Every finding on record at Atlantic Shores Nursing and Rehab Center

Based on observation, and interview, the facility failed to maintain a clean and homelike environment for 6 out of 12 resident rooms on the South wing, resulting in an environment that did not promote resident comfort and safety.Findings:During environmental tours conducted between 6/08/26 and 6/11/26 on the South wing of the facility, the following observations were made:1. In room [ROOM NUMBER]-B, a hole on the wall above the baseboard with crumbling dry wall between beds A and B was observed on 6/08/26 at 9:30 AM, on 6/09/26 at 2:30 PM, and on 6/10/26 at 11:10 AM. On 6/08/26 at 9:30 AM, the resident in room [ROOM NUMBER] bed B said she did not recall how long the hole in the wall above the baseboard was there, but she did not like to see the hole on the wall. 2. In room [ROOM NUMBER]-B, the wall next to the bed had been patched but an area measuring approximately 1 foot by 1 foot was still not sanded nor painted on 6/08/26 at 9:40 AM, on 6/09/26 at 12:47 PM, and on 6/10/26 at 11:25 AM.3. In room [ROOM NUMBER]-A, the wall by the head of the bed revealed paint had been scraped off but was not painted was observed on 6/08/26 at 9:55 AM, and on 6/09/26 at 2:40 PM.4. In room [ROOM NUMBER]-B, observed the paint on the wall at the head of the bed was chipped off on 6/08/26 at 11:30 AM, and on 6/09/26 at 9:30 AM. 5. In room [ROOM NUMBER]-B, observed the paint on the wall at the head of the bed was chipped off on 6/08/26 at 11:40 AM.6. On 6/08/26 at 11:50 AM, on 6/09/26 at 9:22 AM, and on 6/10/26 at 11:30 AM, a hole was on the wall under the window to the left side of the resident in bed B, in room [ROOM NUMBER]-B. The hole was approximately 10 inches long and 3 inches deep with dry wall particles in the wall's edge closer to the floor, the baseboard was bent outwards and the wall had plaster that had not been sanded nor painted. The wall to the right side of resident A's bed was scraped. On 6/11/26 at 10:50 AM, Certified Nursing Assistant (CNA) D said she filled out a maintenance request sheet which was located in a box at the South-wing nurses' station when there were any needs for repairs in the rooms. Review of the blank repair form revealed it was a repair requisition form with blank lines to write the date, location, repair needed, a signature line and an approval line. The repair requisition had two carbon copy pages. The repair forms were kept at the nurses' stations in a plastic box. On 6/11/26 at 10:55 AM, in room [ROOM NUMBER]-B, CNA D explained she was frequently assigned to this room and verified the hole in the wall under the window. CNA D did not recall when but said she thought the hole in the wall had been repaired previously, after she completed a repair request when she saw the hole the first time. She recalled she had not told her supervisor or anyone else about the new hole on the wall. CNA D verified the walls that needed repair and confirmed the resident in 241 bed B was unable to tell anyone herself of the needed repairs.On 6/11/26 at 10:55 AM, the assigned housekeeper on South wing for room [ROOM NUMBER] stated, utilizing CNA D for translation, said room [ROOM NUMBER] was her usual assignment, and she usually spent approximately 30 minutes to clean the room, including cleaning the floors. The housekeeper explained she had not seen the damage on the wall under the window by the B bed, had not reported the damage to her supervisor, and had not filled out a repair requisition form. On 6/11/26 at 11:00 AM, CNA C after visiting room [ROOM NUMBER] and 202, confirmed the damaged walls and said she had previously seen the walls needed repair. She said she thought the Maintenance Department knew about the wall repairs needed in room [ROOM NUMBER] and 202 because they did a deep clean in the rooms not too long ago. On 6/11/26 at 11:15 AM, the Maintenance Director after visiting rooms 200, 202 and 235, confirmed the damaged walls. He said the process for reporting anything that needed repair in the facility was to fill out a repair requisition form and place it in the box at the nurses' stations. He said that previously he received a repair requisition slip for the hole in the wall, and it was fixed but that area on the wall was hit again by a wheelchair. The Maintenance Director explained any repair requisition received for holes in the walls was given priority to be fixed on the day the requisition was received. He said when any repair work was completed, the expectation was for any staff to complete the requisition form and for maintenance staff to complete the repair then sign off with the date and time the repair was completed. He said he was aware that room [ROOM NUMBER] was patched but not sanded nor painted. The Maintenance Director said he did not previously know about the damage in room [ROOM NUMBER], between the A and B beds. He explained he and his assistant did regular rounds in the resident rooms but could not say why he was unaware of the damage in room [ROOM NUMBER], other than staff had not reported it to him.On 6/11/26 at 11:45 AM, the Housekeeping Manager said each housekeeper cleaned each residents' room for 15-20 minutes every day. She said she expected that any repair needed or required was reported to her by the housekeeping staff or a repair requisition slip was filled out. She said she was sure the hole in room [ROOM NUMBER] was reported but could not say why it had not been repaired.On 6/11/26 at 3:52 PM, the Administrator and Director of Clinical Services acknowledged that the observed conditions in residents' rooms did not meet the facility's expectations for maintaining a clean, comfortable environment for the residents. The Administrator said they were working on several projects to improve the environment including residents' rooms.

Based on observation, and interview, the facility failed to maintain an effective infection prevention and control program to prevent the spread of infection by ensuring staff performed hand hygiene while assisting the residents in the dining room before, during and after lunch, in one of two dining rooms of the facility, (South wing). Findings:On 6/08/26 at 11:30 AM, residents were sitting in the South wing dining room in their wheelchairs waiting for the lunch meal service. On 6/08/26 at 11:52 AM, two Certified Nursing Assistants (CNA)s and the Infection Prevention nurse (IP) were in the dining room providing beverages to the residents, setting up the residents' lunches in preparation for them to eat their meal. Staff placed items from each resident's meal tray to the table, helped to open the condiment packages and cut up food items for several residents. CNA F brought the lunch tray from the tray cart to a resident sitting at a table, cut the resident's food then opened the condiment packages for that resident. The CNA returned to the tray cart where the other residents' lunch trays were waiting to be served. CNA F took another meal tray from the tray cart, then delivered the food items to another resident at the same table, cut the food, then opened the packages but did not wash her hands between assisting the residents. CNA F washed her hands after she assisted three residents. Stafff were observed inconsistently performing hand hygiene with either wipes or using the sink. At the sink staff quickly rubbed hands together in the water and did not wash for the appropriate amount of time. Another CNA cleaned her hands with the hand wipes for less than two seconds, then pushed the used hand wipe into a square, white plastic container full of used sanitizing hand wipes on top of the beverage cart. Staff were observed as they quickly swiped the wipe over the surface of the fingers but did not thoroughly utilize the wipe over the hands' surface, then allow them to dry. Review of the undated hand sanitizing wipe packaging directions; hands should be wet thoroughly and allowed to dry without wiping. A short time later on 6/08/26 at 11:55 AM, CNA F cut up the food for one resident with their fork and knife, then moved to the neighboring resident seated at the table. The CNA picked up that resident's fork and knife and cut the neighboring resident's food. CNA F did not sanitize her hands with soap and water or hand sanitizer between the residents. Afterwards CNA F used the sanitizing hand wipes but only wiped off one hand. CNA F assisted several residents to open their butter but did not perform hand hygiene between each resident. On 6/10/26 at 12:15 PM, in the South wing dining room during the lunch meal, CNA F touched a resident's wheelchair handlebars in order to reposition the resident but did not perform hand hygiene, before performing the next task. A few minutes later, CNA F washed her hands with soap and water then picked up a dirty tray but did not perform hand hygiene after touching the dirty trays. She used a hand sanitizing wipe, then carried the wipe she used to the white container on the beverage cart which held the used hand wipes. Next, with her bare hands she pushed down the used wipes further into the container. After discarding the used wipe, CNA F assisted another resident with their lunch but did not perform hand hygiene. At 12:27 PM, CNA F went to the sink to wash her hands on two separate occasions but did not use soap, only water; and washed her hands both times, for less than four seconds. At 12:35 PM, CNA F walked from one table to another speaking with the residents and touched several residents' backs but did not perform hand hygiene. CNA F used the sanitizing hand wipes then placed them in the container by the beverages but with her bare hands pushed down on the already used wipes. On 6/10/26 at 12:57 PM, the South Wing Unit Manager (UM) said CNA F was usually assigned to the dining room where she assisted residents with their meals by cutting their food and opening packages. The UM said the expectation for any CNA assisting residents in the dining room was to assist one resident at a time and wash their hands between the residents they assisted. The UM explained hand hygiene was performed with soap and water, alcohol-based sanitizer or sanitizing hand wipes for 20 seconds or more. She confirmed the hand wipes were to be disposed of in the trash by dropping the used items into the receptacle not pushing down on previously discarded refuse. On 6/11/26 at 1:02 PM, the IP nurse said, the expectation for staff assisting in the dining room was for them to wash their hands with soap and water or alcohol-based hand rub. The IP said staff may use the sanitizing hand wipes but explained they should saturate their hands with the product, use multiple pieces, get all surfaces of their hands clean, then dispose of the wipes in the garbage and air dry their hands. She said staff should perform hand hygiene for at least 20 seconds and were expected to use soap when they wash their hands with water at the sink. The IP nurse stated she had educated all staff on hand hygiene, and they completed hand hygiene competencies through different shifts. She explained nurses and CNAs were educated about hand hygiene during weekly nurses' meetings and as needed. The IP nurse explained she monitored hand hygiene throughout the facility and reinforced hand hygiene with return demonstration. The IP nurse explained it was important to perform hand washing between residents in the dining room due to potential spread of Multiple Drug-Resistant Organisms, and the elderly were more susceptible to infection. She said handwashing was the first line of defense to prevent the residents, the employee, and the employee's family from getting sick. Review of the facility's Infection Prevention and Control Plan revised June 2024 revealed: An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures. Review of the facility's Hand Washing/Hygiene Policy revised on August 2023 revealed the facility considered hand hygiene the primary means to prevent the spread of infections. The policy indicated it was in accordance with national standards from the Centers of Disease Control and Prevention and the World Health Organization. The document specified all personnel should follow the handwashing /hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy detailed that hand hygiene should be performed before and after assisting a resident with meals, staff should wash hands vigorously for a minimum of 20 seconds (or longer).

Based on interview, and record review, the facility failed to revise and review a comprehensive person-centered care plan to meet the resident's needs for their highest well-being, for 2 of 2 residents reviewed for hearing/sensory aids, of a total sample of 41 residents, (#88, and #14).Findings: 1. Review of the medical record revealed resident #88 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, diabetes, and brain bleed.Review of the Minimum Data Set (MDS) admission assessment with Assessment Reference Date (ARD) of 8/05/25 showed section B-hearing revealed resident had minimal hearing difficulty/difficulty with some environments and no hearing aids present. Section C for memory recall showed a Brief Interview for Mental Status (BIMS) of 13 out of 15, which meant the resident had normal cognitive function.Review of the MDS Quarterly assessment with ARD of 3/24/26 showed section B hearing revealed resident had a minimal hearing difficulty/difficulty with some environments, and no hearing aid or other hearing appliance used.On 6/09/26 at 12:55 PM, resident #88 was sitting in a wheelchair in her room, with the television off. Resident #88 said she had a hard time hearing and asked for surveyor to come closer to talk by her ear, then pointed to her ear. She explained she had only one hearing aid, but the other hearing aid was lost. She said she could not wear one hearing aid because her hearing would not be balanced.On 6/09/26 at 4:25 PM, resident #88 was again sitting in her wheelchair in her room. She said the one hearing aid was in her nightstand. She wheeled over to the nightstand and looked inside. She pulled out a hearing aid box, but it did not contain any hearing aids. The resident looked in the nightstand but there was no hearing aid. She explained her son would not have taken it, and she did not recall when she last saw the hearing aids. Review of a progress note with documentation by the Director of Nursing (DON) dated 9/25/25 at 3:42 PM, that the resident stated she wanted to get her purse and hearing aids from the drawer because she was going out with her son. This progress note was the only mention of resident #88's hearing aids in her record. Review of resident #88's care plan revised on 8/12/25, revealed she was at risk for impaired communication related to a hearing deficit. The care plan included the resident had hearing aid for the right ear at bedside. Interventions included allowing ample time for resident to respond, and right-side hearing aid, to observe for deterioration in hearing impairment. Further review of the care plan revealed it was not reviewed or revised to reflect the resident had lost her hearing aids, to show how the facility staff would promote proper communication with others without a hearing device. The care plan was not personalized as it did not reflect if the resident required assistance with the hearing aids and if so, who would assist her with them. Review of the Certified Nursing Assistant (CNA) Kardex revealed no entry or documentation for hearing aid use, assistance or care. The EMR revealed no audiology consult despite resident having a hearing deficit and not having hearing aids. On 6/10/26 at 10:35 AM, CNA D said resident #88 was hard of hearing and she talked louder to her so the resident could hear what she told her. CNA D said she did not know the resident wore a hearing aid. On 6/09/26 at 4:28 PM, Licensed Practical Nurse (LPN) E recalled resident #88 had hearing aids a long time ago, but she did not remember seeing them recently. The nurse said the process was for the nurse or the resident to put the hearing aids in their ears. She said she knew when a resident had hearing aids because nurses communicated this to each other during shift change report. The LPN explained some residents had physician orders to put hearing aids in their ears, and the hearing aids would be kept in the medication cart in the narcotic box then the nurses would sign the treatment administration record to show the nurse put in and removed the hearing aids. On 6/09/26 at 5:06 PM, the MDS nurse said the process for residents with hearing/vision/dental problems was to ask the resident if they had problems and if they said they have worn hearing aids then she tried to find out more information. She said if the residents had the hearing aids, they should be care planned to make sure the resident was assisted by staff with the devices, but the nurse did not know which staff actually was supposed to assist the residents with their hearing aids. The MDS nurse said the vision, hearing and dental problems were checked by the Social Worker, and she would let the MDS nurses know to put it in the care plan. She said she entered the information in the care plan to be triggered in the CNA Kardex for the residents to be assisted with those devices like hearing aids or dentures. The MDS nurse was not sure if there was a physician order and then explained resident #88 answered questions but missed some of the information due to her cognitive deficit. She said resident #88 could hear if she turned her head but she missed some parts of the conversation. A short time later at 5:28 PM, the MDS nurse said she knew the resident had a hearing deficit but did not know resident #88 had a hearing aid. She said her hearing loss was from a head injury from a fall. The nurse said the resident could communicate better now but she had poor recall. She said she always assumed her condition was from cognitive decline due to her brain injury and not a hearing issue. The MDS nurse acknowledged she was not an audiology specialist who would be able to determine if the resident actually had a hearing deficit. She said a consult was usually arranged by Social Services. 6/09/26 at 5:56 PM, the South wing Unit Manager (UM) said if the resident wore glasses, hearing aids or dentures, the process was for the admitting nurse to complete an assessment/evaluation of the resident to determine if he/she had these items. She explained this information was then placed on the care plan by the admitting nurse. The UM said this information was also placed on the property sheet, and it would generate a task for the CNAs to put in the hearing aids. The UM explained there was no designated person from the interdisciplinary team (IDT) team who held the responsibility to update the care plans with information about a resident's glasses, dentures or hearing aids. She explained that once the care plan was updated it triggered a task for the CNAs. On 6/09/26 at 4:50 PM, the Social Services Director (SSD) said she was aware of a resident having hearing aids, dentures or glasses from the inventory sheet which should be completed on admission by the nurse completing the admission assessment. She said she does not initiate the care plans for residents with vision, dental or hearing problems. The SSD explained that if a grievance is written for a missing item, a search would be done, and all staff were notified as well as the information given to the IDT on stand down meeting. She said when a resident has items that are not found such as missing glasses, dentures or hearing aids, a referral would be made for ancillary services. The SSD said resident #88 did not say anything about hearing loss and she was not referred for audiology consultation. On 6/11/26 at 4:18 PM the DON said newly admitted residents were assessed/evaluated by an admitting nurse; the nurse checked resident belongings and completed the inventory form. If the resident had a hearing problem with no hearing aids, the Social Worker would be informed to schedule a consult from audiology services. She said the MDS nurse was to interview the resident and check for the need to refer the resident to audiology services. She said the MDS nurse would edit the care plan or let the UM or herself know if there was a concern related to hearing aids. She stated during the care plan meeting with the resident or representative this information was reviewed. The DON said the nurse and the CNA were expected to make sure the residents had the hearing aids and that they were written in the care plan. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses including hypertension, heart disease, and diabetes. Review of current physician orders included a consult, as needed for Audiology. On 6/09/26 at 10:04 AM, during a telephone interview, the resident's daughter said the facility had lost resident #14's hearing aids four times previously. She explained her father's insurance had replaced them once before. The daughter said she had spoken to the Administrator about replacing the 4th set of missing hearing aids and he told her they would replace the hearing aids and would come up with a plan to keep them from being lost again, but she said she had not been told of what the plan was. Review of the 11/07/24 admission MDS assessment, Section B for hearing revealed the resident was highly impaired in hearing with absence of useful hearing. The section showed the resident used no hearing aids or other appliances. Resident #14's BIMS was 9 out of 15, which indicated moderate cognitive impairment. The 3/17/26 Annual MDS assessment, Section B for hearing showed the resident had minimal difficulty with hearing with unclear speech, he was sometimes understood and sometimes understands. The section included a hearing aid was used in completing the previous question regarding ability to hear. Resident #14 had a care plan initiated 11/01/24 and revised on 3/20/26 for a risk for impaired communication related to cognitive deficits, hearing loss and unclear/soft/mumbled speech at times. Care plan interventions included allow the resident ample time to respond and observe for decline in cognitive status, mood, ADLs, and hearing impairment. There was an additional care plan initiated 2/12/25 and revised 4/10/26 for resident #14's behavior which detailed he was resistive to care related to adjustment to placement, and sometimes he declined his hearing aids. There was no care plan related to care or assistance with resident #14's hearing aids, including missing hearing aids. Review of the CNA Kardex did not show any documentation for hearing aids in the communication task. Review of the medical record revealed no personal effects or inventory form for resident #14. Review of the medical record revealed on 9/23/25, resident #14 had an audiology evaluation. The audiologist note indicated the resident's daughter was present for the evaluation and the resident was evaluated because one of his hearing aids was lost. The consult detailed hearing loss severity as moderately severe sloping to severe sensorineural hearing loss in both ears. The note revealed the resident required help from staff to insert and remove the hearing aid daily and change batteries weekly. The note indicated the resident's daughter would assist with weekly battery changes. Review of a psychiatry progress note dated 3/03/26 revealed documentation resident #14 was hard of hearing and had lost his hearing aids. In interviews on 6/09/26 at 1:30 PM, and 2:40 PM, and on 6/10/26 at 10:35 AM, CNA D said the nurse was supposed to put in the hearing aids, but resident #14 did not like to keep them in his ears. She said she had seen resident #14 placed his hearing aids on the bedside table or on the basket on his bedside table previously. The CNA said she knew when a resident had a hearing aid from the task in her computer where she got the residents' information. On 6/09/26 at 4:28 PM, LPN E said resident #14 did not like to put in his hearing aids and he only wanted them when his daughter was there. The usual process, she said, was for the nurse to have them in the medication cart in the narcotic drawer. LPN E said she recalled the resident had hearing aids a long time ago, but unsure what happened to the current pair. She said staff knew if a resident had hearing aids from what was communicated via the change of shift report. The nurse explained sometimes nurses signed off on the Treatment Administration Report that they had put them in or removed them to the narcotic box. In interviews on 6/09/26 at 5:06 PM, and 5:20 PM, the MDS nurse said the process for residents with hearing/vision/dental problems was to ask the resident if they had problems and if they said they wore hearing aids she tried to find out more information. The nurse said if the resident had the hearing aids, they should be care planned to make sure the resident was assisted with these devices, as needed. The MDS nurse was not aware of which staff actually assisted the residents with their hearing aids. She said vision, hearing and dental problems were checked by the Social Worker, who would let her know to put in the care plan. Next, she said she entered the information in the care plan to be triggered in the CNA Kardex for the residents to be assisted with the hearing aids or denture cleaning. The MDS nurse was not sure if there was a physician order and then explained resident #88 answered questions but missed some of the information due to her cognitive deficit. She explained any problem identified by a team member was care planned since information was obtained from different sources taking an interdisciplinary approach. The MDS nurse said they also got information for care planning from observations, interviews, therapy evaluations, past histories especially behaviors and observation of behaviors. She said her interviews included the resident, family, guardians, and she explained a problem was identified or communicated via verbal communication from the CNA to the nurse to the UM for example, for order changes like antibiotics, or falls. The MDS nurse said, usually on the Quarterly MDS assessment, she or the other MDS nurse would ask about hearing, and the Social Worker had a book for these services. The MDS nurse explained if there was an issue, Social Services was informed to refer the resident for a consult with audiology care. The MDS nurse said she did not know anything about resident #14 having hearing aids and did not know when they were brought in for him. She acknowledged there was a behavior care plan for him which indicated he declined the hearing aids but did not recall that he did not wear the hearing aids. She said she was not familiar with resident #14 but knew he did not like to wear his hearing aids but was unaware as to why he did not like to wear them. She agreed staff should have personalized direction for how to care for each resident's hearing aids. On 6/09/26 at 5:56 PM, the South wing UM said for a resident who wore hearing aids, the process was for the admitting nurse to do and assessment/evaluation of the resident to determine if he/she has these items and this information will be placed on care plan by the admitting nurse. UM said this information was placed on the property sheet, and this generated a task for the CNAs to put in the dentures or hearing aids and put on the glasses. The UM said for resident #14, the nurse put in the hearing aids because he has misplaced the hearing aids before. The UM said she wrote a progress note about this and she wrote a note at the nurse station. She said she did not write an order and explained there is no designated person from the IDT team who holds the responsibility to update the care plans with information about a resident's glasses, dentures or hearing aids. She explained that once the care plan is updated it will trigger a task for the CNAs. UM explained the process to report missing items is when an item is reported to nursing then they will do a search for the item and if not found, a grievance is generated. On 6/09/26 at 4:50 PM, the SSD said she knew a resident had hearing aids, dentures or glasses from the inventory sheet which would be completed on admission by the nurse completing the admission assessment. She said she did not initiate the care plans for residents with vision, dental or hearing problems. The SSD explained if a grievance was written for a missing item, a search would be done, and all staff were notified as well as the information given to the IDT on stand down meeting. She said when a resident had items that could not be found such as missing glasses, dentures or hearing aids, a referral would be made for ancillary services. On 6/10/26 at 1:57 PM, the Administrator said resident #14 had a hearing evaluation done at the facility recently by the contracted audiologist group and they were replacing the hearing aids. He confirmed he told resident #14's daughter a plan would be in place to prevent future loss of the hearing aids but acknowledged there was no plan as of yet. He said the resident's daughter insists that he wears the hearing aids despite resident's refusal. He said that he expects documentation related to the use of the hearing aids when the hearing aids are replaced.The Facility assessment dated and revised 9/23/25 showed the facility may accept/admit residents with a category of hearing loss and maintains contracts for service providers including audiology. On 6/11/26 at 5:15PM, the Regional Nurse Consultant, stated the facility had no hearing aid policy or assistive device policy. The facility's policy and procedure for Comprehensive Person-Centered Care Plans revised August 2023 revealed the policy was for the center to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. The policy specified the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and as changes in the resident's care and treatment occur. The policy indicated any interdisciplinary team member could enter the updates under the guidance of a registered nurse responsible for the resident. The policy further detailed the care plan should be re-evaluated and modified as needed to reflect changes in care, service and treatment. The document indicated the care plan evaluations would occur in response to changes in residents' physical, emotional, functional, psychosocial, or communicative status as they occurred.

Based on interview, and record review, the facility failed to ensure a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice that took account of the resident's experiences and preferences in order to eliminate or mitigate triggers which could cause re-traumatization of the resident, for 1 of 2 residents reviewed for diagnosis of Post Traumatic Disorder (PTSD), of a total sample of 41 residents, (#11).Findings:Resident # 11 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of T11-T12 vertebra, subsequent encounter for fracture with routine healing, Type 2 diabetes mellitus, major depressive disorder, unspecified dementia and PTSD.Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of [DATE] showed the resident had a Brief Interview for Mental Status Score of 8 out of 15, which indicated her cognition was moderately impaired. The assessment listed PTSD as one of the active diagnoses listed under Psychiatric/Mood Disorders.A review of a psychiatrist progress notes on [DATE] revealed, Trauma: Patient reported a history of a physical altercation many years ago with one of her brothers, who is now deceased , which resulted in trauma to her right hand. Patient denied any current triggers. She reported disliking aggressively yelling types of environments but denied current concerns at this time. A review of resident #11's Comprehensive Care Plan revealed no specific care plan addressing PTSD nor the resident's dislike of aggressively loud environments. The Kardex did not indicate special instructions for Trauma Informed Care. A review of the Assessments/ Evaluations showed no Trauma Informed assessment was completed even though PTSD was listed on the admission assessment.On [DATE] at 1:45 PM, the Social Services Director acknowledged trauma informed care was not part of the resident #11's assessments nor did the comprehensive care plan address the resident's diagnosis of PTSD. She said the facility process was the Social Services Department was responsible to complete the evaluation and would gather the history of a resident. If triggers were identified, they would initiate a care plan and an automatic psychiatrist referral. She explained that the care plan and Kardex were important to complete so that all staff were aware of how to avoid triggers to not cause the resident any unneeded distress. The Social Services Director continued to explain she was on medical leave at the time the initial assessment was done for resident #11, but acknowledged the assessment was incomplete and that someone from the team should have addressed it. On [DATE] at 2:02 PM, the assigned Licensed Practical Nurse (LPN) A explained that resident #11 had PTSD as one of her diagnoses but could not find anything on the care plan. She stated nothing was listed regarding care or triggers as identified on another resident with PTSD on her assignment. On [DATE] at 2:10 PM, the North Wing Unit Manager said for Trauma Informed Plan of Care, it is a team effort to discuss the care plan and acknowledged resident # 11 did not have the Trauma Informed Care Plan. She explained she would address this with the team because it was important for the resident to have one. The MDS Coordinator who was at the nurse's station at that time, said she assisted with care plans, but the Social Services Department was primarily responsible for trauma informed care plans and assessments. On [DATE] at 2:14 PM, the assigned Certified Nursing Assistant (CNA) B said resident #11 was fine and she was not aware of any special instructions regarding her care. She then retrieved the Kardex for resident #11 which did not identify any special care instructions. On [DATE] at 2:35 PM, the Director of Nursing (DON) acknowledged resident #11 had no care plan for Trauma Informed Care and confirmed one should have been done. The DON explained that the Trauma Informed Care plan is important for staff to know how to care for residents with PTSD so that they could avoid any re-traumatization.The facility did not have a policy on Trauma Informed Care.

Based on observation, interview, and record review, the facility failed to timely review pharmacy consultant recommendations and implement the physician's revised medication order for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 41 residents, (#5).Findings:Review of the medical record revealed resident #5, an [AGE] year-old male was admitted to the facility from an acute care hospital on 5/25/24. The resident's diagnoses included type 2 diabetes mellitus, hypertension, hyperlipidemia, history of pulmonary embolism, and dementia with psychotic disturbance.The most recent Comprehensive Minimum Data Set (MDS) Annual Assessment with an Assessment Reference Date of 4/28/26 indicated during the look-back period, resident #5 had severely impaired cognitive daily decision making skills, short term and long term memory problems, was dependent on staff to complete activities of daily living/functioning, able to propel himself in a wheelchair up to 150 feet, and sustained one fall with minor injury prior to the previous MDS assessment. The resident received high-risk anti-psychotic, anti-depressant, anti-coagulant (blood thinner), diuretic (fluid removing), opioid (narcotic pain), hypoglycemic (blood sugar lowering), and anti-convulsant (anti-seizure) medications.Review of the Care Plan Report included risk for skin impairment with an intervention (6/19/24) to use caution during transfers/bed mobility to prevent striking arms, legs, and hands against sharp/hard surfaces, (revised 2/02/26) impaired cognitive/communication function/impaired thought process related to dementia with behaviors, (revised 6/03/26) risk for falls as evidenced by dementia, decreased mobility, psychotropic medication use, impulsivity, behaviors, crawls out of bed, and poor safety awareness, (revised 4/29/26) impaired vision functioning, (revised 4/22/26) leaning to right side of wheelchair, and (6/19/24) anticoagulant therapy with a goal for decreased risk of adverse reaction from use and interventions to monitor for multiple abnormal bleeding signs and symptoms.Adverse effects of Eliquis may cause increased excess/abnormal bleeding complications including spinal clots leading to paralysis. It is highly advised to be extra careful to avoid injuries, (retrieved from mayoclinic.org on 6/12/26).The Pharmacy Consultation Report dated 4/06/26 recommended discontinuing Eliquis because of long term use since 6/18/24. The physician signed the form on 5/14/26 to discontinue the medication.The April, May, and June 2026 Medication Administration Records (MARs) documented resident #5 received Eliquis (blood thinner) 5 Milligrams twice daily for blood clot prevention until it was discontinued on 6/04/26.On 6/11/26 at 1:29 PM, the North Unit Manager said she received the Pharmacy Consultation recommendations from the Director of Nursing (DON). She explained she placed them in a binder on the nursing unit for the physician to review and she also called to get verbal/telephone orders. She said she checked every day to make sure the recommendations were addressed, and the Medical Records Coordinator also checked daily to monitor any missing items.On 6/11/26 at 1:45 PM, the Medical Records Coordinator said she was in her role for three years. She explained that she checked both units a minimum of two times per week, usually more for the signed pharmacy recommendation forms and she also called the physician when she noticed anything was missing or not reviewed yet. She said she provided the signed forms to the DON or Unit Managers to enter orders, and they returned them to her for uploading them to the Electronic Health Record.In a joint interview with the DON and Regional Nurse Consultant (RNC) on 6/11/26 at 1:57 PM, the DON explained she received the pharmacy recommendations via email and then she gave them to the Unit Managers to follow up with the physicians. She stated, we have 30 days to act on the recommendations; some things are more urgent than others. The DON conveyed it was important to review use of high-risk anticoagulants due to the risk of bleeding, especially with head injuries. She checked the pharmacy recommendation form earlier provided to surveyors dated 4/06/26 signed by the physician on 5/14/26 to discontinue resident #5's Eliquis and said she was not aware it wasn't discontinued until 6/04/26 however, she would check the records.On 6/08/26 at 2:43 PM, resident #5 was observed in the North Unit common area propelling himself in his wheelchair.On 6/11/26 at approximately 3:30 PM, the RNC provided another copy of the same Pharmacy Consultation Report dated 4/06/26 and signed as M . on 6/04/26 by a different provider whom she stated was the Nurse Practitioner, which was why it was delayed. The form included a handwritten note, pt (patient) does not get out of bed and marked to decline the recommendation to discontinue Eliquis. The RNC did not explain why the note showed the resident didn't get out of bed after the surveyor stated the resident was previously observed in his wheelchair during the survey. Review of the facility's standards and guidelines titled Medication Regimen Review (MRR) dated 6/01/24 outlined the facility was responsible for timely alerting physicians of pharmacy recommendations and notifying the Medical Director of untimely responses. Non-time sensitive issues are expected to be addressed by the physician before the Pharmacy Consultants next monthly MRR.

Based on interview, and record review, nurses failed to follow physician's orders and failed to monitor condition changes in a timely manner for 1 of 3 residents reviewed for Change of Condition, of a total sample of 4 residents, (#4). Findings: Review of the medical record revealed resident #4, an [AGE] year old male was admitted to the facility on [DATE], re-hospitalized on [DATE], and readmitted from an acute care hospital on 12/22/24. The resident's diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke), aphasia (language communication dysfunction), dysphagia (difficulty swallowing), end stage kidney disease, seizures, encephalopathy (brain dysfunction), hypertensive (high blood pressure) urgency, dialysis dependence, anemia, primary hypertension, and coronary (heart) artery disease (CAD). The Minimum Data Set 5-Day assessment with an Assessment Reference Date of 11/06/24 showed during the look back periods, resident #4 scored 13 out of 15 on the Brief Interview for Mental Status exam that indicated he was cognitively intact. The assessment noted there were no behaviors or rejections of evaluation or care, received scheduled pain medications, received one injection, high-risk anti-platelet, and anti-convulsant medications, and hemodialysis while a resident. The Comprehensive Care Plan included focuses, interventions, and goals for altered cardiovascular status related to CAD, hypertension, anemia with interventions for nurses to monitor for changes and complications, and hemodialysis therapy with interventions for nurses to observe and monitor for complications and side effects including elevated blood pressure. The December 2024 Order Recap report included physicians medication orders for: Carvedilol 25 Milligrams (MG) once daily every Monday, Wednesday, Friday, and Sunday morning, and once in the evening on Tuesday, Thursday, and Saturday for high blood pressure, Clonidine 0.3 MG three times daily every Monday, Wednesday, Friday, and Sunday, and once in the evening every Tuesday, Thursday, and Saturday for high blood pressure, Hydralazine 100 MG three times daily every Monday, Wednesday, Friday, and Sunday, and once in the evening every Tuesday, Thursday, and Saturday for high blood pressure, Isosorbide Mononitrate 30 MG once daily every Monday, Wednesday, Friday, and Sunday morning, and once in the evening on Tuesday, Thursday, and Saturday for angina with a hold for blood pressure parameters, Metoprolol 100 MG twice daily every Monday, Wednesday, Friday, and Sunday, and once in the evening every Tuesday, Thursday, and Saturday for high blood pressure, and Nifedipine 60 MG twice daily every Monday, Wednesday, Friday, and Sunday and once in the evening every Tuesday, Thursday, and Saturday for high blood pressure. Review of the Nurse Progress Note completed by Licensed Practical Nurse (LPN) B on 12/12/24 at 12:48 AM, revealed the nurse received an additional as needed physician's medication order of Clonidine 0.2 MG to treat resident #4's elevated blood pressure reading of 232/91 mmHg (millimeters of mercury). The Order Audit Report noted on 12/11/24 at 11:03 PM, LPN B entered physician's medication orders for Clonidine 0.2 MG every six hours as needed for systolic blood pressure greater than 170 or diastolic blood pressure greater than 90 mmHg. The eINTERACT Change In Condition Evaluation completed by LPN A and the South Unit Manager on 12/12/24 documented the dialysis center contacted the facility to report that resident #4 required emergency transport to the hospital when he arrived at the dialysis center for treatment in the afternoon on 12/12/24. On 1/28/25 at 10:55 AM, in a telephone interview, LPN B recalled that on 12/12/24 during the 11:00 PM to 7:00 AM shift, resident #4 had an elevated blood pressure which she reported to the nurse practitioner by phone. LPN B said she obtained medication orders and administered the medication. She explained she recorded subsequent blood pressures during the night in the medical record. On 1/27/25 at 2:15 PM, LPN A recalled that on 12/12/24, she took resident #4's blood pressure before he went to dialysis and administered medication for an elevated reading. She said the same afternoon, a little while after he left for dialysis, the facility was notified by the dialysis center they had initiated 911 for emergency transport to the hospital. LPN A said LPN B had not mentioned during oncoming report on 12/12/24 that resident #4's blood pressure was high and the provider had been notified. Review of the Weights and Vitals Summary report noted resident #4's blood pressure was recorded as 167/91 on 12/11/24 at 10:47 PM, by LPN B but was not documented again until 12/12/24 at 12:41 PM by LPN A, approximately 12 hours later. The December 2024 Medication Administration Record (MAR) noted the only as needed dose of anti-hypertensive blood pressure medication was the Clonidine 0.2 MG which was administered by LPN A on 12/12/24 at 12:41 PM. On 1/27/25 at 2:25 PM, the South Unit Manager recalled at lunchtime on 12/12/24, she noticed resident #4 was lying in bed which was different than his normal routine of being out of bed in his wheelchair. She said she thought he may not be feeling great and noticed hadn't eaten any of his lunch. She explained nurses took the resident's blood pressure which was elevated, so an as needed dose of medication was administered before he went to dialysis treatment at approximately 1:00 PM. She said she remembered seeing a note earlier that morning from the night shift nurse about the resident's blood pressure that required a provider notification and additional medication orders. Review of the pharmacy delivery invoice noted resident #4's Clonidine 0.2 MG medication was delivered to the facility on [DATE] at 12:30 PM. On 1/28/25 at 12:07 PM, the South Unit Manager checked resident #4's medical record and acknowledged LPN B had not completed a Change Of Condition evaluation nor did the MAR show she administered the as needed blood pressure medication as ordered by the nurse practitioner. The Unit Manager said she expected nurses to complete the Change Of Condition form and LPN B should have documented any medication that was administered. She said Clonidine 0.3 MG was available in the electronic medication dispensary machine, and questioned that LPN B might have given the medication that was available but did not document it. On 1/29/25 at 12:19 PM, in a joint interview with Director of Nursing (DON) and Nursing Home Administrator, the DON explained she expected nurses to monitor, follow up, and complete a Change In Condition evaluation when the provider was notified of any concerns. She recalled on 12/12/24, resident #4 went to dialysis and stated, I believe he was acting up with the driver. She checked the medical record and could not find any documentation that LPN B administered resident #4's additional order for blood pressure medication nor monitored the resident after the nurse practitioner was notified. The DON conveyed that LPN B may have administered the medication on hand of Clonidine 0.3 MG instead of 0.2 MG and mis-transcribed the order. She said LPN B would be re-educated for the incident. On 1/29/25 at 1:30 PM, the DON stated, there is no policy for change in condition. Review of the Facility assessment dated [DATE] documented the facility provided care for residents with combinations of conditions that require complex medical care and management, . Management of medical conditions, Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions .

Based on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 39 residents, (#57). Findings: Resident #57 was admitted to the facility on [DATE] with diagnoses including pneumonitis due to inhalants of food and vomit, adult failure to thrive, hypertensive heart disease, anemia, CVA with Left-sided hemiparesis. Review of the Minimum Data Set admission assessment with an assessment reference of 8/30/24 revealed resident #57 had a Brief Interview for Mental Status score of 2 out of 15, which indicated she was severely cognitively impaired. On 9/23/24 at 11:59 AM, resident #57 was observed lying on her back in bed watching television. Her nightstand had a square basket with personal items, including a bottle of 15 millimeter (ml) Visine eye drops and B& C Ointment wound dressing with a 60-gram tube observed at the bedside. The resident, unable to communicate verbally pointed to a paper with a phone number for her daughter. Resident #57's daughter was then interviewed by telephone. She said she brought the eye drops to the facility and placed the bottle in the basket on her mother's nightstand. The daughter also stated she put the drops into her mother's eyes each time she visited because the drops made her eyes feel better. She stated her mother used eye drops previously when she was at home. On 9/23/24 at 2:01 PM, the resident's nightstand was observed by assigned Registered Nurse (RN) A. She acknowledged the Visine eye drops 15 ml and B& C Ointment wound dressing 60 grams tube. A few minutes later she reviewed the resident's physician orders and acknowledged there were no orders for the Visine eye drops and B & C ointment found on the resident's nightstand. RN A explained before a resident could self-administer medication, they must have a self-administration evaluation completed and a physician order initiated. RN A confirmed there was no order for the Visine eye drops or the B & C ointment. She also confirmed the resident had not had a self-administration evaluation to determine if she was able to self administer the medications. On 9/25/24 at 9:36 AM, the Director of Nursing stated the self-administration assessment should be done by the Interdisciplinary Team (IDT) to ensure the resident could safely self-administer medications. She acknowledged resident #57 would not be safe to self-administer based on her severe cognitive impairment. Review of the facility's policy and procedure for Medication Administration dated 8/23 revealed, A resident may only self-administer medications after the (IDT) has determined which medications may be self-administered.

Based on observation, interview, and record review, the facility failed to ensure nurses administered Intravenous (IV) medications according to physician's orders for 1 of 4 residents reviewed for Quality of Care and Treatment, of a total sample of 10 residents, (#1). Findings: A review of the medical record revealed resident #1, a [AGE] year old female was admitted to the facility on [DATE] from an acute care hospital with diagnoses of fractures of the right arm and shoulder, severe aortic (main heart artery) valve stenosis (narrowing), severe malnutrition, need for assistance with personal care, and osteoporosis. On 2/09/24, she was diagnosed with a stage four pressure wound to her sacrum (tailbone), sacral osteomyelitis (infection of bone), deep tissue pressure wounds to her left and right heels and ankles, and a non-pressure wound to her right elbow. The Minimum Data Set (MDS) Modified Admission assessment with Assessment Reference Date (ARD) 1/19/24 noted resident #1 scored 15 out of 15 for the Brief Interview for Mental Status (BIMS) which indicated she was cognitively intact, and did not reject evaluations or care. The assessment showed the resident required staff assistance to complete Activities of Daily Living (ADLs), was incontinent, and she had one stage three pressure ulcer documented as present upon admission during the look-back period. The MDS Discharge Return Anticipated assessment with ARD 2/18/24 showed the resident had one stage four, and four deep tissue pressure ulcers that were not present upon admission during the look-back period. The Comprehensive Care Plan included focuses for osteomyelitis infection with interventions to administer physician ordered IV medications and treatments, pressure wounds to sacrum, both heels and ankles, and right elbow with interventions to administer physician ordered medications and a wound vacuum (negative-pressure therapy). The Order Summary Report noted physicians' orders for antibiotic (infection) medications included Doxycycline 100 Milligrams (MG) every 12 hours for osteomyelitis on 2/02/24, Cefdinir 300 MG every 12 hours on 2/09/24 for infection, Peripherally Inserted Central Catheter (PICC) line insertion for IV medications, Vancomycin HCI 750 MG IV solution every morning for osteomyelitis on 2/09/24, and Levaquin 500 MG once daily for osteomyelitis on 2/16/24. On 3/20/24 at 11:19 AM, Licensed Practical Nurse (LPN) A explained nurses had 24/7 access to certain medications that included IV solutions and supplies from the Pyxis(automated dispenser). She showed the surveyor where the machine was located and demonstrated how nurses accessed it with written laminated administration instructions secured to the machine. On 3/20/24 at 11:29 AM, the North Unit Manager accessed the Pyxis and printed an Inventory Report that showed there were several vials of Vancomycin IV solution. She explained nurses could access the machine for medications if needed. She said she was not aware the IV form was there, and nurses, Usually wait for the pharmacy. Review of the February 2024 Medication Administration Report (MAR) showed IV Vancomycin HCI Solution was signed as administered on 2/12/24, 2/13/24, and 2/18/24 at 6:00 AM. The report did not show any documentation that nurses administered the IV Vancomycin HCl Solution on 2/10/24, 2/11/24 or 2/17/24. A Nurse Progress Note completed by LPN B on 2/09/24 at 4:48 PM read, IV not ready yet. A Nurse Progress Note completed by the North Unit Manager on 2/09/24 at 2:38 PM read, Patient will be on IV Vanco (Vancomycin) after PICC line insertion. Another Nurse Progress Note documented by LPN B on 2/10/24 at 7:43 AM read, Awaiting pharmacy delivery. The Physician/Practitioner Progress Note completed on 2/13/24 at 6:15 AM by the Infectious Disease Advanced Practice Registered Nurse (APRN) read, Wound culture has been obtained and grew MRSA (Methicillin-resistant Staphylococcus aureus) (bacteria) . Another Physician's Progress Note completed by the Medical Director on 2/10/24 at 3:30 PM, read, . worsening leukocytosis (excess white blood cells that fight infections) starting IV Vancomycin and omnicef . consult ID (Infectious Disease) . On 3/20/24 at 12:00 PM, the Director of Nursing (DON) reviewed the medical record and explained pharmacy delivery records showed resident #1's IV medication was delivered on 2/10/24 at 7:48 AM which was after the night nurse had given report to the oncoming day shift nurse at 6:00 AM. She said if the medication was not delivered, nurses would pass it on and let the oncoming shift know so they administered it after delivery. She could not explain why nurses had not accessed the Pyxis (automated dispensary). She stated the first dose was administered 2/11/24 at 6:00 AM and could not explain why the MAR showed nurses had not signed the medication was administered on 2/11/24. She said the 2/10/24 day shift nurse should have administered the medication. On 3/20/24 at 11:48 AM, the North Unit Manager said IV medications should be started immediately after they were obtained from the pharmacy who delivered routinely twice daily with emergency deliveries in between if needed. The IV Services progress note documented on 2/09/24 at 4:45 PM, read the Registered Nurse placed a PICC in the resident's left arm. In an interview with the Medical Director on 3/20/24 at 12:27 PM, he recalled resident #1 and explained he had ordered IV antibiotic medication to treat her sacral (tailbone) osteomyelitis (infection of bone) on 2/09/24. He said he was not aware the resident's treatment was delayed when nurses had not administered the medication until 2/11/24 at 6:00 AM as reported by the DON, or that the MAR was not signed for 2/11/24. He acknowledged at best; the delay was 37 hours after the IV catheter access was placed. He said the facility had emergency kit medication resources, and nurses were expected to administer critical medications as soon as possible and no later than within a few hours. He said if problems arose with obtaining medications, nurses needed to let him know and stated, They should've contacted me. The facility's standards and guidelines titled Intravenous Therapy Policy SHCRC30005.01 read, . 3. Record in the progress notes: . results of interventions, care provided, adjustments in the interventions . Review of the facility's standards and guidelines dated 12/13/23 titled LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual revealed that facilities may use an Automatic Medication Dispensing System to access emergency medications, first dose medications, or scheduled medications, per applicable laws. Review of the Center Assessment Tool dated 10/27/23 revealed the facility was able to care for residents who required Special Treatments including IV Medications.

Based on record review, and interview, the facility failed to involve residents and/or their representatives in the care planning process for 3 of 3 residents reviewed for care planning of a total sample of 42 residents, (#19, #44, #67). Findings: 1. Review of resident #19's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included dementia, depression, and anxiety. Review of resident #19's Minimum Data Set (MDS) Change in Status assessment with Assessment Reference Date (ARD) 9/08/22 revealed she had a Brief Interview for Mental Status score of 0 which indicated she was severely cognitively impaired. On 12/20/22 at 9:29 AM, during a telephone interview, resident #19's daughter and Power of Attorney (POA) stated she had only been invited to and attended one care plan meeting since her mother was admitted to the facility. She explained the care plan meeting was held around the summer time and she had not heard of any other care planning meetings since then. On 12/20/22 at 3:08 PM, the MDS Coordinator explained her responsibilities included completing assessments, inviting residents and/or representatives to care plan meetings, and attending the meetings. She stated she scheduled care plan meetings 2 weeks after the ARD. She indicated care plan meetings were held a couple of times per week and included participation from members of the interdisciplinary team such as social services, dietary, activities, the resident and/or resident representative. She indicated she used a form to invite residents. She said she was behind inviting people to care plan meetings. When asked for copy of the letters she had sent to resident #19's POA, she stated she did not have very many. She stated she wrote it in her calendar. Later at 3:37 PM, she provided a copy of a Care Plan Attendance Log dated 5/19/22 which showed participation of resident #19's POA via phone conference. The MDS Coordinator stated she was only able to find this conference log. She explained there should have been another care plan meeting in August, but she could not find evidence of any other meetings. She indicated the purpose of care plan meeting was to review and update the care plan and provide an opportunity for the resident or representative to voice any concerns. 39943 2. Resident #44 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease, type 2 diabetes, osteoarthritis, asthma, and dementia. The resident's quarterly MDS assessment dated [DATE], revealed the resident was cognitively intact. On 12/20/22 at 12:37 PM, the resident stated she did not know anything about a care plan meeting. She stated no one had ever said anything about attending a care plan meeting and she had never received a written invitation to a care plan meeting. Review of the resident's medical record revealed she was admitted on [DATE] and had an admission and Medicare 5-day MDS assessment completed on 8/19/22 and a quarterly MDS assessment on 11/18/22 that was still in progress. There was no documentation in the record to indicate the resident had attended a care planning meeting. 3. Resident #67 was admitted to the facility on [DATE], with diagnoses to include peptic ulcer, mood and anxiety disorder. Her MDS quarterly assessment dated [DATE], revealed she was cognitively intact. On 12/20/22 at 12:39 PM, the resident stated she had never attended a care plan meeting. Review of the resident medical record noted an admission and Medicare 5-day MDS assessment completed on 7/29/22. A quarterly MDS assessment was completed on 10/29/22. There was no documentation in the record to indicate the resident had attended a care planning meeting. On 2/20/22 at 3:12 PM, the MDS Coordinator stated care plan meetings were scheduled two weeks from the Assessment Reference Date and quarterly assessments. She stated a care plan invite form was filled out and taken to the resident room and she invited the family using a letter or a phone call. She said residents #44 and #67 have not had a care plan meeting to date. I am behind because there are usually 2 people in MDS but I have been by myself pretty much since June. She explained corporate office helped with the assessments and would send someone to help when they could. Review of the Care Plan Conference policy, revised date 2/18/19 revealed: Facility staff have a responsibility to assist resident to engage in the care planning process, e.g., helping residents and resident representatives, if applicable understand the assessment and care planning process; holding care planning meetings at the time of day when the resident is functioning best; planning enough time for information exchange and decision-making; encouraging a resident's representative to participate in care planning and attend care planning conferences. Fundamental Information: The interdisciplinary team, in conjunction with the resident, resident's family, surrogate or representative, will develop the plan of care based on the comprehensive assessment. The care plan conference is held to identify resident needs, establish obtainable and measurable goals. Review of the Resident Care Specialist (MDS Coordinator) job description revealed the following:Direct Care Related Responsibilities: Work directly with the resident to evaluate their needs, document the evaluation, develop the residents care plan, and discuss the care plan with the resident's family and other team members in accordance with applicable laws, regulations, and standards. Indirect Care Related Responsibilities: Assure that care planning component is developed with input from staff, physician, resident, and family.

Based on observation, interview and record review, the facility failed to obtain a physician order for 1 of 1 resident receiving oxygen, failed to follow physician ordered dosage for oxygen administration for 2 of 2 residents, and failed to monitor water in the oxygen humidifier for 1 of 1 resident out of 8 residents reviewed for oxygen therapy of a total sample size of 42 residents, ( 89, 551, 76, 38). Findings: 1. Resident #89 was admitted to the facility on [DATE] with diagnoses of anxiety disorder, vascular dementia, and transient ischemic attack. Review of the resident's medical record showed a Minimum Data Set (MDS) admission assessment dated [DATE] that did not show oxygen therapy. Review of the care plan dated 9/26/22 showed no focus, goals, or interventions for oxygen. Review of the resident's physician orders active and discontinued from 9/26/22 to current showed no orders for oxygen. On 12/19/22 at 10:49 AM and 12:16 PM, resident #89 was noted with oxygen via nasal cannula infusing at 2 liters per minute. On 12/19/22 at 12:37 PM, Licensed Practical Nurse (LPN) A stated resident #89 received oxygen at 2 liters per nasal cannula. He stated the resident's oxygen was checked in the mornings. LPN A reviewed resident #89's physician orders and said there were no orders for oxygen. The LPN did not explain why the resident received oxygen therapy when there were no physician orders for oxygen to be administered. 2. Resident #551 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, pneumonia, acute respiratory failure with hypoxia, and emphysema. Review of resident's care plan dated 12/6/22 revealed a focus for impaired gas exchange/ineffective airway clearance with interventions for medications and treatments to be given as ordered. Review of the resident's physician orders dated 12/6/22 showed oxygen via nasal cannula at 2 liters per minute every shift. Review of nurse's progress note dated 12/8/22 at 11:30 PM, read oxygen infusing at 3 liters per minute. On 12/19/22 at 9:57 AM, and 12:14 PM, noted the resident's oxygen infusing flow meter set at 3 liters per minute. On 12/19/22 at 12:31 PM, the resident's assigned nurse, LPN A acknowledged the resident's oxygen was set at 3 liters per minute. LPN A reviewed the physician orders and reported a physician order dated 12/6/22 showed oxygen was ordered at 2 liters per minute. He stated the resident's oxygen was checked in the morning but added he had not checked for the correct flow rate. 3. Resident #76 was initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, and acute chronic respiratory failure with hypoxia. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] showed the resident received oxygen. Review of the care plan initiated on 3/28/22, and revised on 10/28/22 revealed focus, goal and interventions for impaired gas exchange. On 12/19/22 at 12:15 PM, the resident was observed with oxygen infusing at 3 liters per minute with humidifier bottle. The humidifier bottle was empty. On 12/19/22 at 12:44 PM, LPN A acknowledged the humidifier was empty and was unsure how long it had been empty. On 12/19/22 at 12:48 PM, the Director of Nursing (DON) stated the nurses were responsible to ensure oxygen was administered as ordered, and should follow physician orders. He said, if a resident was receiving oxygen, there has to be a doctor's order for the oxygen. Review facility policy Physician Orders revised 10/24/17 revealed PURPOSE Physician orders are obtained to provide a clear direction in the care of the resident. Review of the facility's Policies and Procedures for Oxygen Administration revised 5/22/18 showed under PROCEDURE 1. Check Physician's Order. 9. If using a reusable humidifier, fill bottle to the correct level with distilled water and attach to the oxygen unit. 11. Turn the unit on to the desired flow rate and assess equipment for proper functioning. 39943 4. Resident #38 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, chronic obstructive pulmonary disease, anxiety, and atrial fibrillation. Review of the resident's medical record revealed a physician order dated 1/24/22 for oxygen via nasal canula at 3 liters per minute, every shift. The resident's care plan for oxygen therapy included intervention to administer oxygen as indicated and as per physician orders. The Minimum Data Set, quarterly assessment dated [DATE], reflected the resident had shortness of breath on exertion, when sitting, at rest, and when lying, and used oxygen. On 12/19/22 at 11:30 AM and 1:23 PM, resident #38's oxygen concentrator showed it was set at two liters per minute. On 12/19/22 at 1:25 PM, LPN C reviewed the resident's physician orders and stated the oxygen was ordered at 3 liters per minute. LPN C then checked the resident's oxygen flow rate and acknowledged it was set at 2 liters. She noted the resident had breathing issues and her oxygen should be on the liter flow ordered by the physician.

Based on interview, and record review, the facility failed to complete and submit the Minimum Data Set (MDS) comprehensive annual assessment within the required 366 days of the previous comprehensive assessment for 1 of 5 residents reviewed for completion of MDS annual assessments of a total sample of 42 residents, (#63). Findings: Resident #63 was admitted to the facility on [DATE]. A review of the resident's medical record revealed the MDS comprehensive annual assessment with Assessment Reference Date (ARD) 12/01/22 was not completed. In interviews on 12/20/22 at 2:54 PM, and on 12/22/22 at 12:15 PM, the Licensed Practical Nurse MDS Coordinator confirmed resident #63's comprehensive annual assessment ARD was 12/01/22 and should have been completed and submitted by 12/15/22. She explained she had not completed the assessment as she had too much on her plate. On 12/22/22 at 12:17 PM, the Regional Director of Clinical Services stated her expectation was the MDS assessments were completed and submitted by the ARD date. The facility's Resident Assessment Instrument Process policy revised 3/27/18, contained the regulatory timeframes for MDS assessments and directed staff must follow the schedule for opening, completing and transmitting MDS assessments. The document noted the specific timing of the completion date to be within 366 days from the most recent comprehensive resident assessment and within 14 days of the ARD.

Based on interview, and record review, the facility failed to complete and electronically transmit Minimum Data Set (MDS) assessments timely for 1 of 5 residents reviewed for MDS assessment completion and submission from a total sample of 42 residents, (#75). Findings: Resident #75 was admitted to the facility on [DATE]. A review of resident #75's medical record revealed the MDS quarterly assessment had an assessment reference date (ARD) of 11/11/22. Review of the history of the quarterly MDS assessment showed it was completed on 12/19/22, locked and accepted on 12/19/22. On 12/20/22 at 2:54 PM, the Licensed Practical Nurse MDS Coordinator reviewed the resident's medical record and stated his quarterly assessment was due 14 days from the ARD date, 11/25/22. She confirmed the quarterly assessment was not completed and submitted until 12/19/22, 24 days late. The MDS Coordinator stated she was responsible for ensuring MDS assessments were submitted timely and explained she had too much on her plate at that time. On 12/20/22 at approximately 3:00 PM, the Director of Nursing acknowledged resident #1's MDS quarterly assessment was late as noted by the MDS Coordinator. He stated he became aware of the late MDS assessments near the end of November 2022. The facility's Resident Assessment Instrument Process revised 3/27/18 contained the regulatory timeframes for MDS assessments and directed staff must follow the schedule for opening, completing and transmitting MDS assessments. The document noted the specific timing of the completion date to be, within 14 days of the Assessment Reference Date .

Based on interview, and record review, the facility failed to electronically transmit Minimum Data Set (MDS) quarterly assessments timely for 2 of 2 residents reviewed for MDS assessments, from a total sample of 42 residents, (#73, #72). Findings: 1. Resident #73 was admitted to the facility on [DATE] . A review of the resident's medical record revealed the MDS quarterly assessment dated [DATE] had not been transmitted. 2. Resident #72 was admitted to the facility on [DATE] with a previous admission on 5/9/21. A review of the resident's medical record revealed the MDS quarterly assessment dated [DATE] had not been transmitted. On 12/20/22 at 2:53 PM, the Licensed Practical Nurse (LPN) MDS Coordinator stated MDS Quarterly, Annual and Discharge assessments submissions were due in 14 days from the Assessment Reference Date (ARD). She validated the Quarterly assessments for resident #73 and resident #72 were greater than 120 days, and was not submitted timely. She stated her superiors as well as corporate personnel were aware she was late with MDS assessment submissions. She stated, it is my responsibility to make sure Quarterly assessments are transmitted timely. Review of LPN MDS Coordinator job description of Resident Care Specialist Manager signed and dated on 12/1/22, showed under Summary Within the scope of practice as defined by the state, develops, implements, and coordinates the RAI process. Maintains compliance in accordance with current professional practice standards, physician's orders, company policies and procedures, and local state, and federal regulations. The facility's Resident Assessment Instrument (RAI) Process Policy revised 3/27/18 revealed PROCEDURE 5. The facility must follow the schedules for all MDS assessments and tracking forms as set forth in the RAI manual. This includes the timing for opening, completing and transmitting of the assessments.

Based on interview, and record review, the facility failed to develop a baseline/interim care plan related to fall risk for 1 of 2 residents reviewed for hospitalization of a total sample of 42 residents, (#99). Findings: Resident #99 's medical record revealed she was admitted to the facility on [DATE] from an acute care hospital with diagnoses of dizziness, repeated falls, and muscle weakness. The AHCA (Agency for Healthcare Administration) Form 5000-3008 dated 9/23/22 showed primary diagnoses included orthostatic (to stand up) falls and patient risk alerts included falls. The form noted the resident ambulated with an assistive device and needed assistance of 1 staff person for transfers. The 5 Day Minimum Data Set (MDS) assessment dated [DATE] showed the resident had 1 fall without major injury since her admission to the facility. The baseline care plans created on 9/28/22 included ADL (Activities of Daily Living) Self Care Performance, Decreased Nutritional Status, Impaired Communication, Impaired Gas Exchange, Impairment to Skin Integrity, Person Centered Care and Plan to Return Home with Family. There was no evidence that a Fall Risk interim/baseline care plan was initiated. On 10/9/22 resident #99 was transferred to the hospital after a fall with skin tear and did not return to the facility as of 12/21/22. There was no baseline care plan initiated to address risk for falls or interventions to mitigate the risk. On 12/21/22 at 3:47 PM, the MDS Coordinator verified resident #99 did not have a care plan initiated for falls. She explained a care plan for fall risk should have been initiated as the resident was at risk and had history of falls. She noted it had been difficult to keep up with the care plans as she was the only staff person doing the assessments since June 2022. The facility's Baseline (Interim/Initial/IPOC) Plan of Care, revised 2/18/19 read, The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care .A comprehensive care plan can be developed in place of the Baseline Care Plan .including, but not limited to .physician orders .The nurse will consider the following areas when developing individualized care plan for each resident .Update the Interim (Initial) Plan of Care on and ongoing basis, as necessary, until the Comprehensive Plan of Care is finalized .

Based on interview, and record review, the facility failed to ensure drug regimen review was done monthly for 2 of 5 residents, (#7 and #67), and failed to address a pharmacy recommendation for 1 of 5 residents (#63) reviewed for unnecessary medications of a total sample of 42 residents. Findings: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses to include heart disease, diabetes, dementia, heart failure, anxiety, and schizophrenia. Review of the Medication Regimen Review Report revealed no monthly pharmacy reviews for resident #7 to indicate the pharmacist had reviewed the resident's drug regimen for the months of July, August and September 2022. 2. Resident #67 was admitted to the facility on [DATE] with diagnoses of diverticulosis, peptic ulcer, suicidal ideations, mood disorder, anxiety disorder, and post-traumatic stress disorder. Review of the Medication Regimen Review Report revealed no monthly pharmacy reviews for resident #67 to indicate the pharmacist had reviewed the resident's drug regimen for the months of July, August, and November 2022. 44313 3. Resident #63 was admitted to the facility on [DATE] with diagnoses that included hypertension, anxiety disorder, major depressive disorder, alcohol abuse, and bone density disorder. Resident #63's care plan for acid reflux disease initiated 4/12/22 included intervention to give medications as ordered. Review of the physician's orders revealed an order for Protonix tablet delayed release 40 milligrams (mg) by mouth twice a day for acid reflux disease dated 5/03/22. Protonix (Pantoprazole) is a drug that decreases the amount of acid produced in the stomach. It is recommended to be used at the lowest dose for the shortest amount of time needed to treat the condition. Published observational studies suggest use of this drug was associated with an increased risk of severe colon infection and bone density related fractures when taken more than once a day over a long period of time (retrieved on 12/28/22 from www.drugs.com). Review of the Medication Administration Report for November and December 2022 revealed resident #63 received the Protonix tablet delayed release 40 MG tablet twice a day from 11/01/22 to 12/21/22. Review of the consulting pharmacy Consultation Report for 10/01/22-10/31/22 revealed a recommendation to change the ordered Pantoprazole (Protonix) 40 MG twice a day to Omeprazole 20 MG once daily unless there was an indication that required it to be given twice a day. The rationale given for the recommendation was, dosing more frequently than once daily may increase the risk for adverse effects like bone density type fractures and colon infections. The report listed several references the consulting pharmacist used to make the recommendation. In interviews on 12/22/22 at 1:07 and 1:53 PM, the Director of Nursing (DON) explained he was new and stated the Consultant Pharmacist emailed the monthly reviews to himself and the Assistant Director of Nursing. He indicated the reviews would then be printed and given to the Unit Managers to review any recommendations with the physicians. The DON stated he could not find the physician signed consultation report from October for resident #63 and did not know if any physician had even reviewed it. He stated he did not know how the previous DON ensured pharmacy recommendations were reviewed by the physicians. He said he realized, The system was broken previously. On 12/22/22 at 2:16 PM, during a telephone interview, the Consultant Pharmacist stated he was on vacation and did not have his computer so he would not be able to answer any questions about specific residents. He explained his process was to review the medication regimen of all residents including new admissions monthly and make recommendations as necessary. He said he emailed the all consults to the facility monthly but if something is urgent, I would contact the Director of Nursing. He explained the physician did not have to agree with his recommendations, but had to respond to them. The Consultant Pharmacist described the purpose of having the pharmacist review the medications was to benefit the resident and improve their medication safety. He stated he felt as a pharmacist the recommendations were important to ensure the therapy the residents were on were the best for them. The Medication Regimen Review policy and procedure document with most recent revision date 3/03/20, described the procedure for staff to ensure the physician or other responsible parties received the medication review and acted upon the recommendations contained in them. The document described the procedure for the attending physician to document in the resident's health record that any irregularity was reviewed and what if any action was taken to address it, including any rationale if no changes were made. Additional procedures included actions for the facility staff to make if the recommendations were not addressed by the attending physician in a timely manner.

Based on observation, interview and record review, the facility failed to ensure all staff were fully vaccinated, implement their additional precautions for personal protective equipment (PPE) of their COVID-19 staff vaccination policy, and identify an appropriate clinical reason for the contraindication of the COVID-19 vaccine for two of five staff reviewed. This deficient practice has the potential to affect residents that reside on one of two units. Findings include: 1. Failed to ensure all staff were fully vaccinated: According to the facility COVID-19 Vaccine - Staff policy effective 1/27/2022 each staff will be educated and vaccinated unless medically contraindicated or already immunized. The policy also stated that staff approved for exemption will be required to take additional infection prevention measures, such as enhanced PPE, frequent testing, avoidance of certain areas of the center, restrictions on treating high-risk patients and limiting exposure with other staff members. On 5/6/22 at 10:20 AM review of the staff vaccination status provided revealed that out of 157 staff, 139 were fully vaccinated, 17 had requested a religious exemption and 1 had a medical exemption. However, the staff who was granted a medical exemption did not have a qualifying clinical reason; therefore, the staff vaccination rate was 99.4%. Review of the Medical Exemption From COVID_19 Vaccination form dated 12/1/21 and signed by a practitioner revealed that the reason for the medical exemption for staff C was pregnancy or anticipated pregnancy. Review of the list provided by the Centers for Disease Control for acceptable medical conditions to qualify for a medical exemption for not getting vaccinated, did not include pregnancy or anticipated pregnancy. Interview with administrative staff A at 12:32 PM confirmed that anticipated pregnancy was the reason for the medical exemption. At 1:30 PM administrative staff B confirmed staff C, who had a medical exemption, worked on 4/30/22. Review of the schedule confirmed that staff C worked on 4/30/22 and one of the residents he/she was assigned to work with was placed on droplet precautions because he/she had just returned from the hospital on 4/27/22. Additionally, at 12:42 PM Nursing staff D was not able to provide any testing results for staff C on 4/30/22. Staff D also stated that Staff [NAME] not been at the facility for 2 months before 4/30/22 and was not tested prior to working on 4/30/22 at this facility. 2. Failed to wear enhanced PPE for unvaccinated staff according to facility policy: On 5/6/22 at 11:55 AM Nursing staff E was observed on the unit passing medications. He/she was wearing goggles and a surgical mask. At 12:35 PM nursing staff E was observed sitting at the nurse's station with a surgical mask and goggles. When asked what COVID protocol he/she had to follow he/she stated a mask and goggles. The staff said that when we go in an isolation room we wear gloves and a gown. At 1:35 PM Nursing staff E was observed walking down the hall with a surgical mask and goggles. At 1:58 PM observations revealed Nursing staff E was in a resident room with a surgical mask and this was confirmed by Nursing staff D. Review of the staff vaccination status provided revealed that Nursing staff E was not vaccinated but had a religious exemption. According to the facility policy for unvaccinated staff effective 1/5/2022 unvaccinated staff are required to wear N 95 and eye protection (face shields preferred) at all times while in the center . The facility failed to implement their policy for unvaccinated staff that had access to residents on the unit.

Based on interview and record review, the facility failed to accurately assess functional range of motion (ROM) of the upper extremity for 1 of 2 resident reviewed for mobility of a total sample of 40 residents, (#53). Findings: Resident #53 was admitted to the facility on [DATE], and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, with assessment reference date 1/13/21, revealed the resident's cognition was severely impaired, with a brief interview of mental status (BIMS) score of 03/15. The resident required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. For Functional Limitation in Range of Motion the assessment indicated the resident had no impairment to her upper extremity (shoulder, elbow, wrist, hand). Observations on 02/08/21 at 11:26 AM and at 12:39 PM, showed resident #53 in her room. Her right hand was contracted and the resident did not have a splint on her right hand. On 02/10/21 at 11:33 AM, observation with Licensed Practical Nurse (LPN) D showed resident #53 out of bed, sitting in a chair. Her right hand was contracted and the resident did not have a splint. The findings were noted by LPN D. On 02/11/21 at 2:48 PM, the MDS coordinator was not available, so the resident's quarterly MDS assessment was reviewed with the Director of Nursing (DON). The DON acknowledged the assessment was not correct as the resident had impairment of her right upper extremity.

Based on interview and record review, the facility failed to develop a person-centered care plan for vision for 1 of 2 residents reviewed for vision/hearing of a total sample of 40 residents, (#11). Findings: Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data set (MDS) assessment with assessment reference date 12/03/20 revealed the resident's vision was assessed to be highly impaired with no corrective lenses. Her cognition was severely impaired, with a brief interview of mental status (BIMS) score of 0/15. A review of the resident's clinical records revealed a care plan for vision could not be found. On 02/11/21 at 10:24 AM, the Corporate Senior Resident Care Specialist stated the facility did not have a current MDS Coordinator. She said that MDS assessments were completed by doing a seven day look back at the resident's clinical records, and included interviews with staff, and residents as needed. On 02/11/21 at 2:08 PM, the Director of Nursing (DON) stated that care plans were developed from the MDS assessment. The DON added the Social Services Director was responsible to develop the vision care plan. Review of the resident's MDS revealed the section for vision was assessed by the Corporate Senior Resident Care Specialist. On 02/11/21 at 2:48 PM, the DON stated that in review of the resident's clinical records, she could not identify a care plan for vision for the resident. The DON said that a vision care plan should have been developed and stated that the Corporate Senior Resident Care Specialist was not available for interview. The facility's policy, Comprehensive Person-Centered Care Plans revised on 2/18/2019 read, The facility must develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview and record review, the facility failed to ensure hand splints were applied as per physician orders [REDACTED].#53, #68). Findings: 1. Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The resident's physician orders [REDACTED]. The quarterly Minimum Data Set (MDS) assessment, with assessment reference date 1/13/21, revealed the resident's cognition was severely impaired, with a brief interview of mental status (BIMS) score of 03/15. The resident required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Observations on 02/08/21 at 11:26 AM, and at 12:39 PM showed resident #53 in her room. Her right hand was contracted and she was not wearing a splint. On 02/10/21 at 11:06 AM, Licensed Practical Nurse (LPN) D stated the resident's right hand was contracted, but she was not sure if the resident had splints. The resident's physician's orders [REDACTED]. The LPN stated that an order for [REDACTED]. On 02/10/21 at 11:33 AM observation with LPN D showed resident #53 out of bed, sitting in chair. Her right hand was contracted, and the resident was not wearing a splint on her right hand. On 02/10/21 at 12:13 PM, Certified nursing assistant (CNA) E acknowledged the resident's right hand was contracted, and the resident did not have a splint for her right hand. On 02/10/21 at 2:11 PM, the Rehab Manager stated that resident #53 was discharged from Occupational Therapy (OT) on 1/12/21. an order for [REDACTED]. The Rehab Manager added that nursing and therapy were responsible to ensure splints were applied to residents. The Rehab Manager added the resident had a standard hand splint, and all CNAS were trained by therapy to don/doff the standard splint. She said staff were to document when the splint was applied, when it was taken off, and the resident's tolerance for the splint. Review of the clinical records at this time did not identify documentation of donning/doffing of the right-hand splint for the resident. The Rehab Manager acknowledged there was no documentation of donning/doffing of the splint. Review of the OT Evaluation and Plan of treatment for [REDACTED].#53 revealed the short term goal was, Staff will increase ability to don/doff splint .using R(right) elbow orthosis and R wrist/hand orthosis wearing schedule during daily tasks in order to .maintain joint integrity and prevent contracture progression . On 02/10/21 at 2:39 PM, the resident's physician's orders [REDACTED]. She acknowledged there was an order for [REDACTED]. She stated the order populated in the general order, and nursing should have followed up for splint application. The DON noted that orders were reviewed by the Interdisciplinary Team (IDT) in the morning meetings. She said a twenty-four hour order listing was also conducted, and the team would be aware of residents on splint by review of the list provided by therapy. She stated the order for the resident's splint was missed. The DON noted that nurses were responsible to review the physician orders [REDACTED]. She added that nursing should have ensured the resident's splint was applied. On 02/11/21 at 10:00 AM, the Rehab Manager stated that splints were ordered to prevent further contractures and if the splint was not applied, contractures could increase/worsen. The resident's care plan Self-care deficit related to decreased strength and endurance created on 11/16/18 with revision on 1/24/20 included interventions dated 1/12/21 for, Right Resting Hand splint to be applied daily by nursing during AM care and worn as tolerated by resident. 2. Resident #68 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident's physician order [REDACTED]. The quarterly MDS assessment with assessment reference date 1/27/21, revealed the resident's cognition was intact with a brief interview of mental status (BIMS) score of 15/15. The resident required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. He was totally dependent on staff for transfers and had impairment on one side of his upper extremities. The resident's OT Evaluation and Plan of treatment for [REDACTED].Nursing is managing patient's contracture impairment, RNP (Restorative Nursing Program) for splinting to be set up. The OT Discharge Summary revealed the resident received OT therapy from 12/4/20-1/4/21. The summary noted, Restorative Nursing Program set up for L(left) UE (upper extremity) orthosis, staff to demo. OT Treatment Encounter Note dated 1/4/21 read, .Pt made aware of discharge from skilled OT services to begin Restorative Nursing Program for UE exercises and for splint application. The resident's care plan Requires assistance with ADL self-care performance created on 6/03/19 and revised on 1/13/21 included, Left resting Hand splint to be applied daily by nursing during AM care and worn as tolerated by Resident. Skin checks pre/post application. On 02/10/21 at 10:47 AM, resident #68 was lying in bed on his back. His left hand was contracted and the resident was not wearing a splint. On 02/10/21 at 11:35 AM, resident #68 stated he wore a splint on his right hand, but the splint took feet and went away. Resident #68 stated that when he first went to Rehab, he was given the left-hand splint. He said he did not know where the splint was and had asked the staff about it. At this time, LPN D acknowledged resident #68 was not wearing a splint to his left hand. A review of the resident's physician orders [REDACTED]. On 02/10/21 at 11:15 AM, CNA F stated that resident #68 required assist of two persons for most of his ADLs and did not have a splint for his left hand. On 02/10/21 at 2:11 PM, the Rehab Manager stated that if residents required splints, therapy would train the Restorative CNA to don and doff the splint. This task would then be transitioned to nursing after twelve weeks. The Rehab Manager stated resident #68 was discharged from OT on 1/04/21 and an order for [REDACTED]. On 02/10/21 at 2:39 PM, the DON stated that trials of splints were started by therapy prior to residents' discharge from therapy. The resident would then be discharged from therapy with recommendation to nursing status [REDACTED]. A review of the resident's orders and care plan was conducted with the DON. She acknowledged the physician order [REDACTED]. On 02/11/21 at 10:00 AM, the Rehab Director stated that resident #68 had a splint prior to his admission to the facility, and therapy monitored the resident to ensure the splint was still applicable and appropriate. She said the splint was ordered to prevent further contracture, and if it was not applied, the contracture could worsen. If that happens, therapy would have to do ROM, to open the resident's hands, and would possibly have to change his splint. The Rehab Manager stated that therapy and nursing were responsible to monitor splints in the facility. She stated there was a breakdown in communication. The Facility assessment dated [DATE] indicated that services and care offered based on the residents' needs included Mobility .contracture prevention/care.

Based on observation, interview and record review, the facility failed to obtain physician orders [REDACTED].#12). Findings: Resident #12 was initially admitted to the facility on [DATE] then readmitted on [DATE]. His [DIAGNOSES REDACTED]. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required oxygen therapy. On 02/08/21 at 2:06 PM, resident #12 was resting in bed. He was alert and oriented. He had oxygen via nasal cannula attached to a concentrator with setting of 4 liters per minute (LPM). He stated he was dependent on oxygen especially when walking in the room as he had a hard time breathing. He said he did not touch the control knob of the oxygen concentrator as he did not want to be liable if something happened. On 02/09/21 at 9:57 AM, resident #12 was reclining in bed. He was receiving oxygen by nasal cannula at 4 LPM. He stated he needed to be on oxygen continuously. On 02/09/21 at 2:29 PM, Licensed Practical Nurse (LPN) B stated resident #12 required continuous oxygen at 2 LPM. She added he needed to be reminded to put it on. She also stated that nurses had to make sure the concentrator was calibrated correctly. She noted that nurses were to follow the physician's orders [REDACTED]. On 02/09/21 at 2:42 PM, the Unit Manager (UM) observed resident #12's oxygen flow setting and stated it was set at 4.5 LPM. She checked the physician's orders [REDACTED]. She then reviewed the hospital discharge orders and stated there was an order for [REDACTED]. On 02/11/21 at 10:37 AM, the Director of Nursing (DON) stated that upon admission to the facility, the admitting nurse should have called the physician to verify orders. She said there was no evidence the physician was notified of the hospital oxygen order. A review of the Policy and procedure on Oxygen Administration with a revised date of 05/22/2018 indicated that under Procedure #1. Check physician's orders [REDACTED].>