Based on observation, interview, facility policy review, and record review, the facility failed to implement the care plan interventions related to oxygen administered for one (1) of 19 care plans reviewed. Resident #79. Findings Included: A record review of the facility's policy, Care Plan Process revised 12/24, revealed, .The overall care plan should be oriented towards .10. Assessing and planning for care to meet the resident's medical, nursing, mental, and psychosocial needs .The Care Plan Format includes .the interventions, the staff responsible to carry out the interventions . A record review of the Comprehensive Care Plan revealed Resident #79 had a care plan Focus The resident has a hx (history) of Asthma .Interventions .Oxygen at 2L/MIN (Liters per minute) per NC (Nasal Cannula) as needed for SOB (Shortness of Breath). On 4/16/25 at 9:15 AM, during an observation of Resident #79 in bed, the oxygen concentrator at the bedside was observed to be running at a flow rate of three (3) liters per minute. A record review of the Order Listing Report revealed Resident #79 had a Physician's Order, revised 4/15/25, for oxygen via nasal cannula at 2 liters per minute for shortness of breath or oxygen saturation of 93% or below every 24 hours as needed. On 4/17/25 at 9:10 AM, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that the physician order and care plan for Resident #79 indicated that the resident should be receiving oxygen at two (2) liters per minute via nasal cannula. LPN #1 confirmed that the oxygen should not have been set at three (3) liters and acknowledged that staff are expected to follow the resident's physician orders and care plan interventions as written. On 4/17/25 at 9:40 AM, during an interview with the Director of Nursing (DON), she confirmed that care plan interventions must be implemented as written. She acknowledged that a discrepancy between the oxygen flow rate provided, and the resident's physician order and care plan represent a failure to follow the individualized plan of care. She stated that if the resident requires an adjustment to the oxygen level, the nurse must obtain a physician's order and update the care plan accordingly. A record review of the admission Record revealed the facility admitted Resident #79 on 3/10/2025 with current diagnoses including Cough and Wheezing. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated his cognition was moderately impaired. Further review revealed under Section O that he was receiving oxygen therapy.

Based on observation, staff interview, record review, and facility policy review, the facility failed to revise a comprehensive care plan for a resident with an indwelling catheter for one (1) of 19 care plans reviewed. Resident #79 Findings include: A review of the facility' policy, Care Plan Process dated 12/2024 revealed . The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided . On 04/14/25 at 12:29 PM, during an observation, Resident #79 was sitting in a wheelchair in his room and catheter tubing was observed near his leg. A record review of the Care Plan Report revealed Resident #79 had a care plan focus of The resident has a .Catheter. There was no intervention related to how often catheter care should be performed or the position responsible for providing the care. A record review of the Task List Report, initiated on 3/10/25, revealed Certified Nurse Aides (CNAs) documented the task of Bladder Voiding and Toilet Use, Cath Use every shift for Resident #79. A record review of theFollow Up Question Report for 04/01/25 through 04/16/2025 revealed catheter care was provided by CNAs for Resident #79. On 04/15/2025 at 10:05 AM, in an interview with CNA #1, she explained that the CNAs are responsible for catheter care and documenting in the Electronic Health Record (EHR). She stated that catheter care is displayed on the computer for them to document the task every shift. On 04/16/2025 at 11:16 AM, in an interview with Registered Nurse (RN) #1 she confirmed that the care plan for Resident #79 did not include an intervention for routine catheter care. She stated that a physician's order is not required for catheter care and they had not added it to the care plan. She agreed that routine catheter care should have been included as an intervention and the care plan revised to reflect the frequency and discipline responsible for the care. On 04/17/2025 at 08:59 AM, during an interview with the Director of Nursing (DON), she stated that she was made aware that the care plan related to catheter care for Resident #79 had not been revised to include an intervention for routine catheter care. She reported that the care plan team had already begun to correct this issue. A record review of the admission Record revealed the facility admitted Resident #79 on 03/10/2025 with diagnoses including Acute Kidney Failure. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/25 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated his cognition was moderately impaired. Further review revealed he had an indwelling catheter.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the oxygen flow rate was consistent with the physician's order for one (1) of one (1) resident reviewed for oxygen administration. (Resident #79) Findings included: A record review of the facility's policy Drug Administration and Documentation, revised 3/25 revealed, .The complete act of administration entails .verifying it with the physician's orders . A record review of the Order Listing Report revealed Resident #79 had a Physician's Order, revised 4/15/25, for oxygen via nasal cannula at two (2) liters per minute for shortness of breath or oxygen saturation of 93% (per cent) or below every 24 hours as needed. During an observation on 4/16/25 at 8:40 AM, Resident #79 was observed receiving oxygen via nasal cannula at a flow rate above three (3) liters per minute. During an observation and interview with Licensed Practical Nurse (LPN) #1 on 4/16/25 at 9:22 AM, Resident #79's oxygen flow was observed at 3.4 liters per minute. LPN #1 stated the resident's oxygen typically runs at three (3) liters per minute. During an observation and follow up interview with LPN #1 on 4/16/25 at 11:08 AM, LPN #1 confirmed the oxygen flow was above 3 liters per minute. She stated she had checked the oxygen flow that morning and she had not changed the setting. She confirmed the physician's order was for 2 liters per minute as needed and acknowledged the oxygen should never be adjusted without a new physician order. She explained that receiving oxygen at a higher rate than ordered could lead to adverse effects and make it harder for the resident to breathe. During an interview on 4/17/25 at 10:37 AM, the Director of Nursing (DON) stated when a resident receives more oxygen than ordered, their lungs may have to work harder to exhale. She stated the nurse should check the order and ensure it is followed every shift. A record review of the admission Record revealed the facility admitted Resident #79 on 3/10/2025 with current diagnoses including Cough and Wheezing. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated his cognition was moderately impaired. Further review revealed he was receiving oxygen therapy.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were not left unattended at the bedside or on the medication cart for two (2) of four (4) residents observed during medication administration. Residents #19 and #79. Findings Included: A review of the facility's policy, Drug Administration and Documentation, revised 3/25, revealed, .Under no circumstance is medication to be left at the bedside or given to the resident without him/her swallowing it in your presence . Do not leave any medication on top of the medication cart unattended . Resident #19 A record review of the Order Listing Report revealed Resident #19 had a Physician's Order, revised 9/3/2024, for Polyethylene Glycol 3350 Oral Powder 17 gram/scoop, one (1) scoop orally two (2) times daily, mix in juice or water. On 4/16/25 at 8:00 AM, during an observation of medication administration, Licensed Practical Nurse (LPN) #2 administered Polyethylene Glycol 3350 Oral Powder 17 gram/scoop in water to Resident #19. She left the medication at the bedside and informed the resident she was going to leave it for her to finish drinking. On 4/16/25 at 10:46 AM, during an interview with LPN #2, she stated that some days she leaves Polyethylene Glycol 3350 at the bedside and that the amount left varies. She stated the resident takes a while to drink it and she does not want to rush her. She confirmed that Polyethylene Glycol 3350 is a medication and should not be left at the bedside. She acknowledged that if the medication is left unattended, there is no way to confirm whether the resident consumed the full dose, and that physician orders required a full dose to be taken. A record review of the admission Record revealed the facility admitted Resident #19 on 9/6/19 with diagnoses including Constipation. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/14/25 revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated her cognition was moderately impaired. Resident #79 On 4/16/25 at 9:22 AM, during an observation of medication preparation for Resident #79, LPN #1 was observed placing a vial of Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) on top of the medication cart and leaving the medication unattended while she left to retrieve supplies. The medication cart was unattended for two (2) to three (3) minutes. On 4/17/25 at 10:15 AM, during an interview with LPN #1, she acknowledged that she should not have left Resident #79 medication on the cart and stated she was not thinking. She admitted that she knew better and that leaving medication unattended on the cart could result in another resident taking it. On 4/17/25 at 10:33 AM, during an interview with the Director of Nursing (DON), she confirmed that no medications should be left unattended on the cart or in residents' rooms. She stated that leaving medications unattended could result in uncertainty about whether the resident took, discarded, or pocketed the medication. She stated that staff are expected to always follow medication administration policy. A record review of the Order Listing Report revealed Resident #79 had a Physician's Order, revised 4/15/25, for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (a type of nebulizer medication) every 12 hours as needed for wheezing and cough. A record review of the admission Record revealed the facility admitted Resident #79 on 3/10/2025 with current diagnoses including Cough and Wheezing. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated his cognition was moderately impaired.

Based on interviews, record review and facility policy review, the facility failed to provide the Resident and/or the Resident's Representative with written notification for the reason the residents were transferred to local hospital for two (2) of three (3) residents reviewed for hospitalizations. Residents #36 and # 56. Findings Include: A review of the facility's policy titled, Discharge Transfer and Planning, revised 9/23, revealed, Before a facility transfers or discharges a resident, the facility must .Notify the resident and the resident's representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand . Resident #36 A record review of the Transfer notices dated 8/13/23, 9 /9/23 and 11/15/23 revealed, the facility failed to provide the resident and the resident's representative with written notification of the reason for transfer from the facility. The form, utilized at that time, only stated that the facility was no longer able to meet the resident's needs in the facility and the transfer was necessary for their welfare. A record review, of the facility's Face Sheet, revealed the facility admitted the Resident #36 on 2/18/22, with diagnoses that included Acute on Chronic Congestive Heart Failure and Unspecified Dementia. A record review of the Quarterly Minimum Data Set (MDS) for Resident #36, with an Assessment Reference Date (ARD) of 10/9/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #56 A record review of the Departmental Notes, Category: Nurses Notes for Resident #56 dated 2/13/23, 5/30/23, and 8/4/23, revealed the resident was transferred to a local Behavior Health Unit due to increased behavior. A record review of Resident #56's MDS with an ARD of 2/13/23, MDS with an ARD of 5/30/23, and MDS with an ARD of 8/4/23, revealed the resident was discharged to a Psychiatric hospital. A record review of the facility hospitalization letters dated 2/13/23, 5/30/23 and 8/4/23,revealed the letters did not provide written notification as to the reason Resident #56 was sent to the local Behavior Health Unit. During an interview on 12/13/23 at 3:37 PM, the Director of Nursing (DON) confirmed the facility failed to provide a written explanation to the resident and Resident Representative (RR) with the reason the resident was transferred to another facility. The DON said the nurses normally call the families and notify them of the hospital transfer and the reason. During an interview on 12/13/23 at 3:50 PM, the Accounts Manager (AM) revealed she is responsible for sending out the hospitalization letters. The AM also stated that she just answers the questions after each resident is transferred to the local hospital. The AM stated that she does not know the specific reason why the resident is sent out, however, she will start putting the specific reasons on the notices prior to sending them out to the resident or RR. During an interview on 12/13/23 at 4:00 PM, the Administrator confirmed the facility had failed to inform residents and RR with the specific reasons why the residents were transferred out of the facility. The Administrator stated that writing we are no longer able to meet your needs in the facility and the transfer is necessary for your welfare, was insufficient. The Administrator stated the facility policy states the facility is responsible for providing written notification to the resident and resident's representative for the reason for the transfer in a language that they can understand.

Based on observation, interview, record review and facility policy review the facility failed to prevent the possible spread of foodborne illness for 83 of 89 residents residing in the facility. Findings Include: A review of the facility's policy, Food Storage Labeling, revision date 5/2018, the facility will ensure the safety and quality of food by following good storage and labeling procedures. The facility's, policy, Recommended Food Storage Chart, dated 9/2012, condiments open 6 months in cooler and salad dressing open 3 months in cooler. On 08/24/21 at 10:33 AM, an initial tour of the kitchen with the Interim Dietary Manager (IDM) revealed the following: The walk in cooler contained a one (1) gallon sweet pickle relish, 1/3 full, with an opened date of 6/30 with no year indicated. There was black mold on the outside and rim of the container. There was a one (1) gallon container of barbeque sauce, 1/4 full, not labeled with the date opened, that had black and green mold at the top of the container and around the rim. There was a one (1) gallon container of Italian Dressing, 1/3 full, with an opened date of 5/21 with no year indicated. The expiration date on this container was illegible. There was black mold on the outside of the container and around the rim. There was an one (1) gallon container of dill pickle chips 2/3 full with an opened date of 8/12 with no year recorded that had an expiration date of 4/12/20. This container had black mold at the top of the container. In an interview on 8/25/21 at 10:55 AM with the IDM, she stated food containers with mold had the possibility of causing foodborne illness. She further stated mold could affect a lot of things for the residents. The IDM state the residents already had compromised immune systems. The IDM stated the items should have been discarded and staff should date all items before placing them in the cooler. She agreed the barbeque sauce container was not dated. On 8/26/21 at 11:08 AM in an interview with Dietary [NAME] #2, she stated the containers with mold should have been thrown away and it coud have made the residents sick. She stated the mold could possibly get in the food. She stated anyone in the kitchen might check the food in the cooler. On 8/26/21 at 2:42 PM in an interview with IDM #1 she stated it was the responsibility of the cook to check and dispose of the molded food items. On 8/26/21 at 4:10 PM in an interview with Administrator, he stated the molded containers should have been pulled and discarded. He stated it was the cook and dietary staff's responsibility to check the food items. He stated there was currently an interim dietary manager and it was currently the administrator's responsibility to oversee the dietary staff. The administrator stated he had been in the kitchen frequently to check on dietary staff and expected them to discard foods when needed. An interview on 08/27/21 at 01:50 PM with Licensed Practical Nurse #1, the Infection Preventionist, she stated residents could get upset stomachs and mold could cause foodborne illness. She stated if the date revealed the item was good but it had mold on it, the dietary staff needed to throw it away.