**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide quarterly financial statements for one Resident (#89) with a Personal Needs Account (PNA) out of a sample of 26 residents. Specifically, the facility failed to provide quarterly financial statements to his/her Conservator. Findings include: Resident #89 was admitted to the facility in April, 2023 with diagnoses including dementia. A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) Score of 12 out of a possible 15 indicating moderate impairment. Review of the medical record indicated that Resident #89 has a decree of Conservatorship dated 12/21/23. (A Conservator is a court-appointed individual responsible for managing the financial affairs and property of a protected person who is deemed unable to do so themselves). During an interview on 3/19/25 at 10:03 A.M., the Business Office Manager (BOM) said Resident #89 has a PNA account. She said the facility has been the representative payee ( a representative payee is a person or organization authorized by the Social Security Administration (SSA) to manage and cash certain benefit checks) since 5/24/23. The BOM said she has been mailing the Resident's financial quarterly statements to his/her family member. The BOM said the Resident's family member is not legally responsible for the Resident's finances so she should not be receiving the quarterly statements. The BOM said the Resident has had a Conservatorship in place since 12/21/23. The BOM said she should be mailing the Resident's financial quarterly statements to the Conservator because she is legally responsible for the Resident's finances. During a telephone interview on 3/20/25 at 8:20 A.M., the Conservator said she has never received quarterly statements from the facility since she was appointed on 12/21/23. She said she expects the facility to mail the Resident's financial quarterly statements to her since she is legally responsible for his/her finances.

Based on observations, record review and interview the facility failed to develop and implement a comprehensive resident-centered care plan for one Resident (#92) out of a total sample of 26 residents. Specifically, for Resident #92, the facility failed to develop a care plan for use of a psychotropic medication (used to treat or manage a psychiatric symptoms or challenging behavior). Findings include: Resident #92 was admitted to the facility in March 2023 with diagnoses including anxiety and dementia. Review of the physician orders dated March 2025 indicated the following orders: -Valproic acid (mood stabilizer) solution; 250 mg (milligrams)/5 mL (milliliters); amount 2.5 ml; oral twice a day for anxiety. Review of the current care plan for Resident #92 failed to indicate a focus, goals and interventions for the use of the mood stabilizer medication Valproic Acid. During an interview on 3/19/25 at 12:14 P.M., with Nurse #1 she said she did not know how to monitor a resident for adverse effects of a psychotropic medication. During an interview on 3/19/25 at 12:19 P.M., Nurse #2 she said she could look up any side effects of psychotropic medications and that it seems like there should be a care plan to address psychotropic medication use. Nurse #2 said she would think that there should be a care plan to address psychotropic medication use. During an interview 3/20/25 at 8:08 A.M., Unit Manager #2 said that psychotropic medication use is usually addressed in a behavior care plan, but the care plan does not address adverse effects of psychotropic medications. During an interview on 3/20/25 at 9:15 A.M., the Director of Nursing said if a resident is on a psychotropic medication they should have a care plan in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow professional standards of practice for 3 Residents (#97, #421, and #424) out of a total sample of 26 residents. Specifically; 1. For Resident #97, the facility failed to follow a physician's order for a weekly skin check. 2. For Resident #421, the facility failed to follow physician's order for air mattress setting. 3. For Resident #424, the facility failed to follow physician's order for air mattress setting. Findings include: 1. Review of the facility policy titled Prevention of Pressure Ulcers, dated April 2020, indicated the following: - Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Resident #97 was admitted in September 2023 with diagnoses including osteoarthritis and failure to thrive. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #97 scored a 14 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the Norton Plus Pressure Ulcer Scale (a tool used to asses risk of developing a pressure ulcer), dated 7/10/24, indicated Resident #97 was at high risk for developing a pressure ulcer. Review of the weekly skin check observations for July 2024 indicated that skin checks were completed on 7/9/24 and then again on 7/23/24. The medical record failed to indicate that a skin check was done on the week of 7/16/24. Review of the skin check, dated 7/23/24, indicated Resident #97 had a left heel pressure wound. Review of the nursing progress notes, dated 7/23/24, indicated Area to left heel measuring 3.2cm (centimeters) x 3cm. New treatment order in place. Resident encourage [sic] to elevate leg and use heel booties while in bed. During an interview on 03/19/25 at 12:09 A.M., Unit Manager #2 said that if there is an order for skin checks to be completed weekly, then skin checks should be completed. Unit Manager #2 confirmed that there was a missing skin check for the week of 7/16/24, but said that there might be information regarding the skin check in the nursing progress notes. Review of the nursing progress notes failed to indicate any documentation related to a skin check.

Based on observation, interviews, and record review the facility failed to maintain respiratory equipment according to professional standards of practice for one Resident (#83), out of a total sample of 26 residents. Specifically, For Resident #83, the facility failed to ensure the oxygen concentrator and filter were clean. Findings include: Review of the facility's policy, titled 'Oxygen Concentrator', dated 12/3/24, indicated the purpose is to establish responsibilities for the care and use of oxygen concentrators. -The main body cabinet should be dusted when needed and can be wiped clean with damp cloth and mild household cleaner if necessary. On 3/18/25 9:15 A.M., the surveyor observed the oxygen filter on the oxygen concentration had a layer of gray dust and the main body cabinet had a layer of powder and gray dust. Review of Resident #83's physician order, dated 2/19/24, indicated oxygen- change tubing, rinse filter, wipe down concentrator weekly. Label/date/bag tubing with each change. Once a day on Tuesday nights Review of Resident #83's Treatment Administration Record (TAR), dated 3/18/25, indicated 'oxygen-change tubing, rinse filter, wipe down concentrator weekly' was initialed as completed. On 3/19/25 at 12:25 P.M., the surveyor and Unit Manager #1 observed Resident #83's oxygen concentrator and filter. The oxygen filter was observed to have a thick layer of gray dust, and the main body cabinet had a layer of powder and dust. Unit Manager #1 said the concentrator and filter were dirty and needed to be cleaned. Unit Manager #1 said the oxygen concentrator is scheduled to be cleaned weekly with oxygen tubing change. On 3/20/25 at 9:17 A.M., the Director of Nursing said the oxygen concentrator and filter should be cleaned weekly.

Based on record review and interviews, the facility failed to implement a pharmacy recommendation for one Resident (#85) out of a total sample of 26 residents. Findings include: Review of the facility policy titled 'Medication Regimen Review' dated April 2024, indicated the following but not limited to: -Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Resident #85 was admitted to the facility in February 2024 with diagnoses including anxiety disorder. Review of Resident #85's most recent Minimum Data Set (MDS) assessment, dated 1/30/25, indicated the Resident score a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the consultant pharmacist recommendation to prescriber report dated 2/16/25 indicated the following: -Resident is receiving the following PRN (as needed) psychotropic medication. These medications are required to be re-evaluated after 14 days. If therapy is to be continued beyond 14 days, please note medical justification for continued use in progress note and specify the number of days the PRN order is to continue. Trazadone and Clonazepam. Review of the physician response to the pharmacy recommendation dated 2/18/25 indicated the following: -I agree - please see new order- please add 14-day re-eval for clonazepam. Review of the medical record failed to indicate a 14-day re-evaluation for clonazepam was added to the physician order. During an interview on 3/19/25 at 1:47 P.M., Unit Manager #1 said the pharmacy recommendations should be implemented as soon as the physician addresses them. During an interview on 3/20/25 at 9:15 A.M., the Director of Nursing said pharmacy recommendations should be addressed and implemented within 24-48 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure that PRN (as needed) ordered psychotropic drugs were limited to 14 days for four Residents (#32, #85, #421 and #424) out of a total sample of 26 residents. Specifically, 1. For Resident #32, the facility failed to implement a 14 day stop date for a PRN Ativan (an antianxiety medication). 2. For Resident #85, the facility failed to implement a 14 day stop date for a PRN Clonazepam (an antianxiety medication). 3. For Resident #421, the facility failed to implement a 14 day stop date for a PRN Clonazepam (an antianxiety medication). 4. For Resident #424, the facility failed to implement a 14 day stop date for a PRN Ativan (an antianxiety medication) Findings include: Review of the facility policy titled 'Psychotropic Medication Use' undated, indicated the following but not limited to: -A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. -Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: -Anti-psychotic -Anti-depressants -Anti-anxiety medications and -Hypnotics. -Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. -PRN orders for psychotropic are limited to 14 days. 1. Resident #32 was admitted to the facility in October 2024 with diagnoses including anxiety disorder. Review of Resident #32's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the Resident #32's physician's order, dated 2/28/25, indicated the following: -Ativan (Lorazepam) 0.5 milligrams (mg). 0.25 mg by mouth PRN (as needed) nausea/vomiting once a day. Review of the Resident #32's Medication Administration Record (MAR), dated March 2025, indicated he/she received PRN Ativan on 3/4/25. During an interview on 3/19/25 at 1:47 P.M., Unit Manager #1 said as needed psychotropic medications need a 14 day stop date and re-evaluation by the physician. During an interview on 3/30/25 at 9:15 A.M., the Director of Nursing (DON) said PRN psychotropic medications need a 14 day stop date. 2. Resident #85 was admitted to the facility in February 2024 with diagnoses including anxiety disorder. Review of Resident #85's most recent Minimum Data Set (MDS) assessment, dated 1/30/25, indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of Resident #85's physician's order, dated 2/10/25, indicated the following: -Clonazepam 1 mg one tab by mouth twice a day as needed. Special instructions only two PRN doses allowed per day. Review of Resident #85's Medication Administration Record (MAR), dated March 2025, indicated he/she received as needed clonazepam on the following dates: -3/1/25, 3/3/25, 3/4/25, 3/6/25, 3/7/25, 3/8/25, 3/9/25, 3/11/25, 3/12/25, 3/14/25, 3/15/25, 3/16/25, 3/17/25, 3/18/25, and 3/19/25. During an interview on 3/19/25 at 1:47 P.M., Unit Manager #1 said as needed psychotropic medications need a 14 day stop date and re-evaluation by the physician. During an interview on 3/30/25 at 9:15 A.M., the Director of Nursing (DON) said PRN psychotropic medications need a 14 day stop date. 3. Resident #421 was admitted to the facility in March 2025 with diagnoses including anxiety disorder. Review of Resident #421's most recent Brief Interview for Mental Status (BIMS) dated 3/14/25 indicated the Resident scored a 15 out of a possible 15 indicating he/she was cognitively intact. Review of Resident #421's physician's order, dated 3/12/25, indicated the following: -Ativan (Lorazepam) 1 mg tablet administer one tablet by mouth every 8 hours as needed for anxiety. -Review of Resident #421's Medication Administration Record (MAR), dated March 2025, indicated he/she received as needed Ativan on the following dates: -3/13/25, 3/14/25, 3/25/25, 3/16/25, 3/17/25, and 3/18/25. During an interview on 3/19/25 at 1:47 P.M., Unit Manager #1 said as needed psychotropic medications need a 14 day stop date and re-evaluation by the physician. During an interview on 3/30/25 at 9:15 A.M., the Director of Nursing (DON) said PRN psychotropic medications need a 14 day stop date. 4. Resident #424 was admitted to the facility in March 2025 with diagnoses including bipolar disorder, delusional disorder and anxiety. Review of Resident #424's most recent Brief Interview for Mental Status (BIMS) dated 3/10/25 indicated the Resident scored a 15 out of a possible 15 indicating he/she was cognitively intact. Review of Resident #424's physician's order, dated 3/9/25 indicated the following: -Clonazepam 0.5 mg administer one tablet by mouth twice a day for anxiety. Review of Resident #424's Medication Administration Record (MAR), dated March 2025, indicated he/she received as needed Clonazepam on the following date: -3/10/25 During an interview on 3/19/25 at 1:47 P.M., Unit Manager #1 said as needed psychotropic medications need a 14 day stop date and re-evaluation by the physician. During an interview on 3/30/25 at 9:15 A.M., the Director of Nursing (DON) said PRN psychotropic need a 14 day stop date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review, the facility failed follow professional standards for weight management for one Resident (#101) out of a total sample of 5 residents. Specifically, the facility failed to conduct reweights for weights outside of acceptable parameters per facility policy. Findings include: Review of the facility policy titled Weighing and Measuring, revised 10/2019 indicated: Residents are weighed: On admission or readmission (Do NOT use prior hospital weight) Weekly for the first 4 weeks after admission Monthly thereafter Per physician's order K. Check current weight against prior recorded weight L. Notify the licensed nurse if weight is three or more pounds different (gain or loss) from prior weight M. Re-weigh the resident within 24 hours to verify accuracy of the weight N. Record the re-weight in the Vital Signs section of the electronic medical record Resident #101 was admitted to the facility in January of 2024 with diagnoses including Type 2 diabetes mellitus (non insulin-dependent diabetes), sepsis (the presence of bacteria in the blood often associated with severe disease) and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) of 15 out of 15. Further review of Section GG of MDS indicated Resident #101 required assistance with set up and clean up of meals and of Section K indicated that he/she had weights loss of 5% or more in the last month or 10% or more in the last 6 months, not on a physician-prescribed weight-loss regimen. On 4/10/24 at 1:50 P.M., Resident #101 was observed laying in his bed. He/she said that the staff weigh him/her and say that he/she is losing weight. The Resident said that his/her appetite was not what it used to be and they offer what he/she likes. Review of the medical record indicated the following: Vitals Report (1/19/24 - 4/11/24) Resident weights: 1/20/24: 245.4 lbs (pounds) 1/27/24: 240.4 lbs 2/10/24: 227.6 lbs 2/20/24: 246 lbs 3/6/24: 231.6 lbs 3/12/24: 229.4 lbs 3/19/24: 224.4 lbs 3/26/24: 225 lbs 4/2/24: 220.6 lbs 4/5/24: 218.2 lbs 7/24: 218.2 lbs 4/9/24: 216.6 lbs Review of the medical record failed to indicate that a reweight was obtained for Resident #101 when a weight difference of three or pounds was noted on the following dates: 1/27/24, 2/10/24, 2/20/24, 3/6/24, 3/19/24 and 4/2/24. Review of the Nutrition Progress Note dated 3/27/24 at 12:22 P.M., indicated the Resident #101's weights: 3/26/24 225 lbs, 3/6/24 231.6 lbs, 2/20/24 246 lbs, 1/20/24 245.4 lbs. Possibly 1/20 and 2/20 weights were an error? Resident consumes 75%+ of most meals. He/she enjoys meals with a good appetite. During an interview on 4/11/24 at 11:24 A.M., the Registered Dietician said that the policy of the facility was that if a resident's weight changes by 3 pounds from the previous weight, a re-weight needs to be done and documented. She said she expects the weight change to be reported to her so she can determine interventions based on the clinical needs and the resident's wishes. She said there is a weekly At Risk meeting that she attends, but if weights are not in the record, she cannot make recommendations. She said Resident #101 is eating, asking for snacks, refuses Glucerna and large portions, says he/she doesn't want more food. He/She has clinical issues and is hypermetabolic so even though he/she eats a lot, he/she is burning a lot. During and interview on 4/11/24 at 12:15 P.M. with the Director of Nursing (DON) and Quality Assurance (QA) Nurse, the DON said she expects the nurses to follow the Weight Policy. Weights should be done on admission, then weekly for 4 weeks, if there is a weight loss/gain 3 pounds or more, a reweight should be done and recorded. If weight is validated, nursing should talk with the resident, notify the physician and dietitian. She said the facility has weekly weight and wound (At Risk) meetings, and risk notes should be put into medical record so they can always refer back to chart with any changes. She said that the risk notes did not make it into Resident #101's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide supervision and cuing during meals per the plan of care for 2 Residents (#87, #106) out of a total of 22 sampled Residents. Findings include: 1. Resident #87 was admitted to the facility in November 2020 with diagnoses including Alzheimer's disease and depression. Review of Resident #87's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she scored 3 out of a possible 15 on the Brief Interview for Mental Status Exam indicating severe cognitive impairment. Additional review of the MDS indicated Resident #87 required physical assistance with bathing and dressing and supervision with eating. On 4/4/23 at 11:47 A.M., the surveyor observed staff deliver Resident #87's lunch meal to his/her room. Staff left his/her tray on the bedside table and left the room. At 12:12 P.M., the surveyor observed Resident #87 asleep in bed with his/her plate untouched, except for some bites of pudding. Resident #87 woke and said that he/she was not hungry and wanted to sleep. Review of Resident #87's Activities of Daily Living Care Plan dated 11/3/20, review date 2/22/23 indicated: Eating, assist and prompt with cues and encouragement to complete meal. Review of the Dietitian's Quarterly assessment dated [DATE] indicated: Resident with a 14 lb 10% weight loss in 6 months. Staff provides cueing and encouragement with meals. On 4/5/23 at 8:02 A.M., the surveyor observed Resident #87 in his/her room adjusting his/her bedding. Resident #87's breakfast tray was on the bedside table and was untouched except for 2 bites from his/her breakfast sandwich. Resident #87 asked the surveyor what was on the breakfast tray and then asked if he/she could go back to sleep. There were no staff providing cueing or encouragement per his/her plan of care. On 4/5/23 at 11:48 A.M., the surveyor observed Resident #87 seated at the side of his/her bed and then adjust himself/herself into a laying position. Resident #87's lunch meal was on his/her bedside table untouched except for some bites of pudding. There was no staff providing cuing or encouragement per his/her plan of care. On 4/6/23 7:47 A.M., the surveyor observed CNA #1 deliver Resident #87's breakfast meal to his/her room, set up the tray and leave. The surveyor then approached CNA #1 who said that Resident #87 requires set up for meals and eats by himself/herself in his/her room. CNA #1 said that Resident #87 is not a big eater. During an interview with Charge Nurse #1 on 4/6/23 at 12:58 P.M., she said that Resident care plans should be followed. 2. Resident #106 was admitted to the facility in July 2022 with diagnoses including Review of Resident #106's most recent Minimum Data Set assessment dated [DATE] indicated he/she scored a 10 out of a possible 15 on the Brief Interview for Mental Status Exam indicating moderate cognitive impairment. The MDS also indicated Resident #106 requires supervision with meals. On 4/4/23 at 8:16 A.M., the surveyor observed Resident #106 eating breakfast alone in his/her room. Resident #106 appeared thin and frail and was coughing after taking bites of his/her meal. There was no staff in the room providing assistance or supervision. Review of Resident #106's Physician's Orders indicated the following: 1:1 assistance with all meals, Aspiration precautions with meals, 3/27/23. Review of Resident #106's nursing progress note indicated the following: Seen by speech, diet changed to ground fortified foods with moderately thick liquids. 1:1 assistance with all meals and aspiration precautions, 3/27/23. Review of Resident #106's Nutrition Care Plan, dated 7/19/22 indicated an intervention for Resident #106 to be 1:1 with meals due to aspiration precautions. On 4/5/23 at 8:26 A.M., the surveyor observed Nurse #1 deliver Resident #106's breakfast meal to his/her room. Nurse #1 set up the tray and then left the room. At 8:32 A.M. the surveyor observed Resident #106 eating his/her meal alone his/her room without supervision per his/her plan of care. On 4/5/23 at 12:06 P.M., the surveyor observed Resident #106 seated in the dining room with 3 other Residents at his/her table eating his/her meal. There were no staff seated with Resident #106 providing 1:1 per his/her care plan. During an interview with Charge Nurse #1 on 4/6/23 at 12:58 P.M., she said that Resident care plans should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to identify and address a significant weight loss for 1 Resident (#7) out of a total of 22 sampled Residents. Findings include: Resident #7 was admitted to the facility in August 2022 with diagnoses including Parkinsons, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of Resident #7's most recent Minimum Data Set assessment dated [DATE] indicated he/she scored 11 out of a possible 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Additional review of the MDS indicated that Resident #7 requires assistance with bathing, dressing and transfers. During an interview on 4/4/23 at 9:48 A.M., Resident #7 appeared thin and frail. Resident #7 said that he/she forces himself/herself to eat. Review of Resident #7's Nutritional Status Care Plan, initiated 8/11/22, indicated the following interventions: Diabetic snack at HS (hour of sleep). Diet: Regular solids, fortified foods, no fish. Honor preferences within diet. Offer menu selection. Monitor Intake. Fortified foods; super cereal daily with breakfast, super pudding daily with lunch. Supplements; Ensure plus high protein 8 oz BID (twice daily), Weight; monthly. Review of Resident #7's physician's orders indicated orders for Ensure twice daily, (initiated 9/22/22) and fortified food with meals, (initiated 10/12/22). Review of Resident #7's weights indicated the following: 1/2/23: 106.4 lbs (pounds) 2/5/23: 98.8 lbs a loss of 7.14% of his/her total body weight in one month 3/6/23: 97 lbs 4/2/23: 99 lbs Review of the clinical record indicated that Resident #7 was not assessed by the Dietitian until 3/22/23: 46 days after the weight loss was first identified. Review of the Dietitian's assessment failed to identify Resident #7 had a significant weight loss between January 2023 and February 2023 and failed to introduce new interventions in response to the weight loss. Review of the facility's Risk Meeting minutes failed to include Resident #7 in the February 2023 or March 2023 meetings for significant weight loss. During an interview with Charge Nurse #1 on 4/6/23 at 12:58 P.M. she said that Resident #7 had a weight loss although he/she does have a good appetite. Charge Nurse #1 said that Resident #7 is a picky eater and sometimes orders out and a friend comes and visits once a month and will bring in food. Charge Nurse #1 said that Resident #7's family hasn't been to visit as frequently. During interviews with the Dietitian on 4/6/23 at 12:30 P.M. and 12:52 P.M. she said that she in the facility 20 hours a week and is alerted by the staff of any new weight loss and also can run a report through the electronic health record. The Dietitian acknowledged she did not assess Resident #7's weight loss until 3/22/23 for his/her Quarterly assessment. The Dietitian said she did not introduce any new interventions addressing Resident #7's weight loss because it was reported to her that Resident #7 often refuses his/her Ensure supplement and the Resident's family also frequently brings in snacks and food items for Resident #7. The Dietitian said he/she was not aware that the Treatment Administration Records (TAR) for February 2023 and March 2023 indicated that Resident #7 only refused the Ensure 3 times. The Dietitian said that she was also not aware that staff had reported that Resident #7's family had not been visiting regularly. The Dietitian did not say if the use of an appetite stimulant, larger portions, or other interventions had been considered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observations, record review and staff interviews, the facility failed to obtain physician's orders for oxygen administration for one Resident (#1), in a total sample of 22 residents. Findings include: Review of the facility policy titled, Oxygen Therapy, dated as revised 2/2022, indicated: -an order by the physician or designee must be in the resident's record indicating the oxygen equipment and flow rate of oxygen desired. Resident #1 was admitted to the facility in February 2023 with diagnoses including end stage renal disease, atrial fibrillation, heart failure, hypoxemia (low oxygen). Review of the Minimum Data Set (MDS) assessment, dated 3/3/23, indicated Resident #1 required oxygen administration. Review of the Hospital Discharge summary, dated [DATE], indicated that Resident #1 required continuous oxygen administration. During observations on 4/4/23 at 8:39 A.M., 4/4/23 at 1:33 P.M., 4/4/23 4:02 P.M., and on 4/5/23 at 6:50 A.M., Resident #1 was in his/her room receiving oxygen via nasal cannula. Review of the physician's orders dated 2/28/23-4/5/23, indicated there was no documentation to support an active physician's order for Resident #1's oxygen administration. During an interview on 4/6/23 at 11:52 A.M., the Charge Nurse #2 said that oxygen administration requires a physician's order. During an interview on 4/6/23 at 10:20 A.M., the Quality Assurance Nurse said that oxygen administration requires a physician's order. During an interview on 4/6/23 at 2:04 P.M., the Director of Nursing said that oxygen administration requires a physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide counseling services for 1 Resident (#7) out of a total of 22 sampled Residents. Findings include: Resident #7 was admitted to the facility in August 2022 with diagnoses including Parkinsons, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of Resident #7's most recent Minimum Data Set assessment dated [DATE] indicated he/she scored 11 out of a possible 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Additional review of the MDS indicated that Resident #7 requires assistance with bathing, dressing and transfers. During an interview on 4/4/23 at 9:48 A.M., Resident #7 was tearful and anxious. Resident #7 said that he/she was depressed and noted he/she had lost his/her child, was missing his/her family and did not want to be in a long term care facility for the rest of his/her life. Review of Resident #7's clinical record indicated a referral/screening request form dated 9/28/22 for Resident #7 to receive individual counseling from psychiatric services for individual counseling due to anxiety, depression, and adjustment. Review of the clinical record failed to indicate that Resident #7 had received any counseling services since his/her admission to the facility. During an interview with Social Worker #1 on 4/5/23 at 12:35 P.M. she confirmed the referral was placed but did not know why Resident #7 had not been seen for counseling services.