Every finding on record at Berea Health & Rehab Center

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to store food, in one of one kitchens, in a sanitary manner.The findings include:On 3/3/26 at 12:00 PM, an observation was conducted in the kitchen with the following findings: in the walk-in refrigerator, observation of a two-gallon zip lock bag unsealed with fish dated 3/2/26. The cook sealed the zip lock bag. The cook stated, the bag should be completely sealed, it was not, our standard is to have refrigerated food in sealed containers.On 3/4/26 at 5:00 PM, the Administrator and the Director of Nursing were informed of the above concerns.A review of the facility's Storage of Refrigerated Foods policy revealed, Store all food/leftovers in covered, approved, food grade containers.No further information was provided prior to exit.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to follow infection control practices for two of 36 residents in the survey sample, Residents #26 and #17 and in one of one laundry room.The findings include:1. For Resident #26 (R26), the facility staff failed to disinfect a blood pressure cuff prior to use on 3/4/2026. On 3/4/2026 at 8:15 AM, an observation was made of registered nurse (RN) #1 rolling a vital sign monitor over to Resident #75 in the dining area on the unit where they resided at the facility and checking their blood pressure. RN #1 did not disinfect the blood pressure cuff after use. At 8:23 AM, RN #1 was observed using the same blood pressure cuff and monitor to check the blood pressure of Resident #26 in their room without disinfecting it prior to use or after use. On 3/4/2026 at 2:17 PM, an interview was conducted with RN #1 who stated that the blood pressure cuffs should be cleaned using the disinfectant wipes after each use. She stated that she was nervous and had forgotten to disinfect the blood pressure cuff during the observation that morning. On 3/5/2026 at 8:06 AM, an interview was conducted with licensed practical nurse #3 who stated that the nurses normally did their own vital signs and they had a system to disinfect the monitor and cuff between each use. The facility provided policy, Cleaning and Disinfection of Resident Care Equipment revised 7/7/2025, documented in part, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to CDC (Centers for Disease Control) and EPA (Environmental Protection Agency) recommendations for disinfection . According to the CDC's Disinfection of Healthcare Equipment it documented in part, . Medical equipment surfaces (e.g., blood pressure cuffs, stethoscopes, hemodialysis machines, and X-ray machines) can become contaminated with infectious agents and contribute to the spread of health-care–associated infections. For this reason, noncritical medical equipment surfaces should be disinfected with an EPA-registered low- or intermediate-level disinfectant. Use of a disinfectant will provide antimicrobial activity that is likely to be achieved with minimal additional cost or work . This information was obtained from the website: Disinfection of Healthcare Equipment | Infection Control | CDC On 3/4/2026 at approximately 5:25 PM, Administrator #1, Administrator #2, the Director of Nursing, the Infection Preventionist and the Administrator in Training were made aware of the findings. No further information was presented prior to exit. 2. For Resident #17 (R17), the facility staff failed to disinfect a blood pressure cuff prior to use on 3/4/2026. On 3/4/2026 at 8:23 AM, an observation was made of registered nurse (RN) #1 rolling a vital sign monitor into Resident #26's room and using a blood pressure cuff to check their blood pressure without disinfecting it after use. At 8:37 AM, RN #1 was observed checking Resident #17's blood pressure in their room with the same blood pressure monitor and blood pressure cuff without disinfecting it prior to use or after use. On 3/4/2026 at 2:17 PM, an interview was conducted with RN #1 who stated that the blood pressure cuffs should be cleaned using the disinfectant wipes after each use. She stated that she was nervous and had forgotten to disinfect the blood pressure cuff during the observation that morning. On 3/5/2026 at 8:06 AM, an interview was conducted with licensed practical nurse #3 who stated that the nurses normally did their own vital signs and they had a system to disinfect the monitor and cuff between each use. On 3/4/2026 at approximately 5:25 PM, Administrator #1, Administrator #2, the Director of Nursing, the Infection Preventionist and the Administrator in Training were made aware of the findings. No further information was presented prior to exit. 3. The facility staff failed to use a separate entrance into the facility's laundry room for soiled linens to prevent cross contamination. On 03/05/2026 at approximately 10:00 a.m. an observation in the facility's utility hallway revealed a sign on a door on the right side of hallway that documented, Soiled Laundry. Observation of the next doorway on the right led to the clean side of the laundry room. Upon entering observations revealed tables for folding clean laundry to the left and clothes dryers straight ahead. Continued observations revealed clothes washing machines and soiled laundry bin to the right. At approximately 10:05 a.m., an observation revealed a housekeeper/laundry aide pushed a bin, containing three compartments of soiled laundry, through the entrance and down the short hallway entering the clean side of the laundry room to the clothes washers. Further observation revealed that the housekeeper/laundry aide did not enter the laundry room with soiled laundry through the soiled laundry room door. On 03/05/2026 at approximately 10:00 a.m. an interview was conducted with the facility's Director of Housekeeping and Laundry. When informed of the observation stated above, he stated that clean and soiled laundry should not be taken I and out through the same door to prevent cross contamination. The facility's policy Linen Management Policy documented in part, Policy: Linens will be handled, transported and processed in a manner which reduces the risk of contamination or cross-contamination. On 03/05/2026 at approximately 3:04 p.m., the Administrator # 2 and the Director of Nursing, were made aware of the findings. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain a catheter bag in a sanitary manner for one of 36 residents in the survey sample, Residents #43.The findings include:1. For Resident #R43 (43), the facility staff failed to prevent the catheter bag from resting on the floor surface. R43 diagnoses include but were not limited to retention of urine (1), neuromuscular dysfunction of bladder (2), obstructive and reflux uropathy (3).On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/15/26, R43 scored 13 out of 15 on the BIMS (brief interview for mental status). Section H Bladder and Bowel code R43 as having an indwelling catheter for urinary retention, neuromuscular dysfunction of bladder and obstructive and reflux uropathy. On 3/4/26 at 8:53 AM R43's catheter bag was observed touching the floor. R43 stated it was leaking and he had informed staff about 15 minutes ago. On 3/4/26 at 10:17 AM, R43 states staff changed the catheter bag. The catheter bag was observed touching the floor surface on the left side of the bed while R43 was lying in the bed in the lowest position. On 3/4/26 at 11:20 AM an observation was made of R43's resident's catheter bag hanging on the left side of the bed. The bed was observed in the lowest position, and the catheter bag was observed touching the floor surface.The physician's order for R43 documented in part Catheter Care: Foley Catheter: Indicate size (16F) (French) and balloon size (10ml). DX (diagnosis): Urinary retention secondary to obstructive uropathy. Order Dated 2/28/26 A review of the comprehensive care plan dated 10/27/25 revealed, PROBLEM: The resident requires an indwelling urinary catheter related to urinary retention. Failed voiding trial 10/24/25. APPROACH: Do not allow tubing or any part of the drainage system to touch the floor.On 03/04/2026 2:17 PM an interview was conducted with RN#1 who stated to maintain catheter bags they are placed below the level of the bladder, privacy bag are placed over them and they clean the area daily. Bags should not be on the floor for infection control. RN #1further stated they keep R43 bed in a low position because of his fall risk. She stated she will talk to the manager about positioning the bag.The facility's policy Indwelling Urinary Catheter Care Procedure documented in part, 10. The urinary drainage bag must be placed below the bladder level but not on the floor.On 3/5/2026 at 10:30AM Admin (administrator) #2, Director of Nursing, IP/ADON (infection preventionist/assistant director of nursing) and the regional director of operations were notified of the findings. No further information was provided prior to exit.References:1. Urinary retention is a condition in which you cannot empty all the urine from your bladder. https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-retention2. Neurogenic bladder is a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition. https://medlineplus.gov/ency/article/000754.htm3. Obstructive uropathy is a condition in which the flow of urine is blocked. https://medlineplus.gov/ency/article/000507.htm

Based on staff interview and clinical record review, it was determined that the facility staff failed to administer a vaccine for one of five residents in the immunization record review, Residents # 27. The findings include:For Residents # 27 (R27) the facility staff failed to administer the pneumococcal vaccine (1). On the most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of [DATE], R27 was coded as having both short- and long-term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. The EHR (electronic health record) for R27 documented in part, Preventative Health. Pneumococcal - [DATE] education provided. Note: Education on risks/benefits/alternative reviewed via (by) pneumococcal VIS (vaccine information sheet) with resident. Resident verbalized understanding. RP (responsible party) contacted via phone. Consent obtained from resident and RP. Further review failed to evidence that R27 received the pneumococcal vaccine was administered. On [DATE] at approximately 11:00 a.m. an interview was conducted with the Assistant Director of Nursing (ADON) regarding the pneumococcal vaccination for R27. She was asked to describe the procedure for documenting when the pneumococcal vaccine is administered to a resident. She stated when the vaccine is administered, the date it was given, and the lot number of the vaccine(s) is documented in the resident's electronic health record under preventative health. She stated they were unable to locate documentation of when R27 received the pneumococcal vaccine. She further stated that R27's spouse was contacted by telephone and stated that she recalled that R27 had received the vaccinations at the facility. The ADON also stated at the time R27 was scheduled to receive the pneumococcal vaccine, there was a batch of vaccines that had expired and it was already documented in R27's record that consent was given and education was provided regarding the pneumococcal vaccine, the date R27 received the vaccine was not documented. On [DATE] at approximately 3:04 p.m., the Administrator # 2 and the Director of Nursing, were made aware of the findings. No further information was presented prior to exit. References:(1) Can prevent pneumococcal disease. Pneumococcal disease refers to any illness caused by pneumococcal bacteria. These bacteria can cause many types of illnesses, including pneumonia, which is an infection of the lungs. Pneumococcal bacteria are one of the most common causes of pneumonia. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a610017.html.

Based on staff interview and clinical record review, it was determined that the facility staff failed to administer a vaccine for one of five residents in the immunization record review, Residents # 27. The findings include:For Residents # 27 (R27) the facility staff failed to administer the COVID-19 vaccine (1). On the most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of [DATE], R27 was coded as having both short- and long-term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. The EHR (electronic health record) for R27 documented in part, Preventative Health. COVID-19 - [DATE] education provided. Education on risks/benefits/alternative reviewed via (by) Covid-19 VIS (vaccine information sheet) with resident. Resident verbalized understanding. RP (responsible party) contacted via phone. Consent obtained from resident and RP. Further review failed to evidence that R27 the COVID-19 vaccine was administered. On [DATE] at approximately 11:00 a.m. an interview was conducted with the Assistant Director of Nursing (ADON) regarding the COVID-19 vaccination for R27. She was asked to describe the procedure for documenting the COVID-19 vaccine when it is administered to a resident. She stated when the vaccine is administered, the date it was given, and the lot number of the vaccine(s) is documented in the resident's electronic health record under preventative health. She stated they were unable to locate documentation of when R27 received the COVID-19 vaccine. She further stated that R27's spouse was contacted by telephone and stated that she recalled that R27 had received the vaccination at the facility. The ADON also stated at the time R27 was scheduled to receive the COVID-19 vaccine, there was a batch of vaccines that had expired and it was already documented in R27's record that consent was given and education was provided regarding the COVID-19 vaccine, the date R27 received the vaccine was not documented. On [DATE] at approximately 3:04 p.m., the Administrator # 2 and the Director of Nursing, were made aware of the findings. No further information was presented prior to exit. References:(1) Used to prepare the body's immune system to protect against COVID-19. COVID-19 vaccines have been shown to do a very good job of: Preventing infection with the SARS-CoV-2 virus, which causes COVID-19, protecting against serious illness, hospitalization, and death from COVID-19 and reducing the risk of people spreading COVID-19. This information was obtained from the website: https://medlineplus.gov/ency/article/007775.htm.

Based on observation, staff interview and clinical record review, the facility staff failed to implement fall precautions for one of 36 residents in the survey sample, Resident #4. For Resident #4 (R4), the facility staff failed to implement fall mats on both sides of the bed when the resident was in bed. On 3/3/26 at 2:02 p.m., and 3/4/26 at 8:38 a.m., R4 was observed lying in bed. A floor mat was observed on the left side of the bed. No floor mat was observed on the right side of the bed. The mat was observed rolled up, against the wall, in the corner of the room.R4's comprehensive care plan dated 11/19/25 documented, Resident has had an actual fall and is at risk for fall r/t (related to) muscle weakness/other reduced mobility/osteoarthritis, psychotropic med use, incontinence, impaired safety awareness/dementia. Bilateral floor mats.On 3/5/26 at 12:30 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #4. LPN #4 stated that when a care plan documents bilateral floor mats, a mat should be on the floor, on each side of the bed, while the resident is in bed.On 3/5/26 at 3:08 p.m., Administrator #2 and the Director of Nursing were made aware of the above concern.No further information was presented prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice to promote residents highest level of well-being for one of eight residents in the medication observation sample, Resident #34.The findings include1. For Resident #34 (R34), the facility staff failed to follow professional standards of practice during medication administration.On 3/4/2026 at 8:29AM, an observation was made of registered nurse (RN) #1 preparing medication for R34. RN#1 was observed crushing one 40 mg (milligrams) pantoprazole (1) tablet, delayed release and administered it to R34.Review of the physician orders for R34 document in part, Pantoprazole tablet, delayed release (DR/EC) (delayed released/enteric coated); 40 mg; Amount 1 tab oral once a day. Start Date 10/27/25. On 03/05/2026 at 8:18 AM, an interview was conducted with LPN (licensed practical nurse) #3, who stated that the process for administering crushed medication is to review the eMAR (electronic medical administration record) and check for orders to crush the medication. She further stated that she verifies if a medication can be crushed and that she crushes each medication separately and places it in a cup with applesauce. She stated that she informs each residents what medications she has given them and educate them as needed. LPN #3 stated if a medicine cannot be crushed and the resident cannot swallow the medication without it being crushed, she would reach out to the doctor to see if there is a liquid form of the medication or another substitute medication for the resident. On 03/05/2026 at 9:37 AM, an interview was conducted with the pharmacist who stated that extended-release pantoprazole should not be crushed as it can change the medication. When asked if there are any potential adverse side effects, stated I don't think there would be any side effects but the effectiveness of the medication may be less. The pharmacy provided document Common Oral Dosage Forms That Should Not be Crushed, dated 2024, has pantoprazole listed as one.On 3/5/2026 at 10:30AM, Administrator #2, Director of Nursing, IP/ADON (infection preventionist/assistant director of nursing) and the regional director of operations were notified of the findings. No further information was provided prior to exit.No further information was provided prior to exit.Reference:Pantoprazole is used to treat damage from gastroesophageal reflux disease. Pantoprazole comes as a delayed-release (releases the medication in the intestine to prevent break-down of the medication by stomach acids) tablet and as delayed-release granules to take by mouth. https://medlineplus.gov/druginfo/meds/a601246.html

Based on observations, staff interview facility document review and clinical record review, it was determined the facility staff failed to develop/implement the care plan for three of 36 residents in the survey sample, Resident #6, Resident #4 and Resident #43.The findings include:1.The facility staff failed to develop the comprehensive care plan for fluid restriction for Resident #6 (R6). R6 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident), CHF (congestive heart failure), pneumonitis and chronic respiratory failure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/13/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 1/8/26 revealed, PROBLEM: The resident has impaired cardiovascular status related to CHF. APPROACH: Monitor/ document/ report any signs/symptoms of congestive heart failure: dependent edema of legs and feet, SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness and weight gain unrelated to intake. A review of the physician orders dated 1/13/26 revealed, Fluid restriction 1500 milliliters (mL)/24 hours (hrs). 1500cc Fluid Restriction: Dietary to give 960mL (BREAKFAST 480mL, LUNCH 240mL, DINNER 240mL). Nursing to give up to 540mL/24hr (day SHIFT 180mL, evening SHIFT 180mL, night SHIFT 180mL). A review of the January, February and March 2026 MARs (medication administration record) revealed fluid restriction provided as ordered. Observations on 3/4/26 breakfast and 3/5/26 lunch revealed R6 on fluid restriction as ordered. On 3/5/26 at 8:05 AM, an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 described the care plan as a document with the purpose of detailing the plan for the residents and providing care to the resident. The care plan should be developed and implemented for resident safety. Fluid restrictions should be on the care plan, because it is resident safety and the CNAs (certified nursing assistants) do not have access to the MAR (medication administration record) which is where the nurses document the fluid restriction. On 3/5/26 at 2:30 PM, the administrator and the director of nursing were informed of the concern. According to the facility's Comprehensive Care Plan policy, which revealed, The facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetable to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. These plans will be focused on resident choices and abilities with the intent of maintaining or improving resident functional abilities and quality of life. The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes or change in condition. In additional problem areas are identified not triggered by the MDS, the care plan will be updated to reflect these area(s). No further information was provided prior to exit. 2. For Resident #4 (R4), the facility staff failed to implement the resident's comprehensive care plan for bilateral floor mats. R4's comprehensive care plan dated 11/19/25 documented, Resident has had an actual fall and is at risk for fall r/t (related to) muscle weakness/other reduced mobility/osteoarthritis, psychotropic med use, incontinence, impaired safety awareness/dementia. Bilateral floor mats. On 3/3/26 at 2:02 p.m., and 3/4/26 at 8:38 a.m., R4 was observed lying in bed. A floor mat was observed on the left side of the bed. No floor mat was observed on the right side of the bed. The mat was observed rolled up, against the wall, in the corner of the room. On 3/5/26 at 12:30 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #4. LPN #4 stated the care plan is basically an outline of care; the best plan of care for that resident and the goals that staff are trying to accomplish while the resident is at the facility. LPN #4 stated that when a care plan documents bilateral floor mats, a mat should be on the floor, on each side of the bed, while the resident is in bed. On 3/5/26 at 3:08 p.m., Administrator #2 and the Director of Nursing were made aware of the above concern. No further information was presented prior to exit. 3. For Resident #43, (R43) the facility staff failed to implement the comprehensive care plan for care of a urinary catheter bag (1). R43 diagnoses include but were not limited to retention of urine (2), neuromuscular dysfunction of bladder (3), obstructive and reflux uropathy (4). The most recent MDS (minimum data set) quarterly assessment with an ARD (assessment reference date) of 1/15/26 documented R43 having an indwelling catheter for urinary retention, neuromuscular dysfunction of bladder and obstructive and reflux uropathy. A review of the comprehensive care plan dated 10/27/25 revealed, PROBLEM: The resident requires an indwelling urinary catheter related to urinary retention. Failed voiding trial 10/24/25. APPROACH: Do not allow tubing or any part of the drainage system to touch the floor. Observations failed to evidence positioning of catheter bag off the floor. On 3/4/26 at 8:53 AM an observation of R43's catheter bag on the floor. On 3/4/26 at 10:17 AM, R43 stated the staff changed his catheter bag however the catheter bag was observed touching the floor surface while R43 was lying in the bed with the bed in a low position. On 3/4/26 at 11:20 AM an observation was made of R43's catheter bag hanging on the left side of the bed. The bed was observed in the lowest position, and the catheter bag was observed touching the floor surface. 03/04/2026 at 2:17 PM an interview was conducted with RN (registered nurse) #1. RN#1 stated that in order to maintain foley catheter bags they were placed below the level of the bladder; they place a privacy bag over them and clean the area daily. RN#1 further stated catheter bags should not be on the floor for infection control. On 3/5/2026 at 10:30AM ADM (administrator) #2, Director of Nursing, IP/ADON (infection preventionist/assistant director of nursing) and the regional director of operations were notified of the findings. No further information was provided prior to exit. References: A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. https://medlineplus.gov/ency/article/003981.htm Urinary retention is a condition in which you cannot empty all the urine from your bladder. https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-retention Neurogenic bladder is a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition. https://medlineplus.gov/ency/article/000754.htm Obstructive uropathy is a condition in which the flow of urine is blocked. https://medlineplus.gov/ency/article/000507.htm

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to promote dignity for one of 36 residents in the survey sample, Resident #75.The findings include:For Resident #75 (R75), the facility staff failed to promote dignity when they checked the residents blood pressure in the dining room during breakfast on 3/4/2026.On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 11/25/2025, the resident scored four out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were severely impaired for making daily decisions.On 3/04/2026 at 8:15 AM, an observation was made of R75 sitting in the dining area on the unit where they resided at a table with two other residents eating breakfast. R75 was observed to have finished their breakfast and was sitting at the table with the other residents who were still eating. Registered nurse #1 was observed rolling a vital sign monitor over to R75 at the table and proceeded to check their blood pressure at the table in the dining room.On 3/5/2026 at 8:06 AM, an interview was conducted with licensed practical nurse #3 who stated that residents vital signs were taken in the residents room and normally they waited if the resident was in the dining room. She stated that this was done for privacy and resident rights because doing any type of patient care in open areas lacked privacy.On 3/5/2026 at 12:32 PM, an interview was conducted with certified nursing assistant #1 who stated that most of the time the nurses did the vital signs themselves. She stated that if she were doing any vital signs they would be done in the residents room not out in the public areas.The facility provided policy, Resident Rights and Facility Responsibility revised 10/7/25 documented in part, It is the facility's policy to comply with all Resident Rights .On 3/5/2026 at approximately 3:03 PM, administrator #2, administrator #3, the director of nursing, the regional director of clinical services, the regional director of operations, the infection preventionist and the administrator in training were made aware of the findings. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to honor a food allergy for one of 36 residents in the survey sample, Resident #15. The findings include:For Resident #15 (R15), the facility staff failed to honor the resident's pineapple allergy on 11/27/25. A review of R15's clinical record revealed the resident was allergic to pineapple. On R15's admission minimum data set assessment, with an assessment reference date of 9/10/25, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 3/3/26 at 2:06 p.m., an interview was conducted with R15. R15 stated the resident was allergic to pineapple and displayed a meal ticket that documented the resident was allergic to pineapple. R15 stated that on Thanksgiving (11/27/25), the facility cooked ham with pineapple, removed the pineapple, and served the ham to the resident. On 3/4/26 at 8:26 a.m., an interview was conducted with the Dietary Manager. The Dietary Manager stated R15 was served ham that was cooked with pineapple on Thanksgiving Day. The Dietary Manager stated that on that day, the ham was cooked with pineapple rings then the pineapple rings were discarded before R15 was served. The Dietary Manager stated R15's ham should have been cooked separately but the cook did not think about it. The Dietary Manager stated he educated staff regarding this. On 3/5/26 at 3:08 p.m., Administrator #2 and the Director of Nursing were made aware of the above concern. The facility food allergies policy documented, Individuals with food allergies will be provided with safe foods and fluids, and appropriate substitutions to maintain health. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow the provider's order for the administration of insulin for two of five residents in the survey sample, Residents #1 and #2.The findings include:1. For Resident #1 (R1), the facility staff failed to follow the provider's order to notify the provider of blood sugar levels exceeding 400 on multiple occasions in September and November 2025.A review of R1's provider's orders revealed the following order dated 9/16/25: Insulin lisproSolution (1); 100 unit/mL (milliliter); Amount to Administer: Per Sliding Scale.If blood sugar is greater than 400, call MD (medical doctor).A review of R1's MARs (medication administration records) revealed the following dates and times when R1's blood sugar was greater than 400: 9/14/25 1:01 p.m. Blood Sugar: 452; 9/17/2025 5:27 p.m. Blood Sugar: 435; 9/18/25 12:58 p.m. Blood Sugar: 449; 11/20/25 5:22 p.m. Blood Sugar: 461. Further review of R1's clinical record revealed no evidence that the provider was notified of these blood sugar levels.On 12/3/25 at 3:37 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated that orders for sliding scale insulin administration most always include the instruction to contact the provider if the blood sugar is above a dangerously high level. She stated if she obtained a blood sugar reading that exceeded the parameter, she would notify both the provider and the RR (resident representative). She added: An order is an order.On 12/3/25 at 4:06 p.m., ASM (administrative staff member) #1, the regional director of clinical services, ASM #2, the director of nursing, and ASM #3, the regional vice president of operations, were informed of these concerns. On 12/3/25 at 4:16 p.m., RN (registered nurse) #1, a unit manager, was interviewed. He stated that the local hospital frequently discharges residents to the facility with orders for frequent blood sugar checks and for insulin administration according to the blood sugar readings. He stated that while the facility is in the process of reviewing the orders containing instructions to call the provider with blood sugar levels over a certain amount, the nurses are responsible for following the orders as currently stated. He explained that he had reviewed R1's blood sugars and could not find evidence that the provider had been notified when the blood sugar level exceeded 400. He stated the nurses had not followed the provider's order in those cases in which the provider had not been notified.A review of the facility policy, Physician/Provider Orders, revealed no information related to the nursing staff's responsibility to follow providers' orders.No additional information was provided prior to exit.Reference(1) Insulin lispro injection products are used to treat type 1 diabetes (condition in which the body does not produce insulin and therefore cannot control the amount of sugar in the blood). Insulin lispro injection products are also used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) who need insulin to control their diabetes. This information is taken from the website https://medlineplus.gov/druginfo/meds/a697021.html?utm_source=mplusconnect&utm_medium=application.2. For Resident #2 (R2), the facility staff failed to follow the provider's order to notify the provider of blood sugar levels exceeding 400 on multiple occasions in September and October 2025.A review of R2's provider's orders revealed the following order dated 8/25/25: Novolog FlexPen U-100 Insulin (insulin aspart u-100) insulin pen (1); 100 unit/mL (milliliter); Amount to Administer: Per Sliding Scale.If blood sugar is greater than 400, call NP/PA (nurse practitioner/physician assistant).A review of R2's MARs (medication administration records) revealed the following dates and times when R2's blood sugar was greater than 400: 9/2/25 at 5:00 p.m. Blood Sugar 423; 9/18/25 at 8:00 a.m. Blood Sugar 435l 9/19/25 at 8:00 a.m. Blood Sugar 413; 9/19/25 at 5:00 p.m. Blood Sugar 503; 9/26/25 at 5:00 p.m. Blood Sugar 432; 10/9/25 at 12:00 p.m. Blood Sugar HIGH; 10/27/25 at 5:00 p.m. Blood Sugar HIGH. Further review of R2's clinical record revealed no evidence that the provider was notified of these blood sugar levels.On 12/3/25 at 3:37 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated that orders for sliding scale insulin administration most always include the instruction to contact the provider if the blood sugar is above a dangerously high level. She stated if she obtained a blood sugar reading that exceeded the parameter, she would notify both the provider and the RR (resident representative). She added: An order is an order.On 12/3/25 at 4:06 p.m., ASM (administrative staff member) #1, the regional director of clinical services, ASM #2, the director of nursing, and ASM #3, the regional vice president of operations, were informed of these concerns. On 12/3/25 at 4:16 p.m., RN (registered nurse) #1, a unit manager, was interviewed. He stated that the local hospital frequently discharges residents to the facility with orders for frequent blood sugar checks and for insulin administration according to the blood sugar readings. He stated that while the facility is in the process of reviewing the orders containing instructions to call the provider with blood sugar levels over a certain amount, the nurses are responsible for following the orders as currently stated. He explained that he had reviewed R2's blood sugars and could not find evidence that the provider had been notified when the blood sugar level exceeded 400. He stated the nurses had not followed the provider's order in those cases in which the provider had not been notified.No additional information was provided prior to exit.Reference (1) Insulin aspart injection is used to treat type 1 diabetes (condition in which the body does not produce insulin and therefore cannot control the amount of sugar in the blood) and type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood). Insulin aspart is a short-acting, man-made version of human insulin. Insulin aspart works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy. It also stops the liver from producing more sugar. This information is taken from the website https://medlineplus.gov/druginfo/meds/a605013.html?utm_source=mplusconnect&utm_medium=application.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to preserve a resident's right for the notification of the provider and RR (resident representative) of a change in condition for two of five residents in the survey sample, Residents #1 and #2.The findings include:1. For Resident #1 (R1), the facility staff failed to notify the provider and RR of blood sugar levels exceeding 400 on multiple occasions in September and November 2025.A review of R1's provider's orders revealed the following order dated 9/16/25: Insulin lisproSolution (1); 100 unit/mL (milliliter); Amount to Administer: Per Sliding Scale.If blood sugar is greater than 400, call MD (medical doctor).A review of R1's MARs (medication administration records) revealed the following dates and times when R1's blood sugar was greater than 400: 9/14/25 1:01 p.m. Blood Sugar: 452; 9/17/2025 5:27 p.m. Blood Sugar: 435; 9/18/25 12:58 p.m. Blood Sugar: 449; 11/20/25 5:22 p.m. Blood Sugar: 461. Further review of R1's clinical record revealed no evidence that either the provider or the RR was notified of these blood sugar levels.On 12/3/25 at 3:37 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated that orders for sliding scale insulin administration most always include the instruction to contact the provider if the blood sugar is above a dangerously high level. She stated if she obtained a blood sugar reading that exceeded the parameter, she would notify both the provider and the RR (resident representative). She added: An order is an order.On 12/3/25 at 4:06 p.m., ASM (administrative staff member) #1, the regional director of clinical services, ASM #2, the director of nursing, and ASM #3, the regional vice president of operations, were informed of these concerns. On 12/3/25 at 4:16 p.m., RN (registered nurse) #1, a unit manager, was interviewed. He stated that the local hospital frequently discharges residents to the facility with orders for frequent blood sugar checks and for insulin administration according to the blood sugar readings. He stated that while the facility is in the process of reviewing the orders containing instructions to call the provider with blood sugar levels over a certain amount, the nurses are responsible for following the orders as currently stated. He explained that he had reviewed R1's blood sugars and could not find evidence that either the provider or RR had been notified when the blood sugar level exceeded 400. A review of the facility policy, Resident Change in Condition, revealed, in part: The licensed nurse will recognize and intervene in the event of a change in resident condition. The Physician/Provider and the Family/Responsible Party will be notified as soon as the nurse has identified the change in condition and the resident is stable.No additional information was provided prior to exit.Reference(1) Insulin lispro injection products are used to treat type 1 diabetes (condition in which the body does not produce insulin and therefore cannot control the amount of sugar in the blood). Insulin lispro injection products are also used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) who need insulin to control their diabetes. This information is taken from the website https://medlineplus.gov/druginfo/meds/a697021.html?utm_source=mplusconnect&utm_medium=application.2. For Resident #2 (R2), the facility staff failed to notify the provider and RR of blood sugar levels exceeding 400 on multiple occasions in September and October 2025.A review of R2's provider's orders revealed the following order dated 8/25/25: Novolog FlexPen U-100 Insulin (insulin aspart u-100) insulin pen (1); 100 unit/mL (milliliter); Amount to Administer: Per Sliding Scale.If blood sugar is greater than 400, call NP/PA (nurse practitioner/physician assistant).A review of R2's MARs (medication administration records) revealed the following dates and times when R2's blood sugar was greater than 400: 9/2/25 at 5:00 p.m. Blood Sugar 423; 9/18/25 at 8:00 a.m. Blood Sugar 435; 9/19/25 at 8:00 a.m. Blood Sugar 413; 9/19/25 at 5:00 p.m. Blood Sugar 503; 9/26/25 at 5:00 p.m. Blood Sugar 432; 10/9/25 at 12:00 p.m. Blood Sugar HIGH; 10/27/25 at 5:00 p.m. Blood Sugar HIGH. Further review of R2's clinical record revealed no evidence that the either the provider or RR was notified of these blood sugar levels.On 12/3/25 at 3:37 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated that orders for sliding scale insulin administration most always include the instruction to contact the provider if the blood sugar is above a dangerously high level. She stated if she obtained a blood sugar reading that exceeded the parameter, she would notify both the provider and the RR (resident representative). She added: An order is an order.On 12/3/25 at 4:06 p.m., ASM (administrative staff member) #1, the regional director of clinical services, ASM #2, the director of nursing, and ASM #3, the regional vice president of operations, were informed of these concerns. On 12/3/25 at 4:16 p.m., RN (registered nurse) #1, a unit manager, was interviewed. He stated that the local hospital frequently discharges residents to the facility with orders for frequent blood sugar checks and for insulin administration according to the blood sugar readings. He stated that while the facility is in the process of reviewing the orders containing instructions to call the provider with blood sugar levels over a certain amount, the nurses are responsible for following the orders as currently stated. He explained that he had reviewed R2's blood sugars and could not find evidence that the provider or RR had been notified when the blood sugar level exceeded 400. No additional information was provided prior to exit.Reference (1) Insulin aspart injection is used to treat type 1 diabetes (condition in which the body does not produce insulin and therefore cannot control the amount of sugar in the blood) and type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood). Insulin aspart is a short-acting, man-made version of human insulin. Insulin aspart works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy. It also stops the liver from producing more sugar. This information is taken from the website https://medlineplus.gov/druginfo/meds/a605013.html?utm_source=mplusconnect&utm_medium=application.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence documentation of current side rail assessment and consent for one of six residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility failed to evidence an assessment or consent for the use of bed rails. The MDS (minimum data set) assessment was not due at the time of the survey. On the nursing admission assessment dated [DATE] documented R2 being alert and oriented to person, place and time. The assessment documented R2 having weight bearing limitations and and being non-weight bearing on the left extremity. On 7/16/2024 at 2:35 p.m., an interview was conducted with R2 in their room. Bilateral bar shaped rails were observed on the resident's bed. R2 stated that they used the bilateral bar shaped rails when in bed to turn and position and when getting out of bed. R2 stated that they had recently been admitted to the facility and the rails were on the bed when they arrived and they had been using them since admission. R2 stated that they did not recall signing a consent form for the rails but they did want to have them because they used them every day. Review of the clinical record for R2 revealed a Enabler/Physical Restraint/Side Rail Review dated 7/13/24 which failed to evidence an assessment for use, a discussion of the risk and benefits or consent for the use of the bilateral bar shaped rails. An additional observation of R2 was made on 7/17/2024 at 7:59 a.m. R2 was observed in bed with the bilateral bar shaped bed rails in place. On 7/16/2024 at approximately 4:00 p.m., a request was made via written list to ASM (administrative staff member) #1, the administrator, for evidence of a bed rail assessment for R2. On 7/17/2024 at approximately 1:38 p.m., ASM #2, director of nursing, provided a bed rail assessment dated [DATE] at 11:33 a.m. for R2. On 7/17/2024 at 1:34 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident used bed rails the nurse confirmed that the resident wanted to use them and completed an assessment with the resident to make sure they were able to use them safely. She stated that they documented the assessment in the medical record on the computer. She stated that this was done during the admission process. LPN #1 reviewed the Enabler/Physical Restraint/Side Rail Review dated 7/13/24 for R2 and stated that by looking at the assessment they could not say that the resident used bed rails. She stated that the bed rails should have been documented on the assessment and consent should have been documented. On 7/17/2024 at 3:24 p.m., ASM #1, the administrator, ASM #2, director of nursing, ASM #3, assistant administrator, and ASM #4, regional director of clinical services were made aware of the above concern. On 7/17/2024 at 4:28 p.m., OSM (other staff member) #3, the director of rehab provided a physical therapy evaluation and plan of treatment for R2 dated 7/15/2024 and stated that it addressed R2's weight bearing status. She stated that the therapy staff normally explained the risks and benefits of the bed rails, and determined if the resident needed them and documented it in their notes. OSM #3 reviewed the physical therapy evaluation and plan she provided and stated that she did not see where they had educated R2 in the notes. On 7/17/2024 at 4:42 p.m., a follow up interview was conducted with R2. When asked if they had been educated on the risks and benefits of bed rails by facility staff, R2 stated, No. R2 stated that they had used the rails during their previous admission and they thought they were part of the beds. On 7/17/2024 at 4:43 p.m., ASM #1, the administrator was notified that the concern remained. No further information was provided prior to exit. The facility policy Bed rail policy dated 1/25/24 documented in part, If a bed or side rail or bar is used, the facility will: a. Evaluate the potential risks associated with the use of bed rails including the risk of entrapment, prior to bed rail installation using the Bed and Bed Rail Safety Inspection Checklist. b. Evaluate the risk versus benefits of using a bed rail and review them with the resident or if applicable, the resident ' s representative. c. Obtain informed consent for the installation and use of bed rails prior to the installation .

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the proper assistance while providing ADL (activities of daily living) care which resulted in a fall from the bed for one of 34 residents in the survey sample, Resident #219. The resident sustained a right leg fracture which constituted harm cited at past non-compliance. The findings include: For Resident #219 (R219), the facility staff failed to implement the plan of care while providing ADL care which resulted in the resident falling from the bed and suffering a fractured right tibia and fibula (1). R219 was admitted to the facility with diagnoses that included but were not limited to osteomyelitis (2) and osteoarthritis (3). On the residents MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/10/2022, the resident scored 9 out of 15 on the BIMS (brief interview for mental status) indicating the resident was moderately impaired for making daily decisions. Section G documented R219 being totally dependent on two persons for transfers and requiring extensive assistance of two persons for bed mobility. The assessment further documented R219 being frequently incontinent of bowel and bladder and having two falls without injury since the previous assessment. The progress notes for R219 documented in part; 11/09/2022 13:12 (1:12 p.m.) Monthly Nursing Note .Two+ persons physical assist with transfers. Two+ persons physical assist with bed mobility. One person physical assist with eating. Resident is a two+ persons physical assist with toilet use . 11/13/2022 07:15 (7:15 a.m.) Type: Head to Toe Eval. (evaluation) Overview: This note is a follow up to witnessed fall. Resident is Oriented to room location. Resident knows staff names/faces. Resident is responsive. Resident is Anxious. Resident in pain and crying out. Neurological checks are within normal limits. Evidence of pain noted R (right) hip and leg. Non- verbal signs of pain noted. Pain level is 10 out of 10. The pain is constant .Family notified of incident and is aware resident was sent to the ER (emergency room ) via EMS (emergency medical services). The physician orders for R219 documented in part, Send Resident to ER for evaluation and treatment s/p (status post) fall. Order Date: 11/13/2022. The comprehensive care plan for R219 documented in part, - Risk for falls characterized by history of falls, injury, and/or multiple risk factors related to: Intractable seizures, osteoarthritis, dementia. Actual fall: 11/13/22. Date Initiated: 08/05/2022. Under Interventions it documented in part, 10/24/22: bed in lowest position when in bed. Pain medication review. Date Initiated: 10/24/2022 . - At risk for self care deficit r/t (related to) dementia, seizures, risk for malnutrition, muscle weakness, abnormalities of gait and mobility. Date Initiated: 08/05/2022. Under Interventions it documented in part, .Encourage turning and repositioning, assist as needed. Date Initiated: 08/05/2022 . - Alteration in musculoskeletal status r/t right tibial and fibula fracture. Date Initiated: 11/14/2022. The fall risk assessment for R219 dated 11/8/2022 documented the resident being a high risk for falls. On 5/31/2023 at 5:23 p.m., a request was made to ASM (administrative staff member) #1, the administrator, for the synopsis of fall event which occured on 11/13/2022 for R219. On 6/1/2023 at approximately 8:00 a.m., ASM #1 provided a folder containing a plan of correction for the fall on 11/13/2022 for R219. The document contained a Quick Response dated 11/13/2022 which documented in part, .Resident with witnessed fall out of bed onto her right side on top of her fall mat. Send to ER for evaluation due to right leg pain, X-rays at hospital show right tibia and fibula fracture. Resident unable to give description . The Witnessed Fall document dated 11/13/2022 documented in part, This nurse was alerted that the resident had a witnessed fall. The resident's CNA (certified nursing assistant) was repositioning the resident to her side to change her brief. The aide reports that the resident rolled off the bed. The aide reports that the bed was in a low setting. Bed was in lowest setting when this writer entered the resident's room. Resident was lying on her back on a fall mat to the R (right) of her bed. The aide reported that resident fell on to her R side. Resident unable to give description . On 6/1/2023 at 9:42 a.m., an attempt was made to contact CNA #6 who took care of R219 at the time that they rolled out of bed. The phone number was no longer in service. On 6/1/2023 at 10:26 a.m., an interview was conducted with LPN #3 who worked with R219 on 11/13/2022 on the date of the fall. LPN #3 stated that they were called into R219's room on 11/13/2022 after the resident had rolled out of the bed, when the CNA was providing care. R219 was observed on the floor on the fall mat and was yelling out in pain. The bed was raised to the CNA's waist level. The CNA stated that they were changing the resident and the resident had slipped off of the bed, and the CNA was the only staff person in the room at the time of the fall. LPN #3 stated that they had assessed the resident, checked the vital signs, and then transferred the resident back to the bed which was lowered before they put the resident back in bed with the draw sheet. LPN #3 stated that they should have used a hoyer lift to transfer the resident back to the bed and knew that now. LPN #3 stated that after they got the resident back in the bed they had called the former director of nursing, physician and the family. R219 did not speak English very well and they had spoken with the family member who advised them that the resident did not want to go to the hospital but advised them that they felt that the resident needed to be sent out due to the amount of pain they were having in the leg. LPN #3 stated that the family member was able to convince the resident to go to the emergency room and the resident was sent out. On 6/01/2023 at 1:10 p.m., an interview was conducted with CNA #1. CNA #1 stated that they determined the assistance level of residents from the resident if they were able to tell them or from the previous CNA in walking report. CNA #1 stated that they also had a care plan that they reviewed in the computer which showed the assistance levels for residents. CNA #1 stated that they worked with the other aides for residents who required two person assistance and the nurses would help them if the aides were unavailable. CNA #1 stated that they would not attempt to provide care alone for a resident if two persons were needed. On 6/01/2023 at 1:20 p.m., an interview was conducted with CNA #3. CNA #3 stated that they determined the assistance level of residents from the report from the previous CNA, from therapy, or the Kardex on the computer. CNA #3 stated that when the resident required two persons for bed mobility they asked the other CNA's to assist them and would never attempt the care alone due to safety. Review of the plan of correction provided by ASM #1 for R219's fall on 11/13/2022 documented a date of compliance of 11/30/2022. The plan of correction folder contained written staff statements from LPN #3 and CNA #6 and an investigation completed by the former director of nursing who no longer worked at the facility. The plan of correction documented audits conducted of current residents bed mobility, care plans and Kardexs, education provided to staff, including the aide involved in the event on falls and positioning, including bed mobility, turning and positioning and assisting a resident after a fall. The plan of correction folder further documented resident audits completed for the appropriate level of care assistance based on their Kardex and care plan. Verification of the facility plan of correction was completed by observations, staff interviews and review of the facility audits, staff education and resident audits. No concerns were identified. On 6/1/2023 at 1:55 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern for harm. No further information was provided prior to exit. Based on the acceptable plan of correction, all components of the plan verified, and no concerns identified during the survey, this deficient practice is cited at past non-compliance. Reference: (1) The lower leg is made up of two bones: the tibia and fibula. The tibia is the larger of the two bones. It supports most of your weight and is an important part of both the knee joint and ankle joint. The tibia is the larger bone in your lower leg. Tibial shaft fractures occur along the length of the bone. This information was obtained from the website: https://orthoinfo.aaos.org/en/diseases--conditions/tibia-shinbone-shaft-fractures/ (2) Osteomyelitis is a bone infection. It is mainly caused by bacteria or other germs. This information was obtained from the website: https://medlineplus.gov/ency/article/000437.htm (3) Osteoarthritis, sometimes called OA, is a type of arthritis that only affects the joints, usually in the hands, knees, hips, neck, and lower back. It's the most common type of arthritis. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html

Based on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to follow professional standards of quality for two of 34 residents in the survey sample, Resident #18 and Resident #65, which resulted in harm for Resident #65. The findings include: 1. The facility staff, registered nurse (RN #2), failed to ensure oxygen was administered at an acceptable rate for Resident #65, who had a diagnosis of COPD (chronic obstructive pulmonary disease); and, failed to call the physician and/or 911 immediately, when the resident had a significant change in condition. Resident #65 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), CVA (cerebral vascular accident), CHF (congestive heart failure), and acute and chronic respiratory failure with hypoxia. A review of the comprehensive care plan dated [DATE], included: INTERVENTIONS: 02 (oxygen) as ordered. Monitor for signs/symptoms of decreased cardiac output, rapid, slow, weak or diminished pulse, hypo/hypertension, dizziness, syncope, dyspnea, chest pain, fatigue, restlessness, cyanosis, altered mental status, congestion and shortness of breath. Notify physician as needed with any changes. A review of the physician's orders dated [DATE], revealed, 4L (liters) continuous oxygen NC (nasal cannula) - check setting every shift and on rounds every day shift for O2 (oxygen) Saturation. A review of the facility's Standing Orders revealed, Shortness of breath (SOB)/difficulty breathing: may place oxygen at 2 liters/minute via nasal cannula as needed for SOB or saturation below 89%. If oxygen saturation less than 87% with difficulty breathing, obtain stat chest x-ray and call physician STAT (immediately). Transfer: In case of an emergency when attending physician is unable to be reached, you may transfer to hospital. A review of the nursing progress note written by RN #2, dated [DATE] at 8:03 AM included, Note Text: Resident was seen lethargy, with an oxygen level of 70% at room air during change of shift. resident was repositioned and 15 liter oxygen was administer via non-rebreather mask. resident O@ [sic] went up to 97 % and resident was responsive and having conversion with staff. resident called her full name and was able to identify where she was. O2 level was reduced to 10 liter via non-rebreather mask after resident became stable, alert and oriented X4 and verbally responsive. resident was being monitored every 1 hr. resident retained an oxygen level of 94 to 97% on a simple mask with o2 at 8Lmp. at 0400 resident verbalized abdominal pain and was given hydromorphone 2mg which was effective. at this time, writer called (physician hospital group) on-called [sic] and was awaiting a call back to discuss resident's condition with the DR. (doctor) but to no avail. at 5 am, resident was stable and resting in bed with an O2 level of 94% via simple mask. at 0540, resident was seen unresponsive. there was no pulse or respiration noted. Writer began CPR and another nurse called 911. 911 arrived at about 0559 and began high pressure CPR. resident could not be resuscitated and was pronounce [sic] dead at about 0626. Resident is he [sic] own responsible party . An interview was conducted on [DATE] at 8:30 AM with LPN (licensed practical nurse) #3. When asked the amount of oxygen that should be given to a resident with COPD, LPN #3 stated, We would follow the orders, but I would not ever go past 5 liters per minute. An interview was conducted on [DATE] at 9:10 AM with ASM (administrative staff member) #4, the nurse practitioner (NP). When asked when should the NP be notified for oxygen saturation, ASM #4 stated, We should have been notified for anything less than 87% per the standing orders. When asked what are the maximum oxygen liters per minute for a COPD resident, ASM #4 stated, It is ,d+[DATE] liters per minute. An interview was conducted on [DATE] at 9:49 AM with RN (registered nurse) #2, who was the nurse on duty at the time of the event. When asked to describe the events of [DATE]-[DATE] with Resident #65, RN #2 stated, I got there late, between 11:30 PM-12:00 AM on [DATE]. I made my rounds and the resident was laying across the bed. Her oxygen (O2) was not on. She was lethargic. Her vital signs were normal and O2 saturation was low about ,d+[DATE]%. I increased her to 15 LNC (liters nasal cannula), got her situated and her O2 saturation came up to ,d+[DATE]%. Then she was alert and oriented. RN #2 stated, I kept monitoring her oxygen and trying to decrease it. I could not get it back to 4 LNC because her saturation would drop. I had her on a rebreather and finally got her down to 8 liters. I told her that I have to send her to the hospital. She did not want to go. She started having stomach pain, so I gave her narcotic for the pain. RN #2 stated, At 4:00 AM, I called the hospital doctor exchange. I did not get a call back. I called the DON (director of nursing) to let her know of the situation. Resident was reassessed with O2 saturation in 90's on the 8 L face mask. About 5:00 AM, I called the hospital doctor exchange again, talked to resident, and said I have to send you out but the Resident refused to go. RN #2 added, I was the only nurse on the unit, with one CNA .around 5:40 AM, I went to check on (Resident #65) and she was unresponsive. I put her on the floor and started CPR (cardiopulmonary resuscitation). When asked if there were orders to adjust the oxygen, RN #2 stated, No, there was no order. We have standing orders, but they do not cover higher oxygen. I could not keep her on that low oxygen rate. That's the reason I called the physician exchange and the DON. The resident was stable on the higher oxygen, she was not critical at the time, so I did not call 911. I did my due diligence and got her oxygen saturation back up by increasing her oxygen level. There was not documentation in the clinical record that the director of nursing was called at 4:00 AM as stated in the interview with RN #2, nor was there was no documentation of the second attempt to reach the on-call physician nor did RN #2 call the facility medical director. There was no documentation in the clinical record that RN #2 told Resident #65 that she'd have to be sent out to the hospital, nor that the resident refused to go. An interview was conducted on [DATE] at 11:10 AM with ASM #7, the medical director who concurred that the physician should be notified for an O2 saturation of 70%. When asked what the maximum oxygen rate for a resident with COPD, and acute and chronic respiratory failure with hypoxia should be set at, ASM #7 stated, The maximum is oxygen ,d+[DATE] liters per minute. On [DATE] at approximately 11:35 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services was made aware of the findings. A review of the facility's Oxygen Administration (all routes) policy dated ,d+[DATE], reveals, Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. In an emergency situation, clinicians may administer oxygen and obtain a provider's order as soon as practicably possible after patient stabilization or transfer. [NAME] Nursing Standards of Practice 11th Edition, page 180, revealed, Administer oxygen in the appropriate concentration and device. Low concentration (,d+[DATE]%) may be appropriate for patients prone to retain CO2 (carbon dioxide) [COPD, drug overdose] who are dependent on hypoxemia (hypoxic drive) to maintain respiration. If hypoxemia is suddenly reversed, hypoxic drive may be lost and respiratory depression and, possibly respiratory arrest may occur. No further information was provided prior to exit. 42106 2. For Resident #18 (R18), the facility staff failed to administer a medication that was available in the in-house medication supply on [DATE] at 9:00 a.m. and 1:00 p.m. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of [DATE], the resident scored 15 out of 15 on the BIMS (brief interview for mental status) indicating they were cognitively intact for making daily decisions. On [DATE] at 12:07 p.m., an interview was conducted with R18 in their room. R18 stated that the nurse's frequently ran out of their medications. R18 stated that they kept track of the medications that they took and how many so they noticed if there was less than the normal amount in the cup when they brought it in the room and questioned the nurses. R18 stated that it happened with multiple medications including their Parkinson's medications, vitamins, supplements and heartburn medication. R18 stated that the nurses told them that they were out of the medication or they could not find it. A review of R18's clinical record revealed the following physician's orders: - Carbidopa-Levodopa (1) Tablet ,d+[DATE] MG Give 2 tablet by mouth three times a day for Parkinson's disease. Order Date: [DATE]. A review of R18's [DATE] eMAR failed to reveal evidence that Carbidopa-Levodopa tablet ,d+[DATE] mg was administered on [DATE] at 9:00 a.m. and 1:00 p.m. A review of the eMAR note dated [DATE] 08:08 (8:08 a.m.) and 15:36 (3:36 p.m.) documented, Med on order will administer once arrived. On [DATE] at 11:35 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that if a resident's medication was not available they checked the extra storage on the medication cart and medication room. LPN #1 stated that if the medication was not available in house they contacted the pharmacy to deliver the medication stat. LPN #1 stated that if they were unable to get the medication delivered stat, they contacted the physician for an alternate order or hold order. LPN #1 stated that they had an automated dispensing system for a variety of stock medications in their medication room and it had been in place since they had begun working there in April. LPN #1 stated that all nurses had access to the automated medication dispensing system that they knew of and they could pull medications from it for stat medications and for medications that were not on the cart for residents when on order from the pharmacy. LPN #1 stated that if the resident was out of the medication the nurse should call the physician to notify them that the dosage was missed and document in the eMAR notes. The facility policy Medication Shortages/Unavailable Medications with a revision date of [DATE] documented in part, .Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the medication shortage is discovered at the time of medication administration, Facility staff should immediately take action to notify the Pharmacy .If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose . On [DATE] at 4:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were made aware of the above concern. Reference: (1) The combination of levodopa and carbidopa is used to treat the symptoms of Parkinson's disease and Parkinson's-like symptoms that may develop after encephalitis (swelling of the brain) or injury to the nervous system caused by carbon monoxide poisoning or manganese poisoning. Parkinson's symptoms, including tremors (shaking), stiffness, and slowness of movement, are caused by a lack of dopamine, a natural substance usually found in the brain. Levodopa is in a class of medications called central nervous system agents. It works by being converted to dopamine in the brain. Carbidopa is in a class of medications called decarboxylase inhibitors. It works by preventing levodopa from being broken down before it reaches the brain. This allows for a lower dose of levodopa, which causes less nausea and vomiting. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601068.html

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to immediately notify the physician of a significant change in condition for one of 34 residents, Resident #65, which constituted harm. The findings include: For Resident #65, the facility staff failed to immediately notify the physician of a significant change in oxygen saturation. Your blood oxygen level (blood oxygen saturation) is the amount of oxygen you have circulating in your blood (1). Resident #65 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CVA (cerebral vascular accident), CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease), CKD (chronic kidney disease), DM (diabetes mellitus), Cirrhosis of Liver and acute and chronic respiratory failure with hypoxia. A review of the comprehensive care plan dated [DATE] revealed, FOCUS: At risk for altered cardiac /respiratory status. anemia, CAD (coronary artery disease), hyperlipidemia, pulmonary HTN (hypertension), COPD, with acute and chronic respiratory failure with hypoxia, pleural effusion, patent foramen ovale and GERD (gastro-esophageal reflux disease). INTERVENTIONS: 02 as ordered. Monitor for signs/symptoms of decreased cardiac output, rapid, slow, weak or diminished pulse, hypo/hypertension, dizziness, syncope, dyspnea, chest pain, fatigue, restlessness, cyanosis, altered mental status, congestion and shortness of breath. Notify physician as needed with any changes. A review of the physician's orders dated [DATE], revealed, 4L (liters) continuous oxygen NC (nasal cannula) - check setting every shift and on rounds everyday shift for O2 (oxygen) Saturation. A review of the facility's Standing Orders revealed, Shortness of breath (SOB)/difficulty breathing: may place oxygen at 2 liters/minute via nasal cannula as needed for SOB or saturation below 89%. If oxygen saturation less than 87% with difficulty breathing, obtain stat chest x-ray and call physician STAT (immediately). Transfer: In case of an emergency when attending physician is unable to be reached, you may transfer to hospital. A review of the nursing progress note, dated [DATE] at 8:03 AM included, Note Text: Resident was seen lethargy, with an oxygen level of 70% at room air during change of shift. resident was repositioned and 15 liter oxygen was administer via non-rebreather mask. resident O@ [sic] went up to 97 % and resident was responsive and having conversion with staff. resident called her full name and was able to identify where she was. O2 level was reduced to 10 liter via non-rebreather mask after resident became stable, alert and oriented X4 and verbally responsive. resident was being monitored every 1 hr. resident retained an oxygen level of 94 to 97% on a simple mask with o2 at 8Lmp. at 0400 resident verbalized abdominal pain and was given hydromorphone 2mg which was effective. at this time, writer called (physician hospital group) on-called [sic] and was awaiting a call back to discuss resident's condition with the DR. but to no avail. at 5 am, resident was stable and resting in bed with an O2 level of 94% via simple mask. at 0540, resident was seen unresponsive. there was no pulse or respiration noted. Writer began CPR and another nurse called 911. 911 arrived at about 0559 and began high pressure CPR. resident could not be resuscitated and was pronounce [sic] dead at about 0626. Resident is he [sic] own responsible party . An interview was conducted on [DATE] at 8:55 AM, with RN (registered nurse) #3. When asked what would be change of condition indicators for physician notification, RN #3 stated, We would call the physician for grossly abnormal vital signs, any change in baseline, altered mentation, oxygen saturation level below ,d+[DATE]%. An interview was conducted on [DATE] at 9:05 AM, with LPN (licensed practical nurse) #4. When asked what would be change of condition indicators for physician notification, LPN #4 stated, We would notify the physician for abnormal vital signs, change in mentation, oxygen saturation less than 91%. Blood sugar changes and would initiate standing orders if applicable. Call the physician and if no response from the physician or condition worsens immediately call 911. An interview was conducted on [DATE] at 9:10 AM with ASM (administrative staff member) #4, the nurse practitioner (NP). When asked when should the NP be notified for oxygen saturation, ASM #4 stated, We should have been notified for anything less than 87% per the standing orders. We did not receive notification to my knowledge. When asked what are the maximum oxygen liters per minute for a COPD resident, ASM #4 stated, It is ,d+[DATE] liters per minute. An interview was conducted on [DATE] at 9:49 AM with RN (registered nurse) #2, who was the nurse on duty at the time of the event. When asked to describe the events of [DATE]-[DATE] with Resident #65, RN #2 stated, I got there late, between 11:30 PM-12:00 AM on [DATE]. I made my rounds and the resident was laying across the bed. Her oxygen (O2) was not on. She was lethargic. Her vital signs were normal and O2 saturation was low about ,d+[DATE]%. I increased her to 15 LNC (liters nasal cannula), got her situated and her O2 saturation came up to ,d+[DATE]%. Then she was alert and oriented. RN #2 stated, I kept monitoring her oxygen and trying to decrease it. I could not get it back to 4 LNC because her saturation would drop. I had her on a rebreather and finally got her down to 8 liters. I told her that I have to send her to the hospital. She did not want to go. She started having stomach pain, so I gave her narcotic for the pain. RN #2 stated, At 4:00 AM, I called the hospital doctor exchange. I did not get a call back. I called the DON (director of nursing) to let her know of the situation. Resident was reassessed with O2 saturation in 90's on the 8 L face mask. About 5:00 AM, I called the hospital doctor exchange again, talked to resident, and said I have to send you out but the Resident refused to go. RN #2 added, I was the only nurse on the unit, with one CNA .around 5:40 AM, I went to check on (Resident #65) and she was unresponsive. I put her on the floor and started CPR (cardiopulmonary resuscitation). When asked if there were orders to adjust the oxygen, RN #2 stated, No, there was no order. We have standing orders, but they do not cover higher oxygen. I could not keep her on that low oxygen rate. That's the reason I called the physician exchange and the DON. The resident was stable on the higher oxygen, she was not critical at the time, so I did not call 911. I did my due diligence and got her oxygen saturation back up by increasing her oxygen level. There was no evidence in the clinical record regarding the second attempt to call to the on-call physician or that the resident refused to go to the hospital. An interview was conducted on [DATE] at 11:10 AM with ASM #7, the medical director. When asked if the physician should be notified for an O2 saturation of 70%, ASM #7 stated, Yes, of course. I expect the staff to call 911 and send the resident to the hospital like we do during the day. Patient safety is the first thing. On [DATE] at approximately 11:35 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services was made aware of the findings and concern for harm. On [DATE] at 11:37 AM, an interview was conducted with ASM #2, the director of nursing, who stated, The nurse called me around 6:00 AM and said the EMTs (emergency medical technicians) were there and CPR was being done. I do not believe I was called at 4:00 AM. I do not remember the nurse saying she could not reach the on-call physician. I was not aware this had been going on for hours. During the survey, three other residents, Residents #58, #60 and #272 were assessed to confirm physicians were notified of a significant change in condition. Two residents, Residents #58 and #60 were transferred to the hospital and returned to the facility with no concerns regarding care they were provided. Resident #272 was placed on hospice and expired in the facility. No pattern of failure to notify a physician for a significant change in condition was found. A review of the facility's Resident Change in Condition policy dated ,d+[DATE], revealed, The licensed nurse will recognize and intervene in the event of a change in resident condition. The Physician/Provider and the Family/Responsible Party will be notified as soon as the nurse has identified the change in condition and the resident is stable. The Nurse will address any emergency care required given the situation and then gather information prior to contacting the physician/provider. If, after discussion with the physician/provider, the care or observation cannot reasonably be provided in the facility, the physician will authorize transfer to the hospital or alternative facility. If the attending or covering physician/provider does not respond in a timely manner, the nurse will notify the Medical Director for guidance, consultation, and orders. In the event of an emergency situation, 911 will be called immediately and the Physician or Provider/Family/Responsible Party will be notified as soon as practicably possible. No further information was provided prior to exit. Reference: (1) https://my.clevelandclinic.org/health/diagnostics/22447-blood-oxygen-level

Based on resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to maintain ongoing communication with the dialysis center for two of 34 residents in the survey sample, Residents #22 and #35. The findings include: 1. For Resident #22 (R22) the facility staff failed to evidence communication with the dialysis center for 16 of 23 days the resident went to dialysis, from 4/5/2023 through 5/31/2023. And, the facility staff failed to check the dialysis book after dialysis on 5/29/2023. On the most recent, MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/25/2033, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, the resident was coded as receiving dialysis while a resident at the facility. An interview was conducted with R22 on 5/31/2023 at approximately 11:30 a.m. as R22 was getting ready to leave for dialysis. The resident had told the CNA (certified nursing assistant) to get the nurse so they could give them the prescription that was still in the front of the communication book. R22 stated that their dialysis book was missing for a while, and this is the second book they've had since being admitted to the facility. The dialysis book was reviewed. There was no communication sheet for 5/29/2023. A nurse came and took the prescription from R22. On 5/31/2023 at 2:46 p.m. the above prescription was reviewed. The prescription dated, 5/29/2023, documented, Renvela (1) 800 mg (milligrams) 2 tabs (tablets) q (every) 8 hrs (hours) with meals. A request was made on 6/1/2023, for the missing dialysis communication sheets. On 6/1/2023 at 12:54 p.m. ASM (administrative staff member) #3, the assistant director of nursing, presented dialysis communication sheets dated 4/5/2023 through 5/11/2023. When asked where these documents came from, ASM #3 stated she printed them from the electronic record. When asked if these were the ones sent with the resident for dialysis, ASM #3 stated she had just printed these off today. The forms were blank where the dialysis center would document on the forms. The resident interview above was shared with ASM #3. The comprehensive care plan dated, 4/7/2023, documented in part, Focus: Resident receives dialysis treatments 3 times weekly. The Interventions documented in part, Maintain communication with dialysis staff and physician per routine. An interview was conducted with LPN (licensed practical nurse) #4 on 6/1/2023 at 1:58 p.m. When asked for the process when a resident goes to dialysis, LPN #4 stated the nurse should take the resident's vital signs, document in the computer on the dialysis communication form, print the form out and send with the resident. LPN #4 was asked the process for when the resident returns from dialysis, LPN #4 stated the nurse should look at the book to see if the dialysis center filled in their section and see if there is any communication from the dialysis center that needs to be initiated or action taken on. When asked if a prescription in the book needs to have action taken on, LPN #4 stated, absolutely. The observation of the prescription that was still in the book from 5/29/2023 and still in the book on 5/31/2023, was shared with LPN #4. The facility policy, Hemodialysis Care Policy documented in part, Pre-dialysis process: Administer/hold medications as ordered by provider. Assess resident's condition and communicate any concerns to dialysis provider. If the resident's stability to go to dialysis is in question, notify the dialysis provider for discussion and/or assessment to ascertain if treatment is advisable. If treatment is deferred, the primary provider will be notified for any further orders. Document assessment in the Dialysis Communication Tool. Assessment includes: Vital signs, Pre-treatment weight (unless performed at dialysis), Medications administered before treatment, Time of last meal, Fluid intake, Any additional alerts or information, Print the Tool and send with resident to dialysis (if off-site), Arrange for packed meal to be sent with resident if they will be gone over a mealtime .Post-dialysis process: Receive report from dialysis provider and/or review Dialysis Communication Tool documentation by dialysis provider. Contact dialysis provider promptly with any questions or concerns. Information post-dialysis will include: Amount of fluid removed, Vital signs, Post-treatment weight (unless to be completed by SNF), Lab draws and/or results, Medications administered during or after treatment, Any new orders, Any additional alerts or information, Monitor fistula/graft/catheter site for bleeding, Monitor vital signs and notify provider if outside of parameters ordered, Monitor for dizziness, Meal and/or fluids consumed at dialysis, For fistulas and grafts, dressings may be removed the evening after treatment. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 5/31/2023 at 4:38 p.m. No further information was provided prior to exit. (1) Renvela is used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis. This information was obtained from the following website: Sevelamer: MedlinePlus Drug Information. 2. For Resident #35 (R35) the facility staff failed to evidence communication with the dialysis center on 4/21/2023, 5/3/2023 and 5/17/2023. On the most recent MDS assessment, a quarterly assessment, with an assessment reference date of 4/4/2023, the resident scored a 15 out of 15 on the BIMS score, indicating the resident is not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, R35 was coded as receiving dialysis while a resident at the facility. The dialysis communication book was reviewed for April 2023 through May 31, 2023. There was missing communication for 4/21/2023, 5/3/2023 and 5/17/2023. A request was made on 6/1/2023 for the missing documents. On 6/1/2023 at 3:43 p.m. ASM (administrative staff member) #2, the director of nursing, stated they didn't have the missing documents. An interview was conducted with LPN (licensed practical nurse) #4 on 6/1/2023 at 1:58 p.m. When asked about the process for when a resident goes to dialysis, LPN #4 stated the nurse should take the resident's vital signs, document in the computer on the dialysis communication form, print the form out and send with the resident. LPN #4 was asked the process for when the resident returns from dialysis, LPN #4 stated the nurse should look at the book to see if the dialysis center filled in their section and see if there is any communication from the dialysis center that needs to be initiated or action taken on. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 5/31/2023 at 4:38 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure complete and accurate documentation for two of 34 residents, Resident #58 and Resident #268. The findings include: 1. For Resident #58, the facility staff failed to document the removal of a PICC line (1), to include the length of the catheter removed. The physician order dated 5/23/2023, documented, DC (discontinue) PICC line one time only for 1 day. A request was made on 6/1/2023 at 12:06 p.m. for the documentation of the removal of the PICC line. On 6/1/2023 at 1:14 p.m., ASM (administrative staff member) #2, the director of nursing, presented the May 2023 MAR (medication administration record) that documented the above order. The order was signed off as completed by RN (registered nurse) #4. When asked where the documentation of the length of the catheter that was removed was, ASM #2 stated, It should be documented, but I don't see it. An interview was conducted with RN #4 on 6/1/2023 at 2:03 p.m. RN #4 had approached the surveyor to state, I was on my way off shift for the day. I didn't have the resident, but I was the only RN on duty that day. They asked me to take it out. When asked about the process she followed, RN #4 stated I did hand hygiene, talked to the resident, told them to hold their breath and turn their head away from me. I made sure I had the head of the catheter was at the top. RN #4 was asked if she measured the catheter after it was removed, RN #4 stated she looked at the tube itself. RN #4 stated there was nothing in the chart (medical record) to compare it to. RN #4 stated, What I didn't do was put a note in the record. I made sure the family was aware of it being removed. The facility policy, Central Vascular Access Device (CVAD) Removal (Non-Tunneled), documented in part, Documentation in the medical record includes, but is not limited to:32.1 Date and time. 32.2 Reason for removal. 32.3 Length and condition of catheter and tip. 32.4 Site assessment. 32.5 Patient response to procedure. 32.6 Any action taken if catheter was removed due to complication. 32.7 Patient/significant other teaching. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 5/31/2023 at 4:38 p.m. No further information was provided prior to exit. (1) PICC - Peripherally inserted central catheter, is a long-line catheter made of soft silicone or Silastic material that is placed peripherally but delivers medications and solutions centrally. [NAME], [NAME] & [NAME], Fundamental of Nursing, 5th edition, 2007, page 1423. 42183 2. For Resident #268, the facility staff failed to evidence complete and accurate documentation for bladder and bowel elimination continence status. Resident #268 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: stroke, and hemiplegia. Resident #268's most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an assessment reference date of 8/21/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of MDS Section H- Bowel and Bladder: coded the resident as always continent for bladder and bowel. A review of the ADL (activities of daily living) record for August 2022 revealed missing bladder and bowel elimination continence status documentation for 2 out of 16 day shifts, 15 out of 17 evening shifts and 11 out of 17 night shifts. A review of the ADL record for September 2022 revealed missing bladder and bowel elimination documentation for 4 out of 23 day shifts, 20 out of 22 evening shifts and 16 out of 22 night shifts. An interview was conducted on 9/1/23 at 1:00 PM with LPN (licensed practical nurse) #2. When asked if she remembered Resident #268, LPN #2 stated, Yes, she .was very non-compliant. There were so many safety concerns and she would change position by immediately standing up and going to the bathroom. She was continent of both bowel and bladder but did not ring her bell for assistance . An interview was conducted on 9/1/23 at 2:15 PM with CNA (certified nursing assistant) #1 who stated the resident was was continent and would go to the bathroom on her own. When asked if the resident being continent should be documented on the ADL record, CNA #1 stated, Yes, it should. When asked what the blanks in documentation meant, CNA #1 stated, Well, since she was continent, it means that the documentation was not complete. On 6/1/23 at approximately 4:40 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were made aware of the findings. There is no facility policy regarding a complete and accurate medical record. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for five of 34 residents, Residents #56, #59, #18, #65, and #22. The findings include: 1. For Resident #56 (R56) the facility staff failed to implement the comprehensive care plan to A) teach the resident how to use communication devices and B) provide leisure supplies in the residents primary language. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of [DATE], the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. Section B documented R56 having moderate difficulty with hearing and wearing hearing aids. It also documented R56 having impaired vision, wearing corrective lenses and able to see large print but not regular print. Section F documented having books, newspapers and magazines to read and participating in religious services or practices somewhat important to them. It documented a resident representative completing the assessment for the resident. On [DATE] at 1:02 p.m., R56 was observed sitting in a wheelchair in their room listening to the radio. At this time an interview was attempted with R56. R56 stated, No English. R56 proceeded to pick up their cell phone and attempted to make a call with no answer. No communication tools were observed in R56's room. No leisure supplies in the residents primary language were visible in the room. On [DATE] at 2:28 p.m., an interview was conducted with R56's granddaughter who was visiting in the room. When asked how the staff communicated with (R56), they stated that they were unsure. R56's granddaughter stated that R56 knew a few words, could point to things and staff would call them as needed. R56's granddaughter stated that they were not aware of any type of communication tools that the facility staff used. (A) The facility staff failed to implement the care plan to teach the resident how to use communication devices. The comprehensive care plan for R56 documented in part, Inability to express emotion, listen and share information. Alteration in communication related to: hearing deficit, Language barrier, blindness. Date Initiated: [DATE]. Created on: [DATE]. Under Interventions it documented in part, .Teach resident how to use communication book/ board/ electronic device. Date Initiated: [DATE]. Created on: [DATE] . The progress notes for R56 documented in part, - [DATE] 19:31 (7:31 p.m.) Note Text : IDT (interdisciplinary) team notified by family member of resident's hard of hearing, blindness and language barrier. Resident speaks Hungarian. Assistive devices in use: Resident's has hearing aides. Communication board offered to resident- resident's son requests that facility calls him for interpretation. Son visits everyday- requests that son's number is placed by bedside wall. - [DATE] 10:55 (10:55 a.m.) Nursing note .residents' primary language is not English, daughter was able to help resident communicate needs during shift . - [DATE] 12:22 (12:22 p.m.) Nursing note .Resident is alert and oriented x 4 (person, place, time and situation) but does have difficulty expressing needs due to language barrier. Resident uses body language many times to express needs, which is effective . - [DATE] 22:58 (10:58 p.m.) Nursing note .Resident is alert and oriented x 3 (to person, place and time), with language barrier. Resident's primary language is Hungarian. Resident is able to say a few words in English to communicate needs, and uses body language to communicate. Resident's family does provide assistance with translating . - [DATE] 18:13 (6:13 p.m.) Nursing note .Some language barriers, but able to make needs known to staff . - [DATE] 13:41 (1:41 p.m.) This writer observed that resident began to cry and became very emotional after son stated resident will remain LTC (long term care) due to the increased amount of assistance with ADLs (activities of daily living). Resident stated in native language that she feels lonely and does not have companionship due to language barrier. Son has been coming in to visit resident every day and is communication with nursing staff/SW (social worker). Son has advised to always call him for translation. SS (social services) will assist in finding LCAs, organizations/groups that speak Hungarian/Romanian for resident companionship. Resident and resident's son agrees. On [DATE] at 8:52 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. LPN #1 stated that they were not aware of R56 having any communication devices. On [DATE] at 8:48 a.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated that R56 used hand gestures, nodded their head and gives them the thumbs up to communicate. CNA #4 stated that R56 understood limited English and could point to the juice, coffee and water to make decisions. CNA #4 stated R56 did not have any communication devices because they could speak but could not speak English. On [DATE] at 8:58 a.m., an interview was conducted with OSM (other staff member) #8, life enrichment. OSM #8 stated that they had taken their communication board when they went to visit with R56 but they did not leave it in the room. OSM #8 stated that they thought that perhaps social services was working on setting up a personalized communication board for R56. On [DATE] at 9:05 a.m., an interview was conducted with OSM # 6, the director of social services. OSM #6 stated that they had requested R56's son to set up a communication board and the director of rehab was working with them. OSM #6 stated that they had discussed this about a month ago. OSM #6 stated that they had reached out to a few organizations and were still trying to find churches in the area that may offer volunteers to come to the facility for R56. On [DATE] at 9:17 a.m., an interview was conducted with OSM #5, the director of rehab services. OSM #5 stated that they were not technically working on setting up a communication board for R56. OSM #5 stated that they had spoken to R56's son who stated that they would work with activities to facilitate a communication board. OSM #5 stated that they were told by the former activities director that R56's son did not comply with setting up the communication board. OSM #5 stated that it was not the families responsibility to facilitate the communication devices that it was the facilities. On [DATE] at approximately 9:30 a.m., a request was made to ASM (administrative staff member) #3, assistant director of nursing, for evidence of facility interventions regarding communication devices attempted with R56. On [DATE] at approximately 10:10 a.m., ASM #2, the director of nursing provided the progress note dated [DATE] documented above. On [DATE] at approximately 11:00 a.m., a follow up interview was conducted with OSM # 6, the director of social services. When asked about the progress note provided dated [DATE], OSM #8 stated that R56's son had declined the communication board that they offered on [DATE]. OSM #6 stated that R56's son did not really state why he declined the communication board other than it would not work. OSM #6 provided the communication board from their desk, a laminated page approximately 8.5 x 11 inches in size with large pictures of ADL tasks with the English words written underneath. OSM #6 stated that R56 was blind and hard of hearing. When asked if R56 was legally blind and could feed themselves, OSM #6 stated, Yes. When asked if R56 would be able to see a communication board, OSM #6 stated, Yes. OSM #6 stated that this conversation was with R56's son when R56 was at the facility for short-term rehabilitation and they had not had any conversations or approached the subject with the son or the resident since the decision had been made to stay at the facility long term. OSM #6 stated that they had not had a care plan meeting since the transition to long term care but it was scheduled this month. (B) The facility staff failed to implement the care plan to provide leisure supplies in Hungarian due to a language barrier. The comprehensive care plan for R56 documented in part, Resident has a variety of leisure interests but prefers to participate in self-directed leisure. Date Initiated: [DATE]. Created on: [DATE]. Under Interventions it documented in part, Resident will be given leisure supplies in Hungarian due to language barrier. Date Initiated: [DATE]. Created on: [DATE] . The progress notes for R56 failed to evidence documentation of leisure supplies provided in R56 primary language. On [DATE] at 8:52 a.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. LPN #1 stated that R56 did not speak English but knew a few words and could make hand gestures to communicate what they needed. On [DATE] at 8:58 a.m., an interview was conducted with OSM (other staff member) #8, life enrichment. OSM #8 stated that they worked with R56 and provided activities like doing their nails and taking them outside. OSM #8 stated that they had attempted to get them to participate in group activities but they had refused by shaking their head no. OSM #8 stated that they had not provided any books or magazines for R56 in Hungarian but that it was a good idea. OSM #8 stated that they were not aware that the intervention Resident will be given leisure supplies in Hungarian due to language barrier was on the care plan and that the former activities staff member had written it. The facility policy, Comprehensive Care Planning Policy with a revision date of [DATE] documented in part, The facility must develop a comprehensive Person Centered Care Plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments .All staff must be familiar with each resident's Care Plan and all approaches must be implemented . On [DATE] at 12:42 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were made aware of the concern. No further information was provided prior to exit. 2. For Resident #59 (R59), the facility staff failed to implement the care plan to administer oxygen at the prescribed rate. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section O documented R59 received oxygen at the facility. On [DATE] at 12:56 p.m., R59 was observed in bed wearing an oxygen cannula. The oxygen was observed to be dated ,d+[DATE] and was set at a rate of 2.5 lpm (liters per minute). Additional observations were made of R59 on [DATE] at 4:10 p.m. and [DATE] at 8:48 a.m. wearing the oxygen cannula with the rate at 2.5 lpm. The comprehensive care plan for R59 documented in part, At risk for altered cardiac/resp (respiratory) status related to aortic stenosis, CAD (coronary artery disease), white coat syndrome. Date Initiated: [DATE]. Revision on: [DATE] . Under Interventions it documented in part, O2 (oxygen) as ordered . The physician orders for R59 documented in part, Oxygen: via NC (nasal cannula) at 3L (liters) to maintain SPO2>90% (oxygen saturation greater than 90%), SPO2 check Q (every) shift, every shift. Order Date: [DATE]. On [DATE] at 11:35 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that oxygen was checked every day and administered at the rate based on the order. LPN #1 stated that the flowmeter ball should be centered on the line for the number of the ordered rate. LPN #1 stated that when they checked the rate of the oxygen they read it at eye level. LPN #1 observed R59's oxygen and stated that it was set at 2 lpm. LPN #1 reviewed the order for R59's oxygen and stated that it was ordered at 3 lpm and someone must have set it wrong. On [DATE] at 8:52 a.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. LPN #1 stated that if the care plan said to administer oxygen as ordered, then that was what they did to implement the care plan. On [DATE] at 4:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were made aware of the concern. No further information was provided prior to exit. 3. For Resident #18 (R18), the facility staff failed to implement the care plan to administer medications as ordered in March and April of 2023. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of [DATE], the resident scored 15 out of 15 on the BIMS (brief interview for mental status) indicating they were cognitively intact for making daily decisions. On [DATE] at 12:07 p.m., an interview was conducted with R18 in their room. R18 stated that the nurse's frequently ran out of their medications. R18 stated that they kept track of the medications that they took and how many so they noticed if there was less than the normal amount in the cup when they brought it in the room and questioned the nurses. R18 stated that it happened with multiple medications including their Parkinson's medications, vitamins, supplements and heartburn medication. R18 stated that the nurses told them that they were out of the medication or they could not find it. The comprehensive care plan for R18 documented in part, The resident is on Antibiotic Therapy r/t (related to) UTI suppression. Date Initiated: [DATE]. Revision on: [DATE]. Under Interventions it documented in part, Administer medications as ordered. Date Initiated: [DATE]. Revision on: [DATE] . The care plan further documented, The resident has Parkinson's Disease, restless leg syndrome, and neuropathy related to DM (diabetes mellitus). Date Initiated: [DATE]. Revision on: [DATE]. Under Interventions it documented in part, Give medications as ordered by the physician. Monitor/document side effects and effectiveness. Date Initiated: [DATE] . A review of R18's clinical record revealed the following physician's orders: - Pantoprazole Sodium Tablet Delayed Release 40 MG (milligram) Give 1 tablet by mouth two times a day for gerd (gastroesophageal reflux disease). Order Date: [DATE]. - Calcitonin (Salmon) Nasal Solution 200 UNIT/ACT (Calcitonin (Salmon)) 1 spray Alternating nostrils one time a day for compression fracture alternate nostrils daily. Order Date: [DATE]. - Nitrofurantoin Macrocrystal Capsule 50 MG Give 2 capsule by mouth at bedtime for Chronic UTI (urinary tract infection) Suppression. Order Date: [DATE]. - Ocuvite-Lutein Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for supplement. Order Date: [DATE]. - Ropinirole HCl ER (extended release) Tablet Extended Release 24 Hour 12 MG Give 1 tablet by mouth at bedtime for restless leg syndrome. Order Date: [DATE]. - Carbidopa-Levodopa Tablet ,d+[DATE] MG Give 2 tablet by mouth three times a day for Parkinson's disease. Order Date: [DATE]. A review of R18's [DATE] eMAR (electronic medication administration record) failed to reveal evidence that Ocuvite-Lutein was administered on [DATE] at 9:00 a.m., Ropinirole 12 mg on [DATE] at 9:00 p.m., Nitrofurantoin 50 mg on [DATE] at 9:00 p.m., and Calcitonin nasal solution on ,d+[DATE]-[DATE] at 9:00 a.m., ,d+[DATE]-[DATE] at 9:00 a.m. and [DATE] at 9:00 a.m. A review of R18's [DATE] eMAR failed to reveal evidence that Pantoprazole 40 mg was administered on [DATE] at 8:00 a.m. and [DATE] at 8:00 a.m. The eMAR failed to reveal evidence that Carbidopa-Levodopa tablet ,d+[DATE] mg was administered on [DATE] at 9:00 a.m. and 1:00 p.m. A review of the eMAR note dated [DATE] 08:08 (8:08 a.m.) and 15:36 (3:36 p.m.) documented, Med on order will administer once arrived. On [DATE] at 11:35 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that if a resident's medication was not available they checked the extra storage on the medication cart and medication room. LPN #1 stated that if the medication was not available in house they contacted the pharmacy to deliver the medication stat. LPN #1 stated that if they were unable to get the medication delivered stat, they contacted the physician for an alternate order or hold order. LPN #1 stated that if the resident was out of the medication the nurse should call the physician to notify them that the dosage was missed and document in the eMAR notes. On [DATE] at 8:52 a.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. LPN #1 stated that if the care plan said to administer medications as ordered, then that was what they did to implement the care plan. On [DATE] at 4:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were made aware of the above concern. 42183 4. For Resident #65, the facility staff failed to follow the comprehensive care plan for oxygen administration and physician notification for a change in condition. Resident #65 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease), acute and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an ARD (assessment reference date) of [DATE], coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section O-special procedures coded oxygen as 'yes'. A review of the comprehensive care plan dated [DATE], revealed, FOCUS: At risk for altered cardiac /respiratory status. anemia, CAD (coronary artery disease), hyperlipidemia, pulmonary HTN (hypertension), COPD, with acute and chronic respiratory failure with hypoxia, pleural effusion, patent foramen ovale and GERD (gastro-esophageal reflux disease). INTERVENTIONS: 02 as ordered. Monitor for signs/symptoms of decreased cardiac output, rapid, slow, weak or diminished pulse, hypo/hypertension, dizziness, syncope, dyspnea, chest pain, fatigue, restlessness, cyanosis, altered mental status, congestion and shortness of breath. Notify physician as needed with any changes. A review of the physician's orders dated [DATE], revealed, 4L (liters per minute) continuous oxygen NC (nasal cannula) - check setting every shift and on rounds everyday shift for O2 Saturation. A review of the nursing progress note dated [DATE] at 8:03 AM, revealed, Resident was seen lethargic, with an oxygen level of 70% on room air during change of shift. resident was repositioned and 15-liter oxygen was administer via non-rebreather mask. resident O2 went up to 97 % and resident was responsive and having conversation with staff. resident called her full name and was able to identify where she was. O2 level was reduced to 10 liters via non-rebreather mask after resident became stable, alert and oriented X4 and verbally responsive. resident was being monitored every 1 hr. resident retained an oxygen level of 94% to 97% on a simple mask with O2 at 8L per minute. at 0400 (4:00 AM) resident verbalized abdominal pain and was given hydromorphone 2mg which was effective. at this time, writer called hospital on call physician and was awaiting a call back to discuss resident's condition with the physician. but to no avail. at 5 am, resident was stable and resting in bed with an O2 level of 94% via simple mask. At 0540 (5:40 AM), resident was seen unresponsive. there was no pulse or respiration noted. Writer began CPR and another nurse called 911. 911 arrived at about 0559 and began high pressure CPR. Resident could not be resuscitated and was pronounce dead at about 0626 (6:26 AM). Resident is her own responsible party. An interview was conducted on [DATE] at 8:32 AM, with LPN (licensed practical nurse) #3. When asked to describe what changes in condition would necessitate physician notification, LPN #3 stated, not alert, could not arouse, if affect different, talking complete nonsense, oxygen saturation, bleeding, falls. When asked if the care plan has intervention of oxygen as ordered and resident is ordered 4 (liters nasal cannula), but oxygen is adjusted to ,d+[DATE] liters, is the care plan being followed, LPN #3 stated, No, not following care plan in that instance. An interview was conducted on [DATE] at 9:00 AM, with RN (registered nurse) #3. RN #3 concurred that if the resident has oxygen orders for 4 liters via nasal cannula, with care plan intervention identified as oxygen as ordered, and oxygen is adjusted to ,d+[DATE] liters, that the care plan was not being followed. On [DATE] at approximately 11:35 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services was made aware of the findings. No further information was provided prior to exit. 27660 5. a. For Resident #22, the facility staff failed to implement the comprehensive care plan for communication with the dialysis center. The comprehensive care plan dated, [DATE], documented in part, Focus: Resident receives dialysis treatments 3 times weekly. The Interventions documented in part, Maintain communication with dialysis staff and physician per routine. An interview was conducted with R22 on [DATE] at approximately 11:30 a.m. R22 was getting ready to leave for dialysis. The resident had told the CNA (certified nursing assistant) to get the nurse so they could give them the prescription that was still in the front of the communication book. R22 stated that their dialysis book was missing for a while, and this is the second book they've had since being admitted to the facility. The dialysis book was reviewed. There was no communication sheet for [DATE]. A nurse came and took the prescription from R22. Review of the clinical record failed to evidence documentation of communication with the dialysis center for 16 of 23 days the resident went to dialysis, from [DATE] through [DATE]. And the facility staff failed to check the dialysis book after dialysis on [DATE]. On [DATE] at 2:46 p.m. the above prescription was reviewed. The prescription dated, [DATE], documented, Renvela (1) 800 mg (milligrams) 2 tabs (tablets) q (every) 8 hrs (hours) with meals. A request was made of on [DATE], for the missing dialysis communication sheets. On [DATE] at 12:54 p.m. ASM (administrative staff member) #3, the assistant director of nursing, presented dialysis communication sheets dated [DATE] through [DATE]. When asked where these documents came from, ASM #3 stated she printed them from the electronic record. When asked if these were the ones sent with the resident for dialysis, ASM #3 stated she had just printed these off today. The forms were blank for where the dialysis center would document on the forms. The resident interview above was shared with ASM #3. An interview was conducted with LPN (licensed practical nurse) #4 on [DATE] at 1:58 p.m. When asked the process for when a resident goes to dialysis, LPN #4 stated the nurse should take the resident's vital signs, document in the computer on the dialysis communication form, print the form out and send with the resident. LPN #4 was asked the process for when the resident returns from dialysis, LPN #4 stated the nurse should look at the book to see if the dialysis center filled in their section and see if there is any communication from the dialysis center that needs to be initiated or action taken on. When asked if a prescription in the book needs to have action taken on, LPN #4 stated, absolutely. The above observation of the prescription still in the book from [DATE] and still in the book on [DATE], was shared with LPN #4. On [DATE] at 8:52 a.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on [DATE] at 12:40 p.m. No further information was provided prior to exit. 4.b For Resident #22 (R22), the facility staff failed to implement the comprehensive care plan for administering treatments per the physician order. The comprehensive care plan dated, [DATE], documented in part, Focus: Impaired skin integrity related to: diabetic foot ulcer to left lateral ulcer. The Interventions documented in part, Wound treatment per protocol and physician orders. The physician orders dated, [DATE], documented, Skin Prep Bilateral Heels qs (every shift) and prn (as needed), every shift for skin integrity. The [DATE] MAR (medication administration record) documented the above order. There were blanks, which indicated the treatment was not performed, on the MAR for the day shift on [DATE] and [DATE] and on the evening shift on [DATE]. The [DATE] MAR documented the above order. There were blanks on the MAR for the day shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. There were blanks on the MAR for evening shift on [DATE] and [DATE]. There were blanks on the MAR for the night shift on [DATE]. An interview was conducted with LPN (licensed practical nurse) #4 on [DATE] at 8:47 a.m. When asked what do the blanks on a TAR mean, LPN #4 stated, It wasn't done. On [DATE] at 8:52 a.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on [DATE] at 12:40 p.m. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility record review, it was determined that the facility staff failed to ensure one of 34 residents were provided the opportunity to participate in the care planning process, Resident #18. The findings include: For Resident #18 (R18), the facility staff failed to evidence inclusion of the resident in the interdisciplinary care planning process. On the most recent MDS (minimum data set), an annual admission assessment with an ARD (assessment reference date) of 5/1/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 6/1/2023 at 2:09 p.m., an interview was conducted with R18 in their room. R18 stated that they had resided at the facility for about a year. When asked if they were invited to participate in the care planning process, R18 stated that they had never been asked to attend a care plan meeting. R18 stated that they would be interested in attending any meeting that discussed their care and goals because they wanted to be involved in their care at the facility. Review of R18's clinical record failed to evidence documentation of care plan meeting notes or invitations provided to R18. On 6/1/2023 at 3:18 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing, for evidence of R18 being invited and/or notified of the care plan meetings. On 6/1/2023 at 3:44 p.m., ASM #2 stated that they did not have evidence of a care plan invitation/notification for R18 to provide. On 6/2/2023 at 9:05 a.m., an interview was conducted with OSM (other staff member) #6, the director of social services. OSM #6 stated that they set up the care plan meetings every quarter and annually. OSM #6 stated that they normally provided telephone notice to the residents responsible party if applicable and spoke to the residents in person and gave them an invitation letter. OSM #6 stated that they documented the invitation in the progress notes, however they did not have evidence of that for R18. OSM #6 stated that they were not having care plan meetings as often for a while because there really was no nursing department so they were meeting with the MDS coordinator. OSM #6 stated that they had met with R18's sister a couple of times and met with R18 directly a couple of times in the past. The facility policy, Comprehensive Care Planning Policy with a revision date of 7/19/2019 documented in part, .The Interdisciplinary Care Planning Team may consist of: 1. The resident, the resident's family and/or the resident's legal representative The facility designee is responsible for delivering to each resident who is scheduled for conference an invitation to attend the meeting. The letter of requested participation (original) is presented to the resident at least five (5) days prior to the date of conference. A designated time of meeting is given to each resident. (Those residents who have been deemed legally incompetent or has documentation in their medical record, as medically incompetent by their attending physician would be exempt from this procedure.) A copy of the letter is maintained for reference . On 6/1/2023 at 4:38 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were made aware of the above concern. No further information was presented prior to exit.