Autumn Breeze Health And Rehab

Based on observation, staff interview, and review of the facility's policies titled Date and Label, and Employee Hygiene, the facility failed to ensure expired food items were discarded by the expiration date, and opened items were labeled and dated after opening. In addition, the facility failed to ensure dietary staff were wearing beard guards while working in the kitchen area. The deficient practice increased the risk for 81 residents who were on an oral diet from a census of 83 residents to consume expired food items. Findings Include:Review of facility's policy titled Date and Label, dated 03/2025, documented in the Policy Statement: It is the policy of the facility to handle food in a safe and sanitary manner. The government has mandated with the following statement: labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (when applicable) or discarded.' All food, whether frozen, fresh, or cooked, has specific guidelines for discarding. Nonperishable foods may adhere to the expiration or used by date listed on the container. Perishable foods must be discarded within a safe period after the product is opened or prepared to ensure bacteria growth is limited and the food remains safe.Review of facility's policy titled, Employee Hygiene dated 03/2025, documented in Procedure: 3. Facility approved hair restraints will cover all hair. [NAME] nets will be used to cover facial hair.During the initial tour on 3/10/2026 at 9:10 AM, of the kitchen with Dietary Manager (DM) inspection revealed food in dry storage pantry was conducted, focusing on labels, dating, expiration, and the past use dates of food items. The dry storage revealed multiple opened, unlabeled packages, which contained two 10-lb (pound) enriched macaroni products, one 5-lb devil food cake mix, and one 15-ounce brown gravy mix. One 5-lb bag of coconut with expiration date 02/15/2026.The stand-alone deep freezer was inspected and revealed one single blue trash-like bag containing frostbitten vegetables. The DM verified that it is a 10-lb. bag of frostbitten carrots and peas, which lack labeling. Additionally, there was one clear trash-like bag of frozen biscuits that also lacked labeling, alongside another similar bag that had a label and an expiration date of 02/21/2026. The DM confirmed that a total of 100 biscuits were counted. Furthermore, 18 hashbrowns were found in one gallon bag, along with 33 pancakes, 15 French toast slices, and seven dinner rolls, all of which were confirmed by DM to be missing the required labeling and dating. Lastly, there was one gallon bag labeled French fries with an expiration date of 11/02/2025.A review of the emergency preparedness revealed ten cases of six one-gallon water containers, with expiration date 12/31/2025. The DM confirmed that he is the sole individual responsible for overseeing the monitoring of expiration dates for emergency preparedness food. During the tour observation, several items were found to be expired: 12 glass jars of 4-oz baby food; six glass jars of chicken and gravy with expiration date of 01/31/2026; and six glass jars of beef and gravy, with expiration date of 02/28/2026. Additionally, there were 10 two-packs of 4-oz peach baby food with expiration date of 01/29/2025, six cans of 52 oz sloppy joe with an expiration date of 12/17/2025, and three cans of 60 oz cranberry juice. Furthermore, there were two boxes of instant oatmeal containing 64 counts, expiring on 10/31/2025, and two boxes of cereal with 96 counts of 1.42 oz, with expiration date 07/27/2025. Throughout the initial tour the DM failed to wear beard guard. Observation on 03/11/2026 at 12:11 PM, with the DM during the follow-up tour revealed three 14-oz seasoning; ground coriander with expiration date 02/02/2026, curry powder with expiration date 01/04/2026, and whole fennel seed with expiration date 11/20/2024 each was confirmed with the Dietary Manager and discarded. Throughout the follow-up tour the DM failed to wear beard guard. Observation of Dietary Aide (DA) FF without beard guard operating the low-temperature dishwasher. An interview conducted on 03/11/2026, at 12:32 AM, with DA FF confirmed that he has been employed at the facility for two months and has not received any in-service training regarding the uniform policy related to wearing a beard guard. DA FF elaborated that his responsibilities in the kitchen include cleaning and preparing side menu items, such as tea, lemonade, water, and desserts. DA FF mentioned that no one has ever commented on facial protection, as he typically shaves every day, except for today.An interview conducted on 03/11/2026, at 12:37 AM, with DM confirmed that neither he nor the other male present in the kitchen, DA FF, was utilizing a beard guard.DM revealed that he possesses a length of facial hair and that all males should have a beard guard. DM further expressed that there is no reason for him or DA FF to be out of full uniform.An interview was conducted with the Administrator on 03/12/2026, at 4:50 PM, regarding the observation of the kitchen, she confirmed that she would increase her visits to the kitchen, ensure in-service training, and address the risks associated with unlabeled items, expired products, and uniform compliance concerning facial hair protection, as these factors could potentially lead to illness among residents.

Based on observation, staff interviews, and review of the facility policy titled Enhanced Barrier Precautions, the facility failed to follow Enhanced Barrier Precautions (EBP) for one resident (R) (R5) from a sample of 19 residents. The deficient practice increased the risk of cross contamination and the spread of infection between staff and residents. Findings include:Review of the Facility's Policy Enhanced Barrier Precautions dated 12/01/2022 documented Enhanced Barrier Precautions. refer to the use of gown and gloves for use during high-contact resident care activities (e.g., residents with wounds or indwelling medical devices). Section 1c documented clear signage will be posted on the door or wall outside the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves.Observed wound care for R5 on 03/11/2026 at 11:00 AM with Licensed Practical Nurse (LPN) BB and Certified Nursing Assistant (CNA) DD. R5 was positioned on his left side for wound care by CNA DD. LPN BB and CNA DD performed hand hygiene but did not dress out in a gown prior to starting the wound care procedure. CNA DD put on two pairs of gloves and held the resident in position. R5 had a stage IV pressure wound to his sacrum, a urinary catheter and a capped trach. LPN BB performed wound care without wearing a gown. The room door for R5 did not exhibit any signage indicating the need to use enhanced barrier precautions.Interview on 3/12/2026 at 7:41 AM with the Director of Nursing (DON) revealed that all residents with wounds, catheters or need for EBP should have signage on the door of the room and PPE {Personal Protective Equipment} available on the door or in the hallway. She stated she expects all her staff to wear mask, gown and gloves when performing care. She stated that in the memory unit the expectation is the same. The DON revealed that she is the Infection Preventionist Nurse (IP) and her Unit Managers are responsible for hanging signs and following through with PPE. Observation with interview of room door for R5, the DON confirmed there was no signage on the door. She stated that she thought it had fallen off and they must have put it somewhere.Interview on 03/12/2026 at 7:45 AM with Registered Nurse (RN) CC in the Memory unit, when asked who needed to have these type of precautions EBP, she stated that residents with Covid, Flu and wounds. RN CC confirmed that a sign should be up on the door and PPE available. Interview on 03/12/2026 at 7:50 AM with Certified Nursing Assistant (CNA) AA who was working in the Memory unit stated she thought EBP was the fall mats and the non-skid socks.

Based on observations, resident and staff interviews, and record review, the facility failed to provide dental services for one of 38 sampled residents (R) (R25). This failure had the potential to negatively impact R25's quality of life.
Findings include:
Review of the electronic medical record (EMR) revealed that R25 was admitted to the facility with diagnoses including but not limited to cerebral infarction, acute and chronic respiratory failure, tobacco use, muscle weakness, vascular dementia with agitation, major depressive disorder, type 2 diabetes mellitus without complications, hypertensive heart disease, history of falls, hemiplegia, left hand contracture.
Review of the quarterly Minimum Data Set (MDS) assessments dated 12/19/2024 for R25 revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive deficit. Section L (Oral/Dental Status) revealed no complaints of problems with eating, chewing or pain related to his oral status. Section G (Functional Status revealed R25 is dependent with all activities of daily living (ADLs).
In an observation and interview with R25 on 2/4/2025 10:53 am, he revealed that didn't recall getting dental care routinely. It was noted by surveyor that his teeth were in different stages of decay and were chipped and broken. When asked if he had seen a dentist recently, he stated he did not recall seeing one in a long time. When asked if he had been offered dental care, he stated there were no offers from staff to help him see a dentist.
In an interview on 2/5/2024 at 1:26 pm with the Social Worker, she revealed that she did not recall R25 being in her book for residents needing dental care, nor had she been notified that R25 needed to be seen. She did state the facility could have the mobile dental unit add R25 to the schedule for their visit coming up later in February.
In an interview on 2/5/2024 at 4:15 pm with the DON, she stated R25 did not complain of dental issues or problems on his annual or quarterly MDS assessments this year. She stated when there were dental concerns or issues with residents, staff reported them to her, and she ensured they were scheduled for care through the SW.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, electronic and paper medical record reviews, facility policy reviews, and staff interviews, the facility failed to ensure care plan interventions for emergency tracheostomy (trach) care were developed for four residents (R) (R#6, R#91, R#96, and R#256) reviewed for tracheostomy care. Additionally, the facility failed to ensure a care plan was developed to include special treatments (hemodialysis) for one resident (R#85) reviewed for dialysis. The sample size was 47 residents.
On 11/10/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator, the Regional Consultant, and the Director of Nursing were informed of the Immediate Jeopardy for F656 on 11/10/22 at 11:10 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/7/22.
An Acceptable Removal Plan was received on 11/13/22. The removal plans included placing tracheostomy supplies at the bedside in the residents' rooms, extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revisions, and re-education of all clinical staff. The survey team interviewed facility staff, observed tracheostomy supplies, reviewed revised care plans, and reviewed staff in-services for emergent trach care. The survey team verified all elements of the facility's IJ Removal Plan and removed the IJ on 11/13/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies.
Findings include:
Review of an undated facility policy titled Care Planning-Interdisciplinary Team, indicated, The comprehensive, person-centered care plan will include identifying problem areas .and developing interventions that are targeted and meaningful . The resident's physician (or primary healthcare provider) is integral to this process.
1. Review of R#6's undated Face Sheet, provided by the facility, revealed R#6 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy (surgical procedure to open a direct airway through an incision in the trachea [windpipe]).
Review of R#6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/6/22, located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview Mental Status (BIMS) score of 10 out of 15 indicating R#6 was moderately cognitively impaired and had a tracheostomy and required suctioning.
Review of R#6's comprehensive Care Plan, located in R#6's EMR, revealed no interventions for the tracheostomy (trach) including size, type, or style (cuffed or uncuffed) and no intervention for emergency management of the tracheostomy.
2. Review of R#256's undated Face Sheet, provided by the facility, revealed R#256 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy.
Review of R#256's RESPIRATORY NOTES, dated 11/9/22 and provided by the facility, revealed .Suction (PRN) (as needed) . Suctioning removes thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing.
Review of R#256's comprehensive Care Plan, located in R#256's EMR, revealed no interventions for trach including size, type, or style (cuffed or uncuffed) and no intervention for emergency management of tracheostomy.
3. Review of R#91's undated Face Sheet, provided by the facility, revealed R#91 was admitted to the facility on [DATE] with a re-admission on [DATE] and multiple diagnoses to include tracheostomy.
Review of R#91's quarterly MDS with an ARD of 9/15/22, located in the EMR under the MDS tab, revealed a BIMS without a score, and indicated R#91 was severely cognitively impaired, had a tracheostomy, and required suctioning.
Review of R#91's comprehensive Care Plan, located in R#91's EMR, revealed no interventions for trach including size, type, or style (cuffed or uncuffed) and no intervention for emergency management of tracheostomy.
4. Review of R#96's undated Face Sheet, provided by the facility, revealed R#96 was admitted to the facility on [DATE] with a re-admission on [DATE] and multiple diagnoses to include tracheostomy.
Review of R#96's comprehensive Care Plan, located in the EMR, revealed no interventions for trach including size, type, or style (cuffed or uncuffed) and no intervention for emergency management of tracheostomy.
During an interview on 11/9/22 at 1:01 p.m., the Director of Nursing (DON) confirmed there were no emergency procedures documented on Care Plans for R#6, R#256, R#91, or R#96. The DON also stated that the Care Plans should most definitely address emergency care for tracheostomies.
5. Review of R#85's electronic medical record (EMR) located under the Basic Information tab, revealed R#85 was admitted to the facility on [DATE] with diagnoses including anemia, hypertension, end stage renal disease, anxiety disorder, and depression.
Review of R#85's MDS with an ARD of 10/18/22 revealed R#85 was assessed as having a BIMS score of 14 out of a possible 15 which indicated R#85 was cognitively intact.
Review of R#85's Physician's Orders, dated 11/7/22, revealed R#85 was to have hemodialysis: Monday, Wednesday, Friday, and monitor dialysis access on right side chest for intact lines and signs/symptoms of infection.
Review of R#85's Care Plan, dated 7/1/22, revealed no information regarding her dialysis care. Review of R#85's paper chart also did not contain a Care Plan regarding dialysis care.
During an interview with the DON on 11/9/22 at 3:29 p.m., confirmed that R#85's Care Plan in the EMR did not address dialysis care. The DON also stated that it was an expectation to address dialysis care on R#85's Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility (1) failed to ensure that staff conducted weekly skin assessments to monitor a rash for one of 47 sampled residents (R) (R#34); (2) failed to followed physician's orders for wound care for one of 47 sampled residents (R#39); and (3) failed to obtain a physician's order for fingerstick glucose levels for two of 47 sampled residents (R#29 and R#3).
Findings include:
Review of facility-provided policy titled Wound Care, undated, revealed The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Verify that there is a physician's order for this procedure . Assemble the equipment and supplies as needed .
Review of facility-provided policy titled Obtaining a Fingerstick Glucose Level revealed The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level . Verify that there is a physician's order for this procedure .
1. Review of R#34's Face Sheet located in the electronic medical record (EMR) under the Basic Information tab, revealed an admission date of 6/9/22, with medical diagnoses that included muscle wasting and morbid obesity.
Review of R#34's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/2/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R#34 was cognitively intact. The MDS revealed R#34 required limited assistance for bed mobility and extensive assistance with transfers.
During an interview with R#34, on 11/7/22 at 12:42 p.m., she stated she had a rash on her back that hurt. She stated staff will use cream occasionally.
During an interview with Licensed Practical Nurse (LPN) 4, on 11/11/22 at 1:44 p.m., LPN4 stated R#34 had an order for and received a skin assessment every Wednesday during the afternoon shift. LPN4 stated findings should be documented after the skin assessment was completed and the doctor should be notified if necessary. LPN4 stated if weekly skin assessments were not completed the resident would run the risk of Not getting the care they need or miss necessary treatments. She stated she was aware R#34 had a red rash, and the physician was contacted.
During an interview with the Assistant Director of Nursing (ADON) on 11/11/22 at 5:18 p.m., she stated a skin assessment should be done for every resident on a weekly basis. The ADON stated there should be documentation every shift until the resident completed the Lotrisone treatment and skin assessments should be completed weekly to monitor the rash.
During an interview with the ADON on 11/12/22 at 11:44 a.m., the ADON stated if a resident were receiving treatment for 14 days there should be documentation throughout the course of the treatment.
During an interview and observation with R#34, on 11/12/22 at 11:51 a.m., she stated she still had the rash and it continued to hurt. R#34 raised her right arm and pointed to her underarm area. The underarm area was observed to be bright red with small white bumps, the size was approximately three inches by three inches.
During an observation of R#34, on 11/12/22 at 11:58 a.m., R#34's skin revealed a rash on her torso, both front and back. A highly concentrated area of raised, red, unopened blisters was present in her axillary area on her right side and under her right breast. Her back was nearly covered with these raised, red areas that the resident stated hurt. She stated she had shingles in the past and this felt the same, but this itches more. She stated she had the same rash starting down her right leg behind her knee. The Regional Nurse Consultant entered the room to observe the rash and perform a full skin assessment.
Review of the Weekly Skin Assessment, dated 9/7/22 and provided by the facility, revealed Rashes noted on back area, treatment ongoing. A review of the 9/14/22 and 9/22/22 Weekly Skin Assessment did not reveal any documentation related to a rash. There was no skin assessment for 9/28/22.
Review of the October 2022 Medication Administration Record (MAR), found under the EMR Orders tab, revealed R#34 had Lotrisone Cream [steroidal antifungal cream] apply to rash under breast, and rash on back twice a day x14 days, start date 10/3/22 and stop date 10/17/22.
Review of the Progress Note, dated 10/2/22 and provided by the facility, revealed Resident has red flat rash noted under breast and back . itching and stated she has been scratching what she can reach.
Review of the Progress Note, dated 10/3/22 and provided by the facility, revealed Area under breast and back improving, resident stated it is not itching as bad.
Review of the Progress Note, dated 10/4/22, provided by the facility, revealed Rash on back and under breast much improved, complained of itching intervals.
Review of the Weekly Skin Assessment, dated 10/12/22 and 10/18/22 and provided by the facility, did not reveal any documentation related to a rash. There was no skin assessment for 10/5/22 or 10/26/22.
Review of the Weekly Skin Assessment, dated 11/2/22 and provided by the facility, did not reveal any documentation related to a rash. There was no skin assessment for 11/9/22.
During an interview with LPN1, on 11/12/22 at 12:55 p.m., LPN1 stated she had talked to the physician about the rash. LPN1 stated she did not document anything about R#34's rash except the notes on 10/2/22, 10/3/22 and 10/4/22. She stated she had seen the rash last week but did not document her observations. LPN1 stated R#34 had received an order today, 11/12/22, for medication that would treat the rash.
Review of the November 2022 MAR, found under the EMR Orders tab, revealed R#34 had Triamcinolone[steroidal cream] .5% cream apply cream under BIL breast, back behind BIL knees (red rash) twice a day x14 days. Document every shift until rash is healed, start date 11/13/22.
Review of the November 2022 MAR, found under the orders tab, revealed R#34 had Benadryl Allergy 25 mg ultra, take one tablet by mouth every six hours as needed for itching, start date 11/12/22.
During an interview with CNA4 on 11/12/22 at 1:00 p.m., she stated she knew R#34 had a rash on her back. She stated she had seen the rash two weeks ago. She stated she had told the nurse. CNA4 stated when she told the nurse, the nurse gave her some cream (Triamcinolone) that she put on R#34's back while providing care.
Review of the Progress Note, dated 11/12/22 and found under the Progress Notes tab, revealed Resident noted to have red flat rash on right side back, under bil[lateral] breasts, behind bil[lateral] knees and stated it is itching MD [Medical Director] notified and resident and daughter made aware.
Review of the Progress Note, dated 11/13/22 and found under the Progress Notes tab, Resident upper back looks worst [sic] today, rash looks redder and has spread. TX [treatment] started last pm that was ordered by MD.
2. Review of R#39's undated Face Sheet, provided by the facility, revealed R#39 was admitted to the facility on [DATE] with a readmission date of 8/19/19 and multiple diagnoses to include diabetes.
Review of R#39's quarterly MDS with an ARD of 8/8/22, located in the EMR under the MDS tab, revealed BIMS score was 14 out of 15 indicating R#39 was cognitively intact.
Review of R#39's POST BIOPSY INSTRUCTIONS undated, under the Consents tab located in the hard chart revealed, . remove bandage and soak a soft cloth or gauze with Vinegar water to cleanse (1 tablespoon white vinegar to 1-pint warm water) Hold the cloth or gauze to the affected area for 5-10 minutes twice a day until healed. This will prevent infection and promote healing . This should be done twice daily for 10-14 days . (11/4/22).
Review of R#39's handwritten Physician's Orders under Physician's Orders tab located on R#39's hard chart revealed Cleanse lesion on nostril with gauze and warm white vinegar water . verbal order signed by Wound Care (WC) Nurse-Licensed Practical Nurse (LPN) dated 11/3/22.
Review of R#39's Active Order under the Order tab located on his EMR and dated 11/3/22, revealed . CLEAN LESION ON NOSTRIL WITH GAUZE AND WARM WHITE VINEGAR WATER . 2 X DAY . with no direction for hold gauze to affected area for 5-10 minutes.
Review of R#39's Treatment Record (TAR), dated November 2022 and located under the Orders tab of the EMR revealed . CLEAN LESION ON NOSTRIL WITH GAUZE AND WARM WHITE VINGAR WATER . 2 X DAILY FOR 14 DAYS . with order date of 11/3/22. Review of this TAR revealed no check mark or staff initials, indicating order was not performed for the following dates:
a. 11/5/22 at 5:00 p.m.
b. 11/6/22 at 9:00 a.m. and at 5:00 p.m.
During an observation on 11/7/22 at 11:10 a.m., WC prepped for R#39's wound care treatment. WC heated a Styrofoam cup of tap water in the microwave in the nursing office. WC mixed yellow liquid with water and saturated an abdominal pad and held to R#39's nose. WC confirmed the yellow liquid was apple cider vinegar (not white vinegar) that she obtained from the facility's kitchen.
During an observation/interview on 11/7/22 at 11:35 a.m., the WC and Dietary Manager (DM)
verified that the dietary department supplied WC nurse with the apple cider vinegar she used for R#39's dressing change/wound care.
Review of R#39's Progress Notes, dated 11/7/22 at 12:36 p.m. and under the Progress Notes tab located in the EMR, revealed . Wound care done to lesion on nostril this morning . Order clarification from . to use apple cider vinegar to clean site until white vinegar is available . signed by WC.
During an interview on 11/10/22 at 2:12 p.m. WC confirmed she used apple cider vinegar on resident's nose wound care because white vinegar was not available. WC confirmed she should have called the physician that wrote the order for white vinegar to notify them that white vinegar was not available. WC confirmed she did not follow R#39's wound care physician's order to use white vinegar.
During an interview on 11/10/22 at 2:32 p.m., the Medical Doctor of Internal Medicine (MDI) confirmed he expected the facility's staff to follow the physician's orders. MDI confirmed he expected the facility's staff to call prior to making a substitution of apple cider vinegar instead of white vinegar for R#39's dressing change.
During an interview with 11/10/22 at 3:30 p.m., the Assistant Director of Nursing (ADON) confirmed her expectation for the facility's staff was to follow the physician's orders. The ADON confirmed she expected the staff to inform the person responsible for providing medical supplies and notify the physician to get an alternative if the supplies were unavailable. The ADON confirmed she expected WC to notify the physician prior to substituting any medical supply used on R#39's wound.
During a phone interview on 11/11/22 at 9:37 a.m., the Medical Doctor of Dermatology (MDD) confirmed he expected the facility staff to follow the physician's order for wound care treatment for R#39's nose wound. The MDD stated he expected the facility staff to take a teaspoon of white vinegar and mix it with sterile saline and soak gauze. The MDD confirmed that the facility staff should not substitute apple cider vinegar for the white vinegar for R#39's nose wound dressing. The MDD stated if the facility did not have white vinegar, he expected the facility to call his office and inform him of such and request directions/order. The MDD confirmed he did not want apple cider vinegar used as a substitution for white vinegar for R#39's wound.
3. Review of R#19's undated Face Sheet, provided by the facility, revealed R#19 was admitted to the facility on [DATE] with multiple diagnoses to include diabetes.
Review of R#19's quarterly MDS with an ARD of 10/12/22 located in the resident's EMR under the MDS tab revealed a BIMS score of 12 out of 15 indicating R#19 was moderately cognitively impaired.
Review of R#19's Active Order, for 11/22 and under Order tab in the EMR, revealed no order for a blood sugar test per fingerstick.
Review of R#19's MAR for 11/22 revealed no order for a blood sugar test per fingerstick.
During a medication administration observation on 11/11/12 at 10:59 a.m., LPN 4 performed R#19's blood sugar by fingerstick without a physician's order. LPN 4 verified R#19's MAR, located in the EMR, did not include a physician's order for fingerstick blood sugar.
Review of R#3's undated Face Sheet, provided by the facility, revealed R#3 was admitted to the facility on [DATE] with multiple diagnoses to include diabetes.
Review of R#3's quarterly MDS with an ARD of 10/23/22 and located in the EMR under the MDS tab revealed a BIMS score of 14 out of 15 indicating R#3 was cognitively intact.
Review of R#3's Active Order, for November 2022 under the Order tab located in the EMR, revealed no physician's order for blood sugar per fingerstick.
Review of R#3's MAR for November 2022 revealed no physician's order for blood sugar per fingerstick.
During a medication administration observation on 11/11/12 at 11:15 a.m., LPN3 performed R#3's blood sugar by fingerstick without a physician's order and verified R#3's MAR located in the EMR did not have a physician's order for fingerstick blood sugar.
During an interview on 11/11/22 at 3:30 p.m., the ADON confirmed the facility's residents should have a physician's order for Accu-checks [a fingerstick blood glucose measuring system]. The ADON verified R#19 and R#3 did not have a physician's order in the EMR or on the MAR for blood sugar per fingerstick.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff interviews, and policy review, the facility failed to ensure staff were trained for emergency care of tracheostomies (trachs) and provide emergency tracheostomy kits for four of four residents (R) (R#96, R#91, R#6, and R#256) reviewed for tracheostomy care. The facility's failure to train staff and provide emergency tracheostomy kits in the event that the resident's airway was compromised, placed all residents with tracheostomies at increased likelihood of serious harm or death.
On 11/10/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator, the Regional Consultant, and the Director of Nursing were informed of the Immediate Jeopardy for F695 on 11/10/22 at 11:10 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/7/22.
An Acceptable Removal Plan was received on 11/13/22. The removal plans included placing tracheostomy supplies at the bedside in the residents' rooms, extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revisions, and re-education of all clinical staff. The survey team interviewed facility staff, observed tracheostomy supplies, reviewed revised care plans, and reviewed staff in-services for emergent trach care. The survey team verified all elements of the facility's IJ Removal Plans and removed the IJs on 11/13/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies.
Findings include:
Review of a facility-provided document titled Trach Care, dated 8/2/22 revealed eleven licensed staff members signed the sign in sheet. Review of the content of the material taught was titled Tracheostomy Care and revealed The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas . and did not contain information regarding trach emergency kits or trach emergency management.
During an interview on 11/8/22 at 6:30 p.m., the Director of Nursing (DON) confirmed the facility did not provide the clinical staff training for accidental dislodgement of a tracheostomy or emergency trach kits. DON stated the facility did not have a policy for trach emergency kits or dislodgement of resident's tracheostomy.
1. Review of R#96's undated Face Sheet, provided by the facility, revealed R#96 was admitted to the facility on [DATE] with a re-admission on [DATE] and multiple diagnoses to include tracheostomy (trach).
Review of R#96's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/22 and located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R#96 was cognitively intact, had a tracheostomy, and required suctioning. Suctioning removes thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing.
Review of R#96's Physician's Orders, for November 2022 and under the Orders tab in the EMR, revealed . TRACH CARE EVERY SHIFT AS NEEDED . The order did not include orders for trach emergency management, tracheostomy size, type, style (cuffed or uncuffed), suctioning trach, and/or changing the trach dressing or collar.
During an observation on 11/8/22 at 5:46 p.m. of R#96's room, with the DON and another surveyor, emergency tracheostomy supplies were not visible. The DON confirmed R#96 should have an emergency tracheostomy kit at his bedside and visible in the event of an emergency situation for staff to provide care.
Review of R#96's Telephone Orders, under Physician Orders located in the hard chart, revealed the following orders for emergency care of the tracheostomy:
8/30/22 Send Resident to ER for Eval & TX [evaluation and treatment] [resident] pulled out trach
Review of R#96's Progress Note, under the Progress Notes tab located in the EMR revealed the following:
08/30/2022 12:17 p.m. 07:45: During morning rounds, charge nurse for A hall noticed resident's trach collar was loose and out of place. Upon assessment the nurse noticed the entire trach and inner cannula was out of the stoma [opening into trachea/windpipe] and laying [sic] on his upper chest. Attempts to reinsert was [sic] unsuccessful because the stoma was closed . Resident transferred to the ER at approximately 09:30 a.m.
During an interview on 11/11/22 at 3:03 p.m., the ADON confirmed R#96 was sent out to the ER because of dislodgement of his tracheostomy in August 2022. The ADON confirmed the facility failed to ensure the nursing staff were competent with trach care for the past year. The ADON confirmed the facility did not provide R#96 with quality care for his tracheostomy.
During an interview on 11/11/22 at 5:02 p.m., the Wound Care Nurse-Licensed Practical Nurse (WC) confirmed she called 911 twice to transfer R#96 to the hospital since his admission to the facility. WC stated once R#96's trach came out and she could not replace it. WC stated the second time R#96 had respiratory distress and his oxygen saturations kept dropping. WC confirmed she was not provided trach training competency, in the past year at the facility. WC confirmed the facility should have provided training to her for tracheostomy care. WC confirmed residents' complications with tracheostomy and respiratory could be life threating. WC confirmed residents' tracheostomy was their airway and the only way they could breathe to keep them alive.
2.Review of R#91's undated Face Sheet, provided by the facility, revealed R#91 was admitted to the facility on [DATE] with re-admission on [DATE] and multiple diagnoses to include tracheostomy.
Review of R#91's quarterly MDS with an ARD of 9/15/22, located in the EMR under the MDS tab, revealed a BIMS without a score, which indicated R#91 was severely cognitively impaired, had a tracheostomy, and required suctioning.
Review of R#91's Physician's Orders, for November 2022 under Orders tab in the EMR revealed . TRACH CARE EVERY SHIFT AS NEEDED . SUCTION AS NEEDED EVERY SHIFT, order dated of 7/22/22. The order did not include trach emergency management, tracheostomy size, type, or style (cuffed or uncuffed), and/or orders for changing the trach dressing or collar.
Review of R#91's Progress Notes under Progress Notes tab located on R#91's EMR revealed 9/25/22 9:45 a.m. This writer notified by charge nurse that resident pulled his trach [NAME] [sic] out. Resident assessed and in no form of resp distress at this time. 911 called to transfer resident to . ER for track (sic) reinsertion . 9/26/22 12:12 a.m. Resident returns . [from] ER at 5:30 p.m. via stretcher accompanied by two ambulance attendants for [after] trach re-insertion .
During an interview on 11/8/22 at 4:04 p.m., Certified Nursing Assistant (CNA) 3 confirmed she has provided routine care for R#91. CNA3 confirmed the facility had not provided her with training/in-service for caring for residents with a trach.
During an observation on 11/8/22 at 5:46 p.m. of R#91's room, with the DON and another surveyor, no emergency tracheostomy supplies were available. The DON confirmed R#91 should have an emergency tracheostomy kit at his bedside and visible in the event of an emergency situation for staff to provide care.
During an interview on 11/12/22 at 1:45 p.m., the ADON confirmed R#91 was sent to the emergency room because his tracheostomy was dislodged, and the facility staff attempted but were unable to re-insert his tracheostomy.
3. Review of R#6's undated Face Sheet, provided by the facility, revealed R#6 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy.
Review of R#6's quarterly MDS with an ARD of 10/6/22. located in the EMR under the MDS tab, revealed a BIMS score of 10 out of 15 indicating R#6 was moderately cognitively impaired, had a tracheostomy, and required suctioning.
Review of R#6's Physician's Orders, for November 2022 under Orders tab in the EMR, revealed an order for . TRACH CARE EVERY SHIFT AS NEEDED . SUCTION TRACH AS NEEDED EVERY SHIFT . dated 9/26/22 without an order for trach emergency management, tracheostomy size, type, or style (cuffed or uncuffed), changing trach dressing or collar.
During an interview on 11/8/22 at 4:15 p.m., Registered Nurse (RN) 2 confirmed the facility did not provide her with trach training and would not know what to do if R#6's trach became dislodged.
During observation on 11/8/22 at 5:30 p.m., RN2 confirmed she was providing care for R#6 on 11/8/22. RN2 confirmed R#6 did not have an emergency trach kit at his bedside.
During an observation on 11/8/22 at 5:40 p.m. of R#6's room, with the DON and another surveyor, revealed emergency tracheostomy supplies were not visible. DON confirmed R#6 should have an emergency tracheostomy kit at his bedside and visible in the event of emergency situation for staff to provide care.
4. Review of R#256's undated Face Sheet, provided by the facility, revealed R#256 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy.
Review of R#256's Physician's Orders, for November 2022 under Orders tab in the EMR, revealed no order for trach emergency management, tracheostomy size, type, or style (cuffed or uncuffed), suctioning trach or changing trach dressing or collar.
Review of R#256's RESPIRATORY NOTES, dated 11/9/22 and provided by the facility, revealed . Suction (PRN) (as needed) .
During an observation on 11/8/22 at 5:46 p.m. of R#256's room, with the DON and another surveyor, emergency tracheostomy supplies were not visible. The DON confirmed R#256 should have an emergency tracheostomy kit at his bedside and visible in the event of an emergency situation for staff to provide care.
During an interview 11/12/22 at 12:02 p.m., the ADON confirmed R#256's tracheostomy was surgically inserted in October 2022 and was admitted to the facility on [DATE]. The ADON confirmed that a physician was the only discipline/professional able to perform R#256's first tracheostomy replacement. The ADON confirmed the facility's nursing staff were not made aware of R#256's tracheostomy post op date and was not aware that a physician would have to change the tracheostomy for the first time.
During an interview on 11/12/22 at 12:10 p.m. the ADON confirmed the facility did not have a process to ensure the facility staff was aware of the date of surgical insertion of trach or to ensure the physician was the staff responsible for re-insertion the resident's first trach.
During an interview/observation on 11/8/22 at 4:04 p.m., CNA6 confirmed she provided care for residents with trachs, including R#96. CNA6 confirmed the facility had not provided her with training/in-service for caring for residents with a trach.
During an interview on 11/8/22 at 4:38 p.m., Unit Manager (UM) 1 stated he had worked in the facility nearly five years, and he regularly worked with residents with tracheostomies. When asked what to do if a residents trach came out UM1 stated, that's a 911 situation - we would call the MD & 911. When asked how he would maintain the resident's airway until EMS arrived, UM1 had no answer. UM1 stated he had been trained a few months ago when an RT (respiratory therapist) came in and showed them how to reinsert a trach. When asked about the emergency trach care supplies, he had no response regarding what was needed at bedside in case of an emergency. UM1 confirmed on 11/8/22 that he provided and was responsible for caring for three of the four residents with trachs.
During an interview on 11/8/22 at 4:40 p.m. CNA 4 confirmed the facility did not provide him with trach care training and stated that [training for trach care] was only for the nurses.
During an interview on 11/8/22 at 4:48 p.m., CNA2 stated we work with every patient, and rotate halls [for assignments]. CNA2 stated she had received trach training in September 2022 and was trained to clean the trach. CNA2 stated she was trained to clean around the trach with cotton and would notify the nurse if the trach needed suctioning. CNA2 stated she knew nothing about an emergency kit for tracheostomy.
During an interview on 11/8/22 at 5:00 p.m., CNA5 confirmed she was assigned to the hallway with three of the four residents with trachs and provided routine care. CNA5 confirmed the facility did not provide her training or in-service for caring for residents with a trach.
During an interview on 11/8/22 at 5:05 p.m., CNA1 stated she did not remember ever receiving trach training and did not know anything about an emergency kit for trachs. CNA1 stated she would call the nurse if the trach fell out.
During an interview at 11/8/22 at 5:45 p.m., the DON confirmed all the facility staff including CNAs should have in-service training provided by the facility for providing care for residents with trach. The DON confirmed the facility had a respiratory therapist on staff who provided services at the facility once a week. The DON stated if dislodgement of a resident's trach occurred, she expected the nursing staff to re-insert the resident's trach. DON stated the staff would be expected to use the old trach to maintain the trach opening to maintain the airway while another staff member retrieved a new trach to insert. The DON confirmed if the staff were unable to insert the new trach, she would expect the staff to call 911.
During an interview on 11/8/22 at 6:30 p.m., the DON confirmed the facility did not provide the clinical staff training for accidental dislodgement of a tracheostomy or emergency trach kits training. DON stated the facility did not have a policy for trach emergency kits or dislodgement of resident's tracheostomy.
During an interview and observation on 11/8/22 at 9:50 p.m. with ADON and DON confirmed they were unsure if the facility had an arbitrator/hemostat (required in an emergency kit) for all four of the residents with trachs in the building. ADON confirmed that before 11/8/22 at 4:00 a.m. the physician's orders in the medical records for all four of the residents with trachs did not include whether the trachs were cuffed or uncuffed or the type or size of the trachs. The ADON confirmed that information was necessary for the care of the trach.
During an interview on 11/9/22 at 2:59 p.m., the Medical Director confirmed he provided care for residents with trachs. The Medical Director confirmed he expected the facility to have emergency equipment at the bedside for trach residents that was appropriate, but that the respiratory therapist would have all the emergency equipment. (The respiratory therapist came to the facility once a week). The Medical Director confirmed he would expect the physician's order would include type, size, and cuff or non-cuffed trach. The Medical Director confirmed he expected the facility policies would include emergency management and trach care .The Medical Director confirmed he expected the facility would provide education for CNA staff training with basic knowledge of providing care for residents with a trach. The Medical Director confirmed he expected the facilities to educate the nursing staff on emergency management of residents with trach.
During an interview on 11/9/22 at 3:28 p.m., the Administrator stated she was not aware the facility needed a specific emergency kit to provide care for the residents with a tracheostomy. The Administrator confirmed the staff had not been trained on trach care. The Administrator confirmed there were some nurses trained and not all the staff regarding tracheotomy and no emergency management of tracheotomy training was provided to the facility's staff. The Administrator confirmed the facility should provide CNA staff training for providing care for residents with a tracheostomy. The Administrator confirmed she, along with the DON and ADON, were responsible for ensuring residents had the necessary medical supplies including trach emergency kits. The Administrator stated she was not aware of any residents with tracheostomy at the facility suffering dislodgement. The Administrator confirmed resident (with tracheostomy) care plans should include specific interventions, including tracheostomy emergency management. The Administrator stated the facility assessment included the facility accepted residents with tracheostomy. The Administrator verified the facility assessment included trach as condition accepted. The Administrator confirmed the facility did not provide quality care to the four residents with traches residing at the facility. The Administrator confirmed the facility was not prepared to provide care for the four residents with tracheotomy prior to their admission because the facility did not have proper supplies and the staff were not properly trained. The Administrator confirmed the facility's administration did not follow through with their responsibilities for the four residents with tracheotomy. The Administrator confirmed the facility did not have a policy regarding trach emergency management and should have a policy. The Administrator stated the staff would not be able to provide the proper care in a trach emergent situation without training.

Based on observations, staff interviews, record review, and policy review, the facility failed to ensure six of 47 sampled residents (R) (R#68, R#18, R#27, R#53, R#84, and R#34) were monitored for specific behaviors.
Findings include:
Review of facility policy titled, Assessment of Psychoactive Medication, undated, revealed, Patients who receive antipsychotic, sedative, hypnotic, antidepressant, or any medications prescribed to modify behavior are evaluated to determine the effectiveness of the medication . Based on a comprehensive assessment of a resident, the facility must ensure that . the facility must evaluate the effectiveness of the medications . After initiated or increasing the dose of a psychotropic medication, the behavioral symptoms much be reevaluated periodically to determine the potential for reducing or discontinuing the dose.
1. Review of R#68's Face Sheet located in the electronic medical record (EMR) under the Basic Information tab, revealed an admission date of 4/30/22, with medical diagnoses that included schizoaffective disorder (severe mental illness of hallucinations (hearing, seeing, touching, smelling objects not present) and delusions (firmly held beliefs not based on reality), insomnia, unspecified psychosis (disconnection from reality), major depression, anxiety disorder, bipolar disorder (mental illness of periods of depression and elevated mood), auditory hallucinations.
Review of R#68's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/21/22, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R#68 was cognitively intact. The MDS revealed R#68 had physical behaviors directed toward others and required supervision for all activities of daily living (ADL).
Review of R#68's Care Plan, located in the EMR under the Care Plan tab with a problem onset date of 11/8/22, revealed R#68 Displayed physically/verbally aggressive behaviors when I feel that I am being attached either verbally or physically by other residents. Goal: I will not display any physically/verbally aggressive behaviors towards other residents. Approaches: Social Services to evaluate and visit with me, Activities staff to visit with me . Monitor and document my behavior .Identify causes for my behavior . Discuss my options . praise me for demonstrating desired behavior, talk with me in a calm voice.
Review of R#68's Medication Administration Record (MAR) located in the EMR under the Orders tab, dated November 2022, revealed Zyprexa [anti-psychotic] 5 mg [milligram] tablet, take 1 tablet by mouth at HS [bedtime], start date 10/20/22, for anxiety disorder, Behavior Monitoring for Psychotropic Drugs - Observe for mood swing, agitation, restlessness, tardive dyskinesia every shift, start date 11/12/22.
During an interview with Licensed Practical Nurse (LPN) 2 on 11/10/22 at 1:20 p.m., LPN2 stated if R#68 had behaviors, staff would review the care plan, look at interventions, and document the behaviors in the nurses' behavior notes. She stated anytime abnormal behavior with a resident is observed, the behavior should be documented in the behavior notes. LPN2 reviewed the notes and confirmed there were no specific behaviors documented from 5/1/22 through 11/10/22 and specific behaviors were not in the care plan.
2. During an observation of R#18, on 11/7/22 at 10:27 a.m., R#18 was smiling and kissing a baby doll.
During an observation of R#18, on 11/7/22 at 11:10 a.m., R#18 was sitting in her wheelchair outside of her room. She was crying and holding two baby dolls.
During an observation of R#18, on 11/8/22 at 1:35 p.m., R#18 was sitting up in bed, holding one baby doll and laughing.
During an observation of R#18, on 11/11/22 at 2:05 p.m., R#18 was sitting in her wheelchair in her room. She was crying and holding one baby doll.
During an observation of R#18, on 11/12/22 at 1:15 p.m., R#18 was sitting in her wheelchair in her room. She was crying and holding two baby dolls.
During an interview with Certified Nursing Assistant (CNA) 4, on 11/11/22 at 2:05 p.m., CNA4 stated if she observed a behavior, she would report the behavior to the nurse. She stated that crying was a behavior. She stated she had not received any special education related to working with R#18 or her specific behaviors.
Review of R#18's Face Sheet located in the EMR under the Basic Information tab, revealed an admission date of 1/18/21, with medical diagnoses that included major depression and psychotic disorder with delusions.
Review of R#18's quarterly MDS located in the EMR under the MDS tab with an ARD of 10/1/22, revealed a BIMS score of three out of 15, indicating R#18 was severely impaired cognitively. The MDS revealed no mood or behavior symptoms.
Review of R#18's Care Plan, located in the EMR under the Care Plan tab and reviewed 7/18/22, revealed R#18 did not have any behavior care plans.
Review of R#18's MAR located in the EMR under the Orders tab, dated November 2022, revealed Mirtazapine [antidepressant] 15 mg tablet by mouth at bedtime, start date 5/25/22, for major depressive disorder. Xanax [antianxiety] .5 mg tablet, take one tablet by mouth at bedtime, start date 11/3/22 for dementia. Further review of the November 2022 MAR revealed no identification and/or monitoring of target behaviors for the use of the antidepressant and antianxiety medications.
3. Review of R#27's Face Sheet, located in the EMR under the Basic Information tab, revealed an admission date of 7/18/22, with medical diagnoses that included bipolar disorder, major depression, schizophrenia, unspecified psychosis, and insomnia.
Review of R#27's quarterly MDS located in the EMR under the MDS tab with an ARD of 10/24/22, revealed a BIMS score of nine out of 15, indicating R#27 was moderately impaired cognitively. The MDS revealed no mood or behavior symptoms.
Review of R#27's Care Plan, located in the EMR under the Care Plan tab and reviewed 7/18/22, revealed R#27 did not have any behavior care plans.
Review of R#27's MAR located in the EMR under the Orders tab, dated November 2022, revealed Valproic Acid [Anticonvulsant] 250 mg/5ml [milliliters] soln [solution], give 750 mg per peg tube two times a day, start date 7/18/22 for Bipolar Disorder. Further review of the November 2022 MAR revealed no identification and/or monitoring of target behaviors for the use of Valproic Acid for bipolar disorder.
4. Review of R#53's Face Sheet, located in the EMR under the Basic Information tab, revealed an admission date of 8/9/22, with medical diagnoses that included generalized anxiety disorder, major depression, and insomnia.
Review of R#53's quarterly MDS located in the EMR under the MDS tab with an ARD of 10/2/22, revealed a BIMS score of 15 out of 15, indicating R#53 was cognitively intact. The MDS revealed no mood or behavior symptoms
Review of R#53's Care Plan, located in the EMR under the Care Plan tab and reviewed 7/23/22, revealed R#53 did not have any behavior care plans.
Review of R#53's MAR, located in the EMR under the Orders tab and dated November 2022, revealed Alprazolam [Antianxiety] .5 mg tablet, give one tablet by mouth daily at HS scheduled, start date 8/9/22 for generalized anxiety disorder. Further review of the November 2022 MAR revealed no identification and/or monitoring of target behaviors for the use of the antianxiety medication.
5. Review of R#84's Face Sheet, located in the EMR under the Basic Information tab, revealed an admission date of 7/28/21, with medical diagnoses that included unspecified psychosis, major depression, restlessness, and agitation.
Review of R#84's quarterly MDS located in the EMR under the MDS tab with an ARD of 10/7/22, revealed a BIMS score of three out of 15, indicating R#84 was severely impaired cognitively. The MDS revealed no mood symptoms, but documented R#84 had delusions.
Review of R#84's Care Plan, located in the EMR under the Care Plan tab and reviewed 9/28/22, revealed R#84 did not have any behavior care plans or identification of what delusions R#84 exhibited, and staff were to monitor.
Review of R#84's MAR located in the EMR under the Orders tab and dated November 2022, revealed Divalproex SOD DR [Anticonvulsant] 250 mg tab[let] take one tablet by mouth twice a day at 9:00 a.m. and 1:00 p.m., start date 8/10/21 for unspecified psychosis. Divalproex SOD DR 500 mg tab take one tablet daily at 5:00 p.m., start date 8/10/21 for unspecified psychosis. Depakote [Anticonvulsant] DR 250 mg tablet give one tablet by mouth daily at 9:00 a.m. and 1:00 p.m., start date 8/5/21 for unspecified psychosis. Behavior monitoring for psychotropic drugs: Observe for s/s [signs/symptoms] of psychotic behavior (mood change, crying, anger, etc.). start date 11/12/22. Further review of the November 2022 MAR revealed no monitoring of signs and symptoms of psychotic behavior.
6. Review of R#34's Face Sheet, located in the EMR under the Basic Information tab, revealed an admission date of 6/9/22 with medical diagnoses that included muscle wasting and morbid obesity.
Review of R#34's quarterly MDS located in the EMR under the MDS tab with an ARD of 10/2/22, revealed a BIMS score of 15 out of 15, indicating R#34 was cognitively intact. The MDS revealed R#34 had no behaviors documented.
Review of R#34's Care Plan, located in the EMR under the Care Plan tab and reviewed 10/2/22, revealed R#34 did not have any behavior care plans.
Review of R#34's MAR located in the EMR under the Orders tab and dated November 2022, revealed Ativan [Antianxiety]) .5 mg tablet, give 1 by mouth daily at bedtime, start 11/7/22 for Anxiety Disorder. Celexa [Antidepressant] 20 mg tablet take one tablet by mouth daily, start date 10/21/22 for major depression. Mirtazapine [Antidepressant]) 15 mg tablet take one tablet by mouth at bedtime, start date 6/17/22 for major depression. Monitor for s/s of restlessness/agitation/aggression due to use of anti-anxiety (Ativan), start date 11/12/22. Further review of the November 2022 MAR revealed no monitoring of the target behaviors/signs/symptoms for the use of the antianxiety medications.
During an interview with the Assistant Director of Nursing (ADON) on 11/11/22 at 1:01 p.m., the ADON stated monitoring all residents' behaviors was very important and behaviors should be identified and written in the care plan. She stated that behaviors should also be documented on the MAR and monitored every shift. She stated that monitoring changes in mood, expression, and observations of irritation, anger or crying, were very important behaviors to monitor. The ADON confirmed behaviors were not documented on the MAR.
During an interview with LPN4, on 11/11/22 at 1:44 p.m., LPN4 stated if a resident had behaviors, she would notify the social worker or the Administrator. She stated there was no written communication they would just communicate as the social worker walked by the nurses' station. She stated nurses should document but do not always do that.
During an interview with the Administrator on 11/11/22 at 12:00 p.m., the Administrator stated that she was sure the social work had not documented any information about any psychotropic or behavior meetings.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable level of well-being four of four residents (R) (R#96, R#91, R#6, and R#256) reviewed for tracheostomy care and for seven residents reviewed for abuse (R#156, R#16, R#11, R#23, R#25, R#39, R#101 and R#27).
Specifically:
1. The facility administration failed to ensure competent clinical staff and provide supplies to care for residents with tracheostomies to include emergency care for accidental trach dislodgement for four of four residents (R) (R#96, R#91, R#6, and R#256).
Cross Refer to F695.
2. The facility administration failed to ensure the environment was maintained free from abuse from R#68.
Cross refer to F600.
On 11/10/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator, the Regional Consultant, and the Director of Nursing were informed of the Immediate Jeopardy for F835 on 11/10/22 at 11:10 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/7/22.
An Acceptable Removal Plan was received on 11/13/22. The removal plans included placing tracheostomy supplies at the bedside in the residents' rooms, extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revisions, re-education of all clinical staff related to tracheostomy care, re-education of all staff related to abuse and the Elder Care Act, and placing R#68 on continuous one to one supervision until appropriate placement can be found. The survey team verified all elements of the facility's IJ Removal Plan and removed the IJ on 11/13/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies and includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care related to abuse.
Findings include:
Review of the facility Administrator's job description revealed Lead and direct the overall operation of the facility in accordance with resident needs . training employees . and under the ESSENTIAL JOB FUNCTIONS heading revealed . Directs and coordinates medical, nursing and administrative staffs and services . Implements and communicates policies and procedures for various departments . Maintain a working knowledge and ensure compliance with all governmental regulations . Understands, complies with and promotes all rules regarding Residents' Rights .
1. Review of the facility-provided document titled, Facility Assessment, undated, under the heading Staff training, education and competencies . revealed . Ongoing staff training/education and competencies are necessary to provide the level and types of support and care needed for our resident population . education, training, competency instruction, and testing policies . specialized care . trach [tracheostomy] care/suctioning.
Review of a facility-provided document titled Trach Care, dated 8/2/22 revealed eleven licensed staff members signed the sign in sheet. Review of the content of the material taught was titled Tracheostomy Care and revealed The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas . and did not contain information regarding trach emergency kits or trach emergency management.
During an interview on 11/8/22 at 6:30 p.m., the Director of Nursing (DON) confirmed the facility did not provide the clinical staff training for accidental dislodgement of a tracheostomy or emergency trach kits. DON stated the facility did not have a policy for trach emergency kits or dislodgement of resident's tracheostomy.
The following residents were observed, and staff interviewed regarding emergency trach supplies:
During an observation on 11/8/22 at 5:46 p.m. of R#96's room, with the Director of Nursing (DON) and another surveyor, emergency tracheostomy supplies were not visible. The DON confirmed R#96 should have an emergency tracheostomy kit at his bedside and visible in the event of an emergency situation for staff to provide care.
During an interview on 11/12/22 at 12:36 p.m., the admission Director confirmed he discussed R#96's admission to the facility with the Administrator prior to R#96's admission and the Administer was aware R#96 had a tracheostomy.
During an interview on 11/12/22 at 1:04 p.m., the Administrator confirmed she approved R#96's admission to the facility and was aware he was admitted with a trach.
During an interview on 11/8/22 at 4:15 p.m., Registered Nurse (RN) 2 confirmed the facility did not provide her with trach training and would not know what to do if R#6's trach became dislodged.
During observation on 11/8/22 at 5:30 p.m., RN2 confirmed R#6 did not have an emergency trach kit at his bedside and no ambu bag (a handheld manual resuscitator used to provide ventilation to an individual not breathing on their own) visible in his room.
During an observation on 11/8/22 at 5:46 p.m. of R#256's room, with the DON and another surveyor, emergency tracheostomy supplies were not available. The DON confirmed R#256s should have an emergency tracheostomy kit at his bedside in the event of emergent situation for staff to provide care.
During an interview on 11/12/22 at 12:38 p.m. the admission Director confirmed he discussed R#256's (with tracheostomy) admission to the facility with the DON and the DON approved her admission. The admission Director confirmed the Administrator was informed of all facility resident admissions prior to admission to the facility.
During an interview on 11/8/22 at 4:40 p.m., CNA4 confirmed the facility did not provide him with trach care training and stated that was only for the nurses.
During an interview on 11/8/22 at 4:38 p.m., Unit Manager (UM) 1 stated he had worked in the facility nearly five years, and he regularly worked with residents with tracheostomies. When asked what to do if a residents trach came out UM1 stated, that's a 911 situation - we would call the MD [physician] & 911. When asked how he would maintain the resident's airway until EMS arrived, he had no answer. UM1 stated he had trained a few months ago when a Respiratory Therapist came in and showed them how to reinsert trachs. When asked about the emergency trach care supplies UM1 had no response regarding what was needed at bedside in case of an emergency.
During an interview on 11/8/22 at 4:48 p.m., CNA2 stated the staff work with every patient, and rotate halls. CNA2 stated she had received trach training in September and was trained to clean the trach. CNA 2 stated she was trained to clean around the trach with cotton and would notify the nurse if the trach needed suctioning. CNA2 stated she knew nothing about an emergency kit for trachs.
During an interview with CNA1 on 11/8/22 at 5:05 p.m., she stated she did not remember ever receiving trach training. CNA1 stated she would never clean a trach and did not know anything about the emergency kit for trachs in the facility. CNA1 stated she would call the nurse if the trach fell out.
During an interview at 11/8/22 5:45 p.m., the DON confirmed all the facility staff including CNAs should have in-service training provided by the facility for providing care for residents with trachs. The DON confirmed the facility had a respiratory therapist on staff who provided services at the facility once a week. The DON stated if dislodgement of a resident's trach occurred, she expected the nursing staff to re-insert the resident's trach. The DON stated the staff would be expected to use the old trach to maintain the trach opening or maintain the airway with the old trach holding with gauze while another staff member retrieved a new trach for the staff to insert. The DON confirmed if the staff were unable to insert the new trach, she would expect the staff to call 911. The DON stated she expected the staff to hold the oxygen mask over resident's trach site.
During an interview on 11/9/22 at 3:28 p.m., the Administrator stated she was not aware the facility needed a specific emergency kit to provide care for the residents with trachs. The Administrator confirmed some nurses were trained on trach care and that no emergency management of trachs training was provided to the facility's staff. The Administrator confirmed the facility should provide CNA staff training for providing care for residents with trachs because it would affect how the CNA staff provided the care for those residents. The Administrator confirmed she (along with DON and ADON) were responsible for ensuring residents had the necessary medical supplies including trach emergency kits. The Administrator confirmed the facility did not have any trach emergency kits in the facility. The Administrator confirmed the facility should have emergency kits for all four of the residents with trachs. The Administrator verified the facility assessment included tracheostomies as a condition accepted. The Administrator confirmed the facility was not prepared to provide care for the four residents with trachs prior to their admission because the facility did not have proper supplies and the staff were not properly trained. The Administrator confirmed the facility did not have a policy regarding trach emergency management, did not have a trach emergency kits that staff would not be able to provide the proper care in a trach emergency situation without training.
2. Review of the facility's abuse policy titles Abuse, Neglect, and Exploitation, undated, revealed:
The facility must: 1.) not use verbal, sexual, physical abuse, corporal punishment, or involuntary seclusion. 2.) Ensure all residents are free of physical or chemical restraints . 5.) Prevention of Abuse .a.) train staff appropriate interventions to deal with residents aggressive and/or catastrophic reactions by residents . d.) Education on what constitutes abuse, neglect, or misappropriation. e.) react to all allegations or questionable abuse from residents, staff, family members, and/or visitors. f.) Take appropriate actions whenever abuse is reported/suspected .13.) In response to allegations of abuse, neglect, exploitation, or misappropriation the facility MUST: a.) Ensure all alleged violations involving abuse, neglect, .misappropriation or mistreatment, including injuries of unknown origins . are reported immediately, but not later than two hours after the incident occurs b.) have evidence that all alleged violations are thoroughly investigated .d.) Report the results of investigations to the administrator .and other government officials in accordance with state laws, including reporting to the State Survey Agency .and corrective action must be taken.
During an interview with the Administrator, on 11/9/22 at 1:17 p.m., she stated she was not aware of the incident between R#25 and R#68 on Tuesday (11/8/22) morning. The Administrator stated she would talk to R#25. She said yesterday she talked with R#25 and assured her they would do everything, so she [R#25] did not have to be afraid. The Administrator stated they had started the process on 11/9/22, to find R#68 a more appropriate place to live and had sent referral paperwork to one facility. She stated she was waiting to hear from them and would follow up.
During an interview with the Medical Director, on 11/9/22 at 3:03 p.m., he stated that he was aware that R#68 had been aggressive, but the facility had been looking for placement. He stated having an aggressive resident in a facility was similar to having a neighbor who was aggressive. He stated there was no way to guarantee protection of residents due to staffing restrictions and [residents] history of mental impairment. The Medical Director stated he was concerned that another resident was afraid but trusted that staff were monitoring R#68. He stated unfortunately we cannot restrain or medicate the resident. The Medical Director said he was usually not part of conversations related to R#68's behavior.
During an interview with the Director of Nursing (DON) on 11/9/22 at 7:47 p.m., the DON stated the facility had not put any other interventions in place for R#68 or increased supervision of the resident since his last incident on Monday morning (11/7/22). She stated they have begun looking for another placement for R#68.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview, record reviews, and facility policy review, the facility failed to evaluate its resident population and identify the resources needed to provide the necessary care and services to meet the needs of four of four residents (R) (R#6, R#256, R#91, and R#96) requiring tracheostomy (surgical procedure to open a direct airway through an incision in the trachea [windpipe]) care and suctioning (removal of thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing) on the facility assessment.
Findings include:
Review of facility-provided policy titled Facility Assessment, undated, revealed A facility assessment is conducted annually to determine and update our capacity to meet the needs of and completely care for our residents during day-to day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment . The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps determine budget, staffing, training, equipment, and supplies needed . The facility assessment is reviewed . as needed . resident changes or modifications that may prompt a reassessment sooner include . resident census and /or overall acuity of our residents .
1. Review of R#6's undated Face Sheet, provided by the facility, revealed R#6 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy.
Review of R#6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/6/22, located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview Mental Status (BIMS) score of 10 out of 15 indicating R#6 was moderately cognitively impaired, had a tracheostomy, and required suctioning.
2. Review of R#256's undated Face Sheet, provided by the facility, revealed R#256 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy.
Review of R#256's RESPIRATORY NOTES, dated 11/9/22 and provided by the facility, revealed . Suction (PRN) (as needed) .
3. Review of R#91's undated Face Sheet, provided by the facility, revealed R#91 was admitted to the facility on [DATE] with a re-admission on [DATE] and multiple diagnoses to include tracheostomy.
Review of R#91's quarterly MDS with an ARD of 9/15/22, located in the EMR under the MDS tab, revealed a BIMS without a score, and indicated R#91 was severely cognitively impaired, had a tracheostomy, and required suctioning.
4. Review of R#96's undated Face Sheet, provided by the facility, revealed R#96 was admitted to the facility on [DATE] with a re-admission on [DATE] and multiple diagnoses to include tracheostomy.
Review of R#96's quarterly MDS with an ARD of 10/28/22, located in the EMR under the MDS tab, revealed a BIMS score was 13 out of 15 indicating R#96 was cognitively intact, had a tracheostomy, and required suctioning.
Review of facility-provided Facility Assessment, with a review date of 10/11/22, revealed Nursing facilities will . include . resident population . and resources the facility needs to care for their residents . Acuity Based on Special Treatments and Conditions . Suctioning 1 [resident] . Tracheostomy 1 [resident] . indicating three of four residents with tracheostomy and requiring suctioning were not included in the assessment.
During an interview on 11/9/22 at 6:48 p.m., the Administrator verified the facility assessment had one resident entered for Tracheostomy care and Suctioning. The Administrator confirmed the facility assessment for one resident with trach and one for suctioning was incorrect. The Administrator confirmed the facility had four residents with trachs and required suctioning and the assessment should reflect those numbers to inform the admission staff including the Director of Nursing (DON). The Administrator confirmed she was responsible for updating the facility's assessment and had not updated or included the increased number of residents. The Administrator stated she updated the facility assessment two weeks ago incorrectly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff interviews, and policy review, the facility failed to ensure competent clinical staff were trained to care for residents with tracheostomies and for emergency care for accidental trach dislodgement for four of four residents (R) (R#96, R#91, R#6, and R#256) reviewed for tracheostomy care. The facility's failure to properly train staff for complex care of tracheostomies and emergency airway maintenance placed all residents with tracheostomies at increased likelihood of serious harm or death.
On 11/10/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator, the Regional Consultant, and the Director of Nursing were informed of the Immediate Jeopardy for F695 on 11/10/22 at 11:10 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/7/22.
An Acceptable Removal Plan was received on 11/13/22. The removal plans included placing tracheostomy supplies at the bedside in the residents' rooms, extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revisions, and re-education of all clinical staff. The survey team interviewed facility staff, observed tracheostomy supplies, reviewed revised care plans, and reviewed staff in-services for emergent trach care. The survey team verified all elements of the facility's IJ Removal Plans and removed the IJs on 11/13/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies.
Findings include:
Review of facility-provided paper document titled, Facility Assessment, undated, under the heading Staff training, education and competencies . revealed, . Ongoing staff training/education and competencies are necessary to provide the level and types of support and care needed for our resident population . education, training, competency instruction, and testing policies . specialized care . trach [tracheostomy] care/suctioning.
Review of the facility-provided document titled, Director of Nursing . job description revealed the position was, . plan, organize, develop, and direct the overall operations of the Nursing Service Department . to ensure that the highest degree of quality of care is maintained at all times .
Review of the facility-provided paper document titled, Assistant Director or Nursing (ADON) job description revealed . Assists in developing and maintaining nursing service objectives, standards of nursing practice, nursing policy and procedure .
Review of facility-provided paper document titled; Licensed Practical Nurse LPN job description revealed . Attends in-services and participates in training new staff .
Review of facility-provided paper document titled, Certified Nursing Assistant (CNA) job description revealed . Assist in orientation and training of other staff. Attend orientation, mandatory in-service, and education programs .
The facility administration failed to ensure sufficient and competent clinical staff to care for residents with tracheostomies and for emergency care for accidental trach dislodgement.
a. Review of R#96's undated Face Sheet, provided by the facility, revealed R#96 was admitted to the facility on [DATE] with a re-admission on [DATE] and multiple diagnoses to include tracheostomy (trach).
Review of R#96's Physician's Orders, for November 2022 and under the Orders tab in the EMR, revealed . TRACH CARE EVERY SHIFT AS NEEDED . The order did not include orders for trach emergency management, tracheostomy size, type, style (cuffed or uncuffed), suctioning trach, and/or changing the trach dressing or collar.
Review of R#96's Telephone Orders, under Physician Orders located in the hard chart, revealed the following orders for emergency care of the tracheostomy: 8/30/22 Send Resident to ER for Eval & TX [evaluation and treatment] [resident] pulled out trach
During an interview on 11/8/22 4:04 p.m., CNA3 confirmed she provided care for R#96. CNA3 confirmed the facility had not provided her with training/in-service for caring for residents with trach.
During an interview on 11/11/22 at 3:03 p.m., the ADON confirmed R#96 was sent out to the emergency room because of dislodgement of his tracheostomy in August 2022. The ADON confirmed the facility failed to ensure the nursing staff were competent with trach care for the past year. The ADON confirmed the facility did not provide R#96 with quality care for his tracheostomy.
b. Review of R#91's undated Face Sheet provided by the facility revealed R#91 was admitted to the facility on [DATE] with re-admission on [DATE] and multiple diagnoses to include tracheostomy.
Review of R#91's Physician's Orders, for November 2022 under Orders tab in the EMR revealed .TRACH CARE EVERY SHIFT AS NEEDED . SUCTION AS NEEDED EVERY SHIFT, order dated of 7/22/22. The order did not include trach emergency management, tracheostomy size, type, or style (cuffed or uncuffed), and/or orders for changing the trach dressing or collar.
Review of R#91's Progress Notes under Progress Notes tab located in the EMR revealed 9/25/22 9:45 a.m. This writer notified by charge nurse that resident pulled his trach [NAME] [sic] out. Resident assessed and in no form of resp distress at this time. 911 called to transfer resident to . ER for track (sic) reinsertion . 9/26/22 12:12 a.m. Resident returns . [from] ER at 5:30 p.m. via stretcher accompanied by two ambulance attendants for [after] trach re-insertion .
During an interview on 11/12/22 at 1:45 p.m., the ADON confirmed R#91 was sent to the emergency room because his tracheostomy was dislodged, and the facility staff attempted but were unable to re-insert his tracheostomy.
c. Review of R#6's undated Face Sheet, provided by the facility, revealed R#6 was admitted to the facility on [DATE] and multiple diagnoses to include tracheostomy.
During an interview on 11/8/22 at 4:15 p.m. Registered Nurse (RN) 2 confirmed the facility did not provide her with trach training. RN 2 confirmed she had no idea what to do if R#6's trach became dislodged.
During observation on 11/8/22 at 5:30 p.m. RN2 confirmed she provided care for R#6 on 11/8/22.
d. Review of R#256's undated Face Sheet, provided by the facility, revealed R#256 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy.
Review of R#256's Physician's Orders, for November 2022 under Orders tab in the EMR, revealed no order for trach emergency management, tracheostomy size, type, or style (cuffed or uncuffed), suctioning trach or changing trach dressing or collar.
Review of R#256's RESPIRATORY NOTES, dated 11/9/22 and provided by the facility, revealed .Suction (PRN) (as needed) .
During an interview/observation on 11/8/22 at 4:04 p.m., CNA6 confirmed she provided care for residents with trachs, including R#96. CNA6 confirmed the facility had not provided her with training/in-service for caring for residents with a trach.
During an interview on 11/8/22 at 4:38 p.m., Unit Manager (UM) 1 stated he had worked in the facility nearly five years, and he regularly worked with residents with tracheostomies. When asked what to do if a residents trach came out UM1 stated, that's a 911 situation - we would call the MD & 911. When asked how he would maintain the resident's airway until EMS arrived, UM1 had no answer. UM1 stated he had been trained a few months ago when an RT (respiratory therapist) came in and showed them how to reinsert a trach. When asked about the emergency trach care supplies, he had no response regarding what was needed at bedside in case of an emergency. UM1 confirmed he provided and was responsible for caring for three of the four residents with trachs on 11/8/22.
During an interview on 11/8/22 at 4:40 p.m. CNA4 confirmed the facility did not provide him with trach care training and stated that [training for trach care] was only for the nurses.
During an interview on 11/8/22 at 4:48 p.m., CNA2 stated we work with every patient, and rotate halls [for assignments]. CNA2 stated she had received trach training in September 2022 and was trained to clean the trach. CNA2 stated she was trained to clean around the trach with cotton and would notify the nurse if the trach needed suctioning. CNA2 stated she knew nothing about an emergency kit for tracheostomy.
During an interview on 11/8/22 at 5:00 p.m., CNA5 confirmed she was assigned to the hallway with three of the four residents with trachs and provided routine care. CNA5 confirmed the facility did not provide her training or in-service for caring for residents with a trach.
During an interview on 11/8/22 at 5:05 p.m., CNA1 stated she did not remember ever receiving trach training and did not know anything about an emergency kit for trachs. CNA1 stated she would call the nurse if the trach fell out.
During an interview at 11/8/22 5:45 p.m., the DON confirmed all the facility staff including CNAs should have in-service training provided by the facility for providing care for residents with trach.
During an interview 11/8/22 at 6:30 p.m., DON confirmed the facility did not provide the clinical staff training for accidental dislodgement of tracheostomy or emergency trach kits training. DON stated the facility did not have a policy for trach emergency kits or dislodgement of resident's tracheostomy.
During an interview on 11/9/22 at 1:04 p.m., the Administrator stated the DON and ADON were responsible for all training. The Administrator stated she was in the process of hiring a Staff Development Coordinator.
During an interview on 11/9/22 at 2:59 p.m., the Medical Director expected the facility to provide education for CNA staff training with basic knowledge of providing care for residents with a trach. The Medical Director confirmed he expected the facilities to educate the nursing staff on emergency management of residents with a trach.
During an interview on 11/9/22 at 3:28 p.m., the Administrator confirmed not all the nursing staff were trained, and the training did not include emergency management of a trach. The Administrator confirmed the facility should provide all the nursing staff training and include trach emergency management. The Administrator confirmed the facility should provide CNA staff training for providing care for residents with a trach. The Administrator stated the staff would not be able to provide the proper care in a trach emergent situation without training.
During an interview on 11/9/22 at 5:15 p.m., the Respiratory Therapist (RT) confirmed that a resident's dislodgement of their trach was a life-threatening emergency. RT confirmed she provided trach care in-service to some nursing staff at the facility in August 2022. RT confirmed she instructed the nursing staff to replace the resident's dislodged tract during the in-service. The RT confirmed the facility's entire nursing staff or CNAs did not attend the in-service. RT stated nursing staff without trach emergency management or trach care should not be assigned to provide care for residents with trach. RT stated nursing staff without trach emergency management training should call their supervisor or 911 if the resident's trach became dislodged or fell out. RT confirmed it was important to have emergency supplies at the residents with trach bedside, trach correct size and size smaller, obturator, and ambu bag.

Based on observations, record review, policy review, and staff interviews, the facility failed to ensure that three residents of 47 sampled residents (R) (R#18, R#34, and R#19) had a clean, comfortable, and homelike environment.
Findings include:
Review of the Routine Cleaning and Disinfection policy, implemented 11/5/22 and provided by the facility, revealed Cleaning refers to the removal of visible soil .Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in resident rooms.
Review of the Environmental Services Cleaning Procedures for Common Items policy, dated 2022 and provided by the facility, revealed Floors .Clean on a regular basis when soiled.
During an observation on 11/7/22 at 10:27 a.m., R#18's room observations revealed multiple brown crumbs and a one-inch by two-inch piece of brown cake like substance, along the baseboard on left side of bed, which was up against the wall.
During an observation on 11/7/22 at 12:42 p.m., R#34's room observations revealed the floor had a sticky feel while walking on it and back/brown crumbs on the right side of bed.
During an observation on 11/8/22 at 9:50 a.m., R#18's room observations revealed that multiple brown crumbs and a one-inch by two-inch piece of brown cake like substance, along baseboard on left side of bed, which was up against the wall, remained.
During an observation and interview with R#19, R#18's roommate, on 11/8/22 at 1:35 p.m., multiple brown crumbs and a one-inch by two-inch piece of brown cake like substance, along baseboard on left side of bed, which was up against the wall, remained. R#19 stated, They [staff] do good some of the times, but when they lack help, it is not good.
During an interview at 11/10/22 at 10:07 a.m., Housekeeper (HSK) 1 stated she will usually go into each room and sweep the floor including under the bed. She stated if the resident were not in the bed, she would move the bed and sweep behind the bed. She stated she had been off the last two days and had noticed the debris under the bed and along the wall when she came in on 11/9/22. She stated, It was terrible, and when she had cleaned the room, she had moved the bed, swept the debris, and mopped the area. She stated R#18 will sometimes spit her food, so the area needs to be monitored daily.
During an interview with the Housekeeping Director on 11/10/22 at 10:18 a.m., he stated he expected every housekeeper to clean each room thoroughly including under the bed daily. He stated leaving crumbs and cake under the bed for two days was unacceptable.
During an interview with the Administrator, on 11/10/22 at 11:31 a.m., she stated that all rooms should be cleaned daily, and it was unacceptable to have crumbs and a piece of cake under the bed for two days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews, and policy review, the facility failed to maintain an environment free from verbal and physical abuse for eight residents (R#156, R#16, R#11, R#23, R#25, R#39, R#101 and R#27) of 47 sampled residents.
Specifically:
1. R#68 engaged in ongoing verbal and physical abuse of residents including R#156, R#16, R#11, R#23, R#25, R#39, and R#101.
2. R#27 was physically held down by a staff member while being dressed.
On 11/10/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator and the Regional Consultant were informed of the Immediate Jeopardy for F600 on 11/11/22 at 4:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/7/22.
An Acceptable Removal Plan was received on 11/13/22. The survey team interviewed facility staff, reviewed policies and staff in-services on abuse prevention and reporting. R#68 was observed to be on continuous one to one supervision. The survey team verified all elements of the facility's IJ Removal Plan and removed the IJ on 11/13/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care related to abuse.
Findings include:
Review of the facility's abuse policy titled Abuse, Neglect, and Exploitation, undated, revealed:
The facility must: 1.) not use verbal, sexual, physical abuse, corporal punishment, or involuntary seclusion. 2.) Ensure all residents are free of physical or chemical restraints . 5.) Prevention of Abuse .a.) train staff appropriate interventions to deal with residents aggressive and/or catastrophic reactions by residents . d.) Education on what constitutes abuse, neglect, or misappropriation. e.) react to all allegations or questionable abuse from residents, staff, family members, and/or visitors. f.) Take appropriate actions whenever abuse is reported/suspected .13.) In response to allegations of abuse, neglect, exploitation, or misappropriation the facility MUST: a.) Ensure all alleged violations involving abuse, neglect, .misappropriation or mistreatment, including injuries of unknown origins . are reported immediately, but not later than two hours after the incident occurs b.) have evidence that all alleged violations are thoroughly investigated .d.) Report the results of investigations to the administrator .and other government officials in accordance with state laws, including reporting to the State Survey Agency .and corrective action must be taken.
1. Review of R#68's Face Sheet located in the electronic medical record (EMR) under the Basic Information tab, revealed an admission date of 4/30/22, with medical diagnoses that included schizoaffective disorder (serious mental illness of hallucinations [hearing, seeing, smelling, touching objects not there] and delusions [firmly held unrealistic beliefs]), insomnia, unspecified psychosis (loss of reality), major depression, anxiety disorder, bipolar disorder (mental illness with periods of depression and mania), and auditory hallucinations.
Review of R#68's Quarterly Minimum Data Set (MDS) assessment located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/21/22, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R#68 was cognitively intact. The MDS revealed R#68 had physical behaviors directed toward others.
Review of a facility investigation report revealed that R#68 (the alleged perpetrator) was admitted on [DATE] and two residents had been his roommates without incident for over a year. R#68, the aggressor, was ambulatory with stand-by assist. R#68 readily admitted that he hit R#156 when he was interviewed by the CNAs and the DON at the time the investigation was initiated and reported to the SSA. R#68 insisted that .[R#156] stole one of his shoes and he was going to beat it out of him .
Review of Progress Notes, found in R#68's EMR under the Progress Note tab and dated 5/1/22 at 10:59 a.m., revealed, Resident [R#68] up this shift pacing on hallway. Resident was noted yelling at another resident [R#16] stating stop staring at me, she always stares at me. Staff continues to monitor and to redirect .
Review of the Progress Note, found in R#68's EMR under the Progress Notes tab and dated 7/8/22, indicated Resident [R#68] was noted yelling out at another resident [R#11] stated that the other resident asked him to move out of the way . Resident was noted pacing on the hallway most of the shift. Psychiatrist was notified and new orders received to begin congentin [Anti-Tremor] 1mg po [by mouth] tid [three times per day], Haldol [Anti-Psychotic] 5mg po every 8 hours x14 days for agitation.
Review of Social Services (SS) Progress Note, dated 7/10/22 at 2:44 a.m., revealed R#68 was transported out to the hospital for behavior management evaluation following a physical altercation with R#23. This resident [R#68] punched another resident [R#23] in the face inflicting injury to his nasal region. The latter fell on the floor as a result of the punch . Family responsible party made aware. MD notified and verbal order given to transfer to the hospital for evaluation. No new orders were received.
Review of a SS Progress Note, dated 10/17/22 at 4:49 p.m., revealed .SS spoke to resident [R#68] about the incident. Resident is alert and oriented x3. Resident stated that he punched another resident [R#11] several times because he kicked him several times after he was called the N word. Both exchanged verbal abuse at that time and then [R#68] began punching the discharged resident [R#11] and pushed him out of his wheelchair onto the floor. Both residents were separated . [the psychiatrist] was notified about the incident; she requested behavior health assessment followed up with inpatient treatment.
During an interview on 11/7/22 at 12:15 p.m., R#25 stated R#68 threatened to hit her on Monday (11/7/22) night. R#25 stated, He scares me, I'm afraid he will come into my room and hurt me. R#25 stated she's heard that R#68 will go into rooms and steal things. R#25 stated the nurse witnessed R#68 who threatened her and told R#68 to go away.
During an interview on 11/8/22 at 8:00 a.m., R#68 was asked about altercations with other male residents, and he stated he had two incidents one with a resident that had been discharged and another who was still at the facility. When asked about altercations with female residents R#68 denied having any problems.
During an interview on 11/8/22 at 9:51 a.m., R#25 stated interaction with R#68 occurred on the morning of 11/8/22 between 8:00 a.m. and 9:00 a.m. R#25 stated R#68 asked her, Why am I looking at him like that? She stated he accused her of using the N word. She stated the Administrator observed the interaction and sent her to her room. R#25 stated it was not fair that she be sent to her room. She stated, I'm not a kid, I'm not four, I felt like a bad girl. She stated on the morning of 11/7/22 she had another interaction with R#68. She stated he was so close to me I could feel him spitting on my face. She stated the night nurse had observed the interaction and yelled at R#68 to leave her alone. She stated the nurse said, I've called the police on you before, I'll do it again. R#25 stated, I felt scared. R#25 stated R#68 said, I've never hit a woman, but you might be the first. R#25 stated R#68 then grabbed the wheelchair handle and shook it. She stated, I'm feeling like I can't leave my room without him looking at me, why me, I'm [AGE] years old. She stated she was not comfortable going to the social worker because she will get angry, R#68 is her pet.
An observation by the survey team on 11/8/22 at 11:20 a.m. near the nurse's station and lobby area, revealed two residents (R#39 and R#68) in a verbal altercation both were screaming and exhibiting aggressive behaviors. R#68 stated he was called the N-word, but the other resident denied that. The situation was escalating when the Administrator approached and separated the two residents. The Administrator reported the incident and began an investigation.
During an interview with Certified Nursing Assistant (CNA) 2 on 11/8/22 at 4:48 p.m., CNA2 stated she received abuse training in October 2022. CNA2 stated that verbal abuse and neglect were the only types of abuse. CNA2 stated if she overheard a resident state I've never hit a resident, you might be the first, she would not consider that abuse. She said if she saw two residents fighting, she would try to get them to stop. CNA2 stated she had seen R#68 walk by R#101's room and R#101 made a comment and R#68 rushed at her. CNA2 stated she walked with him away from the room and reported this to her nurse. CNA2 did not recall the date of the event. CNA2 stated she was aware the resident went to the hospital frequently for his behaviors, but he kept coming back to the facility.
During an interview with the Administrator on 11/8/22 at 5:42 p.m., she stated she did not have the investigations from the incidents with R#68 on 5/1/22 or 7/10/22. The Administrator stated she was currently working on both investigations.
Observations throughout the day on 11/9/22 revealed R#68 up and walking all over the facility with no staff present. There were no further altercations observed; however, there was no increased supervision of the resident.
During an interview with the Administrator, on 11/9/22 at 1:17 p.m., she stated she was not aware of the incident between R#25 and R#68 on Tuesday (11/8/22) morning. The Administrator stated she would talk to R#25. She said yesterday she talked with R#25 and assured her they would do everything, so she [R#25] did not have to be afraid. The Administrator stated they had started the process on 11/9/22, to find R#68 a more appropriate place to live and had sent referral paperwork to one facility. She stated she was waiting to hear from them and would follow up.
During an interview with the Medical Director, on 11/9/22 at 3:03 p.m., he stated that he was aware that R#68 had been aggressive, but the facility had been looking for placement. He stated having an aggressive resident in a facility was similar to having a neighbor who was aggressive. He stated there was no way to guarantee protection of residents due to staffing restrictions and [residents] history of mental impairment. The Medical Director stated he was concerned that another resident was afraid but trusted that staff were monitoring R#68. He stated unfortunately we cannot restrain or medicate the resident. The Medical Director said he was usually not part of conversations related to R#68's behavior.
During an interview with Licensed Practical Nurse (LPN) 2 on 11/10/22 at 1:20 p.m., LPN2 stated when R#68 had behaviors, staff would review the care plan, look at interventions, and document the behaviors in the nurses' behavior notes. LPN2 stated anytime abnormal behavior was observed those behaviors should be documented in the behavior notes. LPN2 reviewed the notes and confirmed there were no behaviors documented for R#68 from 5/1/22 through 11/10/22.
During an interview with the Director of Nursing (DON) on 11/9/22 at 7:47 p.m., the DON stated the facility had not put any other interventions in place for R#68 or increased supervision of the resident since his last incident on Monday morning (11/7/22). She stated they have begun looking for another placement for R#68.
During an interview with R#39 and R#25 on 11/10/22 at 11:22 a.m., R#39 stated approximately one month ago, he had a list of residents who were afraid of R#68. R#39 stated that he had given it to the social worker. R#39 stated that when he talked to the Administrator (after the incident with R#68 on 11/8/22), the Administrator did not know about the list. R#39 stated he told the Administrator I had given it to the social worker to give to you.
2. Review of the undated EMR Face Sheet, revealed R#27 was admitted to the facility on [DATE] with diagnoses including dementia, hemiplegia (paralysis on one side), and schizophrenia (serious mental illness of hallucinations [hearing, seeing, touching, smelling objects not present] and delusions [firmly held beliefs not real]).
Review of R#27's quarterly MDS with an ARD of 8/22/22, revealed R#27 was ambulatory via wheelchair, occasionally exhibited behaviors/refusals of care, and had a BIMS score of 10 out of 15 indicating R#27 was moderately impaired cognitively.
During an interview in R#27's room on 11/8/22 at 10:00 a.m. and 11/10/22 at 2:30 p.m., R#27 was pleasantly confused at both visits. He stated he kind of remembered the incident but couldn't remember who it was that punched me or exactly when it happened. He stated, they took care of it . when asked who took care of it, he replied them and pointed to his door toward staff. He didn't offer additional info when prompted but did say he feels safe in the facility when asked.
Review of the facility's investigation revealed that when the Administrator interviewed CNA5, and in CNA5's written statement, CNA5 said . he had to hold [R#27] down to get him dressed and cleaned up. In the written statement CNA5 reported . I used one hand to dress him and with left hand pressed my arm into his shoulder because he was trying to get up .
CNA5 was hired with appropriate background checks on 3/26/20 and terminated related to the determination of resident abuse on 5/22/22.