Every finding on record at Bay Bluffs-Emmet County Medical Care Facility

Based on interview and record review, the facility failed to ensure training of no less than 12 hours per year was completed for five Certified Nurse Aide (CNA's) [B, J, K, L & M) of five CNA's reviewed for nurse aide training hours. Findings include:During an interview on 5/13/26 at 7:41 a.m., the Director of Nursing (DON) reported the 12-hours of training in a year is based on the CNA's hire date. The DON acknowledged the facility uses online training.Review of facility documents provided by the Nursing Home Administrator (NHA) revealed the following:CNA B was hired on 11/11/19 with 9.25 hours of training from 11/11/24-11/2/25CNA J was hired on 1/8/24 with 5.75 hours of training from 1/8/24-1/8/25.CNA K was hired on 11/6/22 with 7.25 hours of training from 11/6/24-11/7/25.CNA L was hired on 11/7/21 with 9.25 hours of training from 11/7/24-11/8/25.CNA M was hired on 10/13/08 with 10 hours of training from 10/13/24-10/31/25.During an interview on 5/13/26 at 9:45 a.m., the NHA reported the facility uses online training and presented the printouts of the online training for CNA'S ( B, J, K, L, and M) which verified the above total hours of training for each CNA.Review of policy titled In-Service Training Program, Nurse Aide last approved 7/14/25, read in part .All personnel are required to complete in-service training.annual in-services must:.be no less than 12 hours per employment year [based on hire date].address areas of weakness as determined by nurse aide performance reviews.[online training name] can be assigned in a group of courses or individual courses for employees.

Based on interview and record review, the facility failed to complete an annual performance review at least every 12 months for five Certified Nurse Aides (CNA's) [B, J, K, L, & M] of five CNA's reviewed for performance reviews. This deficient practice resulted in the potential for inadequate care and unmet resident care needs for all 68 residents residing in the facility.Findings include:Review of facility personnel records demonstrated the following:CNA B was hired on 11/11/19 with no performance review.CNA J was hired on 1/8/24 with no performance review.CNA K was hired on 11/6/22 with no performance review.CNA L was hired on 11/7/21 with no performance review.CNA M was hired on 10/13/08 with no performance review.During an interview on 5/13/26 at 8:42 a.m., when queried about staff performance reviews the Nursing Home Administrator (NHA) stated, We have not completed performance reviews of staff since prior to covid.if the staff have their competencies done and are still with us after going through covid that is good enough.Review of policy titled In-Service Training Program, Nurse Aide last approved 7/14/25, read in part .The facility will complete a performance review of nurse aides at least every 12 months. Inservice training will be based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews.

Based on observation, interview and record review, the facility failed toEnsure the use of Enhanced Barrier Precautions (EBP) and safe handling of an indwelling urinary catheter bag during transfers according to current infection control standards for one Resident (#70) of two residents reviewed for catheter care, and Follow through with their plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility. Findings include: On 5/11/2026 at 1:29 PM, two water fountains were observed on Lilac Lane with clear plastic bags wrapped around them and out of order signs posted above each fountain. During interview at this time with Maintenance Director (MD), X, he stated that both sets of water fountains have not been in use since Covid began in 2020. He stated that the facility had problems with employees dumping liquids into the sinks. He stated that the water to the fountains had been disconnected. When MD X pushed the button on the two fountains, water came out of the water nozzles. Record review of the facility flushing schedule revealed that the water fountains were not included in the flushing schedule. On 05/11/2026 at 3:18 PM the two water fountains on the Lilac Lane were observed to have been removed and a brown sludge was observed running down the walls from the plumbing openings. On 5/11/2026 at approximately 3:15 PM, two drinking fountain units were observed on a metal utility cart on Lilac Lane. A water pipeline was observed exiting the wall in a vacant space where a drinking fountain had just been uninstalled. A brown sludge-like substance appearing to be rust was observed in the bottom of the water pipeline. Resident #70 (R70) Review of the Minimum Data Set (MDS) assessment, dated 5/12/2026, revealed R70 was admitted to the facility on [DATE] and had diagnoses including urinary tract infection (UTI), neurogenic bladder, Parkinson's Disease, and dementia. Review of the electronic medical record (EMR) revealed R70 was hospitalized on [DATE] for urosepsis and returned to the facility on 4/06/2026 with an indwelling, urinary catheter in place. An observation on 5/13/2026 at 8:55 AM revealed a wheeled cart containing personal protective equipment (PPE), including protective gowns and gloves, positioned in the doorway of R70's room. Atop the cart was a Centers for Disease Control and Prevention (CDC) sign indicating the use of EBP (use of protective gown and gloves to prevent the transmission of multidrug-resistant organisms/MDROs) during care of R70. Review of the sign revealed the following: Providers and Staff must . Wear gloves and a gown for the following high-contact resident care activities: Dressing. Bathing/Showering. Transferring. Changing linens. Providing hygiene. Changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. On 5/13/2026 at 9:05 AM Certified Nursing Assistant (CNA) N and Registered Nurse (RN) O were observed providing wound care to R70. After completion, RN O removed the gown and gloves worn during wound care, performed hand hygiene, applied clean gloves but no protective gown. From the right side of the R70's bed, RN O assisted CNA N in turning the Resident side to side to position a lift sling for transfer, making direct contact with the Resident and soiled bed linens. Once the lift sling was in place, CNA N utilized the lift to raise R70 from the bed at which time RN O stated, Don't forget the catheter bag. CNA N was then observed to unhook the dependent drainage bag from the bed frame. CNA N held the drainage bag in her left hand as she reached up to grasp the arm of the lift to turn the resident to be seated in the wheelchair. It was noted the position of the dependent drainage bag was held approximately 12 inches above R70, until he was lowered to the wheelchair, at which time the bag was attached to the underside of the wheelchair seat. During the transfer, RN O was observed standing behind the wheelchair to guide R70 while he was lowered into the chair. RN O and CNA N then both worked to remove the lift sling from under R70. RN O did not don a protective gown at any time during the transfer of R70. During an interview immediately following the transfer, RN O was queried regarding the indication for the use of EBP. RN O stated EBP was to be utilized, Any time there is exposure to the wound or when handling the catheter. RN O reported EBP was not indicated during the transfer of R70 from the bed to the wheelchair. When queried regarding the position of R70's urinary catheter drainage bag during the transfer she stated the position of the bag should be always held below the level of the bladder. During an interview on 5/13/2026 at 9:35 AM, CNA N was asked if she was aware of the need to ensure urinary catheter bags were held below the position of the resident during transfers. CNA N reported she was aware of the need and stated, But he [R70] is hard to maneuver due to his pain. Review of R70's April 2026 Medication Administration Record (MAR) revealed the following undated order: Enhanced barrier precautions r/t [related to] foley catheter. Review of R70's comprehensive care plan revealed the following: I have an indwelling medical device. I am at risk for acquiring a MDRO . Use enhanced barrier precautions (EBP) with me during prolong closed [sic] contact during personal cares, such as: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting. Date Initiated: 4/07/2026. Review of the facility policy titled, Appropriate Use of Indwelling Catheter, Last revised 3/21/2025, revealed the following: Additional care practices include . securement of the catheter to facilitate flow of urine, prevent kinks in the tubing and positioning below the level of the bladder . Review of the facility policy titled, Enhanced Barrier Precautions Policy, last revised 3/24/2025, revealed the following: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact care activities include: . Transferring .

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 05/12/2026 at 7:57 AM observed the kitchen hand sink was slow to drain after washing hands. The Certified Dietary manager (DM) stated that it has been draining slow for a while now and a new hand sink is being installed as soon as maintenance can get to it. According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. On 05/12/2026 at 8:07 AM observed ice condensation buildup on the ceiling and fan cover of the walk-in freezer. The compressor fan was running, and the fan blades were heard hitting the chunk of ice condensation that was frozen into the fan cover.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 05/12/2026 at 8:12 AM observed the in-line water filter for the ice machine with a discharge line extending directly down into the floor drain, without an air gap present.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. P

Based on interview and record review, the facility failed to provide information of pending changes in Medicare coverage and the right to appeal this decision for one Resident (R81) of three residents reviewed for reception of a Notice of Medicare Non-coverage (NOMNC) form.Findings include:On 5/12/2026 at 9:30 AM, the Beneficiary Notice - Residents discharged within the Last Six Months worksheet was received from the facility with 14 residents listed as discharged . Three Residents were selected to determine if the facility provided timely NOMNC.During an interview on 5/12/2026 at 10:07 AM, Administrative Staff A stated she did not find a NOMNC for R81.During a follow up interview on 5/12/2026 at, Staff A confirmed, We looked high and low and do not have it.The facility policy titled Advance Beneficiary Notice dated as Last Revised 12/16/2025 read in part, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage.

Based on observation and interview, the facility failed to maintain general repair of one exterior door, resulting in the potential for pest entry. Findings Include: On 05/12/2026 at 10:00 AM observed the door sweep missing from the base of the maintenance door and approximately a half inch of daylight visible underneath. The exterior door sweep on the vendor entrance door was damaged and partially detached from the base. The Maintenance Director MD said that they do have occasional mice but felt those were getting in from the attic areas, and that pest traps were kept up there to prevent the pests from getting down into the facility.

Based on interview and record review, the facility failed to ensure the clinical record documented a medical condition justifying the continued use of an indwelling urinary catheter for one Resident (#8) of four residents reviewed for urinary catheters.Findings include:Resident #8 (R8)On 5/11/26 at 12:04 PM, R8 was observed with catheter tubing extending from under a blanket. The catheter tubing was draining light yellow urine with sediment. When asked the reason for the urinary catheter, R8 said he did not know the reason for the catheter. R8 moved freely in the bed without signs or symptoms of pain or discomfort.Review of the clinical record revealed R8 was transferred to the hospital on 3/16/26 without a urinary catheter and returned to the facility with a urinary catheter on 3/23/26.A Minimum Data Set (MDS) assessment dated [DATE], prior to the hospitalization of R8, did not document the use of an indwelling urinary catheter. The MDS coded R8 as always continent of bowel and bladder.Review of the most recent MDS with an assessment reference date of 3/31/26 indicated R8 utilized an indwelling urinary catheter; however, the assessment did not identify a qualifying medical condition supporting catheter use.Review of physician orders identified an order for urinary catheter changes, but the order did not include a diagnosis, clinical condition, or reason indicating the need for the catheter.A diagnosis of urinary retention was added to R8's list of diagnoses on 3/23/26 when R8 returned from the hospital, but review of Electronic Medical Record (EMR) including R8's comprehensive assessment, care plan, progress notes, physician documentation, and hospital records failed to identify a medical diagnosis or clinical condition indicative of the need for continued use of an indwelling urinary catheter.A progress note dated 5/12/26 at 2:36 PM indicated R8 was irritated by the urinary catheter and referred to the catheter as a piece of wood in his private area. The note read, in part: .He was talking to RN about the piece of wood in his private area. Realized that he was referring to the Foley catheter and let him know that it is a silicone catheter in place to drain the urine from his bladder.On 5/13/26 at 8:18 AM, Licensed Practical Nurse (LPN) T said R8 came back from the hospital with the catheter and did not have a catheter prior to hospitalization. LPN T said R8 was voiding sufficiently prior to going to the hospital and had no history of urinary retention. LPN T said the decision was made to keep the catheter because R8 was having a large amount of urinary output.During an interview on 5/13/26 at 9:39 AM, the Director of Nursing (DON) said she did not know R8 well enough to speak on the catheter and requested questions be directed to the nurse manager. The DON said the facility should have documentation identifying the medical reason for an indwelling urinary catheter.The nurse manager, Registered Nurse (RN) D, was interviewed on 5/13/26 at 9:43 AM. RN D said she did not know if R8 had an indwelling urinary catheter in place prior to hospitalization because R8 was on a different unit prior to being sent to the hospital. RN D confirmed there had been no trial discontinuance of the urinary catheter since R8 was readmitted from the hospital. When asked the reason R8 had a urinary catheter, RN D said R8 had a catheter because he was on hospice and was not getting out of bed as often as he was before he was hospitalized .RN S was interviewed on 5/13/26 at 10:03 AM. RN S verified she was the nurse manager on the unit where R8 resided prior to hospitalization. RN S confirmed R8 never had a urinary catheter prior to the hospitalization. RN S said she would review paperwork from the hospital to ascertain the reason for the catheter and determine if R8 experienced urinary retention while in the hospital.On 5/13/26 at approximately 11:13 AM, RN S reported she was unable to determine the reason R8 returned from the hospital with the urinary catheter and the reason R8 was given a new diagnosis of urinary retention. RN S reported there was no documentation indicating R8 had urinary retention. RN S acknowledged the medical record for Resident R8 did not contain documentation supporting the continued use of the catheter.The surveyor reviewed 118 pages of hospital documentation. No documentation was found to indicate the medical necessity or clinical indication to justify the use of the urinary catheter.The facility policy regarding urinary catheter use, Appropriate Use of Indwelling Catheters dated as approved on 4/1/26, directed staff to ensure indwelling urinary catheters were used only when medically necessary and that the medical record documented clinical indication for catheter use. The policy read, in part: .An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary. Residents. who are admitted with an indwelling urinary catheter, or residents who subsequently receive and indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary.

Based on observation and interview, the facility failed to maintain safe water temperatures in the resident's environment. Findings include:On 05/11/2026 at 12:4 2PM, when asked about hot water temperatures at hand sinks, Dietary Manager (DM) stated the hot water at the hand sink should not be above 140 degrees and then corrected herself and said it should not be above 120 degrees. A temperature was taken of the hot water at the hand sink in the Trillium Dining Room and was observed at 147 degrees. The DM said that this sink could be used by the residents. Three residents were observed in the dining room, and a resident was noted in a wheelchair passing directly in front of the hand sink. Record review of the facility's temperature monitoring revealed that this sink temperature is not monitored or documented on a log sheet on a routine basis.

Based on interview and record review, the facility failed to ensure pressure injury assessments and wound measurements were consistently documented and treatments were completed as ordered by the physician for one Resident (#13) of four residents reviewed for pressure injuries.Findings include: Resident #13 (R13)During an interview on 5/12/26 at 8:02 AM, R13 was observed sitting in a recliner in his room. R13 indicated he had wounds on both buttocks. He said the wounds had previously healed but had re-opened. No pressure reduction cushion was visualized in the recliner beneath R13. When asked if he had a chair cushion on the recliner, R13 said the cushion was in his wheelchair. A pressure reduction cushion was observed in a wheelchair on the other side of R13's bed.Licensed Practical Nurse (LPN) P was interviewed on 5/12/26 at 10:46 AM. LPN P said R13 was admitted to the facility in April 2026 with two stage 2 pressure injuries (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer). LPN P said R13 went to the hospital and returned with worsening of the wounds, and the documentation of monitoring was in the Skin/Wound notes in the EMR of R13 and in the weekly skin assessment documentation.On 5/12/26 at 2:11 PM, Registered Nurse (RN) Q and Certified Nurse Aide (CNA) R assisted R13 from his recliner into his bed so treatments to his wounds could be completed R13 said he had been in the recliner for 2-3 hours. He said, Sometimes I'm in it a lot longer than that. There was no cushion observed in the recliner R13 had just vacated.RN Q and CNA R positioned R13 on his right side. R13 was observed to have a shallow, linear dark purple area of deep tissue injury on his left buttock from superior to the gluteal cleft down to near his scrotum. The right buttock had a linear, shallow stage 2 pressure injury along the lateral gluteal cleft.The electronic medical record (EMR) revealed R13 was admitted to the facility on [DATE] with wounds to his bilateral buttocks. A Skin/Wound note in the electronic medical record (EMR) dated 4/20/26 at 8:05 PM documented, in part: .Wound bed is minimal depth, scant amount of bleeding. Open area is 8.5 cm [centimeters] x [by] 4.5 cm [length and width, respectively] on left [buttock], 7 cm x 2.5 cm on right side [buttock].R13 was transferred to the hospital emergency department [ED] on 4/28/26 and returned to the facility on 4/30/26. A Skin/Wound note in the EMR dated 4/30/26 documented, in part: . Returned from hospital stay w/ [with] worsened pressure/shearing wound on bilat buttocks and intergluteal cleft. Right side from intergluteal cleft to widest area of wound measuring 5.5 cm With [sic] total length along cleft 15 cm.Left side wound bed measures 6 cm at widest and joins w/ right side at intergluteal cleft measuring 15 cm. This wound has worsening areas of pressure with > [greater than] 20% dark purple, non-blanching [indicates impaired blood flow and tissue damage]. Suspected unstageable deep tissue injury [pressure-induced damage to underlying tissues, such as muscles, bones, and subcutaneous layers that may initially appear as intact skin with discoloration] .The EMR of R13 did not contain wound assessments after 4/30/26.The last skin assessment in the EMR was recorded on 4/30/26. The skin assessment on 4/30/26 documented a stage 2 pressure injury [partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer] on left buttock, unstageable on right buttock. The left buttock was measured at 15.0 cm x 6.0 cm x 0.1 cm (length, width, depth respectively). The right buttock measured 15.0 cm x 5.5 cm x 0.1 cm.After 4/30/26, pressure injury assessments and documentation were absent related to monitoring of the pressure injuries including wound measurements, drainage, appearance, and healing progress.During an interview on 5/12/26 at 2:44 PM, RN S expressed she was the nurse manager. RN S reviewed the EMR of R13 and confirmed no wound assessments, no wound monitoring, and no skin assessments had been completed since 4/30/26 despite documented worsening of the wounds when R13 returned from the hospital on 4/30/26. When asked why pressure injury assessments and skin assessments had not been completed to assess for new pressure injury development or worsening of the existing pressure injuries, RN S said she did not know.Review of the Treatment Administration Record (TAR) of April 2026 revealed R13 did not have treatment orders for the wounds on his bilateral buttocks until 4/22/26, 2 days after the initial admission to the facility. Physician orders were obtained on 4/22/26 for daily treatments for the pressure injuries. The April TAR revealed the daily treatments were completed two times (4/22/26 and 4/26/26) from the admission date of 4/20/26 until R13 was transferred to the ED on 4/28/26.The TAR for May 2026 contained no documentation for daily treatments being completed on 5/6/26 and 5/8/26 as ordered by the physician. Further review of the May TAR revealed the treatments were changed to twice daily treatments on 5/8/26. The twice daily treatments were not documented as completed on 5/8/26 and 5/11/26 in accordance with physician orders.There was no documentation in progress notes or the EMR to indicate the missing treatments in April and May were performed, refused, or otherwise unable to be completed.The Director of Nursing (DON) was interviewed on 5/13/26 at 9:40 AM. The DON said wounds were expected to be assessed at least weekly and documented in Skin/Wound notes in the EMR. The DON said nurses were expected to complete skin assessments weekly and document in the EMR. The DON confirmed treatments were expected to be completed as ordered by the physician and documented on the TAR.The policy titled Pressure Injury Prevention and Management dated as last revised 5/19/25 read, in part: .Licensed nurses or trained designee will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and as needed due to change in condition. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse, and documented in the EMR.Compliance with interventions will be documented in the weekly skin / wound assessment charting. The RN Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly

Based on interview and record review, the facility failed to provide written notifications of transfers and bed holds, and provide requisite resident information to the receiving provider for three Residents (#13, #8, & #70) of four residents reviewed for hospitalizations.Findings include:Resident #13: On 5/11/26 at 12:44 PM, R13 was sitting in a wheelchair in his room with an oxygen concentrator next to his bed. An oxygen mask was atop the concentrator. R13 said he went to the hospital a few weeks ago because he couldn't breathe. Review of the electronic medical record (EMR) revealed R13 was admitted to the facility on [DATE] with diagnoses that included but were not limited to heart failure, atrial fibrillation, chronic kidney disease, and presence of a cardiac pacemaker. A Minimum Data Set (MDS) assessment dated [DATE] documented R13 required staff assistance for Activities of Daily Living (ADL), received anticoagulant medication, was on insulin for diabetes, had two pressure injuries, and had an indwelling urinary catheter. A progress note dated 4/28/26 at 8:52 PM documented R13 experienced shortness of breath, a productive cough, and difficulty with respirations. The progress note described R13 as diaphoretic and utilizing accessory muscles for breathing. R13 was subsequently sent to the hospital emergency department (ED) on 4/28/26. Written notifications of transfer and bed hold were not located in the EMR of R13, nor were these documents referenced in the EMR. An Interact Transfer document titled SNF/NF to Hospital Transfer Form was dated as completed on 4/29/26 but contained an effective date of 4/28/26. The Interact Transfer document did not include R13's usual functional status, primary admission diagnosis, use of an indwelling urinary catheter, presence of pressure injuries, medications including when last received, diet order, use of insulin, risk for bleeding including the use of anticoagulant medication, or relevant lab or diagnostic test information. The EMR did not indicate the Interact Transfer document had been provided to the ED when R13 was transferred. There was no documentation in the EMR detailing what resident-specific information was provided to the ED when R13 was transferred. The Nursing Home Administrator (NHA) was interviewed on 5/12/26 at 11:47 AM. The NHA said she was monitoring for written notifications of transfer and bed hold and acknowledged there were no written notifications provided when R13 was transferred to the ED on 4/28/26. The NHA confirmed there was no documentation indicating information was provided by the facility to the ED on 4/28/29 regarding R13. Resident #8 (R8) An MDS assessment dated of 1/26/26 documented R8 was admitted to the facility on [DATE] with a primary medical condition of debility, and cardiorespiratory conditions. Section C Cognitive Patterns, assessed R8 with severe cognitive impairment and coded R8 as requiring staff assistance with ADLs. The EMR of R8 included physician's orders for blood glucose monitoring and an order for hypoglycemic medication. A progress note in the EMR dated 3/16/26 at 7:01 PM documented R8 was transferred to the ED for hematochezia (the passage of fresh, bright red blood in the stool indicative of bleeding from the lower gastrointestinal tract). The Interact Transfer document titled SNF/NF to Hospital Transfer Form did not include R8's primary diagnosis for admission to the facility, usual functional status of ADLs, usual mental/cognitive status, diet order, or medications including date and time of last medication administrations. Written notifications of transfer and bed hold were not located in the EMR of R8, nor were these documents referenced in the EMR. The EMR did not indicate the Interact Transfer document had been provided to the ED when R8 was transferred. There was no documentation in the EMR detailing what resident-specific information was provided to the ED when R8 was transferred. On 5/13/26 at 7:57 AM, the NHA said she was unable to confirm the resident information was provided to the ED when R8 was transferred to the hospital. The NHA said written notifications of transfer and bed hold were not issued when R8 went to the ED on 3/16/26. The policy Resident Transfer and Discharge - Including AMA dated as last revised 12/23/25 documented, in part: . For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident; b. Resident representative information, including contact information; c. Advance directive information; d. All other information necessary to meet the resident's needs, which includes, but may not be limited to: i. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; ii. Diagnoses and allergies; iii. Medications (including when last received); and iv. Most recent relevant labs, other diagnostic tests, and recent immunizations. e. Additional information, if any, outlined in the transfer agreement with the acute care provider . Resident #70 (R70) Review of a Progress Note gleaned from the EMR, dated 3/30/2026, revealed R70 was emergently transferred to an acute care hospital for evaluation on 3/30/2026 related to suspected sepsis. Further review of the EMR revealed R70 was subsequently hospitalized with return to the facility on 4/06/2026. Review of the EMR revealed no evidence that written notification of transfer/discharge or written notification of the facility's bed hold policy were provided to R70 or his representative for the referenced transfer on 3/30/2026. On 5/12/2026 at 4:25 p.m. the Neighborhood Coordinator, Registered Nurse (RN) D, was queried regarding the facility process for provision of the written notification of transfer/discharge and bed hold policy. RN D reported nursing does not provide written notifications. Instead, residents and their representatives were verbally provided with information at the time of transfer regarding the need for transfer and asked if they would like to hold a bed. During a record review at the time of the interview, RN D referenced the following Progress Note: 3/30/2026, 16:20 [4:20 p.m.]. Resident's sister and DPOA [Durable Power of Attorney, name redacted] notified via [sic] of condition change and physician order to send to ER for suspected sepsis. [DPOA] verbally agrees to send [R70] to hospital for evaluation and treatment and to hold bed . It was noted there was no documentation of notification provided, in writing, of the reason for transfer or of what information was relayed regarding the facility bed hold policy, including how long the bed would be held and reserve bed payment information. During an interview on 5/13/2026 at 4:25 p.m., the DON reported nursing staff were responsibility for verbally notifying resident representatives via telephone of the reason for transfers and information regarding bed hold requirements. The DON confirmed that no written notification or bed hold policy was provided by nursing staff. On 5/13/2026 at 10:00 a.m. the Nursing Home Administrator (NHA) was queried regarding the facility procedure for providing notification of transfer/discharge and the facility bed hold policy. The NHA reported the facility did not provide written notifications to residents or their representatives for emergent transfers or hospitalizations. Review of the facility policy titled, Resident Transfer and Discharge – Including AMA, last revised 12/23/2025, revealed the following: Transfer and Discharge include movement of a resident to a bed outside of the certified facility whether . The facility transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand . Generally, the notice must be provided at least 30 days prior to a transfer or discharge. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because . The immediate transfer or discharge is required by the resident's urgent medical needs . In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman as soon as practicable before the transfer or discharge.

This citation pertains to intake 2979976.Based on interview and record review, the facility failed to ensure residents were free from misappropriation of resident property when a dose of controlled pain medication was diverted from one Resident (#75) of one resident reviewed for misappropriation. This deficient practice resulted in the potential for ongoing or increased pain and anxiety.Findings include:Resident #75 (R75)Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed R75 was admitted to the facility on [DATE] for hospice services with a primary diagnosis of end stage lung cancer. Further review revealed the following pain assessment documented under Section J Health Conditions:Have you had pain or hurting at any time in the last 5 days? Yes. How much of the time have you experienced pain or hurting over the last 5 days? Almost constantly. Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? Almost constantly . Please rate the intensity of your worst pain over the last 5 days. Severe.Review of a Facility Reported Incident (FRI), submitted to the State Agency (SA) on [DATE] at 2:54 p.m. revealed the following: On [DATE] [2026] the resident relocated from the Birch Neighborhood to a suite on the Apple Blossom Neighborhood to provide more room for family to be with him overnight. On this date, an order for Morphine Sulfate ER [long-acting opioid pain medication] 30 MG [milligram] was to begin during the morning shift, scheduled for administration twice per day, to address consistent pain management. The first dose was administered as ordered with the day shift nurse accessing the medication from the back-up Cubex [secure back up medication supply] as the routine medication would arrive with the pharmacy delivery later in the evening. That evening the [R75's] son requested [Registered Nurse (RN) U] address his father's pain to which she responded that she could not give any long acting medication due to it being unavailable until after midnight from the pharmacy . On the morning of [DATE], the resident's son shared his concern with the Neighborhood Coordinator [RN D], that the long-acting medication had not been able to be administered. [RN D] immediately began an investigation, evaluating the comfort level of the resident and reviewing medication orders . Neighborhood nurse interviews were conducted with the day shift nurse, [LPN T] and the night shift nurse, [RN U]. [LPN T] . indicated she witnessed the [RN U] retrieve the [evening] dose of the medication . from the Cubex for administration of the evening dose, as would be expected, as the pharmacy would arrive with the routine medication card after the scheduled dose administration time. [LPN T] did not witness the administration of the medication. Upon conducting a phone interview with [RN U], the DON [Director of Nursing] and [Human Resources] Director requested the night nurse [RN U] complete a drug test as her description of the discussion with family and med administration did not match the day-shift nurse report or evidence from the medication administration audit conducted by the DON. The test was set up by the HR Director and she was instructed to complete the test by 5:00 PM on [DATE]. The nurse failed to complete the drug test on [DATE] and was given until noon on [DATE] to complete the test. The nurse failed to complete the required drug test and has not made contact with the facility since the morning of [DATE]. The employment of this nurse has been terminated as of [DATE]. Due to the refusal of the night nurse to cooperate with the investigation and the fact that the medication was not found, destroyed, wasted or reported lost, it is suspected that the medication intended for this resident may have been diverted, resulting in misappropriation of resident property . The Administrator and HR Director reported the suspicion of drug diversion to the [law enforcement] on [DATE] . A complaint filed with the [state licensing body] regarding the employment status of the nurse in question due to the suspicion of diversion as of [DATE].During an interview on [DATE] at 10:37 a.m., Human Resources Director, Staff V reported no current contact information was available for RN U. Staff V reported RN U had severed all contact with the facility during investigation of missing pain medication and after failing to show for two scheduled drug tests ordered as a condition of continued employment.During an interview on [DATE] at 4:15 p.m., RN D confirmed R75's son had reported to her the Resident did not receive his long-acting pain medication on the evening of [DATE]. RN D stated the resident's son was very attentive and knew what R75's medications looked like and he reported when he asked RN U about the missing medication, she reported they would have to wait until the pharmacy arrived with the medication later in the evening. RN D reported the facility had a back-up supply of medication for use when new medications had yet to arrive from the pharmacy. RN D reported the incident to the DON.Review of the facility investigation documents revealed the following interview summary conducted by the DON on [DATE]: 3:30 PM [RN U] . stated that she removed 2 tabs of MS ER [morphine sulfate extended release] 15 mg from the Cubex but could not locate the order on the MAR. She claimed [LPN T] assisted her in searching for the order between 7:30 PM and 8:00 PM. [RN U] asserted that she did administer the medication around 9:30 PM - 10:00 PM while the resident's son was present, but intentionally omitted the documentation .Further review of the facility investigation documentation revealed a written statement signed by LPN T on [DATE]: On the evening of [DATE] at approx. [sic] 1930 [7:30 p.m.], this nurse went to the Cubex with the NOC [night shift] nurse to pull [R75's] MS ER. Together we pulled two 15 mg MS ER tablets for HS [bedtime] administration as medication had not arrived from [pharmacy] . NOC shift nurse was in possession of medication after pulling this from the Cubex .Review of R75's [DATE] Medication Administration Record (MAR) revealed an order for Morphine Sulfate ER Oral Tab 30 MG, Give 1 tab by mouth two times a day for cancer pain. To start 3/9 in a.m. Start Date: [DATE] 0600. Further review revealed the first dose was documented as administered for the AM dose on [DATE] but the PM dose remained incomplete, indicating the order was present on the MAR for administration the morning of [DATE].Review of the Cubex access records revealed two MS ER 15 mg tablets were removed from the facility back up supply (Cubex) by RN U and LPN T on [DATE] at 7:34 p.m.Further review of R75's electronic medication record (EMR) revealed no significant change in the Resident's pain level after missing the scheduled evening dose of MS ER 30 mg on [DATE]. R75 expired under hospice care at the facility on [DATE].During an interview on [DATE] at 12:05 p.m., the DON and NHA reported RN U's refusal to participate with the drug screen during the facility investigation into the missing MS ER 15 mg tablets presented the assumption that the medication was diverted by the RN.Review of the facility policy titled, Abuse, Neglect, & Exploitation Prevention Program Policies & Procedures, effective [DATE], revealed the following: . Residents have the right to be free from . misappropriation of their property . Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of resident's belongings or money without the resident's consent.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:An audit of all transactions from the Cubex and narcotic proof of use logs for the past 30 days as compared to the MARs.Blind audits of narcotics in the back-up medication system.Review and revision of policies related to medication administration, controlled substance management, and access to the back-up medication system to include procedures on accessing narcotics, documentation requirements, two-nurse verification requirements, and reconciliation of narcotic counts.Staff education on new procedures for narcotic removal from the back-up supply, medication administration documentation and narcotic reconciliation.Pharmacy consultation, review and approval of procedures.Implementation of weekly reconciliation of the back-up medication supply records with the MARs.The facility was able to demonstrate monitoring of the corrective action and maintained compliance as of [DATE].

Based on interview and record review, the facility billed for a personal room telephone which was not present for one Resident (#25) of one resident reviewed for billed services.Findings include:Resident #25 (R25) During a room visit on 5/11/2026 at 4:12 PM, R25 and her Durable Power of Attorney (DPOA) stated they had concerns of improper billing for telephone services. They stated, The facility continues to charge us for a phone (R25) is not using. The DPOA stated R25 came into the facility last November. The DPOA indicated he paid the bills and had spoken to the office. Each month they continued to charge for a phone, and she did not have one. Upon inspection of the room, no telephone was present.During an interview on 5/12/2026 at 10:08 AM, Administrative Staff A stated, Everyone pays $23.00 (for a telephone) if not on skilled care. The admission packet should explain that. When asked if a resident did not have a phone in their room would there be a charge, Staff A said, If no phone is in their room the resident can use the phone at the desk, but there would not be a charge to their bill. Staff A stated R25 had a phone as a recent audit of telephones had taken place. On 5/12/2026 at 10:15 AM, R25's room was observed again. R25 was present and said, I don't have a phone; they took it out of my room when I first got here several months ago. No phone was present.During an interview on 5/12/2026 at 10:19 AM, Certified Nurse Aide (CNA) B said she did not think R25 ever had a phone.During an interview on 5/12/2026 at 10:22 AM, Licensed Practical Nurse (LPN) C stated, She (R25) had a phone when she first got here. She said she could not hear out of it, so they took it out (of her room). I believe they tried another, but she never could use it. LPN C said, Her (R25) hearing is quite bad. So, they took it out and I don't believe she has one now.On 5/12/2026 at 11:26 AM, the billing statement of 5/1/2026 for R25 was presented by Staff A. It was reviewed and did contain a charge of $23.00 for Phone.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failure to properly label and date food products. B. Failure to ensure expired foods were discarded on or before the identified expiration date. C. Failure to ensure high temperature dish machines were routinely tested for proper sanitizing of food contact surfaces. D. Failure to ensure the kitchen area was restricted to food service staff during meal service. E. Failure to ensure staff washed their hands during identified opportunities for hand hygiene. F. Failure to demonstrate proper testing of sanitizing solution and maintain acceptable concentration parameters for meal preparation countertops and dining room surfaces. These deficient practices had the potential to result in food borne illness among any or all of the 61 residents in the facility. Findings include: The following were observed during the initial tour of the walk-in freezer in the main kitchen on [DATE] at 10:12 AM: 1. Opened frozen pancakes, separated from original packing, undated. 2. Opened frozen waffles, separated from original packing, undated. 3. Hamburger patties in original plastic bag, unsealed and open to air. On [DATE] at 10:18 AM, the following observations were made in the Lilac satellite kitchen: 1. Opened cartons of half and half and liquid egg mix in the reach-in refrigerator without a use-by date. 2. Opened frozen pancakes, separated from original packing, undated, in the reach-in freezer. On [DATE] at 10:24 AM, the following observations were made in the Trillium satellite kitchen: 1. Opened cartons of half and half, liquid egg mix, and chocolate milk in the reach-in refrigerator without a use-by date. 2. A plastic container labeled Chicken salad with a discard date of [DATE] in the reach-in refrigerator. 3. An unlabeled, uncovered stainless steel bowl containing what appeared to be pancake mix in the reach-in refrigerator. [NAME] J immediately removed the bowl and stated, This goes in the trash .it's from [breakfast service] this morning. 4. Opened frozen pancakes, separated from original packing, undated, in the reach-in freezer. On [DATE] at 10:29 AM, the following observations were made in a temporary food storage room on the 400 unit: 1. An open container of milk, undated. On [DATE] at 10:32, Certified Dietary Manager (CDM) I confirmed all opened food products should be labeled with a use-by date and discarded at that time. The Food and Drug Administration (FDA) 2022 Food Code states: ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. On [DATE] at 11:51 AM, the high-temperature dishwasher in the main kitchen was observed for appropriate sanitation temperatures. CDM I stated a temperature recording was expected for each meal service (3 times per day). Review of the dishwasher temperature log in the past 30 days revealed the following missing entries: [DATE] - lunch service [DATE] - breakfast and lunch service [DATE] - breakfast and lunch service [DATE] - breakfast and lunch service [DATE] - breakfast and lunch service [DATE] - dinner service [DATE] - dinner service [DATE] - breakfast service The FDA 2022 Food Code states: ,d+[DATE].11 Hot Water and Chemical. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: (A) Hot water manual operations by immersion for at least 30 seconds and as specified under S ,d+[DATE].111; P (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS ,d+[DATE].15, ,d+[DATE].112, and ,d+[DATE].113 and achieving a UTENSIL surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator. On [DATE] at 11:46 AM, an unidentified staff member entered the main kitchen during the lunch time meal service without a hair net on. On [DATE] at 7:30 AM, Resident Assistant (RA) K was observed walking behind the Trillium satellite kitchen service line with ,d+[DATE] inches of loose hair hanging out of the bottom of her hair net during the breakfast meal service. On [DATE] at 7:32 AM, RA K was observed dropping a straw wrapper on the dining room floor. RA K picked up the wrapper, prepared a cranberry juice, placed it on a breakfast tray, and delivered it to a resident without performing hand hygiene. RA K then delivered another breakfast tray without performing hand hygiene. On [DATE] at 8:29 AM, RA M was observed delivering breakfast trays in the Lilac dining room. RA M was observed pulling her scrub top over her mouth, coughing into her hand, and then proceeded to pour coffee and roll silverware without performing hand hygiene. On [DATE] at 12:01 PM, an interview was conducted with Registered Nurse/Infection Preventionist (RN/IP) O regarding hand hygiene expectations. RN/IP O stated the facility has been providing ongoing education regarding handwashing and will continue to make it a focal point based on dining room observations. Review of the facility policy titled, Handwashing/Hand Hygiene, revised [DATE], read, in part: This facility considers hand hygiene the primary means to prevent the spread of infections .use an alcohol-based hand rub .or .soap .and water for the following situations: .before and after eating or handling food; before and after assisting a resident with meals . The FDA 2022 Food Code states: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S ,d+[DATE].12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES P and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms . Except as specified in ,d+[DATE].11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking . ,d+[DATE] Hair Restraints ,d+[DATE].11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. On [DATE] at 7:40 AM, a 6-quart visual compliance sanitation bucket was observed in the Trillium dining room. A test strip submerged in the bucket was observed to be pink in color with a visual caution symbol, indicating the solution was out of compliance. RA L, who was assisting with the breakfast meal, was asked who was responsible for ensuring the sanitation buckets were maintained at the appropriate concentration. RA L stated the resident assistants were primarily responsible for filling the sanitizing buckets before each meal service. When asked if the sanitation bucket met appropriate concentration parameters, RA L retrieved a new test strip, submerged it in the bucket for approximately 2 seconds, and compared it to the graphic on the bucket. RA L stated, It's not as dark as that [graphic on the bucket], but I think it's okay. On [DATE] at 8:46 AM, a 6-quart visual compliance sanitation bucket was observed in the Lilac dining room without an indicator strip in the viewing window. [NAME] N confirmed she had prepared the sanitation bucket prior to breakfast service. When [NAME] N was asked to demonstrate compliance, she dripped a test strip in the solution for approximately ,d+[DATE] seconds. After removing the strip, it was observed to be pink in color with a visual caution symbol, indicating the solution was out of compliance. When asked to interpret the results, [NAME] N stated, Pink means it's good to go. On [DATE] at 2:33 PM, an interview was conducted with CDM I regarding proper testing of sanitizing solution. CDM I stated the test strips should be submerged in the sanitation bucket and the solution should be changed when the test strip turned pink and displayed a caution symbol. CDM I continued, The strips should be submerged .it's not a dip-stick test. Review of the manufacturer's guidelines for the sanitizing solution read: 1. Insert a test strip into the bucket window 2. Fill the bucket with Sink & Surface Cleaner Sanitizer 3. Clean and sanitize hard food contact surfaces according to product label 4. When the product goes out of compliance, the test strip will turn from blue to pink and a caution symbol will appear 5. Empty the bucket, replace the test strip, and refill with fresh solution to stay in compliance.

Based on interview and record review, the facility failed to ensure monthly pharmacy medication regimen reviews were performed for one Resident (R30) of five residents reviewed for pharmacy services. Findings include: Resident #30 (R30) Review of R30's pharmacy consultation progress notes, dated October 2024 through April 2025, revealed R30 did not have a pharmacy medication regimen review completed for the month of October 2024. On 4/16/25 at 3:50 PM, an interview was conducted with the Director of Nursing (DON), who was asked if R30 had a pharmacy medication regimen review for October 2024. The DON replied, I would have to look and get back with you. It may have not been scanned into the medical record or it could be in the hard chart. On 4/17/25 at 8:00 AM, the DON provided an audit of pharmacy medication regimen reviews for the month of October 2024, which revealed R30 did not have a pharmacy medication regimen review (MRR)/pharmacy consultation progress note completed. The DON stated R30 did not have a MRR for the month of October 2024 and revealed a total of three residents were overlooked during that same time period. Review of policy titled, Medication Regimen Review, dated 3/28/25, read in part, Policy Statement - The Consultant Pharmacist shall review the medication regimen of each Resident at least monthly. Policy Interpretation and Implementation - 1. The Consultant Pharmacist will perform a medication regimen review (MRR) for every Resident in the facility receiving medication. 2. Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated .

Based on observation, interview, and record review, the facility failed to prevent the development of deep tissue injuries for one Resident (R29) of one resident reviewed for the pressure ulcers. Findings include: Resident #29 (R29) Review of R29's Minimum Data Set (MDS) assessment, dated 12/12/24, revealed under section M skin conditions, R29 was at risk for developing pressure ulcers/injuries and had no open areas at the time of the assessment. Review of R29's MDS, dated [DATE], revealed under section M skin conditions, R29 had developed and had one unhealed pressure ulcer/injury rated as unstageable (wound bed obscured with dead tissue). Review of R29's progress notes, dated January 2025 through April 16, 2025, revealed R29 experienced a health status decline as evidenced by spending more time in their bed and developed a deep tissue pressure injury on both heels with a start date of 3/6/25. Review of R29's progress note, dated 3/6/25 at 10:45 AM, read in part, Notified by floor staff of new skin concerns to heels. On assessment: Left medial heel DTI (deep tissue injury) measures 2.0 x 2.5 cm (centimeters). There is a serous blister with intact roof leaking serous fluid to adjacent skin .Right lateral heel DTI measures 1.2 x 1.5 cm with no blistering noted. Both sites are faint discoloration at this time . Review of R29's Braden scale, dated 12/12/24, revealed R29 was At risk for developing pressure sores. Review of R29's care plan, dated 5/1/20, read in part, .Focus: I am at increased risk of skin breakdown r/t [related to] decreased immobility and incontinence. Goal: I will maintain or develop clean and intact skin by the review date. Interventions/Tasks . R29's care plan had no new interventions, such as floating heels, for pressure injury prevention despite spending increased time in bed. On 4/16/25 at 11:45 AM, an observation was made of R29 lying in their bed with a foot cradle to keep the sheets off their feet and a heels manager device below their feet. A dressing was observed on R29's left heel dated 4/14/25. Registered Nurse (RN) C' was observed peeling back the dressing revealing an unstageable pressure injury. R29's right heel was without a dressing and the skin was slightly discolored but intact. On 4/16/25 at 11:55 AM, an interview was conducted with Registered Nurse/wound treatment nurse (RN) A who was asked if R29 should have had interventions to float heels because of spending increased time in their bed. RN A replied, Yes, I was not made aware that they had declined and were spending increased time in bed. The care plan should have been updated to float heels, and the pressure injuries should have been avoidable. RN A further explained R29's right heel was a discoloration of skin only and the left heel was opened and unstageable.

Based on interview and record review, the facility failed to ensure a comprehensive discharge summary was completed for one Resident (#2) of two residents reviewed for a discharge to the community. Findings include: Resident #2 (R2) Review of R2's electronic medical record (EMR) revealed admission to the facility on 3/5/25 with diagnoses including a fracture of the second cervical (neck) vertebra and repeated falls. R2 was discharged from the facility on 4/2/25. Review of R2's EMR revealed no discharge plan, recapitulation of stay, reconciliation of pre/post-discharge medications, or physician discharge orders. On 4/16/25 at 3:22 PM, an interview was conducted with the Director of Nursing (DON) regarding discharge documentation expectations. The DON confirmed a discharge summary by discipline was expected to be included in the EMR. The DON stated, There is a protocol for discharge documentation, there's just some new nurses on the rehab unit who don't know what to do. On 4/16/25 at 3:31 PM, an interview was conducted with MDS [Minimum Data Set] Coordinator P who confirmed a nursing progress note should be documented in the EMR, indicating a reconciliation of medications took place with the resident prior to discharge. Review of the facility policy titled, Resident Transfer and Discharge - Including AMA revised 4/15/25, read, in part: .Anticipated Discharge to the Community: Facility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care . A member of the interdisciplinary team will complete relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: a. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results. b. A final summary of the resident's status. c. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). d. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment .

Based on interview and record review, the facility failed to revise care plans to reflect the needs of two Residents (R24 and R29) of 12 residents reviewed for care plans. Findings include: Resident #24 (R24) Review of R24's physician order, dated [DATE], revealed an order of DNR (Do Not Resuscitate). Review of the facility document signed by R24 titled, Code Status, dated [DATE], revealed a selection of No Code, indicating R24 did not wish to receive cardiopulmonary resuscitation (CPR) in the event their heart or breathing stopped. Review of R24's care plan, date revised [DATE], read in part, Focus: I could have an alteration in respiratory status and psycho-social wellbeing related to COVID-19, Influenza, RSV [respiratory syncytial virus], etc. [and so on]. I am at high risk due to my age, comorbidities and residing in a facility setting. Goal: I am a full code and wish to be sent to the hospital for suspected or confirmed respiratory illness . On [DATE] at 3:50 PM, an interview was conducted with the Director of Nursing (DON), who was asked if the care plan was to reflect R24's advanced directives and physician orders. The DON replied, Yes, the care plan, advanced directives, and physician order should be the same on the care plan. Resident #29 (R29) Review of R29's progress notes, dated February 2025 through [DATE], revealed R29 experienced a health status decline as evidenced by spending more time in their bed as well as the development of two deep tissue pressure injuries to bilateral (both) heels on [DATE]. Review of R29's Braden scale, dated [DATE], revealed R29 was At risk for developing pressure sores. Review of R29's Minimum Data Set (MDS) assessment dated [DATE], reflected a significant change in status assessment. Review of R29's progress note, dated [DATE], read in part, Reviewed nursing assessments .collaborated with unit staff and IDT (interdisciplinary team) to discuss res (resident) usual performance with functional abilities/goals .Data will be reflected on MDS. Review of R29's care plan, dated [DATE], read in part, .Focus: I am at increased risk of skin breakdown r/t [related to] decreased immobility and incontinence. Goal: I will maintain or develop clean and intact skin by the review date. Interventions/Tasks . R29's care plan lacked any new interventions to address pressure injury prevention, such as floating heels, despite spending increased time in bed. On [DATE] at 11:55 AM, an interview was conducted with Registered Nurse/wound treatment nurse (RN) A who was asked if R29 required additional pressure reduction interventions due to an increased amount of time in bed. RN A replied, Yes, I was not made aware that they had declined and were spending increased time in bed. The care plan should have been updated to float heels, and the pressure injuries should have been avoidable. Review of policy titled, Comprehensive Person-Centered Care Plans, dated [DATE], read in part, Policy Statement - A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the Resident's medical, nursing, mental and psychological needs is developed for each Resident, consistent with the comprehensive assessment and Resident Rights. Policy Interpretation and Implementation - 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 8. The comprehensive, person-centered care plan will . j. Reflect the resident's expressed wishes regarding care and treatment goals . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . c. At least quarterly, in conjunction with the required quarterly MDS assessment .

Based on observation, interview, and record review, the facility failed to prevent unauthorized access to the facility's three medication storage rooms by allowing unlicensed personnel to retain keys and access the three medication storage rooms. Findings include: On 4/17/24 at 8:55 a.m., 9:05 a.m., and 9:11 a.m., the Housekeeping Supervisor, Staff A, was observed using a magnetic swipe-card to enter three medication storage rooms without a licensed nurse in attendance. When questioned regarding access to medication storage rooms, Staff A said the housekeeping staff had magnetic-swipe cards to access the medication storage rooms for cleaning of the rooms. Medication storage audits were conducted on the 200 unit and 500 unit medication storage rooms on 4/17/24 at 9:43 a.m. Ophthalmic solutions, insulins, syringes, over-the-counter medications, and biological agents were observed in the medication storage rooms. Staff B was observed utilizing a magnetic swipe-card to enter the medication storage room on the 200 unit on 4/17/24 at 12:14 p.m. Staff B confirmed she was a housekeeper and said the building had three medication storage rooms. Staff B said, all housekeepers have access to the med rooms to clean them. Staff B confirmed the housekeepers were not accompanied by nurses when accessing and cleaning the medication rooms. Registered Nurse (RN) C was interviewed on 4/17/24 at 12:20 p.m. regarding the housekeepers' access to medication storage rooms. RN C confirmed housekeepers accessed the three medication rooms in the facility and the nurses were not required to accompany housekeepers during the cleaning tasks in the medication storage rooms. During an interview with the Nursing Home Administrator (NHA) on 4/17/24 at 12:42 p.m., the NHA was asked regarding staff access to the medication storage rooms. The NHA stated, Only nurses should have access to med rooms. When told the housekeeping staff have magnetic swipe-cards to enter the medication storage rooms, the NHA appeared surprised and said she was not aware of anyone having access to medication storage areas aside from licensed nursing personnel. The Director of Nursing (DON) was interviewed on 4/17/24 at 12:58 p.m. When asked regarding medication storage room access, the DON said the nurses and DON had access to those areas. When asked if housekeepers had access to the medication storage rooms, the DON stated, I don't think so - I think the nurses need to let them in, but I'm not sure. The policy 'Storage of Medications' dated 12/13/23 read in part: (name of facility) shall store all drugs and biologicals in a safe, secure, and orderly manner. 10. Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.

Based on observation, interview, and record review, the facility failed to ensure supervision and safety for one Resident (R162) of two residents reviewed for unsafe wandering. This deficient practice resulted in R162 wandering into a non-resident area where chemicals were located and fell . Findings include: The Fall Report labeled Unwitnessed Date: 4/15/2024 00:00 (Midnight) gave an Incident Description: as follows: This nurse was off hallway to retrieve medication . CNA (Certified Nurse Aide) called writer during this time stating resident was in (sic) floor. Upon entering hallway, resident was observed lying on left side in janitor's closet facing towards back wall with head between mop bucket and shelf. Resident had pants pulled down and had urinated in (sic) floor. Her w/c (wheelchair) was outside of med (medication) room door. She is unable to appropriately describe incident to staff members r/t (related to) her dementia. Gripper socks were in place at time of incident. The Immediate Action Taken was documented as follows: .resident assessed for injuries; mild redness noted to left side of face but resident denied any pain . Janitor's closet door assessed and it is noted that although this door has keypad for entry, it can be opened without entering passcode . Maintenance to be notified via Worx (electronic work order system) Hub re: janitor's closet door not locking The electronic medical record (EMR) progress note dated as 4/16/24 Late Entry read in part: .fall occurred in unit hallway at midnight with minor injury. Unit CNA reports that, Me and (CNA named) were finishing up our midnight rounds, we had come out and saw (R162) car (wheelchair) sitting empty. We checked residents (sic) rooms/kitchen and lastly checked janitors closet because it's supposed to be locked. We saw her on the ground pants off laying on back/left side with urine on the ground. Her head was between the mop bucket and shelf. Wing nurse further reports that resident was lying on her left side . This nurse able to view camera footage leading up to incident. Resident observed at 2330 (11:30 PM) in wheelchair, propelling self in area around nursing station. In/out of dining room and transferring out of wheelchair multiple times . All staff leave the nursing station just before 2357 (11:57 PM) . She pushed her pants down around her thighs . she shuffled back along the handrail until she got to the closet door. Using the knob, the door opened easily and the light automatically triggered as resident stepped inside. At 00035 (12:03.5 AM) she is observed closing the door behind her . Resident admitted to the facility on ,d+[DATE] for LTC (Long Term Care) from (named facility). Had fallen at home on 02-07 sustaining a fracture to upper end of her L (left) humerus (upper arm) . Resident is pleasantly confused; unable to recall safety interventions. During an interview on 4/17/24 at 8:38 AM, the Nursing Home Administrator (NHA) discussed the incident and stated the halls were monitored with cameras and the video timeline revealed R162 was in the janitor's closet for 3.5 minutes. On 04/17/24 at 10:07 AM, the video footage was observed with the Director of Nursing (DON) and the timeline listed in the late entry progress note of 4/16/24 above was confirmed regarding the event on 4/15/24. R162 left her wheelchair, ambulated to several doors, pulled her pants down below her knees, and came to the janitor's closet and was able to enter the closet. The video footage confirms R162 was in the closet unattended for approximately 3.5 minutes. A review of R162's medical record, revealed admission to the facility on [DATE] with diagnoses including Alzheimer's disease, fracture of the left arm, cognitive communication deficit, stroke, and dementia. The fall risk assessment upon admission indicated R162 had a history of falling with a high-risk score for falls of 65. (Scores over 45 are high risk.) The Minimum Data Set (MDS) assessment dated [DATE] documented R162 had a fall with fracture within the last 2-4 months prior to admission and used a wander/elopement alarm daily. The care plan for R162 included: - I am a high risk to wander. I have Dementia and have been taken out of my environment. Date Initiated: 03/27/2024 - Please keep me safe when I wander. Date Initiated: 03/27/2024. - Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Date Initiated: 03/27/2024. - Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Date Initiated: 03/27/2024. - WANDER ALERT: right ankle. Check for placement and light flashing every shift. Date Initiated: 03/27/2024. - I have an ADL (Activities of Daily Living) self-care performance deficit r/t Alzheimer's disease along with a history of a CVA (stroke) with RT (right) sided weakness. I recently had a fall with a LUE (left upper extremity ) fracture. Date Initiated: 03/26/2024. During an interview on 4/15/24 at 12:53 PM, CNA D stated R162 had a one on one today (a staff member assigned to only R162) due to getting out of bed and she was a fall risk. During an interview on 4/17/24 at 10:18 AM, the DON stated it was discovered the janitor storeroom was accessed by R162 when she randomly pushed the lock buttons. On 4/17/24 at 8:40 AM, the Director of Housekeeping/Laundry (Staff A) accompanied this surveyor on a tour of the building checking the doors assessed to need locks to ensure the safety of the residents. The janitor closet where R162 had accessed and fallen contained two chemical products: - A disinfectant with MSDS (Material Safety Data Sheet) warnings of eye irritant and - An odor eliminator available with MSDS warnings of Keep out of reach of children. All individual ingredients of this material have a known acute toxicity. During the lock checking facility tour on 4/17/24 at 9:02 AM, the lock on the kitchen storage room door was determined to be faulty. When the door was checked, it was not locked per coded badge swipe lock but was able to be easily pushed open. During the lock checking facility tour on 4/17/24 at 9:18 AM, the lock on the maintenance storage room with keypad was determined to be faulty. This room stored several hazardous chemical industrial use containers including ice [NAME], spot and stain remover, spray buffing solution, floor sealer, soil extractor carpet cleaner, and stone, tile, and grout sealer. Staff A observed the condition of the room with faulty lock and multiple hazardous chemical agents and said, It is dangerous for sure. During an interview regarding the maintenance door failing to lock on 4/17/24 at 9:51 AM, CNA D stated the door preceding the door in question did not have a lock. This door was alarmed by a wander guarded system whereby those wearing a protective device would trigger the locking of the preceding door. During an interview on 4/17/24 at 12:14 PM, Registered Nurse (RN) E reviewed the current MDS triggered report and stated the unit with the unlocked maintenance storage door and unlocked preceding door had 15 residents on that unit who had a diagnosis of dementia or Alzheimer's disease. RN E said, We have to have the diagnosis and physician acknowledgment of dementia or Alzheimer's Disease prior to completing the MDS. Of the 15 residents on that unit coded with dementia or Alzheimer's Disease, only one resident wore a protective device which would trigger the preceding door to be locked. The facility policy Hazardous Areas, Devices and Equipment dated 4/16/24 read in part, All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples include . g. Access to toxic chemicals . k. Disabled locks, latches, or alarms.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to properly cool and store food which was leftover and planned to be served at a later date. 2. Failing to provide adequate hand washing sinks and water temperatures for hand washing in food service areas. 3. Failing to dispose of expired food in kitchen refrigerators. 4. Failing to develop a system for identifying expired food which was not obviously stamped on manufacturer's containers. 5. Failing to ensure kitchen staff were wearing and using appropriate hair restraints when preparing and serving food. 6. Failing to equip new mechanical dish machines with appropriate devices to effectively monitor proper functioning. 7. Failing to install appropriate back flow prevention devices on three juice dispensing machines and two Combi ovens. These deficient practices have the potential to result in food borne illness among any and all 63 residents of the facility. Findings include: 1. On [DATE] at approximately 7:30 AM, the initial tour was conducted of the kitchen and associated satellite kitchens serving residents. During this observation period breakfast was being served. Temperatures of food on the steam table in the main kitchen were measured using a Super Fast steel probe Thermapen and found a pan of breakfast sausage was being held at 128 F. An interview was conducted with Certified Dietary Manager (CDM) C at this time who acknowledged the food was to be held at or above 135 F. On [DATE] at approximately 7:35 AM, observations of the walk in cooler, in the main kitchen were conducted. A large (2 gallon) Lexan container was observed to be filled to the top with a white sauce like food. The internal temperature was measured with a Thermapen thermometer and found to be 54 F. At this time an interview was conducted with (CDM) C and was learned the product was a rice pudding which had been cooked the previous evening. CDM C confirmed the product should have been cooled and a record of the cooling process made on the facility's cooling logs. A review of the cooling logs revealed there were no entries for the rice pudding. CDM C affirmed the product had not been cooled appropriately and subsequently discarded it. The FDA Food Code 2017 states: ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S,d+[DATE].19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in ,d+[DATE].11(B) or reheated as specified in ,d+[DATE].11(E) may be held at a temperature of 54 C (130 F) or above; ,d+[DATE].14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); P and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. 2. On [DATE] at 10:45 AM, observations of the dish washing rooms for the East and West halls were conducted. The rooms were located adjacent to the respective dining rooms and were provided with self closing doors separating them from the dining room area. Neither dish washing room was equipped with any hand washing sink. This required staff, conducting dish washing activities, to enter the dish room from the dining room and handle clean dishes for resident use, without being able to wash their hands after handling the door. At this same time, an interview was conducted with Dietary Staff J, who was working in the East unit's cook area. Staff J confirmed that staff were unable to wash their hands appropriately while in the dish room before handling clean dishes. On [DATE] at 10:30 AM, an interview with the Nursing home administrator (NHA) who acknowledged the deficiency related to lack of hand washing sinks in the dish rooms. On [DATE] at 11:00 AM, again at 1:30 PM and 3:45 PM, the hand sink in the main kitchen was used to wash this surveyor's hands. The hot water faucet was turned on and allowed to run, waiting for the arrival of hot water. After 3 minutes, the temperature of the water from the faucet, with only the hot spigot on, was measured to be only 65 F. An interview was conducted with Cook F at this time who stated it was common to not have hot water at the hand sink after about 9:00 AM. The FDA Food Code 2017 states: ,d+[DATE].14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S ,d+[DATE].12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. AND ,d+[DATE].12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 38 C (100 F) through a mixing valve or combination faucet. Pf 3. On [DATE] at 9:45 AM, the two door Traulsen refrigerator was observed to have six expired containers of soup base. One container of Ham soup base had a received date of [DATE] written and manufacturer expiration date of [DATE]; five containers of clam soup base had manufacturer expiration dates of [DATE]. A 5 pound container of cottage cheese was observed in the walk in cooler with the following written in black marker: open [DATE]; exp [DATE]. The manufacturer expiration date was stamped as [DATE]. 4. On [DATE] at 9:45 AM two 25 pound tubs of chicken soup base were observed in the two door Traulsen refrigerator, marked with an open date of [DATE]. There was no obvious manufacturer expiration date stamped on the container, rather, a [NAME] calendar date of manufacturer. An interview with Cook F and Assistant Dietary Manager (ADM) E was conducted regarding the shelf life/expiration date of these large containers of food. Neither were aware of the manufacturer's coding and stated shelf life of the products. Cook F stated I thought they lasted forever with all the salt in them. The two staff acknowledged the kitchen did not have a system in place to identify containers stamped with [NAME] calendar coding and information regarding the shelf life the manufacturer identified for each product. The FDA Food Code 2017 states: ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Pf (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest-prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method APPROVED by the REGULATORY AUTHORITY for refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. 5. On [DATE] at approximately 8:30 AM, Cook D was observed in the kitchen preparing food, cleaning dishes and other food service related activities. Cook D had a full face beard, approximately ,d+[DATE] inches in length. Though, wearing a clinical face mask, the facial hair extended beyond the mask and was not restrained by a beard net or other hair restraint device. This same observation was made at 11:15 AM and again at 1:30 PM the same day. On [DATE] at approximately 7:20 AM, Cook D was observed in the kitchen conducting food service activities during the morning meal. A beard net was observed being worn, however, it was down around the staff's neck, and not covering any of the facial hair protruding above the clinical mask. On [DATE] at 11:15 AM, cook G was observed wearing a base ball type cap, with long hair, 15 to 20, extending below the cap and not fully restrained. This same observation was made again at approximately 1:30 PM the same day. An interview with Dietary Manager (DM) C was conducted on [DATE] at approximately 10:30 AM concerning the lack of hair restraints, who stated that the staff had been instructed to wear them correctly. The FDA Food Code 2017 states: ,d+[DATE].11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. 6. On [DATE] at 2:30 PM, the mechanical dish machines were observed in the new dish cleaning rooms off each of the East and West dining rooms. The machines were identified as a high temperature sanitizing machine and lacked a pressure gauge to ensure the final rinse was at the correct pressure. The FDA Food Code 2017 states: ,d+[DATE].118 Warewashing Machines, Flow Pressure Device. (A) WAREWASHING machines that provide a fresh hot water SANITIZING rinse shall be equipped with a pressure gauge or similar device such as a transducer that measures and displays the water pressure in the supply line immediately before entering the WAREWASHING machine; and (B) If the flow pressure measuring device is upstream of the fresh hot water SANITIZING rinse control valve, the device shall be mounted in a 6.4 millimeter or one-fourth inch Iron Pipe Size (IPS) valve 7. On [DATE] at 8:15 AM, observations of the two Combi Vent ovens, located in the newly constructed kitchen facilities on both the West and East dining rooms, was made. These ovens were observed to have a potable water connection, entering the rear of the unit, to the building's draining water supply. There was no back flow prevention device observed between the oven and the location where the supply connected at the shut off valve. The manufacturer specification sheet: CTP7-SPC-0022-EN ,d+[DATE] was reviewed. It stated: Water supply shut-off valve and back-flow preventer when required by local code On [DATE] at 8:20 AM, three juice dispensing machines were observed. One in the main kitchen, and one each in the kitchens of the East and West dining rooms. The dispensers were observed to be connected to the building's potable water supply with a ,d+[DATE] water line and shut off valve. No backflow prevention device was observed on each of the three machines. On the back of each dispenser was a yellow label stating: This dispenser is to be installed with adequate back flow prevention protection to comply with local, state and federal regulations. The FDA Food Code 2017 states: ,d+[DATE].14 Backflow Prevention Device, Design Standard. A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device.

Based on observation, interview, and record review, the facility failed to adequately supervise one cognitively impaired Resident (#100) of four residents reviewed for wandering/elopement, who eloped from the facility and was found by off-duty staff and a local police officer approximately 3 hours later attempting to climb over a fence on private property. This deficient practice resulted in the likelihood of injury for Resident #100 and the potential for unsafe exit from the facility for other wandering residents. The facility monitored the non-alarming door, installed motion detector and room door alarm, and had the electrical panel repaired to restore function to the exit door. The Immediate Jeopardy began on 11/16/20 at approximately 4:50 a.m., when Resident #100 left the facility unnoticed by staff via an exit door which did not alarm. Resident #100 wandered outside for approximately 3 hours before being found off the facility premises near an intersection in the neighborhood, approximately 1000 feet from the back of the facility. Notice of the Immediate Jeopardy was sent to the Administrator and Director of Nursing on 1/7/20, and the abatement plan requested. The Immediate Jeopardy ended on 11/16/20 due to implementation of the facility abatement plan, dated 1/7/21, which read in part: On the morning of November 16, 2020, a resident left the facility unattended. Immediate Actions to reduce any further risk to residents or staff included: -Enactment and immediate implementation of facility Wandering Resident Policy/Procedures. -Notifications of all necessary parties, including (State Agency), local search and rescue authorities, and family. -Identification of the exit from which the resident left the building via surveillance camera review which led to identification of malfunctioning alarm on the delayed egress door. Investigation into door function indicated that a lightening strike or wind related incident created the malfunction which (sic) in the door monitoring panel. -Immediate monitoring of the malfunctioning door by Maintenance and Nursing staff until the door alarm was fixed. -Installation of additional audible alarm at the door and hourly monitoring of that alarm function to ensure staff are alerted to movement around or near the door. Findings include: Review of the facility reported incident revealed on the morning of 11/16/20, Resident #100 was not in his room when Certified Nurse Aide (CNA) D went to check on him at approximately 4:50 a.m. CNA D alerted Registered Nurse (RN) C, who began to search the area, and then called 911. Review of Resident #100's care plan (dated as last reviewed 11/10/20) revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. The focus/ interventions of this care plan included: I am sometimes irritable and impulsive . My insight is poor and my judgment is impaired . I have been wandering and do not know what to do when or where to go . my decisions tend to be poor. I may be up during the night . If I wander to other neighborhoods (facility hall units), please assist me back to my familiar area (within the facility) . Per the local police Incident/Investigation Report dated 11/16/20, the incident was reported at 5:36 a.m. on 11/16/20. This report read, in part: .received information from (Director of Nursing (DON) that camera surveillance showed (Resident #100) exiting the building at 0452 (4:52 a.m.) . Dispatch sent out a 7 mile radius BE ALERT announcement to the public to contact 911 if (Resident #100) was observed. After approximately 1 1/2 hrs (hours) requested . State Police Office K-9 respond to scene VICTIM LOCATED: Dispatch advised a passerby (name) called in advising he believes (Resident #100) is leaning up against a split wooden fence . I responded from (facility) along with (local) EMS and (local) Sheriff Office . I observed (Social Worker (SW) B) make contact with(Resident #100). I assisted (SW B) getting (Resident #100) over the fence and to the Paramedics for medical assessment. (Resident #100) was shivering due to the outside temperature exposure. WEATHER CONDITIONS: Dark/Windy/Vehicle Temperature Gauge-34 Degrees . On the morning of 11/16/20 sunrise was at 6:42 a.m. (www.suntoday.org) and the local temperature was 33-34 degrees from 5 a.m. to 9 a.m., per weatherunderground.com, accessed 12/23/20. Review of the facility Investigation report dated 11/16/20 showed the nurse notes by RN G included the following: Resident (#100) found at 07:50 am .EMS (Emergency Medical Service) brought him back to (facility) . his vital signs were stable 150/80 (blood pressure), temp 97.0 . on middle thigh there is an abrasion that measures 5x3 cm (centimeters) . inside of leg there is 0.5x0.5 cm skin tear . 1x0.8 cm blood blister . on the right thigh, there is 0.5x0.5 cm skin tear and above it a 1x0.8 cm blood blister. No scratches or bruises to chest and back . Left elbow has a skin tear measuring 2.5x1.5 with dark bruising . all areas cleaned with normal saline and covered with opti foam . The Investigation report also indicated the physican assessment was completed on 11/16/20 at around 10:00 a.m and indicated vital signs were fine . Elopement with cold air exposure. Superficial abrasions. Dementia with serious adverse behaviors. Note later in day he was alert and interactive and showing no adverse effects of elopement . During an phone interview on 12/23/20 at 3:41 p.m., CNA D, when asked about the morning of 11/16/20, stated she was doing last rounds checking on residents when she noticed Resident #100 was not in his room. CNA D stated, I always check on him . he wanders all over the place. There was no alarm that time, so we thought he was inside. CNA D reported she notified RN C, the nurse in charge of that neighborhood unit, and they continued to search. CNA D stated she provided Resident #100's picture to the police when they arrived, then noticed the door that didn't alarm. CNA D stated, That's when I knew - he's outside. She reported the non-functioning door to the DON. On 12/28/20 at 11:25 a.m. SW B returned the call requesting an interview (attempts had been made to call SW B on 12/23/20 at 3:06 p.m.). When asked about the morning she found Resident #100, SW B stated she had been driving her son to school and had heard the alert that came to her phone, so she knew Resident #100 was missing. SW B stated the city police officer arrived a few seconds after she did. SW B stated Resident #100 was attempting to get over a fence. When asked if Resident #100 recognized her, SW B answered, No, I'm not his Social Worker. I was calling him by name. I had my (facility) name tag out for him to see . it was no longer dark . there were lots of cars around . his left thigh had some blood on the pant leg . SW B stated Resident #100 appeared to be cold, but was very cooperative. SW B confirmed Resident #100 was wearing flannel pants and shirt, but she couldn't recall what was on his feet. SW B reported she left after the EMS staff had Resident #100 on the gurney, which took a little time. On 12/30/20 at 2:42 p.m., RN C returned the calls made on 12/23/20 at 3:40 p.m. and 12/28/20 at 2:00 p.m. requesting an interview. RN C was asked to recall the morning of 11/16/20, and stated she was asked about Resident #100's whereabouts by CNA D. They checked his room and bathroom, then RN C went out to check the front lobby and library. She confirmed she called 911 shortly after 5:15 a.m., when the day shift nursing staff was starting to arrive. The local police officers looked through the building. RN C stated after the police arrived she was notified by the DON of the Trillium/Wildflower exit door not functioning. When asked if she was aware of Resident #100's location prior to CNA Ds asking, RN C stated Resident #100 had pushed on the Apple Blossom west door earlier which triggered the alarm, and I saw him go back into his room. During a tour of the facility on 12/23/20 with Maintenance Staff A, the door Resident #100 had exited from (at the junction of Wildflower and Trilium neighborhoods) was the first one checked. An observation was made at 11:33 a.m. of the motion sensor which was installed, and Staff A demonstrated how the Maintenance staff were now logging the check of all exit doors of the facility. When asked if there had been any indication of electrical problems prior to the elopement on 11/16/20, Staff A stated they had had no warning that the panel was out. Review of the door log documents provided by the DON on 12/23/20 showed the maintenance checks started on 11/16/20 with seven accessible exits checked daily. This log indicated the circuit board failure was discovered on 11/19/20 and a contracted agency replaced the circuit panel on 11/20/20, with the invoice provided dated 11/20/20. Resident #100 was observed in his room (room [ROOM NUMBER]) at 11:50 a.m. on 12/23/20. He was dressed appropriately, sitting on a chair near his bed. He looked up but did not respond to this Surveyor. Licensed Practical Nurse (LPN) F, who was at the medication cart right outside Resident #100's room, stated the Resident was waiting for his lunch and a staff CNA would sit with him for his meal. During a discussion with the DON and Staff A at approximately 12:30 p.m. on 12/23/20, they confirmed the root cause of the door alarm failure was believed to be some weather activity that knocked out part of the circuit panel. The DON stated she didn't know what else they could have done when they were not aware of the electrical failure until after Resident #100 came up missing.

This citation refers to MI Intake : MI 780 Based on interview and record review, the facility failed to implement effective interventions to prevent Resident to Resident abuse for eight Residents (#6, #13, #20, #S51, #S53, #S54, #S55, #S64) out of 15 Residents reviewed for abuse, out of a total sample of 23 residents. This deficient practice resulted in physical abuse, unwanted sexual contact, and feelings of fear. The Immediate Jeopardy began 9/10/17, when Resident #20 physically assaulted Resident #S53, and then was found exposed (pants down) lying next to Resident #S53 in his bed. These incidents, and subsequent incidents involving the above listed residents, were not reported to the Administrator or the State Agency, and were not investigated per facility policy. The Administrator was notified of the Immediate Jeopardy at 4:05 p.m. on 10/19/17. The Immediate Jeopardy was removed on 10/19/17 when the facility's plan of abatement was accepted, and the following steps were confirmed: Resident #20 was placed on 1:1 supervision, and the staff of the secured dementia unit (where Resident #20 resided) were educated regarding the type of incidents and behaviors to report, when, and to whom those reports were to be made. The deficient practice continued at pattern level at more than minimal harm due to the lack of investigations into potential abuse of residents, and the need for appropriate referrals and medication management for Resident #20, per the facility plan of abatement. Findings include: A review of Resident #20's record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 10/5/17 Minimum Data Set (MDS) assessment revealed he scored 4/15 on the Brief Interview of Mental Status (BIMS) assessment, indicating severely impaired cognition. This MDS assessment also indicated that he was portraying physical behaviors 1-3 days during the lookback period (seven days prior to the assessment). A review of the Progress notes for Resident #20 revealed the following: 7/11/17 Was observed by several staff members as well as one family member, following suitemate (#S53) out of his suitemates room hitting him on his back and head . (Resident #20) was brought back to dining room area for close observation/ 1:1 until additional measures could be put in place. 8/9/17 Another Resident (#S55) wanted to talk with CNA in private . (Resident #20) came up behind (#S55) and grabbed with both hands around (#S55)'s waist . (Resident #20) thought (#S55) was his wife . 8/15/17 . (Physician Q) updated and called with order for CMH (Community Mental Health) consult . 8/15/17 (written by Social Worker (SW) E), (Resident #20) appears to be escalating, (on) 8/9/17 thought female resident was his wife and grabbed her by the wrists because he didn't want her to leave. Female Resident (unidentified) wanted to call the police because the man grabbed her . 8/24/17 Res (#20) repeatedly approaching a female Resident (facility identified this Resident as #S51) and rubbing her neck and shoulders . 9/10/17 .Resident (#20) in a 2nd residents room (#S53) that adjoins bathroom. The Resident (#20) was noted to be in the 2nd Residents (#S53's) bed with his (#20)'s pants partially down, while 2nd Resident (S53) laying with blankets tuck in all around him . 9/10/17 . Another male Resident (#S53) entered into (Resident #20's) room and he shut the door. Both Residents were behind the door, but CNA was able to get into room and witnessed (Resident #20) punching other Resident (#S53) in both arms, chest and back . 9/17/17 CNA reported observing res with his hand on a female resident's breast (#S54) . 9/29/17 .NP (Nurse Practitioner) does not wish to make changes to medication regimen today. CMH pending because (Resident #20) does not have Medicaid yet . 10/13/17 . Heard crying out from female Resident (#S64). Resident (#20) had struck this female resident across the mouth and face and then female Resident (#S64) struck this Resident (#20) back across the face x2 (two times). Female Resident (#S64) crying and nurse (Licensed Practical Nurse (LPN) K) applied wet compress .Resident (#20) walked away from area with staff and struck second female Resident (#6) on back of head . On 10/18/17 at 9:03 a.m., the Director of Nursing (DON) was asked to provide all Incident and Accident Reports (I/As) and investigations regarding Resident #20's resident to resident altercations. On 10/18/17 at 9:30 a.m., the DON reported she only had one I/A report for Resident #20 and it was related to a fall. The DON reported that she did not think that there were any investigations regarding the incident reports involving the other residents. On 10/18/17 at 9:43 a.m., the Administrator confirmed that there were no I/A reports for the numerous physical and sexual incidents involving Resident #20. On 10/18/17 at 11:47 a.m., an interview was conducted with SW E and Unit Manager/Registered Nurse (RN) B regarding Resident #20s altercations. When asked about Resident #20's behaviors, SW E stated, It's intermittent . He's a younger guy, he has a different air about him. He has an intimidating quality about him. I can see why staff are more cautious of him. When asked if the family of Resident #20 or the family of the victims were notified of the incidents, SW E stated, No. When asked why Resident #20 had not been assessed by a Psych professional, SW E stated, We can't get CMH services because he doesn't have Medicaid. When asked if the Resident had ever been sent to the hospital due to his aggressive and sexual altercations, SW E stated, The gravity of what he does doesn't warrant the nurses to transfer him. When asked if Resident #20 was a danger to himself and others, SW E and RN B both stated, I don't know how to answer that. When asked why there weren't I/A reports for each of the incidents documented in the nurses notes, SW E stated, It's more with Residents living with dementia it's a behavior. So we use the behavior forms. A review of the progress note from Resident S53's chart for the 9/10/17 incident revealed, Resident (#S53) was searching for a way to 'go home'. Resident went into room [ROOM NUMBER], to which that Resident (#20) began punching this resident (#S53) in the anterior and posterior torso . Resident (S53) is expressing fear of being hurt at this time. Resident (#S53) inspected for injuries, light pink area to R(right) upper flank noted . This note indicates that at the time of the event, Resident #S53 expressed fear of Resident #20 and had lingering evidence of physical injury. A review of the progress note from Resident #S55's chart for the 8/9/17 incident revealed, .(Resident #20) came up behind her (#S55) and grabbed with both hands around her waist. (Resident #20) asked Resident (#S55) where she was going . Resident (#S55) was upset for a while and refused HS (evening) medications. Resident (#S55) calmed down after an hour . A review of the progress note from Resident #S54's chart for the 9/17/17 incident revealed, CNA reported that another Resident (#20) touched Res' (#S54's) breast while she was wandering in hallway . On 10/18/17 at 3:36 p.m., a phone interview was conducted with LPN K. When asked about Resident #20's aggressive behaviors and sexual contact with Residents, LPN K stated, He can get aggressive. Really impulsive. He punched a CNA in the face. There was a night when him (Resident #20) and another male (S53) resident got into it. He (Resident #20) kept following him around. When asked if Resident #S53 was afraid of Resident #20, LPN K stated, Afterward, yes. He was (afraid). But I don't think he really remembers now. When asked if the staff called the family after the incidents, LPN K stated, No. We write behavior notes. Then the Social Worker, of Unit Manager, they all work together and from there they handle it. On 10/18/17 at 4:24 p.m., a phone interview was conducted with Registered Nurse (RN) O. When asked any incidents she had witnessed of Resident #20, RN O stated, I'm contingent. Friday (10/13/17) he was very difficult in the early a.m., it took myself and two others CNA's to help get him washed. It took a long time. He was trying to break our hands. I walked him to breakfast. He was quiet the whole meal. I let him be. Then he had lunch. He didn't bother anyone. Right after lunch he got up from the dining room and walked out with his slippers in his hand. When he takes off his footwear it usually means his feet hurt. So I said to him to sit in the chair and I'd get some Tylenol. He walked with me to the chair. I turned away, I didn't have eyes on him for a second. He swung out and hit another resident (#S64) in the face. It happened just like that. There were two nurses there. I took care of (Resident #S64). When asked what happened after this, RN O stated, She (S64) hit him back. I didn't witness it but the CN was talking him (Resident #20) through the dining room and she said he biffed (Resident #6) in the back of the head. When asked if she had notified the families of the Residents involved with this incident, RN O stated, No. We were instructed not to. When asked who had told her not to call the families, RN O stated, The DON. She said it was a behavior and that no one was hurt. When asked if the other Residents on the unit were fearful of Resident #20, RN O stated, I know that another Resident (#13) who witnessed it (the 10/13/17 incident) was fearful. She didn't want to go to the music activity because she was afraid he was going to be there.

This citation refers to Intake MI# 780 Based on interview and record review, the facility failed to protect residents, and failed to thoroughly investigate alleged violations involving resident to resident abuse, and failed to report to the State Agency these alleged violations as required, for 10 Residents (#6, #13, #20, #S51, #S53, #S54, #S55, #S59, #S60, #S64) out of 17 Residents reviewed for abuse, from a total sample of 23 residents. This deficient practice resulted in delayed investigations and lack of protection for residents who experienced physical abuse, unwanted sexual contact, and feelings of fear. The Immediate Jeopardy began 9/10/17, when Resident #20 physically assaulted Resident #S53, and then was found exposed (pants down) lying next to Resident #S53 in his bed. These incidents, and subsequent incidents involving the above listed residents, were not reported to the Administrator or the State Agency, and were not investigated per facility policy. The Administrator was notified of the Immediate Jeopardy at 4:05 p.m. on 10/19/17. The Immediate Jeopardy was removed on 10/19/17 when the facility's plan of abatement was accepted, and the following steps were confirmed: Resident #20 was placed on 1:1 supervision, and the staff of the secured dementia unit (where Resident #20 resided) were educated regarding the type of incidents and behaviors to report, when, and to whom those reports were to be made. The deficient practice continued at pattern level at more than minimal harm due to the lack of investigations into potential abuse of residents, and the need for appropriate referrals and medication management for Resident #20, per the facility plan of abatement. Findings include: A review of Resident #20's record revealed that he had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 10/5/17 Minimum Data Set (MDS) assessment revealed he had scored 4/15 on the Brief Interview of Mental Status (BIMS) assessment, indicating severely impaired cognition. This MDS assessment also indicated that he was portraying physical behaviors 1-3 days during the lookback period (seven days prior to the assessment). A review of the Progress notes for Resident #20 revealed the following: 7/11/17 Was observed by several staff members as well as one family member, following suitemate (#S53) out of his suitemates room hitting him on his back and head . (Resident #20) was brought back to dining room area for close observation/ 1:1 until additional measures could be put in place. 8/9/17 Another Resident (#S55) wanted to talk with CNA in private . (Resident #20) came up behind (#S55) and grabbed with both hands around (#S55)'s waist . (Resident #20) thought (#S55) was his wife . 8/15/17 . (Physician Q) updated and called with order for CMH (Community Mental Health) consult . 8/15/17 (written by Social Worker (SW) E), (Resident #20) appears to be escalating, 8/9/17 thought female resident was his wife and grabbed her by the wrists because he didn't want her to leave. Female Resident wanted to call the police because the man grabbed her . 9/10/17 .Resident (#20) in a 2nd residents room (#S53) that adjoins bathroom. The Resident (#20) was noted to be in the 2nd Residents (#S53's) bed with his (#20)'s pants partially down, while 2nd Resident (#S53) laying with blankets tuck in all around him . 9/10/17 . Another male Resident (#S53) entered into (Resident #20's) room and he shut the door. Both Residents were behind the door, but CNA was able to get into room and witnessed (Resident #20) punching other Resident (S53) in both arms, chest and back . 9/17/17 CNA reported observing res with his hand on a female resident's breast (#S54) . 9/29/17 .NP (Nurse Practitioner) does not wish to make changes to medication regimen today. CMH pending because (Resident #20) does not have Medicaid yet . 10/13/17 . Heard crying out from female Resident (#S64). Resident (#20) had struck this female resident across the mouth and face and then female Resident (#S64) struck this Resident (#20) back across the face x2 (two times). Female Resident (#S64) crying and nurse (Licensed Practical Nurse (LPN) K) applied wet compress .Resident (#20) walked away from area with staff and struck second female Resident (#6) on back of head . On 10/18/17 at 9:03 a.m., the Director of Nursing (DON) was asked to provide all Incident and Accident Reports (I/A's) and investigations regarding Resident #20's Resident to Resident altercations. On 10/18/17 at 9:30 a.m., the DON reported she only had one I/A report for Resident #20 and it was related to a fall. The DON reported that she did not think that there were any investigations regarding the incidents. On 10/18/17 at 9:43 a.m., the Administer confirmed there were no I/As for the numerous physical and sexual incidents involving Resident #20. On 10/18/17 at 11:47 a.m., an interview was conducted with SW E and Unit Manager/Registered Nurse (RN) B regarding Resident #20s altercations. When asked about Resident #20's behaviors, SW E stated, It's intermittent . He's a younger guy, he has a different air about him. He has an intimidating quality about him. I can see why staff are more cautious of him. When asked if the family of Resident #20 or the family of the victims are notified, SW E stated, No. When asked why Resident #20 had not been assessed by a Psych professional, SW E stated, We can't get CMH services because he doesn't have Medicaid. When asked if the Resident had ever been sent to the hospital due to his aggressive and sexual altercations, SW E stated, The gravity of what he does doesn't warrant the nurses to transfer him. When asked if Resident #20 was a danger to himself and others, SW E and RN B both stated, I don't know how to answer that. When asked why there weren't I/A reports for each of the incidents, SW E stated, It's more with residents living with dementia, it's a behavior. So we use the behavior forms. When asked if the residents living on the Unit with Resident #20 were afraid of him, RN B stated, No. A review of the progress note from Resident #S53's chart for the 9/10/17 incident revealed, Resident (#S53) was searching for a way to 'go home'. Resident went into room [ROOM NUMBER], to which that Resident (#20) began punching this resident (#S53) in the anterior and posterior torso . Resident (#S53) is expressing fear of being hurt at this time. Resident (#S53) inspected for injuries, light pink area to R(right) upper flank noted . This note indicated that at the time of the event, Resident #S53 expressed fear of Resident #20 and had lingering evidence of physical injury. A review of the progress note from Resident #S55's chart for the 8/9/17 incident revealed, .(Resident #20) came up behind her (#S55) and grabbed with both hands around her waist. (Resident #20) asked Resident (#S55) where she was going . Resident (#S55) was upset for a while and refused HS (evening) medications. Resident (#S55) calmed down after an hour . A review of the progress note from Resident #S54's chart for the 9/17/17 incident revealed, CNA reported that another Resident (#20) touched Res' (#S54's) breast while she was wandering in hallway . A review of the facility policy, Resident-To-Resident Altercations revealed, All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing and to the Administrator .c.Notify each resident's representative (sponsor) and Attending Physician of the incident . g. document in the resident's clinical record all interventions and their effectiveness. h. Consult psychiatric services as needed for assistance in assessing the resident . i. Compled an Report of Incident/Accident form and document the incident, findings and any corrective measurs taken . j. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; and K. Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy . An interview with Supplemental Sample (S) Resident #S60 at 9:40 a.m. on 10/18/17 learned the following: I was confronted by this Resident named (#S59) a month or two ago. He grabbed me by the wrists and he kicked me too. I had to defend myself. The staff needed to intervene to get him away from me. It upset me at the time. Review of a Nurses Note in Resident #S60's electronic medical record dated 8/27/17 confirmed that a physical altercation had occurred between Resident #S60 and #S59. The Nurses Note documented the following: (Resident #S60) Nervous and upset with roommate. Does not want to share room with him. Area on right wrist where his roommate had his hand around the wrist has no marks or red areas. Documentation in the Nurses Notes of Resident #S59 dated 8/27/17 documented the following: Grabbed roommates right wrist and held it. (Resident #S59) then kicked at (Roommate's) right leg above the knee. An interview with the Director of Nursing at 1:00 p.m. on 10/18/17 to determine if a physical altercation between two male residents (#S59 and #S60) had been internally investigated by the nursing facility, learned the following: I can find no Incident/Accident Reports related to the incident on 8/27/17 between those two residents.

Based on observation, interview, and record review, the facility failed to ensure the safe transport of three residents in wheelchairs (#41, #45, #S50) of 6 residents reviewed for safety, from a total sample of 6 residents. This deficient practice resulted in a fracture and hospitalization for one (Resident #41) and the potential for injury for two Residents (#45 and #S50). Findings include: On 7/27/17 at 12:58 p.m, Resident #41, fell from her wheelchair onto the floor while being pushed by Certified Nurse Aide (CNA) A, per the facility investigation report dated 7/28/17. This investigation report included the following witness statements: Staff D states, I was behind her and seen her fall on floor. She was being pushed by a CNA down the hall to go out to the carnival; CNA E wrote: I was coming down the hall walking in the same direction as the resident being pushed by another CNA ., and on the form under wheelchair foot pedals were: she circled 'OFF'. CNA A's witness statement read, I was pushing (Resident #41) down and she abruptly put her feet down and propelled forward. As a result of the fall, Resident #41 sustained a fractured nose, hematoma with laceration to her forehead, a laceration to the bridge of her nose requiring steri-strips, and full facial bruising to her forehead, bilateral cheeks and chin, per observation of video tape on 8/7/17 at 2:24 p.m. and physician note dated 7/27/17 at 6:43 p.m. Resident #41 is an [AGE] year old female who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #41's Minimum Data Set (MDS) assessment score dated 6/28/17 documents this Resident at a 3, indicating severe cognitive impairment. Resident #41's care plan dated 10/11/16 documented the Resident needed extensive assist of 1 staff for locomotion using a wheelchair. On 8/8/17 at 9:40 a.m., video footage of the fall that occurred on 7/27/17 at 12:58 p.m. was again reviewed. Resident #41 was using her left foot to propel herself forward while being pushed in her wheelchair by CNA A. Resident #41 was elevating her right foot off the floor. Resident #41's left foot was observed being pulled back under the seat of the wheelchair and the resident fell face first onto the floor, hitting her face and left side on the floor and laying on her left side. Also observed in the video footage were Resident S50 and Resident #45, both sitting upright with their feet raised, being pushed in wheelchairs without foot pedals by CNA C and Activities Staff B, consecutively. During viewing of the video of the accident which injured Resident #41, the DON stated, I'm just noticing that now when it was pointed out that two additional residents were being pushed in wheelchairs without foot pedals. Observed on 8/8/17 at approximately 11:05 a.m. was a visitor pushing an unidentified resident down the hall towards the huge foyer/entry way. It was observed the wheelchair did not have foot pedals and the resident was wearing shoes and raising her feet. An interview was conducted on 8/8/17 at 10:42 a.m. with CNA A, who stated, I wasn't aware she (Resident #41) needed foot pedals, she never used them before. Her shoe lace got caught, it was the long stretchy kind, but it was all stretched out. When I realized it and she started falling forward, I went to grab her but my gait belt around my waist got caught on the back of the wheelchair, so I didn't get to her in time. It happened in slow motion and scared me to death. I'd have foot pedals now, for sure. At the exit conference on 8/8/17 at 5:45 p.m. the DON stated, This (wheelchair transport of residents with no foot rests) comes as no surprise. Yes, safety comes before resident's preferences.

Based on observation, interview, and record review, the facility failed to implement adequate interventions, including adequate supervision, consistent with a Resident's (#100) falls-risk needs. This deficient practice affected one Resident (#100) out of four residents sampled for falls, out of a total universe of 4 residents. The deficient practice resulted in lack of supervision of Resident #100, who sustained an avoidable fall on June 24, 2017, an intra-cranial hemorrhage, and a six-day hospital stay. Findings include: Resident #100 was a [AGE] year old female. She was newly admitted to the nursing facility on 6/16/17. Her [DIAGNOSES REDACTED]. The nursing facility filed an Incident Detail report on 6/25/17 which documented a fall by Resident #100 in the dining room at 2:32 a.m. on June 24, 2017. The fall was captured on video surveillance footage. This video footage was reviewed by this Surveyor on July 5, 2017. Video visual evidence captured Resident #100 reclined in a Geri-chair in a unit dining room, at 2:20 a.m. on June 24, 2017. The Resident appears awake and/or restless in the Geri-chair, as she is observed moving her head and arms at approximately 2:20 a.m. A Certified Nurses Aide (CNA) B is sitting an arms length away from Resident #100, providing 1:1 staff to resident monitoring and supervision. At 2:23 a.m., CNA B walked out of the dining room. Ten minutes later, Resident #100 gets up from her Geri-chair. Twelve minutes after CNA B left Resident #100 unsupervised, the resident fell backwards and hit her head on the floor. Resident #100 was sent to the hospital for evaluation later on 6/24/17. Per interview with Registered Nurse (RN) A at 10:15 a.m. on July 5, 2017, Resident #100 stayed in the hospital for six days. She was discharged home with hospice care on June 30, 2017. Another interview with RN A at 3:15 p.m. on July 5, 2017 centered on discussion of the role CNA B was performing for Resident #100 just prior to the fall. RN A acknowledged CNA B had been monitoring/supervising Resident #100 on a 1:1 basis for safety and falls prevention immediately before the CNA walked out of the room and out of sight of Resident #100. RN A stated, CNA (B) should have called for another staff member to watch (Resident #100), rather than leaving the resident unattended. A hospital diagnostic test completed 6/24/17 on Resident #100, known as Computed Tomography (CT) of the head without contrast demonstrated evidence of a Stable small-volume subarachnoid hemorrhage (intra-cranial bleed). The Incident Detail report dated 6/25/17 analyzed Resident#100's fall with injury in the Contributing Factors section of the report: She (Resident #100) was under staff supervision (1:1) for about 4 hours prior to the fall when the staff member left to go to the bathroom. Staff did not request for relief to stand watch over the resident in the dining room when she left to use the bathroom. An Incident Report Employee Statement dated 6/25/17 and signed by RN C, documented the following: She (Resident #100) was impulsive, confused, and unsteady since she arrived (on admission 8 days prior). We placed her on 1:1 (6/24/17) and put her in the dining room to keep eyes on her. Resident #100 had been assessed at high risk for falls as evidenced by a Morse Fall Scale score of 95 on the day of admission (6/16/17). The Morse Fall Scale defined any score above 45as representing high risk for falls. A General Nursing Assessment note for Resident #100 dated 6/16/17 documented, Motor Control: unsteady gait. Poor balance. Reported history of falls at home and during recent hospital stay. The electronic medical record documented previous implementation of 1:1 supervision being utilized to keep Resident #100 safe. A Behavior Committee Note dated 6/20/17 documented the following: Resident (#100) was restless in the evening. She repeatedly stood up from her wheel chair or attempted to wander off the wing requiring her to be 1:1 with a staff member for most of the evening. A High Risk Committee Note dated 6/20/17 documented the following: New admission from hospital. Dementia, weakness. Doesn't understand safety needs. 1:1 with staff at times.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONDUCT RELIABLE SWALLOWING AND DENTAL STATUS ASSESSMENTS, FAILED TO IDENTIFY ASPIRATION RISK FACTORS, AND THEN FAILED TO DEVELOP AND IMPLEMENT INTERVENTIONS TO PREVENT CHOKING AND ASPIRATION FOR ONE (RESIDENT #103) OF SIX RESIDENTS REVIEWED FOR SAFE SWALLOWING OUT OF A TOTAL FACILITY POPULATION OF 111. RESIDENT #103 WAS KNOWN BY THE FACILITY TO HAVE COGNITIVE IMPAIRMENTS WITH SWALLOWING DIFFICULTIES AND A RECENT HISTORY OF CHOKING ON HIS PARTIAL DENTAL PLATE. THIS FACILITY DEFICIENT PRACTICE RESULTED IN IMMEDIATE JEOPARDY TO RESIDENT #103'S HEALTH AND SAFETY. ON [DATE] AT 10:30 A.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON [DATE] AND BEGAN ON [DATE] WHEN RESIDENT #103 RETURNED FROM EMERGENCY SERVICES AFTER HIS LOWER PARTIAL DENTAL PLATE BECOME LODGED IN HIS THROAT. THE FACILITY FAILED TO REASSESS RESIDENT #103'S SWALLOWING DIFFICULTIES AND EVALUATE THESE RISK FACTORS AT THIS TIME. IN ADDITION, THE FACILITY FAILED TO IMPLEMENT REVISIONS TO THE PLAN OF CARE TO ADDRESS ALL RISK FACTORS TO ENSURE SAFE SWALLOWING. THEN ON [DATE], RESIDENT #103 AGAIN DEMONSTRATED SIGNS OF CHOKING AFTER HIS BREAKFAST MEAL. THE FACILITY DIRECTED TWO CERTIFIED NURSE AIDES (CNAS "A" AND "B") WHO WERE NOT CERTIFIED IN CARDIOPULMONARY RESUSCITATION (CPR) FOR EMERGENCY CARE, TO TRANSPORT RESIDENT #103 TO A HOSPITAL LOCATED APPROXIMATELY 10 MILES AWAY VIA A FACILITY VAN, EVEN THOUGH RESIDENT #103 HAD DECLARED HIS RIGHT TO BE RESUSCITATED (FULL CODE) IF A LIFE THREATENING EMERGENCY SITUATION OCCURRED. RESIDENT #103'S LOWER PARTIAL DENTAL PLATE WAS REMOVED VIA SCOPE WHILE AT THE HOSPITAL. RESIDENT #103 died AT THE HOSPITAL ON [DATE]. DURING THE COMPLETION OF THE EXTENDED SURVEY ON [DATE], THE IMMEDIATE JEOPARDY WAS REMOVED BY THE FOLLOWING ACTIONS: 1. ALL CURRENT FACILITY RESIDENTS HAVE BEEN REVIEWED FOR REMOVABLE DENTAL APPLIANCES AND THE RISK FACTORS ASSOCIATED WITH THEM. ANY ISSUES RELATING TO THE APPLIANCES HAVE BEEN CARE PLANNED AND CONSULTS ORDERED AS NEEDED WITH APPROVAL FROM THE RESIDENT PHYSICIAN. 2. ALL NURSING STAFF HAVE BEEN GIVEN THE DIRECTIVE TO HAVE A CERTIFIED NURSE AIDE OR HIGHER LICENSED STAFF IN DINING ROOMS WHEN RESIDENTS WITH SWALLOWING DIFFICULTY HAVE FOOD WITHIN THEIR REACH. THIS WAS VERIFIED BY OBSERVATION AND INTERVIEW. THE UNIT CARE COORDINATORS WILL ENSURE PROPER UNDERSTANDING AND FOLLOW-THROUGH. 3. AT THIS TIME, AT LEAST ONE CPR CERTIFIED NURSE WILL BE ON THE PREMISES AT ALL TIMES. ALL NURSES WILL BE REQUIRED, AS PART OF FUTURE EMPLOYMENT, TO BE CPR CERTIFIED BY [DATE]. THIS WAS VERIFIED BY RECORD REVIEW AND OBSERVATION OF MULTIPLE STAFF BEING ON DUTY WITH CURRENT CPR CERTIFICATION. 4. PER RECORD REVIEW, THE FACILITY "VEHICLE PURPOSE AND POLICIES" POLICY HAS BEEN UPDATED TO INCLUDE ONE STAFF MEMBER WILL BE CPR CERTIFIED DURING ANY TRANSPORTATION OF RESIDENTS AND BE AVAILABLE TO TRANSPORT RESIDENTS TO AND FROM APPOINTMENTS AND/OR OUTINGS. 5. PER RECORD REVIEW AND INTERVIEW WITH NURSING STAFF, THE DEVELOPMENT AND INITIATION OF A NEW POLICY TITLED "RESIDENT - CONSULT/HOSPITAL (NON-ADMIT) FOLLOW-UP" TO ENSURE OPTIMAL RESIDENT CARE AFTER A VISIT TO A DOCTOR OR emergency room WAS IMPLEMENTED. 6. THE MANAGEMENT NURSING STAFF WILL REVIEW THE UPDATED POLICY CHANGES WITH THE APPROPRIATE STAFF. STAFF WILL BE REQUESTED TO SIGN A NOTICE OF UNDERSTANDING. STAFF NOT PRESENT ON [DATE], WILL BE REQUIRED TO SIGN OFF ON THE POLICIES PRIOR TO THEIR NEXT SHIFT. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE REMAINED AT AN ISOLATED LEVEL OF ACTUAL HARM DUE TO: 1. RESIDENT #103 CHOKED ON HIS LOWER PARTIAL DENTAL PLATE AFTER BREAKFAST ON [DATE]. REGISTERED NURSE "C" DID NOT FOLLOW CURRENT STANDARDS OF PRACTICE FOR REMOVAL OF A FOREIGN BODY OBSTRUCTION AND SUCTIONED RESIDENT #103'S ORAL CAVITY AFTER A FINGER SWEEP WAS NOT ALLOWED BY RESIDENT #103. THE PARTIAL DENTAL PLATE WAS REMOVED VIA SCOPE IN THE HOSPITAL emergency room . UPON RESIDENT #103'S RETURN TO THE FACILITY AFTER THIS INCIDENT, THE FACILITY MADE NO REVISIONS IN THE PLAN OF CARE TO ADDRESS THE RISK OF ASPIRATION (THE PASSAGE OF FLUID AND SOLID PARTICLES INTO THE LUNG). RESIDENT #103 BECAME MEDICALLY UNSTABLE, WAS SENT TO THE HOSPITAL ON [DATE], WHERE HE WAS admitted TO THE INTENSIVE CARE UNIT WITH ACUTE [MEDICAL CONDITION] AND HEALTHCARE ASSOCIATED PNEUMONIA. RESIDENT #103 expired on [DATE], WITH FINAL [DIAGNOSES REDACTED]. 2. VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH CONDUCTING COMPREHENSIVE ASSESSMENTS, DEVELOPING INDIVIDUALIZED COMPREHENSIVE CARE PLANS TO MEET THEIR RESIDENTS' NEEDS, AND PROVIDING APPROPRIATE CARE AND SERVICES TO ENSURE THEIR SAFETY AND WELL-BEING. FINDINGS INCLUDE: THE ADMISSION FACE SHEET (NOT DATED) REVEALED RESIDENT #103 WAS A [AGE] year OLD MAN admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THIS FACE SHEET ALSO REVEALED RESIDENT #103 WAS A FULL CODE. A FACILITY FORM TITLED "SWALLOWING WAIVER" DATED [DATE], SIGNED BY RESIDENT #103 AND WITNESSED BY RESIDENT #103'S PHYSICIAN, IDENTIFIED RESIDENT #103 AS HAVING A SPEECH-LANGUAGE EVALUATION AND FOUND TO BE UNSAFE WITH REGULAR CONSISTENCY LIQUIDS, AND RECOMMENDED A NECTAR THICKENED LIQUID AND PUREED FOODS. THE WAVIER REFLECTED RESIDENT (#103) "CHOOSE NOT TO FOLLOW THE RECOMMENDATIONS OF THE THERAPIST" AFTER RECEIVING RISKS OF NONCOMPLIANCE WITH THE SWALLOWING RECOMMENDATIONS. THE MINIMUM DATA SET (MDS) assessment dated [DATE] AND [DATE], REVEALED RESIDENT #103 HAD A BIMS (BRIEF INTERVIEW OF MENTAL STATUS) OF ,[DATE] AND ,[DATE] RESPECTIVELY; BOTH SCORES INDICATED MODERATE COGNITIVE IMPAIRMENT. THE FUNCTIONAL STATUS ADDRESSING "EATING", INDICATED RESIDENT #103 WAS INDEPENDENT WITH EATING; REQUIRING NO SUPERVISION. THE "SWALLOWING/NUTRITIONAL STATUS" IDENTIFYING SWALLOWING DISORDERS, SPECIFICALLY "HOLDING FOOD IN MOUTH/CHEEKS ...CHOKING DURING MEALS AND DIFFICULTY ....WITH SWALLOWING" WERE NOT CHECKED, WHICH INDICATED IT WAS NOT A PROBLEM IN EITHER ASSESSMENT. IN ADDITION, THE "ORAL/DENTAL STATUS" WHICH ASSESSED FOR "...LOOSELY FITTING FULL OR PARTIAL DENTURE" WAS NOT CHECKED, INDICATING IT WAS NOT A PROBLEM IN THESE ASSESSMENTS. A FACILITY DOCUMENT TITLED "CARE PLAN HISTORY (ENTIRE) FOR (RESIDENT #103)" DATED [DATE] AND REVISED [DATE], UNDER "PROBLEM: MECHANICALLY ALTERED DIET WITH [DIAGNOSES REDACTED]. -"FOLLOW SLP (SPEECH LANGUAGE PATHOLOGY) GUIDELINES FOR DIET CONSISTENCY AND SAFE SWALLOWING TECHNIQUES. -HONOR FOOD PREFERENCES, -MONITOR AND RECORD FOOD ACCEPTANCE PER POLICY, -MONITOR WEIGHT PER POLICY, -PROVIDE 8 OZ MILK WITH MEALS, -PROVIDE MECH (MECHANICAL) SOFT DIET, -PROVIDE NECTAR-THICKENED LIQUIDS, -PROVIDE PUREED DIET." ALTHOUGH THE FACILITY IDENTIFIED GUIDELINES FOR DIET CONSISTENCY, THE FACILITY FAILED TO IDENTIFY SPECIFIC SAFE SWALLOWING GUIDELINES OR TECHNIQUES TO IMPLEMENT FOR RESIDENT #103. A REVIEW OF RESIDENT #103'S CARE PLAN REGARDING DIET RELATED TO DYSPHAGIA, REVEALED IT WAS REVIEWED ON [DATE], [DATE] AND [DATE]. THE FACILITY MAINTAINED AN ACKNOWLEDGMENT OF THE RESIDENT'S RIGHT TO REFUSE PUREED FOODS. HOWEVER, ON ALL THREE REVISION DATES, THE FACILITY FAILED TO ADDRESS RESIDENT #103'S NEED FOR SAFE SWALLOWING TECHNIQUES OR THE NEED TO PROVIDE APPROPRIATE SUPERVISION TO MONITOR FOR SIGNS OF CHOKING AND/OR ASPIRATION RELATED TO HIS CHOICE TO REFUSE PUREED FOODS AND THICKENED LIQUIDS. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON [DATE] AT 10:45 A.M., IT WAS REVEALED RESIDENT #103 WAS TRANSPORTED TO THE emergency room VIA FACILITY VAN, FOR treatment of [REDACTED]. THE OBSTRUCTION WAS DISCOVERED TO BE RESIDENT #103'S LOWER DENTAL PARTIAL APPLIANCE AND WAS REMOVED WITH A SCOPE. THE DON STATED THIS WAS NOT THE FIRST TIME RESIDENT #103 SWALLOWED HIS PARTIAL PLATE. THERE WAS AN INCIDENT ON [DATE], WHEN RESIDENT #103 ASPIRATED HIS DENTAL PARTIAL AND WAS SENT TO THE emergency room , WHERE HE WAS ABLE TO COUGH UP THE DENTAL PARTIAL SUCCESSFULLY, WITHOUT MEDICAL INTERVENTION. ALL DOCUMENTS RELATED TO THIS INCIDENT WERE REQUESTED. IN A FOLLOW UP INTERVIEW ON [DATE] AT 10:12 A.M., THE DON STATED NO DOCUMENTS RELATED TO THE INCIDENT OF [DATE] WERE FOUND. THE DON STATED: "I SEARCHED AND I DON'T HAVE THEM (ANY DOCUMENTS INCLUDING AN INCIDENT REPORT OR INVESTIGATION, emergency room REPORT, DISCHARGE INSTRUCTIONS AND ANY TYPE OF DENTAL OR SPEECH THERAPY EVALUATION)." THE DON CONTINUED TO CLARIFY THERE WAS NO EVALUATION OF HIS SWALLOWING ABILITY FROM [DATE] TO [DATE]. THE DON ALSO STATED: "NO, WE DIDN'T CHANGE THE CARE PLAN...I'M SURE WE GOT BACK ER (emergency room ) RECOMMENDATIONS, JUST LIKE WE DID IN FEBRUARY ([DATE]), BUT I CAN'T FIND THEM....WE DIDN'T DO AN INCIDENT REPORT SO I HAVE NO DOCUMENTATION REGARDING THAT OR ANY TYPE OF INVESTIGATION. NO, WE DIDN'T IMPLEMENT ANY TYPE OF PREVENTIVE MEASURES... WE DIDN'T. IT IS WHAT IT IS." DURING AN INTERVIEW ON [DATE] AT 2:00 P.M. WITH THE REGISTERED DIETITIAN (RD) "H", SHE STATED SHE WAS NOT AWARE OF ANY RECOMMENDATIONS SENT BACK FROM RESIDENT #103'S emergency room VISIT ON [DATE] OR ON [DATE]. RD "H" STATED SHE MADE NO REVISION TO RESIDENT #103'S CARE PLAN AFTER EITHER INCIDENT. RD "H" STATED THE SPEECH THERAPIST WOULD BE THE PERSON RESPONSIBLE TO ADDRESS SAFE SWALLOWING INTERVENTIONS TO AVOID ASPIRATION RISKS. RD "H" STATED SHE WAS RESPONSIBLE FOR THE SWALLOWING ASSESSMENT ON THE MDS. WHEN THIS SURVEYOR ASKED WHY THE FACILITY FAILED TO IDENTIFY SWALLOWING RISK FACTORS, RD "H" HAD NO RESPONSE. RD "H" WAS ASKED IF THE "SWALLOW WAVIER" SIGNED ON [DATE] WAS RE-EVALUATED WITH RESIDENT #103 OR HIS FAMILY? RD "H" RESPONDED "NO." WHEN THIS SURVEYOR ASKED TO INTERVIEW THE SPEECH THERAPIST, RD "H" RESPONDED BY INFORMING THIS SURVEYOR THE SPEECH THERAPIST WAS A PART TIME EMPLOYEE AND WAS NOT AVAILABLE AT THIS TIME FOR AN INTERVIEW. ON [DATE] AT 2:20 P.M. AND 3:15 P.M., REGISTERED NURSE/CARE COORDINATOR "G" WAS INTERVIEWED. SHE STATED SHE WAS AWARE OF THE INCIDENT ON [DATE] AND ON [DATE], RELATED TO RESIDENT #103 SWALLOWING HIS LOWER DENTAL PARTIAL. CARE COORDINATOR "G" STATED SHE ASSISTED IN THE TRANSFER OF RESIDENT #103 TO THE HOSPITAL FOR MEDICAL EVALUATION AND TREATMENT ON [DATE]. SHE ALSO STATED SHE WAS NOT INFORMED OF ANY RECOMMENDATIONS SENT BACK TO THE FACILITY RELATED TO THIS INCIDENT. CARE COORDINATOR "G" STATED SHE WAS RESPONSIBLE FOR THE CARE PLANS, WHICH INCLUDED ALL REVISIONS. CARE COORDINATOR "G" STATED SHE MADE NO INTERVENTION CHANGES TO RESIDENT #103'S PLAN OF CARE AFTER THE [DATE] AND [DATE] CHOKING INCIDENTS, TO MITIGATE THE RISK OF RESIDENT #103 CHOKING/ASPIRATING WHILE EATING OR DRINKING. A FACILITY REPORT TITLED "PROGRESS NOTES BY RESIDENT (#103)" DATED [DATE] AT 10:15 A.M., READ "EATING BREAKFAST IN DINING ROOM AND WAS COUGHING MORE THAN USUAL. BROUGHT BACK TO ROOM AND HE SAID HE FELT SOMETHING 'WAS IN HIS THROAT'. LOOKED WITH FLASHLIGHT AND TONGUE DEPRESSOR AND VIEWED NOTHING. THEN I SUCTIONED SOME OF HIS HEAVY CLEAR SECRETIONS AND HE KEPT ON COUGHING, TOLD ME HE WAS 'TRYING TO BRING IT UP'... RESIDENT (#103) WAS ABLE TO SWALLOW WATER, TALK, BUT KEPT MAKING GRUNTING NOISE, ASKED IF HE FELT (SOMETHING) WAS THERE AND HE SAID 'YES'. HE SAID HE WANTED TO GO TO THE HOSPITAL." THE FACILITY REPORT TITLED "PROGRESS NOTE BY RESIDENT (#103)" DATED [DATE] AT 10:30 A.M., READ "D.O.N. NOTIFIED AND SAID OK FOR CNA (CERTIFIED NURSE AIDE) (CNA "A") AND (ANOTHER) AIDE TO DRIVE HIM TO THE HOSPITAL TO BE EVAL (EVALUATED). DOCTOR ON CALL...SAID TO SEND (RESIDENT #103) TO BE EVAL AND TX (TREATMENT) FOR FOREIGN BODY IN ESOPHAGUS." DURING AN INTERVIEW ON [DATE] AT 1:25 P.M. WITH REGISTERED NURSE (RN) "C", SHE STATED: "YES, I WAS THE ONE WORKING THAT DAY ([DATE]) WHEN (RESIDENT #103) SWALLOWED HIS PARTIAL. HE COMPLAINED TO A CNA THAT HE FELT SOMETHING WAS STUCK IN HIS THROAT. I TOOK A FLASHLIGHT AND TONGUE DEPRESSOR AND LOOKED... I COULDN'T SEE ANYTHING. HE WOULD NOT ALLOW ME TO DO A FINGER SWEEP, WHICH IS INDICATED... (RESIDENT #103) WOULDN'T LET YOU PUT A FINGER IN HIS MOUTH... I DID SUCTION HIM. THE FINGER SWEEP... IT'S ONE OF THE STEPS TO DO WHEN YOU ARE DEALING WITH A POSSIBLE AIRWAY OBSTRUCTION. I SUCTIONED HIM BECAUSE HE HAD SO MANY SECRETIONS....". WHEN THIS SURVEYOR ASKED RN "C" IF SHE WAS AWARE THAT A FOREIGN BODY OBSTRUCTION, EITHER PARTIAL OR COMPLETE, WAS CONSIDERED A MEDICAL EMERGENCY, RN "C" STATED: "YES, I GUESS SO...BUT HE APPEARED TO BE STABLE AND I FELT THE TRANSFER TO THE HOSPITAL COULD BE DONE IN THE FACILITY VAN." THIS SURVEYOR ASKED RN "C" IF SHE WAS AWARE OF ANY TYPE OF SWALLOWING DIFFICULTIES RESIDENT #103 WAS HAVING? SHE REPLIED, '"YES, THERE WERE A FEW TIMES THAT I SAW HIM AND KNEW HE WAS ASPIRATING. THAT'S WHEN I WAS TOLD THAT HE SIGNED A WAIVER... SO NO I DIDN'T DO ANY KIND OF PREVENTIVE MEASURES." DURING AN INTERVIEW ON [DATE] AT 1:00 P.M. WITH CNA "A" AND AT 1:15 P.M. WITH CNA "B", BOTH REVEALED THEY WERE THE AIDES WHO TRANSPORTED RESIDENT #103 TO THE HOSPITAL ON [DATE], WHEN RESIDENT #103 HAD SWALLOWED HIS LOWER DENTAL PARTIAL. CNA "A" AND CNA "B" STATED THEY WERE NOT CPR (CARDIOPULMONARY RESUSCITATION) CERTIFIED AT THE TIME OF THE TRANSFER. THE FACILITY REPORT TITLED "PROGRESS NOTES BY RESIDENT (#103)" DATED [DATE] AT 13:57 (1:57 P.M.) READ, "AIDE CALLED FROM HOSPITAL AND INFORMED ME (RN "C") THAT RESIDENT (#103) DID SWALLOW HIS PARTIAL, THEY ALSO WANTED TO KNOW IF HE ALSO ATE SOME EGGS, WHICH WERE STILL IN HIS ESOPHAGUS...(SAID) THEY HAVE TO PUT HIM UNDER SO THEY CAN GO IN AND RETRIEVE HIS PARTIAL. D.O.N. NOTIFIED AND UPDATED." THE PROGRESS NOTE DATED [DATE] AT 1630 (4:30 P.M.) READ, "DR WAS ABLE TO USE SCOPE AND REMOVE THE PARTIAL... REPAIR TO SMALL INCISIONS ON THE ESOPHAGUS, THAT WAS PROBABLY DUE TO THE PARTIAL. HE ALSO SAID IT WAS WAS A FEW INCHES PAST THE VOCAL CORD." A HOSPITAL'S REPORT TITLED "emergency room REPORT" REGARDING RESIDENT #103 DATED [DATE] READ, "HISTORY...THE PATIENT IS IN AN EXTENDED CARE FACILITY BECAUSE OF STROKE ...WHO STARTED HAVING TROUBLE SWALLOWING... HE MAY HAVE SWALLOWED HIS UPPER PARTIAL. HE HAD DONE THIS IN THE PAST. HE IS DROOLING AND IS NOT REALLY TALKING MUCH AND MAKING GROANING NOISES. THIS IS HOW HE HAS PRESENTED IN THE PAST WHEN HE SWALLOWED A FOREIGN BODY... X-RAYS OF THE SOFT TISSUE OF THE NECK ARE OBTAINED SHOWING A FOREIGN BODY." THE HOSPITAL DOCUMENT TITLED, "DISCHARGE INSTRUCTIONS" FOR RESIDENT #103 DATED [DATE] READ, "DISCHARGE Diagnosis: [REDACTED]. ONCE YOU ARE EATING NORMALLY: -CUT FOOD INTO SMALL PIECES. -REMOVE SMALL BONES FROM FOOD. -REMOVE LARGE SEEDS AND PITS FROM FRUIT. -REMEMBER TO CHEW YOUR FOOD WELL. -REMEMBER NOT TO TALK, LAUGH, OR ENGAGE IN PHYSICAL ACTIVITY WHILE EATING OR SWALLOWING." A REVIEW OF RESIDENT #103'S PLAN OF CARE DONE AT THE TIME OF THIS SURVEY, REVEALED IT DID NOT INCLUDE THE DISCHARGE INSTRUCTIONS PROVIDED BY THE HOSPITAL, AFTER THE SECOND TIME RESIDENT #103 CHOKED ON HIS PARTIAL DENTAL PLATE. DURING AN INTERVIEW VIA TELEPHONE ON [DATE] AT 11:15 A.M. WITH THE AMERICAN HEART ASSOCIATION (AHA) TRAINER-COORDINATOR "F", WHO WAS ALSO A BCLS (BASIC CARDIAC LIFE SUPPORT) AND AN ACLS (ADVANCED CARDIAC LIFE SUPPORT ) INSTRUCTOR AND CERTIFIED EMS (EMERGENCY MEDICAL SERVICES) PROVIDER, HE STATED A FOREIGN BODY OBSTRUCTION, EITHER PARTIAL OR COMPLETE, IS A MEDICAL EMERGENCY. HE WENT ON TO STATE: "A PARTIAL AIRWAY OBSTRUCTION IS ONE IN WHICH THE PATIENT CAN STILL HAVE THE ABILITY TO MOVE AIR... THEY CAN TALK, SWALLOW BUT THEY CAN TELL SOMETHING IS STUCK IN THEIR THROAT." HE STATED THAT A BLIND FINGER SWEEP (SWEEPING THE VICTIM'S MOUTH WITH A FINGER WHEN THE OBJECT IS NOT VISIBLE) IS NOT INDICATED WHEN THE OBJECT IS NOT VISIBLE. THE AHA TRAINER "F" STATED: " ...SUCTIONING ...TYPICALLY NO, AS A GENERAL RULE, BECAUSE YOU COULD PUSH THE OBJECT FURTHER DOWN AND LODGE IT IN. PARTIAL OBSTRUCTION... PROBABLY NOT (SUCTION)... YOU SUCTION TO MAINTAIN AN OPEN AIRWAY FROM FLUID, BLOOD, SALIVA AND VOMIT... WHAT YOU WANT TO DO IS TO PROTECT THE AIRWAY." THE AHA TRAINER "F" CONTINUED TO STATE: "THEREFORE, FOR THE PATIENT, ESPECIALLY PATIENTS WITH HISTORY OF [MEDICAL CONDITION], YOU PROTECT HIS AIRWAY...HE SHOULDN'T BE GIVEN ITEMS OR FOOD... ANYTHING THAT WOULD CAUSE THE PATIENT TO CHOKE ON OR ASPIRATE. THIS IS COMMON SENSE." THE FACILITY DOCUMENT TITLED "PROGRESS NOTES BY RESIDENT (#103)" DATED [DATE] READ, "RESIDENT (#103) TEMP (TEMPERATURE) ELEVATED, ORAL TEMP 101.5, BP (BLOOD PRESSURE) ,[DATE] P (PULSE 70. 81% 3(LITERS)....(RESPIRATIONS) 26 AND LABORED, RHONCHI (ABNORMAL LUNG SOUND- RUMBLING TYPE OF SOUND) THROUGHOUT LUNGS. ON CALL DOCTOR NOTIFIED...". A HOSPITAL "emergency room REPORT" DATED [DATE] READ, "CHIEF COMPLAINT: RESPIRATORY DISTRESS. HISTORY: ...BROUGHT IN TODAY DUE TO SEVERE RESPIRATORY DISTRESS AS NOTED IN THE NURSING HOME EARLIER TONIGHT...HE WAS RECENTLY IN THE HOSPITAL IN THE EMERGENCY DEPARTMENT DUE TO AN ASPIRATED FOREIGN BODY AND THAT WAS REMOVED BY (DOCTOR) BY DIRECT LARYNGOSCOPE...". THE "RESPIRATORY" ASSESSMENT READ, "THE PATIENT IS NOTED TO HAVE RHONCHOROUS (ABNORMAL LUNG SOUND RUMBLING TYPE OF SOUND) BREATH SOUNDS BILATERALLY. HE IS NOTED TO BE VERY TACHYPNEIC (RAPID RESPIRATORY RATES) WITH RESPIRATORY RATES IN THE MID-30'S AND HYPOXIC (INADEQUATE OXYGEN TENSION AT THE CELLULAR LEVEL) WITH OXYGEN SATURATIONS IN THE LOW 80S ON NON-REBREATHER MASK. RETRACTIONS (A SIGN SHOWING AN INCREASE IN RESPIRATORY EFFORTS) ARE NOTED AS WELL. THE DIAGNOSTIC IMAGING REVEALED THE RESULTS OF A CHEST X-RAY SHOWED "BILATERAL INFILTRATES". THE IMPRESSIONS READ, "1. ACUTE [MEDICAL CONDITION]. 2. HEALTHCARE-ASSOCIATED PNEUMONIA....PLAN: ADMIT TO THE ICU (INTENSIVE CARE UNIT)...". A FACILITY DOCUMENT TITLED "PROGRESS NOTES BY RESIDENT (#103)" DATED [DATE] AT 00:30 (12:30 A.M.) READ, "RESIDENT (#103) admitted TO (HOSPITAL) POSSIBLE ASPIRATION PER emergency room NURSE." ANOTHER FOLLOW UP PROGRESS NOTE DATED [DATE] AT 9:00 A.M. READ, "AROUND 9AM A CALL FROM A STAFF MEMBER AT (HOSPITAL) NOTIFIED ME (RN "C") OF RESIDENT (#103'S) DEATH, SAID HE HAD PASSED AWAY YESTERDAY FROM [MEDICAL CONDITION]." THE DOCUMENT TITLED "CERTIFICATE OF DEATH" DATED [DATE], RECORDED DATE AND TIME OF DEATH AS [DATE] AT 3:22 P.M., WITH CAUSE OF DEATH DOCUMENTED AS "SEPSIS SYNDROME". DURING AN INTERVIEW ON [DATE] AT 12:50 P.M. WITH THE DON, SHE STATED: "AFTER LOOKING AT THIS DURING THIS VISIT... I REALIZE THAT WE DROPPED THE BALL ON THIS GOING BACK TO THE ,[DATE] (2012) INCIDENT... WE DIDN'T DO ANYTHING TO PREVENT IT FROM HAPPENING AGAIN. THERE SHOULD HAVE BEEN AN INCIDENT REPORT COMPLETED AND WITH THAT AN INVESTIGATION TO DETERMINE WHAT HAPPENED AND IDENTIFY RISK FACTORS... I TAKE FULL RESPONSIBILITY... I SHOULD HAVE CAUGHT THIS AND I DIDN'T....". ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THE ENVIRONMENT WAS FREE FROM ACCIDENT HAZARDS FOR 1 RESIDENT (#1) WHOSE LOWER LEFT LEG CAME IN CONTACT WITH AN EXPOSED HOT HEAT PIPE LOCATED BETWEEN THE WALL MOUNTED HEATING UNIT AND THE FLOOR OF HER ROOM (503-504), OF 3 RESIDENTS REVIEWED FOR HAVING THE EXPOSED HEAT PIPE IN THEIR RESPECTIVE ROOMS OF THE TOTAL 26 ROOMS OBSERVED WITH THE EXPOSED HEAT PIPES POTENTIALLY IMPACTING 52 RESIDENTS OF THE TOTAL FACILITY POPULATION OF 117 RESIDENTS. RESIDENT #1 RECEIVED A SECOND TO THIRD DEGREE BURN TO HER LEG, PLACING HER IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 2/5/13 AT 5 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 1/27/13 AT APPROXIMATELY 5 A.M. WHEN RESIDENT #1 HAD FALLEN FROM HER BED AND CERTIFIED NURSE AIDE (CNA) "A" FOUND HER ON THE FLOOR BESIDE THE BED. UPON DISCOVERY, RESIDENT #1'S LEFT LOWER LEG, JUST BELOW THE KNEE, WAS OBSERVED PRESSING AGAINST THE HOT EXPOSED HEAT PIPE RESULTING IN A 2ND TO 3RD DEGREE BURN TO HER LEG. THE FACILITY WAS NOTIFIED OF THE IMMEDIATE JEOPARDY AT 8 A.M. ON 2/6/13 AND A WRITTEN PLAN FOR REMOVAL WAS REQUESTED. ON 2/6/13 AT 12 NOON, THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THE FOLLOWING: - THERE ARE 51 TOTAL RESIDENT ROOMS IN THE FACILITY. TWENTY-SIX OF THOSE ROOMS CONTAINED THE 4 INCH TO 6 INCH EXPOSED HOT HEAT PIPE THAT RAN FROM THE FLOOR UP TO THE ROOM HEATING UNITS. RESIDENT #1'S ROOM (#503-504) WHICH CONTAINED THE PIPE THAT CAUSED THE BURN, AND THE OTHER 3 RESIDENT ROOMS (501-502, 505-506 AND 507-508) ON THE SPECIAL NEEDS UNIT THAT CONTAINED THE EXPOSED HEAT PIPES, WERE COVERED WITH THE INSULATED PIPE COVERS ON 1/27/13. THE ADDITIONAL 22 ROOMS (301-302, 303-304, 305-306, 307-308, 311-312, 313-314, 315-316, 317-318, 319-320, 321, 322-323, 401-402, 403-404, 405-406, 407-408, 409-410, 411-412, 413-414, 415-416, 417-418, 419-420 AND 500) ALL HAD RECEIVED THE PROTECTIVE INSULATED PIPE COVERS BETWEEN 1/28/13 AND 2/5/13. - ON 2/5/13 BY 5 P.M., THE SURVEYOR HAD DETERMINED THROUGH OBSERVATION, THE 26 RESIDENT ROOMS HAD RECEIVED THE INSULATED PIPE COVERS FOR THE EXPOSED HEAT PIPES. DURING THE SAME DATE AND TIMEFRAME, THE ADDITIONAL 25 RESIDENT ROOMS WERE OBSERVED TO HAVE NO EXPOSED HEATING PIPES. - THE "GRAINGER" PIPE INSULATION PRODUCT WAS USED TO COVER THE EXPOSED COPPER HEATING PIPE. THE "GRAINGER" PRODUCT INFORMATION SHEET (PRINT DATE 1994), SHOWED "PIPE INSULATION PRE-SLIT, SELF SEAL COPPER TUBE SIZE...TEMPERATURE RANGE -40 TO 220 DEGREES F (FAHRENHEIT)...MATERIAL OF CONSTRUCTION ELASTOMERIC..." - AT APPROXIMATELY 5:30 P.M. ON 2/5/13, ALL STAFF WORKING WHO HAD RESIDENT ROOM ACCESS, HAD BEEN NOTIFIED ABOUT THE PURPOSE OF THE FOAM WRAPS AND TO CONTACT THE MAINTENANCE DEPARTMENT WITH ANY CONCERNS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL OF POTENTIAL FOR MORE THAN MINIMAL HARM, DUE TO: - THE CONTINUATION OF THE FACILITY'S QUALITY ASSURANCE PROCESS TO HAVE THE MAINTENANCE DEPARTMENT, WITH OVERSIGHT FROM MAINTENANCE DIRECTOR "B", COMPLETE WEEKLY QUALITY ASSURANCE ROOM CHECKS TO ENSURE THE PIPES REMAIN COVERED AND THE INSULATION PIPE COVERS CONTINUE TO INSULATE AGAINST HEAT. THIS WEEKLY PROCESS WILL CONTINUE UNTIL THE QUALITY ASSURANCE TEAM DETERMINES LESS FREQUENT CHECKS ARE WARRANTED. - THE FACILITY'S NEED TO ALERT THE REMAINING STAFF WHO HAD NOT WORKED THE EVENING OF 2/5/13 OR ON 2/6/13, TO CONTACT THE MAINTENANCE DEPARTMENT WITH ANY CONCERNS WITH THE INSULATED PIPE COVERS. - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH PROTECTING RESIDENTS FROM THE EXPOSED HEAT PIPES. FINDINGS INCLUDE: THE FACILITY'S 1/27/13 "INCIDENT DETAILS" REPORT SHOWED ON 1/27/13 AT APPROXIMATELY 5 A.M., RESIDENT #101 HAD FALLEN OUT OF BED AND WAS FOUND BY CERTIFIED NURSE AIDE (CNA) "A" ON THE FLOOR, AND HAD LANDED WITH HER LEFT KNEE "PRESSED UP AGAINST COPPER PIPE EXITING HEAT REGISTER WHICH IS VERY HOT TO TOUCH...COOL COMPRESS TO AREA OF BURN..." THE ATTACHED 1/28/13 "SKIN CONDITION REPORT..." SHOWED "...SECOND DEGREE POSSIBLE THIRD DEGREE BURN..." RESIDENT #1'S 1/22/13 MINIMUM DATA SET ASSESSMENT SHOWED SHE HAD RESIDED AT THE FACILITY SINCE 10/27/11. THE MDS DOCUMENTED HER [DIAGNOSES REDACTED]. THE MDS AND 12/2012 CARE PLAN, SHOWED HER COGNITION AS SEVERELY IMPAIRED, AND SHE RARELY UNDERSTOOD WHAT WAS SAID TO HER. RESIDENT #1, PER THE CARE PLAN, NEEDED EXTENSIVE ASSISTANCE WITH TRANSFERS AND STAFF ASSISTED HER WITH PROPELLING HER WHEELCHAIR. THE CARE PLAN SHOWED BECAUSE SHE RARELY MOVED HER BODY WITHOUT ASSISTANCE, RESIDENT #1 WAS ON A 2 HOUR REPOSITIONING PROGRAM. THE 1/28/13 PHYSICIAN ORDER [REDACTED]...1 TIME PER DAY SPECIAL INSTRUCTIONS: IF DRAINAGE CLEANSE WITH NS AND APPLY ANTIBIOTIC OINTMENT, COVER WITH ABSORBENT PROTECTIVE DRESSING..." THE 1/28/13 "SKIN CONDITION NOTES" DOCUMENTED, "LARGE FLUID FILLED BLISTER PRESENT ON LEFT ANTERIOR SHIN/LATERAL CALF...MEASURES 6 CM (CENTIMETERS) BY 3 CM, UNABLE TO MEASURE DEPTH ...SKIN INTACT AT THIS TIME...REDDENED RING NOTED TO IRREGULAR OUTER EDGES OF BURN. SECOND DEGREE BURN OR POSSIBLE THIRD DEGREE BURN...AREA CLEANSED AND SILVADENE APPLIED TO SITE OF CLOSED BLISTER AREA..." THE REVIEW OF THE 1/29/13, 1/31/13, 2/1/13 AND 2/2/13 "SKIN CONDITION" NOTES, SHOWED NO CHANGE IN SIZE OF WOUND, "...SEROUS DRAINAGE NOTED TO REMOVED DRESSING... UNABLE TO DETERMINE DEGREE OF BURN DUE TO NOT BEING ABLE TO VISUALIZE WOUND BED..." THE DON WAS INTERVIEWED ON 2/4/13 AT 3 P.M. SHE STATED THE "INCIDENT DETAIL" REPORT WAS CORRECT. THE DON SAID THEY DO NOT KNOW HOW LONG RESIDENT #1 LAID WITH HER LEG AGAINST THE HOT PIPE. SHE EXPLAINED THE FACILITY CAMERA SHOWED CNA "A" ENTERED THE ROOM TO CHECK ON HER AT 4:05 A.M. WITH STAFF FINDING RESIDENT #1 ON THE FLOOR AT AROUND 5 A.M. - 5:15 A.M. REGISTERED NURSE (RN) "E" WAS INTERVIEWED ON 2/5/13 AT 8:30 A.M. RN "E" STATED SHE WAS RESIDENT #1'S NURSE AND HAD WORKED WITH HER FOR A LONG TIME. SHE ALSO EXPLAINED SHE WAS THE NURSE ON DUTY TWO HOURS AFTER THE BURN HAD OCCURRED ON 1/27/13, FROM 7 A.M. TO 7 P.M. WHEN ASKED WHY SHE BELIEVED RESIDENT #1 DID NOT REMOVE HER LEG FROM THE HOT PIPE, SHE SAID, "...WITH (RESIDENT #1'S) ADVANCED ALZHEIMER'S SHE WOULD NOT HAVE KNOWN TO REMOVE HER LEG FROM THE PIPE...WE ASSIST HER WITH HER MOVEMENTS..." ON 2/5/13 AT 9:30 A.M., RN "C" AND LICENSED PRACTICAL NURSE (LPN) "D" WERE OBSERVED TREATING RESIDENT #1'S BURN WHILE SHE LAY IN HER BED. RESIDENT #1'S SHIFT NURSE, RN "E", WAS IN THE ROOM. THE PADDED TOPICAL BANDAGE WAS REMOVED SHOWING SEROUS DRAINAGE. THE BURN AREA MEASURED 6.5 CM BY 4 CM WITH AN APPROXIMATE QUARTER INCH REDDENED AREA AROUND THE OUTSIDE OF THE BURN. THE REST OF THE INSIDE OF THE BURN LOOKED TO BE A YELLOWISH SLOUGH-TYPE MATERIAL. RESIDENT #1 SHOWED NO SIGNS OF PAIN AS THE WOUND WAS BEING TREATED. WHEN RN "C" ASKED IF SHE WAS IN PAIN, RESIDENT #1 SHOOK HER HEAD "NO". DURING THE OBSERVATION, THE THREE NURSES WERE ASKED WHAT DEGREE BURN THEY BELIEVED IT TO BE. RN "E" SAID: "...I'VE SEEN OTHER BURNS AND THIS IS A THIRD DEGREE BURN..." THE ADMINISTRATOR AND DON WERE INTERVIEWED ON 2/5/13 AT 3:15 P.M. MAINTENANCE DIRECTOR "B" WAS INTERVIEWED BY PHONE ON 2/5/13 AT 3:30 P.M. MAINTENANCE DIRECTOR "B" STATED IN THE COLD WEATHER, THE EXPOSED PIPE COULD REACH "...150 TO 160 DEGREES (FAHRENHEIT) DEPENDING ON WHERE THE HEATING SYSTEM WAS IN THE CYCLING PROCESS ..." THE 3 STAFF STATED THEY DID NOT THINK OF THE EXPOSED HOT HEAT PIPES AS ENVIRONMENTAL HAZARDS. THE ADMINISTRATOR AND MAINTENANCE DIRECTOR "B" SAID THE PIPES HAD BEEN EXPOSED SINCE THE 1960'S. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND FUNCTIONING ASSISTIVE DEVICES TO PREVENT AN ACCIDENT FOR ONE (#8) OF TEN RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 21 RESIDENTS OUT OF A FACILITY RESIDENT POPULATION OF 118. THIS FAILURE RESULTED IN HARM TO RESIDENT #8 WHEN SHE fell AND SUSTAINED A FRACTURED LEFT WRIST AND FACIAL INJURIES. FINDINGS INCLUDE: A REVIEW OF THE ADMISSION FACE SHEET OF RESIDENT #8 DATED 10/28/11 REVEALED RESIDENT #8 IS [AGE] years OLD WITH ADMISSION [DIAGNOSES REDACTED]. RESIDENT #8 WAS RESIDING ON THE SPECIAL NEEDS DEMENTIA UNIT AT THE FACILITY. REVIEW OF THE MOST RECENT MINIMUM DATA SET (MDS) ASSESSMENT FOR RESIDENT #8 (DATED 5/03/12) REVEALED RESIDENT #8 HAD SIGNIFICANT COGNITIVE IMPAIRMENT AS EVIDENCED BY A "BRIEF INTERVIEW OF MENTAL STATUS" (BIMS) SCORE OF 4 FROM A POSSIBLE 15. IN ADDITION, THE MDS dated [DATE] ALSO SHOWED RESIDENT #8 REQUIRED LIMITED ASSISTANCE AND ONE PERSON PHYSICAL ASSIST WITH HER AMBULATION. A REVIEW OF THE "FALL RISK ASSESSMENT" FOR RESIDENT #8 DATED 2/10/12, REFLECTED RESIDENT #8 WAS AT A HIGH RISK FOR FALLS WITH A TOTAL FALL RISK SCORE OF 15. SCORES GREATER THAN 9 SHOW AN INCREASED RISK FOR FALLING. A REVIEW OF A FACILITY "INCIDENT DETAILS" REPORT DATED 5/24/12, SHOWED AT APPROXIMATELY 7:27 A.M. ON THAT DATE, CNA "I" HEARD RESIDENT #8 CALLING OUT. CNA "I" RESPONDED TO THE CALL AND FOUND RESIDENT #8 LYING ON THE FLOOR IN HER ROOM. ACCORDING TO THE "INCIDENT DETAILS" REPORT, RESIDENT #8 WAS FOUND LYING ON HER ABDOMEN NEAR THE BATHROOM DOOR. SHE HAD REGULAR SOCKS ON HER FEET. THE PRESSURE ALARM WAS OBSERVED ON THE BED BUT WAS NOT SOUNDING. RESIDENT #8 REPORTED THAT SHE HAD GOT UP TO USE THE BATHROOM AND fell on HER WAY BACK TO BED. URINE WAS NOTED IN THE RESIDENT'S TOILET. ACCORDING TO THE "INCIDENT DETAILS" REPORT, THERE WAS A MODERATE AMOUNT OF BLEEDING NOTED FROM THE LEFT SIDE OF RESIDENT #8'S FOREHEAD JUST ABOVE THE BROW LEVEL. ON EXAMINATION, RESIDENT #8 COMPLAINED OF DISCOMFORT TO HER LEFT WRIST. NEURO CHECKS WERE COMPLETED. SOME ABNORMAL ALIGNMENT WAS NOTED TO THE RESIDENT'S LEFT WRIST AREA AND THERE WAS DARK PURPLE BRUISING NOTED TO THE LEFT EYE. RESIDENT #8 WAS SENT TO THE emergency room FOR X-RAYS PER physician's orders [REDACTED].M. THE RESULTS OF THE X-RAY, DATED 5/24/12, REVEALED A CLOSED FRACTURE OF HER LEFT DISTAL END OF RADIUS AT THE WRIST. A REVIEW OF THE PLAN OF CARE FOR RESIDENT #8 UNDER THE CATEGORY OF "FALL RISK, POTENTIAL FOR INJURY" FINDS THE FOLLOWING "APPROACHES" IDENTIFIED FOR RESIDENT #8, EFFECTIVE 11/9/11: "ASSIST TO TOILET AT APPROXIMATELY 4 A.M. AND 6 A.M. TO PREVENT SELF-TRANSFERS AND FALLS", "SENSOR PADS WITH ALARMS, AUDIBLE TO WHEELCHAIR AND IN BED, BED (ALARM) IS ALSO CONNECTED TO (NURSING STAFF) PAGER FOR SAFETY" AND "SHORTEN ALL CLOTHING (RESIDENT #8) MIGHT TRIP ON. SHOES WELL FITTING WITH NON-SLIP SOLES OR GRIPPER SOCKS." A REVIEW OF THE FACILITY'S 5 DAY INVESTIGATIVE SUMMARY FOLLOWING THIS INCIDENT (UNDATED) REVEALED RESIDENT #8 HAD BEEN FOUND ON THE FLOOR IN HER ROOM ON THE MORNING OF 5/24/12. THE REPORT IDENTIFIED THAT RESIDENT #8'S BED SENSOR ALARM WAS NOT SOUNDING AND FURTHER INDICATED RESIDENT #8 HAD A PRIOR HISTORY OF TURNING HER ALARMS OFF IN THE PAST. IN ADDITION, RESIDENT #8 WAS IDENTIFIED AS HAVING REGULAR SOCKS ON WITHOUT "GRIPPY" BOTTOMS TO THEM AS REQUIRED IN HER CARE PLAN. THE SUMMARY IDENTIFIED THAT RESIDENT #8 WAS ON A TOILETING SCHEDULE, BUT NO EVIDENCE WAS PROVIDED TO SHOW THE RESIDENT HAD BEEN TOILETED PRIOR TO HER FALL OR IF THE BED ALARM HAD TRIGGERED A NURSING STAFF PAGER. AN INTERVIEW WAS CONDUCTED WITH CNA "H" ON 5/31/12 AT APPROXIMATELY 2 P.M. CNA "H" HAD BEEN ASSIGNED TO THE CARE OF RESIDENT #8 DURING THE EVENING SHIFT BEGINNING AT 6 P.M. ON 5/23/12 AND ENDING AT 6 A.M. ON 5/24/12. CNA "H" VERIFIED THAT SHE HAD CHECKED THE BED SENSOR ALARM ON THE BED OF RESIDENT #8 WHEN SHE ASSISTED HER TO BED AND STATED THAT IT WAS WORKING. CNA "H" INDICATED THAT SHE HAD CHECKED RESIDENT #8 SEVERAL TIMES DURING THE NIGHT, BUT COULD NOT RECALL HAVING ASSISTED HER TO THE TOILET. ON 6/1/12 AT APPROXIMATELY 11:30 A.M., AN INTERVIEW WAS CONDUCTED WITH CNA "I". CNA "I" WAS ASSIGNED TO THE CARE OF RESIDENT #8 BEGINNING AT 6 A.M. ON 5/24/12, PRIOR TO THE FALL. CNA "I" FOUND RESIDENT #8 ON THE FLOOR AT APPROXIMATELY 7:30 A.M. CNA "I" INDICATED THAT SHE HAD NOT TOILETED OR BEEN INVOLVED WITH RESIDENT #8 PRIOR TO FINDING HER ON THE FLOOR THAT MORNING. ON 6/1/12 AT APPROXIMATELY 11 A.M., AN INTERVIEW WITH THE DON REVEALED THAT IT HAD NOT BEEN DETERMINED WHY THE SENSOR ALARM OF RESIDENT #8'S BED DID NOT SOUND WHEN RESIDENT #8 GOT OUT OF BED SOMETIME ON THE MORNING OF 5/24/12. THE DON STATED THAT A SECOND ALARM, IDENTIFIED IN THE PLAN OF CARE AS BEING ATTACHED TO THE CNA PAGER SYSTEM, HAD NOT BEEN PLACED ON RESIDENT #8'S BED AT THE TIME OF THE FALL TO ALERT STAFF TO HER MOVEMENTS, NOR HAD THE RESIDENT BEEN WEARING GRIPPY SOCKS TO PREVENT SLIPPING ACCORDING TO HER CARE PLAN FOR FALL PREVENTION. AN INTERVIEW WAS CONDUCTED WITH RESIDENT #8 ON 5/30/12 AT APPROXIMATELY 11 A.M. AND AGAIN ON 5/31/12 AT APPROXIMATELY 3:30 P.M. RESIDENT #8 WAS ABLE TO REPORT THAT SHE HAD FALLEN, BUT NOT HOW THE FALL HAD HAPPENED. THE FACILITY HAD IDENTIFIED RESIDENT #8 AS BEING AT RISK FOR FALLS AND APPROACHES HAD BEEN IDENTIFIED IN HER CARE PLAN TO PREVENT RESIDENT #8 FROM FALLING. IT WAS DETERMINED THAT RESIDENT #8 HAD NOT BEEN TOILETED AT 4 A.M. OR AT 6 A.M. ON THE MORNING OF 5/24/12, RESIDENT #8 WAS NOT WEARING "GRIPPER SOCKS" OR SHOES AT THE TIME OF THE FALL, AND AN ALARM ON THE BED THAT WOULD ALERT NURSING STAFF RECEIVING A "PAGE" WAS NOT IN PLACE ON THE BED PER THE RESIDENT'S CARE PLAN. RESIDENT #8 APPEARS TO HAVE GOTTEN UP EARLY ON THE MORNING OF 5/24/12, TOILETED HERSELF WITHOUT STAFF ASSISTANCE AND fell COMING BACK FROM THE BATHROOM, RESULTING IN A FALL AND FRACTURE WHICH COULD HAVE BEEN PREVENTED. ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES RESULTING IN HARMFUL NEGLECT OF ONE FRAIL RESIDENT (#1) OF FIVE SAMPLED RESIDENTS REVIEWED FOR USE OF HOT PACKS OUT OF THE FACILITY RESIDENT POPULATION OF 117. THIS FACILITY'S DEFICIENT PRACTICE RESULTED IN RESIDENT #1 DEVELOPING A SECOND DEGREE BURN TO HER RIGHT SHOULDER WHEN REGISTERED NURSE (RN) "B" NEGLECTED TO FOLLOW PHYSICIAN ORDERS [REDACTED].#1'S SKIN WHEN CERTIFIED NURSE AIDE (CNA) "A" PUT A HOT PACK ON RESIDENT #1'S SHOULDER/NECK AREA, PLACING HER IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. FINDINGS INCLUDE: THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 11/15/11 AT 11:30 A.M. THE IMMEDIATE JEOPARDY BEGAN ON 11/09/11 AT APPROXIMATELY 5:30 A.M., WHEN CNA "A" PLACED A THERMALSOFT GEL HOT PACK TO RESIDENT #1'S SHOULDER/NECK AREA. THE FACILITY'S INVESTIGATION COULD NOT DETERMINE WHEN SPECIFICALLY THE 5:30 A.M. HOT PACK HAD BEEN REMOVED, BUT A HOT PACK WAS REMOVED SOMETIME AFTER 9:00 A.M. THIS LACK OF FOLLOWING PHYSICIAN ORDERS [REDACTED].#1'S RIGHT SHOULDER, WHICH WAS NOT IDENTIFIED UNTIL 11/10/11 AT APPROXIMATELY 10:00 A.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 11/15/11 AT 12:40 P.M. ON 11/15/11 AT 2:45 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THE FOLLOWING: - ALL THERMALSOFT GEL PACKS AND THE MICROWAVES USED TO HEAT THEM HAD BEEN REMOVED - SAMPLED RESIDENTS #1, #2, #3, #4 AND #5 REPORTED DURING INTERVIEWS NO USE OF GEL PACKS AFTER 11/10/11 - REVIEW OF AN 11/10/11 MEMORANDUM SHOWED NOTIFICATION TO ALL DIRECT CARE STAFF THAT THERMAL GEL HOT PACKS WERE NOT TO BE USED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL, WITH ACTUAL HARM TO RESIDENT #1, AND POTENTIAL FOR HARM TO OTHER RESIDENTS, DUE TO: - AWAITING COMPLETION OF ASSESSMENTS WITH ALL RESIDENTS THAT HAD RECEIVED THE THERMAL GEL PACK TREATMENTS AND TO DETERMINE WHAT ALTERNATIVE PAIN RELIEF MEASURES WILL BE PROVIDED. - THE NEED TO REVIEW ALL RESIDENT CARE PROCEDURES TO ENSURE THEY INCLUDE ALL INFORMATION NEEDED TO DIRECT STAFF IN THE APPROPRIATE USE OF RESIDENT CARE DEVICES. - DEMONSTRATION THAT STAFF HAVE BEEN TRAINED AND ARE COMPETENT IN RESIDENT CARE PROCEDURES FOR ANY RESIDENT CARE DEVICES AND IN PROVIDING TREATMENTS. FINDINGS INCLUDE: A REVIEW OF THE FACILITY'S 11/10/11-11/14/11 INITIAL INVESTIGATION SHOWS ON 11/09/11 AT APPROXIMATELY 5:30 A.M., CNA "A" PLACED A THERMALSOFT GEL HOT PACK AROUND RESIDENT #1'S NECK WHICH DRAPED ONTO HER SHOULDERS. ACCORDING TO THE INVESTIGATION REPORT, ON 11/10/11 AT 10:00 A.M DURING RESIDENT #1'S BATH , A SKIN ASSESSMENT PERFORMED BY TREATMENT NURSE RN "I" SHOWED RESIDENT #1'S RIGHT SHOULDER TO HAVE A "3 CM (CENTIMETER) BY 5.5 CM LESION TO TOP RIGHT SHOULDER NEAR CLAVICLE...100 PERCENT SLOUGH WITH LIGHT [DIAGNOSES REDACTED]TOUS BORDER...WITH LIGHT DRAINAGE...(RESIDENT #1) STATES TENDER TO TOUCH, NO BLISTERING AT THIS TIME...AREA APPEARS TO BE A BURN." DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 11/15/11 AT 8:50 A.M. AND AN INTERVIEW WITH TREATMENT NURSE "I" ON 11/15/11 AT 9:00 A.M., BOTH STAFF CONFIRMED THE INVESTIGATION SUMMARY WAS CORRECT AND THE WOUND TO RESIDENT #1'S RIGHT SHOULDER WAS DETERMINED TO BE A SECOND DEGREE BURN. RESIDENT #1'S CLINICAL CHART WAS REVIEWED. HER FACE SHEET DOCUMENTED SHE IS [AGE] years OLD AND WAS admitted to the facility on [DATE]. RESIDENT #1'S [DIAGNOSES REDACTED]. RESIDENT #1'S 9/13/11 MINIMUM DATA SET (MDS) ASSESSMENT AND CURRENT CARE PLAN SHOW SHE MAKES HER OWN MEDICAL DECISIONS AND NEEDS LIMITED ASSISTANCE WITH HER ACTIVITIES OF DAILY LIVING. THE 11/07/11 NURSING NOTES AND 11/07/11 PHYSICIAN NOTES DOCUMENT RESIDENT #1 HAD GONE TO AND RETURNED FROM THE hospital on [DATE] FOR treatment of [REDACTED].#1'S) MEDICAL ISSUES WOULD CONTINUE TO BE AN ISSUE,... AS HER FRAILTY IS RESULTING IN REDUCED RESISTANCE TO INFECTION. SHE IS IN AN END-OF-LIFE SCENARIO..." THE PHYSICIAN NOTES DOCUMENTED THE OFFERING OF PAIN MEDICATION FOR RESIDENT #1'S CHRONIC PAIN WITH RESIDENT #1 STATING SHE PREFERRED COPING WITH THE PAIN RATHER THAN BEING SEDATED. THE PHYSICIAN NOTE ALSO DOCUMENTED, "HER CHRONIC PAIN IS UNLIKELY TO BE CONTROLLED WITHOUT SOME SEDATION..." THE 11/06/11 PHYSICIAN ORDERS [REDACTED]. AN ADDITIONAL INTERVIEW WAS CONDUCTED WITH THE DON ON 11/15/11 AT 10:10 A.M. WHEN ASKED FOR CLARIFICATION REGARDING THE PHYSICIAN ORDERS [REDACTED]. THE DON STATED ALL HOT PACKS WERE CHECKED BY FEELING THE HOT PACK FOR WARMTH. THE DON STATED STAFF WERE NOT DELINEATING ANY DIFFERENCE BETWEEN A WARM PACK VERSUS HOT PACK TREATMENT. SHE EXPLAINED ALL THE TREATMENTS WERE CONSIDERED HOT PACK TREATMENTS. A BRIEF INTERVIEW WAS CONDUCTED WITH RESIDENT #1 IN HER ROOM ON 11/15/11 AT 8:30 A.M,. WHILE SHE WAS LYING IN BED IN HER HOSPITAL-TYPE GOWN. AS THIS SURVEYOR ENTERED HER ROOM, RESIDENT #1 WAS MOANING. WHEN ASKED IF SHE WAS O.K., RESIDENT #1 STOPPED MOANING AND SAID SHE WAS FINE. WHEN ASKED IF HER SHOULDERS HURT, RESIDENT #1 SAID, "NO, I'M FINE..." WHEN ASKED IF SHE KNEW HOW SHE GOT THE BURN ON HER SHOULDER, SHE LOOKED CONFUSED AND SAID SHE WAS FINE BUT TIRED. THE FACILITY'S HOT PACK POLICY TITLED, "USE OF THERMALSOFT GEL PACK IN MICROWAVE" (7/12/11) WAS REVIEWED. THE FIRST PARAGRAPH IN THE POLICY PARTIALLY READS, "...THIS THERAPY IS IMPLEMENTED BY A physician's orders [REDACTED]...2. WRAP GEL PACK WITH 2 LAYERS OF TOWELING ON EACH SIDE...6. REMOVE GEL PACK AFTER MAXIMUM OF 20 MINUTES...7. CHECK SKIN PERIODICALLY DURING TREATMENT..." THE FACILITY POLICY TITLED, "HOT PACK" (5/04/09) "GUIDELINES" READS, "...8. REMOVE HOT PACK AFTER TREATMENT...AND INSPECT FOR ANY ADVERSE SIGNS..." A TELEPHONE INTERVIEW WAS CONDUCTED WITH CNA "A" ON 11/15/11 AT 5:00 P.M. CNA "A" STATED SHE HAD PUT THE HOT PACK ON RESIDENT #1'S SHOULDERS ON 11/09/11 AT AROUND 5:30 A.M., BECAUSE THE CAMERA OUTSIDE RESIDENT #1'S ROOM DOCUMENTED THE DAY AND TIME SHE WENT INTO THE ROOM WITH THE HOT PACK. CNA "A" SAID SHE ALWAYS HAS THE NURSE "FEEL" THE HOT PACK TO MAKE SURE IT'S NOT TOO WARM. SHE STATED SHE WRAPPED IT IN THE PILLOWCASE AND THEN WRAPPED A TOWEL AROUND IT AND PLACED IT AROUND RESIDENT #1'S NECK ON HER SHOULDERS. WHEN CNA "A" WAS ASKED IF SHE CHECKED ON THE CONDITION OF RESIDENT #1'S SHOULDER ANYTIME DURING OR AFTER THE HOT PACK TREATMENT, CNA "A" STATED SHE NEVER DID SKIN CHECKS AND SHE DID NOT REMEMBER EVER REMOVING THE HOT PACK FROM RESIDENT #1. CNA "A" STATED, "I BELIEVE THE NURSES USUALLY REMOVE THE HOT PACKS..." DURING A TELEPHONE INTERVIEW ON 11/16/11 AT 6:30 A.M.WITH RN "B", SHE VERIFIED SHE WAS RESPONSIBLE FOR THE CARE DELIVERED TO RESIDENT #1 ON 11/09/11 AT 5:30 A.M. RN "B" STATED, "I DON'T RECALL DOING SKIN CHECKS...I DON'T RECALL REMOVING RESIDENT #1'S HOT PACK THAT MORNING (11/09/11)...I DON'T 'TIME' HOW LONG IT'S (THE HOT PACK) BEEN ON BECAUSE ESPECIALLY WITH (RESIDENT #1), SHE USUALLY WANTS IT ON LONGER THAN A FEW MINUTES..." RN "B" EXPLAINED SHE DID NOT MONITOR RESIDENT #1'S SKIN BEFORE ALLOWING THE HOT PACK TO REMAIN ON HER SHOULDERS. SHE SAID, "WE PROBABLY SHOULD'VE BEEN MORE CAUTIOUS USING THE HOT PACKS AFTER HER RETURN FROM THE HOSPITAL (11/06/11) BECAUSE (RESIDENT #1'S) NOT BEEN FEELING WELL...(RESIDENT #1) WAS ONLY WEARING THE HOSPITAL GOWN. WHEN WE WOULD PLACE THE HOT PACKS BEFORE, (PRIOR TO 11/06/11) SHE WAS WEARING LAYERS OF CLOTHING THAT WE WOULD LAY THE HOT PACK ON..." DURING THE INTERVIEW WITH TREATMENT NURSE "I" ON 11/15/11 AT 9:00 A.M., TREATMENT NURSE "I" SAID SHE TREATED RESIDENT #1'S BURN PER THE physician's orders [REDACTED]. AN OBSERVATION WAS CONDUCTED ON 11/15/11 AT 9:30 A.M. AS TREATMENT NURSE "I" CHANGED THE DRESSING TO RESIDENT #1'S BURN. THE WOUND WAS APPROXIMATELY 3.0 CM BY 5 CM TO THE TOP RIGHT SHOULDER NEAR THE CLAVICLE. THE [DIAGNOSES REDACTED]TOUS BORDER DOCUMENTED AS PRESENT ON 11/10/11 WAS NOT SEEN DURING THIS OBSERVATION. THE WOUND HAD A BLACK/BLUE ESCHAR WITH NO VISIBLE DRAINAGE. RESIDENT #1 GRIMACED AND YELLED OUT "THAT HURTS" AS THE BANDAGE WAS REMOVED. RESIDENT #1 STATED THERE WAS NO PAIN AS TREATMENT NURSE "I" TREATED THE WOUND, BUT SAID SHE WAS VERY NERVOUS IT WAS GOING TO HURT. A TELEPHONE INTERVIEW WAS CONDUCTED WITH RN "L" ON 11/17/11 AT 9:30 A.M. RN "L" SAID WHEN SHE WOULD APPLY A HOT PACK FOR A RESIDENT, SHE WOULD WRAP THE THERMALSOFT GEL HOT PACK IN A PILLOWCASE BEFORE PLACING IT ON A RESIDENT'S BODY AND MENTIONED NO USE OF A TOWEL. SHE STATED SKIN CHECKS DURING AND AFTER THE HOT PACK TREATMENTS WERE NOT ALWAYS COMPLETED. A TELEPHONE INTERVIEW WAS CONDUCTED WITH LICENSED PRACTICAL NURSE (LPN) "K" ON 11/17/11 AT 9:40 A.M. LPN "K" STATED SHE HAD CONSISTENTLY PLACED HOT PACKS TO RESIDENT #1'S NECK AND SHOULDERS WRAPPED IN A PILLOWCASE. SHE EXPLAINED SHE WAS NOT INFORMED UNTIL AFTER THE 11/09/11 INCIDENT WITH RESIDENT #1, THAT THE HOT PACK SHOULD HAVE BEEN WRAPPED IN TOWELS ALSO. DURING THE INTERVIEW WITH THE DON ON 11/15/11 AT 10:10 A.M., SHE WAS ASKED HOW THE NURSES AND CNAS WERE TRAINED AND HOW CNAS ARE SUPERVISED IN THE USE OF THE THERMALSOFT GEL HOT PACKS. THE DON SAID, THE NURSES WERE GIVEN "WEB ACCESS" TO ALL POLICIES/PROCEDURES. THE DON STATED THERE WAS NO DOCUMENTATION TO DEMONSTRATE THAT STAFF ACCESSED ANY PARTICULAR POLICY AND PROCEDURE, INCLUDING THE PROCEDURE FOR USE OF HOT PACKS. SHE EXPLAINED THERE WAS NO FACILITY DOCUMENTED TRAINING OF THE NURSES OR CNAS IN THE HOT PACK TREATMENT PROCEDURE. THE DON STATED, DURING THEIR ON-GOING INVESTIGATION OF RESIDENT #1'S INCIDENT, SHE DETERMINED CNAS WERE NOT BEING SUPERVISED DURING HOT PACK TREATMENTS. THE DON EXPLAINED HER INVESTIGATION ALSO FOUND CNA "A", RN "B" AND OTHER NURSES WERE NOT TIMING THE HOT PACK TREATMENTS OR PERFORMING SKIN CHECKS PER THE FACILITY'S POLICIES FOR THE USE OF HOT PACKS. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ONE (#1) OF ELEVEN RESIDENTS REVIEWED FOR ADMINISTRATION OF MEDICATIONS WAS FREE OF ANY SIGNIFICANT MEDICATION ERRORS RESULTING IN THE RESIDENT'S LIFE BEING IN JEOPARDY AND ADMISSION TO AN INTENSIVE CARE UNIT IN THE HOSPITAL. FINDINGS INCLUDE: RESIDENT #1 IS AN [AGE] year-old FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO A FACILITY REPORTED INCIDENT/INVESTIGATION (FRI) DATED 4/1/2011 OF AN INCIDENT REPORT DATED 3/29/2011, RESIDENT #1 RECEIVED HER ROOMMATE'S (RESIDENT #2) MEDICATIONS. THE FOLLOWING EVENTS OCCURRED. ON 3/29/2011 AT APPROXIMATELY 9:05 A.M., RESIDENT #1 RECEIVED THE following medications: [REDACTED]. A REVIEW OF RESIDENT #1'S CURRENT PHYSICIAN ORDERS [REDACTED].#1. THE FACILITY REPORTED INCIDENT ALSO SHOWS THAT ON 3/29/11 AT APPROXIMATELY 10:00 A.M., RESIDENT #1 WAS "VERY GROGGY AND MINIMAL RESPONSE TO YES/NO QUESTIONS AND A BLOOD PRESSURE OF 70/55. THE PHYSICIAN AND 9-1-1 WERE CALLED IMMEDIATELY." THE NURSES NOTES DATED 3/29/11 REFLECT THAT AN AMBULANCE ARRIVED AT THE FACILITY AND RESIDENT #1 WAS TAKEN TO THE HOSPITAL AT 10:15 A.M. THE HOSPITAL HISTORY AND PHYSICAL FOR RESIDENT #1 DATED 3/29/2011 READS, "ACCIDENTIAL DRUG OVERDOSE... AND SHE WILL BE admitted TO THE INTENSIVE CARE UNIT AND SUPPORTED; P.R.N. ROMAZICON AND [MEDICATION NAME] WILL BE USED IF SHE HAS EXCESSIVE SEDATION. [MEDICATION NAME] WILL BE USED TO MAINTAIN HER BLOOD PRESSURE." ROMAZICON IS A MEDICATION THAT HELPS TO REVERSE THE EFFECTS OF CERTAIN SEDATIVE DRUGS SUCH AS [MEDICATION NAME]. NARCON IS MEDICATION USED FOR REVERSING THE EFFECTS OF NARCOTICS. A REVIEW OF RESIDENT #1'S MEDICAL RECORD SHOWS SHE WAS REadmitted to the facility on [DATE]. UPON INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 4/14/2011 AT 12:20 P.M., IT WAS CONFIRMED THAT RESIDENT #1 RECEIVED MEDICATIONS THAT WERE NOT PHYSICIAN PRESCRIBED FOR HER. THE DON FURTHER INDICATED THAT THE FACILITY POLICY "DRUG ADMINISTRATION-MED PASS" DATED 3/2/2011 WAS NOT FOLLOWED. THE RESIDENT (RESIDENT #2) THAT THE MEDICATIONS WERE INTENDED TO BE DISPENSED TO WAS ADMINISTERED TO THE WRONG RESIDENT (RESIDENT #1). ( )