**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for oral/dental status (Resident #27) and the use of a hypoglycemic medication (a medication used to lower blood sugar in people diagnosed with diabetes) (Resident #71) for 2 of 20 residents whose MDS assessments were reviewed. Findings included: 1. Resident #27 was admitted to the facility 04/14/17. Review of a dentist's note dated 07/15/24 revealed Resident #27 had 6 teeth pulled and was now edentulous (lacking teeth). The annual MDS assessment dated [DATE] did not reflect Resident #27 was edentulous. Observations of Resident #27 on 02/18/25 at 11:25 AM, 02/19/25 at 8:17 AM, and 2/20/25 at 12:43 PM revealed she did not have any teeth. An interview with the MDS Coordinator on 02/20/25 at 4:49 PM revealed Resident #27's annual MDS assessment should have reflected that she was edentulous, and it was an oversight. An interview with the Director of Nursing on 02/21/25 at 11:26 AM revealed she expected the MDS assessment to be coded correctly. An interview with the Administrator on 02/21/25 at 12:38 PM revealed he expected the MDS assessment to be as accurate as possible. 2. Resident #71 was admitted to the facility 11/01/24 with a diagnosis including diabetes. Review of Resident #71's Physician orders revealed an order dated 11/02/24 for Insulin Glargine 5 units subcutaneously (under the skin) daily for diabetes. Review of Resident #71's November 2024, December 2024, and January 2025 Medication Administration Record revealed she received Insulin Glargine as ordered. Resident #71's quarterly MDS assessment dated [DATE] did not reflect that she received hypoglycemic medication. In an interview with the MDS Coordinator on 02/20/25 at 4:52 PM she confirmed Resident #71's quarterly MDS assessment should have reflected that she received hypoglycemic medication, and it was an oversight. An interview with the Director of Nursing on 02/21/25 at 11:26 AM revealed she expected the MDS assessment to be coded correctly. An interview with the Administrator on 02/21/25 at 12:38 PM revealed he expected the MDS assessment to be as accurate as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to update the care plan to include oxygen therapy for 2 of 2 residents (Resident #16 and Resident #23) reviewed for respiratory therapy. The findings included: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses that included hypoxemia (low levels of oxygen in the blood). A review of Resident #16's physician orders dated 06/28/24 indicated oxygen at 1-3 liters per minute via nasal cannula every shift as needed for hypoxia. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supplemental oxygen. Review of Resident #16's revised care plan dated 12/30/24 revealed the Resident's oxygen use was not care planned. An interview was conducted with the MDS Coordinator on 02/20/25 at 5:33 PM. The MDS Coordinator explained that the purpose of the care plan was to guide the care of the residents and should be individualized for that resident. The MDS Coordinator stated that oxygen should be on Resident #16's care plan because she might have trouble breathing. The MDS Coordinator stated she was still fairly new and overlooked the oxygen care plan. During an interview with the Director of Nursing (DON) on 02/21/25 at 10:57 AM she explained that the care plan should identify the resident and guide the care of the resident. The DON stated her expectation was for oxygen to be on the care plan. On 02/21/25 at 11:50 AM an interview was conducted with the Administrator who indicated that oxygen needed to be on the care plan. 2. Resident #23 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (blood flow to the brain is interrupted). A review of Resident #23's physician orders dated 06/28/24 revealed oxygen 1-3 liters per minute via nasal cannula for comfort/hypoxia (low oxygen levels in the blood) every shift. Review of Resident #23's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was severely impaired and she received supplemental oxygen therapy. Review of Resident #23's revised care plan dated 12/06/24 revealed there was no oxygen care plan. An interview was conducted with the MDS Coordinator on 02/20/25 at 5:33 PM. The MDS Coordinator explained that the purpose of the care plan was to guide the care of the residents and should be individualized for that resident. The MDS Coordinator stated that oxygen should be on Resident #23's care plan because she might have trouble breathing. The MDS Coordinator stated she was still fairly new and overlooked the oxygen care plan. During an interview with the Director of Nursing (DON) on 02/21/25 at 10:57 AM she explained that the care plan should identify the resident and guide the care of the resident. The DON stated her expectation was for oxygen to be on the care plan. On 02/21/25 at 11:50 AM an interview was conducted with the Administrator who indicated that oxygen needed to be on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and Resident and staff interviews, the facility failed to ensure an oxygen concentrator filter was free of dust and failed to ensure a concentrator had an external filter for 1 of 2 residents (Resident #16) reviewed for respiratory care. The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses that included hypoxemia (low levels of oxygen in the blood). A review of Resident #16's physician orders dated 06/28/24 indicated oxygen at 1-3 liters per minute via nasal cannula as needed for hypoxia every shift and change oxygen tubing and clean filter every Thursday night. Review of Resident #16's quarterly Minimum Data Set assessment dated [DATE] revealed the Resident was cognitively intact and received supplemental oxygen. Review of Resident #16's revised care plan dated 12/30/24 revealed the Resident's oxygen was not care planned. A review of Resident #16's Medication Administration Record (MAR) for 02/2025 revealed oxygen at 1-3 liters per minute was delivered every day and every shift since 02/01/25. The MAR also indicated the oxygen filter had been cleaned on Thursday 02/13/25 by Nurse #2 On 02/18/25 at 10:40 AM an observation and interview were conducted with Resident #16 who was sitting in her wheelchair watching TV. The Resident indicated the staff took care of her oxygen. Upon inspection of the oxygen concentrator the filter on the left side was covered with light gray dust build up, that fell to the floor when touched. The vent located on the right side of the concentrator revealed the filter was missing. An observation was made on 02/19/25 at 9:10 AM revealed the oxygen concentrator filter remained covered with dust. During an interview with Nurse #1 on 02/19/25 at 9:17 AM the Nurse explained the oxygen filters were cleaned on third shift every Thursday night by the nurse. The Nurse indicated that nurses should check the filters every so often to make sure they were clean. An observation was conducted in conjunction with an interview with Nurse #1 on 02/19/25 at 9:22 AM. Nurse #1 stated she was assigned to Resident #16. The Nurse observed Resident #16's oxygen concentrator and when she inspected the filter on the left side of the concentrator she stated Oh, it's dirty, and removed the filter. As the Nurse held the dusty filter up, dust particles were observed to fall to the floor. The Nurse then looked at the vent with the missing filter on the right side of the machine and stated there was not a filter there while pointing at the vent where the filter should have been. The Nurse indicated if the dust buildup accumulated that thick in one week, then the filters should be checked and or cleaned more often. Nurse #1 stated she would get a replacement filter right away for the vent and clean the dirty filter. An interview was conducted with Nurse #2 on 02/20/25 at 10:10 AM who explained the oxygen filters were checked and cleaned with water once a week on Thursday nights by the Nurse and the filters should be checked often for dust buildup. Nurse #2 confirmed she was Resident #16's Nurse on the night of 02/13/25 and stated she checked and cleaned Resident #16's oxygen concentrator filter on 02/13/25 but could not remember if the filter was missing. The Nurse stated if the filter was missing, she would have notified maintenance to provide a replacement. The Nurse stated if the filter was extremely dusty then the filters should be cleaned more often that weekly. During an interview with the Director of Nursing (DON) on 02/21/25 at 10:57 AM the DON explained that she had someone auditing the oxygen concentrators other than the nurses and there was nothing on the audits about Resident #16's oxygen concentrator filters being dirty or missing. The DON stated she may need to increase the filter cleaning to twice weekly. An interview was conducted with the Administrator on 02/21/25 at 11:50 AM who indicated his expectation was for the oxygen filters to be clean and in place on the concentrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and resident and staff interviews, the facility failed to secure opened tubes of medicated ointment/skin protectant observed in residents' rooms for 2 of 2 residents reviewed for medication storage (Resident #49 and Resident #27). Findings included: 1. Resident #49 was admitted to the facility 09/13/21 with a diagnosis including non-Alzheimer's dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was moderately cognitively impaired. An observation of Resident #49's dresser on 02/18/25 at 11:12 AM revealed a 0.33-ounce tube of triple antibiotic ointment sitting on top. An interview with Resident #49 at the same date and time revealed Family Member #1 brought her the medication for some sores and Family Member #1 applied the medication, but she could not recall the last time the medication was used. Additional observations of Resident #49's dresser on 02/19/25 at 8:22 AM, 02/20/25 at 12:21 PM, and 02/21/25 at 9:40 AM revealed a 0.33-ounce tube of triple antibiotic ointment sitting on top. An interview with the Director of Nursing (DON) on 02/21/25 at 11:26 AM revealed no medication should be left at the bedside unless the resident had a physician order to leave the medication. The DON confirmed Resident #49 did not have a physician order to leave the triple antibiotic ointment in her room. 2. Resident #27 was admitted to the facility 04/14/17 with a diagnosis including Alzheimer's disease. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was moderately cognitively impaired. An observation of Resident #27's room on 02/19/25 at 12:47 PM revealed two 2-ounce tubes of skin protectant with an active ingredient of Zinc Oxide 20% in a bath basin sitting on top of her dresser. In an interview with Resident #27 at the same date and time she stated the staff applied the cream to her bottom sometimes, but she could not recall the last time the medication was used. Additional observations of Resident #27's room on 02/20/25 at 12:25 PM and 02/21/25 at 9:49 AM revealed two 2-ounce tubes of skin protectant with an active ingredient of Zinc Oxide 20% in a bath basin sitting on top of her dresser. An interview with the Director of Nursing (DON) on 02/21/25 at 11:26 AM revealed no medication should be left at the bedside unless the resident had a physician order to leave the medication. The DON confirmed Resident #27 did not have a physician order to leave the Zinc Oxide cream in her room.