Every finding on record at Greenhurst Nursing Center

Based on observation, record review, and interview, it was determined that the facility did not ensure medications were stored securely while the medication cart was left unattended, for two (Hall 100 and Hall 200) of four medication carts. The findings include: During an observation of medication administration on 07/23/2025 at 9:07 AM, Licensed Practical Nurse (LPN) #1 left the medication cart unattended and proceeded up the hall from the 200-hall dining room to the medication storage room at the front of the facility, out of the sight of this surveyor. The medications left unattended on top of the cart included partial blister packs each of a beta-blocker used to treat high blood pressure, an alpha-blocker used to treat high blood pressure, a diuretic used to treat fluid retention, an anti-diabetic medication, a mineral supplement used to lower potassium levels, and a steroid. There was also one partial bottle each of chewable aspirin, a multi-vitamin with minerals, and a probiotic supplement. At 9:12 AM, LPN #1 returned to the medication cart and confirmed all the medications should have been placed in the medication cart, and the cart should have been locked, before the LPN left the cart. LPN #1 indicated the medications were left unattended on the top of the cart, because the surveyor was standing there with the medications. LPN #1 stated they were trained to not leave the medications out, due to residents or visitors having access to medications, stating “that’s my bad.” During an observation of medication administration on 07/23/2025 11:51 AM, a partial bottle of iron was left unattended on top of the medication cart, while LPN #2 left the cart to give medications across the hall. LPN #2 was out of eyesight of the medication cart for approximately 81 seconds. LPN #2 stated they were trained to ensure all meds were stored in the cart, and the cart was to be locked when unattended. A review of a Med Pass Observation Report, dated 07/18/2025, revealed a check mark on the “Met” column, next to “Medications are not left on top of cart…” with LPN #1’s name and signature on the report. A review of a Med Pass Observation Report, dated 07/18/2025, revealed a check mark on the “Met” column, next to “Medications are not left on top of cart…” with LPN #2’s name at the top of the report. A review of an in-service titled Controlled Substance, Medication Administration, dated 05/12/2025, revealed LPN #1 and LPN #2’s signatures of attendance. The training included medication storage, administration, and secure storage of narcotics. During an interview on 07/23/2025 at 2:08 PM, the Director of Nursing (DON) clarified the facility’s policy and expectation was that medications were not to be left on top of the medication cart, when the cart was left unattended. She confirmed medications were to be secured inside the medication cart. The DON verified LPN #1 and LPN #2 were trained on 05/12/2025, on medication administration and storage, with medication administration audits completed on 07/18/2025 that included both LPN #1 and LPN #2. During an interview on 07/24/2025 at 10:24 AM, the Medical Director confirmed the expectation was that medications should be stored securely and away from non-licensed staff when unattended. During an interview on 07/24/2025 at 11:46 AM, the Administrator confirmed the expectation was that facility staff would follow the facility policies, and medications should be stored securely away from non-licensed staff, when unattended. A review of the “Medication Storage in the Facility,” policy with an effective date of 01/01/2015, read, in part, medications were stored securely, only assessable to licensed nursing personnel or staff members lawfully authorized to administer medications.

Based on record review and interview, the facility failed to ensure an Advanced Beneficiary Notice (ABN) was provided within two business days and notification of their financial liability for care and services after the Medicare coverage was discontinued for one (Resident #4) of three residents reviewed for ABN notices. The findings include: A review of Resident #4’s admission Record indicated the facility admitted the resident on 03/21/2025, with diagnoses which included vascular dementia with mild anxiety, stroke, prostate cancer, bone cancer, and personal history of transient ischemic attack. A review of Resident #4's quarterly Minimum Data Set with an Assessment Reference Date of 04/30/2024, revealed a Brief Interview for Mental Status score of 08, which indicated the resident had moderately impaired cognition. A review of Resident #4’s Care Plan, with a revision date of 03/27/2025, revealed the resident had a stroke. The resident’s Care Plan indicated a goal for Resident #4 to show improvement to maximum potential to perform activities of daily living. A review of Resident #4’s Skilled Nursing Facility Beneficiary Notification Review Forms on 07/23/2025 at 10:55 AM, revealed the form had been signed by Resident #4’s legal representative on 05/01/2025. The ABN revealed Resident #4 would be discharged on 05/01/2025. During an interview on 07/23/2025 at 11:04 AM, the Assistant Director of Nursing (ADON) stated he notified residents or residents’ legal representatives at least two days before a resident was to be discharged . The ADON reported he spoke to Resident #4’s legal representative by telephone two days before the facility was planning to discharge Resident #4 but had no documentation to verify the event. The ADON confirmed the ABN was signed on 05/01/2025, by Resident #4’s legal representative. The ADON stated it was important to notify and provide the ABN to a resident or resident representative, prior to the discharge, so home health, supplies, or referrals could be made in a timely manner. He also stated the ABN gave the information to the residents and/or resident representatives in case they wished to appeal the discharge from a skilled nursing bed. During an interview on 07/23/2025 at 11:15 AM, the Director of Nursing (DON) stated the ADON was responsible for notifying the resident or resident’s legal representative of the anticipated discharge from a skilled nursing bed and to complete the ABN. She verified the ABN was to be completed at least two days prior to the discharge. The DON verified Resident #4’s ABN was signed by their legal representative on 05/01/2025, which was the same day as the resident’s discharge from a skilled nursing bed. The DON reported Resident #4’s legal representative was notified of the anticipated discharge two days prior to the discharge via telephone by the ADON but could not provide documentation to verify the event. The DON stated when the facility notified a resident or resident’s representative by telephone the facility had a witness, and they would both sign the ABN verifying the event took place. During a phone interview on 07/23/2025 at 11:23 AM, Resident #4’s legal representative reported they were not informed via telephone or in person prior to the resident’s discharge. Resident #4’s legal representative revealed they did get informed of the discharge from a skilled nursing bed back to a long-term care bed on 05/01/2025 and the representative came to the facility and signed the ABN. The resident’s legal representative reported they were aware the discharge could have been happening soon, due to Resident #4 not participating with therapy, but was not made aware of a specific discharge date . During an interview on 07/24/2025 at 10:23 AM, the Medical Director verified the facility should notify residents and residents’ legal representatives at least two days before discharge from a skilled nursing bed. During an interview on 07/24/2025 at 11:47 AM, the Administrator stated residents and/or the resident’s legal representatives should be notified of a discharge from a skilled nursing bed and receive an ABN at least three days before the discharge, or when the facility made a determination of anticipated upcoming discharge before the discharge date . The Administrator stated the ABN made the resident or resident legal representative aware of the discharge and gave them the right to appeal the discharge if they decided to. The DON stated the facility did not have a policy related to ABNs.

Based on interview and record review, the facility failed to provide mandatory staffing payroll data in a uniform format to CMS (Center for Medicare and Medicaid Services). The findings include: 1. The data that CMS received from the facility did not include the CASPER (Certification and Survey Provider Enhanced Reporting) PBJ (Payroll Based Journal) mandatory staffing data. According to policy, the failure to not submit the mandatory data within the date range specified to the facility by CMS, constitutes a citation. a. According to CMS regulations, long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. b. The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following: The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS); Resident census data; information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual) distinguishing employee from agency and contract staff. When reporting information about direct care staff, the facility must specify whether the individual is an employee of the facility or is engaged by the facility under contract or through an agency. The facility must submit direct care staffing information in the uniform format specified by CMS. The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. c. On 04/18/2024 at 08:40 AM, the Administrator confirmed being responsible for completing the staffing reports and sending them into CMS. The Surveyor asked, Can you tell me a little bit about the process of submitting the PBJ report? The Administrator stated, Two reports are received. One is from our facility, and the other is for ancillary staff such as Occupational Therapy and Physical Therapy. Both reports are sent in a zip file. I then export the two files and create one zip file to submit. The Administrator was asked who was responsible for checking for accuracy. The Administrator stated, That would be my responsibility as well. The Administrator was asked if she knew when the report had been validated. The Administrator stated, Twenty four hours after upload is successful, you login and run the report and download the PBJ provider validation report and be sure to save it. It's my fault that I did not save the report and I am responsible for this deficiency.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles/practices to prevent administration of medicines that had been opened and stored beyond the manufacturer's specified timeframes, and the administration of expired medications in 1 of 1 medication rooms and 2 of 4 medication carts. The findings are: On 04/15/2024 at 11: 30 AM, in Medication Storage room [ROOM NUMBER] the first upper cabinet had 13 Covid tests that all shared the same expiration date of 11/10/2023. The second upper cabinet contained 1 tube of a nonsteroidal anti-inflammatory cream with an expiration date of 06/2019 and 1 bottle of eye drops that expired 03/2022. On 04/15/2024 at 11:41 AM, the Assistant Director of Nursing (ADON) was asked what nurses do with expired prescription medications. The ADON reported the nurses will bring them to this locked medication storage room. The information, such as name of medication, strength, and quantity is recorded in the blue book. The Pharmacist comes in once a month and picks up the expired medications to destroy them. On 04/16/2024 at 12:29 PM, in a medication cart on the 300 Hall, there was a box of medication used to treat Type II diabetes that had a pen that had been opened. There was no open date on the pen or box. The manufacturer's insert for the medication documented that the pen was good for 56 days after opening. On 04/16/2024 at 02:27 PM, LPN #4 was asked how often he checks his medication cart for expired drugs. He answered, Once weekly. On 04/16/2024 at 09:48 AM, the Administer provided the Medication Storage and Labeling Guidelines which documented, .Drugs are not to be kept on hand after the expiration date which appears on the label. Outdated, contaminated, or deteriorated drugs, and those in containers which are cracked, soiled or without secure closures are to be immediately withdrawn from stock, re-ordered from the pharmacy if a current order exists for any patient, and disposed of in accordance with the procedures for drug destruction .

Based on record review, observation and interview, the facility failed to ensure staff performed hand hygiene to prevent the contamination of clean laundry/linens and further prevent the potential spread of infection. The findings are: Review of a facility policy titled, Infection Control, not dated, specified, [Facility] establishes and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Procedure: Infection control is managed not only through basic hygiene but managed through the QA [Quality Assurance] Committee, for review of infection control tracking and trends; quarterly . Clean Linens and Clothing: Resident should have clean linens to prevent any infections. Linens should be changed and cleaned when dirty or soiled. Clothing should always be clean and look neat . Hands should be washed before handling clean linens . Clean linens and clothing should not be shaken or placed in areas that may contain environmental contamination, i.e. [that is], air conditioners, chairs, etc [etcetera]. Any linens or cloth that is contaminated needs to be rewashed . On 04/16/2024 at 10:57 AM, Laundry Aide #2 entered the laundry room on the clean side carrying a handful of plastic hangers. Laundry Aide #2 placed the plastic hangers on a bar near a sink. The hangers were not cleaned prior to hanging them up. Laundry Aide #2 did not perform hand hygiene after entering the clean side of the laundry room. Laundry Aide #2 was asked if the hangers were sanitized/cleaned prior to hanging them up. Laundry Aide #2 stated, No, I just took them out of the resident's closets and brought them here. We don't sanitize the hangers unless they are in COVID 19 rooms. Laundry Aid #2 was observed to remove a bed pad from a grey plastic container with wheels, containing clean linen, and started folding the bed pad. Laundry Aide #2 did not sanitize/wash her hands prior to folding the bed pad. Laundry Aide #2 was asked if she performed hand hygiene before folding the clean linens. Laundry Aide #2 stated, I sanitized my hands after each resident room. Laundry Aide #2 was asked if she entered from outside the facility, then opened the door to the laundry room before folding linens. Laundry Aide #2 stated, I did not wash or sanitize my hands. Laundry Aide #2 continued to fold clean linen and placing the linen on the folding table without performing hand hygiene. On 04/16/2024 at 11:02 AM Laundry Aide #1 was asked why should hand hygiene be performed before folding clean linens. Laundry Aid #1 stated, Could get germs on it or cross contaminate. On 04/16/2024 at 11:03 AM, Laundry Aide #2 was asked why should hand hygiene be performed before folding clean linens. Laundry Aide #2 stated, So no germs on the linens. On 04/17/24 09:14 AM, the Assistant Director of Nursing (ADON)/Infection Control Nurse was asked how are clean linens handled in laundry? The ADON stated, They have a folding table that is sanitized after every load. The ADON was asked should staff perform hand hygiene before handling clean linens? The ADON stated, They should wash their hands prior to touching clean linens. The ADON was asked why should hand hygiene be performed before handling clean linens? The ADON stated, Distributing germs to clean linens that are going to residents. 49689 On 04/17/24 at 10:05 AM, the Surveyor observed a laundry cart uncovered with clean clothes. Laundry Aide #1 was putting up clothes in room [ROOM NUMBER] and did not use hand hygiene when picking up the next residents' clothes to put up in the same room. Laundry Aide #1 then continued with the task of putting up the clean clothes. On 04/17/24 at 11:15 AM, the Surveyor asked Laundry Aide #1 should clean laundry be covered when transported to the resident's room. Laundry Aide #1 said yes, I always keep my cart covered when transporting laundry. The Surveyor asked what is the concern by not covering clean laundry when transporting. Laundry Aide #1 said well you never know what will happen down the hall, the clothes could get something splashed on them, they could get dirty.

Based on observation, record review and interview, the facility failed to provide specialized respiratory care in accordance with professional standards of practice for 1 (Resident #66) of 5 (#16, #39, #50, #66, #245) sampled Residents who had a Physician's Order for nebulizer treatments as documented on a list provided by the Director of Nursing on 03/16/23 at 9:55 a.m. The findings are: 1.Resident #66 had a diagnosis of Acute Respiratory Failure with Hypoxia. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/23 documented a score of 15 (11-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. On 03/13/23 at 11:15 a.m., Resident #66 was sitting in a recliner beside the bed. A nebulizer machine with tubing and mask were lying on the bed. The tubing and mask were not stored in a bag. b. On 03/13/23 at 01:10 p.m., Resident #66 was sitting in a recliner beside the bed. A nebulizer machine with tubing and mask were lying on the bed. The tubing and mask were not stored in a bag. The Surveyor asked, Who put that mask on your bed? She answered, I did. I started getting those breathing treatments Saturday night. The Surveyor asked, Do you do your own breathing treatments? She answered, Yes. The nurses put the medicine in there and I take it off in 15 minutes when the medicine is gone. c. On 03/14/23 at 01:53 p.m., R #66 was not in the room. The nebulizer machine with tubing and mask were lying on the bed. The tubing and mask were not stored in a bag. d. On 03/14/23 at 02:00 p.m., the Surveyor asked the Director of Nursing (DON) to provide R #66's Assessment for Self-Administration of Medications. She stated, We don't have one for her. e. The facility policy titled, Nebulizer Therapy, which was provided by the Administrator on 03/14/23 at 03:30 p.m. documented, It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique .Observe resident during the procedure for any change in condition .Disassemble and rinse the nebulizer with sterile or distilled water and allow to air dry .Clean after each use .Disassemble parts after every treatment .Air dry on absorbent towel .Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag . f. The facility policy titled, Resident Self-Administration of Medication, which was provided by the Administrator on 03/14/23 at 03:30 p.m. documented, .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .Each resident is offered the opportunity to self-administer medications, and if preferred, after an assessment by the facility's interdisciplinary team .The care plan must reflect the resident self-administration . g. A review of Physician's Order dated 03/15/23 documented, Albuterol Sulfate Inhalation Nebulization Solution 0.63 MG milligrams]/3ML [milliliter], (Albuterol Sulfate) 1 vial inhale orally [by way of] nebulizer three times a day for Wheezing for 7 Days. h. Review of the Care Plan dated 03/15/23 did not document Self-Administration of Medications. i. A review of Defined Assessments dated 03/15/23 showed no assessment for Self-Administration of Medications. j. A review of Resident #66's March 2023 Medication Administration Record (MAR) documented, Albuterol Sulfate Inhalation Nebulization Solution 0.63 MG/3ML (Albuterol Sulfate) 1 vial inhale orally via nebulizer three times a day for Wheezing for 7 Days - Start Date 03/12/23, with nurse initials on 03/12/23, 03/13/23, and 03/14/23 at 9:00 a.m., 5:00 p.m., and 8:00 p.m., and nurse initials on 03/15/23 at 9:00 a.m. k. On 03/15/23 at 11:00 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #2 What do the initials on the MAR mean? She answered, It means the resident received the medication. The Surveyor asked, Does Resident #66 self-administer her medications? She answered, I watch her. The Surveyor asked, Is she assessed to self-administer her medications? She answered, I don't know. The Surveyor asked, What could happen if a resident administers their own medications when they are not assessed? She answered, There's a risk for choking, not taking them completely or getting the entire dose. Or they could throw them in the trash. The Surveyor asked, Does Resident #66 ever refuse her medications? She answered, Not that I know of. The Surveyor asked, How are you supposed to store the nebulizer mask and tubing? She answered, In a Ziplock bag with the date it was changed. The Surveyor asked, What could happen if the nebulizer mask and tubing are not stored appropriately? She answered, Bacteria. l. On 03/16/23 at 09:36 a.m., the Surveyor asked the DON, What should a facility do if a resident wants to self-administer medications? She answered The Interdisciplinary Team meets, and we discuss it. We don't do an assessment form. The nurses still administer the medications to them. We do not leave medications in the room. The Surveyor asked, What could happen if a resident is not assessed to self-administer medications? She answered, It could cause harm. They could take too much or not enough. The Surveyor asked, What is the appropriate way to store a nebulizer mask and tubing? She answered, In a bag. The Surveyor asked, What should the nurse do when a resident takes a nebulizer treatment? She answered, Stay with them. Clean it out. Rinse it and put it in a bag once it's dry. The Surveyor asked, What could happen if a nebulizer mask and tubing is stored incorrectly? She answered, It can grow all kinds of nasty critters.

Based on observation, record review and interview, the facility failed to ensure medications were stored and labeled properly for 1 (Resident #38) sampled Resident on the 100 Hall, and the facility failed to ensure a medication was not left unattended on top of the 200 Hall medication cart. This failed practice had the potential to affect 58 residents who resided on the 100 and 200 Halls, as documented on the Midnight Census Report provided by the Administrator on 03/13/23 at 11:54 AM. The Findings are: 1. Resident (R) #38 had a diagnosis of Fracture Right Radius and Ulna. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/23 documented a score of 15 (11-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. The Care Plan on 03/15/23 at 1:11 PM dated 01/06/23, .desires to administer own medication when dispensed by the nurse . will maintain medicine cup and take within time frame for administration once nurse has dispensed . b. The Physician's Order on 03/15/23 at 1:12 PM, dated 01/16/23 documented, Throat Lozenges Mouth/Throat Lozenge (Throat Lozenges) Give 1 lozenge by mouth as needed for sore throat. c. On 03/13/23 at 11:51 AM, R #38 was sitting in the recliner. A box of Throat Lozenges with no pharmacy label was on the overbed table. d. On 03/13/23 at 01:28 PM, R #38 was sitting in the recliner eating lunch. A box of Throat Lozenges with no pharmacy label was on the overbed table. e. A review of the Electronic Medical Record on 03/14/23 at 8:32 AM showed no Assessment to Self-Administer Medications. f. On 03/14/23 at 08:48 AM, R #38 was in bed with eyes closed. A box of Throat Lozenges with no pharmacy label was on the overbed table. g. On 03/14/23 at 09:05 AM, a review of the pharmacy label the label on the box documented, In case of overdose, get medical help or contact Poison Control Center . h. On 03/14/23 at 10:55 AM, the Surveyor asked R #38, Are those your throat Lozenges? She answered, Yes, I have had a sore throat and I just took a cough drop while ago. The Surveyor asked, How often do you take those? She answered, I don't know how often I can take them. i. On 03/14/23 at 01:52 PM, the Surveyor asked the Director of Nursing (DON) to provide a Self-Administration of Medication Assessment for R #38. She stated, We don't have one for her. j. On 03/14/23 at 03:05 PM, the Surveyor asked the Administrator to provide the policies for Self-Administration of Medication and Medication Storage. k.The facility policy titled, Resident Self-Administration of Medication provided by the Administrator on 03/14/23 at 03:30 PM documented, .Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms . l.The facility policy titled, Medication Storage provided by the Administrator on 03/14/23 at 03:30 PM documented, It is the policy of this facility to ensure all medications housed on our premises will be stored in the .medication rooms .All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) . m. On 03/16/23 at 09:36 AM, the Surveyor asked the DON, What should a facility do if a resident wants to self-administer medications? She answered The Interdisciplinary Team meets, and we discuss it. We don't do an assessment form. The nurses still administer the medications to them. We do not leave medications in the room. She was The Surveyor asked, What could happen if a resident is not assessed to self-administer medications? She answered, It could cause harm. They could take too much or not enough. 2. On 03/15/23 at 8:16 AM, a bottle (17.9 ounces) of [laxative] (1/2 full), was sitting on the top of the medication cart unattended. a. On 03/15/23 at 8:30 PM, a review of the MATERIAL SAFETY DATA SHEET page 1. showed, .#2 Hazards Identification: WARNING! May be harmful if swallowed in amounts greater than indicated . b. On 03/15/23 at 9:50 AM, the Surveyor asked LPN #1 if the bottle of [laxative] should have been left out on top of the cart, and he stated, No ma'am. The Surveyor asked, What could have happened? He stated, A resident could have taken it. c. On 03/15/23 at 9:59 AM, the Surveyor asked the MT if a bottle of [laxative] should have been left out on top of the medication cart and he stated, No ma'am, it is a medication. The Surveyor asked, What could have happened? He stated, A resident could have gotten it and taken it. d. On 03/16/23 at 9:20 AM, the Surveyor asked the Director of Nursing (DON) if a medication should ever be left unattended/unlocked, she stated, No. The Surveyor asked, What could happen? The DON stated, A resident can get it and take it. The Surveyor asked, What could happen if a resident ingests it? She stated, Overdose on whatever it was they got, or it could interact with one of their medications. e. On 03/16/23 at 09:36 AM, the Surveyor asked the DON, How should medications be stored in a resident room? She answered, We don't store them in the resident rooms. The Surveyor asked, What could happen if a medication is not stored correctly? She answered, It could get in the hands of a resident. Also, if it needs to be stored at a certain temperature. The Surveyor asked, Should medications have a label? She answered, Yes. The Surveyor asked, What could happen if a medication does not have a label? She answered, How do you know who it belongs to or the correct dose? How can you do the five rights of medication administration? 46868

Based on observation, record review and interview, the facility failed to accurately record the Minimum Data Set (MDS) assessment for 2 Residents #89, #94 of 22 (#1, #4, #6, #7, #11, #14, #16, #19, #27, #34, #38, #39, #45, #50, #66, #75, #77, #78, #88, #89, #93, #94) sampled Residents whose MDS was reviewed. The findings are: 1.Resident (R) #89 was admitted to the facility on [DATE]with diagnoses of Psychotic Disturbance, Mood Disturbance, and Anxiety Disorder. A Quarterly with an Assessment Reference Date (ARD) of 12/24/22 documented R #89 was severely impaired in cognitive skills for daily decision making on a Staff Assessment of Mental Status (SAMS). Wandering behavior not exhibited documented in section E. Pressure alarms were not documented in section P of the MDS. a. A Record Review Progress Notes dated 11/28/22 at 11:21 documented, .Incident Note Text: Clarification of recent incident report. Resident did not trip over stool. As she was ambulating across the room unassisted her alarm box that was hanging at her side detached and fell to the floor, this caused resident to bend over to pick it up off the floor and when she stood back up, she lost her balance and fell back. Will replace clip alarm with ghost alarm to prevent further falls . b. On 03/13/23 at 11:13 am., R #89 was in her room, sitting in a recliner with the footrest elevated. She had a pressure alarm on the bed and in her chair. She was nonverbal. c. The Physician Orders dated 03/14/23 at 2:25 pm were reviewed and documented, Alarms - (pressure alarm to bed, and ghost alarm to chair) Active 11/28/22 .Change Wander guard as it is due to expire tomorrow on (01/23/24) one time only for 1 Day Active 02/24/23 . CHECK PLACEMENT AND BATTERY OF WANDERGUARD Q SHIFT every shift Active 03/10/22 . d. The Care Plan dated 03/14/23 at 2:52 pm was reviewed and documented, . Bed/chair alarm to alert staff that resident has gotten up, alarm does not inhibit her from getting up and ambulating Revision on: 11/18/22 . Clip alarm changed to ghost alarm Date Initiated: 11/28/22 . e. On 03/15/23 at 8:55 am., the Surveyor asked the MDS Coordinator to look at section P of the Quarterly MDS with ARD of 12/24/22 and if the bed and chair alarm documented on the care plan should be documented in that section. She stated, Yes ma'am, I made an error, I will fix it. The Surveyor asked for the facility Policy and Procedure for MDS assessments. The MDS Coordinator stated, We use the RAI [Resident Assessment Instrument manual] and provided Section P from the CMS [Center for Medical and Medicaid Services] RAI version 3.0 dated October 2019. f. The CMS RAI version 3.0 dated October 2019 documented on page P-9, .Coding instructions .Identify all alarms that were used at any time (day or night) during the 7-day-look-back period. Code the frequency of use: Code 2, used daily: if the device was used on a daily basis during the look-back period . 2. Resident #94 had a diagnosis of Senile Degenerative Brain Disease. The Significant Change MDS with an ARD of 11/28/22 under section O0100K Hospice Care was marked no. a. The Physician's Order dated (11/18/22) documented, admitted to hospice care. b. On 03/13/23 at 9:20 AM, the Surveyor asked the MDS Coordinator to review R #94's MDS Significant Change dated 11/28/22 She stated, It should have been recorded as yes and further stated, RAI manual is used for instructions in completing the assessments. c. Review of RAI version 3.0, dated October 2019, section O0100K documented, Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. 42017

Based on record review and interview, the facility failed to refer 1 (Resident #88) sampled resident who was identified with a newly evident or possibly serious mental illness or intellectual disability to the appropriate state-designated authority for Level II PASARR evaluation and determination. This failed practice had the potential to affect 13 residents in the facility who had a diagnosis of serious mental illness or intellectual disability as documented on a list provided by the Administrator on 03/16/23 at 8:00 AM. The findings are: 1. Resident #88 had a diagnosis of Psychotic Disorder with Delusions Due to Known Psychological Condition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/23 documented a score of 4 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). a. The Physician's Order dated 12/09/22 documented, Seroquel Tablet 25 MG [milligrams], Quetiapine Fumarate Give 0.5 tablet by mouth at bedtime related to other psychotic disorder not due to a substance or known physiological condition - d/c (discontinued) 12/29/22. b. The Physician's Order dated 12/29/22 documented, Seroquel Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime related to PSYCHOTIC disorder with delusions due to known physiological condition - d/c 01/05/23. c. The Physician's Order dated 01/05/23 documented, Quetiapine Fumarate Tablet 25 MG Give 1 tablet by mouth two times a day for Psychoses that may cause her to harm herself related to psychotic disorder with delusions due to known physiological condition -d/c 02/24/23. d. The Physician's Order dated 02/24/23 documented, Quetiapine Fumarate Tablet 50 MG Give 1 tablet by mouth two times a day for delusions/psychosis e. A review of the Electronic Medical Record on 03/13/23 at 02:41 PM, showed no documentation from State Designated Professional Associates. f. On 03/14/23 at 01:11 PM., the Surveyor asked the Director of Nursing (DON) to provide a PASARR for Resident #88. On 03/14/23 at 1:50 PM., the DON stated, It was not required to do one on her. g. On 03/14/23 at 03:13 PM., the Surveyor asked the DON, Please explain to me why R #88 did not require a PASARR? She stated, She was not on Seroquel when she was admitted . The order for Seroquel came months later. The Surveyor asked, Was a Level 2 done with the new diagnosis of Psychosis? She answered, I will have to look. That was before I was the DON. h. On 03/14/23 at 03:15 PM., The Surveyor asked the Administrator to provide the PASARR policy. He stated, I don't think we have a PASARR policy. We just follow the law. The Surveyor asked, What does the law state regarding a new mental health diagnosis? He answered, I know what you are saying. i. On 03/14/23 at 03:30 PM., The Administrator stated, We have not been able to find a State Designated Professional Associates letter for her. We think this may have gotten missed when those were waived. j. On 03/16/23 at 09:20 AM., The Surveyor asked, What should a facility do when a resident gets a new diagnosis of a severe mental illness? The DON answered, We should do a State Designated Professional Associates letter. The Surveyor asked, Why should they do that? She answered, To make sure they are appropriate for the facility.

Based on observation, record review and interview the facility failed to ensure proper placement of gastrostomy tube was checked prior to water flush and medication administration based on professional standards of care for 1 (Resident #79) of 2 (#1, #79) sampled Residents reviewed with Physician Orders for gastrostomy tube feedings. This failed practice had the potential to affect 3 residents according to a list provided by the Administrator on 03/16/23 at 8:00 AM. 1.Resident #79 was admitted to the facility on [DATE] with Diagnoses of Dysphagia following Cerebral Infarction, Disorders of Eustachian Tube, and Encounter for Attention to Gastrostomy. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/22 documented Resident #79 was severely impaired in cognitive skills for daily decision making on a Staff Assessment for Mental Stats (SAMS) and required total one-person physical assistance for eating. Section K documented a Feeding tube. a. The Care Plan dated 06/10/21 documented, Check for tube placement per facility protocol .Provide feedings and flushes as ordered. See Medication Administration Record (MAR) for current orders Date Initiated: 06/10/21 . b. The Record Review of Physician Orders dated 09/05/22 documented, Check peg tube placement Q-Shift (every shift). c. On 03/15/23 at 08:02 AM., Licensed Practical Nurse (LPN) #1 administered medications in Resident #79's room. LPN #1 disconnected Resident #79's continuous tube feeding from the gastrostomy tube, attempted to flush the tube with 50 cc [cubic centimeters] of water but it would not flow, and the water ran out of the syringe on the resident's clothing and sheet. LPN #1 left the room and returned with a de clogger, opened and used it in the feeding tube. She flushed with 50 cc of water, gave medications mixed with water, flushed with another 50 cc of water after the medications were given, reconnected the continuous feeding tubing, and turned the feeding pump back on. LPN #1 did not check for feeding tube placement by auscultation after disconnecting the continuous feeding tubing and flushing with water before administering medications. d. On 03/15/23 at 9:15 AM., the Surveyor asked The Director of Nursing (DON) for a Policy and Procedure on care and de-clogging of feeding tubes including medication administration through the feeding tube. e. On 03/15/23 at 10:15 AM., the Surveyor asked the DON if placement of feeding tube should be completed before flushing with water and administering medications and why. The DON stated, It should have been done, I have retraining to do. The resident could aspirate, the feeding tube could have dislodged or perforated that could cause Peritonitis. f. On 03/15/23 at 10:43 AM., the Surveyor asked LPN #1 if placement of Resident #79's feeding tube should have been checked with auscultation of air before administering water flush and medications. LPN #1 stated, I did it this morning before medication administration, it's checked once per shift. It has always been that way since I have worked here, about a year. It is checked off on the MAR. g. The facility policy titled Gastrostomy Tube Feedings provided by the DON on 03/15/23 documented, .Check placement of tube prior to feeding a. Placement of gastrostomy tubes are checked every time it is disconnected and reattached, and prior to giving medications. d. Be sure tube is in stomach before feeding begins. Check tube position by injecting 10-5 ml [milliliters] of air and listening over the epigastric area with a stethoscope to hear air enter the stomach. You may also aspirate gastric content from the tube .

Based on observation and interview, the facility failed to ensure a utility cart, bulk storage containers, oscillating fans, and the ice machine were maintained in clean condition and clean glasses were allowed to air dry before being used or stored to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 91 residents who received meals from the kitchen (total census: 93), as documented on a list provided by the Dietary Manager on 10/14/2021. The findings are: 1. On 10/10/21 at 9:29 AM during the initial tour of the kitchen, the following observations were made: a. Directly in front of the serving line, there was a tray of stacked glasses with droplets of water in them. The Dietary Manager was asked how clean glasses should be stored. She said, They should be only stacked if they are dry. b. Around the corner from the 3-door refrigerator, there was a large round fan sitting on the floor, with the air blowing upward toward the clean side of the dish room. The fan was covered with fuzzy greyish particles. c. There was a second fan covered with fuzzy greyish particles that was blowing into the dirty side of the dish room. d. Directly behind the serving line, there was a fan on a shelf blowing toward the right of the serving line. The fan was covered in fuzzy greyish particles. When the Dietary Manager was asked if the fans used in the kitchen were clean, she said, I see some dust on them. e. The ice machine located in front of the serving line had a pinkish, unidentified residue on the internal shield. The Dietary Manager took a white napkin and wiped the shield and some of the pinkish residue transferred to the napkin. When asked to identify the residue, the Dietary Manager stated, I see something red. I don't know what it is. The Surveyor asked how often the machine was cleaned, and the Manager stated, It's wiped down weekly. Maintenance cleans it monthly where they run the chemical through it. 2. On 10/12/21 during follow up rounds in the kitchen, the following observations were made: a. At 11:39 PM, there were two stacks of glasses that remained wet, on the beverage serving counter near the beverage dispensers. One stack contained 4 glasses and the other stack contained 5 glasses. The Dietary Manager was asked, Should the glasses be stacked while wet? She stated, No, I will re-wash them. b. At 11:46 PM, there were 3 white, bulk containers with sticky crumbs around the rims. The Dietary Manager was asked if the containers were clean. She said, No, I see what you are talking about. c. At 12:08 PM, there was a kitchen utility cart with a clean pan on the top shelf. There was a sticky unidentified substance on the shelves.

Based on record review and interview, the facility failed to ensure a surety bond was purchased that would cover the balance in the residents' trust fund to prevent potential financial loss for 60 of 60 residents who had trust funds managed by the facility. This failed practice had the potential to affect 60 residents who had trust funds managed by the facility, as documented on the September 2021 Trust Transaction List. The findings are: 1. On 10/13/21 at 12:28 PM, the September 2021 Trust Transaction List documented the total trust fund balance for the period ending 9/30/21 was $30,170.86. The facility's surety bond was for $30,000. 2. On 10/13/21 at 12:46 PM, the Administrator was asked, How much is the surety bond for the residents' trust fund accounts? He replied, It's for $30,000. He was then asked, How much should the surety bond on the residents account be? He replied, It should exceed the amount in the residents trust fund accounts.

Based on record review and interview, the facility failed to ensure a Quarterly Minimum Data Set (MDS) assessment was completed within 3 months after the prior assessment as required for 1 (Resident #75) of 20 (Residents #39, #24, #2, #56, #60, #65, #79, #75, #18, #88, #71, #42, #74, #45, #80, #246, #69, #3, #16, and #1) sampled residents whose MDS assessments were reviewed. The findings are: Resident #75 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. As of 10/11/21 at 10:51 a.m., the MDS history in the electronic health record documented an Annual MDS with an assessment reference date (ARD) of 1/3/21 and Quarterly MDS assessments with ARDs of 4/1/21 and 6/29/21. The next Quarterly MDS would have been due no later than 9/29/21; however, the MDS history documented an Entry MDS with an ARD of 9/1/21; a Discharge Return Anticipated with an ARD of 9/18/21; and an Admission MDS with an ARD of 9/28/21. A Quarterly MDS was not completed as required in September. b. On 10/13/21 at 8:53 a.m., the MDS Coordinator was asked, What is the schedule for MDS Completion, as identified in the Resident Assessment Instrument? Stated, Admission, quarterly, quarterly, quarterly, annual. She was asked, Why did [Resident #75] have an admission MDS completed after she returned from the hospital? Stated, Because she came back Medicare.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) Discharge Return Not Anticipated assessment was completed within 14 days of discharge and transmitted within 14 days after completion to assure accurate and up-to-date quality measures data for 1 (Resident #1) of 3 (Residents #1, #94, and #52) sampled residents who were discharged from the facility. The findings are: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A Progress Note dated 6/19/21 documented, .discharged home. b. On 10/12/21 at 2:38 p.m., the MDS history in the electronic health record documented, .Next Trckng [Tracking] / Dschrg [Discharge] . Discharge - ARD [assessment reference date] 6/19/2021 - 101 days overdue . c. As of 10/12/21 at 3:00 p.m., the facility had not completed and submitted a Discharge Return Not Anticipated MDS. d. On 10/13/21 at 8:49 a.m., the MDS Coordinator was asked to review Resident #1's MDS history. She stated, Oh, the discharge assessment was missed.

Complaint # (AR 792) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to provide in-person access to any resident by a representative of the Office of the State long term care ombudsman, as evidenced by Ombudsman #1 having been asked by the facility's administrator to leave the facility with no alternative method of access offered in lieu of in-person access. This failed practice had the potential to affect all 94 residents who resided in the facility, as per the Census and Conditions of Residents form dated 11/12/2020. The findings are: 1. The Centers for Medicare and Medicaid Services (CMS) QSO-20-28-NH, dated 4/24/2020 (revised 7/9/2020, updated 9/28/2020), documented, . Access to Ombudsman: We are reminding facilities that providing ombudsman access to residents is required per 42 CFR § 483.10(f)(4)(i) and per the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) . Access to Ombudsman . Sections 1819(c)(3)(A) and 1919(c)(3)(A) of the Social Security Act (the Act) and implementing regulations at 42 CFR 483.10(f)(4)(i)(C), require that a Medicare and Medicaid certified nursing home provide representatives of the State Long-Term Care Ombudsman with immediate access to any resident, however during this Public Health Emergency (PHE) in- person access may be restricted. If in-person access is not advisable due to infection control concerns and transmission of COVID-19, facilities must facilitate resident communication (e.g., by phone or through use of other technology) with the ombudsman. Additionally, through this memo, CMS is ensuring nursing homes and other stakeholders are aware of the implementation of the recent CARES Act which states State Long-Term Care Ombudsman shall have continued direct access (or other access through the use of technology) to residents of long term care facilities during any portion of the public health emergency relating to coronavirus until September 30, 2020. The CARES Act does not repeal or amend CMS requirements under sections 1819 or 1919 of the Act or implementing regulations. Nor does it place a time limit or expiration date (e.g., until September 30, 2020) on the CMS requirements providing for resident access to the Ombudsman program, but instead affirms that the current pandemic requires the Ombudsman program and long term care facilities to support resident access and communication in a variety of methods. For additional information regarding resident access to the Ombudsman please see Frequently Asked Questions (FAQ) on Nursing Home Visitation . 2. On 11/12/2020, Ombudsman #2 was asked, What is your professional position? She stated, I am the State Ombudsman. She was asked, Do you direct the activities of the regional ombudsmen, such as (Ombudsman #1)? She stated, Yes. She was asked, Are you aware of an incident involving the facility and (Ombudsman #1)? Please describe your understanding of the incident. She stated, (Ombudsman #1) went to the facility because of a complaint we received in our office. After being screened, (Ombudsman #1) went to the halls, but then was asked by the screener to return to the front because the Administrator was on the phone. It was after 07:00 PM on Friday (11/6/2020). Once she was at the front, the screener gave her the phone and the Administrator told her over the phone he was on his way to the facility. Once the Administrator arrived at the facility, he went to the hall to get (Ombudsman #1) and asked her to go back up front, which she did. He informed her that she should not be walking around the facility with just a surgical mask on and going from hall to hall. She explained to him that all the facilities are different, but nobody had told her that the surgical mask was not adequate for this facility. He then asked her to produce results of a PCR (Polymerase Chain Reaction) COVID-19 test. The ombudsmen are not required to test routinely but it just so happened that (Ombudsman #1) had received an [MEDICATION NAME] test that was negative from that morning while she was at a different facility. The Administrator would not accept the results of the [MEDICATION NAME] test and demanded a PCR result or (Ombudsman #1) would need to leave. Once he asked her to leave, she left, and notified me of the situation. We then forwarded the complaints to Office of Long Term Care for further investigation. 3. An email, dated 11/6/2020 08:12 PM, documented, . (Administrator) wrote: Hello (Ombudsman #1), Per state and federal guidelines, I do not have the proof of PCR covid testing to allow you in my building. Until we work together, and coordinate these requirements, (Facility Name) can't allow you in the building . You requested access to the entire building, and I can't allow that at this time given the situation. 4. An email, dated 11/6/2020 08:42 PM, documented, . (Administrator) wrote: . I asked (Ombudsman #1) to leave. She was wearing a surgical mask and no eye protection; we require N95 and eye protection . (Ombudsman #1) was screened. However, she wasn't given permission to access all the building . 5. An email, dated 11/7/2020 10:29 AM, documented, . From: (Administrator) . Perhaps what sent me out here on Friday night was the fact I asked her to not enter, and she did . 6. On 11/13/2020 at 08:30 AM, the Administrator was asked, What would be the reason that (Ombudsman #1) was denied in-person access to any resident on 11/6/2020? He stated, First of all, I did not know why she was here late on Friday, but she was walking all over the facility with just that surgical mask on. We have our halls basically locked down and even the staff don't go from hall to hall. He was asked, Was she informed that the surgical mask did not meet your requirements? He stated, She stepped over the red rope and just went all over the facility. He was asked, At the time she was denied in-person access, did you offer an alternate method of access in lieu of in-person access? He stated, No.

Based on observation, record review, and interview the facility failed to ensure food items in the dry storage and freezer were properly labeled or dated to prevent food borne illnesses, failed to ensure cooking utensils were covered or inverted to prevent contamination and failed to ensure sanitary food handling practices were maintained by staff serving the lunch meal to prevent potential food borne illnesses in 1 of 1 facility kitchens. These failed practices had the potential to affect 92 residents (Total Census: 95) as documented on the Resident Listing Report provided by the Dietary Supervisor (DS) on 7/1/2020 at 11:58 a.m. The findings are: 1. On 6/29/2020 at 10:56 a.m., the kitchen dry storage area contained 1 box of Cheetos with approximately 30 bags with no open date. 2. On 6/29/2020 at 10:56 a.m., the kitchen dry storage area contained 1 box of Corn Chips with approximately 40 bags with no open date. 3. On 6/29/2020 at 10:56 a.m., the kitchen dry storage area contained 1 box of Doritos with approximately 30 bags with no open date. 4. On 6/29/2020 at 11:00 a.m., the kitchen cooler contained (1) 1/2 gallon of Cultured Buttermilk open with no date. 5. On 6/29/2020 at 11:03 a.m., the kitchen freezer contained approximately 10 patties of a potato like substance opened with no label or date. 6. On 6/29/2020 at 11:06 a.m., the kitchen freezer contained an opened clear bag of breaded okra with no label or date. 7. On 6/29/2020 at 11:06 a.m., the kitchen freezer contained an opened, clear bag of tator tots with no label or date. 8. On 6/29/2020 at 11:08 a.m., the kitchen freezer contained an opened bag of a French fries with no label or date. 9. On 6/29/2020 at 11:08 a.m., the kitchen freezer contained an opened bag of onion rings with no label or date. 10. On 6/29/2020 at 11:10 a.m., the kitchen freezer contained cooked hushpuppies with no label or date. 11. On 6/29/2020 at 11:28 a.m., in the kitchen, by the clean side of the dishwasher, contained 1 large round metal bowl, 3 medium sized metal bowls, and 2 metal, rectangle pans, not covered or inverted. 12. On 6/29/2020 at 12:28 p.m., the Dietary Supervisor (DS) was standing on the serving line and used her right hand to pick up Styrofoam trays from the left and with her right hand picked up maroon tongs from a pan of chicken tenders. She retrieved chicken tenders out of the pan with the tongs, placed the chicken tenders in the Styrofoam trays, laid the tongs on the contaminated prep area where contaminated tray cards, and a black pen laid on the counter. She picked up the black pen and marked on the tray cards, and without washing her hands, used the contaminated tongs to serve the chicken tenders into resident trays. 13. On 6/29/2020 at 12:50 p.m., Dietary Employee (DE) #1, stood at the end of the serving line, placed handled adaptive utensils, on a tray, on top of a contaminated tray card, that had been passed down the line and touched by four Dietary employees' hands. Then served the tray to a resident. 14. On 6/29/2020 at 1:04 p.m., Certified Nursing Assistant (CNA) #1 picked up a weighted spoon and fork from the left of her out of a white basket and placed the weighted spoon and fork, on a tray, on top of a contaminated tray card that had been passed down the serving line and touched by five Dietary employees, and then served the resident the tray. 15. On 6/29/2020 at 1:25 p.m., the 200 Hall nourishment room, by the nurses' station, contained a basket of approximately (8) 1.19 ounce (oz). Fudge rounds, (3) .49 Honey(NAME)cookies and (10) .67 oz Nutty Buddy with no date. 16. On 7/1/2020 at 11:33 a.m., the Dietary Supervisor was asked, Should food items be labeled/dated? She stated, Yes. She was sked, Should cooking utensils be covered/inverted? She stated, Yes. She was asked, Should kitchen utensils used to serve residents be placed on a contaminated surface from tray cards and ink pen? She stated, No. 17. On 7/1/2020 at 11:58 a.m., the facility Food Storage policy and procedure provided by the Dietary Supervisor reviewed. The policy states, .7. Hands must be washed .prior to handling food items .8.c. Food should be dated as it is placed on the shelves .16. Frozen foods: c. Foods should be covered, labeled and dated .

Based on observations, record review, and interview the facility failed to ensure the 400 Hall linen cart cover and the 200 Hall linen cart were clean and maintained and in good condition as evidenced by the covers being frayed, torn, and ripped; and the facility failed to prevent the possible cross contamination and possible infections. This failed practice had the potential to affect 60 residents according to the Daily Census provided by the Administrator on 6/29/2020. The facility failed to ensure residents wheelchair cushions were clean and maintained and in good condition as evidenced by the cushion was ripped, frayed, and torn for 1 (Resident #8) of 6 (Residents #65, #63, #8, #43, #82, #14) sample residents according to a list provided by the Director of Nursing (DON) on 7/2/2020. The findings are: 1. On 06/29/2020 at 11:50 a.m., the linen cart cover on the 400 Hall hat contained clean linen was frayed and ripped. The Housekeeping Supervisor was asked, Should the linen cart cover be ripped and frayed? The Housekeeping Supervisor stated, No. a. On 07/01/2020 at 07:56 a.m., the linen cart cover on the 200 Hall was to be frayed, ripped, and had a hole that measured approximately 2 inches in diameter. b. On 07/01/2020 at 9:18 a.m., Certified Nursing Assistant (CNA) #10 was asked, Should the linen cart covers be frayed, ripped, and have holes in them? CNA #10 stated, No. c. On 07/01/2020 at 09:27 a.m., Registered Nurse (RN) #1 was asked, Should linen cart covers be frayed, ripped, and have holes in them? RN #1 stated, No. d. On 07/01/20 at 02:13 p.m., the Director of Nursing (DON) was asked, Should linen cart covers be frayed, ripped, and have holes in them? The DON, Ideally, no. e. On 07/02/20 at 12:12 p.m., the Administrator was asked, Should the linen cart covers have holes, be frayed, torn, and ripped? The Administrator stated, No. f. A policy titled Handling Clean Linen documented, It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection .Linen can become contaminated with pathogens from contact with skin or body substances, or from environmental contaminants or contaminated hands . 2. On 06/30/2020 at 11:02 a.m., Resident #8 was sitting in her wheelchair. The wheelchair cushion was cracked and frayed with the inside lining showing. a. On 07/01/2020 at 09:17 a.m., Resident #8 was sitting in her wheelchair. The wheelchair cushion was cracked and frayed with the inside lining showing. b. On 07/01/2020 at 09:18 a.m., Certified Nursing Assistant (CNA) #10 was asked, Should the residents wheelchair cushions be ripped, torn, and frayed? CNA #10 stated, They should not. c. On 07/01/2020 at 09:27 a.m., Registered Nurse (RN) #1 was asked, Should the residents wheelchair cushions be ripped, torn, and frayed? RN #1 stated, No. d. On 07/01/2020 at 02:13 p.m., the Director of Nursing (DON) was asked, Should the residents wheelchair cushions be ripped, torn, and frayed? The DON replied, No. e. On 07/02/2020 at 12:12 p.m., the Administrator was asked, Should the residents wheelchair cushions be ripped, torn, and frayed? The Administrator stated, No.

Based on observation, review, and interview the facility failed to ensure the residents environment was free from accident hazards as evidenced by an unknown substance in a medication cup left out in the open in 1 (Resident #14) sampled resident room. This failed practice had the potential to affect 9 residents who were cognitively impaired and mobile on 400 Hall according to a list provided by the Director of Nurses (DON); The facility failed to ensure medications labeled Vics [MEDICATION NAME] and [MEDICATION NAME], were not left on 1 (Resident #3) over bed table. This failed practice had the potential to affect 5 cognitively impaired mobile residents on the 200 Hall according to a list provided by the Director of Nurses; The facility failed to ensure a can of aerosol air freshener was not left on a bedside table in 1 (Resident #43) room. This failed practice had the potential to affect 9 residents who were cognitively impaired on 400 hall according to a list provided by the Director of Nurses; The facility failed to ensure a wheelchair armrest was free of cracks and rips to prevent potential skin injuries for 1 (Resident #82) of 7 sampled residents. This failed practice had the potential to affect 19 residents on the 400 Hall who have wheelchair armrests according to a list provided by the Director of Nurses. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment reference Date (ARD) of 3/22/2020 documented the resident was cognitively intact a Brief interview for Mental Status (BIMS); and required extensive assistance of one person for bed mobility and toileting, limited assistance of one person for transfers, supervision and set up for mobility and eating. a. The Plan of Care with an initiated date of 1/1/2020 documented, .The resident has impaired cognitive function/dementia or impaired thought processes r/t (related to) Dementia .Cue, reorient and supervise as needed . b. The current physician orders [REDACTED]. c. On 06/30/2020 at 10:18 a.m., there was a container labeled [MEDICATION NAME] Cream 0.1% (percent) .apply to affected area twice daily-do not apply to face, armpits, or groin . dated 10/20/17 and a 6 ounce (oz) container of Vicks [MEDICATION NAME] on the resident's overbed table approximately 6 feet from the doorway visible from the hallway. A photograph of the [MEDICATION NAME] Cream and the Vicks [MEDICATION NAME] was taken at this time. d. On 06/30/2020 at 11:07 a.m., Registered Nurse (RN) #2, the nurse working the hallway, was shown the medications and asked, if she could tell me what it was. She stated, .It's a cream, he doesn't even have an order for [REDACTED]. It shouldn't. His girlfriend brings stuff to him. It is from 2017. We just haven't seen it. She always brings him snacks and things. I guess she brought it. He doesn't have and order for the Vicks, or it's not something I give him. I don't know if he has a care plan for this, we have some that are care plan. She reviewed the resident's orders and care plan and stated, It is not anything he has an order for [REDACTED]. It's not something we should have allowed. e. On 07/01/2020 at 02:03 p.m., the Director of Nursing was asked if a resident should have over the counter medications or prescribed medications in their room or on their over bed table. She stated, No. The family brought it in most likely. f. An Admission Agreement provided by the Administrator on 6/30/2020 documented, .no medications are allowed in resident rooms without doctor's orders . 2. Resident #14 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with as Assessment Reference Date (ARD) of 4/9/2020, documented the resident was severely impaired in cognitive skills for daily decision making on the Staff Assessment for Mental Status (SAMS); and required total assistance with 2 staff for bed mobility, transfer, dressing, toilet use, personal hygiene, had upper extremity impairment on both sides, and was always incontinent of bowel and bladder. a. On 06/29/2020 at 11:46 a.m., a medicine cup with 15 cc (cubic centimeters) of thick substance and unlabeled was sitting on the resident's nightstand. b. On 07/02/2020 at10:34 a.m., Certified Nursing Assistant (CNA) #5 was shown a picture of a medicine cup with 15 cc of thick substance and unlabeled and was asked, Can you tell me what is in this cup? CNA #5 stated, Looks like Vaseline. CNA #5 was asked, What would that be used for? CNA #5 stated, Sometimes on the lips. CNA#5 was asked, Is it supposed to be left out? CNA #5 stated, No. CNA #5 was asked, Could that be considered a hazard? CNA #5 stated, Yes. c. On 07/02/2020 at 10:43 a.m., Nursing Assistant (NA) #1 was shown a picture of a medicine cup with 15 cc of thick substance and unlabeled and was asked, Can you tell me what is in this cup. NA #1 stated, Looks like Vaseline. NA #1 was asked, Is it supposed to be left out? NA #1 stated, No. NA #1 was asked, Would this be considered a hazard? NA #1 stated, Yes. d. On 07/02/2020 at 10:44 a.m., CNA #4 was shown a picture of a medicine cup with 15 cc of thick substance and unlabeled and was asked, Can you tell me what is in this cup? CNA #4 stated, Barrier cream, it comes in a brown and white tub, and the nurses have it. CNA #4 was asked, Do you have to get this cream from the nurses? CNA #4 stated, Yes. CNA #4 was asked, Is it supposed to be left out? CNA #4 stated, No. CNA #4 was asked, If a cognitively impaired resident was to wander in the room and obtain this, would that be considered a hazard? CNA #4 stated, Yes. e. On 07/02/2020 at 12:32 p.m., the Administrator was asked should a medication cup with an unknown substance that staff are unable to identify be left in the resident's room. He stated, No. He was asked should any medication be left in the resident's room. He stated, No. 3. Resident #43 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/4/2020 documented the resident scored 14 (13-15 cognitively Intact) on a Brief Interview for Mental Status (BIMS); and required extensive assist of 2 for bed mobility, transfer, and toilet use, and required extensive assist of 1 for dressing, and personal hygiene, had an indwelling Foley catheter, and was occasionally incontinent of bowel. a. On 06/30/2020 at 10:33 a.m., a spray can of air freshener is on the bedside table. Resident #43 was asked do you use that air freshener. Resident #43 stated, Yes. I use it when my roommate goes to the bathroom, and the smell goes right through here to the fan. b. On 07/01/20 at 09:18 a.m., Certified Nursing Assistant (CNA) #10 was asked, Should residents have aerosol cans of air freshener in their rooms? CNA #1 stated, No. CNA #10 was asked, Would this be considered a hazard? CNA #10 stated, Yes. 4. Resident #82 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 6/8/2020 documented the resident scored 13 (13-15 cognitively intact) on a Brief Interview for Mental Status (BIMS); and required extensive assist of 2 for bed mobility, transfer, dressing, toilet use, and personal hygiene; was frequently incontinent of bowel and had a super pubic Foley catheter. a. The Care Plan with a revision date of 6/25/19 documented, . The resident has an ADL self-care performance deficit r/t [MEDICAL CONDITION], Limited Mobility, Limited ROM . Resident is able to propel self in w/c (wheelchair) but needs assistance at times. Assist as needed . b. On 06/29/20 at 12:25 p.m., Resident # 82 sitting in his wheelchair. The wheelchair arms were cracked, frayed, with hard plastic protruding out approximately 0.5 centimeters (cm). c. On 06/29/20 at 01:55 p.m., Resident # 82 wheelchairs arms were cracked, frayed, and had hard plastic protruding out that measured approximately 0.5 cm. Resident #82 was asked, Is this your wheelchair? Resident #82 stated, Yes. Resident #82 was asked, Have you ever been scratched by the arms of your wheelchair? Resident #82 shook his head up and down, in a yes motion. d. On 06/29/20 at 02:03 p.m., CNA #3 was asked to describe Resident #82's arms on wheelchair? CNA #3 stated, It's cracked apart, hard, and sticking out. CNA #3 was asked, Does that have the potential to cause a skin tear? CNA #3 stated, It could. e. On 07/1/20 at 09:18 a.m., CNA #10 was asked, Should the arms on a resident wheelchair be ripped, frayed, torn with hard vinyl protruding out? CNA #10 stated, No. They shouldn't. CNA #10 was asked, Would this be considered a hazard? CNA #10 stated, It could cause skin tears, yes. f. On 07/01/20 at 09:27 a.m., Registered Nurse (RN) #1 was asked should the arms on a resident wheelchair be ripped, frayed, torn with hard vinyl protruding out. RN #1 stated, No. RN #1 was asked, Would this be considered a hazard? RN #1 stated, Yes. g. On 07/01/2020 at 02:13 p.m., the DON was asked, Should the arms on a resident wheelchair be ripped, frayed, torn with hard vinyl protruding out? The DON stated, No. The DON was asked, Would this be considered a hazard/ The DON stated, Yes. h. On 07/02/20 at 12:12 p.m., the Administrator was asked, Should the arms on a resident wheelchair be ripped, frayed, and torn with hard vinyl protruding out? The Administrator, No. The Administrator was asked, Would this be considered a hazard? The Administrator stated, Yes. i. A policy titled Accident and Supervision documented, .Accident and Supervision. The resident environment remains as free of accident hazards as is possible .

Based on observation, record review, and interview the facility failed to ensure Foley catheter bags were contained and off of the floor to prevent potential cross contamination which could result in infection for 1 (Resident #82) of 2 (Residents #43 and #82) sample residents who had orders for Foley catheters according to a list provided by the Director of Nursing (DON) on 7/2/2020. The facility failed to ensure a used face mask and a used medicine cup were contained and off of the floor to prevent potential cross contamination and possible infection. These failed practice had the potential to affect 34 residents who reside on the 400 Hall according to the Daily Census provided by the Administrator on 6/29/2020. The facility failed to ensure personal cell phones and keys were contained and off the counter with clean linens and failed to ensure staff sanitized or washed hands after using a cell phone prior to handling clean linen to prevent potential cross contamination which could result in infection. This failed practice had the potential to affect 95 residents who had linens/clothes laundered by the facility according to the Census and Condition provided by the Administrator on 6/29/2020. The findings are: 1. Resident #82 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/8/2020 documented the resident scored 13 (13-15 cognitively intact) on a Brief Interview for Mental Status (BIMS); and required extensive assist of 2 for bed mobility, transfer, dressing, toilet use, and personal hygiene; was frequently incontinent of bowel and had a super pubic Foley catheter. a. A physician order [REDACTED].Suprapubic Catheter 16f/10cc (cubic centimeters) Bulb as Needed For Occluded May Change . b. The Care Plan with a revision date of 12/5/19 documented, .The resident has Suprapubic Catheter r/t (related to) neuromuscular dysfunction of bladder .Indwelling catheter care- assess for evidence of obstruction or malfunction, suspected infection, and/or compromises such as disconnections or leaks and replace as needed . c. On 06/29/2020 at 12:29 p.m., Resident #82 was in a chair in the day room. His Foley catheter was on the floor under his wheelchair (w/c). There were white substances in Foley catheter tubing. d. On 06/29/2020 at 01:46 p.m., Resident #82 was in the day room eating/self- feeding. The Foley catheter was on the floor. e. On 06/29/2020 at 01:47 p.m., Certified Nursing Aide (CNA) #4 was asked, Should Foley catheters be on the floor? CNA #4 stated, No. CNA #4 was asked, Would that be an infection control issue? CNA #4 stated, Yes. f. On 07/01/2020 at 09:18 a.m., CNA #10 was asked, Should Foley catheters bags be on the floor? CNA #10 stated, No. CNA #10 was asked, Would that be an infection control issue? CNA #10 stated, Yes. g. On 07/01/2020 at 09:27 a.m., Registered Nurse (RN) #1was asked, Should Foley catheters bags be on the floor? RN #1 stated, No. RN #1 was asked, Would that be an infection control issue? RN #1 stated, Yes. h. On 07/01/2020 at 02:13 p.m., the Director of Nursing (DON) was asked, Should Foley catheters bags be on the floor? The DON stated, No. The DON was asked, Would that be an infection control issue? The DON stated, Yes. i. On 07/02/2020 at 12:12 p.m., the Administrator was asked, Should Foley catheter bags be on the floor? The Administrator stated, No. The Administrator was asked, Would that be an infection control issue? The Administrator stated, Yes. 2. On 06/29/20 at 12:27 p.m., a used face mask and a used medicine cup was observed in the floor in the day room. a. On 06/29/2020 at 01:54 p.m., a used face mask and a used medicine cup were observed on the floor in the day room. b. On 06/29/2020 at 02:03 p.m., CNA #3 was asked, Is a used medicine cup and used face mask supposed to be on the floor? CNA #3 stated, No. CNA #3 was asked, Would that be an infection control issue? CNA #3, Yes. c. On 07/01/2020 at 09:18 a.m., CNA #10 was asked, Should used face masks and used medicine cups be in the floor? CNA #10 stated, No. CNA #10 was asked, Would this be considered an infection control? CNA #10 stated, No. d. On 07/01/2020 at 09:27 a.m., Registered Nurse (RN) #1 was asked, Should used face masks and used medicine cups be in the floor? RN #1 stated, No. RN #1 was asked, Would this be considered an infection control issue? RN #1 stated, Yes. e. On 07/01/2020 at 02:13 p.m., the Director of Nurses (DON) was asked, Should used face masks and used medicine cups be in the floor? The DON stated, No. The DON was asked, Would this be considered an infection control issue? The DON stated, It's messy, yes. f. On 07/02/2020 at 12:12 p.m., the Administrator was asked, Should there be used face mask and medicine cup in the floor, and would this be considered an infection control issue? The Administrator stated, I would like to think it was just lazy . 3. On 07/01/2020 at 12:24 p.m., rounds were made in the laundry room area. This Surveyor enter through clean side of laundry. Two phones and a set of keys were observed on the counter next to the clean linen. Laundry/Housekeeper #1 was asked, Should the phone and the keys be on the clean area counter, next to the clean linen? Laundry/Housekeeper #1 stated, No. Laundry/Housekeeper #1 was asked, What concern would there be with the keys and phones on the counter next to the clean linen? Laundry/Housekeeper #1 stated, The bacteria is getting on the clothes. a. On 07/01/2020 at 12:32 p.m., Laundry/Housekeeper #1 was observed to use a cell phone to call her supervisor, then picked up clean laundry and started to fold it. Laundry/Housekeeper #1 did not sanitize or wash hands after using the phone. Laundry/Housekeeper #1 was asked, After you used your phone, should you have sanitized your hands? Laundry/Housekeeper #1 stated, I should have sanitized my hands. b. On 07/01/2020 at 02:13 p.m., the Director of Nurses (DON) was asked, Should cell phones and keys be on the counter next to the clean linen in the laundry room? The DON stated, No. The DON was asked, Would that be considered an infection control issue? The DON stated, Yes. c. On 07/02/2020 at 12:12 p.m., the Administrator was asked, Should personal cell phones and a set of keys be on the counter with the clean linen? The Administrator stated, No. The Administrator was asked, Would a staff member using a cell phone, then picking up clean laundry and not sanitizing hands be considered an infection control issue? The Administrator stated, Yes. 4. A policy titled Infection Prevention and Control Program documented, .Infection Prevention and Control Program .This facility has established and maintains an infection prevention and control program designed to provides a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections .All staff have responsibilities related to the cleanliness of the facility .Linens .Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection .

Based on observation, record review, and interview the facility failed to ensure care plans were person-centered, accurate, complete, and reflect pain management for 1 (Resident #56) of 8 ( Resident #8, #33, #56, #57, #60, #67,#74 and #82) sampled residents whose medical records were reviewed. This failed practice had the potential to affect 22 residents who required routine pain medication, according to the list provided by the Director of Nursing (DON) on 7/2/2020. The findings are: Resident #56 had a [DIAGNOSES REDACTED]. a. A physicians order dated 4/23/18 documented, . [MEDICATION NAME] 50mg (milligrams) 1 tablet by mouth four times a day b. A physician order [REDACTED].[MEDICATION NAME] Capsule 300 MG give 1 capsule by mouth three times a day for chronic pain c. The Comprehensive Care Plan dated 3/7/19, and updated 5/28/2020, did not contain any documentation related to chronic pain medication, side effects, or monitoring. d. On 07/02/2020 at 11:21 a.m., Registered Nurse (RN) #3, the MDS/Care Plan Coordinator, was asked why was routine medications for pain, [MEDICATION NAME] and [MEDICATION NAME] was not addressed on the Care Plan and she stated, I'm not sure but I can add it to her Care Plan.

Complaint # (AR 377) was substantiated (all or in part) in these findings. A. Based on observation, record review and interview, the facility failed to ensure interventions to prevent injury from hot liquids were conveyed to direct care staff and residents were assessed upon admission and reassessed periodically thereafter for the ability to handle hot liquids without supervision / assistance and to determine if assistive devices were needed to minimize the potential for injury from hot liquids for 5 (Residents #5, #9, #12 13, and #14) of 13 (Residents #1, #2, #5, #6, #7, #9, #11, #12, #13, #14, #15, #16, and #20) case mix residents who had the potential to not be able to safely handle hot liquids. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #5, who received a second degree burn to the right hip and thigh on 7/29/14 after spilling hot coffee on her lap; to Resident #12, who received a second degree burn to the right thigh on 7/7/14 after spilling hot coffee on her right thigh; and to Resident #13 who received first degree burns to the bilateral inner thighs after dropping a cup of hot coffee in her lap on 4/22/14. This failed practice had the potential to cause more than minimal harm to 49 residents who were identified to be at risk for injury from hot liquids, according to the Director of Nursing (DON) on 8/8/14 at 6:39 p.m. The Director of Nursing was notified of the Immediate Jeopardy on 8/8/14 at 9:50 a.m. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/1/14 documented the resident was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status; was totally dependent on the physical assistance of two people for transfers, dressing, toileting and bathing; was totally dependent on the physical assistance of one person for locomotion and required extensive physical assistance of one person for eating. a. The resident's Initial Nutritional assessment dated [DATE] documented, "...Special Devices Needed: No... Feeds self (with) assist from staff..." As of 8/5/14 at 12:15 p.m., there was no assessment documented for the ability to handle hot liquids safely. b. The resident's Care Plan with a review date of 7/2/14 documented, "ADL (activities of daily living) dysfunction... Assist with meals PRN (as needed). Does well feeding herself while up in chair for meals. Needs more assistance while in bed... 7/29/14 ...Blister Rt (right) hip ...Tx (treatment) to area Rt hip as ordered, turn from back to (left) hip, keep off Rt hip... Assess for pain (and) give pain meds (medications) as ordered (and) assess for relief... Monitor for any s/s (signs and symptoms) of infection (and) report to MD (medical doctor)... Dietary staff aware - no hot fluids. Safety cup / sippy for warmer fluids... 8/1/14 AIB (antibiotic) as ordered... No coffee (doesn't like coffee)." c. The Nurse's Notes dated 7/29/14 8:30 a.m. documented, "Resident spilled her coffee in her lap. Red burn blistered areas developed within approx (approximately) 12 in (inch) area to R (right) thigh hip. (Physican) gave orders to apply Silvadene cream to areas QID (four times daily) (until) healed. Resident put to bed laying on opposite side. Instructions sent to kitchen to only send drinks in covered cups. Dtr (daughter) (name) notified and came to sit at bedside before lunch, 8:30 a.m., (2) Hydrocodone given for (increased) crying and confirms pain..." The Incident / Accident Report dated 7/29/14 documented, "Resident spilled her coffee in her lap. Red burn blistered areas developed within approx (approximately) 12 in (inch) area to R (right) thigh hip. (Physician) gave orders to apply Silvadene cream to areas QID (four times daily) (until) healed. Resident put to bed (lying) on opposite side. Instructions sent to kitchen to only send drinks in covered cups." d. The Dietary Progress Notes dated 7/29/14 documented, "Dietary notified to add sippy cup to tray card." e. The physician's orders [REDACTED]. Change QD (every day)." f. On 8/6/14 at 11:40 a.m., the resident's wound care by Licensed Practical Nurse (LPN) #1 was observed. The wound presented as a second-degree burn with healing pink edges, yellow-whitish tissue inside the wound, no odor and measured 18.5 centimeters by 4 centimeters. The resident was asked if the wound still hurt. She stated, "Yes." g. On 8/7/14 at 11:20 a.m., Certified Nursing Assistant (CNA) #2 stated, "I was not with her (Resident #5) when she spilled it (hot coffee), but I was the aide that responded first, took her back to her room and told the nurse. I did not give her the coffee and I don't know who did. I'm not sure if she ever got coffee before and she hasn't been here real long... She ate in the activity room. The housekeeper is the one who told me." The CNA was asked how she knew who could have hot coffee? She stated, "I just know the residents..." h. On 8/7/14 at 11:48 p.m., the Director of Nursing (DON) was asked, "Who actually witnessed the coffee spill?" She stated, "I don't think anyone actually witnessed it, but one of the residents' sons was sitting at the table when it happened..." The DON was asked who gave the resident the coffee. The DON stated, "My Activity Assistant (name) gave her the coffee." She was asked, "How did she know the resident could have hot coffee?" The DON stated, "She didn't. She asked the resident if she wanted coffee and she said yes." The DON was asked, "Was (Resident #5) able to handle hot liquids?" She stated, "Yes, there should always be someone (staff) assigned to the assist dining room. (Activity Assistant) was in there the day (Resident #5) was burned." i. On 8/7/14 at 12:00 p.m., the DON was asked about residents who had been placed in the assist dining room for meals without supervision. She stated, "They usually bring them in there. There is no good reason for that." She was asked if there should be someone in there to help the residents with fluids. She stated, "There should be someone in there and assigned to there." j. On 8/7/14 at 12:41 p.m., when asked about the resident's incident of 7/29/14, the Assistant Activity Director stated, "Yes, I pour coffee of the mornings. I asked her (Resident #5) if she wanted a cup of coffee. She said yes, she wanted it black. So I gave her a cup, not full. I asked her if she needed anything else, so I left. I went around and made my rounds in the main dining room." She was asked if there was any staff member in the assist dining room. She stated, "No, maybe a nurse, but I don't know who. There was a family member in there sitting with his grandma and I believe a housekeeper (name)." She was asked, "How do you know who can have hot liquids or not?" She stated, "I have a list they gave us. We've had it for a long time." The Assistant Activity Director was asked for the list. On 8/7/14 at 12:50 p.m., the Assistant Activity Director provided a list titled "Sheet 1", the list that she had stated was the list of residents who could not have hot liquids. Sheet 1 documented, "All Pureed Diets Are Served 3 Compartment Plates, (twelve residents named)... Others Using This Assisted Device (fourteen residents named)... Fluid Restriction, (one resident named)... Nectar Thickened Liquids, (eight residents named)... Honey Thickened Liquids (two residents named)... Pudding Consistency (one resident named)... and Cup (with) Lid (one resident named, Resident #5)." The list did not include documentation of residents who had been assessed for handling hot liquids. k. On 8/7/14 at 12:52 p.m., when asked about the resident's incident of 7/29/14 Housekeeper #1 stated, "I was in the activity room (assist dining room), when (Resident #5) got burned. A family member came up to me, who was with his grandma, and told me this lady just spilled coffee on her. I went to get the CNA to assist her." l. On 8/7/14 at 2:15 p.m., the 7/29/14 facility video of Resident #5's accident in the assist dining room was viewed. The video documented the start of the incident at 7:05 a.m. The video showed four residents sitting at the assist dining table, including Resident #5. The Assistant Activity Director was serving coffee. She served Resident #5 and left the room. At 7:06 a.m., Housekeeper #1 was in room with a fly-swatter, but was not watching residents. A male family member came into the assist dining room but went on into the Activity room office (off of assist dining room). At 7:07 a.m., one of the seated resident's son was standing beside his mother at the table and gave her milk and coffee. At 7:08 a.m., Resident #5 reached for her napkin and pushed it away, hitting her coffee cup and spilling it in her lap. At 7:09 a.m., the other resident's son, who was standing, saw the accident and went to Resident #5. Housekeeper #1 was in the room, but did not see the accident. The resident's son told Housekeeper #1 and she left the room. CNA #2 came into the room with Housekeeper #1 and took Resident #5 in her wheelchair out of the assist dining room. 2. Resident #12 had [DIAGNOSES REDACTED]. The 14-Day MDS with ARD of 7/17/14 documented the resident scored 10 (8-12 indicates moderate cognitive impairment) on the BIMS; required extensive physical assistance of two-plus people for bed mobility, transfers, dressing, toileting and personal hygiene and required extensive physical assistance of one person for locomotion and eating. a. The resident's Annual Nutritional assessment dated [DATE] documented, "...Self Feeding Skills: Dependent..." There was no assessment for hot liquid safety documented on the form. b. The Incident / Accident Report dated 7/7/14 documented, "Res (Resident) noted to have blisters to (right) thigh. Res states she spilt coffee on herself. T. O. (Telephone Order) (physician) Apply Silvadene to area BID (twice daily) until healed... Staff notified to utilize safety cups for liquids." c. The resident's Care Plan dated 7/15/14 documented, "...7/9/14 ...Use safety cup for hot fluids..." d. On 8/7/14 at 4:07 p.m., after the DON was asked if surveyors could see the video of Resident #12 burning her thigh, she stated, "We looked at the video and we can't find where she burned herself. She told the staff in the afternoon that she had spilled her coffee. The staff had asked her about the blister on her thigh and that's what she said, she spilled coffee." 3. Resident #13 had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 5/19/14 documented the resident scored 5 (0-7 indicates severe cognitive impairment) on the BIMS; required extensive physical assistance of two-plus people for bed mobility; required extensive physical assistance of one person for transfers, dressing, toileting and personal hygiene; and required limited physical assistance of one person for eating. a. The resident's Annual Nutritional assessment dated [DATE] documented, "...Self Feeding Skills: Feeds Self or Assistance..." There was no assessment for hot liquid safety documented on the form. b. The Incident / Accident Report dated 4/22/14 documented, "Res was in D/R (dining room) drinking coffee and she dropped it in her lap. Took her to restroom and cleaned area and applied Silvadene Cream to inner leg... Try a different cup and make sure coffee is not (too) hot... 4/24/14... cont (continues) (with) redness to inner thighs Silvadene applied as ordered... 4/24/14... Tx (treatment) to inner thighs no blister - Tx (with) Silvadene - inner thighs (with) no redness - Staff aware to remind resident not to hold coffee cup in lap - Staff not to give (very hot) coffee to resident." c. The resident's Care Plan dated 7/15/14 documented, "...7/9/14 ...Use safety cup for hot fluids..." d. On 8/7/14 at 4:07 p.m., after the DON was asked if surveyors could see the video of Resident #12 burning her thigh, she stated, "We looked at the video and we can't find where she burned herself. She told the staff in the afternoon that she had spilled her coffee. The staff had asked her about the blister on her thigh and that's what she said, she spilled coffee." 4. Resident #9 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 6/10/14 documented the resident scored 12 (8 - 12 indicates moderate cognitive impairment) on the BIMS, required extensive physical assistance of two-plus people for bed mobility and transfers and required supervision and set-up help for eating. a. As of 8/5/14, there was no documented assessment in the clinical record regarding the resident's ability to safely handle hot liquids. b. On 8/8/14 at 8:34 a.m., the resident was observed with her head lowered as she picked up a cup of steaming coffee her hand was shaking. There was no lid on the cup. She was unable to lift her head and there was a slight dribble of coffee on her chin. The resident was asked how she was and she stated, "I still can't raise my head up." 5. Resident #14 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/30/14 documented the resident scored 11 (8 - 12 indicates moderate cognitive impairment) on the BIMS and required supervision and set-up for ambulation, transfers and eating. a. As of 8/8/14, there was no documented assessment in the clinical record regarding the resident's ability to safely handle hot liquids. b. On 8/8/14 at 9:04 a.m., the resident was observed picking up his coffee cup, which was full to approximately 1/4-inch from the top of the cup. There was a slight tremble to the resident's right hand, which he used to pick up the cup. 6. On 8/7/14 at 11:10 a.m., the Dietary Manager stated, "We had the coffee man come in and our coffee was at 170 degrees. He said it could be between 150-205 degrees. We turned it down to 160 degrees and had six complaints it was too cold. We don't have a coffee temperature log." On 8/7/14 at 4:05 p.m., the coffee temperature from the kitchen was 155 degrees. 7. On 8/7/14 at 11:48 p.m., the DON was asked, "How do CNAs know who can have hot liquids or not?" She stated, "It would be on tray card, Care Plan, kiosk system and notify staff. I'm not aware of any resident that has a tray card documented with no hot liquids." The DON was asked if the facility was assessing residents for hot liquids. She stated, "We do on admission." As of this time, no hot liquid assessments were found in the clinical records of any case mix residents. 8. On 8/8/14, the following direct care staff interviews regarding serving hot liquids to residents were conducted: a. On 8/8/14 at 11:19 a.m., Restorative CNA #1 was asked how she knew who could have hot liquids or not. She stated, "Typically it's on their ticket. I didn't have anyone." b. On 8/8/14 at 11:31 a.m., CNA #4 was asked how she knew who could have hot liquids or not. She stated, "Usually it's on dietician cards. No, it didn't say on anyone's ticket not to have hot coffee." c. On 8/8/14 at 11:35 a.m., CNA #5 was asked how she knew who could have hot liquids or not. She stated, "We would just give our liquids in the dining room so they could be watched. No ma'am, I really didn't know who might spill theirs and who might not." d. On 8/8/14 at 11:38 a.m., CNA #6 was asked how she knew who could have hot liquids or not. She stated, "Well, it would either be on their meal ticket or care plan, if they were cautioned. I've not ever had anybody, but if I felt someone was shaky I would use a sippy cup." e. On 8/8/14 at 11:43 a.m., CNA #1 was asked how she knew who could have hot liquids or not. She stated, "One of the things is if they ask for it. You can't tell anyone no. Anyone who needs to be fed or couldn't hold their cup without spilling would need assistance. We have a lot of residents who can feed themselves." 9. The Immediate Jeopardy was removed and the scope and severity was lowered to an 'H' when the facility implemented the following Plan of Removal on 8/8/14 at 2:55 p.m. "(Facility name) Immediate Plan of Removal for Immediate Jeopardy will require our DON or her designee, to monitor the Dining Room for residents identified as being at risk of being served hot liquids every day, starting today, and for the next 7 days, then randomly at a minimum of 1 day weekly until substantial compliance is achieved and any findings are corrected. (Facility name) DON has assessed and identified all residents at risk being served hot liquids today and our plan for removal also consists of Immediate in-service of all 3 shifts of employees. The 7-3 (7:00 a.m. to 3:00 p.m.) shift has been completed and the DON, or designee, will in-service the 3-11 (3:00 p.m. to 11:00 p.m.) and 11-7 (11:00 p.m. to 7:00 a.m.) shifts this evening on following those assessed as being at risk. (Facility name) intervention for immediate safety of residents includes today's delivery of appropriate safety cups (with) protective lids that will be used on all residents identified as being at risk (with) hot liquids. Assessments of those identified will be based on cognitive abilities, motor skills, observation and resident's performance. The Dietary department will order cups easily identified by color for use (with) residents at risk of being served hot liquids. We have made each shifts CNA supervisor, or her designee, to monitor all residents identified at risk and to ensure their staff is aware of said residents and follow all measures put in place today. The Dietary staff will monitor the temps (temperatures) of all hot liquids to ensure none exceed established regulations. The Dietary staff will place a notice of residents identified at risk on the resident's daily menu to help staff monitor any at risk. Red coffee cups (with) lids were ordered today and forms were ordered today to help assess and identify all new admissions to (facility name) in the future." B. Based on record review and interview, the facility failed to ensure post-fall interventions were developed and implemented to decrease the potential for further falls and possible injury for 1 (Resident #15) of 7 (Residents #2, #3, #4, #6, #11, #15 and #16) case mix residents at risk for falls. This failed practice had the potential to cause more than minimal harm to 84 residents at risk for falls (with a total census of 94), according to a list provided by the Director of Nursing (DON) on 8/8/14 at 6:58 p.m. The findings are: Resident #15 had [DIAGNOSES REDACTED]. A 30-Day Minimum Data Set with an Assessment Reference Date of 5/27/14 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status; required extensive physical assistance of two-plus people for bed mobility, transfers, dressing, toilet use and personal hygiene; was totally dependent on the physical assistance of two-plus people for bathing; was non-ambulatory; and had limitation in range of motion of the lower extremity on one side. a. A hospital Report of Consultation dated 4/26/14 documented, HISTORY OF PRESENT ILLNESS: The patient is a [AGE] year-old woman who presented to the emergency room following a fall about 2 weeks ago. The patient is currently unable to give additional history due to mental status changes. History is per the patient's daughter. Per daughter, the patient walks with a walker and was walking from the bathroom when she fell . The patient reported no chest pain of shortness of breath, nausea, diaphoresis, or lightheadedness at the time. The patient presented to the hospital for evaluation at that time and was told that she had a 'hairline fracture of her left hip.' The patient was discharged to home, but progressively worsening pain. Per the patient's daughter, radiology on this admission demonstrated a rib fracture as well as dislocation of her left hip fracture." b. The resident's Plan of Care dated 5/8/14 documented, "Risk for falls... 1. Resident will be free from any fall-related injuries... 1. Lift by two or three via sheet or mechanical lift due to hip, rib and pelvic fractures. 2. Keep call light in easy reach at all times. 3. Keep floor clean, dry and free of clutter. 4. May use bed and chair alarms if needed. 5. Remind resident to call for assistance with any transfers. 6. History of falls while at home. Monitor closely." b. An Incident / Accident Report dated 6/7/14 at 4:00 p.m. documented, "...Pt. (Patient) attempted to stand via self (and) slid to sitting position on foot pedals of w/c (wheel chair). (No) injuries noted from fall... Additional Comments and / or steps taken to prevent recurrence: Keep pt. close to staff to remind not to stand via self - Alarms in place (and) working." An untimed note on the back of the Incident / Accident form was dated 6/9/14 and documented, "Alert, oriented to person. ROM (range-of-motion) WNL (within normal limits) for her-No injury noted from incident-No c/o (complaint of) pain discomfort-much stronger than on admission (4/29/14). Alarms in place. Reminded not to attempt transfer by self-Son states 'she's very independent (and) won't listen' - Staff aware and to monitor closely." There was no documentation of new interventions developed and implemented for the prevention of further falls on the Incident / Accident form or on the resident's Plan of Care. c. An Incident / Accident Report dated 7/8/14 at 10:45 a.m. documented, "...Res (Resident) alarm was sounding, res had been sitting in elevated recliner, tried to stand (and) fell hitting (right) shoulder blade area on chair, also c/o (complained of) bottom hurting... Some redness noted to (right) hip / buttock. (No) other injuries noted. Will x-ray (right) shoulder blade... Additional comments and / or steps taken to prevent recurrence: Staff to monitor closely ensure alarm clip on in place." An untimed note on the back of the Incident / Accident form was dated 7/10/14 and documented, "Alert, oriented to person-self, family-not place or time.-Sm (small) faded red area to (right) hip-Denies any c/o pain / discomfort - No injury noted to (right) shoulder blade. x-ray (right) shoulder - WNL (within normal limits) - Alarms in place - Staff to monitor closely." There was no documentation of new interventions developed and implemented for the prevention of further falls on the Incident / Accident form or on the resident's Plan of Care. d. An Incident / Accident Report dated 7/31/14 at 10:20 a.m. documented, "...Res alarm sounded - CNA's (Certified Nursing Assistant) hurried to res room, res had crawled out of bed (and) fell in floor hit head causing 3 cm (centimeter) laceration to (left) top of head, pressure applied... to wound, cleansed, xeroform (and) wrap applied. PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation). (No) other injuries noted. ROM (range-of-motion) WNL. Will monitor closely." An untimed note on the back of the Incident / Accident form was 8/2/14 and documented, "Alert oriented to person - PERRL - Neuro (neurological) cks (checks) WNL - area to top (left) side of head - healing - dry - No s/s (signs or symptoms) infection - Tx (treat) as ordered. Alarms in place (and) monitored closely by staff - needs supervision (with) transfer." There was no documentation of new interventions developed and implemented for the prevention of further falls on the Incident / Accident form or on the resident's Plan of Care. e. On 8/8/14 at 2:46 p.m., the Director of Nursing (DON) was asked, "(Resident #15) had a fall on 6/7/(14) at 4:00 p.m. Was there any new interventions put into place to try to prevent further falls?" The DON stated, "No, she had alarms on, just close monitoring." The DON was asked, "(Resident #15) had a fall on 7/8/(14) at 10:45 p.m. Was there any new interventions put into place to try to prevent further falls?" The DON stated, "No, besides monitor and close supervision we double alarm her, she already had the pressure alarm and clip alarm." The DON was asked, "(Resident #15) had a fall on 7/31/(14) at 10:20 a.m. Was there any new interventions put into place to try to prevent further falls?" The DON stated, "No, I didn't place anything else."

Complaint # (AR 377) was substantiated (all or in part) in these findings. Based on observation, record review and interview, the Nursing Administration failed to ensure interventions to prevent injury from hot liquids were conveyed to direct care staff and failed to develop and implement a system to ensure residents were assessed upon admission and reassessed periodically thereafter for the ability to handle hot liquids without supervision/assistance and to determine if assistive devices were needed to minimize the potential for injury from hot liquids for 5 (Residents #5, #9, #12 13, and #14) of 13 (Residents #1, #2, #5, #6, #7, #9, #11, #12, #13, #14, #15, #16, and #20) case mix residents who had the potential to not be able to safely handle hot liquids. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #5, who received a second degree burn to the right hip and thigh on 7/29/14 after spilling hot coffee on her lap; to Resident #12, who received a second degree burn to the right thigh on 7/7/14 after spilling hot coffee on her right thigh; and to Resident #13 who received first [MEDICAL CONDITION] the bilateral inner thighs after dropping a cup of hot coffee in her lap on 4/22/14. This failed practice had the potential to cause more than minimal harm to 49 residents who were identified to be at risk for injury from hot liquids, according to the Director of Nursing (DON) on 8/8/14 at 6:39 p.m. The Director of Nursing was notified of the Immediate Jeopardy on 8/8/14 at 9:50 a.m. The findings are: 1. The Director of Nursing Job Description was received from the Assistant Director of Nursing (ADON) on 8/8/14 at 12:30 p.m. and documented, "The Director of Nursing Services' primary responsibility is to ensure the provision of quality nursing care on a 24-hour basis to the residents of (facility name) in accordance with Federal, State and Local standards and regulations. The duties of a Director of Nursing may be as follows... Development and implementation of nursing policy and procedure. These must be aimed at preventing accidents at the facility... Being knowledgeable of incidents at the facility. Assessing the health needs of each resident..." 2. Resident #5 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/1/14 documented the resident was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status; was totally dependent on the physical assistance of two people for transfers, dressing, toileting and bathing; was totally dependent on the physical assistance of one person for locomotion and required extensive physical assistance of one person for eating. a. The resident's Initial Nutritional assessment dated [DATE] documented, "...Special Devices Needed: No... Feeds self (with) assist from staff..." As of 8/5/14 at 12:15 p.m., there was no assessment documented for the ability to handle hot liquids safely. b. The resident's Care Plan with a review date of 7/2/14 documented, "ADL (activities of daily living) dysfunction... Assist with meals PRN (as needed). Does well feeding herself while up in chair for meals. Needs more assistance while in bed... 7/29/14 ...Blister Rt (right) hip ...Tx (treatment) to area Rt hip as ordered, turn from back to (left) hip, keep off Rt hip... Assess for pain (and) give pain meds (medications) as ordered (and) assess for relief... Monitor for any s/s (signs and symptoms) of infection (and) report to MD (medical doctor)... Dietary staff aware - no hot fluids. Safety cup / sippy for warmer fluids... 8/1/14 AIB (antibiotic) as ordered... No coffee (doesn't like coffee)." c. The Nurse's Notes dated 7/29/14 8:30 a.m. documented, "Resident spilled her coffee in her lap. Red burn blistered areas developed within approx (approximately) 12 in (inch) area to R (right) thigh hip. (Physican) gave orders to apply [MEDICATION NAME] cream to areas QID (four times daily) (until) healed. Resident put to bed laying on opposite side. Instructions sent to kitchen to only send drinks in covered cups. Dtr (daughter) (name) notified and came to sit at bedside before lunch, 8:30 a.m., (2) [MEDICATION NAME] given for (increased) crying and confirms pain..." The Incident / Accident Report dated 7/29/14 documented, "Resident spilled her coffee in her lap. Red burn blistered areas developed within approx (approximately) 12 in (inch) area to R (right) thigh hip. (Physician) gave orders to apply [MEDICATION NAME] cream to areas QID (four times daily) (until) healed. Resident put to bed (lying) on opposite side. Instructions sent to kitchen to only send drinks in covered cups." d. The Dietary Progress Notes dated 7/29/14 documented, "Dietary notified to add sippy cup to tray card." e. The physician's orders [REDACTED]. Change QD (every day)." f. On 8/6/14 at 11:40 a.m., the resident's wound care by Licensed Practical Nurse (LPN) #1 was observed. The wound presented as a second-degree burn with healing pink edges, yellow-whitish tissue inside the wound, no odor and measured 18.5 centimeters by 4 centimeters. The resident was asked if the wound still hurt. She stated, "Yes." g. On 8/7/14 at 11:20 a.m., Certified Nursing Assistant (CNA) #2 stated, "I was not with her (Resident #5) when she spilled it (hot coffee), but I was the aide that responded first, took her back to her room and told the nurse. I did not give her the coffee and I don't know who did. I'm not sure if she ever got coffee before and she hasn't been here real long... She ate in the activity room. The housekeeper is the one who told me." The CNA was asked how she knew who could have hot coffee? She stated, "I just know the residents..." h. On 8/7/14 at 11:48 p.m., the Director of Nursing (DON) was asked, "Who actually witnessed the coffee spill?" She stated, "I don't think anyone actually witnessed it, but one of the residents' sons was sitting at the table when it happened..." The DON was asked who gave the resident the coffee. The DON stated, "My Activity Assistant (name) gave her the coffee." She was asked, "How did she know the resident could have hot coffee?" The DON stated, "She didn't. She asked the resident if she wanted coffee and she said yes." The DON was asked, "Was (Resident #5) able to handle hot liquids?" She stated, "Yes, there should always be someone (staff) assigned to the assist dining room. (Activity Assistant) was in there the day (Resident #5) was burned." i. On 8/7/14 at 12:00 p.m., the DON was asked about residents who had been placed in the assist dining room for meals without supervision. She stated, "They usually bring them in there. There is no good reason for that." She was asked if there should be someone in there to help the residents with fluids. She stated, "There should be someone in there and assigned to there." j. On 8/7/14 at 12:41 p.m., when asked about the resident's incident of 7/29/14, the Assistant Activity Director stated, "Yes, I pour coffee of the mornings. I asked her (Resident #5) if she wanted a cup of coffee. She said yes, she wanted it black. So I gave her a cup, not full. I asked her if she needed anything else, so I left. I went around and made my rounds in the main dining room." She was asked if there was any staff member in the assist dining room. She stated, "No, maybe a nurse, but I don't know who. There was a family member in there sitting with his grandma and I believe a housekeeper (name)." She was asked, "How do you know who can have hot liquids or not?" She stated, "I have a list they gave us. We've had it for a long time." The Assistant Activity Director was asked for the list. On 8/7/14 at 12:50 p.m., the Assistant Activity Director provided a list titled "Sheet 1", the list that she had stated was the list of residents who could not have hot liquids. Sheet 1 documented, "All Pureed Diets Are Served 3 Compartment Plates, (twelve residents named)... Others Using This Assisted Device (fourteen residents named)... Fluid Restriction, (one resident named)... Nectar Thickened Liquids, (eight residents named)... Honey Thickened Liquids (two residents named)... Pudding Consistency (one resident named)... and Cup (with) Lid (one resident named, Resident #5)." The list did not include documentation of residents who had been assessed for handling hot liquids. k. On 8/7/14 at 12:52 p.m., when asked about the resident's incident of 7/29/14 Housekeeper #1 stated, "I was in the activity room (assist dining room), when (Resident #5) got burned. A family member came up to me, who was with his grandma, and told me this lady just spilled coffee on her. I went to get the CNA to assist her." l. On 8/7/14 at 2:15 p.m., the 7/29/14 facility video of Resident #5's accident in the assist dining room was viewed. The video documented the start of the incident at 7:05 a.m. The video showed four residents sitting at the assist dining table, including Resident #5. The Assistant Activity Director was serving coffee. She served Resident #5 and left the room. At 7:06 a.m., Housekeeper #1 was in room with a fly-swatter, but was not watching residents. A male family member came into the assist dining room but went on into the Activity room office (off of assist dining room). At 7:07 a.m., one of the seated resident's son was standing beside his mother at the table and gave her milk and coffee. At 7:08 a.m., Resident #5 reached for her napkin and pushed it away, hitting her coffee cup and spilling it in her lap. At 7:09 a.m., the other resident's son, who was standing, saw the accident and went to Resident #5. Housekeeper #1 was in the room, but did not see the accident. The resident's son told Housekeeper #1 and she left the room. CNA #2 came into the room with Housekeeper #1 and took Resident #5 in her wheelchair out of the assist dining room. 3. Resident #12 had [DIAGNOSES REDACTED]. The 14-Day MDS with ARD of 7/17/14 documented the resident scored 10 (8-12 indicates moderate cognitive impairment) on the BIMS; required extensive physical assistance of two-plus people for bed mobility, transfers, dressing, toileting and personal hygiene and required extensive physical assistance of one person for locomotion and eating. a. The resident's Annual Nutritional assessment dated [DATE] documented, "...Self Feeding Skills: Dependent..." There was no assessment for hot liquid safety documented on the form. b. The Incident / Accident Report dated 7/7/14 documented, "Res (Resident) noted to have blisters to (right) thigh. Res states she spilt coffee on herself. T. O. (Telephone Order) (physician) Apply [MEDICATION NAME] to area BID (twice daily) until healed... Staff notified to utilize safety cups for liquids." c. The resident's Care Plan dated 7/15/14 documented, "...7/9/14 ...Use safety cup for hot fluids..." d. On 8/7/14 at 4:07 p.m., after the DON was asked if surveyors could see the video of Resident #12 burning her thigh, she stated, "We looked at the video and we can't find where she burned herself. She told the staff in the afternoon that she had spilled her coffee. The staff had asked her about the blister on her thigh and that's what she said, she spilled coffee." 4. Resident #13 had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 5/19/14 documented the resident scored 5 (0-7 indicates severe cognitive impairment) on the BIMS; required extensive physical assistance of two-plus people for bed mobility; required extensive physical assistance of one person for transfers, dressing, toileting and personal hygiene; and required limited physical assistance of one person for eating. a. The resident's Annual Nutritional assessment dated [DATE] documented, "...Self Feeding Skills: Feeds Self or Assistance..." There was no assessment for hot liquid safety documented on the form. b. The Incident / Accident Report dated 4/22/14 documented, "Res was in D/R (dining room) drinking coffee and she dropped it in her lap. Took her to restroom and cleaned area and applied [MEDICATION NAME] Cream to inner leg... Try a different cup and make sure coffee is not (too) hot... 4/24/14... cont (continues) (with) redness to inner thighs [MEDICATION NAME] applied as ordered... 4/24/14... Tx (treatment) to inner thighs no blister - Tx (with) [MEDICATION NAME] - inner thighs (with) no redness - Staff aware to remind resident not to hold coffee cup in lap - Staff not to give (very hot) coffee to resident." c. The resident's Care Plan dated 7/15/14 documented, "...7/9/14 ...Use safety cup for hot fluids..." d. On 8/7/14 at 4:07 p.m., after the DON was asked if surveyors could see the video of Resident #12 burning her thigh, she stated, "We looked at the video and we can't find where she burned herself. She told the staff in the afternoon that she had spilled her coffee. The staff had asked her about the blister on her thigh and that's what she said, she spilled coffee." 5. Resident #9 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 6/10/14 documented the resident scored 12 (8 - 12 indicates moderate cognitive impairment) on the BIMS, required extensive physical assistance of two-plus people for bed mobility and transfers and required supervision and set-up help for eating. a. As of 8/5/14, there was no documented assessment in the clinical record regarding the resident's ability to safely handle hot liquids. b. On 8/8/14 at 8:34 a.m., the resident was observed with her head lowered as she picked up a cup of steaming coffee her hand was shaking. There was no lid on the cup. She was unable to lift her head and there was a slight dribble of coffee on her chin. The resident was asked how she was and she stated, "I still can't raise my head up." 6. Resident #14 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/30/14 documented the resident scored 11 (8 - 12 indicates moderate cognitive impairment) on the BIMS and required supervision and set-up for ambulation, transfers and eating. a. As of 8/8/14, there was no documented assessment in the clinical record regarding the resident's ability to safely handle hot liquids. b. On 8/8/14 at 9:04 a.m., the resident was observed picking up his coffee cup, which was full to approximately 1/4-inch from the top of the cup. There was a slight tremble to the resident's right hand, which he used to pick up the cup. 7. On 8/7/14 at 11:10 a.m., the Dietary Manager stated, "We had the coffee man come in and our coffee was at 170 degrees. He said it could be between 150-205 degrees. We turned it down to 160 degrees and had six complaints it was too cold. We don't have a coffee temperature log." On 8/7/14 at 4:05 p.m., the coffee temperature from the kitchen was 155 degrees. 8. On 8/7/14 at 11:48 p.m., the DON was asked, "How do CNAs know who can have hot liquids or not?" She stated, "It would be on tray card, Care Plan, kiosk system and notify staff. I'm not aware of any resident that has a tray card documented with no hot liquids." The DON was asked if the facility was assessing residents for hot liquids. She stated, "We do on admission." As of this time, no hot liquid assessments were found in the clinical records of any case mix residents. 9. On 8/8/14, the following direct care staff interviews regarding serving hot liquids to residents were conducted: a. On 8/8/14 at 11:19 a.m., Restorative CNA #1 was asked how she knew who could have hot liquids or not. She stated, "Typically it's on their ticket. I didn't have anyone." b. On 8/8/14 at 11:31 a.m., CNA #4 was asked how she knew who could have hot liquids or not. She stated, "Usually it's on dietician cards. No, it didn't say on anyone's ticket not to have hot coffee." c. On 8/8/14 at 11:35 a.m., CNA #5 was asked how she knew who could have hot liquids or not. She stated, "We would just give our liquids in the dining room so they could be watched. No ma'am, I really didn't know who might spill theirs and who might not." d. On 8/8/14 at 11:38 a.m., CNA #6 was asked how she knew who could have hot liquids or not. She stated, "Well, it would either be on their meal ticket or care plan, if they were cautioned. I've not ever had anybody, but if I felt someone was shaky I would use a sippy cup." e. On 8/8/14 at 11:43 a.m., CNA #1 was asked how she knew who could have hot liquids or not. She stated, "One of the things is if they ask for it. You can't tell anyone no. Anyone who needs to be fed or couldn't hold their cup without spilling would need assistance. We have a lot of residents who can feed themselves." 10. On 8/8/14 at 2:55 p.m., in response to being asked for a facility policy and procedure for hot liquid safety, the Assistant DON stated, "We don't have a policy for hot liquids." 11. The Immediate Jeopardy was removed and the scope and severity was lowered to an 'H' when the facility implemented the following Plan of Removal on 8/8/14 at 2:55 p.m. "(Facility name) Immediate Plan of Removal for Immediate Jeopardy will require our DON or her designee, to monitor the Dining Room for residents identified as being at risk of being served hot liquids every day, starting today, and for the next 7 days, then randomly at a minimum of 1 day weekly until substantial compliance is achieved and any findings are corrected. (Facility name) DON has assessed and identified all residents at risk being served hot liquids today and our plan for removal also consists of Immediate in-service of all 3 shifts of employees. The 7-3 (7:00 a.m. to 3:00 p.m.) shift has been completed and the DON, or designee, will in-service the 3-11 (3:00 p.m. to 11:00 p.m.) and 11-7 (11:00 p.m. to 7:00 a.m.) shifts this evening on following those assessed as being at risk. (Facility name) intervention for immediate safety of residents includes today's delivery of appropriate safety cups (with) protective lids that will be used on all residents identified as being at risk (with) hot liquids. Assessments of those identified will be based on cognitive abilities, motor skills, observation and resident's performance. The Dietary department will order cups easily identified by color for use (with) residents at risk of being served hot liquids. We have made each shifts CNA supervisor, or her designee, to monitor all residents identified at risk and to ensure their staff is aware of said residents and follow all measures put in place today. The Dietary staff will monitor the temps (temperatures) of all hot liquids to ensure none exceed established regulations. The Dietary staff will place a notice of residents identified at risk on the resident's daily menu to help staff monitor any at risk. Red coffee cups (with) lids were ordered today and forms were ordered today to help assess and identify all new admissions to (facility name) in the future."