Every finding on record at Sun Valley Rehabilitation and Healthcare Center

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable in 5 of 5 influenza vaccine single-dose, pre-filled syringes reviewed for vaccine storage and labeling. The facility failed to ensure that all influenza vaccine single-dose, pre-filled syringes were not past their expiration date. The facility's failure could result in residents receiving influenza vaccines at their best therapeutic level. The findings included: During an observation on [DATE] at 01:22 PM, of the influenza vaccines revealed 5 out of 5 influenza vaccine single-dose, pre-filled syringes past the expiration date of [DATE]. During an interview on [DATE] at 01:30 PM, RN A stated the influenza vaccines were expired and should have been discarded. She said she thought they were still good. RN A stated the expiration date was checked before administering the vaccine and would have been caught. During an interview on [DATE] at 01:35 PM, the DON stated they should have known the influenza vaccines were expired and they should have been discarded. The DON stated he would discard them immediately. The DON stated the vaccine’s expiration date was checked before administration and the resident would not have received an expired vaccine. During an interview on [DATE] at 05:35 PM, the DON stated the only policy he could find was the medication administration policy which did not mention expiration dates. He said he looked through all the policies and none mentioned expiration dates. He said he had looked for a policy on vaccinations and could not find anything. B

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for one (Resident #11) of three residents reviewed for infection control, in that: LVN C failed to don personal protective equipment (PPE) before entering Resident #11's room. Resident #11 was under enhanced barrier precautions per physician orders. This failure could place residents who resided in the facility, as well as employees and visitors, at risk for communicable diseases and infections. The findings included: Record review of Resident #11's face sheet dated 07/08/25 revealed a [AGE] year-old male admitted into the facility on [DATE], with a diagnosis of acute hematogenous osteomyelitis, left ankle and foot ( a bone infection caused by bacteria traveling through the bloodstream to the bone), end stage renal failure (a severe medical condition where the kidneys have permanently lost their ability to function), dependance on renal dialysis (when a person's kidneys are no longer able to adequately remove waste and excess fluid from the blood, necessitating regular dialysis treatments to sustain life), and severe sepsis with sepsis shock (a life-threatening condition where the body's extreme response to an infection causes organ damage and dangerously low blood pressure). Record review of Resident #11's Physician Orders dated 06/16/25 revealed Enhanced barrier precautions every shift with high contact care activities. No end date to order noted. Record review of Resident #11's baseline care plan dated 06/16/25 revealed requirement of enhanced barrier precautions to reduce risk of Multidrug-resistant organism (MDRO) transmission. Resident 11 was at risk for infection as evidence by pressure wound, cellulitis wound, current use of indwelling device: foley catheter, and dialysis access permcath (a type of catheter used for long-term hemodialysis or other therapies requiring reliable vascular access). Goal: Will be free from MDRO infection through the next review date. Interventions: Enhanced barrier precautions. Staff to use gowns and gloves during high contact care activities. Record review of Resident #11's baseline MDS dated [DATE] revealed a BIMS score of 15 which meant cognition was intact. During an observation on 06/07/25 at 1:15 p.m., Resident #11 was on enhanced barrier precautions. Outside Resident #11's room was an enhanced barrier sign, and personal protective equipment placed inside plastic drawers with gowns available. Just inside Resident 11's room gloves were available. LVN C entered Resident #11's room without donning a gown but did don gloves. LVN C then went up to Resident 11's bedside. LVN C then proceeded to remove Resident 11's blanket to reveal foley catheter tubing. LVN C touched foley drainage tubing and balloon inflation port to locate foley catheter size. In an interview on 06/07/25 at 1:25 p.m. with LVN C, - LVN C stated when a resident was placed on enhanced barrier precautions, staff needed to put on gloves and gown before they entered their room if contact with the resident occurred. LVN C stated she got nervous and forgot to don gown. LVN C stated it was important to wear personal protective equipment before they entered the room to prevent the spread of infection to staff and other residents. In an interview on 07/09/25 at 5:02 p.m., the DON stated enhanced barrier precautions were in place with high contact care residents. The DON stated enhanced barrier precautions should be followed by all staff for infection control. The DON stated that in-services (training) on infection control were the key to preventing this from happening again. Review of facility's policy titled Infection Prevention and Control Program dated 5/13/2023 revealed; Isolation Protocol (Transmission-Based Precautions):a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.Review of CDC guidelines revealed: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gowns. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #37) reviewed for assessments: Resident #37's quarterly MDS assessment, dated 05/17/2025, did not include a diagnosis of Anxiety. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #37's electronic face sheet dated 07/09/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: Unspecified Dementia, Anxiety Disorder, Type 2 Diabetes Mellitus, Muscle Weakness, Hypertension (high blood pressure), and Major Depressive Disorder. Record review of Resident #37's physician order summary, dated 07/09/2025, reflected the resident had medication order for Buspirone 10 mg tablet for Anxiety with start date of 06/13/2024. Record review of Resident #37's medication administration record, from 07/01/2025 to 07/09/2025, reflected the resident was receiving Buspirone 10 mg tablet as ordered. Record review of Resident #37 's Quarterly MDS dated [DATE] reflected: Section I - Active Diagnoses Psychiatric/Mood Disorder I5700. Anxiety Disorder. The facility did not check off active diagnosis. In an interview on 07/09/25 at 1:53 p.m. with the MDS nurse stated that she was responsible for completing the MDS assessments for the facility. She confirmed, Resident #37 was receiving Buspirone 10 mg for Anxiety. The MDS nurse added that the diagnosis of Anxiety should have been included on the MDS assessment for Resident #37 and was not included as an oversight. She stated there was no system in place that oversees that they were accurately completed. The MDS nurse stated that the MDS assessment accuracy was important on how the resident receives the care that they need and to form a plan of care. In an interview on 07/09/25 at 2:02 p.m. with the DON stated that the MDS nurse was responsible for the MDS assessments. He stated there was a software system in place that checks for accuracy in the MDS assessments called simple and corporate reviews them as well. The DON confirmed that Resident #37 had a diagnosis of Anxiety and that the MDS nurse should have included Resident #37's diagnosis on the MDS assessment. He stated that it was important for the MDS assessment to be completed accurately to make sure that they provide proper care and medication. Record review of the facility policy, titled Assessment Frequency/Timeliness, date reviewed/revised 02/2023, reflected that Policy: The purpose of this policy is to provide a system to complete standardized assessment in a timely manner according to the current RAI [NAME]. Record review of the CMS's RAI Version 3.0 Manual dated October 2024, reflected section: I: Active Diagnoses I: Active Diagnosis in the Last 7 Days-Check all that apply Psychiatric/Mood Disorder I5700. Anxiety Disorder There may be specific documentation in the medical record by a physician, nurse practitioner, physician assistant, or clinical nurse specialist of active diagnosis.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 1 of 5 residents (Resident #59) reviewed for comprehensive person-centered care plans. 1.The facility failed to ensure Resident #59's care plan had the correct interventions for her vision impairment. This failure could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings include: Record review of Resident #59's face sheet dated 07/09/25 reflected an [AGE] year-old female with an admit date of 10/03/23 and an original admission date of 01/18/23. Her relevant diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and need for assistance with personal care. Record review of Resident #59's quarterly MDS assessment dated [DATE] reflected a BIMS score of 99, which indicated her cognition was severely impaired. MDS also indicated Resident #59's vision was moderately impaired (limited vision, not able to see newspaper headlined but can identify objects), and no to corrective lenses. Record review of Resident #59's quarterly care plan dated 06/05/25 reflected: Focus: [Resident #59] has impaired visual function r/t decreased visual acuity (date initiated 01/31/23 and revised on 10/19/23). Goal: The resident will have no indications of acute eye problems through the review date (date initiated 01/31/23 and revised on 03/17/25). Her interventions: in part included remind resident to wear glasses when up. Ensure resident is wearing glasses which are clean, free from scratches and in good repair. Report any damage to nurse/family. An observation on 07/07/25 at 3:30 p.m., Resident #59 was observed sitting in her wheelchair in the dining room during activities and was not wearing glasses. Resident #59 smiled at this Surveyor as she approached her, was able to make eye contact, but was not interviewable. An observation on 07/08/25 at 10:00 a.m., Resident #59 was observed in her room sitting in her wheelchair and was not wearing glasses. An observation on 07/09/25 at 12:15 p.m., Resident #59 was observed in the dining room during lunch and was not wearing glasses. In an interview on 07/09/25 at 12:30 p.m., CNA A said she had cared for Resident #59 for over a year and had never seen her wear glasses. CNA A said she had not noticed Resident #59 had vision problems. In an interview on 07/09/25 at 12:59 p.m., CNA B said she had cared for Resident #59 for over a year and had never seen her wear glasses. CNA B said she had not noticed Resident #59 had vision problems. In an interview on 07/09/25 at 1:10 p.m., LVN C said she was the charge nurse for Resident #59. She said Resident #59 required extensive assistance for all ADLs but had never seen her wear glasses. In an interview on 07/09/25 at 1:45 p.m., the MDS Nurse said it was her responsibility to ensure a resident's MDS assessment was accurate. She said Resident #59 had impaired visual function due to decreased visual acuity. She said whenever a resident suffered a visual impairment, she would enter it on their MDS assessment. She said once the visual impairment had been entered on their MDS, it would trigger a set of interventions for their care plan. The MDS Nurse said she had a pre-selected option she could select that included: Announce self by name, call resident by name, Anticipate and assist with all visual needs, Keep both eyes clean and free from matter, Monitor both eye for redness, drainage, swelling, signs, and symptoms of infection, notify MD as needed, Monitor/document/report PRN any s/sx of acute eye problems: change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky c/o halos around lights, double vision, tunnel vision, blurred or hazy vision, and Remind resident to wear glasses when up. Ensure resident is wearing glasses which are clean free from scratches and in good repair. Report any damage to nurse/family (date imitated 01/31/23).The MDS Nurse said she also had the option to not select the pre-selected interventions and only click on those that applied to that resident. She said Resident #59 did not wear glasses as noted in her MDS assessment. The MDS Nurse said I'm only human, and by that she said she should have selected the interventions that only applied to Resident #59 and the pre-selected interventions. The MDS Nurse said there had been no negative outcome to Resident #59 because her care plan indicated she wore glasses. In an interview and observation on 07/09/25 at 2:00 p.m., the DON said he was pretty sure Resident #59 wore glasses. He was observed as he reviewed Resident #59's care plan and said the reason she wore glasses was because of her vision impairment. The DON was observed as he called Resident #59's RP. While the DON had Resident #59's RP on speaker, he asked her does your [Resident #59] wear glasses and she replied no, I don't think she has ever worn glasses. The DON then asked her She was admitted with glasses, right? and RPs replied no, she was not. After the telephone conversation with Resident #59 RP, the DON said, I know she wore glasses. This Surveyor requested the facility's Care Plan policy several times, but the DON provided Care Plan Revision Upon Status Change.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #39), reviewed for care plans. The facility failed to ensure Resident #31's care plan was revised to reflect an order for an alarm guard. This failure could place residents at risk of current needs not being met. Findings include: Record review of Resident #31's admission record, dated 05/31/2024, reflected the resident was an [AGE] year-old female with an admitted [DATE]. Resident #31had diagnoses which included dementia (general decline in cognitive activities), diabetes (sustained high blood sugar levels), cognitive communication deficit (problems with communication), and anxiety disorder (mental disorder associated with stress.) Record review of Resident #31's significant change status MDS assessment, dated 05/24/24, reflected a BIMS score of 3, which indicated Resident #31's cognition was severely impaired and had no behaviors of wandering. Resident #31 used a wander/elopement alarm daily. Resident #31 used a wheelchair as a mobility device. Resident #31 was transferred from the secured unit to the general population on 05/07/24. Record review of Resident #31's physician orders reflected an order for an alarm guard, to the left arm, start date 05/07/24. An order, dated 05/29/24, reflected an order for the alarm guard to the left ankle. Record review of Resident #31's care plans reflected the resident required a wander guard (alarm guard) bracelet and was at risk for injury from wandering in an unsafe environment, as evidenced by dementia and Alzheimer's, date initiated on 05/29/24. Observation on 05/29/24 at 11:00 AM revealed Resident #31 in bed, wearing an alarm guard on her left ankle. Interview on 05/31/24 at 2:42 PM with the DON revealed Resident #31 was in the secured unit and was transferred into the general population because she became dependent on Hoyer lift transfers and could no longer be in the secured unit. Resident #31 had an order for an alarm guard on 05/07/24 when she was transferred out of the secured unit. As part of an IDT decision, the order for an alarm guard was requested. Interview on 05/31/24 at 10:55 AM with MDS Coordinator E, revealed Resident #31's care plan was not immediately updated to reflect the use of an alarm guard on 05/07/24 until a significant change status MDS was completed on 05/29/24. MDS Coordinator E said she did not remember she was informed about the order until she completed the significant change status MDS that involved an assessment of the resident's care plans. MDS Coordinator E said she developed a care plan to address Resident #31's use of alarm guard until 05/29/24. Interview on 05/31/24 at 1:34 PM with LVN F revealed a care plan was used to gather information on focus areas, goals and interventions. This information was then communicated to the CNAs

Based on interview and record review the facility failed in ensure the right to request, refuse or discontinue treatment for 1 of 14 residents (Residents #17) reviewed in that: 1. The facility failed to make sure Resident #17's out of hospital do not resuscitate (OOHDNR) form was accurately signed. These failures could place residents at risk for inaccurate and incomplete records. The findings include: Record review of Resident #17's face sheet, dated [DATE], revealed Resident #17 was a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) and chronic kidney disease stage 3 unspecified ( kidneys are damaged and can't filter blood as they should). Resident #17's face sheet also revealed her to have an advance directive of do not resuscitate. Record review of Resident #17's MDS, dated [DATE], revealed the resident had a BIMS score of 3, which meant the resident was severely cognitively impaired. Record review of Resident #17's hospice certification and plan of care dated [DATE] revealed Resident #17's hospice start of care date as [DATE]. Record Review of Resident #17 order summery report dated [DATE] revealed an active order for Do not resuscitate with a start date of [DATE] and no end date. Record review of Resident #17's care plan with a revision date of [DATE] revealed focus of Resident #17/Rp request code status of DNR with a goal of Status will be maintained through next review with revision date of [DATE] and a target date of [DATE]. Record review of Resident #17's care plan dated [DATE] revealed an intervention to ensure Advance Directives are in place per resident and responsible party request Record review of Resident #17's OOHDNR dated [DATE], revealed the physician did not sign in the section titled Physician's statement which confirmed I am the attending physician of the above - noted person and have noted the existence of this order in the person's medical record, I direct health care professional acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing (temporarily paces a patient's heart during an emergency and stabilizes them), defibrillation (when an electronic device sends an electric shock to the heart to stop an extremely rapid, irregular heartbeat, and restore the normal heart rhythm), advanced airway management, artificial ventilation. The physician signed section E. titled Declaration on behalf of the minor person: which stated A physician has diagnosed the minor as suffering from a terminal or irreversible condition. I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. During an interview with the Social Worker on [DATE] at 8:55 a.m., the Social Worker confirmed Resident #17's (OOHDNR) was not signed by the physician in the section for the physician's signature. The Social Worker said when incidents like that happen, she will mark the error to clarify that there is an error present. The Social Worker said she had not yet sent out the (OOHDNR) would be sending the (OOHDNR) back to the physician. During an observation and interview with the Social Worker On [DATE] at 9:23 am the social worker showed that she marked the error on the OOHDNR by placing an arrow where the signature was on section E and where it should have been under physician statement. The Social Worker said she had sent the (OOHDNR) to be resigned by the physician. During an interview with the Social Worker on [DATE] at 9:25 am the social worker was asked what could happen to Resident #17 if she coded (went into cardiac arrest) and the (OOHDNR) was not accurately signed. The social work said she did not know because that has never happened before. During an interview with the DON on [DATE] at 12:40 p.m., he said the Social Worker had let him know about the incorrectly signed (OOHDNR) for Resident # 17 and that the facility was working with the hospice and physician to get the out of hospital do not resuscitate form accurately signed by the physician Record review of the facility's policy titled Advance Directives revision date of [DATE] did not address signing the OOHDNR correctly.

Based on interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 14 residents (Resident #42) reviewed for resident records in that: Resident #42's January 2022 MAR did not have completed physicians orders documented on it. This failures could place residents at risk for inaccurate and incomplete records. The findings include: Record review of Resident #42's face sheet, dated 01/27/2022, revealed Resident #17 was a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses that included: covid-19, type 2 diabetes mellitus with peripheral angiopathy( blood vessel disease caused by high blood sugar levels) without gangrene (Decay of tissue caused by lack of blood supply,) and [CONDITION(S)] right eye category 5, low vision left eye category 2. Record review of Resident #42's order summary dated 1/27/2022, revealed an order for [MEDICATION(S)] R [MEDICATION(S)] 100 unit/ml solution pen-injector inject as per sliding scale: if 0 - 200 = 2 units; 201 - 225 = 3 units; 226 - 250 = 4 units; 251 - 275 = 5 units; 276 - 300 = 6 units; 301 - 325 = 7 units; 326 - 350 = 8 units; 351 - 400 = 9 units if bs >400, give insulin and repeat fsbs (finger stick blood sugar) in 1 hour and if still >400, call md, subcutaneously (under skin) before meals and at bedtime for DM (diabetes mellitus) with a start date of 02/10/2021 and no end date. Record review of Resident #42's January 2022 MAR, dated 1/27/2022, revealed a blank for the following medication: - [MEDICATION(S)] R [MEDICATION(S)] 100 unit/ml Solution pen-injector Inject as per sliding scale: subcutaneously before meals and at bedtime for DM (diabetes mellitus) On 01/06/2022 at 4:30 pm this medication was left blank not indicating if the medication was administered, refused or held. Record review of Resident #42's progress notes dated 1/6/2022 did not reveal an explanation/justification for the blood sugar check and [MEDICATION(S)] medication on 1/06/2022 at 4:30pm not being documented and left blank on Resident #42's MAR. During an interview with ADON A on 1/27/22 at 3:02 pm, ADON A said the MAR has different options to code when medication is not given to residents. ADON A reviewed and confirmed the blank on Resident # 42's MAR. ADON A reviewed progress notes and was unable to locate documentation on why Resident #42's MAR was left blank and said she was unsure why the MAR was left blank and referred me to the DON. During an interview with the DON on 1/27/2022 at 4:13 pm, the DON said Resident #42's MAR should have been documented as refused for blood sugar check and held for [MEDICATION(S)] on January 6th because Resident #42 refused his blood sugar check and physician held the [MEDICATION(S)] for Resident #42 on January 6th. Record review of the facility's policy titled Administering Medication revision date April 2019, revealed If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall initial and document on the MAR space provided for that drug and dose.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary and comfortable environment, and to prevent the development and transmission of communicable disease and infections, for two Residents (R#3 & R#4), of five residents observed for infection control practices. LVN D did not perform hand hygiene before and after direct contact with residents R#3 and R#4 during a dining observation. This failure could affect residents who were dependent upon care and place them at risk for healthcare associated cross-contamination, infections, and COVID-19 (Coronavirus). Findings included: Record review of R#3's admission record dated 06/11/2021 revealed R#3 was a [AGE] year-old male admitted to the facility on [DATE]. R#3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of R#4's admission record dated 06/11/2021 revealed R#4 was a [AGE] year-old female admitted to the facility on [DATE]. R#4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an observation on 06/11/2021 at 12:05 p.m., in the dining room, surveyor observed LVN D in the dining room with 10 residents having lunch. Surveyor observed LVN D going up to R#3 and running her fingers through R#3's hair while she talked to R#3. LVN D was not wearing gloves at the time of the observation. LVN D walked away from R#3 and stood in the center of the dining room observing the other residents. No hand hygiene was performed after she came into direct contact with R#3's hair. LVN D was observed assisting R#4 in removing the clothing protector from around R#4's neck and assisting R#4 with donning the surgical mask. LVN D grabbed R#4's tray and placed the tray in the meal cart at the center of the dining room. No hand hygiene was performed before or after LVN D came in direct contact with R#4. In an interview on 06/11/2021 at 12:10 p.m., LVN D said hand hygiene should be performed before and after contact with the residents. LVN D acknowledged no hand hygiene was performed between contact with R#3 and R#4. LVN D said there are hand sanitizing stations in the dining room. LVN D said she may have overlooked it. LVN D said it was important to sanitize between residents to prevent the spread of any infections. In an interview on 06/11/2021 at 12:20 p.m., the DON said the staff should be conducting hand hygiene between contact with residents. DON said the purpose of hand sanitizing is to prevent the spread of infections. Record review of the facility policy titled, Handwashing/Hand Hygiene, dated Revised August 2015 revealed: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; i. After contact with resident's intact skin; p. Before and after assisting a resident with meals;

Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy during care, for one Resident (R#1) of five residents reviewed for privacy, in that: Certified Nurse Aide (CNA) A and CNA B did not provide full visual privacy when conducting incontinent care for R#1. This failure could place residents at risk for embarrassment, poor self-esteem, and unmet needs. The findings were: Record review of R#1's Admission Record dated 06/11/2021 indicated R#1 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of R#1's Comprehensive MDS dated [DATE] indicated R#1: -had adequate hearing without the use of a hearing aide -had clear speech -was rarely/never understood -rarely/never understands others -required total dependence of two staff to physically assist in transfers, toilet use, personal hygiene and bed mobility. Record review of R#1's Care Plan indicated: Focus: The resident has ADL self-care performance deficit r/t Activity Intolerance, Alzheimer's, Impaired balance, Limited Mobility, Limited ROM Date Initiated: 03/16/2021 Revision on: 03/16/2021 Interventions: TOILET USE: The resident requires ext. to total assist of 2 staff for toileting and incontinent care. TRANSFER: The resident requires Mechanical Lift .with (2) staff assistance for transfers. On 06/11/2021 at 12:50 p.m. surveyor observed CNA A and CNA B conduct a two-person mechanical lift transfer for R#1. Once the resident was transferred from the geri chair to bed b, CNA A and CNA B began to conduct incontinent care on R#1. The curtain dividing bed a and bed b was closed but was not pulled all the way leaving the foot of the bed open to view. While the CNAs were conducting incontinent care, the door was opened once by LVN C, who had come into the room to assist with R#1's transfer. LVN C exited the room opened and closed the door to R#1's room. The door was opened one more time while incontinent care was being provided to R#1 by an unidentified female staff. The unidentified female staff knocked on the door and opened it stating that R#2 wanted to come back into the room. CNAs told unidentified female staff that incontinent care was being conducted on R#1. The unidentified female staff backed out of the doorway and said she would come back after they are done with incontinent care. The unidentified female staff closed the door on her way out. In an interview on 06/11/2021 at 1:00 p.m., CNA A and CNA B said the privacy curtain should be closed all around the resident during incontinent care to provide the resident with full visual privacy. CNAs said the curtain and the door need to be closed to provide privacy for the resident in case someone opens the door during care. CNA B said the curtain was not pulled all the way around the resident due to the mechanical lift being in the way of the curtain path. In an interview on 06/11/2021 at 1:35 p.m., the Director of Nurses said each resident should be provided with privacy during all types of care, including incontinent care. The DON said staff should close the door as the first line of privacy and close the curtains around the resident to provide full privacy. In an interview on 06/11/2021 at 3:21 p.m., the Administrator said he could not answer for the staff providing full privacy to the resident because he was not present at the time. The Administrator said the facility policy does not specify that the privacy curtain needs to be pulled completely around the resident. The Administrator said he does not recall reading anything in the regulations about having the curtain pulled all the way. Record review of the facility policy titled Resident Rights Guidelines for All Nursing Procedures, dated Revised October 2010 revealed: Purpose: To provide general guidelines for resident rights while caring for the resident. General Guidelines: 1. For any procedure that involves direct resident care, follow these steps: f. Close the room entrance door and provide for the resident's privacy.

Based on observations, interviews, and record reviews the facility failed to provide services as outlined by the comprehensive care plan to meet professional standards of quality for 1 of 5 residents (Resident #1) receiving respiratory treatments in that: CNA A and CNA B removed R#1's nasal cannula and turned off the oxygen machine to conduct a mechanical lift transfer on the resident. This failure could place all residents on oxygen therapy at risk of [CONDITION(S)] [lack of oxygen] due to not receiving oxygen as ordered by physician. The findings were: Record review of R#1's Admission Record dated 06/11/2021 indicated R#1 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of R#1's Comprehensive MDS dated [DATE] indicated R#1: -had adequate hearing without the use of a hearing aide -had clear speech -was rarely/never understood -rarely/never understands others -required total dependence of two staff to physically assist in transfers, toilet use, personal hygiene and bed mobility. Record review of R#1's Care Plan indicated: Focus: [R#1] requires O2 via nasal cannula 4LPM r/t ischemic [CONDITION(S)] Date Initiated 03/04/2021 Revision on 03/04/2021. Interventions: Apply O2 via nasal cannula as ordered, monitor O2 sats as needed, notify MD of any abnormalities, monitor O2 tank every two hours while resident is using O2 tank. Record review of R#1's Physician's Orders dated 03/01/21 revealed: Order: Oxygen at 4L/min via NC continuously On 06/11/2021 at 12:34 p.m. Surveyor entered R#1's room and observed CNA A and CNA B getting R#1 ready to conduct a [mechanical lift] transfer from the geri chair to the bed. R#1 was next to bed B in the room in the geri chair. R#1 did not have the nasal cannula on, and the oxygen machine was off at the time of the observation. CNA A was moving the [mechanical] lift next to R#1 when R#2 who was in the bathroom at the time called out to the staff that he was ready to be assisted off the commode. Surveyor observed CNA A place the nasal cannula on R#1 and turned on the oxygen machine that was set at 4LPM. CNA A and CNA B both went to assist R#2 in the bathroom. R#2 was assisted out of the room by CNA B. In an interview on 06/11/2021 at 12:45 p.m. CNA A said CNAs are able to remove the nasal cannula from the residents and turn off the oxygen machine while they are conducting a transfer from the geri chair to the bed because the oxygen tubing is not long enough and can get caught. CNA B said they are able to remove the oxygen from R#1 when they are going to conduct a transfer because R#1 is able to tolerate the transfer without oxygen. CNA B said there are other residents that are not able to tolerate it, but R#1 was able to be without oxygen while the transfer is being conducted. CNA A said they have been told that if they were going to conduct a transfer, they were able to remove the nasal cannula and turn off the oxygen machine without notifying the nurse. CNA A was not able to identify who gave her this instruction. CNA A and CNA B said they were both unaware the nurse needed to be notified prior to removing the nasal cannula or turning off the oxygen machine. CNA B said she usually does not work in this hall. CNA B said she usually did was not familiar with the hall she was working and usually worke in hall 100 and there are no residents that use oxygen in that hall. CNA A said she was going to go call the nurse. 06/11/2021 at 12:58 p.m. LVN C came into R#1's room. LVN C was present and assisted CNA A and CNA B with R#1's [mechanical lift] transfer from the geri chair to the bed. LVN C removed R#1's nasal cannula during the transfer. Once R#1 was placed on the bed after the transfer, LVN C assessed R#1's oxygen saturation using the pulse oximeter which read 100% with the oxygen set at 4LPM. In an interview on 06/11/2021 at 1:20 p.m. LVN C said the CNAs should not be removing R#1's nasal cannula or turning off the oxygen machine because it is out of their scope of practice. LVN C said he was not aware CNA A and CNA B had removed R#1's nasal cannula and turned off her oxygen machine prior to the transfer. LVN C said CNAs must always notify the nurse for assistance with the oxygen equipment. In an interview on 06/11/2021 at 1:25 p.m. the DON said CNAs can remove the nasal cannula from residents and they are able to turn off the oxygen machines when conducting transfers. The DON said the oxygen tubing was not long enough to reach. The DON said the CNAs do it when they are conducting transfers and when they are taking the residents to the dining room. The DON said the CNAs were in-serviced on this and they should have documentation of training on their skill check offs. Record review of the facility's skill check off documentation for CNAs revealed there was no mention of CNAs being provided training on oxygen administration. In an interview on 06/11/2021 at 1:35 p.m. the DON said the CNAS were not checked off on turning off the oxygen machine or to remove the nasal cannula from the residents. The DON said that he looked it up and the CNAs were not supposed to be removing nasal cannulas or turning off the oxygen machine, only the nurse. Record review of the facility policy titled, Oxygen Administration, dated Revised October 2010 indicated: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration.