Every finding on record at Harrington Park Health And Rehabilitation

Based on observations, staff interviews, record reviews and reviews of the facility policy titled, Medication Storage in the Care Center, the facility failed to ensure the legible expiration dates were on two bottles of Aspirin on two of two sampled medication carts. This failure had the potential to administer expired medications to residents which could potentially be harmful.Finding include:Review of the facility policy titled, Medication Storage in the Care Center, reviewed 12/21/2025 documented. Intent to facilitate that medications are administrated as prescribed, in accordance with good nursing principles. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, salt, or otherwise compromised are promptly removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists.Observation of medication storage on 03/04/2026 at 8:40 AM with Certified Medication Assistant (CMA) BB revealed a bottle of Aspirin 81mg with an illegible expiration date.Interview on 03/04/2026 8:44 am with CMA BB confirmed that she could not read the expiration date on the bottle. She admitted to only checking for expiration dates when I open the bottles and puts the open date on it. CMA BB admitted that she was not supposed to give the medication from that bottle and should have discarded it.Observation of medication storage on 03/04/2026 at 9:10 AM with CMA AA revealed a bottle of Aspirin 81mg with an illegible expiration date.Interview on 03/04/2026 at 9:14 AM with CMA AA confirmed she was not able to read expiration date on the Aspirin bottle. She stated that she checked her cart daily but denied noticing that the expiration date was illegible. She admitted that she had administered the medication that morning and did not check the expiration date. She stated that the medication should be discarded and replaced with a legible expiration date.Interview on 03/04/2026 at 11:30 AM with the Director of Nursing (DON) revealed that staff are aware that they should be checking their medication carts daily and removing expired medications or medications with illegible expiration dates. She stated that she only has one nurse on duty during the day shift and two CMAs but has two on the night shift because they do not have the added support of the administrative staff. She stated that the unit nurse is also responsible for checking the carts as a second set of eyes.Review of the facility policy titled Medication Storage in the Care Center, reviewed 12/21/2025, documented the intent to ensure medications are administered as prescribed and in accordance with good nursing principles. The policy stated: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or otherwise compromised are promptly removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists.Observation of medication storage on 03/04/2026 at 8:40 AM with Certified Medication Assistant (CMA) BB revealed a bottle of {Name} 81 mg medication with an illegible expiration date.Interview on 03/04/2026 at 8:44 AM with CMA BB confirmed she could not read the expiration date on the bottle. She stated she only checks for expiration dates when I open the bottles and put the open date on them. CMA BB acknowledged she was not supposed to give the medication from that bottle and should have discarded it.Observation of medication storage on 03/04/2026 at 9:10 AM with CMA AA revealed a bottle of Aspirin 81 mg medication with an illegible expiration date.Interview on 03/04/2026 at 9:14 AM with CMA AA revealed she was unable to read the expiration date on the Aspirin bottle. She stated she checked her cart daily but had not noticed the illegible expiration date. She admitted she had administered the medication that morning without checking the expiration date. She stated the medication should be discarded and replaced with one that had a legible expiration date.Interview on 03/04/2026 at 11:30 AM with the Director of Nursing (DON) revealed that staff are aware that they should be checking their medication carts daily and removing expired medications or medications with illegible expiration dates. She stated she has one nurse on duty during the day shift and two CMAs, and two CMAs on the night shift because they do not have the added support of administrative staff. She stated that the unit nurse is also responsible for checking the carts as a second set of eyes.

Based on observations, staff interviews, and a review of the facility's policies titled Hand Hygiene, Infection Prevention and Control Program, Infection Prevention Plan, and Foley Catheter Care, the facility did not follow basic infection control practices while caring for four of the 29 sampled residents(R) (R16, R13, R32, and R6). This failure could allow infections and germs to spread from one resident to another.Findings include:Review of the facility policy titled Hand Hygiene, reviewed 12/27/2025, revealed Intent-It is the intent of this facility to promote and facilitate appropriate hand washing as set forth by the guideline of CDC. Purpose-Hand hygiene was the single most important means of preventing the spread of infection. The use of gloves does not replace handwashing. Guideline: . Glove Use-Wear gloves, according to Standard Precautions when it can be reasonably the policy documented that gloves were to be worn when it can be reasonably anticipated that contact with blood, potentially infectious material, mucous membranes, non intact skin, potentially contaminated skin or contaminated environment could occur. Gloves should not be used as a substitute for hand hygieneReview of the facility policy titled Infection Prevention and Control Program, reviewed 12/27/2025, revealed the intent is each center was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Review of the facility policy titled Infection Prevention Plan, revised 12/27/2025, revealed the goal that the program was to prevent and control the transmission of infectious and communicable diseases, prevent healthcare associated infections, establish guidelines for isolation precautions, maintain a sanitary environment, provide education to personnel, and contribute to the reduction of mortality and morbidity. Scope- Implementation of Preventive Measures- prevention of spread of infection is accomplished by use of standard precautions and other barriers, appropriate treatment and follow up, employee work restrictions for illness.Review of the facility policy titled Foley Catheter Care, reviewed 12/27/2025, revealed that catheter care was to promote hygiene, comfort, and decreased infection risk for patients with an indwelling catheter and was to be performed daily and as needed for soiling.Observation of medication pass on 03/05/2026 at 8:11 AM with Certified Medication Aide (CMA) AA revealed CMA AA assessed the blood pressure for R32 with a shared blood pressure monitor. CMA AA exited the R32 room, placed the monitor on her medication cart, sanitized her hands, and then entered R6 room with the same blood pressure monitor. After exiting R6 room, she again placed the monitor on her medication cart and sanitized her hands. No sanitizing of the blood pressure monitor or the medication cart was observed. CMA AA then removed medications from the cart and began preparing them for administration.Interview on 03/04/2026 at 9:14 AM with CMA AA confirmed she did not sanitize the shared blood pressure cuff between resident use. She stated she should have cleaned the device after each resident and should not have placed it on the cart without cleaning. She also stated she should have sanitized her medication cart.Observation of wound care on 03/04/2026 at 11:40 AM with the Wound Care Nurse (WCN) revealed WCN sanitized her hands prior to donning gloves to clean the tray and cart. She removed gloves, arranged supplies, and donned PPE before entering the room. WCN performed hand hygiene and donned gloves, removed the soiled dressing, and doffed gloves before performing hand hygiene. She then donned gloves, cleaned the wound, and placed a clean dressing onto the wound bed while wearing the same gloves. No glove change or hand hygiene was observed prior to applying the clean dressing. WCN then doffed PPE, performed hand hygiene, and exited the room.Interview on 03/04/2026 at 11:57 AM with WCN confirmed she did not change gloves or perform hand hygiene after cleaning the wound and before placing the clean dressing. She stated she thought she had changed her gloves and did not realize she had not completed the second glove change.Observation of catheter care on 03/05/2026 at 9:41 AM with CNA CC revealed CNA CC donned PPE and set up water and washcloths. She removed a cloth from the basin without folding it around her hand and used it to clean the catheter area. The cloth was observed wiping various areas of the bed and the resident's leg. She then used another area of the same cloth to wipe the perineal area multiple times, allowing it to sweep across the bed and the resident's body. CNA CC used a clean cloth to clean the areas again without folding it, allowing it to sweep across the bed, resident's leg, and perineum. She then used fresh water to rinse the area in the same manner. CNA CC used a large clean towel to dry the perineal area, allowing the towel to drag across the bed, the resident's body, and the catheter. She then used another side of the same towel to continue drying before placing it into the soiled linen bag. CNA CC removed the wash pails and placed the resident's belongings back onto the table without sanitizing it. No glove changes or hand hygiene were observed during the catheter care process. She then doffed PPE, performed hand hygiene, and exited the room.Interview on 03/04/2026 at 9:53 AM with CNA CC revealed she never changed gloves during catheter care. She stated she did not remember seeing that step in the training video. She stated she had been a CNA for over six years and had performed catheter care many times.Interview on 03/04/2026 at 11:30 AM with the Director of Nursing (DON) revealed the Infection Preventionist (IP) was new, having been in the role for about two months. She stated she had been performing IP duties prior to the hiring of the IP. The DON stated that hand hygiene in-service training was done the previous week and she was not sure when PPE training was last completed. She stated infection control in services were for all staff and that her expectation was for staff to follow policies, including clean to dirty technique, to prevent cross contamination. She stated that after learning of the issues, the facility implemented infection observation on the affected residents for 72 hours because the blood pressure cuff was not sanitized between residents. She stated that wound care and catheter care practices were also not followed. She stated she expected staff to wash their hands, wear gloves appropriately, and clean equipment after use.

Based on observations, staff interviews, record review, and review of the facility policy titled Best Practice for PASRR, the facility failed to ensure that one of ten residents (R54) had a correct Level I submitted upon admission. This failure potentially prevented R54 from receiving the level of services required for individuals with mental or intellectual disabilities.Review of the facility policy titled Best Practice for PASRR, undated, it documented: Review PASRR of all new admissions-if you could not locate a Level I or a Level II in the Electronic Medical Record (EMR), follow up with medical records, admissions, or financial and ask that they scan it as soon as possible (ASAP) . The Social Services Director (SSD) should maintain an ongoing, active, and current list of PASRR patients. The list should contain, at a minimum, the patient's name; (SMI) Significant Mental Illness or (ID/ADD) Intellectual Disability/Developmental Disability.Review of the electronic medical record (EMR) revealed R54 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, chronic obstructive pulmonary disease, chronic kidney disease stage 3b, bipolar disorder unspecified, and depression.Review of R54's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11, which indicated R54 had moderate cognitive impairment.Review of R54's physician orders revealed the use of Buspirone 10 milligrams (mg) tablet (BUSPIRONE HCL), 1 tablet by mouth 2 times per day, diagnosis: bipolar disorder unspecified; Celexa 20 mg tablet (CITALOPRAM HYDROBROMIDE), 1 tablet by mouth 1 time per day, diagnosis: depression unspecified; and Wellbutrin XL 150 mg 24 hour extended release tablet (BUPROPION HCL), 1 tablet by mouth 1 time per day, diagnosis: bipolar disorder unspecified.Record review of R54's EMR on 03/04/2026 revealed a Level I submitted on 04/02/2025, which showed no indication of his diagnoses of bipolar disorder, depression, or anxiety. The Level I therefore did not indicate the need for, nor referral for, specialized services.Review of R54's care plan dated 12/30/2025 indicated a problem of Depression-Mood Disorder/Potential for Mood Disturbance. Goals included, but were not limited to, that R54 would interact appropriately with others during the review period and would maintain current psychosocial functioning. Interventions included, but were not limited to, administering medications as ordered, encouraging participation in preferred activities to maintain engagement, providing emotional support and encouraging expression of feelings, observing for significant mood shifts (hypoactive or hyperactive) and reporting to MD/psychiatry, utilizing psychiatric/psychological services as needed, and referring to Social Services when appropriate.Interview/observation on 03/04/2026 at 10:53 AM with the SSD regarding R54's diagnoses revealed that R54's diagnoses of bipolar disorder and depression would have made him eligible for a PASRR Level II. The SSD confirmed these diagnoses were present upon admission and that she was not aware of him having Level II. The SSD confirmed that R54 should have had a PASRR Level II and stated that he fell through the cracks. The SSD admitted that this could have potentially resulted in negative outcomes due to him not receiving the services he needed should he have required them.Interview on 03/05/2026 at 12:11 PM with the SSD revealed that she had resubmitted Level I for R54 and would follow up once she received a response instructing her to submit for a Level II. The SSD admitted that the initial Level I was not completed correctly and stated that she was unsure if she had submitted it. She admitted there was a Level I from the hospital and stated that the information may have been copied from it. She stated that to prevent this error from recurring, she would continue to complete her monthly audits to ensure this did not happen in the future.

Based on observations, staff interviews, and review of Logbook Documentation of Exhaust Fans: Inspect exhaust fans for proper operation and clean, if necessary, the facility failed to maintain a clean and homelike environment by ensuring bathroom ventilation vents were free from debris in two of fourteen rooms on [NAME] Hall (rooms [ROOM NUMBERS]). This deficient practice had the potential to create an unsanitary environment and negatively impact on residents' quality of life and homelike environment. Findings Include:Review of Logbook Documentation of Exhaust Fans: Inspect exhaust fans for proper operation and clean, if necessary, documented Check exhaust fans for proper operation, revealed. 4. Clean vents using vacuum and air compressor, when needed, to remove all dust.Observations on 03/03/2026 at 10:34 AM, and on 03/04/2026 at 9:44 AM, and again on 03/04/2026 at 1:18 PM in room [ROOM NUMBER] revealed the vent located on the ceiling in the resident's bathroom was observed to have grey, fuzzy debris.Observations on 03/03/2026 at 11:13 AM, 03/04/2026 at 9:45 AM, and 03/04/2026 at 1:19 PM in room [ROOM NUMBER] revealed the vent located on the ceiling in the resident's bathroom was observed to have grey, fuzzy debris.Interview/observation on 03/05/2026 at 9:58 AM with Housekeeper DD revealed he had been working at the facility for approximately four months. Housekeeper DD stated his responsibilities included cleaning resident rooms and dusting vents in residents' rooms, and that vents were expected to be dusted every other day. During observation of the bathroom vent in room [ROOM NUMBER], Housekeeper DD stated the vent appeared dusty. Housekeeper DD stated that since he had been working at the facility, he had not dusted this vent and stated it appeared it may need to be changed out. Housekeeper DD stated he would need to inform his director regarding the condition of the vent. During observation of the bathroom vent in room [ROOM NUMBER], Housekeeper DD confirmed the vent was dusty and rusty and stated it may need to be changed. Housekeeper DD confirmed he had not cleaned this vent since he had been working at the facility. When asked about potential negative outcomes, Housekeeper DD stated residents could potentially become sick.Observation/interview on 03/05/2026 at 10:04 AM of room [ROOM NUMBER] with the Housekeeping Director revealed housekeepers were expected to dust daily. During observation of the bathroom vent in room [ROOM NUMBER], the Housekeeping Director observed dust accumulation. The Housekeeping Director revealed that her expectation was that housekeepers should touch and clean everything in the room while performing cleaning duties. The Housekeeping Director stated a potential negative outcome could be that the condition of the vents would not create a home-like environment and would not be acceptable in someone's home.Interview on 03/05/2026 at 10:14 AM with the Administrator revealed housekeeping staff were responsible for cleaning resident rooms. The Administrator stated staff were expected to ensure rooms were dusted and that housekeepers should have a checklist of duties that included dusting, including the vents. The Administrator confirmed the observed condition would not reflect a home-like environment.

Based on observations, interviews, record review, and review of the facility policy titled, Skilled Nursing Services Restorative, the facility failed to ensure splints were applied as ordered by physician for two of 22 residents (R) (R21 and R36). The deficient practice had the probability to further decrease the range of motion and mobility for residents requiring the use of splints to prevent and maintain contractures. Findings include: Review of the facility policy titled, Skilled Nursing Services Restorative, policy dated December 27, 2024, revealed under intent: To be provided a formalized restorative care plan to be implemented by appropriately trained staff and overseen by a nursing supervisor. To establish a communication system between nursing and skilled therapy to assured continuity of care between disciplines. A review of the electronic medical record revealed R21 was admitted to the facility with diagnoses of but not limited to Hemiplegia and hemiparesis following cerebral infarction Dysphagia, Contracture, left elbow, Contracture, right elbow, Neuromuscular dysfunction of bladder, Contracture, left wrist and hypertension. Review of R21's care plan revealed a care plan that stated, At risk for actual contractures r/t (related to) left hemiplegia, interventions indicated splint to left hand as ordered and as allowed. Review of the Nursing Restorative care Program document dated and developed 1/16/2025 goal indicated, Patient will maintain current Range of motion (ROM) to left wrist and hand with the use of splint to decrease worsening of contracture with no signs or symptoms of compromised skin integrity through the review period. Intervention included: Apply the following splint to affected joint for the stated time period. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Pattern) R21 had a Brief Interview for Mental Status (BIMS) that was not indicated due resident was rarely/never understood; Resident was dependent on staff for all activities of daily living. A review of R21's Occupational Therapy notes stated, Passive range of Motion (PROM) on Lower Upper Extremity (LUE) with staff education to ensure continuous joint mobility exercises for ease with splint application and maintain current gained Range of Motion (ROM). Observation on 2/1/2025 at 8:30 a.m., R21 had a left-hand contracture and there was no splint/brace nor a handroll in the hand for comfort. Splint was observed lying on bedside nightstand. Observation on 2/2/2025 at 12:30 p.m., R21 was observed lying in bed with left- hand contracture without splint/brace applied. Splint was observed on nightstand at bedside. Record review for R36 revealed resident was admitted to the facility with diagnoses of but not limited to Hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, Type 2 diabetes mellitus, inflammatory spondylopathy, Methylenetetrahydrofolate reductase deficiency, and Dysphagia. Review of R36's care plan revealed a Care Area for limited mobility related to contracture L wrist/hand, Splint to left hand as ordered. A review of R36's Nursing Restorative care Program document dated 1/16/2025 stated, Patient will maintain current ROM of left wrist and hand with the use of splint to decrease risk of developing or worsening of contracture with no signs or symptoms of compromised skin integrity through the review period. Intervention included: Apply the following splint to affected joint for the stated time period. A review of R36's Occupational Therapy notes stated Patient will tolerate provided splint for at least 4-6 hours daily without pain or signs of skin irritation/breakdown in order to manage/prevent contracture, maintain current ROM and for proper positioning and joint protection. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Patterns) revealed R36 has a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment; Resident requires extensive assistance for all activities of daily living. Observation on 2/1/2025 at 8:33 a.m., R36 had a left-hand contracture and there was no splint/brace nor a handroll in the hand for comfort. Splint was observed lying on bedside nightstand. Observation on 2/2/2025 at 12:35 p.m., R36 was observed lying in bed with left- hand contracture without splint/brace applied. Splint was observed on nightstand at bedside. Interview 2/3/2025 at 9:25 a.m. with Restorative Certified Nursing Assistant (CNA) AA revealed R36 and R21 should have a splint applied on their left hands daily. Further interview revealed that she works Monday thru Friday, and the staff should apply the splints on the weekend when she is not working. Interview on 2/3/2025 at 8:18 a.m., with the Director of Nursing (DON) acknowledged that R21 and R36 were not wearing splints. The DON stated she would follow up with the Restorative Care Coordinator to implement a plan to ensure the residents have their splints on daily and removed as indicated per Restorative care plan.

Based on staff interviews, record review, and review of the facility policy titled, Patients Plan of Care, the facility failed to ensure the plan of care was implemented for two of 22 residents (R) (R21 and R36). The deficient practice had the potential to prevent R21 and R36 from having their needs met according to their care needs. Findings include: Review of the facility policy titled, Patients Plan of Care dated 12/27/2024, revealed under Guideline: Each patient will have a person-centered comprehensive care plan developed and implemented to address the patients' medical, physical, mental, and psychosocial needs while also honoring their preferences and goals. A review of the electronic medical record revealed R21 was admitted to the facility with the diagnoses of but not limited to Hemiplegia and hemiparesis following cerebral infarction, Dysphagia, Contracture, left elbow, Contracture, right elbow, Neuromuscular dysfunction of bladder, Contracture, left wrist and hypertension. Review of R21's care plan revealed a care plan that stated, At risk for actual contractures r/t (related to) left hemiplegia, interventions indicated splint to left hand as ordered and as allowed. Review of the Nursing Restorative care Program document dated and developed 1/16/2025 goal indicated, Patient will maintain current Range of motion (ROM) to left wrist and hand with the use of splint to decrease worsening of contracture with no signs or symptoms of compromised skin integrity through the review period. Intervention included: Apply the following splint to affected joint for the stated time period. Observation on 2/1/2025 at 8:30 a.m., R21 had a left-hand contracture and there was no splint/brace nor a handroll in the hand for comfort. Splint was observed lying on bedside nightstand. Observation on 2/2/2025 at 12:30 p.m., R21 was observed lying in bed with left- hand contracture without splint/brace applied. Splint was observed on nightstand at bedside. Record review for R36 revealed resident was admitted to the facility with diagnoses of but not limited to Hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, Type 2 diabetes mellitus, inflammatory spondylopathy, Methylenetetrahydrofolate reductase deficiency, and Dysphagia. Review of R36's care plan revealed a Care Area for limited mobility related to contracture L wrist/hand, Splint to left hand as ordered. A review of R36's Nursing Restorative care Program document dated 1/16/2025 stated, Patient will maintain current ROM of left wrist and hand with the use of splint to decrease risk of developing or worsening of contracture with no signs or symptoms of compromised skin integrity through the review period. Intervention included: Apply the following splint to affected joint for the stated time period. Observation on 2/1/2025 at 8:33 a.m., R36 had a left-hand contracture and there was no splint/brace nor a handroll in the hand for comfort. Splint was observed lying on bedside nightstand. Observation on 2/2/2025 at 12:35 p.m., R36 was observed lying in bed with left- hand contracture without splint/brace applied. Splint was observed on nightstand at bedside. Interview on 2/3/2025 at 7:48 a.m. with the Director of Nursing revealed she acknowledged the care plan was not being implemented for R21 and R36 and she would follow up with the Restorative Care Coordinator to implement a plan to ensure the care plans were followed as ordered.

Based on observations, staff interviews, record review, and a review of the facility's policy titled Self-Administration of Medication by Patients, the facility failed to ensure that one of 22 residents (R) (R208) was assessed for self-administration of a medications. This deficient practice had the potential to allow unauthorized access to unsecured medications by other residents and visitors. Findings include: Review of the facility's undated policy titled, Self-Administration of Medications by Patients, under Guideline: Each patient who desires to self-administered medication is permitted to do so if the nursing centers interdisciplinary team has determined that the practice would be safe for the patient and other patients of the nursing center and that the patient is able to accurately self-administer. - The ability to appropriately self-administer medications should be documented in the patient's care plan. This evaluation of the patient's ability to correctly and safely self-administer medications is subject to periodic re-evaluation based on changes in the patient's status. Record review for R208 revealed resident was admitted to the facility with diagnoses of but not limited to acute on chronic diastolic (congestive) heart failure, pneumonia, pleural effusion, disease of pulmonary vessels, chronic metabolic acidosis, anemia in other chronic diseases, difficulty in walking, muscle weakness (generalized), and chronic kidney disease. Review of R208's Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of the Physician Orders did not indicate an order for R208 to self-administer medications. Further review also indicated that there was not a physician's order for the use of the medicated ointment that was at the resident's bedside. Observation on 2/1/2025 at 9:00 am in R208's room, a container of medicated Vapor Rub was observed on the resident's bedside table. Observation on 2/2/2025 at 10:00 am, the resident was again observed with the medicated Vapor Rub on the nightstand. Interview on 2/2/2025 at 10:08 am with Licensed Practical Nurse (LPN) Wound Care Nurse DD revealed that she was unaware of any care plan allowing the resident to self-administer medications. LPN Wound Care Nurse DD confirmed and removed the medicated Vapor Rub from the resident's bedside and delivered them to the Director of Nursing (DON). Interview on 2/3/2025 at 11:33 am with the Administrator revealed that all medications should be either locked in the medication storage room or in the locked cabinet in the resident's rooms. The Administrator stated that there was not a resident in the facility who had been assessed to self-medicate safely. Therefore, there should not be any unsecured medications in resident rooms.

Based on observations, record review, staff interviews, and review of facility policy titled, Use of Oxygen Therapy, the facility failed to ensure that the Physician's order to increase oxygen therapy was transcribed into the electronic medical record (EMR) for one of 11 residents (R) (R17) receiving oxygen therapy. This failure had the potential to affect the necessary respiratory care and services that are in accordance with professional standards of practice. Findings include: Review of facility policy titled Use of Oxygen Therapy dated 12/30/2022 revealed Guideline: Physician's order for oxygen should be obtained and include: Oxygen with liter flow or percentage ordered; Indicate if use should be continuous or PRN (as needed); Method of oxygen deliver via nasal canula, mask, etc. Review of R17's EMR revealed diagnoses included but not limited to pan lobular emphysema and dependence on supplemental oxygen. Review of Quarterly Minimum Data Set (MDS) dated [DATE] Section C-Cognitive Status indicated R17 had both short term and long-term memory problems. Section O - Special Treatments and Programs indicated R17 received oxygen therapy. Review of Physicians order for R17 dated 10/5/2023 revealed an order for Oxygen via nasal canula two liters per minute. Observation on 10/13/2023 at 9:47 a.m. revealed R17 was in bed with a non-rebreather mask intact to face and the oxygen concentrator was set at five (5) liters per minute. Observation on 10/13/2023 at 10:06 a.m. revealed R17 remained in bed with the non-rebreather mask intact to face and oxygen concentrator set at 5 liters per minute. Review of nurses noted dated 10/11/2023 at 7:28 p.m. revealed an order was received from the Nurse Practitioner (NP) to increase R17's oxygen to 5 liters per minute and place a non-rebreather mask on resident. Review of R17's orders did not reveal the order had been changed in the EMR. Interview on 10/15/2023 at 8:40 a.m. with the Assistant Director of Nursing (ADON) confirmed R17's orders were not changed in the EMR after NP gave an order to increase oxygen to 5 liters per minute and change nasal canula to a non-rebreather mask. The ADON stated the nurse taking the order should have changed the order in the EMR. The ADON stated other nurses assigned to work with R17 should have noticed a discrepancy between the oxygen concentrator setting and the oxygen order in the EMR because they have to sign off on the medication administration record that the oxygen is being administered according to orders. Interview on 10/15/2023 at 11:05 a.m. with Director of Nursing revealed her expectation is for the nurses to ensure orders are transcribed into the EMR when received from NP or Medical Doctor (MD).

Based on observation, record review, interviews, and review of the facility policy titled Patient's Plan of Care, the facility failed to develop a person-centered comprehensive care plan with planned interventions for one resident (R) (R#1) related to respiratory care, who was admitted to the facility with diagnoses of aspiration pneumonia, congestive heart failure (CHF) and Physician's order for inhalers and a high risk for aspiration. The sample size was 12. On 4/4/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility Administrator, Director of Nursing (DON), and the Regional Nurse Consultant were informed of Immediate Jeopardy on 4/4/2023, at 10:07 a.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on 1/15/2023. At the time of exit on 4/6/2023, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings include: Review of the policy titled Patient's Plan of Care reviewed 12/30/2022 revealed the guideline is for each patient to have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs. The procedure indicated when developing the comprehensive care plan, facility staff should use the Minimum Data Set (MDS) to assess the patient's clinical condition, cognitive and functional status, and use of service. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of left femur, pneumonitis, chronic diastolic (congestive) heart failure, hypertensive chronic kidney disease, encephalopathy, dysphagia, diabetes, atrial fibrillation, and epilepsy. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment. Section G revealed resident required extensive assistance with bed mobility, eating, and toileting, total dependence with personal hygiene, bathing, and dressing. Section O revealed resident received Respiratory Therapy (RT) for five days during the seven days look back period from 12/28/2022 through 1/3/2023. Review of the care plan dated 1/4/2023 revealed there was no evidence that a care area or problem addressing residents' respiratory status was developed. The resident was admitted with a diagnosis of pneumonitis and congestive heart failure. Further review revealed resident was a Full Code. Review of December 2022 Physician Orders (PO) dated 12/28/2022, revealed an order dated 12/29/2022 for Advair Diskus 250-50 micrograms (mcg) dose powder inhalation, inhale one disk with device two times a day for diagnosis of shortness of breath. Interview on 4/5/2023 at 1:34 p.m., Administrator confirmed the resident did not have a care plan in place that addresses respiratory care. She indicated the MDS coordinator was not available due to scheduled leave time. During further interview, she stated the expectation is that care plans should be person-centered and reflect the resident's current conditions. She stated R#1 should have a care plan in place for the diagnoses of aspiration pneumonia, CHF and Physician's order for inhalers and a high risk for aspiration. Interview on 4/6/2023 at 12:59 p.m. Licensed Practical Nurse (LPN) UU indicated if she has a new resident or a resident she has not cared for before she would review the residents medical record, care plan and get information during report. She confirmed R#1 did not have a care plan addressing his respiratory status.

Based on record review, staff and family interviews, review of audio and video recordings, and review of the facility policy titled Abuse Prohibition, the facility failed to ensure one resident (R) (R#1) was protected from neglect from licensed nursing staff, by failing to promptly assess a decline in respiratory status. Specifically, R#1 exhibited symptoms of respiratory distress, became hypoxic and unresponsive, and required emergency intubation by the Emergency Medical Services (EMS) prior to transport to the hospital. R#1 required a tracheostomy for breathing and insertion of a gastrostomy tube for nutrition. On 4/4/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility Administrator, Director of Nursing (DON), and the Regional Nurse Consultant were informed of Immediate Jeopardy on 4/4/2023, at 10:07 a.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on 1/15/2023. At the time of exit on 4/6/2023, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings include: Review of the policy titled Abuse Prohibition reviewed 12/30/2022 revealed the intent is to preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of property. Neglect is defined as the absence or omission of services to the degree that it harms or threatens with harm the physical or emotional health of a disabled adult or elder person. The center will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of patient property is more likely to occur. This will include an analysis of the deployment of staff on each shift in sufficient numbers to meet the needs of the patients, and assure the staff assigned has knowledge of individual patient's needs. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of left femur, pneumonitis, chronic diastolic (congestive) heart failure, hypertensive chronic kidney disease, encephalopathy, dysphagia, diabetes, atrial fibrillation, and epilepsy. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment. Section G revealed resident required extensive assistance with all activities of daily living. Section O revealed resident received Respiratory Therapy (RT) for five days during the seven day look back period. Review of the care plan dated 1/4/2023 revealed there is no evidence that a care area or problem addressing residents' respiratory status was developed. The resident was admitted with a diagnosis of pneumonitis and congestive heart failure. Further review revealed resident was a Full Code. Review of December Physician Orders (PO) dated 12/28/2022, revealed an admitting diagnosis of aspiration pneumonia, with a custom order for swallowing precaution-high risk for aspirations. Review of Nurses Note dated 1/15/2023 at 2:27 p.m. written by the DON revealed assessment noted fluid filled lungs with cough that he was unable to produce and spit out. Eyes were closed and he was unresponsive to verbal stimuli. The DON notified Nurse Practitioner (NP) WW and ordered to send R#1 to the ER for evaluation. Review of Nurses Note dated 1/15/2023 at 2:52 p.m. written by the DON revealed report called to Registered Nurse at {hospital} emergency room (ER) and arranged transportation via {provider} Ambulance Service. Review of Nurses Notes dated 1/15/2023 at 5:22 p.m. written by Licensed Practical Nurse (LPN) CC revealed resident had a sudden decline since the beginning of her shift. Resident was unresponsive to verbal stimuli and several attempts to arouse with sternal rub, were unsuccessful. The Director of Nursing (DON) was called to the residents' room to further assess his decline. Addendum was added at 5:27 p.m. for vital signs were blood pressure 142/72, pulse 79, temperature 97.0 degrees Fahrenheit (F), respirations 20, oxygen saturation (O2 Sat) 94% on room air. Review of Nurses Note dated 1/15/2023 at 5:25 p.m. written by LPN CC revealed resident sent to {hospital} per wife's request. He remains unresponsive to verbal stimuli. Further review of the note revealed the family had removed his belongings earlier in the shift and was overheard stating he won't be back. Review of Resident/Patient Transfer Form dated 1/15/2023 revealed reason for transfer documented shortness of breath/respiratory changes and altered mental status/change in cognitive status. Vital signs included a B/P of 142/72, pulse 79, temperature 97.0 degrees F, respirations 20, and an O2 Sat 94% on room air. Review of video recording provided by family member of R#1 revealed the video shows family member sitting outside of his room. The family member asked an unidentified staff member why the DON had not come back to check on him. The unidentified staff member stated the DON was notified and will be in to see him when she is finished with wound care on another resident. The family member indicated she had asked for oxygen to be placed on him because his oxygen level is low. The family member used her personal pulse oximeter to check his oxygen level. At 1.32 seconds into the video, LPN CC was seen slowly bringing in an oxygen concentrator and supplies into the room. R#1 was visible on the video and was noted to be in respiratory distress, with an audible wet cough with grunting sounds. LPN CC removed the plastic bag from the oxygen concentrator and was heard telling receptionist MM to bring her another concentrator, due to the knob coming off. She proceeded to open the oxygen supplies, without noted urgency. There was no evidence on the video that LPN CC assessed the resident nor obtained vital signs or oxygen saturation level. During further review of the video at 4.20 seconds, the DON arrived outside of the residents' room and began to argue back and forth with the family member of R#1. The DON indicated she was going to call the police and asked the family member to leave. Continued review of the video does not show the DON enter the room to assess the resident or speak to LPN CC about her concerns. At 10.9 seconds into the video, First Responders arrived at the facility. The video ended at 10 minutes and 37 seconds. During the 10 minute 37 second length of the video, there was no evidence that R#1 was assessed by the DON, or the LPN and no evidence oxygen was administered. The video is not time stamped. Review of a second video recording provided by family member of R#1 revealed family member sitting outside of R#1's room. Resident could be heard on the video making grunting sounds and when family member entered room and asked him what was wrong, the resident did not respond. The length of the video was one minute 4 seconds. The video is not time stamped. Review of a picture provided by family member of R#1 time stamped 1/15/2023 at 3:47 p.m. revealed a pulse oximeter (device used to measure the proportion of oxygenated hemoglobin in the blood) attached to the finger indicated a pulse of 97 and oxygen saturation of 67 percent (%). Review of the Fire Department's Prehospital Care Report dated 1/15/2023 revealed at 3: 41 p.m. 911 dispatch was notified of male in respiratory distress/altered mental status. The Fire Unit/First Responders were dispatched to the facility at 3:47 p.m. and enroute at 3:49 p.m. At 3:56 p.m., Fire Unit/First Responders arrived on scene and to resident at 4:04 p.m. The First Responder Narrative Summary revealed upon arrival at the scene, family and facility staff were having a dispute. Upon arrival to resident in room [ROOM NUMBER], the resident was laying in the bed unresponsive with a non-rebreather mask on. The non-rebreather bag was not inflated and not being used at the appropriate liter per minute (LPM) flow rate and the resident's oxygen saturation was at 79%. First Responders personnel changed the resident to portable oxygen cylinder at 15 LPM and resident's oxygen saturation slowly increased. Further review of the report revealed blood pressure was 90/60, pulse was 91 and respiration was 20. Glasgow Coma Scale (GCS) was three with no eye movement, no motor movement, and no verbal response. The resident's wife indicated he has been unresponsive and not at his baseline for two days. Attempt was made to decrease oxygen from 15 LPM to 10 LPM, but saturation slowly decreased, and oxygen was reset to 15 LPM. First Responders personnel monitored the resident until emergency medical services (EMS) arrived. Review of the Call for Service Detail Report created 1/15/2023 at 3:41 p.m. revealed nature of the call was male patient with trouble breathing. At 3:47 p.m. unit recommended Police and Fire/First Responders. Fire/First Responders were en route at 3:49 p.m. Fire/First Responders arrived on scene at 3:56 p.m. Additional request for estimated time of arrival (ETA) for EMS was made at 3:59 p.m. EMS arrived on scene at 4:27 p.m. Review of the ER report dated 1/15/2023 revealed resident arrived at the ER via ambulance at 4:59 p.m. He was unresponsive and hypotensive. He was intubated in the field. His oxygen saturation rate was at 100% and his blood pressure was 85/61 and was febrile. He had a GCS of three. Chest x-ray indicated a right lower lobe infiltrate. Labs were consistent with severe dehydration. Other concerns included acute and chronic renal failure, septic shock, and dehydration. He remained intubated, and a central line was inserted in the ER. He was admitted to the hospital intensive care unit (ICU). Review of the hospital Discharge Summary dated 2/3/2023 revealed discharge diagnoses include septic shock due to klebsiella pneumonia, respiratory failure, and metabolic encephalopathy. Patient presented to the ER brought in by EMS unresponsive and hypoxic. He was intubated in the field. Chest x-ray showed a right lower lobe infiltrate. Labs were consistent with dehydration. COVID-19 test was positive but not likely shedding virus. Admission condition was critical. He was unable to be extubated and received a tracheostomy on 2/1/2023 and had a feeding tube placed on 2/2/2023. His hospital course was complicated by persistent encephalopathy and sepsis. His discharge condition was serious and was discharged to a Long-Term Acute Care Center (LTAC) on 2/3/2023 for further management and his anticipated prolonged ventilator requirements. Review of a Facility Reported Incident (FRI) dated 1/17/2023 revealed the facility received a complaint through the facility Compliance Line related to concerns with care for R#1. The facility initiated an investigation related to alleged patient care concerns. Steps taken by the facility to prevent further occurrences included education with staff related to alleged concerns. Review of a statement written by the DON dated 1/15/2023 revealed she was asked at 1:30 p.m. to assess R#1 due to being unresponsive and unable to accept medications. His family was at bedside. She reviewed the vital signs documented in the electronic medical record. The statement did not indicate she took his vital signs or O2 saturation herself. She assessed his lung sounds and heard crackles and indicated his lungs were fluid filled. The DON indicated she called the NP at 2:13 p.m. and received an order to send him to the ER for evaluation. The DON returned to his room and informed the family at 2:27 p.m. of order to send him to the hospital. The DON left the room to get his paperwork ready. According to the statement, the DON called the ambulance service between 2:30 p.m. and 2:45 p.m. to arrange transport for resident and called report to the hospital. Further review of the statement indicated she was downstairs doing wound care when she received three back-to-back calls from LPN CC at 3:40 p.m., 3:41 p.m. and 3:45 pm. She did not indicate she responded to any of the calls. The DON revealed she received a text message from receptionist MM at 3:52 p.m. indicating R#1's family member was recording LPN CC. The text did not indicate R#1 was in distress. The DON finished wound care and went upstairs to R#1's room. According to the DON statement she arrived at R#1's room and was confronted by the family member. An argument ensued, and the DON left to call the police. She did not indicate she went in to assess the resident or have a conversation with LPN CC about the resident's condition. Review of a statement dated 1/15/2023 and written by LPN CC, revealed she entered R#1's room at 11:40 a.m. and noted he was lethargic, and his wife was trying to feed him. LPN CC attempted to arouse him by rubbing on his sternum and was unsuccessful. The nurse held his medications and removed the food tray from the room. She informed his wife she was going to notify the DON of a change in his condition, since this morning. The statement indicated she notified the DON at 1:25 p.m. (one hour and 45 minutes later) and the DON came to residents' room and performed her assessment and found his lungs were full of fluid. LPN CC indicated she then proceeded to finish her medication administration to other residents, as the DON prepared the paperwork for resident to be sent to the hospital. The statement indicated the DON went back downstairs to continue doing wound treatments, after she had called to make transportation arrangements and called report to the hospital ER nurse. The statement does not indicate a time that the transportation arrangements were made, or the report called to the hospital. LPN CC indicated at 3:35 p.m. she was sitting at the nurse's desk when family member of R#1 ran to the nurse's station and yelled you need to get down here and put some oxygen on my daddy. LPN CC indicated she told the family member resident did not have an order for oxygen. Continued review of the statement revealed LPN CC called the DON three times and all three calls were unanswered. She then texted the DON to come upstairs as soon as possible. She indicated the family member was on the phone with receptionist MM stating that her daddy was in respiratory distress and the nurse was saying she needed to get an order for oxygen. The statement revealed the family member never indicated the resident was in distress. LPN CC obtained a pulse oximeter from the medication cart to check his O2 saturation level, which indicated was 94%. LPN CC indicated resident had the family members personal pulse oximeter on his finger and reading was 75%. She left the room and obtained an oxygen concentrator and supplies. When she removed the plastic covering off the oxygen concentrator the knob came off and she asked another staff member to get her another one. At 3:54 p.m., she indicated the DON replied to her earlier text with I'm on my way, I was finishing up wound care. The statement continued by describing an argument between the DON and the family member of R#1. The statement did not indicate he was assessed by the DON or if he received supplemental oxygen. Interview on 3/14/2023 at 11:45 a.m., DON revealed she called for transport for R#1, after Nurse Practitioner (NP) WW ordered for him to be sent to hospital. She indicated the family called 911 too, as he had not been picked up yet. She indicated after the family called 911, the Fire Department and First Responders arrived. During further interview she confirmed R#1 was not placed on oxygen because he was not in respiratory distress and his O2 saturation level was 94%. She indicated oxygen tanks and concentrators are available for use on each floor. Phone interview on 3/20/2023 at 11:00 a.m. R#1's daughter revealed she called her mother who was visiting resident at the facility. Her mother indicated the resident had a decline in his condition since the early morning and was being sent to the hospital. She stated they have been waiting to be picked up by the ambulance. She indicated she tried to talk to her father on the phone but all he did was moan and would not speak. She decided to come to the facility to check on him. She stated when she arrived, she said her father was exhibiting symptoms of respiratory distress and checked his oxygen saturation level with her personal pulse oximeter, and indicated it was low, in the 60's. She stated that the staff did not act like her father was in respiratory distress, so she called 911 and told them to call the Fire Department/First Responders because the facility was trying to kill her father. She confirmed she yelled for the nurse to bring her daddy some oxygen. She stated the nurse was in no hurry to go to his room, to check on her father. She indicated the nurse got an oxygen concentrator and when she was turning it on the knob fell off and she had to get another one. She revealed the DON came to check on her father after finishing wound care. On 3/28/2023 at 1:44 p.m., an attempt to call the Emergency Medical Technician for interview was unsuccessful. A voicemail message was left to return the call. No return call was received. On 4/5/2023 at 3:10 p.m. a second attempt was made to contact the EMS personnel who responded to the call on 1/15/2023 regarding R#1. A message was left to return the surveyor's call. No return call was received. On 4/6/23 at 10:49 a.m. an attempt was made to contact the Fire Department/First Responders and a message was left to return the call to surveyor. No return call was received. Phone interview on 3/28/2023 at 3:23 p.m. R#1's wife revealed she felt like something was wrong with her husband, because he would not eat, drink, or wake up. She stated LPN CC called the DON to come check on him. She stated the DON listened to his lungs but did not check his vital signs or check his oxygen level. The DON told her his lungs sounded wet and stated he needed to go to the hospital. The DON told her she would get the paperwork ready and call the ambulance to take him to the hospital and she never saw the DON again after that. During further interview, she stated LPN CC tried to give R#1 his medications but he could not swallow. She revealed LPN CC did not take his vital signs. During further interview, she indicated her daughter called her after that she told the daughter he was still the same and no one has come to pick him up or come back to check on him. Interview on 3/29/2023 at 8:00 a.m., DON revealed she reviewed the nurse's notes relating to R#1 and realized the times documented were not correct. She stated all notes are time stamped at the time they are entered, and that's why the nurse's should be adding late entry to the notes. She indicated the nurses should be charting in real time and need to add to the note if entered later, the exact date and time incidents happen and notate as late entry. Interview on 3/29/2023 at 12:02 p.m., Certified Nursing Assistant (CNA) BB revealed she was assigned to care for R#1 on 1/15/2023 during the 7:00 a.m. - 3:00 p.m. shift. She stated he did not want to get out of bed, go to the shower, sit in a chair, or want to turn. She indicated he was fine that morning, maybe less alert but he was talking and refusing everything like normal. She stated she did not know about his decline until he was sent out to the hospital. Interview on 3/29/2023 at 12:30 p.m., LPN CC revealed the morning of 1/15/2023, the resident was at his normal baseline. At lunchtime, she attempted to give him his medications. She stated the wife was trying to feed the resident, but he was not swallowing. She held his medications and called the DON who was in the facility, to come assess the resident. She stated she went to get the equipment and pulse oximeter and took his vital signs. The DON assessed the resident and spoke with the wife about sending him to the hospital. She indicated the resident was not in respiratory distress at that time. She stated the DON then left to call the NP about resident needing to go to hospital. During further interview, she revealed the wife called her daughter and the daughter showed up shortly after that and came out of the room yelling to put oxygen on R#1. The daughter did not say or indicate he was in any type of distress. The nurse went to the residents' room and placed a pulse oximeter on his finger to check his oxygen level, and it read 94%. She stated the daughter had put her personal pulse oximeter on his other hand and it was reading in the 60's. She stated she left the room to get an oxygen concentrator and called the DON to come back to the floor. She revealed when she removed the bag covering the concentrator, the knob came off and she told receptionist MM to bring her another one, from the closet downstairs. When the DON arrived on the floor, the daughter began to yell at her. She revealed after Receptionist MM arrived with another concentrator, about five minutes later, she hooked him up to the concentrator using a non-rebreather mask and turned the O2 as high as it would go. She stated shortly after that the First Responders came in and took over. She stated again that the daughter never indicated R#1 was in distress when she came out of the room yelling at her to put oxygen on him. She stated R#1's wife was visiting him and never came out and told her he started to have problems breathing. LPN CC indicated she was checking on him frequently and never saw the resident having signs or symptoms of respiratory distress. Interview on 3/30/2023 at 10:45 a.m. with the Medical Director (MD) revealed he saw the R#1 on 1/13/2023 and had a discussion with his wife regarding a swallow study, but she refused. He indicated he informed residents' wife that he was not going to improve and would eventually need comfort care/hospice. During further interview with the MD about the incident on 1/15/2023 with R#1 experiencing respiratory distress and the facility's delay in assessing and providing emergency care, the MD never responded with an answer. He responded that he had talked with his wife and offered comfort care and stated there was nothing else that could have been done for him. He stated the facility did not notify him of the residents' condition, but the NP notified him. Interview on 4/4/2023 at 11:02 a.m., LPN LL revealed each floor has a storage room where oxygen concentrators, oxygen tanks, and the crash cart are stored. Confirmation of the first floor storage room with LPN LL verified availability of oxygen concentraors and oxygen tanks. Interview on 4/4/2023 at 11:10 a.m., LPN CC revealed there is a crash cart and oxygen storage available on the second floor. Review of the crash cart and oxygen storage closet were confirmed. She confirmed she did not get the crash when R#1 went into distress, but she got an oxygen concentrator from the closet on the same floor. She indicated the knob came off the unit when she was getting it ready, and she sent a staff member to get another one from the closet. Interview 4/5/2023 at 10:00 a.m. the Administrator revealed they have a Regional Certified Respiratory Therapist (CRT) that is available 24 hours a day seven days a week via phone call. She stated the staff have the option to call the CRT if they have questions about respiratory services or equipment issues. Interview on 4/5/2023 at 12:18 p.m. with the CRT OO revealed staff are encouraged to call for residents that are in respiratory distress, or any issues with respiratory equipment, such as BiPap or CPAP machines, or any respiratory questions. She stated she visits the facility monthly for respiratory audits that include infection control, equipment checks, and training if needed. She revealed staff do not have to call the CRT, but confirmed she or another CRT are always available to the facility if needed. She stated that nobody from the facility contacted her regarding R#1 being in respiratory distress. Interview on 4/5/2023 at 1:40 p.m. the DON revealed when a resident has a change in condition she would assess the change, if the change was related to respiratory status, she would reach out to the CRT if needed. She stated the CRT information was not posted prior to today, but revealed it is now located at each nurse's desk, in the med room on each floor, and in the in-service binder located at each nurse's desk. She indicated the CRT comes to the facility quarterly and looks at all the respiratory supplies and looks at all the oxygen tanks and concentrators. The CRT will do in-services with the staff as needed.

Based on record review, staff and family interviews, the facility failed to provide respiratory care and services for one resident (R) (R#1) exhibiting signs of respiratory distress. Specifically, R#1 had a rapid decline in respiratory status and staff failed to administer oxygen in an emergent situation, resulting in resident becoming hypoxic and unresponsive. The sample size was 12 residents. On 4/4/2023, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility Administrator, Director of Nursing (DON), and the Regional Nurse Consultant were informed of the Immediate Jeopardy on 4/4/2023, at 10:07 a.m. At the time of exit on 4/6/2023, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings include: Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses including but not limited to pneumonitis due to inhalation of food, dysphagia, altered mental status, and encephalopathy. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status Score of three out of 15, indicating severe cognitive impairment. Section O-Therapies and Special Treatments revealed R#1 received respiratory therapy for five of seven days of the look back period. Review of R#1's medical record revealed on 1/15/2023 at approximately 1:30 p.m. LPN CC assessed R#1 and found there was a sudden decline in condition. R#1 was unresponsive to verbal or physical stimuli (sternal rub). The Director of Nursing (DON) was called to assess resident and found R#1 to have fluid filled lungs with a non-productive cough. Resident remained unresponsive to verbal stimuli. DON notified the Nurse Practitioner of residents decline at approximately 2:13 p.m. and received order to send resident to hospital emergency room (ER) for further evaluation. There is no evidence supplemental oxygen was applied in an emergency situation. Review of video recording provided by family member of R#1 revealed the video shows family member sitting outside of his room. The family member asked an unidentified staff member why the DON had not come back to check on him. The family member indicated she had asked for oxygen to be placed on him because his oxygen level is low. The family member used her personal pulse oximeter to check his oxygen level. At 1.32 seconds into the video, LPN CC was seen leisurely bringing in an oxygen concentrator and supplies into the room. R#1 was visible on the video and was noted to be in respiratory distress, with an audible wet cough with grunting sounds. LPN CC removed the plastic bag from the oxygen concentrator and was heard telling receptionist MM to bring her another concentrator, due to the knob coming off. She proceeded to open the oxygen supplies, without noted urgency. There was no evidence on the video that LPN CC assessed the resident nor obtained vital signs or oxygen saturation level. During the 10 minute 37 second length of the video, there was no evidence that R#1 was assessed by the DON or the LPN and if oxygen was administered. The video is not time stamped. Review of a second video recording provided by family member of R#1 revealed family member sitting outside of R#1's room. Resident could be heard on the video making grunting sounds and when family member entered room and asked him what was wrong, the resident did not respond. The length of the video was one minute 4 seconds. The video is not time stamped. Review of first responders log revealed narrative indicated emergency medical services/first responders responded to a male patient with respiratory distress. Upon arrival at the facility the family was having a dispute with the staff. Upon arrival to R#1's room, vital signs taken by the first responders revealed blood pressure (BP) 90/60, pulse 91 and regular, respirations 20 and an oxygen (O2) saturation of 79%. He was lying in bed unresponsive with a non-rebreather on. The non-rebreather bag was not inflated and not being used at the appropriate liters per minute (LPM) and the patient's oxygen (O2) saturation level was at 79%. He was immediately changed to a portable oxygen cylinder at 15 LPM and after a high concentration of O2, his O2 saturation slowly increased to 96%. First responders continued to monitor resident until an ambulance arrived. Review of the hospital Discharge Summary dated 2/3/2023 revealed R#1 presented to the emergency room (ER) brought in by EMS. Upon EMS arrival he was unresponsive, hypoxic, and hypotensive. He necessitated emergent intubation in the field. Physical exam revealed pupils are pinpoint and eyes are deviated to the right. Glasgow Coma Scale (GSC) of three. Breath sounds with rales and rhonchi present. Chest x-ray showed a right lower lobe infiltrate. Labs were consistent with dehydration. COVID-19 test was positive but not likely shedding virus. Admission condition was critical. He was unable to be extubated and received a tracheostomy on 2/1/2023 and had a feeding tube placed on 2/2/2023. His hospital course was complicated by persistent encephalopathy and sepsis. His discharge condition was serious and was discharged to a Long-Term Care Center (LTAC) on 2/3/2023 for further management and his anticipated prolonged ventilator requirements.' Interview on 3/14/2023 at 11:45 a.m. the DON revealed EMS is not fast to respond even if 911 is called. She stated she called 911 for transport, LPN CC called EMS again while the DON was talking to his family. The DON indicated the family called 911 also. She indicated oxygen tanks and concentrators are available for use on each floor. During further interview, she stated R#1 was not placed on oxygen due to resident not being in respiratory distress and his O2 saturation was 94%. Phone interview on 3/20/2023 at 11:00 a.m. with the family of R#1 complainant revealed she called her mother to check on her father due to his decline in condition and to see if he had left the facility to go to the hospital, and her mother indicated he was still there. She stated she decided to go to the facility at that time. When she arrived, she indicated that her father was exhibiting signs of difficulty breathing and she felt like her father was in respiratory distress. She stated she tried to talk to her father and all he did was moan and could not speak. She stated he was gasping for breath. She revealed she went to the door and yelled out for the nurse to come and bring him an oxygen tank. She further stated she had her personal pulse oximeter, and she checked his O2 saturation level and revealed it was low, in the 60's. During further interview, she stated she tried to get the nurses to help her father, but they were just slowly going about caring for him. She indicated the nurse finally went and got an oxygen concentrator and when she was turning it on, the knob fell off and another concentrator had to be retrieved. She stated it seemed like it took forever for another staff member to bring the nurse another concentrator to his room. She further stated she called 911 herself and told them to call the fire department and first responders to come see about her father. She informed the 911 personnel that the facility was trying to kill her father. When asked how long that took she indicated forever. She stated the nurse called the DON to come up and stated she would be there after finishing up her wound care. Phone interview on 3/28/2023 at 3:23 p.m. the spouse of R#1 revealed she felt like her husband wasn't doing well because he would not eat, drink, or wake up the day of incident. She stated the nurse called the DON and she came and listened to his lungs but did not check his vital signs. She stated the DON told her his lungs sounded wet and asked if she wanted him to go to the hospital. She stated she said yes. She revealed the DON told her she would get the paperwork ready for him to go to the hospital and that was the last she saw of her or anyone for a while. During further interview, she stated LPN CC tried to give him medications and realized he could not swallow. She stated LPN CC did not assess his condition or take his vital signs at that time. The wife stated the daughter called her shortly after that and told her he was still the same and no one has come to pick him up or come back to check on him. The wife stated she asked the DON to come back to check on him and was told she was busy doing wound care. The wife stated when the DON finally came up to his room, her daughter had arrived, and the wife indicated the DON wanted to argue with her daughter more than look at her husband. Interview on 3/29/2023 at 12:02 p.m. Certified Medication Aide (CMA) BB revealed she was assigned to the R#1 on 1/15/2023 during the day shift. She stated resident was doing fine that morning, maybe less alert, but he was talking and refusing everything like normal. She stated resident did not eat his lunch. It was after that that he had to go to the hospital. Interview on 3/29/2023 at 12:30 p.m., Licensed Practical Nurse (LPN) CC revealed the resident was at his normal baseline earlier that morning of 1/15/2023. She stated at lunchtime she went to give him some insulin and his medications when she noted the wife force feeding him, and he was not swallowing. She stated she asked residents wife to stop feeding him and removed the tray from the room and called the DON who was in the facility. She stated she went to get the vital sign equipment and pulse oximeter and took his vital signs. She stated the DON came to the room and assessed the resident and spoke with the wife about his condition. She stated the DON left the room to call the Nurse Practitioner (NP). During further interview, she stated the resident did not appear to be in respiratory distress at that time. LPN CC stated the daughter showed up and came out of the room yelling to put oxygen on her daddy. The daughter did not say or indicate the resident was in distress. LPN CC stated she went back to the residents' room and put a pulse oximeter on him, while the daughter was yelling at her. She indicated the pulse oximeter reading was 94%, but she noticed the daughter already had one on his other finger, and that reading was in the 60's. At that point, she stated she went to get an oxygen concentrator and called the DON to come back to the floor. She stated she left the room to get the supplies and another nurse brought her the oxygen concentrator. She stated when she removed the bag that covered the concentrator, the knob came off and she called for another nurse to bring her another concentrator. The DON arrived at residents' room the second time, and the daughter began to yell at her from the doorway of his room, to help her daddy. LPN CC stated another concentrator was brought to R#1's room and she set the O2 setting as high as it would go using a re-breather. LPN CC stated the daughter never said the resident was in respiratory distress when she came out of the room to tell her to put oxygen on him, residents wife was in the room the entire time never came out and told her he started to have problems breathing. During further interview, she stated the First Responders came in and took over. Interview on 3/30/2023 at 10:45 a.m., Medical Director (MD) revealed he saw R#1 on 1/13/2023 and had a discussion with R#1's wife regarding a swallow study, but stated the wife refused the study and refused for resident to get a feeding tube, due to his poor intake. He stated he informed R#1's wife that he was not going to improve and would eventually need comfort care/hospice services. During further interview, the MD indicated he was aware of residents' low hemoglobin (HGB) and indicated resident had a diagnosis of anemia, and replied his levels were low in the hospital. A follow-up interview on 4/4/2023 at 11:10 a.m., LPN CC revealed there is a crash cart and oxygen storage available on each floor. LPN CC confirmed she did not retrieve the crash when R#1 went into respiratory distress. She stated she got an oxygen concentrator from the closet, but the knob came off and she asked someone else to go get another one from the closet. Interview on 4/5/2023 at 10:00 a.m., Administrator stated they have a Regional Certified Respiratory Therapist (RCRT) that is available 24 hours per day and seven days per week via phone call. Interview on 4/5/2023 at 12:18 p.m. Certified Respiratory Therapist (CRT) OO revealed she and one other CRT are always on call. She stated staff are encouraged to call for residents that are in respiratory distress or any respiratory questions related to Bilevel positive airway pressure (BiPap) or Continuous positive airway pressure (C-pap) machines. She stated she visits the facility monthly for respiratory audits that include infection control, equipment checks, and training if needed. She stated the facility does not have any guidance on reaching out to them and stated staff are not required to call them, but they are available by phone if the facility staff need them. Interview on 4/5/2023 at 1:40 p.m., DON revealed when residents have a change in condition, she will assess the resident and if a resident has a change in respiratory condition, she stated she will reach out to the CRT. She indicated the CRT comes in quarterly and looks at all the respiratory supplies and looks at all the oxygen tanks and concentrators. She stated the CRT contact information was not posted prior to today. She indicated it is now located at each nurse's desk, in the med room on each floor and in the education, book located at each nurse's desk. Interview on 4/5/2023 at 2:52 p.m. DON and Central Division Registered Nurse (RN) EE revealed the facility does not have a policy for providing emergent care or standing orders for oxygen use in emergency situations.

Based on observations, interviews, review of the facility policy titled Medication Storage in the Care Center, the facility failed to ensure that two of four medication carts on the second floor were locked and secured when the carts were out of view of the nurse. The census was 49. Findings include: Review of the facility policy titled Medication Storage in the Care Center it noted that medications and biologicals are stored safely, securely, and properly following manufacturer's recommendation or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Observation on 6/18/22 at 1:52 p.m. on the second floor, the medication cart was observed unlocked with no nurse within eyesight. Licensed Practical Nurse (LPN) EE confirmed that the cart was unlocked. She stated that the cart was assigned to Registered Nurse (RN) DD. Observation on 6/19/22 at 9:15 a.m. upon exiting the elevator on the second floor, the medication cart was observed unlocked with no nurse within eyesight. RN CC was observed to exit a resident's room and confirmed that the medication cart was assigned to her and that she had left it unlocked. She stated that she wasn't far. Interview on 6/19/22 at 12:04 p.m. with the Director of Nursing (DON), stated that she had an in-service on 4/11/22 and it included speaking to the nurses about ensuring that the medication carts are locked, when not in use. She stated that she has had a few verbal discussions with specific nursing staff about locking the cart. During further interview, she stated her expectation is whenever the nurses are not at the cart, they push the lock button to secure the cart.

Based on record review, interviews, and review of the policy titled, Skilled Inpatient Services Reporting and Investigating Abuse, the facility failed to ensure a thorough investigation was completed for an injury of unknown origin for one resident (R) (R#21), reviewed for abuse. The facility's census was 49 residents. Findings include: Review of the policy titled, Skilled Inpatient Services Reporting and Investigating Abuse with a review date of 12/4/21 indicated Investigation and follow up: Interviews will be conducted of pertinent parties. Written signed statements from any involved parties will be obtained if possible or a witnessed, signed interview would be an appropriate alternative. Information regarding the event will be gathered from the suspect, person making accusations, patients involved, reliable patients who may have witnessed the incident, and any other persons who may have credible, pertinent information. Identify any possible conflicts between witnesses. All investigative information will be kept on a file in a secure location. All information gathered is confidential in nature. Review of the clinical record for R#21 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Significant Change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 3, which indicated severe cognitive impairment. Section G revealed resident required extensive assistance of two persons for bed mobility and transfers. Review of Nurses Note dated 3/19/22 at 11:08 a.m., written by Registered Nurse (RN) CC, revealed R#21 noted lying in bed, complaining of right lower leg pain, specifically around the ankle region. Resident states the pain becomes more intense if she attempts to move it. Affected area noted swollen, red, and bruised. There is limited range of motion (ROM) to the affected site. Review of Nurses Note dated 3/19/22 at 7:07 p.m., written by RN CC, revealed impression of right ankle x-ray as follows: 1: Acute spiral fracture through the distal fibular metaphysis /lateral malleolus, with up to 5.3 mm lateral displacement and up to 20-degree lateral angulation of the distal fracture moiety. 2: Acute nondisplaced fracture through the base of the medial malleolus Joint subluxation or dislocation seen 4: Severe diffuse osteopenia /[CONDITION(S)]. Residents' medical provider was notified of results and an order was received to transfer resident hospital for treatment. Interview on 6/18/22 at 3:59 p.m. with the Director of Nursing (DON), stated R#21 preferred to stay in bed, and had not gotten out of bed in a long time. She stated that two staff members, Certified Nursing Assistant (CNA) AA and Licensed Practical Nurse (LPN) BB, assisted resident with a transfer back into the bed, after a visit at the dental clinic. The DON stated R#21 did not complain of pain to her ankle until after being put back to bed. She stated that the fracture was believed to have occurred during the transfer, when CNA AA and LPN BB stated they heard a pop of R#21 bones during the pivot and transfer back to bed. During further interview, the DON stated that she investigated the injury, but she could not locate the file at this time. Interview on 6/18/2022 at 4:36 p.m. with CNA AA, stated there was a dental clinic that R#21 attended to get her teeth cleaned. She stated R#21 was sitting in her wheelchair, rubbing her leg, and complaining of pain and did not want to go to the dental appointment. CNA AA stated that she informed the nurse and Activity Director (AD) that resident was complaining of pain to her knee and leg. During continued interview, she stated LPN BB asked her to help assist R#21 back to the bed. She stated that the two of them transferred R#21 with the walker. CNA AA stated she told the DON that she heard R#21 bones pop/crack during the transfer, and stated her bones always make that sound when she is transferred. Telephone interview on 6/18/2022 at 5:32 p.m. with LPN BB, revealed that she and CNA AA assisted R#21 back to bed on the day of the dental clinic. She stated that the R#21 was complaining of pain to her leg prior to being assisted back to bed. During further interview, she stated she did not notice any swelling to R#21's legs or ankles during or after the transfer. Interview on 6/19/2022 at 8:16 a.m. with the Administrator, stated she spoke with R#21, and the resident told her what happened to her leg. Administrator stated that R#21's bones in her legs and shoulders make popping sounds when moved. During continued interview, the Administrator stated the facility did not obtain written investigative statements from the staff during the investigation. She stated that the DON verbally spoke with the staff on the phone during the investigation. She stated she is aware that there should have been documentation related to the investigation. During the interview with the Administrator on 6/19/22 at 8:16 a.m., the DON informed the surveyor that she did not get any statements from the staff for the investigation of R#21's ankle fracture. She provided a 1-page statement that she had written during the investigation. She further stated that she called staff on the phone and spoke to them about R#21's injury, but did not make notes. The DON further stated that usually during an investigation she would get witness statements, but she just didn't with this investigation. At the beginning of the interview with the Administrator 6/19/22 at 8:16 a.m., the DON was in the office and informed surveyor that she did not have any statements from the investigation of R#21's ankle fracture. DON provided surveyor with a 1-page statement that she had written during the investigation. She further stated that she called staff on the phone and spoke to them. DON further stated that usually during an investigation that she would get statements, but she just didn't with this investigation.

Based on observations, record review and interviews, the facility failed to ensure that one of 23 sampled residents (R) (R#37) received treatment and care in accordance with professional standards of practice related to accurate documentations of skin assessments. Findings include: Review of the clinical record for R#37 revealed the resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Significant Change Minimum Data Set (MDS) dated [DATE], revealed R#37's Brief Interview for Mental Status (BIMS) score was 3, which indicated severe cognitive impairment. Observation on 6/17/22 at 11:31 a.m., R#37 was lying in bed on her right side. Her left upper arm was observed with large lateral bruising around the circumference of her arm. Observation on 6/18/22 at 11:29 a.m., R#37 was in her room in bed on her left side. Multiple small circular dime size bruising was observed on her right upper arm. Interview on 6/18/22 at 1:27 p.m. with LPN EE, stated that she was not aware of any bruising on R#37's arms and that the Certified Nursing Assistant (CNA) should have informed the nurse if they observed any bruising during care. She stated that there was no nursing notes or shower sheets related to the resident having any bruising. Observation on 6/18/22 at 1:40 p.m., LPN EE confirmed the bruising on both R#37's arms. She stated that the bruises looked both new and old (some in the healing process). She stated that she had conducted a skin assessment on 6/16/22 and thought that she had put bruising on the skin assessment sheet. During further interview, she stated that those areas of bruising should have been reported and documented. She confirmed that she put bruising on the 5/13/22 and 5/19/22 skin assessments but not on the 6/16/22 skin assessment. Interview on 6/18/22 at 2:03 p.m. with the Director of Nursing (DON), stated if bruising is noticed on a resident during a weekly skin assessment, her expectation is that the bruising is documented thoroughly. During further interview, she stated that bruising should be reported to her so that she can do an investigation and possibly report concerns to the state if necessary. She stated that she had not been made aware of bruising on R#37. Interview on 6/18/22 at 3:40 p.m. with the DON, stated there was no policy or documentation related to Weekly Skin Assessments, but she would expect that all bruising is thoroughly documented on the skin assessments and reported to her to investigate the origin.

Based on observation, review policy titled Skilled Inpatient Services: Storage Areas and staff interview, the facility failed to discard food items in the dry storage area by expiration date. In addition, the facility failed to maintain sanitary conditions of the kitchen food slicer; failed to maintain the holding temperature of two hot foods on the steam table above 135 degrees, and one cold item below 41 degrees and failed to provide full coverage of facial hair. The census was 48 and the sample size was 24. Findings include: Review of the facility policy titled Skilled Inpatient Services: Storage Areas updated for release (MONTH) 2019, revealed the intent of the enter is to store food that maintains quality and safety. Guidelines 1 a. Items will be covered, sealed, labeled and dated appropriately. 1. During observation on 8/26/19 at 10:40 a.m., the food slicer had dried food particles on the sliding tray; in the dry storage area, one 32 ounce jar of opened pickle relish with use by date 7/20/19 and one 64 ounce bottle of opened Teriyaki sauce with use by date 8/19/19. 2. Review of the facility policy titled Skilled Inpatient Service: Personal Appearance and Conduct updated for release (MONTH) 2019, revealed the intent of the center is to establish guidelines for food service associates that promote neat appearance and appropriate conduct. Guidelines 1 a. Hair restraints: A hairnet and/or beard restraint will be worn while in the food prep, production and serving areas. During observation on 8/27/19 at 11:48 a.m., revealed three male employees, dietary aide EE, dietary aide FF and dietary aide GG, in the kitchen working with food items and serving food from tray line, wearing beard guards sitting below the lower lip and did not provide coverage to the hair on the upper lip area. Interview with Dietary Manager (DM) on 8/27/19 at 11:48 a.m., she verified the three male employees beard guard did not provide coverage for the hair above the upper lip. She stated that they are supposed to have all facial hair covered by the beard guard. 3. Review of the facility policy titled Skilled Inpatient Services: Food Preparation and Distribution updated for release (MONTH) 2019, revealed it is the intent of the center to prepare and distribute food in a manner that minimizes the risk of food-bourne illness and promotes safe food handling practices. Guidelines 3. Temperatures letter e: Ready to eat foods that require heating will reach an internal temperature of 135 degrees Farenheit (F). Letter g: Items should be placed in a shallow pan or ice bath for proper cooling. Guidelines 6. Distribution b: Tray line i. A temperature monitoring log will be maintained throughout the meal service. 1. Hot foods will be held at greater than or equal to 135 degrees F, 2. Cold foods will be held at less than or equal to 41 degrees F. During observation of steam table temps on 8/28/19 at 12:11 p.m., obtained by Dietary Cook HH and Registered Dietician DD, with facility's calibrated thermometer, temperatures were below 135 degrees Fahrenheit (F) for chopped pork chop, which was 114 degrees F. The sweet potato wedges temperature at 12:15 p.m. was 123 degrees F. The temperature for a 8 ounce glass of milk was 47 degrees F at 12:19 p.m. The RD removed the two food items from the tray line and placed them in oven to reheat to 165 degrees F. The milk was removed from the cart and placed in ice pan to chill to 41 degrees. Review of the Hot/Cold Temperature Log dated 8/28/19 for lunch service, revealed out of oven temperature for the chopped pork chop was recorded as 195 degrees F; Initial temperature at meal service was recorded as 114 degrees F; Mid meal service temperature was recorded as 196 degrees F; and End of meal service temperature was recorded as 193 degrees F. The out of oven temperature for the sweet potato wedges was recorded as 199.6 degrees; the Initial temperature at meal service was recorded as 114 degrees F; Mid meal service temperature was recorded as 199 degrees F; and the End meal service temperature was recorded as 193 degrees F. There was no recording for the recheck temperature for the milk.

Based on observation, record review, review of the policy titled Patient's Plan of Care and staff interview the facility failed to develop a person centered care plan for three residents (R) #41, R#48 and R#64 related to weight gain and notifying Physician of weight gain; also failed to develop care plan for R#41 for [MEDICAL CONDITION] and R#48 for specific fluid restriction parameters. The sample size was 24. Findings include: Review of the facility policy updated (MONTH) 2013, indicated the facility intent is to develop and maintain an individualized plan of care for each patient. Procedural Guidelines 2. The care plan is developed from the patient assessment (MDS) and in coordination with the attending Physician's regimen of care. 3. The plan of care is available for use by all personal providing care/services for the patient. 3 e. Identify the professional services that are responsible for each element of care. 5. Care plans are revised as changes on the patient's condition dictates. 1. A review of the clinical record for R #41 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. fracture of right femur. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 9, which indicated mild cognitive impairment. Review of Physician's Order dated 7/31/19 revealed an order for [REDACTED]. Review of residents care plan initiated 8/9/19 revealed there was no indication that nursing staff had developed or implemented specific goals with interventions to address the residents [DIAGNOSES REDACTED]. Further review of R#41 care plan had no indication of developement and/or implementaion for contact isolation for stool specimen positive for [MEDICAL CONDITION]. 2. A review of the clinical record for R #48 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 3, which indicated severe cognitive impairment. Review of Physician's Order dated 8/21/19 revealed an order for [REDACTED]. Review of residents care plan initiated 7/10/19 revealed there was no indication that nursing staff had developed or implemented specific goals with interventions to address the residents [DIAGNOSES REDACTED]. Further review of R#41 care plan had no indication that contact isolation had been followed for stool specimen positive for [MEDICAL CONDITION]. Record review of the Nurses Notes for R#48 revealed there was no documentation that the Physician had been notifed of the resident weight gain. An interview on 8/29/19 at 10:54 a.m., with Licensed Practical Nurse (LPN) AA revealed that the night shift nurses are responsible for obtaining weights and to make the notification to the Physician, regarding weight gain. She verified that their was no documentation in the electronic medical record (EMR) pertaining to notifying the Physician of residents weight gain. During further interview, she stated that she does not update resident care plans with changes in condition; the Minimum Data Set (MDS) nurses do the updates. Interview on 8/29/19 at 11:15 a.m., with Minimum Data Set (MDS) Coordinator, revealed that the admitting nurses initiate the baseline care plan on admission. She stated they complete the comprehensive assessment by day eight which includes the review of medical records, all assessments, interviews with staff and face to face assessments with residents, to generate the care plan areas of concern. She stated that they don't necessarily put every piece of information in the residents care plan, pertaining to weight gain and notification of Physician. She further revealed that if it is on the Physician Orders she did not feel like it should be on the care plan. Additional interview on 8/29/19 at 11:38 a.m., with MDS Director, revealed that the care plan for R#41 for weights and notifying Physician of weight gain greater than three pounds, was overlooked by her. She verified that the comprehensive care plan dated 8/3/19 did not address the resident weight status or the order to notify Physician for weight gain of three pounds or more. She stated for the [DIAGNOSES REDACTED]. Interview on 8/29/19 at 1:47 p.m., with Nurse Consultant BB revealed that the facility could not find any notifications to Physician in the EMR for R#41 and R#48 weight gain of greater than three (3) pounds. Cross refer F 684 3. Review of medical record revealed that R#64 had the following [DIAGNOSES REDACTED]. Review of the weights for R#64 revealed weight gain on 4/8/19 from 179.4 to 190.5 for a 11.1 pound weight gain; 5/2/19 from 171.5 to 178.4, for a 6.9 pound weight gain; 5/27/19 from 178.0 to 186.2, for a 8.2 pound weight gain; and 6/13/19 from 172.3 to 186.2, for a 13.9 pound weight gain. Review of the care plan dated 2/9/18, reviewed and continued 5/17/19, for R#64 revealed an intervention that stated that nursing staff should monitor for [MEDICAL CONDITION], and report to the Physician as indicated. An interview on 8/29/19 at 1:50 p.m. with Licensed Practical Nurse (LPN) BB confirmed there was no notification of weight gain, or change in weight, in the medical record or that the Physician had been notified of the resident's weight gain An interview on 8/29/19 at 3:05 p.m. with the resident's Physician revealed he didn't recall receiving any reports of weight gain in R#64 and that he should have been notified of the resident's weight gain. He further revealed that staff should follow the his orders to be notified. Cross refer to F684

Based on observation, record review, review of the policy titled titled Skilled Inpatient Services: Changes in a Patient's Condition and staff interview the facility failed to follow Physician order for [REDACTED]. Findings include: Review of the facility policy titled Skilled Inpatient Services: Changes in a Patient's Condition updated for release (MONTH) 2019, revealed the intent of the center is to notify the patients, his/her attending Physician and responsible party/patient representative of changes ion the patients condition and/or status. Procedural guidelines 5. Changes in the patient's medical condition should be properly recorded in the patient's medical record. 1. A review of the clinical record for R #41 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. fracture of right femur. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 9, which indicated mild cognitive impairment. Review of Physician's Order dated 7/31/19 revealed an order for [REDACTED]. Review of Medication Administration Record [REDACTED]. 2. A review of the clinical record for R #48 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 3, which indicated severe cognitive impairment. Review of Physician's Order dated 8/21/19 reveal an order for [REDACTED]. Review of Medication Administration Record [REDACTED]. Interview on 8/29/19 at 1:47 p.m., with Director of Nursing (DON) with Nurse Consultant BB present, stated it is her expectation that staff should follow all Physician Orders, as they are written. Interview on 8/29/19 at 2:59 p.m., with Medical Doctor II, stated he expects the facility to follow the orders that he writes. He also said, that if he had been notified about a weight gain, he would have wanted to know if the resident was symptomatic and ask them to reweigh the resident. He stated that he does not recall if he was notified about residents weight gain in this facility, 3. A review of the clinical record for R#68 revealed [DIAGNOSES REDACTED]. Observations on 8/27/19 at 2:21 p.m.and 3:53 p.m., 8/28/19 at 9:15 a.m. and 3:00 p.m., and 8/29/19 at 8:15 a.m., revealed resident sitting in wheelchair in different locations around facility, including her room, common area on her wing, in hallway, and in Resident Council review meeting, with legs hanging down each time, and visible [MEDICAL CONDITION] in lower legs and feet. The resident's most recent comprehensive Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated no cognitive impairment. Section N revealed that the resident received diuretics seven out of seven days. Review of the Physician order for [REDACTED]. Additional Physician Orders included, but not limited to, [MEDICATION NAME] daily for [MEDICAL CONDITION]; [MEDICATION NAME] twice a day (bid) for [MEDICAL CONDITION]; [MEDICATION NAME] bid for [MEDICAL CONDITION]; [MEDICATION NAME] bid for hypertension; Potassium chloride daily for supplement; Eliquis bid for [MEDICAL CONDITION]; [MEDICATION NAME] for agitation. Review of Physician Order dated 4/8/19 revealed for (MONTH) 2019 to (MONTH) 2019 the resident was on two different diuretics which included: [MEDICATION NAME] 0.5 milligram (mg) daily (a diuretic), and was increased to 1.0 mg daily on 8/13/19 for [MEDICAL CONDITION]. A Physician Order dated 6/17/19 [MEDICATION NAME] 20 mg two tablets daily for five days, for [MEDICAL CONDITION]. A Physician Order dated 6/30/19 [MEDICATION NAME] 20 mg twice daily (bid) for three days, for [MEDICAL CONDITION]. A Physician Order dated 7/11/19 to 8/9/19 for [MEDICATION NAME] 40 mg bid for [MEDICAL CONDITION]. Review of physician progress notes [REDACTED].#64 and documented the resident had reported to him legs swollen and red for three days, so bad she was unable to wear her stockings. Resident was instructed to elevate legs above heart level. [MEDICATION NAME] was increased for five days. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Between 5/23/19 and 5/27/19 the resident had a eight pound weight gain. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of nurse progress notes revealed there was no documentation that the Physician was notified, a physical assessment was done, or a change of condition (C[NAME]) assessment was done, related to weight gain of greater than three (3) pounds (lbs). An interview on 8/29/19 at 1:50 p.m. with Licensed Practical Nurse BB confirmed there was no notification of the Physician for weight gain in the medical record. An interview on 8/29/19 at 3:05 p.m. with the resident's Physician revealed he was not aware weight gain of three or greater pounds. The Physician further revealed that he did weights to control fluid shift in residents with congested heart failure, or localized [MEDICAL CONDITION], and it needed the weights monitorrd. If there was a large weight difference, he expected staff to reweigh the resident, do a physical assessment, assess them for increased [MEDICAL CONDITION], shortness of breath, difficulty breathing, and fatigue, especially shortness of breath. If they had notified him then he would have asked if the resident was symptomatic. An interview with the Administrator on 8/29/19 at 4:03 p.m. revealed that all staff should follow the Physician Orders.

Based on observation, record review, policy review and staff interview, the facility failed to document behavior monitoring and medication side effects for one resident (R) R#28, who was receiving [MEDICAL CONDITION] medications. The sample size was 15. Findings include: A review of the clinical record for R#26 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicates no cognitive impairment. Review of the Physicians Orders revealed an order for [REDACTED]. Review of Comprehensive Minimum (MDS) data set [DATE] revealed that she received antianxiety and antidepressant medications all seven days of the assessment period. Review of Care plan initiated 4/06/18 revealed resident at risk for depression due to changes in functional mobility and decline in independence with ADL's (activities of daily living). Approaches include administer medications as ordered and monitor for adverse effects, monitor for signs of depression such as crying, withdrawal, changes in appetite, changes in mood or behavior and report to MD as indicated. Resident receives antidepressant medication for management of depression. At risk for adverse effects to medications. Approaches include to monitor for and document behaviors and frequency. Resident receives anxiolytic medication for management ofanxiety. At risk for adverse side effects to medications. Approaches include monitor for and document behaviors and frequency. Review of facility policy titled [MEDICAL CONDITION] Medications revealed the intent is for patients who receive antipsychotic, anxiolytic, sedative, hypnotic, antidepressant or any other medications to modify behaviors are evaluated to determine the effectiveness of the medications for the identified problem. Procedural guidelines indicate that when [MEDICAL CONDITION] therapy is initiated, the patient is monitored quantitatively and qualitatively to determine the effectiveness of the medication and the presence of side effects. Review of electronic medical record (EMar) for the month of (MONTH) (YEAR), revealed no evidence that behavior monitoring was documented for the period of (MONTH) 22, (YEAR) through (MONTH) 29, (YEAR) for [MEDICATION NAME]; and for the period of (MONTH) 17, (YEAR) through (MONTH) 29, (YEAR) for [MEDICATION NAME]. Interview on 5/31/18 at 1:25 p.m., with Certified Nursing Assistant (CNA) BB stated resident has good days and bad days, diabetes affects her moods, she has crying spells but no outbursts and no bad acting out episodes. Interview on 6/1/18 at 10:49 a.m., with Licensed Practical Nurse (LPN) CC stated resident has not exhibited any behaviors, but she stated she does document behaviors in the computer. Interview on 6/1/18 at 11:24 a.m., with Director of Nursing (DON) stated that when resident went to the hospital on [DATE] and was readmitted to facility on 5/17/18, the [MEDICAL CONDITION] medications were not linked to the behavior monitoring and it was not noticed by facility staff until 5/19/18. The DON confirmed that the behavioral and side effect monitoring were missing during this timeframe.