License Reference number 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to store Resident 29's nasal canula and oxygen tubing in a bag that would prevent cross contamination. This had the potential to effect 1 of 1 residents. The identified a census of 56. Findings are: An observation on 10/15/24 10:46 AM, revealed Resident 29's Oxygen tubing was laying across the top of the oxygen concentrator. Resident 29's nasal canula and oxygen tubing were found lying on the floor behind concentrator. Resident 29's nasal canula and oxygen tubing was not placed into the bag attached to the back of the concentrator. Resident 29 is sleeping in her recliner chair at this time. An observation on 10/16/24 at 9:26 AM, Resident 29's Oxygen tubing was laying across the concentrator, the nasal canula laying on the floor behind the concentrator. The nasal canula was not covered or placed into the bag that was attached to the back of the concentrator. The Oxygen tubing revealed a piece of tape placed onto the tubing, with a noted date 10/14/24 wrote on it. Resident is laying in her recliner chair with her call light across her lap. Resident is had their eyes closed. An interview on 10/16/24 at 9:29 AM with Resident 29, revealed they did not self-remove the nasal cannula independently. An interview on 10/16/24 at 10:19 AM with Medication Aide- A (MA-A) confirmed the nasal canula and the oxygen tubing was not placed into the attached bag on the back of the oxygen concentrator. MA-A confirmed the nasal canula and the oxygen tubing was laying on the floor. MA-A confirmed the nasal canula and the oxygen tubing should be placed into the protective bag that is attached to the back of the nasal canula. An interview on at on 10/16/24 at 1025 AM with the Director of nursing (DON) confirmed the nasal cannula and oxygen tubing was laying on the floor behind the concentrator. The DON confirmed the nasal cannula, and the oxygen tubing should be placed into the bag that is attached to the back of the concentrator when it is not in use by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a written notice of bed hold upon transfer to the hospital for 1 (Resident 25) of 1 sampled resident. The facility census was 55. Findings are: Record review of the Bed Hold policy dated 11/2022 stated, 1. in the event a resident requires hospitalization, the Bed Hold Consent will be completed. 7. Upon transfer to another facility, the resident/responsible party will be informed of bed hold policy by nursing staff. This information may be given in person or per telephone conversation, two facility staff will witness the conversation and sign the Bed Hold Consent form. A copy of the Bed Hold Consent will be given to the family. Record review of Resident 25's Registration form last updated 7/7/2023, revealed that the resident admitted to the facility on [DATE] with diagnoses of: dementia (condition of progressive loss of intellectual functioning, with impairment of memory), osteoporosis (bones become fragile and brittle), decreased appetite, gastroesophageal reflux, (stomach acid irritates stomach lining), nausea, chronic pain, and chronic kidney disease. Record review of Resident 25's Progress Note dated 5/21/2023 revealed that Resident 25 had been transferred to the hospital with complaints of pain with an x-ray that revealed a left hip fracture following a fall during the night. Resident 25 returned to the facility on 5/25/2023. Record review of Resident 25's Electronic and Paper Health Record revealed no documentation that a written Bed Hold Consent was provided to the resident and/or resident representative upon transfer to the hospital on 5/21/2023. Interview on 11/1/2023 at 1:30 PM with Licensed Practice Nurse (LPN)-C revealed [gender] was unaware if nurses completed the Bed Hold Consents. LPN-C revealed [gender] believed Administration completed the Bed Hold Consents. Interview on 11/1/2023 at 1:45 PM with the Director of Nursing (DON) revealed no documentation was found regarding a Bed Hold Consent for Resident 25 prior to transfer to the hospital on 5/21/2023. The DON revealed nurses are responsible to complete the Bed Hold Consent and it should have been completed for Resident 25. Interview on 11/2/2023 at 9:15 AM with Registered Nurse (RN)-A revealed that if a Bed Hold Consent was completed it would be in the resident's electronic medical record. RN-A revealed the nurses complete the Bed Hold Consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to follow the provider's orders for medication parameters prior to medication administration for 2 (Resident 24 and 14) of 5 sampled residents. The facility census was 55. Findings are: Record review of the facility's Administering Medications policy dated 11/2016 revealed under Procedures 11. the following information must be checked/verified for each resident prior to administering medications: allergies to medications and vital signs, if necessary. 14. if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document an explanation by adding a comment to the administration note and progress note. A. Review of Resident 24's current clinical diagnoses, dated 11/1/23, revealed the following diagnoses: edema (swelling), essential (primary) hypertension (elevated blood pressure readings), and hypertensive heart disease with heart failure. Review of Resident 24's current physician orders dated 11/2/23 revealed the following medications with parameters: -Furosemide (Lasix) 40mg daily, hold if systolic blood pressure (SBP-top number in a blood pressure reading) is less than (<) or equal to (=) 110 -Losartan 100mg daily, hold if SBP </= 110 -Metoprolol tartrate 100mg twice daily (BID), hold if SBP </=100 and/or heart rate (HR) <60. Review of Resident 24's August thru October 2023 Medication Administration Record (MAR) revealed a box for staff to document the blood pressure and/or heart rate obtained with each ordered administration of Furosemide, Losartan and Metoprolol tartrate. Review of Resident 24's August thru October 2023 MAR revealed that Resident 24 was administered the Furosemide and Losartan 14 times with no blood pressure obtained and the Metoprolol tartrate 32 times with no blood pressure and heart rate obtained and 10 times with no heart rate obtained. Further review revealed that Resident 24 was administered the Losartan on 9/14/23 with a SBP of 99 and that the Metoprolol tartrate was administered 6 times when Resident 24's HR was <60. Review of Resident 24's EHR and paper chart revealed no other documentation of blood pressures or heart rates obtained prior to administration of the Furosemide, Losartan and Metoprolol tartrate. Review of Resident 24's Cardiovascular IPOC revealed the following intervention: -Vital signs per order and update the MD as needed Interview on 11/2/23 at 12:55 PM, Licensed Practical Nurse (LPN)-B revealed that it was the expectation for staff to obtain a blood pressure and/or heart rate and document the readings prior to administration of a medication with parameter and that if the blood pressure and/or heart rate was less than the parameter the medication is not to be administered. Interview on 11/2/23 at 1:49 PM, the Director of Nursing (DON) confirmed that there was no documentation that a blood pressure and/or heart rate had been obtained prior to administration of the Furosemide, Losartan and Metoprolol tartrate for Resident 24. The DON revealed Resident 24 was administered the Losartan and Metoprolol tartrate outside of the ordered parameters. Surveyor: [NAME], [NAME] B. Record review of Resident 14's Registration form last updated on 7/7/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses of: arteriosclerotic heart disease (CAD) (damage or disease in the hearts blood vessels due to buildup of plaque), unspecified combined systolic and diastolic congestive heart failure (the heart is not strong enough to pump blood properly), and atrial fibrillation (an irregular and very rapid heart rhythm). Record Review of Resident 14's MAR dated October 2023 revealed an order for Metoprolol 100 mg orally daily for CAD with parameters to hold medication if pulse less than 60 or systolic blood pressure less than 120. Record review of Resident 14's Care Plan initiated on 2/10/2023 revealed an intervention of vital signs per order and update the MD (medical doctor) as needed under the Cardiovascular plan of care. Record review of the MAR dated October 2023 revealed Metoprolol was given 5 times without a pulse or blood pressure taken. Record review of the MAR dated October 2023 revealed Metoprolol was given 1 time without a pulse taken. Record review of the MAR dated October 2023 revealed Metoprolol was held 13 times due to a low blood pressure and/or pulse, without notification to the physician. The MAR revealed 8 out of the 13 times the medication was held was consecutive days in a row. Interview on 11/1/2023 at 1:05 PM with Medication Aide (MA)-A revealed MA-A would follow provider orders related to parameters. MA-A revealed if the blood pressure was outside of the ordered parameters they would inform a nurse. MA-A revealed it was an issue if vital signs were not taken prior to giving Metoprolol. Interview on 11/1/12023 at 1:00 PM with LPN-D revealed they would expect vital signs to be taken to evaluate the ordered parameters and then either administer the medication or hold it. LPN-D revealed that if the medication is held 2 or more days they would notify the provider. LPN-D revealed it was an issue if vitals were not taken prior to administering a blood pressure medication. Interview on 11/1/2023 at 3:20 PM with DON regarding expectations of medication administration with parameters for a blood pressure medication revealed DON expects the nurse or medication aide to take vital signs prior to giving the medication and then if the medication is held, a reason for holding needs documented and the nurse notified. DON confirmed it is a problem if medication is given without a set of vital signs and physician should have been notified with the Metoprolol being held 13 times the month of October for Resident 14. Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to follow the provider's orders for medication paratmeters prior to medication administration for 2 (Resident 24 and 14) of 5 sampled residents. The facility census was 55. Findings are: Record review of the facility's Administering Medications policy dated 11/2016 revealed under Procedures 11. the following information must be checked/verified for each resident prior to administering medications: allergies to medications and vital signs, if necessary. 14. if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document an explanation by adding a comment to the administration note and progress note. A. Review of Resident 24's current clinical diagnoses, dated 11/1/23, revealed the following diagnoses: edema (swelling), essential (primary) hypertension (elevated blood pressure readings), and hypertensive heart disease with heart failure. Review of Resident 24's current physician orders dated 11/2/23 revealed the following medications with parameters: -Furosemide (Lasix) 40mg daily, hold if systolic blood pressure (SBP-top number in a blood pressure reading) is less than (<) or equal to (=) 110 -Losartan 100mg daily, hold if SBP </= 110 -Metoprolol tartrate 100mg twice daily (BID), hold if SBP </=100 and/or heart rate (HR) <60. Review of Resident 24's August thru October 2023 Medication Administration Record (MAR) revealed a box for staff to document the blood pressure and/or heart rate obtained with each ordered administration of Furosemide, Losartan and Metoprolol tartrate. Review of Resident 24's August thru October 2023 MAR revealed that Resident 24 was administered the Furosemide and Losartan 14 times with no blood pressure obtained and the Metoprolol tartrate 32 times with no blood pressure and heart rate obtained and 10 times with no heart rate obtained. Further review revealed that Resident 24 was administered the Losartan on 9/14/23 with a SBP of 99 and that the Metoprolol tartrate was administered 6 times when Resident 24's HR was <60. Review of Resident 24's EHR and paper chart revealed no other documentation of blood pressures or heart rates obtained prior to administration of the Furosemide, Losartan and Metoprolol tartrate. Review of Resident 24's Cardiovascular IPOC revealed the following intervention: -Vital signs per order and update the MD as needed Interview on 11/2/23 at 12:55 PM, Licensed Practical Nurse (LPN)-B revealed that it was the expectation for staff to obtain a blood pressure and/or heart rate and document the readings prior to administration of a medication with parameter and that if the blood pressure and/or heart rate was less than the parameter the medication is not to be administered. Interview on 11/2/23 at 1:49 PM, the Director of Nursing (DON) confirmed that there was no documentation that a blood pressure and/or heart rate had been obtained prior to administration of the Furosemide, Losartan and Metoprolol tartrate for Resident 24. The DON revealed Resident 24 was administered the Losartan and Metoprolol tartrate outside of the ordered parameters. B. Record review of Resident 14's Registration form last updated on 7/7/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses of: atherosclerotic heart disease (CAD) (damage or disease in the hearts blood vessels due to buildup of plaque), unspecified combined systolic and diastolic congestive heart failure (the heart is not strong enough to pump blood properly), and atrial fibrillation (an irregular and very rapid heart rhythm). Record Review of Resident 14's MAR dated October 2023 revealed an order for Metoprolol 100 mg orally daily for CAD with parameters to hold medication if pulse less than 60 or systolic blood pressure less than 120. Record review of Resident 14's Care Plan initiated on 2/10/2023 revealed an intervention of vital signs per order and update the MD (medical doctor) as needed under the Cardiovascular plan of care. Record review of the MAR dated October 2023 revealed metoprolol was given 5 times without a pulse or blood pressure taken. Record review of the MAR dated October 2023 revealed metoprolol was given 1 time without a pulse taken. Record review of the MAR dated October 2023 revealed metoprolol was held 13 times due to a low blood pressure and/or pulse, without notification to the physician. The MAR revealed 8 out of the 13 times the medication was held was conseutive days in a row. Interview on 11/1/2023 at 1:05 PM with Medication Aide (MA)-A revealed MA-A would follow provider orders related to parameters. MA-A revealed if the blood pressure was outside of the ordered parameters they would inform a nurse. MA-A revealed it was an issue if vital signs were not taken prior to giving metoprolol. Interview on 11/1/12023 at 1:00 PM with LPN-D revealed they would expect vital signs to be taken to evaluate the ordered parameters and then either administer the medication or hold it. LPN-D revealed that if the medication is held 2 or more days they would notify the provider. LPN-D revealed it was an issue if vitals were not taken prior to administering a blood pressure medication. Interview on 11/1/2023 at 3:20 PM with DON regarding expectations of medication administration with parameters for a blood pressure medication revealed DON expects the nurse or medication aide to take vital signs prior to giving the medication and then if the medication is held, a reason for holding needs documented and the nurse notified. DON confirmed it is a problem if medication is given without a set of vital signs and physician should have been notified with the metoprolol being held 13 times the month of October for Resident 14.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify the resident's representative of a significant weight loss for Resident 9. The sample size was 1. The facility census was 57. FINDINGS ARE: A record review of the facility policy titled Weight Status and dated 05/2001, revealed the following; -Parameters for evaluating significance of unplanned and undesired weight loss are: -1 month/5% = significant loss, greater than 5% = severe loss -3 month/7% = significant loss, greater than 7.5% = severe loss -6 month/10% = significant loss, greater than 10% = severe loss A record review of weights recorded for Resident 9 revealed that on 08/29/2022, Resident 9 weighed 100.5 lbs. and on 09/29/2022, Resident 9 weighed 93.7 pounds which is a -6.77% Loss in one month. A record review of weights recorded for Resident 9 revealed that on 03/28/2022, Resident 9 weighed 101.2 lbs. and on 09/29/2022, Resident 9 weighed 93.7 pounds which is a -7.41 % Loss in 6 months. A record review of the facility policy titled Notification of Changes and dated 06/2021, revealed the following: Circumstances requiring notification include: B. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. 1. Life-threatening conditions, or 2. Clinical Complications A record review of the weight loss notification to Resident 9's representative revealed the resident representative had been notified on 10/5/22 at 11:37 AM which was after the request to review the documentation. An interview on 10/05/22 at 01:45 PM with the DON (Director of Nursing), after review of the significant weight loss notification to Resident 9's Representative documented on 10/5/22 at 11:37 AM, confirmed that the notification had not occurred until the information had been requested during the onsite survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 174 NAC 12-006.09B Based on record review and interview, the facility failed to code the MDS (Minimum Data Set -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) to reflect wounds for 1 resident (Resident 51) out of 4 sampled residents. The facility identified with a census of 57 at the time of survey. Findings are: A record review of Resident 51's wound care notes dated 9/25/22 through 10/5/22 revealed a Stage 4 (skin tissue with extensive damage to muscle, bone or supporting structure such as a tendon or joint capsule) pressure ulcer to right lateral foot. An interview on 10/06/22 11:08 AM with Wound Care nurse RN-C (Registered Nurse) confirmed that Resident 51's wound was a Stage 4 pressure wound to the resident's right leg and had been treated for approximately 2 years. Also it was confirmed the wound nurse had staged the wound. A record review of Resident 51's Wound History and Physical from Methodist Health System dated [DATE] stated diagnosis of chronic pressure ulcer of right foot. A record review of Resident 51's Body Check Form completed with baths and signed by a nursing assistant and a nurse dated 9/2/22, 9/13/22, 9/16/22, and 9/20/22 revealed in question #6 Any open ulcers, all were answered no. A record review of Resident 51's MDS, dated [DATE] revealed in question M0210 Does the resident have one or more unhealed pressure ulcers/injuries was answered no. A record review revealed the Facility wound policy, Management of Pressure UIcers dated last revised 1/2021, stated #1. Document in nurses notes. # 2. Only a physician can stage a wound. #3. Notify Director of Nurses (DON). #4. weekly assessments to include measurements. #8. Update careplan. An interview on 10/06/22 01:02 PM with RN-B MDS nurse confirmed the pressure wound was not on the MDS or the careplan and there was not a significant change MDS done and there should have been. An interview on 10/06/22 02:06 PM with DON revealed the DON was not aware of the pressure wound diagnosis.

Based on interview and record review, the facility failed to ensure behavior monitoring was completed to support the use of psychotropic medication for Resident 9. The sample size was 1. The facility identified a census of 57. FINDINGS ARE: A record review of the All Active Orders list with a print date of 10/6/22 revealed Resident 9 was taking Seroquel (an antipsychotic medication used to treat certain mental/mood conditions) 6.25mg in the AM and 37.5 mg every evening. A record review of the document titled Corp-Resident Behavior Chart Detail Report (w/impact) dated 4/8/22 through 10/5/22 and documented by the NA's (Nurse Aides) revealed the following negative behaviors had occurred for Resident 9; verbal behavior on 5 occasions, Physical Behavior on 21 occasions, Socially Inappropriate on 1 occasion, Rejects Care on 6 occasions. A record review of the facility policy titled Behavioral Health Services and dated 11/2020, revealed the following: The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The process includes: 4. ongoing monitoring of mood and behavior An Adverse Behavior is defined as but not limited to: verbally aggressive behavior directed at another resident, such as screaming, cursing, insulting, physically aggressive behavior toward another resident such as aggressive behaviors toward another resident. An interview on 10/05/22 at 03:37 PM with the DON (Director of Nursing) confirmed that the facility expectation and process is that if a negative behavior occurs, the NA should document it in the EMR (Electronic Medical Record) for NA charting and report behaviors to the nurse in charge, the nurse in charge is then expected to document behaviors and non-pharmacological interventions in the Progress Notes, and confirmed that documentation for NA's and Nurses should match regarding behaviors. During the interview on 10/05/22 at 03:37 PM with the DON, after review of the Corp-Resident Behavior Chart Detail Report (w/impact) dated 4/8/22 through 10/5/22 for Resident 9 and the Nursing Progress Notes, confirmed the two did not match.