Based on record review, staff interview, and policy review the facility failed to create and implement upon admission a Baseline Care Plan for 1 of 6 residents reviewed (Resident #11). The facility also failed to implement Baseline Care Plans that included goals residents wanted to archive while living at the facility, significant diagnoses, and symptoms to monitor for, medications and significant medication side effects to monitor, and signatures that the resident and/or Power of Attorney (POA) were aware and agreed for 5 of 6 residents reviewed. The facility reported a census of 27 residents. Findings include: 1. The MDS (Minimum Data Set) for Resident #11 dated 1/16/25, with an admission date of 10/14/24, indicated the resident had diagnoses of coronary artery disease, renal failure, and depression. The orders tab of the resident's electronic health record (EHR) revealed the resident took Escitalopram (depression), Acetaminophen (pain), and Hydrocodone (pain). A Progress Note on 10/15/24 documented the resident also took Methocarbamol (muscle spasms) and Tramadol (pain) when he was admitted , for pain in his hips. During an interview with the Director of Nursing on 03/27/25 at 11:21 AM she reported she didn't know where to locate the Baseline Care Plan for Resident #11. It was not located in the resident's paper chart or in the electronic health record. 2. The EHR for Resident #126 included an admission record with an initial admission date of 3/14/25. It documented diagnoses of pulmonary fibrosis (scarring/thickening of lung tissue), chronic systolic heart failure (left ventricle weakens and can't pump blood effectively), and type 2 diabetes mellitus. The orders tab of the EHR included Acetaminophen (pain), Eliquis (anticoagulant), Lorazepam (anxiety), Citalopram (depression), and Lasix (diuretic). The Baseline Care Plan for Resident #126 did not include goals based on admission orders and the goals of the resident; a summary of medications and diagnoses; pain goals or interventions; mental health diagnoses, medications, or side effects; diabetic management; or monitoring for diuretic and anticoagulant symptoms and side effects. 3. The EHR for Resident #127 included an admission record with an initial admission date of 3/17/25. It included diagnoses of acute respiratory failure with hypoxia (lungs fail to deliver enough oxygen to the blood), major depressive disorder, anxiety disorder, and repeated falls. The orders tab of the EHR included Metformin (high blood sugar), Acetaminophen (pain), Gabapentin (pain), Hydrocodone (pain), Methenamine (UTI prevention), Lispro and Lantus (insulin), and Warfarin (anticoagulant). Progress Notes for Resident #127 documented falls 3/20/25 at 1:35 AM, 3/23/25 at 2:35 AM, and 3/26/25 at 3:15 AM. The Baseline Care Plan for Resident #127 did not include fall history, goals, or interventions; goals based on admission orders; resident goals; a summary of medications and diagnoses; pain goals, medications, or interventions; mental health diagnoses, medications, or side effects; diabetic and insulin management; discharge planning; or monitoring for anticoagulant symptoms and side effects. An interview with Resident #127 on 03/25/25 at 09:24 AM determined she hoped to go home. She did not think staff provided her with a copy of her Baseline Care Plan. 4. The EHR for Resident #128 included an admission date of 3/18/25. Their diagnoses included dementia, peripheral vascular disease, and transient cerebral ischemic attack (temporary interruption of blood flow to the brain). On 03/24/25 at 12:41 PM the surveyor observed a certified nurses aide (CNA) walk to a dining room table with the resident. The resident did not have a gait belt on. Another CNA came over to put one on her and explained that she needed it for safety. The first CNA said it wasn't on the resident's Care Plan or you better believe it would have been on her. The Baseline Care Plan for Resident #128 included a sentence that indicated the resident was up with one assist and her walker. It did not address the need for a gait belt; goals based on admission orders and resident goals; a summary of medications; pain goals or interventions; or monitoring for anticoagulant symptoms and side effects. 5. The Minimum Data Set (MDS) for Resident #12 documented diagnoses of fracture, anxiety, depression, and hypertension. The orders tab included Cyclobenzaprine (muscle relaxant), Acetaminophen (pain), Protriptyline (depression), and Lorazepam (anxiety). On 03/24/25 at 12:02 PM the surveyor observed the resident folded over in her wheelchair, head down on the table. The resident was not easily redirected by staff. The Baseline Care Plan for Resident #12 did not include mental health diagnoses, medications, behaviors, or side effects; goals based on admission orders and the goals of the resident; range of motion interventions; a summary of medications and diagnoses; or pain goals, medications, and interventions. During an interview on 03/25/25 at 11:14 AM Staff B, CNA stated Resident #12 had been there about 2 months. Since admission she had refused to talk or work with some staff. When asked about folding herself in her chair, Staff B stated she did that to avoid things. She thought the resident was using it as a coping mechanism, something she could control when she felt anxious. On 03/25/25 at 12:51 PM the DON corroborated Staff B's statement and added that family had reported a history of depression, possible PTSD, and electroshock therapy. Later that day, at 03:06 PM, the DON provided Baseline Care Plans for residents that consisted of a single sheet of paper. She confirmed they were the Baseline Care Plan for a resident until the Comprehensive Care Plan was completed, and stated they had until 7 days after the MDS was completed to finish them for a total of 21 days. She acknowledged the documents provided did not include diagnoses, medications, mental health information, behavior concerns, code status, signatures, involvement of the interdisciplinary team, or confirmation a copy had been given to the resident or responsible party. During a follow up interview on 03/27/25 at 11:21 AM the DON showed the surveyor a form the facility used to use for Baseline Care Plans that included most of the items missed on the current documents. She stated she didn't know why they stopped using them and thought they could start using them again. An undated facility policy titled Care Planning - Interdisciplinary Team documented baseline care plans would be posted at admission in the nurse's station until the comprehensive care plan was completed. The resident, resident's family, and/or the resident's legal representative were encouraged to participate in the development and revisions to the resident's care plan. The care planning/interdisciplinary team included the physician, registered nurse, dietary manager/dietician, social services, therapists, consultants, DON, charge nurse, nursing assistants, and others as appropriate to meet the needs of the resident.

Based on observation, record review, staff interviews, and written education review, the facility failed to provide services that met professional standards regarding medication administration for 1 of 1 residents observed for insulin administration (Resident #5). The facility reported a census of 28 residents. Findings include: During the Medication Pass Task, an observation on 5/7/24 at 8:15 AM revealed Staff A, Licensed Practical Nurse (LPN) administered Resident #5's insulin. Staff A, LPN obtained a Humalog (insulin) flex pen from the medication cart, put a needle on the tip of the pen, primed the pen with 2 units then dialed up to 10 units and proceeded to administer the insulin. Staff A, LPN failed to keep the needle under the skin for a full count of 10 to ensure the full dose was injected before removing. During the same observation, Staff A, LPN obtained a Lantus (insulin) flex pen from the medication cart, put a needle on the tip of the pen, primed the pen with 2 units then dialed up to 20 units and proceeded to administer the insulin. Staff A, LPN failed to keep the needle under the skin for a full count of 10 to make sure the full dose was injected before removing. In an interview following the insulin injections on 5/7/24 at 8:15 AM, Staff A, LPN stated she was not aware of a need to leave the needle under the skin for several seconds after injecting but stated she would check on it with administration and report back. In an interview on 5/7/24 at 9:59 AM, Staff A, LPN stated she had checked and learned that she was to leave the needle injected under the skin for the count of 10 prior to removing the needle. She stated she had just learned this but would implement the practice from here on out. In an interview on 5/7/24 at 3:39 PM, the Director of Nursing (DON), stated it was the expectation the licensed staff ensure the insulin pen needle be left under the skin after injecting insulin from a flex pen for the full count of 10 before removing the needle from the skin to ensure all the insulin is administered. A facility provided care giver education titled How to Use an Insulin Pen stated after pushing the injection button down firmly to inject the insulin, count to 10 then pull the needle straight out of the skin.

Based on observations, interviews, and record review, the facility failed to obtain parameters for oxygen administration for 1 of 1 resident reviewed with oxygen (Resident #2). The facility reported a census of 28 residents. Findings include: On 5/6/24 at 1:58 p.m., Resident #2 was laying in his bed. He had oxygen on per nasal canula at 1 ½ liters. His respirations were non-labored. On 5/8/24 at 9:57 a.m., Resident #2 was sitting in the common area. Respirations were non-labored. He was not receiving oxygen. A Doctor's Order dated 5/2/24, documented oxygen as needed for comfort. A Treatment Administration Record for May 2024, documented that this resident received oxygen on 5/3/24 and 5/7/24. It did not specify the liter flow. It lacked documentation of the oxygen he received on 5/6/24. On 5/8/24 at 3:03 p.m., the Director of Nursing (DON), stated that this resident's oxygen order should specify the liter flow. She verified it did not. She stated she would call the provider to see what her order was to be. When told the only criteria for when to apply oxygen was for comfort, no pulse oximetry checks (non-invasive test that measures oxygenation level in the blood) and that Resident #2 was receiving oxygen on 5/6/24 but this was not documented on the Treatment Administration Record, the DON acknowledged the concerns. On 5/9/24 at 8:45 a.m., the DON stated she talked with the provider who ordered the oxygen. The DON stated the provider thought this resident was actively dying at the time she wrote the order. The DON stated that the provider said she would be sure to clarify all oxygen orders in the future. An undated Oxygen Administration by Oxygen Concentrator policy, directed staff to administer oxygen to residents when insufficient oxygen is being carried by the blood to the tissues. The facility will administer oxygen to residents when prescribed by a physician to accomplish the following objectives: to relieve hypoxemia (oxygen tension in arterial blood below normal), to relieve hypoxia (insufficient amount of oxygen available to supply the body need), relieve congestion and respiratory distress, to relieve pain and discomfort, and to normalize rate, rhythm, depth, and quality of respirations.