Every finding on record at Wachusett Manor

Based on record review, and interviews, the facility failed to provide notification of transfer and discharge to the State Office of the Long-term Care Ombudsman for five Residents (#51, #43, #53, #92, and #7) out of six applicable residents reviewed, out of total sample of 19 Residents, and one discharged Resident (#89) out of three discharge records reviewed. Specifically, the facility failed to send a copy of the notice of transfer and discharge to a Representative of the Office of the State Long-Term Care Ombudsman when Resident's #51, #43, #53, #92, #7, and #89 were transferred to the hospital. Findings include: Review of the facility policy titled Resident Transfer and Discharge Policy and Procedure dated 2025 indicated:-Ensure resident transfers and discharges are properly documented.-Send a copy of the notice of transfer and discharge to a representative of the Office of the State Long-Term Care Ombudsman.-The facility shall maintain evidence that the notice was sent to the Ombudsman 1. Resident #51 was admitted to the facility in December 2024 with diagnoses including Metabolic Encephalopathy and Gastroesophageal Reflux Disease. Review of Resident #51's Clinical Record indicated:-A Nursing Progress Note dated 4/15/25 indicated the Nurse Practitioner was notified of the Resident having a cough and vomiting. Resident #51 was sent to the hospital for further evaluation.-A Nursing Progress Note dated 4/19/25 indicated Resident #51 was readmitted to the facility from an acute care hospital stay for a Urinary Tract Infection (UTI).-No evidence that the State Office of the Long-Term Care Ombudsman had been notified of Resident #51's transfer to the hospital. 2. Resident #43 was admitted to the facility in June 2025 with diagnoses including End Stage Renal Disease (ESRD) and dependence on Renal Dialysis.Review of Resident #43's Clinical Record indicated:- -A Nursing Progress Note dated 7/4/25 indicated the Resident did not go to their morning dialysis treatment and the Nurse Practitioner ordered Resident #43 be sent to the hospital.- -A Medication Administration Note dated 7/6/25 indicated that the Resident was admitted to the hospital.-No evidence that the State Office of the Long-Term Care Ombudsman had been notified of Resident #43's transfer to the hospital. 3. Resident #53 was admitted to the facility in July 2025 with diagnoses including Rheumatoid Arthritis and morbid obesity. Review of Resident #53's Clinical Record indicated:-A Nursing Progress Note dated 8/1/25 indicated Resident #53's labs were reviewed with the Nurse Practitioner and a new order for the Resident to be sent to the emergency room. Resident #53 was sent by ambulance to the hospital.-A Nursing Progress Note dated 8/2/25 indicated the facility received an update from the hospital and Resident #53 was admitted to the hospital.-Further review of Resident #53's Clinical Record failed to indicate any evidence that the State Office of the Long-Term Care Ombudsman had been notified of the transfer to the hospital. 4. Resident #92 was admitted to the facility in December 2024 with diagnoses including acquired absence of the Right Leg Below the Knee and acquired absence of the Left Leg Below the Knee. Review of the Nursing Progress Notes indicated:-A note dated 8/6/25 indicated the Resident was lethargic and had a strong foul smell coming from the Resident's wound.-The Nurse Practitioner was notified of the Resident's status on 8/6/25, and a new order was obtained to send the Resident to the emergency room for further evaluation.-The Resident returned to the facility on 8/14/25 after being hospitalized since 8/6/25.-Further review of Resident #92's Clinical Record failed to indicate any evidence that the State Office of the Long-Term Care Ombudsman had been notified of the transfer to the hospital. 5. Resident #7 was admitted to the facility in July 2025 with diagnoses including Unitary Tract Infection (UTI) and Adult Failure to Thrive (FTT). Review of the Resident #7's Clinical Record indicated:-A Nursing Progress Note dated 8/15/25 indicated the Resident was presenting with increased confusion, altered mental status, difficulty moving or walking, and increased incontinence. The Nurse Practitioner was updated and gave a new order to send the Resident to the emergency room for further evaluation and treatment.-A Nursing Progress Note dated 8/15/25 indicated the hospital had been called for an update and Resident #7 had been admitted to the hospital.-No evidence that the State Office of the Long-Term Care Ombudsman had been notified of Resident #7's transfer to the hospital. 6. Resident #89 was admitted to the facility in June 2021 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and peripheral vascular disease (PVD). Review of the Resident #89's Clinical Record indicated:-A Nursing Progress Note dated 8/24/25 indicated the Resident was unresponsive to verbal or physical stimuli. The Nurse Practitioner was notified and an order to send the Resident to the emergency room was obtained and the Resident was transferred to the hospital via ambulance.-A telehealth notification note dated 8/24/25 indicated the Nurse Practitioner agreed with plan for hospitalization for urgent evaluation and the Resident was to be sent to the emergency room for further assessment.-No evidence that the State Office of the Long-Term Care Ombudsman had been notified of Resident #89's transfer to the hospital. During an interview on 9/25/25 at 11:00 A.M., Unit Manager (UM) #1 said when a resident is sent out to the hospital, they have a packet with the bed hold and transfer notices that are filled out by the Nurse on duty. UM #1 said the packet is transferred with the Resident to the hospital and a copy is given to the Social Worker (SW). UM #1 said they do not do the Ombudsman Notification, that Social Services does the Ombudsman Notification. During an interview on 9/25/25 11:07 A.M., the SW said she is responsible for the notification to the Ombudsman when residents are transferred out of the building. The SW said she could not provide any evidence that the Ombudsman was notified of the hospital transfers for Residents #51, #43, #53, #92, #7, and #89. The SW said she should be sending the notifications to the Office of the Ombudsman at least monthly and should have notified the Ombudsman about the Residents being transferred out of the facility, but she did not.

Based on record review, and interview, the facility failed to notify the Physician of pertinent information for one Resident (#5) out of a total sample of 19 residents. Specifically, for Resident #5, the facility failed to notify the Physician as ordered, when the Resident's Finger Stick Blood Sugar (FSBS) level was greater than 350 milligrams per deciliter (mg/dl). Findings include:Review of the facility policy titled Change in a Resident's Condition or Status, dated 2001 revised December 2023, included:-The nurse will notify the resident's Attending Physician or Physician on call when there has been a (an): specific instruction to notify the Physician of changes in the resident's condition.-The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Resident #5 was admitted to the facility in July 2024 with diagnoses including Type 2 Diabetes Mellitus (DM 2) with ketoacidosis without Coma, dependence on Renal Dialysis, and unspecified Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5:-was moderately cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 8 out of 15 points,-has a diagnosis of Diabetes-was receiving Insulin injections daily. Review of Resident #5's September 2025 Physician's orders included:-Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro). Inject as per sliding scale:-if 0 - 50 [sic FSBS mg/dl]. Give glucose gel/Glucagon IM (intramuscularly) and notify Provider if no improvement. -51 - 100 = Give OJ (orange juice) if less than 70. -101 - 150 = No coverage needed. -151 - 200 = 4, Give 2 units. -201 - 250 = 6. Give 4 units.-251 - 300 = 8. Give 6 units.-301 - 350 = 10. Give 8 units.-351 - 999 = 12. Give 12 units and notify Provider, subcutaneously before meals for DM 2, scheduled three times each day at 7:30 A.M., 11:30 A.M., and 4:30 P.M. (order date 4/13/25, start date 4/14/25). Review of Resident #5's July 2025, August 2025, and September 2025 Medication Administration Records (MARs) indicated that the Resident's FSBS was documented three times each day and the results noted were between 351 - 999 mg/dl on 47 days of 85 days reviewed, requiring Physician notification.Review of the Resident's MAR for July 2025 indicated a FSBS result between 351 - 999 mg/dl on: 7/2, 7/3, 7/4, 7/11, 7/12, 7/14, 7/16, 7/17, 7/18, 7/22, 7/23, 7/24, 7/26, 7/27, 7/30, and 7/31.Review of the Resident's MAR for August 2025 indicated a FSBS result between 351 - 999 mg/dl on: 8/4, 8/5, 8/7, 8/8, 8/9, 8/10, 8/12, 8/14, 8/15, 8/16, 8/19, 8/21, 8/22, 8/23, 8/24, 8/25, 8/26, 8/27, 8/28, 8/29, and 8/30.Review of the Resident's MAR for September 2025 indicated a FSBS result between 351 - 999 mg/dl on: 9/2, 9/4, 9/9, 9/13, 9/14, 9/16, 9/17, 9/19, 9/20, and 9/21. Review of Resident #5's clinical record failed to provide any evidence that the Physician was notified of any FSBS results between 351 - 999 mg/dl on any dates noted during the months of July 2025, August 2025, and September 2025. During an interview on 9/24/25 at 5:01 P.M., the Director of Nursing (DON) said that she reviewed Resident #5's MARs for July 2025, August 2025, and September 2025. The DON said she identified that the Resident's FSBS was noted to be between 351 - 999 mg/dl on multiple occasions during each month but she was unable to find any evidence in the Resident's record that staff had notified the Physician as ordered, that the FSBS was noted to be between 351 - 999 mg/dl. The DON said that it was an expectation that staff would notify the Physician as ordered any time the Resident's FSBS was between 351 - 999 mg/dl and then document that communication in the Resident's record. The DON said that she was unable to provide any evidence that the staff had notified the Physician as ordered, but they should have done so.

Based on record review, and interview, the facility failed to provide an adequate resolution of a filed grievance on behalf of one Resident (#4), out of a total sample of 19 residents. Specifically, for Resident #4, the facility failed to thoroughly review, investigate, adequately resolve a grievance, and provide a written grievance resolution to Resident #4 when the Resident had complaints of noise in their room at night that affected his/her sleep. Findings include: Review of the facility policy titled, Resident and Family Concerns and Grievances Policy and Procedure, 2025, indicated: -The purpose is to provide prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with applicable federal and state statutes and regulations. -The facility will make reasonable efforts to ensure that all grievances are adequately resolved within thirty (30) calendar days from the day the grievance is received. -The facility will advise the resident of the outcome of the grievance investigation. -The facility will provide the resident with a written grievance decision, which shall include: >the date the grievance was received; >a summary statement of the resident's grievance; >a summary of the pertinent findings or conclusions regarding the resident's concern(s); >a statement as to whether the grievance was confirmed or not confirmed; >any corrective action taken or to be taken by the Facility as a result of the grievance; and >the date the written decision was issued. -In the event that the Facility cannot resolve the grievance within thirty (30) calendar days, the Facility will notify the resident, their family members, guardian or representative of the status and estimated completion date of the grievance resolution. -The facility will document all steps of the grievance resolution in the Facility's records, including whether or not the resident/family was satisfied with the resolution. Resident #4 was admitted to the facility in June 2025, with diagnoses that included Infection of Amputation Stump and Acquired Absence of the left leg below knee. Review of Resident #4's Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of possible 15. Review of the Grievance/ Concern form, received 9/4/25, indicated the following: -Resident #4 reported to the Social Worker (SW), that he/she was having trouble sleeping because his/her room was too loud. -The individual designated to take action for the grievance was the Unit Manager and/or Social Worker. -The date Grievance was to be resolved was 9/7/25. -The resolution of the Grievance/Concern was resolved on 9/5/25 after Resident #4 was offered a room change and declined, and then offered a facility change and declined. -A one-to-one discussion was used to notify the Resident of the resolution. During an interview on 9/24/25 at 9:09 A.M., Resident #4 said that he/she does not sleep well at night because the roommate's television is very loud all night and he/she is unable to get restful sleep. Resident #4 was unaware of any grievance filed on his/her behalf and said that he/she was offered a room change which he/she declined. Resident #4 said that he/she does wear disposable ear plugs, but they do not work. Resident #4 said that he/she had told several staff about the roommate's loud television, but nothing had been done and nobody followed up with him/her. During an interview on 9/24/25 at 1:23 P.M., the SW said that Resident #4 had complained about excessive noise from the roommate's television at night and the facility offered him/her a room change and a facility change/transfer, but both were declined. During an interview on 9/24/25 at 3:56 P.M., the SW said that she had considered the Grievance to be resolved on 9/5/25, when Resident #4 declined a room change and facility change. The SW said that she should not have resolved the grievance because the problem persists and she did not follow up with the Resident. During an interview on 9/25/25 at 9:09 A.M., Resident #4 said that he/she did not sleep well the night before because of the noise level in the room and said that he/she was wearing earplugs all night but said they do not work well. Resident #4 said that the facility recently said there is nothing else they can do about the noise complaints. During an interview on 9/25/25 at 10:03 A.M., the SW said since the surveyor brought this to the facility's attention, they had decided to offer the roommate headphones for the television and had offered the roommate a room change but both offers were declined. The SW said that the facility would continue to work with Resident #4 to find him/her an alternative room. The SW said that the facility could have explored more options with Resident #4 and the roommate when the Grievance was filed on 9/4/25 and should not have resolved the grievance on 9/5/25. During an interview on 9/26/25 at 4:39 P.M., the Administrator said that a Grievance is considered resolved when the Resident is happy with the outcome and the outcome is discussed with the Resident or responsible party.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for one Resident #8), out of a total sample of 19 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the Resident's history of self-injurious behaviors. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised September 2023, included but was not limited to: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. -The interdisciplinary team reviews and updates the care plan: >when there has been a significant change in the resident's condition; >when the desired outcome is not met; >when the resident has been readmitted to the facility from a hospital stay. Resident #8 was admitted to the facility in May 2024 with diagnoses including Schizophrenia, Restlessness and Agitation, and Major Depressive Disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 9/8/25, indicated Resident #8:-was moderately cognitively impaired with a Brief Interview of Mental status (BIMS) score of 11 out of 15. -had mood indicators of feeling down, depressed or hopeless nearly every day. Review of the Hospital Discharge summary dated [DATE], indicated Resident #8 had grabbed a cord and stated he/she would strangle himself/herself. Review of the Psychosocial Evaluation, dated 8/13/25, indicated Resident #8 was at risk for decompensation and increased monitoring for safety, including risk for falls or self-harm should be considered. Review of a Nursing Progress Note dated 8/18/25, indicated Resident #8 was found with blood on the sheets and long cuts/scratches to both wrists and was sent to the emergency room for suicidal ideations (SI). Review of the Social Work Progress Note dated 8/18/25, indicated Resident #8 had reports of self-injurious behavior and suicidal ideation (SI). Review of the Hospital Discharge summary dated [DATE], indicated Resident #8: -had reportedly cut himself/herself with a knife and began to scratch the cuts with his/her fingernails. -was at risk for self-injurious/suicidal behaviors. -engaged in self-injurious behavior by superficially scratching him/herself with his/her nails. -Discharge diagnosis included status-post self-injurious behavior of gesture by superficially scratching himself/herself. Review of Resident #8's Comprehensive Care Plan failed to indicate a history of self-injurious behaviors or SI. During an interview on 9/25/25 at 12:32P.M., the DON (Director of Nursing) said when the Resident caused self-injury to his/her wrists on 8/18/25, the facility did not complete an investigation or facility incident report about self-injurious behaviors. The DON said staff should have completed an investigation which would have prompted a Care Plan for self- injurious behaviors, but they did not complete an investigation or Care Plan. During an interview on 9/26/25 at 11:10A.M., the DON said if a Resident has a history of self-harm, a Care Plan and Kardex should have been implemented to assist staff in identifying behaviors, triggers and interventions which could prevent future incidences of self-harm. During an interview on 9/26/25 at 3:51P.M., the SW (Social Worker) said that if any Resident has a history of self-injurious behaviors, a Care Plan should be implemented with goals and interventions. The SW said that the facility should have updated Resident #8's Care Plan when the hospital paperwork from 7/10/25 indicated a statement about Resident #8 placing a cord around the neck and then on 9/2/25 when Resident #8 returned from a hospital stay related to self-injurious behavior to his/her wrists. The SW said it would have been important to implement the Care Plan for self-injurious behaviors to help keep Resident #8 safe by having staff aware of symptoms, triggers and interventions.

Based on observation, and interview, the facility failed to adhere to infection control standards of practice, increasing the risk of contamination and spread of infections on one unit (second floor short hall unit) out of three units, and three resident rooms located on the second-floor short hall unit. Specifically, the facility failed to: -Ensure proper cleaning and disinfecting of shared resident equipment after use for residents who were on Enhanced Barrier Precautions (EBP- measures using protective barrier gowns and gloves as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDRO] during high contact resident care) when Nurse #1 completed vital signs for two residents. -Follow appropriate hand hygiene standards prior to entering and exiting three resident rooms with EBP precaution signage clearly visible, while completing vital signs monitoring. Findings include: Review of the facility policy titled Enhanced Barrier Precautions, revised December 2024, included but not limited to: -Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. -Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. -Enhanced barrier precautions apply when: <A resident is infected or colonized with a Centers for Disease Control and Prevention (CDC) targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained; <A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and does not have secretions or excretions that are unable to be covered or contained. -Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. -Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. -Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen. Review of the facility policy titled Standard Precautions, revised September 2022, included but not limited to the following practices: <Hand hygiene is performed with alcohol-based hand rub (ABHR) or soap and water; -before and after contact with the resident -after contact with items in the resident's room; and -after removing gloves <Resident Care Equipment -Resident care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevent skin and mucous membranes exposure, contamination of clothing, and transfer of microorganisms to other residents and environments. -Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed. Review of the facility policy titled Handwashing/Hand Hygiene, revised October 2023, included but not limited to: -This facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. -All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. -All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol based hand rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility. <Indications for Hand Hygiene: -Immediately before touching a resident -After contact with blood, body fluids, or contaminated surfaces -After touching a resident -After touching the resident's environment On 9/25/25 at 9:08 A.M. through to 9:39 A.M., the surveyor observed the following: -Three rooms on the second-floor short hall unit with posted signs for EBP which indicated: -STOP: ENHANCED BARRIER PRECAUTIONS >EVERYONE MUST: -clean their hands including before entering and when leaving the room. -9:08 A.M.: Nurse #1 entered the first resident room carrying blood pressure monitoring equipment and failed to perform hand hygiene prior to entering the resident room. Nurse #1 was observed obtaining a resident's blood pressure utilizing the blood pressure equipment. -Nurse #1 exited the first resident room with the blood pressure equipment and walked to his medication cart without performing hand hygiene or sanitizing of the blood pressure equipment. Nurse #1 was observed to open the computer screen positioned on top of the medication cart and opened the medication cart using keys he removed from his pocket. The surveyor observed Nurse #1 remove an item from the medication cart, locked the cart, and turned to enter another resident room. -9:32 A.M., Nurse #1 entered a second resident room with EBP signage posted outside the room without performing hand hygiene. Nurse #1 was observed to close the door when he entered the second resident room. -9:35 A.M., Nurse #1 exited the second resident room and failed to perform hand hygiene. Nurse #1 walked to his medication cart parked at the end of the hall and picked up the blood pressure equipment. -9:36 A.M., Nurse #1 entered the third resident room with EBP signage posted outside the room without performing hand hygiene. The surveyor observed Nurse #1 utilizing the same blood pressure equipment used in the first resident room that was not sanitized or cleaned after use. -9:39 A.M., Nurse #1 exited the third resident room without performing hand hygiene and walked towards his medication cart and placed the blood pressure equipment next to the medication cart without cleaning or sanitizing the blood pressure equipment. During an interview on 9/25/25 at 9:52 A.M., Nurse #1 said he believed there was a protocol in place that he should clean the blood pressure equipment after each use on a resident as a sanitary precaution. Nurse #1 said he did not clean the blood pressure equipment, and he should have. Nurse #1 said he should have used the wipes provided by the facility to clean the equipment prior to using it again on another resident. Nurse #1 said he typically exits the resident rooms and uses alcohol-based hand hygiene on his medication cart to clean his hands. Nurse #1 said that he believes there are facility approved wipes to sanitize equipment after each use on a resident and would find and show them to the surveyor. During a follow-up interview on 9/25/25 at 10:08 A.M., Nurse #1 showed the surveyor a cleaning product labeled Sani-cloth germicidal disposable wipe. Nurse #1 said he should have used the wipe to clean the blood pressure equipment when he exited a resident's room and each time the equipment was used on a resident. Nurse #1 also said that he should wait for 20 minutes to allow the product to dry completely before using the blood pressure equipment again. During an interview on 9/25/25 at 11:59 A.M., the Director of Nursing (DON) said that nursing staff should use the Sani-cloth germicidal wipes and clean the blood pressure equipment after each resident use to prevent the spread of infections. The DON said nursing staff should perform hand hygiene prior to entering and exiting the EBP resident rooms using the alcohol-based hand gel provided.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had recently been readmitted with new diagnoses of aspiration pneumonia (infection caused by inhaling something other than air into the lungs), and pericardial effusion (fluid around the heart), the Facility failed to ensure nursing notified the Provider when he/she experienced further decline with a change in condition. Findings include: Review of the Facility's policy titled, Acute Condition Changes-Clinical Protocol, revised March 2018 indicated: - The nurse will notify the residents' attending physician or physician on call when there has been a significant change in the resident (decrease in food intake, changes in skin color or condition). Resident #1 was admitted to the Facility in December 2024, diagnoses included Atrial Fibrillation, presence of cardiac pacemaker, hypertension, coronary artery disease, unstable angina, and protein calorie malnutrition. Review of Resident #1's Hospital Discharge summary dated [DATE], indicated he/she was seen in the Emergency Department for chest pain, diagnosed with Aspiration Pneumonia and started on antibiotic therapy. The Summary indicated Resident #1 had an echocardiogram (non-invasive ultrasound to create pictures of the heart), that showed cardiac effusion (fluid around the heart). During a telephone interview on 06/24/25 at 12:49 P.M., Certified Nurse's Aide (CNA) #1 said on 06/07/25, Resident #1 had not been feeling well and wasn't his/her usual self, and she reported her concerns to the Nurse. During a telephone interview on 06/24/25 at 12:27 P.M., Nurse #1 said that on 06/07/25 around 4 P.M., Resident #1 reported to her that he/she did not feel well, his/her color was extremely pale, and he/she was more lethargic than usual. Nurse #1 said she applied oxygen at 3 Liters via nasal cannula to Resident #1 due to his/her pale color and bluish tint to his/her lips. Nurse #1 said she continued to monitor Resident #1 and with the application of oxygen his/her lips returned to normal color and skin color improved, but he/she remained feeling unwell. Nurse #1 said she did not notify Resident #1's Provider his/her condition change, of the need to apply oxygen, or to obtain new orders. Review of Resident #1's medical record indicated there was no documentation to support nursing notified the provider on 06/07/25 of his/her decline in condition, despite the need to apply oxygen, which was new for him/her. During an interview on 06/24/25 at 12:42 P.M., the Nurse Practitioner (NP) said she was not notified by nursing staff on 06/07/25 that Resident #1 had a change in condition, that he/she had required oxygen. During an interview on 06/24/25 at 11:59 A.M., the Director of Nursing (DON) said there was no documentation to support that Nurse #1 called the Provider to notify that Resident #1 had a decline in condition, including the need to place oxygen on him/her, which was new. The DON said that it is the facility's expectation that nursing staff assess for acute changes in the resident's condition, notify the resident's Provider, and document and in this case it was not done. On 06/24/25, the Facility presented the Surveyor with a Plan of Correction that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A. Resident #1 no longer resides at the facility. B. On 6/10/25, a Facility wide audit was initiated by the Nursing Administration on residents with acute condition changes to ensure Facility policy was followed. C. Starting on 6/10/25, audits were conducted daily by the DON/designee to ensure that the provider has been notified of any residents with changes in condition, and will be reviewed at the daily morning report until substantial compliance is met and the results of the audits will be reviewed at the next monthly QAPI meeting on 6/25/25. D. On 6/10/25, the education of Nursing and Certified Nursing Assistant (CNA) staff was initiated by the Staff Development Coordinator on the Change in Condition Policy. E. On 06/13/25, an AD HOC Quality Assurance Performance Improvement (QAPI) meeting was conducted, concern areas discussed included: immediate response and ongoing monitoring plan to sustain compliance with Facility Policy on Acute Condition Changes-Clinical Protocol, and results of the Audits. F. On 6/19/25, the Facility completed the Education of all nursing staff on the correct process when a resident has a change in condition. G. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was a full code, who during the evening shift (3:00 P.M. to 11:00 P.M.) on [DATE], was found unresponsive, pulseless with no respirations by the nursing staff, the facility failed to ensure he/she was provided care and services that met professional standards of nursing practice, when although nursing staff initiated a Code Blue, called 911, and provided Cardiopulmonary Resuscitation (CPR), to him/her until Emergency Services arrived, nursing failed to obtain and use the facility's Automated External Defibrillator (AED) device, during the Code Blue. Findings include: Review of the Facility's Policy, titled Emergency Procedure-Cardiopulmonary Resuscitation and Basic Life Support, dated [DATE], indicated the following: - Activation and retrieval of the AED by the lone healthcare provider or by the second person sent by the rescuer, must occur immediately after the check for no normal breathing and no pulse, - Immediately begin CPR and use the AED/defibrillator, - When the second rescuer arrives, provide 2-rescuer CPR and use the AED. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated [DATE], indicated on [DATE], Resident #1 was found unresponsive by a Certified Nurse Aide (CNA, later identified as CNA #1) who alerted the Nurse ( later identified as Nurse #1), a code was called, crash cart obtained and Nurse #1 began compressions and another staff member (later identified as Nurse #2 ) called 911 and assisted with CPR until EMS arrived. Further review of the report indicated Resident #1 expired at the facility. Resident #1 was admitted to the Facility in [DATE], diagnoses included Atrial Fibrillation, presence of cardiac pacemaker, hypertension, coronary artery disease, unstable angina, and protein calorie malnutrition. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was seen in the Emergency Department for chest pain, diagnosed with Aspiration Pneumonia and started on antibiotic therapy. Further review indicated Resident #1 had an echocardiogram (non-invasive ultrasound to create pictures of the heart), that showed cardiac effusion (fluid around the heart). During a telephone interview on [DATE] at 12:49 P.M., (which included review of her written statement) CNA #1 said on [DATE] sometime after 9:00 P.M., she found Resident #1 unresponsive and immediately notified the nurse, (later identified as Nurse #1) who assessed him/her. CNA #1 said Nurse #1 called a code blue over the hand held radio system and initiated CPR after retrieving the crash cart. CNA #1 said Nurse #2 called 911 to activate EMS services and then assisted Nurse #1 with CPR on Resident #1 until EMS arrived. CNA #1 said she was not directed to retrieve the AED device. During a telephone interview on [DATE] at 12:27 P.M., (which included review of her written statement) Nurse #1 said on [DATE] sometime after 9:00 P.M., (exact time unknown) CNA #1 told her that she found Resident #1 unresponsive and pale, that she assessed him/her, found no pulse or respirations and called a Code Blue three times via the hand held radio system, obtained the crash cart and began CPR. Nurse #1 said she did not direct a staff member to retrieve the AED. Nurse #1 said she had directed CNA #1 to alert Nurse #2 who activated EMS services (called 911) and then assisted her with CPR. Nurse #1 said when EMS arrived (exact time of arrival unknown) and took over CPR, they then determined Resident #1 had expired and informed them (herself and Nurse #2) that further resuscitation efforts would not be beneficial. Review of Nurse #2's witness statement (documented by the DON per telephone interview) dated [DATE], indicated he was alerted of the Code Blue, called 911 and went to Resident #1's room to assist with CPR, but did not see an AED in the room. Review of the EMS Provider Response Report, dated [DATE], indicated EMS was activated at 9:29 P.M., units arrived at the facility at 9:34 P.M. and observed two rescuer CPR in progress. The Report indicated the resident had no signs of life and they (EMS) determined further resuscitation efforts were futile. The Report also indicated there was no AED present on Resident #1 or on the scene (in the room). During an interview on [DATE] at 12:42 P.M., the Nurse Practitioner (NP) said, she would have expected nursing to apply to an AED to a resident during a Code Blue, but also said during this event, the use of the AED on Resident #1 would not have changed the outcome due to his/her poor cardiac effusion and cardiac history. During an interview on [DATE] at 11:14 A.M., the Director of Nursing (DON) said she spoke to Nurse #1, who said CNA #1 informed her (Nurse #1) that she found Resident #1 unresponsive and pale sometime after 9:00 P.M. (exact time unknown). The DON said Nurse #1 assessed him/her, he/she was pulseless without respirations and she called a Code Blue, obtained the crash cart and began compressions while, Nurse #2 called 911 to initiate EMS services and then went to assist Nurse #1. The DON said Nurse #1 should have delegated a staff member to retrieve the AED, and it should have been applied and used during the code, but it was not. The DON said her expectation is always nursing best practice, patient-centered care and that all Facility Protocols and Policies are being followed by the nurses and staff. The DON said she holds the nurses to the highest standard for professional conduct for residents' safety. On [DATE], the Facility presented the Surveyor with a Plan of Correction that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A. Resident #1 no longer resides at the facility. B. An Audit was conducted immediately by the Staff Development Coordinator (SDC ) to ensure Nursing staff were current on CPR certifications and determined all nursing staff were current. C. On [DATE], a Facility wide audit was initiated by the Nursing Administration to ensure the Code Cart Daily Checklist and the 11:00 P.M.-7:00 A.M. (night shift) Daily Checklist (which includes checking the AED) were completed. D. Ongoing audits will be conducted daily by the DON/designee to ensure both the Code Cart Daily Checklist, and the night shift Daily Checklist are completed and will be reviewed at the next monthly QAPI meeting on [DATE]. E. On [DATE], the education of Nursing and Certified Nurse Aide (CNA) staff was initiated by the Staff Development Coordinator on the Code Blue Policy, which included assigning and nursing responsibility to ensure a staff member (across all shifts) retrieves and brings the AED in event of Code Blue. F. On [DATE], an AD HOC Quality Assurance Performance Improvement (QAPI) meeting was conducted, concern areas discussed included immediate response and ongoing monitoring plan to sustain compliance with MOLST and Facility Policy on Emergency Procedures and results of the Audits. G. On [DATE], the Facility completed the Education of all nursing staff on the correct process for Emergency Procedures, including but not limited to ensuring the AED is brought and used as directed during a Code Blue. H. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on observation, interview, record and policy review, the facility failed to implement infection control practices designed to prevent development and transmission of infection and provide a sanitary environment for two Residents (#20 and #67) out of a total sample of 19 residents. Specifically, facility staff failed to: 1. adhere to Standard Precautions (infection prevention measures that apply to all resident care, regardless of suspected or confirmed infection status) and Contact Precautions (infection prevention measures used to prevent transmission of infections which are spread by direct or indirect contact with the resident or the resident's environment) when Certified Nurse Aide (CNA) #1 provided personal care to Resident #20, who required Contact Precautions relative to a multi-drug resistant organism (MDRO), then handled Resident #67's wheelchair, increasing Resident #67's risk for illness. 2. distribute ice in a sanitary manner into bins used to keep residents' drink items cool for meal service, increasing the residents' risk for illness. 3. implement the facility's water management program, increasing the risk for illness in residents. Findings include: Review of the facility's policy titled Infection Control Policy and Procedure, dated 2022, indicated the following: -Staff were required to follow hand hygiene practice consistent with accepted standards of practice. -Infectious organisms may be transmitted by direct (skin to skin) or indirect (inanimate objects) contact. -Healthcare staff . often move from resident to resident and therefore may serve as a vehicle for transferring effective organisms. -Staff were required to perform hand hygiene before and after contact with a resident. Review of the Centers for Disease Control and Prevention (CDC) guidelines titled Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, indicated the following: -Protect yourself and your patients from deadly germs by cleaning your hands. -Cleaning one's hands reduces the spread of germs, including those resistant to antibiotics. -After touching a patient or patient's surroundings. -After contact with blood, body fluids, or contaminated surfaces. 1. Resident #20 was admitted to the facility in May 2024 with a diagnosis of urinary tract infection (UTI: bacterial infection of the urinary tract). Review of Resident #20's clinical record indicated the following: -The Resident had an indwelling urinary catheter. -The Resident required Contact Precautions due to having Vancomycin Resistant Enterococcus (VRE: MDRO) in his/her urine. -A Physician's order, start date 8/1/24, for Ampicillin (antibiotic medication) Oral Capsule 500 milligrams (mg), give 1 capsule by mouth every 6 hours for UTI for 7 Days. Resident #67 was admitted to the facility in December 2023, with a diagnosis of Need for Assistance with Personal Care. On 8/8/24 at 7:35 A.M., the surveyor observed a Contact Precautions sign posted outside of Resident #20's and #67's shared room. The surveyor observed the following listed on the Contact Precautions sign: -Everyone must put on gloves and gown before room entry. -Do not wear the same gown and gloves for the care of more than one person. On 8/8/24 at 9:00 A.M., the surveyor observed CNA #1 put on a disposable gown and gloves, and assisted Resident #20 into his/her room by pushing his/her wheelchair. Upon entering the room, CNA #1 released Resident #20's wheelchair handles, then moved to Resident #67 who was sitting in a wheelchair and used her same gloved hands to move Resident #67 closer to his/her bed. The surveyor observed CNA #1 place her hands back onto the handles of Resident #20's wheelchair and move the Resident to his/her bedside. The surveyor observed CNA #1 close the privacy curtain between the two beds. The lower part of Resident #20's wheelchair and the Resident's urinary catheter tubing and urinary collection bag as well as CNA #1's lower legs were visible to the surveyor below the bottom of the privacy curtain. The surveyor observed CNA #1 remove Resident #20's urinary catheter collection bag from underneath the wheelchair and drop it on the floor, then pulled the urinary catheter tubing and bag from underneath the wheelchair to beside the Resident's right foot, dragging the bag on the floor. CNA #1 then assisted Resident #20 into his/her bed. The surveyor then observed CNA #1 open the privacy curtain. The CNA held a full plastic bag in her left hand, walked toward Resident #67 who was still sitting in his/her wheelchair, and moved the Resident in his/her wheelchair to his/her bedside. CNA #1 did not remove her gloves and gown and she did not perform hand hygiene before she assisted Resident #67. The surveyor observed CNA #1 remove her gown and gloves and performed hand hygiene, then exited the room carrying the plastic bag. During an interview on 8/8/24 at 1:45 P.M., CNA #1 said she assisted Resident #20 back to bed that same morning. CNA #1 said she always had a hard time reaching around the Resident's chair to unsecure the urinary catheter collection bag from underneath the wheelchair, so every time she removed the collection bag, it would fall on the floor. CNA #1 said Resident #20's urinary catheter collection bag fell on the floor that morning when she was assisting the Resident back to bed, so she had to drag the urinary catheter collection bag on the floor, under the wheelchair, to make sure it did not get caught on anything when she transferred the Resident to bed. CNA #1 said she had also removed bed linens from Resident #20's bed and placed them in a plastic bag because the bed linens had some dried blood on them and the bed linens were the items in the plastic bag during the surveyor's observation. CNA #1 said she needed to move Resident #67 to his/her bedside in order to exit the room, so she moved the Resident by handling his/her wheelchair, but she did not remove her gloves and gown and perform hand hygiene after she provided personal care to and handled Resident #20's urinary catheter tubing and collection bag. CNA #1 said she should have removed her gloves and gown and performed hand hygiene after she assisted Resident #20, before she assisted Resident #67. During an interview on 8/8/24 at 2:00 P.M., the Infection Preventionist (IP) said Resident #20's urinary catheter collection bag should not have been on the floor, and should have either been properly disinfected or replaced. The IP said Contact Precautions were implemented for Resident #20 to reduce the risk for transmission of infection because the Resident was actively being treated with antibiotics for VRE in his/her urine. The IP also said CNA #1 should have removed her gloves and gown and performed hand hygiene after she assisted Resident #20, before she assisted Resident #67. 2. On 8/8/24 at 7:05 A.M, the surveyor observed that the ice machine in the facility's kitchen was empty and it was not running. The surveyor observed that two large bags of ice were stored in the facility's walk-in freezer. The surveyor also observed that the ice in both bags were thick, solid, and formed as blocks of ice. During an interview on 8/8/24 at 8:45 A.M., the Food Service Director (FSD) said that the ice machine in the facility's kitchen was not working and some parts were on order to fix the ice machine. The FSD said that while the facility awaited the parts and repair for the ice machine, the facility was purchasing large bags of ice and storing them in the walk-in freezer. On 8/8/24 at 11:30 A.M., the surveyor observed a staff member in the facility's kitchen handle a large bag of ice and throw it to the floor. During an interview on 8/8/24 at 3:30 P.M., Dietary Aide #1 said the ice machine in the facility's kitchen did not work and that large bags of ice were being used to place into the plastic bins where the kitchen staff stored containers of milk and juice used for resident consumption at meal times. Dietary Aide #1 said kitchen staff would dump the ice from the bags into the bins with the drinks. At this time, the surveyor observed a grey plastic bin located on top of a three tier cart that contained one unopened half gallon of milk and several plastic pitchers of juice in the kitchen next to Dietary Aide #1. Dietary Aide #1 said ice would be placed into the grey plastic bin to keep the drinks cool, then sent to a resident unit for resident consumption at the evening meal. During an interview on 8/8/24 at 3:43 P.M., the FSD said the ice machine in the kitchen had not been working for a couple of weeks and the facility had parts on order for it to be repaired. The FSD said the facility had been purchasing large bags of ice while waiting for the ice machine to be repaired and that the bags of ice were used to keep drinks cool for meal service. The FSD said the ice pieces in the large bags would stick together, so in order for staff to be able to dump the ice into the drink bins, they would have to drop the bags of ice on the floor, then dump the ice into the bins once the ice was broken up. At this time, the FSD removed one large bag of ice from the freezer and dropped it on the floor in the cold food storage room outside of the walk-in freezer. The FSD then said after breaking the ice, staff would open the bag and dump the ice into the bins that contained containers of drinks for resident consumption. When asked if there was any other way the ice could be broken other than dropping it on the floor, the FSD said the ice could probably be broken on a food preparation table instead. During an interview on 8/8/24 at 4:00 P.M., the IP said staff should not be breaking bags of ice on the floor when the ice was being used to keep resident drink containers cool. The IP said staff should break the ice on a surface that is not the floor, such as a table. 3. Review of the facility's Water Management Program, revised 5/19/23 and reviewed 6/12/24, indicated the following: -Identify where potentially hazardous conditions could exist where pathogens/Legionella (bacteria usually found in soil and water that can become a health hazard when it grows in human made water systems and is spread through the inhalation of contaminated aerosolized water particles) could grow . -Determine where control measures should be applied and conduct regular monitoring to ensure control measures are performing as designed. -Flush dead legs (stagnant or unused section of plumbing that can provide a habitat for the growth of microorganisms) quarterly. -Flush low utilization sinks and fixtures monthly (more often if needed). -Monitor and document implementation of control measures on record keeping logs. During an interview on 8/8/24 at 12:00 P.M., the Maintenance Director said he could not provide evidence that dead legs were flushed quarterly or that low utilization sinks and faucets were flushed monthly since the last recertification survey.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure that the facility was free of pests in the main facility kitchen, on two units (Unit Two and Unit Four) and in the residents rooms for three Residents (#17, #69 and #290). Specifically, the facility staff failed to implement measures to eradicate and contain small flies located in the facility's main kitchen, the kitchenette on Unit Two, dining room on Unit Four, and in Resident's #17, #69 and #290 rooms, increasing the risk for contamination of clean surfaces and transmission of infectious pathogens. Findings include: Review of the North Carolina State University Extension Publication titled Phorid Flies (https://content.ces.ncsu.edu/phorid-flies) dated 11/17/21 indicated: -Phorid flies are mainly nuisance pests, but there are some cases of larval infestations of human orifices such as the eyes, wounds, and intestines. -Phorid flies are capable of transmitting bacterial pathogens onto foods or working surfaces in food preparation facilities. -These instances are fairly rare and the presence of these flies in and around the home is typically only a nuisance to those affected. --Phorid fly control begins with finding and eliminating larval development sites such as rotting food, where moisture exists around plumbing lines and drains and cracks in structures like foundations, walls, windows Review of the facility's Pest Control Service Inspection Report, dated 5/8/24, indicated the following: -The storage area outside of the walk-in refrigerator (main kitchen) was inspected and no pest activity was observed. -The main kitchen's dry storage room was inspected and no pest activity was observed. -The main kitchen area was inspected. A few Phoroid Flies (mainly nuisance pests: flies that are capable of transmitting bacterial pathogens onto foods or working surfaces in food preparation areas) were observed on the trap next to the ice machine. Review of the facility's Pest Control Service Inspection Report, dated 6/12/24, indicated the following: -The scheduled pest control service was completed. -No pest problems were reported in the log book. Review of the facility's Pest Control Service Inspection Report, dated 7/5/24, indicated commercial pest control was provided to the facility relative to a service call for mice. Further review of the Pest Control Service Inspection Report included no evidence that routine pest control services were provided on 7/5/24. On 8/8/24 at 6:55 A.M., the surveyor observed small flies in the facility's main kitchen, specifically in the food preparation area, the cold storage room outside of the walk-in freezer and walk-in refrigerator, and in the dry food storage room. On 8/8/24 at 8:09 A.M., the surveyor observed a meal tray in Resident #17's room that contained uneaten food. The surveyor observed small flies on the uneaten food. On 8/8/24 at 9:36 A.M., the surveyor observed Resident #69 sitting on the edge of his/her bed. The surveyor further observed two small flies in the air above Resident #69's head. On 8/8/24 at 12:00 P.M., the Maintenance Director said that the facility had a pest control program in place. The Maintenance Director said he was not sure how often pest control services were provided, but he thought that someone from the pest control company serviced the facility every other month. The Maintenance Director also said that he was unsure when pest control services were last provided to the facility, but he thought it was a couple of weeks prior, and that the facility had been receiving services to treat for fruit flies. The Maintenance Director said that the pest control company had not left any paperwork from their visits at the facility, but he would contact the pest control company to acquire the pest control service records. On 8/8/24 at 5:15 P.M., the Maintenance Director said he had contacted the pest control company, but the pest control company had not called back as yet. On 8/9/24 at 7:05 A.M., the surveyor observed the following in the Unit Two Short Hall Kitchenette: -Three small dessert plates that were unevenly stacked, with the top plate and the middle plate containing brown food crumbs. -One plastic cup that contained a straw and a small amount of orange juice. When the surveyor tipped the cup to look inside it, the surveyor observed two small flies exit the cup. -One small flying in the air that landed and sat on the inner doorframe of the Kitchenette. During an interview on 8/9/24 at 7:08 A.M., [NAME] #1 said the facility had been dealing with small flies, off and on, for a while. [NAME] #1 said dietary staff from the Kitchen were responsible to make rounds in the mornings to pick up any food items from the evening prior and bring them back to the Kitchen for disposal. [NAME] #1 said that staff on the resident units were supposed to bag any food items still on the units after the Kitchen was closed and place them in the unit Kitchenettes to be picked up in the morning. He said Kitchen staff also left an enclosed cart on the units that meal trays could be placed in, to keep food items contained. [NAME] #1 said sometimes staff did not follow this process and food items were left open on the units. During an interview on 8/9/24 at 7:10 A.M., the Food Service Director (FSD) said the small flies observed by the surveyor in the kitchen areas on 8/8/24 were drain flies. The FSD said that the pest control company was actively servicing the facility for the drain flies and that the services were provided monthly. The FSD said the drain fly activity had not worsened, but it had not improved and that the drain flies had been present for about two years. During an interview on 8/9/24 at 7:30 A.M., the Administrator said that the facility had pest control services in place and that services were provided monthly. The Administrator said that he had not observed any small flies on the resident units at the facility and that he thought the small flies were only present in the lower level of the facility, where the main kitchen was located. The Administrator further said he thought the small fly activity was almost rectified. During an interview on 8/9/24 at 8:37 A.M., Resident #290 said he/she had been at the facility for the past two weeks and observed small flies in his/her room, but had not brought this up to facility staff. During an interview on 8/9/24 at 8:45 A.M., Resident #69 said he/she observed small flies in his/her room a few days prior, but had not brought this up to facility staff. During an interview on 8/9/24 at 10:28 A.M., Housekeeper #1 said the dining room sink on Unit Four often has small flies in it, but that she had not received any specific instruction on how to get rid of them. Housekeeper #1 did not say whether she had communicated observations of small flies in the Unit Four dining room sink to administration. During a follow-up interview on 8/9/24 at 12:10 P.M., the Maintenance Director said he received records from the pest control company relative to pest control services that same morning and provided a copy of the records to the surveyor for May 2024 through July 2024. The Maintenance Director said that he had not contacted the pest control company for the records of services provided until the surveyor requested evidence of a pest control program, so he had no way of knowing whether recommendations in addition to routine monthly services had been made to the facility relative to pest control. The surveyor and the Maintenance Director reviewed the pest control service inspection reports from May 2024, June 2024, and July 2024 with the Maintenance Director. The Maintenance Director further said he had not contacted the pest control company for any additional services relative to small flies anytime between 7/5/24, and when he requested the inspection reports on 8/8/24.

Based on interview and record review, the facility failed to ensure that one resident (#71) out of a total sample of 19 residents received trauma-informed care in accordance with professional standards of practice. Specifically, the facility failed to complete a trauma history assessment for Resident #71 who had a diagnosis of Post Traumatic Stress Disorder (PTSD: a mental and behavioral disorder that develops from having experienced a traumatic event, causing flashbacks, nightmares and severe anxiety), placing the Resident at risk for re-traumatization. Findings include: Review of the facility policy titled Trauma Informed and Culturally Competent Care Level III, last revised August 2022, indicated the following: -Purpose: >To guide staff in providing care that is culturally competent and trauma informed in accordance with professional standards. >To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -Resident Screening: >Utilize initial screening to identify the need for further assessment and care. -Resident Assessment: >Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. Resident #71 was admitted to the facility in August 2022, with diagnoses including PTSD and Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations). Review of the most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #71 was severely cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 5 out of 15 and had an active diagnosis of PTSD. Review of the August 2024 Physician's orders indicated the Resident had an active legal Guardianship (Guardian: a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions) in place. On 8/8/24 at 8:00 A.M., the surveyor observed that Resident #71 had his/her room door closed, privacy curtain closed around the bed, and bed linens pulled up over his/her head. During an interview on 8/8/24 at 9:57 A.M., Resident #71's Guardian said that the Resident had increased behaviors of self-isolating in his/her room and refusing care. During an interview on 8/12/24 at 10:56 A.M., Nurse #4 said Resident #71 refuses care occasionally and likes to keep covered up, with a coat and hat on all the time. Nurse #4 said when the Resident refuses care, staff will tell the Nurse and then the Guardian is notified as required. During an interview on 8/12/24 at 12:51 P.M., CNA (Certified Nurses Aide) #3 said Resident #71 refuses care at times and gets very angry and upset when clothing is removed for care. CNA #3 said the Resident likes to be in his/her room with the privacy curtain closed tight around the bed and the door shut all the time. Review of the comprehensive medical record failed to indicate evidence of any assessment for trauma history when the Resident had an active diagnosis of PTSD and demonstrated increased behaviors of refusal of care and self-isolation. During an interview on 8/12/24 at 4:43 P.M., the Director of Nursing (DON) said a trauma assessment had not been done for Resident #71. The DON said a trauma assessment is important because past history of trauma could affect the delivery of care. During an interview on 8/13/24 at 2:15 P.M., Social Worker (SW) #1 said the trauma informed care assessment should be completed on admission for each resident. SW #1 said Resident #71 had a diagnosis of PTSD and should have been assessed for trauma history and triggers so staff could provide personalized care and manage behaviors. SW#1 said the trauma assessment was not completed until the surveyor notified the DON on 8/12/24 that there was no trauma assessment found in the Resident's medical record. SW#1 further said Resident #71 should have been assessed for trauma informed care on admission to the facility.

Based on observation, interview, and policy review, the facility failed to maintain a clean and homelike environment on one Unit (#4) out of three units observed. Specifically, the facility failed to ensure that the flooring in the Unit #4 multi-purpose room was in good repair and homelike condition. Findings include: Review of the facility's policy titled Homelike Environment, dated 2001 and revised February 2021, indicated the following: -Staff provides person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. -Facility staff and management maximizes, to the extent possible, characteristics of the facility that reflect a personalized, homelike setting. On 8/8/24 at 7:45 A.M., the surveyor observed the following in the residents' multi-purpose room on Unit #4: -Several gouges and holes in the flooring throughout the room. -One area where the flooring was torn and lifted at the transition from the hallway into the multi-purpose room. On 8/8/24 at 8:45 A.M., the surveyor observed several residents seated in the Unit #4 multi-purpose room for breakfast. The surveyor also observed three staff members in the Unit #4 multi-purpose room at this time assisting the residents with the breakfast meal. During an interview on 8/9/24 at 12:10 P.M., the Maintenance Director said the flooring in the Unit #4 multi-purpose room was very old and had several gouged areas and holes in the flooring. The Maintenance Director said he thought the gouges and holes were from the use of equipment such as mechanical lifts and scraping the floor when it needed to be cleaned. The Maintenance Director said the floor had been like this for some time and this was not the first time he had been aware of the condition of the floor. The Maintenance Director also said he was not aware of any plans to make the multi-purpose room floor more homelike for the residents on the unit.

Based on observation, interview, record, and policy review, the facility failed to provide care in accordance with professional standards of practice relative to providing a pressure redistribution cushion (cushion that spreads pressure more evenly across its surface to reduce the amount of pressure on any one part of the body) to a wheelchair when the Resident was at risk for skin breakdown for one Resident (#5) out of a total sample of 19 residents. Specifically, for Resident #5 the facility staff failed to: -Follow a Physician's order to provide a pressure redistribution cushion to the Resident's wheelchair. -Implement the Resident's care plan for a new cushion to the Resident's wheelchair. -Provide a pressure relieving device to the Resident's chair as indicated in the Minimum Data Set (MDS) Assessment and for the Resident who was assessed as being at a high risk for skin breakdown. Findings include: Review of the facility policy titled Support Surface Guidelines, dated September 2013, included: -Review the resident's care plan to assess for any special needs of the resident. -Redistributing support surfaces are to provide comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. -Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface . Resident #5 was admitted to the facility in October 2016 with diagnoses of Spinal stenosis (an abnormal narrowing of the spinal cord resulting in pressure on the spinal cord causing pain or numbness in the arms or legs), abnormal posture, osteoarthritis (a degenerative joint disease that results from breakdown of joint cartilage and underlying bone), difficulty in walking, and muscle weakness. Review of the MDS assessment dated [DATE] indicated that Resident #5 was moderately cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 9 out of 15 and had a pressure reducing device for the wheelchair. Review of the Resident's care plan last revised on 7/30/24, included an intervention of new cushion applied to wheelchair, initiated 1/5/22. Review of the Resident's August 2024 Physician's orders included an active order for a pressure redistribution cushion to chair, initiated on 10/1/22. Review of the Resident's August 2024 Treatment Administration Record (TAR) included at the top heading under unscheduled other orders: Pressure redistribution cushion to chair. On 8/8/24 at 9:49 A.M., the surveyor observed Resident #5 sitting in a wheelchair with no pressure redistribution seat cushion. On 8/8/24 at 4:09 P.M., the surveyor observed Resident #5 sitting in a wheelchair, and there was no pressure redistribution seat cushion observed on the wheelchair. During an interview at the time, Resident #5 said he/she had not been in bed since the surveyor saw him/her last but did use the bathroom a couple of times with staff assistance. During an interview and observation on 8/12/24 at 8:40 A.M., Certified Nurses Aide (CNA) #2 said that she had taken care of the Resident before but does not ever remember using a seat cushion in the wheelchair. CNA #2 checked under the Resident, who was sitting in the wheelchair, and confirmed that there was no seat cushion in use on the Resident's wheelchair. During an interview and observation on 8/12/24 at 8:43 A.M., Nurse #1 said there was no seat cushion in use on the Resident's wheelchair. Nurse #1 reviewed the current Physician's orders and confirmed that there was an active order to use a pressure redistribution cushion on the Resident's wheelchair. During an interview on 8/12/24 at 8:48 A.M., Unit Manager (UM) #2 said that he went to the Resident's room and could not locate any seat cushion in the Resident's unit. UM #2 said that even if there wasn't an order there should have been a seat cushion in place (on the wheelchair). During an interview on 8/12/24 at 8:56 A.M., Resident #5 said that he/she did not remember ever having a seat cushion, but would like one because the wheelchair would be much more comfortable if there was a seat cushion.

Based on observation and interview, the facility failed to maintain resident wheelchairs in a clean and sanitary manner for two Residents (#291 and #293), out of a total sample of 19 residents. Specifically, the facility failed to ensure that: 1. Residents #291's wheelchair was clean, sanitary, and in good repair. 2. Resident #293's wheelchair was clean and sanitary. Findings include: Review of the facility policy titled Cleaning Wheelchairs and Gerichairs (specialized recliners that are upholstered in non-permeable, easily sanitized vinyl), revised 9/5/2017, indicated: -If items (wheelchairs and gerichairs) are the responsibility of Environmental Services, the first step is .arrange to get wheelchairs or gerichairs from the residents at a convenient time for the resident. -Set up a schedule, with input from Nursing, to collect, wash, and dry chairs. -Take chairs to an open area - basement or shower room- use pressure washer or scrub by hand with a brush or sponge and germicide solution. -Rinse thoroughly with water and dry completely with rags. Pay special attention to the seats and wheels. 1. Resident #291 was admitted to the facility in August 2024, with diagnoses of muscle wasting and atrophy (thinning of muscle mass), and hemiplegia (paralysis of one side of the body). During an observation and interview on 8/8/24 at 9:18 A.M., the surveyor observed Resident #291 lying in bed with a wheelchair placed at his/her bedside. Resident #291 said that he/she was recently admitted to the facility for rehabilitation services and the wheelchair was provided to him/her by the facility. The surveyor observed that the left armrest of the wheelchair had a protective cover that was peeling away with no cushioning underneath. The surveyor also observed that the wheelchair cushion had a burn hole, and the wheelchair frame and wheel spokes were covered in dust and debris. 2. Resident #293 was admitted to the facility in August 2024 with diagnoses of Congestive Heart Failure (CHF- caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs) and Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease that causes restricted airflow from the lungs and difficulty breathing). During an observation and interview on 8/8/24 at 9:55 A.M., the surveyor observed Resident #293 in bed with a wheelchair placed at the foot of his/her bed. Resident #293 said that he/she had recently been admitted to the facility for rehab services and the wheelchair was provided to him/her by the facility. The surveyor observed the facility wheelchair cushion to be ripped with duct tape patching an area, a metal connector on the left side was exposed, and the support frame and wheel spokes to be covered with dried brown substance, dust, and debris. During an observation on 8/9/24 at 9:42 A.M., the surveyor observed Resident #293's in bed with the same wheelchair from the day before at the foot of the bed. The surveyor observed the wheelchair frame underneath the seat was caked with debris and dust, observed the seat cushion was sticky and adhered to the frame with brown caked substance between the cushion and the chair when lifted. During an interview on 8/9/24 at 11:17 A.M., Unit Manager #1 (UM#1) said that the facility provides newly admitted residents with wheelchairs until rehab services can assess them for mobility needs. UM#1 said the facility has a wheelchair cleaning schedule and when a resident discharges, housekeeping will clean the wheelchair. She said that housekeeping will notify her at the beginning of the month on what wheelchairs need to be cleaned. During a second interview and observation at 11:26 A.M., the surveyor and UM#1 observed Resident #291's wheelchair. The surveyor observed the left wheelchair armrest had been replaced and was cushioned. The surveyor further observed the wheelchair frame and wheel spokes remained covered with dust and debris. UM#1 said that the wheelchair cushion had a burn hole and that the wheelchair frame was dirty. During the continued observation and interview at 11:26 A.M, the surveyor and UM#1 observed Resident #293's wheelchair. UM#1 lifted the wheelchair cushion which stuck to the seat surface and observed the frame to be dusty with debris. UM#1 said that Resident #291 and #293 wheelchairs were dirty, needed to be cleaned, and did not appear to have been cleaned since the two residents were admitted to the facility. UM#1 said that the housekeeping department was responsible for wheelchair cleaning. During an interview on 8/9/24 at 2:40 P.M. the Housekeeping Director said that she was new in the position and provided the surveyor with a wheelchair cleaning schedule beginning July 2024. The surveyor reviewed the schedule with Housekeeping Director which indicated the unit with Residents #291 and #293 was due to have wheelchairs cleaned the week ending August 3, 2024. The surveyor requested evidence that the wheelchairs were cleaned as indicated on the schedule. The Housekeeping Director said that there were no logs to show evidence that the cleaning schedule was completed. The Housekeeping Director said that a cleaning log would be implemented so she could follow the cleaning schedule more closely.

Based on observation, interview, and record review, the facility failed to provide dental services for one Resident (#2) out of a total sample of 19 residents. Specifically, the facility staff failed to obtain consent for dental services from Resident #2's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) in a timely manner after the HCP had been invoked (made active by the Physician). Findings include: Resident #2 was admitted to the facility in May 2022, with diagnoses that included Alzheimer's Disease (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language) and lack of coordination. Review of the facility policy for Dental Examination/Assessment, last revised December 2023, indicated: -That each resident will undergo a dental assessment within .90 days of admission. -Resident shall be offered dental services as needed. Review of Resident #2's clinical record indicated: -The Resident declined Dental Services on 5/31/22, shortly after admission to the facility. -The Resident's HCP had been invoked by the Physician on 8/4/22. -No evidence that the consent for Dental services had been reviewed and completed by the HCP after the Physician determination that the Resident lacked the capacity to make informed decisions regarding their own medical care. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a total of 15, and was able to communicate their needs verbally. Further review of the MDS Assessment indicated that Resident #2 had no problems with their teeth. Review of Resident #2's care plan for Dentition last revised 5/24/24, indicated: -The Resident was at risk for altered dentition related to broken and missing teeth -An intervention for a dental consult as necessary was initiated 6/29/22 During an interview on 8/8/24 at 10:29 A.M., Resident #2 said he/she would like to receive dental services at the facility and had never been seen by the Dentist. The surveyor observed that Resident #2 had some missing teeth, broken teeth, and stained teeth. Review of the clinical record did not indicate that Resident #2 had been seen by the Dentist during his/her stay in the facility. During an interview on 8/12/24 at 10:05 A.M., Additional Staff #3 (Medical Record Personnel) said she was responsible for obtaining consent for residents to be seen by the contracted facility Dentist but she had not obtained a consent to date for Resident #2. During an interview on 8/12/24 at 11:05 A.M., Additional Staff #2 (Regional Registered Nurse) said that the facility should have contacted the HCP after the HCP had been invoked to obtain the consent for dental care and they had not.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for one Resident (#43) out of a total sample of 19 residents. Specifically, the facility staff failed to: -verify the Physician orders for the appropriate liter per minute (LPM- the flow rate that supplemental oxygen is set for delivery) of Oxygen when the Resident was ordered for seven (7) LPM of Oxygen. -ensure that Resident #43 was administered the appropriate liter flow for the oxygen delivery device (nasal cannula - a thin flexible tube that provides supplemental oxygen to patients through the nose via nasal prongs) being used when the Resident was found to be ordered for and administered greater than six (6) LPM of Oxygen that was not compliant with professional standards of practice. Findings include: Review of the facility policy titled Oxygen Administration, revised October 2010, indicated the following: -Verify that there is a Physician's order for this procedure. Review the Physician's orders or facility protocol for oxygen administration. -Review the Resident's care plan to assess for any special needs of the Residents. -Adjust the oxygen delivery service so that it is comfortable for the Resident and the proper flow of oxygen is being administered. Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All Oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with Physicians' orders or inadequate instruction for Oxygen therapy. -There is a potential in some spontaneously breathing hypoxemic patients with hypercapnia [high carbon dioxide levels in the blood) and chronic obstructive pulmonary disease that oxygen administration may lead to an increase in PaCO2 (carbon dioxide). -Nasal cannulae provide approximately 24-40% oxygen with flowrates up to 6 L/min [LPM] in adults, although the patient's respiratory patterns can influence the actual, delivered FIO2; Oxygen supplied to adults by nasal cannula at flows </= to 4 L/min need not be humidified. -Equipment maintenance and supervision: All oxygen delivery equipment should be checked at least once daily . Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. Resident #43 was admitted to the facility in March 2024, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - a chronic lung disease that block airflow and make it difficult to breathe) and Chronic Respiratory Failure (CRF - a long term condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with symptoms of trouble breathing and fatigue). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #43 utilized Oxygen and was usually able to make him/herself understood. Review of the August 2024 Physician Order Summary Report indicated the following order: -supplemental Oxygen via nasal cannula (a thin flexible tube that provides supplemental oxygen to patients through the nose via nasal prongs) continuous (delivered around the clock) 7 liters (LPM) every shift for shortness of breath. -change humidification bottle every night shift, every seven days for maintenance of oxygen equipment. Further review of the August 2024 Physician's Order Summary Report indicated no orders to titrate (increase or decrease) the Resident's Oxygen liter flow from the ordered 7 LPM. Review of Resident #43's August 2024 Medication Administration Record (MAR) indicated that the Resident received Oxygen via nasal cannula continously at 7 LPM every shift for shortness of breath. During an observation and interview on 8/8/24 at 9:21 A.M., the surveyor observed Resident #43 seated in bed with Oxygen administered via nasal cannula. The surveyor observed that the liter flow on the oxygen concentrator (medical device that uses air in the atmosphere, filters it, and delivers air that is 90 - 95% oxygen concentrated) was set to 8 LPM and had a humidifier bottle attached. Resident #43 said that he/she does not touch the oxygen concentrator and that his/her LPM should be set at 7 LPM. During an observation on 8/12/24 at 7:51 A.M., the surveyor observed the Resident seated in bed with Oxygen administered via nasal cannula and the liter flow on the oxygen concentrator set to 6 LPM with a humidifier bottle attached. During an interview at the time, Resident #43 said that the oxygen concentrator is supposed to be set at 7 LPM. On 8/12/24 at 12:59 P.M., the surveyor and Nurse #3 observed Resident #43's oxygen concentrator and observed that it was set at 6 LPM. Nurse #3 said that it is the Nurse's responsibility to ensure that the oxygen concentrator is set to the appropriate setting, that it should have been set at 7 LPM and it had not been. Nurse #3 said the Resident had behaviors of adjusting the oxygen concentrator flow rate. Nurse #3 also said that breathing in too much oxygen could cause damage to the Resident's lungs and too little [oxygen] could cause shortness of breath and anxiety. Review of Resident #43's clinical record did not indicate documentation that the Resident had personally adjusted and/or changed the settings on his/her oxygen concentrator since his/her admission to the facility. Further review of the clinical record did not indicate care planning for Resident #43 self-adjusting his/her oxygen concentrator liter flow rate or that the facility staff verified the appropriate Oxygen liter flow for the Resident with diagnoses of COPD and CRF. During an interview on 8/13/24 at 8:53 A.M., the surveyor and the Director of Nursing (DON) spoke with Resident #43 regarding his/her oxygen concentrator. Resident #43 said that he/she does not touch the oxygen concentrator and that only the nursing staff adjusts the [liter flow] settings.

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the Resident's status for one Resident (#2) out of a total sample of 19 residents. Specifically, the MDS failed to accurately reflect that Resident #2 was diagnosed with Anxiety Disorder and had natural teeth that were broken. Findings include: Resident #2 was admitted to the facility in May 2022, with diagnoses including Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with daily activities) and lack of coordination (a muscle control issue that makes it difficult to coordinate movements). Review of Resident #2's care plans, last revised 5/24/24, indicated: -The Resident was diagnosed with Anxiety Disorder. -The Resident was prescribed medications to manage their Anxiety Disorder. -The Resident was at risk for altered dentition related to missing and broken teeth. Review of Resident #2's Physician's orders for August 2024 indicated: -To monitor the Resident for signs and symptoms of anxiety. -The Resident was prescribed Olanzapine (anti-psychotic [used to treat psychosis- a collection of symptoms that affect your ability to tell what is real and what is not] medication) 5 milligrams (mg) for anxiety. Review of Resident #2's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident did not have a diagnosis of Anxiety Disorder, nor did the Resident have broken natural teeth. During an interview on 8/13/24 at 11:10 A.M., the MDS Nurse said that the MDS Assessment had been inaccurately coded and should have marked the Resident as having Anxiety Disorder and broken natural teeth.

Based on record review and interview, the facility failed to ensure its staff provided necessary respiratory care for one Resident (#89) with a tracheostoma (opening to make a direct airway through the trachea [windpipe]) and laryngectomy (removal of the larynx [voice box] resulting in the trachea [airway] being brought to the skin as a stoma [opening] in the front of the neck) tube, of one applicably sampled resident, out of a total sample of two discharged residents. Specifically, facility staff failed to provide necessary respiratory care when Resident #89 required assistance to manage his/her laryngectomy tube and experienced a decline in respiratory status on [DATE], and nursing staff administered oxygen and nebulizer (drug delivery device used to administer medication in the form of a mist into the lungs) treatments via nose/mouth versus laryngectomy tube, resulting in the oxygen and medication not reaching the lungs. Resident #89 further decompensated as a result, cardiopulmonary resuscitation (CPR) was initiated, and nursing staff used a bag valve mask (BVM) over Resident #89's nose and mouth versus through the laryngectomy tube, resulting in ventilations not reaching the lungs. Resident #89 was transferred out of the facility with emergency medical technicians (EMTs) and experienced subsequent death. Findings include: Review of the Tracheostomy Care Policy, dated [DATE], provided by the facility included: - Tracheostomy care should be provided as often as needed, and at least once daily for old established tracheostomies . - A replacement tracheostomy tube must be available at the bedside at all times. - A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution must be available at the bedside at all times. - Apply a fenestrated gauze pad around the insertion site for site and stoma care. - Supplemental oxygen mask to be placed over tracheostomy. Resident #89 was admitted to the facility in February 2023 with diagnoses including history of throat cancer and status post (s/p) laryngectomy with laryngectomy tube. Review of Resident #89's Hospital Critical Care History and Physical, dated [DATE], included: - Resident #89 had a history of throat cancer and status post (s/p) laryngectomy. - The Resident had a tracheal stoma and laryngectomy tube in place. - The Resident was placed on empiric antibiotics for possible pneumonia. - The Resident's medication list included Albuterol Sulfate (inhaled medication to prevent and treat difficulty breathing) (Albuterol Sulfate (0.083%), 2.5 milligrams (mg)/3 milliliters (ml) Vial Neb) 2.5 mg inhale every four hours, PRN (as the situation demands) for wheezing. Review of Resident #89's Hospital Otolaryngology Consult Note, dated [DATE], included: - Resident #89 had a history of laryngectomy with a permanent tracheostoma (trach). - Resident #89 did not know how to manage cleaning of the stoma with a tube well. Review of Resident #89's Hospital Discharge Summary, dated [DATE], included: - Resident #89 was being discharged from the hospital to the facility. - Resident #89's discharge medication list included Albuterol Sulfate 2.5 mg/3 ml (0.083%) Solution for Nebulization, 2.5 mg inhalation every four hours PRN for wheezing. Further review of Resident #89's Hospital Discharge Summary included the following hospital course: - status post (s/p: experienced previously) ENT (Ear Nose Throat) consult, s/p tracheostomy in the past, continue routine trach care. - Continue aggressive chest PT. - Continue bronchodilator protocol. Review of Resident #89's Nursing Admission Assessment, dated [DATE], included: no tracheostomy. Further review of Resident #89's Nursing Admission Assessment included no information relative to Resident #89's laryngectomy tube. Review of Resident #89's February 2023 Physician Orders included the following: - The Resident's advance directive status was full code (if one's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive). - Vital signs: temperature, heart rate, blood pressure, respirations, oxygen saturation every shift for admission for three days. - Cover stoma to throat with dry dressing every day shift for wound care. - Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 ml) 0.083% (Albuterol Sulfate) 2.5 mg inhale orally every four hours as needed for wheezing. Further review of the Physician Orders included no orders for routine trach care, chest PT, or bronchodilator protocol. Review of Resident #89's Baseline Care Plan, dated [DATE], Section Three, Health Conditions, did not indicate suctioning or tracheostomy care as special treatments or procedures. Review of Resident #89's Nursing Progress Note, dated [DATE] at 12:07 A.M., included: .have suction at bedside . Review of Resident #89's Skilled Nursing Note, dated [DATE] at 4:43 A.M., included: .laryngectomy tube in place, occasionally will self-suction to remove excess phlegm. Lung sounds with diminished bases with coarse breath sounds . Review of Resident #89's clinical record included no evidence Resident #89 had been assessed to care for his/her own laryngeal tube independently. Review of a Nursing Progress Note, dated [DATE] included: - Resident #89 was noted with bilateral wheezing at lung bases at 11:45 A.M. and Resident #89's oxygen saturation level was 88% (percent; normal oxygen saturation levels between 95% and 100%). - PRN Albuterol Sulfate 2.5 milligrams (mg)/ 3 milliliters (ml) were administered, and the Resident was placed on two liters per minute (LPM: rate of flow) of oxygen via nasal cannula (device used to supply oxygen to an individual through the nose). - Around 1:50 P.M., Nurse #3 re-assessed the Resident. The Resident was unresponsive, the Physician was notified, and CPR as initiated according to code status. - Emergency Medical Technicians (EMTs) arrived at the facility at 2:13 P.M., CPR continued, and Resident #89 was taken to the hospital. Review of Resident #89's Cardiopulmonary (CPR)/Automatic External Defibrillator (AED) Flow Sheet, dated [DATE], indicated the following relative to resuscitation outcome: hospital transfer/Resident passed. Review of Resident #89's Nursing Note, dated [DATE] and electronically signed by Resident #89's Physician included: - The Physician visited Resident #89 earlier in the day on [DATE] because Resident #89 was short of breath. - Resident #89 had a trach and was suctioning him/herself. - Resident #89 had upper respiratory effort and the decision was made to give more nebulizers and more suctioning. - After suctioning, Resident #89 felt better. - After a while, Nurse #3 went to check on Resident #89 and found Resident #89 without pulse and respiratory effort. - At 1:50 P.M., the Physician pronounced Resident #89 dead. During an interview on [DATE] at 1:14 P.M., Nurse #3 said she worked at the facility when Resident #89 was admitted , and that Resident #89 had a laryngectomy tube. Nurse #3 said when a resident was admitted to the facility, the admitting nurse would contact the Physician to let them know the resident had been admitted and to obtain orders. Nurse #3 said no orders had been obtained relative to care of Resident #89's laryngectomy tube and that Resident #89 communicated that he/she cared for it him/herself. Nurse #3 said she saw Resident #89 occasionally clean his/her laryngectomy tube and that Resident #89 would sometimes take a small piece out of the tube and place it on the bedside table. Nurse #3 said Resident #89 experienced shortness of breath and reduced oxygen saturation levels, in the 80's, at 11:45 A.M. on [DATE]. Nurse #3 said she then went to the Oxygen Closet at the facility to obtain an oxygen tank for Resident #89, brought it to Resident #89's room, and applied oxygen to Resident #89's nose using a nasal cannula. Nurse #3 said she also administered a nebulizer (drug delivery device used to administer medication in the form of a mist into the lungs) treatment using a mask that covered Resident #89's mouth and nose. Nurse #3 said she checked on Resident #89 at 12:35 P.M., after the nebulizer treatment had been administered, and Resident #89's oxygen saturation level was still in the 80's and had not improved. Nurse #3 said she thought Resident #89's oxygen level would improve, but that it would take some time since the nebulizer had just been administered. When the surveyor asked Nurse #3 whether administration of oxygen through the nose or a nebulizer treatment through the mouth and nose would be effective for a resident with a laryngectomy tube, Nurse #3 said she could not recall. Nurse #3 then said she checked on Resident #89 again at 1:50 P.M., and the Resident was grey, cold, and without pulse or respirations. Nurse #3 said she then called for help and initiated CPR as the Resident was a full code (all resuscitation procedures to be provided if one's heart stopped beating and/or they stopped breathing) status. Nurse #3 further said she received no education or training from the facility on how to care for a resident with a laryngectomy tube. On [DATE] at 9:02 A.M., the surveyor attempted to contact Nurse #3 by telephone and a message was left. Nurse #3 did not respond to the Department of Public Health's request for a follow-up telephone interview. During an interview on [DATE] at 9:14 A.M., Unit Manager (UM) #1 and UM #2 said they worked the day (7:00 A.M. through 3:00 P.M.) shift on [DATE] and were called to assist Nurse #3 when Resident #89 was identified with no pulse or respirations. UM #1 and UM #2 both said they did not know Resident #89 and that this was the first time they had seen Resident #89 since he/she was admitted to the facility on [DATE]. UM #1 said when the code was called, she obtained the crash cart and brought it to Resident #89's room. UM #1 and UM #2 said they noticed no emergency respiratory equipment in Resident #89's room at that time. UM #2 said when she arrived at Resident #89's room, Resident #89 was on his/her back, in the bed, that oxygen had been applied to Resident #89, through his/her nose, via nasal cannula, and the AED was connected to Resident #89. UM #2 then said she obtained the BVM from the crash cart and placed it over Resident #89's nose and mouth to provide ventilation. UM #2 also said compressions were started. UM #1 and UM #2 both said they did not know of Resident #89 having any kind of opening or tube in his/her neck, so ventilation was only provided using a BVM over Resident #89's nose and mouth. UM #1 and UM #2 said throughout the time CPR was being administered to Resident #89, no shock was advised by the AED. UM #1 and UM #2 said CPR was taken over by EMTs when they arrived at the facility, Resident #89 was transported out of the facility by the EMTs to be transferred to the hospital, but Resident #89 died . During an interview on [DATE] at 12:16 P.M., the Director of Nursing (DON) said she had no evidence licensed nurse staff had been educated or demonstrated competency to care for residents with tracheostomy or laryngectomy tubes. Please refer to F726.

Based on interview and record review, the facility failed to ensure its staff provided treatment and care that met professional standards of quality for one Resident (#89) out of one applicably sampled resident with a tracheostoma (opening to make a direct airway through the trachea [windpipe]) and laryngectomy (removal of the larynx [voice box] resulting in the trachea [airway] being brought to the skin as a stoma [opening] in the front of the neck) tube, out of two total discharged residents sampled. Specifically, the facility failed to ensure its licensed nursing staff provided necessary and timely respiratory care, in an effective manner, when Resident #89 experienced a decline in respiratory status at 11:45 A.M. on [DATE], and nursing staff administered Oxygen via nasal cannula and nebulizer (drug delivery device used to administer medication in the form of a mist into the lungs) treatments via nose/mouth versus laryngectomy tube, resulting in the Oxygen and medication not reaching the lungs. The Resident decompensated, found without pulse or respirations, was provided with inappropriate CPR practices for a laryngectomy tube and was transferred out of the facility with emergency medical technicians (EMTs) and experienced subsequent death. Findings include: Review of Georgetown University School of Medicine's document, titled Rescue Breathing for Laryngectomees and other Neck Breathers, dated [DATE], included: -Laryngectomees and other neck breathers are at great risk of getting inadequate acute care when they experience breathing difficulties or need cardiopulmonary resuscitation. - Many medical personnel are not familiar with the care of laryngectomees (total neck breathers) because laryngectomy is a relatively rare procedure. - The anatomy of laryngectomees is different than the normal anatomy. After total laryngectomy the patient is breathing through the stoma where the tracheostomy opens in the neck. There is no longer a connection between the trachea and the mouth and nose - It is important for medical personnel to differentiate partial neck breathers from total neck breathers (laryngectomees) because their management is different than that of total neck breathers. - In total neck breathers the trachea is not connected to the upper airways and all breathing is through the tracheostomy site. - In contrast in partial neck breathers although there is tracheostomy site there is still a connection between the trachea and the upper airway. Even though partial neck breathers breathe mainly through their stoma, they are able to breathe air through the mouth and nose. - The steps in rescuing a neck breather are to first determine their unresponsiveness; then activate the emergency medical services; position the person raising their shoulders; expose the neck and remove anything covering the stoma (filter, cloth) that may prevent access to the airway; secure the airway by checking the neck for a stoma, remove anything that blocks the airways such as the filter or HME if present; and clear any mucous from the stoma. - Listen for breathing sounds over the stoma. - In neck breathers' ventilation and oxygen administration is done through the stoma . - Although partial neck breathers inhale and exhale mainly through their stoma they still have a connection between their lungs and their nose and mouth. Therefore, air can escape from mouth and/or nose in partial neck breathers thus reducing the efficacy of ventilation. Partial neck breathers should also receive ventilation through their stoma. However, in these individuals the mouth should be kept closed, and the nose sealed to prevent air escape. Review of the American Heart Association CPR (cardiopulmonary resuscitation: an emergency lifesaving procedure performed when the heart stops beating) and First Aid Emergency Cardiovascular Care Adult Basic and Advanced Life Support document, dated 2020, included the following: - Outcomes from advanced airway and bag-mask ventilation interventions are highly dependent on the skill set and experience of the provider. - Prompt initiation of CPR is perhaps the most important intervention to improve survival and neurological outcomes. - A patent airway is essential to facilitate proper ventilation and oxygenation. Resident #89 was admitted to the facility in February 2023 with diagnoses including history of throat cancer, tracheostoma, and status post (s/p) laryngectomy with laryngectomy tube. Review of Resident #89's Hospital Critical Care History and Physical, dated [DATE], included: - Resident #89 had a history of throat cancer and status post (s/p) laryngectomy. - The Resident had a tracheal stoma and laryngectomy tube in place. - The Resident's medication list included Albuterol Sulfate (inhaled medication used to prevent and treat difficulty breathing) (Albuterol Sulfate (0.083%), 2.5 milligrams (mg)/3 milliliters (ml) Vial Neb) Albuterol 2.5 mg inhale every four hours, PRN (as the situation demands) for wheezing. Review of Resident #89's Hospital Otolaryngology Consult Note, dated [DATE], included: - Resident #89 had a history of laryngectomy with a permanent tracheostoma. Review of Resident #89's Hospital Discharge Summary, dated [DATE], included: - Resident #89 was being discharged from the hospital to the facility. - Resident #89's discharge medication list included Albuterol Sulfate 2.5 mg/3 ml (0.083%) Solution for nebulization, 2.5 mg inhalation every four hours PRN for wheezing. Further review of Resident #89's Hospital Discharge Summary included the following hospital course: - status post (s/p: experienced previously) ENT (Ear Nose Throat) consult, s/p tracheostomy in the past, continue routine trach care. - Continue aggressive chest PT. - Continue bronchodilator protocol. Review of Resident #89's Nursing Admission Assessment, dated [DATE], included: no tracheostomy. Further review of Resident #89's Nursing Admission Assessment included no information relative to the Resident's tracheostoma, laryngectomy, or laryngectomy tube. Review of Resident #89's February 2023 Physician Orders included the following: - The Resident's advance directive status was full code (if one's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive). - Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 ml) 0.083% (Albuterol Sulfate) 2.5 mg inhale orally (not indicated to inhale via tracheostoma/laryngectomy) every four hours as needed for wheezing. Review of Resident #89's Baseline Care Plan, dated [DATE], Section Three, Health Conditions, did not indicate a requirement for any special treatments or procedures (e.g., oxygen therapy, suctioning, laryngectomy care .). Review of Resident #89's Skilled Nursing Note, dated [DATE] at 4:43 A.M., included: .laryngectomy tube in place, occasionally will self-suction to remove excess phlegm. Lung sounds with diminished bases with coarse breath sounds . Review of Resident #89's clinical record included no evidence Resident #89 had been assessed to care for his/her own laryngeal tube independently and there was no evidence licensed nurse staff provided routine tracheostoma or laryngectomy tube care. Review of a Nursing Progress Note, dated [DATE] included: - Resident #89 was noted with bilateral wheezing at lung bases at 11:45 A.M. and Resident #89's oxygen saturation level was 88% (percent; normal oxygen saturation levels between 95% and 100%). - PRN Albuterol Sulfate 2.5 milligrams (mg)/ 3 milliliters (ml) were administered, and the Resident was placed on two liters per minute (LPM: rate of flow) of oxygen via nasal cannula (device used to supply oxygen to an individual through the nose). - Around 1:50 P.M., Nurse #3 re-assessed the Resident. The Resident was unresponsive, the Physician was notified, and CPR was initiated according to code status. - Emergency Medical Technicians (EMTs) arrived at the facility at 2:13 P.M., CPR continued, and Resident #89 was taken to the hospital. Review of Resident #89's Cardiopulmonary (CPR)/Automatic External Defibrillator (AED) Flow Sheet, dated [DATE], indicated the following: - Nurse #3 recognized Resident #89 was in arrest at 2:00 P.M. - 911 was called, and compressions and ventilations were initiated by licensed nurse staff at 2:02 P.M. - Resuscitation outcome indicated Resident #89 was transferred to the hospital and the Resident passed. - Review/comments indicated: Great effort by all team members. Code went according to regulations. Team worked well together and communicated clear and effectively. Review of Resident #89's Nursing Note, dated [DATE] and electronically signed by Resident #89's Physician included: - The Physician visited Resident #89 earlier in the day on [DATE] because the Resident was short of breath. - Resident #89 had a trach and was suctioning him/herself. - Resident #89 had upper respiratory effort and the decision was made to give more nebulizers and more suctioning. - After suctioning, Resident #89 felt better. - After a while, Nurse #3 went to check on Resident #89 and found the Resident without pulse and respiratory effort. - At 1:50 P.M., the Physician pronounced Resident #89 dead. During an interview on [DATE] at 1:14 P.M., Nurse #3 said she worked at the facility when Resident #89 was admitted and that the Resident had a laryngectomy tube. Nurse #3 said when a resident was admitted to the facility, the admitting nurse would contact the Physician to let them know the resident had been admitted and to obtain orders. Nurse #3 said no orders had been obtained relative to care of Resident #89's laryngectomy tube and that Resident #89 communicated that he/she cared for it him/herself. Nurse #3 said Resident #89 experienced shortness of breath and reduced oxygen saturation levels, in the 80's (normal oxygen saturation levels are between 95% and 100%), at 11:45 A.M. on [DATE]. Nurse #3 said she then went to the Oxygen Closet at the facility to obtain an oxygen tank for Resident #89, brought it to the Resident's room, and applied oxygen to the Resident's nose using a nasal cannula. Nurse #3 said she also administered a nebulizer (drug delivery device used to administer medication in the form of a mist into the lungs) treatment using a mask that covered Resident #89's mouth and nose. Nurse #3 said she checked on Resident #89 at 12:35 P.M., after the nebulizer treatment had been administered, and the Resident's oxygen saturation level was still in the 80's and had not improved. Nurse #3 said she thought Resident #89's oxygen level would improve, but that it would take some time since the nebulizer had just been administered. When the surveyor asked Nurse #3 whether administration of Oxygen through the nose or a nebulizer treatment through the mouth and nose would be effective for a resident with a laryngectomy tube, Nurse #3 said she could not recall. Nurse #3 then said she checked on Resident #89 again at 1:50 P.M., and the Resident was grey, cold, and without pulse or respirations. Nurse #3 said she then called for the Physician, who was seated at the Nurses' Station to come see the Resident. Nurse #3 said she initiated CPR as the Resident was a full code (all resuscitation procedures to be provided if one's heart stopped beating and/or they stopped breathing) status, and someone called 911. Nurse #3 did not say how much time elapsed between recognizing Resident #89 was grey, cold, and without pulse or respirations, and initiation of CPR. Nurse #3 further said she received no education or training from the facility on how to care for a resident with a laryngectomy tube. On [DATE] at 9:02 A.M., the surveyor attempted to contact Nurse #3 by telephone and a message was left. Nurse #3 did not respond to the Department of Public Health's request for a follow-up telephone interview. During an interview on [DATE] at 9:14 A.M., Unit Manager (UM) #1 and UM #2 said they worked the day (7:00 A.M through 3:00 P.M.) shift on [DATE] and were called to assist Nurse #3 when Resident #89 was identified with no pulse or respirations. UM #1 and UM #2 both said they did not know Resident #89 and that this was the first time they had seen Resident #89 since he/she was admitted to the facility on [DATE]. UM #1 said when the code was called, she obtained the crash cart and brought it to Resident #89's room. UM #1 and UM #2 said they noticed no emergency respiratory equipment in Resident #89's room at that time. UM #2 said when she arrived at Resident #89's room, the Resident was on his/her back, in the bed, that Oxygen had been applied to Resident #89, through his/her nose, via nasal cannula, and the AED was connected to Resident #89. UM #2 then said she obtained the BVM (manual resuscitator - Ambu bag and mask) from the crash cart and placed it over Resident #89's nose and mouth to provide ventilation. UM #2 also said compressions were started. UM #1 and UM #2 both said they did not know of Resident #89 having any kind of opening or tube in his/her neck, so ventilation was only provided using a BVM over Resident #89's nose and mouth. UM #1 and UM #2 said throughout the time CPR was being administered to Resident #89, no shock was advised by the AED. UM #1 and UM #2 said CPR was taken over by EMTs when they arrived at the facility, Resident #89 was transported out of the facility by the EMTs to be transferred to the hospital, and the Resident died . During an interview on [DATE] at 12:16 P.M., the Director of Nursing (DON) said she had no evidence licensed nurse staff had been educated or demonstrated competency to care for residents with tracheostomy or laryngectomy tubes. Please refer to F695.

Based on record review and interview, the facility failed to provide competent nursing staff to care for one Resident (#89), of one applicably sampled resident who had a tracheostoma (opening to make a direct airway through the trachea [windpipe]) and laryngectomy (removal of the larynx [voice box] resulting in the trachea [airway] being brought to the skin as a stoma [opening] in the front of the neck) tube, out of two total discharged residents sampled. Specifically, the facility had no evidence that its licensed nursing staff had the competency and skill sets required to provide the care and services for residents with a laryngectomy tube when Resident #89 experienced a decline in respiratory status on [DATE] and nursing staff administered Oxygen via nasal cannula and nebulizer (drug delivery device used to administer medication in the form of a mist into the lungs) treatments via nose/mouth versus laryngectomy tube, resulting in the Oxygen and medication not reaching the lungs. The Resident further decompensated as a result, cardiopulmonary resuscitation (CPR) was initiated with nursing staff using a bag valve mask (BVM) over Resident #89's nose and mouth versus through the laryngectomy tube, resulting in ventilations not reaching Resident #89's lungs. Resident #89 was transferred out of the facility with emergency medical technicians (EMTs) and experienced subsequent death. Findings include: Resident #89 was admitted to the facility in February 2023 with diagnoses including history of throat cancer and status post (s/p) laryngectomy. Review of Resident #89's Hospital Discharge Summary, dated [DATE], indicated the Resident was discharged from the hospital to the facility s/p remote laryngectomy. Review of a Nurse Note, dated [DATE], indicated: .laryngectomy tube in place . Review of a Nurse Note, dated [DATE], included the following: - Resident #89 was noted with bilateral wheezing at lung bases at 11:45 A.M. and his/her oxygen saturation level was 88% (percent; normal oxygen saturation levels between 95% and 100%). - PRN Albuterol Sulfate (inhaled medication used to treat difficulty breathing) 2.5 milligrams (mg)/ 3 milliliters (ml) were administered, and the Resident was placed on two liters per minute (LPM: rate of flow) of oxygen via nasal cannula (device used to supply oxygen to an individual through the nose). - Around 1:50 P.M., Nurse #3 re-assessed Resident #89; the Resident was unresponsive, the Physician was notified, and CPR was initiated according to full code (if one's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive) status. Review of Resident #89's CPR/Automatic External Defibrillator (AED) Flow Sheet, dated [DATE], indicated the following relative to resuscitation outcome: hospital transfer/Resident passed. During an interview on [DATE] at 8:57 A.M., Nurse #3 said the facility would sometimes provide Nurses with education and training relative to special resident conditions, but this did not always happen. Nurse #3 said if she was unsure about a resident's condition, she would often look it up on the Internet or ask the Director of Nursing (DON) for instruction. During a follow-up interview on [DATE] at 1:14 P.M., Nurse #3 said she worked at the facility when Resident #89 was admitted and that the Resident had a laryngectomy tube. Nurse #3 said the Resident experienced shortness of breath and reduced oxygen saturation levels, in the 80's, at 11:45 A.M. on [DATE]. Nurse #3 said she then went to the Oxygen Closet at the facility to obtain an Oxygen tank for the Resident, brought it to his/her room, and applied Oxygen to the Resident using a nasal cannula. Nurse #3 said she also administered a nebulizer (drug delivery device used to administer medication in the form of a mist into the lungs) treatment using a mask that covered the Resident's mouth and nose. Nurse #3 said she checked on the Resident at 12:35 P.M., after the nebulizer treatment had been administered, and the Resident's oxygen saturation level was still in the 80's and had not improved. She said she thought the Resident's oxygen level would improve, but that it would take some time since the nebulizer had just been administered. When asked whether administration of Oxygen through the nose or a nebulizer treatment through the mouth and nose would be effective for a resident with a laryngectomy tube, Nurse #3 said she could not recall. Nurse #3 then said she checked on the Resident again at 1:50 P.M., and the Resident was grey, cold, and without pulse or respirations. Nurse #3 said she then called for help and initiated CPR as the Resident was a full code (all resuscitation procedures to be provided if one's heart stopped beating and/or they stopped breathing) status. Nurse #3 further said she received no education or training through the facility to care for a resident with a laryngectomy tube. On [DATE] at 9:02 A.M., the surveyor attempted to contact Nurse #3 by telephone and a message was left. Nurse #3 did not respond to the Department of Public Health's request for a follow-up telephone interview. During an interview on [DATE] at 9:14 A.M., Unit Manager (UM) #1 and UM #2 said they worked the day (7:00 A.M. through 3:00 P.M.) shift on [DATE] and were called to assist Nurse #3 when Resident #89 was identified with no pulse or respiration. UM #1 and UM #2 both said they did not know the Resident and that this was the first time they had seen the Resident since he/she was admitted to the facility. UM #2 said when she arrived at the Resident's room, the Resident was on his/her back, in the bed. She said oxygen had been applied to the Resident via nasal cannula and was already being administered. Nurse #2 said compressions were started and she initiated respirations using a bag valve mask (BVM) over the Resident's mouth. UM #1 and UM #2 said they did not know of Resident #89 having any kind of opening or tube in his/her neck. During an interview on [DATE] at 12:16 P.M., the DON said she had no evidence that Nurse staff had been provided education or demonstrated competency to care for residents with laryngectomies. Please refer to F838.

Based on interview, record review, and Facility Assessment Tool review, the facility failed to ensure its staff implemented the Facility Assessment Tool's staff training/education and competencies plan, and updated the Facility Assessment Tool to accurately reflect the resident population and care needs for day-to-day operations and medical emergencies for one Resident (#89) out of one applicably sampled resident with a laryngectomy (removal of the larynx [voice box] resulting in the trachea [airway] being brought to the skin as a stoma [opening] in the front of the neck) tube, out of a total of two discharged residents sampled. Specifically, the facility failed to ensure its staff identified the need for licensed nurse education/training and competencies relative to day-to-day care and emergency care for residents with laryngectomy tubes when Resident #89 was admitted to the facility, and laryngectomy tube care needs were not identified on the Facility Assessment Tool. Findings include: Review of the Facility Assessment Tool, updated [DATE], included the following: - The facility consisted of three units. - Each unit could take care of any admissions. - The facility accepted residents with respiratory conditions including respiratory failure. - Staff were to follow all proper guidelines based off each condition. - All residents were thoroughly screened prior to admission. - If a resident had a need the facility was less familiar with, the facility would work with Regional Nursing Director to clarify proper training and education for facility staff. - The facility would train nurses to develop new skills, and in-service and refresh on current skill level. - The facility would provide necessary resources for residents when conditions change. - Resident acuity over the previous year, or during a typical month included zero to 10 residents who required oxygen therapy and no residents who required suctioning or tracheostomy care. - Staff training/education and competencies necessary for the facility's resident population included suctioning and trach care. Further review of the Facility Assessment tool showed there was no evidence the facility identified residents with laryngectomies/laryngectomy tubes as part of the resident population they served and did not have a competency/education plan in place to address that population's needs. Resident #89 was admitted to the facility in February 2023 with diagnoses including history of throat cancer and status post (s/p) laryngectomy with laryngectomy tube. Review of Resident #89's Hospital Critical Care History and Physical, dated [DATE], included: - Resident #89 had a history of throat cancer and status post (s/p) laryngectomy. - The Resident had a tracheal stoma and laryngectomy tube in place. Review of Resident #89's Hospital Otolaryngology Consult Note, dated [DATE], included: - Resident #89 had a history of laryngectomy with a permanent tracheostoma. - Resident #89 did not know how to manage cleaning of the stoma with a tube well. Review of Resident #89's Hospital Discharge Summary, dated [DATE], included: - Resident #89 was being discharged from the hospital to the facility. - Resident #89's discharge medication list included Albuterol Sulfate (inhaled medication used to prevent and treat breathing difficulty) 2.5 mg/3 ml (0.083%) Solution for Nebulization, 2.5 mg inhalation every four hours PRN for wheezing. Further review of Resident #89's Hospital Discharge Summary included the following hospital course: - s/p ENT (Ear Nose Throat) consult, s/p tracheostomy in the past, continue routine trach care. - Continue aggressive chest PT. - Continue bronchodilator protocol. Review of Resident #89's Nursing Admission Assessment, dated [DATE], included: no tracheostomy. Further review of Resident #89's Nursing Admission Assessment included no information relative to Resident #89's laryngectomy tube. Review of Resident #89's February 2023 Physician Orders included the following: - The Resident's advance directive status was full code (if one's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive). - Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 ml) 0.083% (Albuterol Sulfate) 2.5 mg inhale orally every four hours as needed for wheezing. Further review of the Physician's Orders included no orders for routine trach care, chest PT, or bronchodilator protocol. Review of Resident #89's Baseline Care Plan, dated [DATE], Section Three, Health Conditions, did not indicate suctioning or tracheostomy care as special treatments or procedures. Review of a Nursing Progress Note, dated [DATE] included: - Resident #89 was noted with bilateral wheezing at lung bases at 11:45 A.M. and Resident #89's oxygen saturation level was 88% (percent; normal oxygen saturation levels between 95% and 100%). - PRN Albuterol Sulfate (inhaled medication used to treat difficulty breathing) 2.5 milligrams (mg)/ 3 milliliters (ml) were administered, and the Resident was placed on two liters per minute (LPM: rate of flow) of oxygen via nasal cannula (device used to supply oxygen to an individual through the nose). - Around 1:50 P.M., Nurse #3 re-assessed the Resident. The Resident was unresponsive, the Physician was notified, and cardiopulmonary resuscitation (CPR) was initiated according to code status. - Emergency Medical Technicians (EMTs) arrived at the facility at 2:13 P.M., CPR continued, and Resident #89 was taken to the hospital. Review of Resident #89's Cardiopulmonary (CPR)/Automatic External Defibrillator (AED) Flow Sheet, dated [DATE], indicated the following relative to resuscitation outcome: hospital transfer/Resident passed. Review of Resident #89's Nursing Note, dated [DATE] and electronically signed by Resident #89's Physician included: - The Physician visited Resident #89 earlier in the day on [DATE] because Resident #89 was short of breath. - Resident #89 had a trach and was suctioning him/herself. - Resident #89 had upper respiratory effort and the decision was made to give more nebulizers and more suctioning. - After suctioning, Resident #89 felt better. - After a while, Nurse #3 went to check on Resident #89 and found Resident #89 without pulse and respiratory effort. - At 1:50 P.M., the Physician pronounced Resident #89 dead. During an interview on [DATE] at 1:14 P.M., Nurse #3 said she worked at the facility when Resident #89 was admitted , and that Resident #89 had a laryngectomy tube. Nurse #3 said when a resident was admitted to the facility, the admitting nurse would contact the Physician to let them know the resident had been admitted and to obtain orders. Nurse #3 said no orders had been obtained relative to care of Resident #89's laryngectomy tube and that Resident #89 communicated that he/she cared for it him/herself. Nurse #3 said she saw Resident #89 occasionally clean his/her laryngectomy tube and that Resident #89 would sometimes take a small piece out of the tube and place it on the bedside table. Nurse #3 said Resident #89 experienced shortness of breath and reduced oxygen saturation levels, in the 80's (normal oxygen saturation levels are between 95% and 100%), at 11:45 A.M. on [DATE]. Nurse #3 said she then went to the Oxygen Closet at the facility to obtain an oxygen tank for Resident #89, brought it to Resident #89's room, and applied oxygen to Resident #89's nose using a nasal cannula. Nurse #3 said she also administered a nebulizer (drug delivery device used to administer medication in the form of a mist into the lungs) treatment using a mask that covered Resident #89's mouth and nose. Nurse #3 said she checked on Resident #89 at 12:35 P.M., after the nebulizer treatment had been administered, and Resident #89's oxygen saturation level was still in the 80's and had not improved. Nurse #3 said she thought Resident #89's oxygen level would improve, but that it would take some time since the nebulizer had just been administered. When asked whether administration of oxygen through the nose or a nebulizer treatment through the mouth and nose would be effective for a resident with a laryngectomy tube, Nurse #3 said she could not recall. Nurse #3 then said she checked on Resident #89 again at 1:50 P.M., and Resident #89 was grey, cold, and without pulse or respirations. Nurse #3 said she then called for help and initiated cardiopulmonary resuscitation (CPR) as the Resident was a full code status. Nurse #3 further said she received no education or training from the facility on how to care for a resident with a laryngectomy tube. On [DATE] at 9:02 A.M., the surveyor attempted to contact Nurse #3 by telephone and a message was left. Nurse #3 did not respond to the Department of Public Health's request for a follow-up telephone interview. During an interview on [DATE] at 9:14 A.M., Unit Manager (UM) #1 and UM #2 said they worked the day (7:00 A.M. through 3:00 P.M.) shift on [DATE] and were called to assist Nurse #3 when Resident #89 was identified with no pulse or respirations. UM #1 and UM #2 both said they did not know Resident #89 and that this was the first time they had seen Resident #89 since he/she was admitted to the facility on [DATE]. UM #1 said when the code was called, she obtained the crash cart and brought it to Resident #89's room. UM #1 and UM #2 said they noticed no emergency respiratory equipment in Resident #89's room at that time. UM #2 said when she arrived at Resident #89's room, Resident #89 was on his/her back, in the bed, that oxygen had been applied to Resident #89, through his/her nose, via nasal cannula, and the automatic external defibrillator (AED) was connected to Resident #89. UM #2 then said she obtained the BVM from the crash cart and placed it over Resident #89's nose and mouth to provide ventilation. UM #2 also said compressions were started. UM #1 and UM #2 both said they did not know of Resident #89 having any kind of opening or tube in his/her neck, so ventilation was only provided using a BVM over Resident #89's nose and mouth. UM #1 and UM #2 said throughout the time CPR was being administered to Resident #89, no shock was advised by the AED. UM #1 and UM #2 said CPR was taken over by EMTs when they arrived at the facility, Resident #89 was transported out of the facility by the EMTs to be transferred to the hospital, but Resident #89 died . During an interview on [DATE] at 12:16 P.M., the Director of Nursing (DON) said she had no evidence licensed nurse staff had been educated or demonstrated competency to care for residents with tracheostomy or laryngectomy tubes.

Based on observation, record review, and interviews, the facility failed to ensure the highest practicable physical, mental and psychosocial well-being relative to a vascular ulcer, constipation and relative to [MEDICAL TREATMENT] and a 1500 milliliter (ml.) fluid restriction (Fr.) for 1 of 1 applicable residents on [MEDICAL TREATMENT] (#10) out of 18 sampled residents. Findings include: For Resident #10, the facility failed to ensure appropriate care and services related to: A. [MEDICAL TREATMENT] and management of a 1500 ml. Fr. fluid restriction B. Vascular Ulcers C. Bowel management and treatment for constipation. Resident #10 was admitted to the facility in 1/2015 with [DIAGNOSES REDACTED]. A. [MEDICAL TREATMENT] and failure to ensure a 1500 ml. Fr. daily had been followed. The physician's orders [REDACTED]. Fr. related to [MEDICAL CONDITION] and [MEDICAL TREATMENT]. Review of the clinical record (from 6/2015 - 9/16/15) indicated the total fluid intake would be recorded by the 11:00 P.M. to 7:00 A.M. shift on the Medication Administration Records (MARs). The MARs indicated the totals were not completed, the resident did not receive at least the 1500 ml. in a 24 hour period, or received an excess of 1500 ml. as follows: 6/2015 6/1/15: 1220 ml. 6/2/15: 600 ml. 6/3/15: 360 ml. 6/4/15: 1440 ml. 6/5/15: 340 ml. 6/6/15: 480 + ml. 6/7/15: 1240 ml. 6/8/15: 1080 ml. 6/9/15: 1440 ml. 6/10/15: 340 ml. 6/11/15: 240 ml. 6/12 - 6/15/15: medical leave of absence (MLOA). 6/16/15: 480 ml. 6/17/15: 810 ml. 6/18/15: 420 ml. 6/19/15: 50 ml. (resident hospitalized ,[DATE] - 6/22/15) 6/22/15: Nursing note indicated the resident returned from the Hospital, and received adequate fluid intake since being back in facility on this date. There was no intake documented, and was left blank on the MAR. 6/23/15: 760 ml. 6/24/15: blank. 6/25/15: 1320 ml. 6/26/15: 360 ml. 6/27/15: 600 ml. 6/29/15: blank. 6/30/15: 1200 ml. 7/2015 7/1, 7/2, 7/3, 7/4, 7/7, and 7/9/15 : no totals recorded. 7/5/15: 540 ml. 7/6/15: 450 ml. 7/8/15: 770 ml. 7/10/15: 410 ml. 7/11/15: 908 ml. 7/12/15: 1410 ml. 7/13/15: 990 ml. 7/14/15: 750 ml. 7/15/15: 1290 ml. 7/16/15: 770 + ml. 7/17/15: 1200 ml. 7/18/15: 950 ml. 7/19/15: 630 ml. 7/20/15: 230 ml. 7/21/15: 1260 ml. 7/22/15: 1050 ml. 7/23/15: 750 ml. Review of the [MEDICAL TREATMENT] communication book indicated a note, dated 7/24/15, that Resident #10 consumed 16 ounces (480 ml.) of water, as well as 4 ounces (120 ml.)with medication at [MEDICAL TREATMENT] today. 7/24/15: 450 ml. (600 ml. received at [MEDICAL TREATMENT], therefore this 24 hour intake is inaccurate). 7/25/15: 360 ml. 7/26/15: 900 ml. 7/27/15: 330 ml. 7/28 and 7/29/15: no totals recorded. 7/30/15: 1040 ml. 8/2015 8/1/15: blank. 8/2/15: 1020 ml. 8/3/15: 930 ml. 8/4/15: 520 ml. 8/5/15: 560 ml. 8/6/15: 1120 ml. 8/7/15: 600 ml. 8/8/15: 550 ml. 8/9/15: 860 ml. 8/10/15: 560 ml. 8/11/15: 360 ml. 8/12/15: blank. 8/13/15: 480 ml. 8/14/15: 1340 ml. 8/15/15: no total recorded. Review of the [MEDICAL TREATMENT] Communication book indicated that the resident drank 480 ml. while at [MEDICAL TREATMENT]. 8/16/15: 1260 ml. 8/17/15: 1350 ml. 8/18/15: 960 ml. 8/19/15: 1000 ml. 8/20/15: 1260 ml. 8/21/15: 1080 ml. 8/22/15: 1050 ml. 8/23/15: 1720 ml (Nursing note indicated that the resident requested water several times, and that small amounts were given due to Fr. The note indicated that the resident had labored breathing, an elevated blood pressure of 184/100, oxygen saturation level was low at 88% on room air. The resident was transferred to the hospital, and admitted with acute [MEDICAL CONDITION]/fluid overload). 8/24 - 8/26/15: MLOA 8/27/15: 720 ml. 8/28/15: 790 ml. 8/29/15: blank. 8/30/15: 990 ml. 9/1/15: 840 ml. (Review of the NP's visit note, dated 9/1/15, indicated that Resident #10 has [MEDICAL CONDITION], is on [MEDICAL TREATMENT] and was fluid overloaded.) 9/2/15: 650 ml. 9/3/15: 480 ml. 9/4/15: 1080 ml. 9/5/15: 1050 ml. 9/6/15: 870 ml. 9/7 and 9/8/15: 650 ml. 9/9/15: 640 ml. 9/10/15: 1170 ml. 9/11/15: 600 ml. 9/12/15: 800 ml. 9/13/15: 770 ml. 9/14/15: 60 + ml. 9/15/15: 1020 ml. 9/16/15: 700 ml. On 9/17/15 at 7:10 A.M., and again at 9:30 A.M., the surveyor observed Resident #10 resting in bed with eyes closed. There was a large, green plastic cup (approximately 480 ml.) filled with water, and two 8 ounce cups, 3/4 filled with water (approximately 180 ml. in each cup) on the resident's bedside table in which approximately 840 ml. was available for the resident to drink. During interview on 9/17/15 at 9:30 A.M., Resident #10 said that he can drink the fluids that are in the cups at the bedside, but he/she prefers the drinks colder. The resident said that he/she receives drinks with meals, at [MEDICAL TREATMENT] and with medications throughout the day. The Resident said that he/she is limited on the amount he/she can drink, but believes the facility and [MEDICAL TREATMENT] manages what the amounts are. During interview with Nurse #3 on 9/17/15 at 9:20 A.M., she said that although the intakes on the MARS reflect a lesser than 1500 ml. amount, that the resident receives more than what is documented. The surveyor asked about the resident's intake amount at meals. Nurse #3 indicated those amounts are documented by CNAs on the meal percentage sheets. Review of the meal percentage and intake sheets indicated 100 ml. was provided on one sheet, and 240 ml. was documented on an Intake sheet for 9/17/15. The surveyor then asked Nurse #3 as to what the breakdown was for Nursing and then Dietary to ensure the resident received the restricted amount. Nurse #3 said that [MEDICAL TREATMENT] manages it. Nurse #3 said that the fluid restriction was not calculated between dietary and nursing, and that perhaps dietary knew what it was. Review of the Dietary Slip indicated for each meal indicated that Resident #10 was on a 1500 ml. Fr., but it did not identify how much fluid would be provided by the dietary department. During interview on 9/17/15 at 11:00 A.M. with the Food Service Director (FSD) and the Dietician, they said that the facility has never delegated fluid restriction amounts, based on dietary needs, and then coordinated this with what nursing needs to provide, in order to ensure Resident #10 only received the restricted 1500 ml. ordered, but thought this would be a good idea moving forward. During interview on 9/17/15 at 5:00 P.M., with the DON, the Regional Nurse Consultant and the Administrator, there was no response when the findings were reviewed, relative to the facility not ensuring a 1500 Fr. requirement had been provided, and recorded to ensure Resident #10 received adequate fluids, or did not receive an excess of fluids, beyond the 1500 ml. Fr. for this [MEDICAL TREATMENT] resident. B. Vascular ulcers. Review of the Initial Minimum Data Set (MDS) assessment, dated 1/25/15, and a Quarterly MDS assessment, dated 4/22/15, indicated that the resident had no pressure or vascular ulcers and received [MEDICAL TREATMENT]. Review of the Quarterly (MDS) assessment, dated 7/23/15, indicated that the resident's cognitive abilities were intact, as evidenced by a Brief Interview of Mental Status (BIMS) score of 14/15, received extensive assist for mobility and dressing, had no vascular or pressure ulcers, received no treatment/dressings to feet, and received [MEDICAL TREATMENT]. Review of the 9/2015 Treatment Administration Record (TAR) indicated that on 9/6/15, the resident had sores noted on the top of feet. Review of a 9/10/15 Nurse Practitioner (NP) examination visit note indicated that the resident had [MEDICAL CONDITION] (swollen) feet, were tender to the touch, and the top of the left foot had a venous stasis ulcer. The NP documented that the resident complained the only shoes the resident had were too tight. The NP also indicated that the Podiatrist came in briefly, and will schedule the resident for a follow-up. Review of the 9/13/15 progress note indicated that the resident was observed removing his/her shoes. Review of the 9/16/15 TAR entry, indicated the resident had a wound on the top of the left foot that was draining, a treatment had been ordered and was provided. Review of the 9/16/15 progress note indicated the wound on top of the left foot had a 50% scab formation, 50% granulation and was draining. During interview on 9/17/15 at 9:30 A.M., Resident #10 said that his/her feet hurt terribly, and that wearing shoes hurt his/her feet. Resident #10 was observed sitting on the edge of the bed with both feet flat on the floor. The resident was wearing yellow-colored non-skid slipper socks with sneakers that were tied across the tops of both feet tightly. The resident said that he/she had told the facility many times that his/her feet hurt from wearing the sneakers, but they were still put on the resident. During interview on 9/17/15 at 10:05 A.M., Certified Nursing Assistant (CNA) #1 said that she was assigned to care for Resident #10 today, and that the resident had to wear the non-skid socks to prevent falls. The yellow-colored non-skid socks were thick, and the sneakers were tight. At this time, the Resident's family member was present and asked CNA #1 why the resident had to wear both the non-skid socks and the sneakers, especially, when the sneakers were already tight, caused pain, and the resident had a sore on the top of the foot. CNA #1 said that perhaps the resident could wear one or the other. During observation of the treatment to the resident's left foot on 9/17/15 at 10:15 A.M., the surveyor observed as Unit Manager (UM) #2 removed the resident's sneaker, the resident winced, drew back his/her left foot slightly and said ouch. UM #2 then removed the thick, non-skid sock from the resident's foot. There was a dressing wrapped around the top of the left foot. UM #2 unwrapped the dressing, and the surveyor observed an irregularly shaped, shallow cratered ulcer on the dorsal aspect (top) of the left foot (approximately 3 centimeters {cm} long by 2 cm wide). The wound had a superficial, yellowish dry scab forming, and was moist around the periphery at the wound edges. The surrounding tissue was reddened. UM #2 then said that it was probably not a good idea for the resident to wear a shoe on this foot at all. During interview on 9/17/15 at 11:00 A.M., the Podiatrist was present in the facility, and said that she would be seeing Resident #10 today. Review of the Podiatry visit report, dated 9/17/15, indicated the resident did not have adequate foot gear; had a left foot, partial thickness ulcer midfoot, described as being pink with yellowish drainage, and surrounded by [DIAGNOSES REDACTED] (redness). The Podiatrist indicated the resident's feet were [MEDICAL CONDITION], and had multiple, small, dry scabs on the tops to both feet. The Podiatrist documented, Routine podiatry care is medically necessary due to the patient's [MEDICAL CONDITION] of the extremities due to associated increased risk of bone infection and digital or limb loss. Non-professional treatment is hazardous to the patient. During interview on 9/17/15 at 4:45 P.M. with the Director of Nursing, the Regional Nurse Consultant and the Administrator, there was no response related to the surveyor's findings and the vascular ulcer. Please refer to F328. C. Bowel management and treatment for constipation. Review of the clinical record indicated that the resident was hospitalized briefly on 6/19/15 due to nausea and vomitus that was black, and abdominal discomfort. The resident was readmitted back to the facility on [DATE] with a [DIAGNOSES REDACTED].M. - 11:00 P.M. shift. Review of the physician's orders [REDACTED]. Fr. (related to [MEDICAL TREATMENT]); Renvella 800 milligrams (mg.) three times a day with meals ([MEDICATION NAME] binder medication for patients with kidney disease and who are on [MEDICAL TREATMENT]); [MEDICATION NAME] (narcotic [MEDICATION NAME]) scheduled two times a day, as well as every 4 hours, as needed for pain (limited fluids, narcotics, and [MEDICATION NAME] binders can contribute to constipation). Further review of the physician's orders [REDACTED]. - [MEDICATION NAME] 30 ml. - Bisac-Evac (generic medication for [MEDICATION NAME]) 10 milligrams (mg) suppository, rectally every day, as needed. - Fleet Enema rectally every day, as needed. Review of the facility's protocol for constipation entitled: BM Decision tree (protocol was not dated) indicated the following: - Day 1 = No BM; Day 2 = No BM: Day 3 = No BM by 7:00 A.M. to 3:00 P.M., then the next shift (3:00 P.M. - 11:00 P.M.) starts Protocol by administering Milk of Magnesia (oral medication used to treat constipation). - If No BM by Day 4, then at 6:00 A.M., administer a [MEDICATION NAME] Suppository (medication by rectum to treat constipation). - If no BM by Day 5, then at 6:00 A.M., administer a Fleet enema, and if no BM contact the physician. Review of an instruction/recommendation note from the [MEDICAL TREATMENT] Center to the facility, dated 6/26/15, indicated that the Resident complained of constipation related to the [MEDICATION NAME] binder. The [MEDICAL TREATMENT] Center indicated that the facility should review bowel medications. Review of the 6/2015 Laxative and BM record indicated the resident did not have a BM for 4 days: 6/26, 6/27, 6/28 or 6/29/15. Review of the 6/2015 Medication Administration Record (MAR) indicated that the resident did not receive any of the prescribed bowel medications to treat constipation, in accordance with the facility's BM protocol, physician's orders [REDACTED]. Review of a progress note (dated 6/28/15) indicated that the resident was constipated, had received a suppository (not documented on the MAR) and the resident refused a Fleet enema due to nausea and vomiting. Review of the 7/10/15 progress note indicated that the resident refused to take the prescribed Renvella, and said that it makes him/her sick and constipated. Review of the 7/2015 Laxative and BM record indicated the resident did not have a BM for 6 days: 7/22, 7/23, 7/24, 7/25, 7/26 and 7/27/15. Review of a progress note (dated 7/24/15) indicated that the resident refused Milk of Magnesia (MOM) for constipation, and the Renvella medication. There was no order for MOM. According to the 7/2015 MAR/progress notes, the resident received one dose of [MEDICATION NAME] on 7/25/15, refused a suppository on 7/26/15 (Day 5) and was never offered a Fleet enema, as the protocol indicated to do on Day 5, and then contact the physician. Review of the 7/26/15 progress notes indicated that the resident refused the Renvella medication. The progress note, dated 8/2/15, indicated that the resident complained of nausea, received an anti-nausea medication with good effect, and did not have a BM. The progress note, dated 8/5/15, indicated that the resident received [MEDICATION NAME] for constipation with small results. Review of the 8/23/15 progress note indicated that the resident was sent to the hospital for an illness, and was readmitted back to the facility on [DATE]. The note indicated that the resident stated he/she had a BM earlier on 8/27/15. However, the Hospital report indicated that the last BM was on 8/25/15. Review of a progress note, dated 8/28/15, indicated that the resident was at [MEDICAL TREATMENT], and was sent back to the facility early, because the resident had to use the bathroom. The note indicated that it was against the [MEDICAL TREATMENT] Center's policy to let a resident use the bathroom if unable to stand alone (resident required extensive assist for toilet use). Review of the 8/28/15 - 9/2015 Laxative and BM records indicated the resident did not have a BM for 8 days: 8/28, 8/29, 8/30, 8/31, 9/1, 9/2, 9/3 or 9/4/15. Review of the progress notes (dated 8/30, 9/1 and 9/2/15) indicated that [MEDICATION NAME] was administered for resident's complaints of constipation, with no results. Review of the NP's visit note (dated 9/1/15) indicated that Resident #10 complained about being constipated. The NP documented, will give [MEDICATION NAME] 30 ml for constipation. Review of the physician's orders [REDACTED]. Common side effects related to narcotic use includes constipation. Review of the progress note (dated 9/3/15) indicated that the resident complained and was worrying about being constipated. The nurse documented that the resident refused [MEDICATION NAME] and that education was given. No other medication was documented as being offered to treat the resident's constipation on the 7th day, without a BM. Review of the MARs indicated that the facility did not provide a Bisac-Evac suppository, or a Fleet enema to treat the resident's constipation (8/28/15 - 9/4/15), in accordance with the facility's protocol. During interview on 9/17/15 at 5:00 P.M. with the Director of Nursing, the Regional Nurse Consultant and the Administrator, there was no response relative to the findings related to Resident #10's constipation and the failure to appropriately treat this condition.

Based on observation, record review, and staff interview, the Facility failed to provide adequate supervision and effective interventions to prevent accidents from occurring for 1 resident (#5) of 9 applicable residents in a total sample of 18 residents. Resident #5 experienced two fractured hips, three falls, as well as bruises, abrasions and skin tears in the facility. Findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission documentation indicated that the resident was admitted from a local hospital. The hospital Patient Care Referral Form of 8/14/12 identified that the resident was "ambulating with a walker and assist in wheelchair-poor safety awareness, has had several falls-no injuries." The Hospital Discharge Summary of 8/14/12 indicated that the resident had a "history of multiple falls, including during this hospitalization . No significant injuries." The Discharge Recommendations on the Hospital Discharge Summary were: "Please monitor for safety. Needs ongoing fall precautions. Needs Physical Therapy." The care plan to prevent falls was initiated 8/14/12 and indicated the resident was at risk for falls due to cognitive loss, lack of safety awareness and a gait disorder. Interventions included: -Assess for changes in mental status, pain status and report to physician if indicated. -Place glasses within reach and encourage use. -Resident to participate in skilled Occupational and Physical therapy as per physician orders. -Assist of 1 with ambulation using a rolling walker. -Assist of 1 with transfers out of bed. Review of the physician's progress note of 8/14/12 indicated the resident had experienced visual hallucinations, delusions and increased confusion which resulted in hospitalization . This note indicated the resident had a low blood pressure. Review of the Lift-Transfer-Repositioning Evaluation completed by the facility 8/14/12 indicated the resident was not safe with transferring or with ambulation alone. This record indicated the resident required assistance with ambulation. Review of the 8/14/12 Occupational Therapy Initial Evaluation identified that the resident had "several falls at home; the reason for the referral was a new onset of decrease in functional mobility, decrease in transfers and reduced balance." Review of the nurses' notes of 8/14/12 to 8/21/12 indicated the resident was confused with some wandering behavior requiring redirection. This wandering occurred in the corridor and references the resident not being able to find his/her way to the bathroom. The notes do not explain why the resident was ambulating alone. Review of the initial Minimum Data Set (MDS) Assessment of 8/21/12 indicated the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 11. The resident was coded as requiring supervision with transfers, ambulation, limited assistance of 1 with bathing dressing and toileting. The resident was coded as having no falls prior to admission (inconsistent with hospital referral and discharge summary). The resident was coded as being steady at all times with transfers and walking (inconsistent with the Lift-Transfer-Repositioning Evaluation of 8/14/12). Review of the Care Area Assessment (CAA) for falls completed (8/27/12) indicated the resident was at risk for falls due to decline in cognition and poor safety awareness. The resident was to be care planned. Review of the nurse's note of 8/22/12 indicated the resident was found in the bathroom at 4:30 P.M., with a skin tear on the left forearm. Review of the investigation of 8/22/12 of the skin tear, indicated that staff responded to the resident's call light and found the resident in the bathroom with a skin tear. The investigation did not address why the resident was alone in the bathroom. The investigation indicated the resident thought he/she may have scratched the forearm with a fingernail causing the skin tear. Review of the nurse's note of 8/22/12 at 6:41 P.M., indicated the resident was observed to have a bruise on the left hip. Review of the investigation into the bruise indicated the resident was noted to have a 10 centimeter (cm) by 4 cm purple bruise of unknown origin on the left hip. However the investigation noted that the resident had poor safety awareness, bruised easily and could have bumped into furniture. No mention was made of the skin tear on the left forearm that was noted earlier in the day. The new care plan intervention was to have the resident wear hipsters at all times. Review of the nurses' notes of 8/24/12 to 8/26/12 indicated the resident continued to wander requiring staff redirection. Review of the nurse's note of 8/27/12 indicated the resident was found on the floor at 7:30 A.M. The resident was complaining of left hip pain, the physician was notified and an x-ray ordered by the physician. The results of the x-ray showed a possible left hip subcapital fracture. Review of the investigation into the fall indicated the resident was found on the floor next to the bed. A staff person was walking by the room when the staff person observed the resident on the floor at 7:30 A.M. The resident was observed to have one non-skid slipper sock on. The walker was not with the resident when the resident was found on the floor. The care plan was updated on 8/27/12 to include the following interventions: -Encourage resident to use the call light at all times for assistance with getting out of bed. -Staff to assure that resident has both slipper socks on during periods of ambulation, specifically from 11:00 P.M. to 7:00 A.M. Further review of the nurse's note of 8/28/12 indicated the resident was transferred to the hospital for further evaluation. Review of the nurse's note of 9/1/12 indicated the resident returned to the facility at 11:50 A.M. from the local hospital. The resident had undergone surgical repair of a fractured left hip. The resident returned to the facility with 30 sutures to the left hip. Review of the care plan to prevent falls in effect on re-admission included the following interventions: -Assess for changes in mental status, pain status and report to physician if indicated. -Encourage resident to use the call light at all times for assistance with getting out of bed. -Hipsters to be worn at all times when sutures removed. -Slipper socks at all times -Place glasses within reach and encourage use. -Resident to participate in skilled Occupational and Physical therapy as per physician orders. - Hip precautions. Review of the nurse's note of 9/1/12 at 9:38 P.M., indicated the resident was found on the floor with an abrasion to the lower back. Review of the falls investigation of 9/1/12 indicated the resident was found at 7:00 P.M. on the floor, in the resident's room, with no clothes on. The resident was noted to have a 40 cm long by 1 cm wide abrasion on the lower back. The resident's call light was on. There was a tab alarm that had been placed on the resident's clothes. The alarm did not ring. There was no indication as to how long the resident's call bell had been on and no explanation as to how the resident removed all his/her clothing without the tab alarm sounding. Further review of the care plan in effect 9/1/12 did not indicate a tabs alarm device had been added to the care plan. Review of the nurses' notes of 9/1/12 did not indicate any tabs alarm was on or applied to the resident's clothing upon return from the hospital. Further review of the nurses' notes of 9/2/12 to 9/4/12 indicated the resident complained of pain in the right hip area. The resident developed a bruise on the right buttock on 9/4/12. The resident was placed on bed rest 9/4/12 pending x-ray of the right hip. The care plan was updated 9/4/12 to include the following interventions: -Red mat to left side of bed when in bed. -Wear hipsters when sutures of the left hip removed. -Bed alarm, wheelchair alarm to alert staff of resident's need to ambulate. Review of the x-ray results (of 9/5/12) indicated that the resident did not have a fractured right hip. The care plan was updated 9/5/12 to include the use of a low bed. Further review of the nurses' notes of 9/5/12 to 9/8/12 indicated the resident remained confused with multiple attempts to self ambulate requiring staff intervention to remain safe. Review of the Significant Change MDS Assessment of 9/8/12 indicated the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10. The resident was coded as totally dependent on 2 staff for bed mobility and transfers. The resident was coded as totally dependent on 1 staff for locomotion, bathing, hygiene, and dressing. The resident was coded as being unsteady with transfers, ambulation, of having an impairment on one lower extremity, of using a walker and wheelchair. The resident was coded as having 1 fall with major injury since admission and 1 fall with no injury. The care plan to prevent falls continued and Physical Therapy was continued. Further review of the nurses' notes from 9/9/12 to 9/14/12 indicated the resident's sutures were removed, the resident remained at base line confusion requiring at times, 1:1 supervision to prevent unsafe self transfers. Review of the nurse's note of 9/15/12 indicated the resident experienced a skin tear of the right forearm. The cause of the skin tear was not able to be determined. Review of the nurses' notes of 9/18/12 and 9/19/12 indicated that the resident was agitated, attempting several times to self transfer and requiring 1:1 supervision for safety. Review of the nurse's note of 9/21/12 indicated the resident was attempting to self ambulate in the dining room. The nurse's note of 9/22/12 indicated the resident tried to transfer alone out of bed twice. Nurses' notes from 9/23/12 to 9/26/12 describe the resident as requiring frequent 1:1 supervision due to attempting to self transfer. Nurse's note of 9/27/12 indicated the resident was discovered to have a bruise between two fingers of the left hand. The cause of the bruise was not able to be determined. Review of the nurses' notes of 9/28/12 to 10/7/12 indicated the resident continued with confusion demonstrating unsafe attempts at transfers and ambulate requiring 1:1 supervision at times. Review of the nurse's note of 10/8/12 indicated the resident fell in the dining room. Review of the fall investigation indicated the resident was confused, displayed poor safety awareness, was easily distracted, was restless, wandering at times and had an unsteady gait. This investigation indicated that the resident fell while trying to self ambulate at 6:15 P.M. in the dining room. Review of the staff member's statement (CNA #1, who witnessed the resident fall) indicated that she was providing 1:1 to another resident in the dining room and was monitoring an additional resident for another staff person who had left the dining room to obtain pajamas for a resident. This statement indicated CNA #1 was not close enough to Resident #5 to prevent the fall. The only other staff member in the dining room at the time was a dietary worker who was cleaning up. The resident was assessed by the nurse who indicated the resident denied pain. The resident was assisted by two staff back into a chair at which time the resident complained of pain in the right hip area. Further review of the falls investigation indicated the physician was notified and an order was obtained for an x-ray of the right hip. Review of the x-ray report of 10/8/12 indicated the resident had a new acute right hip fracture. Record review indicated the resident was transferred to the hospital 10/8/12 and returned to the facility 10/15/12, following surgical repair to the right hip. New care plan interventions to prevent further falls after the second fracture (10/8/12) in the facility included: -Encourage resident to attend group activity in the common area when awake. -When resident is awake on the 11:00 P.M. to 7:00 A.M. shift, encourage resident to remain in common area. -Participation in the STARS (program for residents at risk for falls) program. The resident was observed on 1/16/13 at 11:00 A.M., in the main dining room in a wheelchair. During interview on 1/16/2013 at 4:30 P.M., Unit Manager #2 said that Resident #5 has not had any falls since the resident fractured his/her right hip (10/8/12). Unit Manager #2 said that the resident's participation in activities, increased supervision at night, and participation in the STARS program has helped in preventing additional falls. During interview on 1/16/13 at 4:35 P.M., Unit Manager #3 said that when the resident was admitted to the facility from the hospital (8/14/12) the resident was not on any specific close monitoring for falls or specific devices such as alarms to prevent falls despite the hospital referral and Discharge Summary identifying the resident as a high risk for falls. Unit Manager #3 said that the resident's wandering behavior required frequent redirection of the resident. During interview 1/17/13 at 9:00 A.M., the MDS nurse said that the resident was incorrectly coded on the initial Nursing Assessment (8/14/12) and the initial MDS (8/21/12) as having no falls prior to admission. During interview, 1/17/13 at 9:35 A.M., the Occupational Therapist said that resident #5 was never assessed as being independent with transfers or ambulation while in the facility. Please refer to F278.