taking care of thirty plus (30+) residents because another CNA was running late. Per the interview, the CNA stated and it happened a lot, that he was the only CNA for the hall.
8. Closed record review of Resident #56's Electronic Medical Record revealed the facility admitted the resident, on 06/10/2022, with diagnoses which included Diabetes, End Stage Renal Disease, and Heart Failure. Review of Resident #56's Quarterly MDS Assessment, dated 06/27/2023, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), which indicated the resident was cognitively intact.
Review of the facility's Grievance Log revealed the resident did not receive his/her dinner tray on 07/30/2023 until 9:00 PM.
During interview with Certified Nurse Assistant (CNA) #22 on 08/04/2023 at 4:28 PM, she stated there were only two (2) aides per hall. She stated they passed the residents' meal trays and then they assisted residents who needed help with eating.
During an interview with [NAME] #3 on 08/05/2023 at 10:05 AM, she stated she did not know about the facility's always available menu for alternatives for residents for lunch.
During interview with Cook/ Dietary Aide #4 on 08/05/2023 at 2:33 PM, she stated the always available foods for residents each night was sandwiches. She stated the other foods on the list were prepared daily. She stated trays were sent out late because of the work habits of staff in the kitchen.
During interview with the DON on 08/06/2023 at 9:42 AM, she stated there had been a change in dietary staffing. She stated residents were provided meal trays on the night the trays were missed. The DON stated the CNA could ask a resident what they preferred and get the item from the kitchen for them. The DON stated the CNAs asked dietary for the food, and if the food was not available, they returned to the resident and asked what the resident what he/she would like instead.
During interview with the Administrator on 08/06/2023 at 10:08 AM, she stated they have had dietary staff to call off and not work and some were no show. The Administrator stated the residents' meal trays should be delivered on time. She stated, We have employed new staff and they need training. The Administrator stated the CNAs and/or nurses should let Dietary know the resident's request and they should not tell the resident their food request was not available. The Administrator stated they should check with dietary first on the availability of the requested food item. She stated residents had the always available foods, up even until Dietary closed for the night.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store, and prepare food under sanitary conditions.
Observations, during the initial kitchen tour, revealed an ice scoop left stored in the ice machine; staff's personal drink cup was left sitting on the production table; and the snack room had food items not labeled and dated. Additionally, there was tube feeding, dated 04/01/2023, stored on a shelf available for use. The dishwasher temperature log was incomplete from 07/25/2023 to 07/30/2023.
The findings include:
Review of the facility's policy titled, Storage Periods, Use-By Guidelines, dated 05/25/2023, revealed foods with a manufacturer's use-by-date would still require an opened-on date once the item was opened. Continued review revealed all opened containers of food in the dry storage area were to be placed in an enclosed container, labeled, and dated. Further review revealed the expiration date was the last day the product was to be used for the best quality.
1. Observation on 07/24/2023 at 9:20 AM, during the initial tour of the kitchen revealed: a ¼ pound bag of potato chips opened and undated; ingredient bins of oatmeal and flour were not dated; and another staff's personal cup of ice water with no lid was sitting on the table above the ingredient bins.
Observation on 07/26/2023 at 9:31 AM, of the Nourishment Room dry storage revealed a loaf of bread not labeled or dated, and an open vanilla wafer box with a manufacturer's date of 06/04/2023 sitting on the counter.
Observation on 07/31/2023 at 9:50 AM, revealed clear containers of cornflakes and bran flakes that were not labeled or dated, and an open package of chicken flavored gravy mix not dated.
In an interview on 08/05/2023 at 9:51 AM, Dietary Aide #1 stated foods should be labeled and dated when opened with the time and date, and after three (3) days the food could be thrown out. The Dietary Aide stated staff should check with the supervisor on the proper way to dispose of food. Dietary Aide #1 further stated personal cups sitting on the counter could cause cross contamination. She stated the ice scoop should be stored in the holder to prevent cross contamination.
In an interview on 08/05/2023 at 9:57 AM, Dietary Aide #2 stated she labeled and dated the cereal boxes after opening them. The Dietary Aide stated if food was not labeled and dated the food should be thrown out as it would not be known how long it had been on the shelf. She further stated the ice scoop was to be washed daily, and stored in the holder to prevent bacteria.
In an interview on 08/05/2023 at 10:05 AM, [NAME] #3 stated food should be dated when opened and the ice scoop should not be in the ice. She further stated the ice scoop should be stored in the holder.
In an interview on 08/05/2023 at 2:33 PM, Cook/Dietary Aide #4 stated foods should be dated when opened, as it could spoil if not dated. Cook/Dietary Aide #4 stated undated food should be thrown out. The Cook/Dietary Aide stated staff were not to keep drinks on the production tables in order to prevent cross contamination. Cook/Dietary Aide #4 further stated the ice scoop should be stored in the holder and not in the ice machine to prevent cross contamination.
In an interview on 08/05/2023 at 2:46 PM, [NAME] #5 stated food should be placed in a container and dated, and if it was not dated staff were to toss the food item out. [NAME] #5 stated personal items were not allowed in the kitchen as those items could cause cross contamination. The [NAME] further stated the ice scoop should be kept in the holder and not stored in the ice to prevent cross contamination.
In an interview on 08/05/2023 at 10:46 AM, Restorative Certified Nursing Assistant (CNA) #8 stated residents' foods should be labeled with their name and room number, and dated.
In an interview on 08/08/2023 at 8:55 AM, CNA #18 stated residents' perishable foods which were placed in the refrigerator should have the resident's name and date. CNA #18 stated if food had no name or date staff were to dispose of the food.
In an interview on 08/07/2023 at 9:43 AM, the Dietary Supervisor stated her expectations for foods were for the food to be wrapped, put into a plastic container, labeled, and dated. She stated any foods not labeled and dated were to be thrown out. The Dietary Supervisor further stated staff must keep personal drinks covered and in the locker and not on the kitchen counters in order to prevent cross contamination.
In an interview on 08/06/2023 at 9:42 AM, the Director of Nursing (DON) stated all food items were to be labeled and dated and kept in the snack rooms and residents' refrigerators. The DON stated kitchen staff should follow expiration dates and rotate food on a first in and first out basis. Per the DON, food should be labeled and dated when opened and thrown out if not labeled and dated.
In an interview on 08/06/2023 at 10:08 AM, the Administrator stated dietary staff should not place their personal cups on the production counters in the kitchen as that was an infection control and cross contamination concern. The Administrator stated foods should be labeled and dated for First In/First Out, (FIFO) use, and if food was not dated it was to be thrown away.
2. Observation on 07/24/2023 at 9:20 AM, during the initial tour of the kitchen revealed the ice machine had a large scoop stored in the ice, with staff using a small metal scoop to pour ice into individual resident glasses. Continued observation revealed staff had a personal cup with a lid sitting on the pot and pan rack near the hand sink in the main kitchen area.
In an interview on 08/07/2023 at 9:43 AM, the Dietary Supervisor stated the ice scoop should be stored in the scoop holder to prevent possible cross contamination.
In an interview on 08/06/2023 at 9:42 AM, the DON stated it was an infection control concern if the ice scoop was stored in the ice machine and not kept in the holder where it belonged.
In an interview on 08/06/2023 at 10:08 AM, the Administrator stated the ice scoop should be stored in the holder, and if not it was a cross contamination and infection concern.
3. Observation on 07/27/2023 at 3:30 PM, of central supply revealed Glucerna (brand of tube feeding) 1.5 tube feed dated 04/01/2023, seven (7) containers stored on a shelf. Further observation revealed Glucerna 1.2 dated 04/01//2023, five (5) containers were stored on a shelf.
In an interview on 08/06/2023 at 9:05 AM, a Central Supply staff member stated he rotated the tube feeding supplements as they were received, and threw the expired supplements out. He stated he threw the tube feeding out after seeing the expired dates on the containers.
4. Observation on 07/31/2023 at 10:04 AM, of the dish machine temperature log revealed no documented evidence it had been completed from 07/25/2023 through 07/30/2023.
In an interview on 08/06/2023 at 9:42 AM, the Director of Nursing (DON) stated staff working on the dishwasher line should record the dishwasher temperatures because if temperatures were not recorded they would not know if the dishwasher was sanitizing the dishware.
In an interview on 08/06/2023 at 10:08 AM, the Administrator stated the temperature of the dishwasher was to be recorded daily, and the cook/supervisor was to oversee that it was recorded. The Administrator further stated if the dishwasher temperatures were not recorded staff might not know if the dishwasher was not working well or whether it was sanitizing the dishware.
In an interview on 08/07/2023 at 9:43 AM, the Dietary Supervisor stated the dishwasher temperature log should be recorded by the dietary staff as required. The Dietary Supervisor stated if the dishwasher temperatures were not recorded staff would not know if the dishwasher was working correctly and whether it was reaching the necessary temperatures.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to label and date residents' food items. Observations of the residents' refrigerator and freezer revealed unidentified or undated residents' food items.
The findings include:
Review of the facility's policy titled, Food Brought into Facility, dated 03/28/2023, revealed residents were allowed the enjoyment of foods brought into the facility by family and other visitors, while maintaining the safety and sanitation requirements for the residents as set forth by local, state, and federal regulations. Perishable food brought in by a resident, relative, and/or friend, should be eaten immediately or at the next meal. Outside foods requiring storage and refrigeration must be dated, labeled, and stored per the facility's and state's guidelines.
Observation of the residents' refrigerator and freezer, on 07/26/2023 at 9:40 AM, revealed an ice pack, which was a non-food item, pushed into the back right corner and frosted. Continued observation of the freezer revealed one (1) vanilla ice cream 48 ounce (oz.) container unidentified or undated; one (1) chocolate/vanilla ice cream half 48 oz. container unidentified or undated; one (1) package of four (4) Veggie Burgers open at the top, dated 07/02/2023 but unidentified; and one (1) frozen solid soft drink, frosted, twenty (20) fluid ounces, unidentified and undated.
Further observation of the residents' refrigerator revealed an opened package of smoked ham located in the clear covered shelf of the door, dated 09/04/2023 and unidentified; and a package of individually sliced and packaged American cheese slices, dated 10/16/2023 and unidentified. Continued observation of the refrigerator shelf revealed a light mayo container, dated 09/13/2023 and unidentified, and one (1) unidentified whole milk carton, dated 07/17/2023, which was outdated. The food products were not marked with the resident information or identifier on the products.
During an interview with Certified Nursing Assistant (CNA) #8, on 08/05/2023 at 10:46 AM, she stated family/resident's foods should be labeled with a name, date, and room number.
During an interview with CNA #18, on 08/08/2023 at 8:55 AM, she stated residents' perishable foods should be put into the refrigerator with a name and dated, and if there was not a name or date the food was to be disposed.
During an interview with the Director of Nursing (DON), on 08/06/2023 at 9:42 AM, she stated all food items, in the snack room and residents' refrigerator, should be labeled and dated.
During an interview with the Administrator, on 08/06/2023 at 10:08 AM, she stated CNAs knew the process for residents' foods stored in the residents' refrigerator. She stated the CNAs were aware the food should be labeled and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents' right to a dignified existence and communication with and access to persons and services inside and outside the facility for four (4) of sixty-one (61) sampled residents (Residents #4, #40, #51, and #57).
Resident #4 stated staff entered his/her room while he/she was having a private phone conversation with his/her family. Resident #40 stated staff members often turned his/her call light off, left the room not changing him/her, while telling the residents that all the residents were waiting to be changed. Observation revealed staff rolled his eyes at Resident #51 and stated how much he hated sitting with the resident in front of the resident. Resident #57 stated staff had been rude to him/her and laughed at him/her.
The findings include:
Review of the facility's policy, Resident Rights, revised 11/07/2022, revealed it was the policy of the facility to observe and implement Resident Rights as dictated by the Centers for Medicare and Medicaid Services (CMS) and each resident has the right to be treated with dignity and respect. Further review revealed the preferences and goals of the resident should be honored as much as possible and the resident's comfort, safety, and overall welfare should be promoted, protected, and enhanced at all times.
1. Review of Resident #4's medical record revealed the facility admitted the resident on 11/08/2022, with diagnoses which included Metabolic Encephalopathy, Unspecified Protein-Calorie Malnutrition, Diabetes, Morbid Obesity, and Chronic Pain Syndrome. Review of Resident #4's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) which indicated he/she was cognitively intact. Continued review of the MDS under Section G revealed the facility assessed Resident #4 to require the assistance of two (2) persons for bed mobility and transfers and one (1) person assist for dressing and eating.
Review of Resident #4's Comprehensive Care Plan, dated 11/09/2022, revealed the resident had a potential for ulceration, infection, and/or complications of the ostomy site. Further review revealed Resident #4 had a urostomy related to neurogenic bladder. Record review revealed interventions that included: perform urostomy care daily and as needed; maintain urostomy site and keep clean and dry; and check urostomy for leakage.
Observation, on 07/11/2023 at 10:35 AM, revealed a staff member from the therapy department came into the resident's room, while the resident was having a conversation. The staff worked with the resident's roommate, not providing any privacy for conversation with Resident #4. Further observation revealed another staff member knocked on the closed door during the conversation with Resident #4. The resident stated wait a minute, the staff member waited approximately thirty (30) seconds, then opened the door, looked inside, then closed the door.
Observation, on 07/17/2023 at 9:42 AM, revealed Resident #4's urostomy drainage bag was touching the floor with no dignity bag covering it.
During an interview with Resident #4, on 07/11/2023 at 10:30 AM, he/she stated staff would come into his/her room while he/she had visitors or was on the phone, and he/she felt he/she was receiving no privacy. He/she further stated he/she had requested from the scheduler and the main nurse that a male staff member not provide bathing, and he/she continued to receive male staff members for bathing. He/she continued to state staff members often laugh at her when she asked for care.
During an interview with Resident #4, on 07/12/2023 at 9:23 AM, he/she stated his/her urostomy bag was full and leaking, and he/she had asked LPN #6 to change it, and he stated would when he had time.
During an interview with Licensed Practical Nurse (LPN) #6, on 07/17/2023 at 9:45 AM, he stated the urostomy bag should have a dignity bag, and it was an infection control issue for the urostomy bag to touch the floor.
2. Review of Resident #40's medical record revealed the facility admitted the resident on 12/11/2022, with diagnoses which included Hemiplegia, Morbid Obesity, Osteoarthritis, Polyneuropathy, and Weakness. Review of Resident #40's admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15) which indicated he/she was cognitively intact. Continued review of the MDS under section G revealed the facility assessed Resident #40 to require extensive assistance of two (2) persons for bed mobility, transfers, dressing, and one (1) person assist for eating and personal hygiene.
Review of Resident #40's Comprehensive Care Plan, dated 01/09/2023, revealed the resident had an alteration in elimination due to bowel incontinence and a potential for complications associated with urinary incontinence with interventions which included ask/encourage the resident to use the call system to report the need to toilet as needed and to provide incontinence care/peri care after incontinence episodes as needed. Further review revealed the resident had an alteration in comfort related to Osteoarthritis, Cluster Headache Syndrome, Low Back Pain, Muscle Spasms and Neuropathy with interventions which included pain medication per order and observe for effectiveness.
Observation, on 07/16/2023 at 6:58 PM, revealed Resident #40 put on the call light. Observation revealed the call light was answered by Certified Nursing Assistant (CNA) #21 at 7:10 PM. CNA was in the resident's room for approximately thirty (30) seconds, then returned to the hallway and continued picking up dinner trays.
During an interview with Resident #40, on 07/16/2023 at 7:32 PM, he/she stated he/she had asked for incontinence care and CNA #21 told him/her that no one had been changed on the hall yet and he/she would have to wait until he got time to change Resident #40. He/she further stated he/she had not received incontinence care since 2:30 PM and he/she often did not receive every two (2) hour incontinence care as he/she expected. He/she continued to state he/she was embarrassed and worried about skin breakdown because of lack of incontinence care.
During an interview with CNA #21, on 07/16/2023 at 7:35 PM, he stated he was the only CNA on the hall taking care of thirty plus (30+) residents because another CNA was running late and it happened a lot that he was the only CNA for the hall.
During an interview with Resident #40, on 08/03/2023 at 1:22 PM, he/she stated he/she had to wait one and one-half (1 1/2) hours last night for his/her call light last night. He/she further stated some nurses and medication technicians refuse to give him/her the headache medicine (Fioricet) along with my pain pill (Oxycodone) even though physicians and nurse practitioners have told him/her they can be given together. He/she continued to state it made him/her uncomfortable and sad that staff won't follow the doctors orders and left him/her in pain.
3. Review of Resident #51's medical record revealed the facility admitted the resident on 04/07/2023, with diagnoses including Hypertension, Malnutrition, Depression and Anxiety. Review of Resident #51's admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of ninety-nine (99), which indicated the resident chose not to participate, or four (4) or more items were coded as zero (0). Further review of the MDS, Section G, functional status revealed the facility assessed the resident as requiring two (2) person assist for bed mobility and transfers, and review of the MDS, section J revealed Resident #51 had a history of falls.
Review of Resident #51's Comprehensive Care Plan, dated 04/23/2023, revealed the resident was care planned for a risk for falls with interventions including: two (2) staff for ADL care for safety; bolsters to left side of bed; one-to-one (1:1) supervision for safety due to frequent falls; call light within reach at all times, therapy to assess for locking tray table for geri chair; low bed related to decreased safety awareness; full size mattress to right side of bed; and the resident to be taken to activities to help keep him/her engaged in other forms of stimulation.
Observation, on 07/21/2023 at 2:50 PM, revealed CNA #11 sitting with Resident #51 one-to-one (1:1). Resident #51 was observed taking off his/her shirt and CNA #11 stated put your shirt back on, I hate sitting with him/her and I can't wait to get off. Resident #51 stated Sorry.
Observation, on 07/31/2023 at 10:05 AM, revealed LPN #6 had given Resident #51 medications per G-tube with the room door open.
4. Review of Resident #57's medical record revealed the facility admitted the resident on 03/17/2021, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Diabetes, Schizoaffactive Disorder, Bipolar Type, Arthritis, Dysphagia, Pain, Weakness, and Status Post Tracheostomy. Review of Resident #57's admission MDS Assessment, dated 03/16/2021, and Quarterly MDS Assessment, dated 05/03/2023, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact.
Review of Resident #57's Comprehensive Care Plan, dated 03/22/2021, revealed the resident was care planned to be at risk for complications related to his/her tracheotomy with interventions which included to maintain the resident's dignity during care and anticipate the resident's needs.
Observation, on 07/31/2023 at 3:15 PM, revealed Resident #57 in his/her room crying and mouthed words I'll talk to you later.
During an interview with Resident #57, on 08/05/2023 at 11:00 AM, the resident stated the staff laughed at him/her and were mean to me. The resident denied physical abuse but stated he/she felt the staff mocked him/her. The resident had also written notes he/she handed to the State Survey Agency (SSA) Surveyor because the resident had a difficulty time vocalizing words due to having a tracheotomy, which indicated the resident felt the staff made fun of him/her.
During an interview with the Administrator, on 08/07/2023 at 1:45 PM, she stated she was the Abuse Coordinator for the facility and she was unaware of any resident that felt they were being made fun of or laughed at. She further stated she would expect residents to report to her if any staff members were making them feel uncomfortable.

Based on observation, interview, and review of the Maintenance Director's job description, it was determined the facility failed to ensure the resident care equipment was maintained in safe operating condition for one (1) of sixty-one (61) sampled residents (Resident #35). Resident #35's bed was broken for more than two (2) years.
The findings include:
Review of the facility's document titled, Job Description Maintenance Director, undated, revealed the position summary for the Maintenance Director was responsible for planning, organizing, developing, and directing the overall operation of the maintenance department in accordance with current federal, state, and local regulations, and established company policies and procedures. The Maintenance Director's responsibilities also included ensuring supplies and equipment were maintained to provide a safe and comfortable environment.
Review of Resident #35's admission Record revealed the facility admitted the resident, on 09/11/2020, with diagnoses that included Encephalopathy and Acquired Absence of Left and Right Legs Above the Knee.
Review of Resident #35's Annual Minimum Data Set (MDS) Assessment, dated 07/10/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated intact cognition.
Observation on 07/11/2023 at 10:25 AM, revealed when Resident #35 pushed the remote on his/her bed to raise it from the low position, nothing happened. Resident #35's bed remained in the low position.
During interview on 07/11/2023 at 10:25 AM, Resident #35 stated his/her bed could not be raised from its lowest position. The resident stated the bed had been broken for about two (2) years. He/she stated a maintenance request was put in and parts were on order.
In an additional interview with Resident #35, on 07/13/2023 at 3:20 PM, he/she stated he/she did not report his/her bed being broken because he/she could get in and out of his/her wheelchair, adding there were a lot of people who were worse off than he/she was.
The Social Services Director (SSD) stated during an interview, on 07/11/2023 at 3:50 PM, that he was unaware that Resident #35's bed was broken. He stated he did not know why Resident #35 had not said anything to him before now about his/her broken bed.
During an interview on 07/11/2023 at 2:30 PM, the Maintenance Director stated he was not aware of any complaints of a broken bed in Resident #35's room.
During an interview on 08/04/2023 at 4:25 PM, Licensed Practical Nurse (LPN) #12 stated if a resident's bed was broken, she would report it to her supervisor. She stated it was important for beds to be maintained in working order for residents' safety. She stated some examples were the head of the resident's bed must be elevated for tube feeding, and residents who were at risk for falls needed their beds in the lowest position for their safety.
The Minimum Data Set (MDS) Coordinator stated during an interview on 07/25/2023 at 5:01 PM, that leadership staff checked on residents daily in a program referred to as Angel Rounds. She stated resident equipment checks were included in the daily Angel Rounds.
The Medical Records staff member stated during an interview, on 07/26/2023 at 3:45 PM, he had seen Resident #35 during Angel Rounds and would check the resident's room for cleanliness and for things that needed repair like a string for a bathroom light. Often when he checked, Resident #35 was asleep. The Medical Record staff member stated that during the Angel Rounds, he had not checked to see if Resident #35's bed was working.
The Maintenance Director stated during an interview on 07/31/2023 at 2:30 PM, that most of the time when a bed was broken, it was the motor that went out. He stated he did not regularly test beds for working order, nor was there a log or system to test the residents' beds. The Maintenance Director stated he would know if a resident's bed was not working by communication from the CNAs and the nurses to inform him if a resident's bed was broken.
The Administrator stated during an interview on 08/04/2023 at 3:30 PM, that the facility did not know about Resident #35's broken bed. Further, the Administrator stated it was the expectation that the CNAs and nurses would know if a resident's bed was broken and it was the expectation that staff would put in a maintenance work order request. She stated the requests were placed in the work order book located on the outside of the Maintenance Director's door. She further stated it was important for residents' beds to be maintained in working order in case of an emergency, the resident's bed may need to be raised up or down.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program as witnessed by staff using expired disinfectant wipes, dated [DATE], for cleaning the glucometers on [DATE], for two (2) of sixty-one (61) sampled residents, Resident #46 and #11.
The findings include:
Review of the facility's policy titled, Glucose Meter Cleaning Guideline, revised [DATE], revealed the glucose meters would be disinfected between each resident's use to prevent the spread of microorganisms including blood borne pathogens. Per the policy, disinfection of the machine would be completed with PDI Super Sani Germicidal Wipes or Bleach Wipes. The policy stated if the resident had his/her own meter, it still must be cleaned after each use. Per the policy, two (2) disposable wipes would be needed for each cleaning and disinfecting procedure: one (1) wipe for cleaning and the second wipe for disinfecting.
Observation of Licensed Practical Nurse (LPN) #11, during a point of care glucose test, on Resident #46 on [DATE] at 10:06 AM and Resident #11 on [DATE] at 11:10 AM, revealed LPN #11 used expired disinfectant wipes to clean the residents' glucometers. Further observation revealed the treatment cart on 400 Hall was noted to have expired disinfectant wipes that were being used to disinfect the glucometers. These wipes came from a white container with a purple lid, labeled Germicidal Disinfection Wipes, and manufactured by WynnMed Healthcare products. The container had a manufacture date of [DATE] and an expiration date of [DATE].
In an interview with LPN #11 on [DATE] at 11:45 AM, he stated he did not realize the wipes were out of date and immediately discarded them and went to central supply to obtain new wipes for replacement.
Observation of replacement wipes obtained by LPN #1, on [DATE] at 11:50 AM, revealed these new wipes were in a white container with a purple lid labeled Medline Microkill One Germicidal Alcohol Wipes with a manufacture date of 04/2022 and a expiration date of 04/2024.
In an interview with LPN #6 on [DATE] at 8:33 AM, he stated he primarily worked the 400 Hall and that pharmacy came to the unit and audited the carts. He stated he did not know when this occurred. LPN #6 further stated he did not know anything about the treatment cart having outdated disinfectant wipes on it.
In an interview with the Director of Nursing (DON) on [DATE] at 10:23 AM, she stated that Night Shift staff was responsible for checking all the carts, and there were a total of three (3) treatment carts. She stated there was one (1) on each hall except for the 100 Hall. She stated all staff members were responsible for removing any outdated or damaged items and disposing of them. She stated staff members should replace the discarded supplies with proper supplies from the in house stock or pharmacy. She stated she expected the facility's staff to discard any expired disinfectant wipes and obtain new ones that were in date, in order to ensure cleanliness and disinfection. She also stated there were no check off lists for the cart audits. She stated if there was any problem she usually was informed through word of mouth by the facility's staff. However, she stated there were usually no issues with the carts.
During an interview with the Administrator, on [DATE] at 1:45 PM, she stated she expected all staff to follow the facility's policies and the DON was in charge of the nursing staff.

Based on interview, record review, review of store receipts, and review of the facility's policy, it was determined the facility failed to ensure proper bookkeeping techniques. The facility's bookkeeping techniques failed to include an individual record established for each resident on which only those transactions involving his/her personal funds were recorded and maintained. The transactions failed to include information related to when the transactions occurred, what they were, the ongoing balance, and a receipt to give the resident and the facility to retain, for one (1) of sixty-one (61) sampled residents (Resident #14).
The findings include:
Review of the facility's policy titled, Resident Trust Fund Policy, updated 08/08/2022, revealed residents' funds were maintained in accordance with the State guidelines. The management of residents' funds was the responsibility of the Administrator and the Business Office Manager (BOM). Per the policy, residents' funds were maintained in a separate interest-bearing bank account that was the sole property of the residents, completely separate from any facility accounts. The policy stated it was mandatory that a reconciliation between the resident trust fund and the bank statement be completed monthly, and the residents' trust fund statements would be presented to the resident/responsible party on a quarterly basis. Per the policy, it was imperative to have proper segregation of duties in handling residents' funds, and this was for the protection of the individuals that performed the facility cash tasks. The policy stated the individual that received monies, gave receipts for monies, and prepared the deposits should not be the individual assigned to post the transactions into the accounting software. Per the policy, a resident on medical assistance would be notified whenever his/her funds were within two hundred dollars ($200) of the resource asset limit of two thousand dollars ($2,000). The policy stated the BOM was responsible for sending a notification letter to the resident/responsible party whenever his/her funds were within $200 of their resource limit. Per the policy, the BOM consultant would perform regular audits to verify the accuracy and completeness of the facility's trust fund records and cash box monthly reconciliations.
Review of Resident #14's admission Record revealed the facility admitted the resident, on 06/20/2020, with diagnoses of Diabetes, Dementia, and Hypertension.
Review of Resident #14's Quarterly Minimum Data Set (MDS) Assessment, dated 02/12/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15) which indicated moderate cognitive impairment. Review of the Annual MDS Assessment, dated 05/03/2023, and the Quarterly MDS Assessment, dated 08/01/2023, revealed the facility assessed the resident to have a BIMS score of twelve (12) of fifteen (15), indicating moderate cognitive impairment.
Review of Resident #14's variety store receipt for the resident's shopping on 04/22/2023 showed the itemized list that included: renew membership, renew plus membership, five (5) packs of thirty-five (35) cans of Sprite per pack; five (5) packs of thirty-five (35) cans of Coke per pack; five (5) cases of another soda; two (2) cases of root beer; three (3) cases of Ensure; three (3) cases of Faygo soda; two (2) cases of Tropicana; two (2) packs of tea, eighteen (18) per pack; four (4) cases of donuts; three (3) cases of honey buns; two (2) cases of muffins; two (2) snack packs; and multiple illegible items.
Review of the facility's receipt for shopping for Resident #14 included clothes, snacks, drinks, and personals, dated 04/24/2023 for the amount of fifteen hundred and thirty dollars ($1530.00). This was signed by Resident #14.
In an interview on 07/18/2023 at 1:35 PM, the BOM stated she did the shopping for Resident #14 on 04/24/2023. However, she stated the check was made out to the former Receptionist. She stated she and the Administrator could not write checks to themselves to reimburse for purchases made for residents using their own funds. However, she stated they could use a credit card for purchases and corporate would reimburse them after receiving a receipt. She stated the check was made out to the Receptionist because she (the BOM) could not write a check to herself.
Review of Resident #14's receipt from an online purchase for a wheelchair and cushions, dated 04/26/2023 for the amount of $719.73, revealed the Administrator's name was on it. However, the check was made out to the former Receptionist.
In an interview on 07/18/2023 at 3:30 PM, the Administrator stated she purchased Resident #14's wheelchair to spend down the resident's money. She stated she purchased the wheelchair from an on-line retailer, using her credit card. The Administrator stated she signed off on receipts from the BOM for purchases the BOM made for residents. However, she stated she could not verify she signed off on a $800 receipt from 04/22/2023 from the variety store for Resident #14. She stated the check to reimburse her for Resident #14's wheelchair was made out to the former Receptionist because they could not make checks out to themselves.
Review of Resident #14's receipt from an on-line retailer, dated 04/26/2023, revealed items ordered included a ergonomic wheelchair in 16 seat, quick release axis, and red frame for the amount of $629.00. The other items ordered were two (2) comfort gel memory foam wheelchair seat cushions for pressure sores and ulcer pain relief in the amount of approximately $50.00.
Review of Resident #14's other receipts totaling $1530, revealed these were copies and not the original reciepts and they were not legible. These copies looked as though they were altered with tape but they were all ending in the same credit card number.
In an interview on 07/18/2023 at 2:45 PM, the Administrator stated she had not heard of checks being cashed into personal accounts. She stated she had never cashed checks. The Administrator stated she had not signed off on any receipts. She stated she thought the resident's money went to the facility minus $40, but she would have to ask the BOM about the process. The Administrator stated employees that had to sign off on receipts from last year were the MDS Coordinator and the Dietary Manager. She stated this year the employees that had to sign off on receipts were the Medical Records Director, the Scheduler, and the Dietary Manager.
The State Survey Agency (SSA) Surveyor requested the Human Resources (HR) Director for employees' email addresses for terminated employees, the former Receptionist and the former MDS Coordinator, on 07/11/2023 at 11:00 AM. On 07/11/2023, at 1:07 PM, the State Survey Agency (SSA) Surveyor emailed the former Receptionist requesting a call to the SSA Surveyor. On 07/11/2023 at 1:10 PM, the former MDS Coordinator was emailed requesting a call back to the SSA Surveyor.
Interview with the former Receptionist and former MDS Coordinator was attempted, on 07/15/2023 at 3:00 PM, but their phone numbers were not working numbers.
In an interview on 07/18/2023 at 3:15 PM, the Dietary Manager stated she was asked to sign off on receipts, but she had not done so. She stated she had not done any shopping for residents. The Dietary Manager stated she had signed off on two (2) petty cash receipts for residents. She stated she had bought snacks, drinks, and other things for employees.
In an interview on 07/11/2023 at 10:20 AM, Resident #14 stated he/she did not have any concerns with finances. Resident #14 stated he/she was given a trust fund statement recently.
The SSA Surveyor, on 07/18/2023 at 3:45 PM, requested the Director of Nursing (DON) ask the BOM for Resident #14's variety store membership and premium membership cards that were listed on Resident #14's store receipt from purchases dated 04/22/2023.
O 07/18/2023 at 4:40 PM, the SSA Surveyor went to the BOM's office to request to see Resident #14's membership cards. The BOM stated she did not realize she bought her membership cards with Resident #14's money. The BOM stated the purchase was an honest mistake. She stated she had placed the money back into Resident #14's account.
Review of a receipt, dated 07/19/2023 at 9:25 AM, revealed it was a deposit into Resident #14's resident fund account with two (2) deposits listed. One deposit listed was $50 dollars for the variety store membership, and the other deposit was $60 for the variety store plus membership. Both memberships were purchased by the BOM, using Resident #14's account on 04/22/2023.
In an interview on 07/19/2023 at 9:36 AM, the Receptionist stated she had never gone shopping and had not cashed a check for the facility. She stated she only collected the resident's liability for the room and gave it to the BOM when people would pay at the front desk. She stated she had the receipts in a drawer at the front desk.
The SSA Surveyor, on 07/19/2023 at 9:45 AM, requested for the second time from the DON and BOM to view the original receipts for purchases for Resident #14. The SSA also requested the petty cash log and resident advanced checks for the last three (3) months. At that time, the SSA Surveyor saw four (4) packs of thirty-five (35) cans of soda in the BOM's closet. Certified Nursing Assistant (CNA) #15 stated they were for Resident #14 and were stored in the BOM's office.
In an interview on 07/19/2023 at 10:10 AM, the Receptionist stated she had cashed two (2) checks for the facility. She stated these were resident advanced checks, and her name was listed as the vendor being called the petty cashier. She stated she cashed the resident advanced check and gave the money to the BOM. She provided a bank check deposit slip, dated 07/11/2023, which was not legible.
In an interview on 07/19/2023 at 10:12 AM, Certified Nurse Aide (CNA) #15 stated Resident #14 had soda, popcorn, Coke, and peanut butter crackers that staff got from the BOM's office. The CNA stated the resident got new clothes and new athletic/tennis shoes about a month ago.
In an interview on 07/19/2023 at 10:45 AM, the Human Resources Director stated she cashed a check yesterday for $260. She stated this was to replenish the petty cash fund, and she had to cash the check and bring the money back to the facility in all one-dollar bills.
In an interview on 07/19/2023 at 1:15 PM, the BOM and the Regional Director of Operations (RDO), MDS Coordinator, and the DON were present. The SSA Surveyor requested clarification for deposits at the same bank that was the BOM's bank and also the RFMS' (Resident Fund Manager Service) bank. The BOM stated the money went into a main account for the RFMS, and then it was distributed into resident accounts from there. The SSA Surveyor asked about the Human Resources Director cashing a $260 check. The BOM stated the residents came to get petty cash, and the facility had the Human Resources Director cash a check to bring the petty cash amount back to $300.
In an interview, on 07/20/2023 at 8:00 AM, the Guardian Fiduciary stated that residents' monies were all kept in another city. She stated they would send the residents their $30 to $40 each month. She stated if the residents needed clothes or anything, they would send the facility more money. She stated she did not have any concerns.
In an interview on 07/23/2023 at 11:00 AM, Resident #14 stated his/her favorite snacks were popcorn and peanut butter crackers. The resident stated his/her favorite soda was cream soda and Coke. When asked if he/she like honey buns, the resident replied, No.
In an interview on 07/24/2023 at 1:31 PM, the Regional Account Manager stated the residents' funds were held by National Data Care which was the RFMS. He said state guidelines determined the amount a resident was allotted each month; however, he did not know the Kentucky amount. He stated unless the resident had an item D expense (not covered by Medicaid or by a third party like Medicare or private insurance), then the state would allot them more money. He stated the maximum amount for a resident trust fund was $2000. During continued interview, he stated there was an exception when residents were able to exceed this amount, which started with the COVID pandemic in March 2020 and ended six (6) months ago. The Regional Account Manager stated the BOM should not handle any purchases for residents. He stated Social Services, Activities, or a responsible party would help spend down the resident's money and should make purchases for residents. He stated each resident had his/her own interest-bearing account. The Regional Account Manager stated there was a master account which received the statement from the bank. He stated each resident had his/her own routing and account number through National Data Care. He stated the BOM did the reconciliation, and it was sent to the regional office for review. In interview, he stated residents could use money for anything they wanted. He stated the Administrator should be the one who cashed checks to replenish petty cash, and this came from the master petty cash account. The Regional Account Manager stated the process for a request for money was the BOM signed the check request and the check recipient, then it would withdraw from the National Data Care system, and the check would be printed in twenty-four (24) hours. He stated the facility could have checks made to employees if the BOM approved. The Regional Account Manager stated for audits they verified: that purchases were signed for; the amount requested was the amount given; interest was provided to accounts; accounts that needed to be closed were closed in thirty (30) days; checked for outstanding checks, or negative accounts. He stated the BOM reviewed returned receipts. He stated if the BOM did shopping for the resident, which should not happen, the Administrator should review the receipts. He stated if something was bought incorrectly on a resident account, the money should be returned immediately.
In an interview on 08/01/2023 at 3:20 PM, the Administrator stated each resident's trust fund account must be less than $2000. She stated the resident could delegate how he/she wanted any monies spent that exceeded the $2000 account limit. The Administrator stated the BOM should not do any shopping for the residents. She stated the BOM reviewed receipts. However, she stated if the BOM did any shopping, the Administrator or Human Resources Director would sign off on the receipts. The Administrator stated the only time she had done shopping was for Resident #14's wheelchair. She stated she had to put it on her own personal credit card, because the facility did not have a facility credit card. During continued interview, she stated she did not want her employees to endure the cost on their personal credit card. She stated if a personal item was placed on a resident's account, it should be reimbursed immediately. The Administrator stated if the resident requested a copy of the receipt, the facility would give a copy to him/her or the Power of Attorney or Guardian. She stated a resident's Brief Interview for Mental Status (BIMS) score of greater than eight (8), which meant the resident had moderate cognitive impairment or no cognitive impairment, was acceptable to sign off on his/her cash advances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility's policy, the facility failed to protect resident rights to privacy related to electronic medical records (EMRs) as determined by observations of the computer located on top of the medication /treatment cart, on 08/01/2023 and 08/04/2023, being left open and viewable with resident information.
The findings include:
Review of the facility's policy titled, Resident Rights, dated 01/09/2023, revealed it was the policy of the facility to observe and implement resident rights as dictated by the Centers for Medicare and Medicaid Services (CMS). These rights and protections are mandated by federal and state laws and are a requirement in Medicare and/or Medicaid certified nursing homes.
Review of the facility admission packet under title Resident Records, dated 08/01/2023, revealed residents' information in the clinical record was confidential and shall not be disclosed without residents' written consent, except as required or permitted by law.
Observation of the medication/treatment cart located by the nurses' station, on 08/01/2023 at 7:00 PM, revealed the computer was left open with residents' information and the residents' medications in public view. Further observation of the computer screen revealed a resident picture in the upper left-hand corner with rectangular yellow boxes underneath.
Observation of the medication cart on the 300 Hall, on 08/04/2023 at 11:04 AM, revealed a computer with the screen opened with residents' information and the residents' medications in public view.
During an interview with Licensed Practical Nurse (LPN) #17, on 08/01/2023 at 7:03 PM, she stated she took pain medication to a resident in room [ROOM NUMBER] and could not see the computer screen from the room. However, she left the computer screen black and stated it should take two (2) to three (3) minutes for the screen to turn black. She further stated she had not taken over the medication/treatment cart from the nurse at the time the computer screen was viewed by surveyors. She stated if the computer was left open with resident information it could be a Health Insurance Portability and Accountability Act (HIPPA) concern and against facility policy.
During an interview with Registered Nurse (RN) #1, on 08/04/2023 at 11:05 AM, he stated he was responsible for the computer, and he should have locked the computer screen to keep residents' information confidential.
During an interview with the Director of Nursing (DON), on 08/06/2023 at 9:42 AM, she stated the nurse should not have left the computer open with any patient information and it was a HIPAA violation. She further stated the screen should be left black or closed.
During an interview with the Administrator, on 08/06/2023 at 10:08 AM, she stated the computer screen should be closed when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to protect residents from physical and verbal abuse for seven (7) of sixty-one (61) sampled residents, Residents #2, #44, #243, #492, #493, #31, and #39.
On 07/16/2022, staff responded to yelling and entered room shared by Resident #44, and Resident #492, witnessing Resident #492 yelling at Resident #44 and swinging an empty urinal at Resident #44. Resident #44 was covered in urine.
On 04/17/2023, Resident #2 was observed pushing Resident #493 out of the doorway of Resident #2's room, causing Resident #493 to fall.
On 07/13/2023, it was reported to the Administrator Resident #243 was at the nurses station upset and speaking loudly. When the Business Office Manager (BOM) asked Resident #243 what was wrong, Certified Nursing Assistant (CNA) #14 yelled that Resident #243 was an asshole.
On 08/21/2022, Resident #31 made slight contact with Resident #39 at the Nurse's Station.
The findings include:
Review of the facility's Abuse Prevention Program policy, last revised 01/03/2023, revealed it was the policy of the facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property.
1 (a). Review of the Electronic Health Record (EHR) for Resident #492 revealed the facility admitted the resident on 11/15/2021, with diagnoses to include Unspecified Dementia without Behavioral Disturbance, Major Depressive Disorder, and Cognitive Communication Deficit. Continued record review revealed Resident #492's Quarterly Minimum Data Set (MDS) assessment dated [DATE], which noted the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15) indicating he/she had mild cognitive impairment.
Further review of Resident #492's EHR revealed a psychiatry progress note dated 07/21/2022 which noted the resident's medications were reviewed. Continued review of the psychiatry progress note revealed Resident #492 had behaviors when placed in room with a roommate, and he/she was discharged to another facility on 12/12/2022.
(b). Review of EHR for Resident #44 revealed the facility admitted the resident on 07/12/2022 with diagnoses to include Encephalopathy Unspecified, Cognitive Communication Deficit, and Altered Mental Status. Continued review of the EHR revealed Resident #44's admission MDS assessment dated [DATE], noted the facility assessed the resident to have a BIMS score of fourteen (14) out of fifteen (15) indicating no cognitive impairment.
Review of the Long-Term Care Facility - Self-Reported Incident Form dated 08/01/2022 revealed on 07/16/2022 a nurse heard yelling coming from the room shared by Resident #44 and Resident #492. Continued review revealed the nurse went to the room and saw Resident #492 swinging an empty urinal at Resident #44. Per review of the Form, Resident #492 was moved to another room, placed on 1:1 supervision, and emergency medical services (EMS) and police were contacted to take Resident #492 to the hospital, which he/she refused. Further review revealed Resident #44 was cleaned up and assessed, with no injuries noted.
In an interview on 07/12/2023 at 9:45 AM, Resident #44 stated he/she had no recollection of any incident in which a former roommate threw urine on him/her.
In an interview on 07/13/2023 at 10:12 AM, Certified Nurse Assistant (CNA) #2 stated although she had never worked with Resident #492, she heard the resident did not want anyone else in his/her room. She stated Resident #492 had been caught by staff smoking in his/her room on more than one occasion. CNA #2 further stated staff would take away cigarettes and lighters, but Resident #492 would obtain more.
In an interview on 07/14/2023 at 1:11 PM, the DON stated she recalled the situation between Resident #492 and Resident #44. She stated Resident #44 was a new admission at the time, and although Resident #492 understood English, he had limited communication. The DON stated she would not consider the situation involving Resident #44 and Resident #492 as abuse, although Resident #492 had clearly been upset, flailing his/her urinal around and urine got everywhere, including on Resident #44. She stated she could not recall what Resident #492 had been yelling about. She further stated her expectation was that abuse did not occur, and for staff to follow the facility's process, and try to prevent harm to residents as much as possible.
2(a). Review of Resident #2's EHR revealed the facility admitted the resident on 10/14/2015, with diagnoses to include Dementia, Major Depressive Disorder, and Bipolar II Disorder. Continued review of the EHR revealed Resident #2's Annual MDS assessment dated [DATE], which noted the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15) BIMS, indicating no cognitive impairment.
(b). Review of Resident #493's EHR revealed the facility admitted the resident on 10/17/2022 with diagnoses to include Cerebral Ischemia, Impulsiveness, and Unspecified Dementia without Behavioral Disturbance. Further review revealed Resident #493's Quarterly MDS assessment dated [DATE], which noted the facility assessed the resident to have a BIMS score of six (6) out of fifteen, indicating severe cognitive impairment.
Review of the Long Term Care Facility - Self-Reported Incident Form dated 04/21/2023 revealed on 04/17/2023 Resident #2 made contact with Resident #493 outside of Resident #2's room door. Continued review revealed the residents were separated and placed on every fifteen (15) minute checks. Per review of the Form, skin and pain assessments were completed, and Resident #493 was noted with a half-inch discoloration on his/her head, and neurological (neuro) checks were started. Further review revealed the facility noted there were two (2) staff witnesses, and the facility did not substantiate abuse, as it did not determine a willful intent by Resident #2 to cause harm to Resident #493.
Review of the witness statements revealed a statement by Resident #2, undated, in which the resident stated he/she had not pushed Resident #493. Continued review of Resident #2's witness statement revealed Resident #493 had fallen on his/her own, and should not have been in Resident #2's doorway. Review of CNA #2's witness statement dated 04/17/2023 revealed staff heard Resident #2 yelling, observed Resident #493 half-way out the door to Resident #2's room, at which point Resident #2 pushed Resident #493, causing Resident #493 to fall and hit the right side of his/her head.
In an interview on 07/11/2023 at 10:34 AM, Resident #2 stated he/she was treated well by other residents and by staff, and did not recall any incidents with any other residents.
In an interview on 07/12/2023 at 4:58 PM, CNA #2 stated she observed Resident #493 walking into Resident #2's room on the day of the incident, and heard Resident #2 yell get out of my room,. CNA #2 stated she thought Resident #493 was going to walk on out, when she saw Resident #2 come out and push Resident #493. According to CNA #2, she was trying to get to Resident #493; however, everything happened so quick, and resulted in Resident #493 falling. She stated Resident #493 was off-balance, so even a little push could cause a fall. CNA #2 stated she had not noticed any changes in Resident #493's behavior after the incident. She stated Resident #2 was at one (1) minute the sweetest person, and the next moment yelling, that's just how the resident was. CNA #2 stated Resident #493 frustrated a lot of people as he/she had Dementia, and would go into other residents' rooms sometimes. CNA #2 further stated a Velcro stop sign was placed across Resident #2's door at the time, which appeared to be an effective deterrent for Resident #493.
In an interview on 07/14/2023 at 1:11 PM, the DON stated Resident #2 had been placed in a private room as he/she did not like people being in his/her room, and did not get along with others. She stated Resident #493 had been pleasant, and walked around frequently; however, his/her equilibrium had been off. The DON stated Resident #2 pushed Resident #493 as he/she was trying to remove Resident #493 from his/her doorway. She stated she did not believe Resident #2 had meant Resident #493 any harm. The DON stated after the incident, the two (2) residents had been separated, and the facility performed its investigation. She stated as a result, a stop sign had been placed across Resident #2's doorway, and Resident #493 had been placed in the memory care unit due to his/her wandering. The DON stated the facility had not substantiated abuse, as Resident #2 had not willfully tried to hurt Resident #493.
3. Review of Resident #243's admission Record revealed the facility admitted the resident on 07/11/2023 with diagnoses to include: Diabetes, Cerebral Infarction, Hemiplegia and Hemiparesis affecting the right dominant side.
Review of Resident #243's admission Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.
Review of the facility's investigation, dated 07/13/2023, completed by the Administrator revealed on the morning of 07/13/2023 at approximately 6:30 AM the Business Office Manager (BOM) reported to the Administrator, Resident #243 was at the nurses' station observed to be upset and speaking loudly. Continued review revealed when the BOM asked Resident #243 what was wrong, Certified Nursing Assistant (CNA) #14 yelled because he/she was an a-hole. Per review of the investigation, the BOM immediately separated CNA #14 and Resident #243. Continued review revealed CNA #14 was suspended, and Resident #243 was assessed for psychosocial distress. Further review of the investigation revealed the facility's Interdisciplinary Team (IDT) met, discussed the findings, and substantiated the incident, and CNA #14 was terminated.
Review of CNA #1's witness statement dated 07/13/2023, revealed Resident #243 had been upset and CNA #14 was speaking nicely to the resident. Continued review revealed however, CNA #14 did not receive the response she wanted from the resident so she started cussing him/her and stated, fuck your mommy, fuck your dead ass mammy, fuck your granddaddy, fuck you and, I can go home motherfucker.
The State Survey Agency (SSA) Surveyor attempted a telephonic interview with CNA #1 on 07/17/2023 at 6:35 PM and 6:37 PM; and on 07/20/2023 at 8:30 PM; however, received no answer or return call.
Review of CNA #25's witness statement dated 07/13/2023 at 7:46 AM, revealed while standing at the nurses' station she overheard the commotion between CNA #14 and Resident #243. Per review of the statement, CNA #25 reported Resident #243 told CNA #14, bitch, fuck you, suck my dick. Continued review revealed CNA #14 did not walk away and became engaged in a verbal exchange with Resident #243 and told the resident, you had a heart attack, and I didn't.
Review of CNA #14's witness statement dated 07/13/2023, revealed Resident #243 had been at the nurses' station and was upset and yelling. Continued review revealed CNA #14 went and introduced herself to Resident #243 and let him/her know she would be the aide taking care of him/her for the day. Per review, Resident #243 would not calm down and called her (CNA #14) a bitch. Further review of CNA #14's statement revealed the CNA denied verbally abusing Resident #243.
The SSA Surveyor attempted a telephonic interview with CNA #14 on 07/17/2023 at 6:45 PM; however, received no answer or return call.
Review of CNA #14's employee file, dated 12/14/2022, revealed the facility, completed a background check on 12/01/2022, with no concerns noted prior to hiring the CNA on 12/14/2022. Continued review revealed the facility did not complete the Kentucky Adult Abuse registry check until 07/18/2023, which was clear. Further review revealed the CNA was trained on abuse on 06/21/2023.
In an interview with the Business Office Manager (BOM), on 07/17/2023 at 3:50 PM, she stated on 07/13/2023 at approximately 6:30 AM, she was in the front hallway and heard yelling. She stated she went through the doors to the nursing station and heard Resident #243 yelling. The BOM stated she asked Resident #243 what was wrong, and CNA #14 replied, the resident was an A-hole. She stated CNA #14 did not say the full word. According to the BOM, she immediately had CNA#14 go to the Staff Development Coordinator's (SDC's) office. She stated the SDC came to the nurses' station and stayed with Resident #243. The BOM stated she called the Administrator and the Director of Nursing (DON), by way of three (3) way calling, and was instructed to have CNA #14 clock out and leave the building.
Interview with SDC on 07/18/2023 at 4:07 PM, she stated that she was coming on duty when she heard yelling and immediately went to the nurses' station where Resident #243 was observed yelling out. The SDC stated Resident #243's speech was unintelligible at times; however, the SDC did understand the words black bitch and fuck her the resident stated loudly. The SDC stated the CNA was going down the hall saying that Resident #243 was mad because he/she wanted to go to bed because he/she had not slept the night before. She stated while the BOM was on the phone with the Administrator and DON reporting the incident, she was attempting to calm Resident #243. The SDC stated she escorted CNA #14 out of the building.
During an interview on 07/18/2023 at 3:30 PM with the Social Services Director (SSD), he stated he interviewed Resident #243 after the incident. Per the interview, the SSD stated the resident was apologetic for the incident and expressed no psychosocial harm.
Interview with the Director of Nursing (DON), on 07/19/2023 at 1:25 PM, she stated Resident #243 was a resident of the facility for only twenty-four (24) hours when the incident occurred.
In interview on 08/07/2023 at 11:45 AM, the Administrator stated Resident #243 was not coming back to the facility and that was all she was aware of.
In additional interview with the Administrator on 08/07/2023 at 3:03 PM, she stated she was made aware of the incident between Resident #243 and CNA #14 in the morning, on 07/13/2023, after the incident occurred. The Administrator stated she instructed the BOM to send CNA #14 home, while the facility completed a thorough investigation. She stated when the investigation paperwork was completed, the decision was made to terminate CNA #14. The Administrator stated she would not tolerate any form of abuse in the facility, and any allegation of abuse was investigated immediately with the alleged perpetrator being suspended pending the investigation. She stated that all staff were educated on abuse by the SDC after the incident. The Administrator further stated Resident #243 did not return to the facility after his/her hospital stay on 07/14/2023.
4a. Review of Resident #31's admission Record revealed the facility admitted the resident on 11/11/2021 with diagnoses which included Hemiplegia/Hemiparesis, Cerebral Infarction, Aphasia, Malnutrition, Diabetes, Dysphagia, Weakness, Alzheimers, Vascular Dementia, Polyneuropathy, Borderline Personality Disorder, Anxiety, Abnormalities of Gait and Mobility, Lack of Coordination, Abnormal Posture, and Major Depressive Disorder.
Review of Resident #31's admission MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS score of 99, which indicated the resident chose not to participate or scored zero (0) on four (4) or more items because the resident did not answer or gave a nonsensical response. Review of the resident's 04/21/2022 and 08/12/2022 Quarterly MDS revealed the facility assessed the resident to have a BIMS score of 99 on both assessments. Review of the resident's Significant Change MDS, dated [DATE], revealed the facility did not assess a BIMS score and indicated the resident was rarely or never understood.
Review of Resident #31's Comprehensive Care Plan, dated 11/29/2021, revealed the resident had limited physical mobility related to Alzheimers, Neurological Deficits, and Stroke with interventions which included the resident was totally dependent on staff for locomotion. Further review of the Comprehensive Care Plan revealed the resident had a communication problem related to Expressive Aphasia, Neurological Symptoms, and Stroke with interventions which included the resident would tap staff and/or peers on the shoulder or back to get their attention related to communication deficit; this was a communication technique and did not represent a willful intent to harm, and monitor/document frustration level, wait thirty (30) seconds before providing resident with a word. Continued review of the Comprehensive Care Plan revealed the resident had the potential for a psychosocial well-being problem related to Bipolar Disorder, with interventions which included to discuss resident concerns/fears of being unwanted or feeling useless and to discuss with the resident feelings, reminiscence, and issues.
4b. Review of Resident #39's admission Record revealed the facility admitted the resident on 02/02/2018 with diagnoses which included Dysphagia, Diabetes, Heart Failure, and Abnormal Posture. Further review revealed diagnoses added, on 02/05/2020, of Anxiety Disorder and Cognitive Communication Deficit.
Review of Resident #39's admission MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS score of nine (9) out of fifteen (15), which indicated the resident was moderately cognitively impaired. Review of the resident's Quarterly MDS's, dated 08/16/2022 and 08/29/2022, revealed the facility assessed the resident to have a BIMS score of six (6) out of fifteen (15), which indicated the resident was severely cognitively impaired.
Review of Resident #39's Comprehensive Care Plan, dated 11/28/2021, revealed the resident displayed an alteration in cognitive functioning and memory related to dementia with interventions which included to provide one-to-one (1:1) care as needed and staff to provide cueing and prompting as needed.
Review of the facility's investigation, dated 08/21/2022, revealed it was alleged Resident #31 made slight contact with Resident #39 on 08/18/2022 at the Nurse's Station. The residents were immediately separated and Resident #31 was placed on immediate one-to-one (1:1) supervision and a skin and pain assessment was completed for both residents with no injuries or pain noted. The facility determined the incident to be unsubstantiated.
Review of CNA #20's witness statement, dated 08/18/2022, revealed she witnessed Resident #31 make contact with Resident #39. However, there was no further information provided on the specifics of the incident.
Review of an unsigned document, dated 08/18/2022, revealed the Social Services Director (SSD) spoke with Resident #31, who was crying and told the SSD no to questioning if anything happened that date. Further review revealed the SSD spoke with Resident #39 who stated he/she was fine, no one had touched him/her that date, and no one had made him/her feel unsafe.
The State Survey Agency (SSA) Surveyor attempted to telephone CNA #20 on three (3) occasions without a return call.
During an interview with the Administrator on 08/07/2023 at 1:45 PM, she stated she was the Abuse Coordinator for the facility, and she made sure an investigation was completed for all abuse allegations, although she could not speak about allegations that occurred before she came to the facility in the Fall of 2022. She further stated if a resident complained of abuse, she would make sure the resident was safe, pull the resident aside and talk with them, complete a room change if necessary, would notify the Social Services Director for any psychosocial interventions and psychiatric services as needed, and report to the appropriate people immediately. She further stated if a staff member was alleged to be involved, the staff member would be suspended pending the investigation being completed. She continued to state all abuse allegations had been reported, to her knowledge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for three (3) of sixty-one (61) sampled residents, Resident #15, #51, and #56).
The findings include:
Review of the facility's policy titled, admission Transfers Discharge Guidelines, revised 10/03/2022, revealed the guideline discussed admission to the facility. However, there was no evidence of discussion on transferring the resident to the hospital from the facility or notifying the Office of the State Long-Term Care Ombudsman at the time of transfer.
1. Review of Resident #15's admission Record revealed the facility admitted the resident, on 06/16/2023, with diagnoses which included Respiratory Failure, Liver Transplant, and Cognitive Communication Deficit.
Review of Resident #15's admission Minimum Data Set (MDS) Assessment, dated 06/23/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), which indicated the resident was cognitively intact. Continued review of the MDS Assessment, under section G, revealed the facility assessed Resident #15 required a two (2) person assist for bed mobility and one (1) person physical assist with transfers.
Review of Resident's #15 Electronic Medical Record (EMR) revealed the resident was transferred to the hospital on [DATE], 07/14/2023, and 07/28/2023. However, there was no indication a representative of the Office of the State Long-Term Care Ombudsman was notified at the time of any of these transfers.
2. Review of Resident #51's admission Record revealed the facility admitted the resident, on 04/07/2023, with diagnoses including Hypertension, Malnutrition, and Anxiety.
Review of Resident #51's admission MDS Assessment, dated 04/25/2023, revealed the facility assessed the resident to have a BIMS score of ninety-nine (99), which indicated the resident chose not to participate or four (4) or more items were coded as zero (0). Further review of the MDS Assessment, Section G, functional status, revealed the facility assessed the resident to require a two (2) person assist for bed mobility and transfers; and review Section J revealed Resident #51 had a history of falls.
Review of Resident #51's EMR revealed the resident was transferred to the hospital on [DATE], 05/11/2023, 05/30/2023, 06/11/2023, 06/21/2023, 07/01/2023, 07/11/2023, and 07/16/2023. However, there was no indication a representative of the Office of the State Long-Term Care Ombudsman was notified at the time of any of these transfers.
3. Review of Resident #56's admission Record revealed the facility admitted the resident, on 06/10/2022, with diagnoses which included Diabetes, End Stage Renal Disease, and Heart Failure.
Review of Resident #56's Annual MDS Assessment, dated 05/24/2023, and Quarterly MDS Assessment, dated 06/27/2023, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), which indicated the resident was cognitively intact.
Review of Resident #56's EMR revealed the resident was transferred to the hospital on [DATE], 07/04/2023, and 07/31/2023. However, there was no indication a representative of the Office of the State Long-Term Care Ombudsman was notified at the time of any of these transfers.
During an interview with the Administrator on 08/07/2023 at 1:45 PM, she stated the facility had not notified the Office of the State Long-Term Care Ombudsman at the time of the residents transfers to the hospital. She further stated it was the responsibility of the Social Services Director (SSD) to notify the Office of the State Long-Term Care Ombudsman at the time of the transfers, which was not done timely, but was sent to the Ombudsman today. The Administrator stated the SSD been educated today on the notification to the Office of the State Long-Term Care Ombudsman at the time of a resident's hospital transfer.

Based on interview, record review, and review of the Kentucky Pre-admission Screening and Resident Review (PASARR) Manual, it was determined the facility failed to refer residents with newly evident or a possible serious mental disorder for a Level II PASARR screening for one (1) of sixty-one (61) sampled residents, Resident #55.
The findings include:
Review of the Kentucky PASARR Manual, revised April 2020, revealed the federal requirement for PASARR applied to all licensed long-term care nursing facilities that participated in Medicaid programs, regardless of the individual's funding source. The manual stated anyone identified as having a serious mental illness, intellectual disability, or related condition must go through the Level II process.
Review of Resident #55's admission Record revealed the facility admitted the resident, on 05/30/2023, with diagnoses which included Metabolic Encephalopathy, Heart Failure, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #55's admission Minimum Data Set (MDS) Assessment, dated 06/05/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), which indicated the resident was cognitively intact.
Review of Resident #55's PASARR screening revealed the resident's PASARR I screen was completed on 05/31/2023 and did not indicate a PASARR II screen was required at that time.
Review of Resident #55's Initial Psychiatric Consult, dated 06/09/2023, revealed Resident #55 had a history of a diagnosis of Bipolar Disorder. Review of the resident's Face Sheet revealed a diagnosis of Bipolar Disorder, dated 06/09/2023. However, there was no indication the facility completed any additional PASARR screening with Resident #55, even though he/she had the diagnosis of Bipolar Disorder.
During an interview with the Social Services Director (SSD), on 08/03/2023 at 10:00 AM, he stated when a resident was admitted , the resident's information was entered into the Kentucky Level of Care System (KLOCS), which would trigger a PASARR Level II screen if indicated and a Level II screen was based on information other than diagnoses. He stated information was entered into KLOCS by the SSD, MDS Coordinator, and the Business Office Manager (BOM).
During an interview with the BOM, on 08/03/2023 at 10:10 AM, she stated she opened KLOCS and entered the basic information, the MDS Coordinator entered the diagnoses codes, and the SSD entered additional information. She additionally stated the facility's Liaison notified the facility if a resident triggered for a Level II PASARR, at which time a form 4092 was completed which gave the facility extra time to complete the PASARR II. She stated she could find not documentation this process had been completed for Resident #55.
In an interview with the Administrator, on 08/07/2023 at 1:45 PM, she stated she was unaware of the process for completing the PASARR. She further stated the process was completed by the Admissions Coordinator/Business Office Manager.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to implement the Care Plan related to Activities of Daily Living (ADL) for one (1) of eighteen (18) sampled residents, Resident #20.
The findings include:
Review of the facility policy Baseline Care Plan Assessment/Comprehensive Care Plans, revised 08/15/19, revealed the Comprehensive Care Plan would further expand on the resident's risk, goals and interventions using the Person-Centered Plan of Care approach for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs. The facility Interdisciplinary team (IDT) in conjunction with the resident, resident's family, surrogate or representative as appropriate along with a hands on caregiver, such as a Certified Nursing Assistant (CNA) would discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident.
Observation, on 11/24/19 at 11:00 AM, revealed Resident #20's fingernails were long and heavily soiled with a black substance and the 4th/5th fingernails of the right hand were beginning to curl under.
Observation of Resident #20, on 11/27/19 at 2:19 PM, revealed long fingernails on both hands and a thick, black substance under the nails.
Review of the clinical record revealed the facility admitted Resident #20 on 08/10/18 with diagnoses to include Frontal Lobe and Executive Function Deficit following Cerebral Infarction; Hemiplegia and Hemiparesis following Nontraumatic Subarachnoid Hemorrhage affecting Left Non-Dominant Side; Type 2 Diabetes Mellitus; and Muscle Weakness.
Review of Resident #20's Care Plan for impaired cognitive function, initiated 08/21/19, revealed a goal to offer the resident choices (i.e. clothing, activity, menu item) daily to encourage participation in ADL's. Interventions included keeping the resident's routine consistent and trying to provide consistent care givers as much as possible in order to decrease confusion; and providing choices daily to encourage participation in ADL's.
Interview with CNA #4, on 11/27/19 at 2:06 PM, revealed CNA's were responsible for providing nail care on Sundays, shower days, and as needed to ensure residents fingernails were clean and groomed.
Interview with CNA #2, on 11/27/19 at 2:41 PM, revealed CNA's were responsible for cleaning and trimming resident's fingernails and stated it was important to ensure nails were clean because residents used their hands to eat and dirt or germs could get in their mouth.
Interview with the UM, on 11/27/19 at 2:53 PM, revealed CNA's were responsible for assisting residents with ADL care and stated nail care should be provided on shower days and as needed. She revealed she had noticed issues with residents with long or soiled nails.
Interview with the Director of Nursing (DON), on 11/27/19 at 3:50 PM, revealed care plans were patient centered and addressed all resident care needs. The DON further revealed resident care should be provided according to the care plan. She revealed the care plan was not implemented for nail care and stated she recently implemented a new process for monitoring resident showers/hygiene.
Interview with the Administrator, on 11/27/19 at 4:46 PM, revealed the IDT reviewed care plans daily and addressed issues as needed. He further revealed he was not aware of any concerns related to nail hygiene or implementation of care plans.

**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 provide Activities of Daily Living (ADL) care to maintain nail hygiene for two (2) of eighteen (18) sampled residents, Resident #20, and #66.
The findings include:
Review of the policy Dignity, undated, revealed necessary ADL care would be performed so that residents were well groomed and appear to be clean and comfortable as much as possible.
Review of the policy Nail Care, undated, revealed it was the policy of the facility to provide personal hygiene needs and to promote health, safety and the prevention of infection. This included clean, smooth nails at a well-groomed safe length acceptable to the resident.
Observation and interview, on 11/24/19 at 9:29 AM, revealed Resident #66 fingernails were long and he/she wanted them cut.
Observation, on 11/24/19 at 11:00 AM, revealed Resident #20's fingernails were long and heavily soiled with a black substance and the 4th/5th fingernails of the right hand were beginning to curl under. Interview during observation revealed staff did not clean fingernails on shower days.
Observation of Resident #20, on 11/27/19 at 2:19 PM, revealed both hands with long nails and a thick, black substance under the nails. Interview with the resident during observation revealed his/her fingernails needed to be cleaned; however, he/she did not have anything to clean them with.
Interview with CNA #4 during observation revealed she had not noticed Resident #20's soiled fingernails.
Review of the clinical record revealed the facility admitted Resident #20 on 08/10/18 with diagnoses to include Frontal Lobe and Executive Function Deficit following Cerebral Infarction; Hemiplegia and Hemiparesis following Non-traumatic Subarachnoid Hemorrhage affecting Left Non-Dominant Side; Type 2 Diabetes Mellitus; and Muscle Weakness.
Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #20 with a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) and determined he/she was interviewable. Further review of the MDS revealed the resident required extensive assist for maintenance of personal hygiene.
Interview with CNA #4, on 11/27/19 at 2:06 PM, revealed she was assigned to care for Resident #20. She revealed CNA's were responsible for providing nail care on Sundays, shower days, and as needed to ensure residents fingernails were clean and groomed. She stated CNA's also documented nail care on the shower sheet and put the sheet in a binder kept at the nurses station. According to CNA #4, she believed nurses were responsible for trimming resident's fingernails.
Review of shower sheets revealed one (1) shower sheet for October 2019 and two (2) shower sheets for November 2019. Further review of the shower sheets, dated 11/02/19 and 11/10/19, revealed Resident #20's fingernails were not clean and short.
Interview with CNA #2, on 11/27/19 at 2:41 PM, revealed CNA's were responsible for cleaning and trimming resident's fingernails on shower days. She stated if a resident refused nail care it should be recorded on the shower sheet. She stated it was important to ensure nails were clean because residents used their hands to eat and dirt or germs could get in their mouth. She further revealed it could be embarrassing for the resident to have dirt or food under their fingernails. According to CNA #2, she performed range of motion (ROM) on Resident #20 and had not noticed any issues with his/her fingernails.
Interview with the UM, on 11/27/19 at 2:53 PM, revealed CNA's were responsible for assisting residents with ADL care and stated nail care should be provided on shower days and as needed. The UM revealed nail care included cleaning and trimming fingernails; however, nurses were responsible for trimming nails if the resident was a diabetic. The UM further revealed refusals of care should be documented on shower sheets. She stated she reviewed the sheets to monitor care; however, CNA's did not always turn in the sheets. She revealed she had noticed issues with long or soiled nails and stated she educated residents on the importance of nail care; however, there was no documentation of the education.
Interview with the Director of Nursing (DON), on 11/27/19 at 3:50 PM, revealed she tracked shower sheets and had identified concerns related to resident showers. She stated CNA's were expected to use shower sheets to document showers, nail care, and refusals of care; however, shower sheets were not always turned in. She revealed CNA's were also responsible for notifying the UM, ADON, or DON if a resident refused care. According to the DON, fingernails should be clean to prevent potential cross contamination of food during meals. DON stated she was not aware of any issues related to nail care.
Interview with the Administrator, on 11/27/19 at 4:46 PM, revealed he was not aware of any recent concerns related to resident showers or nail care.

**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 medications were not expired. Observations in the medication room revealed two (2) vials of Lantus in the refrigerator, available for use, opened and undated. Additionally, observations revealed a suppository with an expiration date of 08/2018.
The findings include:
Review of the facility's medication storage policy, revised [DATE], revealed outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures were immediately withdrawn from stock by the facility.
Observation, on [DATE] at 9:49AM, revealed in the medication refrigerator, Bisacodyl suppositories with an expiration date of 08/2018, and a vial of Lantus insulin, open, with no date documented when opened.
Interview with Licensed Practical Nurse (LPN) #5, on [DATE] at 9:49AM, revealed staff are to document the date on the container when opening all multi-dose medication containers. LPN #5 stated insulin is good for twenty-eight (28) days after opening. Additionally, LPN #5 stated potentially the insulin may not be effective in lowering the blood sugar level and it may also cause infection because the insulin had been opened and no opened date is documented
Interview with Pharmacy Consultant, on [DATE] after inspection of medication room at 9:49 AM, revealed he/she audited the medication room every two (2) months. The Pharmacy Consultant stated he/she audited all medication, supplies, including the refrigerator, and medication carts. The Pharmacy Consultant stated the last audit of the medication room occurred in [DATE] and the nurses were to sign and date insulin vials when opened.
Interview with the Director of Nursing (DON), revealed she audited the medication refrigerator the previous week and checked the refrigerator for expired medication. The DON stated if staff administered expired medication to a resident, it could have a decreased effectiveness to the resident.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure staff served foods in sanitary conditions to prevent food borne illnesses. Observations and record review revealed the facility was aware of improper temperatures with the wash and rinse cycle of the facility dishwasher but continued to use the machine for sanitization of cookware, resident plates and silverware. Other observations revealed kitchen staff removed wet items from the dishwasher and used the dishes for redistribution of food to residents. Continued observations revealed the facility food equipment contained encrusted dried food like matter and food items unlabled.
The findings include:
Review of facility policy Mechanical Ware Washing (Dish Machine), dated 09/27/18, revealed proper cleaning and sanitization of dishes in the foodservice department was extremely important to the health and safety of the residents. Further review revealed the policy advised to stop the process and contact appropriate persons when the dish machine was not washing/sanitizing properly.
Review of the AM Select Dishwashers Instructions, Form 35320, Rev E, dated October 2012, revealed the minimum rinse temperature should be one hundred eighty (180) degrees Fahrenheit.
Review of facility policy, Nutritional Services: Infection Control, dated 11/17, revealed all dishes and cookware were to be air-dried. In addition, all staff who enter the kitchen must adhere to food safety standards and cover the hair with a net.
Review of policy Food Storage, dated 2017, revealed staff were to ensure label and dates of delivered goods were completed. In addition, food was not to be stored on floors.
Review of policy, Hair Nets, dated 2017, revealed staff were to wear hairnets in all food areas, dishwashing and serving areas. Furthermore, male staff were to wear beard nets.
Review of the Dish Machine Log - High Temp for 11/01/19 through 11/22/19, for breakfast, lunch, and supper meals, revealed all rinse temperatures recorded were less than one hundred eighty (180) degrees Fahrenheit.
Observation of the kitchen, on 11/24/19 at 8:31 AM, revealed the following: encrusted matter covering most areas of the base of the blender, the metal guard to the large mixing bowl, the shelf below the steamer, and the base of the small mixer. The inside of the microwave door contained caked matter.
Observations of the dry storage area, on 11/24/19 at 9:00 AM, revealed six (6) of nine (9) storage racks contained goods unlabeled with a receipt date. Additionally, bins of flour and oatmeal were open, unlabeled, and stacked on the floor.
Observations of the walk-in freezer, on 11/24/19 at 9:55 AM, revealed undated food in boxes and boxes were stored on the floor.
Further observations in the kitchen, on 11/25/19 at 10:45 AM, revealed chunks of a pinkish substance matted to the entire back and front of the slicer. Additionally, the cook did not have a beard cover in place.
Observation of the Dish Machine during a wash/rinse cycle, on 11/25/19 at 11:02 AM and 11:03 AM, revealed rinse temperatures of one hundred thirty-three (133) degrees Fahrenheit.
Observations in the kitchen, on 11/25/19 at 11:31 AM, revealed staff placed eleven (11) wet plate tops onto other dry plate tops. Continued observation revealed what appeared to be water splash over other dry plates and plate tops from these eleven (11) plate tops.
Interview with the Maintenance Director, on 11/26/19 at 10:44 AM, revealed he was aware the dishwasher was not meeting the required temperatures for the rinse cycles.
Interview with the Dietary Aide #1, on 11/26/19 at 11:28 AM, revealed the facility dishwasher temperatures were out of range for months. The aide stated the facility administration was aware. The aide stated the facility continued to use the washer and serve residents from these dishes. The aide stated all food items were to be labeled and dated to ensure food is rotated used by the use by date. The aide stated she was unaware of how improper sanitation of plated could affect residents and staff were to wear and cover hair and beards when in the kitchen. The aide further stated whoever used the equipment was responsible to clean the equipment but was not aware of a cleaning schedule.
Interview with the Dietary Aide #2, on 11/26/19 at 12:15 PM, revealed the facility dishwasher failed to maintain proper temperature's for several months. The aide stated the issue was reported to the DM. The aide stated residents were at risk to get sick. Additionally, the aide stated all items which enter the facility were to be labeled and dated for rotation. The aide stated all equipment were to be clean and staff were to wear hairnets at all times to contain the hair.
Interview with the Dietary Cook, on 11/26/19 2:40 PM, revealed kitchen equipment was routinely dirty or broken. The cook further stated the kitchen staff placed wet dishes, silverware, and other cooking items back into use without allow them to dry. Additionally, the cook stated staff were to wear hair and beard nets at all times and staff were to label and date all stored foods, and not stack boxes on the floor. The Dietary [NAME] stated residents were at risk for illness.
Interview with the Dietary Manager (DM), on 11/26/19 at 9:40 AM, revealed he noticed issues with the temperatures of the dish machine not reaching acceptable levels when he began with the facility, at the end of August 2019. The DM stated he notified Administration of the issues with the dishwasher, but is not aware of any outside vendors attempting to correct the temperatures. The DM stated the dishwasher rinse temperature should be at least one hundred eighty (180) degrees Fahrenheit.
Continued interview with the DM, at 3:19 PM, revealed it was the facility responsibility to ensure dishes were washed/rinsed with acceptable temperatures to sanitize the dishware. The DM stated staff were to have beard guards and hairnets on and properly placed at all times. The DM stated the current staff were not educated on labeling and dating of existing and delivered stock. The DM stated a kitchen-cleaning schedule for equipment and general kitchen did not exist. Additionally, the DM stated if the facility failed to do complete proper sanitation; it could lead to cross contamination and make residents sick.
Interview with the Administrator, on 11/26/19 at 4:36 PM, revealed he expected the dishwasher to reach the manufacturer recommended temperatures for both wash and rinse cycles. The Administrator stated reaching the recommended dishwasher temperatures insured dishware was clean, sanitized, and disinfected. He stated the kitchen cleanliness was previously identified a Quality Assurance (QA) plan was instituted. He stated he expected the facility to provide care to the resident the best care and services to maintain quality care in the facility.

The facility failed to ensure essential kitchen equipment was in proper working order to meet the sanitization needs of the dish and silverware utilized for resident meals. Observations revealed the dishwasher temperatures were lower than the required temperature range of one hundred sixty to one hundred eighty (160/180) during the wash/rinse cycle.
The findings include:
Review of facility policy Mechanical Ware Washing (Dish Machine), dated 09/27/18, revealed proper cleaning and sanitization of dishes in the foodservice department was extremely important to the health and safety of the residents. Further review revealed the policy advised to stop the process and contact appropriate persons when the dish machine was not washing/sanitizing properly.
Review of the AM Select Dishwashers Instructions, Form 35320, Rev E, dated October, 2012, revealed the minimum rinse temperature should be one hundred eighty (180) degrees Fahrenheit.
Review of the Dish Machine Log - High Temp for 11/01/19 through 11/22/19, for breakfast, lunch, and supper meals, revealed all rinse temperatures recorded were less than one hundred eighty (180) degrees Fahrenheit.
Observation of the Dish Machine during a wash/rinse cycle, on 11/25/19 at 11:02 AM and 11:03 AM, revealed rinse temperatures of one hundred thirty-three (133) degrees Fahrenheit.
Interview with the [NAME] Supervisor, on 11/26/19 at 2:40 PM, revealed she was aware the dish machine was not reaching acceptable temperatures. The [NAME] Supervisor stated dishes not washed at acceptable temperatures may not be clean and could make a resident sick.
Interview with the Dietary Manager (DM), on 11/26/19 at 9:40 AM, revealed he noticed issues with the temperatures of the dish machine not reaching acceptable levels when he began with the facility, at the end of August 2019. The DM stated he notified Administration of the issues with the dishwasher, but is not aware of any outside vendors attempting to correct the temperatures. The DM stated the dish machine rinse temperature should be at least one hundred eighty (180) degrees Fahrenheit.
Continued interview with the DM, at 3:19 PM, revealed it was the facility responsibility to insure dishes were washed/rinsed with acceptable temperatures to sanitize the dishware. Additionally, the DM stated failing to do so could lead to contamination and make residents sick.
Interview with the Administrator, on 11/26/19 at 4:36 PM, revealed he expected the dish machine to reach the manufacturer recommended temperatures for both wash and rinse cycles. The Administrator stated reaching the recommended dish machine temperatures insured dishware was clean, sanitized and disinfected.

Based on observation, interview, and facility policy review, it was determined the facility failed to prevent the possible spread of infection on one (1) of four (4) halls, the 200 Hall, during medication administration.
The findings include:
Review of the facility's policy, Infection Prevention and Control, not dated, revealed it was the policy of the facility to ensure a system was in place that prevented and controlled infections and prevented the development and transmission of communicable disease processes for residents, care providers, staff, visitor, and others with the facility in an effort to provide a safe, sanitary, and comfortable environment.
Review of the facility's policy, Medication Administration, not dated, revealed hands were to be washed before beginning medication administration and whenever hands were contaminated.
Review of the facility's policy, Tips for Safe Medication Administration, dated April 2018, revealed hands were to be cleaned before beginning each medication pass and whenever they were contaminated. Staff was to never touch any of the medication with fingers.
Observation of medication administration, on 10/10/18 at 7:45 AM, revealed while as Registered Nurse (RN) #2 prepared medication for administration, he touched his hair and nose and the medication pills with his bare hands.
Interview with RN #2, on 10/10/18 at 7:55 AM, revealed touching medication with bare hands could spread infection and might make the resident sick. He stated he was trained on medication administration during orientation.
Interview with Licensed Practical Nurse (LPN) #1, on 10/10/18 at 8:05 AM, revealed nurses were not supposed to touch pills with bare hands because of the possible spread of infection.
Interview with RN #1, on 10/10/18 at 8:35 AM, revealed nurses were trained not to handle medication with bare hands in order to prevent contamination and spreading germs.
Interview with the Unit Manager, on 10/12/18 at 10:44 AM, revealed staff should not touch pills with hands because their hands might not be clean and staff could pass germs to the resident and make them sick.

Based on observation, interview, and facility policy review, it was determined the facility failed to store and serve food under sanitary conditions. Observation of the kitchen's walk-in freezer and the walk-in refrigerator revealed unlabeled and undated food items. Spice containers were soiled with dark particles stuck to the surface and the stove was soiled with grease and debris. Staff did not have hairnets covering their entire hair and beard while in the kitchen, and did not perform hand hygiene.
The findings include:
1. Review of the facility's policy, Hair Restraints, dated 2017, revealed staff wore hair restraints in all food preparation, dishwashing, and serving areas. The policy stated staff wore hair restraints, hats, and/or beard guards to prevent hair from contacting exposed food.
Observation of the kitchen, on 10/09/18 at 8:21 AM, revealed the Dietary Manager had a beard and wore no beard cover while getting residents' breakfast ready.
Interview with the Dietary Manager, on 10/09/18 at 8:49 AM, revealed he had no beard cover during breakfast preparation in the kitchen.
Observation of Dietary Aide (DA) #1, on 10/10/18 at 11:37 AM, revealed she wore a hairnet covering a hair bun atop her head, but the rest of her hair was uncovered while in the kitchen food prep area.
Interview with DA #1, on 10/10/18 at 11:46 AM, revealed hair nets were supposed to be worn at all times while in the kitchen. She stated the entire hair had to be covered; however, she stated the only thing covered on her head was the bun atop her head. DA #1 stated the reason for wearing the hairnet was to avoid hair from falling into the food, to protect the residents.
Continued interview with the Dietary Manager, on 10/10/18 at 4:26 PM, revealed staff had to wear hairnets prior to entering the kitchen to prevent hair from falling in the food or drinks, as not wearing hairnets was unsanitary.
Interview with the Administrator, on 10/12/18 at 2:15 PM, revealed hairnets and beard covers were supposed to be worn over the entire hair in the kitchen area to prevent hair from getting into food, as hair carried dirt and germs.
2. Review of the facility's policy, Handling Tableware, dated 2017, revealed staff handled all tableware appropriately so that eating surfaces of utensils/tableware were not contaminated.
Observation of DA #3, on 10/09/18 at 1:12 PM, revealed she put silverware/utensils on trays with ungloved bare hands, while she touched her face and opened the refrigerator, and then put gloves on without washing or sanitizing her hands.
Interview with DA #3, on 10/10/18 at 4:05 PM, revealed she should have worn gloves when putting utensils from the silverware basket on trays so that the process would be sanitary. She stated residents could get sick and the facility had trained her on hand hygiene and wearing gloves.
Interview with the Prep Cook, on 10/11/18 at 9:26 AM, revealed staff was to wash hands and use gloves when putting utensils on trays to prevent residents from getting sick.
Interview with the Dietary Manager, on 10/11/18 at 3:58 PM, revealed kitchen staff had to wear gloves when placing silverware on trays because it was not sanitary and residents could get sick.
Observation of DA #2, on 10/10/18 at 7:58 AM, revealed she picked up a sippy cup and handed it to a resident. She went back and grabbed an empty coffee cup, from a cart with glasses and cups, filled it up and handed it to a different resident without having sanitized or washed her hands in-between the two residents.
Interview with DA #2, on 10/10/18 at 4:26 PM, revealed staff needed to wash hands, or use sanitizer, in-between residents to prevent cross contamination and infection. She stated she did not sanitize her hands or wear gloves and she was supposed to. She stated staff wrapped utensils in a napkin and then placed them on the tray with gloved hands. She stated if staff touched utensils without gloves, germs could be passed to residents and residents could get sick.
Interview with DA #1, on 10/10/18 at 11:41 AM, revealed staff should wash hands before putting on gloves and touching silverware to prevent residents from getting sick. DA #1 stated that when she provided any food items or fluids to residents, she wore gloves.
Interview with the Administrator, on 10/11/18 at 2:15 PM, revealed if staff did not follow hand hygiene, it could cause cross contamination, which was an infection control issue. She stated the elderly were weak and more vulnerable and their immune system was more susceptible to germs. She further stated staff was in-serviced on hand washing and hygiene during orientation and annually.
3. Review of the facility's policy, Food Storage, dated 2017, revealed food was stored on shelves in a clean, dry area free from contaminants.
Review of the facility's policy, Labeling and Dating of Foods, dated 2017, revealed once opened, all ready to eat, potentially hazardous food, would be re-dated with the date it was opened and should be used by the safe food storage guidelines or by the manufacturers expiration date.
Observation of the kitchen, on 10/09/18 at 8:30 AM, revealed the walk-in freezer contained a package of ground meet in a zipper bag without a date on it. The walk-in refrigerator contained an open package of ham, wrapped and undated, an opened package of cheese, wrapped and undated, and an opened gallon of whole milk, half empty, with no opened date. Further observation, of the dry storage area, revealed containers of Parsley flakes and imitation Vanilla were soiled with dark particles sticking to the containers.
Continued observation on the kitchen revealed containers of orange, apple, cranberry, and fruit punch concentrate with visibly soiled dispensers. In addition, the gas stove had a buildup of greasy debris.
Interview with DA #2, on 10/10/18 at 4:26 PM, revealed she had to date opened food items and food older than three (3) days were thrown away to prevent residents from getting sick. DA #2 stated opened items must be dated or kitchen staff would not know when food items expired. She further stated she did not know how to clean the dispenser nozzle of the fruit juice and if not done, residents could get sick.
Interview with the Prep Cook, on 10/11/18 at 9:26 AM, revealed he had been educated to date opened items. The [NAME] stated if an item was undated, it could be expired, and he would not know if the item was spoiled, which meant residents could get sick. He further stated dirty containers had to be wiped down because they could get mold or germs and residents could get an infection if the germs got into their food.
Interview with the Dietary Supervisor, on 10/09/18 at 8:53 AM, revealed the grease build up on the stove was from food particles and high heat cooking and the built up was flammable. He stated staff had not cleaned the gas stove for about two (2) weeks.
Interview with the Dietary Manager, on 10/09/18 at 1:28 PM, revealed a gas stove with greasy debris buildup could be a fire hazard and kitchen staff could get burned.
Continued interview with the Dietary Manager, on 10/10/18 at 1:18 PM, 1:49 PM, and 4:26 PM, revealed items had to be labeled as soon as they were opened and discarded after three (3) days. He stated the dirty juice concentrator dispensers were a sanitation concern and he was concerned about cross contamination. He stated he expected staff to clean them daily; however, he stated the dispensers had not been cleaned for two (2) to three (3) days and was an infection control issue.
Interview with the Administrator, on 10/12/18 at 2:15 PM, revealed all opened food items were labeled and dated for staff to know when an item needed to be discarded or if it could be used. The Administrator stated kitchen staff should follow a cleaning schedule every day to maintain a sanitary kitchen. She stated the residents' dining experience should be provided in a clean and sanitary environment.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure residents received meals per facility schedule. Observation revealed three (3) of (4) halls, the 200, 300 and 400 Halls, and the dining room received lunch over an hour later than scheduled. In addition, residents seated at the same table in the dining room were not served meals at the same time.
The findings include:
Review of the facility's policy, Dining Experience, dated 2017, revealed meals and snacks were served at consistent times each day, according to specific times listed at the facility, and residents seated at the same table were served as close to the same time as possible.
Review of the facility's meal times revealed the lunch meal would be delivered to the main dining room at 12:00 PM.
However, observation of the dining room, on 10/09/18 at 1:07 PM, revealed staff delivered a meal tray to Resident #7, over an hour later than scheduled, and at 1:21 PM, staff delivered Resident #69's meal tray. Resident #7 and #69 sat at the same table in the dining room.
Continued observation, on 10/09/18 at 1:25 PM, revealed Resident #47 aggressively banged an empty cup on the table in an attempt to get the attention of staff while waiting for the lunch meal to be served.
Interview with Resident #14, on 10/09/18 1:39 PM, revealed the resident ate regularly in the dining room. The resident stated he/she was hungry while waiting his/her the meal and the meals were usually late.
Further review of the meal times revealed the lunch meal was scheduled to be delivered to the halls 11:30 AM-12:00 PM.
Interview, on 10/09/18 at 12:35 PM, with Licensed Practical Nurse (LPN) #1 on the 200 Hall, revealed breakfast was delivered late, so lunch was late. The LPN stated the residents on the 200 Hall were waiting for lunch trays, which were not available for staff to serve.
Observation of the 200 Hall, on 10/09/18 at 12:47 PM, revealed staff delivered lunch trays to the Hall.
Interview with Resident #37, on 10/09/18 at 12:50 PM, revealed staff served the resident's lunch meal late. The resident stated he/she did not ask for substitutes when he/she did not like the food because staff often served meals late and requesting a substitute further delayed his/her meal.
Interview with Family Member #1, on 10/09/18 at 12:52 PM, revealed the meals were served late on a daily basis, and on the weekends they were served even later.
Interview with Certified Nursing Assistant (CNA) #3, on 10/09/18 at 1:31 PM, revealed lunch should be served for the 300 Hall at 12:15 PM and at 12:30 PM for the 400 Hall. She stated the meal was late.
Observation of the 300 Hall, on 10/09/18 at 1:35 PM, revealed staff delivered lunch trays.
Interview with Resident #32, on the 400 Hall, on 10/09/18 at 12:45 PM, revealed meals were often late.
Observation of the 400 Hall, on 10/09/18 at 1:47 PM, revealed the lunch trays were delivered.
Observation of Resident #32, on 10/09/18 at 1:56 PM, revealed he/she received lunch more than an hour later than expected.
Interviews during Resident Council Group, on 10/09/18 at 3:04 PM, revealed residents complained staff served meals late almost daily, and served lunch after 1:00 PM almost every day.
Interview with the Kitchen Aide, on 10/10/18 at 11:37 AM, revealed the facility had no staff to wash dishes since the new company took over, which caused meals to be delivered late to residents, at least twice a week. She further stated the residents knew there was not enough kitchen staff and waited patiently until staff was able to get the food to them.
Interview with the Certified Medication Technician (CMT), on 10/12/18 at 9:47 AM, revealed residents received their meals late and they should have meals served timely, as the facility was their home.
Interview with the Dietary Supervisor, on 10/11/18 at 12:21 PM, revealed for the last month and a half, he had to work with less staff. He stated the Dietary Department had to make cuts and sometimes when staffing was low, there was an issue between breakfast and lunch, which caused residents to receive meals late two (2) to three (3) times a week.
Interview with the Dietary Manager, on 10/10/18 at 1:49 PM, revealed the reason the meal delivery to residents was so late was that meal carts from breakfast came back late to the kitchen, which delayed the cleaning of dishes and therefore not enough dishes were available to serve the lunch meal timely. He stated this occurred about three (3) to four (4) times a week and happened primarily on weekends. The reason for the late meals was a lack of kitchen staff and residents missed timely meals and were hungry.
Interview with the Administrator, on 10/11/18 at 2:31 PM, revealed late meals meant the facility was not satisfying the schedule they had set forth for resident meal times. She stated late meals could manifest in several different ways such as behaviors and discomfort, especially if residents were hungry. She stated the facility should have timely food delivery and continuity.

Based on observation, interview, and facility policy review, it was determined the facility failed to serve food at palatable temperatures for two (2) of ten (10) sampled residents from Resident Council and (1) of eighteen (18) sampled residents, Resident #32, #37, and #73. Interviews with the residents revealed complaints of cold food.
The findings include:
Review of the facility's policy, Dining Experience, dated 2017, revealed meals would be nourishing, attractive, and palatable.
Review of the facility's meal times revealed the lunch meal would be delivered to the Halls 11:30 AM-12:00 PM.
Observation of the 400 Hall, on 10/09/18 at 1:56 PM, revealed Resident #32 received his/her lunch tray more than an hour later than expected.
Interview with Resident #32, on 10/09/18 at 12:45 PM, whom the facility deemed interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) on 08/12/18, revealed food was often late, and cold and did not taste good.
Interviews during Resident Council Group, on 10/09/18 at 3:04 PM, revealed Resident #73 and #32 complained of cold food that was sometimes plated sloppy and unappealing. The residents stated staff would not rewarm the food or provide substitutes until after passing trays to all the other residents. The residents stated they would eat cold food, although they did not like it, due to the difficulty getting warm food in a timely manner.
Interview with, and observation of, Resident #37, on 10/10/18 at 8:06 AM, revealed he/she was eating breakfast and stated the food was cold.
Interview with the Certified Medication Technician, on 10/12/18 at 9:47 AM, revealed resident were served meals late and their food was not hot enough. She stated residents should have hot food that tasted good, which presented a better dining experience than what she had seen.
Interview with the Dietary Supervisor, on 10/11/18 at 12:21 PM, revealed residents would send food back when items served together had an inconsistent temperature. He stated food was supposed to be hot enough to be a good meal. He further stated he and other staff tried to provide consistent heat for all foods in a meal.
Interview with the Administrator, on 10/12/18 at 2:31 PM, revealed there was a lag in processing dishes after breakfast, which delayed timely meals. She stated because of timing issues, the facility started serving meals to residents on trays and she knew residents might not be happy about it.

Based on observation, interview, and facility policy review, it was determined the facility failed to have sufficient dietary staff to provide meals timely to residents on three (3) of four (4) halls, and in the dining room. In addition, residents seated on the same tables in the dining room were not served at the same time.
The findings include:
Review of the facility's policy, Dining Experience, dated 2017, revealed meals and snacks were served at consistent times each day, according to specific times listed at the facility, and residents seated at the same table were served as close to the same time as possible.
Review of the Dietary Department's staff schedule revealed two (2) Prep Cooks and one Kitchen Aide, plus the Dietary Manager, were scheduled to get resident meals prepared and served.
Review of the facility's meal times revealed the lunch meal would be delivered to the main dining room at 12:00 PM.
However, observation of the main dining room, on 10/09/18 at 1:07 PM, revealed staff delivered a meal tray to Resident #7, over an hour late, and delivered Resident #69's meal tray at 1:21 PM. Resident #7 and #69 were seated at the same table.
Continued observation of the dining room, on 10/09/18 at 1:25 PM, revealed Resident #47 aggressively banged an empty cup on the table in an attempt to get the attention of staff while waiting for the lunch meal to be served.
Interview with Resident #14, on 10/09/18 1:39 PM, revealed he/she was still waiting for his/her meal and was hungry.
Continued review of the meal times revealed the lunch meal would be delivered to the halls 11:30 AM-12:00 PM.
However, observation of the 200 Hall, on 10/09/18 12:47 PM, revealed dietary staff delivered the lunch trays to the Hall.
Interview with Licensed Practical Nurse (LPN) #1, on 10/09/18 at 12:35 PM, revealed dietary staff frequently delivered lunch trays late to the 200 Hall. The LPN stated dietary staff delivered breakfast trays late also, and the late deliveries caused the residents to get their meals late.
Observation, on 10/09/18 at 1:35 PM, revealed kitchen staff delivered the lunch tray cart to the 300 Hall.
Observation of the 400 Hall, on 10/09/18 at 1:55 PM, revealed the lunch trays on the 400 Hall.
Observation, on 10/09/18 at 1:56 PM, revealed Resident #32 received his/her lunch tray, more than one (1) hour later than expected.
Observation, on 10/09/18 at 1:57 PM, revealed staff delivered Resident #66's tray to the resident's room.
Interview with Family Member #1, on 10/09/18 at 12:52 PM, revealed meals were late because there was not enough staff in the kitchen and the weekend meals were served even later.
Interview with Certified Nursing Assistant (CNA) #3, on 10/09/18 at 1:31 PM, revealed the usual arrival times for meal carts on the 300 Hall was 12:15 PM, and the 400 Hall was 12:30 PM.
Interview with the Kitchen Aide (KA), on 10/10/18 at 11:37 AM, revealed the facility had no staff to wash dishes since the new company took over and at least two (2) more staff was needed to get the dishes done. She stated the kitchen manager had to get rid of staff and consequently, meals were delivered late to residents at least twice a week. She stated prior to the new company taking over, ten (10) staff members worked in the kitchen and now they had a cook, a kitchen aide, a prep person, and one manager. She further stated residents knew kitchen staff had no help and waited patiently until staff was able to get the food to them.
Interview with the Prep Cook, on 10/11/18 at 9:26 AM, revealed he knew meals were late least once a week and stated the facility needed more staff in the kitchen.
Interview with the Dietary Supervisor, on 10/11/18 at 12:21 PM, revealed the Dietary Department had to make cuts and sometimes when staffing was low, there was an issue between breakfast and lunch, and meals were late two (2) to three (3) times a week. He stated residents and staff complained about it.
Interview with the Dietary Manager, on 10/10/18 at 1:24 PM, revealed since the new company took over he had to cut staff. He stated yesterday there were three (3) kitchen staff available, and five (5) kitchen staff were needed to perform the meal services efficiently and timely.
Interview with the Administrator, on 10/11/18 at 2:31 PM, revealed late meals meant the facility was not satisfying the schedule they set forth for resident meal times. She stated when the breakfast tray carts came back late to the kitchen, they were late being cleaned, which caused lunch to be served late. She stated the facility should have timely food delivery and continuity.