Every finding on record at Harvard Rest Haven

Licensure Reference Number 175 NAC 12-006.05(E)Based on record review and interview the facility failed to inform the resident/resident representative of the benefits, risks, and alternatives prior to the initiation of psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) for 3 of 5 residents (Residents 14, 2, and 7). The facility census was 23.Findings are:A. Record review of the facility policy titled Use of Psychotropic Medications dated 3/11/25 revealed that it is the intent to ensure that residents only receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated. Psychotropic medications are to be used only when a practitioner determines that the medications are appropriate to treat a resident's specific, diagnosed, and documented conditional and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medications. The resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings prior to initiating or increasing a psychotropic medication. B. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 14 dated 12/11/25 revealed that Resident 14 admitted into the facility on [DATE]. The MDS revealed that Resident 14 took antipsychotic (a psychotropic medication used to manage psychotic disorders), antianxiety, and antidepressant medications since admission into the facility. Diagnoses included anxiety, bipolar disorder, and depression. Record review of the Medication Administration Record (MAR) (a legal record of the medications administered to a resident at a facility by a health care professional) for the month of November 2025 for Resident 14 revealed that Resident 14 was administered Clonazepam 1 milligram (mg) (a psychotropic medication for anxiety) for anxiety disorder on 11/28/25, 11/29/25, and 11/30/25. Resident 14 was administered Quetiapine 50mg at bedtime (an antipsychotic medication for bipolar disorder) for bipolar disorder on 11/28/25, 11/29/25, and 11/30/25. Resident 14 was administered Sertraline 25mg (a psychotic medication for depression) for depression on 11/29/25 and 11/30/25. Record review of the medical record for Resident 14 revealed no consent or education provided to Resident 14 prior to the initiation/administration of the psychotropic medications Clonazepam, Quetiapine, and Sertraline. Record review of the Consent for Use of Psychoactive Medication Therapy dated 3/11/26 (3 months and 11 days after the resident admitted into the facility) for Resident 14 revealed that psychotropic medications ordered were Seroquel (Quetiapine), Zoloft (Sertraline), and Clonazepam. The consent listed target behaviors for which the medication was ordered as depression, rejection of cares. The section titled Clinical side effects or risks associated with the medication revealed that antipsychotic, antidepressant, and antianxiety were checked. The section revealed that many antipsychotic medications contain additional warnings such as increased mortality (death) in elderly patients with dementia-related psychosis. The section titled Specific condition to be treated revealed that depression was checked. The box for bipolar disorder was not checked. The box titled Other was checked and handwritten next to it was Used for with no clarification of what the other condition was. The consent form contained no information related to alternate treatment alternatives. Interview on 5/26/26 at 4:45 PM with the Facility Administrator (FA) confirmed that the facility did not complete a psychoactive consent for Resident 14's sertraline, quetiapine, or clonazepam until 3/11/26. The FA confirmed that the facility did not have a consent for the use of psychoactive medications prior to administering the medications to Resident 14. Interview on 5/27/26 at 1:25 PM with the FA confirmed that the consent for psychoactive medications for Resident 14 dated 3/11/26 did not address educating the resident/resident representative on alternate treatments and non-pharmacological interventions as required. The FA revealed that the form needed to be modified to include that education to the resident. C. Record review of an admission Record revealed that the facility admitted Resident 7 on 02/13/2026 with diagnosis of Bipolar Disorder(a mental health condition that causes extreme emotional highs and lows) and Schizophrenia (a severe chronic brain disorder that impairs how and individual interprets reality). Record review of the comprehensive MDS dated [DATE] for Resident 7 revealed coding to reflect that Resident 7 received an antipsychotic (a psychotropic medication used to treat or manage psychosis, schizophrenia, bipolar disorder, and severe agitation)medication, an antianxiety (a psychotropic medication used to treat or manage anxiety) medication, and an antidepressant (a psychotropic medication used to treat or manage major depressive disorder, anxiety, PTSD and chronic pain) medication during the 7 day look back period for the assessment. Record review of Resident 7's Medication Administration Record for the Month of February 2026 revealed documentation that Resident 7 was administered Citalopram (an antidepressant medication)10 milligrams every day, Paliperidone (an antipsychotic medication) 6 milligrams every day, Quetiepine (an antipsychotic medication) 25 milligrams on 02/14/2026, 02/18/2026, 02/23/2026, and 02/27/2026, and Trazadone (an antidepressant medication) 100 milligrams on 02/14/2026, 02/18/2026, 02/23/2026, and 02/27/2026. Record review of a facility document titled Consent for use of Psychoactive Medication Therapy and dated 02/26/2026 revealed in the area titled Psychotropic Medication Ordered Elavil (an antidepressant medication), Citalopram (an antidepressant medication), Seroquel (an antipsychotic medication), Trazodone (an antidepressant medication), and Paliperidone (an antipsychotic medication) listed. The form listed the target behavior for which the medications were ordered as Depression. The form listed the clinical side effects or risks associated with the medications. The resident's legal representative consented to the use of the medications as listed and signed and dated the form on 03/04/2026. This was 19 days after the resident was admitted to the facility and the facility started administering the residents' medications. The form did not list the benefits to the use of the medication, the alternative treatment options or choices, and or the specific targeted behaviors for the use of the medications. In an interview conducted on 05/26/2026 at 10:14 AM with the ADON, the ADON stated that the facility had identified that they were not completing the facilities Psychoactive Medication Therapy form prior to the residents receiving the medication in the facility. The ADON confirmed that the form that the facility was using did not address the benefits to using the medications and the targeted behaviors that the medication was being used for or the alternative treatment options to be attempted and should. The ADON confirmed that the form for Resident 17 was not completed at the correct time and did not contain all the information needed. D.Record review of Resident 2's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 05/16/2026 revealed an admission date of 02/06/2026. The high-risk medications (specific drug classes identified that carry a high risk of causing significant patient harm, adverse effects, or mortality if misused) identified on the MDS were Sertraline (a medication used for depression), Eliquis (a prescription blood thinner), and Aspirin (a medication used to keep platelets from sticking together). Record review of the Order Summary Report revealed the high-risk mediations that were ordered on admission as of 02/06/2026 were Aripiprazole (used to treat mental health and mood condition), which was not noted on the MDS or on the psychoactive consent, Aspirin, Plavix, and Sertraline. Record review of the Order Summary Report revealed the high-risk medications that were active as of 05/21/2026 were Aspirin, Plavix, and Sertraline. Record review of facility policy titled the Use of Psychotropic Medication(s) dated 03/11/2025 revealed that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives, for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. Record review revealed the Psychoactive Medication Therapy consent was dated and signed on 03/07/2026 by the residents Power of Attorney (POA- a trusted person to make decisions or act on behalf of someone else) and date and signed on 03/11/2026 by the Facility Administrator (FA). There were no noted benefits or alternatives on the consent. An interview with the Assistant Director of Nursing (ADON) and the Interim Director of Nursing (Interim DON) on 05/26/2026 at 10:14 AM revealed there were identified concerns with Psychotropic Consents not completed. The ADON confirmed that the consent should be completed on admission for all residents with medications that are appropriate. The ADON confirmed that original consent on admission for Resident 2 was not completed and then confirmed that there was no psychotropic (the Aripiprazole) checked on the consent.

Licensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview, the facility failed to code the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 3 of 3 sampled residents (Resident 5, Resident 7, and Resident 17) to accurately reflect the medications provided. The facility census was 23.Findings are:Record review of a facility policy titled Conducting and Accurate Resident Assessment and dated 03/11/2025 revealed that all residents were to receive an accurate assessment reflective of the resident's status at the time of the assessment.A.Record review of Resident 5's Comprehensive MDS dated [DATE] revealed Section N0300 Injections was coded to reflect that Resident 5 received one injection during the look back period (the 7 days prior to the assessment reference date of 04/27/2026).Record review of Resident 5's Physician Orders for the month of April 2026 revealed that Resident 5 did not have physician orders to receive any injectable medications or injections during the month of April 2027.Record review of Resident 5's Medication Administration Record (MAR) for the Month of April 2026 revealed no documentation reflecting the resident received an injection or injectable medication during the look back period for the Comprehensive MDS dated [DATE].Record review of Resident 5's Treatment Administration Record (TAR) for the Month of April 2026 revealed no documentation reflecting the resident received an injection or injectable medication during the look back period for the Comprehensive MDS dated [DATE].Record review of Resident 5's Progress Notes for the Month of April 2026 revealed no documentation reflecting the resident received an injection or injectable medication during the during the look back period for the Comprehensive MDS dated [DATE].In an interview completed on 05/26/2026 at 4:05 PM with the facility Assistant Director of Nursing (ADON), the ADON confirmed that Resident 5 did not receive an injection or injectable medication during the look back period for the Comprehensive MDS dated [DATE]. The ADON, who also acts as the MDS Coordinator and is responsible for coding the MDS confirmed that the MDS for Resident 5 dated 04/27/2026 was coded incorrectly.In an interview completed on 05/26/2026 at 4:05 PM with the facility Interim Director of Nursing (IDON) the IDON confirmed that Resident 5's MDS dated [DATE] was not coded correctly.B.Record review of Resident 7's Comprehensive MDS dated [DATE] revealed in section N0415 High risk Drug Classes letter K Anticonvulsant medication was coded to reflect that the resident did not receive an anticonvulsant medication during the look back period (the 7 days prior to the assessment reference date of 02/26/2026).Record review or Resident 7's Physician Orders for the month of February 2026 revealed Resident 7 had orders to receive Lamotrigine (an anticonvulsant medication) 225 milligrams twice a day every day, Levetiracetam (an anticonvulsant medication) 250 milligrams twice a day every day,Record review or Resident 7's MAR for the month of February 2026 revealed documentation that Resident 7 was administered Lamotrigine 225 milligrams twice a day every day and Levetiracetam 250 milligrams twice a day every day during the look back period for the Comprehensive MDS dated [DATE].In an interview completed on 05/26/2026 at 4:05 PM with the facility ADON, the ADON confirmed that Resident 7 did receive the Lamotrigine and Levetiracetam which were anticonvulsant medications as ordered twice daily during the look back period. The ADON confirmed that the Comprehensive MDS dated [DATE] was coded incorrectly.In an interview completed on 05/26/2026 at 4:05 PM with the facility IDON, the IDON confirmed that Resident 7's MDS dated [DATE] was not coded correctly.C.Record review of Resident 17's Quarterly MDS dated [DATE] revealed in section N0415 High risk Drug Classes letter K Anticonvulsant medication was coded to reflect that the resident did not receive an anticonvulsant medication during the look back period (the 7 days prior to the assessment reference date of 05/19/2026).Record review or Resident 17's Physician Orders for the month of May 2026 revealed Resident 17 had orders to receive Gabapentin (an anticonvulsant medication) 800 milligrams three times daily.Record review or Resident 17's MAR for the month of May 2026 revealed documentation that Resident 17 was administered Gabapentin 800 milligrams three times daily every day during the look back period for the Quarterly MDS dated [DATE].In an interview completed on 05/26/2026 at 4:05 PM with the facility ADON, the ADON confirmed that Resident 17 did receive the Gabapentin 800 milligrams three times daily every day during the look back period for the Quarterly MDS dated [DATE]. The ADON confirmed that the Quarterly MDS dated [DATE] was coded incorrectly.In an interview completed on 05/26/2026 at 4:05 PM with the facility IDON, the IDON confirmed that Resident 17's MDS dated [DATE] was not coded correctly.

Licensure Reference Number 175 NAC 12-006.09(E)(i) Based on record review and interview the facility failed to develop a comprehensive care plan for identified resident care needs for 1 residents (Resident 7 ) of 8 sampled residents. The facility census was 23. Findings are: A. Record review of a facility policy titled Comprehensive Care Plans and dated 03/11/2025 revealed it was the policy of the facility to develop and implement a Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) person centered care plan for each resident that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment and meet professional standards of quality. All care assessment areas triggered by the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) will be considered in developing the plan of care. Record review of an admission Record revealed that the facility admitted Resident 7 on 02/13/2026 with diagnosis of Bipolar Disorder (a mental health condition that causes extreme emotional highs and lows) and Schizophrenia (a severe chronic brain disorder that impairs how and individual interprets reality). Record review of the comprehensive MDS dated [DATE] for Resident 7 revealed coding to reflect that Resident 7 received an antipsychotic (a psychotropic medication used to treat or manage psychosis, schizophrenia, bipolar disorder, and severe agitation)medication, an antianxiety (a psychotropic medication used to treat or manage anxiety) medication, and an antidepressant (a psychotropic medication used to treat or manage major depressive disorder, anxiety, PTSD and chronic pain) medication during the 7 day look back period for the assessment. Record review of Resident 7's Care Plan on 05/26/2027 revealed a Focus of the resident was at risk for adverse reactions due to the daily use of antipsychotic medications due to mental illness dated 03/03/2026. Interventions were listed to discuss with the resident and family the number and type of medications the resident was taking and the potential for drug interactions and side effects, if the resident had more than one prescribing provider to ensure that each provider had the full list of the residents medications available, to monitor the resident for possible signs and symptoms of adverse drug reactions, to request that the residents provider review and evaluate the residents medications, and for the pharmacy consultants recommendations be reviewed. Resident 7's Care Plan did not address the residents use of antidepressant and anti-anxiety medications. The residents Care Plan did not address the resident's diagnosis of Schizophrenia and risks to the resident and interventions for the plan of care for the resident due to this diagnosis. In an interview completed on 05/26/2027 at 10:15 AM with the ADON, the ADON confirmed that Resident 17 had a diagnosis of Schizophrenia, and was receiving antidepressant medications. The ADON confirmed that Resident 17's Care Plan did not address the residents diagnosis of Schizophrenia and or the care needs of the resident due to this diagnosis. The ADON confirmed that the residents Care Plan did not address the residents use of the antidepressant medication and the risks to the resident due to taking this medication. The ADON confirmed that the care needed to be provided for the resident due to these things should be covered in the residents Care Plan and was not.In an interview completed on 05/26/2027 at 10:15 AM with the facility Interim Director of Nursing (IDON), the IDON confirmed that Resident 17's Care Plan was not comprehensively completed to identify the care needs of Resident 17 and should be.

Licensure Reference Number 175 NAC 12-006.12(D)(i)Based on observation, interview, and record review the facility failed to ensure expired insulin was disposed of and not being utilized for 1 (Resident 16) of 4 sampled residents. The facility census was 23.Findings are:Record review of a document titled Lantus and dated 2022 revealed to discard the Lantus vial 28 days after opening or the first use. In an observation completed on [DATE] at 11:30 AM of the small refrigerator located in the locked medication storage room revealed the following:-An opened vial labeled Lantus and Resident 16's name was being stored in a bin on the top shelf of the refrigerator. The vial had a white label on it written on the label was an expiration date/discard date of [DATE]. In an interview completed on [DATE] at 11:30 AM with Registered Nurse A (RN)-A, RN-A confirmed that all opened insulin should be discarded 28 days after opening and the open or discard date is written on the insulin at the time it is opened. The RN confirmed that the Lantus insulin vial for Resident 16 had an expiration/discard date of [DATE] and should have been discarded on that date. The RN confirmed that the insulin was expired for Resident 16. In an interview completed on [DATE] at 12:15 with the facility Interim Director of Nursing (IDON), the IDON confirmed that Resident 16's vial of Lantus insulin was expired and should not be being used and should have been discarded on [DATE].

Licensure reference number 175 NAC 12-006.05(B) Based on record review and interview, the facility failed to ensure 1 resident (Resident 32) out of 3 residents sampled, signed a SNF (Skilled Nursing Facility) ABN (Advanced Beneficiary Notice) and NOMNOC (Notice of Medicare Non-Coverage) prior to when the facility determined services would no longer qualify as covered under Medicare. The facility census was 23. Findings are:Record review of the undated Harvard Rest Haven admission Agreement revealed a resident was notified if the resident utilized Medicare Part A SNF benefits, the facility would bill Medicare for covered services. When eligibility had been determined retroactively, the facility would return all payments made by the resident, or by any person on the resident's behalf, for services covered by Medicare. If facility did not believe that Medicare would pay because the resident did not require a Medicare Part A SNF level of care, the facility would provide the NOMNOC indicating the reason the resident's stay would not be paid by Medicare and that the resident would be responsible for any financial cost incurred during the continued stay. Record review revealed that the Utilization Review Committee (UR- a committee that evaluated the appropriateness, medical necessity, and efficiency of healthcare services provided to residents. The multidisciplinary team ensured residents received the correct level of care while managing costs and optimizing facility resources) met on 03/05/2026 and determined that Resident 32's last covered day (LCD- the final calendar day that Medicare paid for an individual's SNF care and after which the resident was responsible for out-of-pocket costs) was on 03/07/2026. There was no documentation that the resident or the resident representative was informed of the date at that time. Record review revealed that Resident 32's SNF ABN (a form that informed patients that Medicare may deny coverage for items or services and required the patient to assume financial responsibility if they chose to proceed) was provided to the resident and signed on 03/09/2026. Record review revealed that Resident 32's NOMNOC (a form given to patients who used Medicare covered services when covered care was ending and explained how to file an expedited appeal if they disagreed with the discharge) was provided to the resident and signed on 03/09/2026. An interview with the Social Services Director (SSD) on 05/26/2026 at 9:30 AM confirmed Resident 32 signed the SNF ABN and NOMNOC after the LCD and the date the resident was to pay out of pocket.

Based on record reviews and interview, the facility failed to notify the ombudsman (a state official who advocates and protects the rights, health, safety, and welfare of individuals residing in nursing facilities) of a resident discharge for 1 (Resident 28) of 1 resident reviewed as required. The facility census was 23. Findings are:Record review of the discharge Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities) for Resident 28 dated 04/14/2026 revealed that they admitted to the facility on [DATE]. Per the MDS, the resident had a discharge date of 04/14/2026. Record review of the ombudsman notifications sent and dated 03/11/2026, 04/03/2026, and 05/06/2026, there was no record of notification that the ombudsman was notified of Resident 28's discharge. The record of notifications indicated that the ombudsman is notified only of hospital transfers. An interview with the Social Services Director (SSD) on 05/26/2026 at 12:56 PM revealed that there was no notification to the ombudsman for the discharge of Resident 28. They confirmed that they only notified the ombudsman of hospital transfers and they did not notify the ombudsman for discharges to home or transfers to other nursing facilities.

Licensure Reference Number 175 NAC 12-006.10Based on observation, record review, and interview the facility failed staff failed to administer insulin per manufacturer direction for 2 residents (Resident 10 and Resident 6) of 2 sampled residents. The facility census was 23.Findings are:A.Record review of a document titled Injection FlexPen dated 02/2023 revealed to keep the needle in the skin for at least 6 seconds keeping the push button pressed all the way to ensure that the full dose of insulin has been administered. In an observation completed on 05/21/2026 from 11:05 AM through 11:30 AM the following was observed during insulin administration by Registered Nurse A (RN)-A the following was observed:A. With gloved hands RN-A used an alcohol wipe to wipe the tip of the insulin pen for 30 seconds and then applied a needle cap to the insulin pen. With the needle cap applied the RN turned the dosage dial to 2 and depressed the push button on the opposite end of the insulin pen releasing the dialed amount of insulin into the needle cap. RN -A then turned the dosage dial to 4 units took the prepared insulin pen to Resident 10 and explained to the resident the procedure about to complete of administering the resident's prescribed insulin. The resident exposed their left arm indicating to the RN the placement of the insulin. The RN used an alcohol wipe to cleanse and area to the back of the residents' arm and then applied the needle end of the insulin pen into the residents skin. The RN then depressed the push button end of the insulin pen injecting the dialed dose of insulin into the residents arm. RN-A then immediately removed the needle from the residents abdomen, thanked the resident and returned to the Medication room. The RN did not hold the insulin pen in place.B. With gloved hands the RN used an alcohol wipe to wipe the tip of the insulin pen for 30 seconds and then applied a needle cap to the insulin pen. With the needle cap applied the RN turned the dosage dial to 2 and depressed the push button on the opposite end of the insulin pen releasing the dialed amount of insulin into the needle cap. RN-A then turned the dosage dial to 6 units took the prepared insulin pen to Resident 6 and explained to the resident the procedure about to complete of administering the resident's prescribed insulin. The RN used an alcohol wipe to wipe a section of the residents abdomen, removed the protective cap from the needle end of the insulin pen, placed the needle into the cleansed area of the resident's abdomen and depressed the push button releasing the dialed dosage of insulin into resident 6's abdomen. The RN then immediately removed the needle from the resident's abdomen thanked the resident and returned to the Medication room. The RN did not hold the insulin pen in place for 6 seconds. In an interview conducted on 05/21/2026 at 11:30 AM with RN-A, RN-A stated that they were unaware that it was the manufacturer instruction for administration of insulin using a pen device to hold the device in place for 6 seconds with the push button depressed to ensure the full dose of insulin was administered.In an interview conducted on 05/21/2026 at 11:50 AM with the facility Interim Director of Nursing (IDON), the IDON stated that the facility did not have a policy or procedure for insulin administration using an insulin pend should ensuring that insulin administration using an insulin pen was performed correctly ensuring that residents received the prescribed dose of insulin. In an interview conducted on 05/21/2026 at 12:02 PM with RN-A, RN-A stated that they had looked up the manufacturer instructions for administration of insulin using the FlexPen and confirmed that the pen should have been held in place for 6 seconds ensuring the prescribed dose of insulin was administered to the resident. The RN confirmed that they did not hold the needle in place as outlined in the manufacturer's instructions for use.

Licensure reference number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, record review, and interview, the facility staff failed to change the oxygen (O2) tubing as ordered for 1 (Resident 2) of 1 resident sampled. The facility census was 23. Findings are: Record review of the facility Policy and Procedure: Oxygen Administration dated 02/26/2023 revealed that the oxygen tubing would be replaced every two weeks by nursing staff. When oxygen was not in use, the tubing should be placed in the mesh bag provided. Record review of Resident 2's Order Summary dated 05/21/2026 revealed an order to change the O2 tubing on night shift every 14 days. Record review of the Administration Record dated 05/26/2026 revealed that the oxygen tubing was changed on 05/15/2026. An observation on 05/20/2026 at 10:41 AM revealed the O2 tubing on the concentrator was loose, not in the mesh bag but off the floor, and dated 05/08/2026 on the tubing. An observation on 05/20/2026 at 1:05 PM revealed the O2 tubing in the mesh bag and dated 05/08/2026 on the tubing. An observation on 05/21/2026 at 7:44 AM revealed the O2 tubing on the concentrator was loose, not in the bag but off the floor, and dated 05/08/2026. An observation on 05/26/2026 at 8:45 AM revealed the O2 tubing in the mesh bag and dated 05/08/2026 on the tubing. An observation on 05/27/2026 at 8:00 AM revealed the O2 tubing in the mesh bag and dated 05/26/2026 on the tubing. An interview with the Assistant Director of Nursing (ADON) and the Interim Director of Nursing (Interim DON) on 05/26/2026 at 10:14 AM confirmed the expectation of the O2 tubing is that the tubing should be in a mesh bag and that the tubing should be changed every 14 days. The ADON confirmed that according to the Administration Record, Resident 2's O2 tubing was changed on 05/15/2026. The ADON visually confirmed that Resident 2's O2 tubing in the room was dated 05/08/2026.

Licensure reference number 175 NAC 12-006.04(B)(i)(ii)(1) Based on record reviews and interviews, the facility failed to ensure 12 hours of ongoing training per year was completed for 3 of 5 Medication Aides (MA) and Nursing Assistants (NA) reviewed. The facility census was 23. Findings are: Record review of facility in-service training for Medication Aide-E (MA-E) revealed that they only completed 8.5 hours of continuing education from 04/12/2025-04/12/2026. Record review of facility in-service training for Medication Aide-F (MA-F) revealed that they only completed 6.4 hours of continuing education from 05/13/2025-05/13/2026. Record review of facility in-service training for Medication Aide-G (MA-G) revealed that they only completed 9.5 hours of continuing education from 08/26/2025-08/26/2026. An interview with the Infection Prevention Nurse (IP nurse) on 05/26/2026 at 1:50 PM confirmed that multiple staff members are not up to date on appropriate continuing education hours including the staff members listed.

Licensure Reference Number 175 NAC 12-006.09(B) Based on observation, record review and interviews the facility failed to ensure the accuracy of the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 1 (Resident 13) of 8 sampled residents related to Continuous Positive Airway Pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while one sleeps) and oxygen use. The facility census was 19. Findings are: A record review of the facility's Guidelines for Resident Care/Provision of Care and Services with the date revised on 7/9/24 revealed: -The facility will use its state-specified RAI manual for guidance with MDS process and care planning. Annual and quarterly assessments completed as guidelines indicate. -All residents will be evaluated upon admission to the facility to determine physical, mental, psychosocial and restorative needs through nursing assessments. Physician orders for Nursing Care are those written or printed orders facility staff need to provide essential care to the resident, consistent with the residents's mental and physical status upon admission. These orders should at a minimum, include dietary, medications, and routine care to maintain or improve the residents functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities), revealed in Chapter 3, Section O Coding instructions for Column b. While a Resident to check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. The example shown in the manual revealed a box in the While a Resident section for Oxygen therapy and for Non-invasive Mechanical Ventilator. An observation on 2/24/25 at 9:58 AM in Resident 13's room revealed a CPAP machine on the night stand besides the bed and an oxygen concentrator with nasal cannula tubing hooked up to the oxygen concentrator in a plastic bag. An interview on 2/24/25 at 9:58 AM with Resident 13 confirmed that Resident 13 used the CPAP at night and had been using the oxygen concentrator at night due to Resident 13's CPAP mask needing replaced. An observation on 2/25/25 at 8:30 AM in Resident 13's room revealed a CPAP machine on the night stand besides the bed and an oxygen concentrator with nasal cannula tubing hooked up to the oxygen concentrator in a plastic bag. A record review of the Admission Record dated 2/26/2025 revealed Resident 13 was admitted to the facility on [DATE] with diagnoses of Obstructive Sleep Apnea (condition that occurs when your breathing repeatedly stops during sleep) and Chronic Obstructive Pulmonary Disease (COPD, lung disease that makes it hard to breathe). A record review of the MDS dated [DATE] revealed Resident 13 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15 which indicated Resident 13 was cognitively intact. Section 0 of the MDS, Respiratory Treatments C1- Oxygen therapy was not checked as being used, and G1- Non-invasive Mechanical ventilator was not check as being used. A record review of medication administration record dated February 2025 revealed check marks indicating Resident 13 used a CPAP every night. A record review of medication administration record dated February 2025 revealed an order for oxygen at 2 liters per nasal cannula at bedtime as needed when Resident 13 was not utilizing their CPAP. An interview on 2/26/25 at 2:30 PM with ADON confirmed that in Section O on Resident 13's 2/11/2025 MDS for the Oxygen therapy and for the Non-invasive Mechanical Ventilator were not marked as being used. The ADON stated that the MDS dated [DATE] was an annual and that those areas did not need to be checked.

Licensure Reference Number 175 NAC 12-006.09(E)(iii) Based on record review, observations, and interviews the facility failed to develop a care plan that reflected 1 (Resident 13) out of 8 sampled residents' use of Continuous Positive Airway Pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while one sleeps) and oxygen. The facility census was 19. Findings are: A record review of the Comprehensive Care Plan policy dated 2/13/25 revealed -It is the policy for this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights,that include measurable objective and timeframe's to meet a residents medical, nursing, and mental and psychosocial needs and all services that are identified in the residents comprehensive assessment and meet profession standards of quality. An observation on 2/24/25 at 9:58 AM in Resident 13's room revealed a CPAP machine on the night stand besides the bed and an oxygen concentrator with nasal cannula tubing hooked up to the oxygen concentrator in a plastic bag. An interview on 2/24/25 at 9:58 AM with Resident 13 confirmed that Resident 13 used the CPAP at night and had been using the oxygen concentrator at night due to Resident 13's CPAP mask needing replaced. An observation on 2/25/25 at 8:30 AM in Resident 13's room revealed a CPAP machine on the night stand besides the bed and an oxygen concentrator with nasal cannula tubing hooked up to the oxygen concentrator in a plastic bag. A record review of the Admission Record dated 2/26/2025 revealed Resident 13 was admitted to the facility on [DATE] with diagnoses of Obstructive Sleep Apnea (condition that occurs when your breathing repeatedly stops during sleep) and Chronic Obstructive Pulmonary Disease (COPD, lung disease that makes it hard to breathe). A record review of the Care Plan (Written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) revealed that the Care plan dated 2/11/25 for Resident #13 did not address focus, goals or interventions for the usage of the CPAP or the oxygen use. An interview on 2/26/25 with the Assistant Director of Nursing (ADON) confirmed that the Care Plan did not address Resident #13's oxygen usage or the usage of the CPAP and these should have been addressed on the Care Plan.

Licensure Reference Number 175 NAC 12-006.05(G), 175 NAC 12-006.12 Based on record review and interview, the facility failed to ensure that Resident 7 was evaluated by a provider prior to renewal of an as needed antipsychotic (drugs used to treat psychosis, or conditions that affect the mind, in which people have trouble distinguishing between what is real and what is not) medication. This affected 1 of 5 residents sampled for unnecessary medications. The facility census was 19. Findings are: A review of the Harvard Rest Haven Use of Psychotropic Medication(s) policy reviewed 1/20/25 revealed: PRN [as needed] orders for antipsychotic medications only, shall be limited to 14 days with no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate. A record review of Resident 7's Admission Record dated 02/25/2025 revealed the resident was admitted on [DATE], and had diagnoses of dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities), paranoid personality disorder (a mental health condition marked by a long-term pattern of distrust and suspicion of others without adequate reason to be), delusional disorder (a mental health condition characterized by persistent, false beliefs that are not based on reality), depression, and anxiety. A record review of Resident 7's Quarterly Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 01/14/2025 revealed the resident had a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 12/15, indicating moderate cognitive impairment. Further review revealed the resident had behaviors including delusions and verbal behaviors directed towards others. A record review of Resident 7's Order Summary Report dated 02/25/2025 revealed a current order for: -Seroquel (an antipsychotic medication) 25 milligrams (mg) by mouth three times a day and every 12 hours PRN with a start date of 02/20/2025 and no end date. A record review of Resident 7's Medication Administration Record (MAR) for December 2024 revealed orders for: -Seroquel 25 mg by mouth at bedtime with a start date of 10/16/2024 and an end date of 12/11/2024. -Seroquel 25 mg by mouth twice a day with a start date of 12/11/2024 and an end date of 01/10/2025. -Seroquel 25 mg by mouth every 12 hours as needed for 14 days with a start date of 11/28/2024 and an end date of 12/10/2024. -Seroquel 25 mg by mouth every 12 hours as needed with a start date of 12/11/2024 and an end date of 01/10/2025. -Seroquel 25 mg by mouth every 12 hours as needed for 14 days with a start date of 12/10/2024 and an end date of 12/24/2024. -Seroquel 25 mg by mouth every 12 hours as needed for 14 days with a start date of 12/24/2024 and no listed end date. A record review of Resident 7's Treatment Administration Record (TAR) for December 2024 revealed orders dated 12/10/2024 and 12/24/2024 to fax the psych Nurse Practitioner (NP) the resident's MAR and TAR and request to renew the prescription for the PRN Seroquel. A record review of Resident 7's MAR for January 2025 revealed orders for: -Seroquel 25 mg by mouth twice a day with a start date of 12/11/2024 and an end date of 01/10/2025. -Seroquel 25 mg by mouth twice a day with a start date of 01/10/2025 and an end date of 01/15/2025. -Seroquel 25 mg by mouth twice a day with a start date of 01/15/2025 and an end date of 02/20/2025. -Seroquel 25 mg by mouth every 12 hours as needed with a start date of 12/11/2024 and an end date of 01/10/2025. -Seroquel 25 mg by mouth every 12 hours as needed for 14 days with a start date of 12/24/2024 and no listed end date. This order did automatically end on 01/07/2025. -Seroquel 25 mg by mouth every 12 hours as needed for 14 days with a start date of 01/10/2025 and an end date of 01/15/2025. -Seroquel 25 mg by mouth every 12 hours as needed for 14 days with a start date of 01/15/2025 and an end date of 02/20/2025. This order did automatically end on 01/29/2025. A record review of Resident 7's TAR for January 2025 revealed an order dated 01/05/2025 to fax the NP and request to renew the prescription for the PRN Seroquel. A record review of Resident 7's MAR for February 2025 revealed orders for: -Seroquel 25 mg by mouth twice a day with a start date of 01/15/2025 and an end date of 02/20/2025. -Seroquel 25 mg by mouth three times a day with a start date of 02/20/2025. -Seroquel 25 mg by mouth every 12 hours as needed with a start date of 02/20/2025. A record review of Resident 7's Progress Notes revealed Notes dated 12/10/2024 and 12/24/2024 that stated the psych NP had been sent a fax requesting the renewal of the as needed Seroquel for 14 days. There was no record of a fax being sent on 01/05/2025. A record review of the Miscellaneous tab in Resident 7's Electronic Health Record (EHR) revealed scanned in New Prescription Summary records for as needed Seroquel refills dated 12/10/2024, 12/24/2024, and 01/06/2025. A record review of Resident 7's in-person and telehealth appointments from 09/01/2024 through 2/26/2025 revealed the resident did not have an appointment with their Primary Care Provider during that time. The resident had in-person appointments with the psych NP at the facility on 10/08/2024 and 01/14/2025, and appointments via telehealth on 09/10/2024 and 02/20/2025. An interview on 02/26/2025 at 1:40 PM with the Assistant Director of Nursing (ADON) confirmed that there was no in-person or telehealth evaluation of Resident 7 done on the dates the PRN Seroquel was ordered.

Licensure Reference Number 175 NAC 12-006.09B1(2) Based on interview and record review; the facility failed to complete a MDS (Minimum Data Set- comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) comprehensive assessment within 14 days of a significant change for 1 (Resident 18) of 1 sampled resident. The facility census was 21. Findings are: Record review of Resident 18's Clinical Resident Profile printed 2/13/2024 revealed that the resident admitted to the facility on [DATE] with diagnosis of: unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (disease affecting loss of memory, language, problem-solving, and thinking), constipation, and weakness. Record review of Resident 18's Comprehensive Assessment MDS dated [DATE] was completed for a significant change (a major decline or improvement in a resident's status) with admission to hospice on 5/26/2023. A record review of a physician's order dated 1/12/2024 revealed that the resident would discharge from hospice services on 1/17/24 due to a prognosis greater than 6 months. A record review of the resident's medical record revealed that a Comprehensive Assessment MDS had not been completed following the discharge from hospices services on 1/17/2024. An interview with the ADON (Assistant Director of Nursing) and DON (Director of Nursing) on 2/14/2023 at 3:00 PM revealed the ADON acknowledged that a Comprehensive Assessment MDS should have been completed within 14 days of the resident discharging from hospice services and was late. An interview with the ADON on 2/15/2024 at 8:00 AM revealed the facility follows the RAI Manual (helps nursing home staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) related to completion of MDS assessments. A record review of the RAI Version 3.0 Manual dated 10/2023 revealed under Chapter 2 Comprehensive Assessments, section 03, that a Significant Change in Status Assessment is required to be performed when a resident is receiving hospice services and then decides to discontinue those services. The ARD (specific end point of look-back periods in the MDS assessment process) must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician or medical directors order stating the resident is no longer terminally ill.

LICENSURE REFERENCE NUMBER NAC 12-006.11E Based on observation and interview, the facility failed to ensure that the kitchen counters and cupboards were clean, and items in the store rooms were not out dated. The facility also failed to ensure that the opened peanut butter did not have old peanut butter around the lid, This had the potential to affect all 20 residents in the facility. Observation on 1/03/23 at 09:40 am of the kitchen revealed the cupboards and drawers inside and out, felt greasy and the grease would wipe off when touched with fingers. Further observation revealed an opened peanut butter container that had been opened and had peanut butter squished between the lid and outside of lid. Observation on 1/03/23 at 0945 AM revealed several items on the storage racks in the dry storage room that were outdated including healthy choice soups, Thickener for drinks, and pickled beets. Interview on 01/09/23 2:21 PM with the DM-I (Dietary Manager) confirmed thatthere was grease in the cupboards and drawers. Further interview confirmed that their were food items outdated on the storage racks. DM-I revealed she had been off work for a week or so.

Licensure Reference Number 175 NAC 12.006.17 Licensure Reference Number 175 NAC 12.006.17A Based on observation, interview, and record review, the facility failed to ensure staff wore surgical masks above the nose to below the chin to prevent the spread of COVID-19, failed to have a Legionella policy and procedure, and failed to ensure Legionella testing had been completed. This had the potential to affect all 20 residents in the facility. The total facility census was 20. Findings are: A. A record review of the facility's COVID-19 Response Planning Policy dated 10/07/2022 revealed if the community transmission level (a level of COVID-19 in the community) is red, universal masking was required for all staff, residents, and visitors. An observation on 01/04/2023 at 01:19 PM revealed the Assistant Director of Nursing (ADON) was at the nurse's station, within 6 feet of a resident, and had a surgical mask below the ADON's chin. An observation on 01/04/2023 at 01:19 PM revealed the Administrator was in the Chapel within 6 feet of residents and had a surgical mask below the Administrator's nose. An observation on 01/05/2023 at 07:41 AM revealed Nursing Assistant (NA)-C was in the Dining Room and assisted a resident with NA-C's surgical mask below NA-C's nose. An observation on 01/05/2023 at 08:02 AM revealed Nursing Assistant (NA)-G took a resident into the bath house a surgical mask below NA-G's nose. An observation on 01/05/2023 at 08:07 AM revealed Nursing Assistant (NA)-C pushed Resident 13 down the hall in a wheelchair with a surgical mask below NA-C's nose. An observation on 01/05/2023 at 09:42 AM revealed Nursing Assistant (NA)-C pushed a resident down the hall to the Chapel in a wheelchair with a surgical mask below NA-C's nose. In an interview with the ADON on 01/09/2023 at 02:50 PM, the ADON confirmed the facility is still in outbreak (had a COVID-19 positive staff or resident within the last 10 days), and staff should have worn a surgical mask from above the nose to below the chin. B. A record review of the facility's Legionella (a bacteria that can cause a severe lung infection that could grow or develop in a facility's water supply) Policy and/or Procedure and testing could not be completed due to the facility did not have a policy, procedure, or testing. In an interview on 01/05/2023 at 08:18 AM, the Maintenance Man (MM)-F confirmed the facility did not have a policy or a procedure for Legionella, and the facility had not tested the water for Legionella.

Based on observation, interview, and record review, the facility failed to ensure staff testing was completed as required, failed to sanitize (disinfect) the COVID-19 testing surface, and failed to wear gloves while touching a COVID-19 testing specimen (test) to prevent the spread of COVID-19. This had the potential to affect all 20 residents in the facility. Findings are: A. A record review of the facility's COVID-19 Response Planning Policy dated 10/07/2022 revealed if the community transmission level (a level of COVID-19 in the community) is red, all staff should be tested for COVID-19 twice a week. If the community transmission level is orange, unvaccinated staff and residents should be tested for COVID-19 one time per week. A record review of an un-named document that the Assistant Director of Nursing (ADON) completed, dated 11/22/2022 - 01/09/2023 revealed: 11/22/2022 - the county transmission rate was orange, and the exposed staff, 2 exposed residents, and the unvaccinated (had not had the COVID-19 vaccine shots) staff should have tested on ce a week. 11/29/2022 - the county transmission rate was red, and all staff and residents should have tested 2 times per week. 12/06/2022 - the county transmission rate was red, and all staff and residents should have tested 2 times per week. 12/13/2022 - the county transmission rate was red, and all staff and residents should have tested 2 times per week. 12/20/2022 - the county transmission rate was red, and all staff and residents should have tested 2 times per week. 12/27/2022 - there were 2 COVID-19 positive staff, and all staff and residents should have tested 2 times per week. 01/09/2023 - the county transmission rate was orange, and all unvaccinated should have tested 1 time per week. A record review of the COVID-19 Staff Vaccination Status for Providers form dated 10/2022 revealed: Nursing Assistant (NA)-C had an exemption (the process of being free from obligation) from the COVID-19 vaccine. NA-D did not have a COVID-19 exemption and was not vaccinated against COVID-19. Dietary Aide (DA)-E did not have a COVID-19 exemption and was not vaccinated against COVID-19. A record review of the facility's Abbott BinaxNow COVID-19 Ag Testing Logs dated 11/18/2022 - 01/09/2023 and the Staff Schedules for December 2022 and January 2023 revealed: NA-C only tested for COVID-19 on: 11/23/2022, 11/28/2022, 12/03/2022, 12/07/2022, 12/11/2022, 12/19/2022, and 01/05/2023, but worked: 11/28/2022, 11/30/2022, 12/03/2022, 12/04/2022, 12/05/2022, 12/07/2022, 12/09/2022, 12/10/2022, 12/11/2022, 12/12/2022, 12/14/2022, 12/17/2022, 12/18/2022, 12/19/2022, 12/21/2022, 12/23/2022, 12/26/2022, 12/28/2022, 12/30/2022, 01/03/2023, 01/04/2023, and 01/05/2023. NA-D only tested for COVID-19 on: 12/24/2022, 12/02/2022, 12/05/2022, 12/07/2022, 12/18/2022, 12/20/2022, 12/27/2022, and 01/01/2023, but worked: 11/28/2022, 11/30/2022, 12/02/2022, 12/03/2022, 12/04/2022, 12/07/2022, 12/08/2022, 12/09/2022, 12/11/2022, 12/12/2022, 12/15/2022, 12/16/2022, 12/18/2022, 12/19/2022, 12/27/2022, 12/28/2022, 12/29/2022, 12/31/2022, and 01/01/2023. DA-E did not test for COVID-19 from 11/18/2023 until 12/22/2022 and then only tested on [DATE] and 01/02/2023, but worked: 12/01/2022, 12/02/2022, 12/05/2022, 12/06/2022, 12/07/2022, 12/08/2022, 12/10/2022, 12/11/2022, 12/12/2022, 12/13/2022, 12/14/2022, 12/16/2022, 12/20/2022, 12/22/2022, 12/24/2022, 12/25/2022, 12/27/2022, 12/28/2022, 12/29/2022, 12/30/2022, 01/04/2023, and 01/03/2023. In an interview and record review with the ADON on 01/09/2022 at 02:11 PM, the ADON confirmed NA-C, NA-D, and DA-E had not been vaccinated for COVID-19, did not test for COVID-19 twice a week and should have, and worked with the facility residents. B. A record review of the facility's BinaxNOW COVID-19 Nasal Swab Policy dated 09/13/2022 revealed that the area of COVID-19 testing should be wiped after each test and specimen card should not be touched without proper gloves. An observation on 01/05/2022 at 01:40 PM revealed the Director of Nursing (DON)-A COVID-19 tested Nursing Assistant (NA)-C. The observation did not reveal the testing surface had been sanitized before or after the test, and a barrier was not used. The observation did reveal the DON-A did remove the gloves used during testing and then touch the specimen card. In and interview with DON-A on 01/05/2022 at 10:40 PM, DON-A confirmed the COVID-19 testing surface was only disinfected in the mornings and not disinfected before or after each COVID-19 test. The DON-A confirmed that the specimen card had been touched with an ungloved hand.

Based on interview and record review, the facility failed to ensure all staff had the COVID-19 vaccine or an exemption (the process of being free from obligation) and failed to ensure the facility's COVID-19 mitigation (reducing the severity) plan for unvaccinated staff was complete to prevent the spread of COVID-19. This had the potential to affect all 20 residents in the facility. Findings are: A. A record review of the facility's COVID-19 Vaccination for Employees Policy dated 11/10/2022 revealed that the facility was required to have a process in place ensuring that all staff were vaccinated against COVID-19 or had an exemption. A record review of the COVID-19 Staff Vaccination Status for Providers form dated 10/2022 revealed Nursing Assistant (NA)-D and Dietary Aide (DA)-F did not have a COVID-19 exemption and were not vaccinated against COVID-19. In an interview and record review with the Assistant Director of Nursing (ADON) on 01/09/2022 at 02:11 PM, the ADON confirmed NA-D, and DA-E had not been vaccinated for COVID-19 or had an exemption, and had worked with the facility residents and should not have. B. A record review of the facility's COVID-19 Response Planning Policy dated 10/07/2022 revealed the only time the facility had a mitigation plan for unvaccinated staff was when the community transmission level (a level of COVID-19 in the community) was orange. In an interview and record review with the ADON on 01/09/2022 at 02:11 PM, the ADON confirmed that the facility's COVID-19 Vaccination for Employees Policy dated 11/10/2022 only had a mitigation plan for unvaccinated staff when the community transmission level was orange, and there should have been one for every level.

Licensure Reference Number 175 NAC 12.006.02(8) Based on observation, interview, and record review, the facility failed to ensure that a fall with major injury was reported to Adult Protective Services (APS) and the Department of Health and Human Services (DHHS) - Division of Public Health for 1 (Resident 17) of 1 sampled resident. Total facility census was 20. Findings are: A record review of the facility's Suspected Abuse or Neglect Policy dated 08/03/2018 revealed the Administrator would review and investigate a serious injury to a resident, the incident should have been reported to APS within 2 hours, and the results of the facility investigation should have been reported to DHHS - Division of Public Health. An observation on 01/03/2023 at 03:53 PM revealed Resident 17 had a brace on the resident's left wrist. An observation on 01/04/2023 at 10:40 AM revealed Resident 17 did not have the wrist brace on, and the brace was in the bed. A record review of Resident 17's Progress Notes dated 11/04/2023 revealed the resident had fallen and complained of pain and discomfort of the left wrist. A record review of Resident 17's Progress Notes dated 11/04/2023 revealed Resident 17's physician was notified and the physician had ordered an X-ray (an image of the internal part of the body) of the left wrist. A record review of Resident 17's Progress Notes dated 11/04/2023 revealed Resident 17's X-ray confirmed Resident 17 had a fracture (break) to the Left Distal Radius (a bone in the wrist). An interview with the Assistant Director of Nursing (ADON) on 01/05/2023 at 10:11 AM confirmed Resident 17 fell and fractured the left wrist. The ADON confirmed that a formal investigation had not been completed, APS had not been notified, and the incident had not been reported to DHHS - Division of Public Health.

Licensure Reference Number 175 NAC 12.006.09D6(7) Based on observation, interview, and record review, the facility failed to follow the provider's oxygen (a colorless, odorless gas) and oxygen humidity (a tank placed on an oxygen system to add humidity the gas) orders for 1 (Resident 17) of 1 sampled resident. The facility census was 20. Findings are: A record review of the facility's Oxygen Administration (delivery) Policy dated 11/20/2013, revealed the facility would verify the physician's order for oxygen administration and report and document the resident's usage in the resident's medical record. The Policy revealed the facility should attach a humidifier (if prescribed) to the oxygen outlet. An observation on 01/03/2023 at 11:15 AM revealed Resident 17 was out of the facility and the resident's oxygen concentrator (a machine that separates the oxygen from the air and send delivers the oxygen to the resident) was on at a setting of 2 liters per minute (l/m). The observation also revealed that the oxygen humidifier was on the oxygen concentrator but was not connected to the oxygen outlet. An observation on 01/03/2023 at 02:40 PM revealed Resident 17 sat on edge of bed, the concentrator was on, but the Nasal Cannula (tubing that runs from the oxygen outlet to the resident's nose) was not on the resident. The observation also revealed that the oxygen humidifier was on the oxygen concentrator but was not connected to the oxygen outlet. An observation on 01/04/2023 at 07:59 AM revealed Resident 17 was asleep in bed, the concentrator was on, but the Nasal Cannula was not on the resident. The observation also revealed that the oxygen humidifier was on the oxygen concentrator but was not connected to the oxygen outlet. A record review of Resident 17's Clinical Physician's Orders dated 01/04/2022, revealed physician's order for oxygen at 2 L/min per Nasal Cannula routine, every shift and add humidification to the oxygen therapy. An observation on 01/04/2023 at 01:19 PM with Licensed Practical Nurse (LPN)-J revealed Resident 17 sat on the side of the bed, the oxygen concentrator was on, but the Nasal Cannula was not in the resident's nose. The observation also revealed that the humidifier was on the oxygen concentrator but was not connected to the oxygen outlet. In an interview with LPN-J on 01/04/2023 at 01:19 PM, LPN-J confirmed that Resident 17 did not have the oxygen on and should have, and that the oxygen humidifier was not connected to the oxygen outlet and should have been.

Licensure Reference Number 175NAC 12-006.05 (21) Based on observation and interview, the facility failed to ensure that staff served each resident seated at the same table before serving other residents in the dining room to maintain resident dignity. This affected 5 residents (Residents 14, 1, 8, 11, and 6) in the facility dining room. The facility census was 18. Findings are: A. Observation in the facility dining room on 8/30/21 at 11:38 AM revealed that Dietary Cook-E (DC-E) served a meal to Resident 6. Resident 14 sat at the table with Resident 6. Resident 14 had not been served. DC-E served a meal to Resident 18 seated at another table. DC-E served a meal to Resident 16 seated at another table. DC-E served a meal to Resident 13 seated at another table. DC-E served a meal to Resident 2 seated at another table. At 11:46 AM DC-E served a meal to Resident 10. Resident 1 sat at the table with Resident 10. Resident 1 had not been served. At 11:48 AM DC-E served a meal to Resident 14. Resident 14 received the meal 10 minutes after Resident 14's tablemate, Resident 6, had been served at 11:38 AM. 5 other residents had been served a meal after Resident 6 received the meal before their tablemate, Resident 14, received their meal. At 11:51 AM DC-E served a meal to Resident 1. Resident 1 received the meal 5 minutes after Resident 1's tablemate, Resident 10, had been served at 11:46 AM. 1 other resident had been served a meal after Resident 10 received the meal before their tablemate, Resident 1, received their meal. B. Observation in the facility dining room on 9/1/21 at 11:40 AM revealed that the Dietary Manager (DM) served a meal to Resident 13. Resident 8 sat at the table with Resident 13. Resident 8 had not been served. At 11:41 AM the DM served a meal to Resident 12. Resident 11 sat at the table with Resident 12. Resident 11 had not been served. The DM served a meal to Resident 16 seated at another table. The DM served a meal to Resident 3 seated at another table. At 11:44 AM the DM served a meal to Resident 8. Resident 8 received the meal 4 minutes after the resident's table mate, Resident 13, had been served at 11:40 AM. 3 other residents had been served a meal after Resident 13 received the meal before their tablemate, Resident 8, received their meal. At 11:46 AM the DM served a meal to Resident 11. Resident 11 received the meal 5 minutes after the resident's table mate, Resident 12 had been served at 11:41 AM. 3 other residents had been served a meal after Resident 12 received the meal before their tablemate, Resident 11, received their meal. At 11:47 AM the DM served the meal to Resident 14. Resident 6 sat at the table with Resident 14. Resident 6 had not been served. Dietary Aide-F (DA-F) took over meal service and served a meal to Resident 2 at another table. DA-F served a meal to Resident 15 seated at another table. At 11:50 AM DA-F served a meal to Resident 6. Resident 6 received the meal 3 minutes after the resident's table mate, Resident 14, had been served at 11:47 AM. 2 other residents had been served a meal after Resident 14 received the meal before their tablemate, Resident 6, received their meal. Interview on 9/1/21 at 3:11 PM with the facility Dietary Manager (DM) confirmed that the facility has no policy on meal service. The DM confirmed that the expectation is for the facility to serve the meal to all residents at the same table before serving other residents. The DM confirmed that this is a dignity issue.

Based on record review and interview the facility professional nursing staff failed to ensure that one resident's (Resident 3) [MEDICATION NAME] (blood thinner) order was clarified with the physician after an INR (International Normalized Ratio: monitors blood levels of thinness) was drawn. The resident sample size was four and the facility census was 27. Findings are: A. Review of Resident 3's Hospital History and Physical dated 8/15/13 revealed that the resident was being treated with [MEDICAL CONDITION] for a metastatic pancreatobiliary [MEDICAL CONDITION] (cancer of the pancreas and bile ducts that had spread). The resident was hospitalized earlier with a large [MEDICAL CONDITION] (blood clot in the lung). The resident was admitted to the hospital for a mild acute embolytic (clot) [MEDICAL CONDITION] ([MEDICAL CONDITION]: stroke). The resident's INR was 1.0 and the physician stated it was unclear why the resident was no longer on [MEDICATION NAME], since the physician had not given the order to discontinue the medication. The History and Physical stated that the [MEDICATION NAME] had stopped around 8/6/13. Review of Resident 3's Physician Telephone Order dated 8/6/13 stated "[MEDICATION NAME] 6 mg (milligrams) i/i (one) po (by mouth) x 3 days then Draw INR." Review of Resident 3's 8/9/13 Consultation/ Clinic Referral revealed that the resident had an INR drawn at the physician's clinic. The INR level was 3.0. The physician ordered to recheck the INR in one week. The physician did not order a [MEDICATION NAME] dose. Review of Resident 3's MAR (Medication Administration Record) dated August 2013 revealed: -The resident had an order for [REDACTED]. -The resident's order for [MEDICATION NAME] dated 7/20/13 through 7/5/13 stated [MEDICATION NAME] 6 mg give one time a day every two days and [MEDICATION NAME] 7.5 mg give one tablet one time a day every 2 days for treatment of [REDACTED]. Review of Resident 3's 8/7/13 Quarterly MDS (Minimum Data Set: a federally mandated comprehensive tool used for care planning) revealed that the resident's BIMS (Brief Interview for Mental Status) total score was 13 (cognitively intact). The resident required limited to extensive assistance with activities of daily living. The resident was on anticoagulant (blood thinning) therapy. Resident 3's care plan updated on 8/7/13 did not address that the resident was on anticoagulant therapy. Review of Resident 3's IDPN (Interdisciplinary Progress Note) dated 8/15/13 revealed: -At 1 pm revealed that the resident complained of not feeling well when the resident returned from the resident's appointment. The resident's temperature was 97.5 degrees Fahrenheit, pulse 70, respirations 20 and blood pressure 130/58. The resident's blood oxygen saturation level was 94%. The resident's speech was slurred and the resident's mouth drooped on the left side. The resident's hand grasp was equal. -At 1:25 pm the resident's speech was not as slurred and the facial droop was not as pronounced. -At 1:35 pm the resident's speech continued to be slurred and the facial droop continued. [MEDICAL CONDITION] Center stated that it was not likely due to the resident's [MEDICAL CONDITION]. -At 1:40 pm the resident's physician's nurse was notified. -At 2:15 pm an order was received to transfer the resident to the emergency room . -At 2:35 pm the resident was transported to the hospital accompanied by family. Interview with the ADON (Assistant Director of Nursing) on 8/27/13 at 10:45 am revealed that the resident had an INR drawn during a physician office visit. The physician ordered a recheck of the resident's INR in one week, but did not order a [MEDICATION NAME] dose. The ADON stated that the facility did not have a specific [MEDICATION NAME] policy and procedure. The ADON stated that if in that position the ADON would call or fax the physician to clarify the order to see what dose of [MEDICATION NAME] the resident should be on or if the physician wanted the [MEDICATION NAME] discontinued. The ADON stated that when the facility received an INR result back from the laboratory the nurses attach a label that stated current [MEDICATION NAME] dose, if [MEDICATION NAME] was to continue, and when the next INR was due. Interview with the DON (Director of Nursing) on 8/27/13 at 10:45 am revealed that if a physician order [REDACTED]. B. Interview on 8/27/13 at 11:30 am with LPN (Licensed Practical Nurse) A, revealed that if the nurse received a Clinical referral form from a physician's clinic with INR results on it and no [MEDICATION NAME] order, the nurse would clarify the [MEDICATION NAME] order. LPN A stated this is part of "nursing judgement."