**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure staff provided care and services for 2 of 12 sampled residents (Resident #1 and #16) care planned for a positioning device and physician orders for devices for pain/swelling to an arm. Failure to apply a positioning device and to follow physician's orders for devices to control edema (swelling)/pain may result in poor posture, increased pain, worsening of edema, and other complications. Findings include: Review of the facility policy titled Positioning occurred on 06/19/24, This policy, dated 02/28/24, stated, . Purpose: To provide proper body alignment for residents in wheelchairs. Position . Resident is upright positioning and weight-bearing equally at hips (does not lean to one side). - Review of Resident #1's medical record occurred on all days of survey and included a diagnosis of dementia and osteoporosis. The current care plan stated, . The resident is at risk for falls R/T [related to] cognition deficit E/B [evidenced by] history of falls. Interventions: . Resident is to use an Evolution chair/Broda chair [reclining wheelchair]. Does tend to slide down in chair, at times. Monitor for sliding in chair at all times. Monitor resident for significant changes in mobility, positioning device, sitting balance and lower extremity joint function. Observations showed Resident #1 in a Broda wheelchair, with her body and head leaning to the left, and no positioning device present at the following times: *06/17/24 in the dining room at 12:02 p.m. in the TV room at 12:31 p.m. and in the dining room at 5:15 p.m. *06/18/24 in the TV room at 9:40 a.m. and 1:30 p.m. When asked if the resident had anything to keep her body and head upright, a certified nurse aide (CNA) (#7) stated, No, but she should have something as she always leans to that [left] side. *06/18/24 at 2:00 p.m. The CNA (#7) assisted Resident #1 to the toilet and laid her on the bed stating, she needs to lay down so she's not leaning. She is tired. *06/18/24 in the TV room at 3:20 p.m., asleep and with her body and head tilted to the left. The CNA (#7) stated the resident was restless and wouldn't stay in bed so she got her up again. *06/19/24 in the TV room at 8:15 a.m. During an interview on 06/19/24 at 1:10 p.m., an administrative nurse (#2) stated the positioning device in Resident #1's care plan is for an L-shaped pad that is supposed to be on the resident's left side in the wheelchair. The administrative nurse agreed the positioning pad should have been in the resident's wheelchair. The facility failed to assess Resident #1's positioning needs. - Review of Resident #16's medical record occurred on all days of survey. A physician's order dated 05/14/24 stated, Apply geri-sleeve [a compression device for edema/swelling and geri-sling [strapped sling] to left arm for swelling. Apply in the morning and remove at hs [hour of sleep] . for swelling to left arm. The care plan stated, . Apply geri-sleeve and geri-sling to left arm for swelling. Apply in the morning and remove at hs . Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, . Carrying Out a Physician's Order . Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. It is the nurse ' s responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. Clarification from any other source is unacceptable and regarded as a departure from competent nursing practice. Observations of Resident #16 occurred on all days of survey and showed edema to the left hand and no geri-sleeve or geri-sling present. During an interview on 06/18/24 at 4:00 p.m., a nurse (#2) stated she assisted Resident #16 that morning and forgot to apply the geri-sleeve and sling. She also stated the sleeve and sling are for swelling and he had quite a bit when they got the order. The facility failed to follow the physician's order to apply Resident' #16's geri-sleeve and sling daily. 1. Based on observation, record review, review of facility policy, and staff and resident interview, the facility failed to provide care and services to maintain the resident's highest level of well-being for 1 of 1 sampled resident (Resident #30) with a change in health status followed by a transfer to the hospital. Failure to monitor and assess the resident's condition on an on-going basis resulted in worsening respiratory symptoms, a delay in treatment, and an admission to the hospital. Findings include: Review of the facility policy titled Notification of Change occurred on 06/19/24. This policy, dated 12/04/23, stated, . A facility must immediately inform the resident, consult with the resident's physician . when there is: . A significant change in the resident's physical, mental or psychosocial status . A need to alter treatment significantly . Observation on 06/17/24 at 11:12 a.m. showed Resident #30 ambulating in her room with oxygen in place via nasal cannula. The resident stated she was good, except I can't breathe. The resident was noticeably short of breath and sat in her recliner. The surveyor asked if the resident would like a staff member to come in, and the resident stated, No, they know, and indicated the doctor would be at the facility that day. The resident identified she has been feeling more short of breath and planned to speak with the doctor about it. Resident #30 stated she has needed increased oxygen in the last five days or so, and was now receiving 3 liters per minute (lpm) of oxygen. The resident also stated she had blisters on her leg and thought they were infected. Observation on the morning of 06/18/24 showed Resident #30 in her recliner with oxygen via nasal cannula at 3 lpm. Resident #30 stated she was still experiencing shortness of breath, and the doctor did not come to see her yesterday. Resident #30 stated she was very disappointed, but was told the doctor would be at the facility today (06/18/24). Review of Resident #30's medical record occurred on all days of survey. Diagnoses included chronic obstructive pulmonary disease (COPD), pulmonary heart disease, and congestive heart failure. Current physician's orders included: *Supplemental oxygen (O2) at 2 lpm *Ventolin HFA (hydrofluoroalkane) (used to treat or prevent bronchospasms) Inhalation Aerosol Solution, 2 puffs inhale orally every 4 hours as needed for shortness of breath (SOB), wheezing. Resident #30's nurses' notes identified the following: *06/14/24 at 5:06 a.m.: . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for SOB, wheezing. coughing with moist cough, inspiratory wheeze . *06/14/24 5:23 a.m.: . Ventolin HFA Inhalation . PRN [as needed] Administration was: Effective . *06/14/24 at 8:15 p.m.: . Entering resident's room and noted a dry hacky cough. She states that she has increased pain to the right mid back. With ascultation [sic] [listening to lung sounds with a stethoscope], noted moderately loud rhonchi [coarse, loud sounds caused by constricted airways] to all lobes on the right and the left was clear. Vitals taken and WNL [within normal limits]. noted that there are 5 intact fluid filled blisters to her RLL [right lower leg] and the left is more red. This was noted when taking off her thigh high ted hose. There was weeping fluid from an opened blister. Xeroform [a wound dressing] place [sic] and covered with gauze and kling [a type of gauze] until provider could be notified. Do [sic] review her weights and noted a 2.5# weight gain in a week and a 9# weight gain over the past month. Did request her ventalin [sic] inhaler to help her with her coughing and feeling winded. 02 is on a [sic] 2L/NC and sats are 96%. Wull [sic] continue to monitor and report to the oncoming shift to notify provider. The record lacked evidence of physician notification. *06/15/24 at 4:19 p.m.: . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for SOB, wheezing. CN [charge nurse] notified . The record lacked evidence of a respiratory assessment or vital signs. *06/15/24 at 5:40 p.m.: . Resident did not go to dining room for her supper because she stated she wasn't feeling well. She has rhonchi in right upper and lower lobes. SOB with any exertion. left lower leg has erythema [redness] 10 x 9 cm [centimeters]. Has oxygen at 3 LPM NC due to increased SOB. Resting in recliner with legs elevated . *06/15/24 at 8:54 p.m.: . Ventolin HFA Inhalation Aerosol Solution . PRN Administration was: Effective no longer wheezing . *06/15/24 at 9:20 p.m.: . LATE ENTRY . States her cough is better tonight. Lung sounds are notably clearer with only a few rhonchi heard. Still turns 02 up to 3 liters with any activity and states this helps. *06/16/24 at 7:20 a.m.: . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for SOB, wheezing. Per CN . The record lacked evidence of a respiratory assessment or vital signs. *06/16/24 at 8:58 a.m.: . Ventolin HFA Inhalation Aerosol Solution . PRN Administration was: Effective . *06/16/24 at 3:32 p.m.: . Right lower leg with 3 large fluid filled blisters and dark red around. Left leg is lighter red with no open areas. She has expiratory wheezes thoughout [sic] all posterior lung fields and left upper lobe. Also has rhonchi to left lower lobe anteriorly. Has had trays today in room. She is short of breath at rest. [Provider name] said she will see Resident tomorrow . *06/16/24 at 8:42 p.m.: . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for SOB, wheezing. The record lacked evidence of a respiratory assessment or vital signs. *06/17/24 at 12:00 a.m.: . Wraps applied at HS [bedtime] tonight after dressing change because they measure bigger than the day shift. Still has a harsh cough but the ventalin [sic] helps her breath [sic]. 02 is on at 3L/nc [nasal cannula] because she feels she breathes better on this. Lung sound still have rhonchi and an audible wheeze noted with activity. Provider will be seeing her this afternoon she states . *06/17/24 at 12:09 a.m.: . Ventolin HFA Inhalation Aerosol Solution . PRN Administration was: Effective less coughing . *06/17/24 at 4:34 p.m.: . received order for Mucinex [used to loosen mucus in the airways and clear congestion] 600mg [milligrams] BID [twice a day] x 1 week. Will see resident at facility tomorrow. *06/17/24 at 9:48 p.m.: . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for SOB, wheezing. The record lacked evidence of a respiratory assessment or vital signs. *06/17/24 at 10:51 p.m.: . Ventolin HFA Inhalation Aerosol Solution . PRN Administration was: Effective . *06/18/24 at 3:28 p.m.: . late entry for 0930 today. This Resident was having difficulty breathing and had wheezes throughout all lung fields. Her lower legs and feet has [sic] 4 PE [pitting edema] and bright red. I asked her if she wanted to go to the hospital and she said yes that she did. (11 [sic, 911] was called and the [NAME] Ambulance was called and they arrived at 10:00 am and transported Resident to [hospital name] . *06/18/24 at 3:55 p.m.: . called [hospital name] and Resident was admitted to the hospital. The medication administration record (MAR) identified Resident #30 received five doses of PRN Ventolin from 06/14/24 to 06/17/24, and had not used the Ventolin prior to this during the month of June. The medical record and interview with Resident #30 identified increasing respiratory distress, pitting edema, lower leg blisters, weight gain, need for continuous oxygen at 3 lpm (versus 2 lpm as ordered), and use of PRN inhalers. The facility failed to report and act on Resident #30's complaints of respiratory distress and increased oxygen needs in a timely manner, assess and monitor the resident's respiratory status on an ongoing basis, and notify the medical provider until the afternoon of 06/16/24. These failures resulted in a delay in treatment and subsequent hospital admission. During an interview on the afternoon of 06/19/24, an administrative nurse (#2) stated staff should complete an assessment when they notice a change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, staff interviews, and information from a complainant, the facility failed to ensure resident safety for 1 of 1 resident (Resident #1) closed record reviewed for smoking safety. Failure to ensure the safety of a resident who smoked placed the resident at risk for adverse events, serious injury, and death. Findings include: Review of the facility policy titled [Facility Name] Smoking Procedure for Residents, Employees and Visitors occurred on [DATE]. This policy dated [DATE] stated, . Smoking and tobacco use in the location is not permitted. On [DATE], all locations of the [Facility Name] implemented a procedure to establish a smoke-free environment. This policy applies to residents, employees, and location visitors. As of [DATE], [Facility Name] does not allow smoking on facility grounds. These procedures are in addition to the Smoking and Tobacco Use - Rehab/Skilled and Outpatient Therapy Policy (dated [DATE]) endorsed by [Facility Name] and [Facility Name] locations. Resident Smoking Procedure. Per [Facility Name] Policy, we do not condone resident smoking. However, if that resident should choose to forgo our recommendations, and they have were [sic] a current resident and smoking before [DATE], they have that right. The outdoor garden space to the west of the building is our designated resident smoking area for those that were a current resident and smoking before [DATE]. Review of Resident #1's medical record occurred on [DATE] and showed the following: * Sustained an injury on [DATE] while outdoors smoking. * Current care plan stated, Focus: The resident has impaired cognitive function/dementia or impaired thought processes . E/B [evidenced by] slight memory impairment, poor judgment skills & safety awareness, and impaired decision-making abilities . Revision on: [DATE]. Focus: The resident uses tobacco products E/B use of cigarettes. Goal: Resident will safely use tobacco products in designated area. Interventions: . Monitor resident via cameras at nurses' station or where easily visible while out in the garden. Revision on: [DATE]. * A smoking assessment, completed on [DATE], stated, . Cognitive Loss . [marked as modified independence] . Physical Limitations . [marked as no] . * admitted to the facility as a smoker in 2019. * Grandfathered in to smoke on the property per facility policy. * On [DATE] only skilled nursing facility smoker. Observation of the facility's main nurses' station on [DATE] at 9:25 a.m. showed a surveillance monitor screen scrolling through views of indoor hallways and outdoor areas, including the designated smoking area. No staff were present in the nurses' station at this time. Observation on [DATE] at 11:00 a.m. with an administrative staff member (#1) showed an interior locked door with a numbered keypad. A code needed to be entered to exit to and enter from the facility's designated smoking area. No alarm sounded when code was entered, or when the door opened. Interviews occurred on [DATE] from 12:39 p.m. to 2:30 p.m. Questions asked: Were the monitors at the nurses' station on at the time of the incident? Were any staff in the nurses' station when Resident #1 went out to smoke? Where/what were you doing during the time of the incident? * Staff (#2) had been in the nurses' station at the start of shift, could not recall if surveillance monitors were on, and was not in the nurses' station when Resident #1 was out smoking. Staff #2 was walking down the hallway carrying a clean soaker pad on the way to a resident's room. A resident walking in the hall told this staff member it smelled like something was burning. Staff member went down the hall and saw the resident in the vestibule, opened the door, tried to assist the resident, called the charge nurse on walkie talkie, smoke alarm went off, and maintenance and charge nurse responded. * Staff (#3) had been in the nurses' station earlier in shift, and the surveillance monitor was on. Staff #3 was in another resident's room when Resident #1 was out smoking, and the fire alarm sounded. * Staff (#4) does not routinely use the nurses' station and does not know if surveillance monitor was on. Staff #4 heard the fire alarm and responded to the area. * Staff (#5) had not been in the nurses' station, does not know if surveillance monitor was on, and was not in the nurses' station when Resident #1 was out smoking. Staff #5 heard the fire alarm while working in the kitchen. * Staff (#6) had been in the nurses' station throughout the morning, and the surveillance monitor was on. Staff #6 was in another resident's room when Resident #1 was out smoking, and the fire alarm sounded. During an interview on [DATE] at 2:45 p.m., when asked how facility staff monitor cameras at the nurses' station if no one is present, an administrative staff member (#1) stated, There is a doorbell that alerts at the nurses' station when that door opens. I don't know if it was on that day. It makes a sound; you can choose ring tones. On [DATE] Resident #1 sustained injury from fire, was transported by ambulance to the hospital, and later to a burn center where the resident died. The facility failed to monitor Resident #1 while smoking in the designated smoking area and ensure an alarm sounded/alerted staff when the resident left the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on information provided by the complainant, record review, policy review, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 2 of 9 sampled residents (Resident #1 and Resident #3) and 1 closed record resident (Resident #4) reviewed for advanced directives. Failure to ensure all methods of communication and/or documentation of code status accurately reflected the resident/resident representative wishes has the potential to limit his/her access to life-sustaining services or unwanted treatment, and did result in unwanted treatment for Resident #4. Findings include: Information provided by the complainants indicated that residents expressed different wishes for code status than what were ordered in the residents medical record resulting in unwanted treatment. Review of the facility policy titled Advanced Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) - Rehab/Skilled occurred on [DATE]. This policy, revised [DATE], stated, . Residents have the right to formulate advance directives.1. If cardiac arrests occurs, [sic] CPR must be initiated unless the resident has: a. A valid DNR [Do Not Resuscitate] order on file that includes the medical order issued by a physician or other authorized non-physician practitioner.Procedure: Admission/re-admission Advance Directive 1. At the time of admission or re-admission, social services or designated staff member asks the resident/healthcare decision-maker whether the resident has prepared an advance directive such as a living will, durable power-of-attorney for healthcare decisions . 2. The designated staff member will meet with the resident/healthcare decision-maker to answer questions and determine if the resident/healthcare-decision maker wish to develop or amend advance directives. 4. As necessary, physicians will be contacted for orders that reflect the resident's wishes.Procedure: Quickly Identifying Resident CPR status in the SNF [skilled nursing facility] . 2. When PCC [Point Click Care, electronic medical record] is available, the nurse may choose to access the code status on the dashboard. During an interview on [DATE] at 3:45 p.m., a staff nurse (#3) stated she verified resident code status by looking at the banner in the electronic medical record. The staff nurse (#3) accessed Resident #1's medical record and looked at the banner. No code status displayed. She stated I would treat this resident as a Full Code. She indicated that is how she was trained as a nurse and did not recall if she received any specific training to code status on orientation. Review of Resident #1's medical record occurred on all days of survey. A physician's order, dated [DATE], stated Full Code. The electronic medical record failed to display Resident #1's code status in the area direct care staff would access prior to providing life sustaining treatment. Review of Resident #3's medical record occurred on all days of survey. A physician's order, dated [DATE], stated Full Code. A social service progress note, dated [DATE], stated, . reviewed his advance directives with resident, and it continues to be DNR, DNI [Do Not Intubate], no tube feeding, Do hospitalize, and use antibiotics . The electronic medical record lacked an updated physician's order reflecting the resident's wishes for code status and failed to display Resident #3's code status in the area direct care staff would access prior to providing life sustaining treatment. Review of Resident #4's closed record occurred on all days of survey. A physician's order, dated [DATE], stated, Full Code. A social service progress note, dated [DATE], stated, . Advance directive was reviewed on admission, and it continues to be DNR, DNI, tube feeding only on a trial basis. He also agreed to the use of antibiotics. POLST [Physicians Order for Life Sustaining Treatment Form] will be sent to his primary for orders. Review of nursing progress notes for Resident #4 showed the following: * [DATE] at 10:14 p.m., stated, At approximately 2030, CN [charge nurse] and CNA [certified nursing assistant] heard residents bed alarm going off. CN went in to check on him and he was on his knees with his torso laying over the bed. CN called for CNA to come assist him back into bed. As we were in the process of trying to get him back into bed, he slumped over and we lowered him the rest of the way to the floor. CN noted that he was cyanotic [bluish coloring of the skin due to lack of oxygen], eyes were glazed over and CN could not find a pulse. CN started CPR and did it over about a minute when resident started to gasp for air and started looking around. In the process CN yelled for CNA to call 911 and report a transfer for a resident who was unresponsive. CN told med aid to go grab an O2 [oxygen] concentrator and start oxygenating him. We got the O2 on him and his color started coming back. Resident still was not responding, but was looking around and would occasionally make a moaning sound. Ambulance showed up and transferred resident to the [critical access hospital] ER [emergency room]. resident was currently intubated. [Physician name] (ER doctor) stated that they were going to air lift resident to the [acute care] hospital where he would be admitted to the ICU [intensive care unit]. * [DATE] at 12:03 p.m., stated, Rec'd [received] signed POLST from MD [medical doctor]. The facility failed to obtain an updated physician's order reflecting the resident's wishes for code status in a timely manner resulting in Resident #4 receiving CPR. The electronic medical record failed to display Resident #4's code status in the area direct care staff would access prior to providing life sustaining treatment. During an interview on [DATE] at 8:45 a.m., two administrative staff members (#1 and #2) confirmed the medical records lacked updated physician's orders for Resident #3 and Resident #4, the physician's orders present in the medical record did not match the documented conversations, and Resident #4 received CPR per facility policy. They confirmed the electronic medical records for all three residents failed to display the code status in an area direct care staff would access prior to providing life sustaining treatment. The administrative staff members (#1 and #2) identified the facility failure to obtain revised physician's orders for code status and provided meeting minutes that showed implementation of a new admission process that began on [DATE]. Education to nursing staff began on [DATE].