Every finding on record at Lanfair Center for Rehab & NSG Care Inc

Based on observation, staff interview, and facility policy review, the facility failed to maintain proper food storage and sanitation in the kitchen. This had the potential to affect all of the residents residing in the facility. The facility census was 80 residents. Findings include:1.Observation on 07/27/26 at 9:03 A.M. revealed the walk-in freezer had a buildup of ice noted to shelves and curtains.Interview on 07/29/26 at 3:27 P.M. with the Dietary Coordinator (DC) confirmed there was a buildup of ice noted to the shelves and curtains of the walk-in freezer. 2. Observation on 07/29/26 at 10:30 A.M. revealed the following concerns: there were three open and undated five-pound bags of pasta in the dry storage area, a scoop stored inside a container of parmesan cheese in the walk-in cooler, a scoop store inside a container of brown sugar on the prep table. Interview on 07/29/26 at 3:34 P.M. with the DC confirmed the bags of pasta should have been dated when opened and the scoop should not be stored inside the brown sugar. Interview on 07/29/26 at 3:35 P.M. with Dietary [NAME] #214 confirmed the scoop was stored inside the parmesan cheese and should have been discarded. Review of facility policy titled Dry Storage and Supplies dated January 2015 revealed all non-perishable food items shall be stored in a manner that optimizes food safety and quality. Opened food shall be stored in resealed containers/ food bags that are labeled/dated.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to complete wound treatments as ordered by the physician. This affected one (Resident #62) of one resident reviewed for skin conditions. The facility also failed to ensure daily weights were obtained as ordered by the physician. This affected two (Residents #6 and #77) of two residents reviewed for edema. The facility census was 80 residents. Findings include: 1.Review of the medical record for Resident #62 revealed an admission date of 07/15/26 with diagnoses including unspecified dementia and Parkinson's disease. Review of a nurse progress note for Resident #62 dated 07/24/26 at 6 P.M. revealed the resident had a fall from his wheelchair which resulted in a skin tear to the resident's left forearm. Staff cleansed the resident's skin tear with normal saline and applied a foam dressing. Staff notified the resident's physician and obtained a treatment order for the skin tear. Review of the physician's orders for Resident #62 revealed an order dated 07/24/26 to cleanse left forearm with normal saline, pat dry, and apply a foam dressing every other day and as needed. Observation on 07/27/26 at 9:21 A.M. revealed Resident #62 was seated in his wheelchair in the hallway with a bandage to his left forearm dated 07/24/26. Observation on 07/27/26 at 3:19 P.M. revealed Resident #62 still had the bandage in place to his left forearm dated 07/24/26. Interview on 07/27/26 at 3:19 P.M. with the Director of Nursing (DON) confirmed Resident #62's bandage was dated for 07/24/26 and the dressing should have been changed on 07/26/26 per the physician's order. Review of the facility policy titled Care of Skin Abrasions-Skin Tears dated 05/01/25 revealed the facility staff would care for alterations in skin integrity using professional standards of practice. 2. Review of the medical record for Resident #6 revealed an admission date of 04/24/26 with diagnoses including fluid overload, acute respiratory failure with hypoxia, congestive heart failure, cardiomegaly, and localized edema. Review of the physician's orders for Resident #6 revealed an order dated 07/04/26 for daily weights and to notify the physician of a weight gain or loss or gain of three pounds in one day and to notify the physician of a gain or loss of five pounds in one week. Review of the daily weight record for Resident #6 revealed daily weights were not completed as ordered on the following dates: 07/08/26, 07/22/26, 07/25/26. Interview 07/30/26 at 1:10 P.M. with the DON confirmed the facility had not obtained daily weights as ordered for Resident #6 on 07/08/26, 07/22/26, and 07/25/26. 3. Review of the medical record for Resident #77 medical record revealed an admission date of 02/29/20 with diagnoses including chronic systolic heart failure and chronic kidney disease. Review of the physician's orders for Resident #77 revealed an order dated 09/09/23 to obtain daily weights and notify the physician of a gain or loss of three pounds or more in one day or a gain or loss of five pounds or more in one week. Review of the daily weight record for Resident #77 revealed daily weights were not completed as ordered on the following dates: 06/05/26, 06/09/26, 06/25/26, 06/26/26, 07/22/26, 07/24/26. Review of the daily weight record for Resident #77 revealed the resident had a 3.2 pound weight gain from 07/01/26 to 07/02/26. Review of the nurse progress notes for Resident #77 dated 07/02/26 revealed they did not include notification to the physician of the resident's 3.2 pound weight gain from 07/01/26 to 07/02/26. Interview on 07/29/26 at 2:26 P.M. with the DON confirmed the facility had not completed daily weights as ordered on 06/05/26, 06/09/26, 06/25/26, 06/26/26, 07/22/26, 07/24/26. The DON also verified no documentation of physician notification of Resident 3.2-pound weight gain between 07/01/26 and 07/02/26. Review of facility policy titled Weight/Reweigh Policy dated 05/01/25 revealed all resident weights will be documented in the clinical record

Based on observation, staff interview and facility policy review the facility failed to follow infection control guidelines during medication administration. This affected two (Residents #47 and #101) of four residents observed for medication administration. The census was 80 residents.Findings include:1.Observation of medication administration on 07/29/26 at 7:53 A.M. for Resident #47 per Licensed Practical Nurse (LPN) #174 revealed the nurse touched the resident's medication with her ungloved hand. Interview on 07/29/26 at 7:56 A.M. with LPN #174 confirmed she removed Resident #47's pill from the medication cup with an ungloved hand. 2. Observation of medication administration on 07/30/26 at 9:48 A.M. for Resident #101 per Registered Nurse (RN) #161 revealed the nurse touched the resident's medication with her ungloved hand before placing it the medication cup for administration to the resident. Interview on 07/30/26 at 9:48 A.M. with RN #161 confirmed she touched Resident #101's medication into ungloved hand before placing into medication cup. Review of the facility policy titled Medication Administration - General Guidelines dated May 2020 confirmed nurses should wear examination gloves when necessary and should wash their hands with soap and water or approved sanitizer. Nurses should not touch resident medications with their bare hands.

Based on medical record review, staff interview, and facility policy review the facility failed to ensure residents were free of significant medication errors. This affected two (Residents #23 and #6) of 19 residents sampled. The facility census was 80 residents. Findings include:1.Review of the medical record for Resident #23 revealed an admission date of 09/17/20 with a diagnosis of type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 07/03/26 revealed the resident was cognitively intact. Review of the monthly physician's orders for Resident #23 dated July 2026 revealed an order for Lantus (insulin glargine) 40 units once a day subcutaneously between 7:00 P.M. to 11:00 PM and regular insulin 18 units subcutaneously three times per day. The orders did not include parameters for withholding insulin. Review of the Medication Administration Record (MAR) for Resident #23 dated July 2026 revealed Lantus insulin was withheld on the following dates: 07/01/26, 07/02/26, 07/11/26, 07/17/26, 07/18/26, 07/20/26, 07/22/26 and regular insulin due at 5:00 A.M. to 7:00 A.M. was withheld on the following dates: 07/02/26, 07/03/26, 07/08/26, 07/09/26, 07/10/26, 07/12/26, 07/14/26, 07/15/26, 07/16/26, 07/18/26, 07/19/26, 07/20/26, 07/23/26, 07/24/26, 07/25/26, 07/27/26, 07/28/26. Review of the progress notes for Resident #23 dated 07/01/26 to 07/28/26 revealed there was no documentation of physician notification regarding withholding insulin. Interview on 07/29/26 at 2:30 P.M. with the Director of Nursing (DON) confirmed nursing staff withheld Resident #23's insulin on multiple dates during the month of July 2026 due to the resident's low blood sugar. The DON confirmed the multiple medication errors regarding Resident #23's insulin as the orders had no parameters for staff to withhold the medication. 2. Review of the medical record for Resident #6 revealed an admission date of 04/24/26 with diagnoses including fluid overload, acute respiratory failure with hypoxia, congestive heart failure, cardiomegaly, and localized edema. Review of the physician's orders for Resident #6 revealed an order dated 07/04/26 for daily weights and to notify the physician of a weight gain or loss or gain of three pounds in one day and to notify the physician of a gain or loss of five pounds in one week and an order dated 07/16/26 to give torsemide 20 milligrams (mg) in the afternoon if the resident had a weight gain of greater than three pounds in one day. Review of the daily weight record for Resident #6 revealed daily weights were not completed as ordered on 07/25/26. Review of the daily weight record for Resident #6 revealed the resident's weight on 07/24/26 was 142.4 pounds, the resident's weight was not checked on 07/25/26, and the resident's weight on 07/26/26 was 146.8 pounds. Review of the MAR for Resident #6 dated July 2026 revealed the staff did not administer torsemide as ordered for a weight gain of greater than three pounds. Interview with the DON on 07/30/26 at 1:10 P.M. confirmed the Resident #6's weight should be checked daily and the nurse should have given the as needed torsemide to the resident per the physician's order. Review of the facility policy titled Medication Administration - General Guidelines dated May 2020 revealed medications should be administered as directed by the prescriber.

Based on medical record review, staff interview, resident interview, and policy review, the facility failed to ensure residents received trauma-informed care. This affected one (Resident #12) of one facility-identified resident with a diagnosis of post-traumatic stress disorder (PTSD). The facility census was 80 residents. Findings include:Review of the medical record for Resident #12 revealed an admission date of 03/02/26 with diagnoses including major depression, anxiety disorder, social phobia, panic disorder, and post-traumatic stress disorder (PTSD). Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 05/14/26 revealed the resident had intact cognition. Review of the care plan for Resident #12 last updated 05/14/26 revealed the care plan did not include information regarding the resident's PTSD diagnosis nor did it include specific triggers to the resident's PTSD symptoms nor did it include interventions for the resident's PTSD. Review of the medical record for Resident #12 revealed it did not include an assessment related to the resident's PTSD. Interview on 07/29/26 at 4:18 P.M. with Social Services Coordinator (SSC) #144 confirmed Resident #12's medical record did not include a trauma-informed care assessment and the resident's care plan did not address the resident's PTSD. SSC #144 stated the facility should have completed an assessment and implemented a care plan for Resident #12's PTSD. Interview on 07/30/26 at 12:15 P.M. with Resident #12 confirmed the facility staff had not talked to her about her PTSD diagnosis or offered support regarding her PTSD since her admission to the facility. Review of the facility policy titled Trauma-Informed Care dated October 2019 revealed the social services coordinator and/or facility designee will assess residents upon admission for a history of trauma utilizing the trauma-informed care observation in the electronic record. If the resident was determined to have experienced a traumatic event or had diagnosis of PTSD, the SSC or designee would initiate the trauma-informed care plan in the electronic record.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were provided with smoking aprons per the plan of care. This affected one (Resident #2) of three residents reviewed for smoking. The facility census was 80 residents. Findings include:Review of the medical record for Resident #2 revealed an admission date of 11/22/21 with diagnoses including end stage renal disease, hypertension, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Alzheimer's disease and vascular dementia.Review of the care plan for Resident #2 dated 06/02/23 revealed the staff should assist the resident with applying a smoking apron before smoking for safety.Review of the progress notes for Resident #2 dated 07/01/26 to 07/30/26 revealed there was no documentation of the resident's refusal to wear a smoking apron.Interview on 07/30/26 at 1:01 P.M. with Resident #2 confirmed she did not wear an apron when smoking outside. Observation on 07/30/26 at 1:25 PM revealed Resident #2 was smoking outside in the designated area under the supervision of Certified Medication Aide (CMA) #201. Resident #2 was not wearing an apron while smoking as per the resident's plan of care.Interview on 07/30/16 at 1:25 PM with CMA #201 confirmed Resident #2 was smoking and was not wearing an apron. CMA #201 stated she forgot the provide the resident's apron. Review of the facility policy titled Resident Smoking dated 05/01/25 revealed the facility would provide the residents who wished to smoke with a safe smoking environment. Staff would provide supervision to residents during smoke times in the designated area and would provide protective equipment and smoking devices such as aprons, holders, etc. shall be provided them while smoking.

Based on medical record review, staff interview, and policy review, the facility failed to complete an updated pre-admission screening and resident review (PASARR) for a resident with new mental health diagnoses. This affected one (Resident #4) of two residents reviewed for PASARRs. The facility census was 80 residents. Findings include:Review of the medical record for Resident #4 revealed an admission date of 06/17/25 with diagnoses including depression and anxiety disorder with additional diagnoses added after admission that included post-traumatic stress disorder (PTSD) and nightmare disorder. Review of the PASARR for Resident #4 dated 01/30/26 revealed the resident's diagnoses of PTSD and nightmare disorder were not included. Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 04/22/26 revealed the resident had intact cognition. Interview on 07/28/26 at 3:45 P.M. with Social Services Coordinator (SSC) #144 confirmed the PASARR for Resident #4 dated 01/30/26 did not include the resident's diagnoses of PTSD and nightmare disorder, and the resident's PASARR should have been updated to reflect the new diagnoses. Review of the facility policy titled Preadmission Screening and Resident Review (PASARR) March 2018 revealed the social worker should complete an updated resident review when a resident had a newly diagnoses serious mental illness.

Based on medical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to ensure call lights were easily accessible for resident use. This affected one (Resident #68) of 19 residents sampled. The facility census was 80 residents. Findings include:Review of the medical record for Resident #68 revealed an admission date of 11/07/23 with diagnoses including Alzheimer's disease and adult failure to thrive. Review of the care plan for Resident #68 dated 11/21/25 revealed a goal for the resident to have his needs met daily. Interventions included staff should check on the resident frequently when he was in his room and would keep the call light in reach of the resident. Review of the Minimum Data Set (MDS) assessment for Resident #68 dated 05/21/26 revealed the resident had impaired cognition. Observation 07/27/26 at 2:08 P.M. of Resident #68 revealed the resident was in his room seated in his recliner and his call light was on top of a bookshelf between the resident's recliner and the bed and was out of the resident's reach. Interview on 07/27/25 at 7:09 A.M. with Resident #68 confirmed he was concerned staff had placed his call light out of reach and he wanted it moved closer to him. Resident #68 was seated in a recliner in his room and the call light was placed on the top of a bookshelf between the recliner and bed. Observations on 07/28/26 at 7:37 A.M. and 8:57 A.M. and on 07/29/26 at 8:50 A.M. revealed Resident #68 was resting in bed, and his call light was placed on the top shelf of a bookshelf next to the bed out of the resident's reach. Interview on 07/29/26 at 8:51 A.M. with Certified Nursing Assistant (CNA) #210 confirmed Resident #68's call light was out of reach and should be accessible to the resident. Review of the facility policy titled Call Light-Answering dated 05/01/25 revealed staff should ask the resident where they prefer the call light device be secured so it is easily accessible.

Based on record review, interview, and policy review, the facility failed to ensure pre-admission screening and resident reviews (PASARRs) were completed accurately. This affected one (Resident #12) of two residents reviewed for PASARRS'. The facility census was 80 residents. Findings include:Review of the medical record for Resident #12 revealed an admission date of 03/02/26 with diagnoses including major depression, mood affective disorder, generalized anxiety disorder, social phobia, panic disorder, and post-traumatic stress disorder (PTSD). Review of the PASARR for Resident #12 dated 03/12/26 revealed the resident had mental disorders listed as mood disorders and panic or other severe anxiety disorder. PTSD was not included on the resident's PASARR Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 05/14/26 revealed the resident had intact cognition. Interview on 07/28/26 at 3:45 P.M. with Social Services Coordinator (SSC) #144 confirmed the PASARR for Resident #12 dated 03/12/26 did not include the resident's diagnosis of PTSD and this should have been included. Review of the facility policy titled Preadmission Screening and Resident Review (PASARR) March 2018 revealed the PASARR should include residents diagnoses of serious mental disorders and/or intellectual disability.

Based on observations, record review, and staff interview, the facility failed to ensure a resident with continued weight loss was provided with nutritional supplements as ordered. This affected one resident (#5) of three residents reviewed for weight loss. The facility census was 82. Findings include: During the annual survey completed 05/08/25, a deficiency was issued related to Resident #5's weight loss. Review of the medical record for Resident #5 on 06/10/25 revealed an admission date of 07/25/24 and diagnoses including dementia, dysphagia, and acute kidney failure. Review of physician's orders revealed an order on 12/24/24 for a pureed diet, nectar thick liquids, and four ounces of Gelato (an ice cream type nutritional supplement containing 260 calories) with meals. Review of the plan of care started on 07/29/24 revealed Resident #5 was at nutritional risk. The goal was for no significant weight change. The interventions included Gelato at all meals (beginning 12/24/24). Observations on 06/10/25 at 11:58 A.M. revealed Resident #5's lunch tray was taken to his room. It contained pureed meat, pureed peas, mashed potatoes, and two glasses of juice. The tray did not contain Gelato. Observations on 06/11/25 at 8:12 A.M. revealed Resident #5 to be eating breakfast in the dining room. He had pureed french toast and sausage and two glasses of juice. He did not have Gelato. He was observed to eat approximately 90% of his food. Interview with Nursing Assistant #102 on 06/11/25 at 8:30 A.M. confirmed Resident #5 did not receive Gelato with his breakfast. Interview with Licensed Practical Nurse #99 on 06/11/25 at 8:35 A.M. confirmed Resident #5 was to receive four ounces of Gelato with his meals and it was placed on his meal trays by the kitchen. Interview with Dietary Aide #103 on 06/11/25 at 8:40 A.M. confirmed the Gelato was not placed on Resident #5's meal tray for breakfast that morning. Review of weight records revealed on 05/06/25 Resident #5 weighed 138.8 pounds. On 05/19/25 he weighed 141.2 pounds. On 06/02/25 he weighed 138.4 pounds. On 06/09/25 he weighed 133.6 pounds. This represents a 7.6 pound, 5 percent significant weight loss in three weeks. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00165834. This deficiency is evidence of continued non-compliance from the survey dated 05/08/25.

Based on observation, interview, record review, facility policy review and review of The Center for Clinical Standards and Quality QSO-24-08-NH memo, the facility failed to follow enhanced barrier precautions (EBP) during wound care. This affected one resident (#61) of one resident observed for wound care. The facility census was 82. Findings included: During the annual survey completed 05/08/25, a deficiency was issued related to the facility's failure to implement EBP during wound care. Review of the medical record for Resident #61 revealed an admission date of 04/25/25 and diagnoses including fracture of right lower leg with orthopedic surgery and sepsis with surgical wound infection. Review of hospital records revealed the resident was admitted with severe sepsis secondary to a right ankle wound infection. The resident had surgery on the right ankle on 04/15/25 and 04/22/25. The surgical culture showed Enterococcus facialis. The resident then admitted to the facility on [DATE]. The resident had physician's orders for a soft cast splint to right lower extremity to stay in place until follow up with surgeon. Review of a communication sheet dated 05/14/25 from the physician revealed presents with stable x-rays. Delayed wound healing. Leave steri strips intact. Paint with betadine. Change absorbable pads/dressing and reapply ace bandage. A physician's order was written on 05/14/25 to paint betadine over right ankle surgical incision. Leave steri strips applied. Change dressing and reapply ace bandage daily and as needed. The resident was started on an antibiotic (Amoxicillin) 500 milligrams every eight hours on 05/15/25 until bone/soft tissue heals. The antibiotics were to continue until 06/26/25. The resident did not have a physician's order for EBP. Review of a wound management report revealed on 06/05/25 Resident #61 had an 18 centimeter (cm) long by 0.1 cm wide surgical incision on the right ankle. She also had a 12 cm long by 0.1 cm wide surgical incision on the right medial ankle. Observations on 06/10/25 at 1:45 P.M. revealed a sign beside the door to Resident #61's room that stated EBP- staff must wear gown and gloves for high contact resident care activities which included wound care-any skin opening requiring a dressing. Observations at that time, revealed Registered Nurse (RN) #95 to perform a dressing change to the resident's right lower leg. She applied gloves but did not wear a gown. She removed a wrap to the resident's leg then removed the soiled dressing. The resident had an incision on each side of her leg. RN #95 then cleansed the incisions, applied betadine, applied padded dressings to each incision, wrapped the leg in Kerlix, then applied an ace wrap to the lower leg. Interview with RN #95 after the dressing change on 06/10/25 at 1:45 P.M. confirmed she did not wear a gown for the dressing change. RN #95 later on 06/10/25 at 2:30 P.M. stated Resident #61 was not on EBP precautions. Review of the facility policy titled Enhanced Barrier Precautions (updated 05/01/25) revealed the facility will utilize EBP as part of their infection prevention and control program to help prevent the development and transmission of communicable disease and infection. EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with chronic wounds. Examples of chronic wounds include unhealed surgical wounds. For residents identified requiring EBP, staff will wear gloves and a gown when performing high contact resident care activities including wound care: chronic wounds that require a dressing. Signage will be posted alerting caregivers that the resident is on EBP. Review of QSO-24-08-NH memo from the Center for Medicare/Medicaid Services (CMS) Center for Clinical Standards and Quality dated 03/20/24 revealed EBP were indicated for residents with wounds. Wounds included unhealed surgical wounds. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00165834. This deficiency is evidence of continued non-compliance from the survey dated 05/08/25.

Based on observation, interview, and facility policy review, the facility failed to label and store food in a safe manner. This affected all the residents residing in the facility, except Resident #69 who was nothing by mouth. The facility census was 82. Findings include: Observation of the walk-in refrigerator on 05/05/25 at 9:30 A.M., revealed an undated jar of minced garlic that was more than half empty, three deli sandwiches, open and undated, and a package of deli meat, open and undated. Interview on 05/05/25 at 9:32 A.M. with Dietary Manager (DM) #194, confirmed three undated items in the walk-in refrigerator. DM #194 dated minced garlic at the time of discovery and discarded the deli sandwiches and package of deli meat. Observation of the pantry on 05/05/25 at 9:35 A.M., revealed, an undated half of a bottle of orange concentrated syrup and a large undated open bag of crackers. Interview on 05/05/25 at 9:40 A.M. with DM #194, confirmed undated items in the pantry. DM #194 dated orange concentrated syrup at time of discovery. She also discarded the undated bag of crackers. Observation of the kitchen serving area on 05/05/25 at 9:45 A.M revealed four large bags of chips (Tostitos, Waffles Chips, Regular Chips and Cheese Curls) opened and undated. Interview on 05/05/25 at 9:50 A.M. with DM #194, confirmed undated items in the kitchen serving area. DM #194 discarded items at the time of discovery. Review of facility Dry Storage and Supplies policy, dated January 2015, revealed that all perishable food shall be stored in a manner that optimizes food safety and quality. It also stated that opened food shall be stored in resealed containers/food bags that are labeled/dated.

Based on observation, interview, record review, facility policy review and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to follow enhanced barrier precautions (EBP) during wound care as guided by the CDC. This affected one (Resident # 182) of one resident reviewed for wound care. The facility census was 78. Findings include: Review of the medical record for Resident #182 revealed admitted [DATE] with diagnoses including multiple fractures of pelvis without disruption of pelvic ring, subsequent encounter for fracture with routine healing, repeated falls, generalized pustular psoriasis, and edema. Review of physician ' s orders dated 05/01/25 included wound care instructions for the right dorsal foot: cleanse with in-house wound cleanser (IHWC), pat dry, apply a thin layer of Silvasorb, and cover with foam dressing daily and as needed. Physician's orders dated 05/02/25 for the left lower extremity wound, the orders directed staff to cleanse with IHWC, pat dry, apply a thin layer of Silvasorb to the open wound bed, cover with a non-adherent dressing, and wrap with Kerlix daily and as needed. Observation on 05/08/25 at 10:20 a.m. revealed wound care being performed on Resident #182 by Registered Nurse (RN) #13. During the procedure, RN #13 confirmed that the wounds on the resident ' s right foot and left lower leg were open and that the skin was not intact. RN #13 acknowledged that Enhanced Barrier Precautions were not followed, as required by CDC guidance. Review of facility policy titled Enhanced Barrier Precautions dated 04/01/24, states for procedures staff will wear gloves and a gown when performing high contact resident care activities. Review of CDC guidance dated 04/02/24 titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) states Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Wound care: any skin opening requiring a dressing.

Based on observation, interview, and medical record review the facility failed to ensure Resident #51 had appropriate diagnosis for psychotropic's and failed to monitor Resident #51's behaviors. This affected one residents (#51) of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: Review of Resident #51's medical record revealed an admitted [DATE] with diagnoses including dementia with psychotic disturbance, cognitive communication deficit, anxiety disorder, major depressive disorder, metabolic encephalopathy, and hypertension. Review of Resident #51's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #51's plan of care dated 03/17/23 revealed the resident received psychotropic medications including antidepressants, antianxiety medications, and antipsychotics related to her diagnosis of dementia with psychotic disturbance. Interventions included observing for side effects, administering medications as ordered, offering nonpharmalogical approaches, reviewing medication dosage, and psychiatry consult if ordered. Review of Resident #51's physician order dated 06/04/24 revealed an order for Quetiapine 25 milligrams (mg) one time a day (an antipsychotic) for crying and restlessness related to dementia. Review of Resident #51's nursing behavior documentation from 04/01/25 to 05/05/25 revealed the only behaviors indicated were restlessness on 04/29/25 and 04/30/25. Review of Resident #51's nurse aide behavior documentation from 04/01/25 to 05/05/25 revealed no behaviors were indicated. Review of Resident #51's progress notes dated 04/02/25, 04/23/25, and 05/03/25 revealed they identically discussed Resident #51's behaviors. Indicating she ambulated on the unit, took items and food, paced on the unit and refused to sit for extended periods of time. Additionally it was indicated she would try to talk with, touch, and kiss any male visitors. Review of Resident #51's progress notes from 04/01/25 to 05/05/25 revealed no documentation indicating specific instances of wandering, taking items, or invading visitors spaces. Observations on 05/05/25 at 2:00 P.M. and 4:51 P.M., and on 05/06/25 at 1:40 P.M. revealed Resident #51 wandering the unit. Interview on 05/06/25 at 1:22 P.M. with Regional Nurse #227 verified Resident #51 was on an antipsychotic for dementia, which was not an appropriate diagnosis. Additionally, verified that behavior documentation did not monitor when Resident #51 wandered despite it being a regular behavior. Interview on 05/06/25 at 2:13 P.M. with Licensed Professional Counselor (LPC) #235 revealed Resident #33's diagnoses included dementia, anxiety and major depression. LPC #235 reported the resident was always roaming the unit.

Based on interview and medical record review the facility failed to ensure the state was notified of a change in mental disease for Resident #28 and #51. This affected two residents (#28 and #51) of two residents reviewed for Preadmission Screening/Resident Review Identification Screen (PASARR). The facility census was 82. Findings include: 1. Review of Resident #28's medical record revealed an admitted [DATE] with diagnoses including dementia, epilepsy, bipolar disorder, other psychotic disorder, and dysphagia. In 2022 diagnoses of schizoaffective disorder and anxiety disorder were added and on 01/14/23 a diagnosis of major depressive disorder was added. Review of Resident #28's medical record revealed the last PASSAR was submitted 08/16/18 and indicated she had a mood disorder and insomnia. Interview on 05/06/15 at 10:40 A.M. with Regional Director of Social Services and Activities #229 verified a PASSAR was not completed when Resident #28's diagnoses changed and should have been. 2. Review of Resident #51's medical record revealed an admitted [DATE] with diagnoses including dementia with psychotic disturbance, cognitive communication deficit, and metabolic encephalopathy. On 03/16/23 major depressive disorder was added and on 10/27/24 anxiety disorder was added. Review of Resident #51's medical record revealed the last PASSAR was submitted on 10/03/22 she was not indicated as having any mental disorders. Interview on 05/06/15 at 10:40 A.M. with Regional Director of Social Services and Activities #229 verified a PASSAR was not completed when Resident #51's diagnoses changed and should have been.

Based on observation, medical record review, interviews and facility policy review, the facility failed to develop a comprehensive plan of care for two residents (#5 and #184) in the area of swallowing strategies and c-pap use. This affected two residents (#5 and #184) of 23 sampled residents. The facility was 82. Findings Include: 1. Review of the medical record for Resident #5 revealed an initial admitted [DATE] with the diagnoses including but not limited to cerebrovascular disease, fungal endocarditis, choledocholithiasis, Alzheimer's disease, hypothyroidism, obstructive and reflux uropathy, dysphagia, hyperlipidemia, seizures, chronic kidney disease, retention of urine, benign prostatic hyperplasia, abdominal aortic aneurysm, gastro-esophageal reflux disease and dementia. Review of the resident's hospital discharge summary dated 07/25/24 revealed the resident's diet order on discharge was to resume his home diet. Review of the Modified Barium Swallow (MBS) results dated 07/22/24 revealed the resident had evidence of trace penetration with nectar thick liquids, however no evidence of aspiration was seen. Recommendations were a pureed diet with honey thick liquids, no straws, medications one at a time, small bites/sips, gradual rate of intake and sit upright during all by mouth intake. The discharge summary indicated the resident's pre-assessment diet was pureed with honey thick liquids, no straws. Review of the resident's admission physician orders dated 07/25/24 revealed the resident's diet was regular pureed diet with nectar thick liquids and weekly weights for four weeks then monthly if weights are stable. Review of the plan of care dated 07/29/24 revealed the resident was at risk for altered nutrition related to urinary tract infection (UTI), candidal endocarditis, calculus of bile duct, hypothyroidism, hyperlipidemia, gastro-esophageal reflux disease, dementia, need for altered texture, diet, need for thickened liquids, dysphagia, speech therapy (ST) evaluation and treatment as needed, recommended gelato with lunch and dinner, 11/01/24 weight stable, intakes are fair to excellent, skin intact, 12/24/24 weight loss over the month significant, intakes are and remain excellent, will recommend to add another gelato at breakfast, 02/04/25 weight stable, skin intact, occasional refusals to be weighed, 04/24/25 weight loss now significant in six months, recommend to add eight ounces of Boost original supplement twice weekly. Inventions included offer menu alternatives as needed, honor food preferences as available and reasonable, monitor weekly weights for four weeks then monthly if stable, notify Registered Dietician (RD) and/or the physician if significant weight change over five percent, observe resident labs as available, review resident skin status, provide diet per physician order and supplements per physician orders. Further review of the plan of care revealed no recommended swallowing strategies. Review of the ST discharge summary dated 08/28/24 revealed the resident was discharged on a regular pureed diet with nectar thick liquids. The ST recommended the following swallowing strategies during oral intake, alternation of liquids/solids, bolus size modifications, effortful swallow and rate modification along with the following maneuvers, upright posture during meals. ST made no recommendations for a restorative program or functional maintenance program. The prognosis to maintain the current level of function was good with consistent staff follow through. Review of the resident's weights revealed on 11/22/24 the resident weighed 160.2 pounds, on 12/23/24 the resident weighed 151.4 pounds indicating an 8.8 pound or 5.49% weight loss in 30 days. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. On 05/07/25 at 4:15 P.M., an interview with Regional Nurse #227 confirmed the resident's plan of care did not contain his individualized swallowing recommendations. 2. Review of the medical record for Resident #184 revealed an initial admitted [DATE] encounter for orthopedic aftercare, status post left knee arthroscope, arthritis due to bacteria left knee, reduced mobility, gout, effusion of left knee, pulmonary embolism, presence of cardiac pacemaker, obstructive sleep apnea, hypertension, diabetes mellitus, chronic kidney disease, anemia, hypothyroidism, osteoarthritis, obesity, constipation, carpal tunnel syndrome, polyarthritis and vitamin D deficiency. Review of resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident did not utilize a non-invasive mechanical ventilator. Review of the resident's plan of care revealed no care plan addressing the resident's use of the c-pap. Review of the resident's physician orders revealed no orders for the c-pap machine. On 05/05/25 11:48 A.M., observation of the resident's c-pap machine revealed the c-pap mask was laying on floor under the bed with no protective bag. On 05/05/25 at 1:08 P.M., observation of the resident's c-pap machine revealed the c-pap mask remained on the floor under the resident's bed with no protective bag. On 05/06/25 at 2:34 P.M., an interview with Regional Nurse #227 confirmed the resident had no comprehensive plan of care for the c-pap use. Review of the facility policy titled, Care Planning Comprehensive, updated 05/01/25 revealed a baseline care plan is completed upon admission within 24 hours based on data available at the time of admission. A comprehensive care plan for each resident is developed within 21 days of admission to the facility. The comprehensive care plan is based on the resident's comprehensive assessment and is developed by members of the interdisciplinary team (IDT). The comprehensive care plan will be updated by a member of the IDT as changes in the resident's condition occurs. The comprehensive care plan will be reviewed by the IDT at least quarterly or when a significant change in condition occurs in which a MDS assessment is completed.

Based on observation, interview and medical record review, the facility failed to provide daily wound care as ordered for Resident #182. This affected one (Resident #182) out of one resident reviewed for skin impairment. The facility census was 82. Findings include: Review of Resident #182's medical record revealed she was admitted on [DATE] with diagnoses that included multiple fractures of the pelvis, falls, pustular psoriasis, diabetes mellitus type 2, moderate protein malnutrition, HLD and low back pain. Review of Resident # 182's physicians orders dated 05/01/25, revealed an order for SilvaSorb gel; cleanse right dorsal foot with IHWC (in house wound cleanser), pat dry, apply thin layer SilvaSorb and cover with foam dressing daily and as needed, and an order dated 05/02/25, to cleanse left lower extremity with IHWC (in house wound cleanser), pat dry, apply thin layer SilvaSorb to open wound bed, cover with non-adherent and wrap with kerlix daily and prn. Review of Resident # 182's care plan dated 05/03/25, revealed a pressure ulcer/injury care plan that stated the resident had pressure injuries to the left and right heels and pustular psoriasis to the left shin, and right top lateral foot with interventions in place. Review of Resident #182's May 2025 treatment administration record, revealed the treatment for Resident #182's right dorsal foot and left lower anterior extremity were signed by the nurse as completed on 05/06/25. Observation on 05/06/25 at 8:00 AM and 3:49 P.M. and on 05/07/25 at 9:50 A.M. revealed dressing to Resident #182's left foot and left leg and dressing to her right foot dated 05/05/25. Interview on 05/07/25 at 10:05 AM with Registered Nurse (RN) #139 confirmed Resident #182 had a left foot and leg dressing and a right foot dressing in place, dated 05/05/25. RN #139 also confirmed that wound treatments for Resident #182's left leg and right foot were daily dressings.

Based on observation, medical record review, interviews, review of Thrive Gelato (a frozen dessert that provides essential nutrients for people with unintended weight loss) nutritional facts and review of facility policy, the facility failed to develop and implement comprehensive and individualized interventions to prevent a significant weight loss for one resident (#5). Additionally, the facility failed to monitor weekly weights for one resident (#62) following a significant weight loss. This affected two resident (#5 and #62) of six residents reviewed for nutrition. The facility census was 82. Findings Include: 1. Review of the medical record for Resident #5 revealed an initial admitted [DATE] with the diagnoses including but not limited to cerebrovascular disease, fungal endocarditis, choledocholithiasis, Alzheimer's disease, hypothyroidism, obstructive and reflux uropathy, dysphagia, hyperlipidemia, seizures, chronic kidney disease, retention of urine, benign prostatic hyperplasia, abdominal aortic aneurysm, gastro-esophageal reflux disease and dementia. Review of the resident's hospital discharge summary dated 07/25/24 revealed the resident's diet order on discharge was to resume his home diet. Review of the Modified Barium Swallow (MBS) results dated 07/22/24 revealed the resident had evidence of trace penetration with nectar thick liquids, however no evidence of aspiration was seen. Recommendations were a pureed diet with honey thick liquids, no straws, medications one at a time, small bites/sips, gradual rate of intake and sit upright during all by mouth intake. The discharge summary indicated the resident's pre-assessment diet was pureed with honey thick liquids, no straws. Review of the resident's admission physician orders dated 07/25/24 revealed the resident's diet was regular pureed diet with nectar thick liquids and weekly weights for four weeks then monthly if weights are stable. Review of the plan of care dated 07/29/24 revealed the resident was at risk for altered nutrition related to urinary tract infection (UTI), candidal endocarditis, calculus of bile duct, hypothyroidism, hyperlipidemia, gastro-esophageal reflux disease, dementia, need for altered texture, diet, need for thickened liquids, dysphagia, speech therapy (ST) evaluation and treatment as needed, recommended Gelato with lunch and dinner, 11/01/24 weight stable, intakes are fair to excellent, skin intact, 12/24/24 weight loss over the month significant, intakes are and remain excellent, will recommend to add another Gelato at breakfast, 02/04/25 weight stable, skin intact, occasional refusals to be weighed, 04/24/25 weight loss now significant in six months, recommend to add eight ounces of Boost original supplement twice weekly. Inventions included offer menu alternatives as needed, honor food preferences as available and reasonable, monitor weekly weights for four weeks then monthly if stable, notify Registered Dietician (RD) and/or the physician if significant weight change over five percent, observe resident labs as available, review resident skin status, provide diet per physician order and supplements per physician orders. Further review of the plan of care revealed no recommended swallowing strategies. Review of the resident's discontinued physician orders identified an order dated 07/30/25 regular puree diet, nectar thick liquids and four ounces of Gelato with lunch and dinner. Review of the speech therapy (ST) evaluation dated 07/31/25 revealed the resident was referred for ST evaluation due to noted modified diet and dysphagia upon admission to facility. A MBS was completed on 07/22/24 with findings of poor oral control, no aspiration/penetration noted on honey thick liquids via teaspoon/cup, nectar thick liquids trace penetration during swallow on nectar thick liquids via cup, absent cough reflex, resident unable to clear with cued cough. The resident was given a soft diet and was unable to complete on any attempts. ST recommended nectar thick liquids with a pureed diet with the goals to increase the ability to safely swallow nectar thick liquids, increase his ability to safely swallow a mechanical soft/ground consistency diet, increase bolus control and tolerate the least restrictive diet safest for by mouth intakes. Review of a diet order dated 08/06/24 revealed the resident's diet was upgraded to mechanical soft, nectar thick liquids, supervision for meals, following a MBS conducted at the facility, however the facility had no documented evidence of the recommendations from the MBS. Review of the medical record revealed no evidence the weekly weight for 08/19/24 was obtained. Review of the ST discharge summary dated 08/28/24 revealed the resident was discharged on a regular pureed diet with nectar thick liquids. The ST recommended the following swallowing strategies during oral intake, alternation of liquids/solids, bolus size modifications, effortful swallow and rate modification along with the following maneuvers, upright posture during meals. ST made no recommendations for a restorative program or functional maintenance program. The prognosis to maintain the current level of function was good with consistent staff follow through. Review of the resident's weights revealed on 11/22/24 the resident weighed 160.2 pounds, on 12/23/24 the resident weighed 151.4 pounds indicating an 8.8 pound or 5.49% weight loss in 30 days. Review of the nutrition progress note dated 12/24/24 at 11:25 A.M. revealed the resident showed a significant weight loss in one month. The resident's body mass index (BMI) was under ideal weight for his age at 20.53. Recommendations were made to add a four ounce Gelato with breakfast also and a reweight. Review of the medical record revealed no evidence the reweight was obtained or that the nutritional supplement Thrive Gelato was being monitored for intake. Additionally, the medical record revealed the resident was not placed on weekly weights following the significant weight loss. Review of the therapy screen dated 02/07/25 revealed the resident and staff reported no changes at that time and the resident refused therapy services. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident had no know weight loss and weight 149 pounds. The assessment indicated the resident received a mechanically altered and therapeutic diet. Review of the resident's weights revealed on 11/22/24 the resident weighed 160.2 pounds, the resident weighed 151.4 pounds, on 01/16/25 the resident weighed 149.4 pounds, on 02/13/25 the resident weighed 145.2 pounds indicating a significant weight loss of 9.3% or 15 pounds, review of the medical record revealed no weight for March 2025, on 04/22/25 the resident weighed 139.8 pounds and on 05/06/25 the resident weighed 138.8 pounds indicating a significant weight loss of 13.36% or 21.4 pounds in six months. Review of the medical record revealed no documented evidence an individualized weight loss intervention was implemented following the 15 pound or 9.3% weight loss in three months. Further review revealed no weekly weights were implemented following the significant weight loss. Additionally, the medical record contained no documentation of the resident holding food and/or fluids in his mouth for extended periods of time. Review of the resident's monthly physician orders for May 2025 identified orders dated 04/28/25 eight ounces of boot twice daily nectar thick, 12/24/24 regular puree diet with nectar thick liquids and four ounces of Gelato with meals. On 05/06/25 at 10:38 A.M., observation of the resident upon opening the resident's door revealed the resident was still eating his breakfast and his mouth was full of food and/or fluids. The resident was encouraged to swallow, however the resident continued to hold the food and/or fluids in his mouth. On 05/06/25 at 10:45 A.M., interview with Licensed Practical Nurse (LPN) #125 revealed the resident always holds food in his mouth. The LPN indicated the resident had worked with therapy several times. On 05/06/25 at 1:12 P.M., an interview with Registered Dietician (RD) #233 confirmed the resident had a significant weight loss and had placed the resident on weekly weights and he was on the list to be weighed on 05/06/25. On 05/07/25 at 11:52 A.M., an interview with State tested Nursing Assistant (STNA) #206 revealed the resident had no specific swallowing strategies, however he was on thickened liquids. The STNA revealed the resident likes to keep his door shut, including during meals. The STNA revealed the resident does hold food/fluids in his mouth at times and she does assist him with removal prior to laying down in bed because it will get all over his bed. On 05/07/25 at 11:52 A.M., an interview with Registered Nurse (RN) #139 revealed the resident had no swallowing strategies and required no supervision with meals. The RN revealed the resident requires an extended time to eat due to his swallowing difficulties. On 05/07/25 at 12:15 P.M., an interview with Speech Therapist (ST) #236 revealed she worked with the resident a handful of time. The ST revealed the resident was discharged with the following swallowing strategies swallowing strategies during oral intake, alternation of liquids/solids, bolus size modifications, effortful swallow and rate modification along with the following maneuvers, upright posture during meals. She said education is provided to the nurse the day of discharge from therapy to educate the aides. On 05/07/25 at 12:19 P.M., an interview with the Therapy Director (TD) #237 revealed the resident was screened in February 2025 and had no issues. The TD revealed they ask the staff and the resident questions for a decline or any problems. The TD revealed the therapy department had no observed the resident eat for the screen conducted in February 2025. On 05/07/25 at 2:30 P.M., an interview with the Director of Nursing (DON) revealed the facility does not track intake of any supplement that comes with the resident's meals as they consider the supplement part of the fortified meal. On 05/07/25 at 2:37 P.M., an interview with the DON revealed he had spoke with RD #233 and the RD placed the resident on the Thrive Gelato nutritional supplement on admission due to the resident receiving nectar thick liquids and because it was part of the fortified foods. The DON revealed the RD indicated the resident was not on the Thrive Gelato nutritional supplement for weight loss. On 05/07/25 at 3:32 P.M., an interview with the Dietary Manager (DM) #194 and the Director of Nutritional Services (DNS) #225 revealed the Thrive Gelato nutritional supplement was considered a fortified food not a supplement so the amount the resident consumed was not documented. DM #194 revealed the resident previously ate in the main dining room for supervision and assistance, however now he prefers to eat in his room and she thought he received supervision and assistance in his room. The DNS #225 revealed he would have expected a resident to be placed on weekly weights with a significant weight loss of 8.8 pounds in one month. On 05/07/25 at 4:15 P.M., an interview with Regional Nurse #227 confirmed the resident was not placed on weekly weights by RD #233 until 04/22/25 despite the significant weight loss. The Regional Nurse also confirmed the weekly weight on 04/29/25 was not obtained and the resident's plan of care did not contain his individualized swallowing recommendations. On 05/07/25 at 4:50 P.M., an interview with the Regional Nurse #227 confirmed the reweight was not obtained as recommended on 12/24/24. 49039 2. Review of the medical record for Resident #62 revealed an admitted [DATE], with diagnoses including urinary tract infection, moderate protein-calorie malnutrition, abnormal weight loss, and type two diabetes mellitus. Review of weight record for Resident #62 revealed on 03/17/2025, the resident weighed 215.6 lbs. On 04/14/2025, the resident weighed 190.8 lbs, which reflects an 11.50% loss. Review of care plan dated 03/20/25 revealed the resident is at risk for altered nutrition related to urinary tract infection, candidal sepsis, impaired skin integrity, diabetes, edema, obesity, and the need for a therapeutic diet. The resident's care approaches included offering menu alternatives as needed, honoring food preferences, monitoring weekly weights for four weeks then monthly if stable, and notifying the registered dietitian and physician if there is a significant weight change over five percent. Review of minimum data set (MDS) 3.0 assessment completed on 03/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident #62 was cognitively intact. Review of Section K: Swallowing/Nutritional Status revealed she receives a therapeutic diet. Review of progress note dated 04/10/25, completed by Dietitian #233, revealed Resident #62 exhibited significant weight loss over the past week, with varied intakes. Current interventions included Carb ProSource and Glucerna once daily. A reweight was suggested by Dietitian #233. Review of weight record for Resident #62 revealed a follow up weight was not completed until 04/14/24, showing an additional 6.8 pound weight loss. Review of progress note dated 04/17/25, completed by Dietitian #233, revealed Resident #62 ' s intakes remained poor/varied, ranging from 1-100% of meals eaten. The resident was declining Carb ProSource twice daily, and acceptance of Glucerna varied. The dietitian recommended initiation of an appetite stimulant. Review of physician visit dated 04/22/25 revealed complaints of nausea. A trial of Reglan (anti-emetic), 5 milligrams four times a day for one week, was ordered. No additional recommendations were made. Interview on 05/06/25 at 12:18 P.M. with Dietitian #233 confirmed Resident #62 triggered for significant weight loss on 04/14/25. She confirmed the requested reweight's were not completed. Additionally, facility staff did not continue to obtain the weekly weights after the significant weight change. Dietitian #233 confirmed per facility policy, residents exhibiting a weight change greater than five percent in one month are to receive weekly weights until the next evaluation. She also confirmed that on 04/17/25, an initial recommendation to implement an appetite stimulant was made and communicated to the physician. Interview on 05/07/25 at 8:21 A.M. with Medical Doctor #240 confirmed he was notified of the significant weight loss. To prevent further weight loss, Reglan was ordered. He confirmed continuing weekly weights would have been beneficial in closely monitoring the resident ' s weight changes. However, he did not feel the weight change was of great concern due to the resident ' s obesity status, but stated the resident would benefit from a controlled and gradual weight loss. Review of the facility policy titled, Weight/Reweight Policy, updated on 05/01/25 revealed a resident's weight will be monitored to evaluate the resident's nutrition status within the parameters of the resident's overall medical condition. A resident's weight will be obtained and recorded in the electronic medical record (EMR) by the nursing staff. A resident's weight will be obtained weekly for a minimum of four weeks for the following situations, new admissions, readmissions, pressure injuries, significant unplanned weight loss of five percent or greater, 10% or greater in six months or determined by the skin and weight assessment team (SWAT). Nursing staff will be notified of residents requiring weekly weights by the SWAT. A monthly weight will be obtained by the nursing staff for all residents in the facility unless the physician determines it is contraindicated. A member of the dietary staff will notify the nursing staff when a re-weigh on a resident is indicated. Re-weighing of a resident may be indicated when there is a plus/minus weight change of five pounds when the resident is over 100 pounds or a plus/minus of three pounds when the resident is under 100 pounds. All weights will be documented in the clinical record.

Based on observation, interview, review of medical record, and review of facility policy the facility failed to have physician orders in place for Resident #184's Bilevel Positive Airway Pressure (BiPAP) and failed to ensure oxygen orders were followed and oxygen administration was documented for Resident #33. This affected two residents (#33 and #184) of three residents reviewed for respiratory care. The facility census was 82. 1. Review of Resident #33's medical record revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, moderate protein- calorie malnutrition, unspecified dementia, generalized anxiety disorder, dysphagia, major depressive disorder, and altered mental status. Review of Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed resident was rarely or never understood. He received oxygen therapy. Review of Resident #33's physician order dated 09/24/23 revealed an order for continuous oxygen at two liters via a nasal cannula as needed. Nursing was to check the placement and record his oxygen concentration every shift. Review of Resident #33's hospice recertification revealed they indicated he was on oxygen continuously at two liters. Review of Resident #33's Medication Administration Record (MAR) from 04/08/25 to 05/06/25 at 1:43 P.M. revealed oxygen had not been documented as having been used. Review of Resident #33's plan of dated 04/09/25 revealed the resident had a potential for alteration in respiratory function related to chronic obstructive pulmonary disease, acute respiratory failure, congestion, and aspiration history. Resident #33 required encouragement to wear oxygen and he preferred not to wear it at times. Interventions included recording oxygen saturation once a month on room air, medications as ordered, oxygen as ordered, respiratory treatment as ordered, encouraging fluids, encouraging to cough and deep breathe, and labs as ordered. Review of Resident #33's progress note dated 04/12/25 revealed the resident was receiving oxygen at three liters per minute. Review of Resident #33's progress note dated 04/17/25 revealed the resident was receiving oxygen at three liters per minute. Review of Resident #33's progress note dated 04/26/25 revealed the resident was receiving oxygen at three liters per minute. Review of Resident #33's progress note dated 04/28/25 revealed the resident was receiving oxygen at three liters per minute. Review of Resident #33's progress note dated 05/05/25 revealed the resident was receiving oxygen at three liters per minute. Observation on 05/05/25 at 9:57 A.M. and 11:30 A.M. and on 05/06/25 at 9:00 A.M. and 1:40 P.M. revealed Resident #33 had oxygen in place. Interview on 05/06/25 at 1:40 P.M. with Program Director #202 verified Resident #33 was wearing oxygen and had been all day. She reported his order was technically as needed, however, he wore it most of the time for comfort. Program Director #202 verified his oxygen use was not indicated in the MARs. Interview on 05/06/25 at 4:55 P.M. with Regional Nurse #227 revealed she clarified Resident #33's oxygen order with hospice and should be receiving two to four liters continuously. 32654 2. Review of the medical record for Resident #184 revealed an initial admitted [DATE] encounter for orthopedic aftercare, status post left knee arthroscope, arthritis due to bacteria left knee, reduced mobility, gout, effusion of left knee, pulmonary embolism, presence of cardiac pacemaker, obstructive sleep apnea, hypertension, diabetes mellitus, chronic kidney disease, anemia, hypothyroidism, osteoarthritis, obesity, constipation, carpal tunnel syndrome, polyarthritis and vitamin D deficiency. Review of resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident did not utilize a non-invasive mechanical ventilator. Review of the resident's plan of care revealed no care plan addressing the resident's use of the c-pap. Review of the resident's physician orders revealed no orders for the c-pap machine. On 05/05/25 11:48 A.M., observation of the resident's c-pap machine revealed the c-pap mask was laying on floor under the bed with no protective bag. On 05/05/25 at 1:08 P.M., observation of the resident's c-pap machine revealed the c-pap mask remained on the floor under the resident's bed with no protective bag. On 05/05/25 at 1:11 P.M., an interview with the Director of Nursing (DON) verified the resident's c-pap mask was not stored appropriately laying on the floor under the resident's bed with no protective bag in place. On 05/06/25 at 2:34 P.M., an interview with Regional Nurse #227 confirmed the resident had no orders for the use and monitoring of the c-pap machine. Review of the facility policy titled, Respiratory CPAP/BIPAP, updated 05/01/25 revealed it was the facility's policy to utilize professional standards of practice when utilizing a CPAP/BiPAP to meet the resident's clinical needs. Verify there is a physician's order for the device that includes the settings for the machine. Monitor the resident's tolerance to the device and document abnormalities in the clinical record.

Based on interview and medical record review the facility failed to ensure the physician gave a clear reason why a pharmacy recommended gradual dose reduction (GDR) was not performed on residents with psychotropic's. This affected two residents (#28 and #51) of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: 1. Review of Resident #51's medical record revealed an admitted [DATE] with diagnoses including dementia with psychotic disturbance, cognitive communication deficit, anxiety disorder, major depressive disorder, metabolic encephalopathy, and hypertension. Review of Resident #51's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #51's pharmacy recommendation dated 09/19/24 revealed the pharmacist recommended trialing a decrease of Quetiapine (an antipsychotic) to 25 milligrams (mg) every other day for seven days due to no documented behaviors on MDS and a dementia diagnosis. The physician indicated there would be no changes, no reason why was indicated. Review of Resident #51's pharmacy recommendation dated 12/16/24 revealed the pharmacist recommended trialing a decrease of Quetiapine to 25 milligrams (mg) every other day for seven days due to no documented behaviors on MDS and a dementia diagnosis. The physician indicated there would be no changes per the families request. Review of Resident #51's pharmacy recommendation dated 03/15/25 revealed the pharmacist recommended trialing a decrease of Quetiapine to 25 milligrams (mg) every other day for seven days due to no documented behaviors on MDS and a dementia diagnosis. The physician indicated there would be no changes per the families request. Interview on 05/06/25 at 8:41 A.M. with the Director of Nursing (DON) verified the GDR's were declined with either no reasoning or no medical reasoning. 2. Review of Resident #28's medical record revealed an admitted [DATE] with diagnoses including dementia, epilepsy, hypertension, bipolar disorder, cognitive communication deficit, other psychotic disorder not due to a substance or known physiological condition , other specified depressive episodes, major depressive disorder, anxiety disorder, schizoaffective disorder, and dysphagia. Review of Resident #28's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #28's pharmacy recommendation dated 06/05/24 revealed the pharmacist recommended a gradual dose reduction as the resident was taking Duloxetine (an antidepressant) 60 mg and Olanzapine (an antipsychotic) 5 mg. The pharmacist indicated if a GDR was contraindicated a reasoning should be provided. The physician declined the recommendation but did not indicate the reasoning. Review of Resident #28's pharmacy recommendation dated 01/16/25 revealed the pharmacist recommended a dose reduction of Olanzapine to 2.5 mg every day. The physician indicated no change per the resident and family request. Interview on 05/06/25 at 8:41 A.M. with the Director of Nursing (DON) verified the GDR's were declined with either no reasoning or no medical reasoning.