**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision for 2 of 3 sampled residents (Resident #38 and #204) with orders for electric heating pad use. Failure to provide adequate supervision during heating pad use resulted in a burn for Resident #38 and placed Resident #204 and all other residents who use heating pads at risk for burns. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 02/07/24. The IJ was identified when a physician's order in Resident #38's medical record, dated 02/08/24, included a treatment for and a diagnosis of a first degree burn to the resident's right hip from an electric heating pad. This finding placed all residents who use an electric heating pad in immediate danger for burns. * 03/11/25 at 10:27 a.m., The survey team notified the administrator and the director of nursing (DON) of the IJ situation, provided the IJ template, and requested a plan for removal of the IJ. * 03/11/25 at 1:09 p.m., The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: * Reviewed all resident medical records for electric heating pad use. Found eight residents with orders. Two of the eight residents had electric heating pads in their rooms which the staff removed. * Staff ensured all resident rooms free from electric heating pads. * All facility owned electric heating pads discarded. * Electric heating pad usage removed from all resident orders. * The updated electric heating pad policy stated, As of 03/11/25 Electric Heating Pads are no longer allowed for use in this facility. * The admission handbook updated to reflect the new policy. * The facility's medical provider notified about the new policy. * Residents, families, and staff notified via electronic and/or paper communication about the new electric heating pad policy. * 03/11/25 at 2:40 p.m., The survey team verified the implementation of the removal plan as of 03/11/25 and the IJ removal. The deficient practice remained at a G scope and severity following the removal of the IJ. Findings include: Review of the facility policy titled HEATING PAD occurred on 03/10/25. This policy, dated December 2024, stated, . Procedure . 3. Set the control to low and plug into . outlet. 4. After the pad warms up you may adjust the control to a warmer setting-watching closely that no increased redness or burns occur. 5. Begin timing the application. Remove heat pad after 15-20 minutes or as ordered. If resident is competent and wishes to use heating pad for more than 10-minute time limit . they must sign a 'Release from Responsibility' form. - Review of the facility's incident report related to Resident #38's burn, dated 02/07/24 at 11:45 p.m., stated, . Describe the Incident/Possible Causes: fragile skin, other: heating pad left on longer than 20 minutes (estimated 2.5 - 3 hours) CNA [certified nurse aide's name] called writer into room to show that heating pad was left on resident's right hip. Upon removal, a large reddened area was present. Heating pad setting was on medium. Usual application time is approximately 8:30 p.m. and heating pad was discovered in place at approximately 11:30 p.m. Time: 03:33 AM [3:33 a.m.] Writer assessed area once again and most of the redness dissipated but still has some blotches or reddened skin near top of pelvis . Review of Resident #38's medical record occurred on all days of survey. A provider visit note, dated 02/08/24, stated . [Resident #38] . requested to have her right hip evaluated, as she and nursing noted that she has a burn on her right hip. Nursing notes that [Resident #38] does have orders to use an electric heating pad, that can be in contact with her skin for up to 20 mins [minutes]. [Resident] notes that she thought the heating pad was turned up too high yesterday and 'fried' her. Nursing notes that the heating pad was left on the patient for about 5 hours. Review of Resident #38's physician's orders identified the following: * 11/01/23, Apply hydrocollator [a heating device which stores temperature controlled moist hot packs] or heating pad [electric] to right hip for 20 minutes daily at bedtime . * 02/08/24, Bacitracin [antibiotic topical ointment] TID [three times a day] to R [right] hip x [for] 7 days, cover w/ [with] Telfa [a non-stick wound dressing] after application. Dx [diagnosis]: 1st degree burn [a mild burn injury of the outermost layer of the skin] R hip. D/C [discontinue] order for heating pad, only use hot packs for up to 20 minutes at a time. * 02/12/24, Bacitracin & [and] telfa to blisters R hip Bid [twice a day] until healed. Review of Resident #38's nursing progress notes, dated February 8-20, 2024, showed the following: * 02/08/24 at 6:22 a.m., . Right hip burn is already starting to form blisters and has one site that is peeling, skin periphery [outer edge] is reddened. * 02/08/24 at 2:30 p.m., . has two blisters but not puffy. * 02/08/24 at 10:00 p.m., . on right hip, redness surrounding blistered area, approximately 2 [cm] [centimeters] x [by] 5 cm. * 02/09/24 at 1:52 p.m., . Burns are blistered and fluid filled. Slightly reddened periphery. * 02/20/24 at 10:23 p.m., . right hip blister, dry healed; will d/c treatment. The facility failed to monitor Resident #38's use of the heating pad which resulted in a burn. - Review of Resident #204's medical record occurred on all days of survey. A physician's order, dated 03/05/25, stated, . Heating pad to areas of pain/discomfort x [for] 15-20 minutes as needed. May keep at bedside to use at own discretion . Observation on 03/10/25 at 5:02 p.m. showed Resident #204 in her room with a heating pad on the high temperature setting located on her upper legs and knees. The resident stated she brought the heating pad from her home and confirmed the pad does not have an automatic shut off. During interviews on 03/10/25 at 4:28 p.m. and at 5:33 p.m., an administrative nurse (#1) stated heating pad means electric heating pads, and some residents use heating pads at their own discretion. The administrative nurse (#1) also stated CNAs apply/remove heating pads and monitor the length of time the pad is in place and a nurse confirms the CNA completed the treatment and documents the treatment completion in the Resident's treatment administration record (TAR). The administrative nurse (#1) confirmed Resident #38's TAR failed to show a start and stop time for the heating pad use and Resident #204's TAR lacked documentation of electric heating pad use. 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 2 of 3 sampled residents (Resident #21 and #41) observed during transfers. Failure to provide transfer assistance, utilize gait belts, and lock wheelchairs placed the residents at risk for falls and/or injury. Findings include: Review of the facility policy titled Transferring Resident with Transfer (gait) Belt occurred on 03/12/25. This policy, dated December 2024, stated, . It is the policy of this facility to use a gait/transfer belt to guide and support residents who: require assistance with transfer . - Review of Resident #21's medical record occurred on all days of survey. Diagnoses included weakness, ataxic gait (poor muscle control), difficulty walking, unsteadiness on feet, and dementia. A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident required substantial/maximal assistance with bed to chair transfers. The care plan stated, I have alteration in . mobility . hx [history] of falls . gait problems . unsteadiness on my feet . Observation on 03/11/25 at 11:23 a.m., showed two CNAs (#3 and #4) entered Resident #21's room. Without staff assistance, the resident sat up in his bed, and in a hunched over position and an unsteady shuffled gait, placed himself into a wheelchair. The right brake of the wheelchair was not locked and the wheelchair moved backwards. Both CNAs (#3 and #4) failed to provide Resident #21 transfer assistance and failed to ensure both wheelchair brakes were locked. - Review of Resident #41's medical record occurred on all days of survey. Diagnoses included hemiplegia (paralysis to one side of the body), muscle weakness, dizziness, and repeated falls. A quarterly MDS, dated [DATE], identified substantial/maximal assistance required with transfers on and off the toilet. The CNA care card identified, . medical staff recommends pivot [transfer] assist of one [staff] with gait belt . Observation on of 3/11/25 at 11:00 a.m. showed a CNA (#3) positioned Resident #41's wheelchair in front of the toilet. The resident used a grab bar to pull herself to a partial standing position, and with an unsteady gait, hopped on her right toes towards the toilet. The residents left foot drug along the floor, and she stumbled during the transfer. The CNA (#3) failed to utilize a gait belt and provide Resident #41 transfer assistance. During an interview on 03/13/25 at 12:20 p.m., an administrative nurse (#1) confirmed she expected staff to utilize a gait belt during Resident #21 and #41's transfers and expected staff to notify nursing of difficult transfers. 3. Based on observation, review of Safety Data Sheets (SDS), and staff interview, the facility failed to ensure an environment free of accident hazards in 1 of 3 open kitchen areas (200 wing). Failure to store chemicals in locked cupboards placed residents in this household at risk for injury. Findings include: Review of an untitled and undated facility policy occurred on 03/13/25. This policy stated, . Housekeepers must keep a constant [NAME] out for chemicals that are within a resident's reach. If it says on the chemical product to keep out of reach of children the product MUST be stored . in the CNA storage room. Observation on the morning of 03/13/25 identified chemicals in unlocked cupboards in an open kitchen area in the 200 wing. Residents frequented the area and could access the cupboards. The cupboards contained the following: * Underneath the sink, an uncovered can of Lysol Disinfectant Aerosol Spray. * Above the right side of the sink, three covered cans of Airworks Aerosol Air Freshener. * Above the microwave, two covered cans of Airworks Aerosol Air Freshener, one container of Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes, and one container of Clorox Healthcare Bleach Germicidal Wipes. Review of the SDS for the chemicals identified the following: * Lysol Disinfectant Aerosol Spray, . CAUTION Causes moderate eye irritation. Do not spray in eyes, on skin or on clothing. KEEP OUT OF REACH OF CHILDREN . * Airworks Aerosol Air Freshener, . Eye Contact: Causes eye irritation. Skin Contact: May cause irritation. Ingestion: Pain, nausea, vomiting and diarrhea. Inhalation: May cause nasal discomfort and coughing. * Clorox Healthcare Bleach Germicidal Wipes, . KEEP OUT OF REACH OF CHILDREN . CAUTION: liquid causes moderate eye irritation. Do not get into eyes or on clothing. Wash thoroughly with soap and water after handling . * Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes, . KEEP OUT OF REACH OF CHILDREN . CAUTION: Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling . During an interview on 03/13/25 at 8:46 a.m., a staff member (#8) stated residents utilize the open kitchen area on Wing 200 as a space outside of their rooms to relax and read. During an interview on 03/13/25 at 8:52 a.m., an administrative nurse (#1) stated she expected staff to store aerosol sprays and disinfectant wipes in locked cupboards/areas.