Baker-Katz Skilled Nursing and Rehabilitation Ctr

Inspectors wroteBased on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for two Residents (#24 and #199) who were assessed to be at high risk for developing pressure ulcers, out of a total sample of 14 residents. Specifically, 1. For Resident #24, the facility failed to implement a physician's order for a treatment and plan for monitoring a blister. 2. For Resident #199, the facility failed to ensure his/her plan of care was implemented related to skin integrity.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that respiratory care services, consistent with professional standards of practice, were implemented for two Residents (#16 and #18), out of a total sample of 14 residents. Specifically, facility staff failed to change oxygen and nebulizer tubing in accordance with the physician's orders.

Inspectors wroteBased on observations and interviews, the facility failed to ensure nursing staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure two of two treatment carts were locked while a nurse was not present.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement infection control practices to prevent the spread of infection. Specifically, two housekeeping staff failed to perform hand hygiene, and one entered a resident's room wearing potentially contaminated gloves.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who on 10/26/24 was found lying on the floor by Nurse #1 after an unwitnessed fall, the Facility failed to ensure nursing reported the incident to the Physician, his/her Guardian, Administrative staff and to the oncoming Nurse as required, and per Facility policy. Findings Included: Review of the Facility's policy, titled Resident Assessment, revised 08/30/24, indicated the Facility shall promptly notify the resident, his/her attending Physician and representatives of changes in the residents medical/mental condition and/or status including an accident or incident involving the resident. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who on 10/26/24, was found lying on the floor by Nurse #1 after an unwitnessed fall, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality care, when although Nurse #1 said she assessed Resident #1 prior to moving him/her off of the floor, there was no documentation to support she adequately assessed Resident #1 after his/her fall for potential injury.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure resident centered care plans were implemented for one Resident (#43) out of a total sample of 14 residents. Specifically, for Resident #43, the facility failed to implement TED hose (compression stockings) as ordered by the Physician.

Inspectors wroteBased on record review, policy review and interview, the facility failed to ensure a plan of care was developed for Trauma Informed Care with individualized interventions, for two Residents (#3 and #41) who have a history of Post Traumatic Stress Disorder (PTSD), out of a total sample of 14 residents.

Inspectors wroteBased on record review and interview, the facility failed to maintain resident's rights after the removal of shaving razors from 1 Resident's (#29) room, out of a total sample of 19 residents.

Inspectors wroteBased on record review and interviews, the facility failed to obtain consent to administer a psychotropic medication for one Resident (#20) out of a sample of 19 Residents.

Inspectors wroteBased on records reviewed and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for a fluid restriction for 1 Resident (#10) who had a diagnosis of heart failure and end stage renal disease, out of a total sample of 19 residents. Specifically, Resident #10's physician's ordered fluid restriction did not have a break down for fluids per shift and staff were not aware of Resident #10's nursing fluid allowance.

Inspectors wroteBased on observation, record review and interviews, the facility failed to revise the plan of care for 1 Resident (#38) out of a total sample of 19 residents. Specifically, the facility failed to ensure that nursing revised a treatment order after Resident #38 who had a diagnosis of heart failure and edema was unable to wear his/her physician's ordered compression stockings (TEDs) on the left leg because Resident #38 sustained an injury.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), specifically providing assistance with nail care, for one Resident (#17) out of a total sample of 19 residents.

Inspectors wroteBased on observation, record review and interviews, the facility and its staff failed to ensure that routine assessments and devices used to maintain hearing were provided for one Resident (#17), out of 19 sampled residents. Specifically, the facility staff failed to provide and implement a treatment plan for chronic ear wax and failed to implement the use of hearing aids when Resident #17 complained of difficulty hearing.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to 1.) ensure an air mattress was on the correct setting for 1 Resident (#41) who had actual skin breakdown and 2.) the facility failed to ensure that an air mattress was on the correct setting and his/her foot was elevated per the plan of care for 1 Resident (#2) with actual skin break down out of a total sample of 19 residents. Review of the facility policy titled Alternating Pressure Air Mattress dated 6/20/2022 indicated the following: Policy: To maintain adequate circulation, to relieve pain due to pressure and aide in healing and prevention of pressure ulcers. Procedures: *Verify MD (Medical Doctor) order and settings in according to manufacturer guidelines. [...]

Inspectors wroteBased on observations, record review and interview, the facility failed to 1.) ensure Residents received oxygen according to professional standards of practice and in accordance with physician's orders for 2 Residents (#22 and #20) and 2.) failed to maintain a continuous positive airway pressure (CPAP) face mask according to professional standards of practice in a way to prevent possible infections for 1 Resident (#17) out of a total of 19 sampled Residents.

Inspectors wroteBased on record review and interview, the facility failed to 1. accurately document a blood sugar vital sign and 2. a meal percentage for 1 Resident (#27) out of a total sample of 19 residents.