Based on record review and interview, the facility failed to ensure medication were administered per the physician's orders for 2 of 5 residents reviewed for unnecessary medications. (Resident 71, Resident 33) Findings include: 1. On 6/12/25 at 11:35 a.m., Resident 71's clinical record was reviewed. The diagnoses included, but were not limited to, congestive heart failure and atrial flutter. A Physician's Order for metoprolol (a medication used to slow the heart rate) 50 mg (milligrams) oral tablet extended release daily, initiated 4/6/25. The medication was to be held if the resident's pulse was below 60 beats per minute. The Medication Administration Record indicated on the following dates, the medication was administered when the resident's pulse was below 60 beats per minute: - On 5/725, 57 beats per minute. - On 5/8/25, 52 beats per minute. - On 5/12/25, 57 beats per minute. - On 5/13/25, 57 beats per minute. - On 5/19/25, 57 beats per minute. - On 5/21/25, 55 beats per minute. - On 5/22/25, 58 beats per minute. - On 5/27/25, 53 beats per minute. - On 6/2/25, 52 beats per minute. - On 6/4/25, 52 beats per minute. - On 6/5/25, 55 beats per minute. - On 6/7/25, 57 beats per minute. - On 6/9/25, 53 beats per minute. 2. On 6/11/25 at 11:05 a.m., Resident 33's clinical record was reviewed. The diagnoses included, but were not limited to, hypertension, atrial fibrillation, and respiratory failure. The Physician Order Report indicated metoprolol tartrate 25 (mg) milligrams administer half tablet by mouth twice a day. Hold the medication if heart rate was less than 60 or the systolic (the top number in a blood pressure reading) blood pressure was less than 110 (order start date 12/27/24). The May 2025 Medication Administration Record (MAR) indicated to administer metoprolol tartrate 25 mg half tablet twice a day. Hold the medication if heart rate was less than 60 or the systolic blood pressure was less than 110. The MAR indicated the following: - On 5/21/25 at 6:30 a.m. - 10:30 a.m. the medication was administered. The pulse was 57. The clinical record lacked documentation of medication being held. The June 2025 Medication Administration Record indicated to administer metoprolol tartrate 25 mg half tablet twice a day. Hold the medication if heart rate was less than 60 or the systolic blood pressure was less than 110. The MAR indicated the following: - On 6/1/25 at 6:30 p.m. - 10:30 p.m. the medication was administered. The blood pressure was 103/76. The clinical record lacked documentation of medication being held. - On 6/7/25 at 6:30 a.m. - 10:30 a.m. the medication was administered. The blood pressure was 100/56. The clinical record lacked documentation of medication being held. - On 6/9/25 at 6:30 a.m. - 10:30 a.m. the medication was administered. The blood pressure was 101/43. The clinical record lacked documentation of medication being held. During an interview on 6/12/25 at 1:35 p.m., the Director of Nursing indicated per physician order, the medication should not have been administered to the resident on the aforementioned dates. On 6/12/25 at 2:01 p.m., the Corporate Administrator provided the facility's policy, Medication Administration, revised date 4/17, and indicated it was the policy being used. A review of the policy indicated, .To safely administer medications as per physicians' order .20. Always take pulse and B/P as indicated if ordered prior to giving certain cardiac or antihypertensive drugs. Notify the physician if the vital signs are not within the acceptable range . 3.1-35(g)(1)

Based on interview and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The IP did not currently dedicate at least part time hours to the role of IP for 2 of 2 staff members reviewed for IP (Director of Nursing and RN 1). Findings include: On 6/8/25 at 11:30 a.m., the Administrator provided documentation which indicated the Director of Nursing (DON) was the facility's Infection Preventionist (IP) nurse. During an interview on 6/12/25 at 2:05 p.m., RN 1 indicated she was responsible for the infection tracking and monitoring. She had not received certification in Infection Prevention and Control. During an interview on 6/12/25 at 2:05 p.m., the DON indicated she was currently responsible for the infection prevention quality and assurance. She indicated she also worked full time in the facility as the DON and was unable to show she devoted 20 hours each week to infection prevention. She confirmed RN 1 did not have infection prevention certification. During an interview on 6/12/25 at 2:26 p.m., the Corporate Administrator indicated he was aware the facility needed to have a staff member devoted to the IP nurse role which was not the DON. On 6/12/25 at 2:26 p.m., the Corporate Administrator provided the IP job description, Infection Preventionist, dated 2023, and indicated it was the job description currently being used. A review of the job description indicated, . Reports To: Director of Nursing . 5. Infection prevention and control (IPC) training must be sufficient to perform the role of the IP . 6. An IP must have obtained specialized PIC training beyond initial professional training or education prior to assuming the role . On 6/12/25 at 2:26 p.m., the Corporate Administrator provided the DON job description, Director of Nursing, dated 2023, and indicated it was the job description currently being used. A review of the job description indicated, . Summary: . He/she assumes responsibility for nursing service compliance in accordance to facility policy and procedure as well as Federal Regulations and State Rules governing the facility .

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was given to the resident or the resident representative for 1 of 4 residents reviewed for hospitalization. (Resident 57) Finding includes: On 4/27/23 at 10:15 a.m., Resident 57's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease, cholecystitis (inflammation of the gall bladder), and diabetes mellitus. A progress note, dated 12/31/22 at 8:30 a.m., indicated Resident 57 was sent to the emergency room. The Notice of Transfer or Discharge, dated 12/31/22, lacked documentation the resident or the resident's representative had been notified of the transfer in writing and provided the appeal rights information in writing including the contact information of the the Office of the State LTC (Long Term Care) Ombudsman after the resident was sent out to the hospital. A progress note, dated 1/13/23 at 9:45 a.m., indicated Resident 57 was sent to the the emergency room. The Notice of Transfer or Discharge, dated 1/12/23, lacked documentation the resident or the resident's representative had been notified of the transfer in writing and provided the appeal rights information in writing including the contact information of the the Office of the State LTC (Long Term Care) Ombudsman after the resident was sent out to the hospital. During an interview on 4/28/23 at 12:25 p.m., the Director of Nursing (DON) indicated the Notice of Transfer or Discharge for Resident 57 lacked the resident or resident's representative notification in writing. On 4/28/23 at 12:51 p.m., the DON provided the facility policy, Transfer/Discharge, dated 1/2015 and indicated this was the policy currently being used by the facility. A review of the policy indicated .(A) Notify the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner that the resident understands. The health facility must place a copy of the notice in the residents' clinical record and transmit a copy to the following: (i) The resident .(iii) The resident's legal representative 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for residents who transferred to the hospital was provided for 1 of 4 residents reviewed for hospitalization. (Resident 57) Finding includes: On 4/27/23 at 10:15 a.m., Resident 57's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease, cholecystitis (inflammation of the gall bladder), and diabetes mellitus. Resident 57's progress notes indicated the following: - On 12/31/22 at 8:30 a.m., Resident 57 was sent to the emergency room. There was no documentation that a written notice that specified the facility's bed-hold policy was provided to the resident or the resident's representative. - On 1/13/23 at 9:45 a.m., Resident 57 was sent to the the emergency room. There was no documentation that a written notice that specified the facility's bed-hold policy was provided to the resident or the resident's representative During an interview on 4/28/23 at 12:25 p.m., the Director of Nursing (DON) indicated Resident 57's bed-hold policy lacked the resident or resident's representative notification in writing. On 4/28/23 at 12:51 p.m., the DON provided the facility policy, Bedhold, revision date 7/2018, and indicated this was the policy currently being used by the facility. A review of the policy indicated .At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident to the resident or resident representative written notice which specifies the duration of the bed-hold policy 3.1-12(a)(25) 3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was labeled and dated for 5 of 5 residents reviewed for respiratory care. (Resident 6, Resident 47, Resident 60, Resident 51, and Resident 44). Findings include 1. On 4/23/23 at 12:05 p.m., Resident 6 was observed in bed in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/25/23 at 9:40 a.m., Resident 6 was observed in bed in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/26/23 at 10:00 a.m., Resident 6 was observed in bed in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/25/23 at 2:30 p.m., Resident 6's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction and chronic obstructive pulmonary disease. A current physician's order with a start date of 8/30/22 indicated the resident was prescribed supplemental oxygen at 2 liters per minute. 2. On 4/23/23 at 12:05 p.m., Resident 47 was observed in bed in his room. On the floor, beside the bed was a nasal cannula and oxygen tubing attached to an oxygen delivery machine. The oxygen tubing had no label indicating the date it was changed. On 4/25/22 at 9:45 a.m., Resident 47 was observed in bed in his room. On the floor, beside the bed was a nasal cannula and oxygen tubing attached to an oxygen delivery machine. The oxygen tubing had no label indicating the date it was changed. On 4/26/23 at 10:05 a.m., Resident 47 was observed in bed in his room. On the floor, beside the bed was a nasal cannula and oxygen tubing attached to an oxygen delivery machine. The oxygen tubing had no label indicating the date it was changed. On 4/25/23 at 2:40 p.m., Resident 47's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease and chronic obstructive pulmonary disease. A current physician's order with a start date of 8/30/22 indicated the resident was prescribed supplemental oxygen at 2 liters per minute. 3. On 4/23/23 at 12:15 p.m., Resident 60 was observed in her chair in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/25/23 at 9:50 a.m., Resident 60 was observed in her chair in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/26/23 at 10:10 a.m., Resident 60 was observed in her chair in her room. She was receiving oxygen via oxygen tubing and a nasal cannula. The oxygen tubing had no label indicating the date it was changed. On 4/25/23 at 3:05 p.m., Resident 60's clinical record was reviewed. The diagnoses included, but were not limited to, chronic respiratory failure and chronic obstructive pulmonary disease. A current physician's order with a start date of 8/31/22 indicated the resident was prescribed supplemental oxygen at 2 liters per minute. 5. On 4/24/23 at 10:51 a.m., Resident 44 was observed to be lying in bed with an oxygen nasal cannula in her nostrils. The tubing for the oxygen and the humidification bottle were undated. On 4/26/23 at 9:42 a.m., Resident 44 was observed to be lying in bed with an oxygen nasal cannula in her nostrils. The tubing for the oxygen was undated. On 4/27/23 at 11:25 a.m., Resident 44 was observed to be lying in bed with an oxygen nasal cannula in her nostrils. The tubing for the oxygen was undated. On 4/28/23 at 10:23 a.m., Resident 44 was observed to be lying in bed with an oxygen nasal cannula in her nostrils. The tubing for the oxygen was undated. Resident 44's clinical record was reviewed on 4/26/23 at 11:07 a.m. The diagnosis included, but was not limited to, chronic respiratory failure. Physician orders, dated 4/27/23, indicated Resident 44 utilized supplemental oxygen via nasal cannula at 2 L (liters) as needed. During an interview on 4/26/23 at 10:25 a.m., the DON indicated the oxygen tubing and humidifiers had no labels as they should have had that indicated when they were changed and Resident 47's tubing and cannula should not have been on the floor. On 4/28/23 at 11:00 a.m., the DON provided the facility policy, Oxygen Therapy, dated 10/2014, and indicated this was the policy currently being used by the facility. A review of the policy did not indicate putting a date on the oxygen tubing or the humidification bottle. 3.1-47(a)(6) 4. On 4/25/23 at 11:51 a.m., Resident 51 was observed in her bedroom receiving concentrated oxygen via nasal cannula. No date was observed on the oxygen tubing nor concentrator. The resident indicated staff change the tubing when they replace the water (concentrator). On 4/26/23 at 10:15 a.m., Resident 51's clinical record was reviewed. The diagnoses included, but were not limited to, asthma, Chronic Obstructive Pulmonary Disease (COPD), obstructive hypertropic cardiomyopathy (a condition in which the heart muscle becomes abnormally thick), and heart failure. Review of the resident's current, April, 2023, physicians orders indicated on 2/10/23, the resident was ordered continuous supplemental oxygen via nasal cannula flowing at 1 liter per minute.