Every finding on record at Stoneybrook Retirement Community

Based on observation, interview, and record review, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. Findings included:- Review of the facility's Nursing Schedule lacked consecutive eight-hour RN coverage for the following dates:02/27/2602/28/2603/1/2603/14/2603/15/2603/29/2604/11/2604/12/2605/09/2605/10/26 On 5/13/26 at 10:15 PM, Administrative Staff A stated they have a scheduler for nursing staff, and then Administrative Nurse D would look over the scheduler. They do have as-needed (PRN) staff and verified that they did not have RN coverage on the above dates.The facility's Competent and Sufficient Staffing dated 09/24, the facility would provide enough staff with the skill sets and competencies necessary to provide care/services for all residents in accordance with resident care plans and the facility assessment. A registered nurse provides services for at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled for more than eight (8) hours, depending on the acuity of the residents.

Based on the interview and record review, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO- a public official who works to resolve resident issues in nursing facilities) when Resident (R) 17 was transferred and admitted to the hospital. Findings included:- R17's Electronic Medical Record (EMR) recorded a Nurse's Note, dated 01/11/26 at 04:02 PM, that documented R17 admitted to the hospital.R17's clinical record lacked evidence of the LTCO notification for R17's 01/11/26 hospital transfer. The facility was unable to provide evidence the LTCO was notified.On 05/12/26 at 02:04 PM, observation revealed R17 sat in a wheelchair on the patio located by the dining room exit door. On 05/14/26 at 10:21 AM, Administrative Staff A stated she was responsible for notifying LTCO when R17 was transferred to the hospital. Administrative Staff verified she had not notified them.The facility's Discharge Criteria Policy, revised 11/28/2017, documented when a resident was transferred or discharged from the facility, staff would send a copy of the discharge notice to a representative of the LTCO within 30 days.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R)1 to address smoking safety. Findings included:- R1's diagnosis included chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dementia (a progressive mental disorder characterized by failing memory and confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R1's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS documented R1 was independent with activities of daily living (ADLs), used a walker for mobility, required staff supervision in the facility, had an elopement alarm that was used daily, and smoked. R1's Elopement Care Plan, dated 04/21/26, directed staff to remind the resident the facility is her home when she asks to leave the facility. The resident had an elopement bracelet, and staff should check to function properly. R1's Care Plan lacked evidence that R1 was a smoker, and the smoking practices included safe storage and smoking material. On 05/12/26 at 04:00 PM, observation revealed R1 sat at a table on the enclosed patio. Further observation revealed staff provided R1 with a cigarette and staff lit the cigarette. R1 smoked the cigarette and used a walker and independently walked back to her room. On 05/12/26 at 03:50 PM, Administrative Nurse D verified R1 smoked and had designated smoking times. Administrative Nurse D said the resident would go out with staff supervision and staff would store her cigarettes. Administrative Nurse D verified the facility lacked a smoking care plan in the resident's electronic health record for staff to view. The Smoking policy, dated November 28, 2017, documented that the facility would offer a resident the opportunity to smoke in a safe environment withing the facility guidelines. Residents would have a smoking assessment completed. Residents requiring supervision while smoking may smoke at posted smoking times in designated areas. The facility would store all residents smoking materials at the nurses' station for residents who require supervised smoking. Smoking materials would be locked and identified with the resident's name. It would be the responsibility of the residents to notify staff if they wish to smoke at the designated smoking times. The Smoking Assessment would be completed quarterly and with any significant change in the residents' condition.

Based on observation, record review, and interview, the facility failed to provide necessary activity of daily living services to maintain good personal hygiene, including bathing, for Resident (R)1 and R26. Findings included:- R1's diagnosis included chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dementia (a progressive mental disorder characterized by failing memory and confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R1's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS documented R1 was independent with activities of daily living (ADLs) but required staff supervision for most ADL including bathing. R1's Care Plan, dated 04/21/26, lacked documentation of R1's required assistance with ADL cares including bathing. R1's bathing/shower Task documentation in the Electronic Health Record (EHR) revealed the resident was scheduled to have a shower/bath twice a week. R1 was admitted to the facility 04/20/26 and received a shower on 04/24/26 and 05/12/26 (17 days with no shower). The bathing report lacked documentation the resident refused a shower or bath. On 05/12/26 at 03:30 PM, observation revealed R1 ambulated independently from her room to the dining room and got a cup of coffee. R1 had on a red T-shirt and black pants. Her hair was uncombed and greasy. On 05/12/26 at 04:00 PM, observation revealed R1 sat at a table on the enclosed patio smoking. Further observation revealed that R1 had a red T-shirt and black pants, and her hair was uncombed and greasy. On 05/14/26 at 10:30 AM, observation revealed R1 sat at a table on the enclosed patio smoking. Further observation revealed R1 had on a red T-shirt and black pants. Her hair remained uncombed and greasy.On 05/14/26 at 11:00 AM, Administrative Staff B verified the residents had scheduled shower days and the aides documented in the electronic health record, and on shower sheets. Administrative Staff B verified the dates the resident received a shower and verified R1 did not receive her twice a week showers. Administrative Staff B verified a few days ago they assigned an aide to give the residents showers, prior to that the aides taking care of the resident would shower the residents. 2. R26's diagnoses included (a progressive mental disorder characterized by failing memory and confusion), sleep apnea (a disorder of sleep characterized by periods without respirations), hemiplegia (paralysis of one side of the body and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R26's Significant Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. The MDS documented R26 was dependent on staff for all activities of daily living (ADLs), including bathing, and used a wheelchair for mobility.R26's Care Plan, dated 02/19/26, lacked documentation of R26's required assistance with ADL cares, including bathing.R26's bathing/shower Task documentation in the Electronic Health Record (EHR) revealed the resident was scheduled to have a shower/bath twice a week on Mondays and Thursdays.R26 received a shower on the following dates:March:03/05/26 and 03/19/26 (13 days, no shower) April4/05/26 (16 days no shower) May:05/10/26 (38 days no shower)05/11/26 The bathing report lacked documentation, the resident refused a shower or bath.On 05/12/26 at 11:00 AM, observation revealed R26 sitting in a wheelchair in his room. He was dressed in street clothes. His hair was greasy and his beard and mustache were scraggly and appeared unkempt.On 05/14/26 at 11:00 AM, Administrative Staff B verified the residents had scheduled shower days, and the aides document in the electronic health record and on shower sheets. Administrative Staff B verified the dates the resident received a shower and verified R26 did not receive his twice a week showers. Administrative Staff B verified a few days ago they assigned an aide to give the residents showers, prior to that the aides taking care of the resident would shower the residents.The Bath and Shower policy, dated November 28, 2017, documented the facility would ensure residents' baths and showers are performed and documented as scheduled according to residents' preference to maintain each resident's hygiene and safety. The policy documented upon admission to the facility, the charge nurse would ask the resident what type of bath he/she preferred(showers/whirlpool) and what time of day he/she prefers to have a bath/shower. The charge nurse would add the residents name to the bath/shower schedule on the days resident prefers indicating the resident's preference of a shower or bath and on the shift that accommodates the time the resident prefers. The Director of Nursing or designated personnel would review the Bathing Report to ensure each resident is receiving a bath/shower and hair care as required.

Based on observation, record review, and interview, the facility nursing staff failed to provide adequate services to support nutrition when staff failed to consistently provide Resident (R) 5 her physician-ordered Boost Plus (nutritional drink). Findings included:- R5's Electronic Medical Record (EMR) documented R5 had a diagnosis of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R5's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R5 had no swallowing disorders, a weight of 134 pounds, and had no weight loss or gain. R5's Care Plan, revised on 04/19/26, documented that R5 was able to feed herself after her food was set up and was a picky eater. The plan documented R5 enjoyed milkshakes and preferred to drink up to five Boost Plus per day as part of her regular meal. The Physician Order, dated 11/14/25 at 05:00 PM, instructed staff to provide R5 with 240 milliliter (ml), of supplement with meals and at bedtime. Review of R5's May 2026 Medication Administration Record (MAR) revealed documentation that R5 had not received her Boost on the following dates:05/02/26 at 08:00 AM and 12:00 PM05/05/26 at 08:00 AM and 12:00 PM05/06/26 at 08:00 AM05/07/26 at 08:00 AM and 12:00 PM05/11/26-05/13/26 at 08:00 AM and 12:00 PMThe MAR noted R5 refused the Boost on 05/07/26, 05/10/26-05/13/26 at 05:00 PMOn 05/13/26 at 12:00 PM, observation revealed Licensed Nurse (LN) I brought R5 a meal tray, consisting of cooked cubed potatoes without a Boost drink. Further observation revealed R5 asked for her Boost. LN I looked in R5's mini refrigerator for the drink, and stated there were none in the refrigerator. LN I stated she would report it to the dietary department. Further observation revealed R5 reported LN I that she had been out for about a week.05/12/2026 at 12:07 PM R5 stated she knew she lost weight because she did not like the food in the facility, which was not her forte. 05/12/2026 12:40 PM, LN I stated R5 only liked cubed potatoes and her chocolate shakes, but R5 was out of the shakes. LN I stated she would only drink chocolate Boost, and the facility had to special order them because the facility's food supplier did not carry them. On 05/13/26 at 01:00 PM, R5 stated she had not received her Boost with her noon meal.On 05/14/26 at 02:40 PM, R5 stated she had not received her Boost drink for about a week because she was out of it. R5 stated she never refused the Boost.On 05/14/26 at 02:45 PM, Dietary Manager (DM) BB stated she was unaware R5 was out of Boost. DM BB stated R5's Boost was not available through the facility's dietary food supplier. DM BB stated the medication aides were to keep track of R5's supply of Boost, and if she was out, report to the business office staff, who was responsible for obtaining it from the local grocery store.On 05/14/26 at 03:00 PM, Administrative Staff C stated she was unaware R5 was out of Boost. Administrative Staff C stated the medication aides were responsible for reporting to the business office when R5 runs out of it, and staff go to the local grocery store and buy it.On 06/14/26 at 10:39 AM, Nurse Consultant GG stated he expected staff to notify nursing when R5 was out of her supplement. Staff should follow the physician's orders because she had a diagnosis of malnutrition.The facilities Physician Orders Policy, revised 09/21/2021, documented physician orders would be followed related to the care needs of individual residents.

Based on observation, interview, and record review, the facility failed to ensure Resident (R) 3's remained free from significant medication errors when staff administered seven units of insulin that had been discontinued. Findings included:- On 05/12/26 at 12:15 PM, observation revealed, after Licensed Nurse (LN) G took R3's blood sugar (the concentration of sugar present in the bloodstream), she stated that R3 did not need any sliding scale insulin (a hormone produced by the pancreas that regulates blood sugar) but did need his noon insulin. LN G's facility tablet showed R3 had an order for insulin aspart (rapid acting), seven units (u), subcutaneously, four times a day. LN G primed (the process of dialing a small, two unit does and expelling it into the air before it was injected) the insulin Flex Pen (a pre-filled, disposable insulin delivery device) and administered the insulin into his abdomen (the belly or midsection).On 05/12/26 at 12:30 PM, during record review and interview with staff, the order for the insulin was not on R3's Medication Administration Record (MAR) or Treatment Administration Record (TAR), or in the Physician Orders. Upon questioning, LN G was unable to find the active order on her desktop computer. Another nurse, LN I, stated that she never gave R3 any other insulin at noon, except for sliding scale insulin, and was unsure where LN G would have seen the order. After further investigation, looking throughout R3's EMR with Consultant GG, the inactive order was located in the Electronic Medical Record (EMR) under the Supply tab. Consultant GG researched the order and stated that R3 had an order for the seven units, along with the sliding scale insulin, but it had been discontinued on 09/30/25. Consultant GG further stated that the Supply tab was meant for the Pharmacy to document how much insulin was available for the resident at the time of that order. Consultant GG verified the order had not been removed from the EMR and that LN G should not have administered the seven units of insulin. LN G stated she would contact the physician for clarification of the order. The facility's Medication Error and Drug Reactions policy, dated 11/28/17, documented that all medication errors and drug reactions must be immediately reported to the physician, the DON, and the resident and/or their representative. A detailed account of the medication error must be recorded in the resident's clinical record. When a drug reaction or error in medication or dose occurs, the resident must be closely monitored. The vital signs are to be taken as follows: any change in the resident's vital signs, cognition, level of consciousness, or mobility must immediately be reported to the physician. The employee administering the medication error is to complete a risk watch occurrence report. The don and administrator are responsible for ensuring a thorough investigation is completed, and all med errors will be reviewed by the quality assurance committee.

Based on observation, interview, and record review, the facility failed to properly store medications when staff failed to discard Resident (R)11 insulin (a hormone that lowers the level of glucose in the blood) outdated flex pen and failed to label R3 and R6s' insulin flex pens when initially opened for use. Findings included:- On [DATE] at 08:10 AM, observation of the Rapid Recovery and Purple Pride nurse medication cart revealed R11's Humalog (rapid-acting insulin) flex pen was labeled with an open date of [DATE]. The insulin had a discard date of [DATE]. R3 and R6's Novolog (fast acting insulin) flex pen was not labeled with an open date or a discard date. On [DATE] at 08:15 AM, License Nurse (LN) H verified the nurses should date the insulin when opened and discard the outdated insulin flex pens. On [DATE] at 01:00 PM, Administrative Nurse D verified the nurse should label and date the insulin flex pens with the date opened and check the insulin flex pens for out dates and discard if expired. Medlineplus.gov directs open, unrefrigerated Novolog and Humalog can be used within 28 days; after that time, they must be discarded. The facility's Storage of Medications policy dated [DATE], documented medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are removed from the stock, disposed of accordingly to procedures for medication disposal, and recorded from the pharmacy, if a current order exists.

Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to keep Resident (R) 3's urinary catheter tubing ( thin, flexible, hollow medical tube designed to be inserted into the bladder to drain, collect, or monitor urine) from dragging on the floor underneath his wheelchair. Staff also failed to disinfect a multi-use glucometer (an instrument used to calculate blood glucose) after using it to obtain a blood sugar reading for R3. Findings included:1. On 05/12/2026 at 12:13 PM, observation revealed Linese Nurse (LN) G checked R3's blood sugar with a glucometer. Further observation revealed LN G placed the glucometer back into the bag and put it on the medication cart without disinfecting it. On 05/12/23 at 12:13 PM, LN G verified the glucometer was a multi-use glucometer and stated she thought maybe the night shift was responsible for disinfecting it. She said she was not sure what she should use to disinfect it. On 05/12/26 at 3:30 PM, Nurse Consultant (NC) GG stated all the residents should have their own glucometer, and LN G was a new nurse at the facility. Consultant GG said LN G should have disinfected the glucometer with a Sani-wipe (disinfectant wipe) before putting it away. 2. On 05/13/26 at 11:00 AM, observation revealed R3 sat in a wheelchair in the dining room with his catheter tubing underneath the seat of the wheelchair, touching the floor carpet. He propelled himself out the patio exit door with the tubing dragging on the carpeted floor and the patio cement floor. On 05/13/26 at 12:00 PM, observation revealed R3 sat in a wheelchair with his urinary catheter tubing underneath his wheelchair seat, touching the carpet floor. On 05/13/26 at 12:02 PM, LN H verified R3's tubing was touching the carpeted floor and stated it should not be. On 05/13/26 at 12:30 PM, Administrative Nurse D stated that staff should position R3's urinary catheter tubing under his wheelchair, off the floor. Upon request, the facility did not provide a urinary catheter policy regarding the placement of urinary catheter tubing or the cleaning of shared equipment.

Based on observation, interview, and record review, the facility failed to ensure that essential equipment in the kitchen was maintained in a safe operating condition, with the ice machine's top panel held on with duct tape. Findings included:- On 05/12/26 at 08:00 AM, observation in the facility kitchen revealed the ice machine's top panel lying on top of the ice machine. The ice machine's motor and internal components were exposed. On 05/12/26 at 08:10 AM, Dietary BB stated that they use duct tape to hold the panel in place due to the holes where the screws go being stripped. Dietary BB stated it had been that way for a month or two.On 05/12/26 at 10:30 AM, Maintenance U stated that the screws were stripped, and he needed to fix them. Staff had been holding the panel in place for a couple of months, and he just needed to find the right screws to fix it. On 5/13/26 at 11:50 AM, Dietary CC stated she had to unscrew the top panel of the ice machine to clean it every month, and the holes where the screw went were stripped, so they held it on with duct tape. On 5/13/26 at 12:45 PM, Administrative Staff A stated that when there is equipment that needs maintenance, it goes into the Tel's system (a web-based building management software designed to track, assign, and manage maintenance requests) so Maintenance U could fix it. Administrative Staff A stated that the panel was usually in place, but I had just been there when the duct tape had not held it in place.Upon request, a policy for maintenance of the facility was not provided.

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 13 or his representative with written information regarding the facility bed hold policy when he was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R13's Electronic Medical Record (EMR) documented R13 had a diagnosis of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections (UTI-an infection in any part of the urinary system) reaction due to having an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag), and sepsis (life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). R13's Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident required substantial to maximal staff assistance with toileting and personal hygiene. R13's Care Plan, revised 05/13/24, documented R13 had an indwelling urinary catheter, was at risk for a UTI, and instructed staff to be sure R13 kept his catheter tubing and drainage bag below his bladder so urine didn't back up into his bladder. The care plan instructed staff to let the nurse know if R13 had pain around his catheter, noticed R13's urine was dark, red, or had very little urine output when draining it, and if the urine was cloudy or if it looked like there were things floating in the urine. The care plan instructed staff if R13 had urine in his brief to assess his catheter to ensure it was not kinked, occluded (to close up or block off), or the drainage bag was too full. The Progress Note, dated 05/06/24 at 10:39 PM, documented R13 was admitted to the hospital. A review of R13's clinical record lacked evidence the resident or representative was provided the bed hold policy when he was transferred to the hospital. On 06/18/24 at 11:54 AM, observation revealed R13 sat in a wheelchair at the dining room table with clear urine in his urinary catheter tubing and the covered catheter bag was hooked underneath the seat of his wheelchair. On 06/24/24 at 11:25 AM, Administrative Staff A verified the resident had not been provided the bed hold policy when he was transferred to the hospital on 05/06/24. Administrative Staff A stated the residents are provided the bed hold policy on admission. The facility's Bed-Hold Policy, revised 11/28/17, documented that a written notice, which specifies the duration of the bed-hold policy, would be provided at the time of transfer of a resident for hospitalization or therapeutic leave. The facility failed to provide R13 or his representative with written information regarding the facility bed hold policy when he was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility.

The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to assess Resident (R) 10's ability to smoke safely. This placed R10 at risk for injury during smoking. Findings included: - R10's Electronic Medical Record (EMR) included diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), right femur (thigh-bone) fracture with routine healing, dementia (a progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and personal history of nicotine and alcohol dependence. The Admission Minimum Data Set (MDS), dated [DATE], documented R10 had refused to answer cognition questions and staff assessed R10 as modified independence with cognitive abilities. R10 had verbal behaviors directed toward others which occurred four to six days of the observation period which significantly interfered with the resident's care and put others at significant risk of physical injury. R10 rejected evaluation or care one to three days of the observation period. R10 required substantial assistance with upper body dressing and personal hygiene and was dependent for lower body dressing and toileting, sit to lying, and chair/bed transfers. The MDS further documented R10 had no current tobacco use and received an antidepressant (class of medications used to treat mood disorders), hypnotic (medication used to induce sleep), anticoagulant (medication used to prevent blood clotting), opioid (medications used to treat pain) and antiplatelet (medication used to stop blood cells from sticking together). The Behavioral Symptoms Care Area Assessment (CAA), dated 05/07/24, documented R10 had many behaviors during the observation period which included verbal outbursts, rejection of care, often yelling and cursing, and becoming agitated and upset about smoking rules. The CAA further documented R10 was provided reminders of smoking rules and policy. R10's Care Plan, dated 05/10/24, documented that R10's smoking supplies were kept locked in the nurses' station. The plan directed staff to notify R10's family members when needing more cigarettes. R10 was able to smoke safely with the supervision of a staff member at smoke breaks but needed assistance to and from the smoke breaks. The care plan further documented R10 became upset at times about the smoke breaks and rules. R10's EMR recorded a Smoking assessment dated [DATE] from a previous admission. The EMR lacked a current admission Smoking Assessment. The Progress Note dated 04/30/24 at 02:06 AM documented R10 had been yelling out throughout the shift, leaving inappropriate, threatening, voicemails on family member's phones. R10 was angry with staff about not being able to smoke at undesignated times. Staff provided R10 with a copy of the smoking rules. The note further documented that at 07:00 PM, R10 refused to come in after one cigar and staff stayed outside with R10 for 70 minutes on the smoking patio. On 06/20/24 at 01:33 PM, observation revealed R10 in the dining room and reported to the activity staff person that he and other residents wondered who was going to bring the smoking supplies. R10 also reported the residents were on time for the smoke break and staff was not there and available for the smoke time. On 06/20/24 at 01:35 PM, observation revealed facility staff brought smoking materials for residents and assisted residents outside to smoke. The staff remains outside with residents during the smoke time. On 06/20/24 at 01:53 PM, observation revealed R10 was assisted through the threshold of the patio door. R10 commented What are you looking at? though no one else was present. He then began to wheel himself through the dining room and another resident began to push his wheelchair toward his room when he remarked We are probably breaking the rules somehow. On 06/24/24 at 10:10 AM, Licensed Nurse (LN) G reported R10 was compliant with the smoking routine although they will push the time longer than the set limit. LN G reported staff had to remind him of the time frames, and staff were present during smoking time. LN G reported a smoking assessment was done on admission and changes in the resident's condition. On 06/24/24 at 10:17 AM, Administrative Nurse D reported initially the nursing staff marked no for resident smoking and that the facility had not completed a smoking assessment for the safety of the resident. The facility's Smoking policy, dated 11/28/17, documented that if a resident chooses to smoke, the facility will offer the resident the opportunity to do so in a safe environment within the guidelines. Residents who express a desire to smoke will have a Smoking Assessment completed. If the resident's smoking assessment indicates he/she is unable to smoke independently, the facility will implement a supervised smoking program. The Smoking Assessment is completed quarterly and with any significant change in the resident condition. If the assessment indicates the resident is no longer able to safely smoke independently, the supervised smoking procedures will be followed. A resident has the right to state a formal complaint or request a smoking re-assessment at any time, should they feel their smoking rights have been violated. The facility failed to evaluate R10's ability to safely smoke with R10's recent admission to the facility. This placed R10 at risk for injury during smoking.

The facility had a census of 35 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to obtain a stop date from the physician for the continued use of Ativan (antianxiety medication) as needed (PRN) for two residents, Resident (R)30 and R188. This placed the residents at risk for complications related to psychotropic (alters mood or thought) medications and unnecessary medications. Findings included: - R30's Electronic Medical Record documented diagnoses of a generalized anxiety disorder (excessive, ongoing anxiety and worry that can interfere with daily activities), convulsions (involuntary series of contractions of a group of muscles), sleep apnea (a disorder of sleep characterized by periods without respirations), obsessive-compulsive disorder (OCD- anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R30 was independent for eating and dependent on staff for all other activities of daily living (ADLs) including mobility. The MDS documented R30 received antianxiety (a class of medications that calm and relax people) medications. R30's Care Plan, dated 05/16/24, stated information regarding the medications R30 received with black box warnings (BBW- highest safety-related warning that medications can be assigned by the Food and Drug Administration) was located in the medication administration record. The care plan stated R30 often became anxious which resulted in fast-talking, restlessness, wiggling around, worried about pain, and other things. R30 had PRN Ativan if needed. The plan directed staff to administer this if needed. The plan documented R30 sometimes would press the call light repeatedly without realizing she was it when she felt anxious. She did this at times even when a staff member or her husband was right next to her. The care plan directed staff to watch for any side effects R30 may have due to the antianxiety medications such as sedation, drowsiness, or dizziness. The plan documented that sometimes instead of alerting staff that she was feeling anxious or upset, she called her husband on her cell phone and talked to him about it. Usually, he called the facility to alert staff of R30's feelings. When R30 feels anxious about her oxygen or breathing, checking her oxygen will help reassure her and calm her down. The Physician Order, dated 06/10/24, directed staff to administer Ativan, 0.5 milligrams (mg) three times daily PRN for anxiety. The order documented it was to be indefinite (no specific stop date). On 06/20/24 at 11:30 AM, observation revealed R30 in bed, awake, and Certified Medication Aide (CMA) M administered medications to her. R30 took the pills whole with water. On 06/24/24 at 1045 AM, Administrative Nurse D verified staff should have obtained a stop date for the use of PRN Ativan. The facility's Psychoactive Medication policy, dated 11/28/2017, stated PRN antianxiety, antidepressant, hypnotic, and sedative medications would be limited to 14 days unless the attending physician or prescribing practitioner believed it appropriate to extend the order. The attending physician or prescribing practitioner must document the rationale for the extended time period in the medical record and indicate a specific duration. The facility failed to obtain a stop date from the physician for the use of Ativan PRN for R30, placing the resident at risk for complications related to unnecessary psychotropic medications. 32358 - R188's Electronic Medical Record (EMR) documented R188 had a diagnosis of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R188's Quarterly Minimum Data Assessment (MDS), dated [DATE], documented R188 had a Brief Interview of Mental Status (BIMS) of 13, which indicated intact cognition. The MDS documented R188 was dependent on staff with most activities of daily living (ADLS). The MDS documented R188 had not received an antianxiety (class of medications that calm and relax people) medication during the observation period. R188's Care Plan, revised 04/09/24, documented R188 received medications that had black box warnings and instructed staff to watch R188 for the indicated reactions and notify the physician right away if they see any of them. The care plan instructed staff to leave R188 alone to either watch television (TV) or write when she became angry or agitated. The Physician Order, dated 06/14/24 at 02:34 PM, instructed staff to administer Ativan, 0.5 milligrams (mg), every four hours as needed (PRN) anxiety. The order lacked an end date for the medication. On 06/20/24 at 08:57 AM, observation revealed R188 rested quietly in bed with eyes open with oxygen on per nasal cannula at two liters. On 06/24/24 at 10:51 AM, Administrative Nurse D verified that R188's physician order for PRN Ativan lacked a stop date and stated it should have a 14-day stop date from when it was ordered. The facility's Psychoactive Medications Policy, revised 11/28/17, PRN antianxiety, antidepressant, hypnotic, and sedative time limitation 14 days order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. The facility failed to obtain a stop date on R188's PRN Ativan. This placed the resident at risk for unnecessary medications and related complications.

F655 [NAME] The facility had a census of 39 residents. The sample included three residents reviewed for quality of care. Based on record review and interview, the facility failed to develop a baseline care plan for Resident (R) 1, which addressed his immediate health needs including his below the knee amputation (surgical removal of a body part), surgical incision, and daily dressing changes. This placed the resident at risk for inappropriate care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of acquired absence of right leg below knee, acute kidney failure (the kidneys suddenly cannot filter waste from the blood), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and hypertension (high blood pressure). The Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R1 had moderately impaired cognition and required substantial to maximum assistance for upper and lower dressing, toileting, sit to stand, chair to bed, putting footwear on and off, and bathing. The MDS further documented R1 had no upper functional impairment, had lower functional impairment on one side, and had a surgical wound. The Baseline Care Plan, dated 10/19/23, documented R1 was alert, required assistance of two staff for transfers, toileting, and one staff for personal hygiene, dressing, bathing, and mobility. The care plan further documented R1 was alert and had no pain. The baseline care plan lacked mention of R1's amputation and/or the presence of a surgical incision and related treatments. R1's hospital Discharge Summary, dated 10/19/23, directed staff to keep the wound clean and dry, and continue with daily dressing changes, 4 x 4 gauze (an absorbent dressing for wounds), Kerlix (stretchy gauze bandage) and an ace wrap (provides moderate support to weak, sore muscles and joints) until seen at his follow-up appointment. The Nurse's Notes, dated 10/19/23 at 06:30 PM, documented R1's right knee skin was clean, dry and intact with sutures placed. R1 had a surgical incision, sutures were present, and the resident was on anticoagulants (blood thinner). The Nurse's Notes, dated 10/23/23 at 04:00 PM, documented R1's family member inquired about R1's dressing change to his incision and stated the surgeon requested a picture of the incision for review. The nurse's note further documented staff reviewed the Discharge Summary for dressing change orders, then removed the soiled dressing which had a moderate amount of dried blood. The note documented R1 had purplish discoloration surrounding the incision and had no odor or warmth to the incision. The dressing was changed as ordered, and staff reapplied the brace. The Treatment Administration Record, dated October 2023 lacked evidence staff provided R1's dressing changes until 10/23/23 (4 days after admission). R1 was discharged from the facility on 10/27/23. On 11/14/23 at 03:10 PM, Licensed Nurse (LN) G stated the nurse completed new admission paperwork and inputs all the orders from the physician into the computer and the following shift reviewed the admission packet to ensure no orders were missed. On 11/16/23 at 10:30 AM, Administrative Nurse D stated the baseline care plan should address his surgical wound and treatments. The facility's Care Plan policy, dated 11/28/17, documented the charge nurse was responsible for creating a baseline care plan within 48 hours after admission to be individualized to address the residents specific needs. The facility failed to develop a baseline care plan for R1, who had a new below the knee amputation and required daily dressing changes. This placed R1 at risk for inappropriate care and services due to uncommunicated care needs.

The facility had a census of 39 residents. The sample included three residents reviewed for quality of care. Based on record review and interview, the facility failed to ensure Resident (R) 1 received wound care as ordered for four days after a below the knee amputation (surgical removal of a body part). This placed the resident at risk for infection and decline. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of acquired absence of right leg below knee, acute kidney failure (the kidneys suddenly cannot filter waste from the blood), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and hypertension (high blood pressure). The Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R1 had moderately impaired cognition and required substantial to maximum assistance for upper and lower dressing, toileting, sit to stand, chair to bed, putting footwear on and off, and bathing. The MDS further documented R1 had no upper functional impairment, had lower functional impairment on one side, and had a surgical wound. The Baseline Care Plan, dated 10/19/23, documented R1 was alert, required assistance of two staff for transfers, toileting, and one staff for personal hygiene, dressing, bathing, and mobility. The care plan further documented R1 was alert and had no pain. The baseline care plan lacked mention of R1's amputation and/or the presence of a surgical incision and related treatment. R1's hospital Discharge Summary, dated 10/19/23, directed staff to keep the wound clean and dry, and continue with daily dressing changes, 4 x 4 gauze (an absorbent dressing for wounds), Kerlix (stretchy gauze bandage) and an ace wrap (provides moderate support to weak, sore muscles and joints) until seen at his follow-up appointment. The Nurse's Notes, dated 10/19/23 at 06:30 PM, documented R1's right knee skin was clean, dry and intact with sutures placed. R1 had a surgical incision, sutures were present and the resident was on anticoagulants (blood thinner). The Nurse's Notes, dated 10/23/23 at 04:00 PM, documented R1's family member inquired about R1's dressing change to his incision and stated the surgeon requested a picture of the incision for review. The nurse's note further documented staff reviewed the Discharge Summary for dressing change orders, then removed the soiled dressing which had a moderate amount of dried blood. The note documented R1 had purplish discoloration surrounding the incision, and had no odor or warmth to the incision. The dressing was changed as ordered, and staff reapplied the brace. The Treatment Administration Record, dated October 2023 lacked evidence staff provided R1's dressing changes until 10/23/23 (4 days after admission). R1 was discharged from the facility on 10/27/23. On 11/14/23 at 03:10 PM, Licensed Nurse (LN) G stated the nurse completed new admission paperwork and inputs all the orders from the physician into the computer and the following shift reviewed the admission packet to ensure no orders were missed. On 11/14/23 at 03:45 PM, Administrative Nurse D stated the dressing change order was missed upon admission and when the family member told the facility, the dressing change was immediately done and placed on the treatment record. Administrative Nurse D further stated education was provided to all the nurses and she expected each nurse to read the admission paperwork thoroughly, so orders were correct and not missed. Upon request a policy for dressing change, following physician orders, was not provided by the facility. The facility failed to ensure R1's dressing change to his surgical wound was changed daily as physician ordered. This placed the resident at risk for infection and decline.

The facility had a census of 39 residents. The sample included three residents, with two reviewed for footcare. Based on observation, record review, and interview, the facility failed to provide footcare to two sampled resident, Resident (R) 2 and R3, who had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and required foot care from a licensed nurse. This placed the residents at risk for complications including poor hygiene, discomfort, and injuries. Findings included: - The Electronic Medical Record (EMR) for R2 recorded diagnoses of diabetes mellitus type 2, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), end stage renal disease (kidneys are damaged and cannot filter blood the way they should), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition and required some assistance with self-care, dependent upon staff for toileting, substantial to maximum assistance with showers, lower body dressing, putting on footwear, and partial or moderate assistance with upper body dressing assistance. R2's Care Plan, dated 11/13/23 directed staff to assess her skin for any impairment during bathing, dressing, toileting. The plan directed staff to have a licensed nurse provide nailcare. On 11/14/23 at 11:30 AM, during wound care, R2 stated she had two sore toes, and she was prone to ingrown nails. Upon request, Licensed Nurse (LN) G removed R2's socks and looked at her feet. Observation revealed R2's toe nails were very thick, brown in color, and were grown over the tips of her toes. On 11/14/23 at 11:30 AM, LN G stated she would have R2 take a whirlpool bath the next day so that R2's toes could soak, and then she would provide R2 toenail care. LN G further stated she would have the podiatrist check R2's toenails on his next visit. On 11/14/23 at 03:34 PM, Administrative Nurse D stated she would make sure R2 was seen the next time the podiatrist came. Administrative Nurse D said she expected a LN to provide toenail care between the podiatrist visits. The facility's Foot Care policy, dated 04/27/18, documented foot care would be provided to residents to ensure they receive proper treatment and care to maintain mobility and good foot health. The facility failed to provide foot care to R2, who had overgrown toenails on both feet, This placed the resident at risk for complications and injury. - The Electronic Medical Record (EMR) for R3 documented diagnoses of diabetes mellitus type 2, candidiasis of nails (yeast infection which caused nails to separate from the finger or toes), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 was cognitively intact, and dependent upon staff for toileting, showers, putting on footwear, and substantial to maximum assistance or personal hygiene. R3's Care Plan, dated 08/24/23, initiated on 06/14/19, directed staff to help keep her fingernails and toenails short as she had trouble trimming them herself, and the care of the nails was to be done by a nurse. On 11/14/23 at 10:30 AM, observation revealed R3's feet were very dry with large flakes of skin coming off of the top and bottoms of her feet. R3's toenails were thick, brown, and grown over the tops of her toes. R3 asked Licensed Nurse (LN) H to put lotion on her feet for her. On 11/14/23 at 10:30 AM, LN H stated R3 received nailcare from the podiatrist that came to the facility, so staff did not do any nail care for her. LN H was unsure when the last time the podiatrist had been to the facility or when he was coming back. On 11/14/23 at 03:45 PM, Administrative Nurse D stated the podiatrist was at the facility the beginning of October but further stated she expected the nurse to provide toenail care between podiatry visits. The facility's Foot Care policy, dated 04/27/18, documented foot care would be provided to residents to ensure they receive proper treatment and care to maintain mobility and good foot health. The facility failed to provide foot care to R3, who had overgrown toenails on both feet, This placed the resident at risk for complications and injury.

The facility had a census of 40 residents. The sample included 14 residents, with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe, hazard free environment for Resident (R) 30, who had severe cognitive impairment and poor safety awareness. She was independently mobile and had a history of wandering throughout the facility. On 01/28/23 staff observed R30 at approximately 10:23 PM. Then, at 10:30 PM, staff noted the resident was not in her room and began a search for her. The facility staff searched every room and the perimeter outside of the facility but could not locate R30. At 11:23 PM, almost an hour after staff last saw the resident, staff located R30 on the floor in a closet, in the kitchen, which was supposed to be locked. The failure allowed R30 to wander unattended into the kitchen area, which had multiple safety hazards including a stove, knives, and chemicals stored in the unlocked kitchen closet, which placed R30 in Immediate Jeopardy. Findings included: - The Electronic Medical Record (EMR) documented R30 had diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety, mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and mood disorder category of mental health problems, feelings of sadness, helplessness, and guilt). The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], documented R30 had severely impaired cognition and required supervision with set-up assistance for locomotion. R30 was independent with transfers and ambulation. The MDS further documented R30 had an unsteady gait, no functional impairment, wandered one to three days, and had no falls. R30's Fall Care Area Assessment (CAA), dated 05/12/22, documented R30 was a fall risk due to her dementia diagnosis and she forgot her walker, at times R30 required supervision from staff to ensure she ambulated with her walker and appropriate footwear. The CAA further documented R30 wandered, at times, to places other than her room or common areas and required redirection. The Elopement Care Plan, dated 02/16/23, initiated 05/27/21, directed staff to make sure all staff members knew of R30's safety risks. Make sure R30's Wander Guard (a monitoring system that triggers alarms for residents who wander) bracelet was on her left ankle and was functioning properly every shift. Take R30's picture and keep a record of her information in case she might ever leave the building unattended, so it could be provided to anyone helping to locate her. Direct R30 to her room or in the right direction if she forgets. The update dated 11/22/22, documented if R30 became confused to her location and talked about needing to leave the facility, and was not redirectable, staff should call R30's family and have them talk to her on the phone. If R30 verbalized wanting to leave the facility or was exit seeking, and was not redirectable, staff should perform visual checks on her every 15 minutes and notify the physician. The Elopement Assessment, dated 11/19/22, documented R30 had Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and she got confused regarding location/situation. R30 wandered but did not usually exit seek at doors but did voice needing to leave the facility. The Nurse's Note, dated 01/28/23 at 10:32 PM documented staff went to R30's room and could not locate her. The staff immediately began to sweep search throughout the hall looking for the resident and alerted the Certified Nurse Aides (CNA) on duty to search other halls and other resident rooms. The note further stated when R30 could not be located, one CNA went to the other side of the building, and one went outside and looked. The DON (Director of Nursing) was contacted and notified of staff's inability to locate R30. At 11:35 PM, a staff member went into the kitchen to search for the resident and located R30 lying on the floor in a closet. R30 was alert with her head facing the closet door, feet toward the wall, and her walker was to her left. The noted documented the DON arrived, assessed the resident, and no injury was found. On 04/03/23 at 07:30 AM, observation revealed R30 walked down the hall with her walker and stopped and asked where she was supposed to go. On 04/03/23 at 12:06 PM, observation revealed the door R30 entered was a dish room door. In order to get to the closet, R30 walked across the kitchen, passing the stove and knives. The stove did not have any safety mechanisms to prevent turning on, the knobs turned freely. The butcher block holder of knives was on a shelf, approximately four feet off the floor, on the east wall. R30 walked past a food preparation table and into a closed closet. Further observation revealed the closet contained supplies, gloves, liquid [NAME] pre-soak and destainer, and Achieve floor cleaner. On 04/03/23 at 11:45 AM, Dietary Staff CC stated the door to the dish room had an automatic lock and she had not heard there were any problem with the lock when the door shut. Dietary Staff CC further stated she received education to make sure the doors to the kitchen locked when the door was shut. On 04/03/23 at 11:55 AM, Administrative Nurse D stated the incident happened during the evening when there were not any dietary staff in the building. Administrative Nurse D said the door to the kitchen dish room had a keypad lock but did not lock automatically that evening, like it usually did. Administrative Nurse D further stated she looked at the facility cameras and saw that the resident went into the kitchen dish room. Administrative Nurse D stated it had been the last place staff checked when they could not locate her. Administrative Nurse D stated another staff member went in the kitchen getting a drink for a different resident but had not noted R30 in the kitchen. Administrative Nurse D stated she contacted Maintenance Staff U immediately to check the keypad and replace it. On 04/03/23 at 12:10 PM, Dietary Staff BB stated no one in the kitchen knew there was a problem with the dish room door not locking automatically and the facility had since replaced it so that it locked when the door shuts. On 04/03/23 at 12:19 PM, Administrative Staff A stated the keypad to the dish room door was not totally replaced, but the settings were changed for the door to lock automatically, once the door closed. At 12:27 PM, Administrative Staff A stated the chemicals in the closet the resident was in were very hard to open as the lids needed to be pushed down to open. On 04/03/23 at 12:29 PM, Maintenance Staff U stated he checked the settings on the dish door keypad and noted it was set to lock after two minutes, so he changed it to lock automatically. Maintenance Staff U further stated he had not been checking the keypad on that door with his weekly checks, but had since started to do so. On 04/03/23 at 01:07 PM, an unsuccessful attempted to contact the Licensed Nurse (LN) on duty on 01/28/23, revealed she no longer worked for the facility. On 04/03/23 at 01:29 PM, CNA M stated she saw R30 wandering in the hallway as she was answering other call lights, but when she went to look for R30 in her room, the resident was not there. CNA M further stated staff looked for the resident and she went outside to look for her but could not find her until about an hour later, when staff found R30 in the closet in the kitchen. CNA M stated R30 wanted off the floor and when staff assessed her, there were no injuries. On 04/05/23 at 10:00 AM, CNA N stated staff had a lot of in-services regarding elopement and the incident with R30. The staff were also educated to keep an eye on R30 when she wandered. On 04/05/23 at 10:38 AM, LN G stated staff were educated to make sure all the doors to the kitchen locked, once they closed. The facility's Elopement policy, dated November 28, 2017, documented the facility would ensure that each resident received supervision and devices to deter elopement. And elopement risk assessment for each resident was to be completed upon admission to the facility, quarterly thereafter and with any significant change. Each resident would have his or her photograph taken, updated as needed, and the photograph would be scanned in the resident's clinical record to be kept in an area accessible to staff members. The residents care plan would be updated to ensure wandering and potential for elopement interventions are included and an elopement monitoring bracelet would be utilized if the resident was determined to be at risk for elopement in facilities equipped with such a system. The facility failed to ensure a safe, hazard free environment when an unlocked kitchen door allowed cognately impaired R30 to wander unattended into the area. The deficient practice placed R30 in Immediate Jeopardy. On 01/31/23 the facility completed the following corrective actions: 1. The Administrator contacted the Maintenance Supervisor to fix the door lock and ensure that it worked properly. 2. Certified Dietary Manager provided education to her dietary staff to double check all door locks in the kitchen area and ensure they lock properly before they exit the facility. 3. The Director of Nursing educated all facility staff regarding the incident and the importance of checking all doors in the kitchen area, maintenance area, therapy room, laundry, supply room, and the main shower room to ensure they are locked. 4. Daily check of all doors in the kitchen area will continue to ensure they are locked. The deficient practice was deemed past non-compliance and existed at a J scope and severity, due to the facility identification and implementation of correction measures, prior to the date of survey.

The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to make good faith efforts to identify multiple issues of concern for the 40 residents, who resided in the facility. This placed the residents at risk for decreased quality of care. Findings included: - Based on observation, record review, and interview, the facility failed to provide Resident (R) 30 and R20 care in a manner to maintain and enhance dignity and respect. Refer to F550. Based on observation, record review, and interview, the facility failed to notify R29's physician of a change of condition. Refer to F580. Based on record review, and interview, the facility failed to place estimated cost on the Medicare Beneficiary Notices for three residents. Refer to F582. Based on observation, record review, and interview, the facility failed to address hypertension (elevated blood pressure) medication in the comprehensive care plan for R29. Refer to F656. Based on observation, record review, and interview, the facility failed to provide routine bathing for R17, R38, and R2. Refer to F677. Based on observation, record review, and interview, the facility failed to provide quality of care for R29 who had a condition change. Refer to F684. Based on observation, record review, and interview, the facility failed to provide incontinent care for R20 and proper urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care for R33. Refer to F690. Based on observation, record review, and interview, the facility failed to provide clean and sanitary respiratory equipment for R4. Refer to F695. Based on record review, and interview, the facility failed to provide competent nursing staff for R29 who had elevated blood pressure and respiratory distress. Refer to F726. Based on observation, record review, and interview, the facility failed to provided physician ordered mental health support for R4. Refer to F740. Based on observation, record review, and observation, the facility failed to provide medically related social service support for R4. Refer to F745 Based on observation, record review, and interview, the facility failed to document medication room refrigerator temperatures. Refer to F761. Based on observation, record review, and interview, the facility failed to obtain hospice (special care to people who are near the end of life) documentation for coordination of care for R1 and R30. Based on observation, record review, and interview, the facility failed to conduct waterborne pathogen test, isolate R26 who had been exposed to COVID (a highly infectious respiratory disease) positive roommate and provide proper urinary catheter care for R33. Refer to F880. On 04/05/23 at 12:45 PM, Administrative Staff A reported she collected data from the interdisciplinary team and other sources of information for the quality assessment and assurance program that meets on a monthly basis to formulate plans of improvement. The facility's QAPI Plan, dated 06/21/22, documented the QAPI program will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice, and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action. We utilize the best available evidence (e.g. data, national benchmarks, published best practices, clinical guidelines) to define and measure our goals. The facility failed to identify multiple issues of concern for the 40 residents who reside in the facility placing the residents at risk for lack of quality care.

The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable disease and infections when the facility failed to develop a water management plan to minimize the risk for development of Legionella (type of bacteria that can cause serious lung infections) or other waterborne pathogens (agents that cause disease or infection) from entering the facility water system. The facility staff further failed to assess and document washing machine temperatures. Staff failed to isolate Resident (R) 36 after exposure to his roommate's symptomatic COVID (highly contagious, potentially fatal respiratory infection). Staff failed to perform appropriate hand hygiene when providing R33's cathter (tube inserted into the bladder to drain urine) cares. These deficient practices placed all residents at increased risk for developing an infection. Findings included: - On 04/04/23 at 08:39 AM, observation of the laundry room revealed a lack of evidence staff assessed and documented the washing machine temperatures. On 04/04/23 at 08:39 AM, Laundry Staff (LS) V stated he checked the washing machine temperature every morning but did not document it. On 04/04/23 at 11:09 AM, Maintenance Staff (MS) U stated he checked the washing machine temperature daily but did not document it. MS U stated he was unaware he needed to document them. On 04/04/23 at 12:42 PM, when asked to see the facility's water management plan, MS U was unaware of a plan and stated the facility did not have one. On 04/04/23 at 02:09 PM, Administrative Staff A stated the facility had a plan but had not been following it. The facility's Legionella Policy, revised 04/27/18, documented the facility would conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. The policy stated annual testing would be completed at least once a year and with any new construction, equipment changes, changes in treatment products(disinfectants), change in water usage, changes in water usage or one or more cases of disease thought to be associated with the system. The facility failed to develop a water management plan for detecting Legionella and other waterborne pathogens in the water system and failed to monitor and record washing machine temperatures. This placed the 40 residents at risk for developing an infection. 32360 - The Electronic Medical Record for R33 documented diagnoses of type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), hyperlipidemia (condition of elevated blood lipid levels), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), urinary retention (a lack of ability to urinate and empty the bladder). R33's Admission Minimum Data Set (MDS), dated [DATE], documented R33 had intact cognition and required extensive assistance of one staff for transfers, dressing, toileting, and personal hygiene. The MDS further documented R33 required the use of an indwelling Foley catheter (tube used for draining urine from the bladder and having an inflatable part at the bladder end that allows the tube to be kept in place for variable time periods), was always incontinent of bowel, and had a urinary tract infection (an infection in any part of the urinary system) in the last 30 days. The Quarterly MDS, dated [DATE], documented R33 had intact cognition and required extensive assistance of two staff for transfers, toileting, and extensive assistance of one staff for bed mobility. The MDS further documented R33 had an indwelling Foley catheter and was frequently incontinent of bowel. The Urinary Catheter Care Plan, dated 03/16/23, initiated on 2/13/22, directed staff to ensure catheter care was performed every shift and as needed, if staff notice R33's urine turning darker in color, encourage good fluid intake. The plan directed if she was experiencing burning, cloudy or foul odor from the urine, let her physician know right away, and replace her catheter as ordered by the physician. Monitor urine output each shift, if staff notice a low urine output, sediment in her urine, abnormal urine color, notify the physician. The update dated 03/16/23 further directed staff to apply a urinary catheter leg drainage bag to her catheter when she was out of her bed or up ambulating. The Physician Order, dated 11/15/22, directed staff to administer cranberry plus probiotic (promotes a healthy urinary tract), one tablet, by mouth, in the morning, for a supplement. The Physician Order, dated 12/02/22, directed staff to insert a 16 French x 30 (cc) cubic centimeters Foley catheter monthly and document urine output every shift for the diagnosis of urinary retention. The Physician Order, dated 01/14/23, directed staff to administer Macrobid (an antibiotic to treat and prevent urinary tract infections), 100 milligrams (mg), by mouth, twice a day, for 10 days for a diagnosis of urinary tract infections (uti). The Nurse's Note, dated 01/13/23 at 07:44 AM, documented R33's catheter was patent and draining, urine was clear and noted sediment, yellow in color. The Nurse's Note, dated 01/13/23 at 11:49 AM, documented staff collected a urinalysis (examination of urine) from R33. The Urinalysis Report, dated 01/13/23, documented R33 had increased protein, and blood in her urine. On 04/04/23 at 08:15 AM, observation revealed R33 laid in bed. Certified Nurse Aide (CNA) O and CNA P applied gloves and pulled down the resident's incontinence brief and pants. CNA O took R33's catheter bag, still full of urine, and guided the bag up the inside of the right pant leg and out the top of R33's pants. Further observation revealed CNA O and CNA P stood there as R33 was exposed from the waist down and discussed who would complete the catheter care and who would drain the catheter bag. Continued observation revealed CNA P took an incontinence wipe, performed incontinence care, and ran out of wipes before she could do catheter care. CNA P opened R33's nightstand drawer with soiled hands and was unable to find gloves. CNA O looked for more incontinence wipes in R33's dresser drawer and stated Well, I guess we need to stock these rooms and took R33's roommates' s incontinence wipes. Observation revealed R33 continued to be exposed from the waist down as the CNAs looked for incontinence wipes. CNA P took an incontinence wipe and wiped around the catheter tubing at the insertion site but did not cleanse the catheter tubing. With the same soiled gloves, CNA P and CNA O pulled up R33's incontinence brief and pants. Further observation revealed CNA O sat a container on the floor to drain the catheter bag, and spilled urine on the floor. CNA O stated, how did it get spilled onto the floor? CNA O failed to cleanse the port of the catheter tubing before clamping the tubing, took the catheter bag and down the top of R33's pants, down the inside of the right pant leg and held onto it as he assisted R33 into her recliner and asked her where she wanted him to place the catheter bag. R33 instructed CNA O to put the catheter bag in the dignity bag and lay it on top on her trash can. On 04/04/23 at 12:20 PM, CNA P stated she knew she had not changed her gloves after incontinence care because she forgot and verified they had not covered R33 up when looking for extra gloves. On 04/05/23 at 11:56 AM, Administrative Nurse D stated staff should not leave residents exposed if they are not providing cares. Administrative Nurse D said the CNA should have removed her soiled gloves before touching other surfaces or the resident. Upon request, a policy for hand hygiene was not provided by the facility. The facility failed perform appropriate hand hygiene when providing incontinence care for R33. This placed the resident at risk for infections. 37450 - On 04/05/23 at 10:00 AM observation revealed R26's room, which he shared with COVID positive R29, lacked personal protective equipment and signage on the door for isolation precautions and a variety of staff entering and exiting the room. On 04/04/23 at 04:08 PM, Administrative Nurse D reported R29 admitted to the hospital, and was positive for COVID 19. Administrative Nurse D reported facility staff initiated COVID-19 testing for all the residents On 04/05/23 at 08:19 AM, LN I reported the facility had no positive COVID residents. LN I confirmed R29 had been admitted to the hospital and was being treated for COVID. On 04/05/23 at 10:30 AM Administrative Nurse D stated R26 did not come out of his room, but staff went in and out of the room. Administrative Nurse D verified R26 should be isolated due to exposure to R29's symptomatic COVID condition and subsequent positive test. The facility's COVID 19 Isolation policy, dated 10/06/22, documented isolation precautions will be utilized when there is a COVID-19 risk. Residents determined to be at risk for COVID-19 will be placed on droplet isolation. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. The facility will post a notice at the door indicating the resident is on droplet isolation. Employees caring for residents on droplet precautions are to wear a gown, gloves, N-95 face mask, and googles/face shield. The facility failed to isolate R26 after exposure to his symptomatic, COVID positive room mate which increased the risk for internal transmission of COVID.

The facility had a census of 40 residents. The sample included 14 residents. Based on interview and record review the facility failed to provide an Infection Preventionist (IP) designated to manage and monitor the facility's Infection Prevention and Control Program (IPCP) for the 40 residents who resided in the facility. This placed the residents at risk for infections and health problems. Findings included: - On 04/04/23 at 10:05 AM, Administrative Nurse D stated she was enrolled in the IP program but had not completed it. Administrative Nurse D said the nurse consultant monitored the IPCP remotely, but the facility had no certified IP to provide oversight and monitor the facility's IPCP at least part-time in the facility. The facility's Infection Preventionist Policy, undated, documented the facility would designate an IP who would be responsible for oversight of the infection IPCP. The IP would have primary professional training in nursing or another related field. This person would work at least part time at the facility and would have completed specialized training in IPCP. The facility failed to provide an IP who held the required certification to manage and monitor the facility's Infection Prevention and Control Program for the 40 residents who reside in the facility. This placed the residents at risk for infections and health problems.

The facility had a census of 40 residents. The sample included 14 residents, with two reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect for two sampled residents, Resident (R) 33, who was unnecessarily exposed from the waist down, and R20, who was taken to the dining room with soiled pants. This placed the resident's at risk for undignified care and services. - The Electronic Medical Record for R33 documented diagnoses of type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), hyperlipidemia (condition of elevated blood lipid levels), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), urinary retention (a lack of ability to urinate and empty the bladder). R33's Admission Minimum Data Set (MDS), dated [DATE], documented R33 had intact cognition and required extensive assistance of one staff for transfers, dressing, toileting, and personal hygiene. The MDS further documented R33 required the use of an indwelling Foley catheter (tube used for draining urine from the bladder and having an inflatable part at the bladder end that allows the tube to be kept in place for variable time periods), was always incontinent of bowel, and had a urinary tract infection (an infection in any part of the urinary system) in the last 30 days. The Quarterly MDS, dated [DATE], documented R33 had intact cognition and required extensive assistance of two staff for transfers, toileting, and extensive assistance of one staff for bed mobility. The MDS further documented R33 had an indwelling Foley catheter and was frequently incontinent of bowel. The Urinary Catheter Care Plan, dated 03/16/23, initiated on 2/13/22, directed staff to ensure catheter care was performed every shift and as needed, if staff notice R33's urine turning darker in color, encourage good fluid intake. The plan directed if she was experiencing burning, cloudy or foul odor from the urine, let her physician know right away, and replace her catheter as ordered by the physician. Monitor urine output each shift, if staff notice a low urine output, sediment in her urine, abnormal urine color, notify the physician. The update dated 03/16/23 further directed staff to apply a urinary catheter leg drainage bag to R33's catheter when she was out of her bed or up ambulating. On 04/04/23 at 08:15 AM, observation revealed R33 laid in bed. Certified Nurse Aide (CNA) O and CNA P applied gloves and pulled down the resident's incontinence brief and pants. CNA O took R33's catheter bag, still full of urine, and guided the bag up the inside of the right pant leg and out the top of R33's pants. Further observation revealed CNA O and CNA P stood there as R33 was exposed from the waist down and discussed who would complete the catheter care and who would drain the catheter bag. Continued observation revealed CNA P took an incontinence wipe, performed incontinence care, and ran out of wipes before she could do catheter care. CNA P opened R33's nightstand drawer with soiled hands and was unable to find gloves. CNA O looked for more incontinence wipes in R33's dresser drawer and stated Well, I guess we need to stock these rooms and took R33's roommates' s incontinence wipes. Observation revealed R33 continued to be exposed from the waist down as the CNAs looked for incontinence wipes. CNA P took an incontinence wipe and wiped around the catheter tubing at the insertion site but did not cleanse the catheter tubing. With the same soiled gloves, CNA P and CNA O pulled up R33's incontinence brief and pants. Further observation revealed CNA O sat a container on the floor to drain the catheter bag, and spilled urine on the floor. CNA O stated, how did it get spilled onto the floor? CNA O failed to cleanse the port of the catheter tubing before clamping the tubing, took the catheter bag and down the top of R33's pants, down the inside of the right pant leg and held onto it as he assisted R33 into her recliner and asked her where she wanted him to place the catheter bag. R33 instructed CNA O to put the catheter bag in the dignity bag and lay it on top on her trash can. On 04/04/23 at 12:20 PM, CNA P verified they had not covered R33 up when looking for extra gloves. On 04/05/23 at 11:56 AM, Administrative Nurse D stated staff should not leave residents exposed if they are not providing cares. Upon request, a policy for dignity was not provided by the facility. The facility failed to promote care in a manner to maintain and enhance dignity and respect for R33, who was exposed from the waist down without cares being given. This placed the resident risk for undignified care and services. 37450 - R20's Electronic Medical Record (EMR), recorded diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), low back pain, overactive bladder, chronic kidney disease, peripheral vascular disease (abnormal condition affecting the blood vessels) and behavioral disturbance. The Quarterly Minimum Data Sheet (MDS), dated [DATE], documented R20 had moderately impaired cognition, required limited assistance of one person for activities of daily living, and physical help of one staff for bathing. R20 had occasional incontinence of urine and bowel, was not steady but able to stabilize without staff assistance. The Urinary Incontinence Care Area Assessment, dated 09/26/22, documented R20 was occasionally incontinent of urine per voiding diary, required limited assistance with toileting and toileting hygiene, and wore incontinent products to help clothing and promote dignity. R20 had been open toilet with cueing and the facility planned for incontinence with the start of toileting program of cueing to toilet at 06:00 AM, after meals, midafternoon and at bedtime to help promote continence. The Progress Note, dated 03/22/23 at 04:16 PM, documented R20 had not walked to the dining room for meals. R20 sat in her walker/wheelchair at the opening to her room and yelled for help. R20 reported she could not walk, but with staff encouragement she did walk to the dining room. On 04/03/23 at 08:03 AM observation revealed R20 walked into the dining room escorted by a Certified Medication Aide (CMA) R. R20's pants, on her buttocks area, were visibly wet. R20's pants sagged with wetness/weight of an incontinent brief. Survey team member brought the wet pants to CMA R's attention. CMA R instructed the hospitality aide to take R20 to the bathroom. The hospitality aide informed CMA R she could not take R20. Licensed Nurse (LN) H identified the name of R20 to the surveyor, and the survey told LN H R20 pants were wet, LN H looked at R20's pants and did not direct staff to provide assistance with the incontinence. Staff then sat R20 in a dining room chair for breakfast. R20 had uncombed oily hair. On 04/03/23 at 12:11 PM observation revealed staff pushed R20 while she sat on the seat of her walker. R20 had uncombed, oily hair. Staff encouraged and assisted R20 into a dining chair with a gait belt. As R20 stood, a round, wet circle was visible on the back of her pants and her incontinent product sagged between her legs. Staff preceded to sit R20 in the chair to eat her breakfast. On 04/03/23 at 01:06 PM observation revealed R20 made it to her room, from the dining room, and called for help as staff were bringing other residents to their rooms. Staff inquired what R20 needed and R20 told them she wanted to go upstairs. Staff then assisted R20 back to the dining room in her walker chair and placed her in front of her plate. On 04/03/23 at 01:29 PM Administrative Nurse D assisted R20 to stand and R20 continued to have a wet spot on the back of her pants. Staff assisted R20 to her room in a wheelchair. Staff assisted R20 to her recliner. Surveyor alerted staff R20 had wet pants and a filled, sagging brief. Staff looked at each other and asked each other if they saw the wetness. Staff then assisted resident to the bathroom and assisted to change R20's pants and brief, before returning R20's recliner. R20's hair remained uncombed and oily in appearance. On 04/03/23 at 01:32 PM Certified Nurse Aide (CNA) O stated R20 had a toileting routine. The routine was to toilet R20 when she got up in the morning, after breakfast, before lunch, the middle of the afternoon, then R20 would sleep until supper time. CNA O was unsure of the toileting schedule for the other shifts. On 04/03/23 at 01:29 PM CMA S stated R20 took usually toileted independently. CMA S stated R20 usually wore pullup undergarments. CMA S stated she was unsure when R20 had changed incontinent undergarment to tabbed briefs from pull ups. On 04/04/23 at 03:00 PM, Administrative Nurse D stated R20 should be assisted with her toileting needs. She verified R20 should not have wet clothing in public spaces and should have clean and combed hair, for the resident's dignity. Administrative Nurse D stated she expected the staff to provide ADL cares including combing hair and other grooming needs and she also expected staff to provide bathing for all resident as directed by their care plan and preferences. The facility's Activities of Daily Living policy, dated 04/27/18, documented residents will be given the appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living. The facility will provide care and services based on the comprehensive assessment of the resident and consistent with his/her needs or choices for the following activities of daily living. Residents who are unable to carry out activities of daily living and are dependent on staff will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to provide a dignified experience for R20 which placed the resident at risk of impaired dignity and decreased psychosocial wellbeing.

The facility identified a census of 34 residents with three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment and adequate supervision for Residents (R) 1 and R2. On 09/05/22, while the facility transported R1 Certified Nurse Aide (CNA) M failed to apply safety belts to R1's wheelchair in the transportation van, causing R1 to fall backwards in the van, which resulted in a laceration (a deep cut or tear in skin or flesh) to the back of R1's scalp measuring 3 centimeters (cm) by 0.5 cm and required four staples, and a laceration to R1's outer left ankle measuring 4 cm by 3 cm, requiring 13 sutures. On 09/05/22, CNA N transported R2 via wheelchair back to her room but took the corner to R2's room too sharply and caught R2's left foot into the door jam, which resulted in fractures (broken bones) to R2's third, fourth, and fifth toes and lacerations to the bottoms of R2's toes. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), [CONDITION(S)] (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R1 required extensive assistance of one to two staff for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing. The MDS further documented R1 required a wheelchair for locomotion and had not had any falls. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 07/06/22, documented R1 required assistance with bed mobility, locomotion, dressing, toilet use, and personal hygiene. R1 struggled with strength and mobility and could not remember to perform daily tasks. The Fall CAA, dated 07/06/22, documented R1 did not remember to use the call light to call for assistance, did not usually try to transfer or ambulate by herself, and would usually wait for staff assistance. The Fall CAA further documented R1 required assistance of one to two staff for transfers and was not steady during transitions. The Cognitive Loss Care Plan, dated 07/17/22, directed staff that R1 could not remember appointment times, mealtimes, and activity times and R1 depended on staff to remember these things for R1 and assist her to such. The [CONDITION(S)] Care Plan, dated 07/17/22, directed staff that R1 required [CONDITION(S)] appointments on every Monday, Wednesday, and Friday. The Fall Care Plan, dated 07/7/22, documented R1 was dependent on staff for locomotion in a manual wheelchair. The Progress Note, dated 09/05/22, documented R1 went to [CONDITION(S)] at 01:34 PM via the facility van. The The State Agency Triage Intake Note, dated 09/05/22, documented R1 went to the local emergency room after not being buckled into the facility van after receiving [CONDITION(S)]. The facility staff [CNA M] took off in the van and R1 flew backwards, sustaining a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) and a laceration to the back of R1's head and a laceration to R1's right ankle. Social Services X reported the incident to Adult Protective Services (APS). The Progress Note, dated 09/05/22 at 09:55 PM, documented R1 returned from the emergency room per van without incident, R1 denied losing consciousness, and did not know how to explain what happened in the van. The Non-witnessed fall/Head injury fall Assessment, dated 09/05/22 at 11:45 PM, documented staff performed neurological checks on R1 every fifteen minutes for one hour, every thirty minutes for two hours, hourly times two hours, and every eight hours times nine hours. All of R1's neurological checks were within normal limits. The Weekly Wound Assessment, dated 09/07/22, documented R1 had a laceration to the back of her head measuring 3 cm by 0.5 cm with four staples securing the laceration. The wound assessment noted R1 had a laceration to her right ankle with 13 sutures securing the wound. The Facility Incident Report, dated 09/08/22, documented R1 was transported back to the facility from [CONDITION(S)]. While CNA M was in route back to the facility, CNA M heard a noise, looked back in her rear-view mirror and did not see R1. CNA M pulled over and found that R1 had tipped backwards while sitting in her wheelchair in the van. CNA M found that R1 had a laceration to the back of her head and contacted the facility for directions. CNA M was directed to take R1 to the emergency room . R1 was treated for a laceration to the back of her head measuring 3cm by 0.5 cm and a laceration to her right ankle measuring 4 cm by 3 cm. R1 was treated by the emergency room and released back to the facility. CNA M reported when she found R1 tipped over, she noted the straps were still attached to the wheelchair, but were loose. R1 was not able to say what had happened. CNA M stated she tightened the straps as best as she could. Maintenance Personnel U checked all of the safety features of the van and verified they were working appropriately, and Maintenance Personnel U could not replicate the incident unless the straps to the front wheels of the wheelchair were not attached. It was determined that CNA M had failed to attach the van's safety straps to the front of the wheelchair. On 10/10/22 at 11:30 AM, observation revealed R1 sat in her wheelchair at the dinner table visiting with another resident. On 10/10/22 at 10:00 AM, CNA O stated that she had not been at work the day of the incident, but she heard in report that CNA M had forgot to put the breaks on to R1's wheelchair and the wheelchair had flipped backwards causing R1's injuries. On 10/10/22 at 10:30 AM, Licensed Nurse (LN) G stated that she had not been on shift the day that incident had happened with R1, but during report she learned the incident was caused by staff not applying the straps correctly or not putting the breaks to the wheelchair on. On 10/10/11 at 11:30 AM, R1 stated that she did not know how the incident in the van happened. R1 stated, It happened so fast. R1 stated she was scared and her head hurt at the time, but it no longer hurt and was healed. On 10/11/22 at 12:00 PM, Maintenance Personnel U stated after the incident he completely checked over all of the safety belts in the van and determined they were all operating correctly. Maintenance Personnel U stated he tried to duplicate the incident and the only way the wheelchair could have tipped over backwards was if the front straps were not applied correctly. Maintenance Personnel U stated the incident was caused by operator error. Maintenance Personnel U stated he had all of the CNA's that drive for the facility complete new competencies showing that they knew how to run all of the safety features on the van. Maintenance Personnel U stated van driving competencies were normally performed yearly, and CNA M had passed her competency on 04/27/22. On 10/10/22 at 12:30 PM, Administrative Nurse D stated she was informed of the incident on 09/05/22 involving CNA M and R1. Administrative Nurse D stated CNA M said that she was distracted when she tried to assist another [CONDITION(S)] patient and could not remember if she had completely strapped R1's wheelchair into the van. Administrative Nurse D stated that she expected all her staff to put the resident's safety before anything else; she told CNA M her responsibility was keeping R1 safe at that moment. The facility's Occurrences, policy, revised 11/28/17, documented the facility will ensure that each resident receives adequate supervision and assistive devices to reduce risk occurrences. Any accident or occurrence will be thoroughly investigated to rule out abuse and neglect and to determine a root cause. Appropriate interventions will be developed based on the root cause analysis. The facility failed to provide a safe environment free from avoidable accidents for R1, when staff failed to properly secure R1's wheelchair in the transport van. As a result, R1 sustained lacerations to her head and leg which required treatment at the emergency room . On 09/08/22 the facility completed all corrective actions which included staff education, transportation vehicle safety inspection and staff competencies. The deficient practice was cited as past noncompliance. - R2's Electronic Medical Record (EMR) documented R1 had diagnoses of type 2 diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), [CONDITION(S)] (an abnormally high body mass), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status score of seven, which indicated severely impaired cognition. The MDS further documented R2 required extensive assistance of one to two staff for bed mobility, transfer, locomotion, dressing, toileting, personal hygiene, and bathing. The Cognitive Loss Care Area Assessment (CAA), dated 12/09/21 documented R2 occasionally was unable to understand what staff were trying to communicate to her, and she was unable to communicate to staff her needs and concerns. The Fall CAA, dated 12/09/21, documented R2 had impaired cognition, incontinence, and impaired mobility. R2 required a full body mechanical lift for transfers, a wheelchair for locomotion; she was dependent on staff for most activities of daily living (ADL's). The Fall/Mobility Care Plan, dated 12/04/21 directed staff R2 used a manual wheelchair with an extended back head rest and bilateral foot pedals with a calf support device that helped R2 from sliding down in her chair, and helped her sit upright better. The care plan directed staff to assist R2 with locomotion. The Incident Report, dated 09/05/22, documented R2 was sent to the emergency room due to cutting her foot on the door frame when Certified Nurse's Aide (CNA) N wheeled R2 in her wheelchair. The report noted CNA N reported R2's foot slid too far up on the foot pedal and caught on the door frame. The Witness Statement, dated 09/05/22, from CNA N noted R2's foot hit the doorway when CNA turned R2's wheelchair into R2's room. The Radiology Report, dated 09/05/22, documented R2 sustained fractures to the proximal phalanx (bone of the toe) of the third, fourth, as well as the distal (farthest away from the body) of the fifth toe. The emergency room Discharge Instructions, dated 09/05/22, documented R2 sustained lacerations to the toes of the left foot and had an open fracture of the toe. The discharge instructions directed staff to keep bandages to R2's foot in place until seen by orthopedics (the branch of medicine dealing with the correction of bone deformities), keep appointment with orthopedics the next day, follow up with R2's primary care physician as needed, and return to the emergency department for new or worsening symptoms. The Progress Note, dated 09/06/22 at 10:32 AM, documented R2 was back to the facility from the emergency room with new orders to start [MEDICATION(S)] (antibiotic) 875/125 milligrams (mg) by mouth twice a day for ten days and to keep the bandages to the left foot in place until R2 was seen by orthopedics. The Progress Note, dated 09/07/22, documented R2 had a boot in place to the left foot with a gauze dressing covering the left toes. Staff observed blood through the gauze dressing. R2 was scheduled to see orthopedics that same day, but R2 could not fit into the van. The charge nurse called the orthopedic clinic to see if they could perform a remote visit to the facility and if they wanted the facility to remove and re-dress the wound as the dressing was soiled. The orthopedic clinic called back and ordered R2 to follow up with her primary care physician. R2's primary care physician was called, and the facility awaited a response. The Progress Note, dated 09/08/22, documented new orders from R2's primary care physician regarding dressing changes. The order directed staff to cleanse the toe lacerations with normal saline, pat dry, apply triple antibiotic ointment, apply nonadherent pad and wrap foot with gauze. Staff were to monitor the dressing each shift to ensure dressing was clean, dry and intact and monitor left foot lacerations for signs and symptoms of infection or worsening. The Progress Note, dated 09/14/22, documented staff assessed R2's lacerations to her left toes. The lacerations were scabbed, and the sutures were embedded into scabs and hard to visualize. The nurse was able to visualize thirteen sutures to the bottom of R2's toes and possibly two to three more she was unable to visualize. The was an area between the fourth and fifth toes, which was open with a moist wound bed. R2 denied pain at rest. On 10/10/22 at 09:45 AM, R2 sat up in her wheelchair in her room and watched television. R2's legs were elevated in a foot box attached to her wheelchair and the left foot was noted to be in a protective boot with a gauze dressing on her upper foot. On 10/10/22 at 09:45 AM, R2 stated that CNA N ran R2's foot into the doorway when CNA N brought R2 back to her room from supper. R2 stated that her foot hurt badly at first, but was just numb now. On 10/10/22 at 10:00 AM, CNA O stated she was not on shift the day of the incident, but she heard in report that staff had ran R2's foot into the door, broke her toes and split her skin open. On 10/10/22 at 10:30 AM, Licensed Nurse (LN) G stated she was not on shift the day the incident with R2 happened. LN G stated she heard the accident happened when staff wheeled R2 into her room, and R2 foot got caught on the doorframe. LN G verified dressing changes to R2's left toes were performed daily. On 10/10/22 at 12:30 PM, Administrative Nurse D stated she was notified of the incident on 09/05/22 and came up to the facility. Administrative Nurse D stated she talked with CNA N about the incident and CNA N stated R2's foot slid up and out on her foot pedal and when CNA N went to wheel R2 into her room, R2's foot got caught on the doorway. Administrative Nurse D stated she educated CNA N regarding making sure to square up wheelchairs to the doorway when wheeling a resident into their room instead of rounding the corner to ensure that all of the residents body parts were in so they would not get caught on anything. On 10/11/22 CNA N remained unavailable for interview. The facility's Occurrences, policy, revised 11/28/17, documented the facility will ensure that each resident receives adequate supervision and assistive devices to reduce risk occurrences. Any accident or occurrence will be thoroughly investigated to rule out abuse and neglect and to determine a root cause. Appropriate interventions will be developed based on the root cause analysis. The facility failed to provide a safe environment free from avoidable accidents when staff failed to ensure safe passage through a doorway for R2, who was dependent upon staff for wheelchair mobility. As a result, R2's foot was caught on the doorframe and R2 sustained fractures to her left third, fourth, and fifth toes and a laceration to her left toes which required treatment at the emergency room . On 09/05/22, the facility provided education to staff regarding wheelchair positioning and ensuring safety when maneuvering wheelchairs through doorways in order to avoid preventable accidents. The deficient practice was cited as past noncompliance.

The facility had a census of 42 residents. The sample included one resident reviewed for [MEDICAL CONDITION] (a surgical procedure in which a cut or opening is made in the windpipe) care. Based on record review and interview, the facility failed to provide Resident (R) 1 necessary [MEDICAL CONDITION] (trach) care and/or suctioning when he became short of breath, suctioning equipment was unavailable, and staff lacked current [MEDICAL CONDITION] education, which led to R1's hospitalization . Two days later the resident became short of breath, pulled out his [MEDICAL CONDITION], staff reinserted [MEDICAL CONDITION], and suctioned the airway. A few hours later staff found the resident unresponsive and he later died from airway obstruction and [MEDICAL CONDITION] (inadequate supply of oxygen). This deficient practice placed R1 in immediate jeopardy. Findings included: - The Hospital Referral Note, dated [DATE], documented R1 had [DIAGNOSES REDACTED]. The Admission Assessment, dated [DATE] at 10:04 AM, recorded the resident was alert and oriented to person, place, time, and situation, required limited assistance for Activities of Daily Living (ADLs), and had a [MEDICAL CONDITION]. R1's respiratory assessment noted he had a regular rate, clear breath sounds on right and left lungs, and no cough. The assessment lacked type or size of [MEDICAL CONDITION]. The assessment recorded the resident received oxygen at ,[DATE] liters (L) but lacked documentation of mode of delivery of the oxygen. The Baseline Care Plan, dated [DATE] at 10:46 AM, recorded R1 required one-person physical assistance with personal hygiene, received oxygen therapy, and [MEDICAL CONDITION] care. The care plan lacked specifics [MEDICAL CONDITION], suctioning needs, the type [MEDICAL CONDITION], delivery device for oxygen, or what [MEDICAL CONDITION] care the resident performed independently. The Hospital Discharge Physician Order, dated [DATE] (untimed), recorded the resident received oxygen [MEDICAL CONDITION] with humidity at 2 LPM (liters per minute) at rest and 3 LPM with activity. The note recorded the resident's expected stay at the nursing facility was 30 days or less. The Physician Order, dated [DATE] at 11:50 AM, directed staff to administer oxygen per nasal cannula, change the tubing weekly, check the resident's oxygen level daily, and notify the physician of oxygen (O2) saturation (sats) below 90%. The Physician order [REDACTED]. The Physician Order, dated [DATE] (untimed), directed staff to administer oxygen [MEDICAL CONDITION] at 3 LPM with activity and 2 LPM when at rest, change tubing weekly, and monitor oxygen saturation every shift. The Progress Note, dated [DATE] at 02:25 PM, recorded the resident arrived at the facility per facility van, seated in a wheelchair. The note recorded the resident was alert and oriented x 3 (person, place, and time), made his needs known, understood what was being said, and voiced no complaints of pain or discomfort. The note recorded the resident had a [MEDICAL CONDITION] with oxygen at 3 L with activity and required two-person assistance with all transfers and bed mobility. The Progress Note, dated [DATE] at 03:00 PM, recorded the resident reported an obstruction to his [MEDICAL CONDITION], coughed, and started to turn red. The note recorded staff sent the resident to the local hospital emergency room (ER) at that time. The emergency room Notes, dated [DATE] (untimed), recorded EMS (Emergency Medical Services) transferred R1 to the ER after he became short of breath and felt like he needed to clear his airway with suctioning. However, R1 did not have suctioning set up. EMS cleared some of the airway and placed R1 on oxygen as his O2 sats were in the low 80%s.The note recorded upon arrival to the ER R1 continued on oxygen until respiratory therapy was able to calm the resident and deep suction him. The note recorded R1 did have some blood clots and fresh blood. ER staff monitored the resident for over an hour until resections and bleeding stopped. Physician JJ [MEDICATION NAME](antibiotic) for tracheitis (infection of the trachea) and directed R1 to follow up with him the following week. The Hospital Patient Visit Information, form dated [DATE], recorded Physician JJ ordered [MEDICATION NAME] (Cipro) 500 milligrams (mg) twice daily, 14 tablets. The document recorded R1 was seen in the ER for tracheal obstruction and tracheitis. The Progress Note, dated [DATE] at 06:00 PM, recorded R1 returned from the local hospital. The Infection Note, dated [DATE] at 01:50 PM, recorded R1 continued to receive an antibiotic for tracheitis. The resident had been suctioning [MEDICAL CONDITION] bloody drainage and had no signs or symptoms of adverse reaction to the medication. Review of R1's medical record lacked information regarding staff supervision of the resident independently suctioning his trach, observation of his suctioning technique, or if the resident needed further education related [MEDICAL CONDITION]. The Infection Progress Note, dated [DATE] at 01:17 AM, recorded R1 continued on an antibiotic for tracheitis, the resident independently suctioned his trach,[MEDICAL CONDITION] blood tinged sputum (mucous secretion from the bronchi and lungs) when suctioned, no adverse reactions from medication, and remained without fever. The Physical Therapy Treatment Note, dated [DATE] (untimed), recorded R1 was lying in bed at the start of therapy, with O2 at 3L with saturations at 64%. R1 was unable to speak, reported his stoma was obstructed, and he couldn't breathe. The note recorded R1 stuck his finger down the stoma (opening of the [MEDICAL CONDITION] in the neck) and staff provided education not to do that. The note recorded Therapy Staff (TS) HH notified Licensed Nurse (LN) H that R1 stated he could not breathe with an obstructed stoma. LN H was unable to clear stoma, so TS HH notified Administrative Nurse E, and Administrative Nurse E took over. The Occupational Therapy Daily Treatment Note, dated [DATE] (untimed), recorded R1 was lying on his back in bed, he complained of difficulty breathing, and reported his stoma was blocked. R1 reported he was too short of breath and fatigued to participate in standing or transfers. R1 was incontinent of urine and needed his brief and bedding changed. TS GG notified LN H about R1's breathing difficulties. LN H turned up R1's oxygen to attempt to clear stoma. The resident's O2 sats were 64%. The Progress Note, dated [DATE] at 02:45 PM, recorded staff called Administrative Nurse E to R1's room. LN H was at R1's bedside. The resident's O2 sat was at 60%. The note recorded R1 had some shortness of air noted and reported R1 pulled out his soft inner canula (tube used to keep airway open) of the trach. Administrative Nurse E reinserted the soft inner canula into R1'[MEDICAL CONDITION] difficulty, then suctioned [MEDICAL CONDITION] times using sterile technique. The note recorded R1 had bloody tinged secretions per baseline and Administrative Nurse E administered a nebulizer treatment (medication to aide in breathing delivered by machine) [MEDICAL CONDITION]. His oxygen level increased to 95% and R1 was in no distress at that time, talked with staff, and communicated well. Staff paged Physician II to increase nebulizers to scheduled and educated staff to oversee R1's [MEDICAL CONDITION] care, frequently visualize R1, and alert the nurse with any changes. Review of R1's Electronic Medical Record (EMR) lacked documentation of frequent visual checks. The Progress Note, dated [DATE] at 04:35 PM, recorded staff called Administrative Nurse E to R1's room and observed R1 was unresponsive, without a pulse, and not breathing. Administrative Nurse E started Cardiopulmonary Resuscitation (CPR) and continued until EMS (Emergency Medical Services) arrived. At 04:42 PM, EMS arrived and took over doing CPR. At 05:20 PM, EMS left the facility with R1 with an obtainable blood pressure (number unknown), and pulse of 95 beats per minute (bpm, normal resting pulse 60 bpm). Administrative Nurse E notified R1's responsible party/significant other and Physician II of the transfer and R1's condition. The emergency room Note, dated [DATE] (untimed), recorded EMS arrived at the ER with R1 for evaluation CODE BLUE (a medical emergency). The note recorded the nursing facility called EMS after staff found R1 unresponsive after a breathing treatment. R1 reported difficulty breathing earlier that afternoon. The note recorded when EMS arrived at the nursing facility R1 was pulseless and apneic (without breath). EMS began CPR and noticed the resident was very difficult to bag (manual positive pressure ventilation to patients who are not breathing or not breathing adequately) through his trach. R1 received several rounds of CPR, [MEDICATION NAME] (medication to increase blood pressure, heart rate, and cardiac output), and [MEDICATION NAME] (used in resuscitation to improve acidotic state). R1 had a pulse and EMS transferred him to the ER. Upon arrival, R1 was pulseless and very difficult to bag, pupils fixed and dilated (flat and widened), and no heart sounds heard. ER staff resumed CPR,[MEDICAL CONDITION] and replaced with an Endotracheal Tube (ET tube-a flexible plastic tube that is placed through the mouth into the trachea (windpipe) to help a patient breathe). R1 was again very difficult to bag and Respiratory Therapy suctioned out some bloody secretions and clots. The note recorded ER staff needle decompressed (a life-saving maneuver performed to relieve excess air in the chest cavity) R1's right chest wall with a rush of air to the right side, needle decompression of the left side without rush of air. R1 continued to be difficult to bag after tracheal suctioning and decompression. ER staff attempted further maneuvers for relieving the obstruction without much success, and the code was called (meaning discontinuation of CPR). The Progress Note dated [DATE] at 06:35 PM, recorded Administrative Nurse E received a call from the hospital ER nurse who stated R1 passed away at 05:27 PM, shortly after arrival at the ER. Review of [MEDICAL CONDITION] and Suctioning Competency Checklist, dated [DATE], documented five of the eleven licensed nursing staff completed the competency checklist consisting of how to gather [MEDICAL CONDITION] supplies, properly perform [MEDICAL CONDITION] suctioning, cleaning the [MEDICAL CONDITION], and assessing cardiopulmonary status and oxygen saturations. LN G's Witness Statement, signed [DATE], documented on [DATE] she was informed of R1's admission to the facility, but not informed he had a trach. Immediately prior to R1's admission, the hospital nurse informed LN G the resident had [MEDICAL CONDITION] he took care of himself. LN G documented she informed Administrative Nurse D and Social Services (SS) X that R1 had a trach. Five minutes later R1 arrived at the facility. LN G obtained his vital signs and weight, then gave him a shower. R1 was alert and talked to the nurse with no complaints of breathing problems during the admission assessment. LN G documented she set R1's oxygen concentrator at 2 L per nasal cannula, then left his room to document her assessments. LN G documented she [MEDICAL CONDITION] review about ,[DATE] weeks prior due to the possibility of receiving a different resident with a trach, but that resident did not come to the facility. LN G documented the last time she performed a hands-on with [MEDICAL CONDITION] test, or took care of a resident with a trach, was two years earlier. LN G documented she watched videos [MEDICAL CONDITION] to educate herself. The witness statement further revealed that LN G documented on [DATE] she did not set up a suction machine in R1's room before his admission or during her shift. LN H's Witness Statement, signed [DATE], documented on [DATE] the facility admitted R1 on the previous shift and informed her in report that R1 had [MEDICAL CONDITION] managed by himself. Shortly after completion of shift report staff notified LN H that R1 was having a hard time breathing with obstruction of his trach. LN H entered R1's room and observed the resident was breathing and able to talk with O2 sats of 96% on oxygen [MEDICAL CONDITION]. LN H documented she could not find a suction machine in R1's room, so she left R1's room to retrieve a suction machine and supplies. LN H documented when she could not find the supplies, she went to Administrative Nurse D informing her the resident had [MEDICAL CONDITION] R1 complained he had an obstruction. Administrative Nurse D gave instructions to call 911 and send R1 to the hospital. After R1 left with EMS, Administrative Nurse D found keys to the supply room and brought a suction machine and [MEDICAL CONDITION] supplies to R1's room. LN H documented R1 returned later that shift without difficulties. On [DATE], TS HH alerted LN H that R1'[MEDICAL CONDITION] an obstruction, LN H entered R1's room and attempted to suction him and was able to bring up a small amount of bloody sputum. R1 was breathing with an O2 sat of 90% on O2 [MEDICAL CONDITION] and was able to talk. LN H left R1's room and informed Administrative Nurse E she was going to send R1 to the hospital. Administrative Nurse E entered R1's room with LN H and found R1's O2 sat dropped to 88% on oxygen. LN H documented staff turned up the oxygen and Administrative Nurse E suctioned R1. After suctioning R1's O2 sat was 92% and he denied obstruction. LN H documented that 40 minutes later Certified Nurse Aide (CNA) R notified LN H that R1 was nonresponsive, LN H started CPR, and notified EMS. LN H documented the last time she performed [MEDICAL CONDITION] suctioning and care was in [DATE], and in [DATE] she verbalized to the Director of Nursing (DON) the steps [MEDICAL CONDITION] and suctioning. On [DATE] at 07:45 PM, CNA M stated the facility admitted R1 on [DATE] and later transferred R1 back to the hospital by ambulance due to the facility not having suction machine and tubes available in the resident's room. On [DATE] after 02:00 PM shift change, LN H told CNA M to go clean up R1 from being incontinent, TS HH was in R1's room and told CNA M that R1 was having difficulty breathing, like he had a blockage in his trach. CNA M told LN H that R1 was having difficulty breathing and had a blockage. LN H told CNA M, You are the third person who told me this and if he can talk, he can breathe, then instructed CNA M to go change R1 and obtain a set of vital signs. CNA M stated LN H eventually went to R1's room, attempted to suction R1, and stated, Oh yea, he is definitely blocked. LN H left the room and Administrative Nurse E came running in. Administrative Nurse E realized R1'[MEDICAL CONDITION] was out, cleaned it, then reinserted it, and started suctioning R1. CNA M stated R1's O2 sat was at 60% when suctioning started, after Administrative Nurse E finished, R1's oxygen sat was between 96% and 98%. R1 said he felt somewhat better, staff gave him the call light, left the room, and checked on him every 15 minutes. CNA M stated approximately an hour or so later R1 was found unresponsive. Administrative Nurse E performed CPR until EMS arrived. On [DATE] at 09:54 AM, Administrative Nurse E stated she reviewed the hospital referral documentation for R1 and accepted him for admittance into the facility, but missed R1 had a history of [REDACTED]. Administrative Nurse E stated normally staff would [MEDICAL CONDITION] that included an oxygen concentrator, suction machine with canister, suction kits, [MEDICAL CONDITION] kits set up in the resident's room prior to the resident's arrival. Administrative Nurse E stated on [DATE], when R1 arrived at the facility, she had left for the day, around 03:30 PM staff called her [MEDICAL CONDITION]. Administrative Nurse E stated staff had to send R1 to the emergency room and he returned the same day. Administrative Nurse E stated on [DATE] around 02:45 PM TS HH notified her that R1's O2 sat was 64%. Administrative Staff E entered R1's room and observed R1 having difficulty breathing and R1 had removed his [MEDICAL CONDITION]. Administrative Nurse E stated she cleaned [MEDICAL CONDITION], applied lubricant, and reinserted the tube back into R1's trach. Administrative Nurse E then suctioned large amounts of clear to pink colored sputum out of R1's trach, after suctioning R1's trach, his O2 sats went up to 97%. Administrative Nurse E instructed nursing staff to monitor R1's O2 sat every 10 minutes and she checked on him every 20 minutes. At 04:10 PM, staff observed R1 in his room doing very well. At 04:27 PM staff notified Administrative Nurse E the resident was unresponsive and not breathing, Administrative Nurse entered R1's room, observed R1 was not breathing and did not have a pulse, so she started CPR. Staff notified EMS, they arrived and took over CPR on R1 before leaving for the hospital. On [DATE] at 12:59 PM, Administrative Staff A stated there was not a facility policy on [MEDICAL CONDITION] care or suctioning, they only had a competency form. On [DATE] at 08:22 AM, Administrative Nurse D stated SS X emailed resident admission referrals to her. Administrative Nurse D stated if she knew the resident had a trach, she expected nursing staff to have suction equipment and supplies set up in the resident's room before the resident arrived. In [DATE] she handed out competency forms [MEDICAL CONDITIONS] to the licensed nurses, it was not a hands-on with demonstration competency, just a paper review. Administrative Nurse D stated [MEDICAL CONDITION] and suctioning training, LN I reviewed the competency form with the other licensed nurses. Administrative Nurse D did not follow up on the [MEDICAL CONDITION] training because the facility did not accept the potential resident with [MEDICAL CONDITION] June. Administrative Nurse D stated it had been a long time since she had a resident with a trach. Administrative Nurse D did not know the facility'[MEDICAL CONDITION] and suctioning policy or protocol. On [DATE] Administrative Nurse E approved R1's admission and was not informed R1 had a trach. On [DATE] in the afternoon, LN H came in the conference room yelling that she needed suction supplies to take care of R1's because he was turning red. Administrative Nurse D stated she told LN H they needed to send R1 out to the emergency room if he was turning red, and we will get the supplies while he was gone. LN H sent R1 to the hospital. Administrative Nurse D stated while R1 was gone she called Administrative Staff A to ask where the suction [MEDICAL CONDITION] were located. Administrative Nurse D had to get into the medical records office to retrieve the key to the central supply room. Administrative Nurse D and the SS X went to the central supply room to get [MEDICAL CONDITION] and gave them to LN H to set up in R1's room before he returned from the emergency room . Administrative Nurse D stated on [DATE] Administrative Nurse E entered R1's room to suction R1 due to his oxygen level of 60%. After suctioning the resident his oxygen sat increased to 97%. Administrative Nurse D stated LN H wanted to send R1 to the emergency room again, but Administrative Nurse E told her no because R1 was doing better and staff were checking on him every 10 minutes. Administrative Nurse D stated she was later told the nurses started CPR, she grabbed the ambu bag (device used to inflate lungs during CPR) and called 911. EMS arrived and took over CPR, then transported R1 to the emergency room . On [DATE] at 09:09 AM, TS HH stated on [DATE] R1 was lying flat in bed when therapy started. TS HH stated R1 was difficult to understand and stated he could not breathe, with an obstruction of his trach. TS HH left the room to get a pen and paper to communicate with the resident and went back into his room. TS HH stated the resident started sticking his finger in his throat and saying he had an obstruction. TS HH told LN H R1 was incontinent, needed changed, [MEDICAL CONDITION] obstructed, and he could not breath per his report. TS HH stated LN H said she would be right there. TS HH stated she took sheets into R1's room and waited for the CNA's to come change R1. TS HH stated the CNAs (names unknown) said LN H sent them down to change R1 and obtain his O2 sat. TS HH left the room to get LN H who was walking down the hall. LN H tried to suction R1's trach, but could not and said she was going to call the ambulance. TS HH ran to get Administrative Nurse E and told her what was happening with the resident and Administrative Nurse E immediately ran to R1's room. C GG stated she did not return to R1's room. On [DATE] at 10:24 AM, Administrative Staff A confirmed the facility had notice R1 had [MEDICAL CONDITION] the initial hospital referral papers (received [DATE]). On [DATE] at 01:22 PM, Physician II stated he would come see a resident only if they would be in the facility long term and he did not know if he wrote instructions on how to take care of the resident's trach. Physician II stated there might have been a communication problem, he did not see R1 in the facility, and he expected the discharging hospital to write orders [MEDICAL CONDITION]. The staff should have contacted him if a resident had a [MEDICAL CONDITION] and he would have agreed with the discharging hospital's orders or given new orders. Physician II stated he did not give orders for suctioning and was not aware the resident would need it. Physician II stated he signed R1's death certificate and cause of death was trachea obstruction and [MEDICAL CONDITION]. The facility failed to properly screen R1who had a [MEDICAL CONDITION] before admission. The facility admitted R1 and failed to have proper suctioning equipment [MEDICAL CONDITION] supplies readily available, and failed to provide staff current [MEDICAL CONDITION] education . Within hours of arriving at the facility R1 became short of breath and complained of tracheal obstruction. There was no suctioning machine [MEDICAL CONDITION] set up and R1 had to be transferred to the ER. He returned to the facility later that day. Two days later the resident's airway became obstructed again, R1 became short of breath and pulled out his [MEDICAL CONDITION]. Staff reinserted the tube. Approximately an hour and a half later, staff found the resident unresponsive, started CPR, called EMS and transported the resident to the ER where he later died . This deficient practice placed R1 in immediate jeopardy. The facility removed the immediate jeopardy on [DATE] at 05:55 PM, when the facility educated all nursing staff on reviewing all aspects of resident care needs prior to admission and communicating with the hospital regarding any special needs in order to ensure all equipment and education to nursing staff was completed prior to admission to the facility, completed [MEDICAL CONDITION] care competencies, educated nursing staff on scope of practice, and educated and moved all [MEDICAL CONDITION] supplies to the nurse's station medication room. The deficient practice remained at a scope and severity of a G.

The facility had a census of 42 residents. The sample included three residents reviewed for hydration. Based on interview and record review, the facility failed to provide one of three sampled residents, Resident (R) 1, assistance with hydration, failed to monitor her condition and continued nausea, dehydration, or notify the physician which caused the resident to hospitalized and placed in an Intensive Care Unit. Findings included: - Review of the medical records documented the facility admitted R1 on 07/05/20. R1's Physician order [REDACTED]. low moods), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin, disorder of electrolyte (minerals that help keep the body's fluid levels in balance, necessary to help the muscles, heart and other organs work properly), altered mental status, gastro [MEDICAL CONDITION] reflux disorder (GERD-backflow of stomach contents to the esophagus), and muscle weakness. The Admission Minimum Data Set (MDS), dated [DATE], recorded the resident had severe cognitive impairment, required supervision and assistance of one staff with eating, dressing and mobility. The MDS recorded the resident received scheduled pain, antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions), and antidepressant (class of medications used to treat mood disorders and relieve symptoms of abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) medications. The Care Area Assessments (CAA) had not been completed related to the resident's short stay. The Initial Care Plan, dated 07/05/20, documented the resident required one staff assistance with toilet use, dressing, and mobility and was in room isolation for 14 days. The document directed staff to immediately notify the resident's family of care plan updates and changes. The Change in Condition Report, dated 07/06/20 at 04:45 AM, recorded the resident was not oriented to time, place, or situation. The assessment recorded the resident had short term memory impairment, confusion, hallucinations (sensing things while awake that appear to be real, but the mind created), and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The assessment recorded the resident required assistance with eating, had nausea without emesis, and the physician ordered a Basic Metabolic Panel (BMP- blood test that gives doctors information about the body's fluid balance and level of electrolytes) and [MEDICATION NAME] (a medication that can prevent nausea and vomiting). The Nursing Progress Note, dated 07/06/20 at 09:40 AM, recorded staff notified the on-call physician the resident felt nauseated and vomited a little orange juice. Review of the resident's July physician's orders [REDACTED].>Review of the July Electronic Medication Administration Record [REDACTED]. The Social Service Note, dated 07/08/20 at 01:00 PM, documented the resident refused to allow staff to assess her, stated to nursing staff she wanted to sleep, and her tummy was upset. The Dietary Assessment, dated 07/10/20 at 03:42 PM, documented the resident received a low concentrated sweet diet, ate independently in her room at that time, had a poor appetite, and nausea. The Nursing Progress Note, dated 07/10/20 at 08:50 PM, documented the resident vomited, had not voided during the shift, had a poor appetite, and poor fluid intake. The note documented the resident had increased confusion and staff notified the physician. The 07/10/20 Nutritional Summary and Plan recorded the resident was independent with meals in her room due to isolation restrictions, poor appetite, and nausea. The notes documented on 07/05/20 the resident's glucose was 116 milligrams/deciliter (mg/dl) (normal 70-130), BUN (blood, urea, nitrogen) 12 (normal 5-20 mg/dl), Creatinine 1.08 (normal 0.6-1.2 mg/dl), Sodium 139 (normal 135-145 milliequivalents per liter (mEq/L), and Potassium 3.4 (normal 3.5-5.1 mEq/L). The note documented nutritional risk factors - potential for poor intake, [DIAGNOSES REDACTED]. The note lacked the recommended 24 hours fluid intake for the resident. The Nursing Progress Note, dated 07/11/20 at 06:01 AM, documented at 05:15 AM the resident vomited watery, brown in color with coffee ground sediment liquid. The note documented staff notified the physician who directed staff to send the resident to the emergency room . The note documented the resident left the facility at 06:00 AM. R1's July Fluid Intake Record recorded the following daily intakes: 07/05/20 - 240 (ml) milliliters 07/06/20 - 720 ml 07/07/20 - 720 ml 07/08/20 - 480 ml 07/09/20 - 720 ml 07/10/20 - 380 ml R1's July Amount Eaten Record recorded the following daily intakes: 07/05/20 - 100% of supper meal 07/06/20 - 0-25% of all three meals 07/07/20 - 75-100% of all three meals 07/08/20 - refused breakfast, 0-25% of lunch and supper 07/09/20 - 100% of breakfast and lunch, 25% of supper 07/10/20 - 51-75 % of breakfast, refused lunch, 0-25% of supper 07/11/20 - 76-100 % of breakfast. Review of R1's Hospital History and Physical, dated 07/11/20 recorded the follow lab results obtained 07/11/20 at 06:37 AM: Sodium 130 mEq/L, Potassium 6.4 mEq/L, Creatinine 8.23 mg/dl. Review of R1's Hospital Record, dated 07/11/20 at 01:05 PM, recorded the resident admitted to the hospital with [REDACTED]. The resident stated she was thirsty/wanting to drink, had not been drinking well because no one brought her fluid, alert, and could follow simple commands. On 07/22/20 at 12:45 PM, Certified Medication Aide (CMA) R stated the resident was very lethargic, vomited, and had trouble taking her medications. CMA R reported she informed the nurse and thought the nurse gave the resident something for nausea before the resident went to the hospital. On 07/22/20 at 01:30 PM Certified Nurse (CNA) M stated when she cared for R1 the resident was unsteady and spilled her drinks, but CNA M did not help R1 eat or drink due to being the only aide working that hall and did not know the resident required assistance. On 07/22/20 at 02:13 PM, Licensed Nurse (LN) G reported the resident ate about half of her meals and had nausea and vomiting the evening before admission to the hospital. LN G reported the resident had not voided on her shift and LN G obtained a physician order [REDACTED]. LN G stated the catheter returned a small amount of dark colored urine and LN G stated she did not notify the physician. On 07/22/20 at 03:17 PM, Administrative Nurse D stated she expected nursing staff to notify the physician of abnormal resident assessments and conditions, and document physician communication and orders. On 07/22/20 at 04:55 PM, Administrative Nurse E reported on 07/06/20 the resident had a tele-med visit with the physician and at that time the physician gave orders for a BMP and [MEDICATION NAME]. Administrative Nurse E stated the order was not sent to the facility, the facility did not follow up on the order, there was no record of the tele-visit, or physician progress notes [REDACTED]. Upon request, the facility failed to provide a hydration policy. The facility failed to provide R1 assistance with hydration, failed to monitor her condition and continued nausea, dehydration, or notify the physician which caused the resident to hospitalized and placed in an Intensive Care Unit.

The facility identified a census of 59 residents. The sample included 3 residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to implement effective interventions for one resident (#1) to prevent the development of unavoidable pressure ulcers, which worsened, increased in size, and required surgical debridement (the removal unhealthy tissue from a wound to promote healing) and wound clinic visits. Findings included: - The facility admitted resident#1 on [DATE]. The Electronic Health Records documented the resident with muscle weakness. Review of the significant change Minimum Data Set Assessment ((MDS) dated [DATE] recorded the resident with a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The resident required extensive assistance from staff for all activities of daily living (ADLs) except required set up assistance for eating, and used a wheelchair for mobility. This same MDS recorded the resident was at risk for development of pressure ulcers, staff performed formal and clinical assessment, turning and repositioning, and currently had no pressure ulcers. Review of the Care Area Assessment (CAA) dated [DATE] for pressure ulcers documented the resident was at risk for development of pressure ulcers, required extensive assistance with bed mobility, and his/her skin was currently intact. The 5-day reentry MDS dated [DATE] recorded the resident returned from an acute care hospital, at risk for pressure ulcers, with his/her skin currently intact. Review of the Braden scale assessment for predicting pressure sore risk dated [DATE], documented a score of 19, that indicated a lower score (,[DATE]) at risk for pressure ulcer development. Review of the plan of care dated [DATE], documented the resident was at risk for development of a pressure ulcer and directed staff to: *Remind the resident to drink fluids in order to stay hydrated to help protect his/her skin. *Provide a pressure-relieving cushion in the wheelchair and pressure relieving mattress that helps reduce pressure to protect the resident from getting pressure sores. The resident prefers not to have a low air loss mattress at this time. *Licensed nursing staff performed Braden scale assessments every quarter and with any significant change in order to make sure the resident does not develop skin problems. *Nursing staff observed the resident ' s skin with every bath, provision of cares, and reported to the nurse with any new issues for treatment right away. *The resident can make slight changes in his/her recliner and wheelchair, however required staff assistance to make major changes in positioning. *Encourage the resident to reposition at least every two hours to prevent skin breakdown and provide assistance as needed. *If the resident developed open areas, notify the dietitian, so the resident ' s nutritional status for wound healing can be assessed. Interventions added included: Updated on [DATE] position rolled blankets on the resident ' s right side to keep pressure off of the wound (open area to right lower extremity), and follow physician orders for treatments. Review of the resident's wound and skin assessment and progress report dated [DATE] documented a 3 centimeter (cm) by 3 cm by 1 cm area on the outer calf right leg wound. The clinical record lacked evidence the facility staff notified the physician. The resident ' s treatment administration record lacked evidence of treatments performed by nursing staff in [DATE], until [DATE]. The clinical record lacked evidence the facility staff notified the registered dietitian of the development of a pressure ulcer until [DATE]. The clinical record lacked evidence of any new care plan interventions to address the development of the wound until [DATE]. Review of the resident ' s wound and skin assessment and progress report revealed weekly measurements of the resident ' s right calf wound. On [DATE], the right calf wound measured 3 cm by 3 cm by 1 cm. On [DATE], measurements documented 3 cm by 3 cm by 1 cm. On [DATE], measurements documented 3 cm by 3 cm by 1 cm. On [DATE], measurements documented 3 cm by 3 cm by 0.5 cm. Measurements on [DATE] recorded 3.4 cm by 3.6 cm x 0.5 cm, stage 2 pressure ulcer to mid right leg from the wheelchair. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. New orders to cleanse the wound, apply skin prep, Therahoney (a honey based wound treatment), and [MEDICATION NAME] gentle (foam dressing with silicone adhesive), daily and prn (as needed). Review of the initial wound progress note dated [DATE] timed 10:58 A.M. right lateral extremity, first observed on [DATE], not present on admission measured 3.1 cm long by 3.0 cm wide by 0.2 cm deep. The dressing change revealed a moderate amount of drainage with no foul odor this morning. The resident stated he/she slept in the recliner with his/her outer leg resting on the chair. A physician telephone order dated [DATE] directed staff to use rolled blankets or pillows to reposition right lower extremity to relieve pressure from wound while in the recliner. A wound progress note dated [DATE] timed 11:51 A.M. recorded the right lower extremity wound measured 3.1 cm by 2.8 cm by 0 cm with a moderate amount of drainage. A physician order dated [DATE] ordered active liquid protein supplement to promote wound healing twice daily, multivitamins with minerals daily, and vitamin C 500 milligrams daily for wound healing. The clinical record revealed these supplements were discontinued when the resident was admitted to the hospital on [DATE]. A wound progress note dated [DATE] timed 10:39 A.M. recorded the right lower extremity wound 3.1 cm x 2.8 cm by 0 cm and an additional on the left lateral foot with a stage 2 pressure ulcer 3 cm by 5 cm by 0 cm. A fax to the physician [DATE] recorded the resident was more confused, required more assistance, and had an open area to his/her left heel and right lower calf. A wound progress note dated [DATE] timed 11:12 A.M. recorded the right lower extremity wound measured 4.0 cm by 3.0 cm by 0.2 cm with moderate amount of drainage and eschar (dead tissue) formed the parameter of the wound bed with a small area of granulation tissue in the wound bed. Will consult with the wound care clinic for appointment. The left lateral foot wound measured 3 cm by 4 cm by 0 cm with a scant amount of serous (clear) drainage. A physician progress notes [REDACTED]. The dressing was saturated with clear fluid and the only dressing in place was [MEDICATION NAME]. The wound surface was uneven. A wound progress note dated [DATE] timed 10:56 A.M. recorded the right lower extremity wound with no change from the last assessment. The left foot wound with no change, measured 3 cm by 2 cm by 0 cm, scant amount of drainage and surrounding tissue blanchable, and bilateral lower extremities with two plus [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues identified by an intention made by pressing with a finger on the extremity and a 2 to 4 millimeter indention detectable for approximately 10 to 25 seconds). A physician progress notes [REDACTED]. On [DATE] a physician order at 9:00 A.M., directed staff to culture the resident ' s right lower extremity wound. Review of the wound consultation note dated [DATE] timed 12:30 P.M., documented the pre debridement of the right lateral calf wound with ligament exposed. Post debridement revealed approximate measurements of 4.7 cm by 3.2 cm by 0.6 cm deep, regular wound borders, and Stage 4 involvement. Post debridement of the left posterior heel revealed approximately 4.2 cm by 2.4 cm by 0.2 cm deep, regular wound borders with Stage 2 involvement. The consultant wound physician orders included cleansing both wounds with saline, for the right lateral calf, pack with silver alginate, cover with foam; and for the left heel apply hydrogel ointment and foam. Offload both areas as much as possible. Apply air boot to the right calf if able, the resident naturally tends to rotate his/her leg outward onto the wound. The clinical record documented on [DATE] at 4:20 P.M. the physician ordered the facility transfer of the resident to the emergency room . The record documented the resident was lethargic, unresponsive, had shallow respirations with a low blood pressure ,[DATE], respirations 12, heart rate of 63, elevated temperature of 102.2, and pulse oximetry of 95 percent. The hospital history and physical dated [DATE] documented the resident had an open wound on the right calf with slight purulent (producing or containing pus), mildly foul-smelling discharge. Review of the hospital wound care nurse report dated [DATE], recorded the right lateral leg appeared to be arterial ulcer (caused by a decreased supply of oxygen to the extremity, or ischemic ulcer) borders, measured 5 cm by 3.5 cm by 1.9 cm and had tendon exposure with 10 percent eschar. The resident had granulation tissue with moderate drainage and slight odor to the dressing. The resident presented with a pressure ulcer to the left heel measuring 2.5 cm by 1.8 cm by 0.2 cm. Results of the right lower leg culture obtained [DATE] at 9:45 A.M., recorded final results on [DATE] that revealed multiple bacteria growth: many proteus mirabilis, moderate number of [MEDICATION NAME] aeruginosa, moderate number of staphylococcus aureus, [MEDICATION NAME] faecalis, [MEDICATION NAME] avium, and moderate to many bacteroides fragilis. The physician ordered treatment with [MEDICATION NAME] 875 milligrams twice daily for 20 days and Bactrim DS twice daily for 10 days. Review of a physician order dated [DATE] ordered and scheduled an angiogram (a test that uses X-rays and dye to help the doctor find narrowed or blocked areas in one or more of the arteries that supply blood to the legs) and angioplasty (a the technique of mechanically widening narrowed or obstructed arteries) on [DATE] at 11 A.M. The resident returned to the facility on [DATE] and recorded the resident readmitted with wound measurements to the right lower leg 4 cm by 6 cm by 0.4 cm with whitish slough material in wound bed and a slight odor. The left heel pressure ulcer measured 1 cm by 1 cm. The physician ordered a follow up appointment for an angiogram and angioplasty and for the resident to follow with wound care at the wound care clinic. A physician order dated [DATE] ordered multivitamins with minerals daily, and vitamin C 500 milligrams daily for wound healing restarted with the resident ' s readmission on [DATE]. Review of a right lower extremity arterial ultrasound dated [DATE] recorded no intervention was warranted and arterial disease did not explain the patients ulceration. The nutritional assessment dated [DATE] timed 11:25 A.M., recorded the resident returned from the hospital with a current diet order of heart healthy, low sodium. The resident has a pressure ulcer to the superior (top portion) left foot, right lateral lower extremity, and left heel. The resident currently received multivitamin and vitamin C supplements. Recommendation to add active liquid protein 30 milliliters twice daily to help aid in wound healing since readmission. Review of the wound care notes dated [DATE] recorded the right lower leg wound 4.5 by 3 cm by 0.6 cm, fascia (a structure of connective tissue that surrounds muscles, groups of muscles, blood vessels, and nerves, binding some structures together, while permitting others to slide smoothly over each other) 3 cm by 1.5 cm, the remainder granulated tissue. A round punched appearance with a [DIAGNOSES REDACTED]. Left lateral heel pressure ulcer measured 2 cm by 1.8 cm. Review of a wound culture report dated [DATE], recorded the wound culture obtained on [DATE] revealed bacterial infection with moderate providencia stuartii (a bacteria commonly found in soil, water, and sewage). Physician orders dated [DATE] documented to discontinue oral antibiotics, place a PICC (peripheral inserted central catheter) line (a form of intravenous access that can be used for a prolonged period of time) and treat the resident with [MEDICATION NAME] one gram (antibiotic to treat soft tissue infection) intravenously every 12 hours for fourteen days. Review of the wound care notes dated [DATE] at 5:05 P.M. recorded the left superior foot wound measured 1.3 cm by 1.3 cm by 0 cm and a left heel Stage 2 press ulcer, which measured 1.8 cm by 2.5 cm by 0 cm. Review of an ultrasound report to bilateral lower extremity venous reflux ultrasound [DATE] recorded findings on [DATE] normal grayscale with severe subcutaneous [MEDICAL CONDITION] bilaterally. Review of the wound clinic note dated [DATE] documented the right lower leg wound 4.5 cm by 2.5 cm by 0.8 cm. Review of the wound clinic note dated [DATE] documented the right lower leg wound 4 cm by 1.8 cm by 0.6 cm. A physician order dated [DATE] ordered for the wound clinic to perform the resident ' s left heel dressing. Review of a wound care note dated [DATE] recorded the superior left foot wound was healed. Review of the wound care clinic note dated [DATE] documented the right lower leg wound 3 cm by 2 cm by 0.8 cm. Directed to keep the leg wrapped unless the resident experienced discomfort and do not discard the (compression) wraps, bring them to the clinic. The right leg wound vac to 150 millimeters of mercury continuous suction. The resident ' s dressings changed at the wound care clinic again on Tuesday, [DATE] at 11 A.M. Please plug the wound vac in, make sure it was turned on, keep charged, and needed to be on at all times. A clinical note from the wound care physician extender dated [DATE] recorded the resident had some fascia exposure in the wound. This fascia unfortunately died . The physician debrided it once already. The resident had a wound vac (negative-pressure wound therapy, a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds) in the area and it is granulating and shrinking. Unfortunately, there continued to be some nonviable tissue that was not yet covered and the resident will probably require another debridement. The resident came in on two occasions with the wound vac either discontinued or not on. Today the wound vac was not charged at all. Discussed with the patient the importance of needing to plug this (wound vac) in at all times and keep the wound vac on. It is vital to preventing infections and closure of the wound, to keep the wound vac on. Nursing note dated [DATE] at 2:22 P.M., recorded the resident with a wound to the foot, wound vac, and current weight 187 pounds, a 5.5 percent loss in one month. The resident ' s current diet order for heart healthy, no-added-salt, received multivitamins and vitamin C. Recommend regular diet and fortified type food that resident would consume. The clinical record revealed a fax to the physician dated [DATE] requested a dietary change, of regular diet with fortified foods. Nursing note dated [DATE] at 12:27 P.M., documented received a fax from the physician ordering regular diet with fortified foods, dietary recommendations. Nursing staff talked with the certified dietary manager, who requested to delay the physician orders to change the resident ' s diet until the registered dietitian visits on [DATE] to discuss discontinuing the no-added-salt heart healthy diet. The clinical record revealed a physician order for [REDACTED]. Review of the clinical record lacked evidence of what types of food the facility would fortify for the resident. Observation on [DATE] at 10:45 A.M. revealed the resident sat in a wheelchair, wore non-skid yellow socks, with a wound vac attached to the back of the wheelchair, wound vac tubing dragging on the floor. The resident ' s right lower leg angled outward and rested against the wheelchair frame without padding to prevent the resident ' s right lower extremity and pressure against the frame of the wheelchair. Observation of the wound care treatment on [DATE] between 1:00 P.M. and 2:20 P.M. revealed wound clinic staff GG and HH unwrapped and removed the compression dressings from both of the resident ' s lower legs. Wound clinic staff washed the resident ' s legs and removed the dressing from the resident ' s left heel and right lower leg. The wound on the resident ' s left heel revealed a dry area of new pink tissue, approximately 1 cm in diameter. The resident ' s right leg pressure ulcer measured 3.2 cm by 1.5 cm x 0.6 cm. Wound clinic staff GG replaced the dressing and applied new tubing and new canister to the wound vac. On [DATE] at 8:35 A.M. the resident moved him/herself in a wheelchair in hall to the dining room with a wound vac attached to the wheelchair, wound vac tubing dragging on the floor, Observation revealed no padding between the resident ' s outward turned right lower extremity with the pressure wound and the wheelchair frame. On [DATE] at 8:45 A.M. dietary staff DD served the resident coffee, water, eggs, and 4-French toast sticks with syrup. The resident ate one-half of the serving of eggs and one French toast stick, drank the coffee and water. On [DATE] at 12:30 P.M. the resident moved in the wheelchair out to the living area, right leg turned out and rested against the wheelchair frame without any protection or padding from pressure. The resident refused lunch and left the building for the wound care clinic. During an interview on [DATE] at 9:20 A.M. direct care staff M reported the resident required extensive assistance from staff for transfers and went to the wound care clinic for treatment. Staff looked at residents skin during cares and bathing and report any changes to the charge nurse. On [DATE] at 9:30 A.M. licensed nursing staff I revealed the nursing staff performed wound care for the resident before he/she started attending the wound care clinic. On [DATE] at 9:45 A.M. licensed nursing staff H revealed the wound care clinic provided all the wound care treatment for [REDACTED]. On [DATE] at 9:45 A.M. administrative nursing staff D reported the resident attended the wound care clinic and the resident ' s wounds were not treated at the facility. On [DATE] at 3:25 P.M. direct care staff P reported the staff notify the nurse when staff identified any change in a resident ' s skin during cares and the nurse performed the treatments. During an interview on [DATE] at 2:10 P.M. consultant wound care physician GG reported the resident required debridement of the right lower leg wound. Initial thinking was the wound was vascular in nature, however, all those tests proved negative and the wound was a pressure ulcer. There had been trouble with the wound vac not being on, either the battery ran down or it was turned off. The resident would be coming to the wound clinic twice a week after today. On [DATE] at 3:30 P.M. direct care staff N reported the staff transferred the resident with extensive assistance and he/she slept in the recliner. The resident had his/her legs wrapped and attended the wound care clinic. Direct care staff N revealed when staff observed a change in the resident ' s skin they notified the charge nurse. On [DATE] at 3:35 P.M. licensed nursing staff K reported the resident required extensive assistance of two staff for transfers from his/her wheelchair to the recliner and attended the wound care clinic for the wound vac dressing changes and compression wraps. On [DATE] at 8:35 A.M., direct care staff O reported the resident required supervision for activities of daily living and ate breakfast in the rapid recovery dining room. On [DATE] at 1:55 P.M. licensed nursing staff J revealed facility nursing staff notify the wound care nurse of resident ' s skin issues to review treatment. Staff also notified the resident ' s physician and responsible party with any change, including a wound. When direct care staff identified a skin concern during cares or bathing, they notify the charge nurse. Licensed nursing staff J reported the licensed staff failed to inform the wound care nurse when first observing the wound on [DATE] and he/she was unaware of the wound until [DATE]. The staff encouraged the resident with repositioning every two hours and the resident ' s plan of care directed staff to use molding blankets to keep pressure off the resident ' s wound. On [DATE] 2:50 P.M. administrative nursing staff D revealed staff failed to notify the resident ' s physician in June of the right lower extremity leg wound and no treatment sheets. The licensed nursing staff failed to follow the facility policy and physician standing orders for notification and providing wound care. The resident ' s clinical record had no treatment sheets for [DATE]. The administrative staff and wound care nurse were unaware of the resident ' s wound until [DATE] and notified the physician at that time. Administrative nursing staff D reported as of [DATE] staff followed the wound policy, measured the wound weekly, updated the physician on the wound progress, and recently started the resident on a fortified diet. On [DATE] at 9:15 A.M. consultant registered dietitian EE revealed facility staff notified him/her of the resident ' s wounds in July and recommended supplements Vitamin C and multivitamin. He/she was not notified in June of the resident ' s wounds did not provide recommendations at that time. The resident experienced weight loss in September and staff added fortified foods to the resident ' s diet for increased calories. The certified dietary manager knows what to add to the resident ' s fortified diets. The menu depends on what was being served. Consultant registered dietitian EE reported he/she was not aware the resident frequently refused lunch and the was sure staff offered the resident snacks and food in between meals. The facility added Ensure plus twice daily yesterday. On [DATE] at 1:45 P.M., consultant physician FF reported the facility had copies of the standing orders for staff to initiate that included treatment for [REDACTED]. ulcer. The facility staff can fax communication sheets to the physician ' s office with concerns and I answer the same day for treatments and orders. On [DATE] at 8:30 A.M. dietary staff CC served breakfast in the main dining room and reported the staff served super cereal as the fortified food for breakfast, which contained milk, butter, brown sugar and more calories. Dietary staff CC revealed, when a resident refused the super cereal, staff asked the resident what they wanted to eat instead. On [DATE] at 8:49 A.M. dietary staff DD served breakfast in the rapid recovery dining room and reported none of the residents in the rapid recovery unit received fortified foods. Dietary staff DD revealed, he/she had no fortified food in the rapid recovery kitchenette. On [DATE] at 9:06 A.M. dietary staff BB revealed the registered dietitian visited weekly and left a summary of all the residents reviewed. Members of the risk meeting and dietary staff received a summary of that report. Dietary staff followed the dietary recommendations made by the management team. On [DATE] at 9:25 A.M. licensed nursing staff L reported the resident received a fortified food diet. On [DATE] at 1:52 P.M. direct care staff Q reported on [DATE], I assisted the resident with a shower and had to take the resident ' s dressings off both legs. After the shower I wrapped up the resident ' s leg wounds like the charge nurse told me. On [DATE] at 4:00 P.M., administrative staff A reported the resident slept in his/her recliner and staff encouraged the resident to sleep in bed. Review of the facility physician standing orders dated [DATE] directed for a Stage 1 ulcer, cleanse and apply [MEDICATION NAME] Gentle, change every 72 hours as needed until healed, then may discontinue. Notify the physician within 24 hours. Review of the facility policy Nutrition Care for Wounds dated [DATE] recorded residents were provided adequate nutrition as necessary to improve wound healing. Wounds were staged by a Licensed Nurse and the Resident at Risk committee would implement appropriate interventions and refer the resident to the Registered Dietitian. Review of the Fortified Foods Protocol dated [DATE], recorded the registered dietitian would indicate on the assessment and/or progress notes the number of fortified foods needed per day. Fortified foods may also be added by the care plan team. The Director of Dining Services will select the most appropriate item and time for the resident, and can modify to any of the choices based on resident acceptance. This information shall be included in the care plan and documented by the Director of Dining Services in the resident ' s progress note. The facility policy for Wound Assessment prevention, and Treatment (undated) directed the resident who entered the facility without pressure ulcers would not develop them unless the individual ' s clinical condition demonstrated that they were unavoidable. In addition, if a resident had a wound, he/she would receive necessary treatment and services to promote healing, prevent infection, and prevent new wounds from developing. If a resident had a wound, the designated skin nurse would assess weekly from admission or date of wound identification. The designated skin nurse would monitor the condition of the wound and surrounding tissue (including size and appearance) and record the information on the Would & Skin Assessment & Progress Report until the wound was healed. All residents would have pressure reducing devices placed on their bed and wheelchair upon admission. If the resident required assistance with reposition, he/she would be repositioned at least every two (2) hours. The dietitian would be notified for consultation. Follow the Nutrition Care for Wounds guidelines in the Dining Services Guideline & Procedure Manual. Prevention of wounds included a licensed nurse would assessment of the resident ' s skin upon admission and weekly thereafter to identify any skin issues. The Skin and Body Assessment was completed at this time. The skin assessment check was documented on the TAR (treatment administration record). If any abnormalities were observed, then a detailed not was placed in the nurse ' s notes. The facility failed to follow physician standing orders for treatment of [REDACTED]. The facility further failed to follow the protocol and provide a fortified diet, and failed to ensure this physically dependent resident identified at risk for development of pressure ulcers did not develop a facility acquired unavoidable stage 4 pressure ulcer, which required debridement at a wound care clinic and a wound vac as treatment.

The facility had a census of 50 residents. The sample included 15 residents. Based on record review and interview the facility failed to ensure acceptable parameters of nutritional status, such as body weight and protein levels, were maintained for 1 of 15 sampled residents. Resident #53, who had an avoidable severe weight loss with deficient protein levels, failed to have dietary interventions implemented by the Registered Dietician and did not receive nutritional supplements as ordered by the physician. Findings included: - Resident #53's medical record revealed [DIAGNOSES REDACTED]. The undated facility Weight Loss Policy directed the staff to identify residents with weight loss and initiate necessary dietary interventions. The policy also directed the staff to notify the (RD) Registered Dietician regarding residents with unresolved and/or continued weight loss. The Registered Dietician's admission Nutrition Risk Assessment, dated 12/21/10, indicated the resident weighed 123 pounds and had a decreased appetite due to increased nausea at meals. The assessment also indicated the resident a high risk for nutritional problems. The assessment further indicated the Registered Dietician recommended the resident receive a fortified shake at 10:00 AM every day. The admission (MDS) Minimum Data Set 3.0 assessment, dated 12/31/10, indicated the resident's (BIMS) Brief Interview for Mental Status total score was 10 (moderately impaired cognitive function). The MDS also indicated the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. The MDS further indicated the resident weighed 123 pounds and had no recent weight loss or nutritional problems. The 01/05/11 dietary progress note indicated the resident refused to drink their fortified shake and it was discontinued. review of the resident's medical record revealed [REDACTED]. The laboratory tests for monitoring the resident's total protein level (protein structures essential to the body for structure and function) and [MEDICATION NAME] level (protein found in blood that is responsible for distribution and maintenance of water in the body) indicated the following results: 12/20/10 - [MEDICATION NAME] level 4.1 (3.5 - 5.0 normal limits) total protein level 6.7 (6.4 - 8.3 normal limits) 01/21/11 - [MEDICATION NAME] level 3.4 (below normal limits) total protein level 5.5 (below normal limits) 01/27/11 - [MEDICATION NAME] level 3.1 (below normal limits) total protein level 5.1 (below normal limits) 02/03/11 - [MEDICATION NAME] level 3.0 (below normal limits) total protein level 4.9 (below normal limits) The 2006 Lippincott Manual of Nursing Practice Eighth Edition indicated reduced protein levels were associated with [MEDICAL CONDITION]. The manual also indicated symptoms of protein deficiency were weakness, malaise and poor resistance to illness/disease. review of the resident's medical record revealed [REDACTED]. levels progressively worsened since the resident's admission to the facility. The 02/11/11 physician's orders [REDACTED]. The 02/23/11 care plan directed the staff to maintain the resident's weight at 113 pounds or more. The care plan also directed the staff to provide the resident with a regular diet and nutritional supplements 3 times a day. The 02/23/11 Dietary Progress Notes indicated the resident weighed 113.0 pounds, down 10.4 pounds (8.4 percent) in the past 2 months. The notes also indicated the resident's average food intake at meals was 46 percent. The notes further indicated the resident received nutritional supplements 3 times a day. review of the resident's medical record revealed [REDACTED]. Resident Weights: 12/12/10 - 123.4 pounds (admission) 12/27/10 - 117.0 pounds 01/10/11 - 120.8 pounds 01/24/11 - 112.8 pounds 01/31/11 - 120.7 pounds 02/11/11 - 123.0 pounds (readmission from hospital after Cervical Laminectomy) 02/16/11 - 112.2 pounds 02/21/11 - 113.0 pounds 03/09/11 - 111.5 pounds 03/23/11 - 100.8 pounds (22.6 pound/18.3 percent weight loss in 3 months, weight loss greater than 7.5 percent indicates severe weight loss) review of the resident's medical record revealed [REDACTED]. Continued review of the resident's medical record revealed [REDACTED]. On 05/25/11 at 11:01 AM, Nurse E verified there was no documentation the resident recieved a nutritional supplement as ordered by the physician. Nurse E also verified the Registered Dietician and physician should have been notified concerning the resident's severe weight loss and protein deficiency. The facility failed to ensure acceptable parameters of nutritional status, such as body weight and protein levels, were maintained for Resident #53.

The facility had a census of 58 residents. The sample included 3 residents. Based on observation, record review and interview the facility failed to provide adequate supervision and assistive devices for 1 of 3 sampled residents at risk for elopement. Resident #1 who the facility identified as cognitively impaired, had poor balance and displayed restless/wandering behaviors exited the facility in the early morning hours through an unknown door without the facility staff's knowledge. The resident walked approximately 9 blocks on a two lane street with a speed limit of 30 miles per hour without staff knowledge. The cognitively impaired resident was absent from facility approximately 55 minutes without staff knowledge. This failure placed the resident in immediate jeopardy. Findings included: - Resident #1 's medical record revealed [DIAGNOSES REDACTED]. The 12/9/10 (no time) nurse's notes indicated a certified nurse aide, last saw the resident, at 1:10 AM, lying on their bed wearing a brief and a T-shirt. Further review revealed at 1:50 AM, the Riley County Police Department notified the facility, by phone, that they had found the resident at a convenience store, approximately 9 blocks from the facility. The nurse's notes further indicated the resident ambulated with a shuffled gait upon return to the facility at 2:05 AM (approximately 55 minutes after last seen by the facility staff). On 1/12/11 at 12:30 PM, observation revealed the resident ambulated with an unsteady gait with stand by assist of a staff member. Throughout the same day observation revealed the resident seated in the main dining room drinking coffee and had a code alert bracelet on their right ankle. The readmission (MDS) Minimum Data Set 3.0 assessment, dated 11/18/10, indicated the resident had short and long term memory loss and moderately impaired decision making skills. The MDS further indicated the resident had moods of restlessness, moving around a lot and significantly intruded on the privacy of others. The MDS also indicated the resident wandered daily and the behavior had gotten worse since admission to the facility on [DATE]. Further review of the MDS revealed, the resident had an unsteady balance when walking. The 11/18/10 Elopement Risk assessment score of 7 (score 8-10 at risk) indicated the resident not at risk for elopement. The Elopement Risk assessment indicated the resident wandered (moves about with no discernable purpose), had periods of restlessness, and unable to comprehend verbal information. Although the 11/18/10 care plan indicated the resident received an antipsychotic medication the Elopement Risk assessment had a blank space for antipsychotic medication (1 point) and failed to identify the resident's antipsychotic medication or include the medication in the score of the assessment. The 11/29/10 care plan directed the staff to visually check the resident at least every two hours and throughout each shift and provide supervision with ambulation when the resident wandered to promote the resident's safety. The care plan also directed the staff to immediately redirect the resident when he/she wandered near an exit door. The care plan indicated the resident a "Potential for injury" related to Impaired Functional Status with decreased mobility, and the use of psychoactive medications. The care plan also indicated the resident a "Fall Risk" due to an unsteady gait. The care plan also identified the resident had difficulty sleeping at night. Although the facility had not assessed the resident as an elopement risk, on 11/18/10 the care plan further identified the resident received an antipsychotic medication. The staff had identified the resident received an antipsychotic medication in the care plan although the area on the "elopement risk " assessment had a blank space and failed to identify the resident received a psychoactive medication or add the point into the resident's elopement score. Review of the 11/28/10 nurse's notes revealed at 8:00 PM the resident in and out of other resident rooms, pulled a mattress off of a bed, turned a nightstand over on its side, tried to remove a seat from a couch, poured coffee on the floor in the main dining room and urinated on the couch. Further review revealed the staff obtained a physician's orders [REDACTED]. Continued review revealed the staff administered 2 doses of the antipsychotic medication and the now incontinent resident continued wandering and refused redirection from the staff. The nurse's notes through the rest of the night revealed the resident wandered to an adjoining unit and at 3:00 AM on 11/29/10 laid himself/herself down on the floor in the lobby and resisted any assistance from the staff. The nurse's notes indicated at 6:00 AM the resident had bowel and bladder incontinence, ambulated in the hallway, "nude", four times, required frequent monitoring and redirection. The nurse's note indicated the staff administered Ativan (antianxiety) medication. A 12/6/10 physician's progress note indicated the staff reported the resident wandered all around the facility. The nurse's notes indicated the resident wandered with an unsteady gait at different times of the day, daily from the following dates 11/22/10 until 12/8/10. (a total of 18 days) On 1/12/11 at 9:30 AM, Administrative Staff B verified the staff were unaware the resident had left the building on 12/9/10 in the early morning hours. Administrative Staff B further verified Riley County Police Department notified the facility by phone at 1:50 AM and informed the facility the resident was at a convenience store 9 blocks from the facility. Staff B further indicated the facility were not sure which door the resident had exited the facility and had not heard a door alarm the morning of 12/9/10 between 1:10 AM and 1:50 AM. On 1/12/11 at 11:30 AM, Nurse C verified the resident frequently wandered throughout the facility during the 6-2 shift for several weeks. At 5:45 PM on 1/12/11. Nurse D also verified the resident had wandered in the evening throughout the halls for several weeks. The facility's investigation failed to identify how the resident exited the building without the staff's awareness. The facility failed to provide adequate supervision for cognitively impaired Resident #1 who had poor balance, an unsteady gait and a history of wandering, and who left the faciity on the early morning of 12/9/10 without staff being aware. This failure placed Resident #1 in immediate jeopardy for serious harm to occur. The immediate jeopardy was abated on December 9, 2010 when the facility placed a wanderguard on the resident and placed the resident on 1:1 with the facility staff for the remainder of the morning of 12/9/10. In addition the facility activated the keypad to the exit door on January 12, 2011 which resulted in the exit door being locked and the need for a code to be entered into the keypad. The facility inserviced the staff on 12/14/10 regarding the elopement policy and procedure. The deficient practice remains at a scope and severity of a D.