Every finding on record at Garden Park Nursing & Rehab CTR, LLC

Based on observation and interview the facility failed to ensure the most recent survey results were readily accessible to the residents, family members or anyone to review. Findings: An observation on 09/08/2025 at 10:00 a.m. failed to reveal the most recent survey result was in the facility's survey binder. During an interview on 09/08/2025 at 10:01 a.m. with S1 Administrator confirmed most the recent survey was not in survey binder and should have been.

Based on record reviews, observations and interviews, the facility failed to ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms for 3 (#15, #58, #139) of 3 (#15, #58, #139) residents reviewed for restraints . The facility failed to ensure:1. a pre-restraint assessment and written consent were in place for the use of Resident #15's lap buddy and 2. a pre-restraint assessment and written consent were in place for the use of Resident #58 and Resident #139's self-releasing seat belt. Findings: Review of the facility's undated policy for Restraints: Physical revealed in part:Policy:A physical restraint is defined as any manual method or mechanical, physical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints include, but are not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions and lap trays the resident cannot remove easily. Also included as restraints are facility practices that meet the definition of a restraint, such as:3. Using devices in conjunction with a chair such as trays, tables, bars or belts that the resident cannot remove easily that prevent a resident from rising out of the chair. Restraint use should be a last resort and only used after all other measures of dealing with the problem have been exhausted. Informed consent must be obtained prior to initiation of a restraint. The facility must explain, in the context of the individual resident's condition and circumstances, the potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use. In effect, restraint use can reduce independence, functional capacity, and quality of life. In the case of a resident who is incapable of making decision, the surrogate or representative may exercise this right based on the same information that would have been provided to the resident. Before a resident is restrained, the facility must complete a pre-restraining assessment and they must demonstrate the presence of a specific medical symptom that requires the use of restraints, and how the use of restraints would treat the medical symptom, protect the resident's safety and assist in reaching the highest level of physical and psychological well-being. Resident #15Review of Resident #15's medical record revealed an admit date of 07/12/2024 with diagnoses including in part major depressive disorder, recurrent, severe with psychotic symptoms, other symptoms and signs involving cognitive functions and awareness, and dementia in other diseases classified elsewhere, severe, with mood disturbance.Review of Resident #15's physician orders revealed an order dated 01/17/2025 for lap buddy to wheelchair at all times to aid with positioning while sitting. Nursing to monitor for placement every shift. Review of Resident #15's annual MDS (Minimum Data Set) dated 06/12/2025 revealed in part a BIMS (Brief Interview of Mental Status) was not performed as Resident #15 was rarely/never understood.Further review of Resident #15's medical record failed to reveal a pre-restraint assessment and written consent for the use of a lap buddy were in place. Observation on 09/09/2025 at 8:20 a.m. revealed Resident #15 sitting in wheelchair with a soft lap buddy in use. Observation on 09/10/2025 at 8:00 a.m., revealed S16CNA (Certified Nursing Assistant) applied and secured a soft lap buddy under the arm rests of Resident #15's wheelchair, while Resident #15 was seated in the wheelchair. Further observation failed to reveal Resident #15 could remove his soft lap buddy from his wheelchair upon request of S16CNA. During an interview on 09/10/2025 at 8:00 a.m., S16CNA acknowledged Resident #15 was not able to remove his soft lap buddy when asked to remove it. Resident #58Review of Resident #58's medical record revealed an admit date of 10/18/2023 with diagnoses including in part cognitive communication deficit, fracture of superior rim of left pubis, Alzheimer's disease with late onset, repeated falls, need for assistance with personal care, dementia in other diseases classified elsewhere-moderate-with agitation, and lack of coordination. Review of Resident #58's physician orders revealed in part an order dated 03/18/2025 for self-release seatbelt to wheelchair at all times while in chair every shift.Review of Resident #58's quarterly MDS dated [DATE] revealed in part Resident #58 had severe cognitive impairment.Further review of Resident #58's medical record failed to reveal an assessment or consent for the use of a self-releasing seat belt. Observation on 09/09/2025 at 10:30 a.m. revealed Resident #58 sitting in a wheelchair with a self-releasing seat belt in place. Further observation failed to reveal Resident #58 could remove her self-releasing seat belt as requested by S7LPN (Licensed Practical Nurse) and S8CNA. During an interview on 09/09/2025 at 10:30 a.m., S7LPN and S8CNA reported Resident #58 would scoot to the end of the wheelchair seat and try to get out. Resident #139Review of Resident #139's medical record revealed an admit date of 11/12/2018 with diagnoses including in part muscle wasting and atrophy, cognitive communication deficit, dementia with mood disturbance.Review of Resident #139's physician orders revealed an order dated 03/11/2024 for self-releasing seat belt while in wheelchair due to multiple falls secondary to dementia with muscle weakness and atrophy. Review of Resident #139's quarterly MDS dated [DATE] revealed a BIMS was not performed as Resident #139 was rarely understood.Further review of Resident #139's medical record failed to reveal a pre-restraint assessment or written consent for the use of a self-releasing seat belt were in place. Observation on 09/08/2025 at 10:39 a.m. revealed Resident #139 sitting in a wheelchair with a lap self-releasing seat belt in use. During an interview on 09/09/2025 at 2:18 p.m., S9Medicare Case Manager reported the facility does not consider a lap buddy or self-releasing seat belt as a restraint so no assessment or consent was required. During an interview on 09/10/2025 at 9:20 a.m., S3Corporate Nurse acknowledged the use of lap buddies and self-releasing seat belts for wheelchairs required a pre-restraint assessment and informed consent prior to use.

Based on record review and interviews, the facility failed to ensure a resident with an order for psychotropic medication as needed (PRN) was not subjected to chemical restraints for 1 (#139) of 4 (#3, #7, #10 and #139) residents reviewed for unnecessary medications. The facility failed to ensure Resident #139's PRN order for psychotropic medication was limited to 14 days. Findings:Review of Resident #139's medical record revealed an admit date of 11/12/2018 with diagnoses including in part muscle wasting and atrophy, cognitive communication deficit, dementia in other diseases classified elsewhere, severe, with mood disturbance.Review of Resident #139's physician orders revealed an order dated 01/28/2025 for Vistaril oral capsule 25 mg (milligram) (Hydroxyzine Pamoate); give 1 capsule by mouth every 8 hours as needed for anxiety and/or restlessness without a stop date.During an interview on 09/09/2025 at 1:00 p.m., S4DON (Director of Nursing) acknowledged Resident #139 had a PRN Vistaril order for anxiety greater than 14 days. S4DON reported the prn Vistaril order should have had an end date and did not.

Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the resident's status for 1(#137) of 1(#137) resident out a total of 46 sampled residents whose assessments were reviewed. The facility failed to complete Resident #137's discharge assessment. Findings: Review of Resident #137's medical record revealed an admission date of 03/11/2025 and a discharge date of 03/17/2025 with a diagnosis of but not limited to low back pain, schizophrenia, hypertensive chronic kidney disease with stage 4 chronic kidney disease, generalized muscle weakness, essential hypertension, and muscle wasting and atrophy. Review of Resident #137's MDS (minimum data set) assessments failed to reveal a discharge assessment had been completed when Resident #137 was discharged from the facility on 03/17/2025. Further review of Resident #137's MDS tracking revealed the following statement: Discharge ARD (assessment reference date) of 03/17/2025, 162 days overdue. During an interview on 09/09/2025 at 10:07 a.m. S10 MDS nurse and S9 Medicare Case Manager confirmed Resident #137's discharge MDS assessment had not been completed and should have been.

Based on record review and interview, the facility failed to refer a resident with newly evident or possible severe mental disorder, intellectual disability, or related conditions for a Level II PASARR (Pre-admission Screening and Resident Review) services for 1 (#23) of 2 (#10, #23) residents reviewed for PASARR. The failure had the potential for residents to not be provided with specialized rehabilitation services, causing feelings of boredom, hopelessness, and a diminished quality of life. Findings:Review of Resident #23's medical record revealed an admit date of 07/11/2019.Review of Resident #23's PASARR dated 07/10/2019 revealed no diagnoses of mental illness and a Level II PASARR was not indicated. Review of Resident #23's medical record revealed a diagnosis of brief psychotic disorder dated 06/04/2020 and a diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms dated 01/01/2025.Further review of Resident #23's medical record failed to reveal a new PASARR had been submitted related to diagnoses received after admission which included brief psychotic disorder and major depressive disorder, recurrent, severe with psychotic symptoms.During an interview on 09/09/2025 at 12:50 p.m. S4DON (Director of Nursing) acknowledged a new PASARR had not been resubmitted upon new diagnosis of mental illness after admission to the facility and should have been.

Based on record reviews and interviews, the facility failed to develop an individualized person-centered care plan to meet the needs of 5 (#3, #5, #58, #69, #111) residents out of 5 (#3, #5, #58, #69, #111) residents reviewed for plan of care. The facility failed to ensure:1. Resident #3's plan of care included appropriate approaches for current diagnosis of non-Alzheimer's Dementia.2. Resident #5's care plan included diagnosis of anxiety and receiving anti-anxiety medications. 3. Resident #58's plan of care included a focus for wound care with appropriate interventions 4. Resident #69's plan of care included appropriate approaches for the current wound care.5. Resident #111 care plan included a focus on use of bed rail/side rail with appropriate interventions. Findings: Resident #3 Review of Resident #3's medical record revealed an admission date 07/15/2025 and diagnoses that included Non-Alzheimer's dementia. Review of Resident #3's comprehensive care plan failed to reveal Resident #3 had been care planned with appropriate interventions for dementia care. During an interview on 09/09/2025 at 1:06 p.m. S10 MDS (Minimum Data Sets) Nurse reported Resident #3 had diagnosis of Non-Alzheimer's Dementia and comprehensive care plan did not include appropriate interventions for Non-Alzheimer's Dementia and should have. Resident #5 Review of Resident #5's face sheet revealed an admission date on 02/04/2021 revealed a diagnoses of generalized anxiety disorder. Review of Resident #5's Quarterly MDS assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 14 indicating intact cognition. Further review of Resident #5's Quarterly MDS revealed Resident #5 received anti-anxiety medication for the last 7 days of the look back period. Review of Resident #5's September 2025 physician orders revealed an order dated 07/01/2024 for Buspirone HCl (hydrochloride) Tab 5 MG (milligram); Give 1 tablet orally two times a day related to generalized anxiety disorder. Review of Resident #5's care plan failed to reveal appropriate interventions were in place for diagnosis of anxiety disorder. During an interview on 09/09/2025 at 9:45 a.m. S6 Care Plan Nurse reviewed Resident #5's care plan and confirmed Resident #5's care plan did not include appropriate interventions for diagnosis of anxiety disorder. During an interview on 09/09/2025 at 11:00 a.m. S4 DON (Director of Nursing) confirmed Resident #5 had a diagnosis of anxiety and received anti-anxiety medications. S4 DON confirmed Resident #5's care plan should have interventions for anxiety disorder. Resident #58 Review of Resident #58's medical record revealed an admit date of 10/18/2023 with diagnoses that include in part unstageable pressure ulcer of left heel. Review of Resident #58's medical record revealed a skin and wound assessment dated [DATE] -Pressure ulcer to left medial foot-unstageable-noted, RP (responsible party) notified, MD (medical doctor) with new orders noted. Review of Resident #58's comprehensive care plan failed to reveal a focus for Resident #58's unstageable pressure ulcer with appropriate interventions. Resident #69 Review of Resident #69's medical record revealed an admit date of 11/03/2022 with readmission date of 09/22/2023 and diagnoses that include in part unsteadiness on feet and repeated falls. Review of Resident #69's physician orders revealed in part: 07/14/2025 Skin tear to right shin: cleanse with wound cleanser; pat dry with 4 x 4 gauze; apply xeroform to wound bed; cover with border dressing prn (as needed) for soilage/dislodgement. 07/14/2025 Skin tear to right shin: cleanse with wound cleanser; pat dry with 4 x 4 gauze; apply xeroform to wound bed; cover with border dressing 3 x times a week MWF (Monday, Wednesday, Friday) until resolved. Review of Resident #69's comprehensive care plan failed to reveal a focus for Resident #69's skin tear to the right shin with appropriate interventions for the skin tear to the right shin. During an interview on 09/09/2025 at 12:05 p.m. with S10 MDS Nurse confirmed Resident #58 had not been care planned for the current foot wound, and Resident #69 had not been care planned for the current shin wound and should have been. Resident #111 Review of Resident #111's face sheet revealed an admission date of 09/12/2022 including the following diagnoses but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, mild vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, lack of coordination, muscle wasting and atrophy to multiple sites. Review of Resident #111's September 2025 physician orders revealed an order dated 04/23/2025 for Bed Rails: side rails upper half of bilaterally to bed related to weakness, secondary to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side to enable resident to assist in turn and repositioning, bed mobility and transfers in/out of bed. Monitor resident for safety concerns with side rails every 2 hours when used. Review of Resident #111's Annual MDS dated [DATE] revealed a BIMS score of 15 indicating cognition intact. Review of Resident #111's care plan failed to reveal a focus on the use of bed rails/side rails with appropriate interventions. Observation on 09/08/2025 at 11:00 a.m. revealed Resident #111 had hand assist bars bilaterally to head of bed. During an interview on 09/09/2025 at 10:30 a.m. S6 LPN (Licensed Practical Nurse) care plan nurse reviewed Resident #111's care plan and confirmed Resident #111's care plan did not include a focus for use of side rails/bed rails with appropriate interventions.

Based on record reviews, observations and interviews, the facility failed to provide services that met professional standards for 1 (#6) of 3 (#6, #42, and #111) residents reviewed for accident hazards and supervision. The facility failed to ensure safe medication administration practices by leaving medications at the bedside. Findings:Review of the facility's Medication Administration undated policy revealed in part:Medications are administered as prescribed, in accordance with good nursing principles and practices and only by person legally authorized to do so. Personnel authorized to administer medications de no only after they have familiarized themselves with the medication.5. Residents are allowed to self-administer medications when specifically authorized by the IDT (Interdisciplinary team) which includes the attending physician and in accordance with procedures for self-administration of medications. (See policy for self-administration of medications)6. Medications are administered at the time they are prepared. Medications are not pre-poured, unless the facility uses the bottle system with individual medication cards for each medication.Essential Points to Remember:5. The person administering medication must remain with the resident until all medication has been swallowed.Review of Resident #6's medical record included an admission date of 10/06/2023 and a BIMS (Brief Interview of Mental Status) score of 15/15, indicating no cognitive impairment.Review of Resident #6's medical record revealed diagnoses included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other chronic pain, and dysphagia, oropharyngeal phase.Review of physician's orders for Resident #6 revealed, in part:Order date 06/25/2024: Eliquis oral tablet 2.5 mg (Milligram) (Apixaban); give 1 tablet orally two times a day related to other persistent atrial fibrillation Order date 07/01/2024: Ascorbic acid tab 500 mg; give 1 tablet orally two times a day related to pressure ulcer of right buttock, stage 2 Order date 07/01/2024: multivitamin adult oral tablet (multiple vitamin); give 1 tablet orally two times a day related to pressure ulcer of right buttock, stage 2 Order date 07/01/2024: Zinc sulfate tab 220 mg (50 mg Zinc equivalent); give 1 tablet orally one time a day related to pressure ulcer of right buttock, stage 2 Order date 07/01/2024: Carvedilol tab 25 mg; give 1 tablet orally two times a day related to essential (primary) hypertension Order date 07/01/2024: Clopidogrel bisulfate tab 75 mg give 1 tablet orally one time a day related to atherosclerotic heart disease of native coronary artery without angina pectoris Order date 07/01/2024: Lisinopril oral tablet 40 mg; give 1 tablet orally one time a day related to essential (primary) hypertension Order date 08/15/2025: Gabapentin oral tablet 100 mg; give 2 tablet by mouth one time a day related to polyneuropathy, unspecified Further review of Resident #6's physician orders failed to reveal an order for self-administration of medication. Observation on 09/08/2025 at 1:20 p.m. of Resident #6's bedside table revealed medication in a cup containing various (8) pills on the bedside table.During an interview on 09/08/2025 at 1:21 p.m. Resident #6 reported S11 LPN (Licensed Practical Nurse) left pills on the bedside table while he was in the bathroom.Observation on 09/08/2025 at 1:25 p.m. with S11 LPN revealed Resident #6's bedside table had medications in a cup containing various (8) pills on the bedside table.During an interview on 09/08/2025 at 1:26 p.m. S11 LPN confirmed medication should not be left at the bedside without an order.During an interview on 09/08/2025 at 1:30 p.m. S4 DON (Director of Nursing) confirmed medications should not be left at the beside without an order.

Based on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice and follow facility's policies for 3 (#49,# 69, #150) of 3 (#49, #69, #150) residents reviewed for respiratory care. The facility failed to ensure resident #49's oxygen concentrator filter was clean and an oxygen in use sign was placed on the outside of resident #69 and #150's room entrance door.Findings: Review of the facility's Oxygen Administration (concentrator or tank) undated policy revealed in part: Policy: While oxygen is in use, No Smoking, signs will be posted at the entrance to the room. .Concentrator filter should be cleaned weekly or as needed. Procedure: 13. Place the No Smoking, Oxygen in Use warning sign on the resident's room door or in other appropriate locations. Resident #49 Review of Resident #49's face sheet revealed an admission date of 07/25/2025 with the following diagnoses but not limited to (COPD) chronic obstructive pulmonary disease with (acute) exacerbation, dependence on supplemental oxygen, and acute and chronic respiratory failure with hypoxia. Review of Resident #49's September 2025 Physician Orders revealed the following orders related to oxygen therapy: 07/25/2025: oxygen at 2 liters/nasal cannula continuously related to a diagnosis of COPD/respiratory failure with hypoxia 7/25/2025: Change oxygen tubing, nasal cannula, humidifier bottle and clean filter every week and as needed; every night shift every Friday Review of Resident #49's admission MDS (Minimum Data Set) Assessment revealed a BIMS (Brief Interview of Mental Status) of 15 indicating intact cognition. Further review of admission MDS revealed Resident #49 had oxygen in use. Review of Resident #49's care plan revealed resident has congestive heart failure with interventions for oxygen settings: humidified oxygen via nasal cannula at 2 liters per minute. Observation on 09/08/02025 at 9:00 a.m. revealed Resident #49's oxygen concentrator filter was coated in a gray fuzzy substance. Observation on 09/08/2025 at 10:28 a.m. revealed Resident #49's oxygen concentrator filter was coated in a gray fuzzy substance. Observation on 09/08/2025 at 2:26 p.m. with S15 RN (Registered Nurse) revealed Resident #49's oxygen concentrator filter was coated in a gray fuzzy substance. During an interview on 09/08/2025 at 2:26 p.m. S15 RN confirmed Resident #49's oxygen concentrator filter need to be cleaned. Resident #69 Review of Resident #69's medical record revealed an admit date of 11/03/2022, readmission date of 09/22/2023 with diagnoses that include in part simple chronic bronchitis, chronic obstructive pulmonary disease with acute exacerbation and dependence on supplemental oxygen. Review of Resident #69's physician orders revealed in part and order dated 12/16/2024 for continuous oxygen at 3 liters per minute via nasal cannula every shift related to chronic obstructive pulmonary disease with (acute) exacerbation. Observation on 09/08/2025 at 10:40 a.m. revealed resident sitting in her room with oxygen in use at 3 liters/minute per nasal cannula via oxygen concentrator. Further observation failed to reveal signage posted on resident's room doorway indicating oxygen was in use. Resident #150 Review of Resident #150's medical record revealed an admit date of 09/05/2025 with diagnoses that include in part acute respiratory failure with hypoxia, and acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. Review of Resident #150's physician orders revealed in part an order dated 09/05/2025 for Oxygen at 2 liters per nasal cannula continuously related to a diagnosis of acute respiratory failure with hypoxia every shift. Observation on 09/08/2025 at 9:00 a.m. revealed Resident #150 in his room with oxygen in use per nasal cannula. Further observation failed to reveal signage posted on resident's room doorway indicating oxygen was in use. Observation on 09/08/2025 at 1:00 p.m. with S4 DON (Director of Nursing) failed to reveal resident #69 and #150 had oxygen in use signage posted outside the room. During an interview on 09/08/2025 at 1:00 p.m. with S4 DON verified there should be an oxygen in use sign posted outside resident #69 and #150's room and was not.

Based on record review, observation, and interviews, the facility failed to ensure proper infection control techniques were practiced to prevent cross contamination during incontinence care for 1 (#124) of 1 (#124) Resident reviewed for urinary catheter and UTI (Urinary Tract Infection). Findings:Review of the facility's Catheter Management undated policy revealed in part: Procedurec. Female resident: separate labia with thumb and forefinger of non-dominant hand and cleanse the area with a wash cloth, soap, and water or personal cleanser using downward strokes. While applying gentle traction to the catheter, cleanse it six inches from the insertion site using downward strokes as well. Flip or change washcloth with each wipe. Review of Resident #124's medical record revealed an admission date of 08/29/2025 and diagnosis of subsequent encounter for closed fracture with routine healing. Review of Resident #124's physician orders revealed an order dated 08/29/2025: Catheter care with soap and water; every day shift An observation on 09/10/2025 at 8:15 a.m. of Resident #124's perineal-care and catheter care with S12 CNA (Certified Nursing Assistant) and S13 CNA revealed Resident #124 had a bowel movement. Further observation revealed S12 CNA failed to cleanse catheter six inches from the insertion site during perineal-care for Resident #124. During an interview on 09/10/2025 at 8:25 a.m. S12 CNA confirmed she failed to cleanse Resident #124's catheter six inches from the insertion site during perineal-care and should have. During an interview on 09/10/2025 at 9:01 a.m. S14 IP (Infection Preventionist) reported Resident #124 had an UTI and S12 CNA's failure to cleanse Resident #124's catheter six inches from the insertion site during perineal-care could lead to a worsening UTI by introducing new or more bacteria. S14 IP confirmed S12 CNA should have cleansed Resident #124's catheter six inches from the insertion site during perineal-care. During an interview on 09/10/2025 at 8:26 a.m. S3 Corporate Nurse confirmed Resident #124's catheter should have been cleansed six inches from the insertion site during perineal-care.

Based on observations, interviews, and record reviews the facility failed to accommodate the needs of 4 (#9, #34, #106, #108) of 4 (#9, #34, #106, #108) residents reviewed for accommodation of needs out of a total sample of 31. The facility failed to ensure the resident's call light was within reach of the resident. Findings: Review of the facility's undated Fall Prevention Program Policy revealed in part: II: Preventive Protocol: A. Admission Guidelines concerning fall: a. Prevention for High Risk residents: 2. Resident will be instructed regarding use of call bell by staff. Call bell will be placed within each resident's reach when feasible while in personal room. Resident will also be instructed to call for assistance when needed. Resident #9 Review of Resident #9's medical record revealed an admitted [DATE] with diagnoses that included lack of coordination, dementia without behavioral disturbances, presence of left artificial knee joint, and Alzheimer's disease with late onset. Review of Resident #9's care plan revealed Resident #9 was at high risk for falls, had a history of falls and required assistance to transfer. Observation on 08/05/2024 at 9:35 a.m. revealed Resident #9 sitting up in her wheelchair with her call light across the room, out of reach. Observation on 08/06/2024 at 9:30 p.m. revealed Resident #9 sitting in her recliner, call light hanging on the wall across the room, out of reach. Observation on 08/06/2024 1:30 p.m. revealed Resident #9 lying in bed, call light stretched behind the headboard to the recliner and in a closed drawer of the bedside table, out of reach. Observation on 08/06/2024 at 3:10 p.m. with S4 LPN (Licensed Practical Nurse) revealed Resident #9's call light was out of reach. During interview on 08/06/2024 at 3:10 p.m. S4 LPN (Licensed Practical Nurse) confirmed Resident #9's call light was out of reach and should not have been. Resident #34 Review of Resident #34's medical record revealed an admitted [DATE] with diagnoses that included muscle wasting and atrophy, essential primary hypertension, lack of coordination, repeated falls, Alzheimer's disease, paroxysmal atrial fibrillation, and major depressive disorder severe with psychotic features. Review of Resident #34's care plan revealed Resident #34 was at high risk for falls, had a history of falls, and requires assistance to transfer. Observation on 08/05/2024 at 9:40 a.m. revealed Resident #34 sitting in her wheelchair near the head of her bed and the call light on the wall, near the foot of her bed, out of reach. Observation on 08/05/2024 at 2:30 p.m. revealed resident sitting up in wheelchair in her room near the head of the bed, call light remained against the wall at the foot of the bed out of reach. Observation on 08/06/2024 at 3:05 p.m. with S4 LPN (Licensed Practical Nurse) revealed Resident #34's call light was out of reach. During an interview on 08/06/2024 at 3:05 p.m. S4 LPN confirmed Resident #34's call light was out of reach and should not have been. Resident #106 Review of Resident #106's medical record revealed an admitted [DATE] with diagnoses that included muscle wasting and atrophy, contracture of left knee and ankle, left foot drop, contracture of right knee, primary generalized (Osteo) arthritis, other forms of scoliosis, major depressive disorder, and need for assistance with personal care. Review of Resident #106's care plan revealed Resident #106 was at high risk for falls, had a history of falls and requires assistance to transfer and uses a reclined Geri chair for locomotion. Observation on 08/06/2024 at 2:50 p.m. revealed Resident #106 sitting in reclined Geri Chair and Resident #34's call light was across the room, out of reach. Observation on 08/06/2024 at 3:10 p.m. with S4 LPN revealed Resident #106 sitting in reclined Geri Chair and Resident #34's call light was out of reach. During an interview on 08/06/2024 at 3:30 p.m. S4 LPN confirmed Resident #106's call light was out of reach and should not have been. Resident #108 Review of Resident #108's medical record revealed an admitted [DATE] with diagnoses that included muscle wasting and atrophy, aphasia, repeated falls, Alzheimer's disease, paroxysmal atrial fibrillation, generalized anxiety disorder, syncope and collapse, and severe dementia with mood disturbance. Review of Resident #106's care plan revealed Resident #108 was at high risk for falls, had a history of falls and requires assistance to transfer. Observation on 08/05/2024 at 9:20 a.m. revealed Resident #108 sitting in her recliner and Resident #108's call light was across the room, out of reach. During an interview on 08/05/2024 at 9:20 a.m. Resident #108 reported she was not supposed to get up unless she called staff but she did not know where her button was. Observation on 08/06/2024 at 1:55 p.m. revealed Resident #108 lying in bed, with her call light stretched behind her headboard and over to her recliner, out of reach. Observation on 08/06/2024 at 3:10 p.m. with S4 LPN revealed Resident #108 lying in bed, call light out of reach. During an interview on 08/06/2024 at 3:10 p.m. S4 LPN (Licensed Practical Nurse) confirmed Resident #108's call light was out of reach and should not have been. During an interview on 08/06/2024 at 3:30 p.m. S1 DON (Director of Nursing) acknowledged resident's call lights should be kept within reach at all times even if they don't remember to use it, they still have to have access to it.

Based on observations, interviews, and record reviews, the facility failed to provide residents' respiratory care and services in accordance with accepted professional standards of practice for 6 (#18, #23, #73, #57, #40, #290) out of 10 (#18, #23, #73, #57, #40, #290, #110, #35, #95, #51) residents reviewed for respiratory care. The facility failed to ensure: 1. Oxygen was administered at the ordered rate for Resident #40; 2. Oxygen tubing and humidification bottles were changed and dated weekly for Resident # 18, #23, #73, #57, and #290, and; 3. No Smoking signs were posted on the entrance to the rooms of residents on oxygen in accordance with facility policy for Resident #73. Findings: Review of the facility's Oxygen Administration (Concentrator or Tank) Policy (undated) revealed in part: While oxygen is in use, No Smoking signs will be posted at the entrance to the room . Humidifier bottles, cannulas and O2 (oxygen) tubing will be changed at least once weekly and dated .When not in use, cannula or mask should be placed in a plastic bag .Oxygen equipment, tanks, humidifier bottles, cannulas, masks and other related items should be checked on a regular basis during oxygen administration for proper functioning. Resident #18 Review of Resident #18's medical record revealed an admitted [DATE] with diagnoses including: persistent atrial fibrillation, pulmonary fibrosis, and essential primary hypertension. Review of Resident #18's physician orders revealed an order dated 11/21/2022 to change oxygen tubing/humidifier bottle and clean filter every week on Friday one time a day. Observation on 08/05/2024 at 8:05 a.m. revealed Resident #18 with oxygen in use at 2 L/min (liters /minute) via nasal cannula (NC). Further observation failed to reveal the oxygen tubing was dated when changed. Observation on 08/06/2024 at 3:00 p.m. revealed Resident #18 lying in bed with oxygen in use via NC, and oxygen tubing remained undated. Observation on 08/06/2024 at 3:30 p.m. with S1 DON (Director of Nursing) revealed Resident #18 oxygen tubing was undated. During an interview on 08/06/2024 at 3:30 p.m. S1 DON confirmed Resident #18's oxygen tubing had not been dated when changed and should have been. Resident #23 Review of Resident #23's medical record revealed an admitted [DATE] with diagnoses including: paroxysmal atrial fibrillation, dependence on supplemental oxygen, anxiety disorder, and chronic obstructive pulmonary disease. Review of Resident #23's physician orders revealed an order dated 07/01/2024 to change oxygen tubing/humidifier bottle and clean filter every week every Friday, night shift. Observation on 08/05/2024 at 8:20 a.m. revealed Resident #23's oxygen concentrator running at 2 L/min with oxygen tubing attached. Further observation failed to reveal the oxygen tubing was dated when changed. Observation on 08/06/2024 at 1:50 p.m. revealed Resident #23 with oxygen in use per NC. Further observation failed to reveal the oxygen tubing was dated when changed. Observation on 08/06/2024 at 3:10 p.m. with S4 LPN (Licensed Practical Nurse) revealed Resident #23 with oxygen in use via NC. Further observation failed to reveal the oxygen tubing had been dated when changed. During an interview on 08/06/2024 at 3:10 p.m., S4 LPN confirmed Resident #23's oxygen tubing was not dated with the date it was changed and it should have been. Resident #73 Review of Resident #73's record revealed an admitted [DATE] with diagnoses including: metabolic encephalopathy and acute upper respiratory infection unspecified. Further review revealed the resident was admitted to Hospice Services on 07/29/2024. Observation on 08/05/2024 at 9:05 a.m. revealed Resident #73 had oxygen in use at 2L/min via NC. Further observation revealed the humidification bottle and oxygen tubing were not dated when changed. Further observation revealed there was not a No Smoking sign on the entrance door to the room. Observation on 08/06/2024 at 3:02 p.m. revealed Resident #73 had oxygen in use at 2L/min via NC per oxygen concentrator. Further observation revealed the humidification bottle and oxygen tubing were not labeled with the date they had been changed. Further observation revealed there was not a No Smoking sign at the entrance to the room. Observation on 08/06/2024 at 3:55 p.m. with S2 RN (Registered Nurse)/Charge Nurse revealed Resident #73 had O2 in use via oxygen concentrator at 2L/min via NC. Further observation revealed the oxygen humidification bottle and oxygen tubing were not labeled with the date they had been changed, and there was not a No Smoking sign at the entrance to the room. During an interview on 08/06/2024 at 3:55 p.m. S2 RN/Charge Nurse confirmed Resident #73's oxygen humidification bottle and oxygen tubing were not dated with the date they were changed and they should be. S2 RN/Charge Nurse further confirmed there was not a No Smoking sign at the entrance to Resident #73's room and there should be. Resident #57 Review of Resident #57's record revealed an admitted [DATE] and diagnoses including: heart failure, shortness of breath, asthma, personal history of nicotine dependence, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and chronic obstructive pulmonary disease. Review of Resident #57's physician orders revealed an order dated 08/25/2023 to change oxygen tubing/humidifier bottle and clean filter every week on Friday. Observation on 08/05/2024 at 8:35 a.m. revealed Resident #57 was up in her wheelchair with O2 2L/min via NC in use via portable oxygen cylinder on the back of the wheelchair. The oxygen tubing was not labeled with the date it had been changed. Further observation revealed an oxygen concentrator next to the recliner in her room with humidification bottle dated 07/19/2024. The oxygen tubing attached to the concentrator was not labeled with the date it had been changed. Observation on 08/05/2024 at 11:55 a.m. revealed Resident #57 was up in her wheelchair with 2L/min via NC in use via portable oxygen tank on the back of the wheelchair. The oxygen cannula had no date indicating when it had been changed. Further observation revealed an oxygen concentrator next to the recliner in her room with humidification bottle dated 07/19/2024. The oxygen tubing attached to the concentrator was not labeled with the date it had been changed. Observation on 08/06/2024 at 3:55 p.m. with S2 RN/Charge Nurse revealed resident #57 was up in her wheelchair with oxygen in use per concentrator at 2L/min via NC with humidification bottle dated 08/06/2024. Further observation revealed the oxygen cannula attached to the concentrator was not labeled with the date it had been changed. Further observation revealed a portable oxygen tank on the back of Resident #57's wheelchair with oxygen tubing that was not labeled with the date it had been changed. During an interview on 08/06/2024 at 3:55 p.m., S2 RN/Charge Nurse confirmed Resident #57's oxygen tubings should both be labeled with the date they were changed and were not. Resident #40 Review of Resident #40's record revealed an admitted [DATE] with diagnoses including: heart failure, dependence on supplemental oxygen, chronic respiratory failure with hypoxia, obstructive sleep apnea, chronic obstructive lung disease. Review of Resident #40's physician orders revealed an order dated 07/01/2024 for oxygen via 2L/min via NC continuous every shift related to chronic respiratory failure with hypoxia. During an observation and interview on 08/06/2024 at 2:17 p.m. Resident #40 was wearing oxygen tubing connected to an oxygen concentrator that was not turned on and was set at 0L/min. During an interview at this time, Resident #40 reported she wore the oxygen all the time. Resident #40 further reported she was a little short of breath. During an observation and interview on 08/06/2024 at 2:51 p.m., S3 LPN confirmed Resident #40's oxygen was turned off and should be on continuous at 2L/min. Resident #290 Review of Resident #290's record revealed an admitted [DATE] and diagnoses including: shortness of breath, dependence on supplemental oxygen, and chronic obstructive pulmonary disease. Review of Resident #290's physician orders revealed an order dated 07/19/2024 to change oxygen tubing, nasal cannula, humidifier bottle and clean filter one time a day every Friday. Observation on 08/05/2024 at 11:55 a.m. revealed Resident #290 had oxygen in use at 2L/min via NC per oxygen concentrator. Further observation revealed the humidifier bottle was not labeled with the date it had been changed. Observation on 08/06/2024 at 1:51 p.m. revealed resident #290 in the therapy gym in her wheelchair. Oxygen was in use via a portable oxygen tank at 2L/min via NC. Further observation revealed the oxygen tubing was not labeled with the date it had been changed. Observation on 08/06/2024 at 3:55 p.m. with S2 RN/Charge Nurse revealed Resident #290 had oxygen at 2L/min via NC in use via oxygen concentrator with a humidifier bottle that was not labeled with the date it had been changed. Further observation revealed a portable oxygen tank on the back of Resident #290's wheelchair with oxygen tubing that was not labeled with the date it had been changed. During an interview on 08/06/2024 at 3:55 p.m., S2 RN/Charge Nurse confirmed Resident #290's oxygen humidifier bottle and the oxygen tubing attached to the portable oxygen tank should be labeled with the date they had been changed and were not. 39897

Based on record review and interview, the facility failed to ensure resident assessments were transmitted within the required timeframe for 1 (#100) of 1 (#100) residents investigated for assessments. Findings: Review of Resident #100's record revealed an admitted [DATE]. Review of MDS (Minimum Data Set) Assessments in Resident 100's electronic medical record revealed annual assessments with assessment reference dates of 07/01/2024 were completed on 07/15/2024 with a status of Export Ready that had not been transmitted. During an interview on 08/06/2024 at 1:41 p.m., S5 MDS Nurse confirmed the 07/01/2024 assessments had been completed on 07/15/2024 and had not been transmitted.

Based on record reviews and interviews the facility failed to ensure 1 (#79) out of 5 (#19, #79, #116, #33, #70) sampled residents reviewed was free of unnecessary medications. The facility failed to monitor behaviors and side effects for Resident #79 while receiving an antidepresant and antipsychotic. Findings: Review of Resident #79's Medical Records revealed an admitted [DATE] with the following diagnoses, in part: Alzheimer's disease with late onset, dementia in other diseases classified elsewhere/mild/without behavioral disturbance/psychotic disturbance/mood disturbance and anxiety, and major depressive disorder/recurrent/severe with psychotic symptoms. Review of Resident #79's Care Plan revealed: - exhibits aggressive behavior with ADLs (activities of daily living) - monitor and document target behaviors - mood state/mood disorder related to diagnosis of major depression disorder - monitor patterns of target behavior - potential for adverse effects due to use of psychotropic medications - depression with psychotic features - monitor for behaviors and side effects Review of Resident #79's Physician's Orders revealed: 06/09/2023 - Depakote ER (extended release) 500mg (milligram) tablet extended release administer 1 tablet oral two times a day every day - major depressive disorder 04/13/2023 - Abilify 5 mg tablet administer 1 tablet oral one time a day - major depressive disorder Review of Resident #79's July and August MAR (Medication Administration Record) failed to reveal monitoring for antipsychotropic side effects and behaviors. During an interview on 08/16/2023 at 12:20 p.m. S3 LPN (licensed practical nurse) reported he documented behaviors and side effects in the notes when Resident #79 had them. S3 LPN was unable to tell surveyor why behaviors and side effects were not monitored daily on the MAR. During an interview on 08/16/2023 at 2:15 p.m. S2 ADON (assistant director of nursing) acknowledged Resident #79's care plan stated there should be monitoring of behaviors and side effects. S2 ADON acknowledged behaviors and side effects should have been monitored daily for Resident #79 and were not. During an interview on 08/16/2023 at 2:15 p.m. S1 DON (director of nursing) acknowledged behaviors and side effects should have been monitored daily for Resident #79 and were not.

Based on observations, interviews, and record review, the facility failed to ensure residents' food preferences were honored for 1 (#114) of 1 (#114) residents investigated for food preferences. Findings: Review of the facility's Nutrition Screening and Evaluation Report policy (Origination date 10/12, no Revised date) revealed in part: The Nutrition Screening and Evaluation Report (NSER) shall be completed by the dietary Manager on all new admissions, scheduled assessments, and quarterly progress .The dietary manager shall use the NSER to collect information necessary to begin meal service and for use in the assessment process. Upon admission, the dietary manager shall visit the new resident as soon as possible on the day of admission, preferably, and begin collecting information using the referenced form. Initial information shall be used to prepare the resident's tray card with food dislikes, preferences, allergies, etc. Review of Resident # 114's record revealed an admitted [DATE] and diagnoses including but not limited to: muscle wasting and atrophy, type 2 diabetes mellitus with diabetic polyneuropathy, unspecified protein-calorie malnutrition, irritable bowel syndrome, heart failure, and major depressive disorder. Review of Resident #114's August 2023 physician orders revealed an order dated 04/18/2022 for a Regular Diet with No Salt on Table (NSOT) and Low Concentrated Sweets (LCS). Review of Resident #114's most recently completed comprehensive MDS (Minimum Data Set) with an Assessment Reference Date of 07/19/2023 revealed a Brief Interview for Mental Status score of 15 out of 15 indicating the resident was cognitively intact. Review of Resident #114's resident nursing and dietary progress notes from 08/01/2022 to 08/15/2023 revealed no mention of the resident's preference for oatmeal at breakfast or her preference of a boiled egg at breakfast/dislike of powdered scrambled eggs. Review of Resident #114's Nutrition Screening Evaluations dated 09/14/2022, 09/14/2022, and 04/13/2023 revealed in part the resident received selective menu of choice, was able to make meal selection or request, and had no new dislikes or food preferences. During an observation and interview on 08/14/2023 at 8:50 a.m. Resident #114 complained of the food she was served at breakfast. Observation at this time revealed the resident's breakfast tray had a bowl of uneaten grits and uneaten scrambled eggs. Resident #114 reported I've told them I want oatmeal and a boiled egg with breakfast, and they keep bringing these powdered things that I won't eat. Resident #114 further reported she did not like grits, and was supposed to get oatmeal with breakfast. Further observation of Resident #114's meal slip on the breakfast tray revealed a note at the top of the slip oatmeal with breakfast. Further observation revealed S5 CNA (Certified Nursing Assistant) entered the room to pick up the tray. Resident #114 was observed telling S5 CNA she didn't like the facility's scrambled eggs and had asked over and over for a boiled egg with breakfast. S5 CNA told her we need to put that on your meal slip so the kitchen knows. Observation on 08/15/2023 at 8:18 a.m. revealed Resident #114's breakfast tray still had scrambled eggs instead of a boiled egg. The meal slip on Resident #114's breakfast tray still did not list her preference for a boiled egg with breakfast or a dislike of the facility's scrambled eggs. During an interview on 08/15/2023 at 4:25 p.m. S1 DON (Director of Nursing) reported the procedure for communicating a residents food requests, preferences, and dislikes would be for the CNAs to inform the nurses of the residents' requests. S1 DON reported the nurses should then fill out a dietary preference slip and send it to the dietary manager, who would add it to their meal slips used for preparing their trays. Observation on 08/16/2023 at 8:20 a.m. revealed Resident #114's breakfast tray had scrambled eggs instead of a boiled egg. The meal slip on Resident #114's breakfast tray did not list a request for boiled egg or a dislike of the facility's scrambled eggs. During an interview on 08/16/2023 at 8:20 a.m. S4 LPN (Licensed Practical Nurse) entered Resident #114's room and indicated he was not aware of Resident #114's dislike of scrambled eggs or her preference for a boiled egg at breakfast. During an interview on 08/16/2023 at 8:37 a.m. S6 Dietary Manager indicated staff use the meal slips when preparing trays, and were trained to substitute dislikes for likes, and to honor requests for specific items as possible and in accordance with any special dietary orders. S6 Dietary Manager further indicated sometimes the kitchen staff missed it, and the CNAs should catch it when serving the trays. S6 Dietary Manager indicated the CNAs should then come to the kitchen to obtain the residents' requested food items. S6 Dietary Manager further indicated she had not been aware of Resident #114's request for a boiled egg with breakfast until today.

Based on observation and interviews, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and environment that promoted his or her quality of life. The facility failed to serve food at the same time to 1 Resident (#90) of 3 Residents (#47, #90, #119) sitting at the same table in the dining area. Findings: An observation on 08/14/23 at 12:10 p.m. revealed lunch trays served to Residents #47 and Resident #119. Resident #90 was sitting at the same table. Resident #90 did not get a lunch tray at that time. During an observation on 08/14/2023 at 12:24 p.m. Resident #47 and Resident #119 continued eating lunch at the same table with Resident #90. Resident #90 did not have her lunch tray and continued to watch Resident #47 and Resident #119 eat. Resident #47 spoke in an aggravated voice and pointed at Resident #90 saying, she needs help! Resident #90 was sitting at the table with her right hand raised up in the air. Resident #90's hand was moving slowing back and forth and looking around at staff as they passed out other lunch trays to other tables. During an observation on 08/14/2023 at 12:26 p.m. Resident #47 spoke out loud again saying she needs help and pointed to Resident #90 who continued to hold her hand in the air as she watched staff walk by with other residents' lunch trays. An observation on 08/14/2023 at 12:30 p.m. revealed Resident #90 was served her lunch tray and Resident #47 and Resident #119 were finished with their lunch. During an interview on 08/14/2023 at 12:30 p.m. S7 Licensed Practical Nurse acknowledged Resident #90 was served her lunch tray after Resident #47 and Resident #119 had already finished eating their meals. An observation on 08/14/2023 at 12:35 p.m. revealed Resident #90 was left eating her lunch by herself when Resident #47 and Resident #119 left the table. During an interview on 08/16/2023 at 2:25 p.m. S6 Dietary Manager reported residents should be served trays at the same time at each table.

Based on record review and interview, the facility failed to provide appropriate care and services according to standards of professional practice for 1 (#33) of 2 (#33, #82) residents reviewed for urinary catheter or [CONDITION(S)] (urinary tract infection) out of a total of 44 sampled residents. The facility failed to ensure urine color and condition was monitored for Resident #33 who had an indwelling (Foley) catheter in place. Findings: Review of Resident #33's medical record reveal Resident #33 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 9/16/2022 Monitor condition of urine Q (every) shift. 1=clear, 2=sediment, 3=mucous, 4=cloudy ****Call MD (Medical Doctor) if changes occur. 9/16/2022 Monitor color of urine Q shift 1=light yellow, 2=dark yellow, 3=amber, 4=bloody, 5=other ****call MD if changes occur. Review of September 2022 MAR (Medication Administration Record) failed to reveal evidence that urine color and condition of urine was monitored and documented every shift. Review of Progress notes revealed a 9/16/2022 note that indicated New order received per __________ NP (Nurse Practitioner) . Foley 16 fr (French)/30cc (cubic centimeters) placed. Review of Care Plan revealed: -Potential for [CONDITION(S)] (Urinary Tract Infection) and/or complications r/t (related to) use of indwelling catheter d/t (due to) urinary retention with interventions that included, in part, monitor color of urine every shift and monitor condition of urine every shift. During an interview on 9/21/2022 at 3:50pm S2 DON (Director of Nursing) reported she had reviewed Resident #33's medical record and it did not include documentation of urine color and condition of urine for each shift and should have.

Based on record review and interview the facility failed to ensure resident's drug regimen was free from unnecessary medications by failing to ensure gradual dose reduction for [CONDITION(S)] medications was conducted for 1 (#72) of 5 ( #7, #45, #48, #72, #230) residents reviewed for unnecessary medications. Findings: Review of Resident #72's medical record revealed Resident #72 was admitted to the facility on [DATE] and had diagnoses that included, in part, major depressive disorder recurrent severe with psychotic symptoms, dementia, generalized anxiety disorder, essential hypertension, [CONDITION(S)], and hypertensive chronic kidney disease. Review of current physician orders revealed the following orders: 1/28/2022 - [MEDICATION(S)] 2 mg (milligram) tablet, give 1 tab PO (by mouth) Q (every) day 11/16/2021 - [MEDICATION(S)] ([MEDICATION(S)]) 5mg tablet, give 1 tab PO BID (two times a day) Review of medical record failed to reveal any GDR (Gradual Dose Reduction) pharmacy request had been conducted in regard to Resident #72's [MEDICATION(S)] and [MEDICATION(S)]. During an interview on 9/21/2022 at 3:45pm S2 DON (Director of Nursing) and S4 Corporate Nurse reported the facility did not have any GDR pharmacy request for Resident #72's [MEDICATION(S)] and [MEDICATION(S)] and should have.

Based on record reviews and interview, the facility failed to ensure resident assessments were transmitted to CMS (Centers for Medicare and Medicaid Services) within the required timeframe for 4 (#2, #3, #78, #92 ) residents of 9 (#2, #3, #4, #47, #55, #56, #77, #78, #92) residents reviewed for assessments out of a total of 44 sampled residents. Findings: Review of Resident #2's MDS (Minimum Data Set) assessments revealed a Quarterly MDS dated [DATE] with a status of open. Review of Resident #3's MDS (Minimum Data Set) assessments revealed a Quarterly MDS dated [DATE] with a status of open. Review of Resident #78's MDS (Minimum Data Set) assessments revealed a Quarterly MDS dated [DATE] with a status of open. Review of Resident #92's MDS (Minimum Data Set) assessments revealed a Yearly MDS dated [DATE] with a status of open. During an interview on 9/21/22 at 1:45pm S3, MDS Nurse confirmed MDS assessments for Resident #2, #3, #78, and #92 were not transmitted to CMS and should have been.

Based on record review and interview the facility failed to ensure an assessment was accurate for 1(#67) of 9 (#2, #3, #4, #47, #55, #56, #77, #78, #92) residents reviewed for assessments out of a total sample of 44. The facility failed to ensure an accurate MDS (Minimum data Set) assessment was entered for resident #67. Findings: Review of resident #67's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order dated 1/17/2022 for Two Cal House Supplement 120 cc (cubic centimeters) PO (by mouth) QID (4 times a day). Review of resident #67's Quarterly MDS with ARD (Assessment Reference Date) of 7/19/2022 revealed Section K - Swallowing/Nutritional Status. (K0300) Weight Loss 1. Yes on physician prescribed weight loss program. Review of resident #67's Comprehensive Plan of Care revealed a problem of potential for altered nutrition and dehydration related to hypertension, [CONDITION(S)], GERD ([CONDITION(S)]), deficiency of other vitamins. Goal is to maintain adequate nutritional status as evidence by maintaining stable weight. During an interview on 9/21/2022 at 1:45 pm S3 MDS Nurse reported she marked resident #67's MDS in error. S3 MDS Nurse reported she thought resident #67 was getting the dietary supplement to lose weight.

Based on record review, interviews and observation the facility failed to ensure a resident received adequate assistance to prevent accidents for 1 (#1) of 5 (#1, #2, #3, #4, and #5) residents reviewed for accidents. The facility failed to use a two-person transfer, as determined necessary by resident #1's minimum data set during a transfer resulting in a femur fracture. The deficient practice resulted in actual harm for resident #1, on 4/22/2022 when resident #1 was lowered to the floor during a transfer to the shower chair. Resident #1 required two person assistance for transfers and was lowered to the floor when resident #1's knees buckled while being transferred from the wheelchair to the shower chair by one staff person. On 4/23/2022, an x-ay revealed resident #1 had an acute distal femur fracture. The resident was hospitalized [DATE] through 4/28/2022. Findings: Review of the facility's Fall Prevention Program revealed in part: It is the policy of this facility to promote safety, dignity, and overall quality of life for our residents. Keeping our residents safe and their environment hazard free is our goal. Review of the facility's Certified Nursing Assistant's Acknowledgement of Resident Wall Care Plan Sheet revealed in part: Each resident should have a Resident Wall Care Plan located in their room either above the bed, on the bulletin board or in another prominent location easily seen by direct care staff. The Resident Wall Care Plan Sheet should include information including but not limited to: transfer status, use of a specific device, ambulatory status, pressure reducing devices and other listed may include splint or brace information if used. It is the responsibility of the CNA (certified nursing assistant) to read and follow the resident's wall care plan instructions for care of each resident. Resident #1 was admitted to the facility on [DATE] with diagnosis that included Dementia classified elsewhere without behavioral disease, History of falling, Persistent [CONDITION(S)], extended spectrum beta lactamase resistance, [CONDITION(S)] and displaced supracondylar fracture without intercondylar extension low right femur 7th degree (4/28/2022). Review of resident #1's Quarterly MDS (minimum data set) dated 2/12/2022 revealed resident #1 had severely impaired cognition and required extensive assistance with two persons with transfers. Review of resident #1's Comprehensive Care Plan revealed the problem of Late Loss ADL (activities of daily living) deficit with potential for decline in bed mobility, transfers related to dementia . with interventions prior to 4/22/2022 that included, manually transfer resident with two person physical assist, assist with bed mobility and turn bars on bed. Review of resident #1's medical record revealed in part: 4/25/2022 9:55 am Note reflecting 4/22/2022: writer called to room by S5 CNA (certified nursing assistant) at approximately 6:00 pm. S5CNA reported resident #1 having a swollen right knee. S6 ChargeNurse assessed resident #1's right knee and noted it was noticeably larger than left knee. Resident #1 initially denied pain but guarded right leg when lightly palpated. Doctor notified and a new order for x-ray noted. Imaging company notified awaiting arrival. 8:00pm ___ Imaging arrived, x-rays performed awaiting results. 10:30 pm S6 Charge Nurse called ___Imaging for results and was notified that they were still pending, report was given to S8 Registered Nurse Supervisor to look out for results. 4/23/2022 3:04pm S7 LPN (licensed practical nurse) received results from __Imaging stating that resident had a comminuted fracture of the supracondylar and intercondylar portion of the distal right femur with minimal displacement fracture segments and large effusion is noted. S2 DON (director of nurses) notified at 8:20am, family notified regarding results at 8:25am. ___Ambulance Service notified for pick up via stretcher at 8:34am and was here at facility to transport resident #1 to ___ Hospital at 9:20am via stretcher accompanied by two attendants. S7 LPN notes that resident #1 does have swelling to her right knee and complains of pain to knee and lower leg when touched or moved, S7 LPN administered APAP (Tylenol) 325mg two tablets at 8:43 am for pain level of 8. At 1:20pm was informed by S9 RN (registered nurse) Supervisor that resident #1 was being admitted to local hospital for evaluation and treatment. Review of resident #1's Emergency Department/Orthopedic Consult Note dated 4/23/2022 revealed the patient is a poor historian but ultimately was complaining of right knee pain with associated swelling which prompted evaluation in the emergency department. Patient had a prior history of remote total knee arthroplasty on the right side. X-rays in the emergency department demonstrated peri-prosthetic distal femur fracture on the right side. Patient not endorsing any significant pain at bedside and states she feels comfortable in the knee immobilizer. Orthopedics was consulted for management of right distal femur peri-prosthetic fracture. Patient denies [CONDITION(S)] or paresthesia, denies antecedent knee pain. Review of resident #1's medical record revealed resident #1 was readmitted to the facility to room 211 on 4/28/2022 under skilled level of nursing followed by Dr. _ and had yellow bruising noted to the right lower extremity, knee immobilizer noted to right extremity. Review of the facility's investigation records revealed in part: Around 10:00am on 4/22/2022 resident #1 was taken into shower room, when S3CNA went to transfer resident #1 from wheelchair to shower chair when the resident #1's knees buckled and resident #1 was lowered to the floor by S3CNA. S3CNA reported she then called for S4CNA to come help her put resident #1 into the shower chair. S3CNA further reported resident #1 was placed in her bed after her shower for the rest of the day. S3CNA confirmed she did not notify resident #1's nurse of resident #1's knees buckling and having been lowered to the floor in the shower. Observation on 5/31/2022 at 9:15 am revealed resident #1 had an immobilizer on her right leg. Further observation revealed a Resident Wall Care Plan above resident #1's bed stating: Falling Star Program (High Risk): Transfers- Vander lift -full lift two person assistance. During an interview on 5/31/2022 at 9:35am S3CNA reported on the morning of 4/22/2022 she took resident #1 to be showered and when transferring resident #1 from the wheelchair to the shower chair alone, resident #1's leg gave out and resident#1 was lowered to the floor. S3CNA reported she then called S4 CNA to assist in putting resident #1 into the shower chair and after completing the shower resident was assisted to bed and remained in bed the rest of the day. S3CNA reported she was not aware that resident #1 required a two-person transfer. S3CNA further reported resident #1 did not complain of pain and confirmed not notifying resident #1's nurse of the incident. During an interview on 6/1/2022 at 8:46am S4CNA reported on the morning of 4/22/2022 S3CNA called her over to assist her in putting resident #1 into the shower chair after resident #1 had been lowered to the floor by S3CNA during an attempted transfer from wheelchair to the shower chair. S4CNA confirmed she helped S3CNA put resident #1 in the chair. S4CNA report leaving the shower after assisting S3CNA. During an interview on 6/1/2022 at 8:50 am S5CNA (3-11 shift) reported when making rounds around dinner time on 4/22/2022 resident #1 was in bed and complained of pain on her right knee as soon as the bed sheets were removed prior to being touched. S5CNA further reported noticing swelling on resident #1's right knee and resident #1 was guarding her right knee. S5CNA confirmed immediately notifying resident #1's nurse and S6 Charge Nurse of resident #1 right knee swelling and complaint of pain. During an interview on 5/31/2022 at 4:30pm S6 Charge Nurse reported being notified of resident #1's right knee swelling and complaint of pain by S5CNA around 6pm on 4/22/2022. S6 Charge Nurse confirmed, upon assessing resident #1 he noted swelling on resident #1's right knee and pain upon light palpation only. S6 Charge Nurse reported he instructed S5CNA to leave resident #1 in bed, elevated resident #1's right knee and notified resident #1's doctor and received an order for an x-ray of the right knee to be done. S6 Charge Nurse also reported the x-ray was completed around 8pm on 4/22/2022, but the results were not available prior to the end of his shift. S6 Charge Nurse reported he notified the oncoming shifts charge nurse of the pending x-ray results. Attempted interview on 6/1/2022 with S7 LPN and S8 RN Supervisor times 2 was unsuccessful. During an interview on 6/1/2022 at 1:30pm S2 DON, reported she was notified by S7 LPN (licensed practical nurse) via phone on 4/23/2022 of resident #1's x-ray results indicating a right femur fracture and of resident #1's transfer and admission to a local hospital for evaluation and treatment of a right femur fracture. S7 DON confirmed resident #1 should have been tranferred with 2 person assistance.

Based on record reviews, interviews, and review of the American Nurses Association of standards of practice, 2010, the facility failed to notify the resident's faimily and physician of a change in condition for 1(#2) of 5 (#1,2,3,4,5) sampled residents. The facility failed to: 1) Have a system in place to ensure the physician was notified of a change in respiratory status on 12/25/11 as evidenced by resident #2's complaint of shortness of breath and requiring the use of [MEDICAL CONDITION] oxygen throughout the daytime rather than just a night. 2) Promptly notifiy the physician on 12/26/11 of resident #2'scontinued complaint of shortness of breath and use of [MEDICAL CONDITION] oxygen in the daytime. Resident #2 was placed in immediate jeopardy on 12/25/11 at 10:00 a.m. when the resident complained of shortness of breath and continued to use [MEDICAL CONDITION] oxygen during the day. The physician was not notified of the change in resident #2's respiratory status which required an increase in oxygen needs for the resident on 12/25/11. The immediate jeopardy ended for resident #2 on 12/26/12 at 2:05 p.m. when the resident was transported to the hospital. The facility was notified of the immediate jeopardy on 2/9/12 at 3:00 p.m for resident #2. The deficient practice was lowered to a scope and severity of G (isolated, actual harm). Findings: Review of resident #2's medical record revealed she was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of resident #2's reentry MDS dated [DATE] revealed in section "G" Functional Status resident #2 required extensive assistance/2 persons physical assist with bed mobility, transfers, dressing, and toileting. Review at section "J" Health Conditions resident #2 had shortness of breath with exertion, at rest and when lying flat. Review of the physician's orders [REDACTED]. Review of resident #2's nurses' notes dated 12/25/11 at 10:00 a.m. revealed resident #2 was resting in bed. Resident #2 complained she was short of breath oxygen mask was placed with effectiveness. Review of resident #2's nurses' note dated 12/25/11 failed to reveal an oxygen saturation level was obtained or the physician was notified of resident #2's complaint of shortness of breath and the need for the [MEDICAL CONDITION] oxygen during the day. During a telephone interview on 12/8/12 at 12:30 p.m. S5LPN stated on the day shift on 12/26/11, resident #2 continued to complain of shortness of breath, wanted to keep her mask on, and did not want to get out of bed. S5LPN was asked if the resident's physician was notified of the change in the resident's condition on 12/25/11 and she stated no, she did not call the physician until 12/26/11. S5LPN further stated resident #2 did not usually complain of shortness of breath. During an interview on 2/8/12 at 10:00 p.m. S5LPN was asked why the the doctor was called at 10:00 a.m. and the ambulance wasn't called until 1:24 p.m.. S5 LPN stated that she just charted everything under 10:00 a.m. and doesn ' t remember exactly what time the physician was notified. Review of an article from the web site currentnursing.com with a copyright date of 2010 revealed standards of practice as outlined by the American Nurses Association that included the nursing process as the standard of professional performance. These standards included: 1) The nurse collects comprehensive data pertinent to the patient's health or situation. 2) The nurse analyzes the assessment data to determine the [DIAGNOSES REDACTED]. 3) The nurse identifies expected outcomes for a plan individualized to the patient or situation. 4) The nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. 5) The nurse implements the identified plan of care.

Based on interviews, record reviews, and review of the American Nurses Association of standards of practice, 2010, the facility failed to provide necessary care by professional standards to residents for1 (#2) of 5 (#1,2,3,4,5) sampled residents. The facility failed to: 1) Have a system in place to employ staff that provide residents necessary care by professional standards. 2) Notify the physician of a change in respiratory status on 12/25/11 as evidenced by resident #2's complaint of shortness of breath and requiring the use of [MEDICAL CONDITION] oxygen throughout the daytime rather than just a night. 3) Obtain a physician's orders [REDACTED]. 4) Promptly notifiy the physician on 12/26/11 of resident #2'scontinued complaint of shortness of breath and use of [MEDICAL CONDITION] oxygen in the daytime. 5) To ensure the RN in charge was notified regarding resident #2's complaint of shortness of breath and the use of [MEDICAL CONDITION] oxygen during day hours on 12/25/11. 6) Obtain and record oxygen saturation levels after resident #2 complained of shortness of breath and required the use of continuous [MEDICAL CONDITION] oxygen during the day on 12/25/11. 7) Obtain and record oxygen saturation levels for resident #2 before and after changing the supplemental oxygen delivery from [MEDICAL CONDITION] to nasal cannual prior to arrival of emergency medical services on 12/26/11. Resident #2 was placed in immediate jeopardy on 12/25/11 at 10:00 a.m. when the resident complained of shortness of breath and continued to use [MEDICAL CONDITION] oxygen during the day. The physician was not notified of the change in resident #2's respiratory status which required an increase in oxygen needs for the resident on 12/25/11. The immediate jeopardy ended for resident #2 on 12/26/12 at 2:05 p.m. when the resident was transported to the hospital. Review of resident #2's emergency room report dated 12/26/11 revealed resident #2 was diagnosed with [REDACTED]. The facility was notified of the immediate jeopardy on 2/9/12 at 3:00 p.m. The deficient practice was lowered to a scope and severity of G (isolated, actual harm). Findings: Review of resident #2's medical record revealed she was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of resident #2's reentry MDS dated [DATE] revealed in section "G" Functional Status resident #2 required extensive assistance/2 persons physical assist with bed mobility, transfers, dressing, and toileting. Review at section "J" Health Conditions resident #2 had shortness of breath with exertion, at rest and when lying flat. Review of the physician's orders [REDACTED]. Review of resident #2's nurses' notes dated 12/25/11 at 10:00 a.m. revealed resident #2 was resting in bed. Resident #2 complained she was short of breath oxygen mask was placed with effectiveness. Review of resident #2's nurses' note dated 12/25/11 failed to reveal an oxygen saturation level was obtained or the physician was notified of resident #2's complaint of shortness of breath and the need for the [MEDICAL CONDITION] oxygen during the day. During a telephone interview on 2/8/12 at 12:30 p.m. S5LPN said she did not place the mask on resident #2 as documented on the nurse's notes, dated 12/25/11, but stated the [MEDICAL CONDITION] mask was already on the resident from the previous night shift. S5LPN stated the resident stayed in bed all day and wanted to keep the [MEDICAL CONDITION] mask on. Review of resident #2's nurses' notes dated 12/26/11 at 10:00 a.m. revealed resident #2 was resting in bed with oxygen mask on at 2L/minute. Resident complained of shortness of breath. Doctor was notified of situation. Resident was transported to local hospital per physician's orders [REDACTED]. Further review of resident #2's nurses' note dated 12/26/11 at 10:00 a.m. failed to reveal an oxygen saturation level for resident #2 was obtained. During a telephone interview on 12/8/12 at 12:30 p.m. S5LPN stated on the day shift on 12/26/11, resident #2 continued to complain of shortness of breath, wanted to keep her mask on, and did not want to get out of bed. S5LPN was asked if the resident's physician was notified of the change in the resident's condition on 12/25/11 and she stated no, she did not call the physician until 12/26/11. S5LPN further stated resident #2 did not usually complain of shortness of breath. During an interview on 2/9/12 at 10:00 a.m. S5LPN stated she did get a pulse ox reading on resident #2 on 12/26/11 but did not remember what time or what the reading was. S5LPN stated she called the physician's office and was told to transfer the resident to the hospital. S5LPN further stated when she told the resident she was going to be transferred to the hospital, S5LPN replaced the [MEDICAL CONDITION] mask with a nasal cannula because it was easier to get the resident dressed if she had on a cannula. During an interview on 2/8/12 at 10:00 p.m. S5LPN was asked why the the doctor was called at 10:00 a.m. and the ambulance wasn't called until 1:24 p.m.. S5 LPN stated that she just charted everything under 10:00 a.m. and doesn ' t remember exactly what time the physician was notified. Review of resident #2's nurses' notes dated 12/1/11 to 12/24/11 revealed no complaints of shortness of breath. Further review revealed resident #2 complained of shortness of breath only on 12/25/11 and 12/26/11. Review of resident #2's nurses' notes for 12/1/11 to 12/24/11 did not reveal the use of [MEDICAL CONDITION] oxygen during the day. Review of the ambulance service's run sheet dated 12/26/11 revealed a call was received from the facility at 1:24 p.m. and the ambulance arrived at the facility at 1:30 p.m. Further review of the ambulance run sheet revealed resident #2 was transported to the hospital at 2:05 p.m. Review of the ambulance service's run sheet dated 12/26/11 at 2:05 p.m. revealed upon arrival to the facility resident #2 was SOB, lying in bed supine, flat. Patient awake, able to follow simple commands, not oriented to time or place. Patient not on O2 because staff "knew we were coming" and took patient off 2L/min. per staff. Patient with O2 saturation in the 70's, patient placed on O2 at 2L/min via her night time [MEDICAL CONDITION]. On arrival RA, oxygen saturation 77? Patient presents in respiratory distress, placed on NRB at 12L/min. Moved patient to stretcher via drawsheet. Patient approximately 290 lbs., loaded into unit, obtained vital signs as shown. Oxygen set at high flow O2 100%. Patient stated she feels much better on O2 NRB. Hooked to CM obtained 12 lead due to extensive cardiac history. NSR, old MI. Established 20 gauge IV in left forearm. Patient complains of middle back pain that started yesterday after therapy. Patient complains of difficulty of getting a good breath for a few weeks now and was worse the past 2 days. Patient with patent airway, skin warm and dry, HEENT (head, ears, eyes, nose, throat) normal and PEARL. (pupils equal and reactive to light) Lungs BBS x4, (bilateral breath sounds) diminished throughout, dry cough reported, no change in route. Further review of the run sheet dated 12/26/11 revealed an elevation in blood pressure to 176/76 at 2:05 p.m. and 178/76 at 2:10 p.m. During an interview on 2/9/12 at 1:15 p.m. S2DON stated S5LPN requested the charge nurse to look at resident #2 on 12/26/11 before she was transported to the hospital. Review of resident #2's nurses' notes for that day failed to reveal any documentation by the charge nurse. Review of resident #2's physician's orders [REDACTED].#2 to the hospital. Review of an article from the web site currentnursing.com with a copyright date of 2010 revealed standards of practice as outlined by the American Nurses Association that included the nursing process as the standard of professional performance. These standards included: 1) The nurse collects comprehensive data pertinent to the patient's health or situation. 2) The nurse analyzes the assessment data to determine the [DIAGNOSES REDACTED]. 3) The nurse identifies expected outcomes for a plan individualized to the patient or situation. 4) The nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. 5) The nurse implements the identified plan of care.

Based on interviews, record reviews, and review of the American Nurses Association of standards of practice, 2010, the facility failed to provide the necessary care to residents in a manner to attain the highest practicable level of well-being for1(#2) of 5 sampled residents (#1,2,3,4,5) The facility failed to: 1) Have a system in place to employ staff that provide residents necessary care by professional standards. 2) Have a system in place to ensure the physician was notified of a change in respiratory status on 12/25/11 as evidenced by resident #2's complaint of shortness of breath and requiring the use of [MEDICAL CONDITION] oxygen throughout the daytime rather than just a night. 3) Obtain a physician's orders [REDACTED]. 4) Promptly notifiy the physician on 12/26/11 of resident #2'scontinued complaint of shortness of breath and use of [MEDICAL CONDITION] oxygen in the daytime. 5) Have an effective system in place for communication among staff to ensure the RN in charge was notified regarding resident #2's complaint of shortness of breath and the use of [MEDICAL CONDITION] oxygen during day hours on 12/25/11. 6) Obtain and record oxygen saturation levels after resident #2 complained of shortness of breath and required the use of continuous [MEDICAL CONDITION] oxygen during the day on 12/25/11. 7) Obtain and record oxygen saturation levels for resident #2 before and after changing the supplemental oxygen delivery from [MEDICAL CONDITION] to nasal cannual prior to arrival of emergency medical services on 12/26/11. Resident #2 was placed in immediate jeopardy on 12/25/11 at 10:00 a.m. when the resident complained of shortness of breath and continued to use [MEDICAL CONDITION] oxygen during the day. The physician was not notified of the change in resident #2's respiratory status which required an increase in oxygen needs for the resident on 12/25/11. The immediate jeopardy ended for resident #2 on 12/26/12 at 2:05 p.m. when the resident was transported to the hospital. Review of resident #2's emergency room report dated 12/26/11 revealed resident #2 was diagnosed with [REDACTED]. The facility was notified of the immediate jeopardy on 2/9/12 at 3:00 p.m. The deficient practice was lowered to a scope and severity of G (isolated, actual harm). Findings: Review of resident #2's medical record revealed she was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of resident #2's reentry MDS dated [DATE] revealed in section "G" Functional Status resident #2 required extensive assistance/2 persons physical assist with bed mobility, transfers, dressing, and toileting. Review at section "J" Health Conditions resident #2 had shortness of breath with exertion, at rest and when lying flat. Review of the physician's orders [REDACTED]. Review of resident #2's nurses' notes dated 12/25/11 at 10:00 a.m. revealed resident #2 was resting in bed. Resident #2 complained she was short of breath oxygen mask was placed with effectiveness. Review of resident #2's nurses' note dated 12/25/11 failed to reveal an oxygen saturation level was obtained or the physician was notified of resident #2's complaint of shortness of breath and the need for the [MEDICAL CONDITION] oxygen during the day. During a telephone interview on 2/8/12 at 12:30 p.m. S5LPN said she did not place the mask on resident #2 as documented on the nurse's notes, dated 12/25/11, but stated the [MEDICAL CONDITION] mask was already on the resident from the previous night shift. S5LPN stated the resident stayed in bed all day and wanted to keep the [MEDICAL CONDITION] mask on. Review of resident #2's nurses' notes dated 12/26/11 at 10:00 a.m. revealed resident #2 was resting in bed with oxygen mask on at 2L/minute. Resident complained of shortness of breath. Doctor was notified of situation. Resident was transported to local hospital per physician's orders [REDACTED]. Further review of resident #2's nurses' note dated 12/26/11 at 10:00 a.m. failed to reveal an oxygen saturation level for resident #2 was obtained. During a telephone interview on 12/8/12 at 12:30 p.m. S5LPN stated on the day shift on 12/26/11, resident #2 continued to complain of shortness of breath, wanted to keep her mask on, and did not want to get out of bed. S5LPN was asked if the resident's physician was notified of the change in the resident's condition on 12/25/11 and she stated no, she did not call the physician until 12/26/11. S5LPN further stated resident #2 did not usually complain of shortness of breath. During an interview on 2/9/12 at 10:00 a.m. S5LPN stated she did get a pulse ox reading on resident #2 on 12/26/11 but did not remember what time or what the reading was. S5LPN stated she called the physician's office and was told to transfer the resident to the hospital. S5LPN further stated when she told the resident she was going to be transferred to the hospital, S5LPN replaced the [MEDICAL CONDITION] mask with a nasal cannula because it was easier to get the resident dressed if she had on a cannula. During an interview on 2/8/12 at 10:00 p.m. S5LPN was asked why the the doctor was called at 10:00 a.m. and the ambulance wasn't called until 1:24 p.m.. S5 LPN stated that she just charted everything under 10:00 a.m. and doesn ' t remember exactly what time the physician was notified. Review of resident #2's nurses' notes dated 12/1/11 to 12/24/11 revealed no complaints of shortness of breath. Further review revealed resident #2 complained of shortness of breath only on 12/25/11 and 12/26/11. Review of resident #2's nurses' notes for 12/1/11 to 12/24/11 did not reveal the use of [MEDICAL CONDITION] oxygen during the day. Review of the ambulance service's run sheet dated 12/26/11 revealed a call was received from the facility at 1:24 p.m. and the ambulance arrived at the facility at 1:30 p.m. Further review of the ambulance run sheet revealed resident #2 was transported to the hospital at 2:05 p.m. Review of the ambulance service's run sheet dated 12/26/11 at 2:05 p.m. revealed upon arrival to the facility resident #2 was SOB, lying in bed supine, flat. Patient awake, able to follow simple commands, not oriented to time or place. Patient not on O2 because staff "knew we were coming" and took patient off 2L/min. per staff. Patient with O2 saturation in the 70's, patient placed on O2 at 2L/min via her night time [MEDICAL CONDITION]. On arrival RA, oxygen saturation 77? Patient presents in respiratory distress, placed on NRB at 12L/min. Moved patient to stretcher via drawsheet. Patient approximately 290 lbs., loaded into unit, obtained vital signs as shown. Oxygen set at high flow O2 100%. Patient stated she feels much better on O2 NRB. Hooked to CM obtained 12 lead due to extensive cardiac history. NSR, old MI. Established 20 gauge IV in left forearm. Patient complains of middle back pain that started yesterday after therapy. Patient complains of difficulty of getting a good breath for a few weeks now and was worse the past 2 days. Patient with patent airway, skin warm and dry, HEENT (head, ears, eyes, nose, throat) normal and PEARL. (pupils equal and reactive to light) Lungs BBS x4, (bilateral breath sounds) diminished throughout, dry cough reported, no change in route. Further review of the run sheet dated 12/26/11 revealed an elevation in blood pressure to 176/76 at 2:05 p.m. and 178/76 at 2:10 p.m. During an interview on 2/9/12 at 1:15 p.m. S2DON stated S5LPN requested the charge nurse to look at resident #2 on 12/26/11 before she was transported to the hospital. Review of resident #2's nurses' notes for that day failed to reveal any documentation by the charge nurse. Review of resident #2's physician's orders [REDACTED].#2 to the hospital. During an interview on 2/9/12 at 2:10 p.m. S3RN stated the facility did not have a policy for emergency situations specific to respiratory status or a policy regarding nurse to nurse communications when a resident has a decline. Review of an article from the web site currentnursing.com with a copyright date of 2010 revealed standards of practice as outlined by the American Nurses Association that included the nursing process as the standard of professional performance. These standards included: 1) The nurse collects comprehensive data pertinent to the patient's health or situation. 2) The nurse analyzes the assessment data to determine the [DIAGNOSES REDACTED]. 3) The nurse identifies expected outcomes for a plan individualized to the patient or situation. 4) The nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. 5) The nurse implements the identified plan of care.

Based on interviews, record reviews, facilty's policy and procedure manuals, and review of the American Nurses Association of standards of practice, 2010, the facility failed to use resources effectively and efficiently for 1(#2) of 5 sampled residents. (#1,2,3,4,5) The facility failed to: 1) Have a system in place to employ staff that provide residents necessary care by professional standards. 2) Have a system in place to ensure the physician was notified of a change in respiratory status on 12/25/11 as evidenced by resident #2's complaint of shortness of breath and requiring the use of [MEDICAL CONDITION] oxygen throughout the daytime rather than just a night. 3) Have a system in place to ensure a physician's orders [REDACTED]. 4) Have a system in place to ensure prompt notification of the physician on 12/26/11 regarding resident #2's continued complaint of shortness of breath and use of [MEDICAL CONDITION] oxygen in the daytime. 5) Have an effective system in place for communication among staff to ensure the RN in charge was notified regarding resident #2's complaint of shortness of breath and the use of [MEDICAL CONDITION] oxygen during day hours on 12/25/11. 6) Have an effective system in place to ensure oxygen saturation levels were obtained and recorded after resident #2 complained of shortness of breath and required the use of continuous [MEDICAL CONDITION] oxygen during the day on 12/25/11. 7) Have an effective system in place to ensure oxygen saturation levels were obtained and recorded for resident #2 before and after changing the supplemental oxygen delivery from [MEDICAL CONDITION] to nasal cannual prior to arrival of emergency medical services on 12/26/11. 8) Have a policy and procedure in place to ensure effective communication among staff when resident #2 had a change in status with shortness of breath requiring [MEDICAL CONDITION] oxygen during the daytime hours on 12/25/12 and 12/26/12. Resident #2 was placed in immediate jeopardy on 12/25/11 at 10:00 a.m. when the resident complained of shortness of breath and continued to use [MEDICAL CONDITION] oxygen during the day. The physician was not notified of the change in resident #2's respiratory status which required an increase in oxygen needs for the resident on 12/25/11. The immediate jeopardy ended for resident #2 on 12/26/12 at 2:05 p.m. when the resident was transported to the hospital. Review of resident #2's emergency room report dated 12/26/11 revealed resident #2 was diagnosed with [REDACTED]. The facility was notified of the immediate jeopardy on 2/9/12 at 3:00 p.m. The deficient practice was lowered to a scope and severity of G (isolated, actual harm). Findings: Review of resident #2's medical record revealed she was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of resident #2's reentry MDS dated [DATE] revealed in section "G" Functional Status resident #2 required extensive assistance/2 persons physical assist with bed mobility, transfers, dressing, and toileting. Review at section "J" Health Conditions resident #2 had shortness of breath with exertion, at rest and when lying flat. Review of the physician's orders [REDACTED]. Review of resident #2's nurses' notes dated 12/25/11 at 10:00 a.m. revealed resident #2 was resting in bed. Resident #2 complained she was short of breath oxygen mask was placed with effectiveness. Review of resident #2's nurses' note dated 12/25/11 failed to reveal an oxygen saturation level was obtained or the physician was notified of resident #2's complaint of shortness of breath and the need for the [MEDICAL CONDITION] oxygen during the day. During a telephone interview on 2/8/12 at 12:30 p.m. S5LPN said she did not place the mask on resident #2 as documented on the nurse's notes, dated 12/25/11, but stated the [MEDICAL CONDITION] mask was already on the resident from the previous night shift. S5LPN stated the resident stayed in bed all day and wanted to keep the [MEDICAL CONDITION] mask on. Review of resident #2's nurses' notes dated 12/26/11 at 10:00 a.m. revealed resident #2 was resting in bed with oxygen mask on at 2L/minute. Resident complained of shortness of breath. Doctor was notified of situation. Resident was transported to local hospital per physician's orders [REDACTED]. Further review of resident #2's nurses' note dated 12/26/11 at 10:00 a.m. failed to reveal an oxygen saturation level for resident #2 was obtained. During a telephone interview on 12/8/12 at 12:30 p.m. S5LPN stated on the day shift on 12/26/11, resident #2 continued to complain of shortness of breath, wanted to keep her mask on, and did not want to get out of bed. S5LPN was asked if the resident's physician was notified of the change in the resident's condition on 12/25/11 and she stated no, she did not call the physician until 12/26/11. S5LPN further stated resident #2 did not usually complain of shortness of breath. During an interview on 2/9/12 at 10:00 a.m. S5LPN stated she did get a pulse ox reading on resident #2 on 12/26/11 but did not remember what time or what the reading was. S5LPN stated she called the physician's office and was told to transfer the resident to the hospital. S5LPN further stated when she told the resident she was going to be transferred to the hospital, S5LPN replaced the [MEDICAL CONDITION] mask with a nasal cannula because it was easier to get the resident dressed if she had on a cannula. During an interview on 2/8/12 at 10:00 p.m. S5LPN was asked why the the doctor was called at 10:00 a.m. and the ambulance wasn't called until 1:24 p.m.. S5 LPN stated that she just charted everything under 10:00 a.m. and doesn ' t remember exactly what time the physician was notified. Review of resident #2's nurses' notes dated 12/1/11 to 12/24/11 revealed no complaints of shortness of breath. Further review revealed resident #2 complained of shortness of breath only on 12/25/11 and 12/26/11. Review of resident #2's nurses' notes for 12/1/11 to 12/24/11 did not reveal the use of [MEDICAL CONDITION] oxygen during the day. Review of the ambulance service's run sheet dated 12/26/11 revealed a call was received from the facility at 1:24 p.m. and the ambulance arrived at the facility at 1:30 p.m. Further review of the ambulance run sheet revealed resident #2 was transported to the hospital at 2:05 p.m. Review of the ambulance service's run sheet dated 12/26/11 at 2:05 p.m. revealed upon arrival to the facility resident #2 was SOB, lying in bed supine, flat. Patient awake, able to follow simple commands, not oriented to time or place. Patient not on O2 because staff "knew we were coming" and took patient off 2L/min. per staff. Patient with O2 saturation in the 70's, patient placed on O2 at 2L/min via her night time [MEDICAL CONDITION]. On arrival RA, oxygen saturation 77? Patient presents in respiratory distress, placed on NRB at 12L/min. Moved patient to stretcher via drawsheet. Patient approximately 290 lbs., loaded into unit, obtained vital signs as shown. Oxygen set at high flow O2 100%. Patient stated she feels much better on O2 NRB. Hooked to CM obtained 12 lead due to extensive cardiac history. NSR, old MI. Established 20 gauge IV in left forearm. Patient complains of middle back pain that started yesterday after therapy. Patient complains of difficulty of getting a good breath for a few weeks now and was worse the past 2 days. Patient with patent airway, skin warm and dry, HEENT (head, ears, eyes, nose, throat) normal and PEARL. (pupils equal and reactive to light) Lungs BBS x4, (bilateral breath sounds) diminished throughout, dry cough reported, no change in route. Further review of the run sheet dated 12/26/11 revealed an elevation in blood pressure to 176/76 at 2:05 p.m. and 178/76 at 2:10 p.m. During an interview on 2/9/12 at 1:15 p.m. S2DON stated S5LPN requested the charge nurse to look at resident #2 on 12/26/11 before she was transported to the hospital. Review of resident #2's nurses' notes for that day failed to reveal any documentation by the charge nurse. Review of resident #2's physician's orders [REDACTED].#2 to the hospital. Review of the facility's Policy and Procedure Manual failed to reveal policies for emergency situations specific to respiratory status or for communication between nursing staff when a change in a resident's status occurs. During an interview on 2/9/12 at 2:10 p.m. S3RN stated the facility did not have a policy for emergency situations specific to respiratory status or a policy regarding nurse to nurse communications when a resident has a change in condition. Review of an article from the web site currentnursing.com with a copyright date of 2010 revealed standards of practice as outlined by the American Nurses Association that included the nursing process as the standard of professional performance. These standards included: 1) The nurse collects comprehensive data pertinent to the patient's health or situation. 2) The nurse analyzes the assessment data to determine the [DIAGNOSES REDACTED]. 3) The nurse identifies expected outcomes for a plan individualized to the patient or situation. 4) The nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. 5) The nurse implements the identified plan of care.