Every finding on record at Rolette Community Care Center

Based on observation and staff interview, the facility failed to monitor hot water temperatures in resident rooms for 1 of 3 wings (wing 200) with elevated water temperatures. Failure to monitor hot water temperatures in resident rooms may result in resident pain, serious harm, serious impairment, or death. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 09/29/25. The IJ was identified when facility water temperatures were taken in resident rooms on the 200 wing. Two of the resident rooms (room [ROOM NUMBER] and 208) registered a temperature of 137 and 133 degrees Fahrenheit (F). This finding placed all resident in immediate jeopardy for hot water burns. * 09/29/25 at 7:48 p.m. The survey team notified the Business Office Manager and the Director of Nursing (DON) of the IJ situation, provided the IJ template, and requested the facility's removal plan for the IJ. * 09/30/25 at 3:50 p.m., the SSA reviewed and accepted the removal plan for the IJ.The removal plan contained the following:* Enviornmental service director (ESD) immediately adjusted the water heater down to 105 degrees F to decrease the temperature of the water and adjusted the temperature control of the recycle water heater to a low temperature. * 09/29/25 at 9:00 p.m.: hot water temperatures were taken in all resident rooms on the 200 wing with a results of 102 degrees F. * 09/29/25 at 9:00 p.m.: hot water temperatures of all resident rooms on the 100, 200, 300, and 400 wings were taken to check for compliance* 09/30/25 at 12:00 a.m. and 4:00 a.m.: hot water temperatures were taken in all resident rooms on the 200 wing with results of less than 110 degrees F.* 09/30/24 at 12:00 a.m., 4:00 a.m.: hot water temperatures were taken in all resident rooms on the 100, 200, 300, and 400 wings were taken to check for compliance.* A new policy titled Safe Water Temperature was implemented.* The ESD was educated by the Business Manager and DON on the policy for safe water temperature, checking for water temperatures, and the proper documentation of water temperature monitoring. * Education to all staff was provided by the ESD on 09/29/25 and 09/30/25 regarding what to do when they identify a change in water temperature. * Audits will be completed by the ESD.* 09/30/25 at 5:13 p.m. the survey team verified the implementation of the removal plan. The deficient practice remained at a scope and severity of an E following the removal of the IJ.The SA called IJ on 09/29/25 at 7:48 p.m. for F689 and presented the facility with the IJ template (attached).The SA accepted the removal plan on 09/30/25 at 3:50 p.m.Verification of the removal plan was confirmed on 09/30/25 at 5:13 p.m.09/29/2025 5:08 PM water temp checked in room [ROOM NUMBER] and noted hot water to be cool to touch and only got warm after about 45 seconds. 09/29/2025 6:15 pm PM Hot water temperatures checked in rooms as follows:rm: 207 137rm: 208: 133Rm 213: 122Rm: 214: 121215: 126At 6:20 observed Maintenance [NAME] entered utility room. Also observed unable to get hot water in multiple rooms down 200. (Rm 207/205)6:25 pm Interview with [NAME] in Maintenance. Denied turning off water or adjusting water temperatures. Stated he was doing weekly water temperature checks and had a spread sheet. Would adjust temperatures if he found any issues.6:30 Went with [NAME] to his office so he could show us his water temperature spread sheet. Unable to find any water temperature documentation. When asked again, admitted he is not checking water temperatures weekly and is doing quarterly. Still unable to find any documentation. When asked why he adjusted the hot water heater temperature, stated I just wanted to be sure no one had messed with it and found the temperature was 115 and felt that was too high and turned it down to 105.Temperature rechecks completed as followsRm 207: 120 6:37 pm

Based on review of the Quality Assurance and Performance Improvement (QAPI) Team Member Attendance Forms and staff interviews, the facility failed to ensure required members of the QAPI Committee, attended 4 of 4 quarterly meetings (October 2024, 01/23/25, 04/24/25, and 07/24/25). Failure to have all required QAPI committee members attend and participate at QAPI meetings deprives the committee of each member's unique contribution for analysis of quality concerns and assisting with decision making based on identified concerns.Findings include:Review of QAPI team member attendance forms occurred on 09/30/25. The July 24, 2025, April 24, 2025, January 23, 2025, and October 2024 (no specific date identified on the form) failed to identify that all required QAPI team members attended the quarterly meetings. The attendance forms show three committee members attended in October 2024, five committee members attended on January 23, 2025, five committee members attended on April 24, 2025, and four committee members attended on July 24, 2025. The facility administrator failed to attend any of the above listed committee meetings.During an interview on 09/30/25 at 7:47 p.m. an administrative staff member (#5) confirmed the facility administrator is not a member of the QAPI committee and has not attended the QAPI committee meetings. The administrative staff member (#5) confirmed the current QAPI committee members are the Director of Nursing (DON) who is also the Infection Control Nurse, Business Office Manager, Minimum Data Set Registered Nurse (MDS, RN), environmental services staff member, Medical Director (MD), pharmacist, Registered Health Information Technician (RHIT) who is also the Social Services Designee (SSD) and Quality Assurance (QA) staff member.During an interview on 09/30/25 at 8:26 p.m. an administrative staff member (#6) confirmed he/she does not have a facility leadership title, and the facility administrator is not a member of the QAPI committee, however, the facility administrator attended one QAPI meeting via Zoom (live stream) but could not identify when.

Based on staff interviews and review of facility job description the facility administrator failed to report to and remain accountable to the governing body. Failure to develop a process and frequency by which the administrator reports to and communicates with the governing body may result in a lack of information necessary for management of the facility. Findings include:Review of the Rolette Community Care Center (RCCC) job description for the administrator occurred on 11/18/25. This unsigned job description, revised on 03/12/23, stated, Duties: As Administrator, Employee will devote his/her full time, energy and skill solely and exclusively to the performance of his/her duties here under and to the day-to-day operations of RCCC. Duties of Administrator include, but are not limited to supervision of staff and employee operations . implementing the board's wishes and directives; internal oversight and timely implementation of state and federal requirements . The expectation is that Administrator will work a minimum of 40 hours a week with regular schedule and work additional hours as needed to meet business needs and workload .On the morning of 11/18/25 an administrative staff member (#6) provided a form identifying the names and addresses of the two board members. The administrative staff member (#6) identified the facility is actively seeking more board members.During a phone interview on 11/18/25 at 2:34 p.m., the facility administrator (#14) stated, If they [Board Members] have any questions for me, they can call me. We meet every once in a while, but I'm not on every one of the meetings. If something needs to be brought to them, [Business Office Manager] or [Director of Nursing] will notify them. When asked who the members of the board were, the administrator replied, I'm not even sure at the moment. I believe there are three board members. When asked how frequently he is able to be present in the facility, the administrator stated, Just depends on if I'm needed then I try to make it, but it's sometimes a couple times a year.Refer to F689 and F868

Based on observation, review of professional reference, review of facility policy, review of refrigerator temperature logs, and staff interviews, the facility failed to maintain cold storage areas and kitchen equipment in a sanitary manner for 1 of 1 kitchen. Failure to clean fans, shelving, and bulk bins in areas where food is stored, failure to ensure proper concentration of sanitizer solution, failure to discard outdated foods, failure to monitor refrigerator temperatures daily, and ensure refrigerator temperatures are within acceptable ranges has the potential for contamination of food and may result in a foodborne illness. Findings include: The 2022 Food and Drug Administration (FDA) Food Code, Chapter 3-16, Section 3-305.11 Food Storage, stated, A. Food shall be protected from contamination by storing the food: . 2) Where it is not exposed to . dust, or other contamination. Chapter 3-28, Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, stated, . shall be maintained . At 57 degrees C [degrees Celsius] (135 degrees F [Fahrenheit]) or above. At 5 degrees C (41 degrees F) or less. Chapter 4-20 and 4-21, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, stated, . (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . Chapter 4-23, Section 4-602.13 Nonfood-Contact Surfaces, stated, . shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The 2022 FDA Food Code, Annex 3, Chapter 4, Equipment . Section 4-101.11 Characteristics, stated, . Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens . Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. Review of the facility policy Refrigerators and Freezers occurred on 09/30/25. This undated policy stated, . Acceptable temperature ranges are 35 degrees F to 40 degrees F for refrigerators . Monthly tracking sheets will include . action taken . if temperatures are not acceptable. Food Service Supervisors or designated employees will check and record refrigerator . temperatures daily. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. Review of the facility policy Sanitizations occurred on 09/30/25. This undated policy stated, . All kitchens . shall be kept clean, free from litter and rubbish . Sanitizing of environmental surfaces must be performed with . 150-200 [parts per million (ppm)] quaternary ammonium compound (QAC) . The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen . Observation of the kitchen on 09/29/25 at 11:40 a.m. with a dietary staff member (#7) showed the following:*Box with 16 containers of raspberries covered in mold. *Upright beverage refrigerator identified a temperature of 50 degrees Fahrenheit. The dietary staff member #7 confirmed the temperature is to be between 41 and 42 degrees. Observation of the kitchen on 09/30/25 at 1:15 p.m. showed the following: * Walk in Cooler - accumulation of thick, dark black dust/dirt on the fans and accumulation of dust on the shelving where food is stored. * Box dated 09/01/25 with 3 containers of raspberries and 3 containers of blueberries covered in mold. * Gallon container of Ranch dressing with mold on the lid and sides, expired September 2024. * Gallon container of mustard with mold on the lid and sides, expired 10/12/24. * Gallon container of coleslaw dressing with mold on the lid and sides, expired June 2025.* Four quarts of heavy whipping cream dated 09/22/25. * Build-up of grease on the handle of the stove and inside the oven. - Observation on 09/30/25 at 10:03 a.m. showed the lids on the bulk storage containers for flour, thickener, and sugar covered with food particles. Two dietary staff members (#8 and #13) stated they did not know where the cleaning schedule was located. - Observation on 09/30/25 at 10:17 a.m. showed a dietary staff member (#13) tested the solution in a sanitization bucket with results of 50 ppm. Review of the upright refrigerator temperature logs, dated August 1 through September 28, 2025, showed 20 of the 58 days without a temperature recorded, and 18 of the 39 temperatures recorded were greater than 40 degrees F (temperatures varied from 41- 48 degrees F). Facility staff failed to check the temperature daily and take immediate action when temperatures were out of range. During an interview on 09/29/25 at 11:40 a.m., an administrative staff member (#7) confirmed the target range for the sanitizing solution is 200 ppm. During an interview on 09/30/25 at 1:15 p.m., an administrative staff member (#7) identified the facility staff had not cleaned the ice machine. The staff member (#7) stated, It's fairly new so we have not cleaned it, no one told us how to clean it. The administrative staff member also confirmed the facility lacked cleaning schedules/logs to document staff routinely cleaned the kitchen and kitchen equipment. During an interview on 09/30/25 at 8:14 p.m., an administrative staff member (#1) stated refrigerator temperatures should be between 32 and 40 degrees.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of medications, discard expired medications and label medications for 1 of 2 medication carts. Failure to securely store, label and discard expired medications may result in unauthorized access to medications, or residents receiving expired or incorrect medications.Findings include:Review of the facility policy titled Medication Labeling and Storage occurred on 09/29/25. This undated policy stated, Policy Statement . The facility stores all medications . in locked compartments . Medication Storage . 2. The nursing staff is responsible for maintaining medication storage. 3. If the facility has discontinued, outdated . medications . the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .4. Compartments (including, but not limited to, drawers . carts . ) containing medications. are locked when not in use . carts used to transport such items are not left unattended if open or otherwise available to others. Medication Labeling . 1. Labeling of medications . dispensed by the pharmacy . the medication label includes . medication name . prescribed dose . strength . expiration date . resident's name . route of administration . appropriate instructions . -Observation on 09/28/25 at 5:20 p.m., showed an unlocked/unattended medication cart in the main living area with medications on the top of the cart for 26 minutes. -Observation on 09/29/25 at 7:23 p.m. showed a medication cart with a glucagon syringe pen (for low blood sugar) with an expiration date of October 2024.-Observation on 09/30/25 at 7:30 p.m., showed three unlabeled Novolog (insulin) pens in the medication cart.During an interview on 09/30/25 at 9:00 p.m., an administrative nurse (#4) stated she expected staff to lock the medication cart, store all medications in the cart when the nurse is not within sight, discard expired medications, and label all resident medications.

1.Based on record review, review of facility policy, and staff interview, the facility failed to ensure staff followed professional standards of practice for 2 of 12 sampled residents (Resident #12 and #14) reviewed for blood sugars and weights. Failure to follow physician's orders for out-of-range blood sugars and weight changes may result in adverse health events.2.Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure staff followed professional standards of practice for 1 of 1 supplemental resident (Resident #3) observed for medications administration via enteral tube. Failure to properly administer medications via feeding tube may result in adverse health events and/or a clogged tube.Findings include: Base 1 Findings: Review of the facility policy titled Change in a Resident's Condition or Status occurred on 09/30/25. This policy, dated February 2021, stated, . The nurse will notify the resident's attending physician on call when there has been a (an): . specific instruction to notify the physician of change in the resident's condition. Review of Resident #12's medical record occurred on 09/30/25. Diagnoses included diabetes mellitus. A physician's order, dated 12/24/24, stated, Humalog insulin . per sliding scale . If Blood Sugar is greater than 450, call MD [Medical Doctor]. Review of Resident #12's blood sugars from August 16 through September 17th, 2025, showed the following: *08/16/25 at 7:32 p.m. 451 *09/14/25 at 5:45 p.m. 455 *09/17/25 at 11:56 a.m. 475 During an interview on 9/30/2025 at 9:13 p.m., an administrative nurse (#4) confirmed the medical record failed to show staff notified the provider of Resident #12's blood sugars greater than 450. -Review of Resident #14's medical record occurred on all days of survey. Diagnoses included chronic kidney disease with renal dialysis. A physician's order dated 09/16/25, stated, Wt [weight] check twice a week, call [provider] with increase or decrease of 4 lbs. [pounds] from base wt. [weight] 146Lbs [pounds] . Review of Resident #14's weights showed the following decreases from baseline: *09/19/25 138.5 lbs (7.5 lbs) *09/22/25 135 lbs (11 lbs) *09/24/25 140.5 lbs (5.5 lbs) *09/26/25 134 lbs (12 lbs) *09/29/25 120.5 (26 lbs) On request on 9/30/2025 5:56 p.m., an administrative nurse (#4) confirmed the medical record failed to show staff notified the provider of Resident #14's weight changes greater or less than 4 lbs. Base 2 Findings include: Review of the facility policy titled, Administering Medications through an Enteral Tube [tube placed directly into the stomach or small intestine] occurred on 09/29/25. This policy, dated November 2018, stated, . The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . Do not add medication directly to the enteral feeding tube . Dilute medication: Dilute crushed (powdered) medication with at least 30 ml [milliliters] purified water (or prescribed amount) . administer each medication separately . -Review of Resident #3 medical record occurred on all days of survey and identified an enteral tube. A physician's order, dated, 7/26/2015, stated, . crush medications . administer via PEG [type of gastrostomy tube] . Observation 09/29/25 at 1:06 p.m. showed a nurse (#9) crushed and placed a medication in a medicine cup with no water. The nurse poured the crushed medication into Resident #3's PEG tube without diluting in water, then poured water down the tube. During an interview on 09/30/25 at 9:00 p.m., an administrative nurse (#4) stated she expected staff to dilute crushed medications with water prior to administering Resident #3's medications through the PEG tube to prevent clogging.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to complete a self-administration of medication (SAM) assessment for 1 of 1 sampled resident (Resident #4) observed with medications at the bedside. Failure to determine a resident's capacity to safely self-administer medications may result in medication errors, adverse drug events, and/or harm to the resident. Findings include:Review of the facility policy titled Self-Administration of Medication's occurred on 01/14/26. This policy, dated February 2021, stated, . comprehensive assessment, interdisciplinary team (IDT) assesses each resident to determine whether self-administration of medications is safe and clinically appropriate for the resident. If deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and in the care plan. Review of Resident #4's medical record occurred on January 13-14, 2026. The record lacked a SAM assessment to determine whether self-administration of medications is safe and appropriate for this resident. Observation on 01/13/26 at 12:30 p.m. identified a clear plastic medication cup containing six pills on the resident's bedside table. During an interview on 01/13/26 at 12:30 p.m. Resident (#4) identified the pills as his/her 8:00 a.m. medications and they've been on the bedside table since this morning.Review of the resident's medications showed morning medications included: aspirin, Coreg (a heart medication), Metformin (a diabetic medication), folic acid, cyanocobalamin (vitamin B-12), and Colace.During an interview on the afternoon of 01/14/26 an administrative staff (#3) confirmed the facility failed to complete a SAM assessment.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received food served in the appropriate consistency for 1 of 2 sampled residents (Resident #13) with an altered diet. Failure to serve liquids according to the physician's diet order may place residents at risk of inadequate nutrition, unplanned weight loss/gain, choking, aspiration, aspiration pneumonia, and worsening of medical conditions.Findings include: Review of the undated facility policy titled Tray Identification occurred on 09/29/25. This policy stated . To assist in setting up and serving the correct food trays/diets to residents, the Food Services Department will use appropriate identification (e.g, color coded or computer generated diet cards) to identify the various diets. The Food Services Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. Nursing staff shall check each food tray for the correct diet before serving the residents. Review of Resident #13's medical record occurred on all days of survey. A physician's order dated 08/20/2024 identified pureed diabetic diet with honey thickened liquids. A nursing progress note, dated 09/01/25, stated, Recent decline in food [intake due] to coughing and trouble with swallowing. Review of Resident #11's meal card identified nectar thick liquids which differs from the physician's order for honey thickened liquids.During an interview on 09/30/2025 at 3:45 p.m., an administrative dietary staff #7 confirmed meal cards are to identify special diets and supplements and staff have no way to communicate changes with dietician.

Based on observation, record review, and resident interview, the facility failed to ensure 1 of 1 sampled resident (Resident #15) with contractures received the necessary hand devices. Failure to consistently place a carrot hand device or small towel roll to the resident's left hand may result in worsening of the contracture, pain, and skin breakdown. Findings Include:Review of Resident #15's medical record occurred on all days of survey. The care plan stated, The resident has hemiplegia [weakness or paralysis] of the L [left] UE [left upper extremity] . to maintain/improve UE ROM [range of motion] to prevent contractures. Recommend for the resident to use a carrot hand positioner or small towel roll for left hand.Observation occurred on all days of survey and showed Resident #15's left hand contracted in a gripped position with no rolled towel or carrot hand positioner in place and the carrot hand positioner on the resident's nightstand. During an interview on 09/30/2025 at 5:59 p.m., Resident #15 stated staff were not placing the carrot support or a rolled washcloth to his left hand and denied pain with placement and denied refusal of placement. Resident #15's medical record failed to show refusal of the carrot hand positioner or a rolled washcloth to the left hand.

Based on observation and staff interview, the facility failed to promote privacy and confidentiality of the medication administration records for 1 of 2 days of survey. Failure to lock the electronic medication administration record (eMAR) may result in unauthorized viewing of confidential resident records by other residents, unlicensed staff, and visitors.Findings include:Review of facility policy titled Security of the Medication Cart occurred on 09/30/25. This policy, revised April 2007, stated, . electronic medication administration records (eMars) are kept locked when not in direct use.Observation on 09/30/25 at 5:46 p.m. showed a medication cart unattended in the living area with the (eMAR) opened to a resident's record for 26 minutes.During an interview on 09/30/25 at 8:30 p.m., an administrative nurse (#4) confirmed she expected nursing staff to lock the eMar at all times when the medication cart is unattended.

Based on observation, record review, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 12 sampled residents (Resident #22) and one supplemental resident (Resident #3) observed during cares. Failure to practice infection control standards related to hand hygiene and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: -Review of Resident #22's medical record occurred on 09/30/25 and identified EBP. A sign outside the door identified EBP and stated caregivers must, clean their hands, including before entering and when leaving the room and providers and staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities including . transferring . device care or use: central line . Observation on 09/30/25 at 10:00 a.m. showed two certified nurse aides (CNAs) (#11 and #12) transferred Resident #22 from the wheelchair to the bed without washing their hands and without wearing gloves and a gown. -Review of Resident #3's medical record occurred on 9/30/25. Diagnosis included dysphagia, and gastrostomy status (feeding tube). The current care plan stated, . the resident needs Enhanced Barrier Precautions related to an indwelling feeding tube . Observation on 09/29/25 at 1:30 p.m. showed a nurse (#9) entered Resident #3's room and administer a nutritional supplement through the feeding tube. The nurse touched the resident's feeding tube and other items in the room, removed her PPE (personal protective equipment) and left the room without performing hand hygiene. Observation on 9/29/25 at 1:45 p.m. showed a CNA (#10) applied a gown and gloves, entered Resident #3's room, provided incontinent cares, removed the soiled gloves and without performing hand hygiene, applied new gloves, and applied a protective barrier cream. After cares, the CNA (#10) removed the soiled gown and gloves and exited the room. The CNA failed to perform hand hygiene. During an interview on 09/30/25 at 9:20 p.m., an administrative nurse (#4) confirmed she expected staff to perform hand hygiene upon entering Resident #3's room, in between glove changes and when exiting the room.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to follow standards of infection control for 3 of 12 sampled residents (Resident #1, #3, and #10) and 1 supplemental resident (Resident #14) observed during cares. Failure to follow infection control practices related to enhanced barrier precautions (Resident #1 and #10) and transmission-based precautions (Resident #3 and #14) has the potential to spread infection throughout the facility. During the on-site recertification survey, the team determined an Immediate Jeopardy (IJ) situation existed on 09/09/24 at 1:32 p.m. The IJ resulted from staff failure to properly doff an N95 mask upon exiting the room of a COVID positive resident and before entering the rooms of COVID negative residents, which had the potential to spread the infection to residents, staff and visitors. *09/19/24 at 11:45 a.m. The survey team notified the director of nursing (DON) and administrator of the IJ situation, presented the IJ template, and requested a plan for removal of the immediate jeopardy. *09/19/24 at 3:10 p.m. The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: *Review of Infection Control, Isolation and personal protective equipment (PPE) policies. No changes needed. *Posted signs demonstrating proper donning and doffing of PPE on all doors of COVID positive resident rooms. *Educated all staff on proper application of gowns, masks (including N95), gloves, when to perform hand hygiene, and PPE guidelines for donning and doffing for COVID positive residents and residents in isolation. This education will be conducted either in person or via phone prior to next scheduled shift. *09/19/24 at 3:30 p.m. The survey team verified the implementation of the removal plan and the IJ removal. The deficient practice remained at a E scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Isolation - Categories of Transmission-Based Precautions occurred on 09/11/24. This policy, revised September 2022, stated, . Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Staff and visitors wear gloves . when entering the room . Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room . Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets . that can be generated by the individual coughing, sneezing, talking . Masks are worn when entering the room . Review of the facility policy titled Enhanced Barrier Precautions occurred on 09/11/24. This policy, revised March 2024, stated, Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities . include: . transferring . device care or use (central line, urinary catheter, feeding tube, . ); and . wound care . Signs are posted in [sic] the door or wall outside the resident room indicating the type of precautions and PPE required. Review of Infection Control Guidance: SARS-CoV-2 [COVID] at https://www.cdc.gov/covid/hcp/infection-control/, dated 06/24/24, stated, . Source control options for HCP [health care providers] include: . A NIOSH [National Institute for Occupational Safety and Health] Approved(R) particulate respirator with N95(R) filters or higher . If they are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated . they should be removed and discarded after the patient care encounter and a new one should be donned. During the entrance conference on 09/09/24 at 12:01 p.m., an administrative nurse (#1) identified Resident #3 and #14 as COVID positive. - Observation on 09/09/24 at 1:16 p.m. showed a certified nurse aide (CNA) (#9) wearing a gown, N95 mask, and face shield exited Resident #3's room and carried a trash bag down the hall to a larger trash cart. A sign on the resident's door stated, special droplet/contact precautions. The CNA failed to remove his gown, N95 mask, and face shield prior to leaving the room and completing other tasks. - Observation on 09/09/24 at 1:32 p.m. showed a CNA (#9) wearing an N95 mask and face shield exited Resident #14's room. A sign on Resident #14's door stated, special droplet/contact precautions. The CNA failed to remove the N95 mask and entered Resident #1's room followed by a staff nurse (#3) who wore a surgical mask. The staff transferred the resident from the wheelchair to the bed. The CNA (#9) exited Resident #1's room wearing the N95 mask worn upon entry, and entered two additional resident rooms. The CNA (#9) failed to remove the N95 mask upon exiting the room of a COVID positive resident (Resident #14) and before entering the rooms of COVID negative residents. During an interview on 09/09/24 at 2:12 p.m., the CNA (#9) stated he could wear the same N95 when providing care for COVID positive residents, but not when he provided care for COVID negative residents. During interviews on 09/09/24 at 2:30 p.m., an administrative nurse (#1) confirmed she expected staff to doff N95 masks prior to exiting COVID positive resident rooms and don a new mask prior to caring for COVID negative residents. - Review of Resident #1's medical record occurred on all days of survey and showed Resident #1 had a feeding tube. Observation on 09/09/24 at 1:32 p.m. showed Resident #1's room lacked signs indicating Resident #1 was in EBP. A CNA (#9) and a staff nurse (#3) entered Resident #1's room and transferred the resident from the wheelchair to the bed. Both staff failed to don gown or gloves. During an interview 09/11/24 at 5:35 p.m., an administrative nurse (#1) confirmed she expected staff to properly don/doff PPE. - Observation on 09/10/24 at 9:50 a.m. showed a nurse (#3) prepared to complete wound care on Resident #10. The nurse (#3) donned PPE and entered the room carrying a closed plastic container with the resident's wound supplies. The nurse placed the plastic container on the resident's bedside stand before cleaning the stand, completed the wound care, then exited the room without cleaning the plastic container and placed it in the bottom drawer of the treatment cart. The nurse (#3) failed to clean the plastic container prior to exiting the resident's room and/or before returning the container to the treatment cart. During an interview on 09/11/24 at 5:44 p.m., an administrative nurse (#1) stated she expected staff to clean any supplies with a disinfecting cloth before removing from a resident's room with EBP and before placing in the treatment cart.

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#4) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 09/11/24 at 10:40 a.m., an administrative manager (#2) confirmed the dietary manager (#4) lacked the required training for the position. The facility failed to ensure the dietary manager (#4) completed the education for a certified dietary manager, certified food service manager, or national certification for food service management and safety from a national certifying body.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 7 of 12 sampled residents (Resident #1, #5, #7, #9, #10, #18, and #20). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered occurred 09/11/24. This policy, revised March 2022, stated, A comprehensive, person-centered care plan that includes measurable objectives and timetables. The comprehensive, person-centered care plan: . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . the interdisciplinary team reviews and updates the care plan . - Review of Resident #1's medical record occurred on all days of survey. Diagnoses included gastrostomy status. The current care plan stated, . Feeding Tube . Resident requires tube feeding . Observation on 09/09/24 at 4:08 p.m. showed a medication aide (MA) (#10) don a gown and gloves prior to entering Resident #1's room. When asked why they were wearing the gown and gloves, the MA (#10) stated, For enhanced barrier precautions because he has a feeding tube. The facility failed to update Resident #1's care plan to include enhanced barrier precautions. - Review of Resident #5's medical record occurred on all days of survey. A progress note, dated 03/09/24, at 8:05 p.m., stated, Fall precaution in place bed in low position. The facility failed to update Resident #5's care plan to include the new fall intervention. - Review of Resident #7's medical record occurred on all days of survey. Observation on 09/09/24 at 12:45 p.m. showed the resident using a pommel cushion (supports the body, prevents slipping and relieves lower back pain). The facility failed to update Resident #7's care plan to include the use of the pommel cushion. - Observations on all days of survey identified an isolation cart outside Resident #9 and #10's rooms with signage identifying the resident required enhanced barrier precautions. The facility failed to update Resident #9 and #10's care plans to include enhanced barrier precautions. - Review of Resident #18's medical record occurred on all days of survey. Diagnoses included end stage renal disease and hyperkalemia (high potassium). The current care plan stated, . Nutritional Status . Resident is on a diabetic diet. Long Term Goal . Resident will accept and be satisfied with meals over the next 90 days. Approach . Resident will be provided with diabetic diet as ordered. A dietary note, dated 05/13/24 at 9:12 p.m., stated, . is a new admit . with a medical hx [history] significant for type 2 diabetes, renal disease, . dialysis . receives a nutrition score of 8 indicating she is at high nutrition risk. The facility failed to update Resident #18's care plan to reflect dialysis related nutrition. During an interview on 09/11/24 at 3:30 p.m., an administrative staff (#1) agreed Resident #18's care plan was very vague. - Review of Resident #20's medical record occurred on all days of survey. The current care plan stated, . Urinary Incontinence . Resident requires an indwelling urinary catheter. The facility failed to update Resident #20's care plan to include enhanced barrier precautions. During an interview on 09/11/24 at 5:35 p.m., an administrative staff member (#1) confirmed she expected enhanced barrier precautions to be identified on Resident #1 and #20's care plans. 46963

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 12 sampled residents (Resident #1, #13, #16, #18, and #20). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION K: SWALLOWING/NUTRITIONAL STATUS The Long-Term Care Facility RAI 3.0 User's Manual, revised October 2023, pages K-2 through K-11, stated, . K0200: Height and Weight . Weight . Base weight on most recent measure in the last 30 days, . K0520: Nutritional Approaches . PARENTERAL/IV FEEDING Introduction of a nutritive substance into the body by means other than the intestinal tract (e.g., subcutaneous, intravenous). FEEDING TUBE Presence of any type of tube that can deliver food/ nutritional substances/ fluids/ medications directly into the gastrointestinal system. Examples include, but are not limited to . percutaneous endoscopic gastrostomy (PEG) tubes. - Review of Resident #1's medical record occurred on all days of survey and showed a physician's order for Jevity 1.5 cal (a nutritional formula) per PEG Tube, four times a day. The quarterly MDS, dated [DATE], identified parenteral feeding coded incorrectly and failed to identify Resident #1's feeding tube. During an interview on 09/11/24 at 3:55 p.m., an administrative staff member (#5) confirmed staff failed to code the MDS correctly for Resident #1. - Review of Resident #18's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified Resident #18's weight as 155 pounds. Review of the record identified Resident #18's weight 167 pounds. The facility failed to use the most recent weight when completing the MDS. SECTION N: MEDICATIONS The Long-Term Care Facility RAI 3.0 User's Manual, revised October 2023, pages N-6 through N-8, stated, . N0415: High-Risk Drug Classes: . Coding Instructions .N0415A1. Antipsychotic: Check if an antipsychotic medication was taken by the resident at any time during the 7-day look-back period . N0415F1. Antibiotic: Check if an antibiotic medication was taken by the resident at any time during the 7-day look-back period . N0415G1. Diuretic: Check if a diuretic medication was taken by the resident at any time during the 7-day look-back period .N0415H1. Opioid: Check if an opioid medication was taken by the resident at any time during the 7-day look back period . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin .) was taken by the resident at any time during the 7-day observation period . N0415J1. Hypoglycemic (including insulin): Check if a hypoglycemic medication was taken by the resident at any time during the 7-day observation period . - Review of Resident #13's medical record occurred on all days of survey. Review of the medication administration record (MAR) for July 2024, showed Resident #13 received the following medications: * clindamycin, an antibiotic * tramadol, an opioid * aspirin, an antiplatelet * Fiasp insulin and Levemir insulin, hypoglycemics The quarterly MDS, dated [DATE], showed staff failed to identify Resident #13 received an antibiotic, opioid, antiplatelet, and hypoglycemics. - Review of Resident #16's medical record occurred on all days of survey. Review of the MAR for June 2024, showed the resident received azithromycin, an antibiotic. The quarterly MDS, dated [DATE], showed staff failed to identify Resident #16 received an antibiotic. - Review of Resident #18's medical record occurred on all days of survey . Review of the MAR for August 2024, showed the resident received bumetanide, a diuretic. The quarterly MDS, dated [DATE], showed staff failed to identify Resident #18 received a diuretic. - Review of Resident #20's medical record occurred on all days of survey. Review of the MARs for June-July 2024, showed Resident #20 received the following medications: * quetiapine, an antipsychotic * amoxicillin, an antibiotic The quarterly MDS, dated [DATE], showed staff failed to identify Resident #20 received an antipsychotic and antibiotic. During an interview on 09/11/24 at 3:59 p.m., an administrative staff member (#5) confirmed staff failed to code the MDS correctly for Resident #13, #16, #18, and #20. 46963

42397 Based on record review, staff interview, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, and review of the federal database for Long-Term Care Survey, the facility failed to ensure timely electronic data submission of required Minimum Data Set (MDS) assessments for 3 of 12 sampled residents (Resident #4, #5, and #20) and one supplemental resident (Resident #75). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.18), page 2-34, stated, . The MDS must be transmitted . electronically no later than 14 calendar days after the MDS completion date . Page 2-35 stated, . The ARD [assessment reference date] must be within 92 days after the previous OBRA assessment . The MDS completion date (item Z0500B) must be no later than 14 days after the ARD. Page 2-38 stated, Entry Tracking Records . Must be submitted no later than the 14th calendar day after the entry . Page 5-1 stated, . All Medicare and/or Medicaid-certified nursing homes . must transmit required MDS data records to CMS' [Center for Medicare and Medicaid Services] Internet Quality Improvement and Evaluation System (iQIES) Assessment Submission and Processing (ASAP) system. - Review of Resident #4's medical record occurred on all days of survey and showed a quarterly MDS with an ARD date of 07/29/24 and a completion date of 08/23/24 (completed 30 days late). - Review of Resident #5's medical record occurred on all days of survey and showed a quarterly MDS with an ARD of 6/26/24, a completion date of 06/28/24, and transmitted to iQIES on 09/01/24 (transmitted 44 days late). - Review of Resident #20's medical record occurred on all days of survey and showed the following: * A discharge return anticipated MDS with an ARD of 6/27/24, and a completion date of 08/17/24 (completed 51 days late). * An entry tracking MDS with an ARD of 6/30/24 and transmitted to iQIES 08/13/24 (transmitted 61 days late). * A quarterly MDS with an ARD of 7/6/24, and a completion date of 08/17/24 (31 days late). - Review of Resident #75's MDS occurred on 09/09/24 and showed the facility completed and transmitted quarterly MDSs with ARD dates of 02/27/24 and 08/27/24. The facility failed to submit an MDS 92 days after the MDS dated [DATE]. During a phone interview on 09/12/24, a facility nurse (#5) confirmed staff failed to submit MDSs in a timely manner.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of medications for 2 of 2 unlocked and unattended carts (medication and treatment carts). Failure to securely store medications may result in unauthorized access to medications. Findings include: Review of the facility policy titled Medication Labeling and Storage occurred on 09/11/24. This undated policy, stated, Policy Statement. The facility stores all medications. in locked compartments. Medication Storage. 2. The nursing staff is responsible for maintaining medication storage. 3. Compartments (including, but not limited to, drawers, . carts, . ) containing medications. are locked when not in use, . carts used to transport such items are not left unattended if open or otherwise available to others. Observation on 09/11/24 at 8:18 a.m., showed an unlocked/unattended medication cart with medications on the top of the cart and an unlocked/unattended treatment cart in the 200-hallway. During an interview on 09/11/24 at 8:34 a.m., an administrative nurse (#1) stated she expected staff to lock the medication cart and keep all medications in the cart when the nurse or medication aide [MA] are not within sight/accessing them.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 2 of 4 sampled residents (Resident #5 and #11) reviewed for psychotropic medication use. Failure to limit as needed (PRN) psychotropic medication use to 14 days unless reevaluated by a practitioner, and failure to monitor the residents on psychotropics placed the residents at risk of receiving unnecessary medications and experiencing adverse drug effects and consequences related to their use. Findings include: Review of the facility policy titled Psychotropic Medication Use occurred on 09/11/24. This policy, dated July 2022, stated, . PRN orders for psychotropic medications are limited to 14 days. PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. Resident receiving psychotropic medications are monitored for adverse consequences, including: . neurologic affects-agitation, distress . tardive dyskinesia . If psychotropic medications are identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication(s) should be continued, and document the rationale. - Review of Resident #5's medical record occurred on all days of survey. The current orders in the electronic medical record and the electronic medication administration record (EMAR) identified alprazolam (medication to treat anxiety) 0.5 milligrams (mg) every 12 hours as needed for uncontrolled anxiety started 08/09/24. The order lacked a stop date. Review of the resident's EMAR for August 1- September 11, 2024 identified the resident received alprazolam on 09/01/24 and 09/02/24. Review of the physician's orders in the resident's paper chart identified an order to discontinue the alprazolam on 07/09/24 with no order to restart the medication. Review of the resident's progress notes failed to identify the provider had given an order for the PRN alprazolam. The resident received two doses of the alprazolam after it was discontinued. The facility failed to write an order for the alprazolam started 08/09/24 and failed to have the physician or prescriber evaluate the resident's need to extend the psychotropic medication beyond the original 14 days. During an interview on 09/11/24 at 4:47 p.m., an administrative nurse (#1) confirmed the facility failed to write the physician's order received via phone for the Alprazolam started on 08/09/24 and failed to have the provider reevaluate the resident for further need of the medication after 14 days. - Review of Resident #11's medical record occurred on all days of survey. Physician's orders included Seroquel (antipsychotic medication) 25 mg at bedtime and a tardive dyskinesia (TD) assessment to be completed every 6 months while on Seroquel (the 6th of every 6th month). The medical record identified an incomplete TD assessment dated [DATE]. During an interview on 09/11/24 at 8:57 a.m., an administrative nurse (#1) confirmed staff failed to fully completed the TD assessment on 02/06/24 and failed to complete another one in the last 6 months.

1. Based on observation, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #10) observed for insulin preparation. Failure to prime an insulin pen correctly may result in residents receiving an inaccurate dose. Findings include: Review of the manufacturer's guidelines titled Fiasp insulin aspart injection. Instructions for use. occurred on 09/11/24. This document, dated July 2023, page 8, states, . Priming your . Pen: Step 7: Turn the dose selector to select 2 units. Step 9: Hold the pen with the needle pointing up. Press and hold in the button until the dose counter shows0. A drop of insulin should be seen at the needle tip. Observation on 09/10/24 at 11:53 a.m. showed a nurse (#3) attached a needle to Resident #10's Fiasp FlexTouch insulin pen, selected two units of insulin, and depressed the plunger while the pen was in the horizontal position. The nurse (#3) failed to hold the pen with the needle pointing up while pushing the plunger button. During an interview on the afternoon of 09/10/24, an administrative nurse (#1) confirmed the nurse (#3) failed to prime the insulin pen correctly. 2. Based on observation, record review, review of policies/procedures, review of professional reference, and staff interview, the facility failed to follow physician's orders for 2 of 12 sampled residents (Resident #1 and #7). Failure to follow physician's orders for notification of blood glucose outside of specific parameters (Resident #7), for tardive dyskinesia assessments, range of motion (ROM) exercises, and changing of oxygen/respiratory tubing (Resident #1) placed Residents #1 and #7 at risk for delayed treatment and adverse health events. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. A review of the facility policy titled Physician Services occurred on 09/11/24. This policy, revised February 2021, stated, . The medical care of each resident is supervised by a licensed physician. Supervising the medical care of residents includes (but is not limited to): . monitoring changes in resident's medical status . - Review of Resident #1's medical record occurred on all days of survey. Diagnoses included cerebral palsy and dependence on supplemental oxygen. Physician's orders identified the following: * 02/11/16 ROM both lower extremities 1-2 x [times] per day, flex extremities at knee 6 reps [repetitions] both extremities . Twice a day. * 12/30/23 change oxygen equipment, date equipment. 1. o2 [oxygen] bag 2. [NAME] [sic] lumen w/c [wheelchair] 3. concentrator 4. neb [nebulizer] (no blue mask) . Every 2 Weeks . * 02/01/24 TD [tardive dyskinesia] Assessment Reglan [anti-nausea medication] every 6 months . Review of Resident #1's point of care (POC) responses (CNA charting), dated 08/01/24 through 09/10/24, showed ROM completed 5 of 41 days. The medical record lacked a tardive dyskinesia assessment completed since 02/01/24. Observations on all days of survey showed Resident #1 wearing oxygen, the oxygen tubing on the concentrator dated 08/24/24, and the nebulizer tubing/mask dated 08/04/24. The facility failed to change oxygen and nebulizer tubing/mask every two weeks as ordered. During an interview on 09/10/24 at 1:59 p.m., a certified nurse aide (CNA) (#8) stated she is the restorative aide and is supposed to work as the restorative aide five times per week but is always on the floor due to staffing. She confirmed Resident #1 did not receive daily ROM exercises. During interviews on 09/10/24 at 2:40 p.m., and 09/11/24 at 8:45 a.m., an administrative nurse (#1) confirmed any CNA can perform ROM exercises for Resident #1, and she expected staff to document each shift if completed/attempted, and staff failed to complete a tardive dyskinesia assessment as ordered. - Review of Resident #7's medical record occurred on all days of survey and included a diagnose of Type 2 Diabetes Mellitus. A physician's order, dated 06/18/24, stated, . If Blood Sugar is less than 100 [mg/dL, milligrams per deciliter], call MD [medical doctor]. If Blood Sugar is greater than 450 [mg/dL], call MD. A physician's order, dated 11/13/23, stated, Accu-check [checks blood sugar levels] PRN [as needed] for symptoms of hypo/hyperglycemia [low blood glucose/high blood glucose] < [less than]100 or > [greater than] 400 CALL PHYSICIAN . Review of Resident #7's blood glucose checks from 08/04/24 through 09/08/24 showed the following: * 09/01/24 5:27 a.m., 63 mg/dL * 08/27/24 7:57 p.m., 403 mg/dL * 08/27/24 11:25 a.m., 55 mg/dL * 08/26/24 5:47 a.m., 80 mg/dL * 08/20/24 5:16 a.m., 421 mg/dL * 08/17/24 7:39 a.m., 430 mg/dL The medical record showed the facility failed to notify the physician of Resident #7's blood glucoses that were less than 100 or greater than 400. During an interview on 09/11/24 at 08:44 a.m., an administrative nurse (#1) confirmed staff failed to notify the provider of Resident #7's blood glucose being out of parameters as ordered. 46963 46964

Based on record review and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer for 1 of 2 sampled residents (Resident #13) transferred to the hospital. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of Resident #13's medical record occurred on all days of survey and identified a hospital transfer on 06/28/24. The medical record lacked evidence the facility provided the resident and/or representative with a written transfer notice. During an interview on 09/10/24 at 4:55 p.m., an administrative staff member (#6) confirmed the facility failed to complete a Notice of Transfer for hospitalization for the resident.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 07/18/19. Based on information from complainant, record review, review of facility policy, and staff interview, the facility failed to provide necessary supervision/assistance to prevent a fall with major injury for 1 of 1 sampled resident (Resident #2) who required total assistance with bed mobility. Failure to lower the bed to its lowest position resulted in Resident #2's fall with major injury. Findings include: Information provided by the complainants indicated nursing staff failed to provide adequate supervision/assistance resulted in resident fall from bed resulting in fractured neck. Review of the undated facility policy titled Side-Lying Position stated, . Reposition the bed to its lowest horizontal position for the safety of the resident. Review of Resident #2's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified severely impaired cognitive skills, contractures, progressive neurological condition, and total dependence for bed mobility, toileting, and transfers. The care plan identified . has knee flex contractures . At risk for falls and injury from falls . bed in lowest position. Resident will be turned every 2 hours when in bed . Review of the facility fall investigation report identified Resident #2 was found on the floor by a CNA [certified nursing assistant] at 1:30 p.m. on 03/23/21. Nursing progress notes from 03/23/21 identified: * 2:26 p.m., Resident was found facing down on floor. Resident has abrasion on left elbow; Right facial redness; Left upper chest has circle within a circle. Resident left arm was downward; right arm was upward. Resident legs were as straight as they can be with knees pointing towards left side of body. * 3:28 p.m., CNA called nurses to resident room. Witnessed resident laying on the floor beside his bed. He was yelling, facing away from the door. First 2 attempts at blood pressure unsuccessful. left arm tucked and he was rolled to his left side. His face appears to be carpet burned, red colored. His right elbow has open area . asked to call 911. Telephone order received from [physician] . send to ED [emergency department]. * 6:25 p.m., Update from [ED], C1 [neck] fracture noted and in neck collar. The nursing progress notes identified the following: :*03/24/21 at 6:35 a.m., Resident returned from ER wth ambulance crew at 12:20 a.m. * 03/25/21 at 3:28 a.m., . crying out . Tylenol [pain medication] given . * 03/25/21 at 1:00 p.m., . Tylenol and [MEDICATION(S)] [pain medication] [given] at approximately 1030 [10:30 a.m.] due to him grimacing and moaning out. * 03/26/21 at 1:56 p.m., . Resident yelling out . he was pointing to his neck . Resident given tylenol . * 03/26/21 at 3:03 p.m., . cried out during turning movement . groaned loudly. PRN [as needed] [MEDICATION(S)] administer [sic] . resident [has] signs and symptoms of discomfort. * 03/27/21 at 12:11 a.m., . pointing to neck . he was in pain. Given Tylenol . * 03/27/21 at 2:56 a.m., . still yelling . given [MEDICATION(S)] . for discomfort. Resident continues to want wedge behind him. * 03/27/21 at 2:55 p.m., . very agitated and restless during the night. given pain medication . but it did not seem to help. restless this morning . points to his door or makes the hand gesture to get out of bed. unable to leave his bed due to recent injury to his neck. New order [[MEDICATION(S)]] [anxiety medication] for restlessness and agitation. * 03/27/21 at 3:28 p.m., . very agitated . hollering out and trying to lift his chest and head up. heard hollering out . administer [sic] PRN [MEDICATION(S)] . see if this would help with the resident behaviors. * 03/28/21 at 3:17 p.m., . heard hollering and moaning. agitated . pointing to get out of his bed. PRN [MEDICATION(S)] given . trying to lift his head up. * 03/29/21 at 1:51 a.m., . crying . He was not settling down. PRN [MEDICATION(S)] given for agitation. continued to cry and yell, after one hour writer gave PRN [MEDICATION(S)] for pain. * 03/29/21 at 10:00 a.m., . restless . still restless . PRN [MEDICATION(S)] for agitation. * 03/30/21 at 4:54 p.m., . Increase [MEDICATION(S)] . * 03/31/21 at 1:09 a.m., . very agitated and screaming . [MEDICATION(S)] given . to decrease agitation. * 04/02/21 at 4:56 p.m., . yelling and pointing to get up. PRN anxiety and pain meds given . * 04/05/21 at 11:23 a.m., . hollering out . given a PRN tylenol for concerns of pain . * 04/06/21 at 4:33 p.m., . yelling and unhappy . * 04/07/21 at 8:57 a.m., . very agitated . hollering out . trying to point to get out of his bed . moaned . [MEDICATION(S)] administered for his increase in agitation. * 04/09/21 at 3:20 a.m., . yelling . given PRN for anxiety . * 04/09/21 at 6:26 a.m., . yelled and cried . PRN anxiety and pain medication given . * 04/09/21 at 11:00 a.m., . very agitated . indicated . he was having pain. given pain med and [MEDICATION(S)] for restlessness and agitation. * 04/11/21 at 5:12 a.m., . agitated . * 04/13/21 at 4:50 p.m., . acting as if in pain. PRN given . * 04/16/21 at 7:59 a.m., . hollering . frequently hollered out and was moaning loudly. very upset . PRN [MEDICATION(S)] for his comfort. * 04/20/21 at 11:49 a.m., . expressing agitation . hollering out and upset . hollering out and moaning. administer PRN [MEDICATION(S)]. again expressing agitation . still upset and is [sic] agitation was increasing . cried out. PRN [MEDICATION(S)] administered at this time for possible pain. * 04/25/21 at 4:19 a.m., . Resident yelling and seemed angry . The March 2021 and April 2021 medication administrative record (MAR) identified the following scheduled pain and anti-anxiety medications Resident #2 received after his fall: * Tylenol Extra Strength (acetaminophen) 500 mg (milligrams) three times a day * [MEDICATION(S)] 25 mg three times a day * [MEDICATION(S)] (sertraline) (anxiety medication) 50 mg once a day The March 2021 and April 2021 MAR identified the following PRN pain and anti-anxiety medications Resident #2 received after his fall: * Tylenol Extra Strength (acetaminophen) 500 mg PRN three times a day * [MEDICATION(S)] 25 mg PRN once a day * [MEDICATION(S)] (lorazepam) 0.25 mg PRN every 8 hours for restlessness and agitation During an interview on 04/26/21 at 3:52 p.m., an administrative nurse (#1) stated, When I entered the room to complete the investigation the bed was not in the lowest position and the resident was facedown and incontinent of bowel. A CNA also self-reported that she did not turn and reposition the resident every two hours according to the care plan. During an interview on 04/27/21 at 4:21 p.m., the administrative nurse (#1) reported implementing corrective action following Resident #2's fall. The facility failed to ensure the necessary care and services to promote safety for Resident #2. The failure resulted in an avoidable fall from bed resulting in a major injury, reduced quality of life, and pain.

BOWEL MANAGEMENT: 1. Based on record review, review of facility protocol, and staff interview, the facility failed to provide the necessary care and services to manage constipation for 4 of 7 sampled residents (Resident #1, #3, #4, and #5) who required as needed (PRN) medications for constipation. Failure to implement less invasive interventions to manage constipation may have resulted in these residents receiving unnecessary suppositories. Findings include: Review of the facility's bowel protocol occurred on 07/22/14. This undated protocol stated, ". . . Bowel assessment done on admission. Care Plan individualized to include: Day 2 non-pharmacological interventions - prune juice, intake (fluid intake) Day 3 oral pharmacological interventions - MOM (Milk of Magnesia), [MEDICATION NAME] tabs (stool softener) Day 4 Suppository followed by fleets (enema) if needed . . ." - Review of Resident #3's medical record occurred on July 21-22, 2014 and [DIAGNOSES REDACTED]. PRN medications included [MEDICATION NAME] suppository and MOM. Non-pharmacological PRN interventions included prune juice, fruit crax (a fruit mixture), or prunes. Resident #3's care plan failed to identify a concern related to constipation. The bowel movement (BM) records for July 13-21, 2014 identified Resident #3 had a BM on July 13th, July 17th, and July 21st. The Medication Administration Record (MAR) identified Resident #3 received a suppository on July 17th and July 21st. (The resident declined prune juice or fruit crax on July 19th). The facility failed to follow their bowel protocol and offer MOM or oral [MEDICATION NAME] tablets prior to administering suppositories. - Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Non-pharmacological interventions included prune juice PRN. Resident #1's care plan failed to identify a concern related to constipation. The BM records for July 14-21, 2014 identified Resident #1 had a BM on July 14 and not again until July 18. The MAR identified Resident #1 received a suppository on July 18, the fourth day without a BM. The facility failed to attempt less invasive interventions for bowel management, including dietary interventions, prior to the administration of a suppository. - Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications ordered to prevent constipation and/or aid in bowel elimination included MOM PRN, and a [MEDICATION NAME] suppository PRN. Non pharmacological interventions included prune juice/fruit crax/prunes every day PRN (initiated on 07/21/14). The BM records for July 15-21, 2014 identified Resident #3 had a BM on July 15 and not again until July 19. The MAR identified the resident received a suppository on July 18, the third day without a BM. The facility failed to attempt less invasive interventions for bowel management, including dietary interventions, prior to the administration of a suppository. - Review of Resident #4's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications administered daily to prevent constipation and/or aid in bowel elimination included [MEDICATION NAME] three times a day, [MEDICATION NAME] tablets at bedtime, and MOM every other day. PRN medications included [MEDICATION NAME] S, a [MEDICATION NAME] suppository, and a Fleets enema. Non pharmacological interventions included prune juice and fruit crax. Resident #4's care plan failed to identify a concern related to constipation. The BM records for July 15-21, 2014 identified Resident #4 had a BM on July 17 and not again until July 21. The MAR and progress notes identified Resident #4 received a tablespoon of fruit crax and prune juice on July 19, no PRN medications or dietary interventions on July 20, and a suppository on July 21, the fourth day without a BM. The facility failed to follow their bowel protocol and administer an oral pharmacological medication on Resident #4's third day without a BM. During an interview on the morning of 07/22/14, an administrative nurse (#1) stated she would expect nursing staff to follow the facility's bowel protocol. HEEL BOOTS 2. Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services to prevent pressure ulcers for 1 of 1 sampled resident (Resident #1) with heel boots. Failure to apply heel boots to the resident's feet while in bed may result in the development of pressure ulcers. Findings include: Review of Resident #1's record occurred on all days of survey. [DIAGNOSES REDACTED]. Resident #1's care plan failed to identify any skin concerns or a risk for pressure ulcers; however, the certified nursing assistants' (CNAs) care guide identified the use of heel protectors while in bed. - Observation on 07/21/14 at 1:00 p.m. showed two CNAs (#3 and #4) transferred Resident #1 from the wheelchair to bed, provided perineal care, and positioned her in bed on her back with her heels resting directly on the mattress. Observations showed blue heel boots on the unoccupied bed in the room. At 5:05 p.m., observation showed Resident #1 remained on her back in bed, heels directly on the mattress, and no heel boots. - On 07/22/14 at 9:35 a.m., two CNAs (#2 and #3) transferred Resident #1 from the wheelchair to bed. After providing cares, the CNAs positioned the resident on her back with her heels resting directly on the mattress. Observation showed the heel boots on the unoccupied bed in the room. During an interview on the morning of 07/22/14, an administrative nurse (#1) stated she would expect facility staff to place the heel boots on Resident #1's feet while in bed.

PAIN MANAGEMENT: 1. Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to attain the highest practicable well-being for 1 of 1 sampled resident (Resident #5) who experienced a "near fall" with fracture. Failure to assess Resident #5's continued pain and bruising in a timely manner resulted in uncontrolled pain and delayed treatment. Findings include: Review of the facility policy titled "Pain Assessment and Management" occurred on 05/14/14. This policy, revised October 2010, stated, ". . . Reporting, Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain . . . 3. Prolonged, unrelieved pain despite care plan interventions." Review of Resident #5's medical record occurred on all days of survey and [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified the resident required total assistance of two or more staff members for transfers. The current care plan stated, ". . . (Resident #5) has DJD ([MEDICAL CONDITION] joint disease), has chronic left hip pain and left knee discomfort . . . (Resident #5) will sign that he has pain by pointing to body area and frowning to indicate pain or discomfort . . . (Resident #5) is extensive to dependent (with) all ADL's (activities of daily living), He has [MEDICAL CONDITION], has generalized [DIAGNOSES REDACTED] and contractures of hands and feet, is tall and leans backwards when transferred . . . Hoyer lift only (revised after incident on 10/17/13). . . ." Review of Resident #5's Progress Notes identified the following: *10/18/13 at 1:09 p.m. - "Resident appeared to be very agitated early in this shift, his skin was cold and clammy and he seemed as though he was having some trouble breathing. He was grimacing and gesturing towards his right leg. O2 (oxygen) was 91% on RA (room air). Resident was given PRN (as needed) [MEDICATION NAME] and PRN ES (extra strength) tylenol of 1000 mg (milligrams) for suspected pain. Resident lyed (sic) down at 11:00 a.m. VS (vital signs) WNL (within normal limits) and resident appears to be in a better mood and appears to be feeling better." *10/19/13 at 8:53 a.m. - "Noted redness on medial side of right forearm. Does not look bruised, but red and skin hardened. When touched (Resident #5) flinches. He has a tendency to let his right arm down to the inside of the w/c (wheelchair) next to his leg. Ice pack applied. (Resident #5) smiled and was happy about the ice bag." *10/20/13 at 9:09 a.m. - "Resident RT (right) outer forearm continues to be red and hard, area does not seem to have grown in size since yesterday. This morning however, RT forearm has a purple bruise noted over the top of the reddened area. Resident is able to move arm with regular strength. Ice pack applied to site, resident seems to be content with ice pack." *10/20/13 at 9:48 p.m. - "resident right forearm tender when touched - did get relief with scheduled pain medication - area bruised and red with raised area at wrist - resident pleasant and cooperative - will continue to monitor." *10/21/13 at 9:09 a.m. - "Redness noted on right medial forearm, cool to touch on 10/19/13. See previous notes. Today floor nurse notified myself that (Resident #5's) right forearm was bruised from elbow to distal fingers. No deformities noted, no crepitus. Facial expression indicated flinching et (and) painful expression. (Resident #5) indicated . . . through nonverbal communication his discomfort through restlessness and anxiety and being diaphoretic. (Name of Doctor) notified and orders to obtain X-rays obtained." *10/21/14 at 6:38 p.m. - "Res (resident) had an apt. (appointment) in (name or town), for x-ray. Res has a broken (RT) lower arm. Res returned at 5:00 p.m. with driver from facility. (RT) arm in a sock, casting and also splint stabilizer. Res. perspiring, skin cool and clammy. [MEDICATION NAME] given for pain at 5:00 p.m., and also [MEDICATION NAME] given per families (sic) request. Res assisted to bed per lift and assit (sic) of four. 6:30 p.m. Res resting quietly." Review of a physician progress notes [REDACTED]. . . scheduled today after injuring his upper extremities some time over this past weekend. Reportedly he was either being transferred or using a standing type of device and his arms were in the device and his legs gave out. He slid to the floor causing some pulling type injury to both upper extremities, nursing contacted me today stating he was having a lot of swelling to the right upper extremity and bruising, some on the left, appeared to have some significant pain to the right upper extremity . . . He has [MEDICAL CONDITION] and communicates by gesturing and some hand signals . . . On the right upper extremity he has a large area of ecchymosis (bruising) from below his elbow to his left hand and thumb . . . x-ray shows a displaced, spiral [MEDICAL CONDITION], mid to distal ulna . . . He is placed in a soft roll wrap and then a forearm splint. Will contact orthopedics regarding further management . . . He has Tylenol and [MEDICATION NAME] for pain already and Rx (prescription) for [MEDICATION NAME] 5 mg . . . provided." An investigation completed by the facility on 10/25/13, stated, ". . . During the course of the investigation all staff that had been on duty 1 day prior to the bruise being noted were interviewed. It was during these interviews that we learned of a near fall from the sit/stand lift on October 17th 2013 . . . The two aides caring for him on 10/17/13 demonstrated what happened when resident's leg buckled and caused him to almost fall . . . The staff were able to lift him from the strapped position and get him into a chair where they then called for the nurse . . . The aides demonstrated and described how he 'hung on' on the lift while they transferred him. . . ." Staff interviews completed during the above investigation of Resident #5's injury identified the following: *". . . the day of Oct. 17, 2013 when we were hoyering him into bed . . . was favoring that arm (Rt) and we had to assist him more to turn him. . . ." *". . . Friday the 18th . . . he seemed agitated and would hollar out. . . ." *". . . Friday 18th crying . . . not acting himself. . . ." *". . . Friday pm he used his Rt hand to tap his knee. This is what he does to tell us his knee hurts. . . ." *". . . On Friday Oct. (October) 18th . . . noticed a bruise on his right arm. It was not very big . . . On Saturday [DATE]th . . . his whole right arm was bruised. He seemed like he was in pain and when we moved him onto his right side . . . we could hear him cry (scream) so we went back . . . we kept on his left side the rest of the night. . . ." *". . . On Sat (Saturday - 10/19/13) - he was very agitated . . . kept right arm close to side. . . ." *". . . 10-21-13 - (Right) arm swollen bruised - left under arm bruised. . . ." During an interview on 05/14/14 at 2:20 p.m., an administrative nurse (#2) stated the staff members on duty failed to report and document the incident with the stand lift at the time it occurred (10/17/13). Failure to report Resident #5's "near fall" resulted in unnecessary pain and delayed treatment. DYSPHAGIA: 2. Based on observation, record review, review of professional reference, and staff interview, the facility failed to provide the care and services necessary to attain the highest degree of safety possible for 1 of 1 sampled resident (Resident #1) with a [DIAGNOSES REDACTED].#1 at risk for aspiration. Findings include: Nancy B. Swigert, "The Source for Dysphagia: Third Edition", LinguiSystems, Inc, 2007, page 125, stated, ". . . During the oral intake of medicines, foods and/or liquids, it is optimal for a patient to be seated at a 90 (degree) angle, whether in a bed or in a chair . . ." Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified extensive assistance for eating and a mechanically altered diet (pureed foods and honey thickened fluids). The current care plan stated, ". . . Monitor swallowing ability . . ." A dietary progress note, dated 04/14/14, stated, ". . . (Resident #1) receives a pureed diet with honey thick liquids. (Resident #1) has a hx (history) of both chewing and swallowing difficulties . . ." - Observation on all days of survey showed a mug of un-thickened water and a straw on Resident #1's night stand. Observation on all days of survey showed Resident #1 at approximately a 45 degree angle while seated in his wheelchair. - Observation on 05/12/14 at 12:10 p.m. showed Resident #1 in the dining room and seated in his wheelchair. An unidentified staff member fed the resident and failed to position him to an upright position. - Observation on 05/13/14 at 12:20 p.m. showed Resident #1 in the dining room and seated in wheelchair. The Certified Nursing Assistant (CNA) (#9) fed the resident a pureed diet and honey thickened juice and water. The CNA failed to thicken Resident #1's chocolate milk and position him to an upright position. - Observation on 05/13/14 at 4:20 p.m. showed Resident #1 seated in his wheelchair. The CNA (#6) assisted Resident #1 with a cup of Ensure (a nutritional drink). The CNA failed to thicken the Ensure and failed to position the resident to an upright position. - Observation on 05/14/14 at 9:35 a.m. showed Resident #1 seated in his wheelchair. The nurse (#19) assisted the resident with a cup of Ensure. When asked if she had thickened the Ensure, the nurse stated she had thickened to nectar consistency. The nurse (#19) failed to thicken the Ensure to honey consistency and failed to position Resident #1 to an upright position. - Observation on 05/14/14 at 4:25 p.m. showed Resident #1 seated in his wheelchair. The CNA (#5) assisted the resident with a cup of Ensure with a straw. The CNA failed to thicken the Ensure and failed to position Resident #1 to an upright position. During an interview on the afternoon of 05/14/14, an administrative nurse (#2) stated the facility recently placed Resident #1 in the current wheelchair because the chairs' reclining ability and better positioning for the resident. The nurse (#2) expected staff to place Resident #1's chair in an upright position during meals, and when providing fluids and expected all fluids thickened to honey consistency. BOWEL MANAGEMENT: 3. Based on record review and staff interview, the facility failed to provide the necessary care and services to manage constipation for 4 of 4 sampled residents (Resident #1, #2, #4, and #7) who required frequent as needed (PRN) medications for constipation. Failure to implement less invasive interventions to manage constipation may have resulted in these residents receiving unnecessary suppositories. Findings include: During an interview on the morning of 05/15/14, an administrative nurse (#2) stated the facility does not have a written policy related to bowel management. The nurse stated if a resident does not have a bowel movement by the third day, the nursing staff administer an as needed (PRN) medication. The nurse (#2) stated she would expect Milk of Magnesia (MOM) (a laxative) administered before a suppository or enema. - Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications included MOM PRN, [MEDICATION NAME] suppository PRN, and a Fleets enema PRN. The record showed Resident #1 received no scheduled medication or dietary intervention for management of constipation. Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], identified memory problems, required extensive assistance for toilet use, and always incontinent of bowel. The current care plan stated, ". . . Ensure adequate bowel elimination . . ." Resident #1's April 2014 and May 01-13, 2014 Medication Administration Record [REDACTED] April: *MOM administered twice: April 4 and 26 *[MEDICATION NAME] suppository administered 6 times: April 14, 17, 20, 24, 27, and 30 May: *[MEDICATION NAME] suppository administered 4 times: May 3, 7, 10, and 13 The bowel movement (BM) records for April and May 01-13, 2014 identified Resident #1 had a BM every third day except once (no BM April 11, 12, or 13). The facility failed to attempt less invasive interventions for bowel managment, including dietary interventions, prior to the administration of a suppository five times in April and four times in May. - Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications included Senna (laxative) daily, MOM PRN, and [MEDICATION NAME] suppository PRN. The record showed no dietary interventions for the management of constipation. The quarterly MDS, dated [DATE], identified Resident #2 required extensive assistance for toileting. The care plan failed to identify any concerns related to constipation. Resident #2's April 2014 and May 01-13, 2014 MAR indicated [REDACTED] April: *MOM administered 4 times: April 13, 15, 19, and 23 *[MEDICATION NAME] suppository administered 5 times: April 2, 5, 8, 22, and 28 May: *MOM administered twice: May 7 and 13 [MEDICATION NAME] suppository administered twice: May 4 and 8 The BM records for April and May 01-13, 2014 identified Resident #2 had a BM at least every other day except once (no BM May 2, 3, or 4). The facility failed to attempt less invasive interventions for bowel management, including dietary interventions, prior to the administration of a suppository five times in April and once in May. - Review of Resident #7's medical record occurred on May 13-14, 2014. [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] syrup (laxative) three times a day, [MEDICATION NAME] (laxative) every other day, MOM PRN, and [MEDICATION NAME] suppository PRN. The record showed no dietary interventions for the management of constipation. The quarterly MDS, dated [DATE], identified Resident #7 required total assistance for toilet use and always incontinent of bowel. The current care plan stated, ". . . Administer bowel protocol prn and document effectiveness . . ." Resident #7's April 2014 and May 01-13, 2014 MAR indicated [REDACTED] April: *No MOM administered *[MEDICATION NAME] suppository administered 10 times: April 4, 8, 10, 12, 15, 20, 23, 25, 27, and 30 May: *MOM administered once: May 9 *[MEDICATION NAME] suppository administered 3 times: May 3, 7, and 9 The BM records for April 16-30 and May 01-13, 2014 identified Resident #7 had a BM at least every third day. The facility failed to attempt less invasive interventions for bowel managment, including dietary interventions, prior to the administration of a suppository 10 times in April and twice in May. - Review of Resident #4's medical record occurred on all days of survey and [DIAGNOSES REDACTED]. The record identified Resident #4 received no dietary interventions for managing the resident's constipation. The current care plan failed to address the resident's constipation and necessary bowel interventions. Resident #4's April and May 01-13, 2014 MAR indicated [REDACTED] April *MOM administered three times: April 10, 14, and 20 *[MEDICATION NAME] suppository administered three times: April 11, 15, and 27 *Fleets enema administered five times: April 1, 4, 21, 24, and 28 May *[MEDICATION NAME] suppository administered twice: May 3 and 5 *Fleets enema administered four times: May 1, 7, 10, and 13 The BM records for April and May 01-13, 2014 identified Resident #4 had a BM at least every three to four days. The facility failed to attempt less invasive interventions for bowel management, including dietary interventions, prior to the administration of suppositories and enemas.

During a standard recertification survey starting on 05/13/13 and ending on 05/16/13, it was determined the facility failed to monitor the hot water temperatures in the facility and allowed the water temperature at the hand washing sinks in residents' room to reach temperatures as high as 145 degrees Farenheit (F) for 2 of 3 resident wings (200 and 400 wing). Water temperatures recorded on 05/14/13 between 12:15 p.m. and 1:35 p.m. on the two wings reached 145.2 degrees F. The survey team contacted management staff at the State Agency (SA) on 05/14/13 at 1:45 p.m. to discuss a potential immediate jeopardy situation. At 2:30 p.m., the survey team determined (in concurrence with management staff at the SA) that an immediate jeopardy situation existed. At 2:45 p.m., the survey team notified the facility Administrator and the Director of Nursing (DON) of the immediate jeopardy situation. At 3:00 p.m., the maintenance supervisor (#3) recorded water temperatures of 137.8 degrees F on the 400 wing and 140.2 degrees F on the 200 wing. At this time, the maintenance supervisor (#3) adjusted the hot water heaters located on each wing. At 3:30 p.m., an administrative staff member (#1) provided a plan for corrective action responding to the immediate jeopardy. The plan included measuring and recording water temperatures in all 3 wings of the facility every hour starting at 4:00 p.m. on 05/14/13 until 8:00 a.m. on 05/15/13. At 3:40 p.m., the survey team contacted the SA by phone and informed them the team received an acceptable corrective action plan related to the immediate jeopardy identified. At 6:15 p.m. the survey team, an administrative staff member (#1), the maintenance supervisor (#3), and a staff nurse (#4) recorded temperatures on all 3 wings of the facility. The highest water temperature recorded was 106 degrees F. At this time the survey team reduced the immediate jeopardy. On 05/15/13 at 8:15 a.m., the survey team met with an administrative staff member (#1) and reviewed the water temperatures gathered during the evening and overnight hours. The information showed that staff failed to monitor hourly temperatures (between the hours of 2:00 a.m. and 6:00 a.m.) as identified on their corrective plan of action. At 10:35 a.m., a conference telephone call occurred with the SA management staff, the survey team, and an administrative staff member (#1). The facility indicated they would resubmit a plan and continue to monitor water temperatures every hour throughout the day. Temperatures recorded hourly from 6:00 a.m. to 5:00 p.m. on 05/15/13 identified 119 degrees F as the highest water temperature (i.e. an acceptable temperature range). At 5:30 p.m., an administrative staff member (#1) provided the survey team with a new plan to maintain safe water temperatures which included new mixing valves, additional staff education, and continued monitoring. After the survey team determined the immediate jeopardy situation in the facility was reduced, the scope and severity was lowered to an "E." 1. Based on observation, review of facility policy and procedure, and staff interview, the facility failed to maintain safe water temperatures at hand washing sinks in residents' room located on 2 of 3 wings (200 and 400). Failure to ensure safe water temperatures may result in injuries/burns to the residents of the facility. Findings include: Review of the facility policy titled "Safety of Water Temperatures" occurred on 05/16/13. This policy, dated 02/02/11, stated, ". . . 1. Water heaters that service resident rooms, . . . shall be set to temperatures of no more than 115 (degrees) F, or the maximum allowable per state regulations. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these in a maintenance log. 3. Maintenance staff shall conduct periodic tap water checks and record the water temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. . . ." - Observation on 05/13/13 at 3:45 p.m., showed a nursing staff member (#6) washed her hands at the sink in a resident's room. This staff member stated "the water was hot" and adjusted the water flow. A similar observation on 05/14/13 at 12:00 p.m., occurred involving the same staff member in the same resident's room. On 05/14/13, the water temperatures taken in residents' bathroom sinks revealed the following hot water temperatures: Room 208 at 12:15 p.m., 144.5 degrees F Room 404 at 12:23 p.m., 130.1 degrees F Room 213 at 1:25 p.m., 139 degrees F Room 405 at 1:35 p.m., 145.2 degrees F Review of a "MAINTENANCE QA (quality assurance) MONTHLY HOT WATER TEMPERATURE CONTROL" occurred on 05/16/13. This log indicated staff last recorded water temperatures on 02/13/12. The facility failed to provide additional information regarding monitoring of water temperatures since 02/13/12. During an interview on 05/14/13 at 2:45 p.m., an administrative staff member (#1) stated he thought staff monitored water temperatures about three months ago. 2. Based on observation, review of facility policies and procedures, and review of warning labels on containers of chemicals, the facility failed to maintain an environment free of hazardous chemicals on 3 of 3 resident care areas (200, 300 and 400 wings). Accessible hazardous chemicals places cognitively impaired and wandering residents at risk for accidents and/or injury. Findings include: Review of the facility's policy titled "Safety and Supervision of Residents" occurred on 05/16/13. This policy, dated 05/10/12, stated, "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities." During the initial tour, on 05/13/13 at 12:47 p.m. observation showed open doors to the shower rooms for each wing, 200, 300, and 400. Each shower room contained a set of lockable cabinets. Random observations of the environment on 05/14/13 at 10:30 a.m. and on 05/15/13 at 8:55 a.m. and 4:00 p.m. identified the following chemicals stored in the shower rooms: * 200 wing: a gallon pump bottle of Lysol IC Quaternary disinfectant Cleaner Concentrate with the warning "Keep out of Reach of Children," Foamy Q & A Acid disinfectant cleaner with the warnings "Keep out of reach of Children" and "DANGER Corrosive," and a spray bottle of diluted (for use) Lysol IC * 300 wing: a gallon pump bottle of Lysol IC Quaternary disinfectant Cleaner Concentrate and two spray bottles of diluted (for use) Lysol IC * 400 wing: a spray bottle of diluted (for use) Lysol IC During an observation on 05/15/13 at 4:00 p.m., an administrative staff member (#1) attempted to lock the cupboard containing a gallon pump bottle of Lysol IC Quaternary disinfectant Cleaner Concentrate and Foamy Q & A Acid disinfectant cleaner located on the 200 unit, but the lock failed to secure the contents. During the environment tour on 05/16/13 at 9:00 a.m. with a maintenance supervisor (#3), the cupboard located on the 400 wing contained the unsecured spray bottle of Lysol IC.

Based on record review and staff interview, the facility failed to provide necessary care and services to prevent the formation of a [MEDICAL CONDITIONS] for 1 of 1 sampled resident (Resident #9) with a history of [MEDICAL CONDITION]. Failure to provide adequate monitoring and review/revise treatment if necessary resulted in Resident #9's admission to the hospital with a blood clot. Findings include: Review of Resident #9's medical record occurred on May 15-16, 2013. [DIAGNOSES REDACTED]. Current medications included [MEDICATION NAME] (an anticoagulant) 2.5 milligrams (mg) daily. A hospital admission history and physical, dated 04/04/13, stated, ". . . He (Resident #9) was seen on rounds because of swelling of his left leg. At this time I examined him and he appeared to have [MEDICAL CONDITION] below the groin, all the way into his foot. There was questionable tenderness over the calf with a positive Homans (a test used to detect [MEDICAL CONDITION]). . . . Recent hospitalization for pneumonia. . . . Ultrasound showed a [MEDICAL CONDITION] of the left common femoral vein. . . . At this time, the patient will be admitted for IV (intravenous) [MEDICATION NAME] (an anticoagulant). Will also start the patient on [MEDICATION NAME]. . . ." Nurses' notes stated the following: *04/04/13 at 5:07 p.m.: ". . . (Physician name) here and examined left lower leg. Has had increased swelling over past two days. Wt. (weight) gain. Orders obtained to send to (hospital name) ER for Doppler study of left leg and chest xray. Concerned due to fact was recently hospitalized and wants to rule out [MEDICAL CONDITION]. . . ." *04/04/13 at 7:19 p.m.: ". . . Resident admitted to (hospital name) for a blood clot found in upper LE (left extremity). . . ." *04/09/13 at 1:01 p.m.: ". . . (Resident #9) returned from acute today at 10:10 a.m. . . . [DIAGNOSES REDACTED]. . ." A physician's orders [REDACTED].e. PT/INR, a lab test that measures the amount of time it takes for blood to clot) monitoring as ordered. *04/17/13 at 2:27 p.m.: ". . . Resident sent to (hospital name) ER due to dark 'bloodlike' secretion in his GI (gastrointestinal) tube. . . . Did have episodes of emesis. The emesis looked mostly like snotty mucus, but later did contain blood. . . ." *04/17/13 at 5:24 p.m.: ". . . Res. (resident) returned from (hospital name) ER . . . orders to start [MEDICATION NAME] (an antibiotic) 500 m.g daily for 10 days, and [MEDICATION NAME] (an antiemetic) gel . . ." *04/18/13 at 2:58 p.m.: ". . . (Provider name) here and examined for rounds. Review last PT/INR. Concerns about last result. No changes made in dosage after Fridays results (04/12/13) and with ER visit yesterday. Order obtained to draw PT/INR now and call results to her tomorrow in the clinic. Will also hold [MEDICATION NAME] dosage tonight. Lab drawn . . ." A provider's progress note stated the following:*04/18/13: ". . . recently was known to have some leg swelling on the left leg and had a positive [MEDICAL CONDITION]. . . . Now his treatment has been [MEDICATION NAME] 12.5 mg daily. He was apparently in the emergency room (ER) earlier this week with a coffee ground emesis and coughing. . . . ASSESSMENT: . . . Recent left leg [MEDICAL CONDITION], now on a large dose of [MEDICATION NAME] with a GI bleed yesterday. . . ." The provider also wrote an order to hold the [MEDICATION NAME] and check Resident #9's PT/INR on 04/18/13. Nurses' notes further identified: *04/19/13 at 2:17 p.m.: ". . . verified residents labs with (provider). new orders to start [MEDICATION NAME] 2.5 (mg) daily. Recheck labs on 04-23-14 (sic). . . ." *05/15/13 at 5:29 p.m.: ". . . Resident has 4+ [MEDICAL CONDITION] to Lt (left) lower leg. (Physician name) notified, orders made to transfer resident to (hospital name). . . ." *05/15/13 at 9:44 p.m.: ". . . Resident will be recieving (sic) treatment at (hospital name). . . . Resident will be staying at (hospital name) and be treated for [REDACTED]. . . ." Resident #9's PT/INR results are as follows: 04/09/13: PT: 17.9 (reference range is 8.9 - 11.1 seconds) INR: 1.8 (reference range is 0.0 - 1.1 seconds, recommended therapeutic range for treatment of [REDACTED]. 04/12/13: PT: 34.7 INR: 3.7 04/18/13: PT: 23.2 INR: 2.4 05/15/13: PT: 10.8 INR: 1.1 Facility staff were unable to locate the order or the results of the labs to be drawn on 04/23/13. During an interview on the morning of 05/16/13, a nursing staff member (#12) stated they transferred Resident #9 to the hospital on [DATE] for treatment of [REDACTED]. The staff member also stated she called the lab, who had no record of labs ordered for Resident #9 on 04/23/13. Although the nurse's note on 04/19/13 identified a decrease in [MEDICATION NAME] dose from 12.5 mg to 2.5 mg (one-fifth of the previous dose) with follow-up labs to be done on 04/23/13, there is no evidence that staff ordered or drew the lab. As a result, Resident #9's PT/INR was not monitored for over three weeks. Failure to adequately monitor Resident #9 (who was previously hospitalized with a [MEDICAL CONDITION]) after decreasing his anticoagulation medication and review/revise the dose if necessary resulted in re-admission to the hospital with a blood clot in his left leg.