**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and review of the facility's policy titled, Snuff and Chewing Tobacco Use, the facility failed to maintain snuff in a secure location for one of 51 sampled residents (R) (R40). The deficient practice had the potential to put the residents at risk for avoidable accidents, injuries, and a diminished quality of life Findings include: A review of the policy titled Snuff and Chewing Tobacco Use with a review date of 12/29/2023 revealed under section titled Intent, Our center realizes the threat that snuff and chewing tobacco use present to the safety and health of the patient. Snuff and tobacco use are prohibited in a tobacco free center. It is not the intention of the center to deprive patients the pleasures of using snuff and chewing tobacco, but to ensure their safety and the safety of other patients. Under section titled Guideline, it revealed, Storage of Tobacco products: Non-smoking tobacco products should be kept at the nurse's station and given to the patient upon request. Non-smoking tobacco products do not have to be limited to smoke breaks unless proper usage and sanitation is not maintained. Further record review of the facilities policy titled, Snuff and Chewing Tobacco Use did not reveal that tobacco products had to be stored in a lock box. A review of electronic health record (EHR) for R40 revealed diagnoses including, but limited to Parkinson's disease without dyskinesia, with fluctuations, and dementia in other diseases classified elsewhere, unspecified severity, with agitation. A review of R40's quarterly Minimum Data Set (MDS) dated [DATE] section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. A review of the care plan for R40 dated 7/1/2024 revealed a focus area of cognitive impairment related to Parkinson's disease as evidence by poor decision making/needs cue. Further review of care plan revealed a focus area of tobacco use related to resident using snuff as evidence by resident using snuff daily. Care plan revealed the goal is that patient will abide by tobacco guidelines when using snuff though review period and interventions are to observe for changes in patients' capabilities and needs. During on observation on 9/11/2024 at 8:58 am in R40's bedroom revealed a can of 'name of snuff' snuff by his bed side table. During an interview and observation on 9/11/2024 at 10:47 am in R40's bedroom, R40 was observed in his wheelchair with no visible snuff in mouth and stated that he liked to use snuff. During this time, observation revealed a can of 'name of snuff' by his bed side table, with the lid on and no spit cup around. Further observation at 10:51 am revealed R40 spitting in cup then putting more snuff in his mouth. During an interview on 9/11/2024 at 9:06 am with Certified Nursing Assistant (CNA) BB revealed that if residents had tobacco products, she would inform the nurse to see if the resident was allowed to have the tobacco product. CNA BB stated usually when residents have snuff, they are given a bit of snuff at a time throughout the day. CNA BB stated she was not aware of all the residents who use tobacco products. During an interview on 9/11/2024 at 10:20 am with Registered Nurse (RN) AA revealed that residents who use tobacco products are care planned and some of them keep the tobacco products in their room. She stated a negative outcome of residents who have tobacco products readily accessible to them would be in infection risk, residents could eat the tobacco product and be poisoned and could even cause death. RN AA further revealed she did know if residents must be assessed to be able to have tobacco products by their bedside. During an interview on 9/11/2024 at 10:36 am with the Director of Nursing (DON) revealed that residents do not keep tobacco products like snuff in their rooms. The DON stated that snuff was normally locked away. The DON further revealed possible negative outcomes caused by having snuff not locked away could be that residents could aspirate and if they have visitors, the visitors could get into the snuff. An interview on 9/12/2024 at 9:38 am with RN CC revealed all residents who use tobacco products were educated on tobacco risks and they were provided with lock boxes. RN CC stated per facility policy, all residents who have tobacco products have lock boxes, but sometimes they lose the keys. An interview on 9/12/2024 at 9:44 am with the Administrator revealed her expectations were that all tobacco products are to be in a lock box or always kept at the nurse's medication cart. The Administrator further revealed that a possible negative outcome was that residents with cognitive issues might eat the tobacco product or make them sick.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and review of the facility's policy titled, Use of Oxygen (O2) Therapy, the facility failed to obtain physician orders for O2 and failed to maintain appropriate O2 levels for one of 16 residents (R) (R62) on O2 therapy. The deficient practice had the potential to place R62 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of the facility's policy titled Use of Oxygen Therapy revealed under the section titled INTENT: To ensure that patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. Under the section titled Guideline, it revealed, Physician's order for oxygen should be obtained and include: Oxygen with liter flow as ordered, indicated if use should be continuous or PRN (as needed), method of oxygen delivery via nasal cannula, mask, etc. A review of the electronic health record (EHR) for R62 revealed diagnoses including, but not limited to chronic diastolic (congestive) heart failure (CHF), chronic obstructive pulmonary disease (COPD), unspecified, and non-ST elevation (NSTEMI) myocardial infarction. A review of R62's quarterly Minimum Data Set (MDS) dated [DATE] revealed in section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. Further review of R62's MDS revealed section O (Treatments) documented O2 treatment. A review of R62's care plan dated 7/25/2024 revealed a focus area of respiratory difficulties/risk for further decline related to diagnosis of COPD and oxygen in place for CGH (Comparative Genomic Hybridization) and COPD, does remove oxygen at times as evidence by Trelegy Ellipta (breathing medication), oxygen via nasal cannula 2 liter per minute (LPM) nasally every eight (8) hours, breathe sounds diminished and oxygen use. Further review of care plan revealed interventions of administer medication/treatments as ordered, monitoring vital signs, notifying physicians of changes, and oxygen as ordered. R62 also had focus area for cardiovascular disease as evidence by history of cardiac related to dyslipidemia and atherosclerosis. Further review of care plan revealed the goal to be that patient will experience no complications related to cardiac symptoms through review period. During an observation on 9/10/2024 at 1:01 pm, R62 was observed in her room with O2 on. Upon further observation, R62's O2 level was set at 3.5 LPM. Upon asking, R62 stated her O2 level was supposed to be set at 2 LPM. During record review on 9/10/2024 it was revealed that there were no physician orders for O2 for R62. During an interview on 9/11/2024 at 10:25 am with Registered Nurse (RN) AA confirmed all residents on O2 must have physician orders since it is considered a medication. RN AA stated it was the responsibility of the nurse in charge to verify all physician orders were obtained. RN AA stated a potential negative outcome of a resident not having physician order for O2 was that the resident's O2 levels could decrease, and residents could be in distress and possibly end up in the hospital. During an interview on 9/11/2042 at 10:29 am with the Director of Nursing (DON) confirmed that physician orders were required for residents who are on O2. The DON stated her expectations were that all residents were required to have physicians' orders when they were receiving O2. She stated it was the nurse in charge's responsibility to make sure all residents who had O2 had physician orders. The DON confirmed that she oversaw nurses in charge and was not aware there was a physician's order missing for O2. The DON stated a negative outcome for not obtaining physician orders for O2 was that it could affect resident care because the facility could not verify if the resident needed O2 or not. The DON further stated a resident could have too much O2 and could cause respiratory issues. Review of the EHR revealed a physician order for Oxygen: Nasal Cannula 2 liter per minute nasally every eight (8) hours. Diagnosis (DX) Chronic diastolic (congestive) heart failure. The order has an order/start date for 9/11/2024. The order was electronically signed by the facility's RN on 9/11/2024. The order was electronically signed by the physician on 9/12/2024. During an observation and interview of R62 on 9/12/2024 at 9:06 am revealed her O2 level set at 1.5 LPM. R62 was receiving .5 LPM less O2 than the prescribed physician orders. R62 once again confirmed that her O2 level was supposed to be set at 2 LPM. During an interview on 9/12/2024 at 9:11 am with Licensed Nurse Practitioner (LPN) DD confirmed R62 was to always be receiving 2 LPM of O2. LPN DD stated it was her or the nurse who was administering medications responsibility to check every eight hours if R62 was receiving prescribed O2 levels. During an interview on 9/12/2024 at 10:28 am with RN CC confirmed R62 did not have physician orders for O2 as of 9/10/2024. RN CC further revealed O2 orders for R62 were ordered on 9/11/2024. RN CC stated nurses in charge and the Unit Manager oversaw submitting orders and RN CC stated R62 most likely came into the facility with O2 and her orders where not transferred over. During an interview on 9/12/2024 at 9:49 am with the Administrator confirmed that R62 O2 levels were supposed to be set at 2 LPM. The Administrator revealed it was her expectations that residents who were on O2 were receiving the correct amount of O2 per physician orders. The Administrator further revealed a negative outcome for residents not receiving proper O2 levels was that residents may experience shortness of breath and may get confused if they don't receive enough or if they receive too much.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to provide documentation of a written agreement or contract with the company providing hemodialysis services for one of four residents (R) (R84) receiving dialysis services. The deficient practice had the potential to result in R84 not to obtain services that meet professional standards and experience diminished quality of life. Findings include: Review of the electronic medical record (EMR) revealed R84 was admitted to the facility with diagnosis including but not limited to end stage renal disease (ESRD). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognition) documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition, Section O (Special Treatments, Procedures, and Programs) revealed R84 received dialysis while a resident in the facility. Review of care plan dated 7/12/2024 revealed Focus: ESRD-Receives dialysis Monday, Wednesday, and Friday. Resident has been on dialysis for years. Resident receives dialysis at 'name of dialysis clinic' per her request, Goal: Patient will not experience complications secondary to dialysis through the review period, Intervention: After dialysis treatment, observe resident for adverse reactions to treatment, communicate patient's status with dialysis center. Review of the Physician's Orders dated 2/18/2024 revealed orders that included: R84 to receive dialysis on Mondays, Wednesdays, and Fridays. Review of facility documents revealed no documentation of a written agreement or contract with the dialysis center, which provides hemodialysis services to R84. Interview on 9/12/2024 at 5:32 pm with the Restorative Nurse (RN) GG who has management responsibilities, revealed R84 had been receiving dialysis services at 'name of dialysis center'. She further revealed that an email was sent to the 'name of dialysis center' office for a copy of the contract to be sent to the facility. Interview on 9/12/2024 at 5:33 pm with the Administrator revealed she confirmed R84 had been receiving dialysis services at 'name of dialysis center' and an email was sent to their office for a copy of the contract to be sent to the facility. She further confirmed that Area Operations Director AOD FF will send a copy of the contract as soon as possible. Phone interview on 9/12/2024 at 5:34 pm with AOD FF, he stated the facility made the request today, 9/12/2024, for a contract with 'name of dialysis center' to be sent to the facility. He further stated that the information from the facility was submitted to the name of dialysis center' legal department and the legal department will make a decision on the effective start of the contract date.