Western State Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 49350 Based on interview, record review, and review of facility policy, the facility failed to ensure patients received care in a safe setting. The findings include: Review of the policy entitled, Preventing and Reporting Patient Abuse, Neglect, and Exploitation, effective 07/01/1996 and last revised March 2026. Per policy review, the policy’s purpose noted all instances of suspected or confirmed adult abuse, neglect, or exploitation “must” be reported according to the guidelines contained in Kentucky Revised Statutes (KRS) 209.030. Continued review revealed the facility was committed to the protection of any patient who might suffer from abuse, neglect, or exploitation. Policy review revealed each employee was expected to be aware of their responsibility to the patients the facility served, and to be constant in efforts to safeguard their (patients) well-being. Further review revealed the staff’s responsibility extended to them taking steps to prevent abuse, neglect, or exploitation from occurring when situations arose that increased the potential for patient abuse, neglect, or exploitation. An anonymous complaint was submitted to the State Survey Agency (SSA) from the Joint Commission (accrediting agency) regarding quality of care and abuse allegations at the facility. Per review, the allegations, contained in the complaint, did not list specific individuals; however, described a broad, chronic problem of abuse in the facility. Continued review of the Joint Commission’s documentation revealed central to the investigation of the anonymous complaint was the observation of the facility’s seclusion or quiet rooms, of which 15 were in operation at the facility. Further review revealed the seclusion/quiet rooms were designated for high-risk behavioral situations and consisted of an empty room with a mattress on the floor and a door. Observation on 05/05/2026 at 12:00 PM, revealed the seclusion/quiet rooms were not monitored with cameras and were empty except for a mattress on the floor. Review of the 2026 SSA complaints were evaluated between the (Eastern) State Hospital and the facility (both psychiatric facilities) for comparison. Per review, the complaint information revealed the (Eastern) State Hospital had eight abuse complaints recorded for the year, with the facility having 38 complaints recorded for the year. Continued review of the information revealed 30 of the 38 complaints, had been submitted to the SSA through self-reporting by the facility. During the SSA Survey the hospital risk management team provided information on 05/06/2026, related to nine cases of altercations which had taken place inside the facility’s seclusion/quiet rooms during the past 12 months. Review of the information revealed the altercations investigated had been related to physical contact between staff members and patients, not approved for care under protocols such as Crisis Prevention Intervention (CPI) techniques, which indicated unapproved physical contact by a staff member to a patient. Continued review of the information revealed the staff to patient physical conflicts were taking place inside of the facility’s quiet/seclusion rooms. Review revealed in some of the cases investigated, by the facility risk management staff, the facility had not been able to fully determine how the physical altercations took place as the facility did not have sufficient monitoring in place for those areas. Observation of patients on the facility’s Unit 56G was completed of patients, including Patients (P)2, P3, P4, P5, and P6. Observation on 05/06/2026 at 9:20 AM, of P2, P3, P4, P5, and P6 revealed the patients were sitting in the commons area of Unit 56G, being educated by staff on bathing and the use of soaps and deodorant. During an interview with Registered Nurse (RN) 1 on 05/05/2026 at 1:10 PM, he stated he felt the nursing staff was “overworked” at times. He further stated that could create “unsafe scenarios” for patients and staff. During an interview with RN 2 on 05/05/2026 at 1:30 PM, he reported he had no specific concerns about abuse. He further denied any problems or perceptions of chronic abuse and neglect at the facility. During an interview with RN 3 on 05/05/2026 at 1:34 PM, she stated she believed the facility was working “short-staffed.” During an interview with RN 4 on 05/05/2026 at 2:00 PM, when the SSA Surveyor asked if she had concerns with abuse or neglect at the facility, she reported a nursing student who worked at the facility “almost killed” a patient during an attack that occurred in a quiet/seclusion room on 03/29/2026. She said the facility did not do anything after the investigation to take appropriate action regarding the attack. The RN explained the alleged perpetrator (Staff 10), had been “cleared” during the investigation and was currently permitted to work in the facility’s human resources department. She stated Staff 10 placed a patient (P11) in a “headlock” inside a quiet/seclusion room until the patient collapsed. The RN reported Staff 10 then punched the patient in the head. RN 4 said that incident had already been investigated at the facility by the Risk Management Department; however, she felt the investigation had not lead to appropriate action and the alleged perpetrator was allowed to remain working at the facility. During an interview with Risk Manager (RM) 3 on 05/08/2026 at 10:30 AM, the SSA Surveyor asked if the facility’s governing body and Quality Committees had discussed the issue of monitoring inside the quiet rooms and possibly placing cameras in the rooms, the RM stated, “we have some emails going back and forth trying to establish additional orders for cameras.” He said when investigating complaints of alleged assault, he looked for physical signs of injury, and at cameras to see who went into the room and whether more than one person was involved. RM 3 explained “we” have some instances where a patient would say someone on the staff had done “something” to them, but no one else was around. He stated and sometimes the facility found the staff person who the patient alleged doing “something” to them had not even been at work at the time. When the SSA Surveyor asked RM 3 about having concerns of the facility not having monitoring in the quiet rooms, the RM stated he would like to have cameras in the quiet rooms because that was where a lot of “our” allegations “come out.” He said he would be more comfortable having cameras in those rooms. RM 3 stated, “I don’t see any privacy issues with those rooms being monitored. Patients and staff know that those spaces are not monitored so more things happen there because they know they can get away with it.” He reported some of the quiet rooms were partially blocked by a wall. When the SSA Surveyor asked why the rate of reporting abuse was so high at that time, he further stated, “we average 60 to 70 cases (of abuse) for a year, but did not elaborate on why that reporting rate was so high. During an interview with the Director of Risk Management on 05/06/2026 at 9:10 AM, he stated the facility had 15 seclusion rooms. He reported the seclusion rooms had recently been a point of discussion because of the nature of the rooms for high-risk situations. The Director of Risk Management said physical conflicts sometimes unfolded in those areas (seclusion rooms) between patients and staff. He explained those rooms were difficult to monitor, and it was difficult to monitor patients’ safety. The Director of Risk Management stated it was also difficult to know what was happening inside those rooms if a disagreement, struggle, or conflict took place. He reported some initial discussions had taken place regarding placing cameras in the seclusion/quiet rooms going forward, so if conflicting accounts of an incident took place, the circumstances could be reviewed. When the SSA asked the Director of Risk Management if the rooms were monitored, he said if a patient were in the seclusion room during a behaviorally elevated situation, that area should be monitored by the staff. He further stated however, from a “leadership perspective,” they had no direct way to ensure the safety of residents inside those room or to evaluate what had taken place in the seclusion room because no camera was present. During an interview with the Director of Nursing (DON) on 05/06/2026 at 10:09 AM, when the SSA Surveyor asked why patients might be confined to a quiet or seclusion room, she stated some patients acted out, “hit a wall,” and some had to be put into restraints. When the SSA asked what approach the facility had taken to try to manage hostile or physical assault type situations in the seclusion/quiet rooms, she stated “we have employees watching at all times.” The DON said “I think that a camera would help” in those areas, as the cameras would help with resolving any issues. She stated, “I would say that once or twice per year at least, the issue of a dispute comes up in the seclusion or quiet room and we cannot see what happened to make a determination of how to manage the situation.” When the SSA Surveyor asked why she thought the facility’s abuse reporting was so high, she said staff might be reporting “everything” they saw, and it was better to report everything than let anything go, so that might be why the numbers were “so high.” The DON stated the facility trained the nurses on “tap out,” where staff were to take a 15-minute break in a crisis situation if things become escalated, to give the staff “time to regroup.” She said “we train them that anything that they think may be abuse should be reported.” When the SSA Surveyor asked her about the complaint abuse allegation, she stated she had been working at the facility for 22 years and did not believe anything was taking place there that would be outside the realm of appropriateness for traditional psychiatric hospital care. She reported a potential negative outcome, to not having cameras in the seclusion/quiet rooms or monitoring of the rooms, was that an employee who harmed a patient could still be working at the facility after an altercation in a seclusion room, as “we could not see what took place” (in those rooms). During an interview with the facility’s Associate Director (AD), on 05/06/2026 at 10:36 AM, when the SSA Surveyor asked what the mindset of a patient who had been confined to a quiet/seclusion room might be, he stated some patients might be scared or they could be upset. The AD said once the patient’s behavioral episode was over staff needed to understand what had caused the behavior. He explained “we” need to understand how patients feel in those type of situations. The AD reported during the current investigation it had been discussed that at present the facility did not have cameras to provide constant oversight of patients in the facility’s seclusion or quiet rooms. He said the seclusion/quiet rooms had increased potential for conflict between patients and staff. The AD stated “I feel that it is problematic that we do not have cameras in the seclusion rooms.” He explained he had a human resources background so he saw “things a different way than clinical” personnel did. The AD reported what was happening in the seclusion rooms, patient rooms, or the shower rooms was important. He said there were other areas of the facility where not being able to see what was happening occurred, like the elevator and that concerned him. During a continued interview on 05/06/2026 at 10:36 AM, the AD stated he had been involved in discussions about adding additional cameras and “we had to decide what was most important and we had to get it right.” He said the facility identified “most of the places where having cameras was important” and placed cameras there. The AD reported the facility was “at the mercy of the state bidding and approval process” when attempting to procure more cameras. When the SSA Surveyor asked why he thought the facility’s abuse reporting numbers were high, he said, “We preach to the team to always report everything and let the investigations being performed play out.” The AD stated the facility had collaborated with another state psychiatric hospital and implemented cameras where they had them, and they had cameras in their seclusion rooms. He reported, “We tell staff to always be aware and to report things when they see them. Our new “tap out” policy is a year or two old, which was where staff step away if the circumstances are becoming problematic.” The AD further stated the expectations were for staff to treat the patients with respect, and that had been the primary goal of installing the cameras. In addition, he said he did not think the facility had “a chronic long-standing problem of abuse,” they just tried to report “things to everybody as required.””

“INFECTION CONTROL SCOPE COMPLEXITY CFR(s): The infection prevention and control program reflects the scope and complexity of the hospital services provided. This Standard is not met as evidenced by: 47852 Based on observation, interview, record review, and review of facility documentation, the facility failed to ensure its infection prevention and control program reflected the scope and complexity of the hospital services provided. The findings include: Review of the facility’s, “Infection Control and Employee Health Manual Standard Operating Procedure Number 12,” reviewed August 2023, revealed hand washing was considered the most important single procedure for preventing infection or the spread of infection in a hospital. Per review, the indications for routine hand washing included washing between patient contact. Continued review revealed gloves were to be used in addition to, not as a substitute for, hand washing. Additionally, review further revealed gloves were to be changed between patients and might need to be changed during the care of a single patient, for example, when moving from one procedure to another. Review of the facility’s, “Infection Control and Employee Health Manual Standard Operating Procedure Number 13,” revised October 2018, revealed gloves were to be worn to prevent contamination of healthcare personnel’s hands when handling or touching potentially contaminated patient care equipment and environmental surfaces. Review of the facility’s, “Infection Control Program” documentation, revised 10/2013, revealed the purpose of the (facility’s) Infection Control Program was for the surveillance, prevention, and control of infection in the facility. Further review revealed the Infection Control Nurse (ICN) was to make rounds in departments and service areas to observe for correct implementation of infection control procedures on a periodic basis. Review of the facility’s job description titled, “Patient Support Associate,” (PSA) updated 05/24/2022, revealed the PSA’s primary responsibilities included assisting with direct care of patients and learning to assist with maintaining a safe and clean patient care environment. Observation on 05/05/2026 at 10:45 AM, revealed Patient (P)6’s catheter bedside drainage bag lying on the floor next to his bed without a barrier or dignity bag. Observation on 05/05/2026 at 10:55 AM, revealed PSA 2 and PSA 11 passing patients’ lunch trays. Further observation revealed both PSAs touched the patients’ trays, then touched the patients, table surfaces, and door frames without performing hand hygiene before continuing to pass other patient trays. Observation on 05/05/2026 at 11:03 AM, revealed PSA 3 and PSA 12 passing patient lunch trays while traveling up and down the hallway and entering the door behind the nurse’s desk area. Further observation revealed the two PSAs were completing all that without performing hand hygiene before continuing to assist with other patient trays. Observation on 05/05/2026 at 11:12 AM, revealed PSA 4 took a patient tray off the tray cart after a patient ate the food and placed the dirty tray on the desk. Continued observation revealed PSA 13 and PSA 14 were wearing gloves while passing patients’ trays. Further observation revealed PSA 13 and PSA 14 touched multiple table/desk surfaces and traveled into and out of two patients’ rooms while wearing the gloves and without performing hand hygiene. Observation on 05/07/2026 at 2:35 PM, revealed PSA 9 passing snacks which included bananas, fruit cups, and drinks. Per observation, PSA 9 wore gloves while passing out those snacks, then reached into his pocket for a key, and opened a door to retrieve further snacks. Further observation revealed PSA 9 placed the key back in his pocket, and continued passing snacks without completing hand hygiene. During an interview on 05/06/2026 at 10:26 AM, PSA 6 stated staff performed hand hygiene before beginning tray pass and again after all trays were passed. PSA 6 further stated however, staff did not necessarily perform hand hygiene between serving the trays. During an interview, on 05/06/2026 at 11:35 AM, PSA 7 stated he always wore gloves while passing trays, but had not been told he had to wear gloves while doing that. He further stated he would perform hand hygiene before beginning the patients’ meal tray pass and after all the trays were passed; however, did not do that between serving the trays. During an interview, on 05/07/2026 at 1:50 PM, the Infection Control Nurse (ICN) stated gloves were to be worn while staff were passing trays. The ICN said staff should only be passing trays without touching patients or objects other than the patient trays. She explained staff should perform hand hygiene before putting on gloves and after taking their gloves off. The ICN reported staff should change gloves and perform hand hygiene if they touched a patient or object other than a patient tray. She stated a patient’s catheter bedside drainage bag should never lie directly on the floor without a barrier or dignity bag, as that would be an infection control concern for bacteria to enter the catheter. The ICN said she did not typically observe staffs’ handwashing techniques, but did receive reports from the nursing supervisors who performed those observations. She further stated it was her expectation for a nurse or licensed personnel to observe the PSAs passing patients’ meal trays and intervene if proper hand hygiene was not performed. During an interview on 05/07/2026 at 3:23 PM, the Director of Nursing (DON) stated staff should perform hand hygiene prior to putting on gloves. She further stated staff should be wearing gloves when passing trays and should perform hand hygiene once the gloves were removed. During an interview, on 05/07/2026 at 3:38 PM, the Nursing Supervisor stated she typically “rounded” on her units two to three times per day. She reported she observed staff performing hand hygiene during her rounds and completed a report that she gave to the Infection Preventionist quarterly. The Nursing Supervisor further stated she observed to ensure staff were wearing gloves when passing patients’ meal trays or snacks. During an interview, on 05/07/2026 at 3:57 PM, the Assistant DON (ADON) stated one of her duties was to work as a Performance Improvement Nurse and gather weekly data regarding staff performing appropriate hand hygiene and wearing gloves while passing trays. She further stated the facility failed to identify any concerns with Infection Control.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 47852 Based on observation, interview, record review, and review of facility policy, the facility failed to ensure an adequate number of staff to provide the nursing care necessary under each patient’s active treatment program. The findings include: Review of the facility policy titled, “Prevention and Management of Ingestion of Non-Nutritive or Harmful Items (Pica and Related Behaviors,” effective September 2025, revealed the policy was intended to protect patients from harm associated with ingestion of non-nutritive or harmful items as well as support an environment of safety through proactive prevention and risk reduction strategies. Per policy review, prevention strategies included removal of high-risk items from patient care areas. Continued review revealed items such as writing utensils, screws, nuts, bolts, batteries, pebbles, and small rocks should only be accessible in areas where active staff supervision was occurring and must never be left in unmonitored or unsupervised spaces. Further review revealed any staff member who observed or suspected ingestion of a non-food item by a patient was to immediately notify the unit Registered Nurse (RN), and an incident report must be completed in accordance with the facility policy. Review of the facility policy titled, “Incident Investigation,” effective May 1997, revealed all employees discovering an incident were to initiate an incident report at the time of the discovery via the electronic medical record (EMR) system or a paper incident report that would be forwarded to the Nursing Coordinator. Further review revealed the Nursing Coordinator would then forward the incident report to Risk Management during morning report on the next business day. Review of the facility policy titled, “24-hour Patient Monitoring,” effective September 1997, revealed patient safety and health was to be maintained by the provision of 24-hour nursing supervision. Per policy review, staff were to observe the environment where care and treatment were being provided. Review of the facility policy titled, “1:1 Supervision,” effective September 1997, revealed patients placed on one to one (1:1) supervision were to be monitored constantly to ensure they received care in a safe setting and to protect vulnerable patients. Per review, staff assigned to monitor a patient (1:1) “must” remain within approximately three feet of the patient unless the order specified otherwise. Continued review revealed staff assigned to monitor a patient “must” be able to view the patient at all times, and conduct himself/herself in a manner that assured the patient’s safety at all times. Further review revealed if the patient was placed on 1:1 supervision for potential for harm to self or others, the staff assigned to monitor the patient “must” be able to see the patient’s head, hands, and neck at all times. Review of P1’s Face Sheet revealed the facility admitted the patient on 01/14/2026, with a diagnosis of bipolar disorder. Review of the facility’s Risk Management forms for the past three months revealed P1 had swallowed foreign objects on 02/14/2026, 03/14/2026, 04/09/2026, and 05/02/2026, and had an unsuccessful attempt on 04/27/2026. Review of the facility’s Event Information for P1 revealed on 04/21/2026 at 3:57 PM, staff noticed P1 put her hand up to her mouth and start making a gagging sound. Per review, staff asked P1 if she had put something into her mouth, and the patient initially stated no and asked for something to drink. Continued review revealed staff again asked her if she had swallowed anything and P1 stated she swallowed a screw which she got out of the phone box while making a call. Additionally, review revealed the physician was notified with a new order for a kidney, ureter, and bladder x-ray and “notifications” were made per policy. Review of the facility’s 04/21/2026, Increased Level of Supervision Documentation, for P1 revealed the patient received 2:1 supervision. Continued review revealed P1 was charted as following directions at 3:45 PM, and “assessed/relinquished” and interacted calmly with others at 4:00 PM. Review of a witness statement form, signed 05/01/2026, by Patient Support Associate (PSA) 1, revealed she had been standing in the doorway at the time P1 made a phone call (on 04/21/2026). Per review, PSA 1 noted she saw staff at the desk dial the phone number for P1 then start talking with other staff. Continued review revealed PSA 1 documented she then stepped into the hallway and P1 asked her for a cup of water and PSA 1 asked the patient what she had swallowed. Further review revealed PSA 1 documented P1 told her (P1) she got a screw out of the phone box and PSA 1 then walked with P1 to the desk to notify the Registered Nurse (RN). In addition, review revealed PSA 1 noted the 2:1 staff were not P1’s “regular” staff. Review of a witness statement form, signed 04/30/2026 by PSA 15, revealed she had been working at the desk at the time P1 made a phone call to her guardian (on 04/21/2026). Per review, PSA 15 noted P1 said she was grabbing a phone number out of the phone box and her hands looked empty when they came out of the box. Continued review revealed PSA 15 documented dialing the phone number for P1 and then went back to doing her paperwork. Further review revealed the PSA noted the staff providing 2:1 supervision of P1 had eyes on the patient at all times. In addition, PSA 15 documented about 15-20 minutes later P1 came back to the desk asking for water and PSA 1 asked the patient if she had swallowed anything to which P1 said she swallowed a nail she got from the phone box. Review of a witness statement form, signed 04/30/2026 by PSA 16, revealed she had been providing 2:1 service for P1 on 04/21/2026 when P1 swallowed a screw. Further review revealed P1 made a phone call, reached into the phone box and pulled out a piece of paper and the screw might have been under the paper. Continued review revealed P1 got a cup of water and went back to her seat, drank some water, then stuck her hand in her mouth. Additionally, PSA 16 asked P1 if she was okay as she thought P1 was gagging herself and P1 stated she was and was going to get more water. PSA 1 then asked P1 if she was okay and P1 stated she swallowed a screw. Review of a witness statement form, signed 05/01/2026 by PSA 14, revealed he noted he had been providing 2:1 supervision for P1 (on 04/21/2026), when he saw the patient reach into the phone box when she was making a phone call. Continued review revealed PSA 14 documented P1 then got some water and put her other hand up to her mouth, but he did not see anything in the patient’s hand. Further review revealed PSA 14 noted another staff member then asked P1 what she had done and the patient said she had swallowed a screw. Review of an email from Registered Nurse (RN) 6, dated 05/02/2026, revealed the RN had not seen P1 swallow the screw (on 04/21/2026); however, had been behind the desk at the time that incident occurred. Per review, RN 1 noted P1 had 2:1 PSA supervision, when she made a phone call, then walked to the water fountain. Continued review revealed another staff member asked P1 if she had put something into her mouth, as the patient put her hands to her mouth and gagged, and then asked for a drink. Further review revealed RN 6 noted another staff member got P1 to admit she swallowed a screw which the patient said she got out of the phone box. Additional review revealed RN 6 notified the physician and received an order for an x-ray the following day. Review of the x-ray report of P1’s abdominal x-ray, dated 04/22/2026, revealed a foreign body was in the patient’s right mid abdomen area. Review of the facility’s video recording, on 05/08/2026 at 9:46 AM, revealed P1 walking in the hallway with assistance of two staff members (PSA 14 and PSA 16), then going to make a phone call. Per continued review of the video, P1 sat in a chair beside the desk and made a phone call. Continued review revealed PSA 14 and PSA 16 standing in front of the desk talking with PSA 15 while P1 was talking on the phone. Further review of the video revealed P1 reaching into the phone box twice during the phone call, and PSA 14 and PSA 16 looking away from the patient at different times while she was on the phone. In addition, the video reviewed had not been dated; however, was identified by Risk Manager (RM) 1, during the review of the video, as being on 04/21/2026. During an interview on 05/05/2026 at 11:38 AM, P1 stated she swallowed items as she made impulsive decisions. The patient further stated she always had two staff members with her currently. During an interview on 05/06/2026 at 10:26 AM, PSA 6 stated P1 required the supervisor of two staff members now because she had multiple episodes of swallowing non-food items. He said P1 became “jealous and upset” when another patient was getting discharged or receiving something new, and her behavior would escalate. PSA 6 reported staff were to dial the phone for P1 and not allow her to sit in the chair by the telephone with the telephone box open. Additionally, he stated P1 looked for any opportunity she could, to find a non-food item to swallow. During an interview on 05/06/2026 at 11:35 AM, PSA 7 stated P1 had to receive paper utensils secondary to swallowing part of plastic silverware in the past. He further stated he was not present when P1 swallowed the screw, but did know she looked for opportunities to get items to swallow. During an interview on 05/07/2026 at 3:23 PM, the Director of Nursing (DON) stated staff should provide the appropriate supervision of patients. The DON further stated when staff were providing 1:1 or 2:1 supervision, they should be able to see the patient at all times. During an interview on 05/07/2026 at 3:38 PM, the Nursing Supervisor stated she had been made aware when P1 swallowed the screw (on 04/21/2026) and told the nurse to “make the appropriate notifications.” She reported there had been some miscommunications about who to make the appropriate notifications to, and Risk Management had not been notified of the incident involving P1, at the time it was discovered. She further stated she expected staff to visualize patients at all times if they were to be providing 1:1 or 2:1 supervision of a patient. Telephonic (Phone) attempts were made on 05/05/2026 at 4:20 PM and 05/06/2026 at 10:18 AM, to speak with P1’s State Guardian; however, were unsuccessful. In a phone call on 05/06/2026 at 10:18 AM, the State Guardianship office staff said P1’s Guardian was on vacation, and a supervisor would call the State Survey Agency (SSA) Surveyor; however, no such phone call was received prior to the SSA’s exit.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 52041 1. Based on observation, interview, record review, and review of the facility’s policies, the facility failed to ensure patients were provided care in a safe setting for one (1) out of six sampled patients (Patient (P)3). Observations on 04/29/2026 at 10:55 AM on unit 56 G, room 6, revealed a staff member sitting on 1:1 with P3 and was not monitoring the patient per the facility’s policy. The findings include: Review of the facility’s policy titled “1:1 Supervision”, revised May 2025, revealed that staff assigned to monitor the patient must be able to view the patient at all times and conduct his/herself in a manner that assures patient safety at all times. Review of the “Facesheet” revealed that P3 was a 74-year-old male and the facility admitted him on 08/24/2025 on an involuntary commitment. Patient (P)3’s admitting diagnosis was principal unspecified bipolar disorder and related disorder. Review of the “Physician Orders” for P3, revealed an order for 1:1 supervision was placed on 03/30/2026 due to falls, leaning over in wheelchair, and choking hazard. Observations on unit 56G in room 6 on 04/29/2026 at 10:55 AM, revealed a double occupancy room where two patients resided in the room and with P3 in bed B. Further observation upon walking into the room revealed P3 to be on 1:1 supervision and staff member sitting sideways in a chair with her feet up, looking at her cell phone, not monitoring the patient. During an interview with RN2 on 04/29/2026 at 11:00 AM, she stated that she usually walked through and checked on everybody and checked on the 1:1 staff every hour to make sure sitters are not sleeping and doing what they are supposed to be doing. She stated that P3 was intellectually disabled and at risk for falls. She stated that he was on 1:1 supervision to keep him from falling and to keep him from touching and feeling on his peers. She stated that he can make his needs known and can tell you if he was thirsty or hungry. During an interview with PSA14 on 04/29/2026 at 1:46 PM, she stated that she was sitting with P3 today (04/29/2026) when state surveyors walked in. She stated that P3 is on 1:1 supervision for fall risk. She stated that she had just been sitting with him for an hour. She stated that she was on her cell phone at that time and she should have been watching him. She stated that the policy stated that staff are a required to make sure they always have eye contact on a patient at all times to make sure they do not harm themselves or anyone else in any way. She stated that some negative outcomes could be the patient could hurt himself or herself, falling, or harming staff or other patients. During an interview with PSA15 on 04/29/2026 at 2:30 PM, she stated that she had worked here for almost a year. She stated that she typically worked in the BA unit. She stated that when a patient was on 1:1, you have to be able to see their hands, face, and neck. She stated that staff are not allowed to be on their phone in patient rooms or on the hall. She stated that if staff needed to use their phones, they needed to step off the floor. She stated that a negative outcome of the 1:1 staff member being on their phone and not watching the patient was that the patient could fall because they were not paying attention. During an interview with LPN1 on 04/29/2026 at 3:00 PM, she stated that she had worked here for almost a year. She stated that she normally did not work on unit 56G, she normally worked on 603-583. She stated that she had been pulled a couple of times down there to work in the area. She stated that she was familiar with the 1:1 supervision policy and she knew that the staff sitting with the patient was to have eyes on the patient the whole time and their head, hands, and neck are supposed to be visible. She stated that it did not matter why they were on a 1:1, whether it be self-harm or fall risk, the policy should be followed. She stated that some negative outcomes that could happen if the patient was not supervised appropriately were that the patient could fall, he could hurt himself badly, especially elderly patients, and just about anything can happen. During an interview with the Assistant Director of Nursing (ADON) on 04/30/2026 at 10:58 AM, she stated that she expected the staff member to know why the patient was on 1:1, monitor the patient constantly, not be on their cell phone or read a book. She stated that their focus should be solely on the patient and within three feet of the patient unless the doctor’s orders were written otherwise. She stated that training for 1:1 was provided PRN when incidents occured, can occur individually, and annually during a skills fair. During an interview with the facility’s director on 04/30/2026 at 11:18 AM, she stated that she expected staff to consistently monitor the patient, and follow policy, ensuring patient safety. Not properly monitoring patients on 1:1 was putting the patient at risk for a multitude of possibilities. 2. Based on observation, interview, record review, and review of the facility’s policies, the facility failed to ensure patients were provided care in a safe setting related to physical environment hazards. Observations in the corridor area outside of unit 582 revealed the tile floor in disrepair. The findings include: Review of the facility’s policy titled “Safety of WSH Residents and Staff”, reviewed April 2019, revealed it was the facility’s policy to maintain a work environment free from recognized hazards that are causing or are likely to cause death or serious physical harm to residents or employees. Observations in the corridor area between unit 582 and 602 on 04/29/2026 at 10:45 AM, revealed the tile floor in disrepair with multiple areas of the floor missing tile and containing loose and crumbled tile. Review of a “Maintenance Work Order”, dated 01/15/2026, revealed the facility’s safety coordinator submitted a work order due to the floor coming apart and screw head sticking up in the hallway outside of unit 582. Review of the facility’s document titled “State Employee’s Report of Injury or Incident”, dated 03/24/2026, revealed Investigator 2 filled out an incident report due to tripping twice on the floor outside of unit 582. Review of email communication between the Director of Risk Management and the maintenance department, dated 03/15/2023, 09/15/2025, and 04/16/2026, revealed the maintenance department was notified by risk management three times about the condition of the floors being a safety concern. Review of “Nurse Notes” for P6, dated 04/15/2026, revealed that the patient was gagging and throwing up and a piece of floor tile was noted to have come out of her mouth. Further review of the note revealed that the patient was unable to swallow it and no injuries were noted. During an interview with Investigator 4 on 04/29/2026 at 10:46 AM, she stated that this tile had been missing/broken and work orders had been placed for maintenance to repair. She stated that someone could easily trip over it and that patients walked through the corridor to get to other places in the hospital or transported to outside appointments. During an interview with the Director of Maintenance on 04/29/2026 at 1:25 PM he stated that he was aware of the issues with the flooring on the second floor. He stated that the third floor was also in disrepair, but not as severe. He stated that he recalled receiving work orders and emails from staff and the director of risk management. He stated that the delay in repair was the skill set of their department and the commonwealth prioritizing work that needed to be done. He stated that the money for these repairs would be coming from a state level maintenance pool. He stated that they have obtained quotes and now it is just a waiting game. He stated that most contractors do not want to take the job because it is going to be a difficult job. He stated that he suspected that the issue with the previous work done on the floor was the contractors used self-leveling grout that had failed. He stated that due to being a high traffic area it got worse. He stated that the tile was not harmful or toxic. He stated that they had a plan of correction made and now it was just a waiting game, but they planned to put down plate steel and tile over it to still have clearance for the doors to open. He stated that he did not know when the plan of correction will be started, that it was out of his hands. He stated that it is in Frankfort’s hands as to when it would be repaired. He stated that a negative outcome of not having the floor repaired was that it is a tripping hazard. During an interview with the director of risk management on 04/29/2026 at 2:00 PM, he stated that the flooring materials on the second floor were bad and a hazard to employees and patients. He stated that he had notified maintenance several times about it and they are aware. He stated that some of the tiles are loose and crumbling, and it was possible that a patient could get access to those pieces and harm themselves. During an interview with the facility’s director on 04/30/2026 at 11:18 AM, she stated that they had been putting in work orders with maintenance and environmental services to keep the area of the building free of debris and ensure the patients are able to travel safely through the building in those areas. She stated she expected staff to appropriately monitor and transport patients.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47567 Based on observations, interviews, record review, and review of facility policy, it was determined that the facility failed to ensure the protection from physical abuse and harassment for one (1) out of ten (10) patients, (Patient (P)1). Observation of a security surveillance video recorded 10/04/2025, time unknown, revealed Patient 1 (P1) lying on the floor in a main corridor being kicked in the upper right leg by (PSA)6. Further review of the surveillance video revealed PSA6 returned to the unit without a staff member or security escort on two additional occasions that same day after being escorted off the unit once the allegations of the incident were reported. The findings include: Observation of a security surveillance video dated 10/04/2025 no time stamp recorded, showed a video for a total of 39:00 minutes over the unit’s main hallway. The video revealed Patient 1 (P1) lying on the floor and being kicked in the upper right leg by (PSA)6. Further review of the surveillance video revealed PSA6 returned to the unit without a staff member or security escort on two additional occasions, the first time approximately five (5) minutes after being removed from the unit and the second time approximately fifiteen (15) minutes after being escorted off the unit once the allegations of the incident were reported. Review of a facility policy titled, “Patient Rights and Responsibilities”, revised 08/2025, revealed the facility will inform patients or their representatives of their rights in advance of furnishing or discontinuing patient care whenever possible, these rights include but are not limited to the patient’s right to be free from abuse and harassment. Review of a facility policy titled, “Reporting Patient Abuse, Neglect, and Exploitation”, reviewed 04/2021, revealed each facility employee is expected to be aware of the facility’s responsibility to the patients served and to be constant in efforts to safeguard their well-being. Further review of the policy revealed staff should intervene immediately to ensure patient safety and the alledged employee shall be removed from direct patient care pending the outcome of the facility’s internal investigation. Review of a facility policy titled, “Incident Investigations”, revised 11/2020, revealed all employees alledged to have committed an incident involving allegations of abuse, neglect, or other serious occurrences or events with potential to cause harm will be moved immediately to a non-direct care position for the duration of the investigation. A staff member will accompany the employee alledged to have committed these incidents to the employee’s supervisor’s office, and if the employee is not immediately cleared or immediately assigned to work in a non-direct care area they will be escorted from the facility by security staff or a nursing supervisor/coordinator. The policy further stated any staff member that has been pulled from direct care due to an incident allegation will not be allowed in any patient care area for any reason until notified by his or her supervisor. The supervisor will ensure the facility director or designee has been notified that the employee has been pulled from direct patient care. If the employee enters a patient care area while pulled from direct care the unit nurse will immediately contact security to escort the employee off the unit, the nusring coordinator and risk management will be notified, and the employee will be subject to the appropriate disciplinary action. Review of a facility document titled, “Incident Report”, dated 10/04/2025 at 6:41 AM, revealed a staff member reported that PSA6 was observed kicking Patient 1 in the leg once while patient was sitting in floor. Further review of the incident report revealed PSA6 was removed from care and P1 was assessed by nursing and determined to have no injuries and denied any pain at that time. Review of a facility document titled, “Final Expanded Investigative Report”, provided to the State Survey Agency (SSA) on 10/10/2025 revealed the facilty substantiated the allegation of abuse committed by PSA 6. Review of facility document titled “Facesheet” revealed (Patient (P) 1) admitted to the facility on 08/24/2025 with diagnoses that included Major Neurocognitive Disorder, Bipolar Disorder, and Intellectual Disorder. In an interview with Patient Support Associate (PSA) 3 on 10/08/2025 at 3:20PM, she stated she was on the unit at the time but did not visually witness the incident. She stated that she was with another patient doing 1:1 observation. She further stated PSA 6 “forgot something” on the unit after he had been removed from care due to the incident allegation so he came back through the unit without an escort to retreive the items and he stated to her and another staff member sitting at the desk that the Shift Coordinator said for him “not to worry about it”. In an interview with Patient Support Associate (PSA) 1 on 10/10/2025 at 1:00 PM, she stated she has been employed at the facility since 08/11/2025. She stated on Saturday around breakfast, staff had passed out breakfast trays and P1 came and sat down in the wrong spot at a table where someone else’s breakfast had been placed. She stated she told P1 that he needed to go and sit somewhere else because that was someone else’s spot, but he did not comply. She stated PSA6 then came over to them and started to yell at P1 to get up and proceeded to grab P1 up by his shoulder and P1 was beginning to fall from the chair. PSA1 stated PSA6 continued to push P1 down towards the floor. She stated P1 and PSA6 continued to go back and forth with each other and that is when she saw PSA6 “kick” P1 in his right leg in an area above the knee. She stated P1 was screaming “abuse” and that he was “going to tell on” PSA6. PSA 1 stated before the patient had the opportunity to tell anyone she went to the office and reported the incident to the nurse on duty. She stated the nurse called the shift coordinator right away she stated she told him to go into office and PSA6 asked “for what”, and as he was asking this, the nurse on unit was coming around the corner she told him to “ask her, (PSA 1) what was going on because she was the one that said something.” She stated this statement was made in front of other staff members, the alleged perpatrator, and shift coordinator. PSA1 stated this situation made her feel very uncomfortable because the nurse just let everyone know who made the report. She stated PSA6 started to ask her “what did he do”, she stated she did not respond. PSA 1 stated at that time the coordinator had told PSA6 to leave the unit. She stated after he left the unit he returned to the unit and would walk close towards where she was sitting 1:1 with the patient that he was originally assigned to because she took over his assignment once he was removed from the floor. PSA1 stated each time when PSA 6 returned to the unit he would walk close towards where she was sitting 1:1 with the patient, and give her “dirty looks” as form of intimidation, and that he was talking to the other co-workers about the event from what she could gather. PSA 1 stated that she was afraid at first because he was coming back and forth to the unit after being escorted off that she may not be able to continue working here but stated she was assured by the risk management that he would not be allowed to come back anymore. PSA 1 stated she has worked with PSA 6 a couple times before and that PSA6 always has a negative attitude when it comes to working and is very negative towards the patients. She stated when she got off work that she went upstairs to make her report and tell someone about what happened but the night shift coordinators had already left for the day and there was no one up there to take her report. She stated she asked the day shift coordinator and he told her they were gone. She stated at first she was really concerned and she thought about quitting her job behind him being able to get back on the unit because that made her feel uncomfortable because if he had no problem doing what he did to a patient she felt like no telling what he would do to her. She stated she was the one who had to call Risk Management, and notify them of the patient returning to the unit as well. In an interview with Patient Support Associate (PSA) 6 on 10/10/2025 at 12:53 PM, he stated around 5:30-6:00AM, he observed P1 trying to take another patient ’ s food where he had sat down at the table at a tray that he had mistaken for his own. He stated he had been informed for the past week the patient had been getting on floor as a behavior. He stated while P1 was on the floor he tried to grab a banana off the tray. PSA 6 stated he went and scooted the tray all the way over out of the patient’s reach and that is when P1 tried to “kick” at him and PSA1 stated he “blocked” the kick with his leg. PSA 6 stated in an effort to stop his leg the second time, PSA 6 lifted up his leg to meet his leg with P1’s leg and stated no pressure was involved or anything. He stated after that he went back to the desk and sat down and the nurse came out and told him to stay in the office, but he was on a 1:1 and because of that he stood in the doorway to watch that patient. PSA 6 stated the TPCA came up to the unit and asked him did he have any personal belongings and he got his things went to the coordinators office and made a “pink slip” (leave form) and that is when she stated that he was being pulled from care and that he would be escorted out of the building. PSA 6 stated that the Shift Coordinator did not state who would be escorting him out. He stated he sat there for a while outside the shift coodinator ’ s office for about 30 minutes and watched the TPCA and the Shift Coordinator for nights both leave at the end of their shift. He stated that he got tired of sitting there so he asked the dayshift coordinator if he could go home and he said “yes he could go ahead and leave” so he left. PSA 6 stated that he did go back up to the unit after he was pulled from care because he had forgot his “juice” and wanted to go retrieve it. He stated that he was not told that he had officially been pulled yet they just told him to go sit outside her office door for a second while they went in the office and talked. PSA 6 stated he was notified on Tuesday that his contract had been terminated. In a telephone interview with Registered Nurse (RN) 1 on 10/08/2025 at 4:05 PM, she stated the incident was reported to her by PSA 1, who was the employee that actually observed the incident and she stated that her report was based off the information reported to her and she reported it to her supervisor and pulled PSA6 from the floor. She stated PSA 1 came into the office and told her that P1 had gotten kicked by PSA 6. She stated that she didn’ t hear any commotion of any kind before or after the incident and was not aware of anything until PSA 1 came to her and reported it. She stated she told him that he needed to go and sit in the office and wait for her and PSA 6 stated “ok”. RN 1 stated she went to go put some things in the medication room and by the time she came out the TPCA had showed up and was taking PSA 6 off the unit. She stated at that time the staff member was asking why he was being removed and what did he do, but the events were happening so fast she did not have time to explain to him why and that the shift coordinator was going to explain it to him. She stated she did not see or hear him return to the unit, but was told that he did indeed return to the unit when she went to provide her witness statement to Risk Management. RN 1 stated staff is not to return to the unit after they have been removed due to an abuse allegation. She stated there shouldn’ t have been any reason for PSA 6 to come back to that unit. She stated if there was something that he had forgotten someone else could have retrieved the items for him. She stated she is not aware of any other incidents with the staff member and other patients stated that this unit was not her usual assignment and that she had only worked with this crew twice since she has worked at the facility. In an interview with the Therapeutic Program Coordinator Assistant (TPCA) on 10/08/2025 at 5:15 PM, she stated that she recalled that morning of the incident, after around 6:00 AM she was asked by the shift coordinator to go retrieve a staff member and bring him down to her office. She stated the staff member went in to the shift coordinator ‘s office and she waited outside and they came out and the shift coordinator asked her to escort him out of the building. She stated she cannot recall what time she was asked to do this but she remembered leaving work for the day at 6:30AM. She stated that when she left PSA6 was sitting in the chair outside of the shift coordinator’s office which was located in an area where everyone signs out for the day. She stated she thought he was waiting for a ride home. The TPCA stated she normally would be the person to walk them (staff) out and watch them leave and go out the door. She further stated was unaware that PSA6 had returned to the unit after being pulled from direct care. She stated she left him in the care of the shift coordinator before she went home and that PSA6 knew he was not to return to the floor after being pulled from care. She stated PSA6 was just pulled from care a week ago and had just returned to the floor that very day he was pulled from care again. In an interview with the Shift Coordinator on 10/08/2025 at 2:50 PM she stated the unit nurse called her that morning and stated a staff member informed her that PSA 6 had kicked P1. She stated she then called the Risk Management staff on-call that day and reported the incident to him. She stated she then had the TPCA go to the unit and escort PSA 6 to her office so that she could go over the “pull” paperwork with him. The Shift Coordinator stated at this time PSA 6 was informed that he was not to be in any patient care areas, and that if he wanted to get his hours in that he could use time off or work in another part of the facility away from patients and that someone from management will be getting in touch with him. She stated the TPCA escorted him off the property after that. The Shift Coordiantor stated that she was not informed that PSA 6 went back down to the unit after being pulled from care, and that it is not normal protocol for them to be on a unit after being pulled from care. She stated there is no way she can actually check and verify if anyone leaves. She stated they walk the staff out but she has no way of actually knowing if the staff truly leave the facility or not. She stated that they don ’ t take their badges or anything just in case the staff member decides they want to work another department while the investigation is being conducted. In an interview with the Security Supervisor on 10/10/2025 at 9:20AM she stated the nursing coordinator is the one responsible for escorting the staff member out the door, and the only time they call them is if the staff member is giving them a hard time about not leaving. She stated that they will request a couple security guards to come and help them with escorting the person out then, but in this case it is up to nursing to ensure that they are off the property and they let them know that particular person is not allowed back on the property. In an interview with Investigator 2 on 10/09/2025 at 2:55PM he stated that he initiated the investigation that Saturday morning. He stated he received a phone call from either the shift coordinator or the nurse from the unit the incident occurred on reporting what happened. He stated she stated to him that another staff member witnessed PSA6 kick a patient. He stated that he asked the nurse to go and assess the patient and asked them what happened and he stated that he never got a return phone call from her. He stated he called the shift coordinator that was on shift later that morning and he stated that he asked him to go and see the patient and do an assessment and check and see how he was. He stated that he followed up with him and the patient did not have any injuries. He stated that later on that morning he received a phone call around 9:00 AM from PSA 1 who had reported the incident and she stated that she was concerned about PSA 6 being able to return to the unit after he was removed and he stated that he reassured her that PSA 6 would not be returning to that unit, and that he requested she write a statement of what happened. He stated he turned over the investigation to Investigator 3 to complete. He also stated that under no circumstances should PSA 6 have been able to come back into any patient care area after being pulled from a care area and that he should have had a staff member with him and escorted off the property right away. He stated that he sent an email to the Nursing Department staff about the staff member returning to the unit when he learned of the incident. In an interview with Investigator 3 on 10/08/2025 at 6:45 PM she stated Investigator 2 initiated the investigation on Saturday as he was the on-call risk management staff for that weekend and she took it over on Monday when she returned to work. She stated she attempted to interview Patient 1 but due to his intellectual abilities he was not able to be interviewed. Investigator 3 stated that she notified Patient 1’s Social Worker and he stated to her that he would contact the guardian. She stated she spoke with PSA 6 over the telephone and he denied the allegations made against him. Investigator 3 stated that she asked PSA 6 to provide her with a written statement but he never did. She further stated that the Risk Mangement Department addressed their concerns of PSA 6 returning to the direct care areas with the Nursing Department but they don’t always provide them with an update on the corrective measure they take. She stated Risk Management will make recommendations and request for the identified problem’s solution when warranted. In an interview with the Director of Nursing (DON) on 10/10/2025 at 9:24 AM, She stated her expectations from nursing staff would be to ensure that patients are safe from abuse and harm and staff pulled from care after an allegation was escorted off the unit and no longer on facility grounds. She stated PSA 6 was terminated on 10/07/2025, the date that the investigation was officially substantiated. She stated that she did not know that PSA 6 had returned to the unit after he had been pulled from care. She stated they will have to meet with Risk Management, and the Facility Director to address possible policy changes about pulling the badge and keys of a staff member under investigation so that they are not able get around the building freely. In an interview with the Facility Director on 10/10/2025 at 2:28 PM, she stated she gets an email as soon as a staff gets pulled from direct care. She stated Risk Management is still working on their investigation because she has not received a final copy to sign. Stated her expectations for any staff and not just nursing would be for them to make sure the patient is safe from any harm.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 49350 Based on record review, facility policy review, and interview it was determined the facility failed to provide treatment plan interventions related to a daily discussion of skin care status for one of nine patients (Patient #5). Patient #5 developed skin breakdown of the buttocks and right foot and was transferred to a local hospital for amputation of the right fifth toe. The facility failed to conduct the treatment plan interventions related to skin care and failed to provide appropriate nursing services to address the skin care issues for Patient #5. The findings included: Review of Patient #5 (P5)’s medical record indicated a last admission date of 02/23/2024 with diagnoses of Schizophrenia, Hypertension, and Hypothyroidism. Review of an admission assessment performed by MD #9 on 02/26/2024 (time unavailable) indicated that the patient was alert, knew place, and person but did not know time. Review of RN #4’s Progress Note dated 01/03/2024, indicated that Patient #5 reported that his foot was swollen. RN #4 assessed Patient #5’s foot and noted the top of the right foot was swollen, red, and hot to touch. The swelling was through the entirety of the right foot and up the calf. Upon further assessment, it was noted that Patient #5 had approximately a half-dollar size wound on the bottom of his right foot under the big toe. Patient #5 was then asked by RN #4 if he had any other sores and he reported he had a spot above his bottom. Patient #5 was noted to have a wound approximately half-dollar size on the left buttock and pinhole-size scabbed area on the right buttock. Review of RN #4’s Wound Assessment dated 01/03/2024 at 1:12 PM, indicated comprehensive measurements for right foot and buttocks were assessed by the RN, measured, and dressings applied per ARNP wound care orders. RN #4’s wound assessments indicated a right foot plantar wound measured approximately 2 cm wide and 1 ½ cm long. Additionally, the wound assessment indicated a left buttock wound measured approximately 3 cm wide and 2 cm long. Review of a post-operative hospital note dated 01/05/2024 at 11:25 AM, from MD #20 confirmed that Patient #5 had the right fifth toe amputated. Review of RN #11’s Nursing Progress Note dated 01/08/2024 at 6:53 PM, indicated Patient #5 was diagnosed with (new) diabetes mellitus and diabetic ulcer and that Patient #5 was on antibiotics at the with a new order for an antibiotic. Review of MD #14’s Physician Progress Note dated 01/09/2024 (time unavailable) indicated that Patient #5 had a new diagnosis of diabetes and one of his toes amputated. Review of Patient #5’s Care Plan initiated on 02/28/20217 and in place during the time of the occurrence indicated that the patient had the problem of multiple psychiatric needs related to schizophrenia with stated goals of demonstrating ability to make his needs known. Accept limit setting and redirection and increase interactions with others. Interventions included nursing monitoring for flight of ideas, monitoring for mood changes, and provide educational activities. The care plan also stated to work with the patient to maintain his skin integrity, every day during 1:1 interactions, encourage to report and/or monitor for signs and symptoms of infection to affected areas. Review of the hospital’s policy entitled “Pressure Ulcers and Wound Care” dated January 2016, revealed that to prevent complications related to pressures ulcers and wounds, the facility would identify patients at risk, implement prevention strategies for patients at risk, and actively treat all identified pressure ulcers and wounds. The policy further revealed that if a braden score required it, weekly skin assessments would be completed on the patient. During an interview with RN #4 on 05/16/2024 at 11:45 AM, Patient #5 complained about his foot hurting, the night shift nurse went to look at it and the patient refused examination at that time until the following day. She stated that when she evaluated it, she recognized cellulitis. No complaints prior to that day about skin condition from the Patient #5. Stated that patient had ability to walk and did not appear to have any problems related to his feet when he would ambulate prior to this incident. RN #4 stated that the facility did not have any set policy or requirement to conduct skin assessments on patients routinely while they are at the facility unless they have some type of identified skin issue and she was not aware of the care plan requirement to discuss his skin integrity as listed in the care plan. She stated she was not aware of any type of daily skin check requirement, quarterly, or every six months, etc. that would be required by the facility to routinely check patient skin condition. She stated she believed she was the first and only person to discover the wounds on his body, on 01/03/2024 when the wounds were discovered. During an interview with RN #9 on 05/16/2024 at 1:55 PM, he stated that as a general skin assessments were not required daily on patients unless they had a known identified issue. He stated Patient #5 has known skin issues now and they were really following him close. He stated Patient #5 had a wound care appointment for his foot and had another one about two weeks ago. The wound on his foot was infected at this time and the wound would not drain during his wound care appointment. RN #9 stated Patient #5 was admitted to the hospital because the attempt to drain the wound on his foot was unsuccessful. He stated that for most part Patient #5 was compliant with his wound care orders and allowed them to do dressing changes. He stated Patient #5 was not on antibiotics at this time and during his last admission for this problem he was given antibiotics. He stated Patient #5’s buttocks area had healed and required no further care. During an interview with Advanced Practice Registered Nurse (APRN) #15 on 05/16/2024 at 2:30 PM, she stated she has been employed by the facility since 2014. She stated she had been providing care and had initiated the initial orders for wound care for the Patient #5 when his wounds were identified as a right foot plantar ulcer with cellulitis. She stated at that at that time she wanted him to be seen by wound care and when a wound culture was completed, he was placed on orders for Keflex 250mg orally 3 times a day. APRN #15 stated Patient #5 was sent to an outside wound care center for treatment and also had dressing changes at that time for the foot ulcer with daily changes. She stated with the buttocks, dressing orders were in place and required daily care to get “him by” until wound care facility treatments took place. The APRN stated that as a healthcare provider she completed annual skin assessments on the patients at the facility but did not know of any specifics as far as routine skin checks at the facility for patients who had no complaints and no known issues. During an interview with the Director of Nursing (DON) #17 on 05/16/2024 at 4:05 PM, she stated there was no requirement for skin assessment for an ambulatory patient. She stated because ambulatory patients had psych issues, “we” talk with them everyday and asked them if they were having any problems and unless they lead “us” to something that required a body audit, it was not something that we would do on a patient like Patient #5 unless something had been identified, then we would check that out. She stated the nurses should have been aware of what was in the treatment plan and they should have been following what the treatment plan said. DON #17 further stated if the treatment plan was not followed, the patient could develop other skin issues. She also stated that upon admission a complete assessment was done for all patients.”