Every finding on record at Powdersville Post-Acute

Based on observation, interview, and review of the facility policy, the facility failed to ensure foods that are stored in the freezer, coolers, and dry food storage were appropriately sealed, labeled, and discarded in 1 of 1 kitchen. In addition, the facility failed to ensure staff served food/drinks under sanitary conditions for 1 of 16 residents observed during dining observation.Findings include:Review of the facility policy titled Labeling and Dating, revealed, Importance of Labeling and Dating: Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that are passed their due date are discarded. Guidelines for Labeling and Dating: All foods should be dated upon receipt before being stored. Food labels must include:o the food item name;o the date of preparation/receipt/removal from the freezer;o The use by date. Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate use by date. Left overs must be labeled and dated with the date they were prepared and the use by date. Use By Dating Guidelines All Ready-To-Eat, Time/Temperture Control for Safety (TCS) foods that are to be held for more than 24 hours at the temperature of 40 F or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7).Review of the facility's undated policy titled, Food Storage: Dry Goods, revealed, Policy Statement, all dry goods will be appropriately stored in accordance with the FDA Food Code. Procedures: 5. All packed and canned food items will be kept clean, dry, and properly sealed.Review of the facility's undated policy titled, Food Storage: Cold Foods, revealed, Policy Statement, All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures: 5. All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.Review of the USDA Food Safety and Inspection Service (FSIS), last updated [DATE], titled Cleanliness Helps Prevent Foodborne Illness, revealed, Food that is mishandled can lead to foodborne illness. The FSIS site states Cleanliness is a major factor in preventing foodborne illness. Even with food safety inspection and monitoring at Federal, State, and local government facilities, the consumer's role is to make sure food is handled safely after it is purchased. Everything that touches food should be clean.Review of Resident (R)69's Face Sheet revealed that R69 was admitted to the facility on [DATE] with diagnosis including but not limited to infection of amputation stump, unspecified extremity, other acute osteomyelitis, right ankle and foot, and type 2 diabetes mellitus with hyperglycemia.Review of R69's Care Plan revealed, resident is at risk for alteration in hydration/malnutrition due to medication use, requiring a mechanically altered diet with thickened liquids r/t recent aspiration pneumonia, dx of risk for malnutrition with fair appetite and dx of Parkinson's with risk for aspiration.During an initial kitchen observation on 08/03/25 at 11:11 AM revealed the following:Dry Food storage revealed a wooden rat trap at the base of water heater;1 - 5 pound (lb.) Peanut butter container with peanut butter on lid marked open 7/29 with no use by date;1 - 32 (ounce) oz bag vanilla wafers in a Ziploc bag marked contents date 10/6;1 - 24 oz package vanilla pudding & pie filling mix in Ziploc bag marked open 7/25 with no use by date;1 - 11 lb tub ready to spread vanilla creme icing marked open 8/3 with no use by date;4 - 24 oz bags lemon pudding & pie filling mix covered in white powdery debris;1 - 22 quart (qt) storage container marked cornmeal dated 11/14 with no use by date;1 - 22 qt container not marked with contents/no open/prep date/ no use by date;1 - 18 qt container marked tri color rotini prepared date 5/15 with no use by date;1 - 18 qt container marked egg noodles marked prepared 6/18 with no use by date;1 - 25 lb box long grain parboiled rice with no open or use by date;1 Ziploc bag with 1 - 10lb bag spaghetti noodles marked 7/8 not sealed properly and no use by date;1 - 22 qt container with 1 bag of macaroni noodles marked prep date 5/15 no use by date;2 - 10 lb boxes enriched macaroni product (lasagna),During an initial kitchen observation on 08/03/25 at 11:40 AM, [NAME] 1 was observed using the same alcohol wipe multiple times, for a total of 4 times before discarding, while temping food for lunch service. Desert bowls consisting of smores parfait and vanilla parfait, were observed on food trays, on four serving carts with temperature reading of 63 degrees.During an initial kitchen observation on 08/03/25 at 12:08 PM, the bread rack beside reach in cooler revealed the following: top tray marked pulled 7/10, 1 hot dog bun with a fuzzy green substance; 1 Ziploc bag containing two cinnamon rolls marked 8/3 with no use by date; 1 Ziploc bag containing five biscuits marked 7/30; 1 Ziploc bag containing three rolls marked 7/28; and 1 pk of six English muffins dated 6/26. During an initial kitchen observation on 08/03/25 at 12:18 PM, the reach in Cooler revealed 3 gallons (gal) whole milk dated [DATE]; 15 pasteurized eggs in box with manufacturer best before date of 26 [DATE].During an initial kitchen observation on 08/03/25 at 1:09 PM, the walk in cooler revealed the following:1 - 32 oz container chopped garlic marked 5/29 with no open or use by date;1 - 16 oz container Low sodium beef base marked 5/15, opened 7/7 with no use by date;1 pan wrapped with foil no clear label of contents, prep or use by date;1 pk of 6 hot dog buns not sealed/closed no open date;1 - 5 lb container Pimento spread, no open/prep date and no use by date;1 - 1 gal sweet pickle relish, no open/prep and use by date,1 - 1 gal pitcher, marked tomato soup, prepared date 7/30, no use by date;1 - 1 gal pitcher, unlabeled with no prep or use by date;1 - 1 gal container Worcestershire sauce marked opened 5/6, no use by date;1 - 1 gal mayonnaise marked 7/10 with no open or use by date;1 Ziploc bag of cooked egg yokes with unclear prep date/no use by date;1 Ziploc bag of Italian sausage unclear prep date;1 container of prepared chicken salad, prepared date 7/29, use by date 7/31;1 container of prepared egg salad, prepared 8/1, no use by date;1 container chilled peaches prepared date 7/28, no use by date;1 Ziploc bag marked Sailsbury date 7/31, use by 7/2;1 container marked lima beans, prepared date 8/1, no use by date;1 container marked [NAME] chop, prepared date 7/27, use by 8/2;1 Ziploc bag marked omelet 8/2, no use by date;1 - 8 lb container 4 Way Fruit Salad in light syrup with best before Jul-29-2025; 2 unlabeled containers - 1 with a red sauce, 1 appears to be cooked noodles in a white substance.During a dining observation on 08/04/25 at 12:21 PM, staff members were observed passing trays to residents on the 300 hall. While delivering trays Certified Nursing Assistant (CNA)1 was observed putting on a gown to enter room [ROOM NUMBER] to deliver Resident (R)69's lunch tray. CNA1 left the door cracked after entering R69's room and was observed knocking over R69's water pitcher then picking it up and placing it back on the resident's over the bed table. R69 was overheard refusing lunch tray and requesting a peanut butter sandwich and milk. CNA1 came to the door and asked CNA2 to get the requested items for R69. When CNA2 returned to the room and passed items to CNA1 at the door CNA1 dropped the milk carton, then picked it up and proceeded to give the sandwich and milk to R69. R69 was observed eating the sandwich and picking up the milk carton and sipping the milk out of a straw. CNA2 came back to the room with a new milk carton to give to CNA1.During a follow up kitchen observation on 08/05/25 at 9:03 AM the walk-in cooler revealed, 1 pan of dice tomatoes marked prepared 7/29 use by 8/4; 1 quart size Ziploc bag cooked rice dated 8-4, no use by date; 1 pan of mashed potatoes dated 8/4 with no use by date; 1 pan marked Roasted Turkey breast 8/4, no use by date; and 1 Ziploc bag BBQ chicken dated 8/4, no use by date.During a follow up kitchen observation on 08/05/25 at 9:12 AM the walk-in freezer revealed, 1 black bin containing 1 bag Pub fish, identified by District Dietary Manager (DDM), marked 6/16, no open or use by date; 1 bag Italian sausage (identified by DDM) marked 6/9 and no use by date and ice particles on the sausages; 1 bag Riblets (identified by DDM) with an unclear date; 1 - 5 lb bag Hashbrowns marked 7/30, no use by date; Container full of debris; 1 bag of frozen peppers marked 7/21 with ice particles; 1 - 5 lb bag hashbrown open unclear date; 1 box coffee cake dated 7/17/25, no use by date, bottom of box revealed a water stain; and 1 Ziploc bag of pepperoni with an unclear date and some pieces appearing grey.During an interview on 08/03/25 at 11:47 AM, [NAME] (C)1 revealed that while temping food for service she will use one wipe multiple times before changing or discarding the wipe.During an interview on 08/03/25 at 1:00 PM, the Dietary Manager (DM) revealed that she has been employed at the facility since September, and that she has completed her courses for certification, but she has not taken the exam. The DM states that they do not have rodents or an issue with pest control. The DM explains that her expectations are that food in the dry food storage, coolers and freezers be labeled and dated, that there be no dented cans among the food to be used and that open food be properly sealed. The DM continued to explain that open containers in the coolers are to be used within 7 days, cooked foods are to be used within 3 days, food items should have an open date and an expiration date. The DM states that foods placed in storage containers should be labeled identifying the contents and a date that the items were placed in the container, and that when the container is emptied it should be cleaned before being refilled. The DM further explains that when boxed items are opened, they should be put in a bag, possibly a trash bag, so that nothing can get in/or around it. The DM states that if items are found with debris on them, they should be checked for holes and wiped down. The DM revealed the date on the milk in the reach in cooler was the use by date of July 31, and states that it was overlooked.During an interview on 08/05/25 at 8:59 AM the District Dietary Manager (DDM) revealed that his expectation for food items in the dry food storage, coolers and freezers should be properly sealed and labeled with a prep/open date and a expiration/use by date. The DDM states frozen items can be kept for 30 - 60 days after being opened, cooked items are good for 3 days and prepared items can be kept for 7 days unless frozen.During an interview on 08/04/25 at 12:39 PM CNA1 revealed that when serving residents during dining the proper procedure is for staff to wash their hands, check the resident's ticket to ensure their diet is correct and there are no allergies. CNA1 states that staff is to knock on resident's doors before entering, ask residents if they need assistance and set up the resident's tray if needed. CNA1 continues to explain that staff should wash their hands after using hand sanitizer 3 times. CNA1 further explains that if any items fall on the floor while assisting residents the item should be discarded. When asked if R69 should have been given the milk carton that was dropped on the floor, CNA1 stated that they should have been given another carton and that it was pure anxiety. CNA1 further revealed that residents are offered hand sanitizer or a wipe prior to and after meals. CNA1 states that the water pitcher that had fallen on the floor has to be sent to the kitchen to be washed and a new one will be given to the resident.During an interview on 08/05/25 at 10:44 AM the Administrator revealed that the Dietary Manager is responsible for the kitchen, however he completes a walk through of the kitchen once a week. The Administrator explains that his expectation is that items are labeled, dated and stored properly, the temperature logs completed, and the equipment is working properly. The Administrator continues to explain that open items should have a prep date, prepared food items should have a date when they were prepared. The Administrator states that staff should follow food safety guidelines and that the expiration would vary depending on the item. The Administrator stated that if food items are open and kept in its original package that his expectation is for staff to refer to the manufacturer's expiration date.During an interview on 08/05/25 at 1:03 PM the Dietitian revealed that she is temporary and is covering for the dietitian who is out on maternal leave. The Dietitian states that she is part time and only works 8 hours a week. The Dietitian explains that the Certified Dietary Manager (CDM) covers the clinical responsibilities for the kitchen, while she shadows high risk residents, monitors resident weights, completes full annual and quarterly assessments. The Dietitian continues to explain that she also conducts walk throughs of the kitchen checking the coolers, freezers and dry food storage and purse anything that is not right. She further explains that she also ensures that the staff is following the menu, ensure that the food is at the proper temperature and that the staff are serving the proper portions.During an interview on 08/06/25 at 11:50 AM CNA2 revealed that during dining service staff are to gather the condiments for the resident; knock on the door before entering; place the tray on the bedside table and ask they resident if they need assistance; and set up the resident's tray if needed. CNA2 continues to explain that hand sanitation is to be done before another tray is pulled from the meal cart. CNA2 further revealed that if anything falls on the floor it should not be used, and that staff should get a new/replacement item.During an interview on 08/06/25 at 11:55 AM the Director of Nursing (DON) revealed that her expectation during dining is for staff to serve one tray at a time, and they should sanitize their hands before and after each tray. The DON further reveals that if any items being used delivered to the resident falls on the floor the items should be thrown away. The DON stated, I don't let them pick up anything off the floor, even if it's a straw in a wrapper.During an interview on 08/06/25 at 1:49 PM the Administrator revealed that they did not have a policy related to the use of items falling on the floor. The Administrator explained that he had called and spoke with his representative and confirmed there was no policy. The Administrator stated that in the real world that if he personally dropped his drink, he would pick it up and continue to drink it. The Administrator states that he was told that the resident drank the milk that was dropped with a straw, and he did not see any thing wrong with it. The Administrator further revealed that dropping items is not normal, but there is no guarantee items from suppliers haven't been dropped or how they were handled during delivery, he did not see an issue with the dropped item being given to the resident.

Based on review of facility policy, observation, and interview, the facility failed to properly store food in 1 of 1 main kitchen. Findings include: Review of the facility policy titled, Food Storage: Cold Foods with a revised date of 2/2023, documented, All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code . 5. All foods will be stored wrapped or in covered containers, labeled and dated . Review of the facility policy titled, Food Storage: Dry Goods with a revised date of 2/2023, documented,All dry goods will be appropriately stored in accordance with the FDA Food Code . 5. All packaged and canned food items will be kept clean, dry, and properly sealed. During an observation on 07/23/24 at 10:21 AM, of the [NAME] refrigerator, revealed the following: 1 case of cucumbers, the cucumbers were covered with grayish/white fuzzy substance, which appeared to be mold. 1 6 pound can of peaches, labeled pears, and not properly sealed. During an observation on 07/23/24 at 10:35 AM, of a standalone refrigerator, revealed the following: Unidentified food items wrapped in aluminum foil, not labeled or dated. During an observation on 07/23/24 at 10:40 AM, of cabinets located in the main kitchen, revealed the following: 1 24 ounce bag of opened [NAME] Gravy mix, in original package, placed in a ziploc bag, not sealed. 1 23 ounce bag of opened [NAME] Sugar, in original package, placed in a ziploc bag, not sealed. During an interview on 07/23/24 at approximately 11:00 AM, the Food Service Director (FSD) verified the concerns with food storage and proceeded to remove the identified food items, and properly seal the dry food items.

Based on review of facility policy, observation, and interview, the facility failed to hold cold foods at a safe temperature in 1 of 1 kitchen. Findings include: Review of the facility policy titled, Food: Quality and Palatability with a revised date of 02/2023, documented, Food will be palatable, attractive and served at a safe and appetizing temperature. Review of the facility policy titled, Food: Preparation with a revised date of 02/2023, documented, All foods are prepared in accordance with the FDA Code. 13. All foods will be held at appropriate temperatures . and less than 41 [degrees] for cold food holding. During an observation on 07/25/24 at 11:41 AM, of the lunch service food temperatures, performed by Cook1 revealed the following: Green bean salad (cold) 53 degrees Fahrenheit. Potato Salad (cold) initial temp 84.7 degrees Fahrenheit, retemp 77 degrees Fahrenheit. Salad (cold) 54.5 degrees Fahrenheit. Caesar salad (cold) 61.6 degrees Fahrenheit. During an observation and interview on 07/25/24 at 12:15 PM, Cook1 was observed plating an egg salad sandwich, that was not temped. This surveyor asked Cook1 if the egg salad sandwich was tempted and Cook1 responded, No. The Food Service Director (FSD)1 stepped in and temped the sandwich. The egg salad sandwich temped at 43.2 degrees Fahrenheit. The FSD1 placed the sandwich back in the refrigerator and stated, Cold foods has to temp below 41. During an observation on 07/25/24 at 12:13 PM, the green bean salad, potato salad, salad, and Caesar salad was retemped and was still not in a safe range. The FSD1 instructed staff to place the cold food items in the freezer. After approximately 30 minutes, all cold foods temped in a safe range. During an interview on 07/26/24 at approximately 1:30 PM, the District Manager for Healthcare Services stated, Both our [NAME] freezer and refrigerator did not seem to recover from our truck delivery this morning due to constant entering and exiting while putting away new inventory. During an interview on 07/26/24 at 1:34 PM, FSD1 stated, If food is above 41, we usually put it in an ice bath and place it in the freezer to help it cool down. She (Cook1) should have temped the food before placing it in the hotbox and on the tray. During an interview on 07/26/24 at 1:43 PM, Cook1 stated, I didn't temp them [egg salad sandwiches] because my assumption was that the sandwiches and potato salad had already been temped because it was ice cold when it was made. During an interview on 07/26/24 at 2:06 PM, the Administrator stated, They need to be at appropriate temps and when they come out on the floor, needs to be at safe temps to prevent bacteria growth.

Based on review of facility policy, observation, and interview, the facility failed to ensure expired medications and biologicals were removed and discarded from storage in 1 of 1 medication room and 2 of 3 treatment carts. Findings include: Review of the facility policy titled Storage of Medications revised on November 2020, states, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During an observation on 07/24/24 at 03:35 PM, of Medication room [ROOM NUMBER], revealed the following: Medline Suture Removal Tray (6 of 6) Ref DYND70900 LOT # 22BBA923 Expires 2024-05-31. Influenza Vaccine Flucelvax SN 3PDRRNA5WW LOT# AU3130B Expires 2024-06-20. During an interview on 07/24/24 at 3:35 PM, Licensed Practical Nurse (LPN)7 verified the expired medications/biologicals, and stated, All expired medications should be discarded in a timely manner. LPN7 than disposed the expired medications/biologicals. During an observation on 07/25/24 at 11:03 AM, of the 100 Hall Medication Cart revealed the following: Medline Evencare G2 Glucose Control Solutions Ref# MPH 1560 08327-0062-83 Lot# 16822052102 Expired 2024-05-09. During an interview on 07/25/24 at 11:20 AM, LPN5 stated, We discard all expired medications. LPN5 verified and discarded the expired medication/biological. During an observation on 07/25/24 at 1:47 PM, of the 300 Hall Medication Cart revealed the following: Acetaminophen suppositories USP, 650 mg ([NAME]) Lot # 1G0377 Expires 06/2024. LPN7 verified and discarded the expired medication/biological.

Based on review of facility policy, observation, and interview, the facility failed to follow proper Infection Control (IC) practices during wound care of Resident (R)53, for 1 of 1 resident reviewed for pressure ulcers. Findings include: Review of the facility policy titled, Non Sterile dressing Change dated September 2013, revealed under the policy, The purpose of this procedure is to provide guidelines for the application of dry, clean dressings . 6. Put on clean gloves, loosen tape and remove soiled dressing . 7. Pull glove over dressing and discard into plastic or biohazard bag . 8. Wash and dry your hands thoroughly . discard disposable items . Review of R53 Face Sheet revealed the facility admitted R53 on 06/24/24, with diagnoses including but not limited to: collapsed vertebra, cord compression, malnutrition, Alzheimer's disease, paraplegia, chronic kidney disease, anemia, hyperlipidemia and sarcopenia. During an observation on 07/25/24 at 12:46 PM, of R53's sacral wound dressing change with the physician (MD) and Wound Nurse. After verbal consent from R53, to observe the dressing change, both the Wound Nurse and MD washed hands, gowned, and donned gloves. All ordered items were on the overbed table barrier, including Dakin's solution bottle, a package of Calcium Alginate and a bottle of wound cleanser. The Wound Nurse removed the soiled dressing. After the MD debrided the sacral wound, she removed the gown and gloves, washed her hands, took her supplies and exited the room. The Wound Nurse failed to remove soiled gloves. The Wound Nurse than poured Dakin's solution straight from the bottle onto a 4x4 gauze. The Wound Nurse applied skin prep to outer perimeter of wound. She applied medi-honey with a sterile q-tip, then packed with calcium alginate that she cut with her scissors. An outer dressing was applied. The Wound Nurse dated the dressing, removed her gloves and cleaned her scissors with an alcohol prep pad before she washed her hands. The Wound Nurse than picked up the wound cleanser, Dakin's bottle, and opened alginate and placed on overbed table after removing the towel barrier. The Wound Nurse gathered the trash and bagged it all. She then removed her disposable gown, washed her hands, picked up items from the table, then exited the room with the contaminated items and placed the Dakin's solution, wound cleanser, and opened package of calcium alginate back into treatment cart without cleaning them. During an interview on 07/25/24 at approximately 1:15 PM, the Wound Nurse confirmed she did not remember changing her gloves during the treatment. She also confirmed the soiled items of wound cleanser, calcium alginate and Dakins solution were not wiped down before she placed the items back into the treatment cart. The Wound Nurse confirmed she used an alcohol prep pad to clean her scissors before placing them in her pocket. During an interview on 07/25/24 at 1:21 PM, the Director of Nurses (DON) stated, We use bleach wipes or sani wipes to clean scissors, but not with an alcohol prep pad. The nurse should have washed her hands after removing the soiled dressing and remove her gloves. She should not have placed the items directly onto the overbed table, then she should have cleaned the bottles and the foil package before placing them directly into the treatment cart.

Based on review of facility policy, observation, record review, and interview, the facility failed to complete a Baseline Care Plan for Resident (R)309 in a timely manner. Furthermore, the facility failed to address R309's need for oxygen therapy in the Baseline Care Plan, for 1 of 4 residents reviewed for Care Plan. Findings include: Review of the facility policy titled, Care Plans - Baseline with a revised date of August 2022, documented, A person-centered baseline care plan of care to meet the resident's immediate needs shall be developed for each resident within forty eight (48) hours of admission. 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. Review of R309's Face Sheet, revealed R309 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), dementia, and acute kidney failure. Review of R309's Physician Orders revealed the following, O2 at 4l via NC, continuously. every day and night shift for acute hypoxemic respiratory failure/chronic heart failure with a start date of 07/10/24. Review of R309's Electronic Medical Record (EMR) under the Evaluations Tab, revealed a Baseline Care Plan dated 07/03/24, with a status of In progress. Further review revealed, Next Evaluation Due: *Baseline Care Plan Person-Centered Care Planning - V3.1 : 21 days overdue - 7/3/2024. Review of R309's Baseline Care Plan dated 07/03/24, did not indicate R309's need for oxygen therapy. Further review revealed, Physician Orders 1. A printed summary of physician orders and instructions including medications, treatments, and dietary orders provided was not checked Yes or No as being included. During an observation on 07/23/24 at 11:25 AM, R309 was not receiving oxygen. The oxygen machine was stored in the opposite corner of the room, away from the resident. During an interview on 07/25/24 at 4:46 PM, the Director of Nursing (DON) stated, MDS [Minimum Data Set] completes the Baseline Care Plan, I am not familiar with the policy. The MDS Coordinator was not available for interview.

Based on review of facility policy, record review, observation, and interview, the facility failed to implement interventions outlined in the care plan for Resident (R)31, for 1 of 1 residents reviewed for comprehensive care plan. Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered dated March 2022, revealed under the policy, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of R31's Face Sheet revealed the facility admitted R31 on 09/11/23, with diagnoses including but not limited to: epilepsy, heart disease, hypertension, cerebral infarction, hemiplegia and hemiparesis affecting left non dominant side, bipolar disorder, schizophrenia, sickle cell disease, and absence of left and right leg above knee. Review of R31's Electronic Medical Record (EMR) revealed a report dated 06/24/24, which documented, staff reported R31 on the floor, was assisted back to bed and denied striking her head and no injuries observed. R31 stated the pad in her wheelchair (W/C) caused her to slip and fall. Review of R31's Care Plan dated 10/13/23, revealed R31 is at risk for falls with or without injury due to impaired mobility, incontinence, med use, anxiety, pain and bilateral AKA. A new intervention directing staff to add Dycem under wheelchair cushion was added to the care plan on 06/24/24. During an observation on 07/24/24 at 4:23 PM, R31 was in bed eating. Her W/C was at bedside. There was no non skid device or Dycem in her W/C. During an observation and interview on 07/25/24 at 3:32 PM, R31 was in her room, receiving therapy with an Occupational Therapist Assistant (OTA). An observation of R31's W/C cushion revealed Dycem was not beneath her W/C cushion. R31 stated, I told the CNA [Certified Nursing Assistant] about it, it's been missing for 3 weeks. The OTA confirmed there was no Dycem in R31's W/C. During an interview on 07/24/24 at 4:40 PM, Certified Nurse Assistant (CNA)1 stated, I heard she had a fall. I don't put anything in her wheelchair cushion unless she asks me to. During an observation and interview on 07/25/24 at 3:45 PM, the OTA returned with Dycem in a box. The OTA stated, I have Dycem and I'm going to add it to [R31's] wheelchair. During an interview on 07/25/24 at 4:04 PM, the Maintenance Director stated, We don't modify the wheelchair cushions in any way. I don't add anything to them at all. My assistant would not add anything to the wheelchair cushions either. During an interview on 07/25/24 at 10:41 AM, the Director of Nurses (DON) stated, The Dycem was a recommendation post fall and should have been in her wheelchair. The DON agreed the plan of care should have been implemented.

Based on review of facility policy, record review, and interview, the facility failed to refer Resident (R)2 for a Preadmission Screening and Resident Review (PASARR) Level II, after the resident received a new diagnosis of a severe mental illness, for 1 of 2 residents reviewed for PASARR. Findings include: Review of the facility policy titled, Admission Criteria with a revised date of March 2019, documented under Policy Interpretation and Implementation, 9. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. Review of R2's Face Sheet revealed the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. R2 was admitted with diagnoses including but not limited to: hypothyroidism, morbid obesity, other psychoactive substance use, schizophrenia, bipolar disorder, and post-traumatic stress disorder (PTSD). Review of R2's Medical Diagnoses revealed the following: psychoactive substance use dated 02/14/23, schizophrenia dated 05/15/24, bipolar disorder dated 09/22/20, and post-traumatic stress disorder dated 09/22/20. Review of R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/08/24, revealed R2 had a Brief Interview for Mental Status score of 13 out of 15, indicating R2 was cognitively intact. Further review of the MDS revealed R2 showed behaviors of delusions (misconceptions or beliefs that are firmly held, contrary to reality), verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), and rejection of evaluation or care (e.g., bloodwork, taking medications, ADL assistance). Review of R2's PASARR - Level I dated 09/22/20, indicated R2's initial PASARR was a Skilled Nursing Facility (SNF) transfer dated 03/25/19. The Level I PASARR also indicated Depression was the only mental illness listed and R2 required no further evaluation, but indicators were present. Review of R2's PASARR - Level I dated 06/31/24, indicated R2 had the following mental illness: bipolar disorder, PTSD, anxiety disorder, major depressive disorder, and schizophrenia. Further review under comments, indicated, Resident noted to be uncooperative during cares, isolating herself from facility activities and disrupting other residents due to yelling/loud talking. The PASARR - Level I also indicated R2 was recommended for further evaluation based on mental illness indicators. Review of R2's Care Plan documented the following problem areas: Resident is non-factual in relating happenings and situations between self and other residents/staff and conversations initiated on 04/23/19, Resident has been exposed to a traumatic event. Resident has had physical/sexual abuse in the past initiated on 01/13/20, and Psychosocial- Behavior: Exhibits or is at risk for behavioral symptoms: yelling out without any causes, hollering at staff due, attempting to kick male CNA in privates, belittling staff, refusing for psych NP to visit with resident to: anxiety, Bipolar disorder, depression, Post-Traumatic Stress Disorder (PTSD) initiated on 05/10/24. Review of R2's Psych Progress Notes dated 03/18/22, documented, Major depressive disorder, recurrent, severe with psychotic features is substantiated . patient endorses little interest or pleasure in doing things, feeling down, depressed, or hopeless, feeling tired of having little energy, overeating, trouble concentrating, and thoughts of being better off dead, psychotic features, delusions present . Patient endorses feeling nervous, anxious, or on edge, not being able to control worry and worrying about many different things, trouble relaxing, restlessness, easily annoy or irritated, feeling afraid something awful might happen. During an interview on 07/25/24 at 11:32 AM, the Social Services Director (SSD) revealed R2's mood and behavior varies by day and by staff that work with her. R2 received psychosocial visits from me and activities department offer her activities. The SSD stated, I did a level II screening and I am waiting on the physician and psych to finish their portions. I am not sure if we get the Department of Health and Human Services (DHHS) involved for a Level II. Level II screening is all done inhouse. We contract our physicians through physician services group to complete the PASARRs. During an interview on 07/25/24 at 5:00 PM, the Director of Nursing (DON) stated, I am not familiar with the PASARR process, that's the Social Worker. During an interview on 07/26/24 at 2:06 PM, the Administrator stated, I would have to look in to that (referring to the PASARR). I had the Social Worker look into that and do an audit. During an interview on 07/26/24 at 2:36 PM, the Administrator and the SSD revealed there was a miscommunication and a Level II PASARR will be sent off and completed for the resident.

Based on review of facility policy, observation, record review, and interview, the facility failed to manage and notify the physician of Resident (R)162's complications related to feeding tube, for 1 of 1 resident reviewed for tube feeding. Findings include: Based on review of facility policy titled, Enteral Tube Feeding via Continuous Pump dated 2018, revealed, If anything suggests improper tube positioning, do not administer feeding or medication, notify the charge nurse or physician. Monitor resident for signs and symptoms of feeding intolerance. Review of R162's Face sheet revealed the facility admitted R162 on 07/05/24, with diagnoses including, but not limited to: malignant neoplasm of nasal cavity, acute pancreatitis, dysphagia, dysarthria, multiple sclerosis, type 2 diabetes, anemia, gastrostomy, acute embolism jugular vein and obstructive sleep apnea. During an observation of R162 on 07/25/24 at 7:40 AM, R162 was lying in bed, awake. Her gastrostomy tube was exposed. Her tube feeding was disconnected. The feeding pole was located across the room. Hanging from the pole was a Glucerna enteral feeding, with no name or rate, and was dated 07/24/24. There was 700 milliliters (ml) remaining in the bottle. Written on the label was a time of 2200 (10:00 PM). Review of R162's Physician Orders revealed an order dated 07/22/24, which indicated, In the evening for nutrition, Glucerna 1.5 @ 55 mL/hour x12 hours starting at 8:00 PM, continuous feeding via pump, one time a day. Stop Glucerna 1.5 feeding at 8:00 AM. Review of R162's Registered Dietician (RD) note dated 07/22/24 at 9:56 AM, revealed, Evaluation do to enteral feed & blood sugars: Glucerna 1.5 @110ml/hr for 12 hours (start at 8pm; off 8am). This provides 1980 calories/day; 109 grams protein; 1001ml from formula + 1050cc from FWF for a total of 2051cc/day. Glucose high, Blood sugars x 24 hours: 340-513mg/dL. By mouth intake varies 25-100% per nursing. RD spoke with Nurse Practitioner about blood sugars and tube feeding regimen. Medications were adjusted. RD recommends decreasing tube feeding to a lower rate to help with blood sugars and allow for hunger. Patient is eager to eat orally. RD recommends glucerna 1.5 55ml/hr for 12 hours. This provides 990kcal/day; 55 g protein; 500cc from formula + 1140cc/day for a total of 1640cc/day. This will meet 50% of kcal and 59% of protein. Can adjust pending weights, labs, and tolerance. During an interview on 07/24/24 at 4:59 PM, Licensed Practical Nurse (LPN)1 stated, [R162] eats puree food. She also receives tube feeding. She gets Glucerna 1.5 for 12 hours at 55 ml/hour x 12 hours. Turned off at 8:00 AM. She just started the puree food recently. During an interview on 07/25/24 at 7:43 AM, LPN3 stated, I came in at 11:00 PM last night. The feeding was already hung. I observed the Glucerna bottle and confirmed a time of 2200, that would be 10:00 PM. LPN3 confirmed 700 ml remained in the bottle. LPN3 stated she just turned off R162's feeding a little while ago because R162 was complaining of a stomach ache. LPN3 concluded, I haven't notified anyone, I gave her pain medication. During an interview on 07/25/24 at 8:00 AM, R162's husband, who was at bedside, stated, Her feeding is supposed to hang from 8:00 PM to 8:00 AM every night. During an interview on 07/25/24 at 11:00 AM, LPN4 stated, I worked 7p-11p last night. [R162's] husband brought [R162] back around 7:00-7:30 PM from on pass. I hung the tube feeding at 2200. I did not notify the MD for hanging her feeding late. Her blood sugar was 450, I held off on her feeding. Sometime after 8:00 PM I gave her 10 units of insulin. I went back later and checked her blood sugar, it was over 100 points less, so I decided to go ahead and hang the tube feeding. I did not record that I rechecked her blood sugar. During an interview on 07/25/24 at 9:34 AM, the Nurse Practitioner (NP) stated, I would want to know if [R162's] tube feeding is being turned on late or cut off early. The nurses should be documenting this and informing me. If her blood sugar is running high, I would have liked to have known that, I need to know that. She's had multiple abdominal surgeries in the past, something may be going on with her stomach that I need to be aware of. I've not been made aware she is having stomach pain either. During an interview on 07/26/24 at 2:20 PM, the Director of Nurses (DON) confirmed the nurse should have notified the MD if the feeding is held for various reasons, including the blood sugars being very high as R162 is a complex resident, as well as notifying him if they take the feeding down early because of pain.

Based on review of facility policy, observation, record review and interview, the facility failed to follow physician orders regarding oxygen therapy for Resident (R)5 and R309, for 2 of 2 residents reviewed for respiratory therapy. Findings include: Review of the facility policy titled, Physicians Orders dated November 2017, documented, The purpose of the physicians orders is to communicate the medical care that the resident is to receive. Adhere to physicians medication orders including strength, specific dose of the medication, mode of administration, reason for administration . Review of the facility policy titled, Oxygen Administration with a revised date of October 2018, documented, Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders for oxygen administration . Reporting 1. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice. 1. Review of R5's Face sheet revealed the facility admitted R5 on 12/08/23, with diagnosis including but not limited to; cerebral infarction, hemiplegia affecting right dominant side, peripheral vascular disease, human immunodeficiency virus, anxiety and depression. Review of R5's Physicians Orders dated 06/25/24, revealed an order for oxygen at 2 liters/minute via nasal cannula every shift. During an observation on 07/23/24 at 3:34 PM, R5's oxygen concentrator was not on or plugged in. During an interview on 07/24/24 at 12:15 PM, Licensed Practical Nurse (LPN)1 stated, [R5] has an order for oxygen every shift. LPN1 confirmed the oxygen was not on or plugged in. During an observation on 07/25/24 at 2:00 PM, R5's oxygen was at bedside, but not plugged in. During an interview on 07/25/24 at 4:48 PM, the Director of Nursing (DON) stated, [R5's] order for oxygen at 2 Liters every shift isn't clear, so I would have to say it should be on at all times, just missing the word, continuous. During an interview on 07/26/24 at 11:20, LPN1 stated, [R5's] oxygen read 2 Liters every shift, it needed to be clarified because it did not say continuous. 2. Review of R309's Face Sheet, revealed R309 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), dementia, and acute kidney failure. Review of R309's Physician Orders revealed the following, O2 at 4l via NC, continuously. every day and night shift for acute hypoxemic respiratory failure/chronic heart failure with a start date of 07/10/24. Review of R309's 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/05/24, revealed R309 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R309 had severe cognitive impairment. Further review of the MDS revealed R309 did not exhibit behaviors of rejection of care, R309 suffered from shortness of breath with exertion and lying flat. Under the section Special Treatments revealed, R309 was receiving oxygen therapy on admission and indicated continuous on admission. Oxygen therapy while a resident, was blacked out. Review of R309's Care Plan revealed a problem area indicating, The resident has altered respiratory status/difficulty breathing r/t COPD, CHF, and Respiratory Failure with an initiated date of 07/20/24 and revised on 07/20/24. The Care Plan directed staff to, Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Oxygen Settings: O2 via nasal prongs @ 4L as tolerated. Review of R309's Progress Notes, revealed the following notes: 7/20/2024 20:24 eMar - Medication Administration Note Note Text: O2 at 4l via NC, continuously. every day and night shift for acute hypoxemic respiratory failure/chronic heart failure. 7/11/2024 13:47 eMar - Medication Administration Note Note Text: Chest xray 2 views STAT for CHF, decreased oxygen saturation, increased oxygen needs Placed STAT order online at imaging website. Conf received as #43124152. 7/10/2024 11:30 Nurse's Note Note Text: Assessed resident, Resident resting in bed with head of bed elevated . swallow breathing noted, encouraged resident to take a deep breath, difficulty getting oxygen sat . Oxygen sat at 69% on 2 Liter via NC. Increased Oxygen to 4l via N/C. Resident oxygen increased to 88%. Will continue to monitor. Notified NP of assessment. New orders to increase oxygen to 4L liters via N/C. Waiting on labs to resultsfrom this am. 7/10/2024 08:40 Nurse Practitioner Note Note Text: Patient's oxygen saturation has progressively decreased throughout rehab course, currently 90% on 2 L NC O2, pulse 118. He is AO to self and situation. He is noted with somewhat shallow breathing and slightly diminished lung sounds bilaterally on today's exam. During an observation on 07/23/24 at 11:25 AM, R309 was not receiving oxygen. The oxygen machine was stored in the opposite corner of the room, away from the resident. During an observation on 07/23/24 at 2:35 PM, R309 was in his room and not receiving oxygen. The oxygen machine was stored in the opposite corner of the room, away from the resident. During an observation on 07/24/24 at 8:42 AM, R309 was sitting up in bed and not receiving oxygen. The oxygen machine was stored in the opposite corner of the room, away from the resident. During an observation and interview on 07/24/24 at 3:48 PM, R309 was moved to room [ROOM NUMBER]. R309 was laying in bed, not receiving oxygen. Observation revealed there was no oxygen machine in the room. R309 states, he has not been receiving oxygen and has a lot of problems breathing. R309 further states he is breathing ok right now. During an interview on 07/25/24 at 9:53 AM, the Nurse Practitioner (NP) stated, she expects if the order is continuous the oxygen should be on and monitored. The NP further stated, If I know they are taking it off, I will educate the staff about it. During an interview on 07/25/24 at 9:56 AM, R309 revealed he is unsure how long they keep the oxygen on. R309 further stated, The nurses take it off, it doesn't make me uncomfortable. During an interview on 07/25/24 at 4:46 PM, the Director of Nursing (DON) revealed, the oxygen should be worn continuous, unless the resident takes it off. The DON stated, we would let the physician know if the resident is not receiving the oxygen continuous. The DON further stated, That order should have been discontinued, physical therapy had him up and walking. During an interview on 07/26/24 at 2:06 PM, the Administrator stated, I would want to review the order. Staff should be following orders, sometimes the residents will pull off the oxygen. We can encourage all we want. Notify and consult the physician to see if the order needs to be changed 48835

Based on observations, interviews, policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore required Personal Protective Equipment (PPE) due to the facility being in an outbreak status. Specifically, four of four residents Residents (R) 149, R150, R255, and R256 were under quarantine as new admissions, and facility staff failed to wear the required PPE to include: N95 mask, eye protection, gowns, and gloves prior to entering the rooms of residents on transmission based precautions (TBP). This failure had the potential to increase the risk of transmission of COVID-19 to all 52 residents living in the facility. Findings include: Review of CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/02/22, revealed . Residents who are not up to date with all recommended COVID 19 vaccine doses and who have had close contact with someone with COVID should be placed in quarantine and healthcare personnel should use full PPE (gowns, gloves, eye protection and N95 or higher-level respirator . Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom . Only patients with the same respiratory pathogen should be housed in the same room. Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals . who . are not up to date with all recommended COVID-19 vaccine doses . and . NIOSH-approved N95 or equivalent or higher-level respirators can also be used by HCP . if healthcare-associated [CONDITION(S)]-CoV-2 transmission is identified and universal respirator use by HCP working in affected areas is not already in place. Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters . Review of facility policy titled, Coronavirus Disease (COVID-19) - Identification and Management of Residents, revised July 2020, revealed For residents who are tested prior to hospital discharge and COVID 19 negative, admit and cohort (in rooms or wings) with other residents of similar status . and . all residents who are not up to date with all recommended COVID 19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admissions . Review of this facility policy revealed no guidance on PPE required during an outbreak. During an interview on 03/21/22 at 9:30 AM, the Assistant Director of Nursing (ADON), who also serves as the facility Infection Preventionist (IP), stated there were four residents on quarantine due to being a new admission with an unknown COVID status. Observation on 03/21/22 at 10:00 AM, revealed R149, R150, R255, and R256 in their rooms with signage observed on the door Droplet Precautions for R149 and R150 and a cart outside of the room with PPE. No signage was observed on the room for R255 and R256, but an isolation cart was outside the room. During an interview on 03/21/22 at 12:30 PM, the IP stated facility staff and residents were being tested twice a week since 03/10/22 when the facility went into outbreak status when a Licensed Practical Nurse (LPN) who had a religious exemption and a dietary employee who was up to date with all recommended COVD 19 vaccine doses, tested positive for COVID-19 on 03/08/22. The IP also stated during the same interview on 03/21/22, that on 03/10/22 a Certified Nursing Assistant (CNA) tested positive, who had a religious exemption. On 03/11/22, two residents tested positive and on 03/17/22, three additional residents tested positive. Four of the five residents were transferred to a sister facility, which has a COVID positive unit, and one resident was cleared to discharge home. The IP stated that staff were 100% vaccinated (105 employees up to date with all recommended COVID-19 vaccine doses (including booster doses, if eligible) and 39 with granted religious exemptions) and no employees had tested positive since 03/10/22. No new residents had tested positive since 03/17/22. The IP verified that the facility remained in outbreak status until no other staff or residents tested positive for two weeks. The IP stated R149, R255, R256 were tested on [DATE] (due to the outbreak status) and were negative. R150 had a history in the last 90 days of testing positive, and the facility was going by the symptom-based strategy instead of testing for determination of potential positive status. Review of R149's Resident Face Sheet, undated, located in the electronic medical record (EMR) under the Profile tab, indicated R149 was admitted to the facility on [DATE] with a negative COVID-19 test, dated 03/08/22. R149 was not up to date with all recommended COVID-19 vaccine doses. Review of R150's Resident Face Sheet, undated, located in the EMR under the Profile tab, indicated R150 was admitted to the facility on [DATE] with a negative COVID-19 test, dated 03/04/22. R150 was up to date with all recommended COVID-19 vaccine doses. Review of R255's Resident Face Sheet, undated, located in the EMR under the Profile tab, indicated R255 was admitted to the facility on [DATE] with a negative COVID-19 test, dated 02/27/22. R255 was not up to date with all recommended COVID-19 vaccine doses. Review of R256's Resident Face Sheet, undated, located in the EMR under the Profile tab, indicated R256 was admitted to the facility on [DATE] with a negative COVID-19 test, dated 03/13/22. R256 was not up to date with all recommended COVID-19 vaccine doses. Observation on 03/21/22 at 10:20 AM of the shared room of R255 and R256, who were on droplet isolation for being new admissions who were not up to date with all recommended COVID-19 vaccine doses (both residents had refused COVID-19 vaccination), revealed Certified Nursing Assistant (CNA) 1 did not use required PPE (N95 face mask, gown, gloves, and eye protection ) for care, only a surgical mask. During an interview on 03/21/22 at 10:25 AM with CNA 1, who has a religious exemption, CNA1 stated R256 was no longer in quarantine and didn't need additional PPE and stated the weekend shift forgot to remove the PPE from outside the door. During an interview with Licensed Practical Nurse (LPN) 3 on 03/21/22 at 10:43 AM, who was only wearing a surgical mask and has a religious exemption, stated the whole room (R255 and R256's) was on isolation, . as you can't necessarily match up residents on isolation, so if residents are in a shared room, the whole room is on isolation . No isolation signage was observed on the door. During an interview on 03/21/22 at 4:00 PM, LPN 2 stated she has received education on wearing PPE. LPN 2 was observed wearing a KN-95 mask under a N95 mask with eye protection on and the N-95 face mask was observed not worn properly. The N-95 mask was observed placed on top of the KN95 mask with the straps of the N-95 face mask placed on the nose of both masks. Observation on 03/21/22 at 9:30 AM, revealed facility staff throughout the building wearing surgical masks, no N95 mask or face shield. Observation on 03/21/22 at 2:00 PM, revealed facility staff throughout the building wearing surgical masks, no N95 mask or face shield. Observation on 03/21/22 at 3:30 PM, revealed facility staff throughout the building wearing surgical masks, no N95 mask or face shield. During an interview on 03/21/22 at 12:30 PM, the IP verified that residents (R149, R150, R255 and R256) were under quarantine for 10 days and staff was to wear all required PPE. The IP stated they follow the CDC guidelines for new admissions and cohorting residents that are not up to date with all recommended COVID-19 vaccine doses (including booster doses, if eligible). Further interview revealed the IP referenced the CDC guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/02/22, that states . Residents who are not up to date with all recommended COVID 19 vaccine doses and who have had close contact with someone with COVID should be placed in quarantine and healthcare personnel should use full PPE (gowns, gloves, eye protection and N95 or higher-level respirator . Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom . Only patients with the same respiratory pathogen should be housed in the same room . After review of the CDC guidance, the IP acknowledge that the CDC guidance had been misinterpreted to allow cohorting of new admissions that are not up to date with all recommended COVID-19 vaccine doses (including booster doses, if eligible). During an interview on 03/21/22 at 4:30 PM with the Administrator and DON, both verified that all facility staff, regardless of vaccination status, are required to wear an N95 and eye protection during an outbreak status.

Based on record review and interview, the facility failed to provide/assist in activity of daily living (ADL) care for 3 of 3 residents reviewed. Residents #1,# 2, and #3 had numerous gaps in their ADL documentation that could not be accounted for by facility staff. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 ADL documentation on July 7, 2021 at approximately 11:30 AM revealed multiple gaps in the resident's bathing, bladder and bowel continence, bowel movements, dressing and undressing, grooming, hydration, oral care, bed mobility and toileting for the months of May and June 2021. Review of care plan for Resident #1 on July 7, 2021 at approximately 11:35 AM revealed staff is to Assist with ADL's, transfers and toileting. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of ADL documentation for Resident #2 on July 7, 2021 at approximately 11:40 AM revealed multiple gaps in documentation for bladder and bowel continence, dressing and undressing, grooming, hydration and fluids, bed mobility, eating, and toileting for the months of April and May 2021. Review of care plan for Resident #2 on July 7, 2021 at approximately 11:45 AM revealed a self-care deficit and impaired mobility. Staff is to assist the resident with ADL care as needed. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of ADL documentation revealed on July 7, 2021 at approximately 2 PM revealed numerous blanks in bladder and bowel continence, bowel movements, call light within reach, dressing and undressing, grooming, hydration, bed mobility and toileting for the month of July 2021. Review of Resident #3 care plan on July 7, 2021 at approximately 2:30 PM revealed impaired functional mobility related to a left femur fracture. Facility staff is to assist with ADLs, transfers, and toileting as tolerated. Interview with the Director of Nursing (DON) on July 7, 2021 at approximately 2 PM confirmed the gaps in the residents' ADL documentation as well as the lack of ADL policy for the facility.

Based on interview and record review, the facility failed to provide quality of care for 1 of 3 residents reviewed. Resident #1 had several gaps in the Treatment Administration Records (TARs) with no associated documentation indicating that treatments had been provided. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of grievances on behalf of Resident #1 on July 7, 2021 at approximately 11 AM revealed two grievances related to resident wound care. Facility responded that resident was noncompliant with wound care. Review of Resident 1's Treatment Administration Records (TARs) on July 7, 2021 at approximately 12 PM revealed multiple missing treatments for May 2021. 1. Cleanse blisters to L heel not done on 5/19/21 2. Cleanse blisters to L heel and apply skin prep not done 5/24/21 3. Cleanse skin tear to back of L ankle not done 5/19/21 4. Cleanse blister to L inner ankle and apply xeroform and kerlix not done 5/19/21 5. Cleanse blister to L outer ankle and apply xeroform and kerlix not done 5/19/21 6. Wrap bilateral extremities with Ace wrap not done 5/24/21 7. Cleanse blister to L inner ankle with skin prep not done day of 5/24/21 or nights of 5/23/21 and 5/27/21 8. Cleanse blister to L outer ankle with skin prep not done day of 5/24/21 or nights of 5/23/21 and 5/27/21 9. Skin prep to back R ankle every day and night shift not done day of 5/24/21, nights of 5/23/21, and 5/27/21 10. Unna boots to bilateral lower extremity not done 5/27/21 Review of Resident #1 Care Plan on July 7, 2021 revealed alterations in skin integrity and staff was to provide treatments as ordered. Interview with the Director of Nursing (DON) at approximately 1:40 PM confirmed the blanks in the TARs. The DON indicated that blanks on 5/19/21 were related to treatment changes and the blanks on 5/24/21 were related to hospitalization . The DON suggested the other blanks were related to resident noncompliance, which was care planned. However, the DON did confirm that none of these were properly documented in the TARs.

Based on observation, interviews and review of the facility's Receiving policy for food item, the facility failed to ensure that expired food was disposed of timely. The dry food area was observed with 4 to 5 packs of corn tortillas (60 count each) with a purchase date of (MONTH) (YEAR) written on the order box and a 75 days shelf life date by the manufacture. 1 of 1 main kitchens observed. The findings included: During the initial tour observation on [DATE] at approximately 9:40 AM of the dry food storage area, a large cardboard box of 4 to 5 packs of corn tortillas with 50 or more tortillas were noted with no expiration date on the packs. The corn tortillas were observed to be extremely soft and flexible. During an interview on [DATE] at approximately 9:45 AM with the Certified Dietary Manager (CDM) who was present during the initial tour observation confirmed the findings that there was no expiration date on the 4 to 5 packs of corn tortillas. The CDM showed the surveyor a black magic marker hand written date and stated the corn tortillas were purchased (MONTH) (YEAR). The CDM further stated he/she would have to contact the District Manager to obtain the expiration date of the corn tortillas. During an interview on [DATE] at approximately 4:06 PM with the CDM and District Manager revealed the food Distribution Company was contacted regarding the expiration date of the corn tortillas. The District Manager stated he/she was informed the corn tortillas had a shelf life date of 75 days and that the corn tortillas have been thrown out. On [DATE] at approximately 10:47 AM the District Manager provided the facility's policy on monitoring the expiration dates on foods. On the Receiving policy under #5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. Under #6 of the policy, All food items will be stored in a manner that ensures appropriate and timely utilization based on principles of first in-first out (FIFO) inventory management. The District Manager further stated he/she had not received the manufacture documentation of the shelf life verification. On [DATE] documentation was provided to the surveyor that the shelf life of the corn tortillas was 75 days and further indicated the 4 to 5 packs of tortilla contained 60 tortillas each.

Based on observation, interview, and review of the facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 56 of 56 residents with ordered diets as evidenced by failing to do the following: Dispose of expired food, handle food sanitarily, calibrate a Fahrenheit (F) temping probe, and clean can opener blade. The findings included: On [DATE] at 10:55 AM, an initial tour of the main kitchen with the Certified Dietary Manager (CDM) revealed: 1.) (4) boxes of chocolate fudge icing mix with best by dates of [DATE]. 2.) (1) box containing (200) Smuckers assorted jelly plastic cups with expiration dates of [DATE]. 3.) The can opener had a large build-up of a black/brown debris on the blade. On [DATE] at 11:20 AM, during an interview with the CDM, s/he verified the icing and jelly were expired and that the can opener blade had a build-up of a black/brown substance. On [DATE] at 11:40 AM, during an observation of the lunch line temping with Cook #1, s/he placed a temperature probe into a pitcher of ice water and the probe read 24 degrees F. Cook #1 verified the probe temperature read 24 degrees F, then attempted to take food temperatures. Cook #1 was asked, What is the correct temperature of a calibrated (F) temperature probe should read, and the cook stated, 30 degrees. The cook was then asked to calibrate the temperature probe to 32 degrees, Cook #1 stated, I don't how to, and the probe does not have a wrench. The CDM verified s/he also did not know how to calibrate a F temperature probe, and confirmed there was not a wrench to adjust the probe. On [DATE] at 1:00 PM, during an observation of the lunch meal on the 200 hall, CNA #1 delivered trays to Resident #50 in their room and a resident in the 200 hall day room. While setting up the resident's trays, CNA #1 used his/her bare hands to pull the bun out of the plastic wrapper and placed the bun onto the residents plate. CNA #1 verified s/he touched the buns and indicated s/he should not touch food with bare hands. Review of the facility policy, Food and Supply Storage Procedures, states under Dry Storage, bullet #4, Remove from storage any items for which the expiration date has expired. Also, the policy, Employee Guidelines-Infection Control Practices, states under, All Dining Services Employees, bullet #8, Use a spatula or tongs, or wear disposable gloves when handling food. Furthermore, the policy, How To Calibrate a Thermometer, states under Step 3,Hold the calibration nut securely with a wrench or other tool and rotate the head of the thermometer until it reads 32 degrees F.

Based on observation, record review, interview, and review of the facility policy, the facility failed to maintain a medication rate of less than 5%. There were 4 errors out of 27 opportunities for error, resulting in a medication error rate of 14.81%. The findings included: Error #1 On 5/22/18 at 11:55 AM, during an observation of Resident #2's medication administration with Licensed Practical Nurse (LPN) #1 revealed Resident #2's Blood Sugar (BS) was 172. The physician ordered Resident #2 to receive 2 units of [MEDICATION NAME]from a [MEDICATION NAME] for a BS between 151-400. LPN #1 attached a needle to Resident #2's [MEDICATION NAME], and without priming the [MEDICATION NAME], selected 2 units on the [MEDICATION NAME]'s Dose Knob dial. LPN #1 then placed the [MEDICATION NAME] onto Resident #2's right lower abdomen and pressed the Dose Knob administration button, holding the Flex Pen for 3-4 seconds against the residents' skin. Following the administration LPN #1 verified s/he did not prime the [MEDICATION NAME] prior to administration, and indicated that s/he did not hold the [MEDICATION NAME] for 6 seconds against Resident #2's skin after pressing the Dose Knob administration button. Review of the [MEDICATION NAME] manufactures recommendations reveals under, Prepare your pen; Prime you pen, states, Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Also, under, Give your injection, states, Insert the needle. Press and hold the dose button. After the dose counter reaches 0, slowly count to 6. Error #2 On 5/22/18 at approximately 4:02 PM, during an observation of Resident #48's medication administration on the 200 hall, LPN #2 administered (2) drops of Artificial Tears into each of the residents eyes. On 5/22/18 at 4:10 PM, during reconciliation of Resident #48's med pass a review of the medication administration record (MAR) and physicians orders revealed an order stating, Refresh Tears Solution ([MEDICATION NAME] Sodium) instill (2) drops in both eyes three times a day for Dry eyes. On 5/22/18 at 4:12 PM, during an interview with LPN #2, s/he verified the medication Artificial Tears eye drops were used instead of the Refresh Tears [MEDICATION NAME] Sodium solution that was ordered. Error #3 On 5/22/18 at approximately 5:00 PM, during an observation of Resident #35's medication administration on the 300 hall, Registered Nurse (RN) #1 administered (1) drops of Artificial Tears into each of the residents eyes. On 5/22/18 at 5:10 PM, during reconciliation of Resident #35's med pass a review of the MAR and physicians orders revealed an order stating, Refresh Tears Solution ([MEDICATION NAME] Sodium) instill (1) drop in both eyes three times a day for Dry eyes. On 5/22/18 at 5:15 PM, during an interview with RN #1, s/he verified the medication Artificial Tears eye drops were used instead of the Refresh Tears [MEDICATION NAME] Sodium solution that was ordered. Error #4 On 5/23/18 at 8:00 AM, during an observation of Resident #255's medication administration on the 300 hall, LPN #3 handed a [MEDICATION NAME] Respimat Aerosol 2.5 Microgram inhaler to the resident. Resident #255 then administered (2) inhalations of [MEDICATION NAME] Respimat Aerosol approximately 15 seconds apart. LPN #3 did not stop or instruct Resident #255 that s/he was only to receive (1) inhalation of [MEDICATION NAME]. On 5/23/18 at 8:10 AM, during reconciliation of Resident #255's med pass a review of the MAR and physicians orders revealed an order stating, [MEDICATION NAME] Respimat Aerosol Solution 2.5 MCG/ACT (1) inhalation inhale orally one time a day for [MEDICAL CONDITION]. On 5/23/18 at 8:12 AM, during an interview with LPN #3, s/he verified Resident #255 received (2) inhalations of [MEDICATION NAME] and was ordered (1). Review of the facility policy, Administering Medications, revealed under guideline (7.) The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and review of the [MEDICATION NAME] manufacture recommendations, the facility failed to administer the correct amount of insulin for 1 of 1 resident's reviewed for insulin administration. Staff did not follow an established procedure to deliver the correct amount insulin to Resident #2. The findings included: On 8/12/15 the facility admitted Resident #2 with a [DIAGNOSES REDACTED]. On 5/22/18 at 11:55 AM, during an observation of Resident #2's medication administration with Licensed Practical Nurse (LPN) #1 revealed Resident #2's Blood Sugar (BS) was 172. The physician ordered Resident #2 to receive 2 units of [MEDICATION NAME]from a [MEDICATION NAME] for a BS between 151-400. LPN #1 attached a needle to Resident #2's [MEDICATION NAME], and without priming the [MEDICATION NAME], selected 2 units on the [MEDICATION NAME]'s Dose Knob dial. LPN #1 then placed the [MEDICATION NAME] onto Resident #2's right lower abdomen and pressed the Dose Knob administration button, holding the Flex Pen for 3-4 seconds against the residents' skin. Following the administration LPN #1 verified s/he did not prime the [MEDICATION NAME] prior to administration, and indicated that s/he did not hold the [MEDICATION NAME] for 6 seconds against Resident #2's skin after pressing the Dose Knob administration button. Review of the [MEDICATION NAME] manufactures recommendations reveals under, Prepare your pen; Prime you pen, states, Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Also, under, Give your injection, states, Insert the needle. Press and hold the dose button. After the dose counter reaches 0, slowly count to 6.

Based on Record review and interview, the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #4 and inaccurately documented the status of a Stage IV pressure ulcer as a Stage II for Resident #3, 2 of 3 residents reviewed for pressure ulcers. The findings included: Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Record review revealed the MDS (Minimal Data Set) coded Resident #4 as requiring extensive assistance to total dependence for all aspects of ADLs (Activities of Daily Living). Review of the Physicians Orders on 08/24/2017 revealed an order dated 06/08/17 for Sureprep to intact blister left outer heel q (every) shift until healed. Additional review revealed an order dated 06/20/17 for a [MEDICATION NAME] dressing to the left heel every Tuesday and Friday for an Unstageable ulcer and on 06/27/17 an order was received to apply [MED] 250 units per gram to eschar, cover with non-adherent pad and wrap with [MEDEQUIP]. On 08/24/17 at 12:17 PM, review of the care plan dated 06/12/17 revealed problem areas included, but were not limited to, Impaired Functional Mobility related to recent [MEDICAL CONDITION] dated 05/31/17. Interventions included assisting with ADLs, assisting with oral care, call light within reach and encourage resident to call for help as needed, PT (Physical Therapy) to evaluate and treat, remove staples in 14 days, and two 1/2 siderails up as needed for increased bed mobility. Further review revealed a care plan dated 06/09/17 for Potential/actual impairment of skin integrity including an intact blister to the left outer heel. Interventions included floating the heels initiated 06/08/17. There were no interventions to prevent pressure ulcers prior to 06/08/17. On 08/24/17 at 12:28 PM, review of the Evaluations revealed a Braden Scale completed 06/01/17 with a score of 14, indicating moderate risk of developing a pressure ulcer. No interventions were implemented to prevent the development of a pressure ulcer until 06/08/17 when the resident was noted to have a blister on her left heel. During an interview on 08/24/17, the Director of Nursing confirmed the care plan indicated that the intervention to float heels was initiated on 06/08/17 and that the resident was identified as being at risk on 06/01/17 per the Braden Scale. S/he also confirmed the onset date of the pressure ulcer was 06/08/17. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 0[DATE] revealed Resident #3 had a Stage IV on the coccyx on 11/14/14. Review of the Weekly Pressure Ulcer log dated 08/17/17 indicated the resident had a Stage II on the coccyx with a date of onset 11/14/16. During an interview on 08/24/17, the Director of Nursing stated the documented onset date of 11/14/16 was an error and that it was the same wound that the resident had since 2014. The Director of Nursing and the wound nurse stated that the wound had the appearance of a Stage II wound when the wound nurse started in that role and that the previous documentation stated the wound was Stage II. The wound nurse stated that since the previous documentation indicated the wound was a Stage II, s/he had continued to document the wound as a Stage II.

Based on observation, record review, and interview, the facility failed to ensure that fall prevention devices were in use and/or functional for Residents #1 and #32, 2 of 4 residents reviewed for fall. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. On 08/22/17, review of the Annual Minimal Data Set revealed the resident was dependent for all aspects of activities of daily living. Review of the History and Physical and Discharge Summary revealed Resident #1 sustained a fracture of the left ankle in September, 2016 due to a fall. Review of the care plan on 0[DATE] at 2:37 PM revealed risk for falls was identified as a problem area. Interventions and approaches included, but not limited to, pad alarm to bed and chair. Observations of Resident #1 at 9:29 AM on 08/22/17, 10:40 AM on 08/22/17, 11:51 AM on 08/22/17, and 12:52 AM on 08/22/17 revealed the resident in a wheelchair without a pad alarm on the wheelchair. On 0[DATE] at 2:44 PM, Resident #1 was observed supine in the bed with a pad alarm intact that appeared non-functional. During an interview at 3:21 PM, Licensed Practical Nurse #1 confirmed the pad alarm in the resident's bed was not functioning due to not having been turned on. The nurse also confirmed the resident was supposed to have a pad alarm on the bed. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. At 4:19 PM on 0[DATE], review of the monthly cumulative physician's orders [REDACTED]. Check and release per policy at meals and activities. Continue bed and wc alarm sensor pad as ordered. During an interview with the Director of Nursing, s/he stated the alarm should have been discontinued when the seatbelt was applied but confirmed the order stated to continue the alarms. Observations of Resident #2 at 9:29 AM on 08/22/17 and 3:29 PM on 0[DATE] revealed the resident in a gerichair with a seatbelt tied behind the chair and a pad alarm which appeared non-functional. At 3:29 PM on 0[DATE], Licensed Practical Nurse #2 confirmed the alarm was not functional.

Based on observation, record review, and interview, the facility failed to update the care plan related to fall prevention interventions for Residents #2, 1 of 4 residents reviewed for fall. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. At 4:19 PM on 0[DATE], review of the monthly cumulative physician's orders [REDACTED]. Check and release per policy at meals and activities. Continue bed and wc alarm sensor pad as ordered. Review of the care plan revealed interventions included a bed alarm when in bed and a seatbelt when in the wheelchair. During an interview with the Director of Nursing, s/he stated the alarm should have been discontinued when the seatbelt was applied but confirmed the order stated to continue the alarms. The care plan had not been updated to include an alarm in the wheelchair. Observations of Resident #2 at 9:29 AM on 08/22/17 and 3:29 PM on 0[DATE] revealed the resident in a gerichair with a seatbelt tied behind the chair and a pad alarm which appeared non-functional. At 3:29 PM on 0[DATE], Licensed Practical Nurse #2 confirmed the alarm was not functional.

On the days of the survey, based on record review and interview, the facility failed to notify the physician timely for 1 of 9 residents reviewed with a change in their condition. The facility did not notify the physician when Resident #7, with history of respiratory distress, respiratory status changed. The findings included: The facility admitted resident #7 with [DIAGNOSES REDACTED]. Review of the nurses notes revealed the following documentation: 6/9/12 11:50 (no am or pm), "Resident stated "I don't feel well and I can't breathe. Resident also stated, Take me to the hospital!" VS (vital signs) are as followed (sic): T (temperature) 99.6, P (pulse) 161, O2 (Oxygen) 51%, Resident diaphoretic and RR (Respirations) labored and uneven. Called on call NP (nurse Practitioner) ____ New order to send to ER. 6/12/12, 3:30 PM Resident returned to facility....... The nurses notes throughout the resident stay described the resident's respirations as "even and unlabored" until 6/26/12. 6/26/12, 1230AM (late entry) ....Resp even and unlabored. 6/26/12, 3:00 AM (late entry) "Resp shallow, lying in bed with eyes closed. Sleeping soundly, hard to arouse. O2 @ 2L (liters) NC (nasal cannula). There was no MD notification of shallow respirations or that the resident was difficult to arouse. 6/26/12, 640 AM (late entry) O2 88% inc. (increased) O2 to 3L, O2 increased to 92%. Informed on coming nurse of residents status. VS 156/70, 22, 91, 97.9. Will continue to monitor resident. There was no MD notification of the decreased oxygen saturation level or the decision to increase the oxygen flow rate for the resident with known [MEDICAL CONDITION]. 6/26/12, 8:15 (no am or pm) Resident noted to be diaphoretic, breathing labored, O2 Sat 83% on 3L/M,, increased O2 to 4L/M via N/C (nasal cannula) v/s 168/76 -92-29-98.8. Called NP (Nurse Practitioner) and spoke to her and she said to contact family and send out....." The physician or nurse practitioner was not notified until 8:15 AM after the resident was noted to be diaphoretic and the resident's oxygen had again been increased to 4L/M. Review of the Resident's Physician orders revealed Oxygen was ordered at 2L/M. There was no Physician's order to increase the Oxygen rate for the resident with [MEDICAL CONDITION]. The resident was sent to the hospital and required intubation for respiratory distress. A Consultation report dated 6/29/12, contained transfer information from the hospital. The report stated, "This patient...admitted on 6/26/12 with shortness of breath and [MEDICAL CONDITION], had to be intubated and was noted to have pneumonia...." During an interview with the Director of Nursing on 7/12/12 at approximately 3:00 PM, she provided a statement from the nurse on duty at the time of the transfer which stated the Nurse Practitioner was called at 7:45 AM. Review of the Standing Orders fir Dyspnea/Cyanosis, stated, "Obtain resident vital signs, pulse oxygen level, note any [MEDICAL CONDITION], have recent and prior weights available, and then notify MD. If RN available, assess cardiac and lung sounds prior to contacting MD. "

On the days of the survey, based on record review, observations and interviews, the facility failed to provide appropriate services for 1 of 1 residents with acute change in respiratory status and 2 of 8 residents with oxygen concentrators. Resident #7 with known respiratory distress did not receive timely intervention for changes in her respiratory status. Resident #1 and one additional random resident did not have filters in place in their oxygen concentrators. The findings included: The facility admitted resident #7 with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. On 6/26/12, the resident was noted to have shallow respirations and was difficult to arouse at 3:00 AM. There was no assessment done to check breath sounds or vital signs once the resident had been noted to be difficult to arouse and had shallow respirations. At 6:40 AM, the resident oxygen saturations were down to 88%, the nurse increased the oxygen flow and failed to notify the physician. There was no no documentation that an assessment had been done. The physician or nurse practitioner was not notified until 8:15 AM after the resident was noted to be diaphoretic and the resident's oxygen had again been increased for the second time to 4L/M. Review of the Resident's Physician orders revealed Oxygen was ordered at 2L/M. There was no Physician's order to increase the Oxygen rate for the resident with [MEDICAL CONDITION]. The resident was sent to the hospital and required intubation for respiratory distress. Review of Perry and Potter, Clinical Nursing Skills & Techniques, 7th Edition, Copyright 2010, Assessment of Signs and Symptoms Associated with [MEDICAL CONDITION] included: Apprehension, anxiety, behavioral changes, decreased level of consciousness, confusion, drowsiness, altered concentration, increased pulse rate and depth of respiration or irregular respiratory patterns, decreased lung sounds, adventitious lung sounds (e.g., crackle, wheezes), elevated blood pressure evolving to decreased blood pressure, Pulse Oximetry (SpO2) less than 90%, Dyspnea, Use of accessory muscles of respiration, rib retractions, cardiac [MEDICAL CONDITION], Pallor, Cyanosis, increased fatigue, Dizziness and clubbing of nails resulting from prolonged, chronic [MEDICAL CONDITION]. The medical record documented the resident's Oxygen Saturation had dropped below 90%. The nurse increased the Oxygen flow on a resident with [MEDICAL CONDITION] without consulting the physician. There was no indication the resident had been assessed for respiratory status which included breath sounds. There was no description of the residents' inspiration or expiration, skin color, or types of breaths. During an interview with the Director of Nursing on 7/12/12 at approximately 11:15 AM, she confirmed she would have expected an assessment to have been done, when the nurse documented the residents respirations were shallow and she was difficult to arouse. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Observation during the Initial Tour on 7/9/12 at approximately 6:45 PM revealed Oxygen concentrators in use in rooms [ROOM NUMBERS] that did not have filters in place. There was a white dust like material within the slots where the filter should have been. Observations on 7/11/12 at 9:05 AM and 7/12/12 at 8:55 AM revealed Oxygen in use in room [ROOM NUMBER] for Resident #1 with no filter in place on the concentrator. Observation on 7/12/12 at 8:48 AM revealed Oxygen in use in room [ROOM NUMBER] with no filter in place. On 7/12/12 at approximately 9:00 AM, Licensed Practical Nurse (LPN) #1 verified there were no filters in place for both concentrators in use in rooms [ROOM NUMBERS]. He stated that both of them should have a filter on the back of the concentrator. When asked, he stated that nursing staff usually document the cleaning of the filters on the treatment sheets. Review of the July 2012 Treatment Administration Record for Resident #1 revealed an entry which stated "Clean O2 (Oxygen) filter every night, Start Date: 7/07/12". The entry had been initialed as having been completed on 7/10, 7/11, and 7/12. Review of the Treatment Administration Record for the resident in room [ROOM NUMBER] revealed no documentation related to cleaning or changing an Oxygen filter as verified by LPN #1.