Vaiden Community Living Center

Based on record review, interview, and facility policy review the facility failed to provide written notice of an involuntary discharge including appeal rights prior to refusing readmission from the hospital for one (1) of three (3) resident reviewed. (Resident #1). Findings Included:Record review of the facility policy titled, Transfer Form, revealed Policy Statement, It is the policy of this facility to provide a completed and accurate transfer form to residents transferred or discharged from this facility .Record review of the facility policy titled, Appealing a Transfer or Discharge Notice revealed Policy Statement, Residenta have the right to appeal transfer or discharge notices.2. Upon notice of transfer or discharge, the resident will be provided with a statement of his or her right to appeal the transfer or discharge.Record review of Progress Notes dated 12/31/25, revealed Resident #1 left the facility at 2:30 PM by facility van to be admitted to [Proper name for psychiatric hospital] for evaluation.Record review of Progress Notes for Resident #1, dated 1/6/26, revealed resident had been discharged from the facility due to aggressive behavior. Further review revealed per conversation with [Proper name for psychiatric hospital], the Administrator and Social Services Director would assist in finding placement for the resident as well as home health if needed. Documentation further indicated that due to threats made, the facility stated it was unable to meet the resident's needs.Record review of Progress Notes for Resident #1, dated 1/6/26, revealed the facility communicated with the resident's family regarding not allowing the resident to return to the facility.Record review of Progress Notes for Resident #1, dated 1/6/26, and interview with the Administrator on 03/24/26 at 10:00 AM, revealed she spoke with the Geri-psych facility on 01/06/26, and they agreed to assist with finding the resident alternative placement. The Administrator revealed she spoke with the resident's family and informed them the resident would not be able to return to the facility. The Administrator verified that the resident and family were not provided a formal involuntary discharge notice and were not provided rights to appeal. The Administrator further verified she could not locate a physician order for discharge. The Administrator stated the formal notice and right to appeal should have been provided and the facility should have obtained a physician order prior to discharge.Record review of the admission Record revealed that the facility admitted Resident #1 on 12/14/21 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure the safety of one (1) of four (4) residents reviewed for safe transport (Resident #1), when staff failed to secure the resident's wheelchair with the appropriate safety belts while being transported in the facility van. This failure resulted in the resident sustaining a sternal fracture and a head laceration with bleeding after her unsecured wheelchair tipped over during transport, causing her to fall to the floor of the van. Resident #1
Due to corrective actions implemented prior to State Agency (SA) entrance on 6/18/25, this was determined to be Past Non-Compliance as of 4/30/25.
Findings Include:
Review of the facility policy titled How to Properly Secure a Wheelchair for Transportation signed and dated by Certified Nurse Assistant (CNA) #1 on 01/03/2025 read . Wheelchair securement systems allow the wheelchair user to drive or ride in a vehicle as safely as anyone else. Securement systems lock the wheelchair in place either with tie-down straps or a mechanical docking device. Securement systems are primarily used in wheelchair accessible vans to safely secure the user in his power chair or wheelchair while the vehicle is in motion. The policy contains a picture diagram of the lap and cross body safety belts and the floor anchorages and pictured the proper way to fasten the residents in the van.´ The policy included diagrammed instructions for securing residents in the van.
Review of the facility policy titled Fleet Safety Policy signed by CNA #1 and dated 01/03/2025 revealed, The purpose of this policy is to ensure the safety of those individuals who drive company vehicles. Vehicle accidents are costly to our company, but more importantly they may result in injury to you or others. It is the driver's responsibility to operate the vehicle in a safe manner and to drive defensively to prevent injuries and property damage .
An interview on 6/18/25 at 10:15 AM, the Administrator (ADM) confirmed Resident #1 was being transported to a medical appointment on 4/28/25 when the wheelchair flipped in the van, throwing the resident to the floor. The van driver pulled to the side of the road and called 911. The van driver (CNA #1) did not notify the facility. The facility was alerted by the emergency room (ER) when Resident #1 arrived with injuries. Resident #1 sustained multiple head lacerations requiring staples and a nondisplaced sternal fracture, per the ER report dated 4/28/25. The facility ADM and the Director of Nursing (DON) attempted to call the van driver on her cell phone on numerous occasions in the afternoon of 4/28/25 and received no contact with the van/bus driver. At approximately 4:00 PM on 4/28/25 the van/bus driver returned to the facility in the van/bus. CNA #1 then gave a written statement to the ADM and DON and confirmed that she had not properly fastened the wheelchair to the van/bus safety belts and had not positioned the wheelchair properly inside the van/bus. CNA #1 was terminated from employment for not following the facility policy for van/bus safety that caused the fall with injuries to Resident #1.
Record review of the typed statement of the facility Administrator (ADM) dated 4/28/25 revealed: Administrator (name of ADM) interviewed employee (name of CNA #1) van driver regarding incident that occurred in the van. (CNA #1) stated I buckled her at the bottom, but I didn't put the seatbelt on.
An attempted phone interview on 6/18/25 at 12:30 PM with CNA #1 resulted in no answer and no voice mail.
Record review of the handwritten statement of CNA #1 dated 4/28/25 revealed: I (name of CNA #1) was transporting a pt. (patient) to an appt. (appointment) at 1:15 PM on hwy (Highway)82. I heard her yell I pulled over once I found a safe place. Pt. wheelchair had flipped over. I called 911, put a diaper under her head to stop the bleeding. Police and EMT's (Emergency Medical Technicians) arrived I waited I followed them to the hospital. Signed by (name of CNA #1).
Record review of the ER report dated 4/28/25 at 2:12 PM documented a 3 (three) cm (centimeter) occipital scalp laceration (closed with four staples), a second 2 (two) cm laceration (closed with two staples), and a confirmed sternal fracture. Resident #1 was hospitalized for additional medical conditions and passed away on 5/03/25 due to acute renal failure, per the death certificate.
Record review of the death certificate of Resident #1 dated 5/3/25 and signed by the corner on 5/6/25 listed cause of death in the hospital as Renal Failure.
An interview and observation on 6/18/25 at 11:00 AM with CNA #2 loading Resident's #2, #3 and #4 into the van for transportation to dialysis confirmed that CNA #2 properly affixed lap and floor belts on three dialysis residents and demonstrated knowledge of policy-compliant securement procedures. Interviews with Residents #2, #3, and #4 confirmed consistent and safe practices during van transportation.
An interview on 6/18/25 at 11:30 AM with the Maintenance Director stated that he inspected the van after the incident and found that the floor stabilizers had not been affixed and the lap belt had not been used. He confirmed that CNA #1 had been previously trained and provided his weekly safety check documentation.
Record review of the Quality Assurance Committee (QA) meeting's sign-in sheet dated 4/29/25 revealed that all members were present at the QA meeting on 4/29/25 to review the incident that occurred on 4/28/25.
Record review of the admission Record of Resident #1 revealed that the facility admitted the resident on 3/18/25 with medical diagnoses that included Heart Failure, Chronic Obstructive Pulmonary Disease (COPD) and Chronic Kidney Disease.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/15/25 revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident was cognitively intact.
The State Agency (SA) validated through interview and record review on 6/18/25 that the facility began with immediate action of van safety in-service for all authorized drivers, van and seat belt safety inspection, conducted a full investigation and terminated CNA #1. Monitoring to be performed by the ADM and DON to ensure Wheelchair Securement System in proper working order 2 times a week for 2 weeks, then 1 time per week for 2 weeks, then monthly for 3 months. This deficiency was cited as Past Noncompliance at actual harm level, corrected prior to the survey entrance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and facility policy review, the facility failed to provide personal hygiene, as evidenced by long facial hair, unkempt hair, and long nails with a brown substance under them for one (1) of 20 residents sampled. Resident #6
Findings include:
Review of the facility policy titled A.M. Care (Day Tour of Duty) dated August 25, 2014, revealed under Purpose: 1. To refresh the resident. 2. To provide cleanliness, comfort, and neatness .
An observation on 10/15/24 at 11:55 AM and again at 3:30 PM revealed Resident #6 lying in bed. Her hair appeared oily and disheveled, and a thick white, flaky substance was noted on her scalp. Resident #6 had facial hair approximately one (1) inch long to her chin and sporadic areas around her mouth. Her bilateral fingernails were approximately one (1) inch long with a brown substance noted under them.
An observation on 10/16/24 at 8:45 AM, revealed Resident #6 lying in bed, with no change in the observation of appearance from the previous day.
During an observation and interview on 10/16/24 at 10:05 AM, Certified Nurse Aide (CNA) #2 stated that Resident #6's hair looks wet and greasy, she has a lot of dandruff, her facial hair hasn't been shaved in quite some time, and her fingernails are long and dirty. CNA #2 revealed, It looks like it's been more than a week or so since she's been really cleaned up. CNA #2 revealed the CNA's are responsible for bathing her, which includes washing her hair, trimming her facial hair, and doing her nail care since she is not diabetic. CNA #2 stated, I was off work yesterday, but she still should have been cleaned up.
During an observation and interview on 10/16/24 at 10:35 AM, the Director of Nurses (DON) confirmed that Resident #6's hair was greasy, with thick white dandruff on her scalp. The DON stated that she's a little hairy when referencing the resident's facial hair and confirmed that her fingernails were long and not clean.
Record review of Resident #6's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Peripheral vascular disease, Lack of coordination, and Hemiplegia and Hemiparesis following cerebral infarction affecting the right dominant side.
Record review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated the resident is severely cognitively impaired.

Based on observation, staff interview, and facility policy review, the facility failed to ensure the proper storage of treatment medications and disinfectant wipes on the treatment cart as evidenced by an unlocked treatment cart in the residents' hallway for one (1) of three (3) survey days.
Findings include:
Record review of facility policy titled, Medications, Individual Medication Storage Cabinets, dated 8/25/14, revealed, Medication administration utilizing individual medication storage cabinets will meet the same criteria for timeliness, infection control, and medication safety as standard medication administration . 4. The medication storage cabinet will remain locked when not in use .
During an interview and observation of a treatment with Licensed Practical Nurse (LPN) #1 on 10/16/24 at 10:05 AM, the treatment cart was left in the hallway while the treatment was being done in the resident's room. Upon the exit of the resident's room, the cart was observed unlocked and unattended in the hallway. LPN #1 stated the lock on the cart had been broken for approximately a month so she was unable to secure the items in the cart. She verified that the cart was locked in the office when not being used, but confirmed when treatments were being done, the unlocked cart was in the hall and not within sight since the resident's door was closed during care. She stated this was a safety concern since a resident could gain access to the treatment items/medications/disinfectant wipes on the cart. An observation of the cart revealed drawers that contained topical medications, creams, treatment medication items such as collagen, xeroform dressings and other supplies as well as disinfectant wipes. She confirmed these treatment medications should be secured in a locked cart to ensure no one had access to these items.
An observation and interview with the Assistant Director of Nursing (ADON) on 10/16/24 at 10:30 AM, revealed the cart would lock but it was difficult to position the lock handle into the locked position and it had to be jiggled and twisted until it went into the place where the lock could be secured. She demonstrated the process that was necessary to lock the cart, which consisted of several seconds of twisting and adjusting the handle and finally getting it into the appropriate spot to lock. She confirmed that not all of the staff that used this cart were notified of how to securely lock this since it had been damaged and not easily locked.
During an interview on 10/16/24 at 10:30 AM, the Administrator confirmed the cart was left unlocked and unattended in the hallway during a treatment and medications used for residents' treatments were on the cart. She confirmed the facility failed to secure medications and disinfectant wipes in a locked room or locked cart to ensure no one had access to those supplies which could affect resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility policy review, and record review, the facility failed to implement an Activities of Daily Living (ADL) care plan for one (1) of the 22 care plans reviewed. Resident #6.
Findings include:
A review of the facility policy, titled Care Plan-Comprehensive, revealed, It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs.
Record review revealed a current care plan for Resident #6 with a focus on ADL self-care performance deficit. Intervention in place revealed that the resident prefers a bed bath and requires extensive to total assistance of one (1) staff member.
During observations on 10/15/24 at 11:55 AM and again at 3:30 PM revealed Resident #6 lying in bed with hair oily and disheveled, and a thick white, flaky substance was noted on her scalp. Resident #6 had facial hair approximately one (1) inch long to her chin and sporadic areas around her mouth. Her bilateral fingernails were approximately one (1) inch long with a brown substance noted under them.
On 10/16/24 at 10:05 AM, during an observation and interview Certified Nursing Assistant (CNA) #2 stated that the resident's Hair looks wet and greasy, she has a lot of dandruff, her facial hair hasn't been shaved in quite some time, and her fingernails are long and dirty. It looks like it's been more than a week or so since she's been really cleaned up. CNA #2 revealed the CNA's are responsible for bathing her, which included washing her hair, trimming her facial hair, and doing her nail care since she is not diabetic.
An interview on 10/16/24 at 10:45 AM, the Minimum Data Set (MDS) Coordinator revealed she is responsible for developing the care plans and revealed the purpose of the care plan is to guide and direct all staff to the individualized care needed for each resident. She confirmed according to Resident #6's care plan, she needs extensive to total assistance with her hygiene needs, and if she was not clean, her plan of care was not being followed. She confirmed that there was no documentation of refusal of care under the ADL care plan.
Record review of Resident #6's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Peripheral vascular disease, Lack of coordination, and Hemiplegia and Hemiparesis following cerebral infarction affecting the right dominant side.
Record review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated the resident is severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and facility policy review, the facility failed to create a clean and safe environment, as evidenced by a dirty wheelchair (Resident #27) and an overbed table and bed headboard in disrepair (Resident #34) for two (2) of the 20 residents sampled.
Findings Include:
A review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment with a revised date of August 2009 revealed that resident-care equipment, including reusable items and durable medical equipment, will be cleaned .
Resident #27
On 10/15/24 at 9:20 AM, an observation revealed Resident #27 was sitting on his bed and his overbed table and headboard were noted to be in disrepair. Resident #27 was not interviewable. His overbed table had the plastic strip edging missing from all four sides and had rough jagged edges exposed. Resident #27's headboard on his bed was unsteady and the upper part of the headboard leaned inward at an eighty-degree angle over his mattress and pillow and revealed that the bed frame and bed was unsteady.
On 10/16/24 at 10:39 AM, during an interview with Assistant Director of Nursing (ADON), she confirmed that the headboard on Resident #27's bed and his over bed table were in disrepair and needed attention. She confirmed the rough, jagged edges on his over bed table and revealed that this could cause lots of issues including wood splinters in the skin and skin tears. ADON also confirmed that Resident #27's headboard was unsteady, that it leaned inward over the mattress and needed to be fixed. She revealed that she was not aware of these issues, that no one had reported them to her, and that she would notify maintenance. She revealed that they had a maintenance logbook at the nurses desk and any issues they had, they documented in the book and also reported them verbally to the Maintenance Director. ADON confirmed that Resident #27's headboard nor the bedside table had been recorded in the maintenance logbook prior to her observation.
On 10/16/24 at 10:46 AM, an observation and interview with the Maintenance Director in Resident #27's room revealed that he had worked there since August 2024, and that the staff usually reported to him verbally and logged any concerns or needed repairs on a Maintenance Work Order form in the maintenance logbook which he checked every morning. He confirmed that Resident #27's headboard was unsteady and was leaning inward over the mattress and needed to be fixed or replaced. He revealed that no one had reported this concern to him, and that if he didn't know about it, he couldn't fix it.
Record review of the Maintenance Work Order form revealed that Resident #27's broken headboard was recorded in the maintenance logbook after the concern was identified on 10/16/24.
Record review of Resident #27's admission Record revealed an admission date of 12/20/22.
Record review of Resident #27's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/03/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 06 which indicated that he had severe cognitive deficits.
Resident #34
An observation on 10/15/24 at 10:40 AM and again at 3:00 PM revealed Resident #34 sitting in her wheelchair. A thick gray substance was noted on the frame of the wheelchair and on the spokes of the wheels.
An observation and interview on 10/16/24 at 9:25 AM, revealed Resident #34 sitting in her wheelchair, which remained dirty and unchanged from the previous day. Resident #34 revealed she wasn't sure when they cleaned the wheelchairs, but it was dirty and needed to be cleaned.
In an interview on 10/16/24 at 11:45 AM, Certified Nursing Assistant (CNA) #1 revealed that the night shift CNAs are responsible for cleaning the wheelchairs, but if any of us notice that they are dirty, we can also clean them off.
During an observation and interview on 10/16/24 at 11:55 AM, the Director of Nurses (DON) revealed that the CNAs on the night shift and/or Sundays are responsible for cleaning the wheelchairs. She revealed, I don't have a check-off list, but the staff are responsible for cleaning them on certain days. I guess I need a check-off list to ensure they are being cleaned. She confirmed that the wheelchair had a gray substance on the frame and wheels and needed to be cleaned.
During an observation and interview on 10/16/24 at 12:05 PM, the Administrator revealed that the wheelchairs are supposed to be cleaned on the night shift. They can take the equipment outside when it's warm or in the shower room when it's cold, but all equipment is to be cleaned. She confirmed Resident #34's wheelchair was not cleaned and stated, This wheelchair is not clean, and it needs to be cleaned.
A record review of Resident #34's admission Record revealed the resident was admitted to the facility on [DATE] .
Record review of the MDS with an ARD of 07/18/24, revealed Resident #34 had a BIMS score of 12, which indicated the resident is moderately cognitively impaired.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure food items in the kitchen refrigerator, freezer, and dry storage room were dated and labeled for one (1) of two (2) kitchen tours completed.
Findings Include:
Review of the facility policy titled, Food Storage dated August 18, 2011, revealed .8. All foods stored in refrigerators and freezers that have been opened, will be covered and labeled with the date and name of food if appropriate, and will be discarded within the appropriate time frame. 9. All leftover foods are to be stored in covered containers, dated, & labeled .
On 10/15/24 at 9:45 AM, an observation during the initial kitchen tour with the Dietary Manager (DM), revealed multiple unlabeled and undated food items in the refrigerator and freezer. The unlabeled and undated foods included one-half of a five pound bag of frozen chicken strips, one-fourth of a two pound bag of frozen French fries, and one-half of a five pound bag of chicken fried steak. There was also a large bag of frozen ground beef in the freezer that had been opened and was undated and unlabeled.
On 10/15/24 at 9:50 AM, an interview with DM revealed that she had worked there since September 2024, and the Dietary Department had been a mess. She revealed that it was everyone's responsibility to ensure opened food items were labeled and dated to make sure they didn't go over past the dates to be used. She revealed that the person who opened the food item was responsible for dating, labeling, and proper storage of the item. DM revealed that if they didn't date and label the food items when opened, they would not know how long it had been in the refrigerator or freezer and could become freezer burned or expired. DM revealed that they were supposed to use or dispose of leftover food items in the refrigerator three days after it was opened and that opened food items in the freezer were supposed to be used within six months.
On 10/15/24 at 9:55 AM, during the initial tour of the dry storage room revealed a bag of opened vanilla wafers that were unlabeled and undated. There were approximately 30 vanilla wafers left in the bag, and it was folded down and was not sealed. There was a twenty-five pound (lb.) bag of white corn meal with the sack torn near the top and it was open to air and setting on top of an empty dry storage container. There was also an undated and opened and unsealed 5 lb. bag of yellow cake mix with approximately one and one-half cups left in the bag.
On 10/15/24 at 9:58 AM, an interview with Dietary [NAME] revealed that the bag of corn meal was supposed to be closed and inside an air proof container. She also confirmed that the bag of corn meal, cake mix, and vanilla wafers were exposed, open to air, and were not dated or labeled. Dietary [NAME] revealed that they were supposed to make sure that any opened food items such as the cake mix, vanilla wafers, and corn meal were wrapped up in plastic and covered to help prevent contamination and prevent bugs and pests from getting inside the packages. Dietary [NAME] also confirmed that all opened food items were supposed to be dated and labeled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy the facility failed to follow a resident's physician prescribed fluid restriction for one (1) of three (3) residents on fluid restriction. Resident #9
Findings include:
Record review of the facility policy titled, Fluids, Encouraging, and Restricting, with a revised date of August 25, 2014, revealed, Purpose: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging and restricting fluids . General guidelines: 1. Follow specific instructions concerning fluid restrictions . 7. When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. If the resident refuses, notify the supervisor and in turn, the physician . Documentation .The following information should be recorded in the resident's medical record . 8. If the resident refuses treatment, the reason why and the intervention taken .
An observation and interview with Resident #9 on 6/13/23 at 11:00 AM, revealed she was on dialysis, and she was to be following fluid restrictions. The staff provided the number of fluids she needs each day. The State Agent (SA) observed a plastic measured water pitcher on the bedside table with 600 ml (milliliters) of water in the pitcher. Resident #9 revealed one of the Certified Nurse Assistant's (CNA's) came in earlier and filled it up with water and ice. Resident #9 confirmed staff are good about making sure she has fresh water.
An observation and interview with Licensed Practical Nurse (LPN) #1 on 6/13/23 at 3:15 PM, confirmed there was a pitcher with water in Resident #9's room and there should not be, because the resident was on a 1000 ml fluid restriction daily. LPN #1 stated that staff should never leave water or any fluids in Resident #9's room and should notify the nurse if the resident is drinking something she should not. LPN #1 confirmed staff were not following Resident #9's fluid restriction orders and that could lead to fluid overload and distress.
A record review of the Order Summary Report dated June 13, 2023 revealed a physician order with an order date of 12/08/22 for Resident #9 Fluid Restriction: 1000 ml/24 hr (hours).Nursing to provide 280 ml/day: 7a-7p 140 ml, 7p-7a 140 ml. Dietary to provide 720 ml/day, B-(Breakfast) 240 ml, L- (lunch) 240 ml, D-(Dinner) 240 ml .
An interview with the Director of Nursing (DON) on 6/13/23 at 3:20 PM, revealed that Resident #9 had a physician's order for 1000 ml fluid restriction daily and confirmed Resident #9 should not have a water pitcher in her room. The DON stated that a resident on dialysis receiving more than the prescribed fluids ordered is fluid overload and confirmed staff are not following physician prescribed fluid restriction orders.
An interview with CNA #1 on 6/13/23 at 3:30 PM, she revealed that she provides care for Resident #9 often and she fills the water pitcher for Resident #9 twice a shift. CNA #1 confirmed she was unaware Resident #9 was on a fluid restriction and that she was not supposed to provide her with water.
An interview with CNA #2 on 6/14/23 at 9:39 AM revealed she provides care for Resident #9 at least two days a week and is aware that the resident is on fluid restriction. She stated that she does not give the resident any fluids other than those that come with her meals. She stated she fills up Resident #9's water pitcher twice per shift and that she never asks for any extra fluids. If she did, she would remind her of her fluid restriction and inform the nurse.
Record review of the admission Record for Resident #9 revealed the resident was admitted to the facility on [DATE] with diagnoses of Chronic kidney disease and Right sided heart failure, unspecified.
Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 4/14/23, revealed that Resident # 9 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated that she was cognitively intact. Review of Section O revealed that the resident was receiving dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and facility policy review the facility failed to clean a visibly soiled overbed light and window blind and replace a broken window blind for two (2) of 58 residents reviewed. Resident #1 and Resident 21.
Findings include:
Record review of the facility policy titled, Maintenance Service with a revision date of June 2000 revealed, Policy Statement: It is the policy of this facility that maintenance service be provided to all areas of the building, grounds, and equipment . Procedure .2. The following functions are performed by maintenance, but are not limited to . k. Others that may become necessary as appropriate. Ex.(example) Replace broken blinds.
Record review of the facility policy titled, Cleaning and Disinfection of Environmental Surfaces with a revision date of August 2009 revealed .Policy Interpretation and Implementation .9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled . 11. Walls, blinds, and window curtains in resident areas will be cleaned when the surfaces are visibly contaminated or soiled .
Resident #1
An interview and observation on 06/13/23 at 2:20 PM, with Resident #1 in her room revealed that her window blinds were not working properly. She stated that the blinds will not close unless she takes her hand and closes each blind slate individually. She stated that she told Maintenance about it a while back and the Administrator a week or so ago, but it's still not fixed.
An interview and observation on 6/14/23 at 8:05 AM with Resident #1 in her room revealed that the lower part of her window blinds was closed, and the upper part was open. This observation revealed there was no wand or string attached to the blinds to close or open them. Resident #1 stated that the blinds had been that way since she moved in this room in March of 2023 and that she closes them by hand.
An interview on 6/14/23 at 8:10 AM, with Registered Nurse (RN) #1 revealed that if staff notices something that is broken then they let maintenance know and put it in his logbook that is kept at the nurse's station. She revealed the staff usually text or call him. She stated that if she notices something that needs to be cleaned then she will let housekeeping know or just clean it herself. She revealed the rooms get deep cleaned per housekeeping schedule and when they do that everything is taken out of the room and the walls are cleaned in addition to everything else.
An interview and observation on 6/14/23 at 8:40 AM, with the Administrator confirmed that resident rooms do get deep cleaned as the Housekeeping Supervisor had revealed. She confirmed that Resident #1 had told her about her blinds being messed up about a week and a half ago and she notified maintenance but has not followed up on the issue. She revealed she did not put it in the maintenance logbook but should have so that would have been followed up on and fixed.
Record review of the maintenance logbook at the nurse's station revealed there was no request for the broken blinds in Resident #1's room.
Record review of Resident #1's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Fracture of Shaft of Humerus, Left Arm, Initial Encounter for Closed Fracture.
Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.
Resident #21
On 06/13/23 at 2:45 PM, an observation and interview with Resident #21 in his room revealed numerous raised spots of a brown substance along with a white substance that was the size of a tennis ball stuck to the light cover that was directly over his bed.
An interview and observation on 6/14/23 at 8:20 AM, with the Housekeeping Supervisor revealed that a different room each day gets deep cleaned. She revealed that when a room gets deep cleaned then the residents are moved out, the floors get stripped and waxed and the walls and everything gets wiped down and dusted. An observation of Resident #21's room with the Housekeeping Supervisor confirmed that there was a brown substance splattered all over half of the residents overbed light and on half of his window blinds. She revealed that this resident's room had been deep cleaned a couple of weeks ago. She stated that they had tried to get the brown substance off the blinds, but they could not, so maintenance had ordered more blinds.
An interview on 6/14/23 at 9:00 AM, with the Maintenance Director and the Administrator revealed that no one had mentioned the substance on the light cover in Resident #21's room to the Maintenance Director. The Administrator stated that she thinks the staff get tunnel vision and don't look up so that is why they never noticed Resident #21's light.
Record review of Resident #21's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Obstructive and Reflux Uropathy, Unspecified.
Record review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 11, which indicated that the resident had moderate cognitive impairment.

Based on observation, resident and staff interview, record review, and facility policy review the facility failed to implement a fluid restriction care plan for one (1) of 17 care plans reviewed. Resident #9
Findings include:
A review of the facility policy titled, Care plans, Comprehensive Person Centered, revealed, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial needs is developed and implemented for each resident .Policy Interpretation and Implementation .7. The comprehensive, person-centered care plan .: b.) describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .
An observation and interview with Resident #9 on 6/13/23 at 11:00 AM, revealed she was on dialysis, and is doing well, and is on fluid restrictions. The State Agent (SA) also observed a plastic measured water pitcher on the bedside table with 600 ml (milliliters) of water in the pitcher.
A review of the care plan revealed Focus: I need dialysis (hemo) hemodialysis related to (r/t) renal failure. I receive hemodialysis Monday, Wednesday, Friday (Mon, Wed, Fri) at (Proper name) of kidney care clinic in (proper name), revision on 3/31/21 .Interventions/Tasks: 1000 ml fluid restriction as ordered. FLUID RESTRICTION: 1000 ml (milliliters)/24 HR (hour). Nursing to provide 280 ML/day: 7a-7p (AM-PM) 140 ML, 7p-7a (PM-AM) 140 ML. Dietary to provide 720 ml/day: B-(Breakfast)240 ml, L-(Lunch) 240 ml, D- (Dinner) 240 ml .
A record review of the medical record for Resident #9 and interview with the Director of Nursing (DON) on 6/13/23 at 3:20 PM, revealed Resident #9 was on a 1000 ml fluid restriction. She revealed the fluid restriction was care planned and on the Care Guide for the Certified Nurse's Assistant's (CNA's) but confirmed the care guide does not reflect the fact that the CNAs are not to give resident any fluids. She also confirmed staff are not following the fluid restriction care plan.
Record review of the Care Guide for the CNAs revealed, FLUID RESTRICTION: 1000 ML/24 HR. Nursing to provide 280 ML/day: 7a-7p 140 ML, 7p-7a 140 ML. Dietary to provide 720 ml/day: B-240 ml, L-240ml, D-240 ml.
An interview with the Minimum Data Set (MDS) Nurse on 6/14/23 at 10:04 AM, revealed the purpose of the comprehensive care plan was to map out the individualized care needed by each resident and confirmed that staff were not following Resident #9's fluid restriction plan of care.
Record review of the admission Record revealed that the facility admitted Resident #9 to the facility on 9/09/19 with diagnoses of Chronic Kidney Disease and Right sided heart failure, unspecified.
Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 4/14/23, revealed that Resident # 9 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated that she was cognitively intact.

Based on observation, staff interview, record review, and facility policy review the facility failed to maintain strict aseptic technique to prevent the spread of infection during an observation of medication administration via percutaneous endoscopic gastrostomy (PEG) tube for one (1) of four (4) medication administration observations. Resident #20
Findings Include:
A review of the facility's policy titled, Cleaning/Disinfection of Resident Care Items and Equipment, dated June 15, 2010, revealed, Policy Statement: Resident care equipment, including reusable items .will be cleaned and disinfected according to the CDC (Centers for Disease Control) for disinfection and OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard .Reusable Items . 1. Single resident use items are to be cleaned/disinfected between uses by a single resident and disposed of afterward .Single use items will be discarded after a single use .
A review of the facility's policy titled, Enteral Tube Medication Administration, dated May 10, 2013, revealed .Procedures .U. Clean feeding syringe and store .
A review of the facility's policy titled, Enteral Feedings-Safety Precautions. dated May 10, 2013, revealed, Purpose: To ensure the safe administration of enteral nutrition Preventing contamination: 1. Maintain strict aseptic technique at all times when working with enteral nutrition systems and formulas .
A review of the manufacturer guidelines for the Enteral Feeding Tube clog remover revealed Once the clog is clear dispose of the wand .Single use only .
An observation of medication administration via PEG tube for Resident #20 with Licensed Practical Nurse (LPN) #2 on 6/14/23 at 7:50 AM revealed, LPN #2 placed the continuous feeding pump on hold, disconnected the tubing from Resident #20's PEG tube and placed it on the resident's bed. After placement check, LPN #2 revealed she could not get the diluted medication to go in the PEG tube confirming it must be clogged. LPN #2 removed the PEG tube adapter and syringe and placed it on the over bed table with no barrier. She then removed an Enteral feeding Tube Clog Remover wand from Resident #20's bedside table drawer that was not bagged and lying open on top of the resident's personal items and inserted the clog remover wand into the PEG tube. She then removed the wand and placed it on the bedside table with no barrier. LPN #2 then picked up the PEG tube adapter that was lying on the bedside table with no barrier and inserted it in the resident's PEG tube. The State Agent (SA) observed LPN #2 repeat this process three times, each time placing the items on the bedside table with no barrier. LPN #2 stated, I cannot get the PEG tube unclogged. I am calling the charge nurse. While waiting for the charge nurse the SA observed the formula tubing that was placed on Resident #20's bed by LPN #2 earlier hanging off the side of the bed and touching the floor. When Registered Nurse (RN) #1 entered Resident #20's room, LPN #2 handed RN #1 the peg tube syringe and clog remover wand from the bedside table with no barrier and RN #1 inserted them into Resident #20's PEG tube to unclog the tube. LPN #2 then picked up the PEG tube adapter from the bedside table and reinserted it into Resident #20's PEG tube and administered all the medications. After completion of administering the medications, LPN #2 flushed the tube placed the PEG syringe in the storage bag on the bedside table without rinsing and drying the syringe, picked up the formula feeding tube that was hanging off the bed and touching the floor and connected it to Resident #20. LPN #2 then rinsed the clog remover wand and placed it back in Resident #20's bedside table drawer with no storage bag.
An interview with LPN #2 on 6/14/23 at 8:15 AM, confirmed she placed the PEG tube syringe, adapter, and tube clog remover on the bedside table with no barrier and confirmed she should have put the supplies on a clean barrier. LPN #2 then revealed both the PEG tube syringe and clog remover should have been rinsed, dried .and stored in a clean storage bag but confirmed that she did not do that. LPN #2 went on to confirm she had placed the formula feeding tube on Resident #20's bed and saw it hanging off but did not realize it was on the floor. She then confirmed the formula tubing should have been placed in a clean area and not on the bed. LPN #2 stated the tubing would be considered dirty after touching the floor and should not have been reconnected to Resident #20's PEG tube. When the SA asked LPN #2 of possible concerns with using equipment considered dirty, LPN #2 replied possible transfer of bacteria, causing a bacterial or gastrointestinal infection could have occurred.
An interview with the Director of Nurses (DON) on 6/14/23 at 8:30 AM, reviewed the findings of the infection control concerns that were observed during medication administration for Resident #20. The DON confirmed the PEG syringe, clog remover, and the formula tubing was considered dirty after not being placed on a clean barrier by LPN #2.
An interview with the RN #1 on 6/14/23 at 1:00 PM, she revealed she believed the equipment that LPN #2 handed her to unclog Resident #20's PEG tube to be clean, and confirmed that the PEG syringe would have been considered dirty if it was placed on the bedside table with no barrier and also confirmed the clog remover wand is single use item only and should have been disposed of.
An interview with the Infection Control nurse on 6/14/23 at 1:20 PM, she revealed any item placed on a dirty surface must be cleaned after use. If items are not cleaned or discarded, then the resident is at risk for transfer of numerous types of infections.
A record review of LPN# 2's Continuing Education Earned form revealed, Infection Prevention in Long-Term Care Setting with a completion date of 5/17/23 and Basics of Enteral Nutrition with a completion date of 5/18/23.
Record review of the admission Record revealed the facility admitted Resident #20 to the facility on 8/15/19.Diagnosis Information included diagnoses that included Encounter for attention to gastrostomy and Dysphagia.
Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on 4/12/23, revealed Resident #20 had a Brief Interview of Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. Section K indicated Resident #20 had a feeding tube while a resident.

Based on interview and record review the facility failed to notify the resident representative in writing of a transfer to the hospital for one (1) of 22 residents reviewed for transfer. Resident #46.
Findings include:
Record review of a Health Status Note dated 10/22/21 revealed Resident #46 was transferred to the local hospital by emergency services and review of a Health Status Note dated 1/28/22 revealed she was transferred to the local emergency room.
An interview, on 02/08/22 at 5:20 PM, with the Social Service Director revealed that she was not aware of transfer forms needing to be sent to the families. She stated that she sends the bed holds and she calls the responsible parties.
An interview, on 02/10/22 at 5:25 PM, with the Administrator revealed that she stated that she dropped the ball. She stated that she accepts responsibility because she should have told her new social worker about the forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to prevent the likelihood of the spread of infection as evidenced by failure to perform hand hygiene while passing meal trays and ice, inappropriate handling of medication during medication pass and failure to screen a vaccinated contract worker for COVID-19 signs and symptoms for two (2) of three (3) days of survey.
Findings include:
Record review of the facility policy, Handwashing dated June 1,2000 revealed, It is the policy of this facility that hand washing be regarded as the single most important means of preventing the spread of infections. Procedure: .2. Appropriate ten (10) to fifteen (15) second hand washing must be performed under the following conditions: f. Before touching, preparing, or serving food .
Hydration Pass
An observation, on 02/07/22 at 11:29 AM revealed Certified Nurse Assistant (CNA) #1 scooped ice from a cooler in the hall, put it into a cup, dispensed some water into the cup and took it to the resident in room [ROOM NUMBER]B without performing hand hygiene. Observed CNA #1 leave room [ROOM NUMBER]B without performing hand hygiene and scoop ice from the cooler, dispense water into a cup and take it to the resident in room [ROOM NUMBER]B. Observed CNA #1 leave room [ROOM NUMBER]B without performing hand hygiene, scoop ice into a cup, dispense water into that cup and take it to the resident in room [ROOM NUMBER]B without performing hand hygiene.
An interview, on 2/7/22 at 11:35 AM with CNA #1 confirmed that she did not perform hand hygiene between the residents while passing ice water. CNA #1 stated, I guess I just got nervous. CNA #1 confirmed that she should have performed hand hygiene between the residents to prevent the spread of germs. CNA #1 revealed that she had been in-serviced on hand hygiene.
An interview, on 2/9/22 at 9:38 AM with the Director of Nurses (DON) confirmed that hand hygiene needs to be performed in between residents when passing out ice and water.
Record review of the facility in-service dated 11/18/21 and titled, Handwashing/Sanitizing Between Trays revealed it was attended by CNA #1.
Record review of CNA #1's CNA (Certified Nursing Assistant) Skills Competency Check Off List revealed that CNA #1 completed a satisfactory completion of handwashing skill on 11/20/21.
Meal Tray Pass
An observation on 2/7/2022 at 12:10 PM, revealed Nursing Assistant (NA) #3 was observed delivering lunch trays to the residents. NA #3 delivered trays to residents in room [ROOM NUMBER], 108, then delivered and set up trays to rooms [ROOM NUMBERS]. NA #3 delivered the tray to room [ROOM NUMBER], then delivered and set up trays to both residents in room [ROOM NUMBER]. Between each of these tray deliveries and set ups, NA #3 did not use hand hygiene.
An interview on 2/7/22 at 2:30 PM, with Nursing Assistant #3, revealed she did not perform hand hygiene between the residents while passing lunch trays on the 100 hall. She stated she should sanitized her hands between tray deliveries to residents to prevent the spread of germs. She revealed she had been in-serviced on hand hygiene and infection control.
Record review of the in-service log revealed NA #3 attended an Infection Control in-service titled Covid-19 Protocols, Infection Control on 11/15/2021.
An interview with the Administrator on 2/9/22 at 11:00 AM, confirmed the facility failed to provide sufficient infection control measures by the trays being passed without proper hand hygiene. She confirmed this could spread infection from one resident to another resident.
Medication Administration
Record review of facility policy titled, Medications, Oral, dated August 25, 2014, revealed, The purpose of this procedure is to provide guidelines for the safe administration of oral medications. The policy also revealed, For tablets or capsules from a bottle, pour the desired number into the bottle cap and transfer to the medication cup. Do not touch the medication with your hands. Return extra capsules/tablets to the bottle.
An observation on 2/8/22 at 8:40 AM, of medication administration by Licensed Practical Nurse (LPN) #1 revealed a concern with infection control. LPN #1 was preparing the oral medications for administration to Resident #13. Resident #13 received 12 different oral pill medications, six of these were in prepackaged, individualized medication cards from the pharmacy. The remaining six were from the individual bottles of stock medications on the medication cart. LPN #1 placed the individual medications from the pharmacy cards into the cup by pushing the medications directly from the card into the medication cup. Then, for each of the other six medications, LPN #1 opened the bottle and poured some of the pills into her ungloved hand, picked one up with her other ungloved hand, placed this one into resident's medication cup, then placed the remaining pills in her hand back into the medication bottle. This process was repeated for the six medications in the stock bottles.
An interview with LPN #1 on 2/8/22 at 4:15 PM, revealed that by pouring the medications in her ungloved hand, placing medication from her ungloved hand into the resident's medication cup, and returning the remaining pills back into the bottle, the medications could be contaminated and spread infection. She revealed she should have placed the medications in the lid and not touch the medications with her bare hands. She stated she had been in-serviced on infection control and handwashing and she was not following infection control guidelines in administering medications.
An interview on 2/9/22 at 11:00 AM, with the Administrator, confirmed medications should not be poured into a bare hand and placed in the resident's medicine cup and remaining pills should not be returned to the medication bottle. She confirmed the facility failed to use proper infection control measures that are needed to ensure that the risk of the spread of infection is decreased. She confirmed this practice could contaminate the medications and spread infection.
Record review of the in-service log revealed LPN #1 attended an Infection Control in-service titled Covid-19 Protocols, Infection Control on 11/15/2021.
Visitor Screening
Review of the facility protocol titled COVID 19 GUIDELINES revealed under Guidelines for Visitation that Medically necessary individuals should be permitted after meeting the testing requirements and being screened (regardless of vaccination and Visitation status).
An observation, on 2/7/22 at 3:30 PM, revealed a contract X-ray Technician entered the front entrance of the facility and was not screened for signs and symptoms of COVID or a body temperature.
An interview, on 2/7/22 at 3:40 pm with the Administrator confirmed that the contract X-ray Technician had not been screened when he entered the building. The administrator revealed that it is the policy of the facility that everyone must be screened when they enter the building to prevent the spread of COVID.
An interview, on 2/7/22 at 4:40 PM with the contract X-ray Technician revealed that a facility staff member let him in the front entrance of the facility. The contract x-ray technician confirmed he did not have his temperature obtained or get screened for COVID signs and symptoms when he entered the facility. The contract x-ray technician revealed he had no signs or symptoms of COVID, and he is fully vaccinated. Review of the vaccination record revealed COVID vaccination dates confirmed as: Moderna 12/28/20 and Moderna 01/25/21.

Based on observation, resident and staff interviews, facility policy review and record review the facility failed to date the oxygen (O2) tubing, failed to provide storage bags for oxygen tubing and failed to place oxygen in use signage on the entrance door to a resident's room, for two (2) of four (4) residents reviewed for oxygen therapy. Resident #4 and #247
Findings include:
Review of the facility policy titled, OXYGEN ADMINISTRATION, dated August 25, 2014, revealed Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps in the Procedure: 2. Place an Oxygen in Use sign on the outside of the room entrance door . The facility policy did not include information regarding dating of the O2 tubing and the humidifier bottle or storage of oxygen tubing in a bag.
Resident #4
An observation and interview, on 02/07/22 at 11:29 AM, revealed Resident #4 did not have a date on her O2 tubing or a storage bag for the O2 tubing. There was no O2 in use signage on the outside of the entrance door. Resident #4 revealed that her O2 tubing had never been placed in a bag when she was not using it.
Record review of the Physician's Orders, revealed Resident #4 had a physician's order for O2 at 2 liters (L), by nasal cannual (BNC), as needed (PRN), dated 1/30/22.
Record review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/5/21 for Resident #4 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #4 is cognitively intact.
Resident #247
An observation and interview, on 02/07/22 at 11:29 AM, revealed Resident #247 did not have a date on her oxygen (O2) tubing, no storage bag for the O2 tubing, and no O2 in use signage on the outside of the entrance door. Resident #247 revealed that her O2 tubing had never been placed in a bag when she was not using it.
Record review of the Physician's Orders revealed Resident #247 had a physician's order for O2, continuously, at 2 liters (L) per minute, by nasal cannula (BNC) dated 2/9/22.
Record review of a Five (5) Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/3/22, for Resident #247, revealed a Brief Interview for Mental Status (BIMS) score of 08, indicating Resident #247 has moderately impaired cognition.
An interview on 2/8/22 at 3:34 PM, with Registered Nurse (RN)#1, revealed the process for set up of O2 in a resident's room included dating on the O2 tubing, on the humidifier bottle, and a storage bag had to be provided and dated for the O2 tubing and an O2 in use sign had to be place on the outside of the resident's entrance door. RN #1 confirmed there was no O2 signage outside Resident #4 and #247's entrance door. RN #1 revealed Resident #4 and Resident #247 were possibly at risk for a respiratory infection because the O2 tubing was not dated, which would have indicated the last time the O2 tubing was changed, and a storage bag was not provided for the O2 tubing when it was not being used by Resident #4 and #247.
An interview, on 2/8/22 at 3:47 PM, with the Director of Nursing (DON), revealed she was not aware Resident #4 and #247 did not have a date on their O2 tubing, a storage bag for O2 tubing, and that there was no O2 in use signage outside Resident #4 and #247's entrance door. The DON revealed Resident #4 and #247could have been placed at risk for a respiratory infection because they did not have a date on their O2 tubing and did not have a storage bag provided for the O2 tubing. The DON revealed the O2 in use signage should have been posted outside Resident #4 and #247's entrance door to alert all staff and visitors to be aware that there was O2 being used in the room and to use appropriate safety precautions.

Based on facility policy review, record review, and facility staff interviews, the facility failed to develop an oxygen care plan for a resident with a physician's order for oxygen therapy for one (1) of four (4) residents reviewed for oxygen therapy. Resident #4.
Findings include:
Review of the facility policy, undated, titled, Care Plan - Comprehensive Policy Statement, revealed It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs.
Record review of the Care Plan with a date initiated of 9/17/2018 revealed Focus I have shortness(SOB) on exertion, history of cough, congestion. Goal I will have no complications related to SOB through the review date 2/3/22. There were no interventions to address the use of oxygen therapy that had been ordered by the physician. Resident #4 did not have a care plan developed for Oxygen (O2) therapy.
Record review, of the Physician's Orders, with an order date of 1/30/22 revealed Resident #4 had a physician's order, Administer 2 liters (L) of O2 BNC ( by nasal cannula), as needed (PRN) .
An interview, on 2/9/22 at 10:40 AM, with the Minimum Data Set (MDS) Nurse, revealed she missed seeing the physician's order for O2 therapy and did not develop an oxygen therapy care plan for Resident #4. The MDS nurse confirmed there was not an O2 care plan in the medical record for Resident #4. The MDS Nurse revealed that there was a possibility that Resident #4 would not receive all of the care needed with her O2 therapy from the nursing staff, because an O2 care plan was not developed.
An interview, on 2/9/22 at 11:00 AM, with the Administrator, revealed she was not aware that Resident #4 did not have an O2 care plan. The Administrator revealed a care plan should have been developed from the physician's order for O2 therapy for Resident #4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review the facility failed to accurately complete a Preadmission Screening and Resident Review (PASRR) Level 2 change in status form for one (1) of three (3) residents reviewed for PASRR. Resident #44.
Findings include:
Record review of a typed statement and signed by the Administrator on 2/9/22 revealed, Currently (Proper Name of Facility) does not have a specific policy related to doing a Level 2.
An interview with the Social Worker on 2/9/22 at 10:30 AM, revealed that at the facility, she is responsible to complete the request for a PASRR Level 2. She stated she was unaware of the requirement that a PASRR Level 2 was needed when the resident had a change of diagnosis or condition. She confirmed she failed to submit the requests. She confirmed that requests for PASRR Level 2 were not done by the facility for the diagnoses of Anxiety Disorder on 8/6/20 and for Mood (Affective) Disorder on 7/19/2021 for Resident #44. She confirmed this was needed to ensure safe placement for the residents.
An interview with the Administrator on 2/9/22 at 10:45 AM, revealed she was not aware that Resident #44 needed a request for PASRR Level 2 and the request had not been done. She confirmed the facility failed to submit the PASRR Level II Change in Status Request for this resident. She confirmed this is needed for the safe care of the resident and to ensure appropriate placement. She confirmed the facility does not have a policy for PASRR submission.
Record review of the admission Record revealed the resident was admitted to the facility on [DATE]. Resident #44 has diagnoses of Unspecified Psychosis not due to a substance or known physiological condition (6/7/2019), Recurrent Depressive Disorders (4/20/18), Anxiety Disorder (8/6/20), and Unspecified Mood (Affective) Disorder (7/19/2021).