Every finding on record at Beaver County Nursing Home

An IJ was identified from 12/11/24 through 12/12/24. The deficient practice remained at isolated level of a potential for harm. On 12/11/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement fall interventions for a resident with severe cognitive impairment and high fall risk. On 12/10/24, Resident #13 had a fall with injury in their room. Resident #13 fell during an independent transfer and was found by staff on the floor with their left foot rotated outward with no range of motion to left hip. Resident #13 was taken to the ER by staff. This fall resulted in Resident #13 acquiring a closed displaced intertrochanteric fracture of the left femur and laceration of scalp. On 12/11/24 at 3:04 p.m., the Oklahoma State Department of Health was notified and verified the existence of a IJ situation. On 12/11/24 at 3:56 p.m., the administrator and DON were notified of the IJ situation and the IJ template was provided. On 12/12/24 at 12:34 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal documented the total number of residents at risk for the same deficient practice was 35. It documented the actions to remove the immediacy of the alleged deficient practice were the following: a. on 12/11/24, Resident #13's care plan completed via phone with the family and the family agreed to move Resident #13 to the east side of the facility to be more closely monitored due to high fall risk; b. on 12/11/24, Resident #13's care plan was individualized with specific fall interventions; c. on 12/11/24, all staff were educated in person and by phone on the policy put into place, where to find the master list for fall risk, the falling leaf program, location of the fall manual, and where to find care plans for each resident; and d. all residents deemed a high fall risk care plan interventions were updated and falling leaf program updated. It documented action taken to prevent recurrence of the alleged deficient practice were the following: a. on 12/11/24, the facility fall policy and procedure manual will be located at the nurse's station for all staff to review at any time. The master list of all high fall risk residents will be located in the front of the binder. A falling leaf program policy will be implemented. Note cards will be available at the nursing station for all residents sorted by hall for quick reference of each residents care needs including fall risk category. The fall intervention list from the care plan for each resident will be available in the fall manual; b. a master fall risk list and note cards will be updated weekly by the DON to ensure accuracy; c. the DON or administrator will randomly interview three to five staff members once a week to ensure each one is aware of the new policies and where to find all the fall risk information. Staff will be reeducated as needed; d. new hires will be educated on fall program and policies and procedures upon hire; e. when a fall happens in the facility, the charge nurse will do a huddle with nursing staff immediately to look for interventions, update care plan if needed, and notify the PCP and family; f. as new interventions are put into place a huddle will be completed with all staff on duty for education; g. the IDT team will meet weekly on all falls. The care plan will be updated with new interventions; and h. the QAPI team will meet monthly and review all falls, monitor tracking and trending, and address any concerns noted. The IJ was lifted, effective 12/12/24 at 2:37 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained isolated with the potential for more than minimal harm. Based on record review, and interview, the facility failed to update and implement individualized fall interventions in the care plan after a fall for residents assessed as a high fall risk for two (#13 and #15) of two sampled residents reviewed for individualized fall interventions. The administrator identified 35 residents were high fall risk. Findings: An undated facility Accidents policy, read in part, The intent of this policy is to ensure this facility provides an environment that is free from accidents hazards over which the facility has control and provides supervision and assistive devices are provided for each resident to prevent avoidable accidents. This includes: a. Identifying hazards and risk, b. Evaluating and analyzing hazards and risk, c. Implementing interventions to reduce hazard, and d. Monitoring for effectiveness and modifying interventions when necessary. The policy also read, Individualized, person centered interventions will be implemented, including adequate supervision assistive devices, to reduce risk related to hazards in the environment. The facility's Falls and Fall Risk, Managing policy, read in part, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. 1. Resident #13 had diagnoses which included anxiety, depression, cataract, and dizziness. Resident #13's Care plan, date initiated 03/02/22 and revised 10/23/24, documented interventions for fall focus, read in part, Fall interventions: purposeful staff rounding, proper seating in chair for W/C, ensure proper foot wear/nonskid socks, exercise program to improve balance, gait, strength, assist, staffing, environment, friendly to reduce clutter, assess medications - side effects and interactions - PCP and pharmacy review, educate resident regarding risk for falls, increased observation, increased activities, restorative care, staff education on falls and interventions, keep items within reach, bed, and low position when occupied with format. Answer, call promptly, re-orientate to call if needed, use of pictures to provide cues and reminders to call for staff assist, evaluate hearing, vision as needed, root cause analysis for falls, assess for illness, open, parentheses delirium, UTI, respiratory, infection, etc in parentheses, educate resident when applying intervention, create something that makes high-risk followers, identifiable, open, parentheses falling, leaf, pictures, etc. In parentheses involve all staff to prevent falls, maintain daily routine, assist WF/toileting before and after each meal, at bedtime as needed. Evaluate B/P for hypotension, rooms/bathrooms with adequate light, call light in reach of resident at all times and remind them to call for staff assist, PT evaluation, evaluate height of bed/toilet seat/chairs, etc. Offer nutritional stacks and meals, offer fluids, everyone- two hours during waking hours promote hydration, proper ambulation, assistive devices (walker, cane W/C space ETC.) and educate on proper use of devices. A Un-Witnessed Fall report, dated 08/01/24, read in part, resident observed laying on her stomach on the floor with no bottoms on. Urine and BM on the floor by the bathroom. Neighbor unsure of how she fell , just that she fell . Resident had abrasions noted to both knees and good range of motion. There was no documentation the care plan was updated with new specific interventions after the fall. Resident #13's Morse Fall Scale, dated 09/19/24, documented high fall risk with a score of 75. A Significant Change assessment, dated 09/23/24, documented Resident 13's cognition was severly impaired. It also documented Resident #13 was independent with walking with walker and going to bathroom independently. A Incident note, dated 11/29/24, read in part, resident reported fall in room- unknown how resident fell . Nurse called to dining room by hospice aid. 2 cuts noted near left eye brow, inner nose swollen and bruised, nurse took resident over to ER- resident refused to stay at ER. Nurse did treatment on eye brow with steri strips and family, PCP notified of her refusal of care in ER. There was no documentation the care plan was updated with new specific interventions after the fall. A Incident note, dated 12/10/24 at 10:41 a.m., read in part, Resident noted yelling out from room. [They]were sitting on floor at foot of bed next to side table. Left foot was rotated outward and [they] did not have ROM in this hip without having pain. [They] also had blood noted running down [their] cheek. Resident stated 'I fell , help me up and leave me alone' Cleaned face up to assess head wound, laceration appears to be superficial. Assisted [them] up into wheelchair without applying weight to left hip. Notified PCP and brought [them] to ER. Also notified DON, ADM, and [family member]. admitted to hospital. There was no documentation the care plan was updated with new specific interventions after the fall. An initial State Reportable Incident, dated 12/10/24, documented Resident #13 was found sitting on their floor in room. It documented Resident #13's left foot was rotated outward and did not have range of motion in the left hip without having pain. It documented Resident #13 arrived at theER on [DATE] at 11:57 a.m. Resident #13's ER report, dated 12/10/24, documented they were treated and then transferred to another hospital for a closed displaced intertrochanteric fracture of the left femur and laceration of scalp. There was no documentation the care plan was updated with new specific interventions after the fall on 08/01/24- no injury, the fall on 11/29/24- laceration above left eye and inner nose, and the fall on 12/10/24- injury obtained. On 12/10/24 at 2:56 p.m., the DON was asked the reason Resident #13 was transferred to bigger hospital. The DON stated for a fractured left hip. On 12/12/24 at 11:02 a.m., MDS coordinator #1 was asked the policy for updating and revising interventions on the care plan. They stated they were updated as needed. MDS Coordinator #1 was asked to review Resident #13's care plan for falls and was then asked if new fall interventions were added, updated or revised after the fall on 08/01/24. They stated no new interventions were put into place. They were then asked about the fall on 11/29/24. They were asked if there were new fall interventions put into place, updated or revised. MDS Coordinator #1 stated, No. MDS Coordinator #1 was then asked if all fall interventions were from a generic list or were they individualized for the specific resident. They stated if staff started a new intervention then they updated or revised the care plan as needed. 46702 2. Resident #15 was admitted on [DATE] with diagnoses which included unspecified dementia without behaviors and anxiety. Resident #15's Care plan, date initiated 12/20/22 and revised on 10/23/24, documented interventions for fall focus, read in part, Fall interventions: purposeful staff rounding, proper seating in chair for W/C, ensure proper foot wear/nonskid socks, exercise program to improve balance, gait, strength, assist, staffing, environment, friendly to reduce clutter, assess medications - side effects and interactions - PCP and pharmacy review, educate resident regarding risk for falls, increased observation, increased activities, restorative care, staff education on falls and interventions, keep items within reach, bed, and low position when occupied with format. Answer, call promptly, re-orientate to call if needed, use of pictures to provide cues and reminders to call for staff assist, evaluate hearing, vision as needed, root cause analysis for falls, assess for illness, open, parentheses delirium, UTI, respiratory, infection, etc in parentheses, educate resident when applying intervention, create something that makes high-risk followers, identifiable, open, parentheses falling, leaf, pictures, etc. In parentheses involve all staff to prevent falls, maintain daily routine, assist WF/toileting before and after each meal, at bedtime as needed. Evaluate B/P for hypotension, rooms/bathrooms with adequate light, call light in reach of resident at all times and remind them to call for staff assist, PT evaluation, evaluate height of bed/toilet seat/chairs, etc. Offer nutritional stacks and meals, offer fluids, everyone- two hours during waking hours promote hydration, proper ambulation, assistive devices (walker, cane W/C space ETC.) and educate on proper use of devices. Resident #15's Morse Fall Scale assessment, dated 01/11/24, documented Resident #15 was at high risk for falling. The facility's Un-Witnessed Fall report, dated 02/08/24, read in part, Neighbor observed sitting on the floor at the foot of [their] bed. Wheelchair was flipped over as well. Neighbor stated [they] were getting up to go to the bathroom and grabbed at the wheelchair when [they] started to fall and it flipped over. Assessed for injuries, reports not hurt and did not hit [their] head. Has good ROM noted. Assisted to standing position and returned to bed. Resident #15's Morse Fall Scale assessment, dated 04/09/24, documented Resident #15 was at high risk for falling. The facility's Witnessed Fall report, dated 04/27/24, read in part, CNA informed nurse of neighbor laying on [their] floor. Neighbor observed to be laying on floor on [their] left side with top of head towards the restroom door,eyes facing towards hall.Neighbor bent at waist with feet and legs pointed towards the hall.ROM performed, neighbor c/o pain to BLE and to back rated at an 8. Asked [them] if [they] hit [their] head and suite mate stated that neighbor did hit [their] head.No skin impairments, hematoma, or injury noted to head. Eyes PERRLA.VS:165/93p-76, T-98.2, O2-92%RA, R-20.Neighbor assisted up slowly via x3 staff to sitting position and then slowly up to WC via x3 staff.Quartersized skin tear noted to left elbow.Call light was observed to be in reach but not on. Alarm to bed was noted to have light on but was not sounding. Neighbor began to vomit into emesis bag.Neighbor then taken to [name withheld] ER. Resident Description: When asked what happened neighbor stated that [they] was going to the restroom. When asked how come [they] didn't use the call light [they] stated 'I did. A Incident Report Form dated 04/27/24, read in part, resident observed lying on the bathroom floor by CNA. Resident stated [they] had gotten up to use the bathroom and fell . It also read, Resident was transferred to [name withheld]. Resident #15's hospital operative report , dated 04/29/24, read in part, L1 vertebral compression fracture. Resident #15's Care Plan fall focus, revised 08/05/24, read in part, [Resident #15] is a (high) risk for falls r/t weakness/gait/balance problems and impaired mobility. The care plan did not document interventions after the falls on 02/08/24 and 04/27/24. Resident #15's quarterly assessment, dated 11/04/24, documented their cognition was moderately impaired and they were dependent on staff for ADLs. On 12/11/24 at 11:43 a.m., MDS coordinator #1 was asked what was the facility fall protocol. They stated after a resident was assessed, they completed a report, and huddled with staff for documentation for additional ideas and interventions in the care plan. They were asked what interventions were added after the two falls on 02/08/24 and 04/27/24 to prevent future accidents and hazards. MDS Coordinator #1 stated there were no interventions added to the care plan after the two falls. They were asked about the fall interventions initiated on 12/20/22 and revised 10/23/24. They stated they had a list of interventions for falls and added them to all residents who fall. MDS Coordinator #1 stated those interventions were not specific to the resident, but all residents that fall. They stated that was part of their facility fall protocol. On 12/11/24 at 12:30 p.m., the administrator was asked to review the care plan for Resident #15. The administrator stated that there was no new interventions added after the falls on 02/08/24 and 04/27/24 and the care plan was not individualized and specific to the resident.

Based on record review and interview, the facility failed to ensure fall interventions were individualized and revised after a fall for residents assessed as a high risk for falls for two (#13 and #15) of two sampled residents reviewed for individualized care plans. The administrator identified 35 residents resided in the facility Findings: An undated facility Accidents policy, read in part, The intent of this policy is to ensure this facility provides an environment that is free from accidents hazards over which the facility has control and provides supervision and assistive devices are provided for each resident to prevent avoidable accidents. This includes: a. Identifying hazards and risk, b. Evaluating and analyzing hazards and risk, c. Implementing interventions to reduce hazard, and d. Monitoring for effectiveness and modifying interventions when necessary. The policy also read, Individualized, person centered interventions will be implemented, including adequate supervision assistive devices, to reduce risk related to hazards in the environment. A Falls and Fall Risk, Managing policy, revised December 2007, read in part the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A Comprehensive Care Plan, policy, dated 05/01/22 read in part, Each resident will have a person-centered comprehensive care plan developed and implemented to meet [their] preferences and goals and address the resident/s ,medical, physical, mental and psychosocial needs. The policy also read, The comprehensive care plan will be reviewed and revised, based on the changing goals, preferences and needs of the resident and in response to current interventions. 1. Resident #13 had diagnoses which included heart failure, weakness, dizziness, cataract, and anxiety. Resident #13's Care plan, date initiated 03/02/22 and revised 10/23/24, documented interventions for fall focus, read in part, Fall interventions: purposeful staff rounding, proper seating in chair for W/C, ensure proper foot wear/nonskid socks, exercise program to improve balance, gait, strength, assist, staffing, environment, friendly to reduce clutter, assess medications - side effects and interactions - PCP and pharmacy review, educate resident regarding risk for falls, increased observation, increased activities, restorative care, staff education on falls and interventions, keep items within reach, bed, and low position when occupied with format. Answer, call promptly, re-orientate to call if needed, use of pictures to provide cues and reminders to call for staff assist, evaluate hearing, vision as needed, root cause analysis for falls, assess for illness, open, parentheses delirium, UTI, respiratory, infection, etc in parentheses, educate resident when applying intervention, create something that makes high-risk followers, identifiable, open, parentheses falling, leaf, pictures, etc. In parentheses involve all staff to prevent falls, maintain daily routine, assist W/toileting before and after each meal, at bedtime as needed. Evaluate B/P for hypotension, rooms/bathrooms with adequate light, call light in reach of resident at all times and remind them to call for staff assist, PT evaluation, evaluate height of bed/toilet seat/chairs, etc. Offer nutritional stacks and meals, offer fluids, everyone- two hours during waking hours promote hydration, proper ambulation, assistive devices (walker, cane W/C space ETC.) and educate on proper use of devices. An Un-Witnessed Fall report, dated 08/01/24, read in part, resident observed laying on [their] stomach on the floor with no bottoms on. Urine and BM on the floor by the bathroom. Neighbor unsure of how [they] fell , just that [they] fell . Resident had abrasions noted to both knees and good range of motion. There was no documentation the care plan was updated with new specific interventions after the fall. A Fall Risk Assessment, dated 09/19/24, documented Resident #13 was a high fall risk with a score of 75. A Significant Change assessment, dated 09/23/24, documented Resident #13's cognition was severly impaired. It also documented Resident #13 was independent with walking with a walker and going to the bathroom independently. A Incident note, dated 11/29/24, read in part, resident reported fall in room- unknown how resident fell . Nurse called to dining room by hospice aid. 2 cuts noted near left eye brow, inner nose swollen and bruised, nurse took resident over to ER- resident refused to stay at ER. Nurse did treatment on eye brow with steri strips and family, PCP notified of her refusal of care in ER. There was no documentation the care plan was updated with new specific interventions after the fall. A Incident note, dated 12/10/24 at 10:41 a.m., read in part, Resident noted yelling out from room. [They]were sitting on floor at foot of bed next to side table. Left foot was rotated outward and [they] did not have ROM in this hip without having pain. [They] also had blood noted running down her cheek. Resident stated 'I fell , help me up and leave me alone' Cleaned face up to assess head wound, laceration appears to be superficial. Assisted [them] up into wheelchair without applying weight to left hip. Notified PCP and brought [them] to ER. Also notified DON, ADM, and [family member]. admitted to hospital. There was no documentation the care plan was updated with new specific interventions after the fall. On 12/12/24 at 11:02 a.m., MDS coordinator #1 was asked the policy for updating and revising interventions on the care plan. They stated they were updated as needed. MDS Coordinator #1 was asked to review Resident #13's care plan for falls and was then asked if fall interventions were updated or revised after the fall on 08/01/24. They stated no new interventions were put into place. They were then asked about the fall on 11/29/24. They were asked if there were fall interventions updated or revised. MDS Coordinator #1 stated, No. MDS Coordinator #1 was then asked if all fall interventions were from a generic list or were they individualized for the specific resident. They stated if staff started a new intervention then they updated or revised the care plan as needed. 46702 2. Resident #15 was admitted on [DATE] with diagnoses which included unspecified dementia without behaviors and anxiety. Resident #15's Care plan, date initiated 12/20/22 and revised on 10/23/24, documented interventions for fall focus, read in part, Fall interventions: purposeful staff rounding, proper seating in chair for W/C, ensure proper foot wear/nonskid socks, exercise program to improve balance, gait, strength, assist, staffing, environment, friendly to reduce clutter, assess medications - side effects and interactions - PCP and pharmacy review, educate resident regarding risk for falls, increased observation, increased activities, restorative care, staff education on falls and interventions, keep items within reach, bed, and low position when occupied with format. Answer, call promptly, re-orientate to call if needed, use of pictures to provide cues and reminders to call for staff assist, evaluate hearing, vision as needed, root cause analysis for falls, assess for illness, open, parentheses delirium, UTI, respiratory, infection, etc in parentheses, educate resident when applying intervention, create something that makes high-risk followers, identifiable, open, parentheses falling, leaf, pictures, etc. In parentheses involve all staff to prevent falls, maintain daily routine, assist with toileting before and after each meal, at bedtime as needed. Evaluate B/P for hypotension, rooms/bathrooms with adequate light, call light in reach of resident at all times and remind them to call for staff assist, PT evaluation, evaluate height of bed/toilet seat/chairs, etc. Offer nutritional stacks and meals, offer fluids, everyone- two hours during waking hours promote hydration, proper ambulation, assistive devices (walker, cane W/C space ETC.) and educate on proper use of devices. Resident #15's Morse Fall Scale assessment, dated 01/11/24, documented Resident #15 was a high risk for falling. The facility's Un-Witnessed Fall report, dated 02/08/24, read in part, Neighbor observed sitting on the floor at the foot of [their] bed. Wheelchair was flipped over as well. Neighbor stated [they] was getting up to go to the bathroom and grabbed at the wheelchair when [they] started to fall and it flipped over. Assessed for injuries, reports not hurt and did not hit [their] head. Has good ROM noted. Assisted to standing position and returned to bed. Resident #15's Morse Fall Scale assessment, dated 04/09/24, documented Resident #15 was a high risk for falling. The facility's Witnessed Fall report, dated 04/27/24, read in part, CNA informed nurse of neighbor laying on her floor. Neighbor observed to be laying on floor on [their] left side with top of head towards the restroom door,eyes facing towards hall.Neighbor bent at waist with feet and legs pointed towards the hall.ROM performed, neighbor c/o pain to BLE and to back rated at an 8. Asked [them] if [they] hit [their] head and suite mate stated that neighbor did hit [their] head.No skin impairments, hematoma, or injury noted to head. Eyes PERRLA.VS:165/93p-76, T-98.2, O2-92%RA, R-20.Neighbor assisted up slowly via x3 staff to sitting position and then slowly up to WC via x3 staff.Quartersized skin tear noted to left elbow.Call light was observed to be in reach but not on. Alarm to bed was noted to have light on but was not sounding. Neighbor began to vomit into emesis bag.Neighbor then taken to [name withheld] ER. Resident Description: When asked what happened neighbor stated that [they] was going to the restroom. When asked how come [they] didn't use the call light [they] stated 'I did. Resident #15's hospital operative report , dated 04/29/24, read in part, L1 vertebral compression fracture. Resident #15's Care Plan fall focus, revised 08/05/24, read in part, [Resident #15] is a (high) risk for falls r/t weakness/gait/balance problems and impaired mobility. The care plan did not document interventions after the falls on 02/08/24 and 04/27/24. Resident #15's quarterly assessment, dated 11/04/24, documented Resident #15's cognition was moderately impaired and they were dependent on staff for ADLs. On 12/11/24 at 11:43 a.m., MDS coordinator #1 was asked what was the facility fall protocol. They stated after a resident was assessed, they completed a report, huddled with staff for documentation for additional ideas and interventions in the care plan. They were asked what interventions were added after the two falls on 2/08/24 and 4/27/24 to prevent future accidents and hazards. MDS Coordinator #1 stated there were no interventions added to the care plan after the two falls. They were asked about the fall interventions initiated on 12/20/22 and revised 10/23/24. They stated they had a list of interventions for falls and added them to all residents who had falls. They stated those interventions were not specific to the resident, but all residents that fall. They stated it was part of their facility fall protocol. On 12/11/24 at 12:30 p.m., the administrator was asked to review the care plan for Resident #15. The administrator stated there were no new interventions added after the falls on 02/08/24 and 04/27/24. They stated the care plan was not individualized and specific to the resident.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours, seven days per week. The administrator identified 35 residents resided in the facility. Findings: A PBJ Staffing Report, dated 07/01/24 through 09/30/24, did not document any RN hours for 07/06/24, 07/07/24, 07/12/24, and 07/13/24. A Nurses Schedule, dated July 2024, were reviewed and schedule did not document RN coverage for 07/06/24, 07/07/24, 07/13/24, and 07/14/24. On 12/11/24 at 11:03 a.m., the administrator was asked what the facility policy for staffing an RN eight hours a day seven days a week. They stated the facility should have RN coverage eight hours a day, seven days a week. The administrator was then asked to review the nurses schedule for 07/06/24, 07/07/24, 07/13/24, and 07/14/24, then asked if the facility had RN coverage for those four days. They stated No.

Based on observation, record review, and interview, the facility failed to ensure a medication rate of less than 5%. A total of 25 opportunities were observed during the medication pass with two errors identified. The total medication error rate was 8% related to two medications held without physician orders for parameters to hold medications for one (#11) of three sampled residents observed during medication pass. The administrator identified 35 residents resided in the facility. Findings: A Adverse Consequences and Medication Errors policy, revised April 2024, read in part, a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders. Resident #11 had diagnoses which include hypertension, edema, and dementia. A Order Summary, dated 12/10/24, documented an order for quinapril [hypertensive medication] 10mg by mouth daily and Lasix (furosemide) (diuretic medication) 10mg daily for edema. There was no documentation in the order directions for holding either medication if the blood pressure reading was below certain parameters. On 12/10/24 at 8:15 a.m., a medication pass was conducted with CMA #1. The CMA stated that the quinapril 10mg and Lasix were being held due to a blood pressure reading of 96/59 for Resident #11. CMA #1 was asked what the parameters were for holding the Quinapril and Lasix. CMA #1 stated they were holding both medications due to a B/P reading of 96/59. CMA #1 was asked the reason Lasix was being held due to B/P being low. CMA #1 had no response. The quinapril and Lasix medications were not given. On 12/10/24 at 9:24 a.m., the DON was asked what medications should be held if not in parameters. The DON stated blood pressure and insulin medications. The DON was then asked what would a Lasix medication be held for. The DON stated they were not sure about holding a diuretic medication.

Based on observation, records review, and interview, the facility failed to ensure staff washed their hands between residents while assisting dependent residents with feeding for three (#11, 19, and #35) of three sampled residents observed during dining. The DON identified six residents required assistance during meals. Findings: The facility's Handwashing/Hand Hygiene policy, revised 08/2015, read in part, Use an alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: The policy also read, Before and after assisting a resident with meals. 1. Resident #11 was admitted on [DATE] with diagnoses which included unspecified dementia and delusional disorder. Resident #11's quarterly assessment, dated 09/30/24, documented the resident's cognition was significantly impaired and required supervision or touching assistance with eating. 2. Resident #19 was admitted on [DATE] with diagnoses which included Alzheimer's disease and metabolic encephalopathy. Resident #19's quarterly assessment, dated 10/21/24, documented the resident's cognition was significantly impaired and they were fully dependent on staff for eating assist. 3. Resident #35 was admitted on [DATE] with diagnoses which included legal blindness, adjustment disorder with depression, and anxiety disorder. Resident #35's quarterly assessment, dated 11/04/24 documented the resident's cognition was mildly impaired and they required partial to moderate assistance with eating. On 12/09/24 at 11:20 a.m., the DON was observed feeding Resident #19 on their right side using their right hand with no glove. The DON then stopped and turned to the resident on their left and picked up Resident #11's eating utensil with their right hand and assisted Resident #11 with feeding. No hand washing or sanitizing between residents was observed between feeding Resident #19 and Resident #11. The DON was then observed getting up from their chair and went to Resident #35. The DON used their right hand and touched Resident #35's plate, patted the resident's shoulder, and sat back down and resumed feeding Resident #19. No hand washing or sanitizing between residents was observed. On 12/09/24 11:25 a.m., the infection preventionist stated they witnessed no hand washing or sanitizing between the residents during dining when the DON was assisting separate residents. They stated they were unsure of the policy and would have to review it. On 12/09/24 at 12:49 p.m., the DON was asked what the infection control issues were during dining on 12/09/24 at 11:20 a.m. The DON stated they got up to move pie on Resident #35's plate, patted Resident #35 on the shoulder, returned their chair to Resident #19 to give a bite, and turned to the right to feed Resident #11 without sanitizer or hand washing between the residents. The DON stated they should of sanitized between each resident.

Based on record review and interview, the facility failed to ensure a resident's physician and family representative was notified of inappropriate behaviors for one (#35) of 16 sampled residents who were reviewed for notifications. The DON identified 35 residents resided in the facility. Findings: Resident #35 was admitted on [DATE] with diagnoses which included legal blindness, adjustment disorder with depression, and anxiety disorder. Resident #35's quarterly assessment, dated 11/04/24, documented the resident's cognition was mildly impaired. A progress note, dated 12/08/24, read in part, Reported by CNA that neighbor was in dining room this morning at breakfast sitting at the table and stood up and pulled [their] pants down and peed on the floor. On 12/10/24 at 10:03 a.m., Resident #35's POA stated they were not notified of the incident on 12/08/24. On 12/12/24 at 11:33 a.m., LPN #2 was asked who and when was someone contacted when a resident had a behavior like pulling pants down in front of others and urinating on the floor. LPN #2 stated they should contact the physician, the family, the DON, and the administrator. They were asked about Resident #35's behaviors. They stated Resident #35 stood up and pulled their pants down and urinated on the floor on 12/08/24 in the dining room. They stated there was no information in the EHR that anyone was contacted regarding the behavior on 12/08/24. On 12/12/24 at 11:40 a.m., the DON was asked to discuss the facility's policy for contacting individuals when there was a behavior in front of other residents such as exposing self and urinating in front of others. They stated first discreetly redirect, notify the charge nurse, notify house keeping, write a progress note, notify family, and the provider. The DON was asked who was contacted on 12/08/24 after the incident. They stated the behavior was out of character for Resident #35 and it was not documented in the EHR the family or the physician was notified. They stated they were unaware if there was a policy regarding notifications. On 12/12/24 at 11:48 a.m., the administrator was asked to discuss the facility's policy for contacting individuals when there was a behavior in front of other residents such as exposing self and urinating in front of others. The administrator stated they should contact the family, the PCP, and the psych provider. They were asked who was contacted on 12/08/24 after the incident in the dining room involving Resident #35. The administrator stated there was no documentation in the EHR the family and/or physician, or psych provider was contacted. They stated the facility did not have a policy regarding notifications.

Based on observation, record review, and interview, the facility failed to ensure the facility policy to change O2 tubing was followed for one (#5) of one sampled resident reviewed for O2 tubing. The DON identified 12 residents had physician orders for O2 therapy. Findings: The facility's Departmental (Respiratory Therapy)-Prevention of Infection policy, revised 11/2011, read in part, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff. The policy also read, Change the oxygen cannula and tubing every (7) days, or as needed. Resident #5 was admitted on [DATE] with diagnoses which included Bartter's syndrome, chronic obstructive pulmonary disease, and anxiety disorder. Resident #5's physician orders, dated 06/19/24, documented O2 at 2 liters via nc and as needed for SOB and HS. On 12/09/24 at 1:35 p.m., Resident #5's O2 tubing was observed labeled in pen on white tape and dated 11/01/24. On 12/12/24 at 2:53 p.m., LPN #2 was asked how often O2 tubing was changed per policy. They stated it should be changed once a month and labeled. They were asked to look at resident #5's O2 tubing and what date was on the O2 tubing. They stated it was dated 11/01/24 and it should of been changed the first of December. On 12/12/24 at 2:57 p.m., the DON what asked what was the facility's policy for changing residents O2 tubing. The DON stated O2 tubing should be changed bimonthly on the first and the 15th by the night nurse. The DON stated there was a form to be completed and it was not documented the O2 tubing was changed. On 12/12/24 at 3:15 p.m., the administrator was asked what the policy was for changing O2 tubing. The administrator stated the tubing should be changed the first of every month. The stated O2 tubing dated 11/01/24 does not follow the policy.

Based on observation, record review, and interview, the facility failed to ensure a diuretic and blood pressure medication were administered per physician's orders for one (#11) of three sampled residents observed during medication pass. The administrator identified 35 residents resided in facility. Findings: A Adverse Consequences and Medication Errors policy, revised April 2014, read in part, a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications. It also read in part, examples of medications errors include: omission- a drug is ordered but not administered. Resident #11 had diagnoses which included hypertension, edema, and dementia. A Order Summary dated 12/10/24, documented order for quinapril (hypertensive medication)10mg by mouth daily and Lasix (furosemide) (diuretic medication) 10mg daily for edema. There was no documentation in the order directions for holding either medication if the blood pressure reading was below certain parameters. On 12/10/24 at 8:25 a.m., CMA #1 was observed holding Resident #11's Lasix 20mg and quinapril 10mg due to a blood pressure of 96/49. CMA #1 was asked why the Lasix was being held. They stated because the blood pressure was low. CMA #1 was then asked if Lasix normally was held for low blood pressure, CMA #1 had no response. CMA #1 was asked what the parameters were for holding the quinapril. They stated it was on the order to hold it. There were no orders found regarding the parameters to hold Lasix or quinapril if blood pressure was too low or to high. On 12/10/24 at 9:24 a.m., the DON was asked what medications should be held if no parameters given by doctor. The DON stated blood pressure and insulin medications. The DON was then asked the reason a diuretic medication would be held. The DON stated they were not sure. The DON was asked to review the Lasix and quinapril orders for Resident #11. The DON was asked if there was an order to hold Lasix for any reason. The DON stated, No. The DON was then asked if there was a parameter written in the order for quinapril. The DON stated, No. The quinapril and Lasix medications were not given. On 12/10/24 at 11:51 a.m., the DON was asked what the facility policy was for medication errors. The DON stated if found, the CMA was to inform the nurse, the nurse informed the DON, and DON informed the doctor. The DON stated then they write up a medication error.

Based on record review, observation, and interview the facility failed to: a. ensure temperatures were obtained and foods were held at 135 degrees on the holding table, and b. ensure dishes and utensils were cleaned/sanitized to prevent food borne illness. The Administrator identified 40 residents who received their meals from the kitchen. Findings: A policy titled, Food Temperatures, review date [DATE], read in part, . Ensure food is served at a safe temperature to prevent food-borne illness .Hot Foods should be maintained at a minimum of 135 degrees F . A policy titled, Dish Washing, review date [DATE], read in part, .Low Temperature Dishwasher(chemical sanitization): Wash-120 degrees F and Final Rinse-50 ppm .hypochlorite .on dish surface in final rinse .The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines . A Monitoring Record, dated [DATE] to [DATE], documented on [DATE], [DATE] and [DATE] holding table temperatures were only recorded one time on these dates. Breakfast items Hot cereal and eggs was the only food items that were documented with temperature checks for the month of [DATE]. On [DATE] at 7:50 a.m., holding table temperatures was obtained with Cook #1 and were as follows: Scrambled eggs 80 degrees, bacon 100 degrees, Malt O Meal 100 degrees, oatmeal 110 degrees, and white gravy 110 degrees. Cook #1 was asked what should the temperature be held at on the holding table. Cook #1 stated, ,d+[DATE]. On [DATE] at 7:58 a.m., the DM was asked what temps should be on the holding table. The DM stated, 165 degrees. The DM was informed the holding table temps were not above 110 on anything temped with Cook #1. The DM was asked if the food should be served to the residents. The DM stated No, it should not. On [DATE] at 8:04 a.m., Cook #1 was observed to plate Malt O Meal, bacon and toast. Cook #1 was asked to obtain a temperature on the Malt O Meal. The Malt O Meal temperature was 120 degrees. Cook #1 sent out the tray to a resident. On [DATE] at 8:06 a.m., the DM took holding temps again with a different thermometer, the results were as follows: Oatmeal 135, white gravy 138, bacon 118 and sausage patty 110. The DM stated, I usually throw the sausage on the grill prior to serving to get the temp up. The DM was asked how they ensured other staff would do the same. The DM stated, I trained them. On [DATE] at 9:55 a.m., The DM was observed using the chemical testing strip during a dishwashing cycle. The testing strip did not register/show any color on the testing strip. The DM attempted to check another cycle and was asked what the strip was showing. They stated, 10 ppm. The DM was asked what should it be. The DM stated, At least 50 ppm. The DM was asked if there had been any recent gastrointestinal outbreaks in the facility. The DM stated, No. The vial of testing strips was observed and had an expiration date of ,d+[DATE]. The DM was unaware the strips being used were expired On [DATE] at 10:20 a.m., DA #1 was asked if they had washed dishes today. DA #1 stated, Yes, I ran the jail dishes. DA #1 was asked what time the dishes were washed. DA #1 stated, Right before 10 [a.m.]. DA #1 was asked if the chemicals were checked. They stated, I didn't. DA #1 was asked how often should chemicals be checked. They stated, Before every meal or every time we start dishes for meals. On [DATE] at 10:22 a.m., DA #2 was asked if they knew the strips were expired. They stated, yes. DA #2 was asked how often the test strips were used. They stated, three times a day. They were asked if they noticed the test strips not reading correctly. DA #2 stated, Yes, was supposed to have 2 new bottles, but I don't know where they are. DA #2 was asked when was the last time they had washed dishes. DA #2 stated, Yesterday, it keeps showing 10 ppm. DA #2 was asked if they had notified anyone. DA #2 stated, Yes my boss [DM]. A dishwashing record, dated [DATE], documented from [DATE] through [DATE], chemical sanitization was 100 PPM three times a day. On [DATE] at 10:30 a.m., the Administrator was asked what the facility would put into place for meals. They stated, We will use paper plates. The Administrator stated, they were not aware of the issue with the chemicals. On [DATE] at 11:10 a.m., the Administrator was asked what temperature should food be on the holding table. They stated, At least 135. The Administrator was asked how often should holding temps be checked. They stated, Every meal. The Administrator was asked how long has the chemicals for the dishwasher been out. They stated, the strips were outdated, and they didn't know how long the strips had been used. On [DATE] at 11:21 a.m., the DM approached this surveyor and stated, I ordered the strips today. The DM was asked what staff had been using. They stated, the expired ones. The DM was asked when they were aware the strips weren't working. The DM stated, They didn't tell me. I was aware of them today. On [DATE] at 12:55 p.m., the DM was asked to review the monitoring records for the month of July. The DM acknowledged holding table temperatures were not obtained correctly.

Based on record review, observation, and interview, the facility failed to report and investigate an injury of unknow origin for one (#24) of one sampled resident reviewed for abuse. The Resident Census and Conditions of Residents, dated 07/19/22, documented 40 residents resided in the facility. A policy titled, Abuse, Neglect, Mistreatment And Misappropriation of Resident Property, approved 05/26/21, read in part, .It is the policy of this facility that reports of abuse ( .including injuries of unknown source .) are promptly and thoroughly investigated .REPORTING AND RESPONSE .The facility will ensure that all alleged violations involving abuse .including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made .in accordance with State law . Findings: Resident #24 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24's admission assessment, dated 06/08/22, documented the resident's cognition was moderately impaired. On 07/19/22 at 10:39 a.m., Resident #24's right hand was observed swollen. The swelling was observed to start above the resident's right wrist and continued to their fingers. There was no documentation in the resident's clinical record regarding an incident that happened to the resident's right hand/wrist. On 07/20/22 at 2:28 p.m., the administrator was asked if the resident had an injury to their right hand. They stated they weren't aware of the resident's hand and didn't see anything documented. On 07/20/22 at 2:35 p.m., LPN #2 was observed to look at the resident's right hand. They stated the resident's hand and wrist were kind of puffy. On 07/20/22 at 2:45 p.m., LPN #1 was observed to look at the resident's right hand. They stated, it's kind of swollen. On 07/20/22 at 3:32 p.m., the Administrator was asked what had been done about Resident #24's hand. They stated, the resident was sent to the hospital for an x-ray. The DON stated, I think it was an incident down in the dining room where [resident] was swinging .arms and .walker. I think I saw a note where one of the CNA's wrote [residents] hand was red. Just on a piece of paper where they told the nurse. The nurse said they didn't follow up on it. The DON was asked who was the nurse. The DON stated, LPN #2. On 07/20/22 4:04 p.m., the DON was asked what the process was when staff reports an injury or abnormal finding. The DON stated the nurse should follow up on it and document it. The administrator stated an investigation needed to be started.

Based on record review, observation, and interview the facility failed to assess, monitor and intervene for an injury of unknown origin for one (#24) of one sampled resident reviewed for injury. The Resident Census and Condition report, dated 07/19/22, documented 40 residents resided in the facility. Findings: Resident #24 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24's admission assessment, dated 06/08/22, documented the resident's cognition was moderately impaired. On 07/19/22 at 10:39 a.m., Resident #24's right hand was observed swollen. The swelling was observed to start above the resident's right wrist and continued to their fingers. There was no documentation in the resident's clinical record regarding an incident that happened to the resident's right hand/wrist. On 07/20/22 at 2:28 p.m., the administrator was asked if Resident #24 had an injury to their right hand. They stated they weren't aware of the resident's hand and didn't see anything documented. On 07/20/22 at 2:30 p.m., the DON and LPN #2 came into the room. The Administrator, DON and LPN #2 was asked if there was any documentation about the residents hand. They stated, they did not see anything. On 07/20/22 at 2:35 p.m., LPN #2 was observed to look at the resident's right hand. They stated the resident's hand and wrist were kind of puffy. On 07/20/22 at 2:45 p.m., LPN #1 was observed to look at the resident's right hand. They stated, it's kind of swollen. On 07/20/22 at 3:32 p.m., the Administrator was asked what had been done about Resident #24's hand. They stated, the resident was sent to the hospital for an x-ray. The DON stated, I think it was an incident down in the dining room where [resident] was swinging .arms and .walker. I think I saw a note where one of the CNA's wrote [residents] hand was red. Just on a piece of paper where they told the nurse. The nurse said they didn't follow up on it. The DON was asked who was the nurse. The DON stated, LPN #2. On 07/20/22 at 4:04 p.m., the DON was asked to describe what the process/expectation was when a CNA reports an unknown injury or abnormal finding to the nurse. The DON stated the nurse should follow up on it and document it. The Administrator stated the CNA should go to the charge nurse, so an investigation can be started. A Health Status Note, created 07/20/22 at 4:56 p.m., read in part, .Late Entry on 07/17/2022 at 20:00 [8:00 p.m.] .it was reported by off going shift that [Resident #24] had some behaviors over the weekend and may have hurt right hand. CMA reported that [Resident #24] had complained to [CMA] that [resident's] right hand was numb. This nurse question [Resident #24] the evening of the 17th about this during 1900-2300 [7:00 p.m.-11:00 p.m.] shift and [resident] moved it around and said it was fine. Nothing further was reported or mentioned by [resident] that evening. Hand was a little red and puff at the time this nurse talked to [Resident #24]. It was passed on to night shift to notify AM shift about what happened if [resident] had any complaints of pain or numbness on Monday morning. Note was passed on about hand, but [Resident #24] never complained about discomfort to anyone the next day .

Based on record review, observation, and interview, the facility failed to ensure FSBS was obtained prior to administering sliding scale insulin for one (#41) of one sampled resident reviewed for insulin administration. The MDS coordinator identified six residents received insulin. Findings: A policy titled, Resident-Centered Medication Pass, review date 05/01/22, read in part, .Purpose: Allow administration of medications according to a resident's schedule/routine while ensuring the safe and accurate administration of all medications .Exceptions to the Resident-Centered Medication Pass Policy/Procedure: Insulin should be administered consistently each day . Resident #41 was admitted with diagnosis of diabetes mellitus. A Physician's Order, dated 03/17/18, documented to administer [MEDICATION(S)] Solution eight units for a FSBS between 151-200. A Physician's Order, dated 06/22/21, documented to obtain FSBS before meals and at bedtime. Resident #41's quarterly assessment, dated 07/04/22, documented the resident's cognition was moderately impaired. It documented the resident received seven insulin injections in a seven day period. On 07/21/22 at 8:12 a.m., LPN #1 stated the resident's FSBS was obtained by the night shift nurse. They stated the FSBS was 155 at 6:18 a.m. LPN #1 was asked if they would recheck FSBS prior to administering the insulin. LPN #1 stated, I usually don't. LPN #1 was observed to draw up eight units of [MEDICATION(S)]. LPN #1 was observed to administer the insulin without obtaining a FSBS. On 07/21/22 at 11:10 a.m., the administrator was asked when was a FSBS to be obtained before administering insulin. They stated, Immediately. The administrator was asked if sliding scale insulin should be administered approximately two hours after a FSBS was obtained. They stated, Absolutely not.

Based on record review and interview, the facility failed to follow up on a physician's response on a GDR for one (#17) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents, dated 07/19/22, documented four residents received antipsychotic medications. Findings: Resident #17 was admitted with diagnoses of [CONDITION(S)] [CONDITION(S)] and dementia with behavioral disturbance. A Physician's Order, dated 10/13/21, documented the resident was to receive [MEDICATION(S)] once a day. A Medication Regimen Review, dated 01/07/22, read in parts, .Could a reduction be tried for the [MEDICATION(S)] . The physician's response read in parts, .defer to .psych provider . There was no documentation in the resident's clinical record the GDR was followed up on. Resident #17's quarterly assessment, dated 05/23/22, documented the resident's cognition was intact. It documented the resident received seven antipsychotic medications in seven days. It documented a GDR hadn't been attempted and there was no documentation of a contraindication. On 07/20/22 at 3:27 p.m., the DON was asked what the policy was for recommendations from the pharmacy. They stated they faxed the recommendations to the physicians and waited to receive the response. They stated the nurses were to document the response. The administrator stated the psych provider completes visits once a month, or as needed, via telemedicine. On 07/21/22 at 11:10 a.m., the administrator was asked for documentation for Resident #17's January 2022 GDR had been addressed by the psych provider as the physician documented. On 07/21/22 at 12:39 p.m., the DON stated there was no documentation located.

Based on observation, record review and interview, it was determined the facility failed to ensure: ~ a resident with a physician's order for pureed diet was provided the correct portion size of cooked turkey for one (#15) and ~ residents with a physician's order for regular texture diet were provided the correct portion size of cooked turkey, stuffing and green bean casserole for two (#22 and #27) of three sampled residents reviewed for meal services. The DM identified four residents with physician's orders for a pureed texture diet and 26 residents with physician's orders for regular texture diet. Findings: On 05/13/21 at 11:06 a.m., cook #1 was observed to prepare cooked turkey in the processor machine for the pureed diets. The cook stated, according to the menu, the resident was to receive four ounces of pureed turkey. The cook utilized an one ounce scoop and placed two scoops of the pureed turkey on a plate. The cook was asked if the scoop was a two ounce scoop. The cook stated, I do not know the size. The DM gave this to me. At 11:29 a.m., the DM was informed the cook had not served the recommended portion size of pureed cooked turkey. The DM acknowledged the recommended portion of cooked turkey was 4 ounces and a different scoop should have been utilized. At 11:37 a.m., cook #2 was observed to place stuffing and green bean casserole utilizing a two ounce scoop. The recommended portion size was a four ounce scoop. The DM was observed to remove the two ounce scoops and replaced them with four ounce scoops. At 11:40 am the DM was asked if the recommended portion size was plated and served. The DM acknowledge the incorrect portion size was plated and served.

Based on observation, record review, resident and staff interviews, it was determined the facility failed to ensure: ~ respiratory medications were administered per the standards of practice for two [# 4 and #185] of three sampled residents reviewed for respiratory services and ~ oxygen saturations were assessed per the standards of practice for one [#185] of three sampled residents reviewed for respiratory services. The facility identified eight residents received oxygen therapy and 14 residents received nebulizer treatments. Findings: A facility policy titled, Pulse Oximetry (Assessing Oxygen Saturation), revised 10/2010, documented, .The purpose of this procedure is to monitor arterial blood oxygen saturation (SaO2) without the use of invasive devices .Normally [pulse oxygen saturation] is between 90 and 100 percent .if less than acceptable level .notify physician . A facility policy titled, Administering Medications through .(Handheld) Nebulizer, revised 10/2010, documented, The purpose of this procedure is to safely .administer aerosolized particles of medication into the resident's airway .Dispense medication into nebulizer cup .Turn on the nebulizer and check the outflow port for visible mist .Remain with the resident for the treatment .five minutes after treatment begins .obtain the resident's pulse .Obtain post-treatment pulse, respiratory rate and lung sounds .Rinse and disinfect the nebulizer equipment .The following information should be recorded in the resident's medical record .Pulse, respiratory rate and lung sounds before and after treatment . 1. Resident #4 was readmitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Solution 0.5-2.5 (3)MG/ 3ML .3 ml inhale orally four times a day . The May 2021 TAR documented the [MEDICATION(S)] was to be administered at 8:00 a.m., 11:00 a.m., 5:00 p.m. and 9:00 p.m. On 05/13/21 at 9:31 a.m., the resident was observed in dining room with staff providing assistance with breakfast. At 10:03 a.m., the resident was observed being assisted back to their room by staff. At 10:04 a.m., staff were observed exiting the resident's room and the resident was observed sitting up in their wheel chair. At 10:52 a.m., the resident's TAR documented the 11:00 a.m. [MEDICATION(S)] had been administered. There was no observation a nurse had administered the nebulizer treatment from 9:31 a.m. to 10:52 a.m. 2. Resident #185 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) MG/3ML 1 dose inhale orally four times a day . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Continuous oxygen at 4L NC three times a day . The May 2021 TAR did not contain documentation that oxygen saturation was obtained. The May 2021 TAR documented the [MEDICATION(S)]-[MEDICATION(S)] solution was to be administered at 8:00 a.m., 11:00 a.m., 5:00 p.m. and 9:00 p.m. The weights and vitals summary report documented two oxygen saturation reading had been completed on 05/10/21 and 05/16/21. On 05/11/21 at 2:10 p.m., the resident was observed sitting on their bed with the nebulizer mask on their face and the machine was on. There was no nurse observed in the room. At 2:15 p.m., the resident was observed to turn the machine off and placed the mask on the machine. There was no nurse observed in the room. On 05/13/21 at 9:26 a.m., the resident was observed in their bed resting with their eyes closed. At 10:52 a.m., the resident was observed walking to their restroom. There was no staff observed in the room. At 10:53 a.m., the resident's TAR documented the 11:00 a.m. [MEDICATION(S)]-[MEDICATION(S)] solution had been administered. There was no nurse observed to have administered the nebulizer treatment from 9:26 a.m. to 10:53 a.m. At 11:42 a.m., the resident was asked if he had received his 11:00 a.m. nebulizer treatment. The resident looked at his watch and stated, No, and it is almost noon. On 05/17/21 at 3:48 p.m., the resident was observed sitting on his bed with the nebulizer mask on and the machine was running. There was no staff observed in his room. At 3:59 p.m., the resident was observed to have the nebulizer mask on and the machine was running. There was no staff observed in his room. At 4:00 p.m., the resident was observed to turn the nebulizer machine off and placed the mask next to the machine. At 4:08 p.m., there was no staff observed to have assessed the resident after the administration of the breathing treatment. On 05/18/21 at 10:30 a.m., the resident was asked to describe what the staff did when they brought his breathing treatment. He stated staff would place the contents of the medication solution into the nebulizer compartment and leave his room. He was asked if the nurse listened to his lungs or checked his vital signs. He replied, No, they put it in the machine and leave. I put the mask on, turn it on, do it and when it's finished, turn it off. He stated he had not received his 11:00 a.m. breathing treatment. At 10:53 a.m., the resident's TAR documented the 11:00 a.m. breathing treatment had been administered. At 10:57 a.m., LPN #1 was asked how often the oxygen saturation was obtained for a resident receiving oxygen therapy. She stated a resident on continuous oxygen should have oxygen saturation checked every shift. She stated it would show on the TAR to be documented. She was asked to describe the procedure when a resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she would leave for 15 minutes, return and turned off the machine. At 11:05 a.m., LPN #3 was asked if she had administered the resident's 11:00 a.m. breathing treatment. She stated, No, I have not. She was asked to describe the procedure when a resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she would leave the room and returned to ensure the resident had completed the treatment. She was asked how often the oxygen saturations were obtained for a resident receiving oxygen therapy. She stated oxygen saturation was checked twice a shift and as needed She stated the oxygen saturations were documented in the nurse's notes or in the vital signs. At 11:17 a.m., the DON was asked to explain the policy for administering the nebulizer treatment. She stated staff should check oxygen saturation and listen to lung sounds before and after the treatment. At 11:26 a.m., the DON was asked how often the oxygen saturations were obtained for a resident receiving oxygen therapy. She stated the facility staff checked every shift. She was asked to review resident's records and show where the oxygen saturation had been checked every shift. She said, It was only documented in system twice. At 11:32 a.m., the DON was asked if the residents administered their own breathing treatments. She stated they didn't but she didn't know the policy for the breathing treatments. She stated she had left a resident during a breathing treatment as well. The DON was made aware and acknowledged the findings.

Based on observation and interviews, it was determined the facility failed to ensure a homelike environment was maintained regarding room temperatures for 13 (#8 and 12 resident council group members) of 13 residents who were reviewed for temperatures. The facility census was 34. Findings: On 05/11/21 at 2:09 p.m., resident #8 was observed to be in her bed with covers across her forehead and from the neck down. Only her face and eyes were exposed. The resident repeatedly called out, It's cold, cold. An attempt was made to interview the resident further but was unsuccessful. On 05/11/21 at 3:49 p.m., the following room temperatures were obtained: ~ Near room 218, the air temperature was 64.2 F; ~ Room 117, the air temperature was 68.7 F. At 4:00 p.m., the air room temperature in the therapy room was 68.5 F. At 4:07 p.m., the air temperature in Room 212 was 66.6 F. On 5/12/21 at 3:30 p.m., 12 alert and oriented residents attended the resident council interview. The residents reported they were always cold. The residents were asked if they had voiced this concern to the staff. They stated the maintenance man was aware but told them the boiler system was antique and could not be turned on and off, switching frequently. A resident stated stated they were informed it would take 2-3 days for the switch to make warm water to heat the air, and the cold snap would be over before the rooms would be warm. One resident reported the a/c was turned on the past weekend. All residents stated the a/c remained on but was supposed to be turned so the fans would not kick on. The residents were asked what staff did if they told them they were cold. They stated, We are offered another blanket. On 05/18/21 at 9:25 a.m., the administrator and AIT were asked if they were aware of the residents' complaints of being cold. The AIT stated the facility struggled with situation every year due to having a boiler type heating/cooling system. He stated this made it difficult to determine when to change the system from heat to cold.

Based on observation and interviews, it was determined the facility failed to make survey results readily available to residents. This had the potential to affect 34 of 34 residents who resided in the facility. Findings: On 05/12/21 at 3:30 p.m., during the resident council interview, twelve residents were asked if the survey results were available to them. The residents stated they could read the results if they told someone they wanted to read them. They stated the request information was posted on the bulletin board next to the front offices. On 05/13/21 at 9:33 a.m., the bulletin board next to the administration offices was observed to have a form labeled [Facility] Nursing Home. The form documented, .Items available in the Public Inspection File accessible to residents, employees and visitors .complete copy of inspection reports .copy of most recent inspection report by OSDH . At 10:03 a.m., RN #1 and BOM were asked where the last survey results were posted. The BOM stated a copy was in the administrator's office for review, and she had one in her office at the other side of the building. They were asked if the information was readily available to residents. RN #1 stated the results were not accessible to the residents due to being in the office areas only.

Based on resident and staff interview, it was determined the facility failed to ensure residents received mail on Saturdays. This had the potential to effect 34 of 34 residents who resided at the facility. Findings: On 05/12/21 at 3:30 p.m., 12 residents that were alert and oriented attended the entirety of the resident council interview. They stated they did not receive mail on Saturdays. They stated the social services and activities persons did not work on the weekend, so mail was not delivered to the residents' rooms. On 05/13/21 at 10:03 a.m., RN #1 and BOM were asked if the residents received mail on Saturdays. They stated the aides were to get the mail from the mailbox on the property and deliver it to the residents. They were asked if this was being completed. They stated they were not aware of a problem but would have to check into it. On 05/18/21 at 10:07 a.m., the administrator and AIT were asked if the residents received mail on Saturdays. The AIT stated there was a mailbox outside, but the staff may not be retrieving it.

Based on record review and interviews, it was determined the facility failed to ensure the resident right for the use of personal furnishings was permitted for four of twelve residents who attended the resident council interview. This had the potential to affect 36 residents who resided in the facility. Findings: A form labeled Information for Incoming Neighbors and Family Members (Effective 8/01/2020 documented, .Things to bring upon admission: .Recliner (must be leather or vinyl, not cloth . A policy was not located to address personal property restrictions being brought into the facility. On 05/12/21 at 3:30 p.m., a total of 14 residents attended the resident council interview. Twelve remained throughout the entirety of the session. The residents were asked what rules they had been informed of regarding furniture from home. They stated the staff had informed them their recliners were required to be leather covered or they could not bring their recliner into the facility. Several residents stated they had been informed the recliners they had at home were covered in microfiber and were not acceptable. Several residents stated they were using recliners that were too big and uncomfortable. One resident stated her family took her to 5 furniture stores to purchase a new recliner in leather but were unable to find one that was not too large. She stated she was made to use a leather recliner that was too big and very uncomfortable while she had a recliner at home that was new but not leather covered. On 05/13/21 at 10:27 a.m., social services #1 was asked if there were any restrictions regarding residents' personal furniture brought into the facility. She stated the admission packet addressed the furniture. She stated there were specific instructions that recliners were required to be made of leather or vinyl and could not be made of cloth. She was asked if the facility had a policy regarding restrictions of residents' personal property/recliners. She stated she was not aware of a written policy. At 10:43 a.m., the BOM and RN #1 was asked if the facility had a policy for residents to be aware of regarding what items they might or might not bring into the facility from home. RN #1 stated, I think they do. The BOM stated the residents were not allowed to bring in cloth recliners. RN #1 requested time to look for a policy. On 05/18/21 at 9:25 a.m., an interview was conducted with the administrator and AIT. They were asked if the facility had a policy regarding personal furniture brought into the facility from home. The administrator stated the facility had a policy that recliners from home must be leather or vinyl. AIT placed a call to inquire of the policy. The BOM arrived with information from the admission packet. The three staff members were asked if the facility had a written policy regarding the restrictions of furniture brought into the facility from home. The administrator, AIT. and BOM all acknowledged the facility did not have a policy regarding personal furniture.

Based on record review and interviews, it was determined the facility failed to ensure residents who received insulin were assessed and monitored. This affected one (#30) of five residents reviewed for unnecessary medications. The facility identified seven residents received insulin injections. Findings: Resident #30 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The FSBS result records documented: ~On 03/28/21 at 612 a.m., the resident FSBS resulted at 422 mg/dl; ~On 03/29/21 at 6:19 a.m., the resident FSBS resulted at 456 mg/dl; and ~On 03/30/21 at 6:27 a.m., the resident FSBS resulted at 446 mg/dl. There was no documentation the FSBS had been repeated to assess and/or monitor the resident condition on 03/28/21 or 03/29/21. A significant change of assessment dated [DATE], documented the resident received insulin injections 7 of 7 days of the assessment period The resident care plan, last updated on 04/27/21, documented, .has Diabetes Mellitus .Monitor/document/report .any s/sx of [CONDITION(S)] . The care plan did not document parameter goals for the FSBS, or nursing interventions for elevated FSBS. There was no documentation for instruction of parameters goals to notify physician of elevated results The current physician orders documented the following: ~administer novolog 12 units twice a day; ~obtain FSBS before meals, at bedtime and as needed. ~administer [MEDICATION(S)] quick pen [insulin] 50 units at bedtime. The physician orders did not document parameter goals for the FSBS, when to repeat the FSBS, nursing interventions or when to notify the physician. 05/18/21 at 9:20 a.m., LPN #1 was asked to review the FSBS in the clinical record. She was asked how often the FSBS were obtained. She stated the facility was obtaining FSBS every morning. LPN #1 was asked if there were any orders/instruction regarding the FSBS results to have parameter for notification. She stated, No, we were just to watch her for a few days. LPN #1 was asked how would staff know when to notify the physician. She stated she would have to look at the information sent from the hospital because there were no written orders. LPN #1 was asked if the physician was notified of the elevated FSBS on 03/28/21 or 03/29/21. She stated she did not know. At 1130, the DON was asked if the resident had been assessed/monitored for elevated FSBS on 03/28/21 or 03/29/21. After she reviewed the clinical record, she stated, It does not look like it. The DON was asked if the physician had been notified. She stated would there are some communication issues at times.