Every finding on record at Maple Healthcare

Based on observation, interview, record review, facility document review, and facility policy review, it was determined that facility failed to ensure residents were free from physical and psychosocial harm for 2 (Resident #5 and 23) of 3 residents reviewed for abuse. The findings include: A review of an admission Record indicted the facility admitted Resident #25 with a diagnosis of dementia with agitation and delirium. A review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/22/2025 revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The MDS also indicated the resident had exhibited physical behavioral symptoms towards others. A review of Resident #25 ' s Care Plan revealed it was noted on 03/03/2025 the resident had the potential to be physically aggressive. A review of an admission Record revealed the facility admitted Resident #5 with a diagnosis of epilepsy (a disorder where nerve cell activity in the brain is disturbed causing seizures). The quarterly MDS with an ARD of 04/12/25 revealed Resident #5 had a BIMS score of 15, which indicated the resident was cognitively intact. A review of a facility incident report, dated 05/10/25 at 4:00 PM and completed by Registered Nurse (RN) #4, revealed: Resident #25 was removed from Resident #5 ' s room after an aide stated Resident #25 had struck Resident #5. RN #4 entered Resident #5 ' s room and observed Resident #5 holding the right side of the resident ' s face. When asked if they could explain what happened, Resident #5 stated, [Resident #25] came in here and was getting onto me and slapping me and hitting me. Resident #5 indicated Resident #25 had struck them in the stomach. Immediate action: Residents were separated with Resident #25 taken to the dayroom for closer observation. At 7:38 PM the Director of Nursing (DON) was notified of the incident between Resident #5 and #25. At 8:36 PM the Medical Director was notified of the incident between Resident #5 and #25. At 8:39 PM the Administrator was notified of the incident between Resident #5 and #25. A statement from Certified Nursing Assistant (CNA) #1 revealed she was in a resident room when she heard Resident #5 screaming. CNA #1 ran to Resident #5 ' s room and witnessed Resident #25 slapping Resident #5. When staff attempted removing Resident #25, Resident #25 hit Resident #5 on their right arm. A statement from CNA #2 revealed they were in another resident room when yelling was heard. CNA #2 went into Resident #5 ' s room and witnessed Resident #25 hitting Resident #5 and taking linens off Resident #5 ' s bed. CNA #2 moved Resident #25 to the dayroom and told the nurse. A stop sign was placed at Resident #5 ' s door to prevent other residents from entering the room. Facility training was completed with staff regarding abuse, neglect, and dementia. During an interview on 06/02/25 at 11:37 AM, Resident #5 stated, [Resident #25] came in and hit my arm and made a big bruise. I don't know why [Resident #25] came in, [Resident #25] just walked in here. During an interview on 06/04/2025 at 12:52 PM, Resident #5 revealed that they were going into their room and getting out of their wheelchair. Resident #5 stated, [Resident #25] walked in and hit my arm and left a big bruise on my arm. I pushed my call light, and the nurse came and got them. Resident #5 reported feeling scared and pain when they were being hit. Resident #5 verbalized telling the Social Director about the bruise. During an interview on 06/04/2025 at 10:53 AM, CNA #1 verified that she witnessed Resident #25 slapping Resident #5 two or three times, and punching them on the arm one time. Resident #25 was trying to take the linens off Resident #5 ' s bed and Resident #5 was stating, No, no, no. CNA #1 confirmed that they put a stop sign across Resident #5 ' s door so Resident #25 couldn't come in and sat Resident #25 alone and kept them away from everybody. CNA #1 confirmed Resident #5 had a bruise on their right arm and their face was red after the incident. CNA #1 said they reported the incident immediately. During an interview on 06/04/25 at 1:42 PM, CNA #1 verbalized that the bruise to Resident #5 ' s right arm was from the same day of the incident on 05/10/2025. During an interview on 06/04/2025 at 5:07 PM, CNA #1 verbalized that depending upon the day, somedays Resident #25 wandered, slept, or was angry. Resident #25 also hit and yelled out. When Resident #25 has behaviors, we leave them alone and let them calm down, the behaviors don't last long. During an interview on 06/03/25 at 1:31 PM, License Practical Nurse (LPN) #3 verbalized that a stop sign had been placed on Resident #5 ' s door to ensure safety. During an interview on 06/04/2025 at 12:20 PM, LPN #3 revealed Resident #5 had a bruise from an incident on 05/10/2025. LPN #3 stated, There was a whole reportable, I thought, I informed the MDS Coordinator and the DON regarding the bruise. During an interview on 06/04/2025 at 5:09 PM, LPN #3 verbalized that with perineal care and personal care Resident #25 often became agitated, and stated the resident did wander. During an interview on 06/04/25 at 6:53 PM, RN #4 stated, [Resident #25] went into [Resident #5 ' s] room. [Resident #5] was saying that they got hit in the stomach or arm, but I can't remember. RN #4 stated, I want to say they put the stop sign on the door that Monday. RN #4 stated, We would just watch [Resident #25] as close as we can. [Resident #25] can become aggressive, labile, and hard to predict. Resident #25 is aggressive. They doesn't like any kind of self-care and tend to get violent with the staff and has behaviors all the time. During an interview on 06/03/25 at 8:13 AM, the DON verbalized that a report for Resident #25 striking Resident #5 was completed, and immediate separation between the two residents was done. Resident #25 was placed on one-on-one supervision, and a stop sign was place on Resident #5 ' s door. Resident #5 was educated to immediately come out and get a staff member if someone came into their room. During an interview on 06/04/2025 at 9:50 AM, the DON verbalized a reportable was not done due to there being no injuries. During an interview on 06/04/2025 at 11:03 AM, the Administrator verified a CNA witnessed Resident #25 slapping Resident #5 ' s cheek. She confirmed that a stop sign was placed the next day. A review of an admission Record indicated the facility admitted Resident #23 with Alzheimer's disease (progressive disease that destroys memory and other important mental functions). The admission MDS with an ARD of 04/16/2025, revealed resident #23 had a BIMS score of 06, which indicated the resident had severe cognitive impairment. A review of a facility reportable, dated 05/27/25 at 6:40 AM and completed by RN #4, revealed: CNA #5 was in another room when they heard someone screaming. CNA #5 observed Resident #25 striking Resident #23 with a cane. CNA #5 attempted to stop Resident #25, but Resident #25 attempted to hit CNA #5 with the cane. CNA #5 was able to get Resident #25 to put the cane down and then called for assistance from CNA #6. Both CNA #5 and #6 were unsuccessful in removing Resident #25 from the room. RN #4 was contacted by CNA #6. When RN #4 entered the room, Resident #25 became aggressive towards RN #4 while the RN was removing Resident #25 from the room. Resident #23 verbalized to RN #4, [Resident #25] came in here, took my cane from me, and began hitting me with it over and over. RN #4 assessed Resident #23 and found discoloration to the right lower extremity in the shin area. A witness statement from CNA #5 revealed she heard someone screaming. CNA #5 reported Resident #25 was in Resident #23 ' s room hitting them with their cane. CNA #5 came in and tried to stop them. CNA #5 revealed, [Resident #25] was trying to hit me. CNA #5 got Resident #25 to put the cane down and then got CNA #6, who went and got RN #4. A witness statement from CNA #6 revealed Resident #25 hit Resident #23 on the legs with the cane. CNA #6 then went to get RN #4 to assist in removing Resident #25 from the room. A witness statement from RN #4 revealed Resident #25 took Resident #23 ' s cane and began hitting Resident #23 with it. RN #4 removed Resident #25 from the room. A witness statement from Resident #23 indicated the resident stated, I was lying in bed and heard my bedroom door open and noticed that it was [Resident #25]. I grabbed my cane that was on my bedside drawer by my bed and pointed it at them and told them to get out. They kept walking towards me and grabbed my cane and hit me several times over my legs with my cane. During an interview and observation on 06/05/2025 at 10:50 AM, Resident #23 was seen with three bruises that were yellowish in color to their right knee. Resident #23 reported Resident #25 beat them with a cane, striking them 5 or 6 times. Resident #23 reported being shocked by the attack, stating, I wasn't thinking about getting hit in a place like this. It irritated me that they had people walking around doing that. Resident #23 reported that no staff were around when it happened. I'm cautious when I walk out the room. I don't feel free to just stroll down the hall anymore. I don't know why they choose me to attack. I don't know if I looked vulnerable or what. I'm not sure what their thought process was. A review of Resident #23 ' s skin observation, dated 05/27/2025 at 8:15 AM, revealing bruising to right lower front leg. A review of Resident #23 ' s skin observation, dated 05/28/2025 at 8:33 AM, revealed bruising to right lower front and rear leg and front of right knee. During an interview on 06/05/2025 at 11:34 AM, CNA #6 revealed that Resident #23 seemed to be nervous following the incident. CNA #6 reported doing a facility training on the incident after it happened. During an interview on 6/05/2025 at 11:47 AM, RN #4 revealed Resident #25 was sent out as an immediate intervention to ensure safety for residents affected and other residents on the unit. RN #4 reported Resident #25 was a one-on-one supervision for a couple of days. RN #4 reported Resident #23 had a bruise on the side of their right leg following the incident. During an interview on 06/05/25 at 11:38 AM, the DON verified that Resident #23 reported another resident struck them, took their cane from them, and began hitting them over and over. During an interview on 06/05/25 at 11:55 AM, the Administrator reported the incident between Resident #25 and Resident #23 seemed to be an isolated incident. The Administrator reported to be working on allowing that hall to have its own nurse. She confirmed that it was important to ensure proper interventions were in place for all residents that have potential for harm to insure all residents' safety. Review of an undated policy titled, Abuse policy, indicated All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown sources (abuse) shall be immediately reported to the administrator/designee and the Director of Nursing and promptly reported to local, state, and federal agencies (as defined by current regulations). These allegations will be thoroughly investigated by the facility management and the findings for abuse investigations will be reported as per local, state, and federal regulations.

Based on interview, record review, and facility policy review, it was determined that the facility failed to report a resident-to-resident altercation to the Office of Long-Term Care for two (Resident #5 and Resident #25) of two residents reviewed for abuse. The findings included: 1. A review of Resident #5 ' s admission Record indicted the facility admitted the resident with diagnoses of intellectual disabilities and history of traumatic brain injury, which included epilepsy. a. A review of Resident #5 ' s quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact mental cognition. b. A review of Resident #5 ' s, Care Plan, initiated 12/18/2022, indicated the resident was deemed appropriate for placement on the memory care unit. The Care Plan also revealed interventions, with an initiation date of 02/18/2025, which directed staff to redirect the resident when exit seeking or if there was an altercation with another resident, speak directly with resident in a calm manner with short sentences and simple questions, attempt task again in a calm manner, when or if the resident becomes agitated or combative. 2. A review of Resident #25 ' s admission Record indicted the facility admitted the resident, with diagnoses which included moderate vascular dementia. a. A review of Resident #25 ' s quarterly MDS with an ARD of 05/22/2025, revealed the resident had a BIMS score of 03, which indicated severe cognitive impairment. b. A review of Resident #25 ' s, Care Plan, revised 03/03/2025, revealed the resident had the potential to be physically aggressive. The Care Plan also revealed interventions, with initiation dates of 03/03/2025 and 03/26/2025, that directed staff to redirect resident, intervene before agitation escalates, redirect from source of distress, utilize calm conversations with resident. If resident is aggressive, walk away and attempt later. 3. During an interview on 06/02/2025 at 11:37 AM, Resident #5 stated, [Resident #25] came in (into Resident #5 ' room) and hit my arm and made a big bruise. I don't know why .they just walked in here. 4. During an interview on 06/04/2025 at 9:50 AM, the Director of Nursing (DON) revealed that there was not a reportable done with Resident #5 and Resident #25 due to no injuries. She verbalized her last training, regarding abuse was a week ago. 5. During an interview on 06/04/2025 at 10:53 AM, Certified Nursing Assistant (CNA) #1 stated, I witness them [Resident #25] slapping [Resident #5] two or three times and punched them on the arm one time. [Resident #25] were trying to take covers off [Resident #5 ' s] bed and [Resident #5] was saying, No, no, no. CNA #1 verbalized they had informed administration immediately following the incident. 6. During an interview on 06/04/2025 at 12:20 PM, Licensed Practical Nurse (LPN) #3 revealed Resident #5 had a bruise from an incident on 05/10/2025. LPN #3 stated, There was a whole reportable, I thought, and I informed the MDS Coordinator and DON regarding the bruise. 7. During an interview on 06/04/2025 at 12:52 PM, Resident #5 reported feeling scared during the time of the incident, and pain when struck. Resident #5 revealed they had a bruise from the hit and had informed the Social Director of the incident. 8. During an interview on 06/04/2025 at 1:42 PM, CNA #1 confirmed the bruise to Resident #5 ' s right arm was from the same day of the incident, on 05/10/2025. 9. During an interview on 06/05/25 at 4:11 PM, the Medical Director revealed that he was not notified of the incident that happened on 05/10/2025. He verbalized that there was an on call that could have been notified. 10. A review of a facility Incident Report, dated 05/10/2025, indicated Resident #5 was gotten onto and hit and slapped by Resident #25. The incident report revealed the DON was notified of the incident on 05/10/2025 at 7:38 PM, and the Administrator was notified of the incident on 05/10/2025 at 8:39 PM. 11. A review of a facility, Abuse and Neglect and Dementia training, dated 05/27/2025, acknowledged with staff listed above stating Investigate and report any allegations of abuse within timeframes as required by federal requirements. 12. A review of an undated facility policy titled, Abuse Policy, indicated All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown sources (abuse) shall be immediately reported to the Administrator/Designee and the Director of Nursing [DON] and promptly reported to local, state, and federal agencies (as defined by current regulations).

Based on observation, record review and interview, the facility failed to ensure dietary staff washed their hands during meal preparation to decrease the potential for contaminating food items for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect all 30 residents (Census: 30) as documented on a list provided by the Director of Nursing (DON) on 3/7/24. The findings are: 1. On 3/6/24 at 10:15 AM, Dietary Employee (DE) #1 prepared a few pans of pizza. DE #1 removed the gloves, picked up a resealable plastic bag and with the right hand, used a black permanent marker to write something on the bag. Without washing her hands, DE #1 put a glove on the right hand, held the resealable plastic bag in the left ungloved hand, and used the right gloved hand to remove left over cheese from a metal pan and place it inside of the resealable plastic bag, sealed the bag and placed it in the refrigerator. 2. On 3/6/24 at 10:27 AM, DE #1 retrieved a bag of sealed lettuce from a refrigerator. Without washing hands, DE #1 put on a pair of gloves, picked up a pair of scissors with the right gloved hand and held the bag with the gloved left hand. DE #1 cut the top of the bag open with the scissors and laid the scissors down and with the same right gloved hand. DE #1 removed a handful of lettuce and placed it in a blender, then placed the top onto the blender with the left hand. DE #1 used the right gloved hand to pulse the blender to chop up the lettuce. After DE #1 had prepared the lettuce and placed it in a metal bowl, DE #1 removed the gloves, placed a piece of aluminum foil over the bowl, used a black permanent marker in the right hand, wrote on the foil and then placed the bowl in the refrigerator. DE #1 took another metal bowl, poured the remaining lettuce from the bag in the bowl and without washing hands put on clean gloves, opened a bag of carrots, and poured them in the bowl. Without washing hands or changing gloves, DE #1 took both hands and placed them in the salad and began to mix the lettuce and carrots together. 3. On 3/7/24 at 10:47 AM, the Dietary Manager was asked, Tell me when do you all wash your hands when you're in the kitchen? The Dietary Manager stated, We always wash our hands when we enter the kitchen, before pulling clean dishes, before touching any food, anytime you handle raw meat or veggies and before and after you take off your gloves. The Dietary Manager was asked what should have been done when a dietary employee puts on gloves and picks up scissors with the gloved right hand while holding a bag of lettuce with the left hand, cut the bag open with the scissors using the right gloved hand, opened the bag and then began using the same gloved right hand to remove lettuce from a bag and place it in a blender. The Dietary Manager stated, [DE #1] forgot to take [DE #1's] gloves off and wash [DE #1's] hands and put on clean gloves before touching the lettuce. The Dietary Manager was asked, What should have been done after a dietary employee took off the gloves, picked up a resealable plastic bag with the left hand and picked up a permanent black marker with the right hand, wrote on the resealable plastic bag, put a glove on the right hand and picked up the left over cheese from a pan and placed it in the resealable plastic bag The Dietary Manager stated, She should've taken her glove off, washed her hands and put clean gloves on before picking up the cheese. 4. A Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices policy provided by the DON on 3/7/24 documented, .6. Employees must wash their hands: .g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks . 10 .The use of disposable gloves does not substitute for proper handwashing .

Based on observation record review, and interview, the facility failed to ensure a resident was assessed and deemed safe for self-administration of medications for 1 (Resident #23) of 1 sampled resident whose medication was left at the bedside. The findings are: The Care Plan with a revision date of 01/24/24 did not address self-administration of medications. The March 2024 Physician Orders did not address self-administration of medications. The March 2024 Medication Administration Record revealed Resident #23 was to receive a nebulizer (updraft) treatment, diuretic, antidepressant, antibiotics, pain, steroid, heart and immunodeficiency medications each morning. On 3/5/24 at 8:31 AM, Resident #23 had a medication cup with 11 pills, a medication cup with a crushed substance and particles with a spoon in it and a clear liquid in the chamber of the nebulizer. Resident #23 was lying on the left side turned away from the medications. On 3/5/24 at 8:32 AM, Licensed Practical Nurse (LPN) #2 was asked if there was anyone who was assessed to self-administer medication. LPN #2 stated, No. On 3/5/24 at 8:33 AM, LPN #2 was asked to accompany the Surveyor to Resident #23's room and to look on the bedside table and explain what he/she saw. LPN #2 stated, It's [Resident #23's] meds [medications] that I gave [the resident]. [The resident] hasn't taken them. I shouldn't leave them without making sure [the resident] swallowed them because a confused resident might wander in there and take them. The Surveyor asked about the liquid in the nebulizer chamber. LPN #2 stated, Yes, that's [Resident #23's] updraft medication. [The resident] didn't finish it. On 3/7/24 at 9:06 AM, the Director of Nursing (DON) was asked if the facility had anyone who is assessed for self-administration. The DON stated, No. The DON was asked to explain what she expected the nurses to do during medication pass once the medication had been prepared for an individual resident. The DON stated, Stay with them till all meds are taken. The DON was asked if the medication should ever be left at the bedside. The DON stated, No; someone one else could go in and take them, the resident could choke on them or not take them or accumulate them and take them all at once.

Based on record review and interview, the facility failed to ensure a psychotropic medication was not used on a PRN (as needed) basis for more than 14 days and without a documented rationale by a provider to promote or maintain the highest practicable mental, physical, and psychosocial wellbeing for 1 (Resident #25) of 2 (Residents #20 and #25) sampled residents who had physician's orders for Ativan on a PRN basis. The findings are: 2. Resident #25 had diagnoses of Alzheimer's Disease, Anxiety Disorder and Dementia. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/12/24 documented the resident had a Staff Assessment of Mental Status (SAMS) score of 3 (03-indicates severely impaired). a. A Physician's Order dated 02/02/24 documented, .Ativan 0.5 mg [milligrams] PO [by mouth] Q [every] 8 hr [hours] prn . There was no end date for this medication. b. A Care Plan revised on 2/27/24 documented, .Resident is at risk for side effects and complications of psychotropic drug use R/T [related to] Dementia with Behavior Disturbance, Depression and anxiety . Antianxiety Medication- Monitor for slurred speech, drowsiness, dizziness, N/V [nausea/vomiting], aggressive / impulsive behavior . Monitor use of medications and assess the need for and make recommendations to physician for psychotropic drug reductions per policy . c. The March 2024 electronic Medication Administration Record (MAR) documented Resident #25 received one PRN dose of Ativan 0.5 mg on 3/1/24, 3/2/24 and 3/4/24 to 3/7/24 and two doses on 3/3/24. d. On 3/7/34 at 2:00 PM, a review of Resident 25's Progress Notes from 2/12/24 to 2/20/24, noted on 2/12/24 at 9:33 PM there was a pharmacy note that documented, Chart reviewed. See report for recommendations. There was no documentation from the provider for a rationale to continue Ativan 0.5 mg on a PRN basis or an end date for the medication. e. On 3/07/24 at 2:07 PM, the Director of Nursing (DON) provided a copy of a Note to Attending Physician that was printed 2/12/24 and signed on 2/20/24 which documented, .No change . There was no end date or rationale for continuing the medication documented on this form for the Ativan PRN. The DON was asked, Who does these forms [A Note to Attending Physician] go to? The DON said, the Pharmacist sends them to me and I send them to (Medical Doctor), and the medical doctor signs them and sends them back.

Based on observation, record review and interview, the facility failed to ensure fingernails were cleaned and trimmed and facial hair was shaved to promote good personal hygiene and grooming for 1 (Resident #12) of 6 sampled residents who required assistance with nail care and 1 (Resident #12) of 4 sampled residents who required assistance with shaving on the secured unit. The findings are: Resident #12 had diagnoses of Unspecified Dementia and Unspecified Lack of Coordination. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/24/24 documented the resident had a Brief Interview of Mental Status (BIMS) scored of 05 (00-07 indicates severely impaired) and required partial to moderate assistance with personal hygiene. a. A Care Plan last revised on 1/29/24 documented, .offer and assist [Resident #12] with showers 2 times weekly, PRN [as needed] and upon request . If [Resident #12] refuses care, approach at a later time and offer care . Keep Nails Smooth, Clean & [and] Trimmed, (Hands & Feet). Report To Nurse PRN Inability To Trim Nails D/T Thickness . b. An ADL Bathing-Shower form documented Resident #12 received physical help with a bathing activity on 2/23/24 and 3/1/24 and refused 2/27/24. There was no documentation from 3/1/24 to 3/6/24 regarding bathing activity. c. On 3/04/24 at 10:21 AM, Resident #12 was awake and sitting up on the side of the bed. The fingernails on both hands had a dark substance underneath them and were greater than a quarter (1/4) inch in length from the fingertip. There was facial hair on the resident's cheeks, chin and neck that was greater than 1/4 inch in length. d. On 3/05/24 at 10:47 AM, Resident #12 was in the dayroom sitting up in a recliner. The fingernails on both hands were greater than 1/4 inch in length from the fingertip and facial hair greater than 1/4 inch in length on the resident's cheeks, chin and neck. e. On 3/06/24 at 08:32 AM, Resident #12 was sitting up in a recliner in the dayroom. There was facial hair to Resident #12's cheeks, chin and neck that was greater than 1/4 inch in length and the fingernails on both hands were greater than 1/4 inch in length from the fingertip. f. On 3/6/24 at 3:08 PM, Certified Nursing Assistant (CNA) #1 confirmed that he/she was familiar with [Resident #12]'s plan of care and that nail care and shaving was offered to residents on their shower days or when they want it. She added they clean the fingernails when they see it's needed and the charge nurse was informed if a resident refused nail care or to be shaved and that they documented this when they completed their ADL (activities of daily living) tasks in the resident's electronic health record. g. On 3/6/24 at 3:28 PM, CNA #1 and this surveyor entered Resident #12's room. CNA #1 described the resident's face as, [Resident #12] didn't get no shave yesterday., and described the resident's nails by stating, Long, sharp and they can be cleaned, dirty nails. h. On 3/6/24 at 3:31 PM, Licensed Practical Nurse (LPN) #1confirmed that if a CNA tells him/her a resident has refused care, he/she tries to encourage the resident to have it done, but if not, he/she charts the refusal in the nurse's notes and when the CNAs document a refusal, an alert comes to them. i. A Fingernails/Toenails, Care of policy provided by the DON on 3/7/24 documented, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . Proper nail care can aid in the prevention of skin problems around the nail bed . Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Documentation . 6. If the resident refused the treatment, the reason(s) why and the intervention taken . j. A Shaving the Resident policy provided by the DON on 3/7/24 documented, .The purpose of this procedure is to promote cleanliness and provide skin care . Reporting 1. Notify the supervisor if the resident refuses the procedure .

Based on observation, record review and interview, the facility failed to ensure parameters were put in place to ensure the correct dosage of oxygen was administered and so the Physician could determine the dosage needed for 1 (Resident #29) of 1 sampled resident. The findings are: 1. Resident #29 was admitted on [DATE] with the diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Unspecified. a. On 03/04/24 at 10:26 AM, Resident #29 was lying in bed with oxygen on via nasal cannula at 2 liters per minute (LPM). b. On 03/05/24 at 07:54 AM, Resident #29 was lying in bed with oxygen on via nasal cannula at 2 LPM. c. A Physicians Order dated 11/13/23 documented oxygen on at 2 liters via nasal cannula to keep sats (saturation, the level of oxygen in the blood) at 90% or above, every shift for shortness of breath. d. A Care Plan with an initiated date of 11/13/23 documented, Resident is at risk for breathing difficulties r/t [related to] COPD. O2 [oxygen] at 2 L/min [liters per minute] via NC [nasal cannula] as needed for SOB (shortness of breath); spo2 [the measurement of how much oxygen your blood is carrying] < [less than] 90% . e. Review of the March 2024 Medication Administration Record (MAR) revealed there was no documentation of pulse oximetry results to follow for correct dosage of oxygen administration. f. On 03/7/24 at 8:18 AM, Licensed Practical Nurse (LPN) #2 was asked how she knew when to increase or decrease the oxygen on Resident #29 to keep her oxygen saturation greater than 90%. LPN # 2 stated, Check her pulse ox [pulse oximetry] LPN #2 was asked if there was an order to check the pulse oximetry. LPN #2 stated, No. LPN #2 was asked how she knew Resident #29's oxygen saturation was above 90% per physicians orders. LPN #2 stated, Well I don't unless I check it. LPN #2 was asked what Resident #29's pulse oximetry was this morning. LPN #2 stated, I haven't checked it. g. On 3/07/24 at 8:43 AM, the Director of Nursing (DON) was asked how do you expect the nurses to determine what an oxygen flow rate should be. The DON stated, That there should be a O2 check per shift to determine if the rate needs to be adjusted. The DON was asked to look at the electronic record and read the current physician's order. The DON stated, There are no parameters and should be. The DON was asked the importance of setting parameters. The DON stated, To make sure that the resident isn't getting cyanotic [bluish or purplish discoloration due to deficient oxygenation of the blood] or that the order needs decreased. h. On 3/7/24 at 10:51 AM, the DON provided a policy titled, Oxygen Administration which documented, The purpose of this procedure is to provide guidelines for safe oxygen administration . Review the Physicians order . Before administering oxygen, and while the resident is receiving oxygen therapy, assess, for the following . oxygen saturation .

Based on observation, record review and interview, the facility failed to store and maintain Oxygen tubing appropriately for 1 Resident (#6) of 4 sampled residents (R #6, R #9, R #10, R #14) who had a Physician's Order for Oxygen. This failed practice had the potential to affect 7 residents who had a Physician's Order for oxygen as documented on a list provided by the Director of Nursing (DON) on 12/21/22 at 12:15 PM. The findings are: Resident #6 was admitted on [DATE] with a diagnosis of Pneumonia, Unspecified Organism, Hypothyroidism, Anemia, Essential Primary Hypertension. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/22 documented the resident scored 4 (0-7 indicates cognitively severe impairment) on the Brief Interview for Mental Status (BIMS). A Physician's Order dated 10/8/22 stated, .O2 at 2 L/min [liters/minute] via [by way of] nasal cannula as needed for Shortness of Breath (SOB) or pulse ox [Pulse Oximetry less than] < 90% [percent]. as needed . a. On 12/20/22 at 8:17 AM, the Oxygen (O2) tubing was not stored correctly, the tubing is rolled up and stuck in the handle of the concentrator. b. On 12/20/22 at 2:52 PM, the O2 tubing was stuffed in the handle of the concentrator. c. On 12/21/22 at 10:00 AM, the O2 tubing was not stored correctly. d. On 12/21/22 at 1:45 PM, the Surveyor asked (LPN) Licensed Practical Nurse (LPN) #1, How should oxygen tubing be stored when not in use? LPN #1 stated, It should be in a bag. The Surveyor asked LPN #1, Why is it important for Oxygen tubing to be stored in a bag? LPN #1 stated, So it does not get contaminated with bacteria. The Surveyor asked LPN #1, What could happen if the oxygen tubing becomes contaminated? LPN #1 stated, The Oxygen will aerosol the bacteria and the resident will breathe it in and possibly cause an infection. e. On 12/21/22 at 02:00 PM, The Surveyor asked the DON, How should Oxygen tubing be stored when not in use? The DON stated, It should be in a bag with the date on it. The Surveyor asked the DON, Why is it important for Oxygen tubing to be stored in a bag? The DON stated, So it does not get contaminated. The Surveyor asked the DON, What could happen if the Oxygen tubing becomes contaminated? The DON stated, A resident using Oxygen could breathe it in and possibly cause a respiratory infection.

Based on record review and interview, the facility failed to ensure the residents' orders and care plan accurately reflected the resident's advanced directive decision that documented they did not want cardiopulmonary resuscitation for 1 (Resident #134) sampled residents whose clinical records were reviewed for advanced directive information. This failed practice had the potential to affect all 32 Residents who resided in the facility, as documented on the Resident Census and Conditions of Residents form provided by the Minimum Data Set (MDS) Coordinator on [DATE] at 11:48 a.m. The findings are: 1. Resident #134 was admitted to the facility on [DATE] with diagnoses of Periprosthetic Fracture around Internal Prosthetic Right Hip Joint, Diabetes Mellitus, and Acute on Chronic Respiratory Failure. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (,d+[DATE] indicates cognitively intact) on the Brief Interview for Mental status (BIMS), required extensive assistance with bed mobility, dressing, limited assistance with transfers, toileting, personal hygiene, and supervision with eating. a. A doctors order dated [DATE] documented, . FULL CODE . b. The form titled Resuscitation Designation Order, that was signed by the resident's POA (Power of Attorney) and the resident's Physician, dated [DATE] documented, . I do not desire Cardiopulmonary Resuscitation to be performed at this facility if I suffer a cardiac or respiratory arrest . c. The care plan with an initiation date of [DATE] documented, . Focus: I have requested that CPR (Cardiopulmonary Resuscitation) measures ARE to be performed (FULL CODE STATUS) . Goal: Staff will respect my wishes and rights in regard to my decision to have CPR performed . Interventions: Communicate my choice to all appropriate staff members . d. On [DATE] at 9:55 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, What is (Resident #134's) doctors order for code status? LPN #1 looked in the electronic record and stated, He is a full code. The Surveyor asked LPN #1, Does (Resident #134) have any directive saying what he wants his code status to be? LPN #1 looked in the Electronic Record and stated, He has paper stating he wants to be a DNR (Do Not Resuscitate). The Surveyor asked LPN #1, Is Resident #134' doctors order for his code status, correct? LPN #1 stated, No. I will get that corrected now. The Surveyor asked LPN #1, What does Resident #134 care plan say his code status is? LPN #1 looked in the Electronic Record and stated, It says full code. The Surveyor asked LPN #1, Is Resident #134 care plan correct based on the Resuscitation Designation order in the chart signed by the Power of Attorney and the Physician? LPN #1 stated, No, it is not correct. The Surveyor asked LPN #1, Why is it important that the residents orders and care plan reflect the residents wishes regarding any advanced directive such as code status, LPN #1 stated, If the resident did not want to be resuscitated and we did resuscitate them we would not be following his wishes which could cause the family to be very upset. e. On [DATE] at 10:00 AM, The Surveyor asked the Director of Nursing (DON), What is Resident #134 doctors order for code status? The DON looked in the Electronic Record and stated, He is a full code, no he is a DNR. The Surveyor asked the DON, Was the order for DNR put in the Electronic Record today? The DON looked at the Electronic Record and stated, Yes it was done today. The Surveyor asked the DON, Does the Resuscitation Designation order in the electronic record dated [DATE] that was signed by the Power of Attorney and the Physician state he wanted to be a DNR? The DON looked in the Electronic Record and stated, Yes. The Surveyor asked the DON, What does Resident #134 care plan say that his code status is? The DON looked in the Electronic Record and stated, It states he is a full code. The Surveyor asked the DON, Is the care plan correct? The DON stated, Based on what we just looked at it is not correct. The Surveyor asked the DON, Why is it important that the residents orders and care plan reflect the residents wishes regarding advanced directives such as code status? The DON stated, It is important so that we know what to do if it comes to that and we can do what the resident wants and wishes. I am going to audit all our residents to be sure there are no more incorrect statuses and update the care plan. f. On [DATE] at 10:15 AM, The Surveyor asked the Administrator, Should the resident orders accurately reflect any advanced directive they have such as their code status? The Administrator stated, Yes. The Surveyor asked the Administrator, Should the residents care plan reflect any advanced directive the resident has such as code status? The Administrator stated, Yes. The Surveyor asked the Administrator, Why is it important that the residents orders and care plan accurately reflect the residents wishes regarding advanced directives such as code status? The Administrator stated, It is important that we have the right code status documented so we know whether they want to be resuscitated or not. g. On [DATE] at 11:35 AM, The policy titled Advanced Directives, with a revised date of [DATE], provided by the Director of Nursing documented, Policy statement: Advanced directives will be respected in accordance with state law and facility policy .Policy Interpretation and Implementation: 1. Upon admission, the resident will be provided written information concerning the right to refuse or accept medical or surgical treatment, and to formulate an advanced directive if he or she chooses to do so . 10. The care plan of each resident will be consistent with his or her documented treatment preferences and/or advanced directive . 15. In accordance with current OBRA (Omnibus Reconciliation Act) definitions and guidelines governing advanced directives, our facility has defined advanced directives as preferences regarding treatment option and include, but are not limited to: . e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods be used .

Based on record review and interview, the facility failed to ensure a written discharge summary was completed that included a recapitulation of the resident's and course of treatment for 1 of 10 discharged residents (Resident #32) of 1 sampled resident who was discharged in the past 90 days. 1. Resident #32 had diagnoses of Other Schizoaffective Disorder, Chronic Embolism and Thrombosis of the other Specified Veins, and Other Recurrent Depressive Disorders. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/18/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 12/21/22 at 09:05 am, The record review was completed by the surveyor and a discharge summary could not be located. b. On 12/21/22 at 09:08 am, the facility found the resident placement at another facility and provided the resident with transportation to the receiving facility. c. On 12/21/22 at 09:38 am, The Surveyor asked the Director of Nursing (DON), Can you provide a discharge summary for R #32? The DON stated, Let me see what I can find. d. On 12/21/22 at 10:00 am, the facility failed to complete a discharge summary. e. On 12/21/22 at 10:15 am, The Administrator stated, The discharge summary was not done at the time of discharge; we are getting it done today. f. On 12/21/22 at 10:32 am, The Discharge Return Not Anticipated MDS with an ARD of 10/28/22 documented discharge planned to another nursing facility. g. On 12/21/22 at 01:45 pm, the Surveyor asked the DON, When should a discharge be completed? The DON stated, At the time a resident discharge from the facility. The Surveyor asked the DON, Why should a discharge summary be completed? The DON stated, So the care a resident gets while in the facility can continue when they leave. 2. The Discharge Summary Policy documented, When the facility anticipates discharge a resident must have a discharge summary . (1) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment .

Based on observation, interview and record review the facility failed to ensure food items were tightly resealed after opening, and dietary equipment was maintained in a clean sanitary condition to prevent the potential for food borne illness. The findings are: 1. On 9/7/2021 at 9:46 a.m., the following observations were made in the kitchen: a. An opened 45 ounce bag of cornflakes and a 160 ounce bag of colored swirled pasta was not resealed. Dietary Employee #1 was asked how food should be stored after opening. She said, It should be in a zipped locked bag. b. A package containing 6 French Toast and a bag containing 4 pan cakes were in the side door of a white one door freezer near the kitchen's back door. Both bags contained clear translucent spots. Dietary Employee #2 was asked what the spots were. Dietary Employee #2 said, It's ice crystals. I am going to throw them away. Ice crystals are not supposed to be on food. It can cause freezer burn. c. A yellowish sticky substance was on the underside of the juice dispenser machine. Dietary Employee #2 was asked to describe what she saw. Dietary Employee #2 said, It's yellowish sticky build up. She was asked how often the dispenser was cleaned. Dietary Employee #2 said, Once a week. The instructions on the inside door of the dispenser suggested daily cleaning. 2. On 9/7/2021 at 12:34 p.m., a black standing fan was covered with a fussy greyish particles and blowing toward the serving line.

Based on record review and interview, the facility failed to ensure the resident's representative was informed of a medication change to provide the family member the opportunity to provide input on care decisions for 2 (Residents #1 and #15) of 2 sampled residents who had refused the COVID-19 vaccine. The findings are: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 15 (,d+[DATE] indicates cognitively intact) per a Brief Interview of Mental Status. a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Tablet Give 3 mg [milligrams] by mouth one time a day for prophylaxis; refusal of cov [COVID]-19 vaccine for 1 Day give 3 tablets to = 9mg total . b. The Progress Notes dated [DATE] through [DATE] did not contain family notification about the new medication initiated after refusal of the Covid Vaccine. 2. Resident #15 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 9 (,d+[DATE] indicates moderately cognitively impaired) per a Brief Interview for Mental Status and received oxygen therapy. a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Tablet Give 3 mg by mouth one time a day every 7 day(s) for prophylaxis; refusal of cov19 vaccine give 3 tablets to = 9mg total. Order Date [DATE] Start Date [DATE] . b. On [DATE] at 1:04 P.M., Resident #15 was asked about the refusal of COVID vaccine. Resident #15 stated, Yes, I refused it. My son died and I don't want anything to do with it. Resident #1 was asked, Did they give you information on the medication [MEDICATION(S)] that they started you on? She stated, I have no idea what you're talking about. What are they giving me? The Surveyor stated, I will go get the Director of Nursing to talk to you about it. c. On [DATE] at 1:26 P.M., the Nurse Consultant was asked, Where can I find documentation that [Resident #15's] husband was notified of the start of the medication [MEDICATION(S)]? She stated, Will check. She was informed, [Resident #15] is concerned that she didn't know what [MEDICATION(S)] is and wants someone to come explain to her. The Nurse Consultant stated, Resident is confused at times and probably just doesn't remember talking about the [MEDICATION(S)]. d. On [DATE] at 1:32 P.M., the Nurse Consultant stated, I just spoke with [Resident #15] and she said we are to talk to her and not call her husband. She was asked, Who signed the paperwork for her to be admitted ? She stated, Her husband. She was asked, You stated the resident is confused at times. [Resident #15] has a BIMS of 9, which is moderately impaired. Should you notify the responsible party of med changes, starting a new medication? She stated, I guess we are going to have to look into that. e. A Charting and Documentation policy provided by the Director of Nursing on [DATE] at 12:58 P.M. documented, .Documentation of procedures and treatments will include care-specific details, including: . Notification of family, physician or other staff, if indicated .

Based on record review and interview, the facility failed to ensure a Comprehensive Care Plan was developed to address C-Pap (Continuous Positive Airway Pressure) use and care for 1 (Resident #22) of 3 (Residents #22, #24 and #31) sampled resident who had a C-Pap and oxygen use for 1 (Resident #20) of 4 (Residents #20, #22, # 23 and #15) sampled residents who received oxygen therapy. The findings are: 1. Resident #22 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan documented, .resident is at risk for breathing difficulties r/t [related to] sleep apnea with intervention Administer and monitor effectiveness of respiratory treatments as ordered . Date Initiated: 08/16/2021 . b. The September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . per presets with O2 @ [at] 2L [liters] and remove per schedule Start Date 05/07/2021 2000 [8:00 p.m.] Apply 2000 off at Remove 0600 [6:00 a.m.] . c. As of 09/09/21 at 10:00 a.m., the Care Plan did not address the storage or cleaning instructions for the C-Pap. d. On 09/09/21 at 2:04 p.m., the MDS Coordinator was asked, Can you identify the cleaning requirements for a C-Pap machine? The MDS Coordinator stated, I believe the tubing and mask are cleaned with vinegar and distilled water. The MDS Coordinator was asked, Should cleaning orders be identified on the Physician Orders? The MDS Coordinator stated, Yes. The MDS Coordinator was asked, Do the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? The MDS Coordinator stated, No it doesn't. e. On 9/9/21 at 2:10 p.m. the Director of Nursing (DON) was asked, Can you identify the cleaning requirements for a C-Pap machine? The DON stated, Not off the top of my head. The DON was asked, Should Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ? The DON stated, Yes they should. The DON was asked, How should the C-Pap equipment be stored when not in use? The DON stated, In the case. f. On 09/09/21 at 2:11 P.M., the Nurse Consultant (NC) stated, The oxygen supply company is supposed to take care of all that for us. She was asked to provide documentation of the cleaning. At 2:32 p.m. the NC stated, I just found out, [company name] does not provide care for the C-Pap's, we are changing companies today. 2. Resident #20 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Plan of Care with an initiated date of 11/20/20 did not address Oxygen use and changing of the tubing. b. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] < [less than] 90 % [percent] Order Date 06/09/21 . O2 via NC [Nasal cannula] @ [at] 3 lpm PRN SOB [shortness of breath] . c. On 09/09/21 at 9:13 A.M., the DON was asked, How does the nursing staff determine which Oxygen order to use for the resident? She stated, By the pulse ox, they do vital signs every shift. She was asked, Where is it charted since it's not on the Medication Administration Record? She stated, It is located on the Treatment Record. She was asked, According to the orders the resident is to have his oxygen on at 3 or 5 liters? She stated, Yes. She was asked, Should the residents oxygen use and cleaning of equipment be on the Care Plan? She stated, Yes.

Based on observation, record review and interview, the facility failed to ensure C-Pap (Continuous Positive Airway Pressure) equipment was cleaned and stored in accordance with accepted standards of nursing practice to promote continuity and quality of care and reduce the potential for infections for 1 (Resident #22) of 3 (Residents #22, #31 and #24) sampled residents who had orders for a C-Pap machine. The findings are: 1. Resident #22 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan documented, .resident is at risk for breathing difficulties r/t [related to] sleep apnea with intervention Administer and monitor effectiveness of respiratory treatments as ordered . Date Initiated: 08/16/2021 . b. The September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . per presets with O2 @ [at] 2L [liters] and remove per schedule Start Date 05/07/2021 2000 [8:00 p.m.] Apply 2000 off at Remove 0600 [6:00 a.m.] . c. On 09/07/21 at 9:55 a.m., Resident #22's C-Pap equipment was lying uncovered on the nightstand. The oxygen tubing running from the concentrator to the C-Pap was not dated. d. On 09/08/21 at 7:58 a.m., Resident #22's C-Pap equipment was lying uncovered on the nightstand. The oxygen tubing running from the concentrator to the C-Pap was not dated. Resident #22 was asked, Can you put on your C-Pap by yourself? Resident #22 stated, Yes. Resident #22 was asked, Can you remove it by yourself? Resident #22 stated, No, they have to turn off the machine. e. On 09/09/21 at 8:56 a.m., Resident #22's C-Pap equipment was lying uncovered on the nightstand. The oxygen tubing running from the concentrator to the C-Pap was not dated. f. On 09/09/21 at 2:04 p.m., the MDS Coordinator was asked, Can you identify the cleaning requirements for a C-Pap machine? The MDS Coordinator stated, I believe the tubing and mask are cleaned with vinegar and distilled water. The MDS Coordinator was asked, Should cleaning orders be identified on the Physician Orders? The MDS Coordinator stated, Yes. The MDS Coordinator was asked, Do the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? The MDS Coordinator stated, No it doesn't. The MDS Coordinator was asked, How should the C-Pap equipment be stored when not in use? The MDS Coordinator stated, In a bag. g. On 9/9/21 at 2:10 p.m. the Director of Nursing (DON) was asked, Can you identify the cleaning requirements for a C-Pap machine? The DON stated, Not off the top of my head. The DON was asked, Should Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ? The DON stated, Yes they should. The DON was asked, How should the C-Pap equipment be stored when not in use? The DON stated, In the case. h. On 09/09/21 at 2:11 P.M., the Nurse Consultant (NC) stated, The oxygen supply company is supposed to take care of all that for us. She was asked to provide documentation of the cleaning. At 2:32 p.m. the NC stated, I just found out, [company name] does not provide care for the C-Pap's, we are changing companies today.

Based on observation, record review, and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician to minimize the potential for respiratory complications for 3 (Residents #15, #20 and #23) of 4 (Residents #23, #20, #15 and #22) sampled residents who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #24, #31 and #22) sampled residents who used a [CONDITION(S)] to minimize the potential for respiratory infection or other respiratory complications. The findings are: 1. Resident #15 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/27/21 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) per a Brief Interview for Mental Status and received oxygen therapy. a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care with initiated date of 01/28/20 documented, .O2 at 2.5 liters/min [liters per minute] per nasal cannula prn [as needed] SOB [shortness of breath] . c. On 09/07/21 at 11:42 A.M., Resident #15 was lying in bed receiving oxygen by nasal cannula at 1.5 liters. d. On 09/08/21 at 10:11 A.M., Resident #15 was lying in bed receiving oxygen by nasal cannula at 1.5 liters. e. On 09/08/21 01:13 P.M., Registered Nurse (RN) #1 was asked, Can you tell me what the resident ' s oxygen concentrator is set on? He stated, 1½. RN #1 turned the oxygen concentrator up to 2½. He stated, It's supposed to be at 2½. RN #1 was asked, How often is it supposed to be checked? He stated, Every shift. 2. Resident # 20 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] < [less than] 90 % [percent] Order Date 06/09/21 . O2 via NC [Nasal cannula] @ [at] 3 lpm PRN SOB . b. On 09/07/21 at 11:37 A.M., Resident #20 was receiving O2 at 4 lpm via nasal cannula. The O2 tubing and humidification water bottle were dated 08/22/21. c. On 09/08/21 at 8:33 A.M., Resident #20 was receiving O2 at 3 lpm via nasal cannula. The O2 tubing and water bottle were dated 8/22/21 and the humidification water bottle was dry. d. On 09/08/21 at 12:30 P.M., the O2 tubing and humidification water bottle had been changed. There was no date on water bottle. Registered Nurse #1 was asked, Did you change [Resident #20's] O2 tubing and bottle? He stated, Yes. He was asked, What was the date on the bottle that you took off? He stated, It was old. He was asked, Did you see the date that was on the bottle and tubing? He stated, It was old. e. On 09/08/21 at 2:30 P.M., the DON was asked, How often should Oxygen water bottles and tubing be changed? She stated, Once a week. f. On 09/09/21 at 9:13 A.M., the DON was asked, How does the nursing staff determine which Oxygen order to use for the resident? She stated, By the pulse ox, they do vital signs every shift. She was asked, Where is it charted since it's not on the Medication Administration Record? She stated, It is located on the Treatment Record. She was asked, According to the orders the resident is to have his oxygen on at 3 or 5 liters? She stated, Yes. 3. Resident #23 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 07/27/21 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) of BIMS and received oxygen therapy. a. The Plan of Care with an initiated date of 06/17/21 documented, .02 @ 3 lpm PRN SOB . b. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 09/07/21 at 11:27 A.M., Resident #23 was lying in bed receiving 02 at 2½ LPM via nasal cannula. The humidifier bottle on oxygen concentrator was empty. d. On 09/08/21 at 8:29 A.M., Resident #23 was lying in bed receiving 02 at 2½ LPM via nasal cannula. The humidifier bottle on the oxygen concentrator was empty and was not dated. e. On 09/09/21 at 8:32 A.M., Resident #23 was lying in bed receiving 02 at 2½ LPM via nasal cannula. f. On 09/08/21 at 12:30 P.M., Resident #23's 02 tubing and water bottle were changed. There was not a date on the water bottle. RN #1 was asked, Did you change [Resident #23's] 02 tubing and bottle? He stated, Yes. RN #1 was asked what Resident #23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . g. On 09/08/21 at 02:30 P.M., the Director of Nursing was asked, How often should oxygen water bottles and tubing be changed? She stated, Once a week. 4. Resident #24 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Plan of Care with an initiated date of 06/12/20 documented, . DX [diagnosis] of Sleep Apnea with the need for C-PAP as per MD (Medical Doctor] orders. b. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 09/07/21 at 11:16 A.M., Resident #24's [CONDITION(S)] machine was sitting on the bedside table to the left of the bed. The tubing from the machine to the mask was off the table down the side of the table with the mask holder and straps in floor. The mask was lying on the top of the bedside table open to air. d. On 09/08/21 at 8:20 A.M., Resident #24's [CONDITION(S)] was sitting on the bedside table to the left of the bed. The tubing from the machine to the mask was off the table down the side of the table with the mask holder and straps in floor. The mask was lying on the top of the bedside table open to air. Resident #24 stated that she is not using it because it makes a bad noise. Resident #24 was asked, Have you told anyone? Resident #24 stated, I have told the nurse that starts it. e. On 09/09/21 at 8:22 A.M., Resident #24's [CONDITION(S)] was sitting on the bedside table to the left of the bed. The tubing from the machine to the mask was off the table down the side of the table with the mask holder and straps in floor. The mask was lying on the top of the bedside table open to air. Resident #24 was asked, Can I turn it on and listen for the noise? She stated, I would rather you leave it alone today. Surveyor left the room. f. On 09/09/21 at 9:13 A.M., the DON was asked, Should [Resident #24's] [CONDITION(S)] tubing and mask be in bag? She stated, Yes. The DON was asked, What could be a complication of the mask lying on bedside table and hose and mask holder being on the floor cause? She stated, Respiratory infection. The DON was informed of Resident #24 saying her [CONDITION(S)] was making a bad noise and that she wasn't using it. 5. Resident #22 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan documented, .resident is at risk for breathing difficulties r/t [related to] sleep apnea with intervention Administer and monitor effectiveness of respiratory treatments as ordered . Date Initiated: 08/16/2021 . b. The September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . per presets with O2 @ 2L [liters] and remove per schedule -Start Date-05/07/2021 2000 [8:00 p.m.] Apply 2000 off at Remove 0600 [6:00 a.m.] . c. On 09/07/21 at 9:55 a.m., Resident #22's C-Pap equipment was lying uncovered on the nightstand. The oxygen tubing running from the concentrator to the C-Pap was not dated. d. On 09/08/21 at 7:58 A.M., Resident #22's C-Pap equipment was lying uncovered on the nightstand. The oxygen tubing running from the concentrator to the C-Pap was not dated. Resident #22 was asked, Can you put on your C-Pap by yourself? Resident #22 stated, Yes. Resident #22 was asked, Can you remove it by yourself? Resident #22 stated, No, they have to turn off the machine. e. On 09/09/21 at 8:56 A.M., Resident #22's C-Pap equipment was lying uncovered on the nightstand. The oxygen tubing running from the concentrator to the C-Pap was not dated. f. On 09/09/21 at 2:04 P.M., the MDS Coordinator was asked, Can you identify the cleaning requirements for a C-Pap machine? The MDS Coordinator stated, I believe the tubing and mask are cleaned with vinegar and distilled water. The MDS Coordinator was asked, Should cleaning orders be identified on the Physician Orders? The MDS Coordinator stated, Yes. The MDS Coordinator was asked, Do the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? The MDS Coordinator stated, No it doesn't. The MDS Coordinator was asked, How should the C-Pap equipment be stored when not in use? The MDS Coordinator stated, In a bag. g. On 9/9/21 at 2:10 P.M. the Director of Nursing (DON) was asked, Can you identify the cleaning requirements for a C-Pap machine? The DON stated, Not off the top of my head. The DON was asked, Should Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ? The DON stated, Yes they should. The DON was asked, How should the C-Pap equipment be stored when not in use? The DON stated, In the case. h. On 09/09/21 at 2:11 P.M., the Nurse Consultant (NC) stated, The oxygen supply company is supposed to take care of all that for us. She was asked to provide documentation of the cleaning. At 2:32 p.m. the NC stated, I just found out, [company name] does not provide care for the C-Pap's, we are changing companies today. 6. A Departmental (Respiratory Therapy) - Prevention of Infection policy provided by the DON on 09/09/21 at 12:58 P.M. documented, . 2. Use distilled water for humidification per facility protocol. 3. Mark bottle with date and initials upon opening and discard after twenty-four (24) hours.7. Change the oxygen cannula and tubing every seven (7) days, or as needed .

Based on record review and interview, the facility failed to inform residents or their representatives of a COVID-19 positive staff member by 5:00 p.m. the next calendar day. The findings are: 1. On 09/08/21 at 2:30 P.M., the Administrator was asked, Who sends notifications out to families when a resident or staff test positive for COVID-19? She stated, I personally go around and tell the residents and Social calls the families. She was asked, Is it charted somewhere? She stated, Yes, it's in the resident's charts. 2. On 09/08/21 at 3:29 P.M., the Social Director was asked, Who sends notifications out to families when a resident or staff test positive for COVID-19? She stated, I send out letters to the families. She was asked, Are they sent by 5:00 P.M. the next day? She stated, I call some families, then I send out letters. 3. On 09/09/21 at 4:23 P.M., Resident #22's Progress Notes documented a Social note on 09/09/21, .Note Text: [resident] [family member] was notified by letter of staff member that tested positive for COVID 19 on 9/1/2021 . 4. On 09/09/21 at 4:40 P.M., Resident #1's Progress Notes documented a Social note on 09/09/21, . Note Text: [resident] [family member], was notified by letter of staff member that tested positive for COVID 19 on 9/1/2021 .

Based on record review and interview, the facility failed to ensure information regarding formulation of Advanced Directives was documented in a prominent part of the clinical record for 2 (Residents #20 and #9) of 14 (Residents #22, #182, #6, #19, #10, #16, #9, #1, #13, #23, #14, #24, #20, and #15) sampled residents whose clinical records were reviewed for Advanced Directive information. The findings are: 1. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/21 documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status. a. As of 09/08/21 at 10:09 a.m., the medical record did not contain an Advance Directive. b. Resident #9's Advance Directive was provided by the Nurse Consultant on 09/08/21 at 2:59 p.m. The Nurse Consultant was asked, Where did you locate this directive? She stated, It was in a binder in the Business Office. She was asked, Was this available to staff if they had to send her out? Stated, stated, No, it is being scanned in now. 2. Resident # 20 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS with an ARD of 08/03/21 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status. a. As of 09/08/21 at 1:02 P.M., the medical record did not contain an Advance Directive. b. Resident #20's Advance Directive was provided by the Nurse Consultant on 09/08/21 at 3:03 P.M. The Nurse Consultant was asked, Where did you locate this directive? She stated, It was in a binder in the Business Office. She was asked, Is it supposed to be in the chart? She stated, Yes, we are working on that.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #22) of 4 (Residents #15, #20, #23, and #24) sampled residents who received oxygen therapy. The findings are: Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an Assessment Reference Date (ARD) of 08/13/21 documented the resident scored 15 (13-15 indicates cognitively intact) per a Brief Interview for Mental Status and did not receive oxygen therapy. a. The September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . per presets with O2 @ [at] 2L [liters] and remove per schedule -Start Date-05/07/2021 2000 [8:00 p.m.] Apply 2000 off at Remove 0600 [6:00 a.m.] . b. On 09/09/21 at 2:01 p.m., The MDS Coordinator was asked, Does [Resident #22] have orders for oxygen? The MDS Coordinator stated, Yes. The MDS Coordinator was asked, Does the Quarterly MDS with the ARD of 8/13/21 document oxygen? The MDS Coordinator stated, No, it does not. The MDS Coordinator was asked, Is the MDS accurate? The MDS Coordinator stated, No, it's not.

Based on observation and interview, the facility failed to ensure expired medications and Insulin without a pharmacy label were not on the medication cart to prevent the potential for medication errors and administration of expired medications in accordance with professional standards of practice, state law and accepted principles of pharmacy laws and regulations. This failed practice had the potential to effect 32 residents who received medications. The findings are: 1. On 09/08/21 at 3:42 P.M., Medication Cart #2 was reviewed with Licensed Practical Nurse #1. There were 7 boxes of [MEDICATION(S)]/[MEDICATION(S)] vials outdated, 1 box of [MEDICATION(S)] was expired and 1 vial of [MEDICATION(S)] R (regular insulin) was found in the top drawer of the medication cart without a pharmacy label, a resident name or directions for use. 2. On 09/08/21 at 04:12 P.M., the Director of Nursing was asked, Should expired medications be left on medication cart? She stated, No. She was asked, What could happen if expired medications were left on cart? She stated, They could be given.

Based on record review and interview the facility failed to ensure documentation the resident or resident representative was provided education material regarding the benefits and potential risks associated with COVID-19 vaccine for 1 (Resident #1) of 5 (Residents #10, #1, #20, #13 and #9) sampled residents. The findings are: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 06/14/21 documented the resident scored 15 (13-15 indicates cognitively intact) per a Brief Interview of Mental Status. a. On 9/8/21 at 11:05 a.m., Resident #1's Immunization History documented the Covid vaccine was refused and the medical record does not contain documentation the educational material regarding the COVID-19 vaccine was provided to the resident or resident representative. b. On 9/8/21 at 2:00 p.m., the Nurse Consultant (NC) was asked, Where is the Covid Education at in the medical record? She stated, It's under the scanned section of [facility software]. The NC reviewed Resident #1's electronic record and stated, It's not here. I'm going to check the binder and have her scan it in today. c. A Covid Policy and Procedure provided by the Nurse Consultant on 09/09/21 at 7:39 a.m. documented .Upon refusal of vaccination . residents will be offered and educated on risk vs. [verses] benefits . documentation shall be kept in EMR [Electronic Medical Record].

Based on observation, record review and interview, the facility failed to ensure when the bathroom door in a resident room was opened it did not push against the hall door to the room preventing the door from being opened so staff could enter the room in the event of an emergency for 1 of 1 (Resident #5) sampled resident who resided on the 300 hall. This failed practice resulted in immediate jeopardy that caused or was likely to cause serious harm, injury or death to Resident #5 who was blocking the hall door with the bathroom door and not permitting staff to enter and there was no other exit to the room in the event of a fire or other emergency and had the potential to affect 8 rooms on the secure unit, 5 rooms on the 300 hall and one room on the 200 hall, according to observations made on 2/17/2020. The Administrator was informed of the Immediate Jeopardy on 2/18/20 at 3:11 p.m. The findings are: 1. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/2019 documented a score of 03 (0- indicates severe impairment) on the Brief Interview for Mental Status (BIMS); had verbal and other behaviors such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste or verbal / vocal symptoms like screaming or disruptive sounds and rejects care; required extensive assistance from two staff members for bed mobility, transfers, walking in room, and toileting; required extensive assistance from one staff member for walking in the corridor, and locomotion on the unit; and utilizes a wheelchair for mobility. a. On 02/17/20 at 12:30 PM, during initial rounds on the secure unit, Certified Nursing Assistant (CNA) #1 was observed standing outside Resident #5's door, knocking on the closed door saying, Let me in. The CNA was unable to get in, so she called for Licensed Practical Nurse (LPN) #2, on her walkie talkie. CNA #1 said, He has the bathroom door open and I can't get in. LPN #2 arrived on the hall and stood outside the room and talked to the resident until he closed the bathroom door so the staff could open the door to the room. b. The Updated Care plan documented, .Focus: (Resident #5) has an alteration in behavioral function d/t (due to) DXs (diagnosis) [MEDICAL CONDITION] with auditory hallucinations, Mild Intellectual Disabilities & (and) Alzheimer's Dementia with Behavioral Disturbances; frequently refuses care &/or meds (medication); easily agitated; episodes of yelling & verbal threats @ (at) staff; cannot share room d/t hx (history)/of violent outbursts, throwing, breaking objects in his room; not easily redirected; potential for easily frustrated d/t inability to always express needs & does not always understand content of messages sent. 9/19/19: increased agitation, struck another Resident that wandered into his room & (Resident) barricaded door after other resident was immediately removed; Geri-Psych units not able to admit immediately. 9/20/2019: struck another resident; threw dinner plate across his room, breaking it; 2/17/2020: barricaded his door using bathroom door to jam entry door. Encourage a calm environment for (Resident #5) Date Initiated: 08/28/2019 . Provide a safe environment for (Resident) on the secured Memory Unit . c. Nurse's notes dated 2/17/2020 at 12:54 documented, .Nursing .Resident after lunch, noted to have had an incontinent episode of urine. CNA encouraged resident to get up out of the bed to get cleaned up and clothes changed. Resident got out of the bed into wheelchair, CNA stripped resident bed. Resident then began yelling out to CNA to 'get out' and kicked CNA in the abdomen. CNA radioed for this nurse. Upon arriving on the unit, CNA was in the hallway and resident had closed door and bathroom door creating a jam. This nurse knocked on the door several times and calling resident's name, asking resident if this nurse could come and make up his bed or get him another piece of cake. Resident would yell out Naw. Resident then opened the door, came out into the hallway and repeatedly refused to change clothes or allow staff to assist with changing clothes. 2. On 02/17/20 at 1:40 PM, all the rooms on 100 hall (secure unit) and 200 hall were checked by the surveyors. The entrance doors to the Resident Rooms 101, 103, 104, 105, 108, 109, 110, 111 and 208 would not open if the bathroom door was opened wide. At 01:49 PM, the resident, in room [ROOM NUMBER], stated, Sometimes the handles from the bathroom door and the room door can get intertwined and they have to jiggle them to get them apart. I've done it myself. On 2/17/20 at 2:00 PM, all the rooms on the 300 Hall were checked by the surveyors. There were five Resident Room (305, 306, 308, 311, and 312) doors that would not open if the handle to the entry door and the handle to the bathroom door hung up together. 3. On 02/17/20 at 1:56 PM, LPN #2 was asked, Has that ever happened before with his door or any others? She stated, It has happened before, to be honest. She was asked, Are there any other rooms that do that? She answered, Under certain circumstances it happens and has the potential to happen with all the doors. She was asked, If the building were to catch on fire could it impede the staff's ability to evacuate himself from the room? She answered, Yes it could. When asked if she had mentioned this to anyone, she stated she informed the maintenance man. The LPN was asked, Did you check the other residents' room to see if this is occurring with their doors? LPN #2 stated, No. On 2/20/20 at 8:15 a.m., LPN #2 was asked, How many times has (Resident #5) barricaded himself in the room? She stated, Maybe three times that I can remember. It's been months ago since it happened, so I don't remember exactly. The LPN was asked, Did you tell anyone when it happened? LPN #2 stated, Once when he pushed the bed against the door that was just a behavior and I did not tell anyone but the two times that the doors were the cause, I told the maintenance man both times. 4. On 02/17/20 at 2:08 PM, the Director of Nursing was asked, Has a resident ever been closed up in a room and you couldn't get to them? She answered, Not to my knowledge. She was taken to the 100 hall and showed how the entry doors will not open if the bathroom door is open wide. She pointed out some spring guards that were attached to the upper hinge of the bathroom door. She stated, Some bathroom doors have them, and some don't. I guess that's why. 5. On 2/17/20 at 2:41 PM, the Maintenance Supervisor was asked if he had knowledge of the bathroom doors impeding the entrance door from opening. He stated, The nurse told me that (Resident #5) had barricaded himself in the room about a week and a half ago. I was exploring options on what to put on the doors to prevent this from happening, because those things will bend that go at the top of the hinge of the door. I told the Business Office Manager or the Administrator to order door stops, since I don't do the ordering. On 2/20/20 at 8:35 a.m., the maintenance person was asked, Has (LPN #2) ever told you in the past that the residents' door was impeding entry to their rooms? He stated No ma'am. My book is out there on the wall and there is nothing in there about it. He was asked did the administrator know that the doors could impede entry. He stated, She thought it was more about the holes in the door. 6. On 2/17/20 at 3:00 PM, the Administrator was asked, Did you have knowledge that the bathroom doors if opened all the way can impede the entrance door from opening? She stated, No. I was told from maintenance that we needed to order door stops, that was last week, because I was under the notion that the doorknobs were putting holes in the walls. When you entered on Monday, we were in the process of ordering the door stops, but we didn't complete the order. I thought maintenance meant the round circle that prevents a hole in the door so that is what we were going to order. We will work on ordering something else today. On 2/20/20 at 8:38 a.m., the Administrator was asked, Do you remember when (Resident #5) barricaded himself in room in (MONTH) (2019)?' She stated, I don't remember that. She was asked, do you know how he did it? She answered, I'd have to look at the I&A (incident and Accident), I don't remember. She was asked, When the doors impeded entry to the room, did (LPN #2) ever tell you, last week or prior to that, that the bathroom doors were impeding entry into the resident's room? She stated, Not that I recall, the (Resident #5) has a history at another facility putting a mattress against the door. The Administrator was asked, Was (Resident #5) due to his behaviors ever put on QA (Quality Assurance) program to monitor? She answered, Should have, can't say whether I did or not She stated, When I talked with ( LPN #2) on Monday she said, (Resident #5) barricaded himself in the room and she was able to coax him out. I read her note and saw where the doors were connected. When I interviewed her again the CNA told her he was up against the door she was trying to coax him to open the door. He was up against the door and she offered him bribery. The door opened and he was by the door. It was after I read the nurses note and saw that it was the door causing it 7. On 2/18/20 at 1:20 PM, CNA #3 was asked, Are you aware of any doors that have closed and staff unable to open them? She answered, I know Resident #5 got connected about 3 weeks ago. I heard about it but wasn't working on this hall that day. I don't remember who was working down here. 8. On 2/18/20 at 1:45 PM, CNA #4 was asked, Are you aware of any doors that have closed and staff unable to open them? She stated, I have heard there was an incident with Resident #5, I don't remember when it happened or who was working. I was not here that day. 9. The Immediate Jeopardy was removed, and the Scope and Severity lowered to an [NAME] on 2/18/20 at 5:30 p.m., when the facility implemented the following Plan of Removal: a. On 02/17/2020, upon notification of deficient practice, The Maintenance Director removed the bathroom door from Resident room [ROOM NUMBER] a private room. b. On 02/17/2020, the Administrator immediately identified 7 residents who had the potential to be affected by the deficient practice by having the Maintenance Director audit using a census list and from going room to room to assess the bathroom doors to ensure that they do not impede the entrance door from opening to prevent the potential for serious injury, harm or death. On 02/17/20, Administrator/Designee are rounding every l5 minutes to ensure that the bathroom doors do not impede the entrance door from opening to prevent the potential for serious injury, harm or death. On 02/17/20, Maintenance Director and staff will apply door stops to all residents' rooms. c. On 02/17/20, the Administrator in-serviced the Maintenance Director and the Department Heads ensuring the bathroom doors do not impede the entrance door from opening to prevent the potential for serious injury, harm or death during their angel rounds. d. Administrator/Designee will monitor the bathroom doors to ensure that they do not impede the entrance door from opening to prevent the potential for serious injury, harm or death by observation and documenting on monitoring log daily for 1week, then 3 times a week for 8 weeks until compliance is verified by OLTC (Office of Long-Term Care). Any negative findings will be corrected immediately, and the Administrator notified. e. Administrator/Designee will present all findings to the monthly QAPI (Quality Assurance and Performance Improvement) committee for further review and recommendations.

Complaint # (AR 783) was substantiated, (all or in part), with these findings. Complaint # (AR 882) was substantiated, (all or in part), with these findings. Based on observation, record review and interview, the facility failed to ensure physician-ordered pain medication was available for administration and failed to document attempts to contact the physician regarding pain medication refill orders to prevent delays in providing pain management for 2 (Residents #15 and #16) of 16 (Residents #1-#4, #6-#10, #12, #13, #14, #15, #16, #18, #19) case mix residents who had physician's orders [REDACTED].#15 and #16, whose supply of pain medication was interrupted, resulting in uncontrolled pain, and had the potential to affect 40 residents who had physician's orders [REDACTED]. 1. Resident #16 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/17 documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), frequently had pain and the intensity level was 7 (0 - 10 where zero indicates no pain and ten the worst pain). a. A physician's orders [REDACTED]. b. A physician's orders [REDACTED].[MEDICATION NAME] Tablet 10-325 mg Give 1 tablet by mouth every 6 hours as needed for pain . c. A Medication Administration Record [REDACTED]. The medication was documented as administered on 1/1/8 at 6:30 a.m., 1/2/18 at 3:35 p.m., 1/3/18 at 3:30 a.m. and 3:45 p.m., 1/4/18 at 4:00 a.m. and on 1/5/18 at 12:00 p.m. There was no documentation the medication was administered on 1/6/18 or 1/7/18. d. A Medication Administration Record [REDACTED]. The medication was documented as administered on 1/1/8 at 11:30 a.m. and 11:30 p.m.; 1/2/18 at 5:30 a.m., at 11:35 a.m., and at 10:40 p.m.; 1/3/18 at 7:45 a.m., 2:10 p.m., and at 8:20 p.m.; 1/4/18 at 2:40 a.m. and 12:05 p.m.; 1/5/18 twice without documentation of times; 1/6/18 at 12:00 a.m.; and on 1/9/18 at 12:57 p.m. There was no documentation the medication was administered on 1/7/18 or 1/8/18. e. The MAR indicated [REDACTED]. The log documented 1/6/18 day shift pain zero, evening shift pain 8, night shift pain 8; on 1/7/18 day shift pain zero, evening shift pain 8/10, night shift pain 8/10. f. The Narcotic log documented 1/7/18 at 10:30 a.m. balance one [MEDICATION NAME] 10/325. No further entries were documented until 1/9/18 at 12:15 p.m. g. A Nursing Note dated 1/8/18 at 8:50 a.m., documented, Called (physician) to sign and send back pain medication scripts to pharmacy. Scripts were faxed to (physician) by pharmacy. h. A Nursing Note dated 1/8/18 at 2:51 p.m., documented, Called (physician) to sign and send back pain medication scripts to pharmacy. Scripts were faxed to (physician) by Pharmacy, after calling pharmacy. (Physician) notified that resident had no more pain medication. i. A Nursing Note dated 1/8/18 at 6:30 p.m. documented, (physician) called r/t (related to) pain medication scripts to fax to pharmacy. j. A Narcotic Log entry dated 1/9/18 at 12:15 p.m., documented a balance of 30 tablets of [MEDICATION NAME] 10/325 mg. k. On 1/10/18 at 3:32 p.m. Resident #16 was asked, Did you run out of pain medication? He stated, Yes for four days. They started working on it last Thursday and had some Saturday morning, none on Saturday night or Sunday morning. I first got pain meds again on Tuesday morning. I've been taking it for ten years. I didn't have any problems this time, like diarrhea. The nurse practitioner was here on Monday and she wrote me a prescription for [MEDICATION NAME], which it did help. He was asked, Did it affect your sleep? It did some. This is the second time this has happened since I've been here. First, when I came here from (another facility), they only sent me with five pills and then they waited until I ran out and got a prescription for me. When it came in, it went to (other facility), so they had to send it back to the pharmacy. This time, I was still getting my [MEDICATION NAME], but it's a baby dose, and I was stretching out the [MEDICATION NAME], because I knew I was getting low. Friday, they told me I only had six pills left for the weekend, so I started stretching them out. You know, after 14 surgeries on your hip, is a lot. But you have to have some quality of life or I wouldn't take the meds. At 4:04 p.m., Resident #16 was asked, What was your pain level when you were out of medications? He stated, Nine. I remember who the nurse was that said she called. It was (Licensed Practical Nurse (LPN) #5). I'm not trying to get anyone in trouble, but she was the one I talked to about it, and she said she had called the doctor. l. On 1/9/18 at 11:39 a.m., LPN #5 was asked, What do you know about (Resident #16) and (Resident #15) running out of pain medication? She stated, They both ran out; the doctor was notified. The pharmacy faxed over the order to (Physician #1) and he said he would sign it when he got home. Never heard anything from (Physician). I talked to the pharmacy yesterday and the day before because they faxed it 2 or 3 times to him. She was asked, Did you document that anywhere? She stated, No I did not. 2. Resident #15 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/17 documented the resident scored 14 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and frequently had pain with an intensity of up to 8 on a scale of 1 to 10, with 10 being the most severe. The Care Area Assessment (CAA) Summary dated 10/19/17 documented the care area of pain triggered and that the resident was care planned for pain related to an open wound of the right ankle. a. A physician's orders [REDACTED]. b. The Plan of Care documented, The resident is on pain medication therapy r/t (related to) open wound of right ankle. Date initiated: 10/18/17 .The resident will be free of any discomfort/adverse side effects from pain medication through the review date .Administer [MEDICATION NAME] medications as ordered by physician . The care plan was signed 1/8/18. c. The Medication Administration Record [REDACTED]. As of 1/11/18, the medication was documented as administered on 1/1/18 at 12:45 p.m., 1/2/18 at 1:30 p.m., 1/3/18 at 6:00 a.m. and 10:50 p.m. and 1/4/18 at 6:00 a.m. There was no documentation the medication was administered after 1/4/18 at 6:00 a.m. 3. On 1/10/18 at 4:23 p.m. Registered Nurse (RN) #1 was asked, Did you call the doctor when (Resident #15 and Resident #16) were out of pain medication? She stated, No. It was probably one of my weekend nurses if they tried to get a hold of (Physician #1). (LPN #8) talked to (Physician #2) about (Resident #15) and I did not speak to the doctor about (Resident #16). When I first noticed on Wednesday they were getting low, I notified (Pharmacy) for both residents. Then I wasn't on the floor anymore, so other nurses took care of it. And (Resident #15) did complain of pain, 7 out of 8. He always has pain on scale of 7. And when I did get back on the floor, I got him a prescription for [MEDICATION NAME] from the APN (Advanced Practice Nurse). (Resident #16) actually ran out on the 7th, which was a weekend. He got his last dose at 10:30 p.m. and, on the 9th at 12:15 p.m., they came in and he got one shortly after that. She was asked, Who is (Physician #1's) back up? She stated, He has no back up. He has a great APN, but they can't write prescriptions for pain meds. (Resident #15) on the 4th had one tablet left and at 4:00 p.m., took the last pill. I wrote a Tylenol order for him. His pain level was 3 or 4 and 7 was the max. This is not the first time it has happened. Everything had been faxed to the pharmacy but we can't get the med until the doctor signs. It is getting more and more difficult because APNs cannot do anything with narcotics anymore. 4. On 1/9/18 at 10:29 a.m., the Medical Director was asked, What happened with (Resident #15 and Resident #16's) pain medications? He stated, I am almost always available. We typically ask for the pharmacy to send us the request. On (Resident #16), they called me on the weekend, and I worked all weekend without a request. (Pharmacy) did not send the request. On (Resident #15), they told me he was not my patient. He was (another physician)'s patient. But I wrote it for him, because I am the Medical Director. On (Resident #16), I wrote [MEDICATION NAME] and [MEDICATION NAME] 10-325 last night. There was five days without pain medication, and that is way too much.

Based on observation, record review, and interview, the facility failed to ensure interventions to prevent weight loss/promote weight gain were consistently implemented, body weight was monitored weekly as planned, and the Dietary Manager assessed nutritional needs upon re-admission to determine any new concerns and to assist with development of new interventions as needed to promote weight gain and prevent further weight loss for 1 (Residents #5) of 5 ( Resident #s 3, 5, 7, 8, and 13) case mix residents who were at risk for weight loss. These failed practices resulted in a pattern of actual harm for Resident #5 who experienced a severe weight loss and had the potential to cause more than minimal harm for 24 residents who were at risk for weight loss according to the list provided by the Administrator on 1/14/16 at 4:05 p.m. The findings are: 1. The facility's policy for Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol received from the Nurse Consultant on 1/13/16 at 2:45 p.m. and Administrator on 1/14/16 at 4:05 p.m. documented, Assessment and Recognition the nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. As part of the initial assessment, the staff and physician will define the individual's current nutritional status . and identify individuals with anorexia, recent weight loss, and significant risk for impaired nutrition; The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month-5% weight loss is significant; greater than 5% is severe 3 months-7.5% weight loss is significant; greater than 7.5% is severe . The Dietician will estimate calorie, nutrient and fluid needs and, with the Physician, will identify whether the resident's current intake is adequate to meet his or her nutritional needs . Treatment/Management . The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes . The Physician will authorize and the staff will implement appropriate general or cause-specific interventions, as indicated, with careful consideration of the following . Nutritional needs: The Dietitian will help the Physician determine the appropriate diet for the resident based on the resident's degree of nutritional impairment . If the resident's nutritional or caloric needs have changed, but the diet has not, this may help to clarify the appropriate interventions . Supplementation: Strategies to increase a resident's intake of nutrients and calories may include fortification foods . providing between meal snacks and/or nutritional supplementation . Monitoring . The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or at risk factors for developing impaired nutrition. Such monitoring may include . Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals . Evaluating the resident's response to interventions should be based on defined criteria for improvement/worsening of nutritional status; for . stabilization of weight . or food . intake . Recognizing the emergence of new risk factors . pressure ulcers . 2. Resident #5 had [DIAGNOSES REDACTED]. The 5-day scheduled Minimum Data Set (MDS) with an Assessment Reference Date of 12/16/15 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, totally dependent on 2 plus person for assistance with transfers, required extensive assistance of one person with bed mobility and dressing, limited assistance of one person for eating, had swallowing problems, weighed 94 pounds, had a weight loss, and was not on a physician prescribed weight-loss regimen. a. admission orders [REDACTED].Regular Pureed . Fortified foods . Ensure 1 can by po (by mouth) Tid (3 times a day) . The Admission Clinical assessment dated [DATE] and signed by Licensed Practical Nurse (LPN) #4 documented the resident weighed 100.3 pounds . Notes: Resident . discharged from (local hospital) where he was treated for [REDACTED]. Pureed diet. Ensure 1 can @ (at) each meal to supplement calories . The Medical Nutrition Therapy assessment dated [DATE], with no signature documented the resident's intake was fair (50-75%), diet was mechanical soft with a supplement of shake and variety of snacks. The weight was 100.3 pounds. b. The Nutritional Progress Notes dated 10/6/15 and completed by the Registered Dietician (RD) documented, New to facility wt (weight) 100.3# (pounds) Ht. (Height) 67 (inches) BMI (body mass index) 15.7 (severely underweight). Est (estimated) needs (approximately) 1150 - 1375 Kcals (kilocalories), 45 gm (grams) Pro (protein), 1364 ml (milliliters) free H2O (water). Diet puree with ensure TID . [MEDICATION NAME] . Meds (medications) include [MEDICATION NAME] has side effect Anorexia & (and) wt. loss. Please review and consider medication that might be appetite friendly. Recommend adding Fort (fortified) foods to diet to (increase) Kcals on wt. Will follow as necessary. c. A Telephone Physician order [REDACTED]. High calorie shakes (with) all meals . d. A physician progress notes [REDACTED].Currently his appetite is fair, nutritional intake is adequate . As of 1/14/16, the physician progress notes [REDACTED]. e. Nurses Notes dated 12/6/15 at 8:05 a.m. documented, Resident continues to refuse meals & fluids . decreased loc (level of consciousness) noted. MD (medical doctor) notified @ 0740 (7:40 a.m.) - order received - Transfer to (hospital) ER (emergency room ) via ambulance . The H& P (History and Physical) for the hospital admission of 12/6/15 documented the resident weighed 100.4 pounds. f. The admission orders [REDACTED].Diet Order: Regular Mechanical Soft (with) Fortified Foods . Ground meat . Supplements: Resource 2.0 60 ml po TID (with) med pass. The nursing home Admission Clinical assessment dated [DATE] and signed by LPN #5 documented [DIAGNOSES REDACTED]. g. A Nutritional Progress Note dated 12/15/15 documented, RD Note: Wt 93# Ht 68 BMI 14.2 Severely underweight. Diet Mech Soft Fort Foods, HiCal shake TID, Resource 2.0 60 ml TID. Was recently hospitalized & readmitted DX (diagnoses) ESBL (extended spectrum beta-lactamase) urine (contact isolation). Meds include . [MEDICATION NAME] . Please advise MD of known side effect of [MEDICATION NAME] . wt loss, Anorexia. Recommend adding liquid protein 30 ml TID and [MEDICATION NAME] or Juven 1 pkg (package) BID (2 times a day) for wound healing & Kcals. Will follow. h. The Care Plan last reviewed on 12/15/15 documented, Problem Date: 12/11/15 Resident is at nutrition Risk: As evidenced by: Resident is very thin and cachectic appearing. Nutritional score 21 indicates High risk . Approaches: Weigh and monitor results. Monitor and report to physician: Signs/Symptoms of malnutrition. Significant weight loss chewing/swallowing . Provide diet as ordered (see current physician orders) Regular Mechanical soft with fortified foods. Vitamin supplements: Multivitamin with minerals qd. Vitamin C 500 mg (milligrams) qd Supplements: Resource 2.0 60 ml Tid with med (medication) pass. Provide/monitor intake of diet/fluids. Allow adequate time to eat. Provide dining room/meal accommodations; one person supervised/limited assist . i. A Nurse's Note dated 12/18/15 at 11:45 a.m. documented, .Reviewed RD recommendations, New orders to add Juven 1 pkt po bid, Prosource 30 ml po tid for wound healing . A Nurse's Note at 1:15 p.m. documented, Spoke with physician further about Anorexic effects of [MEDICATION NAME] gave order to DC patch . j. A Nutritional Progress Note dated 12/24/15 and signed by the Dietary Service Manager documented, Will continue to monitor residents weight due to the D/C (discontinue) of exol ([MEDICATION NAME]) patch. Will check weight in one week. k. The December 2015 Medication Administration Record [REDACTED]. l. Nurses Notes dated 12/25/15, no signature and unable to determine time, documented, T (temperature) 103.3, skin hot, flushed. Does not respond to verbal stimuli. (Physician) notified & order received to transfer to (hospital) ER for evaluation. m. The Nutritional Progress Notes dated 12/28/15 (note resident was in the hospital on this date) and signed by the DSM documented, .Residents current weight is 89.1 (pounds). Will continue to monitor weekly weights. On 1/13/16 at 10:10 a.m., the Dietary Manager was asked, The resident was last evaluated on 12/28/15 for dietary, right? She stated, Yes that was my last note. The Dietary Manager was asked, Are you aware the resident was in the hospital at that time? She stated, Oh well I just go by my MDS information and do my notes from that. n. Nurses Note dated 12/29/15 at 8:30 a.m. documented, Spoke with RN (Registered Nurse) at (hospital) about resident & she stated (resident) very weak, not very verbal & not eating . o. The Admission Clinical assessment dated [DATE] and signed by LPN #6 documented, . Diagnosis: [REDACTED]. How is resident's appetite (poor was checked) . p. The Admission Order sheet dated 1/2/16 documented, .Pneumonia,, Urinary tract infection,[MEDICAL CONDITION] . Diet Regular Mechanical Soft . Juven 1 pkt po bid . The January 2016 Physician order [REDACTED]. Prosource 30 ml PO TID . Diet: Regular mechanical Soft Fortified Food All Meals High calorie shake with all meals . Supplements Resource 2.0 60 ml with med pass . The January 2016 MAR, provided by LPN #3 on 1/13/16 at 8:12 a.m., did not document the order for Prosource or Resource 2.0. q. A Medicare Nurse's note dated 1/3/16 at 1:45 p.m. documented, .Refused breakfast this shift . Resident ate two bites of lunch and drank approximately 60 ml of a Mighty Shake . Nurse's Notes dated 1/4/16 at 12:21 p.m. and signed by LPN #2, documented, .appetite is poor . Nurse's Notes dated 1/5/16 at 10:30 a.m. and signed by LPN #3, documented, .Res (Resident) appetite this a.m. for breakfast 25% (with) 120 cc (cubic centimeters) of fluid . r. On 1/11/16 at 11:38 a.m., initial rounds were conducted with LPN #2. The LPN stated the resident had an excess weight loss. On 1/11/16 at 5:51 p.m., the resident was in the dining room and served the evening meal of soup, cold meat sandwich, lettuce, tomatoes, cookie, mashed potatoes (not fortified per the Surveyor who watched food preparation), 360 ml of tea and a 4 ounce Mighty Shake. The resident was not served the following menu items: fruit, saltine crackers, garnish pickle spear, or fortified foods. Resident #5 was assisted by a nurse with eating. The resident consumed 5% of his supper meal and all fluids totaling 580 ml. s. On 1/12/16 at 12:00 p.m., the resident was assisted by staff CNA #4 with food set up and eating. The resident was served a hot turkey sandwich, mashed potatoes with butter added by staff CNA #4 seasoned peas, four layer delight (desert), 240 ml of iced tea, and a 4 ounce Mighty Shake. The resident consumed 5% of the meal. The resident consumed all of the Mighty Shake and approximately 50 cc of the tea. CNA #4 was encouraging the resident to eat more, but the resident stated, no and don't want anymore. The Dietary Manager was asked what was the fortified food item and the Dietary Manager stated, the mashed potatoes are fortified. t. On 1/13/16 at 7:45 a.m., the resident was served oatmeal with milk in it, eggs, biscuit, sausage crumbles, 240 ml of water, 4 ounces of Mighty Shake, 236 ml of whole milk, and 240 ml of coffee. Certified Nursing Assistant (CNA) #1 assisted the resident with eating. At 8:00 a.m. the resident was offered eggs and he stated, No. The CNA offered the resident sausage and he stated, No don't want anymore. At 8:10 a.m., the Dietary Manager was asked, What is the fortified food served? She stated, It is a malt-o-meal cereal with brown sugar in it. She was asked, What on (Resident #5's) tray is fortified? She stated, Oh, he didn't get anything fortified . I will bring it right now. The Dietary Manager brought a bowl of cereal to the table and gave it to CNA #1. CNA attempted to feed the cereal to the resident and he stated, No, don't want anymore. The resident consumed 5% of the breakfast meal and 50 ml of water, all of the Mighty shake, and whole milk. At 8:25 a.m. CNA #1 was asked, Were you aware that (Resident #5) was on fortified foods? She stated, No. A copy of Resident #5's Meal Tray Card documented, .Mechanical soft with fortified foods . u. On 1/13/16 at 8:12 a.m., LPN #3 was administering medications to Resident #5 in the dining room. The LPN was asked, What meds is he taking at this time? She stated, Juven and regular daily medications. This Surveyor asked to see the resident's Medication Record. LPN #3 stated, This is his current medication and those copies turned backwards are his old ones from where he went to the hospital and came back. There was no documentation on the MAR for Prosource or Resource 2.0. v. On 1/13/16 at 9:50 a.m., the Assistant Director of Nursing (ADON) was asked, When was the resident's last weight? She stated, I guess he hasn't been weighed since December 23rd (2015 dietary notes). The ADON was asked to obtain a current weight on Resident #5. The ADON transported the resident via wheelchair to therapy where he was placed on a scale in the wheelchair. The ADON stated, 123.9 lbs is the weight and the wheelchair weight is 42.3 lbs so he is 81.6 lbs. The ADON was asked, What dietary interventions is (Resident #5) supposed to be care planned for? She stated, Prosource is for weight and wounds . Resource 2.0 cal, high calorie shakes, fortified foods, mechanical soft diet from the pureed diet and I think she did some recommendations on med changes. The ADON was asked, Is there a reason his Prosource or Resource is not on the January 2016 MAR? She stated, We failed him. The ADON was asked whose responsibility it was to ensure those dietary interventions were put back onto the medication record when the resident returned to the facility and she stated, Myself or the Dietary Manager. The ADON was asked, Whose responsibility is it to put the new orders on the Medication Record when the resident returns to the facility? She stated, That would be the nurse who admits them back. w. The Summary Annual Weight report documented the following: 10/15 - 100.3 lbs. 11/15 - 93.8 lbs. 12/15 - 98.3 As of 1/13/16 there was no documentation in the clinical record of the resident being weighed since the resident returned from the hospital on [DATE]. The resident's weight, per the Surveyor's request, on 1/13/16 was 81.6 lbs. This was a loss of 18.7 lbs (18.6% in 3 months) and 16.7 lbs. (16.9% in 1 month). x. On 1/13/16 at 10:00 a.m., the Director of Nursing (DON) was asked, What can you tell me about (Resident #5's) care plan for weight loss? She stated, Resident was put on fortified foods when admitted because of weight loss and (RD #1) recommendation was please advise MD of side effects of [MEDICATION NAME] Patch and added Juven and Prosource on 12/12/15. The DON was asked if she was aware Resident #5 was not getting care planned recommendations and the DON stated, Oh the ADON handles that. I've only been here 3 weeks. On 1/13/16 at 10:10 a.m., the Dietary Manager was asked, Are you aware that the resident did not receive fortified foods for supper on 1/11/16 or for breakfast this morning? The Dietary Manager stated, Oh yeah and we are actually doing an in-service with CNA's on giving fortified foods. She was asked, Isn't that on their tray cards. Are they not looking at them to see if they get fortified foods? She stated, I guess not. 1) On 1/13/16 at 10:30 a.m., the Meal Intake Record/CNA Activities of Daily Living (ADL) Form was requested for October 2015 through today. There were no initials on the forms in the boxes to indicate any morning, evening, or bedtime snacks were given. On 1/15/16 at 8:15 a.m., the DON was asked, Can you tell me why there are no initials in the boxes for snacks or substitutes charted in the Meal Intake or CNA-ADL Tracking forms? She stated, Well I know they are offered, but not sure why they are not documenting it. They should be. 2) On 1/14/16 at 1:00 p.m., the Dietary Manager was asked, When will the resident be evaluated by the RD? She stated, I faxed her the information and she is supposed to email me a new dietary plan for (Resident #5) today. I just realized I am supposed to reassess residents when they are readmitted from hospital. 3) On 1/14/16 at 2:20 p.m., the Administrator was asked, When a resident returns from the hospital who is responsible to ensure dietary interventions are implemented or updated? She stated, The charge nurse with orders, ADON or DON then it goes to the Dietary Manager who makes sure interventions for food and supplements are served to residents. We have a meeting and compare dietary to nursing. 4) On 1/14/16 at 2:30 p.m., the following questions were asked of the DON, ADON, and Dietary Manager: How often is a resident to be assessed for nutritional status? The DON stated, We do weekly weights. We compare, sit down together me, ADON, and Dietary and we address any issues that come up. The ADON stated, On admission and on MDS quarterly, with change of condition and or on re-admission. The Dietary Manager stated, I do it one time unless I have a recommendation from my RD or readmitted from hospital. They were asked, How is weight loss reported to the physician? The DON stated, Once we get our staff in we evaluate and fax the notification order to the MD's office. The Medical Director is here the 3rd Monday. Dr. (physician name) is here the first week of the month. The ADON stated, We, if it's a big one, we call but we also use notification forms. They were asked, What system do you have in place for the monitoring of weight loss and how are interventions and protocols communicated throughout the staff? The DON stated, After we meet we all sit down and look at what we have not done then we come out and speak to our staff, Medical Record and MDS, to make sure we are all on the same plan with Dietary interventions. The ADON stated, We have weekly weight meetings and discuss everything and look at meds and as a team come up with something and use dietary slips and in-service aides to make sure they are aware. They were asked, What methods do you use to ensure all interventions are put in place are being effectively implemented? The DON stated, Check the orders. ADON checks that all orders are written down and put into the chart. The ADON stated, Well monitoring mostly and check backs to see if the orders match dietary orders. The Dietary Manager stated, Cause I monitor them. They were asked, How often do residents get RD visits? The DON stated, She comes once a month. The ADON stated, Usually once a month. The Dietary Manager stated, Once a month. The Dietary Manager was asked, Who makes sure fortified foods are given to residents? She stated, I make tickets. I communicate with dietary staff with what resident needs are or changes made. I make sure dietary knows by looking at dietary cards.