**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of Resident #21's physician order dated 10/8/2024 read, Nitrofurantoin Macrocrystal Capsule 50 mg [milligram], Give 1 capsule by mouth in the morning for prophylactic ABT [Antibiotic] therapy . Status: Active. Review of Resident #21's care plan read, Focus: [Resident #21's name] has an infection/ Colonization of MRSA of the urine [Sic.]. Date Initiated: 10/16/2024; Created on: 10/16/2024 . Revision on: 01/25/2025 . Interventions . Prophylactic medications as ordered. Review of Resident #21's MDS assessment dated [DATE] showed the resident was not taking antibiotics under Section N. Medications, N0415. High-Risk Drug Classes: Use and Indication. During an interview on 4/30/2025 at 9:40 AM, MDS RN stated, I know she takes a prophylactic antibiotic. She has since I've been here. The MDS is wrong. During an interview on 4/30/2025 at 9:50 AM, the DON stated that she expected the information entered on Resident #21's MDS assessment regarding antibiotic use to be accurate. Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 8 residents reviewed, Resident #16, and #21. Findings include: 1) During an interview on 4/27/2025 at 9:32 AM, Resident #16 stated she had never had pneumonia in the facility. Review of Resident #16's MDS assessment dated [DATE] showed the resident had pneumonia under Infections under Section I. Active Diagnoses. During an interview on 4/29/2025 at 10:00 AM, the Infection Preventionist confirmed that Resident #16 did not have pneumonia while in the facility. During an interview on 4/29/2025 at 11:02 AM, the MDS Registered Nurse stated, There is a discrepancy on [Resident #16's Name]'s most recent MDS dated on 3/25/2025 because [Resident #16's Name] didn't have pneumonia. I need to revise it. When asked for the facility policy, the MDS Registered Nurse stated, We do not have a policy. We follow the RAI [Resident Assessment Instrument).

Based on observation, record review, and interview, the facility failed to ensure residents received intravenous (IV) therapy in accordance with professional standards of practice for 1 of 3 residents reviewed for IV medication administration, Resident #156. Findings include: During an observation on 4/28/2025 at 12:38 PM, Staff A, Licensed Practical Nurse (LPN), was preparing Resident #156's Peripherally Inserted Central Catheter (PICC) line on her upper right arm for administration of Meropenem Intravenous Solution Reconstituted 1 gram (Meropenem). Staff A sanitized and flushed the PICC line with 10 ml (milliliters) of normal saline and initiated Meropenem 1 gram antibiotic via infusion pump. Staff A did not check the patency of the line by aspiration for blood return to determine patency prior to flushing or administering medication. During an interview on 4/28/2025 at 12:38 PM, Staff A, LPN, stated, We do not have to aspirate prior to flushing unless there is a physician order to do so. We just flush with saline first and then give the medications as ordered. During an interview on 4/28/2025 at 12:43 PM, the Assistant Director of Nursing stated, The PICC line must be checked for patency by aspiration of blood prior to flushing with normal saline and before administering medication via the line. During an interview on 4/28/2025 at 1:52 PM, the Director of Nursing stated, We should be aspirating prior to flushing to make sure the line is patent. We follow the SASH [Saline flush, Administer medication, Saline flush, and Heparin flush] method. Review of the facility policy and procedure titled Administration of an Intermittent Infusion with the last review date of 4/16/2025 read, Procedure . 16. Maintaining asepsis, attach flush syringes to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access device patency. Flush with prescribed flushing agent. Remove syringe.

Based on record review and interview, the facility failed to ensure the physician/prescriber documented the rationale for declining the pharmacist's recommendations for 2 of 5 residents reviewed for unnecessary medications, Residents #21, and #27. Findings include: Review of Resident #21's physician order dated 10/8/2024 read, Nitrofurantoin Macrocrystal Capsule 50 mg [milligram], Give 1 capsule by mouth in the morning for prophylactic ABT [Antibiotic] therapy . Status: Active. Review of Resident #21's medication regimen review showed the consultant pharmacist's recommendation dated 4/1/2025 that read, Comment: [Resident #21's name] has received nitrofurantoin for UTI [Urinary Tract Infection] prophylaxis since 10/2024. Recommendation: Please reevaluate and perhaps discontinue nitrofurantoin while monitoring for signs and symptoms of recurrent UTI. Rationale for Recommendation: The potential for developing pulmonary fibrosis, hepatotoxicity, C difficile infection, and peripheral neuropathy increases with duration of use . Physician's Response . I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. The form was signed by the physician on 4/4/2025 with no rationale documented. Review of Resident #27's physician order dated 11/13/2024 read, Megestrol Acetate Oral Suspension 40 MG/ML [milligram per milliliter] (Megestrol Acetate), Give 20 ml by mouth one time a day for appetite. Review of Resident #27's medication regimen review showed the consultant pharmacist's recommendation dated 11/15/2024 that read, Comment: (Issued on 11/15/2024) [Resident #27's name] receives megestrol for unintentional weight loss and does not have a diagnosis of AIDS. Recommendation: Please discontinue megestrol. Rationale for Recommendation: Megestrol is approved for anorexia, cachexia, or unexplained, significant weight loos in AIDS. In other populations, the risk may outweigh the benefit as it produces small increases in weight, and is associated with adverse consequences (e.g. thromboembolism). The physician's response read, MD [Medical Doctor] declined at this time. 11/15/24. The form did not include the physician's signature or rationale documented. Review of Resident #27's physician order dated 11/13/2024 read, Pantoprazole Sodium Oral Tablet Delayed Release 20 MG (Pantoprazole Sodium), Give 1 tablet by mouth one time a day for gerd [Gastro-esophageal Reflux Disease]. Review of Resident #27's physician order dated 3/7/2025 read, Sucralfate Oral Tablet 1 MG (Sucralfate), Give 1 tablet by mouth two times a day for ulcer prevention. Review of Resident #27's medication regimen review showed the consultant pharmacist's recommendation dated 3/3/2025 that read, Comment: [Resident #27's name] receives sucralfate in addition to another gastroprotective therapy, Pantoprazole Sodium for GERD. Sucralfate may reduce the effectiveness of other medications and require adjustments to the administration schedule. Recommendation: Please discontinue sucralfate . Physician's Response . I decline the recommendation(s) above and do not wish to implement any changes now due to the reasons below. The form was signed by Staff G, Nurse Practitioner (NP) on 3/7/2025 with no rationale documented. Review of Resident #27's physician order dated 2/24/2025 read, Propranolol HCl Oral tablet 10 MG (Propranolol HCl), Give 1 tablet by mouth every 12 hours for migraines notify MD if sbp [systolic blood pressure] below 110. Review of Resident #27's physician order dated 1/13/2025 read, Carvedilol Oral Tablet 25 MG (Carvedilol), Give 2 tablets by mouth two times a day for HTN [hypertension- high blood pressure] hold if SBP less than 100 or HR [heart rate] less than 60. Review of Resident #27's medication regimen review showed the consultant pharmacist's recommendation dated 4/1/2025 that read, Comment: [Resident #27's name] has orders for duplicate therapy: Propranolol Hydrochloride and Carvedilol- both contain beta-nonselective properties . Recommendation: Please reevaluated [Sic.] and discontinue where appropriate . Physician's Response . I decline the above recommendation(s) above and do not wish to implement any changes due to the reasons below. The form was signed by Staff G, Nurse Practitioner (NP) on 3/7/2025 with no rationale documented. During an interview on 4/29/2025 at approximately 2:30 PM, the Director of Nursing (DON) stated that physicians/prescribers should provide a rationale for not accepting the pharmacist's recommendations, but that they did not do so. Review of the facility policy and procedure titled Medication Regimen Review with the last review date of 4/16/2025 read, Procedure: 1. The consultant pharmacist will conduct MRRs [Medication Regimen Reviews] if required under a Pharmacy Consultant Agreement and will make recommendations based on the information made available in the residents' health record. 2. The facility and consultant pharmacist will follow guidance outlined in the CMS [Centers for Medicare and Medicaid Services] State Operations Manual Appendix PP and current practice guidelines, for the appropriate provision of pharmaceutical care . 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. 9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP. 9.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 9.2.1 If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record.

Based on observation, interview, and record review, the facility failed to ensure food items were stored, labeled, and discarded according to professional standard of practice. Findings include: During an observation while conducting an initial tour of the kitchen on 4/27/2025 at 9:07 AM, there were three ready-to-eat chicken sandwiches wrapped in a bag with a date label reading 4/21, eight pieces of unpackaged meat wrapped together with no identifier label or date, two plates of salad containing lettuce, tomato, eggs and ham with a label dated 4/23 in the refrigerator. There were brown-stained bananas and one opened bag of pasta in the dry storage, and there was poultry stored in the freezer with no identifier label or date. During an observation while conducting the second tour of the kitchen on 4/28/2025 at 10:52 AM, there was a three-tiered kitchen cart obstructing the handwashing sink and eyewash station. The kitchen cart contained soiled oven mitts, an unlabeled and uncovered empty drinking cup, and a green bucket containing liquid and a rag. The green bucket was on the second tier of the cart, next to three bags of hamburger buns. During an interview on 4/28/2025 at 10:54 AM, Staff F, CDM, stated that the items were not permitted on the cart next to the hamburger buns, nor were they permitted to obstruct the handwashing sink. During an interview on 4/28/2025 at 2:00 PM, Staff F, Certified Dietary Manager (CDM), stated that the sandwiches dated 4/21 should have been discarded, the deteriorated salad and browned bananas should have been disposed of, and the open pasta bag and unlabeled/undated poultry were improperly stored. He also stated that the unpackaged meat in the refrigerator should have been labeled and kept in its original packaging. Review of the facility policy and procedure titled Food Storage Principles with the last review date of 4/16/2025 read, Purpose: To preserve food quality before and after food is prepared. Fundamental Information: Proper food storage is essential for preserving food quality. This applies to foods stored prior to preparation, and also to prepared foods (leftovers) that are placed in storage. Storage factors that impact the preservation of quality include holding period, temperature, and humidity. Procedure . 3. Label each package, box, can, etc. with date of receipt, and when the item was stored after preparation. a. Discard foods that have exceeded their expiration date. b. Discard leftover foods that have not been used withing 72 hours of preparation . 5. Keep food storages areas clean and free of spills and leaks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 3 of 4 medication carts. Findings include: During an observation of 400 Hall Medication Cart on [DATE] at 9:18 AM with Staff B, Licensed Practical Nurse (LPN), there were one opened bottle of Timolol Maleate Ophthalmic Solution 0.5% eye drops for Resident #77 with no opened or expiration dates and one opened bottle of Latanoprost 0.005% eye drops for Resident #47 with no opened or expiration dates. During an interview on [DATE] at 9:23 AM, Staff B, LPN, stated, There is no open date or expiration date written on the eye drops. When the eye drops are opened, the date opened and the expiration date are written on the bottle. The eye drops expire in 28 days. During an observation of 300 Hall Medication Cart on [DATE] at 9:29 AM with Staff C, LPN, there was one opened Insulin Lispro 100 unit/ml (milliliter) Pen for Resident #65 with an expiration date of [DATE]. During an interview on [DATE] at 9:30 AM, Staff C, LPN, stated, The insulin is expired and should have been thrown away and replaced. During an observation of 100 Hall Medication Cart on [DATE] at 9:41 AM with Staff D, LPN, there were one bottle of Latanoprost 0.005% eye drops for Resident#16 opened on [DATE] and expired on [DATE], one bottle of Latanoprost 0.005% eye drops for Resident #14 with opened date of [DATE] and expiration date of [DATE], and one Novolog 100 unit/ml Flex pen for Resident #68 opened on [DATE] and expired on [DATE]. During an interview on [DATE] at 9:44 AM, Staff D, LPN, confirmed that the eye drops for Resident #16 and Resident #14 and insulin pen for Resident #68 were expired. During an interview on [DATE] at 9:58 AM, Staff E, LPN, Unit Manager, stated, Eye drops expire 30 days after they are opened, and insulin expires 28 days after it is removed from the refrigerator and opened. The Medications are to be removed from the cart returned to the pharmacy for destruction when they are expired. During an interview on [DATE] at 7:18 AM, the Director of Nursing stated, All medications are to have an open date and expiration date written on the medication and they are to be removed from the cart and disposed of properly when expired. Review of the facility policy and procedures titled 5.3 Storage and Expiration Dating of Medications, Biologicals with the last revision date of [DATE] read, Applicability: This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles Procedure . 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened 5.4. When an ophthalmic solution or suspension has a manufacturers shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container.

Based on observation, record review, and interview, the facility failed to ensure staff followed practice standard for infection prevention and control during medication administration to prevent the possible spread of infection and communicable diseases for 2 of 6 residents reviewed for medication administration, Residents #243 and #7. Finding include: During an observation on 2/6/2024 at 6:48 AM, Staff G, Licensed Practical Nurse (LPN), completed blood sugar monitoring using glucose meter for Resident #73. Staff G did not sanitize the glucose meter before or after use and returned the glucose meter back into the medication cart. During an interview on 2/6/2024 at 6:48 AM, Staff G, LPN, stated, It's my first day on the floor by myself and the glucose meter should be cleaned before and after each patient with the bleach wipe. During an observation on 2/6/2024 at 8:30 AM, Staff H, LPN, popped Carvedilol tablet 6.25 mg (milligram) and Furosemide tablet 20 mg for Resident #243 into her bare non-gloved hand and placed the medication in the medication cup. Staff H proceeded to administer the medication to Resident #243. Then, Staff H injected Humalog solution 100 unit/ml (milliliter) into Resident #243's right upper arm subcutaneously. Staff H did not sanitize the skin with an alcohol pad prior to injection. Staff H proceeded to prepare medications for Resident #7 and popped one Morphine Sulfate oral tablet 30 mg into her bare non-gloved hand and placed the pill into the medication cup. Staff H administered the medication to Resident #7. During an interview on 2/6/2024 at 8:42 AM, Staff H, LPN, stated, I know I shouldn't touch them, but my nails get in the way. I was taught in school that I was supposed to clean the site before any injection of medications. During an interview on 2/6/2024 at 11:35 AM, the Director of Nursing stated, The expectation is for the pills to be popped directly into the medication cup to prevent contamination and prior to administering injection medication the site is to be cleaned with alcohol pad to prevent infection. Blood glucose meters must be cleaned before and after each resident use with germicidal wipes. Review of the guideline provided by the facility titled Guidelines for Cleaning and Disinfecting Blood Glucose Meter read, Procedure Steps 1-5 . 5. Disinfecting the Blood Glucose Meter (Before & after each use). Disinfect the meter with a germicidal wipe (Wrap in Wipe for 3 full minutes). Review of the facility policy and procedures titled Med Pass with Medication cart revised on 12/21/2023 read, Procedure . 11. Prepare the medication . b. Pour the prescribed dosage(s) from the container and place in a souffle cup or calibrated liquid measure cup.

Based on record review and interview the facility failed to complete a discharge summary to include a recapitulation of the resident's stay for 1 of 3 residents, Resident #90, sampled for closed record reviewed. Findings include: Review of Resident #90's record revealed documentation the facility had stopped billing for Resident #90 on 8/1/2022. Review of Resident #90's progress note, dated 8/1/2022, revealed Resident #90 was discharged to an assisted living facility with an effective date of 8/1/2022 at 5:57 PM. Review of Resident #90's discharge records failed to reveal documentation the facility completed a discharge summary to include a recapitulation of stay for Resident #90. During an interview on 8/24/22 at 7:55 AM, the Director of Nursing reported the facility was unable to locate a discharge summary for Resident #90. During an interview on 8/24/22 at 9:04 AM, the Administrator confirmed the facility was unable to find a discharge summary related to Resident #90's discharge that contained a recapitulation of stay. Review of the facility policy titled Transfer and Discharge, last reviewed 2/28/2022, showed the policy read Discharge summary: When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: a. A recapitulation of the resident's stay that includes, but is not limited to: diagnosis, course of illness, treatment &/or [and/or] therapy, and pertinent lab, radiology, and consultation results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide care for central venous access devices in accordance with professional standards of practice for 1of 1 resident with a central venous access device, in a total of 36 residents, Resident #194. Findings include: During an observation of Resident #194 conducted on 8/22/2022 at 10:30 AM Resident #194 was observed sitting in a wheelchair, there was a left upper arm midline catheter with a 2 x 2 gauze that covered the insertion site of the catheter, under a transparent dressing that was dated 8/16/2022. During an interview conducted on 8/22/2022 at 10:30 AM Resident #194 stated, I got that [right midline catheter] put in, in the hospital, they have not changed the dressing on that since I was in the hospital. During an interview conducted on 8/22/2022 at 10:30 AM Staff C, Licensed Practical Nurse (LPN) stated, [Resident #194's name] has one more dose of IV [intravenous] antibiotics, she has a midline, the dressing is within date and doesn't need to get changed. I see the gauze under the dressing. During an observation of Resident #194 conducted on 8/22/2022 at 1:45 PM Resident #194 was observed sitting in bed with a left upper arm midline catheter with 2x2 gauze under a transparent dressing dated 8/16/2022. Review of the medical record documented that Resident #194 was admitted to the facility on [DATE] with the following diagnoses: urinary tract infection, site not specified, unspecified atrial fibrillation (an irregular heart beat), essential (primary) hypertension (high blood pressure), hyperlipidemia (high cholesterol), and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormones). Review of the physician orders dated 8/18/2022 reads, Measure external catheter length on admission, with each dressing change, and PRN [as needed]. Change catheter dressing, change securement device q [every] week every day shift every Wednesday. Review of the physician orders dated 8/22/2022 reads, Flush line with 10 cc [cubic centimeters] NS [normal saline] before and after each dose of medication. During an observation of medication administration conducted on 8/23/2022 at 12:15 PM Staff C, LPN was observed administering 10 milliliters of 0.9% normal saline flush to Resident #194's midline catheter. Staff C, LPN cleaned the needleless connector with alcohol and immediately administered the normal saline. Staff C did not let the needleless connector dry or verify line placement (by checking for blood return) prior to administering the medication. During an interview conducted on 8/23/2022 at 12:25 PM Staff C, LPN stated, I did clean the connector, but should have verified placement. I did not let the needleless connector dry before administering the saline. During an observation of medication administration conducted on 8/24/2022 at 8:20 AM Staff B, LPN, cleaned Resident #194's needleless connector for three seconds and administered 10 milliliters of normal saline intravenously. Staff B did not let the needleless connector dry or verify line placement before administering the medication. During an interview conducted on 8/24/2022 at 8:25 AM Staff B stated, I should have cleaned the hub (needleless connector) longer, I should have let it dry, and checked for blood before administering the normal saline. Review of the Medication administration record documented no midline catheter dressing changes and no measurements for the external catheter length. Review of the treatment administration record documented no midline catheter dressing changes and no measurements for the external catheter length. Review of the nursing admission assessment documented no midline catheter and no measurements for the external catheter length. During an interview conducted on 8/24/2022 at 11:30 AM the Director of Nursing (DON) stated, There is no documentation of the midline catheter or measurements on the nursing admission assessment and there should be. There are no measurements documented according to the orders. The dressing was changed on 8/22/2022, but should have been changed on admission if it had gauze under the dressing. Review of the policy and procedure titled, Midline Catheter Dressing Change with an approval date of 2/28/2022 reads, Considerations: 1. The catheter insertion site is a potential entry site for bacteria that may cause a catheter- related infection. Guidance: 1. Sterile dressing change using transparent dressings is performed: 1:1 Upon admission. 2. When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed: 2:1 upon admission, 2.2 every 2 days. 6. Assessment of the vascular access site is performed: 6.1 upon admission and during dressing changes. 8. Length of the external catheter is obtained: 8.1 upon admission. 8.2 During dressing changes. 9. Arm circumference (10 cm above the antecubital fossa) is obtained: Upon admission, then weekly. 9.4 Compare to baseline measurement to detect possible catheter - associated venous thrombus: a 3 cm increase in arm circumference and edema were associated with upper arm deep vein thrombosis. Reivew of the policy and procedure titled, Midline Catheter Flushing and Locking with an approval date of 2/28/2022 reads, Considerations: 4. Needless connectors require vigorous cleansing with alcohol prior to accessing to reduce the risk of catheter-related bloodstream infection. Guidance: 6. catheter patency must be verified prior to each medication administration. To assess patency, aspirate the catheter to obtain positive blood return. The aspirated blood should be the color and consistency of whole blood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure appropriate treatment and services to prevent the possibility of urinary tract infection for 1 of 3 residents observed for indwelling foley catheters, Resident #77. Findings include: Review of the medical record documented Resident #77 was admitted to the facility on [DATE] with the following diagnoses: neuromuscular bladder dysfunction, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), type 2 diabetes mellitus, and peripheral vascular disease. Review of the physician order dated 3/17/2022 reads, Diagnosis for indwelling catheter: Neuromuscular bladder dysfunction. Change catheter as needed, size 14f [French]. Review of the Nursing Care plan reads, Ensure proper positioning of drainage tube at all times, keep drainage bag below the level of the bladder. During an observation conducted on 8/24/2022 at 7:35 AM Resident #77 was resting in bed, there was an indwelling urinary catheter bag observed on the left side of the bed lying on the floor. During an interview conducted on 8/24/2022 at 7:35 AM Resident #77 stated, My catheter hurts. During an interview conducted on 8/24/2022 at 7:53 AM Staff E, Certified Nursing Assistant (CNA) stated, I have not been in her room yet. I will check residents when I am doing rounds. Catheter bags should not be on the floor.

Based on interview and record review, the facility failed to ensure the medical record for 1 of 3 residents, Resident #55, reviewed for nutrition was complete. Findings include: Record review of Resident #55's care plan, date Initiated 02/01/21, documented Resident #55 was at risk for decreased nutritional status and dehydration related to a history of COVID-19, dysuria, cough, and difficulties with swallowing. Resident #55's care plan documented nutritional interventions to include Monitor PO [by mouth] intakes. Record review of Resident #55's Point of Care Response History for Eating Meal Percentage dated 7/26/22 - 8/23/22, failed to reveal completed documentation of the intake amounts Resident #55 consumed at each meal. Resident #55's meal intake was not recorded on 2 of 28 days, was recorded for 1 of 3 meals for 15 of 28 days and was recorded for 2 of 3 meals for 10 of 28 days. During an interview on 8/24/2022 at 8:32 AM, Staff A, Licensed Practical Nurse/West Unit Manager confirmed staff should be recording Resident #55's meal intake percentages for three meals a day. During an interview on 8/24/2022 at 10:28 AM, the Director of Nursing stated Resident #55's meal intake data had not been recorded for each meal. During an interview on 8/24/2022 at 11:40 AM, the Director of Nursing reported the facility did not have a policy specific to documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive respiratory care services for oxygen administration consistent with professional standards of practice for 4 of 5 residents reviewed for respiratory care, Residents #195, #61, #82, and #32 in a total sample of 33 residents. Findings include: 1) During an observation conducted on 8/22/2022 at 11:04 AM, Resident #195 was observed resting in bed with the head of his bed flat with 4 liters of oxygen being administered through a nasal cannula connected to an oxygen concentrator. The oxygen humidification bottle was empty and not dated. Review of the medical record documented Resident #195 was admitted to the facility on [DATE] with the following diagnoses, COVID-19 Viral pneumonia, liver cirrhosis, liver cell cancer, iron deficiency anemia, chronic obstructive pulmonary disease, chronic kidney disease, major depressive disorder, essential (primary) hypertension, hyperlipidemia, and status post tracheostomy Review of the physician orders dated 8/22/2022 reads, Oxygen via nasal cannula LPM (liters per minute) 2 liters every shift. During an observation conducted on 8/23/2022 at 12:03 PM, Resident # 195 was observed resting in bed with oxygen running at 4 liters through a nasal cannula connected to an oxygen concentrator. During an observation conducted on 8/24/2022 at 7:15 AM Resident #195 was observed resting in bed with oxygen being administered at 4 liters through a nasal cannula connected to an oxygen concentrator. During an interview conducted on 8/24/2022 at 7:20 AM Staff D, Licensed Practical Nurse (LPN) stated, His oxygen is set at 4 liters and that seems kind of high. Let me see what he is supposed to be set at. He should have 2 liters of oxygen running. I will usually check what oxygen is at when I give residents their medications and I just haven't had time to do his meds yet. During an interview conducted on 8/24/2022 at 11:30 AM the Director of Nursing (DON) stated, I expect that nurses will check the amount of oxygen that is running at least when they administer their medications if not more frequently. Review of Policy and Procedure titled, Oxygen Administration via Concentrator approval date 2/28/2022 reads, Purpose: To deliver oxygen to the resident using an oxygen concentrator. A licensed nurse or respiratory care practitioner performs this procedure. Procedure: Setting up the concentrator: 2. Turn to proper flow rate as ordered by the physician. Check the concentrator to assess the maximum flow rate. 2) An observation on 08/22/22 at 10:30 AM showed resident #61 was being administered oxygen at 2 liters/min via nasal cannula. There was no date on the oxygen tubing. An observation on 8/24/2022 at 1:10 PM showed resident #61 was not being administered oxygen. The resident was seated alone in the common area at the end of the East hallway. The oxygen tubing was not dated. During an interview on 8/24/2022 at 1:11 PM Resident #61 stated the facility turned my oxygen off yesterday and told me that they could not give me oxygen until they got permission from the doctor. I need my oxygen. During an interview on 8/24/2022 at 1:51 PM Staff D, LPN stated, I was verbally told this resident's oxygen is as needed. Something happened yesterday and she needed oxygen. I see the order has the oxygen as routine at 3 liters dated 7/19/2022. The residents do not have paper charts. The oxygen tubing does not have a date because whoever changed the tubing did not put a date on the tubing. During an interview on 8/24/2022 at 2:00 PM Staff J, LPN stated, Until today the resident's oxygen order was for 2 liters per nasal cannula routine. Review of the physician's order sheet dated 7/19/2022 reads, oxygen by nasal cannula at 3 liters per minute routinely. 3) An observation on 08/22/22 at 11:37 AM showed the oxygen concentrator was set at 4 liters/min being administered via nasal cannula for Resident #82. The oxygen tubing was dated 8/8/2022. The nebulizer mask was on the bed uncovered/not bagged and was dated 8/8/2022. Review of physician's order for Resident #82 dated 8/1/2022 reads, Oxygen via nasal cannula at 2 liters per minute every shift. An observation on 8/23/2022 at 8:18 AM showed Resident #82 was sitting in a chair eating breakfast. The resident was being administered oxygen via nasal cannula at 4 liters/minute. During an Interview with Resident #82 on 8/23/2022 at 8:20 AM she said, I use 4 liters at night and 3 liters in the daytime, that is too high for me. Resident stated she does not adjust the oxygen rate, I do not touch that, the nurses do. During an interview on 8/24/2022 at 1:38 PM Staff B, LPN stated, The oxygen gets turned up with the CPAP [continuous positive airway pressure] and sometimes it doesn't get turned back down to the liters as ordered by the doctor. The night shift nurses are supposed to label the oxygen tubing Review of the medical record for Resident #82 documented the resident was admitted on [DATE] with the following diagnoses: COVID-19, acute respiratory failure, CHF (congestive heart failure), atrial fibrillation, GERD (gastroesophageal reflux disease), anxiety disorder, acute kidney failure, pacemaker, pulmonary hypertension. Review of the physician's orders dated 8/1/2022 reads, oxygen via nasal cannula at 2 liters per minute every shift. Monitor oxygen saturation and temperature every shift. Notify provider if temperature > [greater than] 100.4, and O2 [oxygen] saturation of < [less than] 98%. Review of the daily temperatures and daily oxygen saturation for the period of 7/30/2022 to 8/23/2022 documented the following: Oxygen Saturation: 7/31/2022 at 22:34 [10:34 PM] of 90%. 8/1/2022 at 21:39 [9:39 PM] - 97%. 8/2/2022 at 21:28 [9:28 PM] - 97%. 8/3/2022 at 07:34 AM and 10:34 AM - 92%, at 21:19 [9:19 PM] - 94%. 8/4/2022 at 07:48 AM - 91%, and at 14:20 [2:20 PM] at 92%. 8/6/2022 at 11:32 - 95%. 8/7/2022 at 20:20 [8:20 PM] - 95%. 8/8/2022 at 22:02 [10:02 PM] - 97%. 8/9/2022 at 07:20 AM and at 07:35 AM - 96%. 8/10/2022 at 10:45 AM - 95%, and at 22:02 [10:02 PM] - 92%. 8/11/2022 at 12:17 PM - 96%, and at 21:08 [9:08 PM] - 95%. 8/12/2022 at 07:23 - 92%, 22:46 [10:46 PM] and 23:55 [11:55 PM] - 97%. 8/14/2022 at 01:00 AM, 07:30 AM and 13:12 [1:12 PM] - 97%. 8/15/2022 at 21:32 [9:32 PM] - 92%. 8/16/2022 at 07:52 AM - 97%, and 22:29 [10:29 PM] - 96%. 8/17/2022 at 19:47 [7:47 PM] - 94%. 8/20/2022 at 11:29 AM - 92%. 8/22/2022 at 07:11 AM - 95%, and at 21:07 [9:07 PM] - 97%. 8/23/2022 at 07:11 AM - 97%. Review of Resident #82's medical record did not contain documentation of the physician having been notified of the oxygen saturations per the physician order. 4) Review of Resident #32's medical record documented the resident was admitted on [DATE] with the following diagnoses: COVID-19, sepsis, metabolic encephalopathy. During an observation on 8/22/2022 at 9:32 AM of Resident #32's room it showed the resident's nebulizer mask was on top of the bedside dresser, uncovered and dated 7/25/2022. At the bedside is a concentrator with a nasal canula tubing hanging in the drawer of the bedside dresser, uncovered and dated 7/25/2022. During an interview with Resident #32 and Resident #32's spouse on 8/22/2022 at 9:33 AM he stated, I use the oxygen at night. During an observation on 8/23/2022 at 8:35 AM it showed Resident #32's oxygen and nebulizer tubing continue to be uncovered and dated 7/25/2022. During an interview on 8/23/2022 at 9:26 AM the East Wing Unit Manager confirmed Resident #32's oxygen tubing and nebulizer mask are dated 7/25/2022 and uncovered. The Unit Manager stated, The tubing is supposed to be changed every Sunday by the night nurses, the tubing must be dated and covered. During an observation on 8/23/2022 at 1:30 PM it showed Resident #32's oxygen tubing and nebulizer mask are dated 7/25/2022. During an interview on 8/23/2022 at 1:30 PM Resident #32's spouse stated, I wished they would put the mask and nasal cannula in a bag because he uses them to put on his face. Review of the physician's order dated 8/23/2022 reads, Oxygen via nasal cannula at 2 lpm [liters per minute] as needed for complaint of SOB [shortness of breath]. Change oxygen tubing every Sunday (11PM - 7 AM). Order dated 8/3/2022 reads, Ipratropium-Albuterol solution 0.5 - 2.5 3mg/3 ml [3 milligrams/3 milliliters], 3 ml. inhale orally every 6 hours as needed for oxygen saturation < 88% via Nebulizer. Review of Resident #32's treatment administration record (TAR) from July 1 through July 31, 2022, revealed respiratory oxygen tubing and nebulizer mask were not changed throughout the month of July 2022. Review of Resident #32's treatment administration record from August 1 through August 24, 2022, revealed respiratory oxygen tubing and nebulizer mask were marked X all throughout August indicating the tubing and mask were not changed. During an interview with the Director of Nursing on 8/24/2022 at 3:00 PM stated, We do not have a policy specific to changing of respiratory tubing, we based it on doctors' orders.