Based on observation, record review, and interviews, the facility failed to ensure supervision and evaluation during transfers for 1 (#17) of 3 sampled residents reviewed for the use of mechanical lifts and accident hazards. The DON identified nine residents that use mechanical lifts.Findings:On 09/10/25 at 11:15 a.m., CNA #2 and CNA #3 were observed to perform a transfer for Resident #17 using the sit to stand lift. The transfer was completed safely. A lift assessment for Resident #17, dated 02/18/25, showed the resident did not need a lift to transfer. No lift assessment was located in the clinical record since 02/18/25. An in-service, dated 03/24/25, covered the following education:a. demonstrated how to safely use mechanical lifts, andb. review of policy, revised 07/2017, titled Safe Lifting and Movement of Residents which read in part Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents .at least two nursing assistants are needed to safely move a resident with a mechanical lift.A Certified Nursing Assistant Competency Assessment for CNA#4, with a completion date of 06/05/25, showed a date of hire as 05/07/25. The assessment read in part, Has duty and responsibility of assist with lifting, turning, moving, positioning and transporting resident into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. There was a Y for competency demonstration. No other documentation of training for mechanical lifts was noted in new hire education. A policy titled Lift Policy, dated 06/06/25, read in part, This facility is to use the mechanical lifts with two staff members for all transfers of newly admitted resident unless they are deemed independent by the nurse.A care plan for Resident #17, initiated 06/23/25, showed the resident required a sit to stand lift at all times with two staff assist with transfers. An Incident report for Resident #32, dated 07/25/25, showed a witnessed fall with no injuries occurred when a CNA was assisting the resident with the sit to stand by themself for a brief change. The report read in part, Educated staff to get help before utilizing equipment and always have a minimum of two person assist.On 09/10/25 at 11:15 a.m., CNA #2 was asked about the use of a mechanical lift. CNA #2 stated they always made sure they had two staff members with any use of the mechanical lift. CNA #2 stated they had in-services for lift use, but it had been a few months ago.On 09/10/25 at 11:20 a.m., CNA #3 was asked about the use of the mechanical lift. CNA #3 stated to always two persons for use, communication between staff on who they use the lifts on, and they have had training. The new CNAs hired were trained by the current CNAs regarding job duties. On 09/11/25 at 12:01 p.m., CNA #4 was asked about sit to stand use. CNA #4 stated they knew now they were to always have two persons, and the resident had to be weight bearing to use the sit to stand. CNA #4 stated they were a new CNA starting in April and they were not taught about sit to stand use in school. CNA #4 stated they were shown by another CNA at the facility, and they did not instruct or educate them correctly on number of staff to use the lift. CNA #4 stated they were told they only needed one staff to change a resident, only two staff if transferring. CNA #4 stated the CNA that did their education at the facility no longer works there and was not a good person to learn from. CNA #4 stated after the incident, the charge nurse did education immediately with them. CNA #4 was asked if there was any education on lifts when hired. CNA #4 stated there may have been, but they did not remember, education was usually CNA to CNA. On 09/11/25 at 12:30 p.m., the DON was asked about evaluation of residents for mechanical lift use. The DON stated if they had therapy, the therapist would tell them, if the resident was non-weight bearing or bedbound they would use them. The DON stated they were not sure if it showed up on the Kardex for the CNA or not, but they usually communicated amongst themself regarding who required a lift and who did not. The DON was asked about education and requirements for staff regarding the use of mechanical lifts. The DON stated they usually knew how to use them when they were hired since they have a certification. The DON stated they did an initial competency check-off for skills they thought had mechanical lifts included. The DON stated a nurse reviewed the check list with them. The DON was asked about care plan updates and lift assessments. The DON stated they were working on getting them all caught up.

Based on record review and interview, the facility failed to ensure RN coverage for 8 consecutive hours per day for 5 (April 2025 through July 2025) of 5 months of staff schedules reviewed for RN coverage.The administrator identified 47 residents resided in the facility.Findings: A PBJ Staffing Data Report, dated 04/01/25 through 06/30/25, showed during quarter three, the facility did not have RN coverage for 04/05/25, 04/06/25, 04/11/25, 04/12/25, 04/13/25, 04/19/25, 04/20/25, 05/16/25, 05/17/25, 05/30/25, 05/31/25, 06/01/25, 06/07/25, 06/08/25, 06/14/25, 06/15/25, 06/21/25, 06/22/25, 06/28/25, or 06/29/25. Payroll detail reports reviewed for registered nurse coverage for the months of 04/2025 through 08/2025, showed the facility did not have eight consecutive hours per day for 04/01/25, 04/08/25. 04/09/25, 04/10/25, 04/13/25, 04/19/25, 04/20/25, 04/27/25, 04/28/25, 05/03/25, 05/05/25, 05/11/25, 05/12/25, 05/14/25, 05/16/25, 05/17/25, 05/18/25, 05/29/25, 05/30/25, 05/31/25 06/01/25, 06/07/25, 06/08/25, 06/14/2025, 06/15/2025, 06/21/2025, 06/22/2025, 06/25/25, 06/26/25, 06/28/25, 06/29/25, 07/05/25, 07/06/25, 07/12/25, 07/13/25, 07/19/25, 07/20/25, 07/26/25, 07/27/25, 08/02/25, 08/03/25, 08/09/25, 08/10/25, 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/20/25, 08/23/25, 08/24/25, and 08/30/25.On 09/10/25 at 2:40 p.m., administrator was asked about RN staffing. The administrator stated they were aware of not having an RN on the weekends and had not had one for some time. The administrator stated they had not had any luck finding a weekend RN that would be a good fit for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a discharged resident's clinical record contained a discharge summary for one (#44) of three sampled residents reviewed for discharge. The Administrator reported 44 residents resided in the facility. Findings: Res #44 admitted to facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and chronic kidney disease stage 3. The electronic health record documented the resident expired in the facility on [DATE]. The resident's record did not contain a discharge summary. On [DATE] at 10:45 a.m., the DON reported a discharge summary had not been completed

Based on record review and interview, the facility failed to develop/implement the care plan related to nutrition/significant weight loss. The Administrator reported 44 residents resided in the facility. Findings: Res #20 was admitted to the facility with diagnoses of dementia. Hypothyroidism, anxiety, and depression. A review of the resident's record documented the resident had a significant weight loss of 13.05% in the last six months. A care plan, revised on 04/11/24, contained no documentation of weight loss. On 06/28/24 at 8:50 a.m., the IP/MDS coordinator reported nutrition should have been care planned.

Based on observation, record review and interview the facility failed to administer medications as ordered by the physician for one (#36) of two resident's sampled for medication administration. The Administrator reported 44 residents resided in the facility. Findings: Res # 36 admitted to the facility with diagnoses of hyperlipidemia, atherosclerosis of aorta, and hypertension. A physician's order, dated 06/09/24, documented Rosuvastatin Calcium oral tablet 10mg, give 1 tablet by mouth one time a day for Lipid control May give 2-10mg tab to equal 20mg till gone. On 06/27/24 at 7:54 a.m., CMA #1 was observed during medication pass preparing medications for Res #36. CMA #1 was observed dispensing one tablet of Rosuvastatin 10mg. On 06/27/24 at 9:40 a.m., CMA #1 was made aware of resident #36's physcian's order for Rosuvastatin 10mg 2-10mg tab to equal 20mg till gone. CMA #1 reported he should have administered two tablets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with a diagnosis of Alzheimer's disease was not given Seroquel (anti-psychotic medication) routinely at bedtime for insomnia for 1 (resident #38) of 5 residents whose records were reviewed for unnecessary medications. Findings: The Administrator identified 44 residents at the facility. Resident #38 admitted to the facility 04/17/24. The MDS, dated 05/01/24, read in part, .Alzheimer's disease . The Physician Orders, dated 04/17/24, read in part, .Seroquel Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for insomnia . The April MAR, documented the resident received Seroquel 14 times at bedtime for insomnia. The May MAR, documented the resident received Seroquel 31 times at bedtime for insomnia. The June MAR, documented the resident received Seroquel 25 times at bedtime for insomnia. On 07/01/24, at 10:30 a.m., the DON stated the resident had received Seroquel for insomnia since his admission [DATE].

Based on observation, record review, and interview, the facility: a. Failed to ensure the removal of expired medication/supplies were removed from the medication storage room. b. Failed to ensure a change of direction sticker was placed on a medication card. The Administrator reported 44 residents resided in the facility. Findings: Res #36 admitted to the facility with diagnosis of hyperlipidemia. A physician order, dated 06/09/24, documented Rosuvastin Calcium 10mg Give one tablet by mouth one time a day for Lipid control May give 2-10mg tab to equal 20mg till gone. On 06/27/24 at 7:54 a.m., CMA #1 was observed during medication pass preparing medications for Res #36. The directions on Res #36's card of Rosuvastatin documented to administer the Rosuvastatin 10mg daily. On 06/27/24 at 9:40 a.m., CMA #1 was made aware of resident #36's Rosuvastatin discrepancy order and what the card read. CMA #1 stated they would put a change of direction sticker on the card. On 06/27/24 at 1:59 p.m., a tour of the medication storage room was conducted with CMA #2 The following medications and supplies were observed to be expired: 2 boxes of Covid-19 test kits with an expiration date of 06/30/23, 5 flu swab kits with an expiration date of 02/29/24, 2 culture swabs with an expiration date of 05/31/23, 3 culture swabs with an expiration date of 05/03/24, 1 culture swab with an expiration date of 02/29/24, 7 culture swab kits with an expiration date of 12/31/23, 1- 18ml bottle of instant hand sanitizer with an expiration date of 03/2022, 1- 18ml bottle of instant hand sanitizer with an expiration date of 06/2022, 11 safety blood collection sets + luer adapter with an expiration date of 08/05/22, 7 house stock bottles of Vitamin C 500mg with a pharmacy label expiration date of 06/19/24, 2 house stock bottles of Acetaminophen 500mg with an expiration date of 05/29/24, 1 open house stock bottle of antacid tablets 500mg with an expiration date of 06/05/24, On 06/27/24 at 2:24 p.m., CMA #2 reported the expired medications should have already been removed from the medication/supply storage room. 06/27/24 at 2:25 p.m., LPN #1 reported the expired supplies should have already been removed from the medication/supply storage room.

Based on record review and interview, the facility failed to maintain documentation of Covid-19 vaccination status for staff. The Administrator reported 44 residents resided in the facility. Findings: On 07/01/24 at 8:48 a.m., the DON was asked for the staff Covid-19 vaccine documentation. They reported they do not keep documentation of them. On 07/01/24 T 8:48 a.m., the DON reported that the staff are not offered vaccines at the facility, they go to the health department to receive them. The DON was asked if they keep documentation for refusals and she reported no because that is their personal stuff.

Based on record review and interview, the facility failed to implement dietary recommendations to promote wound healing for one (#5) of three sampled residents reviewed for wounds. The administrator identified 39 residents resided in the facility. Findings: Resident #5 had diagnoses that included pressure ulcers (stage 3) and diabetes (type 2). A Dietitian's Recommendation for Primary Care Provider for Resident #5, dated 10/19/23, read in parts, Stage 3 PU to left glute, right glute and right heel .add protein shake, vit C, zinc to assist with wound healing . A Dietitian's Recommendation for Primary Care Provider for Resident #5, dated 11/27/23, read in part, .Remove magic cup and mighty shake from diet order. Remove one of the two diets ordered . The dietitian recommendations for Resident #5 dated 10/19/23 and 11/27/23 were not signed as reviewed by the DON nor signed as addressed by their physician. On 12/07/23 at 10:42 a.m., Corp. Nurse Consult. #1 was asked how recommendations from the dietitian were communicated to the physician. Corp. Nurse Consult. #1 stated dietary recommendations were forwarded to the DON or charge nurse to review and then put in the book for the physician to address. Corp. Nurse Consult. #1 was asked if the above dietary recommendations for Resident #5 to promote wound healing had been implemented. After a review of Resident #5's clinical record they acknowledged the above dietary recommendations had not been reviewed by the DON nor addressed by the physician.

Based on record review and interview, the facility failed to ensure blood pressures were not obtained from a resident's arm, where a dialysis fistula was located, for one (#14) of two residents sampled for dialysis services. The Resident Census and Conditions of Residents report, dated 06/19/23, documented three residents received dialysis services. Findings: A Care of AVF's and AVG's policy, read in part, .Do not use the access arm to take blood pressure . Resident #14 had diagnoses which included acute respiratory failure, type 2 Diabetes Mellitus, and chronic kidney disease stage 4. Blood pressure logs for resident #14 were reviewed for 03/06/23 through 06/20/23, and documented the blood pressure was recorded 25 times in the right arm by licensed and unlicensed staff. Resident #14's Physician's orders, dated 5/20/23, read in part, resident received/returned from .hemodialysis treatment this shift (if yes enter progress note and document VS on dialysis assessment tool) every shift for fistula . A care plan for resident #14, dated 06/07/23 through 08/22/23, read in part, Renal Function .Monitor dialysis site as ordered .Skin Integrity .Fistula to right upper arm dressing C/D/I, No S/SX of infection or active bleeding noted every shift . On 06/22/23 at 11:15 a.m., resident #14 remained in the hospital. There was no posting observed in the resident's room regarding obtaining blood pressures, or reminders not to use the resident's right arm for blood pressures. LPN #1 was asked what arm they would use for obtaining resident #14's blood pressure. The LPN reported they used the left arm. On 06/22/23 at 11:20 a.m., the DON was asked if resident #14's care plan documented the location of the resident's fistula. The DON reported it was documented to be in the right upper arm and this information was located in the plan of care, under the care area of skin. The DON was asked to review the blood pressure readings and asked if there were instructions for staff not to use the right arm when obtaining the resident's blood pressure. The DON stated there were not instructions to use a specific arm.

Based on record review and interview, the facility failed to complete a level II PASARR (Preadmission Screening And Resident Review) for one (#13) of one sampled resident reviewed for the completion of a level II PASARR. The DON identified four residents who required the completion of a level II PASARR. Findings: Resident (Res) #13 had diagnoses which included unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, anxiety disorder, and schizophrenia. Physician's orders, dated 10/2021, documented to administer Seroquel 25 mg one tablet in the evening for schizophrenia, buspirone 10 mg one tablet twice per day for anxiety, and Lexapro 10 mg one tablet one time per day for major depression. A quarterly assessment, dated 08/19/21, documented the resident's cognition was intact, had no behaviors, and received antipsychotic, antianxiety, and antidepressant medications seven days of the seven day look back period. A care plan, updated 10/14/21, read in parts, .Focus: Resident has potential for psychological distress of psychosocial well-being AEB/R/T limitations set in place by pandemic .Goal: Resident will demonstrate effective coping skills .Interventions: Assess resident's strengths and positive coping skills and determine ways to utilize in present situation .Assess/record changes in psychosocial well-being . A review of the clinical record revealed the PASARR Level I had not been completed to determine if PASARR level II services were necessary. On 10/20/21 at 12:29 p.m., LPN #1 stated no documentation was found in the clinical record to indicate it had been done.

Based on record review and interview, the facility failed to provide baths to a dependent resident for one (#136) of three sampled residents reviewed for bathing. The Resident Census and Conditions Report identified 14 residents who were dependent on staff for bathing. Findings: The Bath, Bed policy, dated February 2018, read in part, .Purpose: The purposes of this procedure are to promote cleanliness, provide comfort and to observe the condition of the resident's skin . Resident (Res) #136 had diagnoses which included, unspecified dementia, contracture right hand, and rheumatoid arthritis. A significant change assessment, dated 02/29/20, documented the resident's cognition was intact, she required limited assistance for most ADLs, and two person assist for bathing. A review of the clinical record revealed the resident was placed on hospice services on 03/03/2020. The resident received twice weekly baths from the hospice CNAs. In April of 2020 the facility went on COVID-19 lock down and outside agencies were no longer allowed in the facility, at that time the facility would have been responsible for ensuring the resident was bathed. There was no documentation provided to ensure the resident had received baths. On 10/21/21, LPN #1 was asked to provide bath sheets showing when the resident had been bathed. LPN #1 stated there were no bath sheets during that time. LPN #1 stated hospice had been giving the resident baths, but it appeared the facility had not continued that duty after hospice could not come inside the building. On 10/25/21 at 1:15 p.m., the DON was asked who was responsible for ensuring baths were completed. The DON stated she checked the bath sheets daily, signed them, and kept them in a folder. The DON stated she had all bath sheets since she began working at the facility in February of 2021. The DON was asked how staff ensured hospice residents received their baths. The DON stated the hospice CNA gave her a bath sheet as well when they had completed a resident's bath. The DON was asked how bathing was monitored. The DON stated the charge nurse received the sheets first, signed off on them, and then turned them in to her. By the end of the survey no bath sheets were provided for Res #136.

Based on observation, record review, and interview, the facility failed to ensure resident's rights to allow/receive visitors of the resident's choice for two (#7 and #33) of two sampled residents reviewed for visitation. The Resident Census and Conditions Report identified 38 residents resided in the facility. Findings: The Oklahoma State Department of Health (OSDH) guidance on nursing home visitation, dated 08/02/21, read in parts, .Outbreak .Indoor visits suspended .If first round of outbreak testing reveals no additional COVID-19 cases in other areas (e.g., units) of the facility, visitation can resume for residents in areas/units with no COVID-19 cases . An untitled policy, dated 09/14/21, read in parts, .Indoor visitation for unvaccinated residents should be limited solely to compassionate care situations if the COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated .If the facility is in outbreak status visitation will cease until first round of facility testing has been completed and no additional positive cases have been identified . LPN #1 identified 30 out of 38 residents (78.9%) had received the COVID-19 vaccination. 1. Resident (Res) #7 had diagnoses which included heart failure, intellectual disabilities, and sensorineural hearing loss of the right ear. An annual assessment, dated 08/02/21, documented Res #7 had mild cognitive impairment for daily decision making, and the resident reported family or close friend involvement was very important. The care plan, last updated 07/26/21, read in parts .Focus .potential for psychological distress for psychosocial well-being .limitation in place from the pandemic .goal .will demonstrate effective coping skills .interventions .Encourage family-friends to remain involved with resident .Focus .impaired thought processes r/t developmentally delayed .interventions .keep res routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion . A progress note, dated 10/05/21 at 11:05 a.m., read in parts, .Residents and Families were notified that we tested stuff [sic] on 10/01/2021, all of our stuff [sic] were nagative [sic] except one employee. the facility is on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/07/21 at 11:30 p.m., read in parts, .Residents and Families were notified that we tested stuff [sic] on 10/05/2021 and Residents on 10/07/2021 all of our stuff [sic] and Residents were nagative [sic] the facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/11/21 at 5:32 p.m., read in parts, .Residents and Families were notified that we tested stuff [sic] on 10/08/2021 and all results came back nagative [sic], facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/14/21 at 4:54 p.m., read in parts, .Residents and Families were notified that we tested stuff [sic] on 10/12/2021 and all results came back nagative [sic], facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice. A progress note, dated 10/18/21 at 9:07 p.m., read in parts, .Residents and Families were notified that we tested staff on 10/15/2021 and all results came back nagative [sic]. The facility is only allowing porch visitation by appointment . On 10/19/21 at 8:55 a.m., Res #7 asked the surveyor if the facility was still on lock-down and not letting any one inside. Res #7 asked if the surveyor was going to help get the visitations changed. Res #7 was asked if visitors were allowed to visit. Res #7 stated, Not for a very long time. A progress note, dated 10/19/21 at 11:40 p.m., read in part, .Residents and families were notified that,there is covid19 possibility in our facility and we will be on locked [sic] down until further notice,they were also told that we will have window visitation and face time for right now.all staff and Residents were tested and everybody today was nagative [sic] . On 10/20/21 at 10:02 a.m., LPN #1 was asked if the facility was currently allowing visitation. LPN #1 stated, No. Res #7 was observed in the hall stating the facility was on Lockdown. The LPN was asked what Res #7 meant by the home was in Lockdown. LPN #1 stated the facility was in outbreak testing. LPN #1 stated they were confused because they had received a memo stating they could allow visitation after the first round of outbreak testing. 2. Res #33 had diagnoses which included dementia and depression. An admission assessment, dated 10/08/21, documented the resident was severely impaired in cognition, family or significant other participated in completion of the assessment, and reported having family or close friend involved in discussion about care was very important. A progress note, dated 10/05/21, read in part, .Residents and Families were notified that we tested stuff [sic] on 10/01/2021, all of our stuff [sic] were nagative[sic] except one employee. the [sic] facility is on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/07/21, read in part, .Residents and Families were notified that we tested stuff [sic] on 10/05/2021 and Residents on 10/07/2021 all of our stuff [sic] and Residents were nagative [sic] the facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/11/21, read in part, .Residents and Families were notified that we tested stuff [sic] on 10/08/2021 and all results came back nagative [sic], facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/14/21, read in part, .Residents and Families were notified that we tested stuff [sic] on 10/12/2021 and all results came back nagative [sic], facility is still on quarantine for 14 days we will continue face time and window visit, no body is allowed to come in the facility for visit until further notice . A progress note, dated 10/18/21, read in part, .Residents and Families were notified that we tested staff on 10/15/2021 and all results came back nagative [sic]. The facility is only allowing porch visitation by appointment. Temperatures will be taken daily when visitors come to see their loved ones. Masks are required as well as hands sanitizing . On 10/19/21, Res #33 became teary stating their family doesn't visit. The resident was asked how long it had been since family had visited. Res #33 stated it had been a long time but stated They know where I am. A progress note, dated 10/19/21, read in part, .Residents and families were notified that, [sic] there is covid19 possibility in our facility and we will be on locked [sic] down until further notice, [sic] they were also told that we will have window visitation and face time for right now. [sic] all [sic] staff and Residents were tested and everybody today was nagative [sic] . On 10/19/21, during entrance conference, the administrator was asked about the facility's current visitation procedures. The administrator stated on 10/18/21 the facility had started allowing outdoor visitation again, by appointment. On 10/27/21 at 11:24 a.m., the administrator was asked why the facility had not been allowing indoor visitation. The administrator stated they had been more strict than CDC but had been allowing compassionate care visitation.

Based on record review and interview, the facility failed to ensure the physician was notified of abnormal/elevated laboratory results for one (#8) of three sampled residents whose laboratory results were reviewed. The Resident Census and Conditions Report identified 38 residents resided in the facility. Findings: Resident #8 had diagnoses which included benign prostatic hyperplasia. A significant change assessment, dated 05/04/21, documented the resident's cognition was moderately impaired, required assistance with ADLs, and was incontinent of bladder. A care plan, updated 08/02/21, read in parts, .(name withheld) is incontinent of bladder r/t BPH .Monitor need for/schedule appropriate diagnostic procedures as ordered .Report significant changes in bladder status to physician . On 08/02/21, the resident had lab drawn for a Free and Total PSA (prostate specific antigen). On 08/03/21 the lab reported results, an elevated PSA total of 23.5 ng/ml. Normal reference range < or = 4.0 ng/ml. August 2021 nursing progress notes were reviewed. There was no documentation in the progress notes to ensure the physician had been notified of the elevated lab results. On 10/25/21 at 2:45 p.m., LPN #1 was asked if the physician had been notified of the abnormal lab results. She stated she could not find any documentation he had been notified.

Based on record review and interview, the facility failed to provide complete, informed advance notice of discharge from Medicare Part A skilled services for three (#10, 26, and #236) of three sampled residents who were reviewed for beneficiary protection notification. The business office manager identified 10 residents who had been discharged from Medicare Part A skilled services, with benefit days remaining, in the last six months. Findings: 1. Resident (Res) #10 was discharged from Medicare part A skilled services on 05/06/21, but remained in the facility. Res #10 had been provided Form CMS-10095, Notice of None [sic] Covered Medicare. The resident signed the notice on 05/04/21. The Notice of None [sic] Covered Medicare Form CMS-10095, provided to the resident, read in parts, .Your Medicare health plan and/or provider have determined that Medicare probably will not pay for your current {insert type} services .Form CMS 10095-NOMNC (Exp. 10/31/2013) . The Notice of Medicare Non Coverage Form the resident had been provided did not inform the resident of the services that would not be covered as the prompt, on the form, to {insert type} of services had not been completed by the facility. In addition, the facility did not provide Res #10 a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), informing the resident of potential liability for payment of non-covered services. 2. Res #26 was discharged from Medicare part A skilled services on 04/28/21, but remained in the facility. Res #26 had been provided Form CMS-10095, Notice of None [sic] Covered Medicare. The resident signed the notice on 04/26/21. The Notice of None [sic] Covered Medicare Form CMS-10095, provided to the resident, read in parts, .Your Medicare health plan and/or provider have determined that Medicare probably will not pay for your current {insert type} services .Form CMS 10095-NOMNC (Exp. 10/31/2013) . The Notice of Medicare Non Coverage Form the resident had been provided did not inform the resident of the services that would not be covered as the prompt, on the form, to {insert type} of services had not been completed by the facility. In addition, the facility did not provide Res #26 a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), informing the resident of potential liability for payment of non-covered services. 3. Res #236 was discharged from Medicare part A skilled services on 06/10/21. Res #236 had been provided Form CMS-10095, Notice of None [sic] Covered Medicare. The resident signed the notice on 06/08/21. The Notice of None [sic] Covered Medicare Form CMS-10095, provided to the resident, read in part, .Your Medicare health plan and/or provider have determined that Medicare probably will not pay for your current {insert type} services .Form CMS 10095-NOMNC (Exp. 10/31/2013) . The Notice of Medicare Non Coverage Form the resident had been provided did not inform the resident of the services that would not be covered as the prompt, on the form, to {insert type} of services had not been completed by the facility. On 10/21/21 at 2:58 p.m., the business office manager was asked what form was used to inform a resident their Medicare Part A, skilled services were ending. The business office manager stated Form CMS-10095 was the only form they used regardless of whether the resident planned to remain in the facility to receive long term care services or planned to go home. The business office manager was asked when CMS Form 10055, Skilled Nursing Facility Advanced Beneficiary Notice, would be provided to the resident. The business office manager stated they had never used that form. The business office manager was asked how the resident knew what services were not being covered since the type of services prompt on the form had not been completed. The business office manager stated the resident would be informed verbally.

Based on record review and interview, the facility failed to ensure residents were free from physical restraints for one (#138) of two sampled residents who were reviewed for physical restraints. The Resident Census and Conditions Report identified 38 residents resided in the facility. Findings: The Use of Restraints, policy, dated April 2017, read in parts, .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls .Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove . Resident (Res) #138 had diagnoses which included Alzheimer's disease, anxiety, and depression. An Incident Report, dated 09/04/20, documented on 09/24/20, it was reported via the compliance hotline that on 09/04/20, Res #138 was secured into the wheelchair with a safety velcro sign by CNA #4. CNA #4's statement, dated 09/28/20, documented a velcro stop sign was used while Res #138 was in the wheelchair. The statement documented the velcro sign was left loose, hoping Res #138 would not attempt to get up out of the chair and walk since the resident had fallen that morning. The DON's statement, dated 09/25/20, documented on 09/11/20, CNA #4 had wrapped a stop sign that goes on doorways around Res #138 to try to keep the resident from getting up and falling again. Staff in-services from 06/15/20 through 09/09/20 were reviewed and revealed in-services were conducted on the following dates: 06/15/20; 07/10/20; 08/24/20; and 09/01/20. However, the review did not reveal staff had been in-serviced on the use of restraints. A discharge assessment, dated 03/27/21, documented the resident was severely impaired in cognition for daily decision making, required extensive assistance for bed mobility, transfers, toileting, and personal hygiene, always incontinent of bowel and bladder, and had multiple falls. On 10/27/21 at 11:24 a.m., the administrator was asked why the incident, dated 09/04/20, was not investigated until 09/24/20. The administrator stated they started the investigation when the administrator became aware of the incident. The administrator was asked if all staff had received an in-service on restraints following the incident on 09/04/20. The administrator stated staff should have been in-serviced. The administrator was asked if newly hired employees were in-serviced on the use of restraints. The administrator stated it was not on the new hire checklist. On 10/27/21 at 11:50 a.m., RN #1 was asked if they had been aware of the incident involving Res #138. RN #1 stated yes. RN #1 stated on 09/11/20, Res #138 had fallen that morning and the CNA thought the resident should be tied down in the chair. RN #1 was asked if she had reported the incident. RN #1 stated yes, it had been reported to the administrator that day. RN #1 was asked if an incident report had been completed. RN #1 stated they could not remember. RN #1 was asked if the incident had been documented in the progress notes. RN #1 stated they did not think so. On 10/27/21 at 12:05 p.m., the administrator was asked if the incident dated 09/04/20 could have been 09/11/20 which was reported by RN #1. The administrator stated they were not sure. The administrator was asked if the incident had been reported to her on 09/11/20. The administrator stated they did not remember.

Based on record review and interview, the facility failed to complete discharge summaries for three (#35, 136, and #137) of three sampled residents reviewed for discharge summaries. The Resident Census and Conditions Report indicated 38 residents resided in the facility. Findings: 1. Resident (Res) #35 had diagnoses which included acute kidney failure. A discharge assessment, dated 10/19/21, documented the resident had an unplanned discharge to another nursing facility with return not anticipated. A health status note, dated 10/19/21 at 1:31 p.m., read in part, Resident scheduled to discharge to different facility this shift. Family to transport belongings . On 10/26/21 at 9:20 a.m., the DON was asked if the physician routinely provided discharge summaries for the residents. She stated she had not located the discharge summary in the resident's clinical record. No discharge summaries were provided. 2. Res #136 had diagnoses which included, dementia w/o behavioral disturbance. A discharge assessment, dated 11/13/2020, documented the resident's discharge assessment with return not anticipated. A health status note, dated 11/13/2020 at 3:09 p.m., read in part, discharged to home with daughter. All personal belongings accounted for. Meds including Humara and instruction given. On 10/25/21 at 12:23 p.m., the administrator was asked to describe the resident's discharge. She stated the resident had an upcoming 80th birthday. Her daughter wanted to take her out of the facility for the weekend. Residents were not allowed to leave during that time because of the COVID-19 lock down. The daughter came and picked up her mother and never brought her back. On 10/26/21 at 9:20 a.m., the DON was asked if the physician routinely provided discharge summaries for the residents. She stated she had not located the discharge summary in the resident's clinical record. No discharge summaries were provided. 3. Res #137 had diagnoses which included dementia. An entry/discharge assessment, dated 08/29/20, documented the resident was discharged due to his death in the facility. On 10/26/21 at 8:20 a.m., LPN #1 was asked to provide the discharge summary. At 9:27 a.m., LPN #1 reported she had not been able to locate the discharge summary or hard copies of closed records. LPN #1 stated it appeared the staff had not completed any discharge summaries for an extended time.

Based on record review and interview, the facility failed to monitor/re-assess and notify the physician of changes in condition for two (#3 and #28) of 13 sampled residents reviewed for change in condition. The Resident Census and Conditions report identified 38 residents resided in the facility. Findings: 1. Resident (Res) #3 had diagnoses which included COPD; atherosclerotic heart disease; Parkinson's disease; and acute respiratory failure w/hypoxia. A quarterly assessment, dated 07/19/21, documented the resident had mild/moderate cognitive impairment for daily decision making; did not display behaviors; and required extensive assistance for bed mobility, transfers, dressing, toileting, hygiene and bathing. The care plan, updated 09/29/21, read in parts, .complications of Parkinson's Disease .impaired mobility, unsteady gait .observe for memory loss .difficulty swallowing .drooling .notify physician of any changes in resident normal functioning status . Current physician orders, read in parts, .Assess resident for the following S/S related to COVID 19: fever .cough: new or worsening, chills .sore throat .Notify Infection Prevention Nurse and physician at the first sign of any one or combination of symptoms . A progress note, dated 08/18/21 at 8:31 p.m., read in parts, .Health Status Note .Resident stated that she is having to whisper due to voice loss x today. No complaint of sore throat or any throat or mouth discomfort . The clinical record did not contain documentation Res #3 had been re-assessed or monitored for a change of condition. The clinical record did not contain documentation the physician or family were notified of the change of condition. On 10/26/21 at 1055 a.m., the DON, and LPN #1 were asked if Res #3 had been re-assessed or monitored for a reported change of condition. They reviewed the clinical record and stated the resident had not been re-assessed or monitored. They were asked if the physician should have been notified of the change of condition. The DON stated the resident should have been re-assessed and the physician notified at the time she was re-assessed. 2. Res #28 had diagnoses which included: cerebral infarction; occlusion and stenosis of bilateral vertebral arteries; dysphagia; fluid overload; hypertension; atherosclerotic heart disease; GERD; and diaphragmatic hernia. The current physician orders, read in parts, . Assess resident for the following S/S related to COVID 19: .new or worsening .nausea and vomiting .Notify Infection Prevention Nurse and physician at the first sign of any one or combination of symptoms . The order was initiated on 06/14/21. A progress note, dated 09/01/21 at 9:05 p.m., read in parts, .Health Status Note .Resident sitting in front lobby after evening meal. Vomited small amount of evening dinner . The clinical record did not document Res #28 had been re-assessed, monitored, or the physician had been notified. A quarterly assessment, dated 09/24/21, documented the resident had severe cognitive impairment for daily decision making skills; had clear speech, was understood and understood others; did not display behaviors; required cues and limited assistance for ADLs; and had not experienced vomiting. A progress note, dated 09/30/21 at 6:00 p.m., read in parts, .Health Status Note .resident standing at dining room table and slumped over and stated [sic]vomiting .reports she just got dizzy then sick at stomach . The clinical record did not document Res #28 had been re-assessed, monitored, or the physician had been notified. The care plan, updated 10/14/21, read in parts, .at risk for gastrointestinal discomfort r/t GERD, mixed irritable bowel syndrome & diaphragmatic hernia .will be free from discomfort of GI tract .Administer medications as ordered and monitor effectivness [sic] .Monitor for vomiting, nausea, abdominal cramps or fullness, heartburn sensations, tarry stools . On 10/26/21 at 10:55 a.m., the DON and LPN #1 were asked if Res #28 had been re-assessed/monitored or the physician notified after she had been known to vomit on 09/01/21 or 09/30/21. After review of the clinical record, the DON stated the physician was notified last week (week of October 18). The DON was asked if the resident had been re-assessed/monitored and the physician notified in a timely manner. She stated the resident should have been assessed and the physician notified earlier.

Based on interview and record review, the facility failed to ensure a resident receiving dialysis was assessed and dialysis care was communicated and collaborated between the facility and the dialysis center for one (#5) of one sampled resident whose records were reviewed for dialysis services. The Resident Census and Conditions Report identified two residents who received dialysis. Findings: Resident (Res) #5 had diagnoses which included end stage renal disease. An annual assessment, dated 07/28/21, documented the resident was cognitively intact and received dialysis while a resident. Review of a dialysis center note, dated 09/29/21, revealed a registered dietician's recommendation to limit fluids to 1000 ml per day if possible. Review of the clinical record did not reveal documentation of pre and/or post dialysis assessments or that the physician had been notified of the dialysis center recommendation. On 10/26/21 at 2:00 p.m., LPN #2 was asked what assessments were completed on residents before and after dialysis. LPN #2 stated they would document their return but had not performed an assessment on residents when they returned from dialysis. At 2:02 p.m., the DON was asked what assessments were to be completed on residents returning from dialysis. The DON stated documentation should include time of return, vital signs, and a general assessment of the resident. The DON was asked where this information would be documented. The DON stated in the progress notes. The DON was asked who was responsible to notify the physician of recommendations made by the dialysis center. The DON stated the charge nurse would be responsible. The DON was asked if the physician had been notified of the recommendation made by the dialysis center on 09/29/21. The DON stated there was no documentation to support the physician had been notified.

Based on interview and record review, the facility failed to ensure a registered nurse was designated to serve as the director of nursing on a full-time basis. The Resident Census and Conditions Report identified 38 residents resided in the facility. Findings: On 10/19/21, during entrance conference, the administrator identified the DON as an LPN. The administrator stated the RN/DON had unexpectedly resigned about a month ago. At 1:28 p.m., the administrator informed the surveyor the facility had no waiver regarding the requirement to have a registered nurse designated as the DON. On 10/27/21 at 11:25 a.m., the administrator was asked why an RN was not hired as the DON. The administrator stated they did not have an RN on staff that wanted the position but they were actively looking for an RN.

Based on interview and record review, the facility failed to act upon a physician approved pharmacy recommendation for a laboratory test, for one (#21) of five sampled residents who were reviewed for unnecessary medications. The Resident Census and Conditions Report identified 28 residents who received psychotropic medications. Findings: Resident (Res) #21 had diagnoses which included bipolar manic severe with psychotic features and delusional disorder. An admission assessment, dated 06/02/2021, documented Res #21 had severe cognitive impairment, and had verbal behaviors which interfered with care. An MRR, dated 06/11/21, documented the pharmacist recommended a laboratory test to determine the therapeutic level of Depakote, due to Res #21's behaviors. The physician agreed to the pharmacist's recommendation to obtain the Depakote level. A physician order, dated 06/30/21, documented to administer Depakote 500 mg delayed release tablet two times a day for manic depression. A review of the clinical record did not reveal a result of the Depakote level. On 10/25/21 at 9:59 a.m., LPN #1 stated the Depakote level was not drawn as ordered.

Based on interview and record review, the facility failed to ensure laboratory tests were obtained as ordered for three (#5, 8, and #21) of three sampled residents whose records were reviewed for laboratory services. The DON identified all 38 residents received laboratory services. Findings: 1. Resident (Res) #5 had diagnoses which included end stage renal disease, type two diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction, and hypertension. Monthly physician orders, dated October 2021, read in parts, .Laboratory .TSH yearly in July .order date 07/22/20 . On 10/26/21, Res #5's TSH test results were requested from staff. At 12:42 p.m., LPN #1 stated the ordered TSH on Res #5 was not completed. LPN #1 was asked why the ordered laboratory test was not completed. LPN #1 stated they did not know. LPN #1 was asked who was responsible to ensure ordered laboratory tests were completed. LPN #1 stated the nurse who received the order was responsible. 2. Res #8 had diagnosis which included benign prostatic hyperplasia without lower urinary tract symptoms. (Age-associated prostate gland enlargement that can cause urination difficulty.) A physician's order, dated 04/08/20, documented, PSA [Prostate-specific antigen, a blood test to detect high levels of PSA that may indicate the presence of prostate cancer. Enlarged or inflamed prostate can also cause an increase in PSA levels.] yearly in August. The clinical record did not contain PSA test results for August 2020. A care plan, updated 08/02/21, read in parts, .(name withheld) is incontinent of bladder r/t BPH .Monitor need for/schedule appropriate diagnostic procedures as ordered . A quarterly assessment, dated 08/04/21, documented the resident had severe cognitive impairment, incontinent of bowel and bladder, and required extensive assistance with toileting. On 10/25/21 at 12:40 p.m., LPN #1 stated she could not find the PSA results which should have been drawn in August 2020. 3. Res #21 had diagnoses which included bipolar manic with psychotic features, Alzheimer's disease, osteoporosis, hypothyroidism, and atrial fibrillation. A physician's order, dated 09/28/21, documented to obtain a PT/INR, hemoglobin A1C, vitamin D, and prealbumin laboratory tests. On 10/25/21 at 9:30 a.m., LPN #1 stated the hemoglobin A1C, PT/INR, prealbumin and vitamin D laboratory tests were not obtained as ordered.

Based on observation, interview, and record review, the facility failed to follow their COVID-19 policy regarding the use of PPE during an outbreak of COVID-19 and failed to screen visitors for COVID-19 upon entrance to the facility. The Resident Census and Conditions Report identified 38 residents resided in the facility. Findings: The COVID-19 policy, dated 09/14/21, read in part, .All staff, no matter their vaccinations status, will wear a mask and eye wear throughout the facility during the outbreak time . An untitled policy, dated 09/14/21, read in part, .Visitors will be screened . An undated Visitor Screening Tool, read in parts, .Do not write below this line: Official use only .Pre-Visit Temp .Post-Visit Temp .Staff Signature .Date . On 10/19/21 at 8:30 a.m., the first day of survey, four surveyors were allowed to enter the facility without being screened for COVID-19. Two surveyors were later approached by staff and asked to return to the employee entrance to be screened. On 10/19/21 at approximately 11:00 a.m., the IP nurse brought the surveyors face shields and N-95 masks. The IP nurse stated they had a staff member who had tested positive for COVID-19, therefore they were starting their outbreak testing and staff were required to wear face shields and N-95 masks. On 10/20/21 at 5:40 a.m., LPN #3 was observed exiting a resident room. The LPN was not wearing goggles or a face shield. CNA #3 was observed exiting a resident room. The CNA was not wearing goggles or a face shield. CNA #3 stated they had been helping a resident go to the bathroom. CNA #3 was asked if they had worn a face shield or goggles. CNA #3 stated no, they were up there and pointed to the nurses station. At 5:43 a.m., LPN #3 entered a resident room wearing glasses and a mask. LPN #3 was not wearing a face shield or goggles. At 5:47 a.m., LPN #3 stated the facility was in outbreak status, and they should have worn their face shield while providing care in a resident's room. On 10/27/21 at 8:45 a.m., the IP nurse was asked what the process was for visitors to enter the facility. The IP nurse stated visitors were screened prior to entry. The IP nurse was asked where visitors entered the facility. The IP nurse stated they entered through one door. The IP nurse was asked who was responsible for screening visitors prior to entry. The IP nurse stated social services or nursing, when they were available. The IP nurse was asked who was responsible for screening staff upon entry. The IP nurse stated staff screened themselves. The IP nurse was asked who was responsible to ensure screening was conducted upon entry. The IP nurse stated they monitored screening by reviewing the sign in sheet and schedule to ensure everyone had signed in and had been screened. The IP nurse was asked why the staff signature line on the visitor screening tool and the screener field on the sign in sheet were rarely completed. The IP nurse stated they did not have the staff to have someone at the door at all times.

Based on observation, record review, and interview, the facility failed to monitor the dish washing machine to ensure proper sanitation was being conducted. The DON identified 37 residents who received food service from the kitchen. Findings: On 10/19/21 at 9:00 a.m., during the initial tour, dietary aide #1 was asked how it was determined the dish machine was working properly. Dietary aide #1 stated she did not know but was aware the cook was to test the dish machine with testing strips. The cook was not available during the initial tour. The monthly Temperature/Sanitizer Log, dated 10/2021, did not contain documentation the dish machine had been tested for the morning meals on 10/15/21 or 10/16/21; and any meals from the morning of 10/17/21 thru the morning of 10/19/21. At 10:15 a.m., cook #1 was asked to demonstrate how the dish machine was tested to ensure it was in working order. [NAME] #1 stated the chemicals in the dish machine were not tested at the breakfast meal and should have. Cook #1 stated the dish machine had two cycles and required two types of test strips. The water was to get to 130 degrees during the cycle. Cook #1 initiated the dish machine to begin a cycle. Chemical tests strips from two containers were obtained. One was labeled chlorine test strips, and the second labeled for QAC-QR test strips. During the cycle, cook #1 moistened each test strip in the outer basin of the dish machine. [NAME] #1 stated the chlorine test strip read 25 and the QAC-QR strip did not change colors/react. Cook #1 was asked if the dish machine was working properly. [NAME] #1 stated, I think so. Cook #1 was asked what level/color the chlorine test strip should have been, and if the second strip did not change colors, were the dishes sanitized. He stated, I really don't know. On 10/26/21 at 9:00 a.m., dietary aide #1 stated the test strips were outdated and had to be replaced.