Every finding on record at Westminster-Canterbury of Richmond

Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete, accurate clinical record for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed maintain a complete, accurate medical record by documenting assessments, interventions, and vital signs in the clinical record on 10/19/24. A review of R1's nurses' progress notes revealed the following: 10/19/24 19:44 (7:44 p.m.) Resident remains lethargic. BP remains low 88/43. Resident responds to tactile and verbal stimuli. Has declined PO (by mouth) this evening. [Name of attending physician] updated. No new orders. 10/19/24 19:57 (7:57 p.m.) Per [name of attending physician] change Morphine to 15 mg (milligrams) every 8 hours and hold Metoprolol tonight. 10/20/24 01:15 (1:15 a.m.) Resident continues with lethargy, night medications of Morphine, Metoprolol held. Resident blood pressure decline 70/56 and repeat was 56/31. On call NP (nurse practitioner) notified. Gave order for transfer. This note was written by RN (registered nurse) #1. On 10/30/24 at 1:57 p.m., RN (registered nurse) #1 was interviewed. She was caring for R1 at the time of her transfer to the hospital. She stated this was her first time of taking care of R1. The day nurse told her that R1 had been responsive but lethargic, and that Morphine and Metoprolol should be held until the morning. R1 produced a notebook with her notes regarding R1 from the night shift of 10/19/24. She stated her notes indicated that around 9:00 p.m., the resident's blood pressure was 95/57, and that her O2 (blood oxygen saturations) were fluctuation in the low 80s. She applied oxygen at 2 liters per minute, and R1's O2 increased to 95%, She stated at around 10:10 p.m., R1's O2 was still 95%. She stated she looked in on the resident frequently, called her, name, and rubbed her face. She stated the resident always responded to her. She stated around 11:30 p.m., R1's blood pressure was 70/56, She rechecked it and it was 70/40. She notified her supervisor, who rechecked the blood pressure manually, and it was 56/31. At this time, she called the on-call nurse practitioner, who gave the order to send R1 to the hospital. RN #1 stated none of this information could be found in the resident's clinical record because she had not transcribed it from her personal notebook to the facility's electronic medical record. She said if she had it to do over again, she would have recorded this information in R1's clinical record. She stated it is important for the resident's continuation of care for all care that is given to be documented in the clinical record. On 10/30/24 at 2:58 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #2 stated RN #1 did not follow accepted nursing standards of practice for documentation when she did not include all of her assessments and interventions in R1's medical record for 10/19/24, and that R1's clinical record was not complete. She stated the clinical record is a primary method of relaying information from one nurse to another, and for providers to see what has and has not worked. A review of the facility policy, Charting and Documentation, revealed, in part: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record .All observations, medications administered, services performed, etc., must be documented in the resident's electronic medical record or progress notes as indicated. No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for documentation for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to document assessments, interventions, and vital signs in the clinical record on 10/19/24. A review of R1's nurses' progress notes revealed the following: 10/19/24 19:44 (7:44 p.m.) Resident remains lethargic. BP remains low 88/43. Resident responds to tactile and verbal stimuli. Has declined PO (by mouth) this evening. [Name of attending physician] updated. No new orders. 10/19/24 19:57 (7:57 p.m.) Per [name of attending physician] change Morphine to 15 mg (milligrams) every 8 hours and hold Metoprolol tonight. 10/20/24 01:15 (1:15 a.m.) Resident continues with lethargy, night medications of Morphine, Metoprolol held. Resident blood pressure decline 70/56 and repeat was 56/31. On call NP (nurse practitioner) notified. Gave order for transfer. This note was written by RN (registered nurse) #1. On 10/30/24 at 1:57 p.m., RN (registered nurse) #1 was interviewed. She was caring for R1 at the time of her transfer to the hospital. She stated this was her first time of taking care of R1. The day nurse told her that R1 had been responsive but lethargic, and that Morphine and Metoprolol should be held until the morning. R1 produced a notebook with her notes regarding R1 from the night shift of 10/19/24. She stated her notes indicated that around 9:00 p.m., the resident's blood pressure was 95/57, and that her O2 (blood oxygen saturations) were fluctuation in the low 80s. She applied oxygen at 2 liters per minute, and R1's O2 increased to 95%, She stated at around 10:10 p.m., R1's O2 was still 95%. She stated she looked in on the resident frequently, called her, name, and rubbed her face. She stated the resident always responded to her. She stated around 11:30 p.m., R1's blood pressure was 70/56, She rechecked it and it was 70/40. She notified her supervisor, who rechecked the blood pressure manually, and it was 56/31. At this time, she called the on-call nurse practitioner, who gave the order to send R1 to the hospital. RN #1 stated none of this information could be found in the resident's clinical record because she had not transcribed it from her personal notebook to the facility's electronic medical record. She said if she had it to do over again, she would have recorded this information in R1's clinical record. She stated it is important for the resident's continuation of care for all care that is given to be documented in the clinical record. On 10/30/24 at 2:58 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #2 stated RN #1 did not follow accepted nursing standards of practice for documentation when she did not include all of her assessments and interventions in R1's medical record for 10/19/24. She stated the clinical record is a primary method of relaying information from one nurse to another, and for providers to see what has and has not worked. A review of the facility policy, Charting and Documentation, revealed, in part: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record .All observations, medications administered, services performed, etc., must be documented in the resident's electronic medical record or progress notes as indicated. No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 20 residents in the survey sample, Resident #76. The findings include: For Resident #76, (R76), the facility staff failed to hold the resident's insulin on 6/1/24, per a physician's order. A review of R76's clinical record revealed a physician's order dated 1/31/24 for Basaglar KwikPen U-100 insulin, 100 units/milliliter- 10 units once daily for diabetes. The order further documented to hold the insulin if the resident's blood sugar was less than 100. A review of R76's June medication administration record revealed that on 6/1/24, the insulin was administered although the resident's blood sugar was 94. On 6/12/24 at 10:07 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that if a resident has a physician's order to hold insulin for a blood sugar less than 100 and the resident's blood sugar is 94 then the resident's insulin should be held because that is the physician's order. On 6/12/24 at 11:49 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Medication Administration, Including Administration Times documented, Medication will be administered according to best nursing practice for accuracy, timeliness, effectiveness and according to physician's order.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for one of 20 residents in the survey sample, Resident #76. The findings include: For Resident #76, (R76), the facility staff failed to implement the resident's comprehensive care plan for diabetic medication administration. A review of R76's clinical record revealed a physician's order dated 1/31/24 for Basaglar KwikPen U-100 insulin, 100 units/milliliter- 10 units once daily for diabetes. The order further documented to hold the insulin if the resident's blood sugar was less than 100. R76's comprehensive care plan dated 4/5/24 documented, (Name) is at risk for hypo/hyperglycemia and complications of diabetes will be minimized. Administer diabetic meds per MD (medical doctor) order. A review of R76's June medication administration record revealed that on 6/1/24, the insulin was administered although the resident's blood sugar was 94. On 6/12/24 at 10:07 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the care plan is an action plan and includes the things staff sets in place for residents' care. LPN #1 stated the staff individualizes care for each resident and the nurses have to review the care plan monthly. LPN #1 stated that if a resident has a physician's order to hold insulin for a blood sugar less than 100 and the resident's blood sugar is 94 then the resident's insulin should be held because that is the physician's order. On 6/12/24 at 11:49 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Person-Centered Care Plans documented, (Name of facility) Nursing Staff will develop a person-centered comprehensive plan of care to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident.

Based on record review and staff interviews, the facility failed to monitor the neurological status post unwitnessed falls putting the residents at risk for undetected neurological deterioration. This failure affected 2 of 6 residents reviewed for falls (Residents (R) #50 and #68). This deficient practice was evidenced by the following: 1. A review of the medical record revealed, R#50 was originally admitted to the facility on [DATE] with a current admitted [DATE]. The diagnoses including but not limited to fractured shaft of right fibula, pain in right ankle and joints of right foot, Parkinson's Disease, unspecified dementia with unspecified severity, history of repeated falls, unspecified cerebral infarction (stroke) and abnormal posture. R#50's Minimum Data Set (MDS), Brief Interview for Mental Status (BIMS) score was 4 (The BIMS test presents a scoring scale that guides the interpretation: 0 to 7 points indicates severe cognitive impairment, 8 to 12 points indicates moderate cognitive impairment, 13 to 15 points indicates that cognition is intact). A report dated 10/16/2023 at 03:00 PM indicated R#50 was found in the room on the floor next to a wheelchair on their knees. A nurses note dated 10/16/2023, indicated R#50 had an unwitnessed fall in room around 03:00 PM. The Neurological Assessment Flowsheet dated 06/12/2024 indicated neurological assessments were started at 10/16/2023 at 03:00 PM. The neurological assessments for 10/16/2023 at 03:15 PM, 03:30 PM, and 10/17/2023 at 12:00 PM were omitted. 2. R#68 was originally admitted to the facility on [DATE] with the current admitted [DATE]. The diagnoses including but not limited to unspecified Alzheimer's disease and muscle weakness (generalized). R#68's Minimum Data Set (MDS), Brief Interview for Mental Status (BIMS) score was 4 (The BIMS test presents a scoring scale that guides the interpretation: 0 to 7 points indicates severe cognitive impairment, 8 to 12 points indicates moderate cognitive impairment, 13 to 15 points indicates that cognition is intact). - A report dated 03/30/2024 at 04:50 PM indicated, CNA stated #### witness resident losing her balance after bumping into a piece of furniture in another resident room but was unable to brace resident's fall in time and witnessed resident falling onto floor bracing fall with #### left arm and hitting #### head. Per report, the R#68 stated, I hurt my head. The report further stated, nurse assessed resident noted 5.5cm (centimeter) x 4.5cm (centimeter) raised bump on forehead. The Neurological Assessment Flowsheet dated 03/30/2024 indicated neurological assessments were started at 03/30/2024 at 04:50 PM. The neurological assessments for 03/30/2024 at 05:17 PM, 05:35 PM, 06:20 PM, 06:50 PM, 09:50 PM, 03/31/2024 at 01:50 AM, 05:50 AM, 01:50 PM, 09:50 PM, and 04/01/2024 at 05:50 AM were omitted. - A report dated 04/02/2024 at 06:10 AM, staff heard a loud noise and entered the resident's room and resident was lying in front of #### recliner on #### right shoulder. Resident assessed for injuries no new ones were noted. Resident helped into #### bed and neuro checks (neurological assessment) were initiated. The Neurological Assessment Flowsheet dated 04/02/2024 indicated neurological assessments were started at 04/02/2024 at 06:10 AM. The neurological assessments, specifically, motor functions were omitted for 04/02/2024 at 06:25 AM, 06:55 AM, 07:40 AM, and 08:10 AM. Review of facility policy titled, Fall Prevention and Management Program dated 02/08/2022. Under Post Fall Management and Reporting, Section C. Post Fall Management, 3. Unwitnessed falls with unverifiable head trauma by resident and those with head trauma will have a neurological assessment according to Post-Fall management protocol. (Utilize the Post Fall management protocol under attachment A.) Under attachment A Section B Minor Head Trauma, 1. Use the same protocol outlined above and perform neurological assessments as followed: Q (every) 15 minutes x4 Q30 minutes x2 Q1 hour x1 Q2 hours x1 Q4 hours x2 Q8 hours x3 On 06/12/2024 at 03:42 PM, the administrative staff member (ASM)#2 and registered nurse (RN) #1 were interviewed. RN#1 stated that if a resident has experienced an unwitnessed fall or hits head neurological checks must be done. ASM#2 stated the expectation for nursing staff is fully complete neurological checks as prescribed in the facility policy.

Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to ensure an assessment was completed for medication self-administration for one of 20 residents, Resident #30. The findings include: The facility staff failed to ensure Resident #30 was assessed for self-administration of medication. Resident #30 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: osteoarthritis, spondylosis and bipolar disorder. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/21/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 7/19/23, which revealed, FOCUS: The resident has pain due to osteoarthritis and gout. INTERVENTIONS: Assess need for pain medication on each contact. Assess effectiveness of pain medication. A review of the physician orders dated 6/4/23 revealed, Tylenol Extra Strength 500 mg tablet. 1000 mg by mouth every 8 hours as needed (may self-medicate Tylenol per physician). On 6/11/24 at 10:23 AM, in Resident #30's room, observation of one bottle of 500 milligram Tylenol caplets. Bottle had cap on with approximately one half full of the 100-caplet bottle. Resident was not in their room. On 6/11/24 at 11:30 AM, Resident #30 was in their room. A Tylenol bottle was still on bedside cabinet unsecured. When asked about the Tylenol, Resident #30 stated, yes, that is my Tylenol and the facility said I could have it but should keep it in the top drawer, I forgot to put it back in the drawer before I went to art class. Tylenol bottle still on bedside cabinet. On 6/12/24 at 8:00 AM, an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated, we realized that when the resident was readmitted a self-administration of medication evaluation was not done. We did it last night and made sure that the resident knew how to lock the Tylenol up. I have provided you a copy of the evaluation dated 6/11/24at 4:05 PM. On 6/12/24 at 9:05 AM an interview was conducted with LPN (licensed practical nurse) #2 when asked about Resident #30's Tylenol, LPN #2 stated, yes, we did not have the Tylenol locked up and yes, we should have done a self-administration of medication evaluation prior to her having it at the bedside. On 6/12/24 at 11:50 AM, ASM #1, the administrator, ASM #2, the director of nursing and ASM #3 the assistant director of nursing was made aware of the findings. On 6/12/24 at 12:00 PM, ASM #1 stated, we have no further evidence for the finding. A review of the facility's Self-administration of Medication policy revealed, Each resident desiring to self-administer medication is permitted to do so if the facility has determined that the practice would be clinically appropriate for the resident. The ability to self-administer medications will be documented in the physician's orders. The assessment will be completed by the nurse. No further information was provided prior to exit.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure that Residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion, for 1 Resident (#122) in a survey sample of 37 Residents. The findings included: For Resident # 122 the facility staff failed to ensure that the Resident's elbow protectors and resting hand splint were applied correctly as ordered by the physician. On 5/23/23 at approximately 11:30 am, an observation was made of Resident #122 in her wheelchair. Resident #112 was asleep, fully dressed, and she had elbow protectors on both elbows and a resting left hand splint applied over the elbow protector. A cork board in her room displayed written directions for the correct application of the splint as well as a photo Resident #122's left arm with the splint correctly applied. The instruction sheet and photo indicated that the elbow protector was to be over the splint not under the splint as it was observed. On 5/23/23 at 11:30 AM, Resident #122 was observed in her room dozing, eyes closed. Resident #122 had obvious contracture to her left arm and hand. She had elbow protectors on and a blue left hand splint applied over the elbow protector. On 5/23/23 at approximately 4:00 PM, Resident #122 was observed in her room with the splint in the same position over the elbow protector. On 5/24/23 at approximately 9:45 AM Resident # 122 was observed in her room with just palm protectors in her hands no elbow protectors or resting hand splint were applied. On 5/24/23 at approximately 2:20 PM Resident #122 was observed again with just palm protectors no splint or elbow protectors. A review of the clinical record revealed the following orders for the splint application: Posey Elbow protectors to bilateral elbows at all times (as tolerated) - remove every shift for skin check and reapply - Every shift (12 hr. shifts). A review of the clinical record revealed no mention of refusal or resistance to care. Resident #122 is nonverbal and has a BIMS (Brief Interview of Mental Status) of ninety-nine. On 5/23/23 at approximately 4:15 PM, an interview was conducted with RN B who stated that the picture and instruction sheet were the correct way to apply the splint and elbow protectors. When asked who placed that information on the board RN B stated that the OT (Occupational Therapy) department did that so that nurses would apply it correctly. On 5/24/23 at 2:06 PM, an interview was conducted with LPN C and she was asked who applies the splint for Resident #122. LPN C stated it was the nurses responsibility to apply the splints. On 5/24/23 at 2:45 PM, an interview was conducted with Employee E (OT) who was asked why the elbow protectors go over the splint. Employee E stated when we had them under the splint the pressure of the splint made the elbow protectors leave marks, like the elastic of a sock after you have been wearing it all day. When asked how long the splints were to be applied she stated as the physician ordered unless the Resident is not tolerating them. When asked what should be done if the Resident is resistant or not tolerating them she stated that the nursing staff should document that so that PT/OT and the MD will know. On 5/25/23 during the end of day meeting, the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure an accurate medical record for 1 Resident (#69) in a survey sample of 37 Residents. The findings included: For Resident #69 the facility staff failed to correctly enter an order for morphine. On 5/25/23 during the clinical record review it was noted that on 12/11/22 an order was put in the system for Morphine 20 mg every hour PRN. The order stayed on the MAR (Medication Administration Record) as a valid order until 1/4/23 when a pharmacy review was conducted. At the time of the pharmacy review the pharmacy sent a notice that read: ***Clinically Urgent Recommendation Prompt Response Requested**** [Resident #69 name redacted] medication administration record (MAR) or prescriber order sheets (POS) items that need clarification: Current order on the MAR for PRN Morphine = 20 mg every hour PRN. Pharmacy records indicate Morphine 20 mg / ml give 0.25 ml q hour PRN. Recommendation: Please clarify with MD and adjust the dose on the MAR. The facility corrected the dose on 1/4/23 after being notified by the pharmacy. The correct dose should have been 0.25 ml (5 mg) not 20 mg every hour. On 5/25/23 at 11:00 AM interview was conducted with RN B who stated that she did not know how the mistake was made but that it was a transcription error, and she was glad the medication was not given. She stated had the medication been given it would have been an overdose of an opiate. When asked what could have happened with an opiate overdose, she stated the Resident could become lethargic, sleepy, have depressed respirations and become unresponsive. On 5/25/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to provide bed-hold notice at the time of transfer, for 1 Resident (#130) in a survey sample of 37 Residents. The findings included: For Resident # 130 the facility staff failed to provide the bed hold policy notice at the time of transfer from facility to the ER. Resident #130 was system selected as a closed record for transfer to hospital. On 5/25/23, a review of the clinical record revealed that on 3/21/23, Resident #130 was sent to the emergency room due to low oxygen saturation via rescue squad at 8:40 PM. A review of the clinical record revealed that the Resident had a bed hold policy signed on 3/13/23 (8 days prior to the transfer to the hospital). The clinical record contained the copy of the transfer sheet that went to the hospital with the Resident however no bedhold policy was given at the time of transfer. There was no documentation of verbal or phone conversation about bed hold at the time of transfer. On 5/25/23, during the end of day meeting, the Administrator was made aware of the concern and no further information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to continue skilled services and bill the Resident as requested on the SNF ABN notice (Skilled Nursing Facility Advance Beneficiary Notice) issued to 1 Resident (Resident #35) in a survey sample of 3 Residents, reviewed for such notices. The findings included: On 5/22/23, the facility Administrator was asked to provide a listing of Residents who were discharged from Medicare Part A services. From this listing a sample was selected which included Resident #35. The notices issued to these Residents were reviewed and revealed the following: 1. For Resident #35, the facility staff provided a SNF ABN notice prior to skilled care services ending. On the ABN form option 2 was selected which read, I want the care listed above, but don't bill Medicare. I understand that I may be billed now because I am responsible for payment of the care. I cannot appeal because Medicare won't be billed. On 5/24/23 at 2:58 PM, an interview was conducted with Employee E, the therapy manager. The therapy manager confirmed that Resident #35 was skilled until 2/1/23, and then continued physical therapy at a lower frequency under Medicare Part B services. The therapy manager went into detail explaining that speech therapy and occupational therapy ended but physical therapy decreased the frequency to three times a week, which was no longer a skilled care level of care. The therapy manager further confirmed that she was not aware that Resident #35 had selected that he wished for skilled therapy services to continue, and he would be financially responsible as per the ABN form. On 05/24/23 at 03:20 PM, Surveyor C met with Employee F, an accountant who provided copies of the UB04 [billing document submitted to Medicare for payment] for Resident #35. The UB04 was reviewed, and Employee F also confirmed that Resident #35 was skilled until February 1, 2023, and following that date only physical therapy was provided and billed to Medicare. On 05/24/23 at 04:04 PM, Surveyor C met with Employee H, the social worker. The social worker stated that, the ABN is if they are not appealing and are planning to stay with us, they get the ABN form. The social worker was asked to explain the 3 options available for Residents to select and she said, I've never seen the first one [option 1 selected] but it means they are appealing but maybe plan to stay and acknowledge if Medicare doesn't pay, they are still responsible. The second option is that they aren't appealing but want to stay with us beyond that day and the third option is that they wouldn't want the service and would be leaving. The social worker was shown the ABN form that Resident #35 signed and was asked who highlighted option 2. The social worker said, I probably highlighted it to remind myself that was the one if he wasn't appealing. The facility policy titled; Medicare Notice of Non-Coverage Advanced Beneficiary Notice was reviewed. This policy read, .The skilled nursing facility advanced beneficiary notice (SNFABN) and the Advance Beneficiary Notice (ABN) will offer the Resident or Responsible Party the option of agreeing or disagreeing with the decision . SNFABN and ABN will provide information on the Resident's financial liability for non-covered services and provide the Resident's with the opportunity to have their services billed to Medicare for a determination . In the CMS document, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN). This instruction sheet read, .There are 3 options listed on the SNFABN with corresponding check boxes. The beneficiary must check only one option box. If the beneficiary is physically unable to make a selection, the SNF may enter the beneficiary's selection at his/her request and indicate on the notice that this was done for the beneficiary. Otherwise, SNFs are not permitted to select or pre-select an option for the beneficiary as this invalidates the notice . The CMS instructions regarding when a resident selects option 2, read: .When the beneficiary selects Option 2, the care is provided, and the beneficiary pays for it out-of-pocket. The SNF does not submit a claim to Medicare. Since there is no Medicare claim, the beneficiary has no appeal rights. Note: Although Option 2 indicates that Medicare will not be billed, SNFs must still adhere to the Medicare requirements for submitting no pay bills. See Chapter 6 of the Medicare Claims Processing manual for SNF claim submission guidance. Accessed online at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNF-ABN- On 5/25/23 at approximately 11:50 AM, the facility Administrator was made aware of the above findings. No further information was provided.

Based on observation, staff interviews, facility documentation review, and clinical record review, the facility staff failed to implement infection control practices as per the CDC (Centers for Disease Control and Prevention) and CMS (Centers for Medicare & Medicaid Services) guidance/requirements to prevent the spread of COVID-19 within the facility for 2 of 7 sampled residents (#6 & #7) The findings included: 1. The facility staff failed to wear eye protection when providing direct Resident care, while the facility was located in an area of high COVID-19 transmission and in an active COVID-19 outbreak as per the guidance from CDC (Centers for Disease Control and Prevention). Prior to the survey team's entry to the facility the CDC COVID Data Tracker was reviewed and it noted the facility was located in an area with a high level of community transmission for COVID-19. Accessed online at: On 7/27/22, upon the survey team arrival to the facility, during the screening process, the survey team was made aware that the facility was in a current COVID-19 outbreak status. On 7/27/22 at approximately 12:40 PM, the facility Administrator and Infection Preventionist confirmed that the facility was in a COVID-19 outbreak and currently had Residents on quarantine for COVID-19. On 7/27/22 at approximately 1:00 PM, a tour of the facility was conducted with the IP present. Nurses, certified nursing assistants, therapy staff, maintenance, and housekeeping employees were all observed entering Resident rooms wearing only surgical masks. On 7/27/22 at approximately 4:00 PM, LPN B and LPN C were observed administering medications to Residents on unit 1 and unit 3. LPN B and LPN C were observed to enter multiple Resident rooms wearing only a surgical mask. No other PPE, to include but not limited to: eye protection, was observed. On 7/27/22, during a meeting with the facility Administrator, Director of Nursing and IP, the IP confirmed that the facility had remained in a level of high community transmission for months. The facility policy titled, Novel Coronavirus (COVID-19) was reviewed. This policy read, .20. The facility will prepare for a potential outbreak, by addressing: a. Leadership staff will stay informed regarding COVID-19 and potential risks in their geographic location via the CDC Community Transmission Level and CDC COVID Tracker . The CDC guidance document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, with a revision date of Feb. 2, 2022, was reviewed. This document read, Implement Universal Use of Personal Protective Equipment for HCP [health care personnel] .Additionally, HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: .Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters . Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html On 7/27/22, the facility Administrator, Director of Nursing and IP were made aware of the above findings and guidance from CDC was reviewed with them. No further information was provided. 2. The facility staff failed to wear appropriate personal protective equipment (PPE) while providing care to a Resident (Resident #7) who was unvaccinated. On 7/27/22, during a survey entrance conference held with the facility Administrator, Director of Nursing (DON) and Infection Preventionist (IP), the IP identified that the facility was in a COVID outbreak status and had identified their most recent COVID positive Resident that same day. Review of the facility submitted listing of Resident's COVID immunization status revealed that Resident #7 was not up-to-date with COVID immunizations. On 7/27/22 at approximately 4:00 PM, Surveyor B observed LPN B to enter the room of Resident #7 and administer medications. LPN B was observed wearing a procedure mask and no other PPE (personal protective equipment). On 7/27/22, during a group meeting with the facility Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Infection Preventionist (IP), the IP confirmed that that facility had identified a COVID outbreak on 6/24/22, and remained in outbreak status. During this same meeting, the facility staff confirmed that Resident #7 was no up-to-date with COVID immunizations. The facility policy titled, Novel Coronavirus (COVID-19) was reviewed. This policy read, .26. Confirmed Cases of COVID-19 .4. The facility's Infection Preventionist (IP) will collaborate with the Office of Epidemiology along with the CDC for additional guidance .Outbreak Plan: .g. During an outbreak, residents who are not up to date with COVID-19 vaccinations who are in close proximity to a positive resident case or who have had a confirmed exposure to COVID-19: i. will be placed on quarantine with HCP utilizing full PPE when caring for said residents (enhanced droplet precautions) . The Centers for Disease Control and Prevention (CDC) gives facilities guidance in their document titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes Nursing Homes & Long-Term Care Facilities, Updated Feb. 2, 2022. This document read, .New Infection in Healthcare Personnel [HCP] or Residents .Respond to a Newly Identified [CONDITION(S)]-CoV-2-infected HCP or Resident .Residents and HCP who are not up to date with all recommended COVID-19 vaccine doses: .These residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. They should not participate in group activities . Accessed online 7/27/22, at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html During an end of day meeting on 7/27/22, the facility Administrator, DON, ADON (assistant director of nursing) and Infection Preventionist confirmed they were aware of the CDC guidance document referenced above and follow CDC guidance. They were shown the guidance regarding Residents who are not up to date with all recommended COVID-19 vaccine doses being cared for using pull PPE, when the facility is in outbreak. They all confirmed that they were not aware that this meant all Residents who were not up to date. No further information was provided. 3. For Resident #6 and #7, who were not up-to-date with COVID immunizations, the facility staff failed to implement transmission based precautions/(TBP) and require staff to wear full personal protective equipment (PPE) to include N-95, isolation gown, eye protections, and gloves during all direct care encounters while in an active COVID outbreak. On 7/27/22, during a meeting with the facility Administrator, DON, ADON and IP, they identified that they facility was in a COVID-19 outbreak. On 7/27/22, during the entrance conference the IP confirmed that they had some Residents on isolation/transmission based precautions and this was identified by signage on the exterior of the Resident's room door. During a facility tour, Surveyor B observed that (Resident #6 and #7) had no signage for isolation/TPB. The facility staff provided the survey team with a Resident COVID-19 vaccination listing. Review of this listing revealed that Resident #6 and #7, were not up-to-date with COVID vaccinations or were unvaccinated. On 7/27/22 at approximately 1 PM and again at 4:00 PM, a tour of the facility was conducted. Resident #6 and #7's rooms were specifically observed and identified no indication that they were on any type of precautions and gave no indication that additional PPE (N-95, eye protection, gloves and isolation gown) were needed. A review of the facility policy titled, Novel Coronavirus (COVID-19) was conducted. This policy read, .Outbreak Plan: .g. During an outbreak, residents who are not up to date with COVID-19 vaccinations who are in close proximity to a positive resident case or who have had a confirmed exposure to COVID-19: i. will be placed on quarantine with HCP utilizing full PPE when caring for said residents (enhanced droplet precautions) . The Centers for Disease Control and Prevention (CDC) gives facilities guidance in their document titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes Nursing Homes & Long-Term Care Facilities, Updated Feb. 2, 2022. This document read, .New Infection in Healthcare Personnel or Residents: Respond to a Newly Identified [CONDITION(S)]-CoV-2-infected HCP [healthcare personnel] or Resident .Residents and HCP who are not up to date with all recommended COVID-19 vaccine doses: These residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. They should not participate in group activities . During an end of day meeting on 7/27/22, the facility Administrator, DON, ADON (assistant director of nursing) and Infection Preventionist confirmed they were aware of the CDC guidance document referenced above and follow CDC guidance. They were shown the guidance regarding Residents who are not up to date with all recommended COVID-19 vaccine doses being cared for using pull PPE, when the facility is in outbreak. They all confirmed that they were not aware that this meant all Residents who were not up to date. No further information was provided.

Based on interviews and record reviews, it was determined the facility failed to ensure residents were provided a written notice which specified the duration of the bed-hold policy at the time of transfer to the hospital for one of 25 sampled residents (Resident (R) 33). On 12/29/21, R33 was transferred to the hospital because she developed paralysis and hematuria; however, she was not given the written notice that addressed holding the resident's bed during her absence. Findings include: Review of R33's Physicians Progress Note, dated 12/29/21, located in the resident's EMR under the progress notes tab, revealed the resident was sent to the hospital per her physician's recommendation due to a change in condition. It was documented that the Physician notified the resident's' daughter. Review of R33's EMR showed a written notice of transfer to the emergency room was sent to the family by the Director of Nursing (DON). During an interview with the DON on 3/24/21 at 4:00 PM the bed hold notification was requested for R33's transfer to the hospital; however, the DON was not able to produce verification R33 was given a bed hold notice. Interview on 03/25/21 at 9:00 AM with the Vice President/Administrator, he stated the facility did not issue bed hold notices because they do not give the room away. The Vice President/Administrator stated the facility had a bed hold policy, but the policies were never used. The Vice President/Administrator also stated, We are not like an institution; the room is theirs; we just leave the furniture in the room and have it ready for their return. We are nice. We are a CCRC (continuing care retirement community). Review of an admission packet showed Bed Hold is addressed in the admission packet. The form labeled Bed Hold supplied by the VP shows. Bed holds will be in accordance with CMS and corporate protocol. The section #4 The resident's representative will be given the option of continuing payment or having the resident discharged . #5 If a resident's leave of absence is greater than the period for which they have already paid and the resident representative choose not to continue payment, the resident will be discharged . The VP said they never do this, so they do not give bed hold notifications.

Based on observations, interviews, and review of facility policies, the facility failed to date foods in the refrigerators according to the facility policy. The facility failed to air dry dishes and pans before being stacked and stored. The facility also failed to date food in resident refrigerators located in the nursing lounge on three of three floors. These failed practices had the potential to affect the 125 residents in the facility. Findings include: 1. Labeling and Dating Review of facility's undated policy titled, Proper Labeling and Dating, all items in refrigerators were to have a date sticker on them. Also, the item must include the open date or prepared date, use by date, time opened or prepared, name of item, and initials of person opening or preparing. This facility had a main kitchen where all food is prepared and then brought to the three floors in large pans. Each floor, except the first floor, has a North, South, East, and West wing with their own kitchen. The first floor does not have a South wing. There are 11 kitchens on the three floors. On 03/22/21 at 9:00 AM, an initial tour of the main kitchen was made with the kitchen manager. Observation of the main freezer noted opened bags of donut bites and sausage that were not dated. Observation of the main refrigerator noted diced tomatoes and lemon vinaigrette that were also not dated. Storage room observation noted opened bags of grits, breadcrumbs, and polenta, with no dating. On 03/22/21 at 9:00 AM, an interview was conducted with the kitchen manager while touring the main kitchen. The Kitchen Manager (KM) confirmed that dating was not completed and that it would be investigated. On 03/22/21 at 1:45 PM, observation of first-floor West kitchen noted a pan of melon in the refrigerator with no date. On 03/22/21 at 2:14 PM, observation was made of the third-floor South kitchen. The ice cream freezer contained two glasses with food particles frozen onto them. On 03/22/21 at 2:25 PM, observation was made of the third-floor East kitchen. A bowl of ice cream was dipped and covered with no date. 2. Resident Refrigerators Resident refrigerators were located on each of the three floors in the nursing lounge. Review of the facility's undated policy titled, Use & Storage of Food Brought in by Family/Visitors, if food was not consumed immediately by resident, the resident refrigerator may be used for storage. Staff handling residents' food must label the food with the residents' name, room number and the date of storage. On 03/24/21 at 10:30 AM, observation of the first-floor resident refrigerator contained food with no dates. The food items only contained resident names. On 03/24/21 at 10:50 AM, the second-floor resident refrigerator contained food with no dates. The food items only contained resident names. On 03/24/21 at 11:03 AM, the third-floor resident refrigerator contained food with no dates. The food items only contained resident names. On 03/24/21 at 11:20 AM, an interview with the Director of Nursing indicated that the night shift Certified Nurse Aides (CNAs) were responsible for cleaning of the resident refrigerators and monitoring the temperature log. 3. Sanitization and Storage On 03/24/21 at 9:05 AM, observation was made of the main kitchen with the kitchen manager. Stacked pans were observed on a metal rack. The kitchen manager was asked to flip over a pan, and it was wet. Another stack of pans was turned over and they were also wet inside. The manager stated that all dishes and food preparation equipment are to be air dried before stacked. On 03/24/21 at 2:55 PM, observation was made of the second-floor West kitchen. A stack of clean plastic glasses was not air dried according to facility policy and was still visibly wet on the inside. On 03/24/21 at 9:15 AM, observation and interview with the KM of the upright ovens revealed the oven door was opened for the oven to cool down. Continued observations revealed cooked pieces of hotdogs were lying directly on the bottom of the oven. Hotdogs were not on the resident's menu this date. Interview with the kitchen manager noted that the Market Place that is open to the staff and independent living residents was having hot dogs and they were also made for staff as well.

Based on observations, resident and staff interviews, and review of the facility menus, it was determined the facility failed to prepare menus to include portion sizes to ensure residents received adequate amounts of menu items to meet their nutritional needs. This failed practice had the potential to affect the nutritional status of the 125 residents in the facility. The facility also failed to ensure menus were not repetitive in food items. Review of the menus revealed chicken in some form was on the menu for lunch and dinner daily four of four residents (Resident (R) 12, R68, R19, and R110) who ccomplained about the lack of variety if food options. Findings include: 1. On 03/22/21 at 10:45 AM, during observation and interview with R12, the resident indicated she was unhappy with the menu. R12 stated they have chicken at every meal. The resident stated she was tired of the baked chicken and chicken entrées like casseroles. 2. On 03/22/21 at 12:10 PM, observation and interview of R68 revealed he was eating a chicken casserole. When asked how lunch was today, R68 stated they have chicken all the time. R68 stated he would like comfort foods, like meatloaf and beef stew. 3. Review of R19's Detailed Summary [Face Sheet], located in the resident's electronic medical record (EMR) revealed R19 was admitted on [DATE] with diagnoses that included acute embolism and [CONDITION(S)] of unspecified femoral artery [blood clot], vitamin D deficiency, anxiety and hypertension. Review of R19's Physician Orders revealed the resident's diet order, dated 09/27/19 is for a regular diet. Review of R19's quarterly Minimum Data Set (MDS),) with an Assessment Reference Date (ARD) of 12/23/20, Brief Interview of Mental Status (BIMS) score was 15 out of 15, indicating no cognitive impairment. Further review of the MDS revealed R19 did not exhibit behaviors including refusing care and has not had any weight loss. The section for resident's preferences was not assessed. Review of R19's annual MDS with an ARD of 9/25/20, stated it was very important for the resident to make decisions on her preferences related to meals and snacks. Review of R19's Dietary Intake Report supplied by the facility for the period of 01/24/21 through 03/25/21 indicated the resident's intake was an average of 90-93 percent [%]. Review of R19's Care Plan for nutrition located in the EMR stated offer between meals snacks, give appropriate portions for appetite, offer food preferences and provide selective menu at each meal. During an interview conducted on 03/23/21 at 11:10 AM, while being questioned concerning the facility food, R19 stated have been eating a lot of chicken. I told my son I was going to turn into a chicken if I ate anymore of it. When questioned if she could ask for the alternative meal? R19 stated, yes, but it's just more chicken. After a while I just quit asking. 4. Review of R110's Detailed Summary located in the EMR, revealed the resident was initially admitted to the facility on [DATE], with a current readmitted [DATE]. R19's diagnoses included type 2 diabetes mellitus with unspecified complications, hypertensive [CONDITION(S)] with heart failure, chronic kidney disease, moderate. Review of R19's Physician Orders located in the EMR, revealed the resident's diet order dated 02/23/21 is cardiac, regular, no added salt (NAS). Review of R19's admission MDS with an ARD of 03/02/21, revealed the resident was assessed to have a BIMS score of 15 out of 15, indicating no cognitive impairment. The resident's behavioral and mood assessment revealed the resident was not resistant to care and the resident's preferences related to meals and snacks are very important to him. Review of the CAA Analysis for Nutritional Status, description of problem stated .current weight 93% Ideal Body Weight [IBW], Body Mass Index [BMI] 22, triggering for weight loss last 30/90/180 days .intake fair as he does not like the food . Review of the Dietary Intake Report from 01/24/21 through 03/25/21 stated the resident's average food intake was 25-35%. Review of R19's Care Plan located in the EMR revealed .intake 25-50% of meals as he dislikes the food . Approaches instructed staff to offer in between meal diet appropriate snacks and fluids .give appropriate portions per appetite .offer food preferences .prefers comfort foods . During an observation and interview with R19 on 03/22/21 at 12:45 PM in the dining area, R19 was observed to be eating a small piece of chicken, [a thigh approximately the size of a female's palm], one half a cup of mashed potatoes and a cup of green beans. The resident was observed pushing his food around his plate. R19 was asked what he thought of the food at the facility? R19 stated, well, look at this [pointing to his food], I always receive chicken, it's dried out and the skin is like rubber. We are always having chicken. R19 was asked if he could ask for the alternative instead? The resident stated, yes, I'll get the cheese sandwich, and I am tired of those too. The resident asked if he had discussed this with anyone? R19 stated, yes, I spoke to administration. Nothing changed, I bet they are all having steak right now. During an interview conducted with R19 on 03/23/21 at 1:33 PM. the resident was asked what he ate for lunch? The resident stated, they gave me chicken again, always chicken, lots of chicken. On 03/24/21 at 9:31 AM, the facility's weekly menus for four weeks were obtained and reviewed. Baked chicken was on the menu for lunch and dinner as the Healthy Alternative Entrée for the entire week. If chicken was the main entrée or in the main entrée, then chicken would be the only choice a resident would have. A test tray was obtained at 12:45 PM, with all hot food items. The baked chicken had skin that peeled off in one piece. The skin was rubbery and chewy to taste. The portion size of the chicken was very small once it had been removed from the bone. Observation of 11 kitchens in four days, noted very little chicken being consumed by residents. On 03/24/21 at 10:20 AM, the Registered Dietitian (RD) was interviewed. When questioned about the chicken on the menu for every meal, she stated the residents loved chicken. The RD stated they could not take chicken off the menu or the residents would complain. When asked if this has been brought up in Resident Council meetings, the RD stated they had not had them due to COVID. The RD was asked about the portion sizes and did not respond. The RD was asked how weight loss was determined if they did not have spoon/ladle sizes for portion control. The RD did not have an answer. The RD was asked how you determine a resident ate 50% of the meal when there were no portion sizes; however, the RD did not respond to the question. The RD stated that at any time a resident may ask for more food. It was revealed by the dietician the facility had no residents on specialized diets. Observations on 03/22/21, 03/22/23/21, and 03/24/21 starting at 11:45 each day, during the lunch meals of the 11 kitchen/dining areas revealed portion sizes served to the residents varied. During an interview on 03/24/21 at 4:23 PM with the RD and the Administrator, the RD explained that they run an intake list every day. When asked how they knew what a resident ate if there were no portion control, the RD stated it was subjective analysis. The RD was asked if a list of specialized diets could be obtained and again stated they did not have any residents who were on a specialized diet. When asked about the [CONDITION(S)] resident who resided at the facility, the RD stated the resident was on a regular diet with no concentrated sweets and the that the resident was noncompliant with the diet. When asked about the residents who could not convey their need for more or different food, the RD stated that the aides knew their residents. The RD further stated that due to COVID they had to downsize their menu and there would be a new Spring menu soon. The RD shared the manual used to prepare menu planning. The name of the book was Simplified Diet Manual published in 2007. The Administrator stated that they were different here in this community and the diets were liberalized and not institutionalized.

Based on observation, interviews, and record review, the facility failed to provide activities of daily living (ADL) care for one of two sampled residents reviewed for hospice care (Resident (R) 32). This failure has the potential of other residents in hospice care to not receive assistance with ADLs. Findings include: Review of R32's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/07/21, located in the resident's electronic medical record (EMR) under the MDS tab, revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the MDS revealed R32 was totally dependent on staff for bathing and all personal hygiene. R32's MDS also revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated the resident was moderately cognitively impaired. Observation and interview with R32 on 03/22/21 at 11:30 AM, revealed the resident was dressed and her was hair combed; however, R32's hair appeared to be unwashed and greasy. Interview with R32 revealed she would like more care assistance. Review of R32's Care Plan located in the resident's EMR under the care plan tab, revealed R32 was not care planned for refusing care from staff. Continued review of R32's care plan also revealed the resident was to be washed daily. Interview on 03/22/21 at 11:30 AM with Family Member (FM)1 revealed that three weeks prior, while visiting R32, the resident had crusty skin along the hair line. FM1 stated she notified staff of this and then R32's face and hair were washed. Interview on 03/23/21 at 8:40 AM with Licenses Practical Nurse (LPN) 1 revealed R32 only received bed baths. LPN one stated that R32 had not been out of bed in the past few days. Observation on 03//23/21 at 8:29 AM, revealed R32's hair was combed back with the same greasy appearance. Observation on 03/24/21 at 11:00 AM, revealed R32 in a wheelchair with a FM2 present. Continued observation revealed R32 was dressed, and her hair was combed; however, the resident's hair still appeared unwashed with same greasy appearance. Additionally, R32's right eye lashes were thick and matted. Interview on 03/24/21 at 11:00 AM with FM2 revealed R32 would like more care assistance. Review of R32's Progress Notes, dated 03/23/21, located in the resident's EMR revealed R32 was cleaned up and dressed for the day.

The findings included: The facility staff failed to test Residents (Resident #105, 106, 107, and 101) and staff (CNA A and RN A) for COVID-19 every 3-7 days following an outbreak, for a period of at least 14 days since the most recent positive result. On 9/30/2020, the facility had an employee (CNA H), who worked on the first floor within the facility, who tested positive for COVID-19. As a result, the facility was then considered to be in an outbreak of COVID-19 and needed to conduct testing of all staff and residents every 3-7 days until no one tested positive for at least 14 days. On 10/7/2020, the facility had another employee (CNA F), who worked on the third floor of the facility, who tested positive for COVID-19. This extended the period of the facility testing every 3-7 days until at least 10/21/2020. On 10/27/2020 review of the clinical record for Resident #105, who resided on the first floor, revealed they were tested for COVID-19 on 10/1/2020 and 10/7/2020. No other testing was noted after 10/7/2020. There are 14 days between 10/7/2020 and 10/21/2020. On 10/27/2020, review of the clinical record for Resident #106 revealed they resided on the third floor of the facility. Resident #106 was tested for COVID-19 on 10/9/2020 and again on 10/19/2020. There are 9 days between 9/30/2020 and 10/09/2020. There are 10 days between 10/09/2020 and 10/19/2020. On 10/27/2020, a review of the clinical record for Resident #107 revealed they also resided on the third floor. Resident #107 was tested for COVID-19 on 10/9/2020, 10/19/2020, and 10/26/2020. There are 9 days between 9/30/2020 and 10/09/2020. There are 10 days between 10/09/2020 and 10/19/2020. On 10/27/2020, review of the clinical record for Resident #101 revealed they were a Resident on the third floor of the facility. Resident #101 was tested for COVID-19 on 10/9/2020 and again on 10/19/2020. There are 9 days between 9/30/2020 and 10/09/2020. There are 10 days between 10/09/2020 and 10/19/2020. Testing for CNA A, revealed she was tested for COVID-19 on 10/2/2020 and 10/7/2020. There are 14 days between 10/7/2020 and 10/21/2020. Testing for RN A, revealed testing for COVID-19 on, 10/2/2020, 10/7/2020, 10/16/2020, and 10/21/2020. There are 9 days between 10/7/2020 and 10/16/2020. On 10/27/2020 at 1:30 PM, an interview was conducted with Employee D, the Infection Preventionist. Employee D stated that she was aware that following CNA H testing positive on 9/30/2020 that it put the facility in an active outbreak status. Employee D stated she had communicated with their local health department who had advised that since their staff do not work across various floors within the facility, only the Residents on those floors being exposed needed to be tested . On 10/27/2020 at 3:57 PM, an interview was held with the facility Administrator and the Infection Preventionist, (IP). When asked who determines the frequency of testing and when it is scheduled the IP stated, We usually make the decision together. When asked about the frequency of testing, the IP stated, We did it once a week for 2 weeks. The surveyor explained that on Resident #107 testing occurred 10/9 and 10/19 which was greater than 3-7 day frequency. The IP stated, we did 2 tests within a 14 day period, is that not ok?. The surveyor asked if their local health department had given them advice on this frequency of testing and Employee D stated, No. During this call the facility Administrator was asked to describe the testing. The Administrator stated that the facility staff obtain the COVID-19 specimen and then it is sent to the lab for processing. Therefore, there was no issue in scheduling of testing from the lab as a factor. On 10/27/2020, during review of the facility documents the policy titled COVID-19 Resident and Staff Testing Protocols read on page 1: 1. What instances triggers COVID-19 tested : outbreak testing: Test all staff and residents in response to an outbreak (any single new infection). Continue to test all staff and residents that tested negative every 3-7 days until 14 days since the most recent positive result has passed. On 10/27/2020 at 5:30 PM, during an end of day meeting the facility Administrator was made aware of the findings and stated, I can't tell you a reason why we did that. No further information was submitted.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed, for 3 residents (Resident #112, Resident #20, Resident #107) of the survey sample of 44 residents, to provide adequate supervision to prevent accidents, resulting in Immediate Jeopardy. On 6/27/18 at 10:10 A.M., Immediate Jeopardy was called at a level 4 isolated. The Immediate Jeopardy was abated on 6/27/18 at 1:25 P.M. and lowered to a level 2 pattern. 1. For Resident #107, the facility staff to provide adequate supervision to prevent a burn injury from hot liquids. 2. For Resident #20, the facility staff to provide adequate supervision to prevent a burn injury from hot liquids. 3. For Resident #112, the facility staff to provide adequate supervision to [MEDICAL CONDITION] hot liquids. The Findings included: On 6/27/18 a review was conducted of facility documentation, revealing three Facility Reported Incidents relating to burn injuries from hot coffee. The residents were identified and put into the survey sample (Resident # 107, Resident #49, and Resident #20) of 44 residents. In addition an observation was made of a resident (resident #112) who was served coffee at a temperature of 161 degrees and a had a visible tremor. 1. Resident #107 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #107's [DIAGNOSES REDACTED]. The Minimum Data Set, which was an Annual Assessment with an assessment reference date of 5/31/18 coded Resident #107 as requiring the Supervision, Cueing, and Physical Assistance of 1 staff person for eating. On 6/26/18 at 11:20 A.M. an interview was conducted with Resident #20. She stated that she didn't remember spilling the coffee on herself, or being burned. A Facility Reported Incident was submitted on 8/28/17. It read: Incident date 8/28/17. Resident spilled coffee on her left anterior thigh & lower panniculus (abdomen). Large Blister on thigh & small area on L (Left) lower panniculus. First aid for resident & Nurse practitioner notified & coming to see. NOTE: Resident #49 is included to show a pattern of hot liquid spills. Resident #49 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #49's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a 30 Day Scheduled Assessment with an assessment reference date of 4/13/18, coded Resident #49 as requiring the Supervision, Cueing, and Physical Assistance of 1 staff person for eating. A Facility Reported Incident was submitted on 5/5/18. It read: Incident date 5/5/18. Resident spilled coffee on abdomen and left thigh. At this time there is redness with no blistering. Ice applied. 2. Resident #20 was [AGE] year old who was admitted to the facility on [DATE]. Resident #20's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an assessment reference date of 3/28/18 coded Resident #20 as requiring Limited Assistance, Guided maneuvering of limbs of one staff member for eating. On 6/26/18 at 11:00 A.M. an interview was conducted with Resident #20. She stated that she didn't remember spilling the coffee on herself, or being burned. A Facility Reported Incident was submitted on 6/22/18. It read: Incident date 6/22/18. Resident had spilled coffee onto her clothing protector from lidded cup. Burn area to R (Right) medial Breast measuring 7 CM x 3 CM with open blister in center. Also has area L (Left) medial breast near cleavage measuring 4 CM x 0.2 CM. The following written observation was conducted by Surveyor #3 of Resident #20's burn injury, which was sustained on 6/22/18: An observation of the resident's burn was made on 6/27/2018 at 11:15 AM by Surveyor 3. The area is located near the sternum, extending onto the right breast. Per LPN#1 (the Unit Manager), the area measures 7 x 3 cm. The area was cleaned of ointment, and is bright red in appearance. The burn has scabbed and broken skin, especially near the bottom right side. The resident did not express pain during the observation. (end of written observation was conducted by Surveyor #3) The following written statement was submitted by Surveyor #2: 3. Resident #112, an [AGE] year old, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment was a 14 day assessment with an Assessment Reference Date of 5/28/18. Resident #112 had a Brief Interview of Mental Status score of 15 and required extensive assistance with activities of daily living. He was coded to have limited range of motion for both upper extremities. On 6/27/18 at 7:55 a.m., Resident #112 was observed in the 1st floor North dining room. The Dietary Aide (Employee C) preparing breakfast in the unit kitchen took the temperatures of the food, to include the coffee. The coffee was in a carafe which she stated was sent to the unit kitchen from the main kitchen. After opening the lid of the carafe, the Employee C inserted a digital thermometer. The coffee measured 169.3 degrees Fahrenheit (F). At 8:10 a.m., the Employee C poured a cup of coffee out of the carafe which she planned to serve a resident. Steam was observed rising from the coffee cup. The Employee C was asked to temp the cup of coffee before serving it to the resident. The temperature measured 161.0 degrees F. Employee C set the temped cup of coffee to the side to be discarded. She immediately prepared a new cup of coffee. She immediately placed a plastic lid on the new cup of coffee and served it to Resident #112. She was asked to identify Resident #112 by name. At 8:43 a.m., Resident #112 was observed in the dining room. He was wearing a white cotton clothing protector. The material resembled that of a wash cloth. The lid had been removed from the coffee cup. Resident #112 had drank half of the coffee. Resident #112 had visible tremors of the hands. The Registered Nurse A was in the dining area at this time. She was asked to verify Resident #112's name. The temperature logs were kept in a log book in the unit kitchen. Every week, they were collected from the book and taken to the main kitchen. The log form was labeled Temperature Sheet and included the preprinted section that read 180 Coffee with a blank line for the staff to record the temperature of the coffee. The temperature logs for the 1 North unit were reviewed. The breakfast coffee temperatures (in degrees Fahrenheit) were recorded as follows: 6/27/18: 169.3 6/17/18: 163 6/16/18: 161 6/15/18: 173 6/14/18: 164 6/13/18: 159 6/12/18: 163 6/11/18: 160 6/10/18: no temperature 6/9/18: no temperature 6/8/18: 159 6/7/18: 163 6/6/18: 168 6/5/18: no temperature On 6/27/18 at 10:00 a.m., a meeting was held with the Director of Nursing (DON), Administrator in Training (AIT), and the Quality Assurance Nurse. At this time, the DON was asked if the facility assessed residents for the safe handling of hot liquids. The DON stated that nursing performed a hot liquid assessment upon admission and at least quarterly. It was reviewed with the DON that the temperature log used by the facility read that the temperature of coffee should be 180 degrees Fahrenheit. The DON stated that 180 degrees F should be the temperature of the coffee in the coffee pot and 175- 180 degrees F out of the coffee pot. She stated that the facility served hot liquids per the resident preference. On 6/28/18 at 10:25 a.m., a meeting was held at the request of the facility. The DON, Chief Executive Officer (CEO) and AIT were present. The DON stated that the facility did not use a formal Hot Liquids Assessment. She stated that it is a standard of nursing to assess feeding and eating skills. She stated that nurses could identify when adaptive equipment may be required. The DON was asked if the nurse would go through therapy to obtain adaptive equipment. She stated that they do not always need to go through therapy. She gave the example that a nurse may provide a weighted spoon if the need was observed by the nurse. She stated that if the spoon needed to be bent to a special angle, then therapy would be involved. The DON also stated that a physician order [REDACTED]. On 6/28/18 at 11:15 a.m., Licensed Practical Nurse B (LPN B) was interviewed in the presence of the DON. LPN B was asked if she could provide adaptive equipment such as a weighted spoon for a resident. LPN B stated no, she would have to get occupational therapy involved. The DON prompted LPN B to discuss the use of cups with lids or handles. LPN B stated she would get special cups from the dietitian or the DON and would involve Occupational Therapy if the equipment was for long term use. During the interview, LPN B was also asked about the schedule for assessing residents for safety with hot liquids. She stated that the Minimum Data Set (MDS) coordinator sent a weekly schedule that included the names of residents that needed to be assessed. LPN B reviewed the current week's assessment schedule. Included on the schedule was the entry ADLs & safety w/ hot liquids. Care Plan Evals. LPN B stated that the nurses would documented the hot liquid safety review a nursing note. Resident #112's clinical record was reviewed. A hot liquid assessment was not located in the record. On 6/28/18 at 1:00 p.m., the end of day meeting was held with the DON, CEO, Quality Assurance nurse and AIT. At this time, the DON was notified that a hot liquid assessment was not located in the Resident #112's clinical record. It was reviewed with the DON that the survey team understood that the assessment was conducted upon admission and quarterly. The DON stated that was correct. She stated that Resident #112 was on skilled services when he was admitted to the facility and she thought therapy may have assessed him. On 6/28/18 at 1:25 p.m., the MDS Coordinator stated that residents on skilled services are not entered onto the weekly schedule to be reviewed for safety with hot liquids. After residents were off skilled services, they would be included in the weekly schedule when their quarterly hot liquid safety assessment was due. The MDS Coordinator stated that she thought therapy assessed for the safety of hot liquids for a new resident with skilled services. Resident #112's OT (Occupation Therapy) Discharge Summary was provided by the facility staff. Resident #112 was coded as independent for feeding. The summary also read Pt (patient) is highly distractible requiring redirection to tasks after 1 minute. On 6/28/18 at 1:30 p.m., the Therapy Director was asked how independent was defined with regards to feeding. She stated that it meant a resident did not require physical assistance to eat. When asked if a therapist observed a resident eating a meal to determine the feeding status, the Therapy Director stated that a meal observation was not always performed unless there was a specific need. She stated that hand dexterity would be assessed in determining feeding status. When asked if Resident #112 had been observed during a meal, the Therapy Director stated she was unsure. The Baseline Care Plan dated 5/18/18 was reviewed. The Nutritional Status section included Refuses to use lid in cup for hot liquids. Aware of associated risks. The Burn Care Foundation accessed on 6/29/18 at 11:56 p.m. at the website http://www.burncarefoundation.org/safety/hot-water-exposure.html provided the following information on burns: Exposure to 131° F water for 17 seconds would cause a second degree burn and exposure of 30 seconds would cause a third degree burn Exposure to 140° F water for 3 seconds would cause a second degree burn and exposure of 5 seconds would cause a third degree burn The following definition of scald was accessed on 6/29/18 at 12:24 p.m. at the Merriam Webster website found at https://www.merriam-webster.com/dictionary/scald: SCALD: To burn with or as if with hot liquid or steam. In summary, Resident #112 was observed to be served steaming hot coffee of 161 degrees F. The acceptable temperature of coffee served to residents according to the DON was 175- 180 degrees F. Coffee served from the kitchen where Resident #112 ate was consistently documented at temperatures above 160 degrees F. While he was assessed to be independent with feeding and was care planned to remove the lid from his coffee, he was repeatedly exposed to an accident hazard in the form of hot liquid every time he was served the hot coffee. The coffee served to Resident #112 could cause a second degree burn in less than 3 seconds. (end of written statement Surveyor #2) There was no written policy requiring that a hot liquid assessment be conducted on all residents to include the following areas: Risk factor Identification, Cognition, Behavior, Neurological, Musculoskeletal, Vision, Hand Tremors, Coffee Cup Management, Lid Requirement, 2 Handle Requirement, Weighted Cup, History of Spills, Burn Injury, Supervision Requirement for Handling Hot Liquids, Staff Set-Up, Safe Handling, Etc. A review was conducted of coffee temperature logs taken by staff in the 8 kitchens located on the second and third floors. The coffee temperatures were documented as ranging from 177 - 180 degrees during the past 6 months. On 6/27/18 at 10:10 A.M., Immediate Jeopardy was called by the Department of Health, Office of Long Term Care Supervisors. The facility Chief Executive Officer (Administration B), and Director of Nursing (Administration A) were informed immediately. The Immediate Jeopardy was abated on 6/27/18 at 1:25 P.M. The facility submitted the following Abatement Plan: 1. A) Physician notified of resident in room (room number) being at risk [MEDICAL CONDITION] hot liquids due to resident having tremors and being served a cup of coffee at 161 degrees after resident removed safety lid. B) Physician gave new order for OT (Occupational Therapy) to evaluate resident in room (room number) for safe handling of hot liquids 2. A) 100% of all coffee makers in (name of facility) will be removed from the kitchen areas. B) All coffee will be made in the main kitchen area and delivered with thermal air pots. C) The temperature of all hot liquids, including soups, will be taken and will be no more than 135 degrees before it is served to the residents. D) If temperature is greater than 135 degrees it will be held or cooled until 135 degrees or below before being served to the residents. E. 100% of all current residents will have an assessment done to ensure they are safe to handle hot liquids independently via a safety assessment form by a licensed nurse. 3. A) Temperature sheets for all hot liquids will be modified to meet the 135 degrees adjustment B) The Dietary and Nursing Staff will be educated on not serving all hot liquids if above 135 degrees. C) All new admissions will have a Hot Liquids Safety Assessment completed upon admission, quarterly and prn (as needed) 4. A) The Dietary Supervisor will review all temperature logs before each meal served daily x 3 weeks, then weekly ongoing. Any abnormalities will be reported to the Dietician or Dietary Manager immediately. B) The Dietician or Dietary Manager will notify the Director of Nursing or the Administrator of any abnormal findings immediately. C) The Dietician/ Designee will report all findings to the QAPI committee monthly, and recommendations will be made accordingly. D) The DON and DOR will review 100% of all Hot Liquids Safety Assessments completed today and any resident deemed unsafe will be referred to OT for evaluation. Date of Compliance 6/27/18 by 5:00 P.M. On 6/28/18 at approximately 10:00 A.M. an interview was conducted with the Director of Nursing (Administration A). When asked to describe the interventions that were implemented after each burn, she stated, We put lids on the cups. We did not consider the temperatures. It had nothing to do with the coffee being hot it was about her (Resident #20) being burned. The DON stated that the facility began using regular lids with lift tabs after Resident #107 was burned, then changed to using lids with a round hole after Resident #49 was burned. The lids were observed to be the thin very loose-fitting white flexible plastic type used in fast-food restaurants. The DON stated, Spills [MEDICAL CONDITION]. When you go to a restaurant or to my house, the temps aren't taken. We operated within the standard of care. The facility CEO (Administration B) was present. He stated, We knew you would be looking at temperatures because you knew about [MEDICAL CONDITION] you came. We don't agree that a form is necessary because all employees get eight weeks of training. The coffee was hot enough to burn. There's not a facility in the US that knows the temperatures and documents each resident's coffee. Administration B was unable to state what preventive measures had been put in place after the third resident was burned on 6/22/18. On 6/28/18 at 1:43 P.M. an observation was conducted of the Dining Manager (Employee F) preparing the coffee. As an individual cup of coffee was prepared, he took the temperature, and added 2 plastic ice cubes until the coffee cooled down to a temperature of 135 degrees. He stated that he ordered a cooling wand that will arrive within one week. The cooling wand is placed into the coffee pot to cool down the entire pot at one time. On 6/28/18 at 1:30 P.M., the Quality Assurance nurse (RN B) was asked if the facility had a Hot Liquid Assessment Policy. She stated that the facility did not have a policy regarding hot liquid assessments. On 6/28/18 at 9:20 A.M. an interview was conducted with a facility Licensed Practical Nurse (LPN C). She. stated that she had attended an inservice regarding hot liquids on 6/27/18. She stated, We're shooting for 135 degrees. We don't remove coffee lids, to ensure that the resident doesn't get harmed by hot foods and liquids. On 6/28/18 the facility submitted documentation that all of the facility residents had received a Hot Liquid Safety Assessment on 6/27/18. All three residents who had received burn injuries from hot coffee had recommendations that the resident use Blue Mugs with Lids - Resident may drink hot liquids with supervision. The facility also submitted documentation that all dietary and nursing staff who reported to work had received inservice training on hot liquid safety.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed, for 3 residents (Resident #112, Resident #20, Resident #107) of the survey sample of 44 residents, to ensure that hot liquids were served at a safe temperature, resulting in Immediate Jeopardy. On 6/27/18 at 10:10 A.M., Immediate Jeopardy was called at a level 4 isolated. The Immediate Jeopardy was abated on 6/27/18 at 1:25 P.M. and lowered to a level 2 pattern. 1. For Resident #107, the facility staff to provide hot liquids at a safe temperature to prevent a burn injury from hot liquid. 2. For Resident #20, the facility staff to provide hot liquids at a safe temperature to prevent a burn injury from hot liquid. 3. For Resident #112, the facility staff to provide hot liquids at a safe temperature. The Findings included: On 6/27/18 a review was conducted of facility documentation, revealing three Facility Reported Incidents relating to burn injuries from hot coffee. The residents were identified and put into the survey sample (Resident # 107, Resident #49, and Resident #20) of 44 residents. In addition an observation was made of a resident (resident #112) who was served coffee at a temperature of 161 degrees and a had a visible tremor. 1. Resident #107 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #107's [DIAGNOSES REDACTED]. The Minimum Data Set, which was an Annual Assessment with an assessment reference date of 5/31/18 coded Resident #107 as requiring the Supervision, Cueing, and Physical Assistance of 1 staff person for eating. On 6/26/18 at 11:20 A.M. an interview was conducted with Resident #20. She stated that she didn't remember spilling the coffee on herself, or being burned. A Facility Reported Incident was submitted on 8/28/17. It read: Incident date 8/28/17. Resident spilled coffee on her left anterior thigh & lower panniculus (abdomen). Large Blister on thigh & small area on L (Left) lower panniculus. First aid for resident & Nurse practitioner notified & coming to see. NOTE: Resident #49 is included to show a pattern of hot liquid spills. Resident #49 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #49's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a 30 Day Scheduled Assessment with an assessment reference date of 4/13/18, coded Resident #49 as requiring the Supervision, Cueing, and Physical Assistance of 1 staff person for eating. A Facility Reported Incident was submitted on 5/5/18. It read: Incident date 5/5/18. Resident spilled coffee on abdomen and left thigh. At this time there is redness with no blistering. Ice applied. 2. Resident #20 was [AGE] year old who was admitted to the facility on [DATE]. Resident #20's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an assessment reference date of 3/28/18 coded Resident #20 as requiring Limited Assistance, Guided maneuvering of limbs of one staff member for eating. On 6/26/18 at 11:00 A.M. an interview was conducted with Resident #20. She stated that she didn't remember spilling the coffee on herself, or being burned. A Facility Reported Incident was submitted on 6/22/18. It read: Incident date 6/22/18. Resident had spilled coffee onto her clothing protector from lidded cup. Burn area to R (Right) medial Breast measuring 7 CM x 3 CM with open blister in center. Also has area L (Left) medial breast near cleavage measuring 4 CM x 0.2 CM. The following written observation was conducted by Surveyor #3 of Resident #20's burn injury, which was sustained on 6/22/18: An observation of the resident's burn was made on 6/27/2018 at 11:15 AM by Surveyor 3. The area is located near the sternum, extending onto the right breast. Per LPN#1 (the Unit Manager), the area measures 7 x 3 cm. The area was cleaned of ointment, and is bright red in appearance. The burn has scabbed and broken skin, especially near the bottom right side. The resident did not express pain during the observation. (end of written observation was conducted by Surveyor #3) The following written statement was submitted by Surveyor #2: 3. Resident #112, an [AGE] year old, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment was a 14 day assessment with an Assessment Reference Date of 5/28/18. Resident #112 had a Brief Interview of Mental Status score of 15 and required extensive assistance with activities of daily living. He was coded to have limited range of motion for both upper extremities. On 6/27/18 at 7:55 a.m., Resident #112 was observed in the 1st floor North dining room. The Dietary Aide (Employee C) preparing breakfast in the unit kitchen took the temperatures of the food, to include the coffee. The coffee was in a carafe which she stated was sent to the unit kitchen from the main kitchen. After opening the lid of the carafe, the Employee C inserted a digital thermometer. The coffee measured 169.3 degrees Fahrenheit (F). At 8:10 a.m., the Employee C poured a cup of coffee out of the carafe which she planned to serve a resident. Steam was observed rising from the coffee cup. The Employee C was asked to temp the cup of coffee before serving it to the resident. The temperature measured 161.0 degrees F. Employee C set the temped cup of coffee to the side to be discarded. She immediately prepared a new cup of coffee. She immediately placed a plastic lid on the new cup of coffee and served it to Resident #112. She was asked to identify Resident #112 by name. At 8:43 a.m., Resident #112 was observed in the dining room. He was wearing a white cotton clothing protector. The material resembled that of a wash cloth. The lid had been removed from the coffee cup. Resident #112 had drank half of the coffee. Resident #112 had visible tremors of the hands. The Registered Nurse A was in the dining area at this time. She was asked to verify Resident #112's name. The temperature logs were kept in a log book in the unit kitchen. Every week, they were collected from the book and taken to the main kitchen. The log form was labeled Temperature Sheet and included the preprinted section that read 180 Coffee with a blank line for the staff to record the temperature of the coffee. The temperature logs for the 1 North unit were reviewed. The breakfast coffee temperatures (in degrees Fahrenheit) were recorded as follows: 6/27/18: 169.3 6/17/18: 163 6/16/18: 161 6/15/18: 173 6/14/18: 164 6/13/18: 159 6/12/18: 163 6/11/18: 160 6/10/18: no temperature 6/9/18: no temperature 6/8/18: 159 6/7/18: 163 6/6/18: 168 6/5/18: no temperature On 6/27/18 at 10:00 a.m., a meeting was held with the Director of Nursing (DON), Administrator in Training (AIT), and the Quality Assurance Nurse. At this time, the DON was asked if the facility assessed residents for the safe handling of hot liquids. The DON stated that nursing performed a hot liquid assessment upon admission and at least quarterly. It was reviewed with the DON that the temperature log used by the facility read that the temperature of coffee should be 180 degrees Fahrenheit. The DON stated that 180 degrees F should be the temperature of the coffee in the coffee pot and 175- 180 degrees F out of the coffee pot. She stated that the facility served hot liquids per the resident preference. On 6/28/18 at 10:25 a.m., a meeting was held at the request of the facility. The DON, Chief Executive Officer (CEO) and AIT were present. The DON stated that the facility did not use a formal Hot Liquids Assessment. She stated that it is a standard of nursing to assess feeding and eating skills. She stated that nurses could identify when adaptive equipment may be required. The DON was asked if the nurse would go through therapy to obtain adaptive equipment. She stated that they do not always need to go through therapy. She gave the example that a nurse may provide a weighted spoon if the need was observed by the nurse. She stated that if the spoon needed to be bent to a special angle, then therapy would be involved. The DON also stated that a physician order [REDACTED]. On 6/28/18 at 11:15 a.m., Licensed Practical Nurse B (LPN B) was interviewed in the presence of the DON. LPN B was asked if she could provide adaptive equipment such as a weighted spoon for a resident. LPN B stated no, she would have to get occupational therapy involved. The DON prompted LPN B to discuss the use of cups with lids or handles. LPN B stated she would get special cups from the dietitian or the DON and would involve Occupational Therapy if the equipment was for long term use. During the interview, LPN B was also asked about the schedule for assessing residents for safety with hot liquids. She stated that the Minimum Data Set (MDS) coordinator sent a weekly schedule that included the names of residents that needed to be assessed. LPN B reviewed the current week's assessment schedule. Included on the schedule was the entry ADLs & safety w/ hot liquids. Care Plan Evals. LPN B stated that the nurses would documented the hot liquid safety review a nursing note. Resident #112's clinical record was reviewed. A hot liquid assessment was not located in the record. On 6/28/18 at 1:00 p.m., the end of day meeting was held with the DON, CEO, Quality Assurance nurse and AIT. At this time, the DON was notified that a hot liquid assessment was not located in the Resident #112's clinical record. It was reviewed with the DON that the survey team understood that the assessment was conducted upon admission and quarterly. The DON stated that was correct. She stated that Resident #112 was on skilled services when he was admitted to the facility and she thought therapy may have assessed him. On 6/28/18 at 1:25 p.m., the MDS Coordinator stated that residents on skilled services are not entered onto the weekly schedule to be reviewed for safety with hot liquids. After residents were off skilled services, they would be included in the weekly schedule when their quarterly hot liquid safety assessment was due. The MDS Coordinator stated that she thought therapy assessed for the safety of hot liquids for a new resident with skilled services. Resident #112's OT (Occupation Therapy) Discharge Summary was provided by the facility staff. Resident #112 was coded as independent for feeding. The summary also read Pt (patient) is highly distractible requiring redirection to tasks after 1 minute. On 6/28/18 at 1:30 p.m., the Therapy Director was asked how independent was defined with regards to feeding. She stated that it meant a resident did not require physical assistance to eat. When asked if a therapist observed a resident eating a meal to determine the feeding status, the Therapy Director stated that a meal observation was not always performed unless there was a specific need. She stated that hand dexterity would be assessed in determining feeding status. When asked if Resident #112 had been observed during a meal, the Therapy Director stated she was unsure. The Baseline Care Plan dated 5/18/18 was reviewed. The Nutritional Status section included Refuses to use lid in cup for hot liquids. Aware of associated risks. The Burn Care Foundation accessed on 6/29/18 at 11:56 p.m. at the website http://www.burncarefoundation.org/safety/hot-water-exposure.html provided the following information on burns: Exposure to 131° F water for 17 seconds would cause a second degree burn and exposure of 30 seconds would cause a third degree burn Exposure to 140° F water for 3 seconds would cause a second degree burn and exposure of 5 seconds would cause a third degree burn The following definition of scald was accessed on 6/29/18 at 12:24 p.m. at the Merriam Webster website found at https://www.merriam-webster.com/dictionary/scald: SCALD: To burn with or as if with hot liquid or steam. In summary, Resident #112 was observed to be served steaming hot coffee of 161 degrees F. The acceptable temperature of coffee served to residents according to the DON was 175- 180 degrees F. Coffee served from the kitchen where Resident #112 ate was consistently documented at temperatures above 160 degrees F. While he was assessed to be independent with feeding and was care planned to remove the lid from his coffee, he was repeatedly exposed to an accident hazard in the form of hot liquid every time he was served the hot coffee. The coffee served to Resident #112 could cause a second degree burn in less than 3 seconds. (end of written statement Surveyor #2) There was no written policy requiring that a hot liquid assessment be conducted on all residents to include the following areas: Risk factor Identification, Cognition, Behavior, Neurological, Musculoskeletal, Vision, Hand Tremors, Coffee Cup Management, Lid Requirement, 2 Handle Requirement, Weighted Cup, History of Spills, Burn Injury, Supervision Requirement for Handling Hot Liquids, Staff Set-Up, Safe Handling, Etc. A review was conducted of coffee temperature logs taken by staff in the 8 kitchens located on the second and third floors. The coffee temperatures were documented as ranging from 177 - 180 degrees during the past 6 months. On 6/27/18 at 10:10 A.M., Immediate Jeopardy was called by the Department of Health, Office of Long Term Care Supervisors. The facility Chief Executive Officer (Administration B), and Director of Nursing (Administration A) were informed immediately. The Immediate Jeopardy was abated on 6/27/18 at 1:25 P.M. The facility submitted the following Abatement Plan: 1. A) Physician notified of resident in room (room number) being at risk [MEDICAL CONDITION] hot liquids due to resident having tremors and being served a cup of coffee at 161 degrees after resident removed safety lid. B) Physician gave new order for OT (Occupational Therapy) to evaluate resident in room (room number) for safe handling of hot liquids 2. A) 100% of all coffee makers in (name of facility) will be removed from the kitchen areas. B) All coffee will be made in the main kitchen area and delivered with thermal air pots. C) The temperature of all hot liquids, including soups, will be taken and will be no more than 135 degrees before it is served to the residents. D) If temperature is greater than 135 degrees it will be held or cooled until 135 degrees or below before being served to the residents. E. 100% of all current residents will have an assessment done to ensure they are safe to handle hot liquids independently via a safety assessment form by a licensed nurse. 3. A) Temperature sheets for all hot liquids will be modified to meet the 135 degrees adjustment B) The Dietary and Nursing Staff will be educated on not serving all hot liquids if above 135 degrees. C) All new admissions will have a Hot Liquids Safety Assessment completed upon admission, quarterly and prn (as needed) 4. A) The Dietary Supervisor will review all temperature logs before each meal served daily x 3 weeks, then weekly ongoing. Any abnormalities will be reported to the Dietician or Dietary Manager immediately. B) The Dietician or Dietary Manager will notify the Director of Nursing or the Administrator of any abnormal findings immediately. C) The Dietician/ Designee will report all findings to the QAPI committee monthly, and recommendations will be made accordingly. D) The DON and DOR will review 100% of all Hot Liquids Safety Assessments completed today and any resident deemed unsafe will be referred to OT for evaluation. Date of Compliance 6/27/18 by 5:00 P.M. On 6/28/18 at approximately 10:00 A.M. an interview was conducted with the Director of Nursing (Administration A). When asked to describe the interventions that were implemented after each burn, she stated, We put lids on the cups. We did not consider the temperatures. It had nothing to do with the coffee being hot it was about her (Resident #20) being burned. The DON stated that the facility began using regular lids with lift tabs after Resident #107 was burned, then changed to using lids with a round hole after Resident #49 was burned. The lids were observed to be the thin very loose-fitting white flexible plastic type used in fast-food restaurants. The DON stated, Spills [MEDICAL CONDITION]. When you go to a restaurant or to my house, the temps aren't taken. We operated within the standard of care. The facility CEO (Administration B) was present. He stated, We knew you would be looking at temperatures because you knew about [MEDICAL CONDITION] you came. We don't agree that a form is necessary because all employees get eight weeks of training. The coffee was hot enough to burn. There's not a facility in the US that knows the temperatures and documents each resident's coffee. Administration B was unable to state what preventive measures had been put in place after the third resident was burned on 6/22/18. On 6/28/18 at 1:43 P.M. an observation was conducted of the Dining Manager (Employee F) preparing the coffee. As an individual cup of coffee was prepared, he took the temperature, and added 2 plastic ice cubes until the coffee cooled down to a temperature of 135 degrees. He stated that he ordered a cooling wand that will arrive within one week. The cooling wand is placed into the coffee pot to cool down the entire pot at one time. On 6/28/18 at 1:30 P.M., the Quality Assurance nurse (RN B) was asked if the facility had a Hot Liquid Assessment Policy. She stated that the facility did not have a policy regarding hot liquid assessments. On 6/28/18 at 9:20 A.M. an interview was conducted with a facility Licensed Practical Nurse (LPN C). She. stated that she had attended an inservice regarding hot liquids on 6/27/18. She stated, We're shooting for 135 degrees. We don't remove coffee lids, to ensure that the resident doesn't get harmed by hot foods and liquids. On 6/28/18 the facility submitted documentation that all of the facility residents had received a Hot Liquid Safety Assessment on 6/27/18. All three residents who had received burn injuries from hot coffee had recommendations that the resident use Blue Mugs with Lids - Resident may drink hot liquids with supervision. The facility also submitted documentation that all dietary and nursing staff who reported to work had received inservice training on hot liquid safety.

Based on observation, staff interview and facility documentation review, the facility staff failed to prepare and store food in accordance with professional standards for food service safety. Employee-A, a dietary department cook, failed to ensure his hair was properly restrained. The findings included: On 3/28/17 at 2:15 p.m. an initial inspection tour of the kitchen was performed with the Kitchen Manager (Admin-C). Kitchen staff were observed performing hand hygiene, preparing food and running dishes through the dishwasher. Staff were observed to have hair nets, beard restraints or baseball type hats in use when appropriate. On 3/28/17 at approximately 2:30 p.m., Employee-A was observed near the sink where potatoes were soaking. He was wearing a baseball type hat with approximately 2 inches of wavy hair hanging down the back and sides of the hat. When asked if he'd been educated to wear a hair net since his hair hung below the hat, Employee-A stated No, as long as I have the hat on it's ok. On 3/28/17 at 2:45 p.m. Admin-C was questioned why Employee-A did not use a hair net to restrain his hair. Admin-C stated Our local health department does not require us to wear a net, they say the hat is enough. The facility policy on hair restraints was requested. During the course of the survey, meal preparation and food plating was observed in 10 kitchens that the facility had on their 3 floors. All the dietary staff observed on the units had appropriately restrained hair, wore disposable gloves when applicable and performed proper hand hygiene. On 3/29/17 at 4:20 p.m., the Administrator, Director of Nursing and Registered Dietitian (Employee-B) were informed of Employee-A's hair not being properly restrained. When Employee-B questioned why it was a concern, surveyor explained that the baseball hat did not adequately cover or restrain his hair since it hung approximately 2 inches down the side and back of his neck. Employee-B voiced understanding. Facility policy titled Requirements for personnel handling food was reviewed and included: .5. Food handlers must wear hair nets, beard nets or head covering. Long hair should be properly restrained off of the shoulders . On 3/30/17 at 10:15 a.m. an observation of the kitchen was conducted with Admin-C present. Employees observed had appropriate hair restraints in use. No further information was provided by the facility staff.

Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to for one Resident (Resident #5) in a survey sample of 24 residents, to prevent and identify a pressure ulcer prior to the development of a stage 3 pressure ulcer resulting in harm for Resident #5. The facility failed to provide pressure relief interventions to the left elbow despite observations of the resident leaning to her left side and did not identify the pressure ulcer until it had reached a stage 3 ulcer with the presence of slough (dead devitalized tissue), a harm level deficiency. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 2/17/16. She was coded with a Brief Interview of Mental Status score of 4 out of a possible 15 indicating severe cognitive impairment. She required total assistance of one staff member for bed mobility and transferring. The resident was coded as having limitations of range of motion both in the upper and lower extremities. The resident was incontinent of bowel and bladder. The resident did not have recent weight loss. On 3/17/16 at 9:25 AM, Resident #5 was observed in the wheelchair with the left hand side of the wheelchair having an upholstered arm rest. With the assistance of CNA (certified nursing assistant) A, the elbow was uncovered by removing the sweater and shirt sleeve and a small scar was evident on the left elbow olecranon (elbow bony prominence). Review of the weekly skin assessments revealed on 10/20/15 revealed weekly skin assessment completed no new skin impairments noted. CNA (certified nursing assistant)assessments done on 10/21/15 noted no skin impairment. Review of the care plan dated 10/22/15 revealed the following interventions (after the pressure ulcer developed) were noted, Place air mattress for comfort and support. Elbow protectors as tolerated, assess q (every) shift for break in skin integrity. There were no interventions to protect the elbows prior to the development of the ulcer. In addition, an evaluation of a clinically avoidable pressure ulcer indicated interventions in place prior to the development of the pressure ulcer were not checked, including off load of bony prominences, other positioning devices and pressure reducing equipment in chair. Interventions present on the care plan prior to the development of the elbow ulcer included: Weekly skin checks by nurse. Ask/Encourage/assist to toilet provide timely incontinent care. Assist /remind to frequently position in bed/chair. She likes to sit with her head in her hand. Encourage her to change her position throughout the day. Float heels in bed as tolerated. Monitor skin during care. Report any changes to the nurse. Encourage adequate meal and fluid intake. Ensure shoes are well fitted. Avoid shearing force, lift do not slide patient. Apply lotion daily. Monitor food and fluid intake. Notify dietician if intake decreases Supplements as ordered. Review of the clinical record revealed a wound care note dated 10/22/15 at 11:37 AM which read: Wound care for assessment of stage 3 pressure ulcer to left elbow. 50 % slough (dead tissue) tissue, no s/s (signs and symptoms) of infection. New order per MD (physician) elbow protectors as tolerated, air mattress, Santyl (a [MEDICATION NAME] agent) ointment, dry dressing daily. The wound measured 0.6 cm (centimeters) length by 1.0 width and less than 0.1 cm in depth. The pressure area was healed on 11/11/15. The NPUAP (National Pressure Ulcer Advisory Panel) defines a stage III pressure ulcer as: Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a Stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Resident #5's Braden score (indicator of pressure ulcer risk) on 9/20/15, prior to the development of the pressure ulcer, was 14. 18 or less is considered at risk for pressure sore development. On 10/23/15, a physician's note was written by the attending physician (other O). The note read: Left elbow with stage 2/3 pressure ulcer. Under assessment, the note continued, Left elbow ulcer- appears to be from chronic contact with tray- mayu (sic) have been exacerbated by minor trauma from repositioning- wound care to follow. I feel this wound could not have been avoided given her advanced debility/dementia. On 3/16/16 at 2:30 PM, an interview was conducted with RN (registered nurse) B, the facility wound care nurse. She described the wound as having slough or dead tissue. The wound care nurse stated, We prefer to catch at a stage I (redness). She went on to state that the left arm was contracted and that she cannot move the arm. She later stated during the interview, It should not have been found at a stage 3. On 3/17/16 at 10:25 AM, an interview was conducted with the unit manager, RN (A). She stated, She had a 1/2 lap tray (tray on the left side for the left arm to rest on, made of hard plastic). We thought she had a stroke, she was leaning to the left side. She went on to state that the resident was referred to OT (occupational therapy) due to leaning to the left side. She went on to add that the resident now has a padded 1/2 lap tray. RN (A) was asked if pressure relief interventions, such as elbow protectors were used while waiting for the new lap tray and the RN (A) stated, No. The Administrator was asked on 3/27/16 at about 10:30 AM, the same question and the Administrator stated, No, because the area was not red. Review of the OT notes dated 10/13/15 read as followed: Nursing reporting leaning to left side new. OT notes dated 10/20/15 read, Plan for trial arm though (? trough) vs (versus) half lap tray. Information sent to the OLC (office of licensure and certification) supervisor included a note from OT dated 10/22/15, which was not given to the surveyor during the survey, which stated, Spoke with wound nurse due to wound on elbow. Area not related to wheelchair positioning. However, a new, padded arm rest was placed, and the attending physician wrote in his notes, Left elbow ulcer- appears to be from chronic contact with tray. Review of the Pressure Ulcer Treatment Policy and Procedure, under Treatment Program Guidelines, revealed the following: The pressure ulcer treatment program should focus on the following strategies: Assessing the resident for skin breakdown, managing tissue loads, early recognition of tissue injury and continuous and consistent assessment. The policy for prevention and assessment of a pressure ulcer read as followed: Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure and a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. According to www.nursingceu.com <http://www.nursingceu.com> The compression of soft tissue interferes with the tissue blood supply, leading to vascular insufficiency, tissue anoxia, and cell death. Pressure ulcers usually occur over bony prominences such as the sacrum, ischium, heel, and trochanter, where there is less tissue to compress. Other factors previously mentioned also contribute to the tissue breakdown. Pressure ulcers can develop within 24 hours of the initial pressure but may take as long as 5 days to present themselves. According to the article, Decubitus Ulcer Information and Stages of Wounds expertpages.com/news/decubitus, All decubitus ulcers have a course of injury similar to a burn wound. This can be a mild redness of the skin and/or blistering, such as a first-degree burn, to a deep open wound with blackened tissue, as in a third degree burn. This blackened tissue is called eschar. The common areas of decubitus ulcer formation and prevention is a basic nursing principle covered in nursing school curriculum (LVN/LPN or RN) and most nursing assistant programs as well. Prevention consists of changing position every 2 hours or more frequently if needed. This 2-hour time frame is a generally accepted maximum interval that the tissue can tolerate pressure without damage. Prevention also consists of protection and padding to prevent tissue abrasion, and maintaining hydration, nutrition and hygiene. The basic treatment of [REDACTED]. Prevention cannot be stressed too strongly. To this end, there are any number of devices designed to protect and prevent the formation of decubitus ulcers. The decision of which device to use is based on the location and severity of the wound. These devices may be a Medicare/Medicaid/Insurance-covered item when medically necessary. Most insurance's will cover any needed device, material, or equipment necessary to prevent and treat decubitus ulcers. Prevention is the most humane and cost effective approach to care. It remains true that decubitus ulcers are generally considered preventable and the development of decubitus ulcers is evidence of some form of neglect (nutrition, hydration, positioning, infection control, etc). Many paralyzed or terminal individuals with very poor nutrition can remain free of decubitus ulcers. On 3/17/16 at 3:20 PM, interviews were conducted with the attending physician (other O) and the wound care physician (other P). According to Other (P) the presence of slough indicates an unable to stage wound or a stage 3. He also added that if you are watching, the pressure ulcer starts as blanching (turns white when touched) redness to unblanched redness to skin breakdown. When asked what interventions could be used to prevent elbow pressure ulcers, he stated, Pillows, elbow protectors could be used. The physician did state that wounds could develop within hours. Other (O), the attending physician, stated, When I saw it, I thought it was a stage 2-stage 3. He went on to state that if the skin is gone, it is a stage 2, if not seeing tissue, it would be a 3. On 3/17/16, at approximately 11:15 AM, the DON (director of nursing) and Administrator were notified of a harm level deficiency. After review of the deficiency findings, the facility was offered a Past Non-Compliance deficiency status if they provided a plan of correction. The facility rejected this even though they had identified and corrected the deficient practice before the surveyors came on site. Past noncompliance may be identified during any survey of a nursing home. To cite past noncompliance with a specific survey data tag (F-tag or K-tag), all of the following three criteria must be met: 1. The facility was not in compliance with the specific regulatory requirement(s) (as referenced by the specific F-tag or K-tag), at the time the situation occurred: 2. The noncompliance occurred after the exit date of the last standard recertification survey and before the survey (standard, complaint, or revisit) currently being conducted: and 3. There is sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey for the specific regulatory requirement(s) , as referenced by the specific F-tag or K-tag. The above, quoted information was taken from the State Operations Manual at Task 6- Information Analysis for deficiency Determination.

Based on observation, staff interview, facility document and clinical record review, the facility staff failed to assess and treat pain for 2 of 26 (Resident #1, Resident #13) residents in the survey sample. 1. a. Resident #1 had more than minimal pain (groaning, verbalizations, crying out) during a wound care treatment of [REDACTED]. Medication prior to wound treatment was insufficient for pain control. Wound care was continued and the physician was not notified of the pain. b. Also, the resident did not receive pain medication prior to the debridement of the wound, or any pain medication on the following days after debridement. 2. Resident #13' s pain level was not assessed every shift. The findings included: Resident #1, an [AGE] year old female, was admitted to the facility 7/7/11. Her [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1/11/12 was coded as a quarterly assessment. She was coded as having a BIMS (brief interview of mental status) score of (5) or severe cognitive loss. She was coded as having verbally abusive symptoms 1-3 days a week. Resident #1 was coded as requiring extensive to total two person physical assistance with her activities of daily living. Resident #1 was coded as having a Foley catheter (used to drain the bladder). There was no pressure sores coded during this ARD period. The MDS was not coded for pain during the lookback. On 3/29/12, prior to the dressing change, the order for pain medication was reviewed. The order, written 1/3/12, was for "[MEDICATION NAME] 5/500 mg (milligrams) 1-2 tabs qid (four times daily prn (as needed) for left hip pain." At 11:30 AM, prior to the dressing change, Resident #1 received [MEDICATION NAME] 5/500 mg (one tablet) and [MEDICATION NAME] 0.5 mg (order was 1.0 mg). On 3/29/12 at 12:10 PM, observation of wound care to a sacral pressure ulcer was conducted. The resident's brief was lowered by LPN (licensed practical nurse)-A. The sacral wound was approximately 5-6 cm (centimeters) in diameter with the perimeter of the wound having 1-2 inches of redness surrounding the wound. Undermining was present. The wound bed contained yellow slough, and bone and muscle were exposed. RN (registered nurse)-A cleansed the inside of the wound with sterile water and 4 X 4 gauze. During cleansing, Resident #1 began to moan, which increased in volume as the treatment progressed. The resident began to vocalize, "Oh....Oh...." A strip of [MEDICATION NAME] was applied inside the wound, and the resident moaned out, "Oh me, Stop it, stop it." RN-A was questioned if this was a normal amount of pain during the treatment. RN-A stated, "she was medicated with [MEDICATION NAME] and [MEDICATION NAME], she always yells." The treatment continued with application of a dressing. The resident was quiet after application of the dressing. RN-A wrote the time and date of dressing change on the dressing after it was applied to the resident. RN-A gathered the soiled items and items not used. Both nurses left the room, leaving the resident's bed in the high position. Review of the facility's wound tracking for 3/28/12 revealed measurements of 3.5 cm (centimeters) by 3.2 cm with a depth of 0.4 cm with undermining 0.6 cm. Purulent drainage with foul odor was documented. The notes contained an entry: "Resident is on Tylenol for pain management." According to the National Pressure Ulcer Advisory Panel, a stage 3 is defined as "Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling." A stage 4 is defined as "Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling." Potter and Perry (Fundamentals of Nursing, page 209") estimates: "In nursing homes, 70-80% of residents have persistent, untreated pain." The consequences of persistent pain include depression, sleep difficulties, changes in gait and mobility and decreased socialization. Many factors influence the management of pain, including cultural influences, fear related to the use of [MEDICATION NAME] medications, and the problem of pain assessment with cognitively impaired older adults. Nurses caring for older adults have to advocate for appropriate and effective pain management. The goal of nursing management of pain with older adults is to maximize function and improve quality of life." Review of the current (March) MAR (medication administration record) revealed Resident #1 received [MEDICATION NAME] 5/500 mg one tablet prior to the dressing change, and [MEDICATION NAME] (used for anxiety) 0.5 mg. The physician's orders [REDACTED]. Further clinical record review revealed the [MEDICATION NAME] had been discontinued 1/12/12. Review of the March 2012 MAR indicated [REDACTED]. The resident received Tylenol 5 times in the month of March, and none since 3/25/12. The dressing change was ordered daily. b. In addition, Resident #1's sacral wound was sharp debrided (using as scalpel) on 3/26/12. There was no documentation of the resident receiving pain medication prior to the debridement, or on subsequent days after the debridement, until 3/29/12, the day of the treatment observation. Review of physician notes dated 3/27/12 documents the following: "Pt (patient) with stage 3/4 decub (decubitus) ulcer, which is debrided with scalpel/pt underweight/ bone visible under decub (poor appetite)." On 3/28/12 at 2:20 PM, CNA (certified nursing assistant) -A was questioned about Resident #1's pain. She stated, "She yells and cusses out." She will say my tail hurts so bad, I know the nurses give her pills. She has a big hole in her bottom." Review of the current care plan revealed the resident has Alzheimer's dementia with [MEDICAL CONDITION] and behavioral disturbance." On 3/29/12 at 9:00 AM, LPN-A was questioned about Resident #1's pain. She stated, "She has unbelievable pain with dressing changes, we give her [MEDICATION NAME] and [MEDICATION NAME] before the treatment." LPN-A went on to say that the resident is very stiff and will yell if you touch her finger." Review of prn (as needed) [MEDICATION NAME] narcotic records revealed the resident has not received prn [MEDICATION NAME] since 1/5/12. Review of the resident's care plan revealed that Resident #1 "complains of pain less than daily." Staff is to" assess for pain on each contact and determine what type of pain. Offer non pharmacological interventions such as positioning, relaxation, massage, hot packs, ice, diversional therapy, if un-successful offer pain medication as ordered by MD." On 3/30/12 at approximately 2:00 PM, RN-A was interviewed regarding the wound treatment observation. RN-A stated, "her pain was better than usual, it's hard to say, she yells whatever we do; I thought the pain medication was effective." RN-A went on to state, "It's got to hurt." RN-A also stated, "the pain has gotten worse since the debridement on Tuesday (3/27/12), and she may need something more than [MEDICATION NAME]." When asked about pain medication prior to the debridement, RN-A stated, "I thought she had gotten something for pain, she did OK." On 3/30/12 at 6:10 PM, the DON (director of nursing) stated, "She was not medicated prior to the debridement because she was comfortable and drowsy." The DON (director of nursing) and RN-A were asked for the narcotic record for the [MEDICATION NAME]. RN-A stated. "I talked to the nurse who medicated her (LPN-A) and she said she put the narcotic record in the pharmacy folder." On 3/30/12 at 6:30 PM, a phone conversation was conducted with LPN-A. She stated, "I used the last pill in the card (for 3/29/12 treatment), usually comes in 30 count. I cut the top of the card off and put it in the shredder. I put the narcotic sheet in the book- I don't know where it is." It is to be noted that a surveyor and the DON opened the shredder, and could not find the pill package. Review of January and February MAR's revealed no documentation of the [MEDICATION NAME] being given. Two [MEDICATION NAME] had been documented as given on 3/25/12 and 3/29/12. There was no accounting for the remainder of the [MEDICATION NAME]. On 3/30/12 at approximately 3:00 PM, RN-A stated, "We have notified the physician, and received an order for [REDACTED]. Review of the facility's pain management program revealed the following: "Cognitively impaired/non verbal: If a resident is unable to understand and appropriately respond to questions, observe the resident for 3-5 minutes. Document all indicators of pain observed in the 3-5 minute period. Document the location of pain if resident is able indicate location. Document the current pain relief treatment (both medication and non medication). Document the effectiveness of the current program and if not effective, contact resident's physician for additional interventions. Update the resident's care plan." On 3/30/12 at 3:15 PM, the DON and Administrator were notified of harm level findings. 2. Resident #13 was an [AGE] year old admitted to the facility on [DATE]. Resident #13's [DIAGNOSES REDACTED]. The Minimum Data Set which was a Discharge Assessment-Return Anticipated, with an Assessment Reference Date of 12/11/12, coded Resident # 13 as being able to understand and be understood by others. On 3/27/12 a review was conducted of Resident #13's clinical record. The physician ordered, [MEDICATION NAME] 5 MG 1 Tab PO BID (by mouth twice a day) and [MEDICATION NAME] 30 milligrams (mg) one cap by mouth in the AM. Resident #13's care plan read, "2/12/12- Complains of frequent shoulder, hip, knee, and leg pain. Has [MEDICAL CONDITION] Disk Disease, neuritis, [MEDICAL CONDITION]. On [MEDICATION NAME] for chronic pain. Assess the need for pain med on each contact, assess for verbal and non-verbal indicators of pain. Administer pain med per MD order and reassess after approximately 1 hour. Assess the effectiveness of the medication and notify MD if pain is not well controlled." None of the nurse's notes contained documentation of any pain assessments done from March 1, 2012 - March 27, 2012. Resident #13's Treatment Administration Records were reviewed, revealing the following missing documentation: Treatment Dates/Times Assess pain level every shift on a scale of 1-10. 3/1/12-3/7/12 (3rd Shift) 3/8/12-3/31/12 (3rd Shift) Resident #13's clinical record contained the following physician's orders [REDACTED]. "March 2012 - Assess pain level every shift on a scale of 1-10" A review of facility documentation revealed a pain Management Program policy, dated 2/23/12. The policy read, "All residents will be assessed for pain during each shift. Document on the MAR, in the space provided, the level of pain experienced by a resident using a 1-10 scale or the PAINAID scale." On 3/28/12 at 4:10 P.M. an interview was conducted with the Director of Nursing (Administration B) who stated, "The charge nurse is supposed to document the pain level on each shift. The nurse has 24/7 responsibility for their units. The person who does the assessment is the one who should document it."

Based on observation, staff interview, clinical record review, facility documentation review, family interview, and in the course of a complaint investigation, the facility staff failed for one Resident (Resident #4) in a survey sample of 26 Residents to transfer in a manner to prevent serious injury; staff failed for four Residents (Residents' #16, #17, #7, and #1) to implement personal alarm devices; and staff failed to prevent an environment free from safety hazards. 1. A. For Resident #4, the staff failed to transfer from the bed to her chair properly resulting in an open fracture of her leg. B. And the staff failed to appropriately operate the Viking Lift for the transfer of Resident #4. During an observation of the transfer, the left leg of the "Viking" lifted off the ground making it unstable. 2. LPN A left the medication cart open and was not within eye sight. 3. For Resident #16, the facility staff failed to apply a personal alarm; 4. For Resident #17, the facility staff failed to apply a personal alarm; 5. For Resident #7, the facility staff failed to apply a personal alarm; 6. The facility staff failed to secure a full 415-liter oxygen cylinder (tank) in the 2nd floor south oxygen storage room. 7. For Resident #1, the facility staff failed to lower her bed after performing wound care; 8. Scissors were left on the top of the medication cart near room 9322; 9. Scissors were left on the top of the medication cart on Piedmont East; and The findings included: 1. A. For Resident #4, the staff failed to transfer from the bed to her chair properly resulting in an open fracture of her leg. Resident #4, a [AGE] year old female, was admitted to the facility 7/9/09. Her [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1/19/12 was coded as a significant change assessment. Resident #4 was coded as having short and long term memory deficits and required total assistance in making daily life decisions. Resident #4 was also coded as requiring total physical assistance in all of her activities of daily living. Review of Resident #4's clinical record revealed an entry in the interdisciplinary notes, "1/08/12 0845 Writer overhear CNA calling for help! Nurse went to assess the problem. Upon entering resident was noted to be in wheelchair with blood observed to left lower ankle. Bone was noted to be exposed to lower extremity. Pressure was applied with pressure dressing. Unable to obtain blood pressure due to resident anxiousness. Call was placed to 911 Supervisor and Unit Manager was aware of above..." Resident #4 was transported to the hospital and admitted . An open reduction internal fixation (ORIF) was done and Resident #4 returned to the facility 1/9/12. Review of the investigation of the incident revealed a CNA assigned to care for Resident #4 on 1/8/12 had transferred Resident #4 by herself with a manual transfer. As the CNA was no longer at the facility, she was unable to be interviewed. Review of a statement from the CNA at the time of the incident included: "I was getting resident ready for the morning and I put bed up about waist height to transfer her to her wheelchair. I had moved the armrests back out of the way, and the foot pedals were already off from nighttime (I put them back on when I am done with her care). I put my arms around her, underneath her arms and pivoted her into the wheelchair. When I lifted her, to pivot her to the wheelchair, her feet were completely off the ground. I placed her in the wheelchair, I thought I saw her knee bent a little bit, but when I looked at it closely, it had corrected itself. I pulled the armrests down in the right position and turned her around in the opposite direction to face her dresser. At this point I saw small dots of blood leading away from the bed and looked down at her legs and that's when I saw her foot turned in such a way that it looked broken." The CNA noted that she called for help and the nurses came into Resident #4's room. Review of Resident #4's care plan that was in place at the time of the incident included, "May use Mechanical lift and 2 person assistance as needed." The care plan had been initiated 5/16/11 and had been reviewed and updated quarterly on 7/15/11 and 10/12/11. The "NURSES AIDE'S INFORMATION SHEET" included "Mech (mechanical) Sara Lift as needed with 2 assist." A hand written entry was noted on the top of the sheet, "Please two people at all times." Also written was, "Talk to resident as lift is used to (arrow down-decrease) anxiety & agitation." Resident #4 had been assessed for the use of a "Sara" lift. A Sara lift is a mechanical lift utilized to transfer a Resident from one sitting position to another and to also elevate a Resident for toileting. Review of the facility's policy indicated, the Sara lift should only be utilized with two staff members. A "Sara" lift may be utilized when the Resident can assist with standing or weight bearing during the transfer. When interviewed, Resident #4's grandson stated 3/28/12 at 10:55 a.m., he understood the break in her ankle occurred when the CNA attempted to move his grandmother in the wheelchair without the foot pedals. The DON stated 3/30/12 at 3:20 p.m. the investigation determined that Resident #4's leg/ankle was broken when the CNA moved the wheelchair without putting the foot pedals on and her leg was caught. The DON stated the foot pedals should have been put on the wheelchair prior to the CNA attempting to move Resident #4. Resident #4's MDS with an ARD of 10/11/11 (prior to the incident) revealed Resident #4 was totally dependent in transferring and bed mobility. The MDS indicated Resident #4 did not walk either in her room or in the hallway and required assistance with locomotion on the unit. Resident #4 was also coded as only steady with human assistance. Review of the facility's investigation revealed that when the facility interviewed the CNA, the CNA stated she had transferred Resident #4 by herself and did so "If the Resident was not anxious or agitated in the morning." The CNA stated that Resident #4's bed was in the high position, the right arm of the wheelchair was off and the foot rests were off. Observation of Resident #4's room after the incident revealed no blood was on the bed or the wheelchair. The CNA also reported to the DON that after transferring Resident #4 into the wheelchair she did not put the foot rests on the wheelchair prior to moving it away from her bed. The CNA stated she saw Resident #4's knee bend a "little bit, but when she looked closer, it had corrected itself." The CNA further said that after she turned the resident around in her wheelchair to face the dresser, she saw blood on the floor, and saw her foot turned with the bone sticking out of the resident's tights on her left lower extremity. The investigation concluded, "As a result of the facility investigation and interviews conducted, it was determined that the fracture most likely occurred while the resident was being turned around in her wheelchair due to the resident's foot turning under the wheelchair while there were not leg rests in place." As a result of the incident, staff education and monitoring for the use of lifts and foot pedals was to be performed. Documentation revealed the education occurred by email. Monitoring of staff use of lifts, transfers and foot pedals was included in the plan, however no documentation that monitoring of foot pedal use by the staff was performed. B. After the incident, Resident #4 was assessed as requiring a "Viking" lift transfer with 3 staff assistance. Three staff were utilized until Resident #4's ankle and leg fracture healed. Documentation on the care plan and the "NURSES AIDE'S INFORMATION SHEET" at the time of the survey indicated Resident #4 was assessed as requiring a "Viking" lift transfer with 2 staff. A "Viking" lift is a mechanical lift that utilized a sling and required no Resident interaction during the transfer. Review of the facility's policy entitled "Mechanical Lift: Viking" included "Two staff members must be present when a lift is being used." Resident #4 was observed 3/28/12 at 10:16 a.m. during a transfer. She was lying on her back in bed with bolsters and a scoop mattress. Resident #4 was alert and verbally responsive although difficult to understand when she verbalized. CNA C and another staff member were in Resident #4's bedroom when the surveyor entered. CNA C rolled Resident #4 to the left and then right side to put a green lift sling under Resident #4. The sling was secured on the arms of the lift and LPN C utilized the lift mechanism to raise Resident #4 from the level of her bed. CNA C moved Resident #4 to the right to position her over her wheelchair. CNA C pulled Resident #4 towards herself (CNA C), raising the left leg of the lift off the ground in order to position Resident #4 over the wheelchair. CNA C lowered Resident #4 into her wheelchair. The other staff member assisted with holding the wheelchair during the transfer. Review of the facility's policy for the use of the "Viking" lift and the manufacturer's guide did not reveal that the lift legs should lift off the ground during the transfer. Attempts were made to interview CNA C after the observed transfer, however CNA C did not work through the rest of the days of the survey, 3/29 or 3/30/12. CNA J, the staff member caring for Resident #4 on 3/29/12, stated she had not had any problems transferring Resident #4 with the "Viking" lift. CNA J said the legs should stay flat on the floor during a transfer and that Resident #4 was always transferred with the lift and 2 staff members. The administrator and DON were informed of significant harm that occurred to Resident #4 when transferred improperly by a CNA on 1/8/12 during which her lower leg/ankle was broken. The administrator and DON were also informed of the transfer observed with CNA C, 3/29/12 at 5:32 p.m. COMPLAINT DEFICIENCY 2. LPN A left the medication cart open and was not within eye sight. During the medication pour and pass observation LPN A was observed preparing and administering medications to Resident #18, 3/27/12 beginning at 8:04 a.m. After preparing the medications, LPN A left the medication cart and went to where Resident #18 was sitting in the dining room. LPN A administered Resident #18 ' s medications. Upon leaving the medication cart at 8:10 a.m., the cart was unlocked. The medication cart was observed in an alcove behind a wall separating the dining room from the alcove and was unable to be visualized from the dining room. When interviewed, 3/29/12 at 3:20 p.m., LPN A said she did not realize she had left her medication cart open. LPN A stated, " I 'll be honest, if I 'm going to be out in the dining room, I usually leave my cart open. It 's easier to just get things out without having to unlock it." Review of the facility ' s policy, " Administering Medications, " included: " 9. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident 's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. " The DON stated, 3/29/12 at 4:25 p.m., the medication carts should not be left open when the nurse is not within eyesight. The administrator and DON were advised of the failure of LPN A to lock her medication cart when not within sight, 3/30/12 at 3:20 p.m. 3. For Resident #16 the facility failed to implement a physician ordered chair alarm. Resident #16, a [AGE] year old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her most recent minimum data set was a quarterly assessment with an assessment reference date of 3/12/12. She was coded with severe cognitive impairment and required assistance with her activities of daily living. Resident #16's physician orders [REDACTED]. Under the section titled "Protective Devices" read the following order: "1/16/12- Bed/chair tab units at all times- check every shift" On 3/29/12 at 9:10 a.m., Resident #16 was observed in her wheelchair eating breakfast in the hall dining room. She was observed without a chair alarm. At 9:27 a.m., LPN E was in the dining area. She was asked if there was a chair alarm on Resident #16's wheelchair. LPN E stated "no" and said that she would go get it. LPN E did not return with the alarm. On 3/29/12 at 10:00 a.m., the chair alarm issue was reviewed with RN C, Unit 1 Manager. RN C was asked to explain the personal alarms used for Resident #16. In Resident #16's room, RN C showed that Resident #16 had a tab alarm for her bed. RN C stated that there was no tab alarm for Resident #16's chair in her room or her wheelchair. The "Nurse Aide's Information Sheet" kept at the nursing station was reviewed. Each resident had their own "Nurse Aide's Information Sheet." This sheet was used for each resident to indicate the individual care required by the nursing staff. For Resident #16, under the section "Restraint," the box for bed and chair were checked and in the "type" section the word "tabs" was written. The chair alarm issue was reviewed with the Administrator and Director of Nursing on 3/30/12 at 3:50 p.m. At this time, the Director of Nursing stated that the alarm needed to be on the chair. 4. For Resident #17 the facility staff failed to implement a physician ordered chair alarm. Resident #17, an [AGE] year old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her most recent minimum data set was a significant change assessment with an assessment reference date of 3/12/12. She was coded with moderate cognitive impairment and required assistance with her activities of daily living. Resident #17's had a physician ordered chair alarm. Under the section titled "Protective Devices" read the following order: "1/16/12- Sara alarm in bed, chair and wheelchair- check function every shift." On 3/29/12 at 9:13 a.m., Resident #17 was observed in her wheelchair eating breakfast in the hall dining room. She was observed without a chair alarm at this time. At 10:00 a.m. while in the dining room, RN C was asked to identify Resident #17's chair alarm. She stated that Resident #17 did not have an alarm to her wheelchair. RN C was asked to explain the personal alarms used for Resident #17. In Resident #17's room, RN C showed that Resident #17 had an alarm to her bed and chair in her room. RN C stated that they did not use an alarm for Resident #17's wheelchair. The "Nurse Aide's Information Sheet" kept at the nursing station was reviewed for Resident #17. Each resident had their own "Nurse Aide's Information Sheet." This sheet was used for each resident to indicate the individual care required by the nursing staff. For Resident #17, the following was written in the "comments" section "sara in bed, chair and wc." The chair alarm issue was reviewed with the Administrator and Director of Nursing on 3/30/12 at 3:50 p.m. At this time, the Director of Nursing stated that the alarm needed to be on the wheelchair. 5. For Resident #7, the facility staff failed to ensure a wheelchair alarm was applied to Resident #7 ' s wheelchair. Resident #7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #7 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 03/14/2012 coded Resident #7 with severe cognitive impairment. In addition, the Minimum Data Set coded Resident #7 requiring extensive assistance for Activities of Daily Living care and incontinent of bowel and bladder. A review of Resident #7 ' s clinical record was conducted during the survey. The review showed a physician order, dated 01/16/2012. The order read that Resident #7 was to have a TABS unit applied to the wheelchair when in a wheelchair. A TABS unit is a pull-tab alarm that has a pull-string, which attaches magnetically to the alarm, and a garment clip that attaches to the resident. When the resident attempts to get out of a chair, the pull-string magnet is pulled away from the alarm and this causes the alarm to sound. The review showed a care plan dated 10/10/2011. The care plan read that Resident #7 was at risk for falls due to a history of previous falls. The care plan read that the nursing staff was to apply the TABS alarm according to the physician's order [REDACTED]. On 03/28/2012 at approximately 10:45 a.m., Resident #7 was observed in the activity room. Resident #7 was in a wheelchair and had no TABS alarm applied to the wheelchair. On 03/28/2012 at approximately 12:05 p.m., Resident #7 was observed in the dining room. Resident #7 was in a wheelchair and had no TABS alarm applied to the wheelchair. On 03/28/2012 at approximately 5:10 p.m., Resident #7 was observed in the dining room. Resident #7 was in a wheelchair and had no TABS alarm applied to the wheelchair. An interview was conducted with the Director of Nursing (Administration Employee B). The Director of Nursing stated that if a TABS alarm is ordered by the physician then it is expected that staff follow that order. The facility administration was informed of the findings during a briefing on 03/30/2012 at approximately 3:20 p.m. The facility did not present any further information about the findings. 6. The facility staff failed to secure a full 415-liter oxygen cylinder (tank) in the 2nd floor south oxygen storage room. On 03/30/2012 at approximately 9:10 a.m., a tour of the facility ' s environment was conducted with the Director of Facility Services, the Administrator, the Manager of Engineering, and the Manager of Housekeeping. During the tour, a full 415-liter oxygen cylinder was observed unsecured in the 2nd floor south oxygen storage room. The oxygen cylinder was standing, upright, outside the oxygen storage rack. An interview was conducted with the Administrator on 03/30/3012 at approximately 2:35 p.m. The Administrator stated that the oxygen cylinder should have been secured in the storage rack. The facility administration was informed of the findings during a briefing on 03/30/2012 at approximately 5:20 p.m. The facility did not present any further information about the findings. 7. Resident #1's bed was left in the high position after wound care was performed. And scissors were left on the top of the medication cart after use. Resident #1, an [AGE] year old female, was admitted to the facility 7/7/11. Her [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1/11/12 was coded as a quarterly assessment. She was coded as having a BIMS (brief interview of mental status) score of (5) or severe cognitive loss. She was coded as having verbally abusive symptoms 1-3 days a week. Resident #1 was coded as requiring extensive to total two person physical assistance with her activities of daily living. Resident #1 was coded as having a Foley catheter (used to drain the bladder). On 3/29/12 at 12:10 PM, observation of wound care to a sacral pressure ulcer was conducted. The sacral wound was approximately 5-6 cm (centimeters) in diameter with the perimeter of the wound having 1-2 inches of redness surrounding the wound. Undermining was present. The wound bed contained yellow slough, and bone and muscle were exposed. RN (registered nurse)-A cleansed the inside of the wound with sterile water and 4 X 4 gauze. A strip of Silvercell was applied inside the wound. The treatment continued with application of a dressing. RN-A gathered the soiled items and items not used. Both nurses left the room, leaving the resident's bed in the high position. A visitor in the room lowered the bed. 8. On 3/28/12 at approximately 8:30 AM, a medication pour/pass observation was completed. LPN- F prepared medications for room 9322. Using a pair of sharp, household scissors to open a package of medication, the scissors were left on the top of the medication cart. LPN- F went into Resident #2's room and closed the door, leaving the scissors on the cart. The scissors were left on the cart during the completion of the medication cart. On 3/29/12, the DON (director of nursing) was notified of the above findings. The DON stated, "No, they are not to be left on the cart, they are a sharp." 9. LPN F left the medication cart without securing a set of scissors that were approximately 8 inches in length. An observation was made on 03/28/12 at approximately 8:47 am, of LPN F leaving a pair of 8 inch pointed scissors on the medication cart and turning her back on the cart to administer a resident's medication on the third unit. The medication cart was next to a wall with limited view by LPN F. Several resident's were observed to be self-propelling in their wheelchairs past the unsecured scissors on the medication cart. An interview was conducted on 03/28/12 at approximately 8:52 am, with LPN F. When asked about the unsafe practice of leaving scissors unsecured she stated, "I didn't think of it like that." An interview was conducted on 03/28/12 at 9:15 am, with the DON. She stated, "I will get different scissors, more like bandage scissors, and inservice the staff about proper storage." Administration informed of findings on 03/29/12 at approximately 5:17 pm.