Every finding on record at Hanover Hill Health Care Center

Based on observation, interview and record review, the facility failed to follow physician's order for 1 of 5 residents reviewed for skin conditions in a final sample of 23 residents. (Resident identifier is #105.)Findings include:Standard:[NAME], P.A, [NAME], A.G., Stockhart, P.A., & Hall, A. (2021). Fundamentals of Nursing. Elsevier. Page 1262. Changing Dressings A Health care provider's order for wound care indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound.Review on 3/9/2026 of Resident #105's March 2026 Treatment Administration Record revealed a physician order dated 2/12/26 for, Skin tear dressing order-left forearm-Cleanse wound, pat dry, approximate wound with cotton tip applicator, secure with steristrips, cover with nonadherent telfa pad, wrap with kerlix and secure. May apply hydrogel if additional moisture is needed. every night shift for skin tear DC when healed. Discontinue date was 3/6/2026. Further review revealed there was no current orders. Review on 3/9/2026 of Resident #105's progress notes revealed a note dated 3/4/2026, skin tear-left forearm.healed left OTA [open to air]. Further review revealed another note dated 3/5/2026, skin tear-left forearm.OTA [open to air] area healed.Observation on 3/8/2026 at approximately 9:30 a.m. of Resident #105's left forearm revealed a white kerlix dressing. The dressing had grey smudged areas, and the edges were frayed and not uniform.Observation 3/9/2026 at approximately 2:00 p.m. of Resident #105's left forearm revealed a white kerlix dressing. The dressing had grey smudged areas, and the edges were frayed and not uniform. The dressing had a date of 3/4/26 written on it. Interview on 3/9/2026 at approximately 2:00p.m. with Staff A (Licensed Practical Nurse) confirmed the wound was healed and no longer needed a dressing. Staff A also confirmed that the dressing was dated 3/4/26, which indicated that was the day it was applied.

Based on interview and record review, it was determined that the facility failed to ensure residents remained free from significant medication errors, which resulted in a resident needing interventions for hypotension, including hospitalization for multiple nights for one of three residents reviewed for hospitalization s (Resident Identifier #39). Findings include: Review on 12/9/24 of Resident #39's medical record revealed a nursing note, dated 11/8/24, that stated Resident #39 had received Metoprolol (antihypertensive) 150 milligrams (mg) and that Resident #39 was sent to the emergency room due to experiencing dizziness and low blood pressure. Review on 12/11/24 of Resident #39's hospital discharge summary, dated 11/14/24, revealed that on 11/8/24 Resident #39 was admitted to the hospital with a final diagnosis of hypotension with toprol (Metoprolol) overdose. Further review revealed the reason for hospitalization was adverse effects of a beta-blocker. Resident #39 was discharged back to the facility on [DATE] after a 6 day hospital stay. Review on 12/11/24 of Resident #39's November 2024 Medications Administration Record (MAR) revealed an order for Metoprolol Succinate ER (Extended Release), 12.5 mg once a day for hypertension, with a start date of 5/22/24. Further review of Resident #39's November 2024 MAR revealed no orders for Metoprolol 150 mg. Interview on 12/11/24 at approximately 3:00 p.m. with Staff B (Administrator) stated that on 11/8/24 Resident #39 had received another residents medications, which included Metoprolol 150 mg. The incident was immediately identified and reported to Administration and the Nurse Practitioner. The resident was transported to the hospital. Staff B stated that the incident was investigated and corrective action was initiated. Review on 12/12/24 of the facility's corrective action plan revealed the following: All nurses and medication nursing assistants were educated on medication administration on 11/8/24 through 11/13/24, medication administration observations were initiated on 11/13/24, and a quarterly Quality Assurance meeting was held on 12/4/24, where a review of the incident was conducted.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that dishes were handled and sanitized according to professional standard for food services safety in 1 of 1 main kitchen observed. Findings include: Interview on [DATE] at approximately 8:30 a.m. with Staff F (Food Service Supervisor) revealed that the facility utilized a low temperature dishwasher (chemical sanitization). Observation on [DATE] at approximately 8:30 a.m. in the kitchen with Staff F revealed a chlorine test strip for chemical sanitizer solution testing with an expiration date of ,d+[DATE]. Interview on [DATE] at approximately 8:31 a.m. with Staff F confirmed that the chlorine test strip was expired and that they were using them to determine that the concentration of chlorine used during dishwashing was appropriate for sanitizing the dishes. Review on [DATE] of the facility policy titled, Dish Machine Sanitation, with no date, revealed: .Test water using Ecolab Chlorine Test Paper and record results on a test sheet log located in the dish room . Review on [DATE] of the FDA Food Code 2022 revealed XXX,d+[DATE] Duties ,d+[DATE].11 Person in Charge. The PERSON IN CHARGE shall ensure that: .EMPLOYEES are properly SANITIZING cleaned multiuse EQUIPMENT and UTENSILS before they are reused, through routine monitoring of solution temperature and exposure time for hot water SANITIZING, and chemical concentration, pH, temperature, and exposure time for chemical SANITIZING; XXX,d+[DATE].116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device . Observation on [DATE] at approximately 8:31 a.m. of Staff H (Dietary Aide) in the dishwashing room revealed Staff H rinsed food off of dirty dishes and placed them on a dish tray. Staff H then unloaded clean dishes and placed them on racks to air dry. Staff H did not perform hand hygiene between contact with dirty dishes and clean dishes. Interview on [DATE] at approximately 8:30 a.m. in the kitchen with Staff H confirmed the he/she did not perform hand hygiene between contact with dirty dishes and clean dishes. Review on [DATE] of the FDA 2022 Food Code, retrieved from: (https://www.fda.gov/media/110822/download), revealed: XXX,d+[DATE] PERSONAL CLEANLINESS XXX,d+[DATE].11 Clean Condition. FOOD EMPLOYEES shall keep their hands and exposed portions of their arms clean XXX,d+[DATE].14 When to Wash. FOOD EMPLOYEES shall clean /their hands and exposed portions of their arms as specified under S ,d+[DATE].12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: .(E) After handling soiled EQUIPMENT or UTENSILS; . 40522

Based on interview and record review, it was determined that the facility failed to maintain a system of surveillance to identify and manage infections to prevent the potential spread in the facility for 22 residents with gastrointestinal (GI)infections in a facility census of 116 residents (Resident identifiers are #2, #3, #6, #11, #18, #21, #23, #24, #30, #33, #36, #41, #42, #44, #58, #61, #68, #70, #93, #97, #263, and #267). Findings include: Review on [DATE] of the facility's acute gastroenteritis line list with no date revealed 5 residents (Resident #6, #33, #61, #68, and #93) on the second floor with GI symptoms (i.e. nausea, vomiting, and/or diarrhea) with an onset date of [DATE]. Review also revealed that Resident #68 and Resident #61 experienced diarrhea, Resident #33 experienced vomiting, and Resident #6 and Resident #93 experienced diarrhea and vomiting. Further review of the acute gastroenteritis line list with no date revealed that there was no documentation of outcome (i.e. symptom resolution date, hospitalized , and expired) for the 5 residents. Interview on [DATE] at approximately 1:00 p.m. with Staff I (Infection Preventionist) confirmed the above findings. Further interview with Staff I revealed that he/she did not investigate when the 5 residents were identified to have GI symptoms of nausea, vomiting, and/or diarrhea on [DATE]. Interview with Staff I also revealed that the 5 residents with GI symptoms were put on contact precautions. The on-call provider was notified that the 5 residents were symptomatic and the provider did not order contact precautions because it was a quick bug that is viral. Review on [DATE] of the facility's acute gastroenteritis line list dated [DATE] revealed the following additional residents became ill with GI symptoms: 1. 8 residents on the first floor with GI symptoms with an onset date of [DATE] and symptom resolution date of [DATE] (Resident #11, #18, #21, #24, #41, #44, #58, and #97). 2. 3 residents on first floor with GI symptoms with an onset date of [DATE] and symptom resolution date of [DATE] (Resident #2, #3, and #23). 3. 1 resident on first floor with GI symptoms with an onset date of [DATE] and symptom resolution date of [DATE] (Resident #70). 4. 1 resident on second floor with with GI symptoms with an onset date of [DATE] (Resident #267). 5. 2 residents on second floor with with GI symptoms with an onset date of [DATE] (Resident #30 and #263). Interview on [DATE] at approximately 1:05 p.m. with Staff I confirmed the above acute gastroenteritis line list dated [DATE]. Interview with Staff I revealed that when they identified 8 residents with GI symptoms on the first floor last week, symptomatic residents were put on precautions until symptom resolution, the provider was notified, and on [DATE] public health was notified. Review on [DATE] of Staff I's email correspondence to public health, dated [DATE], revealed: .I wanted to update you on GI sx [symptoms] in the facility. As of yesterday [[DATE]] there has been sporadic nausea/vomiting/diarrhea symptoms. Symptoms have mostly been resolving after the initial episode. I do have a line listing I can fax over for you to review. Currently 9 residents on same unit, and one staff member. No fevers noted. Provider does not feel it is necessary to do further testing at this time, as patients are stable and feeling well. We are having the first floor patients refrain from main dining room for 48 hours for precautionary reasons. Contact precautions in place for symptomatic patients as well . Review on [DATE] of the facility's policy titled, Outbreak Investigation, with no date, revealed: It is the policy of [NAME] Hill Health Care Center that outbreak measures will be institutes whenever there is an incidence of infections above what would normally be expected, considering seasonal variations. Procedures: The Infection Preventionist Nurse will conduct the outbreak investigation .Appropriate notifications will be completed within the facility to the Medical Director, Administrator, all departments, attending physician and designated responsible party at minimum and to appropriate state and local agencies. Outbreak monitoring and reporting will continue until resolution. At that time, narrative reports will be completed and forwarded to appropriate state and local agencies. The Infection Preventionist Nurse will have the authority to implement control measures as appropriate, in coordination with facility administration and medical staff as well as state and local agencies. For example, these control measures may include simple resident or unit isolation or quarantine measures for the entire facility . Review on [DATE] of the facility's policy titled, Isolation - Initiating Transmission Based Precautions, revision date of [DATE], revealed: .Policy Statement Transmission-Based precautions are initiated when a resident develops signs and symptoms of a transmissible infection .and is at risk of transmitting the infections to other residents .Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist discontinues them, which occurs after criteria for discontinuation are met. a) In an emergency (for example, an outbreak), the Infection Preventionist, Administrator and/or medical Director have the administrative authority, accountability, and responsibility to implement measures to control or prevent infections within the facility . Review on [DATE] of the facility's policy titled, Norovirus Prevention and Control, revised date of [DATE], revealed: .Policy Interpretation and Implementation 1. Avoid exposure to vomitus or diarrhea. Place residents on Contact precautions in a single room, if possible, when symptoms are consistent with norovirus gastroenteritis .During outbreaks, residents with norovirus gastroenteritis will be placed on Contact Precautions for a minimum of 48 hours after the resolution of symptoms .The following may be considered in an effort to prevent or control norovirus transmission during outbreaks: a) minimize resident movements within the unit; b) restricting symptomatic and recovering residents from leaving the resident-care area unless it is for essential care of treatment; and c) suspending group activities (e.g., dining events) for the duration of an outbreak . Review on [DATE] of the facility infection control meeting related to GI symptoms, dated [DATE], revealed that in attendance were Staff I, the medical director, Staff J (Advanced Practical Registered Nurse (APRN)), Administrator, Director of Nursing, and other staff members. Further review revealed that the sporadic GI symptoms appeared to be viral gastroenteritis that affected residents on 3 of 4 units and no known testing appropriate for short acting gastroenteritis. Reviewed interventions included contact precautions and discontinuation of precautions after 24 hours without symptoms and continued standing order for GI protocol. Review on [DATE] of the acute gastroenteritis line lists for Resident #2, #11, #21, #33, #41, #44, #93, and #267 revealed that onset and resoulution dates for GI symptoms were inconsistant with the medical record: Resident #33 Review on [DATE] of Resident #33's medical record revealed that on [DATE] Resident #33 had two episodes of small emesis overnight and the on call provider was notified. Further review of Resident #33's medical record revealed that on [DATE] Resident #33 had a one time episode of vomiting, which is inconsistent from the above mentioned acute gastroenteritis line list dated [DATE] that Resident #33's symptom resolution date was [DATE]. Resident #93 Review on [DATE] of Resident #93's medical record revealed that on [DATE] Resident #93 had 2 episodes of vomiting and received as needed TUMS (treats indigestion, heartburn and upset stomach) at 5:08 p.m Further review of Resident #93's medical record revealed that on [DATE], Resident #93 had multiple episodes of emesis and diarrhea overnight. Review also revealed that on [DATE] Resident #93 declined dinner related to nausea and he/she had one episode of loose stool in the evening shift which is inconsistent from the above mentioned acute gastroenteritis line list dated [DATE] that Resident #93's symptom onset date and resolution date of [DATE]. Resident #11 Review on [DATE] of Resident #11's medical record revealed that on [DATE] Resident #11 had vomited seven times. On [DATE], Resident #11 received Zofran (anti-emetic) at 3:41 a.m., 12:31 p.m., and 7:10 p.m. for nausea and vomiting. On [DATE], Resident #11 received Cal-Gest (treats indigestion, heartburn and upset stomach) as needed for GI upset at 8:12 a.m. which is inconsistent from the above mentioned acute gastroenteritis line list dated [DATE] that Resident #11's symptom resolution date was [DATE]. Resident #44 Review on [DATE] of Resident #44's medical record revealed that on [DATE] Resident #44 had 2 episodes of vomiting before supper. On [DATE], Resident #14 had 4 loose stools documented at 12:57 a.m., 6:33 a.m., 1:26 p.m. and 8:41 p.m., which is inconsistent from the above mentioned acute gastroenteritis line list dated [DATE] that Resident #14's symptom onset date was [DATE]. Resident #21 Review on [DATE] of Resident #21's medical record revealed that on [DATE], Resident #21 had nausea and diarrhea, the on call provider was notified, and an order of Zofran medication was obtained. On [DATE] at 7:42 a.m. a note revealed that Resident #21 had nausea and vomiting the previous shift and continued with nausea and not feeling well which is inconsistent from the above mentioned acute gastroenteritis line list dated [DATE] that Resident #11's symptom onset date was [DATE]. Resident #41 Review on [DATE] of Resident #41's medical record revealed that on [DATE] Resident #41 vomited two times and had 4 documented loose stools which is inconsistent from the above mentioned acute gastroenteritis line list dated [DATE] that Resident #11's symptom onset date was [DATE] and symptom resolution date of [DATE]. Resident #2 Review on [DATE] of Resident #2's medical record revealed that on [DATE] Resident #2 had an extra large and large amount of vomit (vomited twice), and GI protocol put in place. On [DATE], Resident #2 had vomited four times and had a large loose stool. Resident #2 was given as needed Promethazine (treats nausea and vomiting) at 6:38 a.m. and 6:08 p.m. which is inconsistent from the above mentioned acute gastroenteritis line list dated [DATE] that Resident #2's symptom onset date was [DATE]. Resident #267 Observation on [DATE] at approximately 8:30 a.m. revealed that Resident #267 was not on contact precautions for acute gastroenteritis Observation on [DATE] at approximately 12:30 p.m. revealed that Resident #267 was on contact precautions for acute gastroenteritis. Review on [DATE] of Resident #267's medical record revealed that on [DATE] Resident #267 was sent to the emergency department (ED) at approximately 7:15 p.m. as Resident #267 was pallor, vomiting, had Milk of Magnesia [DATE] and blockage passed and continued to have the runs, and yellow sclera. At 10:53 p.m. resident returned from the ED after receiving fluids, Zofran, immodium, liver function test were not far off baseline and that symptoms attributed to GI virus. Review on [DATE] of Resident #267's ED note, dated [DATE], revealed: .ED Course .much improved after IV [intravenous] fluids. After IV ondansteron [anti-emetic] (pronoun omitted) was tolerable oral liquids now. No further episodes of diarrhea after imodium 4 mg [milligram] p.o other LFTs [Liver Function Test] were stable from prior. Patient was [sic] appears stable for discharge. Given the GI bug going around the nursing home this seems likely to be what (pronoun omitted) has . Interview on [DATE] at approximately 10:30 a.m. with Staff I confirmed the above findings including policies in regards to outbreak investigation and viral GI symptom protocol (Norovirus Prevention and Control policy was provided). Staff I also confirmed that the acute gastroenteritis line list dated [DATE] was inconsistent with the above mentioned resident's medical records and that he/she relied only on nurse's report of GI symptoms. Staff I stated that symptom resolution date was the date when 24 hours had passed since the resident's last GI symptoms. Interview on [DATE] at approximately 1:00 p.m. with Staff J revealed that viral acute gastroenteritis is highly contagious and protocol is that symptomatic residents are placed on contact precautions. Review on [DATE] of the acute gastroenteritis line list dated [DATE], updated on [DATE], revealed 3 residents on first floor were added to the line list with GI symptom onset of [DATE] (Resident #23, Resident #36, and Resident #42).

Based on record review and interview, it was determined that the facility failed to ensure that a resident had an accurate Preadmission Screening and Resident Review (PASARR) screening for an individual with a mental health disorder for 1 of 2 residents reviewed for PASARR in a final sample of 25 residents (Resident Identifier is #30). Findings include: Review on 12/11/24 of Resident #30's medical record revealed that Resident #30 was admitted to the facility in May 2024 with known diagnoses of post-traumatic stress disorder and obsessive-compulsive disorder. Review of Resident #30's initial PASARR, dated 5/14/24, revealed that in Section II titled PASARR Level I Screening for Mental Illness (MI), NO was answered to indicate that Resident #30 did not have a diagnosis of mental illness. Since the PASARR Level I did not include post-traumatic stress disorder and obsessive-compulsive disorder as a diagnosis of mental illness, the facility failed to refer the resident to the appropriate state-designated authority for evaluation and determination for appropriate placement and services. Interview on 12/11/24 at 1:42 p.m. with Staff A (Director of Social Services) confirmed that Resident #30 had a diagnosis of post-traumatic stress disorder and obsessive-compulsive disorder upon admission and the facility did not refer the resident to the appropriate state-designated authority for evaluation and determination.

Based on observation and interview, it was determined that the facility failed to ensure that medications were appropriately stored for 1 of 4 medication carts observed. Findings include: Observation on 12/9/24 at approximately 8:30 a.m. in the First Floor [NAME] cart revealed two clear plastic medication cups containing medications. One medication cup was on top of the other medication cup. Further observation revealed the two medicine cups were not labeled with resident identifiers. Interview on 12/9/24 at approximately 8:30 a.m. with Staff E (Registered Nurse) confirmed that the medication cups were unlabeled with resident identifiers and revealed the cups contained medications for 2 different residents. Review on 12/9/24 of the facility's policy titled, Storage and Expiration Dating of Medications and Biologicals, revision date of 8/1/24, revealed .Facility should ensure that the medications and biologicals for each resident are stored in the containers in which there were originally received .

Based on interview and record review, it was determined that the facility failed to ensure that the facility assessment included specific staffing needs for each resident unit in the facility, specific staffing needs for each shift such as day, evening, night, and was adjusted as necessary based on changes to its resident population. Findings include: Review on 12/12/24 of the Facility Assessment (FA) revealed that the assessment did not include specific staffing needs for each resident unit in the facility and/or identify specific staffing needs by shift. Review on 12/12/24 of CMS (Centers for Medicaid and Medicare Services) form 671, provided and signed by Staff B (Administrator), revealed that the facility had a 24 bed Alzheimer's Unit ([NAME] unit). Review on 12/12/24 of facility Daily Nursing Schedule, dated 12/11/24, revealed the facility had a skilled unit, two long term care units, and the [NAME] unit. Interview on 12/12/24 with Staff B confirmed the above findings.

Based on interviews and record review, it was determined that the facility failed to follow the Center for Disease Control (CDC) return to work guidelines for healthcare personnel who were positive for COVID-19 for 3 of 3 healthcare personnel reviewed for COVID-19 infection. Findings Include: Review on 8/30/23 of the CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, updated September 23, 2022, revealed, . Return to Work Criteria for HCP [Health Care Personnel] with SARS-CoV-2 Infection. HCPs with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed, or if a positive test at day 5-7), and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g. [for example], cough, shortness of breath) have improved. *Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later. HCPs who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since the date of their first positive viral test if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). *Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later . Review on 8/30/23 at 10:30 a.m. of the facility's COVID-19 Outbreak Line List revealed the following: Staff A (Licensed Nursing Assistance (LNA)) tested positive for the COVID-19 virus on 8/23/23 Staff B (LNA) tested positive for the COVID-19 virus on 8/21/23 Staff C (Activities/Social Service) tested positive for the COVID-19 virus on 8/24/23 Further review of the facility's COVID-19 Outbreak Line List revealed no information regarding symptom onset dates, negative test dates, and no return to work dates. Interview on 8/30/23 at approximately 12:55 p.m. with Staff B revealed that he/she tested positive for COVID-19 on 8/21/23 and returned to work on 8/26/23 (Day 5). Staff B stated that he/she had one negative COVID-19 test that was completed at home on 8/26/23. Interview on 8/30/23 at approximately 1:30 p.m. with Staff C revealed that he/she started with a cough, headache, and sore throat and tested positive for COVID-19 on 8/23/23. Staff C stated that they returned to work on 8/29/23 (Day 6). Staff C stated that they completed one negative COVID-19 test at home on 8/28/23 (Day 5). Interview on 8/30/23 at approximately 2:45 p.m. with Staff E (Administrator) confirmed the above information. Staff E stated that Staff C had an onset of COVID-19 symptoms on 8/23/23 and tested positive for COVID-19 on 8/24/23. Staff E confirmed that Staff C completed one negative COVID-19 home test on 8/28/23 and returned to work on 8/29/23 (Day 5) and Staff A had symptoms of COVID-19 on 8/21/23, one self-test at home was positive on 8/23/23 and returned to work on 8/28/23 (Day 7). Review on 8/30/23 of Employee Punch Reports for August 20, 2023 through August 30, 2023, revealed the following: Staff A's first shift worked after testing positive for COVID-19 was on 8/28/23 (Day 7) Staff B's first shift worked after testing positive for COVID-19 was on 8/26/23 (Day 5) Staff C's first shift working after testing positive for COVID-19 was on 8/29/23 (Day 6) Review on 8/30/23 at 3:00 p.m. of the facility's policy dated 05/12/23 titled COVID-19 - Comprehensive . page 3 Entry of Healthcare Personnel and Other Providers of Service section B. Staff returning to work following a positive COVID-19 viral test shall follow the CDC Return To Work Criteria for HCP (healthcare providers) with SARS-CoV-2 infections guidance which includes criteria based on severity of symptoms and presence immunocompromising conditions. Interview on 8/30/23 at approximately 2:45 p.m. with Staff E confirmed that there was not a second negative test done per the CDC guidelines.

Based on observations, interviews, and record review, it was determined that the facility failed to assess residents' ability to self-administer medications for 4 of 4 residents reviewed for self-administration of medication in a final survey sample of 25 residents. (Resident identifiers are #3, #27, #50, and #80.) Findings include: Resident #3 Observation on 11/8/22 at 11:00 a.m. of Resident #3 in their room revealed 2 bottles of antifungal powder on Resident #3's side table. Observation on 11/9/22 at 12:50 p.m. of Resident #3 in their room revealed 2 bottles of antifungal powder on Resident #3's side table. Review on 11/9/22 of Resident #3's medical record revealed no active order to self-administer medication. Interview on 11/9/22 at 12:50 p.m. with Staff A (Director of Nursing) who confirmed Resident #3 did not have an order for self-administration of antifungal powder. Observation and interview on 11/9/22 at 1:15 p.m. with Staff A revealed 2 bottles of antifungal powder on Resident #3's side table and confirmed the finding. Resident #27 Observation on 11/8/22 at 11:10 a.m. of Resident #27 in their room revealed a tube of muscle rub on Resident #27's side table. Interview on 11/8/22 at 11:10 a.m. with Resident #27 revealed nurses routinely leave the tube of muscle rub on Resident #27's side table for self-administration. Review on 11/9/22 of Resident #27's medical record revealed no active order to self-administer medication. Interview on 11/9/22 at 12:50 p.m. with Staff A confirmed Resident #27 did not have an order for self-administration of muscle rub. Resident #50 Observation on 11/8/22 at 10:10 a.m. of Resident #50 in their room revealed a tube of muscle rub and a container of vapor rub on his/her window sill. Observation on 11/9/22 at 12:45 p.m. of Resident #50 in their room revealed a tube of muscle rub and a container of vapor rub on his/her window sill. Interview on 11/9/22 at 12:45 p.m. with Resident #50 confirmed the tube of muscle rub and a container of vapor rub are his/hers available for self-administration. Interview on 11/9/22 at 12:50 p.m. with Staff A confirmed Resident #50 did not have an order for self-administration of muscle and vapor rub. 46510 Resident #80 Observation on 11/8/22 at approximately 10:17 a.m. in Resident #80's room revealed a medicine cup with multiple pills, one tube of hydrocortisone cream, and two insulin pens on Resident #80's bedside table. Interview on 11/8/22 at approximately 10:19 a.m. with Resident #80 revealed that some nurses leave his/her morning medications and insulin on the bedside table for them to self-administer. Review on 11/8/22 at approximately 2:15 p.m. of Resident #80's medical record revealed no self-administration order or self-administration assessment. Interview on 11/8/22 at approximately 2:28 p.m. with Staff F (Licensed Practical Nurse) confirmed that Staff F had left the medications for Resident #80 to self-administers his/her medication. Review on 11/9/22 at approximately 10:00 a.m. of Resident #80's November MAR (Medication Administration Record) revealed the following medications were signed as administered on 11/8/22 in the morning: 1 Asprin 81 milligran (mg) tablet 2 Acetaminophen 325mg tablet 1 Amlodipine Besylate 5mg tablet 1 Cerovite 18mg-0.4mg tablet 1 Duloxetine Hydrochloric Acid (HCL) 30mg capsule 1 Duloxetine HCL 60mg capsule 1 Metorolol Tartrate 100mg tablet 1 Valsartan 160-25mg tablet 1 Bupropion HCL 75mg tablet 1 Metformin HCL 1000mg tablet 1 Zyrtec 10mg Hydrocortisone Cream 40 units Lantus Solostar 100 unit/1 milliliters (ML) insulin Pen Interview on 11/9/22 at approximately 12:50 p.m. with Staff A (Director of Nursing) confirmed that Resident #80 did not have an order for self-administration nor a self-administration assessment.

Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders for 1 out of 2 residents reviewed for hemodialysis in a final survey sample of 25 residents. (Resident identifier is #61.) Findings include: Standards: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Interview on 11/9/22 at approximately 8:15 a.m. with Resident #61 revealed that they leave for dialysis around 9:30 a.m. and return to the facility around 2:30 p.m. on Tuesday, Thursday, and Saturday. Review on 11/9/22 at approximately 8:36 a.m. of Resident #61's November 2022 MAR (Medication Administration Record) revealed an order for sevlamer (hypophosphatemic) with meals with a start date of 10/14/22. Scheduled times are 6:30 a.m., 12:00 p.m., and 4:30 p.m Further review of November 2022 MAR revealed that the sevlamer was circled off as not given on the following dates: 11/1/22, 11/3/22, 11/5/22, and 11/8/22. Review on 11/9/22 at approximately 8:36 a.m. of Resident #61's current physician's orders revealed no order to hold medications while Resident #61 was at hemodialysis on Tuesday, Thursday, and Saturday. Interview on 11/9/22 at approximately 2:19 p.m. interview with Staff E (Licensed Practical Nurse) revealed that the 12:00 p.m. dose of sevlamer is held when Resident #61 is at dialysis. Staff E confirmed there is no order to hold the sevlamer when at dialysis. Review on 11/10/22 of facility policy on Medications, with no initiation or revision date, revealed: .drugs administered in accordance with the written orders of the attending physician .

Based on observation and interview, it was determined that the facility failed to ensure that expired medications were removed from inventory in 1 of 1 medication rooms and two of two medication carts observed. (Resident Identifier is #28) Findings include: Second Floor Medication Room: Observation on 11/8/22 at approximately 8:50 a.m. of the second floor medication room refrigerator with Staff F (Licensed Practical Nurse) revealed the following expired medications: 1 bottle of Acidophilus Probiotic, expiration date 5/22; 7 Acetaminophen suppositories 650 milligram (mg), expiration date 5/22; 1 Acetaminophen suppository 650mg, expiration date 7/21; 1 Acetaminophen suppository 650mg, expiration date 2/21; 3 Acetaminophen suppositories 650mg, expiration date 6/20. Interview on 11/8/22 at approximately 8:58 a.m. with Staff F confirmed the above findings. Second Floor Low Cart: Observation on 11/8/22 at approximately 9:00 a.m. of the second floor low cart with Staff F revealed the following expired medication: 3 Acetaminophen suppositories 650mg, expiration date 5/22. Interview on 11/8/22 at approximately 9:10 a.m. with Staff F confirmed the above findings. First Floor Odd Cart: Observation on 11/9/22 at approximately 9:00 a.m. of the first floor odd cart with Staff E (Licensed Practical Nurse) revealed the following expired medication: Resident #28's Losartan Potassium 100mg, 5 tablets with a pharmacy expiration date of 10/31/22. Review on 11/9/22 at approximately 9:05 a.m. of Resident #28's November 2022 MAR (Medication Administration Record) revealed the following order: Losartan Potassium F/C 100mg tablet, 1 tab by mouth every day with a start date of 8/16/18. Interview on 11/9/22 with Staff E confirmed the above finding. Staff E revealed that Resident #28 did not recieve his/her morning dose on 11/9/22. Staff E revealed that he/she gave the expired Losartan the day prior (11/8/22). Review on 11/9/22 of the facility policy titled, Storage and Expiration dating of Medications, Biologicals, Syringes and Needles, May 2010 revealed: .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; . are stored separate from other medications until destroyed or returned to the supplier.

Based on interview and record review, it was determined that the facility failed to obtain weights as ordered to monitor weight changes for 1 of 1 resident reviewed for [CONDITION(S)] in a final survey sample of 25 residents. (Resident identifier #60.) Findings include: Standards: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 9/8/21 at approximately 1:00 p.m. of Resident #60's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 9/8/21 at approximately 1:00 p.m. of Resident #60's current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 9/9/21 at approximately 1:00 p.m. of Resident #60's July 2021 and August 2021 MAR (medication administration record) revealed the following dates with no daily weight recorded: July 13, 14, 15, 17, 18, 21, 22, 25, 31 August 1, 2, 4, 5, 6, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 22, 24, 25, 26, 27, 28, 29, 31 Review on 9/9/21 at approximately 1:00 p.m. of Resident #60 progress notes revealed no documentation that the provider was notified that weights were not obtained as ordered for the above listed dates. Interview on 9/10/21 at approximately 9:13 a.m. with Staff E (Licensed Practical Nurse) confirmed the above findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure admission medications were readily available for 1 of 1 resident reviewed for new admissions in a survey sample of 25 residents. (Resident identifier #265) Findings include: Interview on 9/08/21 at approximately 9:10 a.m. with Resident #265 revealed that they felt anxious as they had not received their anxiety medication since admission yesterday (9/7/21). Review on 9/8/21 at approximately 9:15 a.m. of Resident #265's physician orders revealed an order for [MEDICATION(S)] (antianxiety) 30 mg (milligrams) twice a day with a start date of 9/7/21. Review on 9/8/21 at approximately 9:30 a.m. of Resident #265's September MAR (Medication Administration Record) revealed that the [MEDICATION(S)] order was marked as not given on 9/7/21 for the evening dose and on 9/8/21 for the morning dose. Review on 9/8/21 at approximately 1:00 p.m. of Resident #265's Nursing Progress Notes revealed no documentation about missed doses of [MEDICATION(S)] or notification to provider or pharmacy. Interview on 9/8/21 at approximately 1:00 p.m. with Staff C (unit manager) confirmed the above findings. Interview on 9/8/21 at approximately 1:30 p.m. with Staff D (Licensed Practical Nurse) stated they could not give Resident #265 the [MEDICATION(S)] as it had not been delivered from pharmacy and it is not something that is carried in the pharmacy back up medications. Staff D stated the [MEDICATION(S)] required a script that was not obtained at admission. Review on 9/9/21 of facility policy titled Medication shortages/unavailable medications revised 1/1/13 revealed, .1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy .2.3 If the medication is not available in the Emergency Medication Supply. Facility staff should notify pharmacy and arrange for an emergency delivery .4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions .

Based on observation, interview, and record review, it was determined that the facility failed to assess 2 of 2 residents reviewed for the ability to self-administrator medications in a final sample of 51 residents reviewed. (Resident identifier is #23 and #92.) Findings include: Resident #23 Observation of Resident #23's room on 9/8/21 at approximately 9:48 a.m. of revealed two inhalers on Resident #23's bedside table. Interview with Resident #23 on 9/8/21 at approximately 9:48 a.m. revealed the inhailent medications are left on the bedside table for Residnet #23 to self-administer. Record review on 9/8/21 at approximately 1:18 p.m.of Resident #23's physician orders revealed orders for administration of one inhaler daily and the other inhalant four times per day. Further record review revealed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review on 9/8/21 at approximately 1:18 p.m.of Resident #23's current care plan revealed no documentation of an assessment by the Interdisciplinary Team (IDT) regarding self-administration of medications and no documentation on the resident care plan regarding self administration of medications. Interview on 9/8/21 at approximately 1:30 p.m. with Staff A (Licensed Practical Nurse (LPN)) revealed that the inhant medications were on bedside table. Staff A stated she/he checks in with the resident to verify she/he self-administered doses then Staff A records completion on the MAR. Interview on 9/8/21 at 1:30 p.m with Staff B (LPN) confirmed that the Resident #23 was not assessed by IDT for self administration of medication, and no care planned for the self administration of medication. Resident #92 Observation on 9/08/21 at approximately 10:00 a.m. of Resident #92's room revealed a bottle of [MEDICATION(S)] (antihistimine) 0.2% eye drops on the night stand. Interview on 9/8/21 at approximately 10:00 a.m. with Resident #92 revealed the eye drops are left at the bed side so they can do their own eye drops in the morning. Review on 9/8/21 at 10:10 a.m. of Resident #92's medical record revealed no active order for self-administration of medication. Further review of Resident #92's medical record revealed no assessment for self-administration of medications. Interview on 9/08/21 at approximately 11:20 a.m. with Staff C (unit manager) confirmed the above findings.

Based on medical record review and interview, it was determined the facility failed to follow physician orders [REDACTED]. (Resident identifier is #47.) Findings include: Review of [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders revealed the following: The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 1/31/2020 of Resident #47's medical record revealed a physician's orders [REDACTED].#47 would have weekly skin assessment. Review on 1/31/2020 of Resident #47's weekly skin condition record revealed that Resident #47 did not receive timely weekly skin assessment. Resident #47 received one on 1/4/2020, which stated wounds to buttocks treated as ordered in MAR (Medication Administration Record) No s/s (signs/symptoms) of infections; the following week 1/11/2020 it revealed that it Continues with multiple open areas to coccyx/buttocks. Dressing and ointments applied as ordered. No changes noted. No s/s infection. This was the last note/input to the skin condition record. Review on 1/31/2020 of Resident #47's care plan revealed that Resident #47 has an alteration in skin integrity r/t (related /to) the pressure of Deep Tissue Injury (DTI). The care plan inventions include dressings as ordered. assesses placement and integrity of the dressing every shift and change if compromised. Interview on 1/31/2020 at approximately 2:00 p.m. with Staff D (Unit Manager) confirmed that Resident #47 developed a DTI on the heel. Staff D confirmed the heels started to be offloaded at this time. Review on 1/31/2020 of physician orders [REDACTED]. Heel foam cups BL (bilateral) heels- change weekly off-loading boot while in bed at all times. Staff D confirmed this was started after the DTI was discovered. Review on 1/31/2020 of Resident #47's medical record revealed no documentation that the heels had been looked at prior to the DTI developing.

Based on interview and record review the facility failed to maintain a complaint/grievance log. Findings include: Review on 1/31/20 of the facility policy and procedure titled Grievances revealed the following: Policy Interpretation and Implementation: 7. The patient/resident, or person filing the grievance on behalf of the patient/resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or her designee, within ten working days of the completion of initial investigation of the grievance. A written summary of the report will also be provided to the patient/resident upon request, and a copy will be filed in the Social Services Office. Review on 1/31/20 of the facility policy and procedure titled Investigating Grievances revealed the following: 3. The Grievance Investigation Report must be filed with the administrator within five (5) working days of the receipt of the grievance. 4. The patient/resident, or person acting on behalf of the patient/resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ten (10) working days of the filing of the grievance. 5. A copy of the Grievance Investigation Report must be filed in the social services office. 6. Copies of all reports must be signed and a written summary of the report will be provided upon request to patient/resident or person acting on behalf of the patient/resident. Interview on 1/30/20 at approximately 11:30 a.m. with Staff [NAME] (Director of Social Services) revealed that grievances/complaints are addressed at the time of the grievance/complaint is reported to the facility. Staff [NAME] confirmed that there was no documented complaint/grievance log to track and/or trend complaints/grievances investigated by the facility within 3 years from the date of a complaint/grievance resolution.

Based on record review, observation, and interview, it was determined that the facility failed to ensure that consents for antipsychotic medication use were complete and correctly executed for 5 of 5 residents using antipsychotic medications in the standard survey sample of 24 residents. (Resident identifiers are #9, #12, #13, #23, and #24.) Findings include: An FDA Alert (2005) addressed Increased Mortality in Patients with Dementia-Related [MEDICAL CONDITION] (see http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm 1.htm accessed [DATE].) A website page last updated [DATE] related, in part, Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. (see http://www.fda.gov/Safety/MedWatch/SafetyInformation/Safety-RelatedDrugLabelingChanges/ucm 6.htm accessed [DATE]). Resident #13 Review of this resident's current Medication Administration Record [REDACTED]. Review of the Informed Consent For Psychoactive Medications signed by the Guardian on [DATE] for use of [MEDICATION NAME] CR, [MEDICATION NAME], and [MEDICATION NAME] reveals that Possible Side Effects/Risks include death: and Nsg 2010 Drug Handbook Lippincott. This signed consent does not clearly address the increased risk of death associated with [MEDICATION NAME]. This was the most recent consent for this resident's Risperidal use in the resident's record on day one of survey ([DATE]). Resident #24 Review of this resident's current MAR indicated [REDACTED]. Review of the Psychoactive Medication Informed Consent for [MEDICATION NAME] reveals it was signed by the daughter on [DATE] and the Possible Side Effects/Risks include death increased with Dementia. The ink color for increased with Dementia did not match the rest of the document and interview with Staff B, LPN, on [DATE] revealed that Staff B added these words to the document on [DATE]. Review of the above Psychoactive Medication Informed Consent on [DATE] revealed the revision of the document was not initialed or dated, and after surveyor pointed this out to Staff B on [DATE], Staff B was observed to initial the change. The revision to the consent was not initialed or signed by the Resident/Resident Representative. Further record review revealed an Interdisciplinary Progress Notes entry dated/timed [DATE] 15:37 (the day after the [MEDICATION NAME] consent was revised) that relates DPOA contacted this shift; informed consent from DPOA obtained regarding use of antipsychotic meds and black box warning for increased mortality/death on elderly with dementia Resident #9. Record review on [DATE] of the facility form titled PSYCHOACTIVE MEDICATION INFORMED CONSENT for Resident #9 dated [DATE] revealed that Resident #9 had a medical [DIAGNOSES REDACTED].@ HS (hour of sleep). Record review and review of this consent form revealed that the facility failed to inform Resident #9 of the black box warnings associated with the use of antipsychotic medications. Resident #12. Record review on [DATE] of the facility form titled PSYCHOACTIVE MEDICATION INFORMED CONSENT for Resident #12 dated [DATE] revealed that Resident #12 had a medical [DIAGNOSES REDACTED]. Record review and review of this consent form revealed that the facility failed to inform Resident #12 of the black box warnings associated with the use of antipsychotic medications. Resident # 23 Review of Resident # 23's record revealed that the document titled Psychoactive Medication Informed Consent dated [DATE] displayed a Black Box warning that reflects the possibility of medical risks including death. On [DATE] the document was added to in the possible side effects/risks section of the form to include increased with dementia but did not have the signature of the change from the durable power of attorney or Staff B who made the change. Interview on [DATE] at approximately 3:00 p.m. with Staff B LPN (Unit Manager) confirmed that this change was made to the document on [DATE] without prior consent.

Based on record review and interview, it was determined that the facility failed to ensure that medical records were complete and accurate for 2 residents in a survey sample of 24 residents. (Resident identifiers are #21 and #24.) Findings include: Resident #24 Review of this resident's Significant Change MDS with an ARD of 6/15/16 revealed that Section L was coded to indicate the resident has: No natural teeth or tooth fragment(s). However review of the Significant change MDS with an ARD of 7/28/16 revealed in Section L that L0200.B. was not checked off, indicating that the resident does have natural teeth or tooth fragments. Interview with Staff C, Administrator, on 8/11/16 revealed that Resident #24 does have teeth and that a modification is being done to correct the MDS error. Resident #21 Review 8/11/16 of the June 2016 MAR for Resident #21 revealed physician orders [REDACTED].(hours) PRN (as needed for) pain (level) 1-5 and [MEDICATION NAME] IR 5 mg 2 tabs po (by mouth)Q (every) 4 .(hours) PRN (as needed for) pain (level) 6 - 10. Review of the July 2016 MAR for Resident #21 revealed physician orders [REDACTED]. tab (let) by mouth every 4 hours as needed for severe pain. and [MEDICATION NAME] HCL 'IR' 5 mg tablet .2 tabs by mouth every 4 hours as needed for severe pain. On interview Staff A, RN, DON, confirmed that the orders did not appear to be correctly transcribed by pharmacy concerning the [MEDICATION NAME] orders for both 1 tab and 2 tabs administration, on the July 2016 Physicians Order Sheet for Resident #21. Additional record review on 8/11/16 reveals there are no medication administration pain level parameters stated in the MAR's in an order for [REDACTED].

Based on observation and interview the facility failed to maintain oxygen concentrators according to manufacturer's instructions. Findings include: Observation during the initial tour of the first floor on 2/20/13 at approximately 9 am revealed 3 out of sample residents had oxygen concentrators in their rooms and the filters were covered entirely with gray dust. During interview with Staff A, (RN/Unit Manager) on 2/20/13, Staff A confirmed the findings of dirty filters for the above concentrators. Staff A further stated the facility vendor (name withheld) provides the maintenance for the oxygen concentrators and Staff A thought the vendor changed the filters but was unsure. Staff A further revealed during interview that Staff A was unsure when the filters were last cleaned or changed and the facility does not keep logs for documentation of filter changes. Review of the Manufacturer's instructions dated 4/09 for cleaning the oxygen concentrators titled, " Platinum Series SSL, 5, 10 Oxygen Concentrators Standard, with Senso 2 and Homefill " revealed the following on page 23: " Note: At a minimum, preventive maintenance MUST be performed according to the maintenance record guidelines. " ... " Note: There are two cabinet filters one located on each side of the cabinet. Remove each filter and clean at least once a week depending on environmental conditions."

Based on the Resident Trust Fund review and staff interviews, the facility made deposits of resident funds into another facility "holding" account commingling it with other facility revenue monies. By doing this, the facility failed to deposit residents' personal funds directly into an interest bearing account dedicated to resident trust fund monies and preclude any commingling of resident funds with facility funds or with the funds of any other person. The resident money deposited into this facility "holding" account did not earn interest for the time it was held in this account. The facility only made a once a month electronic deposit from this facility "holding" account into the resident trust fund account. The facility operated the actual Resident Trust Fund Account with information inputted into the computer ledger for this account incorrectly showing an account balance total which included these intended deposits for the Resident Trust Fund Account. But these intended deposits had NOT actually been deposited into the Resident Trust Fund Account but rather into the facility "holding" account. Also the computer ledger of the Resident Trust Fund Account reflected the date of deposit into the facility "holding" account and not the actual date of deposit (which was only one time a month) into the Resident Trust Fund Account. By these aforementioned practices, the facility did not follow proper accounting principles in the management of resident personal funds entrusted to facility for management in the Resident Trust Fund Account. Findings include: During the Resident Trust Fund review and interview conducted on 12/1/11 in the morning with Staff B (Business Office Manager) and Staff C (Accounts Payable/Resident Trust), Staff B and Staff C responded when asked about the Resident Trust Fund Account that it was an account at a nearby bank, which accrued interest, had no facility monies commingled and that deposits of resident funds were made several times a week to the bank (but did not specify until later in the interview process that although deposits were made several times a week to the bank these deposits were NOT going directly into the Resident Trust Fund Account but rather into a facility "holding" account). During review of the facility monthly reconciliation paperwork of this fund for the month of 10/1/11 - 10/31/11, the ending balance of the bank statement was $26,756.19. This was confirmed during interview with Staff B. Review of the trial balance sheet (statement) computer ledger printout entitled "Hanover Hill Health Care - Fund Balances As Of 10/31/11" for the Resident Trust Fund Account dated 10/31/11 reveals a current ending balance of $34,854.98. This total shows a discrepancy of $8,098.79 from the monthly reconciliation ending balance of $26,756.19. Staff B stated this $8,098.79 was subtracted from the documented "current balance" to give a total in the computer ledger printout for the account, according to Staff B, of $26,756.19. Review of the actual reconciliation paperwork shows this transaction. Staff B stated and Staff C confirmed the difference between $34,854.98 and $26,756.19 is due to resident deposits not showing up in this account until the tenth of every month. Staff B further explained during this same interview that the facility actually makes an electronic deposit into the Resident Trust Fund Account from the facility "holding" account. When asked during this interview for an explanation of what the "holding" account was, the State surveyor was informed by Staff B that the facility had an account into which all facility revenue was deposited including any deposits for the Resident Trust Fund Account. It was explained that "ALL" facility revenue was first put into this account. By doing this the facility failed to preclude any commingling of resident funds with facility funds. Staff B further explained that when asked earlier by the State surveyor about deposits to the resident Trust Fund the response given by Staff B was that the facility makes deposits at the bank several times a week but Staff B explained that those deposits go into the facility "holding" account and NOT the Resident Trust Fund Account as originally inferred. Staff B said a one time a month electronic deposit occurs only on the tenth of every month from the facility "holding" account into the Resident Trust Fund Account. Staff B explained that when Resident Trust Fund money (meant to be deposited) from residents, families or social security ($65.00 monthly allowance) or other sources, Staff B or Staff C reflect the deposit in the computer system with the date received for the Resident Trust Fund even though there is a delay (up to one month) in the money actually being deposited into the Resident Trust Fund Account. Staff B said this "yet to be deposited money" is made available to the resident prior to the actual monthly deposit being made into the Resident Trust Fund Account. Staff B was asked if Resident money put into the facility "holding" account for up to one month prior to being deposited to the actual Resident Trust Fund earned interest as required. Staff B was unsure and no documented evidence was provided by the facility showing interest being accrued for deposits made into the "holding" account. Staff B further explained that all deposits from 10/11/11 - 10/31/11 show up in the computer trial balance sheet (statement) printout dated 10/31/11 for the Resident Trust Fund but were not actually deposited into this account until 11/10/11 when the monthly wire transfer occurs. The $8,098.79 represents funds received from residents as intended deposits from 10/11/11 - 10/31/11 and is backed out of the Resident Trust Fund Account trial balance printout dated 10/31/11 which reads "current balance" of $34,854.98 (which is incorrect). Per Staff B the actual current Resident Trust Fund Account balance total on 10/31/11 is $26,756.19. Thus the Resident Trust Fund Account reflected and was being operated with an incorrect total on its balance sheet on 10/31/11. The method used by the facility does not follow proper accounting principles for the Resident Trust Fund Account. Staff B was asked if a resident made a deposit after the 11th of a given month and then withdrew those funds prior to the actual deposit occurring on the 10th of the following month whose money would that resident be withdrawing? Staff B stated the other residents money in the Resident Trust Fund Account would cover the withdrawal. Staff B was asked how would the resident trust fund recoup interest lost? Staff B stated lost interest for other residents money withdrawn to cover this type of transaction was not considered and not attributed to the account. Staff B provided another print out entitled "Cash Receipt Posting Report - Miscellaneous Receipt 10/1/11 thru 10/31/11" which details facility revenue for that time frame with $8,098.79 listed as "Cash Receipts/Funds (Resident/Portions)" along with totals from other sources of facility income. This report documents deposits to this facility "holding" account including Medicaid payments, private pay resident payments, and insurance payments and copayments, etc. with total receipts listed as greater than one million dollars. During an interview with Staff A (Administrator) on 12/1/11, Staff A confirmed intended deposits (to the Resident Trust Fund Account) of resident monies were held in a facility "holding" account of facility revenue monies, with actual deposits of the resident intended deposit monies actually made to the Resident Trust Fund Account from this holding account only one time a month on the 10th of each month. Staff A did not know if interest was attributed to residents for this time frame.

Based on record review, review of facility policies and procedures and review of facility documentation and interview the facility failed to ensure that it implements policies and procedures to prohibit neglect of a resident with a known history of choking that resulted in the need for immediate emergency medical care and transport to the hospital where the resident expired. Resident identifier is #17. Findings include: Review on [DATE], of the facility's "Aspiration Precautions", policy and procedure reveals, Policy Statement: Facility will maintain optimal safe swallow in patients/residents with identified risk for aspiration. Facility will initiate prompt identification of signs or symptoms of aspiration, changes in swallowing function and sign and symptoms of aspiration pneumonia. " " Policy Interpretation and Implementation: 8. Encourage residents to eat in supervised setting. Provide supervision in residents preferred eating environment if resident does not choose to attend supervised dining areas. 9. Report changes in signs/symptoms of dysphagia to physician. " Review of Resident #17's physician's orders [REDACTED]. Review of the nurses notes dated [DATE] reveals that at 12:30 p.m. Resident #17,"was found choking on lunch, nurse came in and provided two pumps of [MEDICATION NAME] maneuver, airway cleared." Review of the facility's Interdisciplinary Progress Notes Dated [DATE] at 12:55 p.m. reveals a Speech Therapy Screening note, Nsg, (nursing) reported to this writer that Resident choked during lunch meal this date and required the [MEDICATION NAME] maneuver. Resident observed consuming a regular texture with thin liquids. Resident tolerating without overt signs/symptoms of aspiration/choking. No coughing, throat clearing or change in subsequent vocal quality. Choking episode appears to be an isolated event. Recommended to nursing that resident be supervised for next few shifts. Resident without history of dysphagia. Review of the nurse ' s notes from [DATE] through [DATE] Reveals documentation that Resident #17 experienced 2 episodes of choking while eating food one on [DATE] and the second on [DATE] and experienced 2 episodes of difficulty swallowing medications one on [DATE] and one on [DATE]. On [DATE] the facility Nutrition-At-Risk Communication Form, related that a follow up review of Resident #17's status indicated that Resident #17 was being supervised at meals due to recent choking episodes. Nurse's notes dated [DATE] reveals that Resident #17 was seen by Staff A, the primary physician (Medical Director). Review of #17's physician's progress notes dated [DATE] reveals no documented evidence of Resident #17's choking and swallowing difficulties being addressed by the physician. Nurse's notes dated [DATE] reveals Resident #17 was having difficulty swallowing pills, pocketing them inside of cheek. Review of Resident #17's [MEDICAL CONDITION] Risk assessment dated [DATE], indicates Resident #17 has experienced changes since the last assessment dated [DATE] with a total score of 7. Resident #17 is now documented on [DATE] as lethargic, disoriented x 2, feeds self with verbal cues, has difficulty swallowing and frequent choking episodes, food intake is ,[DATE]% at most meals with a total score of 13 for this assessment. (scoring legend ,[DATE] equals high risk). On [DATE] interview with Staff C PT (Physical Therapist, Director of Rehabilitative Services) and Staff D ST (Speech Therapist) revealed that once the facility [MEDICAL CONDITION] Risk Assessment was completed it was also supposed to be referred to the dietician. There was no documentation in Resident #17's record to indicated that the dietician had been referred to as a result of the findings of the facility [MEDICAL CONDITION] Risk Assessment of [DATE]. Staff C and Staff D also revealed that there was no further referral made to their department after the initial [DATE] swallowing screen. Review of Resident #17's medical record reveals no further documented evidence to indicate that the swallowing and choking difficulties were further assessed after speech therapy ' s screening on [DATE]. Review of the Nurse's note dated [DATE] indicates that Resident #17 was eating the evening snack when Staff I, LPN was walking by the residents room at 8:00 p.m. when Resident #17 called the nurse into the room. Resident #17 was noted to be coughing and have difficulty speaking and appeared to be choking. [MEDICATION NAME] done with a piece of peanut butter removed, resident again coughing and spoke to this nurse, then again appeared to have difficulty catching breath. [MEDICATION NAME] done again with no effect. Resident became unresponsive, no breath noted, CPR initiated, 911 called and arrived few minutes later. Unable to intubate, CPR continued. Rescue left facility at 8:35 p.m. resident with no respirations, no heart rate noted on monitor, gray skin color. Resident #17's family member notified the facility that Resident #17 had expired at the hospital. Review of the facility report dated [DATE] reveals a statement by Staff J, LNA indicating that Staff J, LNA, gave Resident #17, 2 peanut butter crackers as the residents nightly snack, along with pitcher of ice water. Shortly after, the nurse summoned Staff J, LNA, to help with [MEDICATION NAME] because Resident #17 was choking. Review of Resident #17's hospital emergency room record dated [DATE] at 8:52 p.m. reveals that Resident #17 arrived at the ER (emergency room ) in [MEDICAL CONDITION]. Resident #17 was unresponsive, no spontaneous respirations and had an airway fully obstructed with peanut butter. Review of the ER's Code 9 Sheet reveals under "Procedures", "Attempting airway by MD, unsuccessful with airway via ET (endotracheal) tube. Pt (Resident #17) with cricothyrotomy tube placed by MD with unsuccessful attempts at resuscitation and Resident #17 expired at 9:05 p.m. Based on record review the Immediate Jeopardy is removed on [DATE], based on the following: - the facility reassessed all of the residents to determine which had swallowing risks - updated the facility policy and procedure on the implementation of the plan of care after assessment of swallowing risk results in a change of status - educated the facility staff on the new facility policies and procedure.

Based upon record review, interview with facility staff, the facility failed to provide a comprehensive assessment to determine appropriate interventions for 1 resident who experienced choking and swallowing difficulties, and subsequently had a choking episode that required immediate emergency medical care and transport to the hospital where the resident expired. (Resident identifier is #17). Findings include Review on [DATE], of the facility's "Aspiration Precautions", policy and procedure reveals, Policy Statement: Facility will maintain optimal safe swallow in patients/residents with identified risk for aspiration. Facility will initiate prompt identification of signs or symptoms of aspiration, changes in swallowing function and sign and symptoms of aspiration pneumonia. " " Policy Interpretation and Implementation: 8. Encourage residents to eat in supervised setting. Provide supervision in residents preferred eating environment if resident does not choose to attend supervised dining areas. 9. Report changes in signs/symptoms of dysphagia to physician. " Record review on [DATE] of Resident #17 reveals that Resident #17 was readmitted to the facility on [DATE] and was on a 2gm (gram), Na (sodium), low cholesterol, regular texture diet. Review of the nurses notes dated [DATE] reveals that at 12:30 p.m. Resident #17,"was found choking on lunch, nurse came in and provided two pumps of [MEDICATION NAME] maneuver, airway cleared." Review of the facility's Interdisciplinary Progress Notes dated [DATE] at 12:55 p.m. reveals a Speech Therapy evaluation note, Nsg, (nursing) reported to this writer that Resident choked during lunch meal this date and required the [MEDICATION NAME] maneuver. Resident observed consuming a regular texture with thin liquids. Resident tolerating without overt signs/symptoms of aspiration/choking. No coughing, throat clearing or change in subsequent vocal quality. Choking episode appears to be an isolated event. Recommended to nursing that resident be supervised for next few shifts. Resident without history of dysphagia. Review of Resident #17's care plan revealed that there was no change made to Resident #17 nutritional care plan or to their 2gm Na low cholesterol regular texture diet after the choking episode of [DATE]. On [DATE], according to nurse's notes at 2:39 p.m., Resident #17 was found "sitting in their mechanical wheelchair reddened in face attempting to cough with difficulty. "Resident #17's afternoon snack of apples was opened in front of them. Resident #17 was able to clear their throat with thick sputum and apple peels present in vomited remnants. The [DATE] nurse's note also indicated that the dietician was present at the time of this incident and the dietician instructed the kitchen to hold bringing the resident apples until further notice. Review of Resident #17's care plan of [DATE] reveals that the care plan was updated to show that Resident #17 should have "NO APPLES." Resident #17's care plan of [DATE] also noted Resident #17's preference for HS (bedtime) snack was consisting of graham crackers with peanut butter. On [DATE] at 3:21 p.m. the nurses notes indicated that Resident #17 "took am pills with much difficulty, resident took a couple of minutes to swallow each individual pill." This nurse ' s note further indicated that Resident #17 "Refused to try taking pills with applesauce or anything to aid with swallowing. On [DATE] at 2:55 p.m., according to the nurse's notes, Resident #17 "tossed pills around in mouth and talking during swallowing." Review of the nurse's notes dated [DATE] reveals that Resident #17 was evaluated by Staff A, Physician (Medical Director). There was no documentation in the physician's progress notes of [DATE] in regards to Resident #17's choking and swallowing difficulties being addressed by the physician. On [DATE] at 12:31 p.m., according to nurse's notes, Resident #17 was noted having "difficulty swallowing pills, pocketing them inside of cheek." On [DATE] the facility Nutrition-At-Risk Communication Form, related that a follow up review of Resident #17's status indicated that Resident #17 was being supervised at meals due to recent choking episodes on apples. The form indicates that Resident #17 will be reviewed again by the committee in two weeks. The form was signed by the physician and dated [DATE] but there was no documented evidence on the form under the section "physician response" to indicate that the physician agreed with the recommendations of the Nutrition at Risk Committee. Review of Resident #17's care plan revealed that the intervention of supervising meals was not documented on the resident's care plan. On [DATE] Staff B LPN (Licensed Practical Nurse) completed a facility [MEDICAL CONDITION] Risk Assessment at 2:13 p.m. which revealed that Resident #17 had a score of ,[DATE] which indicates that Resident #17 was now assessed as a "high risk" because of becoming "Lethargic, disoriented x 2" and for experiencing "difficulty swallowing and frequent choking" episodes. There was no documentation in Resident #17's record to indicate that the facility's Nutrition-At-Risk Committee was notified that Resident #17 had become a high risk as assessed on the [MEDICAL CONDITION] Risk Assessment of [DATE] which scored Resident #17 a total of 13 out of 30 points. Review of the facility's undated policy for "Monitoring Residents/Patients AS Having Significant or Health Altering Nutrition Issues", indicates that the Nutrition-At-Risk Committee will review patients who score 10 or above on the [MEDICAL CONDITION] risk assessment. On [DATE] interview with Staff C PT (Physical Therapist, Director of Rehabilitative Services) and Staff D ST (Speech Therapist) revealed that once the facility [MEDICAL CONDITION] Risk Assessment was completed the result of the assessment went to the dietician. There was no documentation in Resident #17's record to indicated that the dietician had been referred to as a result of the findings of the facility [MEDICAL CONDITION] Risk Assessment of [DATE]. Staff C and Staff D also revealed that there was no further referral made to their department after the initial [DATE] swallowing assessment. On [DATE], according to nurses notes of 10:24 a.m.,"attempted to administer PO medication 4 x"to Resident #17. This nurse's note continued Resident #17"continually refused" medications and on the fourth attempt Resident#17 said "you might as well throw away the pills and save yourself the trouble." Nurses note dated [DATE] at 10:40 p.m. reveals that Resident #17,was "eating evening snack" which consisted of two peanut butter crackers according to the facility investigation report of [DATE]. The nurse's notes of [DATE] continued by stating "this nurse was walking by the room at 8:00 p.m., resident called nurse into room. Noted to be coughing. Then resident noted to have difficulty speaking and appeared to be choking. [MEDICATION NAME] done with a piece of peanut butter removed, resident again coughing and spoke to this nurse, then again appeared to have difficulty catching breath. [MEDICATION NAME] done again with no effect. Resident became unresponsive, no breath noted, CPR initiated, 911 called and arrived few minutes later. Unable to intubate, CPR continued. Rescue left facility at 8:35 p.m. resident with no respirations, no heart rate noted on monitor, gray skin color." Review of the hospital's emergency room record dated [DATE] at 8:52 p.m. reveals that Resident #17 arrived at the ER (emergency room ) in [MEDICAL CONDITION]. Review of the ER physician's record revealed under the initial physical exam section that Resident #17 was unresponsive, no spontaneous respirations and had an airway fully obstructed with peanut butter. Review of the ER's Code 9 Sheet reveals under " procedures " "Attempting airway by MD, unsuccessful with airway via ET (endotracheal) tube. Pt (Resident #17) with cricothyrotomy tube placed by MD with unsuccessful attempts at resuscitation and Resident #17 expired 9:05 p.m." Based on record review the Immediate Jeopardy is removed on [DATE], based on the following: - the facility reassessed all of the residents to determine which had swallowing risks - updated the facility policy and procedure on the implementation of the plan of care after assessment of swallowing risk results in a change of status - educated the facility staff on the new facility policies and procedure.