Every finding on record at Wolfeboro Bay Center

Based on interview and record review it was determined that the facility failed to ensure PRN (as needed) orders for antipsychotic drugs are limited to 14 days in 1 of 5 residents reviewed for unnecessary medications (Resident identifier is #11). Findings include:Review on 4/15/26 of Resident #11's medical record revealed an order for Olanzapine 5mg (milligrams) 1 tablet by mouth every 12 hours as needed for vascular dementia, moderate, with agitation for 60 days with a start date of 2/26/26. Further review revealed that Resident #11 received the PRN dose on April 1, 3, 4, 6, 14, and 15, 2026. Review on 4/15/26 of Resident #11's Medication Regime Review, dated 3/12/26 revealed a recommendation for, Currently has an active order for Olanzapine prn (as needed) with a duration of 60 days. Please note that CMS guidelines do not allow maintaining orders for PRN antipsychotics for greater than 14 days on medication profiles . Prescriber responded: disagree, already documented need for over 14 days. Interview on 4/15/26 at approximately 2:15 p.m. with Staff C (Clinical Consultant) confirmed the above order for Olanzapine 5mg every 12 hours as needed. Review on 4/15/26 of facility policy titled Use of Psychotropic Medications, dated 10/28/2025, revealed, b. PRN orders for antipsychotic medications only, shall be limited to 14 days with no exceptions.

Based on record review and staff interview, the facility failed to ensure medications were administered in accordance with physician orders. This failure resulted in multiple insulin administration errors for 1 of 1 resident reviewed for insulin. (Resident identifier is #33.)Findings include: Resident #33 Record review on 4/14/26 showed a physician's order dated 1/16/26 for NovoLog Flex Pen Subcutaneous Solution Pen-inject 100 unit/ml (Insulin Aspart). Inject 20 units subcutaneously before meals for DM2(Diabetes Mellitus type 2) Hold for BS (blood sugar) under 110. Review of the Medication Administration Record (MAR) on 04/14/2026 revealed insulin was administrated outside ordered parameters on: On January 21st Insulin was administered when the BS was 96 at 7:00 a.m.On January 28th Insulin was administered when the BS was 99 at 5:00 p.m. On February 11th Insulin was administered when the BS was 99 at 5:00 p.m.On February 12th Insulin was administered when the BS was 106 at 11:30 a.m., and at 5:00 p.m. one MAR entry for this date was left blank with no documentation of a BS level and no indication whether insulin was administered or held. On March 4th Insulin was administered when the BS was 103 at 7:30 a.m.On March 9th Insulin was administered at all three meals when BS readings were 109 at 7:30 a.m., 109 at 11:30 a.m., and 97 at 5:00 p.m.On March 13th Insulin was administered when the BS was 91 at 7:30 a.m.On March 19th Insulin was administered when the BS was 72 at 5 :00 p.m. During an interview on 4/15/26 at 1:38 p.m., Staff B (Unit Manager) confirmed the above findings. Review of the facility's policy titled Timely Administration of Insulin, revised 10/28/25, showed under Policy Explanation and Compliance Guidelines . 1. All insulin will be administered in accordance with physician's orders.

Based on observation, interview, and record review, it was determined that the facility failed to ensure a medication error rate was less than 5 percent (%) for 11 of 35 medication administrations observed. (Resident identifiers are #38) Findings include: Resident #38 Observation on 2/21/25 at approximately 8:45 a.m. of Staff B (Licensed Practical Nurse) revealed Staff B prepared the following 11 medications for Resident #1: Aspirin 81 mg (milligram) enteric coated, Magnesium Oxide 400 mg, Vitamin D3 1000 iu (units), Senna 8.6 mg, Miralax 17gm (grams), Buspirone 15 mg, Olanzapine 15 mg (3), Paroxetine 50 mg, Metformin 1000 mg, Carvedolil 25 mg, and Lisinopril 20 mg. Further observation revealed Staff B entered the wrong residents room. Staff B introduced themselves to Resident #38 and was prepared to administer the medications. The surveyor intervened. Interview on 2/21/25 at approximately 8:45 a.m. with Staff B confirmed he/she was going to administer Resident #1's medications to Resident #38. Review on 2/21/25 of facility policy titled Medication Administration reviewed/revised 9/1/24 revealed Policy Explanation and Compliance Guidelines: .10. Ensure that the 6 rights of medication administration are followed: a Right resident . There were 11 medication errors out of a total of 35 medication administration opportunities resulting in a 31.43% error rate.

Based on observation, record review, and interview, it was determined that the facility failed to meet professional standards for 1 of 4 nursing staff observed for medication administration and 1 of 2 residents reviewed for pain in a final sample of 16 residents (Resident identifiers are #164 and #214). Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Resident #214 Observation on 2/20/25 at approximately 9:00 a.m. of Staff E (Medication Nursing Assistant (MNA)) revealed that Staff E administered medications to Resident #214 including Fluticasone Propionate Diskus Inhalation Powder 250mcg/ACT. Further observation revealed that Staff E did not have Resident #214 rinse his/her mouth with water after the inhaler. Interview on 2/20/25 at approximately 9:00 a.m. of Staff E confirmed the above findings. Review on 2/20/25 of Manufacturer instructions for use for Fluticasone Propionate Diskus Inhalation Powder revealed .Step 5 (final step). Rinse your mouth . Review on 2/21/25 of facility policy titled Medication Administration reviewed/revised 9/1/24 revealed Policy Explanation and Compliance Guidelines: .17. Administer medication as ordered in accordance with manufacturer specifications . 47129 Resident #164 Interview on 2/19/25 at 11:00 a.m. with Resident #164 revealed that Resident #164 had chronic pain and was prescribed Oxycodone every six hours. Resident #164 stated that the facility had run out of his/her medication a few weeks ago. Review on 2/21/25 of Resident #164's medical record revealed a physician's order for the following: Oxycodone HCI (Hydrochloride) Tablet 30 mg (Milligram), give 1 tablet by mouth every 6 hours for chronic pain, start date 1/8/25 and discontinued 1/24/25. Oxycodone HCI Tablet 30 mg, give 1 tablet by mouth every 6 hours for chronic pain, start date 1/24/25. Review on 2/21/25 of Resident #164's January 2025 Medication Administration Record (MAR) revealed the Resident #164's Oxycodone HCI Tablet 30 mg was not signed off as administered on 1/24/25 at 9:00 a.m., 1/25/25 at 3:00 a.m., and 1/26/25 at 9:00 a.m. Further review revealed that on 1/25/25 at 9:00 a.m., Resident # 164 was administered 25 MG of Oxycodone not the ordered 30 mg. Review on 2/21/25 of Resident #164's nursing notes on 1/24/25 through 1/26/25 revealed that on 1/24/25 at 9:00 a.m., 1/25/25 at 3:00 a.m., and 1/26/25 at 9:00 a.m., there was documentation that the Oxycodone 30 HCI Tablet 30 MG was unavailable or waiting on delivery from the pharmacy. Interview with 2/21/25 at 2:09 p.m. with Staff F (Nurse Practitioner) revealed that Staff F was unaware that Resident #164 had not been administered his/her scheduled Oxycodone on the above dates and times and that the Oxycodone HCI 30 MG was not available in the facility. Review on 2/21/25 of Resident #164's pain care plan revealed a goal of .will achieve acceptable level of pain control . revised on 1/3/25 and an intervention dated 1/3/24 .Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated.

Based on interview and record review, it was determined that the facility failed to ensure that long term care residents were seen face to face by a physician at least once every 60 days for 2 out of 2 residents reviewed for physician visits in a final sample of 22 residents (Resident Identifiers are #22 and #42). Finding include: Resident #22 Interview on 1/17/24 at 1:13 p.m. with Resident #22 revealed that he/she has seen the nurse practitioner but has not seen the physician. Review on 1/18/24 of Resident #22's medical record revealed he/she was initially admitted to the facility for long term care on 1/23. Further review of the medical record revealed the following face to face provider visits: APRN [Advanced Practice Registered Nurse] saw the resident on 2/13/23, 3/13/23, 6/20/23, 11/20/23, and 1/12/24. Review on 1/18/24 of Resident #22's physician progress notes revealed that there were no face to face visits performed by a physician. Interview on 1/18/24 at 3:00 p.m. with Staff A (Director of Nursing) revealed that Staff A was unable to find any documentation in Resident #22's medical record that Resident #22 was seen face to face by the physician. Interview on 1/18/24 at 4:02 p.m. with Staff J (APRN) confirmed that the physician did not alternate visits for Resident #22 and Resident #22 had not been seen face to face by the physician since admission. Resident #42 Interview on 1/17/24 at 1:40 p.m. with Resident #42 revealed that he/she saw the nurse practitioner all the time but had not seen a doctor in over a year since he/she was in the hospital. Interview on 1/18/24 at 3:00 p.m. with Staff A revealed that the facility's Medical Director had changed in May 2023, and did not see residents unless Staff J was on vacation. Review on 1/18/24 of Resident #42's medical record revealed the following provider visits since July 2023: APRN saw the resident on 7/7/23, 9/14/23, 11/10/23, and 1/9/23. Review on 1/18/24 of Resident #42's physician progress notes revealed that there were no face to face visits by the physician since July 2023. Interview on 1/18/24 Staff J confirmed that Resident #42 was not seen face to face by a physician since July 2023.

Based on interview and record review, it was determined that the facility failed to provide sufficient staff to meet residents' needs for 12 of 30 days reviewed (Resident Identifiers are #3, #10, #13, #15, #19, #21, #22, #29 #43, #46, and #211). Findings include: Review on 1/17/24 of the facility assessment staffing ratios revealed: Solona Unit Licensed Nursing Assistant (LNA) ratios = 1:12 for 7:00 a.m. - 3:00 p.m., 2:16 for 3:00 p.m. - 11:00 p.m. and 1:24 for 11:00 p.m. - 7:00 a.m. Granite Unit LNA ratios = 1:13 for the 7:00 a.m. - 3:00 p.m., 1:13 3:00 p.m. - 11:00 p.m. and 1:19 for 11:00 p.m. - 7:00 a.m. Review on 1/16/24 at 11:00 a.m. of the Facilities Nursing Staffing Scheduled for the past 30 days revealed that the staffing ratios for the LNAs did not meet the established ratios in the above Facility Assessment on the following days: 12/18/23: Granite Unit 3:00 p.m. - 11:00 p.m. shift had 2 full shift LNAs and one other LNA for 4 hours for 35 residents. 12/25/23: Solona Unit 7:00 a.m. - 3:00 p.m. shift had 1 LNA for 23 residents. The 3:00 p.m. - 11:00 p.m. shift had 1 LNA for 23 residents. 12/29/23: Solona Unit 7:00 a.m. - 3:00 p.m. shift had 1 LNA for 23 residents. . 12/30/23: Solona Unit 3:00 p.m. - 11:00 p.m. shift had 1 LNA for full shift and 1 LNA for 4 hours for 23 residents. 1/6/24: Granite Unit 7:00 a.m. - 3:00 p.m. shift had 2 LNAs for the full shift and 1 LNA for 4 hours for 37 residents 1/7/24: Granite Unit 7:00 a.m. - 3:00 p.m. shift had 2 LNAs for the full shift and one other LNA for 4 hours for 37 residents. Solona Unit 3:00 p.m. - 11:00 p.m. shift had 1 LNA for the full shift and 4 hours from another LNA for 23 residents 1/8/24: Solona Unit 7:00 a.m. - 3:00 p.m. shift had 1 LNAs for the full shift and another LNA for 4 hours for 23 Residents. Solona Unit 3:00 p.m. - 11:00 p.m. shift had 1 LNA for 23 residents. 1/9/24: Solona Unit 7:00 a.m. - 3:00 p.m. shift had 1 LNA for the full shift and another for 4 hours for 23 Residents. Granite Unit 3:00 p.m. - 11:00 p.m. shift had 2 LNAs for the whole shift and another for 4 hours for 38 Residents. Granite Unit 11:00 p.m. - 7:00 a.m. had 1 LNA from 3-5 a.m for 38 residents. Solona Unity 11:00 p.m. - 7:00 a.m. had a nurse until 3:00 a.m. and 1 LNA, from 3:00 a.m. - 5:00 a.m when the nurse left at 3:00 a.m. the LNA was alone on that floor for 2 hours. 1/10/24: Solona Unity 3:00 p.m. - 11:00 p.m. shift had 1 LNA for 24 residents. Granite Unit 3:00 p.m. - 11:00 p.m. shift had 2 LNAs for the whole shift and another LNA for 4 hours for 37 residents. 1/11/24: Granite Unit 3:00 p.m. - 11:00 p.m. shift had 2 LNAs for the whole shift and another LNA for 4 hours for 37 Residents. Solona Unity 3:00 p.m. - 11:00 p.m. shift had 1 LNA for the whole shift and another LNA for 4 hours for 24 residents. 1/12/24: Solona Unity 7:00 a.m. - 3:00 p.m. shift had 1 LNA for 24 residents. Solona Unit 3:00 p.m. - 11:00 p.m. shift had 1 LNA for 24 residents. 1/13/24: Granite Unit 7:00 a.m. - 3:00 p.m. shift had 2 LNAs for 39 Resident. Granite Unit 3:00 p.m. - 11:00 p.m. shift had 2 LNAs for the whole shift and another LNA for 4 hours for 39 residents. Solona Unit 3:00 p.m. - 11:00 p.m. shift had 1 LNA for 24 residents. Solona Unit 7:00 a.m. - 3:00 p.m. had 1 LNA for the whole shift and another LNA for 4 hours for 24 residents. Interview on 1/16/24 at 10:00 a.m. with Staff V (LNA) revealed that Staff V, who worked primarily on the Solona/Bay Units, often worked alone on the day shift and that he/she has 24 residents with 5 residents totally dependant on care for transfers. Interview on 1/17/24 At 1:00 p.m. with Staff E (Unit Manager, Licensed Practical Nurse) revealed that Staff E, who worked primarily on the Solona/Bay Units with just one LNA of them during the day shift. Interview on 1/19/24 at 1:00 p.m. with Staff A. (Director of Nursing) confirmed the staffing levels for the above days were below the ratios established in the facility assessment. 47129 Resident #15 Interview on 1/16/24 at 2:28 p.m. with Resident #15 revealed that it would sometimes take up to 30 minutes or longer on the weekends for the call bell to be answered. Resident #15 stated that just last week he/she had to sit in a wet brief for a long time. Review on 1/16/24 of Resident #15's quarterly Minimum Data Set (MDS) with an assessment reference date of 11/29/23 revealed Resident #15 had a Basic Interview for Mental Status (BIMS) score of 14 out of 15 indicating cognitively intact. Resident #22 Interview on 1/16/24 at 12:22 p.m. with Resident #22 revealed that when Resident #22 presses the call bell it takes a while for staff to come. Resident #22 stated my roommate presses the call bell a lot because he/she needs help way more than me, so they think it's him/her calling. One time I was in the bathroom and needed help. I had to scream on the top of my lungs for them to come. Review on 1/16/24 of Resident #22's quarterly MDS with an assessment reference date of 12/7/23 revealed Resident #22 had a BIMS score of 14 out of 15 indicating cognitively intact. Resident #29 Interview on 1/16/24 at 1:22 p.m. with Resident #29 revealed that he/she could wait up to 30 minutes or longer especially on the weekends because he/she is a 2 person assist for care. Review on 1/16/24 of Resident #29's quarterly MDS with an assessment reference date of 12/14/23 revealed Resident #29 had a BIMS score of 15 out of 15 indicating cognitively intact. Interview on 1/17/24 at 12:41 p.m. with Staff G (Unit Manager) revealed that Resident #29 was a 2-3 person assist with transfers and most care. Interview on 1/17/24 at 10:00 a.m. with Resident Council (Resident identifiers are #3, #10, #13, #19, #21, #22, #43, #46, and #211) revealed that there were concerns with long call bell wait time. Resident #21 stated on the weekends, he/she can wait up to 45 minutes for help. 8 out of 9 Residents agreed with the long wait time which can take up to 45 minutes or sometimes longer especially on the weekends. Resident Council members all agreed that staff rush with care because they need to get to the next resident who is calling for help.

Based on observation, interview, and record review, it was determined that the facility failed to monitor medication temperatures to ensure safe temperature controls in 3 out of 4 medication room refrigerators observed. Findings include: Review on 1/16/24 of the Temperature Refrigerator Log in the Bay Unit medication room for January 2024 revealed missing temperatures on 3 of 15 days (1/2/24, 1/4/24, and 1/5/24). Interview on 1/16/24 at 10:59 a.m. with Staff E (Licensed Practical Nurse, Unit Manager) confirmed above findings. Interview on 1/16/24 at 10:43 a.m. with Staff F (Medication Nursing Assistant) revealed that he/she was unable to provide temperature logs for Granite Unit medication room refrigerator. Review on 1/19/24 of the January 2024 Temperature Refrigerator Logs For Vaccines revealed missing temperatures on 4 out of 18 days (1/6/24, 1/7/24, 1/13/24, 1/14/24). Interview on 1/19/24 at 11:20 a.m. with Staff D (Infection Preventionist) confirmed the above findings. Review on 1/19/24 of the facility's policy Medication and Vaccine Refrigerator/Freezer Temperatures dated 8/7/23 revealed .Refrigerators and freezers used to store medications and vaccines will operate within acceptable temperature range and will be checked twice a day . Review on 1/19/24 of the facility's policy title Clinical Nurse Highlight: Medication Storage dated [DATE] under subcategory Refrigerated Medications revealed .Temperature is maintained between 36-46 degrees Fahrenheit. Daily temperature logs must be maintained and visible. If vaccines are stored, the temperature is documented twice daily . Review on 1/19/24 of the facility's policy titled Temperature log for Medication/Vaccination Refrigerators - Fahrenheit, not dated, revealed .Record temps twice each day . 40522

Based on observation, interview, and record review, it was determined that the facility failed to monitor food temperatures to ensure proper preparation. Findings include: Interview on 1/16/24 at 1:00 p.m. with Staff I (Food Service Director) revealed that food temperatures had not been taken for the morning breakfast food service or during the lunch meal service and that he/she was unable to provide any documentation of meal temperature monitoring. Observation on 1/16/24 at 1:30 p.m. of the Meal Temperature Logs revealed the most current log with temperatures were from August of 2023. Interview on 1/16/24 at 1:32 p.m. with Staff I (Food Service Director) confirmed that they had not been taking the temperature of the food prior to service.

Based on record review and interview, it was determined that the facility failed to ensure that the required 12 hours of in-service training was completed for 1of 1 (Licensed Nursing Assistant (LNA)) reviewed for required in-service training. Findings include: Review on 1/19/24 at 11:30 a.m. of Staff S's (LNA) Online Education Transcript Report revealed that Staff S did not contain the required education related to Dementia, Abuse Training, or a minimum of 12 hours of continuing competences for nurse aides. Interview on 1/19/24 at 12:00 with Staff A (Director of Nursing) confirmed the above findings. Review on 1/18/24 at 2:00 p.m. of the facility's policy titled Assessment, dated 2023, section B.2.Acuity-Care Requirements .4. Staff Competency: .3 .Required in-service training for nurse aides, which must be sufficient to ensure that continuing competence of nurse aides, but must be no less than 12 hours per year. Nurse aide training includes dementia management training and resident abuse prevention training. It also addresses areas of weakness as determined in nurse aide performance reviews and facility assessment and may address special needs of residents as determined by the facility staff .

Based on interview and record review, it was determined that the facility failed to ensure that residents' needs were timely addressed for 1 of 3 closed records reviewed (Resident Identifier is #111). Findings include: Review on 1/19/24 of Staff N (Licensed Nursing Assistant (LNA)) written witness statement dated 8/12/23 revealed .I worked from 11-11PM [11 a.m. to 11:00 p.m.] .At 11am I was assigned [Resident #111's name omitted]/ Between 11-11:30am I went in to check and change [pronoun omitted]. [pronoun omitted] breathing seems slightly labored . When I laid [pronoun omitted] flat it appeared [pronoun omitted] had periods of apnea so I raised [pronoun omitted] head again. The PT [Physical Therapy] therapist arrived and told me that we needed to get [pronoun omitted] up in the chair. I was surprised, but [pronoun omitted] went on to say [pronoun omitted] was up yesterday and did well. However when [pronoun omitted] went to help me get [pronoun omitted] up [pronoun omitted] commented that there was a decline. I reported this to the nurse [Staff O (Registered Nurse) name omitted] and [pronoun omitted] said ok. In the meantime I asked the LPN [ Staff P Licensed Practical Nurse (LPN) name omitted] to assist me in changing [pronoun omitted] brief .Around 3PM .[Staff Q (Unit Manager) name omitted] noted that [pronoun omitted] was declining. [pronoun omitted] was no longer responding verbally and breathing seemed more labored than earlier .Shortly after [pronoun omitted] was transferred to the hospital. Interview on 1/19/24 at approximately 1:00 p.m. with Staff P revealed that he/she worked on 8/12/23 and that he/she worked with Resident #111 during his/her stay at the facility but was not assigned to Resident #111 on 8/12/23. Interview with Staff P also revealed that he/she assisted Staff N with Resident #111's incontinence care approximately after 11:30 p.m. and before 3:00 p.m Staff P revealed that during the incontinence care, he/she noticed a change in condition with Resident #111 and he/she notified Staff O. Staff P also stated after 10 minutes unit manager of the Bay Unit was notified as there was no intervention taken by Staff O. Review on 1/19/24 of Staff R's (Physical Therapy Assistant) note, dated 8/12/23, revealed that Resident #111 was very difficult to arouse, unable to keep eyes open for more than a few seconds, no treatment per nursing. Interview on 1/19/24 at approximately 3:00 p.m. with Staff R confirmed the above PT note dated 8/12/23. Staff R stated that he/she went to see Resident #111 the morning of 8/12/23 for treatment and was unable to recall the exact time. Review on 1/19/24 of Staff Q's written statement with no date revealed On Sat [Saturday] 8/12/23 the start of 3-11p, [Staff N name omitted] came to me on the Bay Unit and asked me to come Take a look at [gender omitted] resident [Resident #111's name omitted] on KW [[NAME]] Unit. I asked if [pronoun omitted] nurse looked at [pronoun omitted] 1st. ''Please just come look its an emergency. I quickly left my unit (The Bay) went up the 120's side of granite past 2 nurses @ [at] med cart i quickly called out to them as I walked past them ''has anyone assessed [Resident #111 name omitted]? response from nurse [pronoun omitted] not my patient Upon arriving to [Resident #111's room number omitted] I observed resident in resp [respiratory] distress struggling to breathe, resp 27-30, [pronoun omitted] was on 2L [liters] O2 [oxygen] I bumped it up to 3L .I was able to talk to the nurse that was going off shift [Staff O], explained what was going on & the next steps that needed to be taken . Review on 1/19/24 of Staff O note dated 8/12/23 at 5:03 p.m. revealed that Resident #111 was having trouble breathing. Blood pressure was 96/50, heart rate was 85 and irregular, respirations were 24, oxygen saturation was 77 on 2 liters, increase oxygen to 3 liters, saturation up to 88, temperature was 96.8 Fahrenheit, lung sound was congested. Resident #111 remained unresponsive, family was notified, Third Eye [on-call telemedicine provider] was contacted, and provider gave permission to send Resident #111 to the hospital. Resident #111 was taken to the hospital by ambulance around 4:20 p.m. Review on 1/19/24 of Resident #111's vital sign record revealed the following: 8/12/23 at 9:39 a.m. oxygen saturation was 94% (percent) and at 5:19 p.m. 88%. 8/12/23 at 9:39 a.m. blood pressure was 142/70 and at 5:18 p.m. was 96/50. No other documented oxygen saturation and blood pressure on 8/12/23 between 9:40 a.m. and 5:19 p.m. Review on 1/19/24 of Resident #111's progress notes revealed no documentation of assessments after Staff N notified the nurse of a change of condition with Resident #111 on 8/12/23 at approximately 11:00 a.m. - 11:30 a.m Review of Resident #111's progress notes also revealed that Resident #111 had a telehealth evaluation on 8/12/23 at 2:55 p.m. which indicated that Resident #111 had shortness of breath, increased oxygen requirements, less responsive, increased respiratory rate, and to send Resident #111 to the emergency department. Review also revealed that Resident #111 passed away on 8/12/23 at 7:30 p.m. Review on 1/19/24 of Resident #111's hospital discharge summary, dated 8/12/23, revealed that Resident #111 was found unresponsive with blood pressure in low 60s that continued to drop and hypoxia to low 80s. There is evidence of aspiration pneumonia on X-ray in the setting of known dysphagia. Resident #111 has multiple comorbid conditions including recently diagnosed metastatic squamous cell carcinoma making the prognosis unfavorable. Further review revealed that primary discharge diagnoses were sepsis, aspiration pneumonia, and metastatic squamous cell cancer. Interview on 1/19/24 at approximately 2:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A stated that he/she expected that assessments and interventions such as notifying the provider should have been done immediately after being notified of a change of condition. Review on 1/19/24 of the facility's policy titled Change of Condition: Notification, revision date of 6/1/21, revealed .A Center must immediately .consult with the patient's physician .where there is: .A significant change in the patient's physical [sic] mental, or psychosocial status (that is a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or A decision to transfer or discharge the patient from the Center .

Based on record review and interview, it was determined that the facility failed to complete a performance review of nurse aides at least every 12 months for 1 of 1 Licensed Nursing Assistant (LNA) reviewed for annual performances. Findings include: Review on 1/18/24 at 12:00 p.m. of Staff F's (LNA) employee record revealed they were hired on 8/18/22 and there was no documentation of a performance review. Interview on 1/18/24 at 2:00 p.m. with Staff A (Director of Nursing) confirmed that they had not been doing performance reviews every 12 months for LNAs.

Based on record review and interview, it was determined that the facility failed to ensure that any irregularities reported in residents' drug regimen review were acted upon by the attending physician for 1 of 5 residents reviewed for unnecessary medications (Resident Identifier is #40). Findings include: Review on 1/19/24 of Resident #40's pharmacy consultation report [drug regimen review], dated 12/6/23, revealed that Resident #40 was on Seroquel [antipsychotic] 75 mg [milligrams] by mouth once a day, Seroquel 100 mg by mouth in the evening, and Escitalopram 10 mg one time a day. Further review revealed a comment that CMS [Centers for Medicare & Medicaid Services] guidelines require periodic assessment for need and dose reduction to ensure the lowest effective dose and to decrease the chance of adverse effects. Review also revealed a recommendation that if this therapy is to continue with no changes, it is recommended that the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual. There was no documentation that the attending physician responded to the recommendation. Review on 1/19/24 of Resident #40's physician orders revealed that there were no changes to the Seroquil and Escitalopram orders after the 12/26/23 recommendation. Interview on 1/19/24 at 11:00 a.m. with Staff A (Director of Nursing) confirmed that the above findings. Review on 1/19/24 at 11:30 a.m. of the facility's policy titled 9.1 Medication Regimen Review revision date 08/17/23, .Procedure 8.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, actions have been taken to address it . Further review of the policy revealed no timeframes for the different steps in the medication regimen review process.

Based on interview and record review, it was determined that the facility failed to provide the resident or the resident's representative with a written notice of transfer/discharge and also failed to send a copy of the written notice of transfer/discharge to the Long-Term Care (LTC) Ombudsman for 3 of 3 resident discharged records reviewed in a final sample of 22 residents (Resident identifiers are #28, #59, and #161). Findings include: Resident #59 Review on 1/19/24 of Resident #59's medical record revealed that Resident #59 was discharged from the facility on 11/2/23. There was no documentation of a written notice of transfer/discharge for the 11/2/23 discharge. Interview on 1/19/24 at approximately 2:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A stated that he/she was not aware that residents or residents' representatives are to be provided with written notice of transfer/discharge. Staff A also stated that there were no copies of written notice of transfer/discharge being sent to the LTC Ombudsman. Staff A was unable to provide evidence that Resident #59's copy of written notice of transfer/discharge was sent to the LTC Ombudsman. Interview on 1/19/24 at approximately 2:00 p.m. with Staff M (Social worker) revealed that he/she does not provide the residents, residents' representatives, or the LTC Ombudsman of a written notice of transfer/discharge with any discharges or transfers. Staff M stated that he/she only handled resident admissions. 45419 Resident #28 Review on 1/18/24 of Resident #28's medical record revealed that there was no documentation of a written notice of transfer/discharge of their hospital transfer. Resident #161 Review on 1/18/24 of Resident # 161's medical record revealed that there was no documentation of a written notice of transfer/discharge when Resident #161 transferred to another facility. Interview on 1/18/24 with Staff A confirmed the above findings. Review on 1/22/24 at 11:00 a.m. of the facility's policy titled Policy and Procedures for Discharge and Transfer revision date of 11/15/22, revealed .Policy .Transfer and Discharge .The patient and patient representative must be notified in writing prior to the transfer or discharge and in a language and manner they understand .

Based on interview and record review, it was determined that the facility failed to ensure that residents' records were complete and accurate for 2 residents in a final sample of 22 residents (Resident Identifiers are #59 and #111). Findings include: Resident #59 Review on 1/19/24 of Resident #59's medical record revealed that Resident #59 was discharged out of the facility on 11/2/23. Further review also revealed no documentation from staff or providers of Resident #59's discharge information or situation. Interview on 1/19/24 at approximately 12:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A stated that Resident #59 went out with a friend, he/she did not come back from an outing, and after talking to the previous administrator on the phone, Resident #59 decided not to come back to the facility and left AMA [Against Medical Advice]. Review on 1/19/24 of Resident #59's progress notes revealed that there was no documentation of Resident #59's AMA. Interview on 1/19/24 at approximately 12:00 p.m. with Staff J (Advance Practical Registered Nurse) revealed that he/she heard that Resident #59 left AMA. Staff J was unable to provide any documentation of Resident #59's AMA. Resident #111 Review on 1/18/23 of Resident #111's August 2023 Task Documentation For Meals (eating self-performance, support provided, and amount eaten) revealed that there were missing entries on the following: 2 meals on 8/4/23, 3 meals on 8/5/23 and 8/7/23, and 1 meal on 8/8/23 and 8/11/23. Further review also revealed that Staff T (Licensed Nursing Assistant) documented on 8/6/23 at 12:20 p.m. for a 12:00 p.m. meal, 8/10/23 1:43 p.m. for 8:00 a.m. meal, 8/10/23 1:50 p.m. for 12:00 p.m. meal, 8/11/23 12:54 p.m. for 8:00 a.m. meal, and 8/11/23 12:00 p.m. meal that Resident #59 was independent with eating for self performance and no setup help or physical help from staff. Review on 1/18/23 of Resident #111's medical record revealed that Resident #111 was admitted to the facility on [DATE]. Further review revealed a speech recommendation on 8/7/23 that Resident #111 required close supervision with reminders for strategies, when he/she is coughing, or a change to a wet or gurgly sounding voice, and provider 1 on 1 assistance as needed for safety. Interview on 1/18/23 at approximately 2:00 p.m. with Staff T stated that Resident #111 needed assistance with meals. Staff T confirmed the above task documentation for meals and that he/she inaccurately documented that Resident #111 was independent with meals.

Based on interview and record review it was determined that the facility failed to ensure that residents had access to their funds on an ongoing basis for 1 of 4 residents reviewed for Resident Funds (Resident identifier is #1). Findings include: Review on 11/1/23 of the facility reported incident #45974 dated 10/9/23 revealed that Resident #1 on 10/9/23 was angry and frustrated with not being able to get access to his/her money prior to the staff person who buys cigarettes going on vacation. Resident #1 left the building with the intent to go to the store, but was agreeable to return to the facility and have another staff person purchase cigarettes. Review on 11/1/23 of the facilities policy titled RFMS [Resident Fund Management Service] Petty Cash Box revised December 2022 revealed, .Federal regulations . require residents to have access to petty cash on an ongoing basis and be able to arrange for access to larger funds (those in excess of $100). To be in compliance, each center will maintain an RFMS resident petty cash box and an after hours RFMS resident cash box . Recommended Petty Cash Box amounts are based on the number of RFMS accounts in the center: 60-150 resident accounts: $500 .The center will maintain an After Hours Cash Box for use after business office banking hours . The Resident Petty Cash Box will be . Kept in a secure location after normal business hours (e.g. locked in the Medicine Room or another locked location .) by the After Hours Designee. NHA [Nursing Home Administrator] will appoint the After Hours Designee (e.g. evening/weekend receptionist, charge nurse, unit clerk, etc.) . Review on 11/1/23 of Resident #1's progress notes, dated 10/9/23, revealed Resident #1 was frustrated with not being able to get access to his/her money prior to the staff person who buys the cigarettes going on vacation and he/she had run out of cigarettes. Interview on 11/1/23 at 9:30 a.m. with Staff A (Unit Manager) revealed that the receptionist was the person in the facility who had access to the petty cash and was not aware of anyone else who had access. Interview on 11/1/23 at 9:45 a.m. with Resident #1 revealed that he/she was not always able to get petty cash when he/she wanted, which had most recently caused him/her to run out of cigarettes on 10/9/23. Resident #1 revealed that if the person who controls the petty cash is not in the building, then he/she cannot get money. Interview on 11/1/23 at 10:20 a.m. with Staff B (Receptionist) revealed that he/she was responsible for the petty cash. Staff B stated that he/she worked 8:00 a.m. to 4:00 p.m. four days a week and that the residents know that if they need cash, they were to come when he/she was working. Staff B confirmed that there was no access to petty cash on the weekends or when he/she was not working. Interview on 11/1/23 at 11:20 a.m. with Staff C (Activities Director) revealed that he/she was not able to purchase cigarettes for Resident #1 on 10/3/23 due to Resident #1 not having cash and Staff B not working. Review on 11/1/23 of the above email revealed on 10/3/23 at 4:00 p.m. an email from Staff C to the Former Administrator that read, Was unable to get [Resident #1] cigs[cigarettes] before I left due to waiting on [Staff B] to go to bank . [Resident #1] is upset, if someone can assist that would be great once bank run complete. Further review revealed that the Former Administrator replied at 6:32 p.m. Yes, I'll bring it up in the morning.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the residents' Minimum Data Set (MDS) accurately reflect the resident's smoking status for 4 of 4 residents reviewed for smoking (Resident Identifiers are: #1, #2, #3, #4). Finding Include: Interview on 11/1/23 at 9:20 a.m. with Staff A (Unit Manager) revealed that Residents #1, #2, #3, and #4 were smokers. Resident #2 Interview on 11/1/23 at 9:45 a.m. with Resident #2 revealed that Resident #2 has been a smoker since his admission to the facility 11/25/21. Review on 11/1/23 of Resident #2's care plan dated 2/14/22 with a target date of 11/20/23 revealed a smoking plan of care. Review on 11/1/23 of Resident #2's Annual MDS with an Assessment Reference Date (ARD) of 11/30/22 revealed that under Section J1300 Current Tobacco Use was coded as 0 or No. Interview on 11/1/23 at 11:00 a.m. with Staff D (Director of Nursing) revealed that the MDS was coded incorrectly. Interview on 11/1/23 at 2:46 p.m. with Staff G (MDS Coordinator) confirmed that the above MDS was incorrectly coded. Resident #3 Interview on 11/1/23 at 10:30 a.m. with Resident #3 revealed that Resident #3 has been a smoker since his admission to the facility 6/29/16. Review on 11/1/23 of Resident #3's smoking evaluation dated 6/2/23 revealed that Resident #3 is an independent smoker. Review on 11/1/23 of Resident #3's care plan dated 8/2/2016 and updated on 5/17/23 revealed a smoking plan of care. Review on 11/1/23 of Resident #3's Annual MDS with an ARD of 7/06/23 revealed that under Section J1300 Current Tobacco Use was coded as 0 or No. Interview on 11/1/23 at 12:00 p.m. with Staff D revealed that the MDS was coded incorrectly and that Resident #3 was a smoker. Interview on 11/1/23 at 2:46 p.m. with Staff G confirmed that the above MDS was incorrectly coded. Resident #4 Interview on 11/1/23 at 11:15 a.m. with Resident #4 revealed that Resident #4 has been a smoker since his admission to the facility on [DATE]. Review on 11/1/23 of Resident #4's smoking evaluation dated 11/14/22 revealed that Resident #4 is an independent smoker. Review on 11/1/23 of Resident #4's care plan dated 6/01/2022 and updated on 11/01/23 revealed a smoking plan of care. Review on 11/1/23 of Resident #4's MDS with an ARD of 7/29/23 revealed that under Section J1300 Current Tobacco Use was coded as 0 or No. Interview on 11/1/23 at 11:00 a.m. with Staff D revealed that the MDS was coded incorrectly and that Resident #4 was a smoker. Interview on 11/1/23 at 2:46 p.m. with Staff G confirmed that the above MDS was incorrectly coded. 43002 Resident #1 Observation on 11/1/23 at 8:55 a.m. of Resident #1 smoking outside in the smoking area. Interview on 11/1/23 at 9:45 a.m. with Resident #1 revealed that he/she smokes. Review on 11/1/23 of Resident #1's Smoking evaluations dated 6/30/23 and 10/2/23 revealed that Resident #1 was an independent smoker. Review on 11/1/23 of Resident #1's smoking care plan initiated 12/29/23 with at target date of 1/2/24 revealed that Resident #1 may smoke independently. Review on 11/1/23 of Resident #1's Annual MDS with an assessment reference date of 10/2/23 revealed that under Section J1300 Current Tobacco Use was coded as 0 or No. This section was signed as completed by Staff G on 10/12/23. Interview on 11/1/23 at 2:46 p.m. with Staff G confirmed that the above MDS was incorrectly coded and used the Resident Assessment Instrument (RAI) User's Manual for coding guidance.

Based on observation and interview it was determined that the facility failed to keep medications secured for 1 of 4 medication carts observed (Granite Unit 100 wing medication cart). Findings Include: Observation on 7/18/23 at 8:45 a.m. of the Granite Unit 100 wing medication cart revealed that the medication cart was unlocked, no staff was in the vicinity, and residents were passing by the unlocked cart. Interview on 7/18/23 at 8:53 a.m. with Staff D (Registered Nurse) confirmed the above findings. Standard: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing 7th edition St. [NAME], Missouri: Mosby lsevier, 2009. Page 721; Administering Oral Medications; Step 7; Item O. Do not leave medications unattended.

Based on interviews it was determined that the facility failed to report an alleged misappropriation no later than 24 hours to other officials, including the State Survey Agency (SSA) and the State Board of Nursing for 1 of 2 residents reviewed for alleged violations (Resident identifier is #5). Findings included: Interview on 7/18/23 at 10:50 a.m. with Staff G (Administrator) revealed that on 5/26/23 Resident #5 had one missing Oxycodone Instant Release (IR) [Opioid] 15 milligram (mg) tablet. The interview further revealed that the facility suspected Staff H (Medication Nursing Assistant) of misappropriation of Resident #5's medication. Interview on 7/18/23 at 11:30 a.m. Staff D (Registered Nurse) revealed that he/she worked on 5/26/23 and took over the medication cart from Staff H without counting narcotics. When Staff D's shift was ending at 7:00 p.m., the narcotic count was done with the oncoming nurse, The count identified that Resident #5 had one missing Oxycodone IR 15 mg tablet. Staff D stated that the missing medication was reported to the Administrator and Staff I (Interim Director of Nursing) on 5/26/23. Interview on 7/27/23 at approximately 10:20 a.m. with Staff A (Director of Nursing) revealed that the alleged misappropriation was not reported to the State Board of Nursing.

Based on interview and record review, it was determined that the facility failed to fully report the result of an investigation related to alleged abuse to the State Survey Agency (SSA) for 2 of 2 residents reviewed for alleged abuse (Resident identifiers are #1 and #5). The facility also failed to implement corrective action in response to the alleged misappropriation for 1 of 2 residents reviewed for alleged violations (Resident identifier is #5). Findings include: Resident #1 Review on 7/17/23 of Resident #1's facility-reported incident initial report, received on 6/25/23 by SSA, revealed that Resident #1 reported to the nurse that a staff member that worked last night (6/24/23) provided care and rough-handled the resident. Further review of the final report revealed that Resident #1 was assessed after Resident #1's report and Resident #1 was found to have a skin tear in their right elbow and complained of shoulder pain. Review on 7/17/23 of Resident #1's facility reported incident final report, received on 6/29/23 by SSA, revealed that the facility was unable to identify an alleged perpetrator. Interview on 7/18/23 at 11:17 a.m. with Staff B (Registered Nurse) revealed that he/she initially reported that Resident #1 stated there was an LNA (Licensed Nursing Assistant) that rough handled Resident #1 and that Resident #1 had swelling on their arm. Staff B stated that Resident #1 was unable to name the LNA and that the LNA was female. Interview on 7/18/23 at 11:50 a.m. with Staff A (Director of Nursing) revealed that he/she investigated the allegations related to Resident #1. Staff A stated that, during his/her investigation, he/she had suspected Staff C (Licensed Nursing Assistant) as the alleged perpetrator for the alleged rough handling of Resident #1. Staff A confirmed the final report sent to SSA (State Survey Agency) did not fully reflect what Staff A investigated. 45419 Resident #5 Interview on 7/18/23 at 12:00 p.m. with Staff G (Administrator) revealed that on 5/26/23 Resident #5 had one missing Oxycodone Instant Release (IR) [Opioid] 15 milligram (mg). Further interview revealed the facility determined that the necessary corrective action was to educate nursing staff on proper narcotic counts, exchanging keys on shift changes, and general management of narcotics, and that the facility would audit to monitor narcotic counts. Interview on 7/18/23 with Staff D (Registered Nurse) revealed that they had not received any recent education about narcotic counts and general management of narcotics. Interview on 718/23 at 12:05 p.m. with Staff E (Medication Nursing Assistant) revealed that he/she was a full-time staff. Staff E stated that they had not received any recent education on narcotic counts and general management of narcotics. Interview on 7/27/23 at approximately 10:20 a.m. with Staff A (Director of Nursing) revealed the facility was unable to provide documentation of education to nurses and completed narcotic count audits.

Based on record review, interview, observation, and policy review, it was determined that the facility failed to establish a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation for 1 of 2 narcotic books reviewed (Granite Unit 200 wing narcotic binder) (Resident identifier is #6). Findings include: Observation on 7/18/23 at 8:45 a.m. of the narcotics in the Granite Unit 200 wing medication cart with Staff E (Medication Nursing Assistant) revealed that the total number of narcotic medications prescribed to residents (tablets, capsules, patches, and liquids) was 28. Review on 7/18/23 with Staff E of the facility's Granite Unit 200 wing narcotic binder, revealed that the controlled substance (narcotic) inventory count sheet indicated a total number of resident's narcotic sheets were 27. Interview on 7/18/23 at 8:50 a.m. with Staff E confirmed the above findings. Staff E stated there should be 28 narcotic sheets. Review on 7/18/23 at 9:30 a.m. of the facility's policy titled LTC [Long Term Care] Facility's Pharmacy Services and Procedures Manual 5.4 Inventory Control of Controlled Substances revised on 1/01/22 revealed the following: 1. With respect to Schedule II controlled substances: 1.3.1 Reconcile the total number of controlled medications on hand, add newly received medications to the inventory, and remove medications that are completed or discontinued from the inventory, pursuant to the Controlled Substance Verification/Shift Count Sheet . Review on 7/18/23 of Resident #6's narcotic sheet for Oxycodone Immediate Release (IR) 10 milligram (mg) with a quantity of 30 tablets was received on 7/18/23 and was documented as being received by one nurse. Interview on 7/18/23 at 8:55 a.m. with Staff E confirmed the above narcotic for Resident #6 was received by one nurse. Staff E stated that it is the facility's policy that two nurses receive and document narcotics in the inventory. Interview on 7/18/23 at 11:50 a.m. with Staff A (Director of Nursing) revealed that narcotics received from the pharmacy should have been received and documented into inventory by two licensed nurses. Review on 7/18/23 of the facility policy titled, Controlled Drugs: Management of, revision date 4/1/22, revealed .Storage: Two licensed nurses and/or authorized nursing personnel, per state regulations, are required to document placement of controlled substances into inventory . Interview on 7/18/23 10:50 a.m. with Staff D (Registered Nurse) revealed that on 5/26/23, he/she took over a medication cart with a narcotic lock box and did not perform a narcotic count with another licensed nurse. Review on 7/18/23 of the facility policy titled, Controlled Drugs: Management of, revision date 4/1/22, revealed .Ongoing inventory: A complete count of all Schedule II-IV controlled substances is required at the change of shifts per state regulation or at any time when narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses and/or authorized nursing personnel . Standard [NAME] A. [NAME] and [NAME] [NAME] Fundamentals of Nursing 7th edition page 688 .Medication Regulation and Nursing Practice .The nurse is responsible for following legal provisions when administering controlled substances or narcotics which are carefully controlled through federal and state guidelines .

Based on record review and interview the facility failed to ensure that it develops and implements policies and procedures to prohibit the neglect of all residents in accordance with the resident's chosen cardiopulmonary resuscitation status resulting in 1 resident not receiving cardiopulmonary resuscitation and was pronounced expired. (Resident identifier is #1.) Findings include: Interview on [DATE] with Staff A, Administrator and Staff B, DON revealed that the facility does not have a written policy and procedure for residents who wish to have CPR (cardiopulmonary resuscitation) or full code status performed. Staff A and Staff B indicated that the facility considers it a professional standard of practice for nursing staff to be aware that if a resident is not DNR (do not resuscitate) then the resident would required CPR in which the resident is assessed, CPR initiated and 911 is called. Staff B also indicated that if a resident chooses to be a DNR then a form is completed and signed by the physician as an order. If the resident is not a DNR then the resident is considered a full code requiring CPR. Review of Resident #1's medical record on [DATE] reveals that Resident #1 was admitted to the facility on [DATE] and expired on [DATE]. Resident #1's physician orders [REDACTED]. During an interview on [DATE] at 1:20 p.m. with Staff C, LPN, Staff C indicated that on [DATE] at 5:20 a.m. Resident #1 was found lying face down on the bathroom floor unresponsive and without a pulse or breathing, feet and legs were blue. Staff C went to get Staff D, RN and Staff D told Staff C to call Staff B, DON to inform about Resident #1. Staff C was asked when did you become aware of Resident #1's code status? Staff C replied when Staff C called Staff B, DON at 5:45 a.m. 25 minutes after finding Resident #1 and Staff B asked about the code status and Staff C indicated not knowing what the status was and had to look for it. Staff C indicated having a difficult time trying to find out what Resident #1's status was. Staff C indicated a chart has a sticker on the front page only if the resident is a do not resuscitate (DNR) so she then went through the advance directive information which did not indicate a code status and then found on the physician order [REDACTED]. An interview with Staff B at 2:15 p.m. revealed that Staff C called Staff B at 5:45 a.m. on [DATE] to inform of Resident #1's passing. Staff B indicated asking Staff C about the code status and that Staff C was unaware at that time. At 6:00 a.m. Staff B called back to the facility and was informed that Resident #1 was a full code and no cardiopulmonary resuscitation measures had been initiated. During an interview on [DATE] with Staff E, RN ADON, Staff E was asked where would a residents code status be found. Staff E replied in the advanced directive section of the medical record, physician orders [REDACTED]. During an interview with Staff F, LPN on [DATE] revealed Staff F was asked where would a resident code status be found and Staff F replied on the resident MAR in the area titled advanced directives at the top of the MAR. This area may be blank or full code is imprinted indicating that the resident would require CPR. Residents that have DNR by physician order [REDACTED]. Staff G, Social Services on [DATE] compiled a list of the 84 residents residing in the facility and their code status. The list revealed 26 residents desired full code status. Review of the 84 residents MAR's in the advanced directive section revealed 30 residents with a blank advance directive section. Staff E and Staff F indicated these blanks represent a full code or CPR status. 2 residents MAR's had CPR indicated in the advanced directive section and 1 resident MAR indicates DNR in the advanced directive section but is indicated as a full code on the list provided. Resident's #2, #3, #4, #5, #6, #7 and #8. Review of the medical records revealed these residents had physician orders [REDACTED]. Resident 's #9, #10, #11, #12, #13 and #14. Review of the medical records revealed these residents had a physician order [REDACTED]. Resident's #15, #16, #17, #18, #19, #20, #21, #22, #23 and #24. Review of the medical records revealed these residents did not have a physicians order indicating any code status and the MAR was blank. Documentation is present in the social service notes indicates these residents desire for full code/CPR status. Resident's #25, #26, #27, #28, #29 and #30 Review of MAR's reveals advanced directive section was blank. Resident #31 Review of medical record on [DATE] reveals Resident #31 admitted on [DATE]. There is no documented evidence addressing code status. There is no physician or social service notes completed in the record. MAR reveals advanced directive section as blank. Resident's #32 and #33 Review of MAR reveals advanced directive section indicating CPR. Resident #34 Review of MAR reveals advanced directive section indicating DNR however list provided by facility indicates full code. During interview at 4:30 p.m. with Staff A and Staff B it is confirmed that a residents code status is not consistently documented in the medical record or in the MAR and is not consistently ordered by a physician when full code is desired by the resident.

Based on record review and interview the facility failed to ensure that it provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 resident with a full code status that was not implemented and the resident was pronounced expired. (Resident identifier is #1.) Findings include: Review of Resident #1's medical records on [DATE] reveals that Resident #1 was admitted to the facility on [DATE] and expired on [DATE]. Resident #1 had a physician's orders [REDACTED]. Review of Resident #1's care plan last reviewed on [DATE] reveals Resident #1 desires CPR. Goal is that CPR (cardiopulmonary resuscitation) will be initiated with the absence of no pulse, no blood pressure, and/or no respiration. Interventions indicate to verify the absence of apical pulse, respirations, and/or blood pressure, initiate CPR, call 911 and notify physician. Nurses note dated [DATE] at 5:20 a.m. by Staff C, LPN indicates that Resident #1 was found lying face down in bathroom unresponsive to any stimulus. A nurses' note dated [DATE] at 5:40 a.m. by Staff D, RN indicates that Resident #1 was assessed with [REDACTED]. There is no documented evidence of CPR being initiated or 911 called. During an interview on [DATE] at 1:20 p.m. with Staff C, LPN, Staff C indicated that on [DATE] at 5:20 a.m. Resident #1 was found lying face down on the bathroom floor unresponsive and without a pulse or breathing, feet and legs were blue. Staff C went to get Staff D, RN and Staff D told Staff C to call Staff B, DON to inform about Resident #1. Staff C was asked when did you become aware of Resident #1's code status? Staff C replied when Staff C called Staff B, DON at 5:45 a.m. 25 minutes after finding Resident #1 and Staff B asked about the code status and Staff C indicated not knowing what the status was and had to look for it. Staff C indicated having a difficult time trying to find out what Resident #1's status was. Staff C indicated a chart has a sticker on the front page only if the resident is a do not resuscitate (DNR) so she then went through the advance directive information which did not indicate a code status and then found on the physician order [REDACTED]. An interview with Staff B at 2:15 p.m. revealed that Staff C called Staff B at 5:45 a.m. on [DATE] to inform of Resident #1's passing. Staff B indicated asking Staff C about the code status and that Staff C was unaware at that time. At 6:00 a.m. Staff B called back to the facility and was informed that Resident #1 was a full code and no cardiopulmonary resuscitation measures had been initiated.

Based on medical record review and interview the facility failed to implement the care plan for 1 resident requiring cardiopulmonary resuscitation. (Resident identifier is: #1.) Findings include: Review of Resident #1's medical record on [DATE] reveals that Resident #1 was admitted to the facility on [DATE] and expired on [DATE]. Resident #1 had a physician's orders [REDACTED]. Review of Resident #1's care plan last reviewed on [DATE] reveals that Resident #1 desires CPR. Goal is that CPR (cardiopulmonary resuscitation) will be initiated with the absence of no pulse, no blood pressure, and/or no respiration. Interventions indicate to verify the absence of apical pulse, respirations, and/or blood pressure, initiate CPR, call 911 and notify physician. Nurses note dated [DATE] at 5:20 a.m. by Staff C, LPN indicates that Resident #1 was found lying face down in bathroom unresponsive to any stimulus. A nurses' note dated [DATE] at 5:40 a.m. by Staff D, RN indicates that Resident #1 was assessed with [REDACTED]. Resident #1's medical record reveals no documented evidence that CPR was initiated. Interview with Staff A, Administrator and Staff B, DON indicated that Resident #1 did not receive CPR.

Based on record review and interview the facility failed to ensure that a residents right to receive cardiopulmonary resuscitation is implemented for 1 resident. (Resident identifier is: #1.) Findings include: Review of Resident #1's medical records on [DATE] reveals that Resident #1 was admitted to the facility on [DATE] and expired on [DATE]. Resident #1 had a physician's orders [REDACTED]. Review of Resident #1's medical record on [DATE] reveals that Resident #1 desired to receive full resuscitative measures. Review of the care plan last reviewed on [DATE] reveals Resident #1 desires CPR. Goal is that CPR (cardiopulmonary resuscitation) will be initiated with the absence of no pulse, no blood pressure, and/or no respiration. Interventions indicate to verify the absence of apical pulse, respirations, and/or blood pressure, initiate CPR, call 911 and notify physician. Nurses note dated [DATE] at 5:20 a.m. by Staff C, LPN indicates that Resident #1 was found lying face down in bathroom unresponsive to any stimulus. A nurses' note dated [DATE] at 5:40 a.m. by Staff D, RN indicates that Resident #1 was assessed with [REDACTED]. The facility failed to initiate CPR to Resident #1. Interviews on [DATE] with Staff A, Administrator, Staff B, Director of Nursing and Staff C confirmed that there was no initiation of CPR to Resident #1. Cross Reference F 224, F282 and F309.