Grand Haven Nursing Home

F-F695

The findings include:

Review of the facility's policy titled, Care Plan Policy and Procedure, reviewed 08/27/2024, revealed the patient-focused approach aimed for favorable outcomes by considering each resident's characteristics, the severity of their condition, strengths, needs, abilities, disabilities, diseases, impairments, and significant factors.

1. Review of Resident R9's Face Sheet, located in the resident's electronic health record (EHR), revealed the facility admitted the resident on 11/17/2022 with diagnoses to include obstructive uropathy, protein calorie malnutrition, and ventral hernia.

Review of Resident R9's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/09/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 5 out of 15, which indicated Resident R9 was severely impaired.

Review of Resident R9's Physician Orders, located in the resident's electronic health record (EHR), revealed on 01/17/2025 the resident was admitted to Hospice services with a diagnosis of incarcerated ventral hernia with gastric obstruction.

Review of Resident R9's Comprehensive Care Plan [CCP], dated 12/16/2024, located in the resident's EHR, revealed

the Hospice care focus was not developed until 01/21/2025, four days after Resident R9's admission to Hospice services.

During an interview with the MDS Coordinator on 01/23/2025 at 2:25 PM, she stated Resident R9's CCP should have been developed immediately to include interventions for Hospice care when the resident was admitted to Hospice services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 2. Review of Resident R16's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 08/07/2024 with diagnoses to include acute on chronic respiratory failure with hypercapnia, acute on chronic Level of Harm - Minimal harm or respiratory failure with hypoxia, and encephalopathy. potential for actual harm

Review of Resident R16's quarterly MDS, with an ARD of 12/24/2024, located in the resident's EHR, revealed the Residents Affected - Few facility assessed the resident to have a BIMS score of 15 out of 15, which indicated Resident R16 was cognitively intact. Further review revealed the resident was not assessed for respiratory treatments or oxygen therapy.

Review of Resident R16's Physician Orders, dated 11/12/2024, located in the resident's EHR, revealed to administer oxygen at 3 LPM continuous by nasal cannula.

Review of Resident R16's Comprehensive Care Plan [CCP], dated 01/02/2025, located in the resident's EHR, revealed the facility did not care plan the resident to include supplemental oxygen therapy management.

Observations of Resident R16's room with her oxygen concentrator revealed: 1) on 01/21/2025 at 2:45 PM the liter flow rate was set at 4.5 LPM; 2) on 01/22/2025 at 10:50 AM the liter flow rate was set at 5 LPM; and on 01/23/2025 at 9:34 AM and 01/24/2025 at 1:46 PM the liter flow rate was set at 4 LPM.

During an interview with Licensed Practical Nurse (LPN) 2, Unit Manager, on 01/23/2025 at 10:22 AM, she stated Resident R16 was non-compliant with care and believed that the resident was care planned for noncompliance.

She did not know what the focus of the resident's CCP was related to the noncompliance or if it was specific to respiratory care and ordered oxygen therapy.

During an interview with the Infection Preventionist (IP) on 01/23/2025 at 12:00 PM, she stated Resident R16 was non-compliant with care and would adjust the settings on the oxygen concentrator, and Resident R16 was care planned for noncompliance. However, she did not know what the focus of the CCP was related to the noncompliance or if it was specific to respiratory care and ordered oxygen therapy.

During an interview with the MDS Coordinator on 01/22/2025 at 9:35 AM, she stated the CCP was developed and updated by the MDS Nurse and nursing staff. She stated the CCP was a working document and was to reflect the resident's current status. Additionally, she stated the CCP gave direction to the staff for providing individualized care to residents. She stated changes in residents' conditions were discussed every morning at the Interdisciplinary Team (IDT) meeting. The MDS Coordinator stated each team member contributed to developing an individualized care plan. Per the interview, the IDT consisted of the Director of Nursing (DON), IP, Nurse Managers, MDS Coordinator, Social Worker, Physical Therapy, and the Activities Director.

During additional interview with the MDS Coordinator on 01/23/2025 at 2:25 PM, she stated the CCP should address the resident's needs based on diagnoses and assessments. She stated a noncompliant resident with a specific treatment or medication regimen should be cared for and planned with interventions to address their needs. She stated the MDS assessment and the CCP should show the resident received oxygen therapy. The MDS Coordinator was unaware of why Resident R16's care plan did not address her noncompliance with her treatments, medications, and ordered oxygen therapy.

During an interview with the DON on 01/23/2025 at 10:15 AM, she stated she expected staff to implement care planned interventions. She further stated following the plan of care was important to provide appropriate, resident-specific care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview with the Administrator on 01/24/2025 at 4:20 PM, she stated she was familiar with Resident R16's non-compliance behavior. She stated Resident R16's CCP should have been developed to address the resident's Level of Harm - Minimal harm or oxygen therapy and non-compliance with her treatments and medication regimen. She stated if Resident R16 was potential for actual harm adjusting her oxygen flow, it should have been addressed in the care plan. Additionally, she stated Resident R9's CCP should have been developed immediately to include interventions for Hospice care when the resident was Residents Affected - Few admitted to Hospice services. She stated staff nurses and the MDS nurse were responsible for ensuring the resident had a person-centered care plan. She stated the DON audited the care plans for accuracy. She stated a CCP was important to ensure the resident's well-being and safety. She stated it was her expectation that staff developed and implemented the resident's care plan to ensure care was delivered as prescribed.

During an interview with the Medical Director on 01/24/2025 at 4:15 PM, he stated it was his expectation that nursing staff provided, developed, and implemented a CCP to ensure the facility maintained the resident's highest practicable level of functioning and well-being.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 44001 potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to provide oxygen Residents Affected - Few therapy according to the Physician's Order for 1 of 13 sampled Residents (Resident (R) 16).

Observations on 01/21/2025, 01/22/2025, 01/23/2025, and 01/24/2025 revealed staff failed to ensure Resident R16's oxygen flow was set at three liters per minute (LPM) per the Physician's Orders.

The findings include:

Review of the facility's policy titled, Oxygen Usage Policy, reviewed 11/22/2024, revealed it was the policy of

the facility to ensure proper use of oxygen for residents. Per the policy, regular assessments would be done to monitor oxygen needs and adjust the setting as necessary. Also, documentation and monitoring would include oxygen flow rate.

Review of Resident R16's Face Sheet, located in the resident's electronic health record (EHR), revealed the facility admitted the resident on 08/07/2024 with diagnoses to include acute on chronic respiratory failure with hypercapnia, acute on chronic respiratory failure with hypoxia, and encephalopathy.

Review of Resident R16's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/24/2024, located in the resident's EHR, revealed the facility assessed the resident to have a Brief

Interview for Mental Status [BIMS] score of 15 out of 15, which indicated Resident R16 was cognitively intact. Further

review revealed the resident was not assessed for respiratory treatments or oxygen therapy.

Review of Resident R16's Comprehensive Care Plan [CCP], dated 01/02/2025, located in the resident's EHR, revealed the facility did not care plan the resident to include supplemental oxygen therapy management.

Review of Resident R16's Physician Orders, dated 11/12/2024, located in the resident's EHR, revealed to administer oxygen at 3 LPM continuous by nasal cannula.

Review of Resident R16's Medication Administration Record [MAR], dated 01/01/2025 to 01/24/2025, located in the resident's EHR, revealed no orders for oxygen at 3 LPM continuous by nasal cannula.

Review of Resident R16's Treatment Administration Record [TAR], dated 01/01/2025 to 01/24/2025, located in the resident's EHR, revealed no orders for oxygen at 3 LPM continuous by nasal cannula.

Observation of Resident R16's room on 01/21/2025 at 2:45 PM revealed Resident R16's oxygen concentrator's liter flow rate was set at 4.5 LPM.

Observation of Resident R16's room on 01/22/2025 at 10:50 AM revealed Resident R16's oxygen concentrator's liter flow rate was set at 5 LPM.

Observation of Resident R16's room on 01/23/2025 at 9:34 AM revealed Resident R16's oxygen concentrator's liter flow rate was set at 4 LPM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Observation of Resident R16's room on 01/24/2025 at 1:46 PM revealed Resident R16's oxygen concentrator's liter flow rate was set at 4 LPM. Level of Harm - Minimal harm or potential for actual harm During an interview with Resident R16 on 01/23/2025 at 9:34 AM, she stated her oxygen flow rate should be set at 3 LPM. She stated she did not change the settings. She further stated, It's [oxygen concentrator] old and won't Residents Affected - Few hold the setting. When asked if anyone had come in to check the concentrator, she stated, No.

During an interview with the Infection Preventionist (IP) Nurse on 01/21/2025 at 2:04 PM, she stated the medication nurse was responsible for ensuring oxygen settings were correct. She stated she expected the oxygen settings to be correct as per the physician's order for Resident R16. She stated nursing staff should check any resident on oxygen every shift to ensure oxygen flow was at the correct setting.

During additional interview with the IP on 01/23/2025 at 12:00 PM, she stated Resident R16 was non-compliant with care and would adjust the settings on the oxygen concentrator. The IP stated the resident was care planned for noncompliance. She stated maintaining the correct oxygen setting was the responsibility of the medication nurse, but anyone in the room could check to ensure it was at its ordered flow. She stated she did not know why Resident R16 had not been cared planned for oxygen therapy and why oxygen orders were not on

the MAR or TAR. The IP stated it was important to follow physician orders for the staff to provide care as ordered.

During an interview with the Director of Nursing (DON) on 01/22/2025 at 9:50 AM, she stated it was her expectation that nurses checked the oxygen settings at least once during their shift and periodically as they went in the residents' rooms during their shift. She stated she did not know why Resident R16's oxygen order was not included on the MAR or TAR. The DON stated it was important to follow physician orders to ensure care was delivered as prescribed by the physician.

During an interview with the Administrator on 01/24/2025 at 4:20 PM, she stated to ensure the resident's well-being and safety, it was her expectation that staff followed the physician orders to ensure care was delivered as prescribed.

During an interview with the Medical Director on 01/24/2025 at 4:15 PM, he stated Resident R16 had chronic respiratory failure and had been hospitalized recently. He stated Resident R16 was non-compliant with medical treatments. The Medical Director stated his expectation was that nursing staff provided ordered care for the residents to maintain the residents' highest practicable level of function and well-being.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 51155 Residents Affected - Many Based on observation, interview, record review, and facility policy review, the facility failed to ensure all drugs used in the facility were labeled in accordance with professional standards.

Observation revealed undated, opened, and expired medications in 3 of 4 medication carts and 1 of 1 treatment carts. Those medications included inhalers, an insulin vial, insulin pens, laxatives, antifungal powder, and topical creams.

The findings include:

Review of the facility's policy titled, Medication Storage, dated 08/22/2024, stated, Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs are returned to the dispensing pharmacy or destroyed.

Review of the facility's dispensing pharmacy's form Medication Expiration Dating stated, The following medications must be dated once they are opened. The form listed insulin vials and insulin pens.

1. a. During observation on 01/22/2025 at 8:44 AM of the 200-Hall split medication cart revealed one Trelegy Ellipta inhaler (triple combination medication used to treat adult chronic obstructive pulmonary disease (COPD) and asthma) with an expiration date of 01/08/2025, which LPN1 instructed the staff member at the nurses' station to immediately order another for the resident. Additional observation revealed one opened and undated bottle of Acid Gone (an over the counter antacid) with no opened date. Continued observation revealed albuterol single packets in an opened foil package with no opened date. Furthermore, there were medications observed such as tiotropium bromide (a bronchodilator used to treat COPD and asthma) not in

an original pharmacy package with no name; albuterol two vials not stored in a protective bag and no opened date; and one bottle of Robafen DM Cough Syrup not in the original packaging, with no label or opened date.

b. Observation on 01/22/2025 at 10:00 AM of the medication cart for Rooms 206-212 revealed an opened multi-use vial of insulin lispro (used to treat diabetes mellitus) with an expired date of 01/16/2025 written on

the vial; a bottle of lactulose (used to treat constipation) 10 grams with an expired date of 01/02/2025 written

on the label; an albuterol inhaler (a bronchodilator) opened and undated; a fluticasone inhaler (a corticosteroid used to treat asthma) opened and undated; and five insulin pens opened and unbagged in the same compartment together. Further observation revealed unwasted narcotics found in the narcotic box for a resident who had expired on 01/19/2025.

c. Observation on 01/22/2025 at 10:25 AM of the medication cart for Rooms 200 through 205 revealed three opened insulin pens in the same compartment and unbagged.

During an interview on 01/22/2025 at 10:00 AM with Licensed Practical Nurse (LPN) 3, she stated she was unaware the insulin was expired, and it should have been discarded by the expiration date. She stated expiration dates should be checked prior to administering any medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 2. Observation on 01/22/2025 at 10:18 AM of the treatment cart revealed the Pharmacy Technician was going through the cart with a lot of medications on top of it. When asked what she was doing, she stated she Level of Harm - Minimal harm or went through the cart once a month and paired the medications out of bags with the correct empty bag, potential for actual harm placing the medication back in the bag.

Residents Affected - Many Observation 01/22/2025 at 10:20 AM of the treatment cart revealed nystatin powder with no label, and unbagged and opened tubes of antifungal cream, clotrimazole cream, miconazole cream, and ketoconazole cream (all anti-fungal medications). Further observation revealed a tube of MediHoney (used to treat wounds and burns) was also unbagged and opened.

During an interview on 01/24/2025 at 10:43 AM with LPN 4, she stated medication should be dated upon opening, and the date checked before every administration. She stated medication without opened or expired dates should be removed from the medication cart and discarded. She stated this was important to decrease the risk of medication errors.

During an interview on 01/24/2025 at 9:36 AM with Staff Development, she stated the process when opening and administering medications included to date the medication with the date it was opened so staff would know when to discard it. She stated weekly audits were performed on the medication carts on Mondays. She stated any expired or undated medication should be removed from the carts and replaced. She stated narcotics were removed and wasted by the Director Of Nursing (DON). She stated any home medications brought in for resident use should be discussed with the facility pharmacy. She stated keeping the medication carts free from expired medication was important to prevent harm to residents.

During an interview on 01/24/2025 at 10:20 AM with the Director of Nursing (DON), she stated it was her expectation that medications be dated upon opening. She stated carts were checked weekly for insulin expiration dates. She stated no medication should be in the cart and in use if unlabeled because staff would not know which resident it belonged to. The DON stated narcotics were kept in the cart and included in the count until she wasted the narcotic. She stated wasting narcotics was usually done as soon as possible. When asked about the narcotics for the expired resident, she stated she was told about the medications, and

she forgot about them. The DON stated it was important to keep the medications dated and unnecessary medication removed from the cart to decrease the risk of medication errors.

During an interview on 01/24/2025 at 4:30 PM with the Administrator, she stated it was her expectation that medications be put back in the proper packaging/bags when they were placed back into the medication cart, and they needed to be dated. She stated her expectation was that the dates should be checked every time

the medication was used. She stated if a medication had no label or an expired date, then it should be removed from the cart. She stated any narcotic that needed to be wasted should be reported to the DON.

She stated it was important so residents did not receive wrong or expired medications.

51417

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 51155 potential for actual harm Based on observation, interview, record review, review of the facility's job descriptions, and review of the Residents Affected - Many facility's plan of correction (PoC), dated 03/12/2024, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) process. The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on indicators of the outcomes of care and quality of life that were achieved and sustained. Observation on 01/22/2025 at 10:00 AM revealed insulin lispro was opened, in use, and dated with an expiration date of 01/16/2025. Review of the previous survey, dated 01/07/2024 to 01/11/2024, revealed a repeat issue was found with the expired insulin being used. This affected all 49 current residents residing in the facility.

Refer to

F-F761)

The State Survey Agency (SSA) Surveyor was unable to interview the DON regarding QAPI because she was unavailable, unreachable, and out of the facility on 01/24/2025.

During an interview on 01/24/2025 at 4:30 PM with the Administrator, she stated it was the responsibility of

the DON to monitor QAPI audits. She stated this was important to ensure compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 44001 potential for actual harm Based on observation, interview, record review, review of the Centers for Disease Control and Prevention Residents Affected - Many (CDC) guidelines, review of the manufacturer's instructions for use, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 26 sampled and supplemental residents, Residents (R) 44 and Resident R21. Additionally, the failed to assess and monitor the building's water system for Legionella and other opportunistic waterborne pathogens affecting the total census of 49.

1. Observation on 01/22/2025 at 11:40 AM with Licensed Practical Nurse (LPN) 3 revealed she did not don (put on) personal protective equipment (PPE) in an enhanced-barrier precaution (EBP) room before she provided direct care. Further observation revealed LPN3 failed to prevent contamination of surfaces and clean the glucometer according to the Environmental Protection Agency (EPA) registered disinfectant manufacturer's instructions.

2. Observation on 01/23/2025 at 12:20 PM with Registered Nurse (RN) 1 after administering medication to Resident R21 revealed RN1 cleaned the stethoscope while still wearing dirty gloves.

3. Review of the facility's documentation related to water management and Legionella prevention and detection revealed there was no documentation that control measures to include visible inspections, disinfection, and temperature controls were monitored, documented, and audited. Furthermore, the facility failed to provide documentation of a process flow diagram for the facility's water flow to include identified areas where Legionella could grow and spread.

The findings include:

Review of the CDC's guideline, provided by the facility, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/2021, revealed reusable medical equipment should be cleaned and disinfected according to manufacturer's instructions or the facility's policies before and after use. The guidelines stated facilities should maintain separation between clean and soiled equipment to prevent cross-contamination. Further

review of the guidelines revealed staff should be trained in the correct steps for cleaning and disinfection of shared equipment.

Review of the facility's policy titled, Infection Control Policy and Procedure/Surveillance Plan, reviewed 09/14/2024, revealed the facility maintained an infection prevention and control program designed to provide

a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. Continued review revealed annual skill checkoffs would be performed by the Infection Preventionist (IP) and would cover the use of PPE, isolation precautions, and the safe handling of contaminated equipment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the facility's policy titled, Enhanced Barrier Precautions, revised 11/17/2024, revealed it was the facility's policy to implement enhanced barrier precautions (EBP) for the prevention of transmission of Level of Harm - Minimal harm or multidrug resistant organisms [MDRO]. Furthermore, the policy stated that EBP reduced transmission of potential for actual harm MDROs through gown and glove use during high resident care activities.

Residents Affected - Many Review of the facility's policy titled, Shared Equipment, reviewed 08/22/2024, revealed it was the facility's policy to attempt to decrease the risk of spreading infection and disease through infection control standards for cleaning medical equipment before and after each individual resident use and follow the direction for dwell times (the amount of time a disinfectant must remain visibly wet to kill a pathogen).

Review of the facility's policy titled, Glucometer Cleaning Policy and Procedure, reviewed 03/30/2024, revealed it was the facility's policy to ensure each resident was provided with a clean and non-infectious glucometer. Further review revealed nursing staff would clean the glucometer with SaniCloth wipes and allow

the glucometer to sit and dry for three minutes before and after each use.

Review of the cleaning and disinfecting instructions for the Assure Prism Multi-Blood Glucose Monitoring System, no date, revealed to minimize the risk of transmitting bloodborne pathogens, the exterior of the glucometer should be cleaned of all dirt, blood, and bodily fluids before performing the disinfection procedure, which would prevent the transmission of bloodborne pathogens. Per the instructions, the exterior of the glucometer should remain wet for the appropriate dwell time according to the disinfectant's instructions.

Review of the cleaning and disinfecting instructions for SaniCloth wipes revealed if visibly soiled use one or more wipes as necessary to wet surfaces sufficiently and to thoroughly clean the surface. According to the instructions, all surfaces must remain visibly wet for a two-minute dwell time to assure complete disinfection of all pathogens.

1. Review of Resident R44's Face Sheet, located in the resident's electronic health record (EHR), revealed the facility admitted the resident on 05/03/2024 with diagnoses to include chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and unstageable wound with dressing to right foot.

Review of Resident R44's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/03/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 out of 15, which indicated Resident R44 had moderate cognitive impairment.

Review of Resident R44's Physician Orders, dated 01/24/2025, located in the resident's EHR, revealed there was an order for EBP for a wound with a dressing.

Observation of LPN3 on 01/22/2025 at 11:40 AM revealed she gathered a glucometer, lancet, testing strips, and alcohol wipes, and placed them into a plastic tray before taking them into Resident R44's room. She set the tray

on a barrier cloth on the bedside table and performed a finger stick test. LPN3 did not put on a gown before performing the finger stick on Resident R44. After completing the procedure, LPN3 discarded the barrier sheet from under the tray and placed the tray on an unclean surface. She returned the tray to the medication cart without placing a barrier sheet underneath the contaminated tray. LPN3 then cleaned the contaminated glucometer using one disinfectant wipe and wiping it for 24 seconds. She then placed the device inside the contaminated tray. Furthermore, LPN3 did not adhere to the required dwell time of two-minutes as specified

in the wipe's instructions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 01/22/2025 at 11:50 AM, LPN3 stated each medication cart had at least one glucometer that was shared among residents. When asked what the dwell time for the wipes was, LPN3 Level of Harm - Minimal harm or stated, Two minutes. However, she could not articulate the definition of dwell time. She stated any potential for actual harm equipment taken into a resident's room must be cleaned and disinfected before being used on another resident to prevent the spread of infection or bloodborne pathogens. LPN3 stated further that she did not Residents Affected - Many wear a gown because she believed that performing a fingerstick did not meet the EBP requirements for high-risk direct care. Additionally, LPN3 stated she had received infection prevention and control practice (IPCP) education upon hire and had also received education through in-service trainings provided by the Infection Preventionist/Wound Care Nurse (IP/WCN). She stated the importance of following infection control protocols and EBP requirements was to prevent the spread of infection among staff and residents. After the interview, LPN3 retrieved the glucometer and plastic tray from the medication cart and cleaned them according to facility protocols before using them on a different resident.

During interview with the IP/WCN on 01/23/2025 at 12:00 PM, she stated the facility followed CDC guidelines and recommendations related to IPCP. She stated she provided education to all staff related to IPCP, and all staff was trained on the use of PPE and isolation precautions to include EBP. She stated gowns and gloves must be worn whenever staff entered an EBP room if high-contact care was provided. She stated high contact care included the use of devices. Per the interview, the IP/WCN stated she had not observed any concerns related to staff's failure to follow IPCP or EBP protocols. She stated it was her expectation that all staff followed IPCP. The IP/WCN stated it was important for the safety of residents and staff and to prevent

the spread of infection. She also stated nursing staff was trained to clean and disinfect the glucometer after each use using SaniCloth cleaning and disinfectant wipes with a two-minute dwell time. She stated contaminated glucometers should be placed on a barrier cloth to prevent the spread of infection and cleaned, then disinfected for the appropriate time and stored separately to keep clean.

2. Review of Resident R21's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 10/16/2020 with diagnoses including esophageal obstruction, acute pancreatitis, congenital stenosis, and stricture of the esophagus.

Review of Resident R21's quarterly MDS, with an ARD of 11/25/2024, revealed the facility assessed the resident to have a BIMS score 15 out of 15, indicating the resident had intact cognition.

Observation on 01/23/2025 at 12:20 PM with RN1 after administering medication to Resident R21 revealed RN1 cleaned the stethoscope with an alcohol wipe while still wearing the gloves that she wore when she provided physical contact and medication administration to Resident R21. After cleaning the stethoscope, the dirty gloves were doffed (removed) and discarded, and RN1 washed her hands.

During an interview on 01/24/2025 at 10:17 AM with the Director of Nursing (DON), she stated she expected staff to remove dirty gloves, use proper hand hygiene, and re-glove to clean a piece of equipment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During additional interview with the DON on 01/24/2025 at 10:30 AM, she stated all staff received IPCP training upon hire and periodically throughout the year. In addition, the DON stated staff was updated on Level of Harm - Minimal harm or current CDC guidelines when they changed. She stated the Unit Managers audited staff for compliance. potential for actual harm However, she stated there was no documentation of staff IPCP audits. Per interview, it was the DON's expectation that all staff maintained IPCP guidelines at all times to decrease the potential spread of infection. Residents Affected - Many

During an interview on 01/24/2025 at 4:25 PM with the Administrator, she stated common sense told one to clean equipment with clean gloves. She stated she expected her staff to use clean gloves after patient care when encountering equipment.

3. Review of the facility's policy titled, Legionella Prevention Policy and Procedure, dated 10/13/2024, revealed the facility would attempt to decrease the risk of exposure to Legionella bacteria to residents, staff, and visitors. Policy review revealed weekly water temperature checks, empty room faucet and eyewash station flushes, and cleaning of the ice machines would be performed and logged.

Review of the CDC's Guideline Developing a Legionella Water Management Program, revealed a key component of the water management program (WMP) was a flow diagram used to describe the facility's water systems and identify areas at risk for Legionella growth and spread.

Review of the facility's documentation related to their water management revealed there was no documentation that control measures to include visible inspections, disinfection, and temperature controls were monitored, documented, and audited. Furthermore, the facility failed to provide documentation of a process flow diagram for the facility's water flow to include identified areas where Legionella could grow and spread.

Review of the facility's WMP revealed the facility did not include a flow diagram to describe the facility's water system or identify where in the facility there were areas at risk for Legionella or other waterborne pathogens to grow and spread.

During an interview with the Maintenance Director on 01/22/2025 at 9:11 AM, he stated he did not know about the facility's WMP. He stated he checked water temperatures throughout the building and documented them on a sheet of paper.

During an interview with the Administrator on 01/22/2025 at 9:40 AM, she stated she was responsible for water management in the facility. She stated she performed in-house monitoring of the water supply quarterly using a testing kit. The Administrator stated the facility did not have a flow diagram to describe the water system and identify areas where Legionella could grow. She stated she was familiar with the CDC's tool kit to help facilities development of a WMP. She stated further that she had not completed a Legionella Environmental Assessment Form (LEAF) to help identify areas at risk for Legionella growth and spread. She stated the Maintenance Director performed water monitoring and flushing.

During an interview with the Infection Preventionist (IP) on 01/22/2025 at 1:37 PM, she stated the Administrator was responsible for the WMP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview with the Administrator on 01/24/2025 at 4:20 PM, she stated it was her expectation that staff followed the facility's IPCP policies and procedures to prevent the spread of infection to residents and Level of Harm - Minimal harm or staff. potential for actual harm

During an interview with the Medical Director on 01/24/2024 at 4:15 PM, he stated the facility followed CDC Residents Affected - Many guidelines and recommendations. The Medical Director stated it was his expectation that the facility followed all its policies and procedures, and he further expected the DON and the IP to oversee and implement infection prevention and control policies.

51417

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or 44001 potential for actual harm Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) Residents Affected - Some document, and review of the facility's policy, the facility failed to ensure the medical record included documentation of the resident's or resident representative's (RR) education regarding the benefits and potential side effects of immunizations for 5 of 5 residents sampled for immunizations (Resident (R) 6, Resident R9, Resident R16, Resident R21, and Resident R44).

The findings include:

Review of the facility's policy titled, Immunization/Vaccination Policy and Procedure, dated 11/09/2024, revealed the facility would educate and offer residents available immunizations against infections to minimize

the risk of acquiring or transmitting disease. Per the policy, residents would be assessed for medical contraindications of immunizations and receive education regarding the benefits and potential side effects of

the immunizations.

Review of the documentation provided to residents regarding vaccine education showed the facility stated

they offered residents the CDC's Vaccine Information Sheets (VIS) for the COVID-19 and Respiratory Syncytial Virus (RSV) vaccines, both dated 10/19/2023. The facility did not offer residents current 2024-2025 VIS sheets.

1. Review of Resident R6's Face Sheet, located in the resident's electronic health record (EHR), revealed the facility admitted the resident on 05/07/2024 with diagnoses to include debility, asthma, and seizure disorder.

Review of Resident R6's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/30/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of five out of 15, which indicated Resident R6 had severe cognitive impairment.

Review of Resident R6's Immunization Record, located in the resident's EHR, revealed Resident R6 received his RSV vaccine

on 10/03/2024. He received his influenza vaccine on 10/07/2024. For both immunization records, No was answered to the question about whether education was provided by the nurse. There was no documentation that the RR was provided updated vaccine information. Other vaccine information was historical.

Resident R6 was non-interviewable, and his RR was not contacted.

2. Review of Resident R9's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 11/17/2022 with diagnoses to include obstructive uropathy, protein calorie malnutrition, and ventral hernia.

Review of Resident R9's quarterly MDS, with an ARD of 12/09/2024, revealed the facility assessed the resident to have a BIMS score of 5 out of 15, which indicated Resident R9 had severe cognitive impairment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Review of Resident R9's Immunization Record, located in the resident's EHR, revealed Resident R9 received her RSV vaccine

on 10/03/2024. She received her last influenza vaccine on 11/17/2022. For both immunization records, No Level of Harm - Minimal harm or was answered to the question about whether education was provided by the nurse. There was no potential for actual harm documentation the RR was provided updated vaccine information. Other vaccine information was historical.

Residents Affected - Some Resident 9 was non-interviewable, and her RR was not contacted.

3. Review of Resident R16's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 08/07/2024 with diagnoses to include acute on chronic respiratory failure, encephalopathy, and non-compliance with medical regimen.

Review of Resident R16's quarterly MDS, with an ARD of 12/26/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated Resident R16 was cognitively intact.

Review of Resident R16's Immunization Record, located in the resident's EHR, revealed Resident R16 received her RSV vaccine on 10/03/2024. She received her influenza vaccine on 10/14/2024. For both immunization records, No was answered to the question about whether education was provided by the nurse. There was no documentation the resident was provided updated vaccine information. Other vaccine information was historical.

During an interview with Resident R16 on 01/23/2025 at 9:34 AM, she stated she was not provided a VIS to read or sign prior to administration of her last vaccines. She stated education regarding the benefits and risks and potential side effects associated with the vaccine was good information to have to make an informed decision.

4. Review of Resident R21's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 10/16/2020 with diagnoses to include esophageal obstruction, acute pancreatitis, and congenital stenosis and stricture of the esophagus.

Review of Resident R21's quarterly MDS, with an ARD of 12/26/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated Resident R21 was cognitively intact.

Review of Resident R21's Immunization Record, located in the resident's EHR, revealed Resident R16 received his RSV vaccine on 10/03/2024. He received his Influenza vaccine on 10/14/2024. For both immunization records, No was answered to the question about whether education was provided by the nurse. There was no documentation the resident was provided updated vaccine information. Other vaccine information was historical.

During an interview with Resident R21 on 01/23/2025 at 9:55 AM, he stated he did not remember any education about

the vaccines or that he was given a VIS to read or sign prior to administration of his last vaccines. He stated

he was just asked if he wanted the vaccine.

5. Review of Resident R44's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 05/03/2024 with diagnoses to chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and unstageable wound to right foot.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Review of Resident R44's quarterly MDS, with an ARD of 12/03/2024, revealed the facility assessed the resident to have a BIMS score of 11 out of 15, which indicated Resident R44 had moderate cognitive impairment. Level of Harm - Minimal harm or potential for actual harm Review of Resident R44's Immunization Record, located in the resident's EHR, revealed Resident R44 declined the influenza vaccination for this season. He had also declined the pneumococcal vaccination. For both immunization Residents Affected - Some records, No was answered to the question about whether education was provided. There was no documentation the resident was provided updated vaccine information.

During an interview with Resident R44 on 01/22/2025 at 11:52 AM, he stated he declined both immunizations when offered. He stated he was not provided a VIS to read or sign.

During an interview with the Infection Preventionist (IP) on 01/23/2025 at 12:00 PM, she stated the facility followed the CDC's recommendation for all immunizations and vaccines. She stated the facility provided vaccine education to residents. The IP stated she did not know why the sampled resident files did not have vaccine education documentation. The IP did not answer why the facility was using outdated VIS sheets from 2023 for the 2024-2025 vaccines. The IP stated it was important for the facility to educate and offer residents recommended vaccines and follow CDC's recommendations for vaccines and immunizations to prevent the spread of diseases and infections.

During an interview with the Director of Nursing (DON) on 01/24/2025 at 10:30 AM, she stated the facility followed CDC recommendations for resident and staff immunizations and vaccines. She stated it was important for residents to be educated about and offered all recommended immunizations and vaccines. She stated the IP provided updated VIS information to educate staff and residents. Furthermore, she stated immunization or declination of the vaccine should be documented in resident files as part of a comprehensive infection control program.

During an interview with the Administrator on 01/24/2025 at 4:20 PM, she stated it was important the facility maintained the appropriate documentation to reflect that it provided the required COVID-19 vaccine education to employees to comply with CDC recommendations and adhere to the facility's infection control program. The Administrator stated the IP Nurse was responsible for infection control oversight, but everyone must follow policies. She stated further that following policy and CDC guidelines was important for the safety of residents and staff.

During an interview with the Medical Director on 01/24/2024 at 4:15 PM, he stated the facility followed CDC guidelines and recommendations. The Medical Director stated it was his expectation that the facility followed all its policies and procedures, and he further expected the DON and the IP to oversee and implement infection prevention and control policies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm 44001

Residents Affected - Some Based on interview, record review, review of the Centers for Medicaid and Medicare Services (CMS) document, and review of the facility's policy, the facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for 4 of 4 sampled staff, Licensed Practical Nurse (LPN) 2, LPN7, Certified Nurse Aide (CNA) 2, and the Business Office Manager (BOM).

The findings include:

Review of the CMS's Center for Clinical Standards and Quality/Quality, Safety & Oversight Group's QSO-21-19-NH Memo, dated 05/01/2021, revealed Long-term Care facilities (LTC) must offer staff vaccination against COVID-19 when vaccine supplies were available to the facility. Per the memo, LTC facility's must screen staff prior to offering the vaccination for prior immunization, medical precautions, and contraindications to determine whether they were appropriate candidates for vaccination. Per the guidance,

the vaccine might be offered and provided directly by the LTC facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity.

Review of the facility's policy titled, Immunization/Vaccination Policy and Procedure, dated 11/09/2024, revealed the facility would educate and offer staff members and volunteer workers available immunizations against infections to minimize the risk of acquiring or transmitting disease. Per the policy, staff and volunteers would be assessed for medical contraindications of immunizations and receive education regarding the benefits and potential side effects of the immunization. The policy stated staff was encouraged to be immunized annually to prevent infection and transmission of infectious diseases and its complications.

1. Review of LPN2's employee file revealed no documented evidence noting the LPN was offered the COVID-19 vaccination. Additionally, there was no documentation that education regarding the benefits, risks, and potential side effects of the vaccine was provided to the employee.

During an interview with LPN2 on 01/22/2025 at 9:40 AM, she stated she received education regarding the COVID-19 vaccine, but she did not recall if she signed any documentation acknowledging the education or being offered the COVID-19 vaccination.

2. Review of LPN7's employee file revealed no documented evidence noting the LPN was offered the COVID-19 vaccination. Additionally, there was no documentation that education regarding the benefits, risks, and potential side effects of the vaccine was provided to the employee.

LPN7 was unavailable for interview.

3. Review of CNA2's employee file revealed no documented evidence the facility had provided CNA2 with education regarding the benefits, risks, and potential side effects of the vaccine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 185332 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185332 B. Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Nursing and Rehabilitation Center 105 Rodgers Park Cynthiana, KY 41031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 During an interview with CNA2 on 01/23/2024 at 9:38 AM, she stated she received education regarding the COVID vaccine but did not sign any documentation acknowledging the education or offering of the Level of Harm - Minimal harm or COVID-19 vaccination. potential for actual harm 4. Review of the BOM's employee file revealed no documented evidence the facility had provided the BOM Residents Affected - Some with education regarding the benefits, risks, and potential side effects of the vaccine.

The BOM was unavailable for interview.

During an interview with the Infection Preventionist (IP) on 01/23/2025 at 12:00 PM, she stated the facility followed the Centers for Disease Control and Prevention's (CDC) recommendation for all immunizations and vaccines. She stated the facility provided vaccine education to staff on hire. The IP stated she did not know why the sampled employee files did not have the employee's COVID-19 vaccine education documentation. However, she stated it was important for the facility to educate staff about and offer the COVID-19 vaccine. Additionally, the IP stated the facility should keep documentation of employees' immunizations or declinations of the vaccine in their files. She stated it was important to follow the CDC's recommendations for infection prevention and control to prevent the spread of diseases and infections.

During interview with the Director of Nursing (DON) on 01/24/2025 at 10:30 AM, she stated the facility followed infection control guidelines as per the CDC to include recommendations for staff immunizations and vaccines. She stated knowing the employees' vaccination status was essential for everyone's safety. She stated it was important for staff to be educated about and offered the COVID-19 vaccine. Furthermore, she stated the staff members' immunizations or declinations of the vaccine should be documented in their files, as part of a comprehensive infection control program.

During an interview with the Administrator on 01/24/2025 at 4:20 PM, she stated it was important that the facility maintained the appropriate documentation to reflect that it provided the required COVID-19 vaccine education to employees to comply with CDC recommendations and adhere to the facility's infection control program. The Administrator stated the IP Nurse was responsible for infection control oversight, but everyone must follow policies. She stated further that following policy and CDC guidelines was important for the safety of residents and staff.

During an interview with the Medical Director on 01/24/2024 at 4:15 PM, he stated the facility followed CDC guidelines and recommendations. The Medical Director stated it was his expectation that the facility followed all its policies and procedures, and he further expected the DON and the IP to oversee and implement infection prevention and control policies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 185332