Based on observation, record review, interviews, and a review of facility policies and procedures, the facility failed to ensure that the residents' environment was as free of accident hazards as was possible for one (Resident #108) of 34 residents in the total survey sample. Razors were discovered at Resident #108's bedside. The findings include: On 04/29/25 at 13:52 PM, medication (an oral inhaler) was observed at the bedside of Resident #108. (Photographic evidence obtained). The resident stated, They gave it to me so I can take it when I need it. A review of Resident #108's medical record revealed an admission date of 3/24/25 and diagnoses including unspecified sequelae of other cerebrovascular disease, COPD (chronic obstructive pulmonary disease), nicotine dependence, and anxiety disorder. A review of the admission MDS (minimum data set) assessment, dated 4/1/25, revealed a BIMS (brief interview for mental status) score of 12 out of 15 possible points, indicating moderate cognitive impairment. The resident required set-up/clean up assistance with eating, substantial/maximal assistance with toileting and transfer tasks, and partial/moderate assistance with bed mobility. A review of the resident's active physician's orders revealed she was receiving the following: - Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 108 (90 Base) mcg/act (micrograms per actuation), 1 inhalation, inhale orally every 6 hours as needed for wheezing/asthma signs/symptoms, and 1 inhalation orally three times a day for COPD/cough for three days (4/10/25) There was no physician's order for self-administration of medications or treatments. A review of the most recent smoking evaluation, dated 3/26/25, revealed that the resident scored 11.0 (unsafe smoker). There was no evidence of an assessment having been completed for self-administration of medications. A review of the active Care Plan revealed the following focus areas: - Resident is at risk for impaired gas exchange/ineffective airway clearance related to COPD, respiratory failure with hypoxia, chronic pulmonary edema, asthma, and lobar PNA (pneumonia). (Date Initiated: 03/24/2025, revised 4/15/25) Goals/interventions in place and appropriate. - Resident is a an unsafe smoker as evidenced by smoking evaluation. (Created 03/26/2025, revised 03/26/2025) Goals/interventions in place and appropriate. - Resident has impaired cognitive function/impaired thought process. (Created 04/01/2025, revised 04/01/2025). Goals/interventions in place and appropriate. The entire care plan was reviewed and there was no evidence of the resident having been care planned for self-administration of medications or treatments. On 05/01/25 at 11:44 AM, an interview was conducted with Certified Nursing Assistant (CNA) A. When she was asked if residents were permitted to give themselves any kind of medication on their own, she replied, No. She was asked if residents were permitted to keep medications in their rooms or in their possession. She stated, No. She was asked what she should do if she observed medications in the resident's room or in their possession. She replied, Go and get my nurse or Unit Manager immediately. On 05/01/25 at 1:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) B. When she was asked what the facility's protocol was for a resident who wanted to self-administer their own medications, she replied, They don't allow them to administer their own medicine. She was asked of there were any residents on her assignment who self-administered medications. She stated, No. She was asked if residents were permitted to give themselves any kind of medication on their own. She stated, No. She was asked if residents were permitted to keep medication in their room or in their possession. She stated, No, like on admission we give medications to the family to take back home so the residents wont have them. She was asked what she should do if she observed medications in the resident's room or in their possession. She stated, I would get it. They might be a little upset with me, but I would get them because its not supposed to be there. Then I would call the family and notify the MD (physician). On 05/01/25 at 2:00 PM, an interview was conducted with CNA C. She was asked if she had observed Resident #108 with her inhaler in her room at the bedside or in her purse. CNA C replied, Yes. She was asked if she had observed Resident #108 using an inhaler on her own, and she replied, No. She was asked if the facility provided any guidance/training/education on how to respond if you observe medications in the resident's room. She stated, No, but I know how to handle that; let the nurse know. She was asked if she had reported the resident having the inhaler in her possession. She stated, No, I have not reported the inhaler to the nurse, but she had to have seen it herself, she could not miss it, it was in there today in plain site. A review of the facility's policy and procedure titled Self-Administration of Medications (SHCRC30004.01B, revised 8/2023), revealed: Purpose: To allow the resident and or legal representative the right to self-administer medication (SAM) when it has been deemed by the interdisciplinary team (IDT) that it is clinically appropriate. A resident may only self-administer medications after the IDT has determined which medications may be self-administered. Document the self-administration of medication on the resident's comprehensive care plan. [NAME] medication administration records to identify individual medicines that are self-administered by each resident. .

Based on observation, record review, interviews, and a review of the facility's policies and procedures, the facility failed to provide respiratory care consistent with professional standards of practice for one (Resident #33) of four residents reviewed for oxygen administration. Resident #33 was receiving oxygen without a physician's order. The findings include: On 04/29/25 at 11:13 AM, an interview was attempted with Resident #33. He offered no verbal response to interview questions, and instead covered his head. Oxygen was observed infusing at 3.5 L/min (liters per minute) via nasal cannula (NC). A review of Resident #33's medical record revealed an admission date of 3/26/2013 and diagnoses including heart failure, COPD (chronic obstructive pulmonary disease) and acute and chronic respiratory failure with hypoxia. A review of the resident's active physician's orders revealed no orders for oxygen therapy. A review of the Quarterly MDS (minimum data set) assessment, dated 4/16/25, revealed a BIMS (brief interview for mental status) score of 15 out of 15 possible points, indicating intact cognition. The resident was independent with eating. He was dependent on staff for toileting and transfer tasks, and required substantial/maximal assistance with bed mobility. A review of the active Care Plan revealed the following focus areas: - [Resident #33] is at risk for impaired gas exchange related to COPD and chronic respiratory failure. (created 7/20/20, revised 3/10/25). Goal: Resident will have decreased risk of complications related to impaired gas exchange through the review date. Interventions: Oxygen as ordered. Clean concentrator/filters as ordered. Change oxygen tubing as ordered. - [Resident #33] requires assistance with ADLs related to limited mobility and muscle weakness secondary to CHF (congestive heart failure), COPD, AFIB (atrial fibrillation), urine retention, chronic respiratory failure, neuromuscular dysfunction of bladder, depression, obesity, anemia, hypokalemia, dorsalgia, sleep apnea, diabetes mellitus, right foot drop, obstructive/reflux uropathy, ADHD (attention deficit hyperactive disorder), hydrocephalus, and HTN (hypertension). Goals/interventions in place and appropriate. A review of the resident's progress notes revealed a note dated 4/11/2025 at 20:35 (8:35 p.m.) that noted the resident was evaluated by the provider for COPD management. The patient is currently on a complicated pulmonary regimen to consist of Albuterol as needed. The patient remains on intermittent oxygen. Patient does report at times some shortness of breath with exertion. On 05/01/25 at 11:39 AM, an interview was conducted with Certified Nursing Assistant (CNA) A. She was asked if the facility provided any training/education for how to care for a resident who received oxygen therapy. She stated, No, because it's considered medicine so it's taken care of by the nurse. She was asked to describe the care she provided for a resident who was receiving oxygen. She stated, We just make sure that they keep it in their nose and that the tank is full. Anything else, you notify the nurse. For instance, if the tubing looks dirty or clogged or if it's on the floor, or if the tank is empty. She was asked if she had ever been required to change the oxygen flow rate settings. She stated, No. She was asked what she would do if the resident became short of breath. She stated, Notify the nurse or the Unit Manager. On 05/01/25 at 1:42 PM, an interview was conducted with Licensed Practical Nurse (LPN) B. She was asked if the facility provided any training/education for how to care for a resident who received oxygen therapy. She stated, Yes. She was asked to describe the care she provided for for a resident who was receiving oxygen therapy. She stated, We monitor their saturations, provide the breathing medication, and if they have orders for oxygen we make sure the oxygen is set at right level and make sure the room is comfortable. She was asked who was responsible for changing oxygen flow rate settings. She stated, Yes, only the nurse is supposed to change the settings. She was asked what she would do if the resident became short of breath. She stated, First make sure the head is elevated, monitor the oxygen saturations, give the medication, and I may need to increase the oxygen level. When they get stable, I reach out to the medical doctor. She was asked if Resident #33 used oxygen. She stated, Yes, at times. She was asked how often he used it. She stated, I think he uses it on a daily basis but he medicates himself. He takes it on and off. She was asked how she determined the resident's oxygen flow rate. She stated, Whatever the doctor orders. She was asked to access the resident's orders in the EMR (electronic medical record) and confirm how many liters the doctor ordered for Resident #33. She confirmed that the resident did use oxygen daily and did not have an order for it. On 05/01/25 at 3:44 PM, a policy/procedure for oxygen administration was requested. The Regional Nurse Consultant stated, We don't have an oxygen policy. A review of the facility's Procedural Guideline (SHCEDU0001.11M, effective: 1/2023, updated: 6/28/2024) for Physician's Orders revealed: A new order should include: date of order, resident name, identification number, date of birth , physician's/prescriber's name and pertinent ancillary instructions, reason for use, stop order date, as appropriate, and administration parameters, if applicable. .

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, affecting one (Resident #73) of 103 residents, by failing to eliminate pests from the resident's room. Failure to ensure the necessary housekeeping and maintenance services are provided for residents can increase the risk of disease-causing organisms within the facility. The findings include: On 5/30/23 at 10:28 a.m., Resident #73's room was observed with small roaches crawling on the floor at the doorway entry and on the side of the trash can in the resident's bathroom. (Photographic evidence obtained) A review of the facility's pest control provider's invoices from March 3, 2023 through June 1, 2023, revealed that pests were identified as well as spilled food material on the floors of multiple resident rooms and food debris inside of resident nightstands during their visits. (Copies obtained) A review of the facility's In-House Pest Control Measures from December 2022, through June 2023, revealed no In-House Pest Control Measures were completed in May 2023. On 6/1/23 at 2:00 p.m., the Maintenance Director was asked how the facility maintained an effective pest control program so that the facility remained free of pests. He stated wheelchairs were cleaned and audit logs were completed. In-house pest control of common areas was completed by Maintenance twice weekly. The facility's pest control service sprayed for pests monthly and when needed or when they were called by the facility. Pest complaints were noted in the maintenance log at each nurses' station. A review of the facility's policy and procedure titled Infection Control: Cleaning and Disinfecting of Residents' Rooms (revised 5/2022) revealed: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. Procedure 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled . 7. Personnel should remain alert for evidence of rodent activity (droppings) and report such findings to the environmental services director. Steps in the Procedure, Resident Room Cleaning: . 7. Clean personal use items (e.g., lights, phones, call bells, bedrails, etc) with disinfectant solution at least twice weekly. (Copy obtained). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Residents #47, #102, and #237) of [NAME]-seven sampled residents. The findings include: 1. On 5/31/2023 at 12:02 p.m., Certified Nursing Assistant (CNA) C was observed in Resident #47's room with the door ajar. From the hallway, the CNA could be seen transferring the resident to bed using a mechanical lift (Hoyer lift) by himself. Upon seeing the surveyor in the hallway, the CNA immediately pulled the privacy curtain preventing further observation. CNA C was then observed exiting Resident #47's room at 12:08 p.m. He was asked about the observation of him transferring the resident using the mechanical lift by himself without assistance and whether this was his routine. He stated it depended upon whether the resident was skilled or not. He stated he had been employed by the facility since 1993, adding that things had changed since that time and he had never left. He stated nursing numbers had gone downhill and Sometimes you have to multi-task and do the best you can with what you have. He was asked if there were any agency staff that could have assisted him. He replied that there were no agency staff in the building so he had to do what he had to do. During an interview with Resident #47 on 6/1/2023 at 11:49 a.m., he was asked how he was transferred by staff. He stated the staff used the Hoyer lift for transfers and that it was usually done with one staff member. During an interview with the Regional Nurse Consultant (RNC) on 6/01/2023 at 3:22 p.m., she stated therapy conducted the staff training for use of the Hoyer lift. She stated there always needed to be two people assisting when transferring a resident via a Hoyer lift, adding that there was not a time one person should be transferring a resident using the Hoyer lift. During an interview on 6/02/2023 at 1:00 p.m. with Director of Rehabilitation (DOR) D, she was asked about the staff training for the use of the Hoyer lift. She stated, We train them to use two persons for the Hoyer. Our company policy is to always have two people present. She was asked to provide a copy of the company policy. She stated, I'm not sure if that's documented anywhere. I know for safety we always require them to have two people present. A review of Resident #47's record revealed that he was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting his right dominant side; cognitive/communication deficit; type 2 diabetes mellitus; acute kidney failure; thoracic aortic aneurysm without rupture; and benign neoplasm of the brain. A review of his physician's orders included a 3/21/2023 order for the resident to Utilize Hoyer lift device for transfers with assist times two. A review of the most recent care plan revealed: FOCUS - Needs assistance with ADLs (activities of daily living) due to anemia from GI (gastrointestinal) bleed and stroke (created 10/24/2022, revised 3/14/2023); GOAL: Resident will maintain current level of function through review date; INTERVENTIONS: Transfers Hoyer lift device for out of bed transfers with assist x 2 (revised 1/12/2023) A review of the Minimum Data Set (MDS) assessment, dated 2/21/2023, revealed Resident #47 was totally dependent on staff for transfers; required extensive assistance with bed mobility, dressing, toilet use and personal hygiene, as well as supervision with locomotion on and off the unit and for eating. A review of the resident's progress notes revealed that Resident #47 was at risk for falls. He had recently sustained falls in the facility on 5/16/2023 and 5/20/2023. 2. On 5/30/2023 at 9:22 a.m., Resident #102 was observed in her room sitting in a Broda chair (tilt-in-space positioning chair) next to her bed. The resident was observed leaning to the left. She was moaning with facial grimacing. She complained of pain from a sore on her buttocks. She stated she needed to get back in bed and had been trying to get back in bed since breakfast. The resident asked for help getting her in bed to relieve the pressure and pain from the sore on her buttocks. The resident was instructed to press her call light for assistance. With assistance, Resident #102 pressed her call light and at 9:26 a.m., a male Certified Nursing Assistance (CNA) responded to the call light. He greeted the resident and asked what she needed. Still moaning in pain, the resident asked to be put back in bed to relieve the pain from the sore on her buttocks. The CNA stated he was not the resident's assigned CNA. He advised the resident that he would find her CNA to help her get back in bed. He then turned off the resident's call light and exited the room. While still on the hallway leading to Resident #102's room, the resident's call light was observed to still be illuminated at 9:31 a.m. A female staff member knocked then entered the resident's room. From the hallway the resident could be heard moaning in pain. The call light was turned light off and the female staff member was seen exiting the resident's room. At 9:32 a.m., the female staff member returned, knocked, and opened the resident's door, partially entering and was overheard telling the resident that her CNA (Employee C) was on his break for 15 minutes and that she would let the nurse know what the resident needed. Again, the resident could be heard moaning with pain. CNA C was observed on the hall at 9:51 a.m. Per the assignment board at the nurses' station, he was assigned to Resident #102's room, however, he still did not go to the room to assist Resident #102. He was observed entering two adjacent rooms in spite of being told Resident #102 needed care. On 6/1/2023 at 11:18 a.m., Resident #102 was observed lying in bed. She denied any pain. She stated she was feeling okay but wanted to be moved over in the bed a little more. She was advised to press her call light for assistance. The resident reached behind her and looked around for the call light which was not in sight. She asked for assistance getting the call light. The call light was in the top drawer of the resident's night stand. (Photographic evidence obtained) The resident asked for the call light so she could call for help. Before the resident could be given the call light, CNA C knocked then entered the resident's room. On 6/2/2023 at 12:00 p.m., Resident #102 was observed lying in bed on her right side/back. She complained of pain. She asked for help turning over to her left side to get her off of the sore on her buttocks in order to relieve the pain. She continued to complain of pain related to the sore on her buttocks. The resident's call light was observed lying on top of her sheets, but not within reach or clipped to the sheet. The resident was asked if she had pressed the call light. She stated she could not get to it. She began to feel around the top of the sheets for it, but she could not reach it. She asked for help clipping the call light to the sheet within her reach. She continued to moan with pain. When she was asked how long she had been in pain, Resident #102 replied that she had been put back in bed after breakfast and had remained in that position on her right side since that time. The resident's call light was pressed for assistance. Upon exiting the resident's room, no nursing staff were observed on the hallway, however, there was one staff member, Housekeeper F, a few rooms away from Resident #102's room. On 6/2/2023 at 12:14 p.m. Housekeeper F was observed entering Resident #102's room. From the hallway she could be heard asking Resident #102 what she needed. Resident #102 was heard asking to be turned because she was in pain. The resident's call light was turned off and Housekeeper F exited the resident's room. Housekeeper F returned to the room she was in previously. She was not observed alerting any nursing staff of Resident #102's needs. She continued entering and exiting other rooms on the hall. Unable to locate nursing staff on the the resident's hallway to ask for assistance, at 12:18 p.m., Resident #102's room was entered again. The resident remained in pain. Her call light was pressed again. At 12:19 p.m., Housekeeper F re-entered the resident's room and turned the light off. She was heard asking the resident what she needed. The resident responded, I already told you. Can't you just move me? As Employee F was preparing to exit the room she acknowledged the surveyor then exited the hall. She was seen going to an adjacent hall. She returned with two CNAs who knocked then entered Resident #102's room, immediately closing the door behind them. During an interview with Licensed Practical Nurse (LPN) B on 6/2/2023 at 1:09 p.m., she stated she was familiar with Resident #102. She stated the resident had a small wound on her buttocks and received pain medication as needed. She stated the resident did not like sitting up in the chair because of the wound. She referred to it as a small wound on the resident's left buttock adding, We try to get her up so she can be out of her room. When asked about the progress of the wound she stated, I don't know if it's healing. I've only worked here three weeks. She was asked about call light response time expectations. She stated, Everybody is responsible for answering the call lights. Every single person. She stated the CNAs should be doing rounds at least every two hours for toileting and repositioning. She further stated she conducted follow-up rounds on the floor and checked the CNAs' charting to verify that they turned and repositioned the residents. She stated the facility's policies were accessible to staff and they could review any policy if they were confused about any subject or requirement. During an interview with the Regional Nurse Consultant (RNC) on 6/2/2023 at 1:27 p.m., she stated the facility did not have a call light response policy. On 6/2/2023 at 1:41 p.m., during an interview with CNA E (identified as one of the CNAs observed entering the room of Resident #102 on 6/2/2023 at 12:19 p.m.), she stated she had been employed with the facility for about 11 months. She further stated she consulted the [NAME] (resident-specific, clinical quick reference for nursing staff/CNAs) or the nurse for resident information such as how the resident transferred, their functional status, how long they should be sitting up, etc. CNA E stated she did rounds with the outgoing shift to get report about whether there were any changes with the residents she would be caring for during her shift. She stated residents were supposed to be checked every two hours. When she checked on her residents, she asked if they needed to be changed. She stated if a resident complained of pain, she asked what was wrong. If the resident wanted medication, she reported that to the nurse. If the resident wanted to be repositioned, then she got another staff member to assist her with repositioning the resident. When asked about Resident #102, she stated she was familiar with the resident. She stated the resident had a wound and required repositioning. She stated the resident was alert and was able to express her needs. She can tell you when she's in pain. CNA E also added that the resident will tell you when and how she wants to be repositioned and when it's hurting her and she just let's you know when her bottom is hurting and when she needs to be turned. When asked about call light response time expectations, CNA E stated that it was everyone's responsibility to answer the call lights. She acknowledged assisting Resident #102 earlier. She stated, Even if it's not your patient, you answer it. During an interview with Housekeeper F on 6/2/2023 at 2:44 p.m., she stated she had been employed with the facility for seven years. She acknowledge receiving training on Resident Rights and Abuse and Neglect as well as Call Light Response Times. She stated she was taught to cancel the call light and ask what the resident needed. If it was something she could do, such as getting ice or a snack, then she would do it. If not, she would get the nurse or CNA. She was asked about Resident #102. She stated she was familiar with the resident. She referred to the resident as with it. She was asked about the observations made of her entering and exiting the resident's room. She stated the resident wanted to be turned over because her bottom was hurting. She was asked what happened after the resident requested to be turned over. She stated, I didn't know where her nurse was but her CNA was on break, so I didn't get anyone. So the second time I went to the other end by the 400/500 hall and found the other two CNAs and told them what she needed. I couldn't turn her. We're not allowed to touch them. On 6/2/2023 at 3:08 p.m., Director of Rehabilitation (DOR) D was asked about an assessment for call light use. She stated there wasn't one. She stated if there were concerns that a resident could not use their call light, they'd change it out. She stated she was familiar with Resident #102 and was not aware of any concerns with the resident using her call light. DOR D went to the resident's room. The resident was observed in bed with the call light attached to a towel laid across her midsection not within easy reach. The resident was asked to demonstrate the use of her call light. As the surveyor asked the resident whether she could reach her call light, DOR D unclipped the call light from the towel and handed it to the resident. The resident pressed and successfully illuminated the call light. DOR D was advised of the call light observations throughout the survey. She denied knowledge/observations of any of the concerns stated. She stated she would look into it further and change the call light if needed. On 6/2/2023 at 3:29 p.m., DOR D advised that the call light for Resident #102 had been replaced with an easier to use air bulb style call light. On 6/2/2023 at 3:48 p.m., Resident #102's room was entered. The call light had been replaced and was within reach of the resident. The resident was able to use the new call light. She stated it was so much better. The resident expressed thanks and had no additional concerns at that time. A record review revealed that Resident #102 was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting her left non-dominant side; dysphagia; non-pressure chronic ulcer of the buttock with unspecified severity; type 2 diabetes mellitus without complications; acute respiratory failure with hypoxia; cognitive/communication deficit; need for assistance with personal care, and abnormal posture. Her physician's orders included the following orders dated 1/18/2022: Pain evaluation Q shift (every shift). Norco oral 5-325 mg (milligrams) (narcotic pain medication), 1 tablet by mouth for wound pain 30 minutes prior to wound care, hold for lethargy and give 1 tablet by mouth every 8 hours as needed for moderate to severe pain scale 5-10. Per the 4/10/2023 quarterly Minimum Data Set (MDS) assessment, the resident's Brief Interview for Mental Status (BIMS) score was documented as 15 out of a possible 15 points, indicating intact cognition. There were no moods or behaviors documented. She was totally dependent on staff for all activities of daily living (ADLs). Unhealed pressure ulcers, one or more was checked yes. Moisture associated skin damage was also checked yes. A review of the resident's most recent Care Plan included: FOCUS - [Resident #102] has been noted to yell out due to a diagnosis of stroke. Resident will often yell out as opposed to utilizing the call bell. History of making allegations. GOAL - Resident will demonstrate effective coping skills through the review date (rev 3/20/23). INTERVENTION: Anticipate needs. Resident needs food thirst toileting needs comfort level body positioning pain etc. Evaluate for side effects of medications, medications as ordered, psych evaluation as needed. FOCUS - [Resident #102] is at risk for pain. GOAL: Resident will not have interruption in normal activities due to pain through the review date (rev 3/20/23). INTERVENTION: Analgesics as ordered. Discuss with resident the need to request pain medications before pain becomes severe. Evaluate characteristics of pain location severity on scale of 0-10 and frequency identify existing conditions which may increase pain and/or discomfort. Monitor for probable cause of each pain episode. Monitor for side effects of pain medication. Note any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms or complaints of pain/discomfort. Observe for signs of relief /effectiveness with interventions, utilize non-medication interventions for pain relief. 3. A record review revealed that Resident #237 was admitted to the facility on [DATE], with a re- entry on 10/11/2022, and a discharge on [DATE]. Her diagnoses included acute kidney failure, dysphagia - oropharyngeal phase, need for assistance with personal care, adult failure to thrive, and dementia without behaviors. A review of the resident's physician's orders, revealed orders dated 2/9/2023 for a regular diet, mechanical soft texture, nutritional treat with meals, and a house shake four times a day. A review of the Advanced Practice Registered Nurse's (APRN's) note, dated 3/22/2023, read, Resident presented today out of bed in wheelchair at bedside, noted grunting, neck hyper-extended, rhonchi lung sounds, orders given for chest x- ray, nursing reports patient appears to be uncomfortable frequently throughout today. There was no documentation indicating the facility nursing staff notified the physician or APRN about the resident's change in condition prior to the APRN arriving at the facility. A review of the radiology report dated 3/23/2023, revealed left basilar airspace disease and modest left pleural effusion. A Nursing Progress note, dated 3/23/2023, indicated that the resident had a chest x- ray done. It resulted in left basilar airspace disease and modest left pleural effusion. New orders were given for doxycyline hyclate (antibiotic medication), oral tablet 100 milligrams (mg) two times a day for pneumonia (PNA) for 7 days, and oxygen via nasal canula at 2 liters per minute (L/min) as needed. A Change in Condition note, dated 3/23/2023, indicated that the resident was transferred to the emergency room (ER) via Emergency Medical Services (EMS) due to a low oxygen saturation of 89 percent (%) at 2 liters of oxygen. The resident's Care Plan, dated 10/27/2023, indicated the resident had Impaired Gas Exchange/Ineffective Airway Clearance related to Chronic Obstructive Pulmonary Disease (COPD). She also needed assistance with ADLs due to chronic kidney failure, seizures and dementia. The resident's Quarterly Minimum Date Set (MDS) assessment, dated 1/18/2023, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 points, indicating moderate cognitive impairment. She was documented as totally dependent on staff for bed mobility, transfers, toilet use, and required supervision assistance for eating. On 6/2/2023 at 9:11 AM, the Regional Nurse Consultant (RNC) and the Director of Nursing( DON) were interviewed related to Resident #237's change in condition. The RNC stated the resident had a chest x- ray due to a cough and was sent to the ER (emergency room) due to low blood oxygen saturation. When asked when the change in condition occurred, they both confirmed that there was no documentation about when it occurred, however, the chest x-ray was ordered on 3/22/2023 and obtained on 3/23/2023. They confirmed that there was no documentation on 3/23/2023 during the 7-3 shift about the resident's condition or status of the chest x-ray. The RNC and the DON stated the facility's policy was to contact the physician, family and DON for any changes in a resident's condition. When asked about the turning and repositioning documentation expectations, the DON stated the facility's protocol was to turn and reposition residents every two hours, but staff did not document every time they repositioned a resident. In an interview with Licensed Practical Nurse (LPN) G/Wound Care Nurse on 6/2/2023 at 9:47 a.m., she stated Resident #237 had a small area on her sacrum but it resolved by the time of discharge. She mentioned that the wound healed so quickly that the resident was not seen by the rounding wound care physician. She added that the care plan included turning and repositioning per facility protocol to prevent any new skin breakdown. When asked about the resident's functional status, she stated the resident was totally dependent on staff for all ADLs including bed mobility. She was then asked about the resident's change in condition. She stated she worked on 3/23/2023 on the 3-11 shift. The morning nurse reported the resident's respiratory discomfort and that she was awaiting chest x-ray results. LPN G added that when she checked on the resident, she noted that she had chest congestion. She contacted the radiology department, which provided the x-ray results. The physician was notified of the x-ray results and nursing obtained orders for antibiotics related to infiltration pneumonia, however, the resident's oxygen saturation started dropping before the initiation of the antibiotic. She contacted the physician again and was given orders to transfer the resident to the ER via emergency medical services. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that two (Residents #57 and #85) of two residents reviewed for limited range of motion, from a total of 37 residents in the sample, received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. The findings include: 1. On 5/31/23 at 11:29 AM, Resident #57 was observed in bed. His right upper extremity was contracted to his chest. When the resident was asked if he was able to extend his arm, he held it with the left hand as he tried to stretch it, then shook his head no. He was then asked if he was attending any therapy and again he shook his head no. He stated he had a splint but staff were not consistent with applying it. On 5/31/23 at 3:00 PM, the resident was observed in bed with no splint on his right upper extremity (RUE). On 6/01/23 at 10:05 AM, the resident was observed in bed with no splint on his RUE. On 6/02/23 at 10:30 AM, the resident was observed in bed with no splint on his RUE. He stated staff had just completed providing his morning care. A review of the medical record revealed that Resident #57 was admitted to the facility on [DATE]. his diagnoses included cerebrovascular disease, aphasia and muscle spasms. A review of the resident's physician's orders, dated 1/9/23, indicated that the resident was to participate in the Restorative Nursing Program (RNP) for orthotic management and upper extremity range of motion (ROM) seven times a week as tolerated. Notify rehab of any adverse reaction for pain. Another order, dated 1/30/23, indicated that Resident #57 was to utilize a right upper extremity (RUE) comfy elbow extension and RUE [NAME] air T-hand splint up to six hours per day as tolerated. Monitor skin integrity throughout to ensure no adverse reaction and doff splint immediately and notify rehab if noticed. (Photographic evidence obtained) A review of the care plan, updated on 5/31/23, revealed that the resident was at Risk for Symptoms/Complications related to History of Contracture (RUE). This places him at risk for pain. Interventions included to provide adaptive equipment/splints as tolerated to assist with mobility. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/17/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. He required extensive assistance with bed mobility, transfers and toilet use. He was totally dependent on staff for eating. The MDS did not indicate that the resident was on a restorative program. 2. On 5/30/23 at 1:37 PM, Resident #85 stated she had left-sided weakness and was getting occupational therapy (OT) until last Thursday, 5/25. She added that she was being splinted and was not sure whether she should continue being splinted since therapy stopped. She added that she would like to continue having it as it helped with the pain caused during movement. The resident's splint was observed in her drawer. (Photographic evidence obtained) A review of the medical record revealed that the resident was admitted to the facility on [DATE] with an admitting diagnosis noted as sequelae of unspecified cerebrovascular. A review of her physician's order, dated 2/14/23, revealed the following: Resident may participate in RNP 7 times a week for 15 weeks for contracture management. Resident to utilize Left [NAME] air T-hand orthotic for contracture management. A review of the Care Plan, revised on 5/31/23, revealed that the resident required assistance with activities of daily living (ADLs) and fluctuated from requiring extensive to total assistance/total care except for eating, which she required supervision for due to a diagnosis of stroke. Her ability to perform ADLs varied over the course of the day. Interventions included utilizing a Left [NAME] Air hand orthotic for contracture management. (Photographic copy obtained) A review of the Quarterly MDS assessment, dated 5/12/23, revealed that the resident had a BIMS score of 13, indicating intact cognition. She was assessed to be totally dependent for bed mobility, transfers, toilet use and needed supervision with eating. The resident was not documented to be receiving Restorative Therapy. A review of the Occupational Therapy (OT) notes dated 5/25/23, revealed that the resident had been discharged from OT when her highest practicable level was achieved. The notes further indicated that the resident was placed back on the RNP for passive ROM and splint placement. In an interview with Certified Nursing Assistant (CNA) I on 6/2/23 at 1:08 PM, she stated she had been employed by the facility for three years. She further stated Resident #85 required total care assistance. She confirmed that the resident was contracted and she had seen her with a splint at one time and therapy was placing the splint. She added that the resident was no longer on therapy and nursing staff should be applying the splint. She added that therapy normally taught staff how to apply the splints. A joint interview with the Director of Rehabilitation (DOR) and Licensed Practical Nurse (LPN) H/Restorative Nurse was conducted on 6/2/23 at 1:47 PM. The DOR stated residents were screened quarterly for functional status. If issues were noted, residents were further evaluated for skilled therapy or restorative nursing. She stated residents who were getting discharged from the skilled therapy case load and who remained in the facility, were normally discharged to restorative nursing from therapy. The DOR said, Normally, the frequency for Restorative is 5-7 days a week as tolerated, depending on what is going on. Restorative aides and/or nursing staff are provided with education with return demonstration as to what kind of services the residents need during discharge from skilled therapy. When asked about Residents #57 and #85's contractures, the DOR stated both residents were on the Restorative Nursing case load for splinting. The DOR stated Resident #85 completed skilled rehab on 5/25/23 and was placed back on the RNP. Both the DOR and LPN H accompanied the surveyor to the resident's room and confirmed that the splint was not on the resident. The resident pointed out that the splint was in the closet. The Infection Control Nurse/Restorative Nurse obtained the splint behind a stack of clothes in the closet. LPN H added that sometimes residents were uncomfortable with splints and they were taken off or staff took them off during care. When asked about how the resident tolerated the splints, she stated the staff were expected to document when they were applied and when they were removed. She could not provide documentation for the Restorative Nursing Program. During an interview with the Regional Nurse Consultant (RNC) on 6/2/23 at 4:45 PM, she confirmed that the facility had no documentation on it's Restorative Nursing Program. She added that the facility had identified that the RNP had stopped and had initiated a performance improvement program (PIP) in April 2023. When asked for the audits, she stated, There was no audit, only an in-service was conducted to initiate the program. I learned during the survey that it was not initiated. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who required respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (Resident #2) of six residents receiving respiratory treatment, from a total of 37 residents in the sample. The findings include: During an interview with Resident #2 on 5/30/2023 at 2:19 p.m., she advised that she stopped breathing when she slept. She stated Licensed Practical Nurse (LPN) A/Unit Manager was supposed to have ordered her a CPAP device two months ago but it still hadn't arrived. A review of Resident #2's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included heart failure; type 1 diabetes; ischemic cardiomyopathy; hemiplegia/hemiparesis; obstructive sleep apnea; atherosclerotic heart disease of native coronary artery; COPD; pulmonary hypertension; and presence of automatic cardiac defibrillator. A review of the Care Plan revealed the following: FOCUS - Impaired Gas Exchange/Ineffective Airway Clearance related to a diagnosis OSA history of bronchitis (rev 5/23/22) GOAL - Resident will be free of sign/symptoms of respiratory infections through the review date. INTERVENTIONS - BiPAP at 25/20 cm (centimeters) H20 (water) on room air with humidification. BiPAP to be worn during hours of sleep (4/12/22); Monitor for sign/symptoms of respiratory distress; respirations, pulse oximetry, increased heart rate; restlessness, diaphoresis, headaches; lethargy; confusion; atelectasis; hemotysis; cough; pleuritic pain; accessory muscle usage; skin color; vital signs as ordered. Per the Quarterly Minimum Data Set (MDS) assessment, dated 3/23/23, the resident's Brief Interview for Mental Status (BIMS) score was 15/15, indicating intact cognition. There were no moods or behaviors documented. She required supervision with locomotion on/off unit and eating; total dependence with toileting, and extensive assistance with transfers, bed mobility and dressing. A review of the resident's physician's order dated 5/11/23, revealed: BiPAP @ 25/20 cm H20 on room air with humidification to be worn during hours of sleep; Monitor mobile cardiac monitor with it in place on chest, may secure with chest; Please apply supplemental O2 QHS (oxygen at bedtime daily) at 2L (2 liters per minute) for sleep apnea. Will continue until CPAP {*clerical error} has been fixed. During an interview on 6/1/2023 at 1:51 p.m. with LPN B, she was asked to clarify whether the resident was ordered a CPAP or BiPAP device. She replied, I don't know. She stated she had only been employed with the facility for three weeks, and although she was familiar with the resident, she did not have knowledge of this information. She deferred to LPN A. At this time, a person exited from a door behind a desk at the nurses' station. She advised the surveyor this was LPN A. The surveyor made an introduction and explained what was needed. An interview was conducted on 6/1/2023 at 1:53 p.m. with LPN A, who stated she had been employed with the facility for approximately 19 months. She was asked about Resident #2 and the equipment. She stated at times the resident was noncompliant with the CPAP. She stated the resident would mess with it and lost the cord. She further stated she called the company and they were sending a new cord to the facility. She was asked to clarify whether the resident had been ordered a CPAP or BiPAP device. She could not clarify this and stated she would have to look into it. She also could not confirm how long it had been since the cord had been ordered and the resident had been without use of the device. She also could not provide any documentation such as a workorder, invoice etc. for the equipment repair/part ordered. During an interview on 6/1/2023 at 5:07 p.m. with the Regional Nurse Consultant (RNC), she confirmed the equipment was a BiPAP device. She stated they were in communication with the supplier in an attempt to get the equipment sent overnight to the facility. On 6/2/2023 at 9:33 a.m., the RNC advised that the BiPAP cord had been received and delivered to the resident overnight. During an interview on 6/2/2023 at 4:08 p.m. with LPN A, she confirmed the device was a BiPAP and that it had been received. She stated the resident said she was getting an error message that air was leaking from it. She stated she called the supplier and they said the settings were too high and they needed to verify the setting. She stated she was able to confirm the correct setting and they were still working on other possible fixes. She stated she was working with the nurse on the other shift as well to see whether they could get the right fit for the resident, as she had two masks for the device. Again, she was asked how long the issue had been going on. She stated since approximately 5/11/2023. On 6/2/2023 at 4:33 p.m., LPN A advised that she had spoken to the provider and it was determined that there was a crack in the water reservoir of the device which would cause the seal not to seal properly. She was asked to provide correspondence from the onset of the issue on 5/11/23 to current date. She stated there wasn't anything that she could provide as proof that the facility had been making attempts to have the equipment repaired. There are no record of the repair calls to the supplier or a technician with the supplier or the facility, nor were there any work orders or invoices. There were no receipts, payment coupons, or sell slips provided. She stated the phone representative at the supplier stated she could see where she had called in the past, however she could not provide any documentation of this. She again stated there was no documentation to confirm anything had been done to make repairs to the equipment prior to the survey team entering the building. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide care and treatment in accordance with professional standards of practice, by delaying hospitalization for one (Resident #51) of two residents reviewed for hospitalizations from a total sample of 40 residents. The findings include: A review of Resident #51's medical record revealed an admission date of 4/14/21 and a readmission date of 7/21/21. Her primary medical diagnosis was nondisplaced intertrochanteric fracture of right femur. Secondary medical diagnoses included osteoarthritis, dementia with behavioral disturbances, osteoporosis, and fracture of sacrum. A significant change assessment dated [DATE] revealed resident's cognition was moderately impaired, and she required limited to extensive assistance with activities of daily living. A nursing progress note dated 7/18/21 at 2:24 AM indicated Resident #51 was observed lying on her back next to her bed. An abrasion was noted above the right eye. The resident stated she slipped and fell. She denied pain at the time of the assessment. A post fall review dated 7/18/21 indicated the fall occurred at 2:10 AM. The resident was ambulating unassisted. A review of Resident #51's physician order dated 7/18/21 at 1:26 PM indicated a STAT x-ray of the right femur and right knee for pain. A nursing progress note dated 7/18/21 at 1:27 PM indicated Resident #51 was to have a stat x-ray of the right knee and right femur due to pain. An x-ray result dated 7/18/21 at 9:03 PM indicated a minimally displaced obliquely oriented acute intertrochanteric fracture. The examination date for Resident #51 was on 7/18/21 at 8:15 PM. A physician order dated 7/18/2021 at 10:06 PM read, Transfer the resident to the emergency room for a right femur fracture. A nursing progress note dated 7/18/21 at 11:52 PM indicated Resident #51 was diagnosed with a right femur fracture. The physician was notified, and order was obtained for transfer to the emergency room for evaluation. A nursing progress note dated 7/19/21 at 2:00 AM indicated ambulance service arrived and resident was taken to the emergency room. An attempt to interview the nurse that transferred the resident to the hospital was made. However, the nurse was no longer employed at the facility. A review of Resident #51's hospital history and physical dated 7/19/21 indicated she presented to the emergency department with right leg pain following an unwitnessed fall around 5 AM. The note read, She was apparently ambulatory for a few hours after the fall but then reported she was having too much pain to be able to walk. She had imaging done and was found to have a right femur fracture. On 9/23/21 at 10:01 AM, an interview was conducted with the Employee B, Licensed Practical Nurse (LPN)/Unit Manager (UM). She explained that she was out of the building conducting a mock survey at another facility. The UM stated, she wasn't sure why the resident's transfer to the hospital was delayed. On 9/23/21 at 12:40 PM, an interview was conducted with the Regional Nurse Consultant (RNC). When she was asked about the lapse of time between the second x-ray being ordered and Resident #51's subsequent transfer to the hospital, she stated, she wasn't sure why the delay had occurred. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement interventions to address a resident's acute pain related to a fracture after sustaining a fall for one (Resident #51) of two residents reviewed for pain management from a total sample of 40 residents. The findings include: A review of Resident #51's medical record revealed an admission date of 4/14/21 and a readmission date of 7/21/21. Her primary medical diagnosis was nondisplaced intertrochanteric fracture of right femur. Secondary medical diagnoses included osteoarthritis, dementia with behavioral disturbances, osteoporosis, and fracture of sacrum. A significant change assessment dated [DATE] revealed resident's cognition was moderately impaired, and she required limited to extensive assistance with activities of daily living. A nursing progress note dated 7/18/21 at 2:24 AM indicated Resident #51 was observed lying on her back next to her bed. An abrasion was noted above the right eye. The resident stated she slipped and fell. She denied pain at the time of the assessment. A post fall review dated 7/18/21 indicated the fall occurred at 2:10 AM. The resident was ambulating unassisted. A review of Resident #51's physician order dated 7/18/21 at 1:26 PM indicated a STAT x-ray of the right femur and right knee for pain. A nursing progress note dated 7/18/21 at 1:27 PM indicated Resident #51 was to have a stat x-ray of the right knee and right femur due to pain. An x-ray result dated 7/18/21 at 9:03 PM indicated a minimally displaced obliquely oriented acute intertrochanteric fracture. The examination date for Resident #51 was on 7/18/21 at 8:15 PM. A physician order dated 7/18/2021 at 10:06 PM read, Transfer the resident to the emergency room for a right femur fracture. A nursing progress note dated 7/18/21 at 11:52 PM indicated Resident #51 was diagnosed with a right femur fracture. The physician was notified, and order was obtained for transfer to the emergency room for evaluation. A nursing progress note dated 7/19/21 at 2:00 AM indicated ambulance service arrived and resident was taken to the emergency room. A review of Resident #51's hospital history and physical dated 7/19/21 indicated she presented to the emergency department with right leg pain following an unwitnessed fall around 5 AM. The note read, She was apparently ambulatory for a few hours after the fall but then reported she was having too much pain to be able to walk. She had imaging done and was found to have a right femur fracture. A review of Resident #51's physician order dated 4/14/21 revealed an order for a Lidoderm patch to be placed on the resident's lower back. The resident had no other orders for analgesics prior to the fall and no ordered analgesics until after returning from the hospital. A review of the medication administration records (MAR) for July 2021 revealed pain evaluation results of 0 on each shift prior to the resident transferring to the hospital. A review of the comprehensive care plan for Resident #51 dated 4/15/21 revealed a focus area for pain. Interventions included analgesics as ordered, evaluate characteristics of pain: location, severity on a scale of 10, and frequency, identify existing conditions that may increase pain or discomfort, observe for signs of relief/effectiveness with interventions. On 9/22/21 at 2:16 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She explained that she had worked at the facility for approximately nine years and that she was familiar with Resident #51. Regarding the fall on 7/18/2021, the nurse explained that the fall occurred on night shift and that she reported to work the following morning. She explained that as the day shift CNA was assisting the resident to stand, the resident complained of pain. The CNA notified the nurse and the nurse went in to assess the the resident. The resident pointed to her knee. The nurse explained that she notified the physician and obtained an order for a STAT x-ray. When asked about interventions to address the resident's pain, the nurse stated she believed she had given the resident tylenol. The nurse then reviewed the medical record and asked Employee B, LPN/Unit Manager to review the record. The UM stated, she didn't see anything on the 18th or 19th. On 9/22/21 at 3:13 PM, Employee A, LPN confirmed, she did not give Resident #51 anything for pain. Initially, she stated, I didn't give her anything. The doctor didn't tell me to give her anything. But, she had a lidoderm patch on her back. When asked to confirm whether the resident's acute pain was discussed with the physician, the nurse didn't answer the question but stated, I don't know, I don't remember. On 9/23/21 at 10:01 AM, an interview was conducted with the UM. She explained that she was out of the building conducting a mock survey at another facility when the resident fell. The UM reviewed the resident's record and confirmed that the record contained no documentation of interventions to treat the resident's pain. On 9/23/21 at 12:40 PM, an interview was conducted with the Regional Nurse Consultant (RNC). She explained that the facility conducted an investigation for Resident #51's fall on 7/18/21. The RNC stated, she had spoken with the nurse about the fall after it was brought to her attention during the survey and that the nurse told her she obtained an x-ray order because the resident was grimacing while walking. The RNC acknowledged that, after reviewing the record and speaking with Employee A, LPN the resident received her routinely scheduled lidoderm patches but no other analgesics were adminsitered to treat the acute pain. A review of the facility's pain management policy titled Pain Evaluation directed staff to assess the resident's pain characteristics, contact the physician for orders, and include interventions in the resident's comprehensive plan of care. .