Every finding on record at Marquis Hope Village

Based on interview and record review, it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (# 1) reviewed for change of condition. This placed residents at risk for potential adverse side effects. Findings included:Resident 1 was admitted to the facility in 3/2026 with diagnoses including bipolar disorder and major depressive disorder.The emergency room after visit summary dated 3/13/26 indicated Resident 1 was prescribed the following medications:-Tylenol 650mg four times a day.-Betamethasone lotion (used to reduce inflammation) daily.-Lamotrigine (an anticonvulsant to treat epilepsy or mood stabilization) 100mg daily.-Levothyroxine (a thyroid medication) 100mcg daily.-Lorazepam (an antianxiety medication) 0.5mg as needed.-Metformin (a medication used to control blood sugars) 750mg twice a day.-Olanzapine (an antipsychotic medication) 5mg twice a day.-Sertraline (an antidepressant medication) 100mg daily.-Potassium chloride (a supplement) 10MEQ daily. -Triamcinolone cream (used to treat inflammation of the skin) three times a day. Resident 1's 3/2026 MAR indicated she/he was not administered the following medications from 3/16/26 through 3/30/26, a total of 14 days:-Levothyroxine 75mcg daily-Lovastatin 20mg nightly-Metformin 750mg daily-Olanzapine 5mg twice a day-Potassium chloride 10MEQ daily-Sertraline 100mg daily-Triamcinolone three times a [NAME] 8/4/26 at 11:01 AM, Witness 1 (Complainant) stated she became aware Resident 1's medications were not administered once the resident arrived at the hospital. Witness 1 called the facility to inform them of the missing medication, but the facility stated they were not aware of any missing medications.During record review, it was determined that Resident 1's 3/16/26 signed physician orders were only partially transcribed and sent to the pharmacy.On 8/4/26 at 10:00 AM and on 8/5/26 at 3:00 PM, Staff 4 (CNA), Staff 3 (CNA) and Staff 7 (CNA) confirmed Resident 1's had no significant behavior changes throughout her/his stay. On 8/5/26 at 10:00 AM, Staff 5 (RN) stated she inputted Resident 1's orders and faxed them to the pharmacy. Staff 5 acknowledged Resident 1's medications were not transcribed completely, which was discovered after the resident left the facility. On 8/5/26 at 12:37 PM, Staff 1 (DNS) and Staff 2 (Interim Administrator) acknowledged Resident 1's medications were not administered according to the resident's physician orders.The deficient practice was identified as Past Noncompliance based on the following:On 3/31/26, the deficient practice was identified by the facility and was corrected when the facility completed an investigation of the incident and determined there was a failure to transcribe several pages of medications. The plan of correction included: 1. Staff were educated on proper admission order transcription, 2. all current residents at that time were reviewed for accuracy. 3. admission policy and procedure was updated to demonstrate permanent increased auditing, 4. Admissions were audited weekly for four weeks, then monthly for success.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 3 of 3 sampled CNA staff (#s 7, 8 and 9) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 5/22/25 indicated the following employees had not received their annual performance evaluations: -Staff 7 (CNA), hired date was 2/2019 and a performance review was not completed. -Staff 8 (CNA), hired date was 1/2019 and a performance review was not completed. -Staff 9 (CNA), hired date was 4/2020 and a performance review was started in 4/2025 and not completed. On 5/23/25 at 9:45 AM PM Staff 2 (DNS) confirmed annual performance reviews were not completed for Staff 7, Staff 8 and Staff 9.

Based on observation, interview and record review it was determined the facility failed to ensure kitchen staff wore appropriate hair restraints during meal preparation and tray line for 1 of 1 facility kitchen reviewed for sanitation. This placed residents at risk for unsanitary foods and food-borne illness. Findings include: Review of the US FDA Food Code 2022 revealed: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. On 5/19/25 at 9:10 AM on the initial kitchen tour observed Staff 10 (Dietary Manager) had facial hair and was observed putting breakfast items and cleaning the kitchen counters without a beard restraint in place. On 5/22/25 at 11:40 AM, Staff 10 was observed without a beard restraint while preparing lunch meals, taking food temperatures, and plating food. On 5/22/25 at 1:04 PM Staff 10 stated he expected his staff to follow hygiene protocols and wear hair restraints while working in the kitchen. Staff 10 stated he had offered beard restraints in past, but had never worn one himself. On 5/22/25 at 1:18 PM Staff 1 (Administrator) stated she expected the dietary staff to follow hygiene procedures and wear hair restraints including a beard restraint when working in the kitchen.

Based on observation, interview and record review it was determined the facility failed to ensure dental services were provided for 1 of 2 sampled residents (#19) reviewed for activities of daily living. This placed residents at risk for lack of dental care needs. Findings include: Resident 19 was admitted to the facility in 4/2024 with diagnoses including major depressive disorder. Resident 19's 5/24/24 Dental Care Plan revealed the following: -The resident had upper and lower dentures. -Staff were to provide the resident with oral hygiene supplies and assist with oral hygiene if she/he was too weak. -Staff were to assist with proper storage and clean the resident's dentures daily. A Social Services Quarterly assessment dated [DATE] indicated the resident had moderately impaired cognition, had no dental status changes and continued to use her/his dentures. On 5/19/25 at 3:36 PM Resident 19 was observed in bed without dentures in place. On 5/21/25 at 9:36 AM Staff 12 (CNA) stated Resident 19 had not worn her/his dentures for at least a year. Resident 19's denture case was observed on the counter next to her/his bedroom sink. Staff 12 opened the case, and the resident's dentures were observed in a clear fluid and the dentures were covered with black debris. When asked why the resident no longer wore her/his dentures, Staff 12 stated they did not fit. On 5/21/25 at 10:03 AM Staff 11 (CNA) stated the resident had not worn her/his dentures for a few months. Staff 11 stated the dentures caused the resident pain and he reported the concern to a nurse approximately two months ago. On 5/21/25 at 3:20 PM Staff 15 (LPN) stated she was unaware of any dental concerns for Resident 19 and was unsure if the resident wore dentures. On 5/22/25 at 10:43 AM Resident 19 was observed without top and bottom dentures in place. The resident stated the dentures needed to be adjusted. On 5/23/25 at 8:56 AM Staff 4 (Social Services Director) stated she was responsible for arranging dental services for residents with dental needs, including dentures. Staff 4 stated she was unaware of any concerns regarding Resident 19's dentures. On 5/23/25 at 9:11 AM Staff 3 (RNCM) stated staff were expected to report concerns regarding resident dentures to Staff 4 so dental services could be scheduled. Staff 3 stated she was unaware of reported concerns regarding Resident 19's dentures or she/he no longer wore dentures. Staff 4 acknowledged an appointment for dental services should had been initiated for Resident 19.

Based on observation, interview and record review it was determined the facility failed to ensure care plan interventions were in to prevent falls for 1 of 2 sampled residents (#18) reviewed for accidents. This placed residents at risk for injuries. Findings include: Resident 18 was admitted to the facility in 3/2025 with diagnoses including fracture of the humerus (a bone which connects the shoulder to the elbow). The Admission MDS dated [DATE] indicated Resident 18 was cognitively intact and she/he had a history of falls with no fractures in the last six months. A review of Resident 18's medical record revealed the resident fell on ce on 3/28/25, twice on 4/14/25, once on 4/30/25 and once on 5/11/25. Resident 18's 5/11/25 Care Plan revealed the following: -The resident was to be seated in a high visibility area. -The resident was to have a visual cue in her/his room to remind her/him to use the call light. -The resident was on frequent checks. -The resident was not allowed to be left alone in her/his room unsupervised. A observation on 5/20/25 at 11:38 AM revealed Resident 18 had no visual cues or reminders in her/his room to utilize the call light. A observation on 5/20/25 from 4:40 PM to 4:50 PM, revealed Resident 18 was in her/his wheelchair by the front door of her/his room and no staff were present. On 5/22/25 at 9:35 AM, Staff 11 (CNA) stated he was unaware if Resident 18 was on frequent checks and stated all residents are on fall precautions. On 5/22/25 at 10:25 AM, Staff 12 (CNA) stated she was unaware if Resident 18 had any recent falls. Staff 12 stated she was unsure how often she was supposed to check on Resident 18. On 5/22/25 at 10:53 AM Resident 18 was observed in another resident's room and looked through papers on the bedside table. Resident 18 looked through another resident's personal papers without asking for permission. On 5/22/25 at 11:23 AM, Staff 13 (CNA) stated Resident 18 wandered the hallways often. Staff 13 stated she was unsure how often the resident needed to be checked on but thought Resident 18 should be supervised because she/he made threats to leave the facility. Staff 13 stated she had not observe any visual cues in the resident's room to remind her/him to use the call light. On 5/22/25 at 2:55 PM, Staff 14 (LPN/Resident Care Manager) stated Resident 18 should have a visual cue reminder in the room to remind her/him to use the call light and was unaware one was not in the resident's room. Staff 14 stated she expected staff to frequently check on Resident 18 which she defined as every 15 minutes. Staff 14 further stated Resident 18 was not to be left alone in the room when she/he was up and in her/his wheelchair. On 5/22/25 at 3:54 PM, Staff 2 (DNS) acknowledged the Resident 18 had no visual cues posted in her/his room to remind the resident to utilize the call light. Staff 2 stated staff were expected to implement and follow the care plan and acknowledged the care plan was not followed.

Based on observation, interview and record review it was determined the facility failed to identify, in a timely manner, a resident who experienced a significant change in status for 1 of 2 sampled residents (#18) reviewed for accidents. This placed residents at risk for injuries and unidentified care needs. Findings include: Resident 18 was admitted to the facility in 3/2025 with diagnoses including falls. Resident 18's 3/26/25 Admission MDS indicated the resident was cognitively intact and had no behavioral symptoms, including wandering. The resident had no functional limitations and was able to use her/his upper extremity freely. A 4/30/25 Unwitnessed Fall Investigation revealed Resident 18 fractured her/his left arm when she attempted to self-transfer to the bed. A 5/1/25 progress note revealed Resident 18 was to be monitored and placed on alert charting for 14 days to determine if the resident experienced a significant change in condition. A review of Resident 18's medical record revealed no indication the resident refused care or was placed on alert charting. On 5/22/25 at 9:35 AM, Staff 11 (CNA) stated Resident 18 was not resistant to care when she/he was admitted to the facility but had since become resistant to care. Staff 11 stated Resident 18 exhibited verbal aggression toward staff. Staff 11 stated Resident 18 was able to perform peri-care and complete upper body dressing independently. On 5/22/25 at 10:53 AM Resident 18 was observed in another resident's room and looked through papers on the bedside table. Resident 18 looked through another resident's personal papers without asking for permission and the other resident was unaware of the incident. On 5/22/25 at 11:23 AM, Staff 13 (CNA) stated Resident 18's functional status declined after sustaining a fracture. Staff 13 stated the resident did not have behaviors and was able to complete upper body tasks independently when she/he admitted to the facility. Staff 13 stated Resident 18 experienced a change in her/his baseline, refused care and wandered the halls. On 5/22/25 at 12:38 PM, Staff 4 (Social Service Director) stated Resident 18 was cognitively intact and able to make decisions about her/his care upon admission but had since become cognitively impaired. Staff 4 stated Resident 18 was moderately impaired for decision-making. Additionally, Staff 4 stated Resident 18 had not exhibited behaviors at the time of admission but later voiced suicidal ideations and threatened her/his roommate. On 5/22/25 at 2:55 PM, Staff 14 (LPN Resident Care Manager) stated she/he was unsure of the criteria of when to complete a Significant Change of Condition Assessment. Staff 14 stated she placed Resident 18 on alert charting for two weeks. She acknowledged no progress note was made to determine if the resident experienced a significant change and needed to converse with Staff 2 (DNS). On 5/22/25 at 3:54 PM, Staff 2 stated no progress note was made regarding a significant change of condition. Staff 2 acknowledged Resident 18's cognition and functional abilities changed. Staff 2 stated she was unsure if Staff 14 spoke to the staff about recent ADL decline. Staff 2 acknowledged a significant change of condition assessment should have been completed.

Based on observation, interview and record review the facility failed to implement enhanced barrier precautions for residents with diabetic wounds for 1 of 3 sampled residents (#2) reviewed for skin conditions. This placed residents at risk for facility acquired infections. Findings include: Resident 2 admitted to the facility on [DATE] with diagnoses including diabetic ulcers. Resident 2's 4/9/25 wound care orders instructed staff to apply idosorb 0.9% to the resident's diabetic foot ulcers, cover with gauze, and secure with a foam dressing daily. There was no evidence in Resident 2's medical record that she/he was on enhanced barrier precautions for her/his diabetic ulcers. On 4/10/25 at 11:43 AM, observation of Resident 2's wound revealed Staff 3 (LPN) did not wear a PPE gown and utilize enhanced barrier precautions when she completed wound care to the resident's three diabetic foot ulcers. On 4/10/25 at 12:57 PM, Staff 3 verified she did not wear a PPE gown when she completed Resident 2's wound care. On 4/10/25 at 12:59 and 1:10 PM, Staff 2 (DNS/Infection Preventionist) acknowledged Staff 3 did not follow enhanced barrier precautions when she completed Resident 2's wound care.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 9 of 30 days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include: Review of the 11/25/23 through 12/24/23 DCSDRs indicated the following days when the number of RN staff and hours worked were inaccurate on the daily postings: -11/25/23, 12/2/23, 12/3/23, 12/9/23, 12/10/23, 12/16/23, 12/22/23, 12/23/23, 12/24/23 On 12/28/23 at 1:43 PM Staff 5 (Staffing Coordinator) stated the DCSDRs were incorrect, the facility had RNs who worked on the identified dates and was unsure why the DCSDR weekend sheets were inaccurate. On 12/29/23 at 1:56 PM Staff 1 (Administrator) acknowledged the DCSDRs were inaccurate.

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 1 of 6 sampled residents (#240) reviewed for medication administration. The facility's medication error rate was 8%. This placed residents at risk for adverse medication consequences. Findings include: Resident 240 was admitted to the facility in 12/2023 with diagnoses including a fracture of the left femur (thigh bone). a. Resident 240's 12/8/23 Physician's Orders included torsemide (used to treat fluid retention) 10 mg tablet with instructions to administer 0.05 tablet daily. On 12/27/23 at 8:04 AM Staff 10 (CMA) was observed to administer torsemide to Resident 240. The torsemide 10 mg tablet was split in half prior to administration to the resident. On 12/28/23 at 12:00 PM Staff 10 acknowledged she administered Resident 240 half of the torsemide 10 mg tablet for a dose of 5 mg. She verified the order was to administer torsemide 0.05 tablet and not the 0.5 tablet which she administered to the resident. On 12/29/23 at 1:20 PM Staff 2 (RNCM) and Staff 3 (RNCM) stated when a physician's order required clarification the CMA was to notify the nurse, RNCM or DNS to check the order and contact the physician if needed for clarification. Staff 3 acknowledged this was not done for Resident 240's torsemide dose. b. Resident 240's 12/8/23 Physician's Orders included a lidocaine patch [used to treat pain (the resident could have up to three patches daily)] to be applied topically for pain. The facility's Self-Administration Medication policy last revised on 5/2010, indicated the following: -As part of their overall evaluation, the staff and practitioner assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. -In addition, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's ability to read the medication labels; comprehension of the purpose and proper dosage and administration time for her/his medications; ability to remove medications from container and the ability to recognize risks and major adverse consequences. -Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. On 12/27/23 at 8:04 AM Staff 10 (CMA) was observed to leave two lidocaine patches on Resident 240's overbed table. Review of Resident 240's clinical record indicated the resident was not assessed for medication self-administration prior to the lidocaine patches being left in the resident's room. On 12/29/23 at 1:20 PM Staff 2 (RNCM) confirmed Resident 240 did not have a physician's order to self-administer at the time the lidocaine patches were left in the resident's room. She stated her expectation was a self-administration assessment was completed and a physician's order in place prior to allowing the resident to self-medicate.

Based on interview and record review it was determined the facility failed to ensure dialysis treatment and care was in place including physician orders and communication with the dialysis provider for 1 of 1 sampled resident (#1) reviewed for dialysis. This placed residents at risk for dialysis complications. Findings include: Resident 1 admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependent on dialysis (a procedure to remove waste products from the blood when the kidneys stop working). a. The 11/27/23 Admission MDS indicated at baseline the resident received dialysis treatments three times a week at a clinic outside the facility. Resident 1's care plan for renal failure with dialysis, created on 11/21/23, indicated treatment to the dialysis access site was to be followed per the physician orders. The 11/21/23 admission physician orders and the 12/18/23 last signed physician orders did not include any dialysis care orders. On 12/28/23 at 3:51 PM Staff 19 (RN) stated when the resident returned to the facility from the dialysis center, the charge nurse completed a physical assessment of the resident to ensure the pressure dressing was around the dialysis access site and there was no active bleeding. She indicated she removed the dressing several hours after the resident's return and continued to monitor for bleeding. Staff 19 stated every resident who was on dialysis had physician orders related to dialysis care. When asked if Staff 19 could show the surveyor the physician orders for dialysis care she could not locate any in the resident's chart. On 12/29/23 at 10:39 AM Witness 2 (Dialysis RN) stated every nursing facility should have physician orders for a resident's dialysis care. Witness 2 stated the facility was to remove the pressure dressing from Resident 1's dialysis access site several hours after the resident returned from the dialysis center and the resident was to be monitored for bleeding. On 12/29/23 at 9:29 AM Staff 2 (RNCM) acknowledged there were no physician orders in place for the resident's dialysis care. b. A dialysis communication form was reviewed and indicated the facility was to complete the section for Resident 1's last recorded weight, current blood pressure, any concerns, and the nursing staff signature and date. The dialysis center was to complete the section for pre and post dialysis weights, treatment provided, post dialysis instructions, staff signature and date, and when the next scheduled dialysis treatment was. A review of dialysis communication forms from 11/24/23 through 12/24/23 revealed incomplete communication forms on: 11/24/23, 11/27/23, 12/4/23, 12/11/23, 12/13/23, 12/15/23, 12/18/23, 12/20/23 and 12/22/23. These included missing information in both sections from the facility and the dialysis center. A review of the resident's clinical record revealed no documentation related to communication between the facility and the dialysis provider. On 12/28/23 at 12:40 PM Staff 7 (LPN) and on 12/28/23 at 3:51 PM Staff 19 (RN) stated the dialysis communication forms were completed by the facility and sent with Resident 1 to dialysis. Staff 7 and Staff 19 stated upon return to the facility, the charge nurse entered the resident's weights and any new orders from dialysis. Staff 19 stated if the communication form was incomplete from the dialysis center, the charge nurse attempted to call the dialysis center to obtain information. When the charge nurse was not successful, the RNCM followed up the next day. On 12/29/23 at 9:29 AM Staff 2 (RNCM) stated the communication between the facility and the dialysis center was a challenge. Staff 2 stated she requested the completed forms from the dialysis center and never received them. Staff 2 acknowledged the incomplete dialysis communication forms which included incomplete information from the facility and from the dialysis center.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 2 of 5 randomly selected staff members (#s 11 and 13) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: A review of the facility's staff training records revealed the following: -Staff 11 (CNA), hired 1/10/19, had six hours of documented training. -Staff 13 (CNA), hired 7/15/22, had one hour of documented training. On 12/29/23 at 1:26 PM Staff 5 (Staffing Coordinator) stated it was the facility's expectation that staff complete their trainings online and in person. On 12/29/23 at 1:56 PM Staff 1 (Administrator) acknowledged Staff 11 and Staff 13 did not meet the 12 hours required and provided no additional documentation.

Based on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 1 of 1 sampled resident (#26) reviewed for foot care. This placed residents at risk for lack of nail care and increased infections. Findings include: Resident 26 admitted to the facility in 11/2023 with diagnoses including stroke and depression. A 12/4/23 Progress Note indicated Staff 17 (LPN) Trimmed nail on both hands. Res requested toenails be cut, they are too thick. The resident stated her/his doctor usually did this, and [she/he] was agreeable to follow up with doctor on discharge. On 12/26/23 at 2:30 PM and 12/28/23 at 12:45 PM Resident 26's toes were observed with all toenails discolored, deformed, thickened (half-an-inch) and longer than one inch. Resident 26's right large toenail was brownish/black and the nail vertically extended above the face of the nail bed over one inch. On 12/28/23 at 12:50 PM Resident 26 stated she/he requested to have her/his toenails trimmed but it was not done. On 12/29/23 at 9:42 AM Staff 16 (LPN) stated she was aware of Resident 26's diabetic toenails because she was not able to trim her/his nails due to the thickness. Staff 16 stated Staff 14 (Social Service Director) was to be notified and was responsible for making a podiatrist appointment. On 12/29/23 at 11:54 AM Staff 2 (RNCM) stated nurses were responsible to trim diabetic toenails and was aware this was not being completed because of the condition of Resident 26's toenails. Staff 2 stated Staff 14 was responsible for addressing podiatrist appointments. On 12/29/23 at 1:14 PM Staff 14 (Social Service Director) stated she was out of the facility due to being sick and was not aware of Resident 26's foot needs. Staff 14 stated she was responsible for making the podiatry appointments.

Based on interview and record review it was determined the facility failed to implement bowel care and follow physician orders timely for 2 of 5 sampled residents (#s 20 and 21) reviewed for medications. This placed residents at risk for adverse side effects and constipation. Findings include: 1. Resident 21 admitted to the facility in 11/2023 with diagnoses including chronic ulcerative colitis and dementia. A review of Resident 21's 11/29/23 Admission Physician Orders revealed an order for diphenoxylate-atropine (used in the management and treatment of diarrhea) 2.5-0.025 mg, give two tablets by mouth as needed for diarrhea twice daily. A Pharmacy Recommendation dated 11/30/23 revealed Resident 21 had an order for Lomotil (diphenoxylate-atropine), which was a controlled substance medication, and noted, The pharmacy had not received a valid order and was unable to dispense the medication. Provide the pharmacy with a valid order for the medication to prevent a delay in dispensing. A Packing Slip dated 12/1/23 at 2:33 AM indicated Lomotil (diphenoxylate-atropine 2.5-0.025 mg) was delivered to the facility. A review of Resident 21's 11/2023 and 12/2023 MARs revealed Resident 21 did not receive the Lomotil until 12/2/23 at 11:16 AM (three days after it was ordered, and more than 24 hour after it was received by the facility). On 12/28/23 at 7:26 PM Witness 1 (Family Member) stated Resident 21 had chronic ulcerative colitis and the Lomotil was important and helped reduce her/his chronic ongoing diarrhea. On 12/29/23 at 9:32 AM Staff 18 (LPN) stated Resident 21 had chronic diarrhea and Lomotil was necessary to help reduce her/his diarrhea. Staff 18 was not aware there was an issue with the Lomotil not being dispensed due to not having a valid prescription. Staff 18 stated if a prescription was not valid, then a new prescription had to be completed and signed by the physician before the Lomotil could be dispensed. On 12/29/23 at 11:54 AM Staff 2 (RNCM) stated Resident 21 had a physician order for Lomotil on 11/29/23, but the prescription was not valid. Staff 2 stated they had to get a new prescription written from the physician before the Lomotil could be dispensed. Staff 2 stated they received a new prescription but it did not arrive until early in the morning on 12/1/23 and the resident was not offered a dose until 12/2/23. 46841 2. Resident 20 was admitted to the facility in 7/2022 with diagnoses including stroke. The facility's 4/5/18 Bowel Care Policy indicated: - The nurse was to review residents' bowel results daily and initiate a list of residents who did not have a BM (bowel movement) in 48 hours. - PRN bowel medication was to be administered after no BM in 48 hours. - PRN bowel medication (laxatives) order of administration was (MiraLAX or senna, Dulcolax suppository, tap water enema). - If the resident declined PRN bowel medications the refusal was to be documented and the physician notified. - If no bowel movement after all three PRN medications the physician was to be notified. Resident 20's Physician Order Summary Report as of 12/28/23 indicated the following PRN bowel medication orders: - MiraLAX PRN for no BM in 48 hours. - senna PRN for no BM in 48 hours. - Dulcolax suppository PRN for no BM, if MiraLAX or senna not effective within 24 hours. - Tap water enema, if Dulcolax suppository not effective within 8 hours. Resident 20's BM records from 11/30/23 through 12/28/23 indicated the resident did not have a BM on the following dates: - 12/3/23 through 12/6/23 (four days). - 12/8/23 through 12/11/23 (four days). - 12/13/23 through 12/17/23 (five days). - 12/24/23 through 12/28/23 (five days). No evidence was found in the resident's clinical record to indicate PRN bowel care medications were administered timely, or the physician was notified. On 12/29/23 at 10:03 AM Staff 7 (LPN) stated residents with no BM in 48 hours were included on the bowel care list and were to be administered PRN bowel medications as ordered. Staff 7 stated when a resident refused PRN bowel medications she documented the refusal on the MAR, assessed the resident and contacted the physician as indicated. On 12/29/23 at 1:37 PM Staff 3 (RNCM) stated Resident 20 was frequently on the bowel care list and often refused PRN bowel medications. Staff 3 stated she expected bowel care medications to start after a resident did not have a BM for 48 hours and proceeded as the physician ordered. Staff 3 acknowledged this did not occur for Resident 20.

Based on interview and record review it was determined the facility failed to ensure residents received Advance Beneficiary Notification (ABN) information for 1 of 3 sampled residents (#22) reviewed for discharge. This placed residents at risk for financial hardship. Findings include: Resident 22 was admitted to the facility on [DATE] with diagnoses including diabetes. The 11/30/23 NOMNC (Notice of Medicare Non-Coverage) indicated Resident 22's skilled days ended on 12/3/23. Review of Resident 22's medical record indicated the resident remained in the facility pending Medicaid. There was no documentation indicating Advance Beneficiary Notification information was provided to the resident. On 12/28/23 at 11:21 AM Staff 4 (Admission Care Coordinator) stated Resident 22 was pending Medicaid and acknowledged the resident did not receive Advance Beneficiary Notification information, including the daily cost if Medicaid was not approved.

Based on interview and record review it was determined the facility failed to assess a resident for safe self-administration of medication for 1 of 1 sampled resident (#26) reviewed for ADL care. This placed residents at risk for unsafe medication administration. Findings include: The facility's Self-Administration Medication policy last revised on 5/2010, indicated the following: -As part of their overall evaluation, the staff and practitioner assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. -In addition, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's ability to read the medication labels; comprehension of the purpose and proper dosage and administration time for her/his medications; ability to remove medications from container and to ingest and swallow them and the ability to recognize risks and major adverse consequences. -Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Resident 26 admitted to the facility in 11/2023 with diagnoses including stroke and depression. A Physician Order dated 11/30/23 revealed Resident 26 was to receive nicotine polacrilex (assists a person to quit smoking) mouth/throat gum, 2 mg, one piece by mouth every eight hours related to tobacco use. A 12/6/23 Admission MDS indicated Resident 26 had a BIMS score of 14 and she/he was cognitively intact. A review of Resident 26's clinical record revealed no evidence that a self-administration of medication assessment was completed. On 12/28/23 from 9:29 AM through 10:30 AM, Resident 26 was observed in bed asleep and on her/his bedside table was a small pill cup with a green square object inside the pill cup. On 12/28/23 at 10:45 AM Staff 10 (CMA) stated the contents of the pill cup on Resident 26's bedside table was nicotine gum, which she always left there for the resident to use when she/he craved a cigarette. On 12/29/23 at 11:54 AM Staff 2 (RNCM) stated Resident 26's should not have been allowed to self-medicate unless a self-medication assessment was completed. Staff 2 acknowledged Resident 26 did not have a self-administration assessment completed.

Based on interview and record review it was determined the facility failed to ensure a resident was free from misappropriation of property for 1 of 1 sampled resident (#4) reviewed for misappropriation. This placed residents at risk of stolen property. Findings include: Resident 4 admitted to the facility in 2022 with diagnoses including heart failure. The 1/2/23 Lost Resident Property Investigation Report revealed Resident 4 reported two missing gold rings. One ring had a diamond and sapphire, the other was a gold band. Resident 4 reported she/he had worn both rings to bed on 1/1/23. The investigation revealed law enforcement was involved. The 1/18/23 Offense/Incident Report (police report) indicated Resident 4 reported she/he awoke on 1/2/23 to find the two rings on her/his left hand, one ring on her/his right hand and a necklace she/he wore were gone. Resident 4 reported going to sleep with the jewelry on. The first and second offenses were documented as Aggravated Theft I - Other and the third offense was Criminal Mistreatment I - All Other. The report revealed Witness 2 (Police Detective) identified Staff 4 (Agency CNA) as the perpetrator. The 5/13/23 Supplemental (police) Report indicated two rings were recovered at a local pawn shop and Staff 4 had additional charges of criminal mistreatment in the first degree and theft in the first degree for the theft of Resident 4's rings and theft in the second degree (by deception) for selling the stolen jewelry to the pawn shop. On 5/30/23 at 12:22 PM Staff 1 (Administrator) verified Resident 4 had jewelry including two gold rings stolen. Staff 1 further stated law enforcement identified Staff 4 as the perpetrator.

Based on interview and record review it was determined the facility failed to notify the State Agency of misappropriation of resident property for 1 of 1 sampled resident (#4) reviewed for misappropriation. This placed residents at ongoing risk for stolen property. Findings include: Resident 4 admitted to the facility in 2022 with diagnoses including heart failure. The 1/2/23 Lost Resident Property Investigation Report revealed Resident 4 reported two missing gold rings. One ring had a diamond and sapphire, the other a gold band. Resident 4 reported she/he had worn both rings to bed on 1/1/23. The investigation revealed law enforcement was involved. The 1/2/23 and 5/13/23 police reports revealed Resident 4's jewelry was stolen by Staff 4 (Agency CNA). On 5/30/23 at 12:22 PM Staff 1 (Administrator) verified Resident 4 had two gold rings stolen, law enforcement was involved and identified Staff 4 as the perpetrator and stated the facility did not submit a FRI as required.

Based on interview and record review it was determined the facility failed to immediately report alleged violations involving resident sexual abuse to the State survey and certification agency and failed to report the results of investigations within five working days to the State survey and certification agency for 1 of 1 sampled residents (#1) reviewed for abuse. These failures placed residents at risk for repeat and continued abuse. Findings include: The facility's policy, Abuse Prevention Program, revised 12/2020 stated Our facility is committed to protecting our residents from abuse by anyone .mandated staff training the protection of residents during abuse investigations .timely and thorough investigations of all reports and allegations of abuse .the reporting and filing of accurate documents relative to incidents of abuse .an ongoing review and analysis of abuse incidents. The facility's Abuse, Neglect and Exploitation-Clinical Protocol, revised 10/2020 stated The nurse will assess the individual and document related findings .for events of suspected Acute Sexual assault, the facility/nurse will immediately protect resident and notify authorities (Police and Protective Services). The facility staff will follow state and federal regulations for reporting suspected cases of abuse or neglect. [The policies did not include reference to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken.] Resident 1 was admitted to the facility in 11/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's 11/2020 MDS assessment indicated the resident had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. A public complaint submitted on 2/8/22 indicated Resident 1 alleged they were sexually abused in 11/2020. There was no documentation found or provided by the facility the 11/2020 allegation of sexual abuse was reported to the State Agency. On 8/16/22 Staff 3 (SSD) stated Resident 1 originally did not want to say anything about allegedly being sexually abused until she/he overheard Staff 3 asking other residents questions about their care and Staff 13 (Agency CNA). Local law enforcement were notified, arrived and interviewed Resident 1. Staff 3 stated she gave her notes over to law enforcement and the Administrator. Staff 3 stated Resident 1 did not fill out a grievance form. Staff 3 stated she did not send in a report to the State Agency. On 8/30/22 at 3:44 PM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility should have sent in a report to the State but felt the complaint was tied with another allegation and did not see a need to report.

Based on interview and record review it was determined the facility failed to conduct a thorough investigation of alleged sexual abuse for 1 of 1 sampled residents (#1) reviewed for abuse. This placed residents at risk for future abuse. Findings include: Resident 1 was admitted to the facility in 11/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the facility's Abuse, Neglect and Exploitation-Clinical Protocol revised 10/2020 a thorough investigation included: -The nurse will conduct an assessment and recognition of resident; -Immediately protect resident and notify authorities (Police and Protective Services); -Report findings to the physician and the physician will assess the resident to verify or clarify such findings; -The management and staff, wth the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations; -Facility staff will follow state and federal regulations for reporting suspected cases of abuse or neglect; -The staff and physician will monitor individuals who have allegedly been abused at least until their medical condition, mood, and function have stabilized and periodically therafter. There was no documented evidence the facility conducted an investigation to determine whether abuse had or had not occurred. There was no documented evidence the facility notified the attending physician. There was no documented evidence showing Resident 1 was placed on additional monitoring. On 8/30/22 at 3:44 PM Staff 1 (Administrator) and Staff 2 (DNS) stated due to law enforcement involvement and a verbal statement from the police officer not to investigate, the facility did not investigate and never followed up to complete the investigation.

Based on interview and record review it was determined the facility failed to notify a resident's representative of a change in condition for 1 of 3 sampled residents (#8) reviewed for resident rights. This placed residents at risk for uninformed representatives. Findings include: Resident 8 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 8's 12/4/20 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan for hospice services, initiated on 12/7/20 indicated to keep the resident's representative informed of the resident's condition. A 12/7/20 at 9:49 PM progress note indicated Resident 8 was responsive and her/his vital signs were stable. A 12/8/20 at 7:11 PM progress note written by Witness 11 (Former RN) indicated Resident 8 was unresponsive and her/his oxygen saturation dropped to 79%. The progress note did not indicate the resident representative was notified of Resident 8's change in condition. A 12/9/20 at 8:36 AM progress note indicated Resident 8 passed away in the facility. On 10/6/21 at 2:04 PM Witness 3 (Complainant) stated Resident 8's resident representative was not notified of the resident's change of condition on 12/8/20. On 10/11/21 at 2:14 PM Witness 10 (Hospice RN) stated the hospice provider was not notified of Resident 8's change in condition on 12/8/20. Attempts to contact Witness 11 on 10/11/21 and 10/12/21 regarding this investigation were unsuccessful. During an interview on 10/13/21 at 10:05 AM with Staff 2 (DNS) and Staff 6 (RNCM) the staff acknowledged there was no evidence to indicate Resident 8's representative was contacted regarding the change of condition on 12/8/20.

Based on observations, interviews and record review it was determined the facility failed to provide and monitor respiratory care for 3 of 5 sampled residents (#s 1, 3 and 4) reviewed for oxygen (O2) usage. Resident 1 was hospitalized and died from [MEDICAL CONDITION]. Findings include: 1. Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] local hospital physician's transfer orders indicated the resident was diagnosed with [REDACTED]. The (MONTH) (YEAR) TAR included the [DATE] physician's order for ,[DATE] LPM of O2 during the evening and night shift. There were check marks to indicate the resident received O2 during the evening and night shifts though there was no documentation of the resident's O2 saturation levels. The (MONTH) (YEAR) TAR included the documentation of the [DATE] physician's order for the use of [REDACTED]. The documentation indicated the [MEDICAL CONDITION] was used on the night shift [DATE] and included the initials of Staff 6 (LPN) who provided the [MEDICAL CONDITION]. The [DATE] progress notes written at 10:02 PM documented the O2 sats were 90 percent on 3 LPM of O2. The vitals summary form for [DATE] at 10:24 PM documented the resident's O2 sats were 90 percent. At 10:28 PM the resident's respiration rate was 16 breaths per minute. (The normal respiration rate for residents [AGE] years or older is ,[DATE] breaths per minute). The [DATE] progress notes written at 12:35 AM documented O2 sats were 90 percent on 3 LPM of O2 and a [MEDICAL CONDITION] (continuous positive airway pressure) was in use. The vitals summary form on [DATE] at 10:38 AM included documentation by Staff 9 (CNA) of the resident's respiration rate of 32 breaths per minute. There was no documentation of a nursing assessment of the resident's respiration rate. The [DATE] progress notes written at 12:33 PM by Staff 4 (LPN) indicated there was a physician's order clarification and the order was changed to ,[DATE] LPM of O2 through NC (nasal cannula) for goal of O2 sats of ,[DATE] percent and the facility staff was to check the O2 sats every shift. The progress notes also indicated there needed to be a clarification of [MEDICAL CONDITION] order and order was changed for [MEDICAL CONDITION] to be provided at night and PRN SOB The [DATE] Occupational Therapy (OT) Notes written by Staff 7 (OT) documented the resident was asleep seated in wheelchair. Resident 1 appeared groggy, fatigued and requested to return to bed. The resident was assessed by the therapist to have very shallow, rapid respirations at 39 breaths per minute. Staff 7 documented the resident's O2 sats at rest were 95 percent on 3 LPM of O2 and O2 sats decreased to ,[DATE] percent with activity. Staff 7 documented the RNCM was notified. Staff 7 documented she was in the resident's room later in the afternoon when she assisted Resident 1's room-mate. Staff 7 documented she observed Resident 1's face was flushed, forearms/hands were warm to the touch and respirations were quick/shallow. Staff 7 documented the resident's respirations were 46 breaths per minute and she notified the afternoon charge nurse. There was no documentation on [DATE] to indicate the nursing staff were aware of the resident's respiration rate and conducted an assessment. There was no documentation the facility contacted the physician regarding the resident's respiration rate and change in condition. On [DATE] at 9:27 AM Staff 7 (OT) was asked if she remembered her assessment of Resident 1 on [DATE]. Staff 7 reviewed her documentation and stated she could not remember the facility staff she talked with about the resident. Staff 7 stated she knew Staff 5 (RNCM) was involved with the resident in the past. On [DATE] at 2:26 PM Witness 6 (Physician) was informed of the documentation of the resident's respirations from 32 through 46 per minute. Witness 6 stated she would expect the facility to either contact her or to place the resident on a [MEDICAL CONDITION] for shortness of breath. On [DATE] at 3:20 PM Staff 4 (LPN) was asked about the resident's respiration rates documented on [DATE] from 32 through 46 respirations per minute. Staff 4 stated she was not informed of the respiration rates. Staff 4 stated if she knew about the resident respiration rates she would check the resident's O2 saturation rate, would conduct neuro (neurological) checks, lung sounds and would inform RNCM (Staff 5) for her to assess the resident. On [DATE] at 5:11 PM Staff 6 (LPN) was asked about the resident's respiration rates documented on [DATE] from 32 through 46 respirations per minute. Staff 6 stated he would check the O2 levels and would contact the resident's physician or on call for further orders as there was a concern of carbon [MEDICATION NAME] retention. On [DATE] at 2:31 PM Staff 9 (CNA) stated in (MONTH) (YEAR) she was on light duty so was responsible to obtain Resident 1's vital signs and did not provide any other care for the resident. Staff 9 stated she would inform the charge nurse when a resident's respirations were above 22 breaths per minute. Staff 9 stated she could not remember if she informed the charge nurse of Resident 1's respiration rate of 32 on [DATE]. On [DATE] at 3:13 PM Staff 5 (RNCM) verified she was the RNCM for Resident 1. Staff 5 was asked about the resident's respirations of 32 recorded the morning of [DATE] by Staff 9 (CNA), and respiration rates of 39 and 46 recorded by Staff 7 (OT) on [DATE] with description of very shallow and rapid breathing. Staff 5 stated the respirations were very fast and she would have instructed Staff 7 to put a hold on therapy and contact the physician. Staff 5 stated she did not remember being informed by Staff 7 on [DATE] of the resident's respiration rate. Staff 5 stated if she knew about the respiration rate she would have assessed the resident and contacted the resident's physician. On [DATE] at 4:40 PM Staff 5 (RNCM) and Staff 13 (Corporate RN Consultant) called and Staff 5 stated she was not able to locate any contact with Witness 6 (Physician) other than the progress note written at 12:33 PM by Staff 4 (LPN) for clarification of the physician's orders. On [DATE] at 10:11 AM Staff 1 (Administrator) provided type-written documentation to indicate the Staff 2 (DNS) interviewed Staff 7 (OT). Staff 2 documented Staff 7's notes on [DATE] regarding the resident's respirations of 46 per minute indicated she was in the resident's room between 3:15 PM through 3:24 PM. Staff 7 indicated a nurse was entering the resident's room as Staff 7 was leaving though she could not recall the name of the nurse. The [DATE] Activities of Daily Living (ADLs) information written at 2:59 PM by day shift charge nurse Staff 4 (LPN) indicated the resident did not exhibit shortness of breath or trouble breathing when lying flat, sitting at rest. The documentation indicated the resident did not have shortness of breath or trouble breathing with exertion. The resident did not experience wheezing or chest tightness while at rest. The [DATE] progress notes written at 3:14 PM by Staff 4 (LPN) documented the resident was very sleepy during the day shift, O2 sats were 96 percent on 3 LPM of O2 and the O2 was decreased to 2 LPM and O2 sats were 92 percent. The [DATE] progress notes written at 3:46 PM written by Staff 5 (RNCM) indicated a discussion was held with Resident 1 and the family member about the POLST form (Physician's Orders for Life-Sustaining Treatment). The vitals summary form on [DATE] at 6:31 PM documented the resident's O2 sats were 95 percent on room air. The [DATE] progress notes written at 9:54 PM by Witness 3 (Former LPN) documented the resident was more lethargic, sleepy but responsive. Witness 3 documented In the afternoon, O2 levels dropped and level of consciousness declined. (O2) Levels were difficult to maintain. O2 dropped to 70 percent, resident clammy, drooling and nail beds blue. O2 turned up to 3.5 LPM. O2 sats were 94 percent. Family insisted on [MEDICAL CONDITION] machine and O2 sats were 80 percent when on [MEDICAL CONDITION]. Family requested the resident be evaluated at the local hospital emergency department There was no documentation as to when the resident's O2 sats dropped and when her/his level of consciousness declined. On [DATE] at 10:11 AM Staff 1 (Administrator) provided documentation the facility called the local emergency services transport services at 8:51 PM. The [DATE] local hospital emergency department notes written at 10:22 PM documented the resident's family members reported they left the facility around 3:00 PM, asked the facility staff to check the resident's O2 sats and to provide the resident with the [MEDICAL CONDITION]. The family reported they returned to the facility at 8:00 PM and discovered the resident's [MEDICAL CONDITION] was not provided and found the resident's nasal cannula was in place though the O2 was not hooked up to the O2 concentrator. The family members reported the resident did not have O2 in use for over 6 hours. The notes documented during the resident's last hospitalization she/he was at respiratory baseline of 3 LPM of O2 at all times. The resident required [MEDICAL CONDITION] during sleep as she/he desaturated and started to retain carbon [MEDICATION NAME] if she/he did not wear [MEDICAL CONDITION]. The [DATE] local hospital history and physical documented the provision of [MEDICAL CONDITION] in the emergency department failed and the family members declined the provision of intubation (placement of flexible plastic tube into the trachea (windpipe) to maintain an open airway). On [DATE] at 2:26 PM Witness 1 (family member) stated she had written documentation regarding Resident 1. The written documentation indicated Resident 1 was readmitted to the facility on [DATE]. Witness 1 indicated she visited Resident 1 on [DATE] with another family member between 2:45 PM and 3:00 PM. Witness 1 indicated the resident was extremely tired and unable to stay awake for the visit. Witness 1 indicated Resident 1 was breathing more shallow than normal and there was no oximeter (apparatus to check O2 saturation levels) in the resident's room. Witness 1 asked the facility staff at the front desk to check the resident's O2 sats as she was worried the resident was either over or under [MEDICATION NAME]. The facility staff indicated they would check on the resident. Witness 1 left the facility though returned at 8:00 PM and found the resident awake though unresponsive with shallow breathing. Resident 1 sweat through her/his clothes, was in the same position and her/his finger nails and finger tips were extremely blue. Witness 1 indicated the resident's O2 sats were 64 percent when Witness 3 took it around 8:15 PM. Witness 1 indicated Witness 3 saw Resident 1's nasal cannula was out of her/his nose but on her/his face. When Witness 3 moved the cannula she said there was no air coming out of the cannula. Witness 3 pulled on the cannula tubing and found it was not hooked up to the O2 concentrator. Witness 1 indicated the O2 concentrator was stored in the bathroom and when Witness 3 moved the O2 concentrator out of the bathroom Witness 1 saw the tubing was hooked up to the resident's [MEDICAL CONDITION] machine and not the nasal cannula. Witness 1 indicated because of the resident's low O2 level the [MEDICAL CONDITION] machine was the best way to swiftly increase the resident's O2 intake. Witness 1 indicated the cushion to the resident's [MEDICAL CONDITION] mask was missing and she was not able to locate the cushion in the resident's room. Witness 1 and the other family members requested the resident be evaluated at the local hospital emergency department. On [DATE] at 3:14 PM Witness 3 (Former LPN) stated Resident 1's condition was normal for most of the afternoon. Witness 3 stated after dinner the family members were concerned about the resident's condition. Witness 3 stated when she assessed the resident she found the resident's O2 sats to be very low and discovered the resident was not hooked up to the O2 concentrator. Witness 3 stated it appeared the resident was not hooked up to the O2 concentrator after the dinner meal. Witness 3 stated the dinner meal was served between 5:30 and 6:00 PM and thought Staff 5 (RNCM) assisted the resident with the dinner meal. Witness 3 stated the resident's family visited the facility around 7:00 PM and attempted to use the [MEDICAL CONDITION] though the cushion was not available. Witness 3 stated she was not able to get the resident's O2 level to an adequate range and the family members requested Resident 1 be evaluated at the local hospital. On [DATE] Staff 2 (DNS) provided a type-written note to indicate on [DATE] (sic) at 3:00 PM-3:30 PM Resident 1's family member contacted Staff 2 and expressed concerns of Resident 1's [MEDICAL CONDITION] machine not connected correctly. Staff 2 indicated she went to check on the resident along with Staff 8 (RNCM) to ensure the connection was correct. Staff 2 documented the resident was wearing the [MEDICAL CONDITION] mask and they found the tubing with the mask attached appropriately to the O2 concentrator. Staff 2 indicated the resident was partly asleep in bed and was able to respond to verbal stimuli. Staff 2 documented the resident was wearing her/his mask at this time. On [DATE] at 3:13 PM Staff 5 (RNCM) verified she was the RNCM for Resident 1. Staff 5 stated on [DATE] at 5:00 PM she assisted Resident 1 with her/his dinner meal in the resident's room. Staff 5 stated when she entered the room she noticed the resident's O2 was not on. Staff 5 stated she knew the resident received continuous O2 and the O2 concentrator in the resident's bathroom was set to 3 LPM. Staff 5 stated she placed the nasal cannula on the resident's face and did not check to determine if O2 was coming out of the nasal cannula. Staff 5 stated she did not check the resident's O2 sats level. Staff 5 stated the resident was warm and did not appear to be in distress. Staff 5 was asked to review the resident's record and to call if there were any additional information. On [DATE] at 4:40 PM Staff 5 (RNCM) and Staff 13 (Corporate RN Consultant) called and Staff 5 stated she reviewed the physician's order for Resident 1 and discovered there had been a change in the physician's order regarding the resident's O2 and [MEDICAL CONDITION] on [DATE]. Staff 5 stated she did not review the physician's orders on [DATE] though knew the resident had been on ,[DATE] LPM of continuous O2. Staff 5 stated Resident 1 did not have a nasal cannula with O2 or [MEDICAL CONDITION] in place when she entered the resident's room at 5:00 PM. Staff 5 stated she placed the nasal cannula on the resident's face. Staff 5 stated she did not check the O2 sats and did not check to ensure O2 was coming out of the nasal cannula as she assumed the O2 was coming out. Staff 5 stated the O2 concentrator was set to 3 LPM of O2. Staff 5 stated she assisted the resident with the dinner meal from 5:00 PM to 5:20 PM. Staff 5 stated the resident was warm and did not appear to be in distress. Staff 5 stated the [MEDICAL CONDITION] was on the resident's dresser and appeared to be intact. Staff 5 was asked who documented the resident's O2 sats on [DATE] at 6:31 PM and Staff 5 stated she was able to determine Witness 3 (Former LPN) obtained the O2 sats level at the time. Staff 5 stated on [DATE] at 3:00 PM she talked with resident and the resident's family in the resident's room about the POLST form and the resident was not in respiratory distress. Staff 5 verified the resident's [MEDICAL CONDITION] was used on the night of [DATE] through the morning of [DATE]. On [DATE] at 11:00 AM Staff 8 (RNCM) stated on [DATE] Staff 2 (DNS) approached her in the hallway and asked her to check Resident 1's [MEDICAL CONDITION] machine. Staff 8 stated when she went into Resident 1's room she observed the resident to have the O2 nasal cannula in place. Staff 8 stated she plugged in the [MEDICAL CONDITION] into the wall outlet and determined it was functional. Staff 8 stated all of the parts of the [MEDICAL CONDITION] appeared to be in place. Staff 8 stated she did not plug the [MEDICAL CONDITION] machine into the O2 concentrator. Staff 8 stated she did not check the resident's O2 sats at the time. Staff 8 stated she was only asked to ensure the [MEDICAL CONDITION] was operational. Staff 8 stated when the [MEDICAL CONDITION] was in use the [MEDICAL CONDITION] was to be attached to the O2 concentrator for O2 to be delivered through the [MEDICAL CONDITION]. Staff 8 stated the resident remained on O2 through the nasal cannula. On [DATE] at 10:11 AM Staff 1 (Administrator) provided type-written documentation by Staff 2 (DNS) to indicate she was in the resident's room at 3:00 PM through 3:30 PM with Staff 8 (RNCM) to look at the [MEDICAL CONDITION], resident was not in distress and there were no concerns noted. Staff 2 documented she interviewed Staff 5 (RNCM) who indicated she was in the resident's room the afternoon of [DATE] and assisted Resident 1 with her/his meal at 5:00 PM. Staff 5 indicated the resident appeared weak though was not short of breath. On [DATE] at 10:11 AM Staff 1 (Administrator) provided a type-written written letter from Witness 6 (Physician) to indicate Resident 1 was quite frail and experienced several life threatening events including being intubated in (MONTH) of (YEAR). Witness 6 wrote the resident stated she/he had an acute hypoxic event on [DATE] and talked with the resident's family and they decided against hospitalization at the time. On [DATE] the resident's family requested she/he be sent to the local hospital and required intubation. A palliative care physician at the local hospital talked with the resident's family about the need for hospice services though the resident's family was not ready for hospice services. Witness 6's letter indicated the medical team felt it was medically appropriate for the resident to receive hospice services from [DATE] forward. 2. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The local hospital physician transfer orders indicated the resident was to receive ,[DATE] LPM (liters per minute) of O2 to maintain O2 sats level of 92 percent. Periodic observations of Resident 3 on [DATE] from 10:45 AM through 11:31 AM revealed the resident was provided O2 through a nasal cannula. On [DATE] at 11:31 AM Resident 3 stated she/he had no issues with the provision of O2. Resident 3's record was reviewed and the Medication Review Report indicated there was no physician's order for O2 and O2 sats until [DATE]. The [DATE] physician's orders indicated the resident was to receive ,[DATE] LPM nasal cannula PRN for O2 sats less than 90 percent. On [DATE] the physician's order was changed for the O2 sats goal of 88 to 94 percent. The progress notes and vital signs summary form from [DATE] through [DATE] were reviewed and there were occasions the facility staff documented the resident's O2 sats levels and the amount of O2 used. There was no documentation of the amount of O2 used and the resident's O2 sats levels for the evening shift of [DATE], the evening shift of [DATE], the day and evening shift of [DATE], the evening shift of [DATE], the day shift of [DATE], all shifts of [DATE] and the day shift of [DATE]. The (MONTH) (YEAR) TAR did not contain the resident's need for O2 and the O2 sats levels until [DATE]. On [DATE] at 2:00 PM Staff 2 (DNS) was asked about the physician's order for O2 and the O2 sats level. Staff 2 verified there was no physician's order for the resident's O2 and saturation level until [DATE]. Staff 2 verified the TAR did not include the resident's need for O2 until after the surveyor asked about the information. Staff 2 also verified the resident's O2 sats levels were not consistently monitored. 3. Resident 4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 10:00 AM Resident 4 was not identified by the facility to require the use of O2. At 11:45 AM Resident 4 was observed in her/his room with a nasal cannula with O2 provided and the resident stated she/he received PRN O2. The (MONTH) (YEAR) and (MONTH) (YEAR) Medication Review Report did not contain physician's orders for O2 and O2 sats levels to be maintained. On [DATE] at 2:00 PM Staff 2 (DNS) was informed of the observation of the resident and asked to provide documentation of physician's orders for O2 and O2 sats levels. At 2:25 PM Staff 2 stated she could not locate the physician's orders for O2 and O2 sats levels. At 3:02 PM Staff 2 provided copies of the physician's order dated [DATE] to indicate the resident was to receive O2 at 2 LPM per nasal cannula if the O2 sats level was below 92 percent every shift.