Every finding on record at Shenandoah Valley Westminster Canterbury

Based on staff interview and facility document review, it was determined that the facility staff failed to ensure eight consecutive hours of RN (registered nurse) coverage for one of 46 days reviewed for nurse staffing.The findings include:The facility staff failed to ensure eight consecutive hours of RN coverage on 9/13/2025.Review of the PBJ (payroll-based journal) Staffing Data Report for Quarter three and Quarter four 2025 revealed concerns related to the facility's requirement to have a Registered Nurse on duty for at least 8 consecutive hours a day. The report documented no RN hours on multiple dates including 9/13/2025. On 4/29/2026 at approximately 8:17 AM during entrance conference, the Director of Nursing (DON) stated that the facility did not have any staffing waivers in place in the facility.On 4/29/2026 at approximately 4:30 PM, a request was made to the DON for evidence of RN coverage for all triggered dates on the PBJ reports including 9/13/2025.On 4/30/2026 at approximately 8:30 AM, the DON provided evidence of an RN on duty for 8-12 hours each day triggered on the PBJ reports except 9/13/2025.On 4/30/2026 at 10:25 AM, an interview was conducted with the DON who stated that they had managers on duty 9/13/2025 but did not have an RN that day. On 4/30/2026 at 1:10 PM, an interview was conducted with other staff member (OSM) #1, Staffing Coordinator. OSM #1 stated that they had full time and part time RN staff which they filled in the schedule with when the full-time staff were off. She stated that she always tried to make sure there was an RN scheduled on the healthcare unit each day. On 5/1/2026 at approximately 8:00 AM, the DON stated that the facility did not have a policy regarding RN coverage.On 4/30/2026 at 3:32 PM, the Administrator and DON were made aware of the concern. No further information was presented prior to exit.

Based on staff interview, and facility document review, it was determined that the facility staff failed to maintain COVID-19 staff vaccination status. The findings include: During the facility task of Infection Prevention and review of facility documents, on 4/29/26, there was no evidence of maintenance of new hired staff COVID-19 vaccination status.On 4/30/26 at 11:00 AM an interview was conducted with the Infection Preventionist. Asked when she started in this role, she stated, two years ago in June of 2024. Asked to provide the evidence of maintenance of new hired staff COVID-19 vaccination status, the Infection Preventionist stated, Human Resources has been responsible for the screening of new hires, and they have not been screening them for the COVID-19 vaccination status. It may be asked but it is not followed up on and documentation is not maintained. As of today, Infection Prevention will be overseeing the new hired staff COVID-19 vaccination status. In my previous job, that was my responsibility. This is regulation 887 that we do not have the evidence. On 4/30/26 at 1:05 PM an interview was conducted with the director of Human Resources. Asked the process for hiring new staff, the director of Human Resources stated, Human Resources does not collect and maintain a staff list of COVID vaccination status. The new hires sign a consent to be tested for COVID and that they understand parameters of returning to work if they become ill with COVID.On 4/30/26 at 3:30 PM, the Administrator and the Director of Nursing were made aware of the findings. A review of the facility's Managing COVID-19 After the End of the Public Health Emergency policy revealed, The facility will provide education on the benefits of the COVID vaccination to staff and will encourage staff to obtain vaccinations.No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain one of one kitchen and one of three nourishment areas in a sanitary manner. The findings include:On 4/29/26 at 8:35a.m., an observation was conducted in the kitchen with the following findings: in dry storage, one approximately 48oz bag of Sysco Fancy Pecan Pieces, inside a clear plastic bag without a label and date; one opened 5lb box of Pearl [NAME] Yellow Corn Meal, in the original box, without a label and date; one approximately 5lb box of Quaker Creamy Wheat labeled with the month and date but no year; one approximately 5lb box of Gold Medal Chocolate Fudge Cream Icing Mix opened and uncovered; and a food scooper left inside of a brown rice bin. The dietary manager stated he would speak with the stock person about labeling and dating. When asked about the food scooper the dietary manager stated, it should not be inside there. On 4/29/26 at approximately 2:00 p.m. an observation was conducted of the nourishment refrigerator on the Redbud Unit. There were multiple items inside the refrigerator undistinguishable between residents and staff because of not being labeled or dated. Items observed in the freezer: two [NAME] Daz's coffee ice cream 14fl oz, unopened without a label or date; one Trader Joe's chicken shawarma bowl 11.3 oz, unopened without a label or date; one [NAME] Giant rice veggie blend Asian stir fry 10oz, unopened without a label or date; one frozen veggies with noodles in a clear manufacturer's package, unopened without a label or a date. In the refrigerator: two restaurant styled plastic containers, closed without a label or date; one bowl of fruit in a medium-sized yellow bowl covered in plastic wrap without a label or date; five plastic grocery bags with items inside and four slices of bread inside a large zip-lock bag without a label or date. CNA (certified nurses' assistant) #1 accompanied the surveyor to the nourishment area. When asked if the food in the refrigerator belonged to staff, she stated yes, because the staff shared the refrigerator with the residents. On 4/29/26 at 3:20 p.m., an interview was conducted with the dining service manager. He stated that staff on Redbud Unit have a lounge with a refrigerator, but they also store their food in the resident's nourishment refrigerator. He stated staff do not label their food items placed in the nourishment refrigerator. When asked where is resident's food stored that is brought from the outside, he stated in the nourishment refrigerator. When asked who takes responsibility for the nourishment refrigerator, he states that dietary cannot take responsibility for food items however if he is personally given an item to store in the nourishment refrigerator, he would put the resident's name and date on the item and set a reminder to remove it from the nourishment refrigerator in three days if not eaten. A review of the facility's Food Storage policy, revised 5/3/23, revealed, Opened foods.cover, label and date; Dry bulk foods.store scoops in a separate holder. A review of Food from Outside policy, revised 5/31/18, revealed, the dining department is assigned responsibility for monitoring refrigeration units in food service areas and discarding outdated food every other day.On 4/30/26 at 3:30 p.m., the Administrator and Director of Nursing were made aware of the above findings.No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined that the failed to designate a qualified individual(s) onsite, who was responsible for implementing programs and activities to prevent and control infections. The findings include: The facility staff failed to ensure the acting infection preventionist had completed specialized training in infection prevention and control. On 3/20/23 during the entrance conference, ASM (administrative staff member) #1, the administrator, was asked to provide evidence of the infection preventionist's credentials. ASM #1 stated the facility did not currently employ an infection preventionist and stated the former infection preventionist recently left the position without working out a full notice, and the facility had not yet employed a new person to fill the role. She stated no other staff members had credentials that meet the regulatory requirements of an infection preventionist. She stated she and ASM #2, the director of health services, were currently filling the role. On 3/22/23 at 4:30 p.m., ASM #1, ASM #2, and ASM #3, the chief operating officer, were informed of these concerns. A review of the job description for Infection Preventionist Educator revealed, in part: The infection control preventionist (IP) is responsible for identifying, investigating, monitoring, and reporting healthcare associated infections to various committees. The IP collaborates interdepartmentally to create infection prevention strategies, feedback, and sustain infection prevention strategies .Certification in infection control preferred .Knowledge of infection control practices in the healthcare setting preferred. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to implement the comprehensive care plan for six of 17 residents in the survey sample, Residents #4, #36, #22, #6, #17 and #34. The findings include: 1. For Resident #4 (R4), the facility staff failed to implement the comprehensive care plan to provide non-pharmacological interventions prior to administration of as needed Tylenol with Codeine #3 (1). On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 1/4/2023, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section J documented R4 having pain frequently and receiving as needed pain medications. Section J further documented R4 not receiving non-medication interventions for pain. On 3/21/2023 at 11:22 a.m., an interview was conducted with R4. R4 stated that they had pain at times and the nurses gave them medication to help. R4 stated that sometimes the staff tried to give them a pillow but most of the time they just gave the medication. The comprehensive care plan for R4 dated 8/9/2022 documented in part, (Name of R4) has chronic pain r/t (related to) old right ankle fx (fracture) and arthritis. Date Initiated: 08/09/2022. Revision on: 01/18/2023 . Under Interventions it documented in part, .Medications as ordered. Non-medication interventions to be offered. Date Initiated: 08/25/2022. Revision on: 08/25/2022 . The physician order's for R4 documented in part, - Tylenol with Codeine #3 Tablet 300-30 MG (milligram) (Acetaminophen-Codeine) Give 1 tablet by mouth every 6 hours as needed for For pain scale of 6-10. Order Date: 12/22/2022. Start Date: 12/22/2022. The eMAR (electronic medication administration record) dated 1/1/2023-1/31/2023 documented the Tylenol with Codeine #3 administered to R4 a total of 26 times for pain levels ranging from 6-10. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the as needed Tylenol with Codeine #3. The eMAR dated 2/1/2023-2/28/2023 documented the Tylenol with Codeine #3 administered to R4 a total of 14 times for pain levels ranging from 6-8. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the as needed Tylenol with Codeine #3. The eMAR dated 3/1/2023-3/31/2023 documented the Tylenol with Codeine #3 administered to R4 a total of 10 times for pain levels ranging from 7-8. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the as needed Tylenol with Codeine #3. The progress notes for R4 from 1/1/2023-3/22/2023 failed to evidence documentation of non-pharmacological interventions attempted or offered prior to the administration of the as needed pain medication documented on the eMARs. On 3/22/2023 at 10:56 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the purpose of the care plan was for everyone to know what the residents problems were and for the staff to know what they were to do for the resident. LPN #2 stated that if the non-medical interventions were not documented on the eMAR that it could not be proven that they were offered or that they were implementing the care plan for the resident. On 3/22/2023 at 11:35 a.m., ASM (administrative staff member) #2, the director of health services stated that they did not have evidence of non-pharmacological interventions offered to R4 prior to the administration of the Tylenol with Codeine #3 from 1/1/2023-3/22/2023. The facility policy Care Plan, Comprehensive dated 10/17/2022 documented in part, .All services provided or arranged by the facility to meet the needs identified in the written plan of care meet professional standards of quality and are provided by qualified persons in accordance with each resident's written plan of care. On 3/22/2023 at approximately 2:33 p.m., ASM #1, the administrator, ASM #2, the director of health services, ASM #3, the chief operating officer and LPN #2, the healthcare unit coordinator were made aware of the concern. No further information was provided prior to exit. Reference: (1) Tylenol #3 The combination of acetaminophen and codeine is used to relieve mild to moderate pain. Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. Codeine belongs to a class of medications called opiate (narcotic) analgesics and to a class of medications called antitussives. When codeine is used to treat pain, it works by changing the way the brain and nervous system respond to pain. When codeine is used to reduce coughing, it works by decreasing the activity in the part of the brain that causes coughing. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601005.html 2. For Resident #36 (R36), the facility staff failed to implement the comprehensive care plan for monitoring for adverse side effects related to the physician prescribed medication, Celexa (1). The comprehensive care plan for R36 documented in part, (Name of R36) uses antidepressant medication Celexa r/t (related to) Depression. Date Initiated: 02/28/2022. Revision on: 02/28/2022. Under Interventions it documented in part, .Monitor/document/report PRN (as needed) adverse reactions to Antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL (activities of daily living) ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs (problems), movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt (weight) loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date Initiated: 2/28/2022 . The care plan further documented, I have a mood problem r/t Major Depressive Disorder. Date Initiated: 02/10/2023. Revision on: 02/10/2023. Under Interventions it documented in part, Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/10/2023 . The physician orders for R36 documented in part, - Celexa 20mg (milligram) 1 tablet by mouth in the morning related to Major Depressive Disorder, recurrent unspecified. Order Date: 8/27/2021. The eMARs (electronic medication administration records) dated 1/1/2023-1/31/2023, 2/1/2023-2/28/2023 and 3/1/2023-3/31/2023 for R36 documented the resident having received the Celexa as ordered daily through 3/22/2023. On 3/22/2023 at 10:25 a.m., ASM (administrative staff member) #2, the director of health services stated that they did not have any evidence that the facility staff had been monitoring for side effects for the Celexa for R36. ASM #2 stated that monitoring should be done and they now were aware of this and it would be corrected. On 3/22/2023 at 10:56 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the purpose of the care plan was for everyone to know what the residents problems were and for the staff to know what they were to do for the resident. LPN #2 stated that psychotropic medications should be monitored by staff to ensure residents did not have any side effects from them. LPN #2 stated that they should do this to make sure that the treatment they were providing was not causing any other issues to the resident. LPN #2 stated that they had not had a system in place for monitoring antidepressants, antipsychotics and antianxiety medications. LPN #2 stated that they could not say that they were implementing the care plan for the resident without evidence to support it. On 3/22/2023 at 2:33 p.m., ASM #1, the administrator, ASM #2, the director of health services, ASM #3, the chief operating officer and LPN #2, the health care unit coordinator were made aware of the above concern. No further information was provided prior to exit. Reference: (1) Celexa Citalopram is used to treat depression. Citalopram is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a699001.html 3. For Resident #22 (R22), the facility staff failed to implement the comprehensive care plan for monitoring for adverse side effects related to the physician prescribed medications, Seroquel (1) and Cymbalta (2). The comprehensive care plan for R22 documented in part, (Name of R22) uses antidepressant medication Cymbalta. Resident with dx. (diagnoses) of anxiety and adjustment disorder with depressed mood. Date Initiated: 11/04/2019. Revision on: 02/01/2023. Under Interventions it documented in part, .Monitor/document/report PRN (as needed) adverse reactions to Antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL (activities of daily living) ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs (problems), movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt (weight) loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date Initiated: 11/04/2019 . The care plan also documented, [Name of R22] uses antipsychotic medication Seroquel r/t hallucinations. Date Initiated: 02/02/2023. Revision on: 02/02/2023. Under Interventions it documented in part, .Monitor/document/report PRN any adverse reactions of Psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 02/02/2023 . The care plan further documented, I have a mood problem r/t Major Depressive Disorder, Anxiety Disorder and Adjustment Disorder. Date Initiated: 01/19/2023. Revision on: 01/19/2023. Under Interventions it documented in part, Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 01/19/2023 Date Initiated: 01/19/2023 . The physician orders for R22 documented in part, - Seroquel Tablet 25 MG (milligram) (Quetiapine Fumarate) Give 0.5 tablet by mouth in the morning for hallucinations. Order Date: 12/19/2022. Start Date: 12/20/2022. - Seroquel Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime related to Hallucinations, unspecified. Order Date: 11/17/2022. Start Date: 11/17/2022. - Cymbalta Capsule Delayed Release Particles 30 MG (Duloxetine HCl) Give 1 capsule by mouth in the morning related to Major Depressive Disorder, Recurrent, Unspecified; Anxiety Disorder, Unspecified. Order Date: 12/07/2020. Start Date: 12/08/2020. The eMARs (electronic medication administration records) dated 1/1/2023-1/31/2023, 2/1/2023-2/28/2023 and 3/1/2023-3/31/2023 for R22 documented the resident having received the Seroquel and Cymbalta as ordered daily through 3/22/2023. On 3/22/2023 at 10:25 a.m., ASM (administrative staff member) #2, the director of health services stated that they did not have any evidence that the facility staff had been monitoring for side effects for the Seroquel and Cymbalta for R22. ASM #2 stated that monitoring should be done and they now were aware of this and it would be corrected. On 3/22/2023 at 10:56 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the purpose of the care plan was for everyone to know what the residents problems were and for the staff to know what they were to do for the resident. LPN #2 stated that psychotropic medications should be monitored by staff to ensure residents did not have any side effects from them. LPN #2 stated that they should do this to make sure that the treatment they were providing was not causing any other issues to the resident. LPN #2 stated that they had not had a system in place for monitoring antidepressants, antipsychotics and antianxiety medications. LPN #2 stated that they could not say that they were implementing the care plan for the resident without evidence to support it. On 3/22/2023 at 2:33 p.m., ASM #1, the administrator, ASM #2, the director of health services, ASM #3, the chief operating officer and LPN #2, the health care unit coordinator were made aware of the above concern. No further information was provided prior to exit. Reference: (1) Seroquel Quetiapine tablets and extended-release (long-acting) tablets are used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). Quetiapine tablets and extended-release tablets are also used alone or with other medications to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). In addition, quetiapine tablets and extended-release tablets are used with other medications to prevent episodes of mania or depression in patients with bipolar disorder. Quetiapine extended-release tablets are also used along with other medications to treat depression. Quetiapine tablets may be used as part of a treatment program to treat bipolar disorder and schizophrenia in children and teenagers. Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a698019.html (2) Cymbalta Duloxetine is used to treat depression in adults and generalized anxiety disorder (GAD; excessive worry and tension that disrupts daily life and lasts for 6 months or longer) in adults and children 7 years of age and older. Duloxetine is also used to treat pain and tingling caused by diabetic neuropathy (damage to nerves that can develop in people who have diabetes) in adults and fibromyalgia (a long-lasting condition that may cause pain, muscle stiffness and tenderness, tiredness, and difficulty falling asleep or staying asleep) in adults and children [AGE] years of age and older. It is also used to treat ongoing bone or muscle pain such as lower back pain or osteoarthritis (joint pain or stiffness that may worsen over time) in adults. Duloxetine is in a class of medications called selective serotonin and norepinephrine reuptake inhibitors (SNRIs). It works by increasing the amounts of serotonin and norepinephrine, natural substances in the brain that help maintain mental balance and stop the movement of pain signals in the brain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a604030.html 31753 4. For Resident #6 (R6), the facility staff failed to implement the resident's comprehensive care plan for pressure injury treatments. A review of R6's clinical record revealed a pressure injury assessment dated [DATE] that documented the resident presented with a deep tissue injury on the outer aspect of the left lateral foot (present on admission 2/13/23). A physician's order dated 2/14/23 documented to apply skin prep to the left lateral foot wound twice a day. A review of R6's February 2023 and March 2023 MARs (medication administration records) and TARs (treatment administration records) failed to reveal the physician's order for skin prep to the left lateral foot twice a day, and failed to reveal the treatment was administered. A review of nurse's notes for February 2023 and March 2023 failed to reveal skin prep was applied to the left lateral foot on any dates except for 2/27/23, 3/1/23, 3/2/23, 3/6/23, 3/7/23 and 3/10/23. R6's comprehensive care plan dated 2/27/23 and revised on 3/1/23 documented, (Name of R6) has actual impairment to skin integrity r/t (related to) pressure injuries .Tx (Treatment) as ordered . On 3/22/23 at 10:40 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses evidence that treatments are done by signing them off on the TAR and that would be the only physical place to see that the treatments were done. On 3/22/23 at 10:53 a.m., another interview was conducted with LPN #2. LPN #2 stated the purpose of the care plan is, So everyone knows what the resident's problem is and what we are doing to help care for that problem and the steps for the interventions .It gives a guide to their care. In regard to care plan implementation, LPN #2 stated, The medications are on the medication MAR for the problem, the TAR has treatments, any tasks are on the poc (point of care computer system) for CNAs (certified nursing assistants). On 3/22/23 at 2:34 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of health services) were made aware of the above concern. 32642 5. For Resident #17 (R17), the facility staff failed to implement the comprehensive care plan for monitoring for adverse side effects related to the physician prescribed medications, Risperdal (1) and Lorazepam (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/11/23, R17 was coded as being severely cognitively impaired for making daily decisions. The resident was coded as having received an antipsychotic medication six of seven days of the look back period, and as having received an antianxiety medication all seven days of the look back period. A review of R17's physician orders revealed the following orders: Risperdal Tablet 0.5 MG (risperidone) Give 1 tablet by mouth at bedtime for hallucinations and delusions. This order was dated 1/25/21. Lorazepam Intensol Concentrate 2 MG/ML (Lorazepam) Give 0.25 ml by mouth in the morning. This order was dated 12/16/22. Further review of R17's MARs revealed the resident received Risperdal and Lorazepam as ordered in January 2023, February 2023, and March 2023. A review of R17's comprehensive care plan revealed, in part: Monitor the resident every shift for safety. The resident is taking ANTI-ANXIETY meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. This portion of the care plan was initiated on 5/8/18, and updated 8/6/21. This review further revealed, in part: Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (extrapyramidal side effects) (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. This portion of the care plan was initiated on 1/20/22. On 3/22/23 at 8:12 a.m., ASM #2 stated she could not provide evidence that the facility staff had been monitoring for side effects for the Lorazepam and Risperdal. ASM #2 stated the facility staff should be monitoring for side effects to make sure residents are not experiencing adverse reactions from medications that are intended to help them. On 3/22/23 at 10:56 a.m., LPN (licensed practical nurse) #2, the unit manager, was interviewed. She stated the purpose of a care plan is for everyone to know what a resident's problems are, and how the facility staff is going to take care of those problems. She stated: It is a guide to their care. She stated if a care plan includes an intervention to monitor a resident for side effects of a medication, the nurse should be looking to make sure that the medication is not indirectly causing other problems for a resident. She stated the facility does not have a clear, concise system for documenting the monitoring of residents for medication side effects. She stated the facility staff had not been following R17's care plan. On 3/22/23 at 4:30 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the chief operating officer, were informed of these concerns. No further information was provided prior to exit. (1) Risperidone (generic for Risperdal) is used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) in adults and teenagers [AGE] years of age and older. It is also used to treat episodes of mania (frenzied, abnormally excited, or irritated mood) or mixed episodes (symptoms of mania and depression that happen together) in adults and in teenagers and children [AGE] years of age and older with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). Risperidone is also used to treat behavior problems such as aggression, self-injury, and sudden mood changes in teenagers and children 5 to [AGE] years of age who have autism (a condition that causes repetitive behavior, difficulty interacting with others, and problems with communication). Risperidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a694015.html. (2) Lorazepam (brand name Ativan) is used to relieve anxiety. Lorazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682053.html. 6. For Resident #34 (R34), the facility staff failed to implement the comprehensive care plan for monitoring for adverse side effects related to the physician prescribed medication, Lorazepam (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/22, R34 was coded as being moderately impaired for making daily decisions, having scored eight out of 15 on the BIMS (brief interview for mental status). The resident was coded as having received an antianxiety medication and an antidepressant medication on all seven days of the look back period. A review of R34's physician orders revealed the following order: Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth before meals for tremors. This order was dated 2/2/23. A review of R34's March 2023 MAR (medication administration record) revealed the Lorazepam had been administered as ordered each day. A review of R34's comprehensive care plan revealed, in part: Monitor/document/report PRN (as needed) any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. This intervention was initiated 9/19/22. On 3/22/23 at 8:12 a.m., ASM #2 stated she could not provide evidence that the facility staff had been monitoring for side effects for the Lorazepam. ASM #2 stated they facility staff should be monitoring for side effects to make sure residents are not experiencing adverse reactions from medications that are intended to help them. On 3/22/23 at 4:30 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the chief operating officer, were informed of these concerns. No further information was provided prior to exit. (1) Lorazepam (brand name Ativan) is used to relieve anxiety. Lorazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682053.html.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide care and services for a pressure injury for one of 17 residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to evidence treatment was provided for the resident's left lateral foot pressure injury, as ordered by the physician, on multiple dates during February 2023 and March 2023. A review of R6's clinical record revealed a pressure injury assessment dated [DATE] that documented the resident presented with a deep tissue injury on the outer aspect of the left lateral foot (present on admission 2/13/23). A physician's order dated 2/14/23 documented to apply skin prep to the left lateral foot wound twice a day. A review of R6's February 2023 and March 2023 MARs (medication administration records) and TARs (treatment administration records) failed to reveal the physician's order for skin prep to the left lateral foot twice a day and failed to reveal the treatment was completed. A review of nurse's notes for February 2023 and March 2023 failed to reveal skin prep was applied to the left lateral foot on any dates except for 2/27/23, 3/1/23, 3/2/23, 3/6/23, 3/7/23 and 3/10/23. R6's comprehensive care plan dated 2/27/23 and revised on 3/1/23 documented, (Name of R6) has actual impairment to skin integrity r/t (related to) pressure injuries .Tx (Treatment) as ordered . On 3/22/23 at 10:40 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses evidence that treatments are done by signing them off on the TAR and that would be the only physical place to see that the treatments were done. LPN #2 stated she entered the physician order for skin prep to the left lateral foot into the computer system and when she did this, she was supposed to select an order type for TAR so the order would transfer to the TAR. LPN #2 stated she did not do this and there was no evidence that the treatment was done per physician's order. On 3/22/23 at 2:34 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of health services) were made aware of the above concern. The facility policy titled, Pressure Injury Prevention and Care Protocol documented, Standard: A program of prevention, care, and treatment of pressure injury is carried out for all Health Care residents to prevent skin breakdown and promote healing.

Based on resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to provide a complete pain management program including implementation of non-pharmacological interventions prior to the administration of as needed pain medications for three of 17 residents in the survey sample, Residents #4, #97 and #34. The findings include: 1. For Resident #4 (R4), the facility staff failed to evidence implementation of non-pharmacological interventions prior to administration of as needed Tylenol with Codeine #3 (1). On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 1/4/2023, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section J documented R4 having pain frequently and receiving as needed pain medications. Section J further documented R4 not receiving non-medication interventions for pain. On 3/21/2023 at 11:22 a.m., an interview was conducted with R4. R4 stated that they had pain at times and the nurses gave them medication to help. R4 stated that sometimes the staff tried to give them a pillow but most of the time they just gave the medication. The physician order's for R4 documented in part, - Tylenol with Codeine #3 Tablet 300-30 MG (milligram) (Acetaminophen-Codeine) Give 1 tablet by mouth every 6 hours as needed for For pain scale of 6-10. Order Date: 12/22/2022. Start Date: 12/22/2022. The eMAR (electronic medication administration record) dated 1/1/2023-1/31/2023 documented the Tylenol with Codeine #3 administered to R4 a total of 26 times for pain levels ranging from 6-10. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the as needed Tylenol with Codeine #3. The eMAR dated 2/1/2023-2/28/2023 documented the Tylenol with Codeine #3 administered to R4 a total of 14 times for pain levels ranging from 6-8. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the as needed Tylenol with Codeine #3. The eMAR dated 3/1/2023-3/31/2023 documented the Tylenol with Codeine #3 administered to R4 a total of 10 times for pain levels ranging from 7-8. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the as needed Tylenol with Codeine #3. The progress notes for R4 from 1/1/2023-3/22/2023 failed to evidence documentation of non-pharmacological interventions attempted or offered prior to the administration of the as needed pain medication documented on the eMARs. The comprehensive care plan for R4 dated 8/9/2022 documented in part, [Name of R4] has chronic pain r/t (related to) old right ankle fx (fracture) and arthritis. Date Initiated: 08/09/2022. Revision on: 01/18/2023 . Under Interventions it documented in part, .Medications as ordered. Non-medication interventions to be offered. Date Initiated: 08/25/2022. Revision on: 08/25/2022 . On 3/22/2023 at 10:56 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that prior to administration of as needed pain medications the nurse assessed the residents pain by asking them to describe the pain, the location of the pain and to rate the pain on a 0-10 pain scale. LPN #2 stated that they attempted non-medication interventions prior to administering medications because sometimes the pain could be alleviated without medication. LPN #2 stated that they attempted non-medication interventions such as repositioning, music or offering a snack or drink to the resident. LPN #2 stated that they would reevaluate the resident afterwards and if the pain was not relieved then would administer the medication. LPN #2 stated that the non-medication interventions were documented on the eMAR under the supplemental documentation with the as needed pain medications. LPN #2 stated that the nurses should be documenting a Y or N for yes or no when offered. LPN #2 stated that if the non-medical interventions were not documented on the eMAR that it could not be proven that they were offered to the resident prior to administration of the as needed pain medications. On 3/22/2023 at 11:35 a.m., ASM (administrative staff member) #2, the director of health services stated that they did not have evidence of non-pharmacological interventions offered to R4 prior to the administration of the Tylenol with Codeine #3 from 1/1/2023-3/22/2023. The facility policy Pain Management in the Long Term Care Setting dated 10/14/2022 documented in part, .Document present and past treatments utilized by the resident for the treatment of pain, include: a. medications both prescription and OTC (over the counter) and length of time on each. b. alternative treatments such as positioning, heat and cold applications. c. specify the treatment by each site of pain. d. record the effectiveness of each treatment .Considerations: .For pain related to degenerative joint disease (e.g., arthritis, etc.). Positioning, relaxation, and distraction techniques are particularly important in this population. The use of ice or heat as ordered by the physician or APRN can also be used for pain relief . On 3/22/2023 at approximately 2:33 p.m., ASM #1, the administrator, ASM #2, the director of health services, ASM #3, the chief operating officer and LPN #2, the healthcare unit coordinator were made aware of the concern. No further information was provided prior to exit. Reference: (1) Tylenol #3 The combination of acetaminophen and codeine is used to relieve mild to moderate pain. Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. Codeine belongs to a class of medications called opiate (narcotic) analgesics and to a class of medications called antitussives. When codeine is used to treat pain, it works by changing the way the brain and nervous system respond to pain. When codeine is used to reduce coughing, it works by decreasing the activity in the part of the brain that causes coughing. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601005.html 31753 2. For Resident #97 (R97), the facility staff failed to initiate a complete pain assessment and failed to attempt non-pharmacological interventions when the as needed pain medications acetaminophen and oxycodone were administered on multiple dates in March 2023. Resident #97's (R97) baseline care plan dated 3/14/23 documented the resident takes opioids. Further review of R97's clinical record revealed a physician's order dated 3/14/23 for oxycodone 5 mg (milligrams) every four hours as needed for pain on a scale from seven to ten and a physician's order dated 3/15/23 for acetaminophen 500 mg every six hours as needed for pain on a scale from one to six. A review of R97's March 2023 MAR (medication administration record) revealed the resident was administered as needed oxycodone on 3/14/23, 3/15/23, 3/16/23, 3/18/23, 3/19/23 and 3/20/23. Further review of R97's clinical record (including the March 2023 MAR and March 2023 nurses' notes) failed to reveal a complete pain assessment (including location, quality and duration) was completed on 3/18/23, 3/19/23 and 3/20/23, and failed to reveal non-pharmacological interventions were attempted on 3/15/23, 3/16/23, 3/18/23, 3/19/23 and 3/20/23. Further review of R97's March 2023 MAR revealed the resident was administered as needed acetaminophen on 3/15/23 through 3/20/23. Further review of R97's clinical record (including the March 2023 MAR and March 2023 nurses' notes) failed to reveal a complete pain assessment (including location, quality and duration) was completed on 3/15/23, 3/16/23, 3/18/23, 3/19/23 and 3/20/23, and failed to reveal non-pharmacological interventions were attempted on 3/15/23 and 3/17/23. On 3/22/23 at 10:53 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated non-medication interventions such as repositioning, music, food and drink should be offered prior to the administration of as needed pain medications. LPN #2 stated, Well, if you can alleviate without medication that's wonderful and sometimes you could just be uncomfortable in your sitting. If you sit too long, you may get a cramp and can alleviate with getting up and not taking a medication. In regards to pain assessments prior to the administration of as needed pain medications, LPN #2 stated, If a resident says they are having pain, of course I'm going to ask them where the pain is, how does it feel, any other specifics, radiation, pain scale on a scale of zero to ten then from there I would try a non-medication intervention and if that didn't work then I would give the prn (as needed) pain medication. On 3/22/23 at 2:34 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of health services) were made aware of the above concern. 32642 3. For Resident #34 (R34), the facility staff failed to implement nonpharmacological interventions prior to administering as needed Tylenol on multiple occasions in March 2023. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/22, R34 was coded as being moderately impaired for making daily decisions, having scored eight out of 15 on the BIMS (brief interview for mental status). The resident was coded as having experienced no pain during the look back period. A review of R34's physician order revealed the following order: Acetaminophen Tablet (Tylenol) 325 MG (milligrams) Give 2 tablets by mouth every 4 hours as needed for pain. This order was written 2/19/23. A review of R34's March 2023 MAR (medication administration record) revealed the resident received as needed Tylenol 15 times. Further review of R34's clinical record revealed no evidence that nonpharmacological interventions were attempted to relieve the resident's pain prior to administration of the as needed Tylenol. On 3/22/23 at 10:56 a.m., LPN (licensed practical nurse) #2, the unit manager, was interviewed. She stated prior to administering an as needed pain medication, she would attempt non-medical interventions such as repositioning, soft music, and offering a snack or fluids. She stated if pain can be alleviated without medication, that is in the resident's best interests. She stated attempts at nonpharmacological interventions should be documented either on the MAR or in a progress note. On 3/22/23 at 4:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, and ASM #3, the chief operating officer, were informed of these concerns. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure residents were free from unnecessary medications for two of 17 residents in the survey sample, Residents #97 and #98. 1. For Resident #97 (R97), the facility staff administered the as needed pain medication, oxycodone, outside of the physician ordered parameters, which was for pain rated between seven to ten (7 to 10 on a pain scale of 1-10) on 3/20/23. The staff administered oxycodone for a pain rating of three (3 out of 10 on the pain scale). A review of R97's clinical record revealed a physician's order dated 3/14/23 for oxycodone 5 mg (milligrams) every four hours as needed for pain on a scale from seven to ten and a physician's order dated 3/15/23 for acetaminophen 500 mg every six hours as needed for pain on a scale from one to six. A review of R97's March 2023 MAR (medication administration record) revealed the resident was administered as needed oxycodone on 3/20/23 for pain rated as three. On 3/22/23 at 10:53 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated as needed pain medications should be given per the physician ordered parameters. LPN #2 was shown R97's physician's orders for oxycodone and acetaminophen. LPN #2 stated that if R97 complained of pain rated as three then the resident should be administered Tylenol (acetaminophen). LPN #3 stated oxycodone should not be administered for pain rated as three because the oxycodone parameter is pain rated seven to ten. On 3/22/23 at 2:34 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of health services) were made aware of the above concern. The facility policy titled, Pain Management in the Long Term Care Setting documented, When treating pain, start with a drug appropriate to the resident's current level of pain . 2. For Resident #98 (R98), the facility staff failed to monitor the resident for side effects (bleeding) of the anticoagulant (blood thinning) medication Eliquis (1). A review of R98's clinical record revealed a physician's order dated 3/9/23 for Eliquis 2.5 mg (milligrams) every 12 hours for atrial fibrillation. A review of R98's March 2023 MAR (medication administration record) revealed the resident was administered Eliquis every 12 hours from 3/9/23 through 3/20/23. Further review of R98's clinical record (including the March 2023 MAR and March 2023 nurses' notes) failed to reveal the resident was monitored for side effects (bleeding) from the Eliquis. On 3/22/23 at 1:11 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that if a resident takes an anticoagulant medication then the nurses certainly watch for blood in their stools, blood in their urine, petechiae (small red or purple spots on the skin caused by bleeding), and increased bruising. On 3/22/23 at 3:53 p.m., ASM (administrative staff member) #2 (the director of health services) stated she could not provide documentation to evidence the facility staff were monitoring R98 for side effects related to anticoagulant use. ASM #2 was made aware of this concern. On 3/22/23 at 5:04 p.m., ASM #1 (the administrator) was made aware of the above concern. The facility policy titled, Anticoagulant Therapy documented, 1. Observe for signs of bleeding Blood in urine or stool (black, tarry stools) Bleeding of gums, nose Small purplish, hemorrhagic spots on skin Excessive and easy bruising Bleeding from tumors, ulcers, or lesions Confusion, change in mental status. Reference: (1) ELIQUIS is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF) .Bleeding Risk: ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding. This information was obtained from the website: https://www.eliquis.com/eliquis/hcp/wellcareform?cid=sem_2167331&ovl=isi&gclid=64c052d127001aa9ec1836cd1510884c&gclsrc=3p.ds&

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure residents were free of unnecessary psychoactive medications for five of 17 residents in the survey sample, Residents #17, #34, #98, #22, and #36. The findings include: 1.a. For Resident #17 (R17), the facility staff failed to document the rationale for extending the administration of an as needed Lorazepam beyond the original 14 days. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/11/23, R17 was coded as being severely cognitively impaired for making daily decisions. The resident was coded as having received an antipsychotic medication six of seven days of the look back period, and as having received an antianxiety medication all seven days of the look back period. A review of R17's physician orders revealed the following order: Lorazepam Concentrate 2 MG/ML (milligrams per milliliter) Give 0.25 ml by mouth every 6 hours as needed for agitation or anxiety. This order was dated 9/20/22, and was discontinued 3/17/23, A review of R17's MARs (medication administration records) revealed the resident received as needed Lorazepam three times in January 2023, two times in February 2023, and once in March 2023. Further review of R17's clinical record revealed no evidence that R17's order for as needed Lorazepam was reviewed or renewed beyond the initial 14 days of the order. On 3/22/23 at 10:29 a.m., ASM (administrative staff member) #2, the director of nursing, stated she could not provide evidence that the order for as needed Lorazepam for R17 had been reviewed or discontinued beyond the initial 14 days. She stated ordinarily she gets a notification from the pharmacy for all new psychoactive medication orders for all residents. She follows up to make sure any as needed psychoactive medication orders have a 14 day stop date. On 3/22/23 at 12:02 p.m., ASM #4, the medical director, was interviewed. She stated she is aware that Lorazepam is limited to 14 days of use as an as need medication. She stated: I know it can be renewed or lengthened. She stated: Someone should have told me in a week or two to review the medication and to see how [R17] was doing on it. She added: You shouldn't stay on a PRN (as needed medication). It should either be discontinued or scheduled. On 3/22/23 at 4:30 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the chief operating officer, were informed of these concerns. A review of the facility policy, Restraints, Chemical and Antipsychotropics, revealed, in part: A PRN (as necessary) antipsychotic agent should be used: to titrate the resident's total daily dose UP, to achieve symptoms relief; or DOWN, to avoid side effects; or DOWN, to effect a gradual dose reduction; or to manage unexpected harmful behaviors that may affect the residents or staff's safety that cannot be controlled otherwise. If such behaviors remain unmanageable after seven days, reassessment of the resident is indicated. No further information was provided prior to exit. (1) Lorazepam (brand name Ativan) is used to relieve anxiety. Lorazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682053.html. 1.b. For R17, the facility staff failed to monitor the resident for adverse side effects of Risperdal (2) and Lorazepam. A review of R17's physician orders revealed the following orders: Risperdal Tablet 0.5 MG (risperidone) Give 1 tablet by mouth at bedtime for hallucinations and delusions. This order was dated 1/25/21. Lorazepam Intensol Concentrate 2 MG/ML (Lorazepam) Give 0.25 ml by mouth in the morning. This order was dated 12/16/22. Further review of R17's MARs revealed the resident received Risperdal and Lorazepam as ordered in January 2023, February 2023, and March 2023. A review of R17's comprehensive care plan revealed, in part: Monitor the resident every shift for safety. The resident is taking ANTI-ANXIETY meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. This portion of the care plan was initiated on 5/8/18, and updated 8/6/21. This review further revealed, in part: Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (extrapyramidal side effects) (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. This portion of the care plan was initiated on 1/20/22. On 3/22/23 at 8:12 a.m., ASM #2 stated she could not provide evidence that the facility staff had been monitoring for side effects for the Lorazepam and Risperdal. She stated they facility staff should be monitoring for side effects to make sure residents are not experiencing adverse reactions from medications that are intended to help them. On 3/22/23 at 1:13 p.m., RN (registered nurse) #1 was interviewed. She stated when a resident first goes on a psychoactive medication, the nurses watch the resident carefully to see how the resident is responding. She stated there is no protocol or routine for this kind of monitoring. On 3/22/23 at 4:30 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the chief operating officer, were informed of these concerns. A review of the facility policy, Restraints, Chemical and Antipsychotropics, revealed, in part: Specific behaviors, nursing interventions with outcomes, and medication side effects will be monitored each shift and documented on the electronic medical record. No further information was provided prior to exit. (2) Risperidone (generic for Risperdal) is used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) in adults and teenagers [AGE] years of age and older. It is also used to treat episodes of mania (frenzied, abnormally excited, or irritated mood) or mixed episodes (symptoms of mania and depression that happen together) in adults and in teenagers and children [AGE] years of age and older with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). Risperidone is also used to treat behavior problems such as aggression, self-injury, and sudden mood changes in teenagers and children 5 to [AGE] years of age who have autism (a condition that causes repetitive behavior, difficulty interacting with others, and problems with communication). Risperidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a694015.html. 2. For Resident #34 (R34), the facility staff failed to monitor the resident for adverse side effects of Lorazepam (1) and Celexa (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/22, R34 was coded as being moderately impaired for making daily decisions, having scored eight out of 15 on the BIMS (brief interview for mental status). The resident was coded as having received an antianxiety medication and an antidepressant medication on all seven days of the look back period. A review of R34's physician orders revealed the following: Celexa Tablet 10 MG (milligram) (Citalopram Hydrobromide) Give 1 tablet by mouth in the morning for anxiety. This order was dated 9/2/22. Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth before meals for tremors. This order was dated 2/2/23. A review of R34's March 2023 MAR (medication administration record) revealed the Celexa and Lorazepam had been administered as ordered each day. A review of R34's comprehensive care plan revealed, in part: Monitor/document/report PRN (as needed) any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. This intervention was initiated 9/19/22. On 3/22/23 at 8:12 a.m., ASM (administrative staff member) #2, the director of health services, stated she could not provide evidence that the staff had been monitoring R34 for side effects of the Celexa and Lorazepam. She stated the facility staff wants to make certain the resident is not having any adverse reactions to a medication that would require a change in the dosage or the type of medication. She stated it is the facility's responsibility to monitor consistently for signs and symptoms that a resident is reacting adversely to a medication. On 3/22/23 at 1:13 p.m., RN (registered nurse) #1 was interviewed. She stated when a resident first goes on a psychoactive medication, the nurses watch the resident carefully to see how the resident is responding. She stated there is no protocol or routine for this kind of monitoring. On 3/22/23 at 4:30 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the chief operating officer, were informed of these concerns. No further information was provided prior to exit. (1) Lorazepam (brand name Ativan) is used to relieve anxiety. Lorazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682053.html. (2) Citalopram is used to treat depression. Citalopram is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. This information is taken from the website https://medlineplus.gov/druginfo/meds/a699001.html. 31753 3. For Resident #98 (R98), the facility staff failed to monitor the resident for adverse side effects from the antidepressant medication duloxetine (1). A review of R98's clinical record revealed a physician's order dated 3/15/23 for duloxetine 30 mg (milligrams) in the morning for depression. A review of R98's March 2023 MAR (medication administration record) revealed the resident was administered duloxetine 30 mg every morning from 3/16/23 through 3/20/23. Further review of R98's clinical record failed to reveal the resident was monitored for side effects from duloxetine. On 3/22/23 at 10:53 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that when a resident receives an antidepressant medication, nurses should look to ensure the medication isn't causing any harm or issues. On 3/22/23 at 3:53 p.m., ASM (administrative staff member) #2 (the director of health services) stated she could not provide documentation to evidence the facility staff were monitoring R98 for side effects related to antidepressant use. ASM #2 was made aware of this concern. On 3/22/23 at 5:04 p.m., ASM #1 (the administrator) was made aware of the above concern. Reference: (1) Duloxetine is used to treat depression in adults. Some side effects can be serious: unusual bruising or bleeding, pain in the upper right part of the stomach, swelling of the abdomen, itching, yellowing of the skin or eyes, dark colored urine, loss of appetite, extreme tiredness or weakness, confusion, unsteady walking that may cause falling, flu-like symptoms, agitation, fever, sweating, confusion, fast or irregular heartbeat, and severe muscle stiffness or twitching, loss of coordination, nausea, vomiting, or diarrhea, seizures, hallucinations (seeing things or hearing voices that do not exist), blisters or peeling skin, rash, hives, difficulty breathing or swallowing, swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs, hoarseness, difficulty urinating . This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a604030.html 42106 4. For Resident #22 (R22), the facility staff failed to monitor the resident for adverse side effects from the medications Seroquel (1) and Cymbalta (2). The physician orders for R22 documented in part, - Seroquel Tablet 25 MG (milligram) (Quetiapine Fumarate) Give 0.5 tablet by mouth in the morning for hallucinations. Order Date: 12/19/2022. Start Date: 12/20/2022. - Seroquel Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime related to Hallucinations, unspecified. Order Date: 11/17/2022. Start Date: 11/17/2022. - Cymbalta Capsule Delayed Release Particles 30 MG (Duloxetine HCl) Give 1 capsule by mouth in the morning related to Major Depressive Disorder, Recurrent, Unspecified; Anxiety Disorder, Unspecified. Order Date: 12/07/2020. Start Date: 12/08/2020. The eMARs (electronic medication administration records) dated 1/1/2023-1/31/2023, 2/1/2023-2/28/2023 and 3/1/2023-3/31/2023 for R22 documented the resident having received the Seroquel and Cymbalta as ordered daily through 3/22/2023. The comprehensive care plan for R22 documented in part, [Name of R22] uses antidepressant medication Cymbalta. Resident with dx. (diagnoses) of anxiety and adjustment disorder with depressed mood. Date Initiated: 11/04/2019. Revision on: 02/01/2023. Under Interventions it documented in part, .Monitor/document/report PRN (as needed) adverse reactions to Antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL (activities of daily living) ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs (problems), movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt (weight) loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date Initiated: 11/04/2019 . The care plan also documented, [Name of R22] uses antipsychotic medication Seroquel r/t hallucinations. Date Initiated: 02/02/2023. Revision on: 02/02/2023. Under Interventions it documented in part, .Monitor/document/report PRN any adverse reactions of Psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 02/02/2023 . The care plan further documented, I have a mood problem r/t Major Depressive Disorder, Anxiety Disorder and Adjustment Disorder. Date Initiated: 01/19/2023. Revision on: 01/19/2023. Under Interventions it documented in part, Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 01/19/2023 Date Initiated: 01/19/2023 . On 3/22/2023 at 10:25 a.m., ASM (administrative staff member) #2, the director of health services stated that they did not have any evidence that the facility staff had been monitoring for side effects for the Seroquel and Cymbalta for R22. ASM #2 stated that monitoring should be done and they now were aware of this and it would be corrected. On 3/22/2023 at 10:56 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that psychotropic medications should be monitored by staff to ensure residents did not have any side effects from them. LPN #2 stated that they should do this to make sure that the treatment they were providing was not causing any other issues to the resident. LPN #2 stated that they had not had a system in place for monitoring antidepressants, antipsychotics and antianxiety medications. On 3/22/2023 at 2:33 p.m., ASM #1, the administrator, ASM #2, the director of health services, ASM #3, the chief operating officer and LPN #2, the health care unit coordinator were made aware of the above concern. No further information was provided prior to exit. Reference: (1) Seroquel Quetiapine tablets and extended-release (long-acting) tablets are used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). Quetiapine tablets and extended-release tablets are also used alone or with other medications to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). In addition, quetiapine tablets and extended-release tablets are used with other medications to prevent episodes of mania or depression in patients with bipolar disorder. Quetiapine extended-release tablets are also used along with other medications to treat depression. Quetiapine tablets may be used as part of a treatment program to treat bipolar disorder and schizophrenia in children and teenagers. Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a698019.html (2) Cymbalta Duloxetine is used to treat depression in adults and generalized anxiety disorder (GAD; excessive worry and tension that disrupts daily life and lasts for 6 months or longer) in adults and children 7 years of age and older. Duloxetine is also used to treat pain and tingling caused by diabetic neuropathy (damage to nerves that can develop in people who have diabetes) in adults and fibromyalgia (a long-lasting condition that may cause pain, muscle stiffness and tenderness, tiredness, and difficulty falling asleep or staying asleep) in adults and children [AGE] years of age and older. It is also used to treat ongoing bone or muscle pain such as lower back pain or osteoarthritis (joint pain or stiffness that may worsen over time) in adults. Duloxetine is in a class of medications called selective serotonin and norepinephrine reuptake inhibitors (SNRIs). It works by increasing the amounts of serotonin and norepinephrine, natural substances in the brain that help maintain mental balance and stop the movement of pain signals in the brain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a604030.html 5. For Resident #36 (R36), the facility staff failed to evidence the resident was monitored for adverse side effects related to prescribed Celexa (1), and failed to conduct a review for a GDR (gradual dose reduction) or document that a GDR was contraindicated. The physician orders for R36 documented in part, - Celexa 20mg (milligram) 1 tablet by mouth in the morning related to Major Depressive Disorder, recurrent unspecified. Order Date: 8/27/2021. The eMARs (electronic medication administration records) dated 1/1/2023-1/31/2023, 2/1/2023-2/28/2023 and 3/1/2023-3/31/2023 for R36 documented the resident having received the Celexa as ordered daily through 3/22/2023. The comprehensive care plan for R36 documented in part, [Name of R22] uses antidepressant medication Celexa r/t (related to) Depression. Date Initiated: 02/28/2022. Revision on: 02/28/2022. Under Interventions it documented in part, .Monitor/document/report PRN (as needed) adverse reactions to Antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL (activities of daily living) ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs (problems), movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt (weight) loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date Initiated: 2/28/2022 . The care plan further documented, I have a mood problem r/t Major Depressive Disorder. Date Initiated: 02/10/2023. Revision on: 02/10/2023. Under Interventions it documented in part, Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/10/2023 . On 3/22/2023 at 10:25 a.m., ASM (administrative staff member) #2, the director of health services stated that they did not have any evidence that the facility staff had been monitoring for side effects for the Celexa for R36. ASM #2 stated that they did not have evidence of a review for a GDR of the Celexa for R36. ASM #2 stated that monitoring should be done and they now were aware of this and it would be corrected. On 3/22/2023 at 10:56 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that psychotropic medications should be monitored by staff to ensure residents did not have any side effects from them. LPN #2 stated that they should do this to make sure that the treatment they were providing was not causing any other issues to the resident. LPN #2 stated that they had not had a system in place for monitoring antidepressants, antipsychotics and antianxiety medications. On 3/22/2023 at 2:33 p.m., ASM #1, the administrator, ASM #2, the director of health services, ASM #3, the chief operating officer and LPN #2, the health care unit coordinator were made aware of the above concern. On 3/22/2023 at approximately 4:15 p.m., ASM #2 stated that they had confirmed with the consultant pharmacist that they did not have evidence of a review for a potential GDR for the Celexa for R36. No further information was provided prior to exit. Reference: (1) Celexa Citalopram is used to treat depression. Citalopram is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a699001.html

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to issue a bed hold notice to one of 17 residents in the survey sample, Resident #34. The findings include: For Resident #34 (R34), the facility failed to issue a bed hold notice when the resident was transferred to the hospital on 12/13/22. A review of R34's clinical record revealed the resident was transferred and admitted to the hospital on 12/13/22. The resident was readmitted to the facility on [DATE]. Further review of R34's clinical record failed to reveal evidence a bed hold notice was issued to the resident or to the RP (responsible party). On 3/22/23 at 8:12 a.m., ASM (administrative staff member) #2, the director of health services, was interviewed. She stated a bed hold notice had not been issued to R34 on 12/13/22. She stated the resident is unable to sign for themselves, and the resident's (significant other) was unable to sign in a timely manner. She stated the facility has contracts with its residents, and there is never a question if the resident will be able to return to the facility. On 3/22/23 at 4:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, and ASM #3, the chief operating officer, were informed of these concerns. A review of the facility policy, Bed Hold Policy, revealed, in part: A continuing care contract .stipulates that a bed in the Health Care Center be available for a LCC (life care contract) resident if and when it is needed .Residents who do not have a life care/continuing care contract .are considered per diem and are not guaranteed a bed unless it is paid for through daily charges or a Bed Hold Agreement .[name of facility] cannot guarantee the availability of a bed at the time the resident needs or desires to return unless there is a signed Bed Hold Agreement. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to provide residents (or their representatives) with a summary of the baseline care plan for two of 17 residents in the survey sample, Residents #97 and #98. The findings include: 1. For Resident #97 (R97), the facility staff failed to provide the resident (or their representative) a summary of the baseline care plan. R97 was admitted to the facility on [DATE]. A review of R97's clinical record (including the baseline care plan effective 3/14/23, and progress notes for March 2023) failed to reveal the facility staff provided R97 or the resident's representative a summary of the baseline care plan. On 3/21/23 at 4:54 p.m., an interview was conducted with ASM (administrative staff member) #2, (the director of health services). ASM #2 stated that upon completion of the baseline care plan, the minimum data set coordinator is supposed to finalize the baseline care plan and provide a copy to the resident and/or family. ASM #2 stated there was no evidence this was done for (R97). At this time, ASM #1 (the administrator) and ASM #2 were made aware of the above concern. On 3/23/23 at 7:15 a.m., per ASM #2, the facility did not have a policy regarding baseline care plans. 2. For Resident #98 (R98), the facility staff failed to provide the resident (or their representative) a summary of the baseline care plan. R98 was admitted to the facility on [DATE]. A review of R98's clinical record (including the baseline care plan effective 3/10/23, and progress notes for March 2023) failed to reveal the facility staff provided R97 or the resident's representative a summary of the baseline care plan. On 3/21/23 at 4:54 p.m., an interview was conducted with ASM (administrative staff member) #2, (the director of health services). ASM #2 stated that upon completion of the baseline care plan, the minimum data set coordinator is supposed to finalize the baseline care plan and provide a copy to the resident and/or family. ASM #2 stated there was no evidence this was done for (R98). At this time, ASM #1 (the administrator) and ASM #2 were made aware of the above concern. No further information was provided by the facility staff.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to revise a resident's care plan for one of 17 residents in the survey sample, Resident #34. The findings include: For Resident #34 (R34), the facility staff failed to update the resident's care plan with the resident's use of a knee brace and non-weightbearing status. On 3/21/23 at 8:38 a.m., R34 was seated at a table in the dining room. A knee brace was visible on the resident's right knee. A review of R34's clinical record revealed the following orders: Resident to be non-weight bearing for 6 weeks or until physician releases. This order was dated 2/5/23. R (right) knee neoprene brace to be on when out of bed &skin check to be performed on removal of brace qs (every shift). This order was written 2/23/23. A review of R34's comprehensive care plan dated 9/8/22 revealed no information regarding the knee brace or the non-weightbearing status. On 3/22/23 at 1:25 p.m., LPN (licensed practical nurse) #1, the MDS (minimum data set) coordinator was interviewed. She stated she is responsible for updating the care plans as new opportunities arise with changes in residents' conditions. She stated the team meets daily and weekly to review new medications, treatments, or condition changes, and that the knee brace and non-weightbearing status should be on the care plan. After reviewing R34's care plan, she stated she could not determine that the care plan had been updated. On 3/22/23 at 4:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, and ASM #3, the chief operating officer, were informed of these concerns. A review of the facility policy, Care Plan, Comprehensive, revealed, in part: The plan is periodically reviewed and revised by a team of qualified persons after each assessment. The resident and / or families are involved in care planning and updating to the extent possible. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to provide care and services to maintain a resident's highest level of well-being for one of 17 residents in the survey sample, Resident #35. The findings include: For Resident #35 (R35), the facility staff failed to obtain a physician recommended urinalysis on 2/25/23. A review of R35's clinical record revealed a nurse's note dated 2/25/23 that documented, CNA (Certified nursing assistant) (name) reports that it appears resident has blood in (the resident's) urine. CNA showed this nurse resident's adult brief and it did have blood mixed in with the urine. This nurse placed a note in the doctor communication book asking that doctor assess resident. Further review of R35's clinical record failed to reveal any further documentation regarding bloody urine or that this was addressed by the physician. On 3/21/23 at 11:27 a.m., ASM (administrative staff member) #2 (the director of health services) presented a provider communication log dated 2/25/23. The log documented, Based on resident's undergarment, it looks as though (the resident) has blood in (the resident's) urine (possible UTI [urinary tract infection]). The physician's response documented, UA C&S (urinalysis with culture and sensitivity). ASM #2 stated the urinalysis was never obtained. On 3/22/23 at 10:53 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that if there is a non-emergent medical concern and the physician is not in the building then the nurses will write the concern in a communication log. LPN #2 stated that the next time the physician comes in, she checks the book, makes her assessment, gives verbal orders or writes the orders in the book. LPN #2 stated the nurses are responsible for creating the order in the computer system and carrying out the order. On 3/22/23 at 2:34 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. A policy regarding the implementation of physician recommendations was requested. The policy provided and titled, Documentation of the Clinical Record failed to document information regarding the above concern.

Based on observation, staff interview and facility document review, the facility staff failed to store food in a sanitary manner in one of four kitchens, the Wisteria kitchen. The findings include: The facility staff failed to label and date a container of prepared tuna salad observed in the Wisteria kitchen. On 3/20/23 at 6:43 p.m., observation of the Wisteria kitchen was conducted with OSM (other staff member) #1 (the dining services manager). A metal container of prepared tuna salad was observed in the refrigerator. The container did not contain a label documenting the contents or the date. OSM #1 identified the contents as tuna salad and discarded it. On 3/21/23 at 4:25 p.m., an interview was conducted with OSM #1. OSM #1 stated the name of food products should be labeled on the containers. OSM #1 stated this should be done in case there is a need to trace back to the product. On 3/21/23 at 4:52 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of health services) were made aware of the above concern. The facility policy titled, Food Safety documented, 10. All foods prepared in operation must be covered and labeled as to the contents and date of preparation prior to storage in refrigerators and freezers. Labels for potentially hazardous foods also must include time of storage.

Based on staff interview, facility document review and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 17 residents in the survey sample, Resident #14. The findings include: For Resident #14 (R14), the facility staff failed to document the resident's refusal of a pressure injury assessment on 3/7/23. A review of R14's clinical record revealed an assessment of R14's coccyx pressure injury on 2/28/23. Further review of R14's clinical record failed to reveal another assessment of the resident's coccyx pressure injury until 3/17/23. On 3/22/23 at 10:50 a.m., an interview was conducted with LPN (licensed practical nurse) #2, who was the nurse who typically documented pressure injury assessments. LPN #2 stated she was off on 3/7/23 but her understanding was that the physician and another nurse attempted to assess R14's pressure injury on that date and the resident refused because visitors were present. LPN #2 stated there was no note to evidence this, but the nurse was going to document a late entry. A nurse's note created on 3/21/23, and effective for 3/7/23 documented a late entry that R14 preferred to not have the pressure injury assessed during wound rounds on that date because the resident had visitors. On 3/22/23 at 1:11 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated a resident's refusal of a pressure injury assessment because, It's something that was wanted to be done and they are refusing for us to do what was needed. On 3/22/23 at 2:34 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of health services) were made aware of the above concern. The facility policy titled, Documentation of the clinical record documented, The nurse's notes are the responsibility of the licensed nursing staff. They must show the progress the resident is making following orders written by the physician. It provides a permanent legal record of the nursing care, treatments, and medications administered.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner. The facility staff failed to discard an opened 16 ounce carton of liquid egg yolks with an expiration date of 9/14/21, failed to discard an opened half gallon carton of whole milk with a best if used by date of 9/10/21 and failed to discard a container of mushrooms labeled with a use by date of 9/14/21. The findings include: On 9/21/21 at 11:15 a.m., observation of refrigerator #37 in the satellite health care center kitchen was conducted with OSM (other staff member) #2 (the executive chef). The following was observed: -One opened 16 ounce carton of liquid egg yolks with a manufacturer's printed expiration date of 9/14/21. -One opened half gallon carton of whole milk with a manufacturer's printed date of 9/14/21 (the date did not specify if it was an expiration date, sell by date or best if used by date; however, the manufacturer's documentation for the milk documented the stamped printed date was a best if used by date). -One metal container of mushrooms covered with plastic wrap and labeled with a prep date of 9/8 and a use by date of 9/14. All of the above items were discarded by OSM #2 during the observation. On 9/22/21 at 10:53 a.m., an interview was conducted with OSM #1 (the dining services manager). OSM #1 stated the cooks should inspect the refrigerator daily. OSM #1 stated the cooks should make sure everything is labeled/dated and discard items the day before an item's expiration date or best if used by date. OSM #1 stated items with a labeled use by date should be discarded on that date. On 9/22/21 at 4:34 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of health services) were made aware of the above concern. The facility policy titled, Food Safety documented, 15. Food left over on the self-service bars, buffets, or food lines after the meal period may be reused only if the self-service stations are monitored consistently throughout the service by SERVSAFE-trained employees. Leftover food must be discarded if so required by local, state, or provincial health department regulations. No further information was presented prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide documented evidence of facility-initiated transfer requirements for two of 22 residents in the survey sample, Residents #48 and #12. The facility staff failed to provide evidence that all required information was provided to the hospital staff when Resident #48 was transferred to the hospital on [DATE], and failed to provide Resident #12's comprehensive care plan goals to the receiving hospital upon the residents transfer to the hospital on [DATE]. The findings include: 1. Resident #48 was admitted to the facility on [DATE]. Resident #48's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #48's admission minimum data set assessment with an assessment reference date of [DATE], coded the resident's cognition as severely impaired. Review of Resident #48's clinical record revealed a nurse's note dated [DATE] that documented the resident was discharged to the hospital for shortness of breath and a low oxygen level. Further review of Resident #48's clinical record failed to reveal documentation to evidence that all required information, including physician contact information, resident representative contact information, special instructions for ongoing care, advance directives and comprehensive care plan goals, was provided to the hospital staff. On [DATE] at 11:49 a.m., ASM (administrative staff member) #2 (the director of health services) presented a blank checklist form that documented, Resident Name ____Date___ CHECKLIST FOR TRANSFERRING A RESIDENT TO THE HOSPITAL Check off as you complete: 1. __Receive order from MD (medical doctor) 2. __Notify '911' or (name of transportation company) - or if longer than necessary wait- Utilize '911' for emergency situations. 3. __ Notify the Front Desk that rescue personnel will be arriving. 4. __ Send the following to the hospital in an ORANGE FOLDER/ENVELOPE via the emergency personnel. 4.1 __ 2 Copies of the Face Sheet (1 copy to EMT [emergency medical technician]/ 1 copy in the folder) 4.2 __ Copy of the DNR (do not resuscitate) document 4.3 __ Copy of any Advance Directive [Living Will, Durable Power of Attorney for Health Care, 5 Wishes] 4.4 __ MAR (medication administration record) 4.5 __ eInteract Transfer form 4.6 __ Print off Care Plan send to hospital . Nurses' Signature ___ Date ___. At this time, ASM #2 stated she could not locate a checklist for when Resident #48 was discharged to the hospital on [DATE] and was unable to validate information provided to the hospital staff. On [DATE] at 1:30 p.m., an interview was conducted with RN (registered nurse) #1, regarding information provided to hospital staff when a resident is transferred to the hospital. RN #1 stated the nurses have a checklist and provide a face sheet (that includes the doctor's information and family contact information), living will information, power of attorney information, any information possibly related to treatment in the hospital, the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 stated this information is sent with the resident when they leave the facility unless there is an emergent situation such as providing cardiopulmonary resuscitation. RN #1 stated that in the case of an emergent situation, information is faxed to the hospital. RN #1 stated nurse's evidence the information provided to hospital staff by completing and signing the checklist form, by documenting a nurse's note or by a fax confirmation. On [DATE] at 4:34 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, (Name of facility) Initiated Transfer and Discharge documented, 4) The medical record: a) will clearly identify the basis or reason for transfer or discharge. b) Identify Information provided to the receiving provider which at a minimum will include: i) Contact information of the practitioner who was responsible for the care of the resident; ii) Resident representative information, including contact information; iii) Advance directive information; iv) Special instructions and/or precautions for ongoing care, as appropriate, which must include, if applicable, but are not limited to: Treatments and devices (oxygen, implants, IVs tubes/catheters); v) Precautions such as isolation or contact; vi) Special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; vii) The resident's comprehensive care plan goals; and viii) All information necessary to meet the resident's needs, which includes, but may not be limited to: (1) Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; (2) diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No further information was presented prior to exit. 2. Resident #12 was admitted to the facility on [DATE] with a recent readmission on [DATE]. with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of [DATE], coded Resident #12 as not completing the interview for the BIMS (brief interview for mental status) score, but coded the resident as having no short or long term memory difficulties. A nurse's note dated, [DATE] at 10:47 a.m. documented, Resident's pendant and call light ringing. Went to go to room when resident was seen lying on the floor between his doorway and hall. Resident unresponsive and not breathing. CPR (cardiopulmonary resuscitation) initiated. 911 contacted and security called. Continued with CPR until AED (automated external defibrillator) arrived. ESD (sic) in place and instructions began. CPR and breaths given, O2 (oxygen) at 15/L (liters per minute). Suction given for possible mucous plug in mouth. Resident taking breaths at this time sporadically. Arrival of 911. Resident transferred to (initials of hospital). The SNF/NF (skilled nursing facility/non skilled nursing facility) to Hospital Transfer Form dated [DATE], documented the resident's name, vital signs, responsible party contact information, primary care physician name, and functional status. The form did not document if the comprehensive care plan goals were sent/provided to the hospital. A request was made on [DATE] at 10:30 a.m., to ASM #2 for the documentation that Resident #12's comprehensive care plan goals were sent to the hospital upon the residents transfer on [DATE]. On [DATE] at 11:49 a.m., ASM (administrative staff member) #2 (the director of health services) presented a blank checklist form that documented, Resident Name ____Date___ CHECKLIST FOR TRANSFERRING A RESIDENT TO THE HOSPITAL Check off as you complete: 1. __Receive order from MD (medical doctor) 2. __Notify '911' or (name of transportation company) - or if longer than necessary wait- Utilize '911' for emergency situations. 3. __ Notify the Front Desk that rescue personnel will be arriving. 4. __ Send the following to the hospital in an ORANGE FOLDER/ENVELOPE via the emergency personnel. 4.1 __ 2 Copies of the Face Sheet (1 copy to EMT [emergency medical technician]/ 1 copy in the folder) 4.2 __ Copy of the DNR (do not resuscitate) document. 4.3 __ Copy of any Advance Directive [Living Will, Durable Power of Attorney for Health Care, 5 Wishes] 4.4 __ MAR (medication administration record) 4.5 __ eInteract Transfer form 4.6 __ Print off Care Plan send to hospital. Nurses' Signature ___ Date ___. [DATE] at 12:35 p.m. ASM (administrative staff member) #2, the director of health services) stated she could not validate that the care plan was provided upon transfer to the hospital. ASM #2 stated it was a crazy morning with (Resident #12) coding and CPR initiated. On [DATE] at 1:30 p.m., an interview was conducted with RN (registered nurse) #1, regarding information provided to hospital staff when a resident is transferred to the hospital. RN #1 stated the nurses have a checklist and provide a face sheet (that includes the doctor's information and family contact information), living will information, power of attorney information, any information possibly related to treatment in the hospital, the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 stated this information is sent with the resident when they leave the facility unless there is an emergent situation such as providing cardiopulmonary resuscitation. RN #1 stated that in the case of an emergent situation, information is faxed to the hospital. RN #1 stated nurses evidence the information provided to hospital staff by completing and signing the checklist form, by documenting a nurse's note or by a fax confirmation. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of health services, were made aware of the above concern on [DATE] at 4:30 p.m. No further information was provided prior to exit. References: (1) Pneumonia: An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. This information was obtained from the following website: https://medlineplus.gov/pneumonia.html. (2) [CONDITION(S)] (chronic obstructive pulmonary disease) - general term for chronic, nonreversible lung disease that is usually a combination of [CONDITION(S)] and chronic [CONDITION(S)]. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124.

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for two of 22 residents in the survey sample, Residents #13 and #2. 1. The facility staff failed to review and revise Resident #13's comprehensive care plan to address the care needs and use of oxygen. 2. The facility staff failed to review and revise Resident #2's comprehensive care plan to reflect interventions documented in the nurses notes to ensure implementation after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: 1. Resident #13 was admitted to the facility on [DATE]. Resident #13's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13's quarterly minimum data set assessment with an assessment reference date of 7/1/21, coded Resident #13 as being cognitively intact. Section O coded Resident #13 as receiving oxygen while a resident. Review of Resident #13's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's comprehensive care plan initiated on 7/6/17 failed to reveal the care plan was reviewed or revised for oxygen use. On 9/21/21 at 12:10 p.m., Resident #13 was observed in a wheel chair receiving oxygen at two liters per minute via nasal cannula. On 9/22/21 at 8:50 a.m., ASM (administrative staff member) #2 (the director of health services) presented a portion of Resident #13's care plan that documented, (Resident #13) has an ADL (activities of daily living) self-care performance deficit r/t (related to) Impaired balance, unsteady gait, deconditioning, OA ([CONDITION(S)]) Dx (diagnosis), and [CONDITION(S)] Dx. A red line was drawn beside the intervention, Treatments per orders. Date Initiated: 12/20/2020. This portion of the care plan did not address oxygen use. ASM #2 also presented a revision of Resident #13's care plan dated 9/22/21 that documented, Focus: The resident has oxygen therapy ordered at night due to [CONDITION(S)] (low oxygen levels in your tissues). Goal: The resident will have no s/sx (signs or symptoms) of poor oxygen absorption through the review date. Interventions: OXYGEN SETTINGS: O2 (Oxygen) via NC (nasal cannula) per orders and PRN (as needed). Monitor for s/sx of respiratory distress and report to MD (medical doctor) PRN . On 9/22/21 at 9:01 a.m., an interview was conducted with LPN (licensed practical nurse) #1, the staff responsible for reviewing and revising care plans. LPN #1 stated oxygen was addressed under the ADL portion of the care plan that documented, Treatments per orders. LPN #1 was made aware that Treatments per orders on the ADL portion of the care plan was dated before Resident #13's oxygen was ordered and the ADL care plan documented nothing regarding the resident's respiratory status or oxygen use. LPN #1 stated That was my catch all. I put treatment per order; it covers if I miss something. LPN #1 stated a resident's care plan should be reviewed and revised for the use of oxygen if she knows about the new order for and implementation of oxygen. LPN #1 stated the care plan should include the reason for use if she knows what it is, whatever the goal might be and Keep sats (oxygen saturation level) above something (a certain level) or to comfort. LPN #1 stated Resident #13's care plan was revised this morning (9/22/21) to include the use of oxygen. When asked the purpose of a care plan, LPN #1 stated, It is supposed to be for nursing staff to know what the issues are, what our hopes are and what we plan to achieve. When asked if the ADL portion documenting Treatments per orders of Resident #13's care plan reflected the purpose for oxygen use, LPN #1 stated, But this is a catch all. On 9/22/21 at 4:34 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Resident Assessment using the Minimum Data Set (MDS 3.0)/Resident Instrument (RAI) documented, 9. The care plan will be reviewed and revised by the interdisciplinary team and will be reviewed and/or modified as resident status changes and new needs/preferences are identified. The facility policy titled, Oxygen Therapy- Mask, Nasal Cannula, and Humidification documented, Oxygen is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties .13. Update Care Plan as needed. No further information was presented prior to exit. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (3) The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 9/9/2021 coded Resident #2 as scoring a 12 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. The resident was coded as requiring limited assistance of one staff members for moving in the bed, transfers, ambulation, and locomotion. The resident was coded as requiring extensive assistance of one staff member for dressing, eating, toileting and personal hygiene. A nurse's note dated 4/1/2021 at 3:40 p.m. documented, Resident sitting in w/c (wheelchair) & (and) slid down onto her buttocks behind the leg rests with feet in front of the leg rests. Resident's head was leaning back against w/c seat & cushion. No injuries notes [Sic.], resident moving all extremities. Assisted to recliner with use of maxi-lift. Neuro (neurological) checks in progress r/t [related/to] unwitnessed fall. Resident to be placed in recliner with pressure alarm for decreased awareness & fall prevention. A nurse's note dated, 4/7/2021 at 5:32 p.m. documented, Resident was being assisted from the chair to wheelchair, once in w/c she attempted to move herself back but wheelchair wasn't locked, as she went to move she lifted her bottom chair moved and she landed on floor on her buttocks. No injury noted, does c/o (complain of) bottom hurting while setting on the floor waiting to be assisted off floor with maxi lift. The comprehensive care plan for Resident #2 dated, 6/24/2020 and last reviewed on 4/14/2021, documented in part, I (Resident #2) am at risk for falls. I have a history of falls. The Interventions were dated from 6/24/2020 through 2/24/2021. The Interventions dated, 4/7/2021, documented, Ambulate with staff and assistance device as needed. Re-education staff. Use wheelchair for transfers off unit only. Wheelchair to be used on for transport off of community. The comprehensive care plan failed to include the interventions documented in the nurses note after the fall on 4/1/21, for: Resident to be placed in recliner with pressure alarm for decreased awareness & fall prevention. An interview was conducted with LPN (licensed practical nurse) #1, the MDS coordinator, on 9/22/2021 at 2:21 p.m. When asked who updates the care plans, LPN #1 stated she was the only one that touches care plans. LPN #1 stated, No nurse's here update care plans but me. When asked if she attends morning meetings to find out if anyone fell , LPN #1 stated most of the time they mention the fall and then move on, no details are shared unless I ask. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of health services, were made aware of the above concern on 9/22/2021 at 4:30 p.m. No further information was provided prior to exit. References: (1) Alzheimer's disease: a progressive loss of mental ability and function, often accompanied by personality changes and emotional instability. Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and Chapman, page 26. (2) [CONDITION(S)] a disease in which elevated pressure in the eye, due to obstruction of the outflow of [MEDICATION(S)] humor, damages the optic nerve and causes visual defects. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 247. (3) Meniere's disease a disease of the inner ear, characterized by recurrent episodes of dizziness, progressive hearing loss and ringing in the ears. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 360.

Based on staff interview, facility document review, and clinical record review it was determined the facility staff failed to ensure one of 22 residents in the survey sample, received the care and services in accordance with professional standards and the comprehensive care plan for Resident #32. The facility staff failed to administer the physician ordered diuretic medication, [MEDICATION(S)] to Resident #32 as ordered. The findings include: Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (1) The most recent MDS (minimum data set) assessment, a Medicare 5 day/Admission assessment, with an assessment reference date of 8/17/2021, coded Resident #32 as scoring a 14 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living, except eating in which she was coded as being independent. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] > (greater than) 122 administer PRN (as needed) [MEDICATION(S)] (diuretic) per order one time a day related to hypertension (high blood pressure). The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The August MAR (medication administration record) for Resident #32 was reviewed and documented the above physicians order for [MEDICATION(S)]. On 8/20/2021, Resident #32's weight was documented as 126.4. There was a blank on the MAR for the administration of [MEDICATION(S)] on 8/20/2021. Review of the nurse's notes failed to evidence documentation of the administration of the [MEDICATION(S)] as ordered by the physician. On 8/21/2021 there was no weight for Resident #32 documented on the MAR or in the vital sign section of the clinical record. Review of the nurse's notes failed to evidence documentation for the administration [MEDICATION(S)] or a weight for Resident #32. On 8/23/2021, Resident #32's weight was recorded as 127.4. There was a blank on the MAR for the physician prescribed [MEDICATION(S)] on 8/23/2021. Review of the nurse's notes failed to evidence documentation for the administration of the [MEDICATION(S)] ([MEDICATION(S)]) as ordered by the physician. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] > 128, administer PRN (as needed) [MEDICATION(S)] per order one time a day related to hypertension. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] >128. Review of the September MAR for Resident #32, revealed the above documented the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/20/2021, Resident #32's weight was documented as 128.4. There was a blank on the MAR for administration of the physician ordered [MEDICATION(S)] on 9/20/2021. Review of the nurse's notes failed to evidence documentation for the administration of the [MEDICATION(S)] as ordered by the physician. The care plan dated, 8/26/2021, documented in part, Focus: The resident has hypertension. The Interventions documented in part, Give antihypertensive medications as ordered. Monitor for side effects such as [CONDITION(S)] and increased heart rate. Monitor for and document any [CONDITION(S)]. Notify MD (medical doctor). An interview was conducted with LPN (licensed practical nurse) #3 on 9/22/2021 at 2:00 p.m. The above physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #3. When asked what a blank on the MAR indicated, LPN #3 stated, I don't know if it was documented, we don't know if that was given. When asked if the resident should have received the PRN (as needed) [MEDICATION(S)] on the above days, LPN #3 stated, Yes. The facility policy, Medication Administration - General Guidelines documented in part, Standard: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis, in accordance with local, state, and federal laws, rules and regulations .Responsibility of the person administering medications is to be aware of the classification, action, correct dosage, and side effects of a medication before administration Medications are administered in accordance with written orders of attending physicians, manufacturer's specifications and professional standards of practice . Only the licensed or legally authorized personnel who prepares a medication may administer it. This individual records the administration on the resident's MAR after the medication is given. AT the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses were administered and all administered doses were documented. In case should the individual who administered the medications report off-duty without first recording the administration of any medications When PRN medications are administered, the following documentation is provided: date and time of administration, dose, route of administration (if other than oral), and if applicable, the injection site. Complaints or symptoms for which the medication was given. According to Fundamentals of Nursing, Seventh Edition, 2009: by Perry and Potter Chapter 35 Medication Administration Chapter 35, pg. 707 read: Professional standards, such as the American Nurses Association's Nursing: Scope and Standards of Nursing Practice (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication, 2. The right dose, 3. The right client, 4. The right route, 5. The right time, and 6. The right documentation. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of health services, were made aware of the above concern on 9/22/2021 at 4:30 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 243. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 8.html

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care and services according to professional standards of practice for one of 22 residents in the survey sample, Resident #12. The facility staff administered oxygen to Resident #12 without specific physician ordered parameters for titration of the oxygen flow rate. The findings include: Resident #12 was admitted to the facility on [DATE] with a recent readmission on 8/31/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Many germs, such as bacteria, viruses, and fungi, can cause pneumonia) (1), [CONDITION(S)] ([CONDITION(S)] - general term for chronic, nonreversible lung disease that is usually a combination of [CONDITION(S)] and chronic [CONDITION(S)]) (2), and repeated falls. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 9/7/2021, coded the resident as not completing the interview for the BIMS (brief interview for mental status) score, but coded the resident as having no short or long term memory difficulties. The resident was coded as requiring extensive assistance to being dependent upon one or more staff members for all of his activities of daily living. In Section - O, Special Treatment, Procedures and Programs, documented Resident #12's use of oxygen while a resident at the facility. Observation was made of Resident #12 on 9/21/2021 at 12:45 p.m. The resident was lying across the bed, appearing restless. Resident #12 had oxygen on via a nasal cannula connected to any oxygen concentrator. The flow meter of the oxygen concentrator was set at 3.5 LPM (liters per minute). On 9/22/2021, at 9:57 a.m., Resident #12 was observed sitting on the side of the bed, his oxygen was not on, and the nasal cannula was observed around his neck. Resident #12 was observed mouth breathing and restless. The oxygen concentrator flow meter was set at 5 LPM. CNA (certified nursing assistant) #1 entered the room and assisted Resident #12, with reclining in the bed. CNA #1 then requested a housekeeper get the nurse. LPN (licensed practical nurse) # 2 entered the room at 10:05 a.m., and was asked to read what Resident #12's oxygen concentrator flow rate was currently set at, LPN #2 stated, 5 LPM [liter per minute]. LPN #2 stated the night nurse stated he was on 4.5 LPM through the night. At this time, LPN #2 was asked to check Resident #12's oxygen saturation level (O2 sat) with a pulse oximeter. LPN #12 was observed checking Resident #12's oxygen saturation using a pulse oximeter. The resident's O2 saturation was 91%. LPN #2 stated the nurses can titrate his [Resident #12's] oxygen up if he drops below something and we titrate him up until he levels out. At this time, the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 stated, His (Resident #12) [CONDITION(S)] has gotten worse while he was in the hospital this past time. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's TAR (treatment administration record) for September 2021, documented the above physicians order for oxygen. The TAR documented the resident received oxygen at the flow rate of 2 - 5 LPM on the day shift, 3 - 6 LPM on the evening shift, and 4 - 5 LPM on the night shift throughout September. The TAR documented the Resident #12's oxygen concentration levels as: 90 -98% on the day shift, 90 -95% on the evening shift and 90 -95% on the night shift. The comprehensive care plan for Resident #12, dated, 9/9/2021, documented in part, Focus: I [Resident #12] tested positive for COVID. The Interventions documented in part, Provide supplemental O2 as ordered. An interview was conducted with ASM (administrative staff member) #3, the facility nurse practitioner, on 9/22/2021 at 12:04 p.m. The above physicians order for oxygen was reviewed with ASM #3. When asked how a staff nurse knows how and what flow rate to titrate the oxygen to for Resident #12, ASM #3 stated, Great question. Off that order, I wouldn't know how to do it. The man has [CONDITION(S)]. ASM #3 stated, Before he was using oxygen, his O2 sat was between 93% - 94%. When asked if the order should have parameters, ASM #3 stated, Absolutely. An interview was conducted with ASM #2, the director of health services, on 9/22/2021 at 12:40 p.m. The above physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked how the staff nurse knows what flow rate of oxygen to administer, ASM #2 stated, (ASM #3) is making modifications to the order now. ASM #2 stated the staff have no parameters for the oxygen flow rate. When asked if it is within a nurse's scope of practice to decide the amount of oxygen to be given, ASM #2 stated she would have to look that up. ASM #2 stated, Oxygen can be considered a medication and titrating it without parameters could be considered prescribing. The facility policy, Oxygen Therapy - Mask, Nasal Cannula and Humidification documented in part, Standard: Oxygen is administered appropriately to resident to improve oxygenation and provide comfort to residents experiencing respiratory difficulties. Policy: Oxygen administration requires a physician and/or primary care provider order. Oxygen is administered by licensed staff and/or by the resident under supervision of the licensed nurse .Procedures: d. Turn on the oxygen source to the prescribed liter flow. The center of the float ball must be on the line of the ordered level of oxygen. The center of the float ball must be observed at eye level. The licensed nurse should check the level at least twice a shift. According to Fundamentals of Nursing, Perry and Potter, 6th edition, page 1122, Oxygen should be treated as a drug. It has dangerous side effects, such as atelectasis or oxygen toxicity. As with any drug, the dosage or concentration of oxygen should be continuously monitored. The nurse should routinely check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The six rights of medication administration also pertain to oxygen administration. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of health services, were made aware of the above concern on 9/22/2021 at 4:30 p.m. No further information was provided prior to exit. References: (1) This information was obtained from the following website: https://medlineplus.gov/pneumonia.html. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124.