Every finding on record at Lincoln Healthcare Center

Based on record review, and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment regarding discharge and dental. This is true for two (2) of (18) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #56, #11 and #32. Facility census: 59. Findings include: a) Resident #56. A discharge medical record review of Resident #56 revealed a progress note on 05/22/25 at 12:24 PM stated that Resident #56 was discharged to the emergency room. According to the Minimum Data Set (MDS) Discharge assessment for Resident #56, with an Assessment Reference Date (ARD) May 22, 2025, Section A (Identification information) was marked Planned and was not accurately assessed for, unplanned to an acute Hospital. During an interview on 06/11/25 at 9:58 AM the Director of Nursing confirmed Resident #56's Discharge MDS was incorrect. She stated that Resident #56 discharged was unplanned to an acute hospital. b) Resident #11 During an interview on 06/09/25 at 12:19 PM, Resident #11 stated her lower dentures did not fit well and she would like to have them adjusted. The resident stated she also had upper dentures, but her upper dentures fit well. Review of Resident #11's comprehensive care plan showed the following focus, [Resident's name] is at risk for oral/dental problems d/t [due to] edentulous status, dysphagia - oral phase. Resident #11's annual minimum data set (MDS) assessment with assessment reference date (ARD) 06/02/25 answered no to the item as to whether the resident was edentulous, having no natural teeth or tooth fragments, and answered yes to the item as to whether the resident had obvious or likely cavity or broken natural teeth. On 06/11/25 at 9:32 AM, the Registered Nurse Assessment Coordinator (RNAC) confirmed Resident #11's MDS with ARD 06/02/25 was incorrect. She stated she would modify the resident's MDS to indicate the resident was edentulous. No further information was provided through the completion of the survey. c) Resident #32 During an interview of 06/09/25 at 4:09 PM, Resident #32's dentures appeared to be loose. She confirmed she had lower dentures which were loose. Review of Resident #32's medical records showed a nursing admission evaluation dated 03/18/25 that indicated the resident had her natural teeth. Review of Resident #32's comprehensive care plan showed the following focus, [Resident's name] has her own teeth with some missing/broken. Resident #32's admission MDS with ARD 10/07/24 indicated the resident was edentulous, having no natural teeth or tooth fragments. On 06/11/25 at 9:12 AM, the Director of Nursing confirmed Resident #32's admission MDS with ARD 10/07/24 was incorrect. She stated Resident #32 had some natural teeth with lower partial dentures. She stated the MDS would be modified to correct this item. No further information was provided through the completion of the survey. The facility failed to ensure a complete and accurate MDS.

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure enhanced barrier precautions for a resident with a chronic wound. This was true for one (1) of three (3) residents reviewed for the care area of transmission-based precautions. Resident Identifier: #14. Facility census: 59. a) Resident #14 The facility's policy titled, Enhanced Barrier Precautions, with effective date 04/14/22 and revision date 02/02/23 stated enhanced barrier precautions apply to residents with infection or colonization with a novel or targeted multi-drug-resistant organisms when contact precautions do not apply. According to guidance from the Centers for Disease Control and Prevention, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, available on-line, enhanced barrier precautions generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, and chronic venous stasis ulcers. Review of Resident #14's medical records showed the resident received daily dressing changes to diabetic ulcers to the second and third toes of her left foot. Assessments on 06/10/25 showed the wounds measured 1.3 centimeters (cm) by 1.1 cm by 0.2 cm and 0.8 cm by 1.0 cm by 0.1 cm. The resident did not have a physician's order for enhanced barrier precautions. However, the resident's comprehensive care plan had an intervention initiated 06/26/24 for, Enhanced barrier precautions when dressing/bathing/showering/ transferring/personal hygiene, changing linens, toileting, and peri-care, providing care to wound care for skin openings that require a dressing. During multiple observations on 06/09/25, 06/10/25, and 06/11/25, Resident #11 did not have signage on her door to indicate she required enhanced barrier precautions. During an interview, on 06/11/25 at 10:09 AM, the Director of Nursing (DON) confirmed Resident #11's comprehensive care plan indicated the resident was in enhanced barrier precautions. The DON stated the back of the resident's door had a caddy containing personal protective equipment. She stated the caddy indicated to staff the resident required enhanced barrier precautions. However, she stated Resident #11 should have a sign. On 06/11/25 at 10:57 AM, the Infection Preventionist stated Resident #11 did not require enhanced barrier precautions because her wounds were very small. The Infection Preventionist stated this information came from the corporate office, but she might have misunderstood. No further information was provided through the completion of the survey.

Based on resident interview, record review and staff interview, the facility failed to follow a physician's order for therapy screening for one (1) of one (1) residents reviewed for the care area of position/mobility. Resident identifier: #11. Facility census: 59. Findings included: a) Resident #11 During an interview on 06/09/25 at 12:24 PM, Resident #11 stated she had a diagnosis of multiple sclerosis. She stated she had no movement of her lower extremities and limited movement of her upper extremities. Resident #11 stated she was not currently receiving physical therapy. However, she stated she independently works on moving her arms and straightening out her fingers every day. Review of Resident #11's medical records showed the resident was transferred to the hospital at approximately 3:00 AM on 03/28/25 for flu-like symptoms. The resident also reported an increased upper extremity weakness. The resident was evaluated by a neurologist whose final report on 03/28/25 at 5:01 PM stated, Arm strength bilaterally is improved today compared to yesterday - she is not at her baseline but there is definitely improvement .She would benefit from rehab directed at her UEs [upper extremities] at the facility. Resident #11 returned to the facility on [DATE]. The resident's medical records showed a physician's order for PT [physical therapy], OT [occupational therapy], ST [speech therapy] to evaluate. There was no order date, but the order was revised on 03/29/25. The order had been discontinued, with an end date of 04/03/25. During an interview on 06/11/25 at 2:10 PM, the Director of Therapy Services stated the therapy department had not received a screening request for Resident #11 around 03/29/25. She stated that an order for therapy services or therapy screening does not go directly to the therapy department. She stated when a therapy screening order is entered into the electronic medical records system, nursing needs to follow-up with the order by sending it to the therapy department. The Director of Therapy Services stated the therapy department was not aware of the order for therapy screening around 03/29/25 and was not aware of the discharging hospital's recommendation for therapy. She stated Resident #11 was scheduled for her quarterly therapy screening today (06/11/25). According to documents provided by the Director of Therapy Services, Resident #11 received occupational therapy from 01/30/25 to 02/26/25 to improve ability to reach for objects and improve ability to feed herself using adaptive aids. No further information was provided through the completion of the survey process.

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Signage for Enhanced Barrier Precautions (EBP) was not placed in a location that could be viewed by everyone entering the residents' rooms. This was true for four (4) of four (4) residents reviewed for the care area of transmission-based precautions (TBP). Resident identifiers: #16, #51, #45, and #22. Facility census: 59. Findings included: a) Policy review The facility's policy regarding Enhanced Barrier Precautions (EBP) with effective date 04/14/22 and most recent revision date 02/02/23 stated, Ensure appropriate signage is placed at the entrance of the resident room. b) Resident #45 Review of Resident #45's physician's orders showed the following order written on 06/09/23: Enhanced barrier precautions related to: hx [history] of MRSA [Methicillin-resistant Staphylococcus aureus] when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to resident with history of or colonized multi-drug resistant organism. On 10/02/23 at 12:30 PM, the entrance to Resident #45's room was observed. There was no signage indicating the resident was on Enhanced Barrier Precautions. No Personal Protective Equipment (PPE) was noted. On 10/02/23 at 12:37 PM, the Regional Director of Clinical Operations (RDCO) confirmed the resident was on enhanced barrier precautions. He demonstrated the back of the resident's door had a sign indicating the resident was on enhanced barrier precautions and also a hanger containing PPE. He stated he would move the signage to the front of the door. On 10/02/23 at 12:44 PM, the RDCO stated he had spoken to the regional infection preventionist who had instructed for the sign and PPE to be placed on the back of the resident's door where they could be seen and accessed by staff who closed the door to provide care. c) Resident #51 Review of Resident #51's physician's orders showed the following order written on 08/21/23: Enhanced barrier precautions related to: hx of ESBL [Extended Spectrum Beta-Lactamase] when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to resident with history of or colonized multi-drug resistant organism. On 10/03/23 at 09:35 AM, signage for EBP and PPE were noted on the back of Resident #51's door. The entrance to the resident's door contained no signage. d) Resident #22 Review of Resident #22's physician's orders showed the following order written on 08/21/23: Enhanced barrier precautions related to: hx of ESBL [Extended Spectrum Beta-Lactamase] when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to resident with history of or colonized multi-drug resistant organism. On 10/03/23 at 09:38 AM, signage for EBP and PPE were noted on the back of Resident #22's door. The entrance to the resident's door contained no signage. e) Resident #16 Review of Resident #16's physician's orders showed the following order written on 06/09/23: Enhanced barrier precautions related to: hx of ESBL [Extended Spectrum Beta-Lactamase] when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to resident with history of or colonized multi-drug resistant organism. On 10/03/23 at 09:40 AM, signage for EBP and PPE were noted on the back of Resident #16's door. The entrance to the resident's door contained no signage. f) Interview During an interview on 10/03/23 at 09:55 AM, the RDCO confirmed the residents' EBP signage was placed on the back of the residents' doors although the facility's policy specified the signage was to be placed at the entrance to the residents' rooms. The RDCO was informed by the surveyor that there could be interaction with the resident or residents' environment that would not involve closing the resident's door, such as changing the residents' bed linens. In these cases, the signage would not be seen by those providing care. The RDCO stated he understood, and signage would be placed on the front of the residents' doors.

Based on observations and staff interviews, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the floor of the walk-in freezer was dirty. The racks holding the cups, bowls, and thermal warmers needed to be cleaned. This had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 59. Findings included: a) Kitchen tour During the kitchen tour on 10/02/23 at 11:15 AM, it was discovered the floor of the walk-in freezer had debris along the back wall. The bowls, cups, glasses were stored rim down on racks and the thermal plate warmers were also stored on racks with a crusted dust build up. An interview with the Dietary Manager on 10/02/23 at 11:25 AM, verified the floor of the walk-in freezer was dirty and needed to be cleaned. She also agreed the racks storing the cups, bowls, glasses and thermal plate warmers were crusted with dust.

Based on observations and staff interview the facility failed to ensure an appropriate pest control program. This deficient practice had the potential to affect all residents dining or attending activities in this area. A random opportunity for discovery revealed a swarm of gnats in and around the uncovered trash can located in the dining room. Facility census: 59. Findings included: a) Pest control During a random observation of the dining room on 10/02/23 at 11:35 AM, it was discovered a trash can did not have a lid and when the Director of Plant Maintenance (DPM) moved the trash can gnats swarmed from the trash can. On 10/02/23 at 11:35 AM the DPM reported he was instructed to have the trash can removed from the dining room and it was not to be used until the new replacement lid arrived. He also reported he had ordered the replacement lid last week and he had not removed the trash can timely.

.Based on record review and staff interview, the facility failed to ensure the completion of a new Preadmission Screening and Resident Review (PASARR) for a resident with a newly added psychiatric diagnosis. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the PASARR care area. Resident identifier: #14. Facility census: 59. Findings included: a) Resident #14 Review of Resident #14's medical records showed the resident's most recent Preadmission Screening and Resident Review (PASARR) was performed on 08/29/2019. The mental illness and intellectual disability assessment in the PASARR showed current diagnoses of seizure disorder and schizophrenic disorder. Level II evaluation was determined to not be required. Review of Resident #14's diagnosis report showed on 10/10/22 a history of bipolar disorder was added to the resident's diagnosis list. During an interview on 10/03/23 at 2:09, the Social Worker confirmed that when a history of bipolar disorder was added to Resident #14's diagnosis list, a new PASARR was not completed completed to determine whether continued long-term care placement was appropriate. No further information was provided throughout the completion of the survey.

Based on medical record reviews and staff interviews the facility failed to ensure resident's Physician's Order for Scope of Treatment (POST) forms conveying their end of life wishes were complete. The POST forms were not completed per directions specified by the [NAME] Virginia Center for End-of-Life Care. This was true for two (2) of 15 POST forms reviewed for the Long-Term Care Survey Process. Resident Identifiers: #13 and #4. Facility Census: 59. Findings included: a) Resident #13 A medical record review on 10/03/23 for Resident #13 revealed the POST form completed on 08/12/22 was incomplete. Section F did not contain the physician's phone number. In an interview on 10/03/23 at 11:30 AM with the Regional Director for Clinical Operations (RDCO) verified the POST form for Resident #13 did not include the physician's phone number. b) Resident #4 A medical record review on 10/03/23 for Resident #4 revealed the POST form completed on 12/19/22 was incomplete. Section F did not contain the physician's phone number. In an interview on 10/03/23 at 11:35 AM with RDCO verified the POST form for Resident #4 did not include the physician's phone number.

Based on observations, record reviews and staff interviews the facility failed to provide respiratory care and services in accordance with professional standards of practice. This deficient practice affected two (2) of two (2) residents reviewed for respiratory care. Residents #158 and #29 were not receiving oxygen therapy at the correct flow rate. Resident identifiers: #158 and #29 Facility census: 59. Findings included: a) Resident #158 During an observation for Resident #158 on 10/02/23 at 11:42 AM, it was discovered the oxygen concentrator was administering oxygen at a flow rate of three (3) liters per minute (lpm) and not the prescribed two (2) lpm. A record review on 10/02/23 revealed Resident #158 had an order to receive oxygen therapy at two (2) lpm. The Regional Director for Clinical Operations ([NAME]) on 10/02/23 at 11:44 AM verified the oxygen concentrator flow rate was set on three (3) lpm and not the correct two (2) lpm as ordered. b) Resident #29 During an observation for Resident #29 on 10/02/23 at 11:46 AM, it was discovered the oxygen concentrator was administering oxygen at a flow rate of three (3) lpm and not the prescribed two (2) lpm. A record review on 10/02/23 revealed Resident #29 had an order to receive oxygen therapy at two (2) lpm. The Regional Director for Clinical Operations ([NAME]) on 10/02/23 at 11:48 AM verified the oxygen concentrator flow rate was set on three (3) lpm and not the correct two (2) lpm as ordered.

Based on record review and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice was true for (1) of one (1) resident reviewed for the care area of tube feeding. Resident #2 had an order for weights to be done every Sunday and this was not done as ordered. Resident identifier: #2. Facility census: 59. Findings included: a) Resident #2 During a medical record review on 10/03/23 Resident #2 had an order for weekly weights to be done on day shift every Sunday with a start date of 05/28/23. A review of the weights recorded since 05/28/23 indicated there were no recorded weights on Sunday 06/04/23, 07/09/23 and 09/03/23. Instead, the weights were obtained on Wednesday 06/07/23, 07/12/23 and 09/06/23. An interview on 10/03/23 at 1:30 PM with the Regional Director for Clinical Operations (RDCO) verified the weights were not obtained on Sunday as ordered.

.Based on record review and staff interview, the facility failed to ensure the development of a comprehensive care plan in the area of weight loss for one (1) of two (2) residents reviewed for the care area of nutrition. Resident identifier: #24. Facility census: 59. Findings included: a) Resident #24 Review of Resident #24's weights showed on 03/05/2023, the resident weighed 96 pounds (lbs) and on 09/06/2023, the resident weighed 85 lbs. This was an 11% weight loss in six (6) months. Review of Resident #24's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 08/01/23 showed the resident had a weight loss of 5% or more in the last month or a loss of 10% or more in the last six (6) months. Resident #24's current comprehensive care plan did not contain a focus related to potential or actual weight loss. During an interview on 10/03/23 at 12:26 PM, the Clinical Care Specialist confirmed Resident #24's current comprehensive care plan did not contain a focus related to weight loss.

Based on record review and staff interview, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified when four (4) of five Resident's reviewed for the care area of hospitalization were discharged to the hospital. Resident identifier: #55, #57, #9, and #5. Facility census: 57. Findings included: a) Resident #55 Review medical records for Resident #55 revealed a transfer to a local hospital for low blood pressure and labs that indicated an infection on 04/13/21. On 05/17/22 at 3:38 PM, the Director of Nursing (DON) confirmed the ombudsman has not been notified of the transfer. b) Resident #57 During a review of medical records revealed Resident # 57 was transferred to a local hospital for [CONDITION(S)] on 08/17/21. On 05/17/22 at 3:38 PM, the Director of Nursing (DON) confirmed the ombudsman has not been notified of the transfer. c) Resident #9 On 05/17/22 at 9:15 AM, a medical record review was completed for Resident #9. The record review did not find a notification to the State Ombudsman for a transfer to an acute care facility on 02/08/22. On 05/18/22 at approximately 1:30 PM, the Director of Nursing (DON) stated, I can't find any information on the transfer. d) Resident #5 Record review on 05/17/22 found Resident #5 was transferred to the hospital for a low hemoglobin and hematocrit (H&H) and bleeding from abdominal wounds on 04/09/22. On 05/17/22 at 3:38 PM, the Director of Nursing (DON) confirmed the ombudsman has not been notified of the transfer.

Based on record review and staff interview, the facility failed to ensure six (6) of thirteen Residents reviewed for the care area of advance directives had the West Virginia Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: #5, #54, #355, #15, #50, and #51. Census: 57. Findings included: a) Resident #5 Record review found the resident's responsible party completed a copy of the 2020 POST form on [DATE]. The form indicated verbal consent was obtained from the resident's health care surrogate (HCS) with 2 facility witnesses. The POST form directed: Do Not Resuscitate (DNR) with limited interventions, intravenous (IV) fluids for ,d+[DATE] days and a feeding tube-long term. On [DATE] at 10:33 AM, the Director of Nursing (DON) confirmed the POST form had not been signed by the HCS. Review of the booklet, Using The Post Form, Guidance for Healthcare Professionals, 2020 Edition, states: The patient or representative/surrogate and physician/APRN/PA must sign the form in this section. These signatures are mandatory. A form lacking these signature is NOT valid. b) Resident #54 Medical record review found the resident was admitted to the facility on [DATE]. On [DATE] the resident completed a post form saying she wanted cardiopulmonary resuscitation (CPR) with full interventions, a feeding tube and IV (intravenous) fluids for ,d+[DATE] days. The resident did not initial Section D, which states: If I lose decision making capacity and my condition significantly deteriorates, I give permission to my MPOA (Medical Power of Attorney)representative/surrogate to make decisions and to complete a new form with my MD/DO/APRN/PA (physician) in accordance with my expressed wishes for such a condition or, if these wishes are unknown or not reasonable ascertainable, my best interests. On [DATE] The resident's daughter, the health care surrogate (HCS) completed a new post form and directed the following: do not resuscitate, limited interventions, IV fluids for ,d+[DATE] days and a feeding tube. On [DATE] the resident's physician appointed a new health care surrogate. The reason for the new appointment was, the daughter was removed by DHHR (Department of Health and Human Resources) for financial exploitation. On [DATE] the resident's son who was appointed the new HCS completed a post form directing: No CPR, comfort - focused treatments, and no artificial means of nutrition desired. On [DATE] at 8:52 AM, the Director of Nursing (DON) confirmed the resident did give consent to her medical representative to change any of the advance directives. c) Resident #355 Record review found the resident was admitted to the facility on [DATE]. On [DATE] the resident's son completed a POST form for the resident. On [DATE] the physician determined the resident had capacity to make medical decisions. On [DATE] at 01:01 PM, the DON was asked why the resident's son completed the POST form when the resident has capacity. In addition, there was no indication in the medical record the son had any legal authority to make medical decisions for the resident and no indication the Resident ask the son to assist with the POST form. On [DATE] at 9:37 AM, the DON said, I don't know why his son completed the form, we are correcting the POST form now. d) Resident #15 Medical record review on [DATE] at 1:00 PM, found a WV POST form, signed and dated [DATE], by the Resident. The WV POST form was not signed or dated by the individual completing the form. During an interview with the Director of Nursing (DON) on [DATE] at 9:43 AM, she acknowledged the POST form was void of signature and date of the individual completing the form. The DON confirmed the POST form was not completed in its entirety. e) Resident #50 Medical record review on [DATE] at 1:52 PM found a WV POST form signed and dated by the physician on [DATE]. The Patient Information Section was void of the last 4 (four) digits of the social security number and date of Birth of Resident #50. During an interview with the Director of Nursing (DON) on [DATE] at 9:15 AM, she acknowledged the POST form was void of the last of the social security number. The DON confirmed the POST form was not completed in its entirety. f) Resident #51 Review of medical records on [DATE] at 12:52 PM, found the Post form for Resident #51, did not have the signature of the Health Care Surrogate. The post form was dated, [DATE]. During an interview on [DATE] at 11:00 PM, the DON agreed the Post form was not signed by the health care surrogate.

Based on record review and staff interview, the facility failed to revise Resident #5's care plan when pressure ulcers resolved. This was true for one (1) of four (4) residents reviewed for the care area of pressure ulcers. Resident identifier: #5. Facility census: 57. Findings included: a) Resident #5 Review of the resident's current care plan found the focus: (Name of resident) has the potential for additional pressure ulcer development r/t (related to) impaired mobility, impaired sensation, incontinence, terminal prognosis, history of pressure ulcers and current pressure ulcers to right medial foot, right ankle, left lateral ankle. At 11:15 AM on 05/17/22, the Director of Nursing (DON) and the Clinical Care Supervisor (CCS) #17 confirmed the care plan had not been updated when two (2) of the three (3) pressure ulcers healed/resolved. CCS #17 provided documentation confirming the area on the right front ankle resolved on 03/25/22. The pressure area on the right medial foot resolved on 05/03/22.

Based on record review and staff interview the facility failed to develop a comprehensive care plan for Resident #51 for accidents/falls. This failed practice was true for one (1) out of 13 residents reviewed for care plans. Facility census 57. Findings included: a.) Resident #51 Medical record review found Resident #51 fell from the wheelchair on 03/30/22 and 04/13/22. A review of the care plan found the facility failed to develop a new care plan for actual falls and interventions to prevent further falls from occurring. The current care plan is as follows: Focus: Resident # 51 is at risk for falls related to confusion, incontinence, psychoactive drug use, Alzheimer's, [CONDITION(S)]. Goal: Patient will be free of falls through the review date: Interventions/task: Ask the patient to demonstrate operation of the call light as needed. Ensure call light is within reach and encourage patient to use it to call for assistance as needed. Respond promptly to requests for assistance. Provide a safe environment for the patient by observing the condition of his/her room every shift and correcting any identified issues PT (physical therapy) evaluate and treat as ordered or PRN (as needed.) On 05/17/22 at 1:30 PM, the Director of Nursing (DON) agreed the facility failed to update the care plan.

Based on record review, policy review, and staff interview the facility failed to communicate necessary information to the resident, continuing care provider and other authorized persons at the time of discharge. The facility failed to dictate a discharge summary at the time of discharge. This had the potential to effect one (1) of one (1) Resident reviewed for discharge during the long term care survey process. Resident identifier # 54. Facility Census 57. Findings Included: a) Resident # 54 A review of a facility provided policy labeled Discharge of a Resident found the following: .a discharge summary and post-discharge plan of care will be developed to assist the resident in his/her new living environment and will be provided to the resident at or before the time of discharge . .8. When the facility discharges a resident to a health care institution or provider, documentation must include: h) All other necessary information, including a copy of the resident discharge summary . A review of Resident # 54 medical records revealed an acute care transfer note with a date of 09/04/21 that read as follows: Patient is being transferred to: (Name of a local hospital.) Reason for Transfer: increased confusion, refusing medication, and labs. Family request resident be sent to hospital. A continued review of the medical record found a general patient note with a date of 09/07/21 that read: Patient discharged home from hospital. A further review of the medical record failed to reveal a discharge summary. On 05/17/22 at 8:47 AM, the Director of Nursing (DON) acknowledged no discharged summery had been dictated for Resident #20. The DON stated We had identified this as a current issue and are working on correcting the problem.

Based on observation and staff interview, the facility failed to follow physician's orders consistent with professional standards of care for oxygen therapy. This was a random opportunity for discovery. Resident identifier: #2. Facility Census: 57. Findings Included: a) Resident #2 During observation on 05/17/22 at 8:45 AM, the oxygen concentrator was noted with a setting of 4 (four) liters per minute (LPM). A review of the a physician's orders found a physician's order dated 02/12/22 for oxygen at 2 LPM via nasal cannula continuously. On 05/17/22 at 8:45 AM, Licensed Practical Nurse (LPN) #55 confirmed the oxygen concentrator setting was incorrect and should be set at 2 LPM. On 05/17/22 at 9:42 AM, the Director of Nursing (DON) was notified of the incorrect oxygen setting. No further information was obtained during the survey process.

Based on record review and staff interview, the facility failed to ensure the environment remained as free of accident hazards as possible. Resident #20 was transferred with out proper staff assistance. This was true for one (1) of three (3) residents reviewed for falls. Resident Identifier: #20. Facility Census 57. Findings Included: a) Resident # 20 A review of Resident # 20's care plan revealed a care plan focus that reads as follows: Resident # 20 has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) [CONDITION(S)], Spinal Cord trauma S/P (status post) MVA (motor vehicle accident) A further review of Resident # 20's care plan revealed care plan with interventions that reads as follows: Weight bearing status: Non weight bearing, Date Initiated: 05/04/2020 Bed mobility self-performance: Patient is assist of 2 (two) for bed mobility. Patient uses bilateral 1/2 (half) upper side rails. Date Initiated: 06/13/2018 Transfer: (redacted) Resident # 20 requires Mechanical lift for transfers with staff assistance X 2 (two) Date Initiated: 03/06/2018 A continued review of the medical records found a bed mobility task report which indicated Resident #20 had one (1) person physical assist on the following days and times in the month of May: 05/03/22 at 12:26 AM 05/04//22 at 2:50 AM 05/05/22 at 2:55 AM, 1:59 PM, and 9:53 PM 05/06/22 at 1:59 PM 05/07/22 at 12:37 PM 05/08/22 at 12:08 AM and 11:28 PM 05/10/22 at 2:30 AM and 9:06 AM 05/10/22 at 2:39 AM and 9:06 AM 05/11/22 at 1:18 AM and 1:46 PM 5//12/22 at 12:38 AM, 1:42 PM, 9:10 PM, and 11:58 PM 05/14/22 at 12:39 AM 05/15/22 at 2:22 AM 05/16/22 at 12:25 AM and 6:24 AM On 05/16/22 3:10 PM, the Director of Nursing (DON) confirmed Resident # 20 is care planned for bed mobility requiring two (2) person assist and had only one (1) person assist on the above mentioned days and times.

Based on observation, staff interview, and record review the facility failed to maintain appropriate urinary catheter care for 3 of 3 residents reviewed for catheter care. Secure devices for drain tubing of indwelling urinary catheters was not properly utilized in order to facilitate flow of urine, preventing kinking of the tubing and prevent excessive tension on the catheter. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #54, #31, #26. Facility census: 57 a) Resident #54 On 02/16/21 at 3:30 PM, observation was made of Resident #54 lying in bed utilizing a bed side drainage bag for a collection device of a suprapubic urinary catheter. Licensed Practical Nurse (LPN) #74 was asked to assist surveyor to ensure catheter was properly secured by an anchoring device. LPN #74 exposed the Residents abdomen and upper legs to reveal no anchoring device was in use. The suprapubic catheter was not secured to the abdomen by tape or to Resident's leg with a secure device. The suprapubic catheter tubing was pulled tight with tension running directly across the Resident's lower abdomen off the right side of the bed to the drainage bag that was hanging on bed rail at the midway point of the bed. b) Resident #31 On 02/16/21 at 2:40 PM observation was made of Resident lying on Resident's right side utilizing an indwelling Foley catheter with a bedside drain bag for collection. Registered Nurse (RN) #98 was asked to assist surveyor to ensure catheter secure device was in use. The Resident's indwelling catheter drainage tubing was exposed by RN #98 to reveal no secure device was in place, the drainage tube extended out of the right leg of the brief and was positioned curled up under the resident's right thigh, off the right side of the bed to the bed side drain bag at the foot of the bed. Resident #31 complained of pain around the catheter insertion site, stating it hurts all the time. The bed side drainage bag was directly touching the floor at the foot of the bed leaned up agains bed rail. RN #98 repositioned the catheter drainage tubing and moved the bedside drain bag to higher position on the bed rail. c) Resident #26 On 02/16/21 at 2:15 observation was made of Resident #26 lying in bed utilizing a bed side drain bag for a suprapubic indwelling catheter. Certified Nursing Assistance (CNA) #37 was asked to assist surveyor to ensure a catheter secure device was in use for the drainage tube. CNA #37 unfastened the right side of the Resident's brief exposed the catheter drainage tube and revealed no catheter secure device was in place. The drainage tube was not secured to the leg or taped the resident's lower abdomen. The Resident stated, I had a bowel movement and got some on the strap and they were supposed to bring me a new one. The drainage tube was stretched tight with tension at suprapubic catheter insertion site with red indentation of the tube in the Residents skin where the tube was tight against the right leg coming out of Resident's brief. d) Record Review Review of facility's policy Urinary Catheter Care Procedure, Effective date 11/18/19, revised date 2/17/20 indicated in step #11 to secure the catheter. e) Staff Interview During an interview on 2/21/21 at 11:00 AM, the Director of Nursing (DON) was asked if the expectation for proper urinary catheter maintenance was for the drainage tubes to be secured with a an applicable securement device and the DON stated, Yes we use leg straps (retaining strap worn around the leg to secure the catheter tube in place), they (Residents) should have them on. I will make sure all Residents with a catheter are looked at and have one.

Based on record review, observation and staff interview the facility failed to maintain an appropriate infection control program to prevent to the spread of infection in regard to respiratory hygiene, nephrostomy care, wound care and proper infection control procedures in the laundry room. This failed practice had the potential to affect a more than a limited number of residents. Resident identifiers: #54, #31, #1. Facility census: 57 Findings included: a) Resident #54 Respiratory Care During initial tour of the long-term survey process on 02/16/21 at 3:45 PM, Resident #54 in room A-7 was being administered humidified Oxygen (O2) via nasal cannula route at 2 L/min (liters per minute). The humidity bottle, O2 concentrator, nasal canula and tubing in use was not labeled with any information to indicate last maintenance date. A clear plastic storage supply bag was hanging from liter flow device on O2 concentrator containing O2 tubing. The bag was labeled with name of Resident #43, Room A-8, and date of 1/11/21. Licensed Practical Nurse (LPN) #74 verified that was not Residents name or room number and disposed of O2 supply bag. Review of facility's Nursing Policy, Respiratory Care revise date 11/18/19, indicated oxygen tubing and humidification should be changed every seven (7) days and as needed. The filter should also be cleaned every seven (7) days. During an interview at 4:00 PM on 2/16/21 the Director of Nursing (DON) stated, They have been placing a piece of tape on the back of the concentrator to stating the maintenance/check date, did you check there? The DON verified no information was present on the back of the O2 concentrator and verified the respiratory equipment to be noncompliant with maintenance standards and infection control precautions. The DON instructed LPN #74 to make sure they clean and maintenance the concentrator in Resident #54's room, and document it. b) Resident #54 Nephrostomy Care During observation of Nephrostomy Care performed by Registered Nurse (RN) #78 on 02/22/21 at 03:15 PM, Resident #54 Nephrostomy tube and insertion site was found to be improperly cared for. Resident #54 was assisted to a position on the side opposite of tube placement that allowed access of the Nephrostomy site on the right side of Resident's lower back, it was noted the insertion site was exposed without any type of dressing. RN #78 stated, I'm looking for the dressing, there is none on it, it's not even rolled up in the sheets. RN #78 verified the Nephrostomy insertion site did not have any type of sterile dressing or other securement device to protected it from possible infection or accidental dislodgement of the tube. The insertion site was red, slightly swollen with a small amount of thin serosanguinous drainage around tube entry site. A dime-size amount of serosanguinous drainage was present on the bed linens where the Resident had been laying on her back with the insertion site and tube exposed directly against the sheets. The stitches holding the Nephrostomy tube in place were loose allowing the tube to move in and out of the skin approximately one (1) centimeter as the resident was inhaling and exhaling. The urine draining from the Nephrostomy was a dark tea colored in the bedside drain bag and red tinge color in the drainage tube. During an interview the Director of Nursing on 2/22/21 at 4:00 PM, the DON verified the nephrostomy site should always be kept covered with a dressing to prevent the spread of infection. c) Resident #31 Indwelling Catheter Care On 02/16/21 at 2:40 PM observation was made of Resident's bed side drainage bag for the indwelling urinary catheter directly touching the floor at the foot of the bed. The drainage bag was resting on the floor leaned up against the bed rail. RN #98 verified the bed side drainage bag was not properly maintained in order to prevent spread of infection and re-located the catheter drainage bag to an appropriate placement and height on the bed rail. d) Resident #1 During an observation of pressure ulcer care on 2/23/21 at 10:22 AM, Licensed Practical Nurse (LPN) #33, entered the room failed to clean the table with a disinfectant, failed to remove a vase with flowers and balloons from between her and the supplies, and haphazardly placed three (3) paper towels on the table. LPN #33 put gloves on and removed the dressing, then changed gloves without any hand hygiene prior to placing on new gloves. LPN #33 cleaned the pressure injury with saline and 4x4 glaze, then packed the wound, then placed a dressing over the wound. There was three (3) opportunities for hand hygiene and changing gloves. f) Mop Heads Observation on 02/23/21 at 10:54 AM, Laundry worker #91 was about mop heads hanging in the soiled room to dry. Laundry worker #91 stated, the mops heads hang there to dry. Environmental Supervisor confirmed the mop heads were being dried in the soiled room. e) Laundry Room During on observation on 2/23/21 at 11:00 AM, it was discovered that the exhaust fan in the the soiled laundry room was not working. A check on the air flow from the soiled room to the clean laundry room revealed the air flow was going from soiled to clean. This was confirmed with Environmental Supervisor.

Based on medical record review, staff interview, family interview, review of hospital records, and interview with the treating physician, the facility failed to obtain timely medical intervention for one (1) of three (3) sampled residents who exhibited decreased fluid intake, decreased level of consciousness, and no urinary output. This failure resulted in harm to Resident #31 who was transferred to the hospital at the family's request and subsequently was admitted for inpatient treatment of [REDACTED]. Facility census: 58. Findings include: a) Resident #31 Review of Resident #31's medical record found this [AGE] year old female resident suffered from dysphagia and required nectar consistency fluids. Further review found she had a [DIAGNOSES REDACTED]. The resident was determined to lack the capacity to understand and make informed medical decisions, and a legal representative (Family #1) was serving as her surrogate decision-maker for all medical decisions. On 09/14/10 at 3:23 p.m., a nurse recorded in the nursing notes that blood was observed in the resident's urine. The treating physician was notified, and a urinalysis with culture and sensitivity was ordered, and the resident was ordered Bactrim DS. The resident received her first dose of Bactrim DS at 9:00 p.m. on 09/14/10. A subsequent note nursing, dated 09/15/10 at 7:20 a.m., documented the resident had decreased level of consciousness (LOC). Review of the resident's nutritional assessment, dated 02/16/10, found the resident weighed 160.6 pounds (#) at that time and required 2190 cc of fluids each day (calculated as 30 cc per kilogram (kg)). According to an interview with the director of nursing (DON - Employee #71) on 10/22/10 at 12:15 p.m., the resident's weight was 130#. At 30 cc per kg, the resident would require 1776 cc of fluid each day to maintain fluid balance. Review of the intake and output records found the resident only consumed 1020 cc on 09/13/10, 1100 cc on 09/14/10, 890 cc on 09/15/10, and no (0) cc on 09/16/10. Review of the nursing notes found an entry by a registered nurse (RN - Employee #68), dated 09/16/10 at 8:35 a.m., documenting the resident had no urinary output on the night shift. In the section of the nursing note entitled "Physician contact" was documented "N/A" (not applicable). In the section entitled "Responsible party notification" was documented also "N/A". The next nursing note, dated 1:55 p.m. on 09/16/10, documented that the physician on-call was notified of the family's request to transport Resident #31 to the emergency room for further evaluation. An interview with Family #1 (Resident #31's legal representative), at 10:10 a.m. on 10/20/10, revealed the facility did not contact her concerning the decline in her mother's medical condition. Family #1 stated she did not become aware of her mother's critical condition until she was called by a relative who was visiting the resident on the afternoon of 09/16/10. She stated that, had the facility notified her at any time, she would have requested that her mother be sent to the hospital. An interview with the licensed practical nurse (LPN - Employee #61) who worked the day shift of 09/16/10 was conducted via telephone at 1:45 p.m. on 10/21/10. She verified that a family member (not Family #1) came in to the facility close to lunch time and asked her how Resident #31 was doing. Employee #61 stated she told this family member that Resident #31 was not doing very "good" and she couldn't get her to eat or drink anything. Employee #61 stated this family member called Family #1 (the resident's legal representative), who came to the facility and decided to send the resident to the hospital. Review of Employee #61's nursing note, dated 1:13 p.m. on 09/16/10, documented the resident's nutritional supplement was withheld "due to lethargic, will not swallow at this time". A subsequent note, written by Employee #68 (the 09/15/10 night shift RN) on 09/16/10 at 1:55 p.m., documented the following, "Resident with decreased LOC and decreased V/S (vital signs). Dr. on call notified of families (sic) request for transport to ER (emergency room ) for further evaluation. Send to ER for further evaluation." A review of Resident #31's hospital record found the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician ordered intravenous fluid replacement of 5% [MEDICATION NAME] and water to run at a rate of 125 cc per hour. The resident's blood urea nitrogen was 116 mg/dl (normal 7.0 to 18.0 ml/dl), and her creatinine level was 6.0 ml/dl (normal 0.5 to 1.1 ml/dl). An interview with the treating physician, on the afternoon of 10/21/10, revealed the physician expected to be notified of any resident displaying a decreased level of consciousness and no urinary output.

Based on observation, record review, policy review, staff interviews, and review of 64CSR13 (the Nursing Home Licensure Rule), the governing body failed to ensure the facility was administered in an efficient and effective manner as evidenced by the presence of system failures in the areas of quality of care, infection control, and dietary services, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. This failure placed more than an isolated number of residents in immediate jeopardy related to the failure to ensure all staff was knowledgeable of the location of an assembled suction machine ready-for-use in the event of a medical emergency; placed all residents at risk for more than minimal harm related to an ineffective infection control program that was not based on current standards of professional practice; and presented the potential for more than minimal harm to all residents related to the facility's failure to procure the services of a qualified dietary manager during the extended absence of the dietary department supervisor. These actions resulted in findings of immediate jeopardy and substandard quality of care. The administrator of this facility was ultimately responsible for the operation of this facility, as this individual alone possessed the authority to manage the facility and make needed changed to facility systems. Facility census: 58. Findings include: a) Findings of immediate jeopardy During random observation of the resident environment on 09/15/10 at 2:20 p.m., a call for help was heard from Resident #28's room. Employee #56 was observed to retrieve the crash cart located by the nursing station and race to the resident's room. It was noted that no suction machine was present on the crash cart. Observation in Resident #28's room found Resident #28 slumped forward in his wheelchair and unresponsive to attempts by nursing staff to arouse him. Staff lifted the resident onto his bed and called for oxygen. Employee #56 was observed to search through the drawers of the crash cart and open two (2) bags of oxygen tubing without locating a nasal cannula. A staff member was heard to state, "Where's my oxygen?", when Employee #56 ran to the clean utility room to obtain a nasal cannula. Following transportation of the resident to the hospital, Employee #56 was asked, at 2:55 p.m., to locate a suction machine. Employee #56 immediately went to the crash cart and searched through the drawers without locating a suction machine. She then entered the clean utility room and searched the shelves without locating a suction machine. She then walked up the A-wing hallway, past the dining room, to the service hallway and opened the door to a room labeled nursing storage. She was searching this room for a suction machine when a records information systems clerk (Employee #47) entered the room and asked Employee #56 if she was looking for a suction machine. Employee #56 stated that she was looking for a suction machine for the crash cart. Employee #47 stated that suction machines were on the crash carts in the dining room and in the activities room. Employee #56 stated she did not know about suction machines in the dining room or the activities room but needed one (1) for the crash cart. Employee #47 asked Employee #56 if she checked the bottom drawer of the crash cart. Employee #56 stated that she had looked and there was no suction machine. A members of the environmental services staff (Employee #46) approached and stated that a suction machine was in the dining room and the activities room. He located an unassembled suction machine in a drawer in the dining room at 3:02 p.m., a total of seven and one-half (7.5) minutes after the first request was made for the location of a suction machine. Employee #46 was then asked to locate the suction machine in the activities room. He entered the activities room, pointed to an empty section of counter and stated, "It should be right there." There was no suction machine located in the activity room at that time. -- At 3:05 p.m., nursing staff members present at the nursing station were asked for the list of items to be kept on the crash cart. The staff members stated the list was kept in the top drawer of the crash cart. All the drawers of the crash cart were searched with no list being located. At 3:15 p.m., the director of nursing (DON) was asked to provide the list of items to be kept on the crash cart. She was unable to provide one and stated that she would look for it. This surveyor located the list in a stack of folders on top of a shelf in the nursing station at 3:40 p.m. The nursing staff members confirmed this was the list used for the crash cart. Review of the document entitled "Crash Cart Contents" found the following information: "Top Of Cart - Extra Back Board (1) Suction Machine (1) Nebulizer (1) Adult Manual Resuscitator with Mask (1)...". At 3:45 p.m. on 09/15/10, the administrator was informed that the facility placed residents in immediate jeopardy of injury or death by the failure to ensure that a suction machine was kept assembled and readily available for use during a choking emergency. The immediate jeopardy was abated at 4:08 p.m. on 09/15/10, when staff assembled a suction machine, placed it on top of the crash cart, and inserviced all personnel present on its use and location. (See citation at F309 for additional details.) -- b) Infection control 1. Residents #55, #50, #40, #53, #35, #58, #48, and #29 Review of facility's infection control logs, on the afternoon of 09/20/10, revealed Residents #55, #50, #40, #53, #35, #58, #48, and #29 contracted a nosocomial UTI during the month of July 2010. Observation of incontinence care for an uncircumcised male (Resident #4), on 09/20/10 at 2:20 p.m., found the nursing assistant (NA - Employee #16) utilizing a soapy washcloth to cleanse the resident's pubis. She then made one (1) downward stroke with the washcloth toward the resident's urethra. Employee #16 did not retract the resident's foreskin to cleanse this area. This practice placed Resident #4 at risk of contracting a UTI from the contaminated washcloth utilized to first cleanse his pubis. Failing to first cleanse the resident's meatus and area under the foreskin, prior to cleansing the pubis, introduced organisms to the resident's urethra and placed him at risk of infection. The director of nursing (DON - Employee #66) was advised of the above observation and provided a policy on perineal care at 3:00 p.m. on 09/20/10. Review of the perineal care policy (revised 05/01/06), under the section entitled "Steps in the Procedure", found the following: "10. For a male resident:... b. Wash perineal area starting with the urethra and working outward... (1) Retract foreskin of the uncircumcised male." Employee #66 was asked for evidence that staff members had been inserviced on proper perineal care, as this is a common source of UTIs. She provided evidence of an inservice for perineal care dated 07/23/09, as being the last inservice given on this topic. When asked, on 09/21/10 at 11:05 a.m., for evidence that the facility conducted an investigation into the causal factors related to the nosocomial UTIs for July 2010, the DON could provide no evidence of any investigation conducted by the facility. - 2. Residents #5, #17, #30, #39, #52, and #59 Further review of the facility's infection control logs found that the six (6) residents identified above contracted nosocomial UTIs requiring the use of antibiotics in the month of August 2010. - 3. As of 09/21/10, the facility could provide no evidence to reflect an investigation had been conducted into the causal factors related to fourteen (14) facility residents requiring medical treatment for [REDACTED]. Additionally, the facility failed to assure that nursing staff was provided appropriate training and monitoring related to the provision of perineal care. (See citation at 441 for additional details.) -- c) Dietary department On 09/16/10 at 10:30 a.m., a request was made to speak with the dietary manager, to obtain a list of residents who regularly eat in their room. Employee #33 provided the list and was identified as being the acting dietary supervisor. Review of the numbered list of employees provided by the facility found that Employee #33 held the title of dietary services assistant and Employee #37 was identified as the dietary services supervisor. The administrator was asked, on the morning of 09/16/10, if Employee #33 was a certified dietary manager. He stated Employee #33 was not certified and was taking the place of Employee #37 while she was on maternity leave. He stated Employee #37 had been absent since the last of August 2010 and was unable to determine how long she would remain absent. Review of Employee #37's payroll records found her to be absent as of 08/20/10. Review of 64CSR13-8.15.a.3. found the following: "The dietary manager, under the direction of the dietitian, is responsible for the daily operation of the dietetic service." Review of 64CSR13-8.15.a.2.A. through C. of the nursing home licensure rule found the following: "A dietary manager shall be employed if a dietitian is not employed full-time and shall be one of the following: "- A dietetic technician, registered by the American Dietetic Association; "- A certified dietary manager, as certified by the Dietary Manager's Association; or "- A graduate of an associate or baccalaureate degree program in foods and nutrition or food service management." The facility provided no evidence that a qualified dietary manager was present to oversee the daily operations of the dietetic department. (See citation at F492 for additional details.) .

Based on observation, staff interview, review of the facility's list of items to be kept on the crash cart, and review of facility documents, the facility failed to ensure an assembled, readily available suction machine was present in the event of a choking emergency. A facility licensed practical nurse (LPN - Employee #56) brought the crash cart from the nursing station to the room of a resident found to be nonresponsive (Resident #28). Employee #56 was observed to be unable to locate a nasal cannula on the crash cart for administration of oxygen to the resident. It was further noted that the crash cart did not contain a suction machine in the event this resident required suctioning to clear his airway. Following the transportation of Resident #28 to the hospital, Employee #56 was asked to locate a suction machine for use in a choking emergency. Employee #56 searched the drawers of the crash cart, the clean utility room, and the nursing storage room without locating a suction machine. With the assistance of the records information systems clerk (Employee #47) and a member of environmental services (Employee #46), an unassembled suction machine was located in a drawer in the dining room. Seven and one-half (7.5) minutes elapsed before staff could locate a suction machine in the building. The facility identified fourteen (14) residents with swallowing problems and/or who were fed by gastrostomy tube with a facility census of fifty-eight (58) residents. Residents #24, #21, #23, #44, #33, #20, #9, #32, #10, #26, #17, #22, #43, and #56 were placed at risk of serious injury or death from choking should they aspirate food or fluids without a suction machine assembled, readily available, and all staff having knowledge of its location. The administrator was notified that the inability of staff to locate a suction machine in a timely manner placed the fourteen (14) residents with swallowing difficulties in immediate jeopardy of injury or death in the event of a choking emergency. The immediate jeopardy was abated at 4:08 p.m. on 09/15/10, when staff assembled a suction machine, placed it on top of the crash cart, and inserviced all personnel present on its use and location. Resident identifiers: #24, #21, #23, #44, #33, #20, #9, #32, #10, #26, #17, #22, #43, and #56. Facility census: 58. Findings include: a) During random observation of the resident environment on 09/15/10 at 2:20 p.m., a call for help was heard from Resident #28's room. Employee #56 was observed to retrieve the crash cart located by the nursing station and race to the resident's room. It was noted that no suction machine was present on the crash cart. Observation in Resident #28's room found Resident #28 slumped forward in his wheelchair and unresponsive to attempts by nursing staff to arouse him. Staff lifted the resident onto his bed and called for oxygen. Employee #56 was observed to search through the drawers of the crash cart and open two (2) bags of oxygen tubing without locating a nasal cannula. A staff member was heard to state, "Where's my oxygen?", when Employee #56 ran to the clean utility room to obtain a nasal cannula. Following transportation of the resident to the hospital, Employee #56 was asked, at 2:55 p.m., to locate a suction machine. Employee #56 immediately went to the crash cart and searched through the drawers without locating a suction machine. She then entered the clean utility room and searched the shelves without locating a suction machine. She then walked up the A-wing hallway, past the dining room, to the service hallway and opened the door to a room labeled nursing storage. She was searching this room for a suction machine when a records information systems clerk (Employee #47) entered the room and asked Employee #56 if she was looking for a suction machine. Employee #56 stated that she was looking for a suction machine for the crash cart. Employee #47 stated that suction machines were on the crash carts in the dining room and in the activities room. Employee #56 stated she did not know about suction machines in the dining room or the activities room but needed one (1) for the crash cart. Employee #47 asked Employee #56 if she checked the bottom drawer of the crash cart. Employee #56 stated that she had looked and there was no suction machine. A members of the environmental services staff (Employee #46) approached and stated that a suction machine was in the dining room and the activities room. He located an unassembled suction machine in a drawer in the dining room at 3:02 p.m., a total of seven and one-half (7.5) minutes after the first request was made for the location of a suction machine. Employee #46 was then asked to locate the suction machine in the activities room. He entered the activities room, pointed to an empty section of counter and stated, "It should be right there." There was no suction machine located in the activity room at that time. -- At 3:05 p.m., nursing staff members present at the nursing station were asked for the list of items to be kept on the crash cart. The staff members stated the list was kept in the top drawer of the crash cart. All the drawers of the crash cart were searched with no list being located. At 3:15 p.m., the director of nursing (DON) was asked to provide the list of items to be kept on the crash cart. She was unable to provide one and stated that she would look for it. This surveyor located the list in a stack of folders on top of a shelf in the nursing station at 3:40 p.m. The nursing staff members confirmed this was the list used for the crash cart. Review of the document entitled "Crash Cart Contents" found the following information: "Top Of Cart - Extra Back Board (1) Suction Machine (1) Nebulizer (1) Adult Manual Resuscitator with Mask (1)...". At 3:45 p.m. on 09/15/10, the administrator was informed that the facility placed residents in immediate jeopardy of injury or death by the failure to ensure that a suction machine was kept assembled and readily available for use during a choking emergency. The immediate jeopardy was abated at 4:08 p.m. on 09/15/10, when staff assembled a suction machine, placed it on top of the crash cart, and inserviced all personnel present on its use and location. -- The administrator was asked to provide the facility's policy related to choking episodes. At 10:00 a.m. on 09/15/10, he provided a document from the nursing procedural manual, Section IV (issue date 01/15/93) entitled "Emergency Procedures General". Review of the document found the following: "A. Purpose "1. To provide a mechanism for assuring that emergency services are available to all residents, staff or visitors in time of emergency... "d) Inability to breathe due to choking... "B. Equipment... "3. Suction -- machine. "C. Procedure... "2. a. Position resident to facilitate breathing: place an airway in the resident's mouth; suction as needed;...". .