Every finding on record at Shattuck Nursing Center

Based on observation, record review, and interview, the facility failed to ensure medications were safely and securely stored to prevent residents from access to unprescribed medications in resident rooms and for 1 of 2 medication carts observed. The administrator identified 43 residents resided in the facility. Findings: On 07/30/26 at 8:30 a.m., multiple bottles of medications were observed on top of the medication cart sitting by the nurse's station in the center of the building. The medications included: Miralax (a laxative) 179 ounce, three quarters full, multi-vitamin, 1,000 tablets, one quarter full, thiamin b1 vitamin, 100 tablets, one quarter full, fish oil 1,000mcg, 2 capsules, vitamin C 500mg, 1,500 tablets, one quarter full, acidophilus pectin (a probiotic) 100 tablets, one quarter full, Fiber-lax (a laxative) 90 capsules, one half full, I-vite (a vitamin) 60 capsules, one quarter full, Calcium plus D (a vitamin) 600mg, one quarter full, zinc (a supplement) 50mg, 100 tablets, three quarters full, Zyrtec (an antihistamine) 10mg, 100 tablets, one half full, loratadine (an antihistamine) 10mg, 90 tablets, one quarter full, omeprazole (an acid reducer) 20mg, 10 tablets, iron 325mg, 100 tablets, three quarters full, famotidine (an acid reducer) 20mg, 300 tablets, three quarters full, b12 500 micrograms, one half full, magnesium G (a supplement), 500 tablets, full, magnesium oxide (a supplement), 120 tablets, one quarter full, diphenhydramine (an antihistamine) 25mg, 1,000 tablets, full ibuprofen (a pain reliever) 200mg, 1,000 tablets, three quarters full, antacid tablets 500mg, 150 tablets, one half full, ferrous gluconate (a supplement) 324mg, 100 tablets, one half full, and thermotabs (a supplement), 100 tablets, full. On 07/30/26 at 8:38 a.m., CMA #1 left the medication cart unattended on the South hallway with the 23 bottles of medication sitting on top. CMA #1 entered a resident's room and stepped behind a curtain out of the line of sight of the medication cart. On 07/30/26 at 8:55 a.m., CMA #1 returned to the medication cart on the South hallway. On 07/30/26 at 9:02 a.m., CMA #1 left the medication cart unattended on the South hallway with the 23 bottles of medication sitting on top. CMA #1 entered a different resident's room and closed the door. On 07/30/26 at 9:06 a.m., CMA #1 returned to the medication cart on the South hallway. On 07/30/26 at 9:11 a.m., CMA #1 left the medication cart unattended on the North hallway with the 23 bottles of medication sitting on top. CMA #1 entered a different resident's room and closed the door. On 07/30/26 at 9:14 a.m., CMA #1 returned to the medication cart on the North hallway. On 07/30/26 at 10:30 a.m., one tube of Preparation H was observed in Resident #41 and Resident #7's bathroom. On 07/30/26 at 10:47 a.m., one package of Gas X was observed on Resident #9's bedside table. A policy titled Bedside Storage of Medication, dated 06/21/17, read in part, Bedside medications will be stored in a locked area .The facility will take special care to assure that other residents do not have access to bedside medications. On 07/30/26 at 10:30 a.m., Resident #41 stated staff did not apply the Preparation H, they applied it themself. On 07/30/26 at 10:47 a.m., Resident #9 stated they took Gas X twice a day and it stayed on their bedside table. On 07/30/26 at 9:18 a.m., CMA #1 stated they should not have left the medication cart unattended but did not usually do that. On 07/30/26 at 9:36 a.m., the DON stated medications were not to be left unattended, and they had told CMA #1 not to do that earlier that morning. On 07/30/26 at 11:12 a.m., the DON stated that beside medications should be locked.

Based on observation, record review, and interview, the facility failed to ensure food was maintained at proper temperature controls for 2 of 2 kitchen observations.The administrator identified 42 residents received food prepared in the kitchen and one resident received nutrition and hydration solely through a feeding tube. Findings:On 07/28/26 at 12:16 p.m., a tour of the kitchen was conducted. Two wells on the steam table were observed not in working condition. One warmer contained green beans and the temperature measured at 128 degrees F.On 07/29/26 at 11:17 a.m., a tour of the kitchen was conducted. The following observations were made:a. a large bowl of salad sat on the counter at room temperature,b. a bowl of cucumbers in one of the wells of the steam table warmer was at room temperature, andc. a bottle of dressing was sitting out on the counter at room temperature.On 07/29/26 at 11:26 a.m., a food test tray was obtained from the kitchen. Temperatures were measured and showed:a. brisket at 126.9 degrees F,b. squash at 127.8 degrees F, andc. salad at 56 degrees F.A maintenance work order log, dated 07/2026, showed the only entry for the month was on 07/27/26. The work order log, read in part, Same steamtable or Hot Bar that hasn't worked since I started two and half (sic) years ago.An undated policy titled Food Service Hygiene, read in part, Food is maintained at acceptable temperatures during service .a. Hot foods - 140 degrees and above .b. Cold foods - 41 degrees or below.On 07/30/26 at 9:35 a.m., [NAME] #1 stated the wells on the steam table had not held heat for two and one half years. On 07/30/26 at 3:05 p.m., the maintenance supervisor stated the wells on the steam table did not heat or burn the food. The maintenance supervisor stated they had worked at the facility about a year, and the steam table warmers had not worked in that time.On 07/30/26 at 3:08 p.m., the maintenance supervisor stated that one of three wells on the steam table worked and they had been notified by word of mouth the warmers did not heat. On 07/31/26 at 12:36 p.m., the administrator stated they were told about the wells on the steam table not working and was not sure how long they had not worked.

Based on observation, record review, and interview, the facility failed to ensure:a. staff performed hand hygiene during medication administration for 2 (#8 and #20) of 5 sampled residents observed during medication pass observations, and b. oxygen tubing was changed per physician's order for 1 (#3) of 1 sampled resident observed for oxygen. The administrator identified 43 residents resided in the facility and two residents utilized oxygen. Findings:1. On 07/30/26 at 8:38 a.m., CMA #1 was observed to prepare Resident #20's medications at the medication cart. CMA #1 did not use hand sanitizer or wash their hands.On 07/30/26 at 8:48 a.m., CMA #1 was observed to administer Resident #20's medications. CMA #1 did not use hand sanitizer or wash their hands.On 07/30/26 at 9:00 a.m., CMA #1 was observed to prepare Resident #8's medications at the medication cart. CMA #1 did not use hand sanitizer or wash their hands.On 07/30/26 at 9:02 a.m., CMA #1 was observed to administer Resident #8's medications. CMA #1 did not use hand sanitizer or wash their hands.On 07/30/26 at 9:32 a.m., CMA #1 stated they did not use hand santizer or wash their hands between residents during the medication pass.2. On 07/31/26 at 2:00 p.m., Resident #3's oxygen tubing was observed to have a label with a date of 06/24.A physician's order for Resident #3, dated 08/12/21, showed their oxygen tubing was to be changed every Tuesday.On 07/31/26 at 2:04 p.m., the infection preventionist stated oxygen tubing was to be change either every two weeks or monthly. They stated, Regardless, it should have been changed by now.On 07/31/26 at 3:15 p.m., the DON stated oxygen tubing was changed every Tuesday on the night shift. They stated Resident #3's oxygen tubing had been changed since 06/24. The DON stated they did not know why the tubing had a date of 06/24.

Based on observation, record review, and interview, the facility's medication error rate was less than 5%. The medication error rate was 11.11%. The administrator identified 43 residents resided in the facility. Findings:1.On 07/30/26 at 8:48 a.m., CMA #1 was observed to administer Resident #20's medications. CMA #1 did not administer their Brimonidine Tartrate Ophthalmic Solution 0.2 % (an eye drop to lower high eye pressure).A medication administration record for Resident #20, dated 07/30/26, showed they were scheduled to be administered Brimonidine Tartrate Ophthalmic Solution 0.2% twice daily at 9:00 a.m. and 9:00 p.m.On 07/30/26 at 8:50 a.m., Resident #20 was heard asking CMA #1 if they would receive their Brimonidine Tartrate Ophthalmic Solution with their morning medications. CMA #1 stated they received that eye drop only at night.On 07/30/26 at 11:42 a.m., CMA #1 stated they were not aware Resident #20 was scheduled to receive their Brimonidine Tartrate Ophthalmic Solution twice daily and did not administer it with Resident #20's morning medications.2. On 07/30/26 at 9:00 a.m., CMA #1 was observed to administer Resident #8's medication to include:a. ciprofloxacin (an antibiotic) 500mg,b. divalproex sodium (a mood stabilizer) 500mg, andc. apixaban (a blood thinner) 2.5mg.A medication administration record for Resident #8, dated 07/30/26, showed they were scheduled to be administered their ciprofloxacin and apixaban twice daily at 7:00 a.m. and 7:00 p.m. The record showed they were to be administered their divalproex sodium three times daily at 7:00 a.m., 12:00 p.m., and 5:00 p.m.On 07/30/26 at 8:55 a.m., CMA #1 stated they had an hour window before and after the scheduled medication time to administer a resident's medication. CMA #1 stated they were still almost an hour late to administer Resident #8's medications.On 07/30/26 at 9:35 a.m., the DON stated CMA #1 should not have been late to administer Resident #8's medications. They stated medications should be administered to all residents according to their order and time scheduled. The DON stated medications should be given within one hour before or after the scheduled time.

Based on observation, record review, and interview, the facility failed to ensure food service staff was adequately trained on acceptable food temperature for hot and cold foods and on labeling of food and expiration dates.The administrator identified 42 residents received food prepared in the kitchen and one resident received nutrition and hydration solely through a feeding tube. Findings:On 07/28/26 at 12:16 p.m., a tour of the kitchen was conducted. Two wells on the steam table were observed not in working condition. One warmer contained green beans and the temperature measured at 128 degrees F.On 07/28/26 at 12:21 p.m., seven loaves of bread were observed in the kitchen without an expiration date.On 07/29/26 at 11:17 a.m., a tour of the kitchen was conducted. The following observations were made:a. a large bowl of salad sat on the counter at room temperature,b. a bowl of cucumbers in one of the wells of the steam table warmer was at room temperature, andc. a bottle of dressing was sitting out on the counter at room temperature.On 07/28/26 at 12:17 p.m., [NAME] #2 stated they did not know what the holding temperature should be for green beans or other foods.On 07/28/26 at 12:21 p.m., [NAME] #2 stated the bread should be dated, but they did not know what items should be dated on shelves or the refrigerator. [NAME] #2 stated the kitchen had a lot of new employees and not everyone knew.On 07/29/26 at 11:16 a.m., [NAME] #1 stated they were unsure if salad and cucumbers should be on ice.On 07/30/26 at 9:33 a.m., [NAME] #1 stated they had completed a food handler's program but most of their training had been hands on. [NAME] #1 stated [NAME] #2 had gone through food server training but also had hands on training. [NAME] #1 stated they had a lot of new staff.

Based on observation, record review, and interview, the facility failed to ensure the steam table in the kitchen was maintained in safe operating working condition for 1 of 1 kitchen observation.The administrator identified 42 residents received food prepared in the kitchen and one resident received nutrition and hydration solely through a feeding tube.Findings:On 07/28/26 at 12:16 p.m., a tour of the kitchen was conducted. Two wells on the steam table were observed not in working condition. One warmer contained green beans and the temperature measured at 128 degrees F.A maintenance work order log, dated 07/2026, showed the only entry for the month was on 07/27/26. The work order log, read in part, Same steamtable or Hot Bar that hasn't worked since I started two and half (sic) years ago. An undated policy titled Food Service Hygiene, read in part, Food is maintained at acceptable temperatures during service .a. Hot foods - 140 degrees and above .b. Cold foods - 41 degrees or below.On 07/30/26 at 9:35 a.m., [NAME] #1 stated the wells on the steam table had not held heat for two and one half years. On 07/30/26 at 3:05 p.m., the maintenance supervisor stated the wells on the steam table did not heat or burn the food. The maintenance supervisor stated they had worked at the facility about a year, and the steam table warmers had not worked in that time.On 07/30/26 at 3:08 p.m., the maintenance supervisor stated that one of three wells on the steam table worked and they had been notified by word of mouth the warmers did not heat. On 07/31/26 at 12:36 p.m., the administrator stated they were told about the wells on the steam table not working and was not sure how long they had not worked.

Based on record review and interview, the facility failed to ensure residents were transported safely in the transport van for 1 (#27) of 13 sampled residents reviewed for accidents and injuries. The administrator identified 43 residents utilized facility transportation. Findings:An incident report for Resident #27, dated 11/07/25, showed the resident was transported in the facility's van. The report showed as the activity assistant drove up a hill, Resident #27's wheelchair began tipping backward which prompted the activity assistant to press the brake. Once the activity assistant pressed the brake Resident #27's wheelchair moved forward and hit the seat back. The report showed Resident #27 sustained a skin tear to the right hand, swelling in the left knee, and pain in both knees and both shoulders. An ER visit summary for Resident #27, dated 11/07/25, showed the resident had no fractures. The visit summary showed Resident #27 was diagnosed with rib, leg, and right wrist pain. Pain medication administered in the ER. No new orders. An employee counseling form for the activity assistant, dated 11/07/25, showed the activity assistant was given a verbal warning for not safely transporting Resident #27 and educated on safe transport.A quality assurance meeting sign-in sheet, dated 12/07/25, showed the QA committee met, but there were no minutes available to detail what was discussed.A quarterly assessment for Resident #27, dated 07/01/26, showed they had a BIMS score of 3, which indicated severe cognitive impairment.On 07/29/26 at 12:57 p.m., the activity assistant stated Resident #27's wheelchair was not seat belted into the transport van during transport. They stated Resident #27 slid back when going up a hill which prompted them to stop the van. Resident #27 then rolled forward in their wheelchair and hit the back of the seat, sustaining a skin tear to their right arm. The activity assistant stated they immediately notified the administrator who directed them to take Resident #27 to the emergency room. They stated they were educated on safe transport, importance of ensuring residents were buckled into the van during transport, and the facility had obtained a new transport van with better seat belts. On 07/29/26 at 1:56 p.m., the administrator stated the activity assistant and the previous employee (transport assistant) that was present during the transportation of Resident #27 were both written up and educated on safe transportation of residents. They stated during their QA meeting on 12/07/25 the committee addressed safe transportation of residents.

Based on record review and interview, the facility failed to ensure resident assessments were not back dated for three (#23, 37 and #45) of 13 sampled residents who were reviewed for resident assessments. The DON identified 45 residents resided in the facility. Findings: 1. Resident #23's Quarterly Assessment, dated 08/25/24, documented the ARD was 08/25/24. Section Z0500 documented the DON signed the assessment was completed on 09/08/24. Section Z0400 documented MDS #1 completed sections A-E, GG, and H-Q on 10/03/24. 2. Resident #37's Quarterly Assessment, dated 09/05/24, documented the ARD was 09/05/24. Section Z0500 documented the DON signed the assessment was completed on 09/19/24. Section Z0400 documented the DON completed sections A-E, GG, and H-Q on 10/22/24. 3. Resident #45's Quarterly Assessment, dated 08/29/24, documented the ARD was 08/29/24. Section Z0500 documented the DON signed the assessment was completed on 09/12/24. Section Z0400 documented the DON completed sections A-E, GG, and H-Q on 10/03/24. On 10/24/24 at 4:36 p.m., the DON and MDS #1 were asked how assessments were signed by the DON before the sections were completed. MDS #1 stated they collected the data and completed resident interviews timely, but were not able to input the data. The DON stated they changed the date on the MDS to reflect when the assessment (data and interview) had been completed.

Based on record review and interview, the facility failed to ensure care plans were updated for use of alarms for one (#3) and failed to ensure the care plan specified what behaviors were being treated with psychotropic medications for one (#30) of eight sampled residents whose care plans were reviewed for behaviors and alarms. The DON identified 45 residents resided in the facility. Findings: 1. Resident #3 had diagnoses which included senile degeneration of the brain. An Order Summary Report, dated 05/23/24, documented the resident had an order for a fall alert monitor device. Resident #3's quarterly assessment, dated 07/20/24, documented the resident's cognition was severely impaired. It documented a bed and chair alarm were used. A Care Plan, dated 10/03/24, did not document an alarm was utilized. On 10/24/24 at 3:55 p.m., the DON stated the care plan did not address the alarms. 2. Resident #30 had diagnoses which included psychosis. An Order Summary Report, dated 03/20/24, documented the resident received Seroquel (antipsychotic medication). Resident #30's quarterly assessment, dated 06/30/24, documented the resident's cognition was severely impaired. It documented the resident received an antipsychotic. A Care Plan, dated 05/09/24, documented the resident received Seroquel, but it did not specify what behaviors the Seroquel was being used for. On 10/24/24 at 4:45 p.m., the DON stated the care plan did not have a list of specific behaviors. They stated it documented a list of side effects.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for two (#15 and #30) of 13 sampled residents whose resident assessments were reviewed for accuracy. The DON identified 45 residents who resided in the facility. Findings: The Long-Term Care Facility Resident Assessment Instrument, dated October 2023, documented alternative medicine products were considered as a dietary supplement. It documented medications such as melatonin should not be counted as a medication. 1. Resident #15 had diagnoses which included insomnia. An Order Summary Report, dated 04/20/24, documented Resident #15 received melatonin at bedtime for insomnia. Resident #15's quarterly assessment, dated 08/10/24, documented the resident received a hypnotic. 2. Resident #30 had diagnoses which included insomnia. An Order Summary Report, dated 03/20/24, documented Resident #30 received melatonin at bedtime for insomnia. Resident #30's quarterly assessment, dated 06/30/24, documented the resident received a hypnotic. On 10/25/24 at 4:40 p.m., MDS #1 was asked how medications were coded correctly on the MDS. They stated they look for new orders, order summaries, and MARs during the date range needed for the MDS. They were asked to list hypnotic medications. They stated melatonin. MDS #1 stated they should look at the classification of the medication. 41318

Based on record review and interview, the facility failed to ensure resident assessments were completed and submitted to CMS for nine (#13, 17, 21, 23, 25, 37, 40, 42, and #45) of 13 sampled residents who were reviewed for resident assessments. The DON identified 45 residents resided in the facility. Findings: 1. Resident #21's Annual Assessment, dated 09/15/24, documented the ARD was 09/15/24. Sections B, C, D, F, GG, J, L, M, N, P, and Q did not contain any data. Section Z0400 did not contain any signatures documenting the assessment had been completed. On 10/24/24 at 5:34 p.m., MDS #1 stated Resident #21's assessment was not completed. 2. Resident #13's Quarterly Assessment, dated 08/29/24, documented the ARD was 08/29/24. Section Z0500 documented the DON signed the assessment 09/12/24. A MDS Final Validation Report, dated 10/22/24, documented Resident #13's assessment was submitted late (more than 14 days after section Z0500.) On 10/24/24 at 5:30 p.m., MDS #1 stated Resident #13's assessment was not submitted timely. 3. Resident #17's Quarterly Assessment, dated 09/07/24, documented the ARD was 09/07/24. Section Z0500 documented the DON signed the assessment 09/21/24. A MDS Final Validation Report, dated 10/22/24, documented Resident #17's assessment was submitted late (more than 14 days after section Z0500.) On 10/24/24 at 5:34 p.m., MDS #1 stated Resident #17's assessment was not submitted timely. 4. Resident #23's Quarterly Assessment, dated 08/25/24, documented the ARD was 08/25/24. Section Z0500 documented the DON signed the assessment 09/08/24. A MDS Final Validation Report, dated 10/08/24, documented Resident #23's assessment was submitted late (more than 14 days after section Z0500.) On 10/24/24 at 5:24 p.m., MDS #1 stated Resident #23's assessment wasn't submitted timely. 5. Resident #25's Quarterly Assessment, dated 09/16/24, documented the ARD was 09/16/24. Sections B, C, D, GG, J, L, M, N, P, and Q did not contain any data. Section Z0400 did not contain any signatures documenting the assessment had been completed. On 10/24/24 at 5:36 p.m., MDS #1 stated Resident #25's assessment was not completed. 6. Resident #37's Quarterly Assessment, dated 09/05/24, documented the ARD was 09/05/24. Section Z0500 documented the DON signed the assessment 09/19/24. A MDS Final Validation Report, dated 10/22/24, documented Resident #37's assessment was submitted late (more than 14 days after section Z0500.) On 10/24/24 at 5:40 p.m., MDS #1 stated Resident #37's assessment was not submitted timely. 7. Resident #40's Quarterly Assessment, dated 09/22/24, documented the ARD was 09/22/24. Sections B, C, D, GG, L, M, N, P, and Q did not contain any data. Section Z0400 did not contain any signatures documenting the assessment had been completed. On 10/24/24 at 5:38 p.m., MDS #1 stated Resident #40's assessment was not completed. 8. Resident #42's Quarterly Assessment, dated 09/16/24, documented the ARD was 09/16/24. Sections B, C, D, GG, L, M, N, P, and Q did not contain any data. Section Z0400 did not contain any signatures documenting the assessment had been completed. On 10/24/24 at 5:38 p.m., MDS #1 stated Resident #42's assessment was not completed. 9. Resident #45's Quarterly Assessment, dated 08/29/24, documented the ARD was 08/29/24. Section Z0500 documented the DON signed the assessment on 09/12/24. A MDS Final Validation Report, dated 10/08/24, documented Resident #45's assessment was submitted late (more than 14 days after section Z0500.) On 10/24/24 at 4:10 p.m., MDS #1 stated Resident #45's assessment was not submitted timely.

Based on record review and interview, the facility failed to follow their protocol and the resident's care plan by not completing weekly wound assessments for one (#15) of two sampled residents reviewed for pressure ulcer care. The Resident Matrix, dated 10/22/24, documented two residents had pressure ulcers. Findings: An undated Wound Care Protocol, documented wounds would be drawn and documented on the pressure ulcer chart and documented in the skin assessment book every Saturday. Resident #15 had diagnoses which included pressure ulcer. Resident #15's Care Plan, dated 05/29/24, documented to follow the facility's protocol, assess, record, and monitor wound healing weekly. A Weekly Observation Tool, dated 09/11/24, documented the resident had a stage three pressure ulcer to their right hip and a stage two pressure ulcer to their left hip. This was the last documented weekly wound assessment. On 10/24/24 at 9:55 a.m., Resident #15's skin was observed with LPN #1. LPN #1 stated they completed skin assessments weekly. They stated they are behind on them. They stated they were documented, but not the in the EHR. LPN #1 stated they had them documented in a notebook, but did not have the note book with them.

Based on record review and interview, the facility failed to ensure a medication was available for one (#44) of five sampled residents reviewed for medications. The DON stated 45 residents resided in the facility. Findings: Resident #44 had diagnoses which included Huntington's disease. An Order Summary Report, dated 03/25/24 documented to give Austredo (VMAT2 inhibitor medication) 24 mg daily, and another order, dated 04/08/24, documented to give Austredo 6 mg daily. Both medications were to treat Huntington's disease. Resident #44's quarterly assessment, dated 08/21/24, documented the resident had moderate cognitive impairment. A CMA Medications report, dated September 2024, documented the resident did not receive either one of the Austredo medications for 18 out of 30 days. A CMA Medications report, dated October 2024, documented the resident did not receive either one of the Austredo medications for 22 out of 23 days. On 10/24/24 at 12:46 p.m., CMA #1 was asked what they knew about Resident #44's Austredo medication. They stated the pharmacy could not fill it because insurance would not cover it. They stated the medication had not been available for a couple of months.

Based on record review and interview, the facility failed to ensure the physician was notified when a medication was unavailable for one (#44) of five sampled residents reviewed for medications. The DON stated 45 residents resided in the facility. Findings: Resident #44 had diagnoses which included Huntington's disease. An Order Summary Report, dated 03/25/24, documented to give Austredo (VMAT2 inhibitor medication) 24 mg daily, and another order, dated 04/08/24, documented to give Austredo 6 mg daily. Both medications were to treat Huntington's disease. Resident #44's quarterly assessment, dated 08/21/24, documented the resident had moderate cognitive impairment. A CMA Medications report, dated September 2024, documented the resident did not receive either one of the Austredo medications for 18 out of 30 days. A CMA Medications report, dated October 2024, documented the resident did not receive either one of the Austredo medications for 22 out of 23 days. On 10/24/24 at 12:46 p.m., CMA #1 was asked what they knew about Resident #44's Austredo medication. They stated the pharmacy could not fill it because insurance would not cover it. On 10/24/24 at 1:33 p.m., the DON stated the neurologist was last notified the medication could not be filled on 09/23/24. On 10/24/24 at 1:42 p.m., the DON stated the PCP had not been notified.

Based on observation, record review, and interview, the facility failed to provide privacy for two (#11 and #13) of five sampled residents reviewed for privacy. The Resident Census and Conditions of Residents report, dated 08/01/23, documented 31 residents resided in the facility. Seven residents had seizure disorders. Findings: A Notice of Privacy Practices policy, dated 04/14/03, read in parts, .[Name of facility] may use your health information for purposes of providing you treatment .[Name of facility] has established a policy to guard against unnecessary disclosure of your health information . 1. Resident #11 had diagnoses which included epilepsy, and conversion disorder with seizures or convulsions. On 08/02/23 at 2:46 p.m., a Seizure Disorder sign was observed hanging on the wall above Resident #11's bed and was visible from the hallway door. 2. Resident #13 had diagnoses which included unspecified convulsions, persistent vegetative state, and aphasia. On 08/02/23 at 2:38 p.m., a Seizure Disorder sign was observed hanging on the wall above Resident #13's bed and was visible from the hallway door. On 08/02/23 at 3:06 p.m., the DON was asked to observe the sign Seizure Disorder above the resident's head of the bed and asked why that sign was posted. They stated to notify the staff. They were asked if they could see the sign from the door. They stated, Yes. They were asked if that is a dignity or privacy issue. They stated, Yes.

Based on observation, record review, and interview, the facility failed to: a. ensure staff were aware of the system used to identify CPR/DNR status, and b. ensure clinical health records correctly identified CPR/DNR status for three (#3, 17 and #19) of twelve sampled residents reviewed for advanced directives. The Resident Census and Condition of Residents report, dated [DATE], documented 31 residents resided in the facility. Five residents had advanced directives. Findings: A Life-Sustaining Treatment Decisions policy, dated [DATE], read in parts, .Do Not Resuscitate Orders . A Resident's request to have a DNR Order entered on the chart is to be noted in the medical record .The DNR order should be communicated to all relevant healthcare providers and documented in the Resident's Care Plan .If the Resident or family consent, a DNR wristband could be used to assist identifying the Resident who has a current DNR order. If a DNR wristband is not allowed, a sticker on the resident's chart will be used to identify the DNR resident . 1. Resident #3 had diagnoses which included type two diabetes mellitus, acute kidney failure, and encephalopathy. Resident #3's chart was observed to have a blue dot on the spine of the chart, there was no signed DNR in the chart. An OKLAHOMA DO-NOT-RESUSCITATE (DNR), dated [DATE], documented Resident #3 was a DNR. A Hospice IDG Comprehensive Assessment and Plan of Care Update Report, dated [DATE] to [DATE], documented Resident #3 was a full code. On [DATE] at 10:25 a.m., the DON was asked what the colored dots meant on the residents' charts. They stated, they did not know, no one had told them that. On [DATE] at 10:30 a.m., CNA #1 was asked what the dots on the resident charts meant. They stated, I do not know. RN #1 was asked what the dots meant. They stated they were unsure. CNA #1 was asked how they identified if a resident was a DNR or full code status. CNA #1 stated they use hearts and wings on the residents' name labels on their doors to identify CPR/DNR, but they were not up anymore. CNA #1 stated there was a DNR list, but it had not been updated. RN #1 was asked what if a signed DNR was not in the chart. They stated it should be. On [DATE] at 10:39 a.m., RN#1 was shown Resident #3's chart and asked if there was a signed DNR in the chart. They reviewed the chart and stated, No. They were asked how they know how to respond. RN #1 did not answer. RN #1 was asked what the electronic clinical health record documented. They stated a DNR. On [DATE] the DON provided a DNR/full code list which documented Resident #3 was a DNR. They were asked where the copy is normally kept. They stated in the medication room, but someone had taken the information down. They were asked if the DNR sheet was accurate related to Resident #3. The DON stated No. 2. Resident #19 had diagnoses which included heart disease, muscle weakness, and depressive disorder. Resident #19's electronic health record did not document a DNR or full code status. Resident #19's hard chart was observed to have a blue dot on the spine of the chart. On [DATE] at 11:02 a.m., the DON was shown Resident #19's EHR and asked if it documented a code status or physician order. They stated, No. 3. Resident #17 had diagnoses which included high blood pressure, chronic kidney disease, and abnormal coagulation profile. The electronic health record did not document a DNR or full code status. Resident #17's hard chart was observed to have a blue dot on the spine of the chart. On [DATE] at 11:02 a.m., the DON was asked if there should be a code status identification in the resident's electronic health record for full codes. They stated, Yes. The DON was asked if there should be a physician order for a full code. They stated, Yes. The DON was asked if the staff do not know what the dots on the charts meant, how did they know what to do. They stated to look in the EHR. On [DATE] at 11:50 a.m., the Administrator was asked how residents were identified for DNR or resuscitation. They stated there was a list and a red dot on the chart.

Based on record review and interview, the facility failed to ensure MDS assessments were accurate for two (#7 and #23) of 12 residents sampled for accuracy of MDS assessments. The Resident Census and Conditions of Residents report, dated 08/01/23, documented 31 residents resided in the facility. The DON identified nine residents used oxygen. Findings: 1. Resident #7 had diagnoses of atherosclerosis and heart failure. A Physician Order, dated 11/10/22, read in part, .02 at 0.5 L via n.c at HS . An Annual Assessment, dated 07/05/23, did not document oxygen therapy was used during the 14 day look back. On 08/02/23 at 4:01 p.m., the MDS Coordinator was asked about Resident # 7's respiratory orders. They stated Resident # 7 had orders for supplemental oxygen at night prescribed since 11/10/22. They were asked what the date was of most recent MDS. They stated it was on 07/05/23. They were asked if section O documented Oxygen therapy, They stated, No, it does not document oxygen by nursing on the TAR,so I did not document it in the MDS. On 08/02/23 at 4:17 p.m., the ADON was asked if Resident #7 was utilizing oxygen during 14 day look back for MDS dated [DATE]. They stated yes, the resident always wear their oxygen at night. 2. Resident #23 had diagnoses which included asthma and chronic obstructive pulmonary disease. A Physician Order, dated 01/12/22, read in part, .Oxygen 1L to 2L per NC PRN . An Annual Assessment, dated 07/02/23, read in parts, .Special Treatment, Procedures, and Programs .Respiratory Treatments .Oxygen therapy . did not document oxygen therapy was used during the 14 day look back. On 08/02/23 at 3:48 p.m., Resident #23 was observed to be wearing their oxygen. On 08/03/23 at 9:30 a.m., the MDS Coordinator was asked to discuss Resident #23's respiratory orders. They stated Resident #23 wears oxygen PRN. They were asked what MDS section O, dated 07/02/23, documented. They stated it documented Resident #23 did not use oxygen therapy. The MDS coordinator was asked if the MDS was correct. They stated, No, it needs to be corrected. The nurses did not document the PRN oxygen on the TAR so I checked no for the 14 day look back. I should know the resident wears oxygen daily. On 08/03/23 at 9:39 a.m., the Administrator was asked to review the MDS, dated [DATE], for Resident #23 section O and asked if the assessment was accurate. The Administrator stated, No, it needs to be corrected. On 08/03/23 at 9:40 a.m., the ADON stated that Resident #23 always wears oxygen and they had contacted the the physician to change from PRN to continuous oxygen. The ADON was asked if the resident was wearing/using oxygen during the 14 day look back period for the MDS dated [DATE]. The ADON stated, Yes, [the resident] likes to wear it continuously. On 08/03/23 at 10:07 a.m., the Administrator stated they did not have a policy for documenting accurate MDS assessments.

Based on observation, record review, and interview, the facility failed to administer a pneumococcal vaccination for one (#32) of five sampled residents reviewed for immunizations. The Resident Census and Conditions of Residents documented 31 residents resided in the facility and 21 residents had receive the pneumococcal vaccination. Findings: An undated, Influenza/Pneumonia Vaccines policy, read in parts, .It is the intent of [name of facility] to follow the guidelines of the CDC and ACIP (Advisory Committee on Immunization Practices) on the administration of the influenza and pneumococcal vaccines to their residents with written consent from the residents' POA, representative or the resident, upon admittance to the facility and annually as indicated . Findings: Resident #32 had diagnoses which included, dementia, thrombocytopenia, and high blood pressure. A [Name of Facility] vaccination consent form, dated 05/26/23, documented the Resident's power of attorney had signed for Resident #32 to be administered the pneumococcal vaccination. An Admission Assessment, dated 06/05/23, documented Resident #32 had severe cognitive impairment. Resident #32's EHR did not contain documentation the resident had a history of or had been administered the pneumococcal vaccination. On 08/04/23 8:58 a.m., the ADON was asked why hadn't the pneumonia shot been administered. They stated, We don't have the vaccine in yet. The ADON was asked why is it not administered as a one time dose. They stated, We have had a hard time getting it from [facility pharmacy] On 08/04/23 at 11:38 a.m., the Administrator was asked why was the pneumonia vaccination only offered from September through March. They stated, it is offered on admission. They were asked if Resident #32's family member consented to it, why had it not been given yet. They stated, they can order the shot through the pharmacy individually and was unsure why it had not been ordered. On 08/04/23 at 11:41 a.m., the Administrator was asked if the pneumococcal vaccination been administered by now. They stated, Yes.

Based on observation, record review, and interview, the facility failed to maintain infection control during medication observation for two (#17, and #28) of four sampled residents reviewed during medication observation. The Resident Census and Conditions of Residents report, dated 08/01/23, documented 31 residents resided in the facility. 1. Resident #17 had diagnoses which included high blood pressure, chronic kidney disease, and abnormal coagulation profile. 2. Resident #28 had diagnoses which included high blood pressure, dementia, and anxiety. On 08/03/23 at 7:04 a.m., CMA #1 was observed to remove the b/p cuff from the top of the cart and obtained a blood pressure on Resident #17. CMA #1 was observed to return to the medication cart and placed the b/p cuff on top of the cart. CMA #1 was not observed to sanitize the b/p cuff. On 08/03/23 at 7:19 a.m., CMA #1 was observed to remove the b/p cuff from the top of the cart and obtained a blood pressure on Resident #28. CMA #1 was observed to return to the medication cart and placed the b/p cuff on top of the cart. CMA #1 was not observed to sanitize the b/p cuff. On 08/03/23 at 10:02 a.m., CMA #1 was asked if they had sanitized the blood pressure cuff between residents during medication pass. They stated, I never sanitized the blood pressure cuff. CMA #1 was asked when should they sanitize the blood pressure cuff. They stated at one time they were, but have not been lately. On 08/03/23 at 1:20 p.m., the DON was asked when the b/p cuff should be sanitized. They stated between every resident.

Based on record review and staff interview, it was determined the facility failed to ensure a resident was provided a notice of involuntary discharge that met the federal requirements for one (#1) of three sampled resident reviewed for discharge. The DON identified two residents who had been given involuntary discharge notices in the past nine months. Findings: The facility's policy Involuntary Discharge, dated 03/23/22, read in part, .The notice must include .Reason for the transfer/discharge .Proposed effective date .Location to which the resident will be transferred or discharged .Documentation needs to be provided from a physician if the transfer/discharge is related to either the resident's health, or the health/safety of other residents . Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's quarterly assessment, dated 05/11/22, documented the resident's cognition was intact, the resident required assistance from staff for toilet use, and there was no active discharge planning occurring for the resident to return to the community. A combined initial and final state reported incident, dated 07/04/22, read in part, .Incident Location .Resident Room .at approximately [9:00 p.m.] .Description of Incident .CNA reported to Charge nurse on this date and time .Observed resident at laptop with monitor open to site with little girls in bikinis varying in age from toddler to [NAME] [sic] school age .It was reported to the Adm. [sic] 7/5/22 . relevant resident history .Resident had prior incident in June 2021, where [the resident] was observed watching suspected child pornography on [their] pc. At that time, it was reported to approp, [sic] agencies. Law enforcement confiscated all [the resident's] electronic devices at that time .no charges were filed at that time . final reports .At this time, after discussion . due to [the resident's] behavior being considered trafficking and he is a danger to other [NAME] [sic] resident and to [themselves], The facility is within its right to immediate emergency discharge. At [11:20 a.m.] [local sheriff and deputies arrived] .[Resident] was notified of the allegations, and formally dc'd [sic] to [sheriff] . Resident #1's Discharge instructions, dated 07/07/22, did not document where the resident was discharged to. Resident #1 was not provided their rights to appeal the discharge, and had no notice of discharge. Resident #1's progress note, dated 07/07/22 at 2:05 p.m., read in part, .Resident escorted out door .by [local sheriff's department] .walking independently with [four wheel walker] .Resident has discharge paperwork and medications. Few sets of clothes, ostomy supplies, and daily care supplies . On 09/16/22 at 8:33 a.m., Resident #1 was interviewed via phone. Resident #1 stated they had resided in the facility for approximately seven years, then was discharged to a local hotel. Resident #1 was asked why they were discharged . Resident #1 stated it was an emergency deal. Resident #1 was asked if they wanted to be discharged . Resident #1 stated, Not necessarily. Resident #1 stated they felt the administrator had problems with the resident while the resident resided in the facility. Resident #1 stated, They were trying to get me to leave the entire time. Resident #1 was asked if they received options to appeal the discharge. Resident #1 stated, No. Resident #1 was asked how they got from the facility to the hotel. Resident #1 stated the sheriff transported them. DON #2, of the facility the resident was currently residing in, stated the resident admitted to them on 08/18/22. Resident #1 resided in the hotel for 41 days from 07/07/22 to 08/18/22 On 09/16/222 at 9:25 a.m., the DON and ADON was asked to describe the facility's policy to involuntary discharge a resident. The DON stated they contact the ombudsman and follow the steps and advice that was provided. They were asked if a resident had been involuntary discharged from the facility. The ADON stated Resident #1 had been. They were asked to describe the involuntary discharge of Resident #1. The ADON stated the ombudsman stated the resident had to be discharged because the resident was looking at child porn and it was illegal. The DON stated the sheriff's department took the resident to a local hotel. On 09/16/22 at 9:45 a.m., the administrator stated the basis for discharging the resident involuntarily was due to the resident committing a criminal act and it could extend to other vulnerable residents and visitors. The DON, ADON, and administrator were asked if there was documentation from the physician related to why Resident #1 had been discharged . The ADON stated the physician didn't give any orders and stated they weren't getting involved. They were asked if Resident #1 was given the right to appeal the discharge. The administrator stated they provided the information to call into the complaint hotline with the State Health Department. On 09/16/22 at 10:11 a.m., APS worker was interviewed via phone. The APS worker stated they became involved with the resident two days after the resident was discharged from the facility. The APS worker stated the resident had two days of medication, and didn't ambulate very well. The APS worker stated the resident didn't have any money to buy food, had no money or transportation to get more medication, or food, and the cell phone the resident had wasn't working. The APS worker was asked if charges had been brought against the resident. The APS worker stated, No. The APS worker stated a supervisor had made a call to sheriff's office and were told, might not do anything with it. On 09/16/22 at 10:27 a.m., the local sheriff was called and they stated they transported the resident to the local hotel. The sheriff was asked if there was any charges against the resident. The sheriff stated OSBI was investigating, but the sheriff doubted the resident would be charged. On 09/16/22 at 11:20 a.m., the administrator was asked what interventions had been in place related to the incidents. The administrator stated the IT person put a blocker on the wifi network, back in 2021, but the resident found a way around it. The administrator was asked if anything had been provided to Resident #1 after they discharged . The administrator stated they took a pair of shoes, a razor, and two days of medications to the resident on 07/09/22, two days after the resident was discharged . The administrator was asked if any thing else had been provided to the resident after discharge. They stated, That's all I took. On 09/16/22 at 11:48 a.m., the administrator stated Resident #1 had stopped taking their medications which managed the residents anger. The administrator was asked how Resident #1 was dangerous when the resident stopped taking them medications. The administrator stated, You don't know what [the resident] would do to vulnerable resident and visitors. On 09/16/22 at 12:20 p.m., the administrator was asked when was Resident #1 given the notice of their discharge. The administrator stated We didn't because it was emergent. The DON, ADON, and administrator were asked what interventions had been implemented, prior to discharging Resident #1. No response was given.