**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Based on interview and record review it was determined the facility failed to complete a thorough fall investigations for 2 of 3 sampled residents (#s 15 and 23) reviewed for accidents. This placed residents at risk for injury. Findings include: a. Resident 23 admitted to the facility in 2021 with diagnoses including a stroke and seizures. The 4/29/22 Quarterly MDS indicated the resident was cognitively intact and had no history of falls since admission. A 5/26/22 Nursing Progress Note completed by Staff 19 (LPN) indicated the resident fell and there was no injury noted or complaints of pain voiced. There was no further information provided in the note. A 5/26/22 Fall Investigation completed by Staff 19, indicated that evening, Resident 23 had a witnessed fall by an unidentified CNA. The note indicated the resident fell off the edge of the bed and sustained a skin tear to the right knee and prn pain medication was administered. The resident was assessed with no major pain. The resident stated, my mattress is slippery and moves when I roll to the side, that is probably what caused it. A summary completed by Staff 4 (Former DNS) indicated Resident 23 had a witnessed fall from bed with a CNA present and sustained no serious injuries. Fall precautions were noted to be in place. Abuse and neglect were ruled out. The investigation did not include witness statements, a mental status or pain level assessment, predisposing factors, the root cause of the fall, interventions to prevent further falls, and if the care plan was updated. The investigation was dated as completed on 6/2/22 (seven days after the incident). The Fall Care Plan, last updated 6/23/22, indicated the resident was at moderate risk for falls due to gait/balance issues, incontinence, deconditioning, and chronic fatigue. There was no indication the resident experienced a fall. The care plan indicated Resident 23 required one staff member to turn and reposition in bed. On 11/28/22 at 11:18 AM Resident 23 stated she/he believed in April 2022, the resident's mattress was not on the bed properly and the resident fell off. Resident 23 was unable to provide more details. On 11/29/22 at 1:30 PM Staff 19 (LPN) stated a former CNA (Staff 26) informed him Resident 23 fell off the bed during a brief change. Staff 19 did not believe the resident sustained any injuries. Staff 19 was unable to recall further information but stated he did not believe a witness statement was completed by Staff 26. On 11/29/22 at 2:05 PM Staff 2 (Regional RN) confirmed there were no witness statements for Resident 23's 5/26/22 fall and Staff 26 no longer worked at the facility. Attempts were made to contact Staff 26 on 11/29/22 at 2:13 PM and 11/30/22 at 11:50 AM but the phone number was out of service. On 11/30/22 at 10:26 AM Staff 4 (Former DNS) was unable to state the root cause of Resident 23's fall. Staff 4 confirmed the investigation did not include a witness statement, mental status and pain assessments, what the predisposing factors were prior to the fall, and a discussion of care plan interventions. Staff 4 confirmed there were no new care plan interventions put in place to prevent further falls and stated the expectation was to complete investigations within five days, but the 5/26/22 investigation was not completed until the seventh day. 1. Based on observation, interview, and record review it was determined the facility failed to ensure a resident was assessed and interventions were implemented to prevent aspiration for 1 of 3 sampled residents (#13) reviewed for accidents. This failure resulted in an immediate jeopardy situation. This placed residents at risk for aspiration and death. Findings include: Resident 13 admitted to the facility on [DATE] with diagnoses including pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit, dysphagia (difficulty swallowing), stroke and hemiparesis (weakness to one side of the body). The 1/25/22 Speech Therapy Evaluation indicated Resident 13 had the following history: -2/13/19 diagnoses included pneumonitis due to inhalation of food and vomit. -1/25/22 diagnoses included dysphagia. The 12/13/21 Care Plan indicated Resident 13 had chewing problems, swallowing problems and required limited to extensive assistance of one staff or family at meals. The 9/20/22 Quarterly MDS indicated Resident 13 was cognitively intact and required extensive assistance for eating. The 10/6/22 progress note indicated Resident 13 was assisted during meals and had a possible swallowing disorder. On 11/30/22 at 9:17 AM and 12/1/22 at 2:57 PM Resident 13 stated she/he sometimes coughed after drinking coffee and after eating food. Resident 13 stated this happened throughout the day during meals or between meals. Resident 13 further stated it had been a while since speech therapy evaluated her/him. On both occasions Resident 13 was observed to be alone in her/his room with candy and multiple drinks with straws on the bedside table within reach. A review of Swallowing Tasks Sheets indicated staff were to monitor coughing or choking during meals or when swallowing and staff were to document yes or no. Documentation was completed three times daily by CNA staff. Resident 13 had a progression of choking or coughing incidents as follows: *August 2022: 13 occasions *September 2022: 10 occasions *October 2022: 13 occasions *November 2022: 26 occasions No evidence was found to indicate a speech therapy evaluation was completed for Resident 13 since 2/24/22. The Therapy Quarterly Screen had a section for swallowing concerns (yes/no). The form dated 6/21/22 and 9/21/22 indicated no under swallowing concerns. There was no documented evidence a full speech therapy evaluation was completed for Resident 13 on 6/21/22 or 9/21/22. Interviews on 11/30/22 revealed the following: -9:43 AM Staff 31 (CNA) stated Resident 13 needed assistance with meals and eats candy and drinks fluids independently. Staff 31 further stated she observed the resident coughing during meals and believed the resident had a signed a risks versus benefits form for the current diet texture. -9:47 AM Staff 5 (LPN) stated Resident 13 received assistance with meals and the resident had candy at the bedside. Staff 5 stated she was not aware of Resident 13 choking or coughing at meals as no staff reported incidents to her. -9:55 AM Staff 6 (CNA) stated Resident 13 coughed after drinking fluids and she documented it on the task sheets. Staff 6 stated she did not report coughing incidents to nursing staff. -3:47 PM Staff 7 (CNA) stated he assisted Resident 13 with meals, and he observed her/him choking and coughing after taking bites of food. Staff 13 stated the resident was able to drink fluids independently and had snacks at the bedside. -4:05 PM Staff 8 (CNA) stated he observed Resident 13 to both cough and choke when eating and drinking. He stated he documented the incidents but did not report them to nursing staff unless it looks like [she/he] aspirated or it's not cleared up. He stated there was nothing rising to the level of reporting to the nurse. Staff 8 stated he saw empty candy wrappers in the resident's room but did not observed the resident to eat the candy on her/his bedside table. -4:31 PM Staff 9 (CNA) stated she observed Resident 13 cough during meals maybe a minute at most and the incidents happened while eating. Staff 9 stated Resident 13 had a hard time swallowing sometimes. Staff 9 further stated she did not see the resident eat candy, but she/he was able to consume candy independently if she/he wanted to. -4:45 PM Staff 10 (CNA) stated he observed Resident 13 cough and choke with every meal. He stated the resident coughed and aspirat[ed] kind of, more when drinking fluids. Staff 10 further stated he documented the incidents and I would think nursing staff is aware of it. On 12/1/22 at 10:40 AM Witness 2 (Family Member) stated Resident 13 liked having chocolates on her/his bedside table. Witness 2 stated Resident 13 had pneumonia from aspirating on 11/22/21 and he often observed the resident eating and drinking and she/he mainly had problems when swallowing drinks and coughed like she/he swallows it wrong and aspirating. Witness 2 stated that is how Resident 13 ended up in the hospital last time, she/he swallowed and went into lungs. On 12/1/22 at 9:59 AM Staff 2 (Regional RN) stated no Risks Versus Benefits form was completed for Resident 13's diet as the resident was on the diet that speech therapy recommended. On 12/1/22 at 11:19 AM Staff 12 (Therapy Director) stated she was unaware of the 26 documented choking/coughing episodes from 11/1/22 through 11/29/22 for Resident 13. Staff 12 stated the expectation was for staff to report incidents of choking/coughing to therapy after a resident had 1-2 coughing/choking episodes so speech therapy could evaluate the resident and possibly alter their diet as soon as possible for safety. On 12/1/22 at 1:12 PM Staff 11 (SLP) stated he was unaware of Resident 13's 26 choking/coughing episodes from 11/1/22 through 11/29/22, which placed Resident 13 at risk for aspirating on food or fluids. The facility identified two additional residents at risk for aspiration risk not including Resident 13. On 12/1/22 at 3:10 PM Staff 1 (Administrator), Staff 2 (Regional RN), and Staff 30 (Regional RN) was notified of an immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately assessed regarding meals. An immediate plan of correction (POC) was requested. On 12/1/22 at 6:43 PM the facility submitted a final POC. The IJ Removal Plan included: -Provider contacted for speech therapy orders for Resident 13 to evaluate and treat as indicated; -Facility staff spoke with Resident 13 regarding downgrading diet for safety pending speech therapy evaluation and treatment. Resident refused to accept a modified texture diet even on a temporary basis and a risk vs. benefit was completed with resident and provider was informed; -Resident 13 assessed for signs/symptoms of aspiration; none noted; -Candy and drinks were removed from bedside 12/1/22; Resident 13 was not agreeable to this and demanded the return of [her/his] items so [she/he] could have them as [she/he] chooses. Risk vs. benefit done with resident including the risk vs. benefits of consuming candy or drinks on [her/his] own in [her/his] room; -Call was placed to Resident 13's spouse and discussed the risk vs. benefit completed; -Resident 13's care plan reviewed and updated regarding episodes of coughing/choking that have a noted increase in frequency per documentation; -Resident 13 was placed on alert monitoring x 72 hours for signs/symptoms of aspiration; -Staff education was started regarding the need to communicate noted changes in coughing/choking episodes observed during meals. Staff would sign in-service attendance sheet acknowledging they understand the information provided and have had the opportunity to ask questions. Staff list would be cross-referenced to validate that all staff receive education. This would include current agency staff; -New hires and agency staff new to the center would be educated on the need to communicate noted changes in coughing/choking episodes observed during meals. Staff would sign in-service sheet acknowledging they received and understood the education provided; -Residents in center were reviewed for any changes/increases in coughing/choking episodes during meals by reviewing POC documentation for the past 90 days; -Residents in center would be reviewed to identify those with an active diagnosis of dysphagia and/or aspiration pneumonia as an active problem upon admission to ensure care plan accurately identifies the risk factors and interventions for noted residents; -Speech therapy to evaluate residents in center to determine aspiration risk; -Residents in center at risk for aspiration reviewed to ensure care plan is current and accurately identifies the resident's risk factors and interventions. On 12/2/22 the immediacy was removed based on implementation of the IJ removal plan. 2. Based on interview and record review it was determined the facility failed to ensure residents were free from accident hazards for 1 of 3 sampled residents (#13) reviewed for accidents. This failure resulted in Resident 13 spilling coffee on her/himself and receiving a second-degree burn. This placed residents at risk for accidents. Findings include: o First-degree burns involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. o Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. Resident 13 admitted to the facility on [DATE] with diagnoses including stroke and hemiparesis (weakness to one side of the body). The 9/20/22 Quarterly MDS indicated Resident 13 was cognitively intact. The 12/13/21 Care Plan indicated Resident 13 required limited to extensive assistance of one staff or family at meals. An 8/4/22 Progress Note Late Entry [for 8/3/22] indicated Resident was drinking coffee last night at around 8:00 PM and spilled coffee on [her/his] chest. CNA reported to LN [licensed nurse]. The coffee caused a first-degree burn on resident's chest. Slight separation of skin. The 8/4/22 11:46 PM Nursing Progress Note indicated Resident 13 had a large burn on her/his chest and right groin. Chest burn is approximately 12 [cm] x 6 [cm] and starts at her/his chest and down to her/his right breast. Resident's chest is open, red around the edges and the area that goes down to her/his right breast is blistered. The area on her/his right groin is approximately 4 [cm] x 2 [cm] and is blistered. Resident had no bandage on and no treatment orders. Dressing applied and placed call to on-call physician, awaiting call back for treatment orders. The 8/3/22 at 8:00 PM Non-Pressure Skin Investigation completed by Staff 19 (LPN) indicated the following: -Resident was drinking coffee last night at around 8:00 PM and spilled coffee on her/his chest. CNA reported to licensed nurse. The coffee caused a first-degree burn on the resident's chest. Slight separation of skin. Resident unable to give a description. Assessment was done on wound. Slight separation of skin. No complaints of pain at the time of accident. Licensed nurse was able to get triple antibiotic ointment on skin and cover with bandage. CNAs were able to get an ice pack to relieve some discomfort. -Family member notified on 8/4/22 at 6:30 PM. (Noted by Staff 19). -The assessment did not include pain level, mental status, predisposing environmental factors, predisposing physiological factors, predisposing situation factors and witness list or witness statements. -The 8/10/22 Summary completed by Staff 4 (Former DNS) indicated Resident 13 had a history hemiplegia, dysphagia, and strokes. The resident had a diagnosis of pneumonia related to MRSA. Resident 13 was drinking hot coffee and spilled it on her/himself and had burn noted to right chest and on right groin. This seemed to be related to the cups the resident prefers to re-use from her/his favorite coffee place in the community her/his husband gets coffee from. Family notified this cup is not appropriate for re-use and to ensure that coffee is under 150 F when serving to resident to avoid burns. Hot beverage evaluation completed with resident and family and physician notified. Treatment put in place to open area. Resident is not voicing complaints of pain at this time. Abuse and neglect ruled out and resident and family educated on a new coffee mug for her/him to drink hot beverages from to avoid future issue with hot beverages. Temperature protocol utilized to ensure residents do not burn themselves [Noted by Staff 4 (DNS)]. -In an 8/16/22 interview with Staff 18 (Nursing Assistant) completed by Staff 4 (Former DNS), Staff 18 stated: I measured the temperature and it was not more than it should have been. I checked the temperature before and it was within range. I got the coffee from the break room. It went into the cups that Resident 13 always had, it's like a paper cup and at that time it felt like I could hold it in my hand easily like it wasn't too hot. I told her/him that if it feels too hot to wait a minute. I don't remember off the top of my head the temperature because it was several days ago, I just referenced the paper that was right there hanging in the break room. There was no indication a Hot Beverage Safety Evaluation was completed for the resident until 8/10/22. The safety evaluation indicated the following: -Resident demonstrated impaired orientation in one or more of the following areas: person, place or time; -The resident had a diagnosis of neuropathy or other neurological impairment; -The resident had a history of injury related to independent consumption of hot beverages. The 8/17/22 provider note indicated staff reported resident has chest burn from spilling coffee on [her/his] chest while eating. On examination, medial blister on chest .Active medical problems second degree burn. Assessment and plan second degree burn apply Silvadene cream cover with dressing, leave open to air .Diagnoses: Burn of second degree of chest wall, initial encounter. There was no indication the physician was notified the day the burn occurred on 8/3/22 and no indication treatments were implemented except for triple antibiotic ointment on 8/2/33. On 11/28/22 at 10:31 AM Witness 2 (Family Member) stated approximately three months prior staff used the single-cup coffee maker in the staff break room, the coffee was boiling hot and Resident 13 spilled it all over [her/himself]. Witness 2 further stated Resident 13 did not go to the hospital afterward and felt the facility down-played it. Witness 2 stated the resident had a blister on her/his chest and on the crevice of her/his leg. Witness 2 and Resident 13 showed the surveyor the area on the upper right chest just below the collar bone that was healed, but a red area remained and was approximately the size of the palm of a hand. On 11/29/22 at 1:34 PM Staff 19 (LPN) stated he worked on 8/3/22 and Resident 13 was drinking a lot of coffee that day. Staff 18 (Nursing Assistant) made the coffee too hot and Resident 13 spilled it on her/himself because she/he was not able to hold the cup. Staff 19 stated Staff 20 (CNA) reported it to him and the resident was kind of painful and had discomfort on [her/his] chest and right thigh from the burn. Staff 19 stated the area was red and she/he was given a cold pack and medication. Staff 19 stated Resident 13 had a history of spilling stuff. Staff 19 stated he was unsure if he notified the physician of the burn and acknowledged he did not put treatments in place on 8/3/22. Staff 19 stated he did not get witness statements the evening the burn occurred (8/3/22). On 11/30/22 at 12:08 PM Staff 29 (LPN) stated when she came to work on 8/4/22 a CMA or CNA asked her to look at the burn on Resident 13 and she/he had an open area at the top of her/his chest, maybe where a blister was that opened, and it blistered as it went down to her/his right breast and also had a burn on her/his groin area, she stated the areas were not covered, it looked awful and it made me sick. Staff 29 stated Resident 13 complained that she/he was hurting. Staff 29 stated the burn was not a first degree burn because it was open and blistered and was more than red, at least a second degree burn. Staff 29 stated there were no treatment orders in place on 8/4/22 and she called the physician to get orders. She further stated the physician ordered to clean the area and apply Silvadene (burn cream). Staff 29 stated the burn happened the evening shift on 8/3/22 and she worked night shift on 8/4/22, and the resident went over a day without treatment. Staff 29 stated she made the DNS, the physician and the family aware of Resident 13's burn. She confirmed the progress note that indicated the measurements of 12 x 6 on the chest and 4 x 2 on the groin were measured in centimeters. Staff 29 stated the area was slow to heal and staff stopped giving Resident 13 coffee that was too hot and the facility got rid of the single-cup coffee machine. On 11/30/22 at 12:26 PM and 12:42 PM Staff 4 (Former DNS) stated Resident 13 received a burn on her/his chest and leg from hot coffee spilling on her/him on 8/3/22 and he was made aware of it the next day. Staff 4 acknowledged the physician was not notified of the burn until the evening of 8/4/22, there was no indication the care plan was updated, no indication the area was treated or measured until 8/4/22, and he did not start the investigation until 8/10/22, seven days after the burn occurred. Staff 4 further acknowledged he did not interview Staff 18 (Nursing Assistant) until 8/16/22, 13 days after the burn occurred. Staff 4 acknowledged there were no witness statements for the investigation. Staff 4 further acknowledged the hot beverage assessment was not completed until 8/10/22, seven days after the burn occurred, and there was no prior hot beverage assessment. Staff 4 further acknowledged there was no ongoing monitoring or measuring of Resident 13's burn after it occurred. On 12/5/22 at 7:59 AM Staff 20 (CNA) stated she worked on 8/3/22 when the resident was burned and Staff 18 (Nursing Assistant) got a cup of coffee from the single-cup coffee maker and placed it in a disposable cup once she arrived to the resident's room. She further stated there was a thermometer in the break room but not everyone used it. Staff 20 stated Resident 13 required a cup with a lid and a straw due to both of her/his arms being shaky. Staff 20 further stated Resident 13 pushed her/his call light and when Staff 20 responded the resident told her the lid was not all the way closed on the coffee cup and the resident spilled it on her/himself. Staff 20 stated Resident 13 reported being burned on her/his right side of the chest and groin and when she checked the burn, it was really bad, the skin was peeling off, it didn't blister it just peeled off. Staff 20 stated she reported the burn to Staff 19 (LPN). On 12/5/22 at 1:29 PM Staff 2 (Regional RN) acknowledged Resident 13 received a burn and notes indicated there was separation of skin indicating at least a second- degree burn. Staff 2 further acknowledged the physician was not notified of the burn on 8/3/22 when it occurred, and treatments were not put in place on 8/3/22 by Staff 19 (LPN). Staff 2 further acknowledged the physician and Witness 2 were not notified until 8/4/22 and there was no indication besides the progress note on 8/4/22 that the area was measured and assessed and there was no ongoing monitoring for the burn. Staff 2 acknowledged the Non-Pressure Skin Investigation was not thorough and did not include the resident's level of pain, mental status, injuries reported post incident, predisposing environmental factors, predisposing physiological factors, predisposing situation factors or witness statements. Staff 2 further acknowledged Staff 4 (DNS) indicated he knew about the burn on 8/4/22 and did not start the investigation until 8/10/22, 7 days after the burn occurred and did not interview Staff 18 (Nursing Assistant) until 8/16/22, 13 days after the burn occurred . Staff 2 further acknowledged the care plan was not updated to reflect the need for Resident 13 to have non-disposable cups, the history of the burn or the appropriate temperature for hot liquids. Staff 2 acknowledged the TARs indicated Resident 13 did not receive treatments on 8/9/22, 8/19/22 or 8/22/22. Staff 2 stated the policy was for an investigation to be completed within 72 hours. 3. Based on observation, interview and record review it was determined the facility failed to ensure pain patches were properly disposed of for 1 of 1 observation during medication administration. This placed residents at risk for accidents. Findings include: The 8/2018 Disposal of Medications and Medication-Related Supplies indicated the following: C. Options to dispose of non-flushable prescription drugs include: 2d. Use a commercially available pharmaceutical disposal system that meets Federal and State disposal requirement (e.g. Rx Destroyer or Drug Buster) for proper disposal. On 12/2/22 at 8:19 AM Staff 23 (CMA) was observed to remove buprenorphine 15 mcg patch (opioid pain patch) from Resident 19 using gloves. Staff 23 then turned the gloves inside out, folding the patch inside of the gloves, and disposed of it in the trash located on the side of the medication cart in the hallway. On 12/2/22 at 8:20 AM Staff 23 stated the used pain patch should probably go in the sharps container, but since it's cloth I don't put it in there. On 12/5/22 at 1:41 PM Staff 2 (Regional RN) stated the expectation was for staff to use the Drug Buster for disposal of pain patches and a witness was needed to destroy the patch. Staff 2 stated opioid pain patches were not to be discarded into the trash. b. Resident 15 admitted to the facility in 2021 with diagnoses including dementia and muscle weakness. The facility's 2016 Charting for Event Investigation Report Policy indicated investigations should include observable factors and what was reported by the person involved. The 1/26/22 Care Plan indicated Resident 15 had impaired cognitive function related to dementia with behaviors. The Care Plan indicated the resident was a high risk for falls due to confusion. A 11/19/22 Fall Investigation indicated Resident 15 was found in between the bed and the bathroom. It appeared the resident self-transferred and attempted to walk. Resident 15 was noted to have dementia and was unable to explain the fall. The investigation did not include information related to potential factors contributing to the fall such as environmental, physiological, situational or when the resident was last visualized and received cares. The investigation did not include the name of the witness or a witness statement. On 12/2/22 at 12:18 PM Staff 2 (Regional RN) stated a book with witness statements was kept but was unable to be located. Staff 2 confirmed the 11/19/22 fall investigation for Resident 15 was not thorough.