Every finding on record at Horizons Living and Rehab Center

Based on record review and interview, the facility failed to notify the resident, family and/or the resident's representative in writing of the transfers/discharge to an acute care hospital for 5 of 6 residents sampled for hospitalization s (Residents #7, #108, #31, #28 and #35). Findings: 1. Documentation in Resident #7's clinical record indicated that the resident was transferred to the hospital on 3/2/24 and 4/7/24 and subsequently admitted . The clinical record lacked evidence that Resident #7 and/or the resident representative were provided with written transfer/discharge notices upon either transfer. 37015 2. Documentation in Resident #108's clinical record indicated that the resident was transferred to the hospital on 8/23/24 and returned on 8/24/24. The clinical record lacked evidence that Resident #108 and/or the resident representative were provided with written transfer/discharge notices upon transfer. On 8/26/24 at 2:34 p.m., in an interview with a surveyor, the nurse manager of the [NAME] Unit stated the nurses do not send the notices with the resident at the time of transfer. On 8/26/24 at 2:40 p.m., in an interview with a surveyor, the Admissions Director stated once a resident is admitted to the hospital, he/she or the facility's social worker, will send the notices to the resident's family. The notices are not sent for residents who are not admitted to the hospital. The Admissions Director confirmed that Resident #108 was not provided with a transfer/discharge notice. 44049 3. Documentation in Resident #31 clinical record indicated that resident was transferred to the hospital on 8/19/24 and 8/21/24 and admitted for overnight observation and treatment. The clinical record lacked evidence that Resident #31 and/or the resident representative were provided with written transfer/discharge notices upon either transfer. 48648 4. Documentation in Resident #28's clinical record indicated that the resident was transferred to the hospital on 5/1/24 and 6/24/24 and subsequently admitted . The clinical record lacked evidence that Resident #28 and/or the resident representative were provided with written transfer/discharge notices upon either transfer. 5. Documentation in Resident #35's clinical record indicated that the resident was transferred to the hospital on 1/12/23, 10/29/23 and 4/7/24 and subsequently admitted . The clinical record lacked evidence that Resident #35 and/or the resident representative were provided with written transfer/discharge notices with all three transfers. On 8/27/24 at 9:05 a.m. during an interview, the Admissions Director confirmed the above residents and/or the resident representative were not provided with written transfer/discharge notices upon transfers.

Based on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member and/or legal representative for 5 of 6 sampled residents who had been transferred to the hospital ((Residents #7, #108, #31, #28 and #35). Findings: 1. Resident #7's clinical record revealed the resident was transferred to an acute care hospital on 3/2/24 and 4/7/24 and subsequently admitted . The clinical record lacked evidence that Resident #7 and/or the resident representative were provided with a written bed hold notices upon either transfer. 37015 2. Resident #108's clinical record revealed that the resident was transferred to the hospital on 8/23/24 and returned on 8/24/24. The clinical record lacked evidence that Resident #108 and/or the resident representative were provided with a written bed hold notice upon transfer. 44049 3. Resident 31's clinical record revealed the resident was transferred to an acute care hospital on 8/1924 and 8/21/24 and admitted . The clinical record lacked evidence that Resident #31 and/or the resident representative were provided with a written bed hold notices upon either transfer. 48648 4. Resident #28's clinical record revealed the resident was transferred to an acute care hospital on 5/1/24 and 6/24/24 and subsequently admitted . The clinical record lacked evidence that Resident #28 and/or the resident representative were provided with a written bed hold notices upon either transfer 5. Resident #35's clinical record reveals the resident was transferred to an acute care hospital on 1/12/23, 10/29/23 and 4/7/24 and subsequently admitted . The clinical record lacked evidence that Resident #35 and/or resident representative were provided with a written bed hold notices upon all three transfers. On 8/27/24 at 9:05 a.m. during an interview, the Admissions Director confirmed the above residents and/or resident representative were provided with a written bed hold notices upon transfers.

Based on interviews and record reviews the facility failed to ensure all facility staff maintain training in cardiopulmonary resuscitation (CPR) for Healthcare Providers, resulting in staff who are responsible for providing CPR without an active CPR certificate for 8 of 27 days reviewed. This has the potential to effect all of the residents. Findings: On [DATE] an anonymous staff member expressed concerns about facility staff not recieving education or maintaining their CPR Certification. On [DATE] at 2:24 p.m., during an interview, the Director of Nursing (DON) stated she herself was not CPR certified, it's not a facility requirement for staff and she does not know what staff are current with their CPR certification. On [DATE] at 3:20 p.m., the Administrator confirmed there are 7 of 56 residents who are Full Code and could potentially require CPR however, all residents are at risk for choking. A review of the facility staffing with CPR certification for the month of August had the following shifts where there were no staff available with current CPR certification: [DATE] night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification [DATE] evening and night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification [DATE] night shift did not have any staff who were current in their CPR certification The following facility Policy's and Procedures: > Emergency response policy, last revised [DATE] states, It is the policy of Horizons Living and Rehab Center to provide emergency care with a quick response, during a life or death situation regardless of code status. Examples of emergency may include (but are not limited to) severe bleeding and choking. > Finding a resident with no pulse or respiration, last revision on [DATE], instructing staff to If a resident is a full code, Call 911 and Immediately begin CPR. > Obstructed airway/choking episode/Heimlich Maneuver last revision on [DATE], instructing staff to establish that the victim is actually choking . immediately begin Heimlich maneuver. On [DATE] at 2:00 p.m., the facility provided documentation of current CPR certifications for 4 of 14 Registered Nurses, 2 of 12 Licensed Practical Nurses and 7 of 51 Certified Nurses Aids. The above was confirmed with both the Administrator and the Director of Nursing who stated going forward there would be a CPR certified staff on every shift while other staff are obtaining their certification.

Based on review of annual evaluations and interviews, the facility failed to complete a annual performance evaluation for Certified Nursing Assistants (CNA) at least every 12 months, for 5 of 5 CNA's reviewed with employment greater than 1 year (CNA #12, CNA #13, CNA #14, CNA #15, CNA #16). Findings: On 8/28/24, a surveyor reviewed the following employee files: 1. CNA #12 was hired on 8/19/2020. The employee file lacked evidence of an annual review being completed since date of hire. 2. CNA #13 was hired on 8/4/2021. The employee file lacked evidence of an annual review being completed since date of hire. 3. CNA #14 was hired on 8/10/2022. The employee file lacked evidence of an annual review being completed since date of hire. 4. CNA #15 was hired on 9/16/2021. The employee file lacked evidence of an annual review being completed since date of hire. 5. CNA #16 was hired on 7/29/2020. The employee file lacked evidence of an annual review being completed since date of hire. On 8/28/24 at 12:30 p.m., during an interview, the Director of Nursing confirmed that the annual performance review for 5 of 5 employees had not been completed since their date of hire.

Based on the cumulative effect of deficiencies cited during the recertification survey from [DATE] through [DATE], the facility was not administered in a manner that enabled residents to attain or maintain their highest practicable well-being as evidenced by Federal findings listed under 483.10- Resident rights (F558, F585); 483.15- Resident Notification (F623, F625); 483.24- Quality of Life (F678); 483.25- Quality of Care (F684); 483.35- Nursing Services (F726, F730, T206); 483.60- Food Safety (F812) and 483.95- Training Requirements (F940, F947). These failures to assure a process was in place to monitor staff development and resident care resulted in the facility failing to assist residents to maintain their highest functional and practicable well-being and has the potential to affect all 56 residents. In addition, the Administration failed to follow the Facility Assessment ensuring staff education/training and competencies were completed and failed to ensure policies and procedures were reviewed and updated annually. Findings: 1. Based on interviews and record review, the facility failed to ensure that accommodations were made for a resident, to include the facilities bathing schedule and resident preferences for 1 of 1 resident reviewed for activities of daily living (Resident #24). (F558) 2. Based on interviews and record review the facility failed to develop and implement a grievance policy which includes the resident's rights to a grievance, how to file and/or access grievance forms including anonymously and the response or resolution to grievances. (F565) 3. Based on record review and interview, the facility failed to notify the resident, family and/or the resident's representative in writing of the transfers/discharge to an acute care hospital for 5 of 6 residents sampled for hospitalization s (Residents #7, #108, #31, #28 and #35). (F623) 4. Based on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member and/or legal representative for 5 of 6 sampled residents who had been transferred to the hospital ((Residents #7, #108, #31, #28 and #35). (F625) 5. Based on interviews and record reviews the facility failed to ensure all facility staff maintain training in cardiopulmonary resuscitation (CPR) for Healthcare Providers, resulting in staff who are responsible for providing CPR without an active CPR certificate for 8 of 27 days reviewed. (F678) 6. Based on interviews and record reviews, the facility failed to provide follow up care for 1 of 1 resident reviewed with a pacemaker (Resident #11). (F684) 7. Based on observations, interviews and record reviews, the facility failed to ensure that staff maintained the appropriate competency and skill required to provide Cardio-Pulmonary Resuscitation (CPR) for 11 of 12 newly hired nursing staff reviewed. This has the potential to effect 7 residents in the facility that maintained a Full Code status. (F726) 8. Based on review of annual evaluations and interviews, the facility failed to complete an annual performance evaluation for Certified Nursing Assistants (CNA) at least every 12 months, for 5 of 5 CNA's reviewed with employment greater than 1 year (CNA #12, CNA #13, CNA #14, CNA #15, CNA #16). (F730) 9. Based on record reviews and interviews, the facility failed to ensure nursing policy & procedure were in place, to develop and implement continuing education for nursing staff, evaluate nurse competencies and develop and maintain a job description for each level of nursing personnel. (T206) 10. Based on observations and interviews, the facility failed to serve and store food in a sanitary manner during 1 of 1 observations of the refrigerator in the main dining room. (F812) 11. Based on interview and employee personnel record reviews, the facility failed to implement and maintain effective training programs for nursing staff in the areas of cardiopulmonary resuscitation (CPR), nursing competencies, dementia care, resident rights and the required 12 hours of annual in-service education training for Certified Nurses Aid (CNA) for 11 of 12 newly hired nursing staff reviewed and 4 of 5 randomly selected CNAs employed greater than 1 year. (F940) 12. Based on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training and the mandatory yearly trainings for dementia care and resident rights for 4 of 5 randomly selected CNAs employed greater than 1 year (CNA #13, CNA #14, CNA #15, CNA #16). (F947) 13. Review of the Facility Assessment, revised on [DATE] states The facility assessment collects information about the facilities resident population to identify the number of resident; facility capacity; the care required; staff competencies . the facilities resources are identified and evaluated to ensure that care can be provided to meet residents needs during the day-to-day operations. Under section, Staff education, Training and Competencies states, every position has a job description that identifies the required education and credentials for the specific job. All credentials in education are verified before hiring . competencies are based on current standards of practice and may include knowledge and a test, knowledge and a return demonstration and observed ability, knowledge and observed behavior in an annual performance evaluation. Competencies are based on the care and services needed by the resident population. Under section, Policies and Procedures for the Provision of Care states, Policy and procedures are reviewed and updated at least annually and as needed with the introduction of new resident care needs, new technology or equipment or a change in the physical plant or environmental hazards. Creation of new policies/revision of existing policies will be done in consultation with the regulatory view in resident needs. On [DATE] at 11:42 a.m., during an interview, the Administrator and the Director of Nursing confirmed the facility had never developed or implemented a skills fair or competencies for the nursing staff neither upon hire or annually. In addition, the Director of Nursing confirmed the lack of job descriptions and was unable to provide job descriptions for the following staff: Registered Nurses, Licensed Practical Nurses, Certified Nurses Aid and Certified Medication Technician. Review of the following policies, contained the following: > Emergency Response, was last revised [DATE]. > Obstructed airway/choking episode/Heimlich Maneuver was last revised on [DATE]. In addition, the policy does not reflect the need for Basic Life Support / Cardiopulmonary Resuscitation (CPR) training for staff. > Finding a resident with no pulse or respiration, was last revised on [DATE] and instructs staff to confirm the resident code status by visualizing a [NAME] dot on the resident's chart binder indicating the resident is a FULL CODE and No dot indicates resident is a DNR (Do Not Resuscitate). The policy does not reflect the need for CPR training and/or maintaining a CPR certificate. On [DATE] upon entrance to the facility, the Administrator stated there were no longer any hard charts for the residents, all the resident's records are now in an Electronic Medical Record form (online). On [DATE] at 2:22 p.m., during an interview, the Administrator confirmed the facility did not have a grievance policy or procedure in place.

Based on interview and employee personnel record reviews, the facility failed to implement and maintain effective training programs for nursing staff in the areas of cardiopulmonary resuscitation (CPR), nursing competencies, dementia care, resident rights and the required 12 hours of annual in-service education training for Certified Nurses Aid (CNA) for 11 of 12 newly hired nursing staff reviewed and 4 of 5 randomly selected CNAs employed greater than 1 year. Findings: Review of the Facility Assessment, revised on [DATE] under section, Staff education, Training and Competencies states, every position has a job description that identifies the required education and credentials for the specific job. All credentials in education are verified before hiring. All employees are trained in the following topics upon hire and annually: Resident rights and Dementia and dealing with difficult behaviors and competencies are based on current standards of practice and may include knowledge and a test, knowledge and a return demonstration and observed ability, knowledge and observed behavior in an annual performance evaluation. Competencies are based on the care and services needed by the resident population. 1. On [DATE] at 2:24 p.m., during an interview, the Director of Nursing (DON) stated she herself was not CPR certified and the facility does not require a CPR certification for staff. On [DATE] at 2:00 p.m., the facility was only able to provide documentation of current CPR certifications for 4 of 14 Registered Nurses, 2 of 12 Licensed Practical Nurses and 7 of 51 Certified Nurses Aids. 2. On [DATE] at 11:42 a.m., during an interview, the Administrator and the Director of Nursing stated the facility had never developed or implemented a skills fair or competencies for the nursing staff neither upon hire nor annually. 3. On [DATE], review of CNA #13, CNA #14, CNA #15 and CNA #16 employee education files lacked dementia and/or resident rights education as well as 12 required hours for continuing education yearly. On [DATE] at approx. 2:15 p.m., the above was discussed with the Administrator and Director of Nursing

Based on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training and the mandatory yearly trainings for dementia care and resident rights for 4 of 5 randomly selected CNAs employed greater than 1 year (CNA #13, CNA #14, CNA #15, CNA #16). Findings On 8/28/24, a surveyor reviewed the following employee education files: 1. CNA #13 was hired 8/4/21. Review of CNA #13 Employee In-service/attendance Records lacked evidence of dementia and resident rights training. In addition, she has 7.5 of the 12 hours required for continuing education for the year of 2023. 2. CNA #14 was hired 8/10/22. Review of CNA #14 Employee In-service/attendance Records lacked evidence of dementia training. In addition, she has 9 of the 12 hours required for continuing education of the year 2023. 3. CNA #15 was hired 9/16/21. Review of CNA #15 Employee In-service/attendance Records lacked evidence of dementia training and resident rights training. In addition, she has 11 of the 12 hours required for continuing education of the year 2023. 4. CNA #16 was hired 7/29/20. Review of CNA #16 Employee In-service/attendance Records lacked evidence of resident rights training. In addition, she has 5.5 of the 12 hours required for continuing education of the year 2023. On 8/28/24 at 12:30 p.m., in a interview, the Director of Nursing confirmed the above findings.

Based on interviews and record review, the facility failed to ensure accommodations were made for a resident, to include the facility's bathing schedule and resident preferences for 1 of 1 resident reviewed for activities of daily living (Resident #24). Findings On 8/26/24 at 8:20 a.m. and again on 8/27/24 at 7:55 a.m. during interviews, Resident #24 stated he/she had not received a shower in seven days and prefers to be bathed in the morning two times a week. Resident #24 stated he/she has informed the Certified Nurses Aide (CNA), a Registered Nurse, and the Nurse Practitioner of his/her preferences on multiple occasions. On 8/26/24 at 12:46 p.m., observation of the Stowes Unit weekly shower schedule dated 5/2/24 indicated Resident #24 was to receive a shower Wednesday evenings. At this time during a brief interview, CNA #11 stated, the posted shower schedule was incorrect, and she follows the daily CNA schedule, which has the showers to be completed for that shift highlighted. She confirmed Resident #24 does not receive showers twice weekly. On 8/27/24 review of CNA bathing documentation stated Resident #24 received showers on 8/7/24 and 8/14/24 with the last shower documented on 8/18/24 on the evening shift. The admission [NAME] data set dated [DATE] under section F preferences for customary routine and activities states it is important for him/her to choose their bathing options. On 8/27/24 the Staffing and Transport Coordinator provided the updated Stowes Unit weekly shower schedule, which states Resident #24 receives showers on Thursday evenings once a week. On 8/28/24 at 2:15 p.m., the above information was discussed with the Administrator and Director of Nursing.

Based on interviews and record reviews, the facility failed to provide follow up care for 1 of 1 resident reviewed with a pacemaker. (Resident #11) Finding: Review of the admission Minimum Data Set (MDS) assessment completed on 12/6/23 noted he/she had an implanted pacemaker listed under diagnosis. A further review of the Electronic Medical Record (EMR) lacked any details about the implanted pacemaker or facility follow and/or monitoring of the pacemaker's functioning. The care plan instructed the Registered Nurse (RN) to monitor/document/report a pulse rate lower than programmed rate. The programmed rate was not located in the EMR. On 8/27/24 at 1:04 p.m. during an interview, the Licensed Practical Nurse #1 confirmed she did not know Resident #11 had a pacemaker. On 8/27/24 at 2:00 p.m. during an interview, the RN #2 stated anyone with a pacemaker would be followed by cardiology. RN #2 was unable to provide documentation on Resident #11's pacemaker programmed rate, if his/her pacemaker checks had been completed and if he/she was seen or followed by a cardiologist since admission on 12/6/23. On 8/28/24 at 9:45 a.m., during an interview, the Director of Nursing confirmed the standard of care for a pacemaker was not met for Resident #11.

Based on observations and interviews, the facility failed to serve and store food in a sanitary manner during 1 of 1 observations of the refrigerator in the main dining room. Finding: On 8/26/24 at 12:20 p.m., observaton of the main dining room refrigerator lacked documentation of temperature monitoring and a very large amount of a red fluid covered the bottom of the freezer. At this time, the food service manager confirmed the observation.

Based on interviews and record review the facility failed to develop and implement a grievance policy which includes the resident's rights to a grievance, how to file and/or access grievance forms including anonymously and the response or resolution to grievances. Findings: On 8/27/24 at 1:30 p.m. during an interview with resident council members. Residents #32, #35, and #40 were unaware that they could file a grievance, how to make a formal grievance, or that a grievance could be filed anonymously. Resident #32 stated on each unit there is a box where he/she believes a resident can make a complaint. He/she stated the box on the [NAME] Unit is behind the medication cart, inaccessible and too high for residents to reach in wheelchairs. On 8/27/24 observation of the comment and suggestion boxes on all three units ([NAME], [NAME], and [NAME]) are inaccessible for residents in wheelchairs, in addition [NAME]'s comment and suggestions box was located behind the medication cart. On 8/26/24 at 1:50 p.m., during an interview, the Director of Social Services stated the facility does not have a formal grievance process/policy or have forms accessible to residents. On 8/26/24 at 2:22 p.m., during an interview, the Administrator stated the facility has no grievance policy or procedure in place and residents are to come to him with concerns, and he will determine if the concern/complaint is a grievance.

Based on record review, observation and interviews, the facility failed to date biological's after opened and according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication rooms, 3 out of 3 medication carts and 1 of 3 treatment carts. In addition, the facility failed to adequately store controlled substances in a permanently affixed compartment and double locked in 1 of 2 medication rooms observed. Findings: Guardian Pharmacy policy and procedure for Controlled Substance Storage, effective 5/1/18 states in Section B: Schedule [II-V] medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications or per state regulation and Section C: Controlled substances that require refrigeration are stored within a locked box within the refrigerator. For NF/SNF facilities, this box must be attached to the inside of the refrigerator. 1. On 5/10/22 at 7:20 a.m., observation of the facilities main medication room, [NAME] unit medication cart and treatment cart with a Licensed Practical Nurse (LPN) the following was observed: * In the main medication room: one opened bottle of [MEDICATION(S)] 1 milligram (mg) tablets with an expiration date of 3/22 and two opened multi use vials of [MEDICATION(S)] (TB) with manufactures directions to discard opened product after 30 days, further observation revealed that the TB vials did not have an opened date nor a discard date. * [NAME] Medication cart: one bottle of [MEDICATION(S)] 1 mg tablets with an expiration date of 3/22 and an opened bottle of Acidophilus, Probiotic, with manufactures instruction to Refrigerate after opening. * [NAME] Treatment cart: an opened Basaslar Kiwi insulin Pen, with a manufacturer specification indicating after first use to discard unused medication after 28 days, further observation revealed the insulin pen did not have an opened date nor a discard date. At this time the LPN confirmed the above observations. 2. On 5/10/22 at 7:39 a.m., observation of the [NAME] unit medication cart with a Registered Nurse (RN) the following was observed: * One opened bottle of [MEDICATION(S)] 1 mg tablets with an expiration date of 3/22 * One opened bottle of Acidophilus, Probiotic, with manufactures instruction to Refrigerate after opening. At this time the RN confirmed the above observations. 3. On 5/10/22 at 7:52 a.m., observation of [NAME] unit medication cart and the medication room with an LPN the following was observed: * In the [NAME] medication cart: One opened bottle of stool softener, [MEDICATION(S)] 100 mg tablets with expiration date of 4/22, an opened bottle of [MEDICATION(S)] 1 mg tablets with an expiration date of 3/22 and an opened bottle of Cetirizine 10 mg with expiration date of 4/22. * In the [NAME] medication room refrigerator, containing OTC medications, on the door of the refrigerator, was an opened bottle of liquid [MEDICATION(S)] (controlled substance, schedule IV) for Resident #53. The [MEDICATION(S)] was not stored in a permanently affixed and double locked compartment separate from other medications. On 5/10/22 at 11:31 a.m., observation of the main medication room refrigerator with the Director of Nursing (DON), contained a locked toolbox, not affixed to the fridge. The Director of Nursing stated the only liquid [MEDICATION(S)] that is double locked is in the emergency kit (the toolbox) for which the key is obtained through the Pyxis. Otherwise, resident's liquid [MEDICATION(S)] is in the fridge on the units, under one lock. At this time, the surveyor discussed the above findings with the DON who confirmed the liquid [MEDICATION(S)] in the toolbox was not affixed to the fridge.

Based on observations and interview, the facility failed to adequately ensure maintenance services necessary to maintain resident's wheelchairs in good repair and sanitary condition and failed to maintain a clean homelike environment on 2 of 3 units ([NAME] and [NAME]). Findings: From 5/9/22 - 5/10/22 a surveyor observed the following: 1. [NAME] unit; room 119, 102A and 121 wheelchair armrests were ripped/torn and missing material, creating uncleanable surfaces. 2. [NAME] Unit: room 113 wheelchair armrests were ripped/torn and missing material, creating uncleanable surface. 3 stained ceiling tiles in between the nurse's station and the kitchenette, 1 stained ceiling tile above the cabinets in kitchenette and 2 stained ceiling tiles in the TV room across from the kitchenette. The hall fan wire cover, between room 105 and 107, was ripped from the wall, peeling off paint with several pieces of scotch tape holding it in place. On 5/10/22 at 4:32 p.m., a surveyor confirmed the above findings during the environment tour, with the Administrator.

Based on record review and interview, the facility failed to ensure that a care plan included a care area for diabetes management for 1 of 36 sampled residents with care plans developed electronically (#25), Finding: Resident #25 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record lacked evidence that a comprehensive care plan had been developed in the areas of diabetes mellitus management. On 5/11/22 at 12:45 p.m., during an interview with the Director of Nursing, a surveyor confirmed this finding.

Based on record review and interview, the facility failed to establish a system of records for disposition for all controlled drugs to enable accurate reconciliation for the use of [MEDICATION(S)] (controlled substance, schedule II) transdermal patch for 2 of 3 residents reviewed for [MEDICATION(S)] transdermal patch use (#37 and #51). Findings: On 12/10/21 at 4:19 p.m., Division of Licensing received the following facility report of drug diversion: On 12/10/21 at 9:30 a.m., Licensed Practical Nurse (LPN #1) became acutely ill while working and was sent to the hospital. LPN #2 was unable to find Resident #37's [MEDICATION(S)] patch on his/her person that had noted to be in place at the onset of LPN #1's shift and discovered the narcotic count for the Resident #37 [MEDICATION(S)] patches was missing one patch. On 12/15/21 the facilities follow up indicated both of the patches were found at the hospital with LPN #1. The actions taken by the facility stated, they had revised our [MEDICATION(S)] patch polices to include a policy of two nurse's signing off when removing and old patch and accounting for the destruction of the used patch. Guardian Pharmacy: Control Substance Disposal policy and procedure, effective 5/1/18 states in Section B. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed staff, and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substance wasted for any reason. Controlled Substance Storage policy and procedure, effective 5/1/18 states in Section E: At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two appropriately licensed/certified personnel and is documented. Facilities Monitoring the Placement of [MEDICATION(S)] Patches on Residents, after application and Removal of the Used Patches policy and procedure, revised on 12/16/21 after the drug diversion incident, to include the following: Removal and disposing of used [MEDICATION(S)] patch. 1. When removing a [MEDICATION(S)] patch, two licensed nurses, must dispose of the used patched together into a sharp container. 2. Both licensed nurses shall sign off and acknowledge the destruction of the used patch on the form titled Disposal of Open and Used [MEDICATION(S)] Patches On 5/9/22 Resident #37's medical record lacked evidence of [MEDICATION(S)] patch destructions with 2 nurses prior to 12/19/21. Further review noted on 4/21/22 the record lacked documentation of destruction of the [MEDICATION(S)] patch by 2 nurses. On 5/9/22 Resident #51's medical record lacked evidence of the [MEDICATION(S)] patch destruction with 2 nurses on 4/29/22 and there was no evidence of [MEDICATION(S)] patch placement review for the month of March and April of 2022. On 5/11/22 at 12:29 p.m., in an interview with the Director of Nursing (DON) she confirmed the above findings and stated she could not find March and April 2022 [MEDICATION(S)] patch placement review. On 5/9/22 at 1:35 p.m., in an interview with LPN #3 she stated, prior to December, she was allowed to remove a [MEDICATION(S)] patch from the resident and destroy it without a second nurse witness. Since then, she is required to have another nurse witness destruction of the used [MEDICATION(S)] patch. She then stated they had always counted the cart with 2 nurses and checked to verify the patch placement when changing shifts. On 5/9/22 at 1:45 p.m., in an interview with LPN #4, she stated, prior to December, she doesn't believe [MEDICATION(S)] patches were destroyed with 2 nurses. On 5/9/22 at 1:49 p.m., in an interview with the DON, she stated she has been working in a nurse capacity since 2010 and has never had to have 2 nurses sign off to destroy [MEDICATION(S)] patches stating, nurses were always able to destroy by themself and It wasn't until the incident (12/10/21) when we updated the policy to have 2 nurses verify destruction of [MEDICATION(S)] patches. She then stated, on 12/10/21 LPN #1 was responsible for the medication cart containing narcotics but did not sign to verify placement of the patch on Resident #37 or the count for the patches. On 5/11/21 at 1:32 p.m., during an interview with the LPN #2, she stated she was called into work on 12/10/21 because LPN #1 was sent to the hospital. When she arrived approx. 9:30-10:00 a.m., she took over the medication cart from the Nurse Manager and did not count the controlled substances at that time. When it was time to administer Resident #37's new [MEDICATION(S)] patch, the count was wrong. On 5/11/22 at 2:13 p.m., during an interview with the Director of nursing, the above concerns were discussed.

Based on electronic medical records review and interviews, the facility failed to ensure that a Minimum Data Set, version 3.0 (MDS) was accurately coded in the area of restraints for 12 of 12 residents reviewed for restraints. In addition, the facility failed to ensure that an MDS was accurately coded in the area of Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #36, #37, #44). Findings: The facilities Side Rail Consent form states: Side rails are used as enablers (to help us do something) or because they are medically necessary (as [CONDITION(S)] precautions as an example). They are never used as a restraint at Horizons Living and Rehab Center. 1. Review of Resident #8's electronic charting revealed completion of a Side Rail Consent Form dated 5/21/18 which noted the Resident uses 2 side rails to assist resident in repositioning in bed. Resident #8's Annual MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint. 2. Review of Resident #11's electronic charting revealed completion of a Side Rail Consent Form dated 11/25/20 which noted the resident uses 2 side rails for bed mobility. Resident #11's Annual MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint. 3. Review of Resident #18's electronic charting revealed completion of a Side Rail Consent Form dated 5/14/19 which noted the resident uses 2 side rails to assist with turning side to side in bed and transferring in/out of bed. Resident #18's Annual MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint. 4. Review of Resident #25's electronic charting revealed completion of a Side Rail Consent Form dated 1/14/21 which noted the Resident uses one ½ side rail on the left side for bed mobility. Resident #25's Quarterly MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint. Resident #25's clinical record also indicated he/she was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 5. Review of Resident #26's electronic charting revealed completion of a Side Rail Consent Form dated 5/21/18 which noted the Resident uses 2, ½ side rails for positioning and bed mobility. Resident #26's Quarterly MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint. 6. Review of Resident #29's electronic charting revealed completion of a Side Rail Consent Form dated 7/11/17 which noted the Resident uses 2 side rails for bed mobility. Resident #'29s Quarterly MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint. 7. Review of Resident #30's electronic charting revealed completion of a Side Rail Consent Form dated 10/12/16 which noted the Resident uses 2 side rails to aid in turning/repositioning within the bed. Resident #30's Quarterly MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint. 8. Review of Resident #33's electronic charting revealed completion of a Side Rail Consent Form dated 7/29/16 which noted the Resident uses one side rail for bed mobility/transfer. Resident #33's Quarterly MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint. 9. Review of Resident #35's electronic charting revealed completion of a Side Rail Consent Form dated 7/7/20 which noted the Resident uses 1 side rail for enabler for bed mobility. Resident #35's Annual MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint. 10. Review of Resident #36's electronic charting revealed completion of a Side Rail Consent Form dated 4/29/14 which noted the Resident uses 1 side rail for bed mobility. Resident #36's Quarterly MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint. 11. Review of Resident #37's electronic charting revealed completion of a Side Rail Consent Form dated 5/15/14 which noted the Resident uses 2 side rails for bed mobility, transfers. Resident #37's Quarterly MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint 12. Review of Resident #44's electronic charting revealed completion of a Side Rail Consent Form dated 2/6/20 which noted the Resident uses 2 side rails to assist with bed mobility. Resident #'44s Quarterly MDS assessment dated [DATE], was inaccurately coded in Section P: Physical Restraints, stating bed rails used daily was a physical restraint. On 5/10/22 at 3:04 p.m., in an interview with the MDS Coordinator she stated, Nobody here uses side rails as physical restraint and confirmed the above residents were coded incorrectly and the use of the side rails do not meet the definition of a physical restraint. On 5/11/22 at 12:45 p.m., during an interview with the Director of Nursing, a surveyor confirmed the lack of coding under Activie diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, day of the month, a breakdown of the number of registered and licensed nursing staff responsible for direct resident care and indicate which shifts the numbers corresponded to, for 2 of 3 survey days. Finding: On 5/11/22 at 10:15 a.m., two surveyors observed that the posted nurse staffing information date was for 5/9/22. On 5/11/22 at 10:30 a.m., in an interview with the Director of Nursing the surveyor confirmed, that the posted nurse staffing information was not up to date.

Based on interview and record review, the facility failed to ensure the medical record for 1 of 3 sampled discharged residents (Resident #1) included documentation by the physician to support the decision to disallow a resident to return to the facility at the end of a therapeutic leave of absence period. The facility indicated the decision to disallow the return was due to the safety of individuals (or residents) in the facility is endangered due to the clinical or behavioral status of the resident. This had the potential to affect any resident on a therapeutic leave of absence. Findings: On 4/16/20, progress notes in the electronic clinical record, written by the Licensed Social Worker (LSW) indicated, Conversation with both (family members) related to LOA (leave of absence) and wish to bring (him/her) home tomorrow 4/17/20 under Mainecare LOA days. Clarity on number of days is needed, as (family member) stated it was 30, but it is believed to be 20. At home they have a hospital bed, hoyer lift and a suction machine. They are in need of meds, feeding supplies, and personal care needs i.e. briefs/wipes/etc. Request for van to transport (the Resident) home, also to have someone meet them at (the) window at 1pm to pick clothing requested. Items will be taken out to family. Discussed that resident would be discharged after allotted days if (he/she) does not return and that the facility is currently closed to Admissions. Both (family members) understand the risk with the [MEDICAL CONDITION] and potential for issues should it become a factor i.e. non readmission. Will clarify questions with Administrator and DON (Director of Nursing), and call (family member) back. Later on 4/16/20, progress notes in the electronic clinical record, written by the Licensed Social Worker (LSW) indicated, Conversation with (family member). The van is being fixed and is currently unavailable for all transports. Facility will provide meds, tube feeding supplies, and personal care needs. Question on amount of days is being clarified at this time. An answer will be provided before (the resident) leaves the building. This worker will meet the parents at the resident's window to assist with picking out clothing and any other items they may wish to take home. Also beacon hospice will continue to follow the resident and provide services when (he/she) is home. Will contact (the family( in the morning. On 4/17/20, progress notes in the electronic clinical record, written by the Licensed Social Worker (LSW) indicated, Conversation with (family members) via phone to explain conditions of LOA to ensure they fully understand, there will be an LOA form to sign. Our house Dr will not follow the resident in the community, they understand they are responsible for having (his/her) medical care covered while on LOA. Leave will begin on 4/17/20 and is allotted 20 days under Mainecare; (he/she) may or may not be able to return to the facility should there be an outbreak with the Covid-19 virus. Medication, feeding supplies and necessities will be given upon leaving the building. Both stated they understood the guidelines put forth. The clinical record revealed a Leave of Absence Form was signed and dated by Resident #1's family/guardian on 4/17/20. The Leave of Absence indicated, - (Resident #1) will being (his/her) Leave of Absence on 4/17/20 and can last up to 20 days at that time (he/she) will be discharged from the facility. - The facility staff will provide (his/her) nutrition and medications for the next 20 days upon the beginning of (his/her) leave of absence - (Resident #1) may not be able to return to the facility due to COVID-19 outbreak within or after the Leave of Absence timeframe. - (Resident #1) will have to seek medical care outside of the physician services of Southern Maine Geriatrics as (he/she) begins (his/her) Leave of Absence. As (his/her) guardian I am making these decisions and understand the consequences of these decisions. On May 7, 2020, the facility issued a Notice of Transfer/Discharge to Resident #1, indicating the safety of individuals (or residents) in the facility is endangered due to the clinical or behavioral status of the resident. The surveyor could find no documentation in the clinical record by the resident's physician outlining the conditions which supported the decision to disallow Resident #1's return to the facility. During an interview with the Medical Director on 9/2/20 at 12:10 PM, the decision was based on the community outbreak of COVID-19 at the time the leave of absence ended and the complex respiratory needs of Resident #1, which required frequent suctioning. The Medical Director stated that aerosolization of the coronavirus occurs during suctioning, creating a need for airborne precautions. The Medical Director stated the facility is not equipped to manage the needs of residents requiring those kinds of precautions and the facility continues to lack the necessary N95 masks. The Medical Director stated this puts all residents and staff at risk. The Medical Director confirmed during the interview that he/she did not discuss with the family the risks (i.e., the potential inability to allow the resident to return) associated with a therapeutic leave of absence during the community outbreak. On 9/3/2020 at 8:23 AM, in an interview with Resident #1's guardian, the guardian stated he/she would have brought (him/her) back but also we were working with the CDC to try to get some special kind of [MEDICATION NAME] care visitation because this is such an unusual situation. On 9/3/2020 at 8:37 AM, in an interview with the Director of Nursing, the surveyor confirmed the clinical record does not contain documentation by the physician describing the risks to other residents and staff if the resident returned to the facility after a therapeutic leave of absence.

Based on observations and interviews, the facility failed to ensure the confidentiality of protected health information for 3 of 62 residents 2 of 4 days of survey (Residents #2, #25 and #37). Findings: 1. On 10/22/19 at 7:40 a.m., a surveyor observed the Longfell ow Medication Cart computer, located in the hallway, with a full open display monitor unlocked, leaving Resident #37's electronic Medication Administration Record [REDACTED]. There were two residents near the area. Approximately five (5) minutes later, a Licensed Practical Nurse (LPN) returned to the Longfell ow Medication cart computer and secured the screen from view. The LPN stated he/she had brought a resident to the main dining room off the unit. On 10/22/19 at 7:45 a.m. in an interview with the LPN, the surveyor confirmed that the screen with the eMAR was open and confirmed the concern for exposing clinical information on the medication cart computer. 2. On 10/23/19 at 8:30 a.m., a surveyor observed medication administration on the Longfell ow Unit with a LPN. The LPN prepared medications for Resident #2 at the medication cart in the unit corridor, then proceeded to Resident #2's room down the corridor to administer the medications, leaving the eMAR open, exposing Resident #2's identifying and clinical information in areas where unauthorized personnel pass through. On 10/23/19 at 9:00 a.m., the surveyor observed medication administration on the Longfell ow Unit with the same LPN. The LPN prepared medications for Resident #25 at the medication cart in the unit corridor and left the medication cart to retrieve liquid [MEDICATION NAME] from the medication refrigerator, leaving the eMAR open exposing Resident #25's identifying and clinical information. On 10/23/19 at 9:10 a.m., in an interview with the LPN, the surveyor informed the LPN that he/she had left Resident #2 and #25's eMARs open, exposing confidential clinical information for both residents. During the interview the LPN acknowledged the privacy concern and the surveyor confirmed the privacy finding. On 10/24/19 at 9:14 a.m., in an interview with the Director of Nursing, the surveyor informed him/her of the privacy concern and confirmed the finding.

Based on performance evaluation reviews and interview, the facility failed to complete a performance evaluation at least every twelve months for 4 of 4 Certified Nurse Assistant (C.N.[NAME]) performance evaluations reviewed (C.N.[NAME]#1, 2, 3 and 4). Findings: 1. A review of C.N.[NAME] #1's performance evaluations indicated that C.N.[NAME] #1 received a performance evaluation on 8/20/18. 2. A review of C.N.[NAME] #2's performance evaluations indicated that C.N.[NAME] #2 received a performance evaluation on 5/17/18. 3. A review of C.N.[NAME] #3's performance evaluations indicated that C.N.[NAME] #3 received a performance evaluation on 6/29/18. 4. A review of C.N.[NAME]#4's performance evaluations indicated that C.N.[NAME] #4 received a performance evaluation on 5/15/18. On 10/23/19 at 1:21 PM, in an interview with the Director of Nursing (DON) and the Licensed Practical Nurse (LPN), Nursing Support Services, the surveyor confirmed the 4 sampled CNA employee files lacked performance evaluations in the past 12 months.

Based on record review and interview, the facility failed to ensure that each resident recieved adequate supervison to prevent accidents for 8 of 17 sampled residents (# 1,8,10,19,32,43,64,68). 1. Resident #43 had a [DIAGNOSES REDACTED]. Attached to the care plan was an " Aspiration Precaution Policy " . The policy identified interventions that included one on one supervision, close supervision, and distant supervision while eating. As of 6/20/12, the residents care plan was not individualized to identify the level of supervision the resident needed to ensure the safest level of monitoring during his/her dining experience. In an interview with the Assistant Director of Nurses, on 6/20/12 at 10:00 a.m., she confirmed the care plan did not address what level of supervision the resident needed. 2. Resident #32 had a [DIAGNOSES REDACTED]. Attached to the care plan was an " Aspiration Precaution Policy " . The policy identified interventions that included one on one supervision, close supervision, and distant supervision while eating. As of 6/20/12, the residents care plan was not individualized to identify the level of supervision the resident needed to ensure the safest level of monitoring during his/her dining experience. In an interview with the Assistant Director of Nurses, on 6/20/12 at 10:00 a.m., she confirmed the care plan did not address what level of supervision the resident needed. 3. Resident #1 had been identified as needing thickened liquids and ground solids due to a history of coughing while eating. He/she was identified to need medical management for the risk for aspiration on the care plan. Attached to the care plan was an " Aspiration Precaution Policy " . The policy identified interventions that included one on one supervision, close supervision, and distant supervision while eating. As of 6/20/12, the residents care plan was not individualized to identify the level of supervision the resident needed to ensure the safest level of monitoring during his/her dining experience. In an interview with the Assistant Director of Nurses, on 6/20/12 at 10:00 a.m., she confirmed the care plan did not address what level of supervision the resident needed. 4. Resident #68 had a [DIAGNOSES REDACTED]. Attached to the care plan was an " Aspiration Precaution Policy " . The policy identified interventions that included one on one supervision, close supervision, and distant supervision while eating. As of 6/20/12, the residents care plan was not individualized to identify the level of supervision the resident needed to ensure the safest level of monitoring during his/her dining experience. In an interview with the Assistant Director of Nurses, on 6/20/12 at 10:00 a.m., she confirmed the care plan did not address what level of supervision the resident needed. 5. Resident #10 had a [DIAGNOSES REDACTED]. Attached to the care plan was an " Aspiration Precaution Policy " . The policy identified interventions that included one on one supervision, close supervision, and distant supervision while eating. The resident had a " Dietary Waiver " that indicated the refusal of recommended therapeutic diet. As of 6/20/12, the residents care plan was not individualized to identify the level of supervision the resident needed to ensure the safest levle of monitoring during his/her dining experience. In an interview with the Assistant Director of Nurses, on 6/20/12 at 10:00 a.m., she confirmed the care plan did not address what level of supervision the resident needed. 6. Resident #8 had a [DIAGNOSES REDACTED]. Attached to the care plan was an " Aspiration Precaution Policy " . The policy identified interventions that included one on one supervision, close supervision, and distant supervision while eating. The resident had a " Dietary Waiver " that indicated the refusal of recommended therapeutic diet. As of 6/20/12, the residents care plan was not individualized to identify the level of supervision the resident needed to ensure the safest level of monitoring during his/her dining experience. In an interview with the Assistant Director of Nurses, on 6/20/12 at 10:00 a.m., she confirmed the care plan did not address what level of supervision the resident needed. 7. Resident #19 had a [DIAGNOSES REDACTED]. Attached to the care plan was an " Aspiration Precaution Policy " . The policy identified interventions that included one on one supervision, close supervision, and distant supervision while eating. As of 6/20/12, the residents care plan was not individualized to identify the level of supervision the resident needed to ensure the safest level of monitoring during his/her dining experience. In an interview with the Assistant Director of Nurses, on 6/20/12 at 10:00 a.m., she confirmed the care plan did not address what level of supervision the resident needed. 8. Resident #64 had a [DIAGNOSES REDACTED]. Attached to the care plan was an " Aspiration Precaution Policy " . The policy identified interventions that included one on one supervision, close supervision, and distant supervision while eating. As of 6/20/12, the residents care plan was not individualized to identify the level of supervision the resident needed to ensure the safest level of monitoring during his/her dining experience. In an interview with the Assistant Director of Nurses, on 6/20/12 at 10:00 a.m., she confirmed the care plan did not address what level of supervision the resident needed.

Based on observations and interviews, the Administrator failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evidenced when the Administrator was not aware of warnings in the fireplace owner's manual or of elevated surface temperatures for the fireplaces used within the facility and accessible by the residents. Findings: 1. On 4/11/12 at 12:55 p.m., in the central seating area on Chamberlain Unit, a surveyor observed a gas fireplace operating. This fireplace did not have any protective barrier in front of it. The surveyor also noted that the temperature of the metal fireplace frame was too hot to touch. Residents were observed in this area unsupervised. At 1:07 p.m., the surveyor notified the Administrator of this observation. 2. On 4/11/12 at 1:08 p.m., on the Longfell ow Unit, a surveyor observed a gas fireplace without a protective barrier in place. At that time, facility staff was shutting the fireplace off. The surveyor was unable to touch the metal fireplace frame due to the high heat. Neither the Registered Nurse nor a Certified Nursing Assistant (C.N.A.) would touch the metal fireplace frame. They stated they knew that it was hot and didn't want to get burned. The C.N.A. also confirmed that residents were left unsupervised in this area and that she makes sure that residents were not placed too close as she did not want the residents to be too hot or to get burned. 3. On 4/11/12 at 1:25 p.m., the surveyor and the Administrator reviewed the fireplace owner's manual. The front of the owner's manual contained the following warning, "Warning Hot Surfaces! Glass and other surfaces are hot during operation and cool down. Hot glass will cause burns. High temperatures may ignite clothing or other flammable materials." In addition, the owner's manual indicated the following: "If you expect small children or vulnerable adults may come into contact with this fireplace, the following precautions are recommended: Install a physical barrier such as: ? A decorative fire screen ? Adjustable safety gate The surveyor confirmed the contents of the owner's manual with the Administrator at the time of the review. 4. On 04/11/12 at approximately 3:00 pm, a surveyor asked the Administrator if he or his maintenance department had read the owner's manual regarding the safety measures and warnings when operating the fireplaces, he stated, "who has time to read the manuals?" Refer to F454 regarding temperatures and Life Safety Code violations. Based on record review and interview, the Administrator failed to ensure that an alleged violations involving a missing [MEDICATION NAME] was investigated and reported immediately to the State Agency. Finding: The surveyor conducted a review of the facility's internal investigation in regards to missing [MEDICATION NAME]es from 11/20/11 and 11/21/11. There was no documentation to indicate that the facility had completed a report of its findings and forwarded that report within 5 days to the State Agency consistent with the facility's policy and State requirements. This finding was confirmed with the Director of Nursing in an interview conducted, on 3/12/12 at 11:08 a.m. Based on record reviews and interviews, the Administrator failed to identify possible neglect related to a resident's death. Finding: On 04/09/12 at approximately 11:00 a.m., an interview was conducted with the Administrator regarding the choking incident which involved Res #90 on 6/26/11. The Administrator revealed that he and the DON did not consider this resident's choking and resultant death to be a possible incident of neglect. Therefore, an investigation was not conducted and the incident not reviewed, preventative measures were not monitored to ensure the safety of other residents who were at risk for choking or aspiration. Based on interviews and record reviews, the Administrator failed to ensure an incident of choking was brought to the quality assurance committe, and eduction was provided to all staff on choking procedures subsequent to a resident's death from choking. Finding: 1. Facility staff interviews between 4/9/12 through 4/17/12, revealed there was no education provided on emergency procedures following a choking event which resulted in a resident's death 2. On 04/11/12 at 9:45 a.m., during an interview with the facility's Medical Director, he stated that he was unaware of any education or prevention implemented following the event or QA meeting in August. Based on record reviews and interviews, the Administrator failed to effectively monitor residents at risk for choking and aspiration. Findings: 1. During an interview with the Administrator and DON on 04/13/12 at 2:40 p.m., it was revealed that there has been no monitoring and modifications made based on their findings as it relates to the choking incident involving Resident #90. 2. Interviews with facility staff revealed there was no education provided on emergency procedures following the event. 3. The facility's Medical Director stated he was unaware of any education or prevention implemented following the event.

Based on interviews and record reviews, the facility failed to ensure that all allegations of neglect and a missing resident medication were reported to the State Agency, allegations were reported within required time frames and/or thoroughly investigated for 2 of 4 incidents reviewed that required notification to the State Agency. The facility's failure to identify, report and thoroughly investigate the choking incident and subsequent death of Resident #90 placed all residents with swallowing and choking issues at risk of possible neglect. In addition, the facility's failure to identify, report and thoroughly investigate allegations of neglect, and missing narcotic medication belonging to residents placed all the residents at risk for ongoing neglect, abuse and/or misappropriation of resident's medication. Findings: 1. On [DATE], Resident # 90 was in the dining room for breakfast, choked on a piece of banana and subsequently died . There was no evidence found that indicated that the facility had reported this incident of alleged neglect to the State Agency. On [DATE] at approximately 11:00 a.m., a surveyor interviewed the Administrator regarding the choking incident which involved Resident #90. He stated that he and the Director of Nursing (DON) did not consider this resident's choking and resultant death to be a possible allegation of neglect. During this interview, the Administrator was asked what he would consider reportable and he stated "I would report something huge." In addition, the Administrator indicated that they did not conduct an investigation into the incident. However, the facility did have an "Incident Investigation" report. On [DATE] and [DATE], when a surveyor was at the facility for a complaint investigation, the facility gave the surveyor the "Incident Investigation" report for this incident. On [DATE], the "Incident Investigation" report regarding this incident was given to a surveyor. The "Incident Investigation" report given to the surveyor on [DATE] was different than the incident report given to the surveyor, on [DATE] and [DATE]. Additions had been made to the "Incident Investigation" report that was given to the surveyor on [DATE]. The surveyor interviewed the Administrator and the DON, on [DATE] at 2:40 p.m. They were unable to given any explanation as to the differences in the "Incident Investigation" reports given to the surveyors on [DATE], [DATE] and [DATE]. There was no evidence provided to the surveyors that indicated that the facility had thoroughly investigated this incident. The "Incident Investigation" report indicated that four employees were interviewed regarding Resident #90's choking incident and subsequent death. A review of the schedule for [DATE] indicated that 12 staff were working. The surveyors also discovered that the Nurse Manager, who was off duty, was in the building and observed the emergency interventions that occurred in the resident's room. On [DATE] at 2:40 p.m., in an interview with the Administrator and DON, the DON indicated that she was unaware that the Nurse Manager was in the building at the time of the incident. On [DATE] at 4:20 p.m., the surveyors interviewed Registered Nurse #1, who was involved with the choking incident. She indicated that the documentation, by the facility, of her interview was incorrect. 2. A surveyor reviewed the facility's internal investigation in regards to missing [MEDICATION NAME]es from [DATE] and [DATE]. There was no evidence that the facility had reported the results of this investigation to the State agency within five working days of the incident. The surveyor discussed this finding, in an interview with the Director of Nursing, on [DATE] at 11:08 a.m. 3. A surveyor reviewed an incident report, dated [DATE], which contained an allegation of abuse. There was no evidence that the facility had reported this allegation of abuse, to the State Agency, until [DATE], four days after the incident. The surveyor confirmed finding in an interview, with the Administrator on [DATE] at 9:11 a.m.

Based on record reviews and interviews, the facility failed to ensure that the facility's policies and procedures regarding abuse, neglect reporting and investigation were followed for 2 of 5 incidents that required a report to the State Agency. The facility's failure to identify, report and thoroughly investigate the choking incident and subsequent death of Resident #90 placed all residents with swallowing and choking issues at risk of possible neglect. In addition, the facility's failure to identify, report and thoroughly investigate allegations of neglect, which placed all the residents at risk for ongoing neglect and misapproprion of a resident's medication . Findings: The facility's Abuse Prevention Policy and Procedure and Investigation/ Reporting/Response was reviewed. The facility's policy indicated the following: The Administrator or designee will report all available details to the Division of Licensing and Regulatory Services at [PHONE NUMBER] within 24 hours of the alleged incident or the next working day if the incident occurs on a holiday or weekend; the Director of Nursing (DON) or designee will interview all employees/visitors involved in the incident; All statements made by employees/visitors will be reduced into writing, signed and dated; The Director of Nursing will review all statements made and report the findings of the investigation to the Administrator and the Division of Licensing and Regulatory Services within five working days of the alleged incident; and Reporting to the appropriate licensing board/registry will be done by the Administrator or designee. 1. On [DATE], Resident # 90 was in the dining room for breakfast, choked on a piece of banana and subsequently died . There was no evidence found that indicated that the facility had reported this incident of alleged neglect to the State Agency. On [DATE] at approximately 11:00 a.m., a surveyor interviewed the Administrator regarding the choking incident which involved Res #90. He stated that he and the Director of Nursing (DON) did not consider this resident's choking and resultant death to be a possible allegation of neglect. During this interview, the Administrator was asked what he would consider reportable and he stated "I would report something huge." In addition, the Administrator indicated that they did not conduct an investigation into the incident. However, the facility did have an "Incident Investigation" report. On [DATE] and [DATE], when a surveyor was at the facility for a complaint investigation, the facility gave the surveyor the "Incident Investigation" report for this incident. On [DATE], the "Incident Investigation" report into this incident was given to a surveyor. The "Incident Investigation" report given to the surveyor on [DATE] was different than the incident report given to the surveyor on [DATE] and [DATE]. The "Incident Investigation" report that was given to the surveyor on [DATE] contained more information. The surveyor interviewed the Administrator and the DON, on [DATE] at 2:40 p.m. They were unable to given any explanation as to the differences in the "Incident Investigation" reports given to the surveyors on [DATE], [DATE] and [DATE]. There was no evidence provided to the surveyors that indicated that the facility had thoroughly investigated this incident. The "Incident Investigation" report indicated that four employees were interviewed regarding Resident #90's choking incident and subsequent death. A review of the schedule for [DATE] indicated that 12 staff were working. The facility did not follow their policy regarding interviewing all employees/visitors involved in the incident; and obtaining written statements from all employees. The surveyors also discovered that the Nurse Manager, who was off duty, was in the building and observed the emergency interventions that occurred in the resident's room. On [DATE] at 2:40 p.m., in an interview with the Administrator and DON, the DON indicated that she was unaware that the Nurse Manager was in the building. On [DATE] at 4:20 p.m., the surveyors interviewed Registered Nurse (RN) #1, who was involved with the choking incident. She indicated that the documentation, by the facility, of her interview was incorrect. 2. A surveyor reviewed the facility's internal investigation in regards to missing [MEDICATION NAME]es from [DATE] and [DATE]. There was no evidence that the facility had reported the results of this investigation to the State agency within five working days of the incident. The surveyor discussed this finding, in an interview with the Director of Nursing, on [DATE] at 11:08 a.m.