**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to recognize a cardiorespiratory arrest (a life-threatening medical emergency that occurs when the heart and lungs stop functioning properly) for one of three sampled residents (Resident 1), which resulted in a delay in performing CPR (or cardiopulmonary resuscitation, a procedure to keep the blood pumping when the heart stops or when it beats too ineffectively to circulate blood to the brain and other vital organs) on Resident 1 who was a full-code (a medical directive indicating that a patient wishes to receive all possible life-saving measures in the event of a medical emergency) after he was found unresponsive. This failure led to Resident 1 ' s death. Findings: During an interview on [DATE] at 9 a.m., Complainant 5 stated he arrived at the facility on [DATE] approximately five to seven minutes after receiving a call about an unresponsive patient who was having difficulty breathing. Complainant 5 stated he found Resident 1 on a non-rebreather mask (a mask that delivers high concentrations of oxygen), but was apneic (not breathing spontaneously), unresponsive and diaphoretic (covered with sweat), and pulseless. Complainant 5 stated he immediately started chest compressions on Resident 1. Complainant 5 stated he continued to perform CPR on Resident 1 until his time of death, about 20-25 minutes later. Complainant 5 stated there was an AED (automated external defibrillator, or a portable medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm) at Resident 1 ' s bedside, but the machine was not on nor were the pads applied on Resident 1 ' s chest. Complainant 5 stated he was later told by the staff that Resident 1 had been unresponsive and had oxygen saturation levels (a measure of how much oxygen is in your blood) in the 60 ' s or 70 ' s approximately 40 minutes before his arrival (the normal range for oxygen saturation is typically between 95% and 100%). A review of Resident 1 ' s Face Sheet indicated he was admitted to the facility with diagnoses including acute and chronic respiratory failure (a condition where the body is not getting enough oxygen due to a failure of the lungs to properly exchange gases, which can occur suddenly or over time). A review of Resident 1 ' s Progress Notes, dated [DATE], indicated, . At around 1650 (4:50 p.m.) respiratory nurse was doing her rounds and noticed this resident was not wearing his NC (nasal cannula [a device with two prongs that deliver oxygen directly into the nostrils]). The nurse put resident back on his O2 (oxygen) via NC, states when she was with the pt (patient) he woke up but didn ' t say anything. At around 1655 (4:55 p.m.) this writer went to give resident his evening medications. Resident was asleep and unable to wake up. This LN (Licensed Nurse) did a sternum rub (to determine if a person is conscious and responsive) and resident would wake up and fall straight back to sleep. This LN then took resident V/S (vital signs) again . BP (blood pressure) 150/74, 97.5 F, 22 RPM (respirations per minute), 75 SPO2 (oxygen saturation), BG (blood glucose [blood sugar level]) 156 on 2L (2 liters of oxygen) via NC. Immediately this LN called the respiratory nurse, put his bed into high fowlers [positioned with the head elevated between 60-90 degrees], increase his 02 (oxygen) to 4L, and gave this resident his nebulizer tx [a treatment involving a device that delivers medications directly into the lungs], Resident's 02 was not increasing so this writer called 911. Respiratory nurse and Nurse Supervisor 2 was with the resident monitoring (sic). Upon completion of nebulizer tx resident's 02 was unchanged. The respiratory nurse then put a nonrebreather mask on resident and increased the 02 to 15L. Resident's 02 then went up to 97%. At around 1730 (5:30 p.m.) at the same (sic) this resident stopped breathing, and the paramedics arrived on scene. CPR was initiated by paramedics . 30 minutes of CPR was conducted. Time of death was called at 1753 (5:53 p.m.) . During an interview on [DATE] at 1:31 p.m., Licensed Staff A stated she was called into Resident 1 ' s room because of his oxygen level was low. Licensed Staff A was unable to recall the time nor how low the oxygen level was. Licensed Staff A stated she replaced Resident 1 ' s nasal cannula to a non-rebreather mask. Licensed Staff A stated Resident 1 was diaphoretic and would briefly open his eyes as she performed sternal rubs. Licensed Staff A stated she told Licensed Staff C to call 911, as she and another staff stayed at Resident 1 ' s bedside. Licensed Staff A stated she continued to monitor Resident 1 ' s breathing and performing sternal rubs. Licensed Staff A stated Resident 1 stopped breathing very suddenly, and as she was about to get the crash cart from outside the room, she almost ran straight into the paramedics. Licensed Staff A stated she never had a chance to start CPR. During an interview on [DATE] 1:40 p.m., Licensed Staff B stated she recalled Resident 1 ' s death and added she was in the room very briefly. Licensed Staff B stated Resident 1 was nonresponsive to sternal rubs. Licensed Staff B demonstrated gasping motions when asked to describe how Resident 1 ' s breathing was. Licensed Staff B stated she was checking Resident 1 ' s carotid pulse (the rhythmic pulse of the carotid arteries located on either side of the neck) while she was at the bedside, and stated Resident 1 never lost a pulse. Licensed Staff B stated there was an AED at the bedside, but it was not used. Licensed Staff B stated she had never used an AED outside of training. Licensed Staff B stated AED pads were placed on patients when CPR was started, and the AED was used when a patient became pulseless. During an interview on [DATE] at 1:58 p.m., Licensed Staff C stated she was about to give Resident 1 his medications the evening of [DATE] when he would not wake up. Licensed Staff C stated Resident 1 would briefly open his eyes as she did sternal rubs but would fall back to sleep after. Licensed Staff C stated Resident 1 ' s vital signs (temperature, blood pressure, heart rate and respiratory rate) were normal except for his low oxygen saturation. Licensed Staff C stated she started the nebulizer treatment and called for Licensed Staff A for further assistance. Licensed Staff C stated after a few minutes of the nebulizer treatment, she called 911. Licensed Staff C stated she brought the AED to Resident 1 ' s room per 911 ' s instructions. Licensed Staff C stated the AED was for Licensed Staff A and B to use, as they were at Resident 1 ' s bedside. Licensed Staff C stated CPR was not started on Resident 1 as he never lost pulse, nor had his breathing stopped. During an interview on [DATE] at 3:10 p.m., the Director of Nursing (DON) stated CPR was performed when someone was unresponsive, not breathing or has lost their pulse. The DON stated she expected staff to follow the paramedics ' instructions during emergency situations. A review of a national standard by the American Heart Association titled, Cardiac Arrest, dated 2025, indicated, Cardiac arrest can strike without warning . The signs are: Sudden loss of responsiveness - The person doesn ' t respond, even if you tap them hard on the shoulders or ask loudly if they're OK. The person doesn ' t move, speak, blink or otherwise react. No normal breathing - The person isn ' t breathing or is only gasping for air . If you think the person may be suffering cardiac arrest and you're a trained lay rescuer: Ensure scene safety. Check for response. Shout for help. Tell someone nearby to call 911 or your emergency response number. Ask that person or another bystander to bring you an AED, if there ' s one on hand. Tell them to hurry - time is critical. If you ' re alone with an adult who has signs of cardiac arrest, call 911 and get an AED (if one is available). Check for no breathing or only gasping. If the person isn ' t breathing or is only gasping, begin CPR with compressions. Administer high-quality CPR. Push down at least two inches in the center of the chest at a rate of 100 to 120 pushes a minute. Allow the chest to come back up to its normal position after each push. Use an AED. As soon as it arrives, turn it on and follow the prompts. Continue CPR. Administer it until the person starts to breathe or move, or until someone with more advanced training, such as an EMS team member, takes over . A review of the document titled, CPR Facts and Statistics by The American Red Cross Training Services, published [DATE], indicated, Out-of-Hospital Cardiac Arrest Facts: Survival chances decrease by 10% for every minute that immediate CPR and use of an AED is delayed. Immediate CPR can triple the chance of survival . Based on interview and record review, the facility staff failed to recognize a cardiorespiratory arrest (a life-threatening medical emergency that occurs when the heart and lungs stop functioning properly) for one of three sampled residents (Resident 1), which resulted in a delay in performing CPR (or cardiopulmonary resuscitation, a procedure to keep the blood pumping when the heart stops or when it beats too ineffectively to circulate blood to the brain and other vital organs) on Resident 1 who was a full-code (a medical directive indicating that a patient wishes to receive all possible life-saving measures in the event of a medical emergency) after he was found unresponsive. This failure led to Resident 1's death. Findings: During an interview on [DATE] at 9 a.m., Complainant 5 stated he arrived at the facility on [DATE] approximately five to seven minutes after receiving a call about an unresponsive patient who was having difficulty breathing. Complainant 5 stated he found Resident 1 on a non-rebreather mask (a mask that delivers high concentrations of oxygen), but was apneic (not breathing spontaneously), unresponsive and diaphoretic (covered with sweat), and pulseless. Complainant 5 stated he immediately started chest compressions on Resident 1. Complainant 5 stated he continued to perform CPR on Resident 1 until his time of death, about 20-25 minutes later. Complainant 5 stated there was an AED (automated external defibrillator, or a portable medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm) at Resident 1's bedside, but the machine was not on nor were the pads applied on Resident 1's chest. Complainant 5 stated he was later told by the staff that Resident 1 had been unresponsive and had oxygen saturation levels (a measure of how much oxygen is in your blood) in the 60's or 70's approximately 40 minutes before his arrival (the normal range for oxygen saturation is typically between 95% and 100%). A review of Resident 1's Face Sheet indicated he was admitted to the facility with diagnoses including acute and chronic respiratory failure (a condition where the body is not getting enough oxygen due to a failure of the lungs to properly exchange gases, which can occur suddenly or over time). A review of Resident 1's Progress Notes , dated [DATE] , indicated, . At around 1650 (4:50 p.m.) respiratory nurse was doing her rounds and noticed this resident was not wearing his NC (nasal cannula [a device with two prongs that deliver oxygen directly into the nostrils]). The nurse put resident back on his O2 (oxygen) via NC, states when she was with the pt (patient) he woke up but didn't say anything. At around 1655 (4:55 p.m.) this writer went to give resident his evening medications. Resident was asleep and unable to wake up. This LN (Licensed Nurse) did a sternum rub (to determine if a person is conscious and responsive) and resident would wake up and fall straight back to sleep. This LN then took resident V/S (vital signs) again . BP (blood pressure) 150/74, 97.5 F, 22 RPM (respirations per minute), 75 SPO2 (oxygen saturation), BG (blood glucose [blood sugar level]) 156 on 2L (2 liters of oxygen) via NC. Immediately this LN called the respiratory nurse, put his bed into high fowlers [positioned with the head elevated between 60-90 degrees], increase his 02 (oxygen) to 4L, and gave this resident his nebulizer tx [a treatment involving a device that delivers medications directly into the lungs], Resident's 02 was not increasing so this writer called 911. Respiratory nurse and Nurse Supervisor 2 was with the resident monitoring (sic). Upon completion of nebulizer tx resident's 02 was unchanged. The respiratory nurse then put a nonrebreather mask on resident and increased the 02 to 15L. Resident's 02 then went up to 97%. At around 1730 (5:30 p.m.) at the same (sic) this resident stopped breathing, and the paramedics arrived on scene. CPR was initiated by paramedics . 30 minutes of CPR was conducted. Time of death was called at 1753 (5:53 p.m.) . During an interview on [DATE] at 1:31 p.m., Licensed Staff A stated she was called into Resident 1's room because of his oxygen level was low. Licensed Staff A was unable to recall the time nor how low the oxygen level was. Licensed Staff A stated she replaced Resident 1's nasal cannula to a non-rebreather mask. Licensed Staff A stated Resident 1 was diaphoretic and would briefly open his eyes as she performed sternal rubs. Licensed Staff A stated she told Licensed Staff C to call 911, as she and another staff stayed at Resident 1's bedside. Licensed Staff A stated she continued to monitor Resident 1's breathing and performing sternal rubs. Licensed Staff A stated Resident 1 stopped breathing very suddenly , and as she was about to get the crash cart from outside the room, she almost ran straight into the paramedics. Licensed Staff A stated she never had a chance to start CPR. During an interview on [DATE] 1:40 p.m., Licensed Staff B stated she recalled Resident 1's death and added she was in the room very briefly . Licensed Staff B stated Resident 1 was nonresponsive to sternal rubs. Licensed Staff B demonstrated gasping motions when asked to describe how Resident 1's breathing was. Licensed Staff B stated she was checking Resident 1's carotid pulse (the rhythmic pulse of the carotid arteries located on either side of the neck) while she was at the bedside, and stated Resident 1 never lost a pulse. Licensed Staff B stated there was an AED at the bedside, but it was not used. Licensed Staff B stated she had never used an AED outside of training. Licensed Staff B stated AED pads were placed on patients when CPR was started, and the AED was used when a patient became pulseless. During an interview on [DATE] at 1:58 p.m., Licensed Staff C stated she was about to give Resident 1 his medications the evening of [DATE] when he would not wake up. Licensed Staff C stated Resident 1 would briefly open his eyes as she did sternal rubs but would fall back to sleep after. Licensed Staff C stated Resident 1's vital signs (temperature, blood pressure, heart rate and respiratory rate) were normal except for his low oxygen saturation. Licensed Staff C stated she started the nebulizer treatment and called for Licensed Staff A for further assistance. Licensed Staff C stated after a few minutes of the nebulizer treatment, she called 911. Licensed Staff C stated she brought the AED to Resident 1's room per 911's instructions. Licensed Staff C stated the AED was for Licensed Staff A and B to use, as they were at Resident 1's bedside. Licensed Staff C stated CPR was not started on Resident 1 as he never lost pulse, nor had his breathing stopped. During an interview on [DATE] at 3:10 p.m., the Director of Nursing (DON) stated CPR was performed when someone was unresponsive, not breathing or has lost their pulse. The DON stated she expected staff to follow the paramedics' instructions during emergency situations. A review of a national standard by the American Heart Association titled, Cardiac Arrest , dated 2025 , indicated, Cardiac arrest can strike without warning . The signs are: Sudden loss of responsiveness - The person doesn't respond, even if you tap them hard on the shoulders or ask loudly if they're OK. The person doesn't move, speak, blink or otherwise react. No normal breathing - The person isn't breathing or is only gasping for air . If you think the person may be suffering cardiac arrest and you're a trained lay rescuer: Ensure scene safety. Check for response. Shout for help. Tell someone nearby to call 911 or your emergency response number. Ask that person or another bystander to bring you an AED, if there's one on hand. Tell them to hurry - time is critical. If you're alone with an adult who has signs of cardiac arrest, call 911 and get an AED (if one is available). Check for no breathing or only gasping. If the person isn't breathing or is only gasping, begin CPR with compressions. Administer high-quality CPR. Push down at least two inches in the center of the chest at a rate of 100 to 120 pushes a minute. Allow the chest to come back up to its normal position after each push. Use an AED. As soon as it arrives, turn it on and follow the prompts. Continue CPR. Administer it until the person starts to breathe or move, or until someone with more advanced training, such as an EMS team member, takes over . A review of the document titled, CPR Facts and Statistics by The American Red Cross Training Services , published [DATE] , indicated, Out-of-Hospital Cardiac Arrest Facts: Survival chances decrease by 10% for every minute that immediate CPR and use of an AED is delayed. Immediate CPR can triple the chance of survival .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 1), who had a history of Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and amputation (surgical removal) of his right leg above the knee, received care consistent with nursing standards of practice and the resident's individualized care plan when: 1) Licensed nursing staff did not document daily skin assessments (to identify skin injury) for Resident 1, as indicated in his Nursing Care Plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes); 2) Licensed nursing staff did not document the condition Resident 1's remaining foot (left) for a period of approximately one month prior to the identification of his necrotic (necrosis; death of body tissue; also known as necrosis) second toe. 3) Licensed nursing staff did not notify Resident 1's covering physician (via the on-call advice nurse) immediately when they identified his toe was black in color; they did not communicate Resident 1's potentially life-threatening condition during the initial phone call, they informed the physician in a subsequent phone call; and 4) Licensed nursing staff did not ensure Resident 1 was promptly transferred to the hospital once his emergent condition was discovered on the morning of 10/13/24, he was transported to the hospital hours later at 4:34 p.m.; the facility did not arrange transportation the hospital, an outside provider group (Provider Group F) called for ambulance transport. These failures: 1) Caused Resident 1's necrotic toe to go undetected until it had advanced to the wet gangrene (a type of necrosis when infection is present; can be fatal if left untreated) stage, when infection and sepsis (the body's extreme response to an infection; a life-threatening medical emergency) were already present, thereby placing him at risk of death and necessitating an emergent transfer to the hospital. 2) Prevented Resident 1's physician from knowing the declining status of his foot/toe, impairing his ability to intervene earlier in the disease process and order diagnostic testing and potential treatment to mitigate disease progression. 3) Contributed to the amputation of Resident 1's left, second toe. 4) Contributed to Resident 1 developing sepsis. 5) Delayed his arrival to the Emergency Department, thereby delaying sepsis treatment (antibiotic [medication to treat infection] administration); and 6) Contributed to Resident 1 experiencing foot pain he described as 6/10 (Pain Scale: a tool health care professionals utilize to help assess a person's pain: 0 is no pain and 10 is the worst pain imaginable). Findings: During a telephone interview with a confidential family member (CF) on 11/7/2024 at 11:54 a.m., CF stated her family member (Resident 1) called her on Sunday (10/13/2024) and told her he had pain in his left foot and his toe had been black for a while. CF stated a certified nurse assistant (CNA E) took a picture of Resident 1's foot and sent it to her; CF stated the photo showed his toe was black in color and nearly falling off. She stated the facility nurse, Licensed Nurse C (LN C), called Resident 1's provider group (Provider Group F; group of physicians covering for/working with Resident 1's physician, Physician D) and spoke to the on-call nurse. CF stated LN C told her the on-call physician had ordered Resident 1 to be given Gout (painful joint swelling) medication and have ice placed on his foot. During the same telephone interview on 11/7/24 at 11:54 a.m., CF stated she reviewed Resident 1's medical record (via computer access) after the call was made to Provider Group F and stated LN C had reported to them that Resident 1 had a painful and swollen left foot (not a black toe). CF stated she called the facility and told LN C that gout medication and ice would not help her father because he had gangrene. CF stated LN C became nervous and told her she would call Provider Group F again. During the same telephone interview on 11/7/24 at 11:54 a.m., CF stated she called Provider Group F herself (after speaking with LN C) and spoke to an on-call nurse; CF informed her that Resident 1's toe was black and nearly falling off, but LN C was not worried. CF stated the on-call nurse called a physician and told her Resident 1 needed to come by ambulance (to the hospital) right away. CF stated one hour later, Resident 1 was still at the facility (he had not been transported to the hospital). CF stated the on-call nurse (not a facility nurse) eventually called an ambulance for Resident 1. CF stated when Resident 1 arrived in the Emergency Department (ED), he was septic (sepsis; life-threatening infection) and his toe was subsequently amputated. Review of Resident 1's medical record facesheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was originally admitted to the facility 5/17/21 and had diagnoses that included, but were not limited to: Diabetes Mellitus, peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), acquired absence (amputation) of right leg above the knee, and acquired absence (amputation) of the left great toe. Review of a hospital physician note, dated 10/13/24 at 10:02 p.m. indicated Resident 1 came to the hospital with, . necrotic left toe . the patient thinks the toe has been black for some time . Review of Resident 1's medical record revealed a physician note by Physician D (Resident 1's doctor), dated 10/25/20 at 10:58 a.m., that indicated Resident 1 had been admitted to the hospital from [DATE] through 10/23/24. The progress note indicated Physician G (Resident 1's doctor at the hospital) documented Resident 1 , .presents (came to the hospital) with fever and necrotic left second toe . Blood culture (blood test that indicates infection) returned Strep pyogenes (bacteria was present in the blood culture; infection was present) . ID (infectious disease physician) consulted and agreed with continuing zosyn/vanco (antibiotics given to treat Resident 1's infection) . Taken to OR (operating room) on 10/15 (2024) and underwent amputation of 2nd toe . During an observation and concurrent interview on 11/8/24 at 11:30 a.m., Resident 1 was lying on his back in bed; his bed contained a foot cradle (device attached to the bed to keep blankets/sheets from touching and rubbing legs and feet). Resident 1 stated he had had four toes on his left foot but was now down to three; he stated the second toe had turned black. Resident 1 stated the second toe was getting green on Friday (10/11/24; two days prior to transport to the hospital) and on Sunday (10/13/24), an ambulance was called, and he was sent to the hospital. He stated he spent twelve days in the hospital. When asked about the wound (treatment) nurse at the facility, Resident 1 stated they take care of his heel now but, they missed the black toe. During an interview on 11/8/24 at 11:50 a.m., Certified Nursing Assistant E (CNA E) stated she had worked with Resident 1 a lot in the past and had seen him on Friday (10/11/24). She stated she had not noticed anything (unusual) Friday morning and LN B had not noticed anything, either. CNA E stated Resident 1's toe had turned black on Saturday and he was sent out (to the hospital) on Sunday. During an interview on 11/8/24 at 1:52 p.m., Licensed Nurse B (LN B) stated she was the facility's wound (treatment) nurse and had been working with Resident 1. LN B stated she had seen Resident 1 Friday and Saturday (10/11/24 and 10/12/24) prior to his hospital transfer but she did not work on Sunday (10/13/24). LN B stated Resident 1 had had back lesions (prior to 10/13/24) that were kind of infected and she had been applying ointment to them. She stated she had taken photos of his back lesions. She stated Resident 1 also had super dry skin and she had put lotion on his leg. LN B stated she had not seen a black toe when she had applied the lotion. Review of Resident 1's medical record revealed a nurse progress note from the LN B (dated 10/15/24 at 4:14 p.m.- two days after Resident 1 was sent to the hospital) that indicated, Performed wound care on patient Friday and Saturday October 11, and 12 (sic) to his lower back when turning patient and helping him roll over and take blankets down (sic). I used moisturizer lotion to patients dry left leg. Patient wasn't noted with any black discoloration to left foot. Review of Resident 1's medical record indicated LN B documented a skin assessment titled, Evaluated on [DATE] - 13:05 (1:05 p.m. - over six weeks prior to his left/second toe amputation) that indicated Resident 1 had an open lesion (tissue injury) on his right scapula (shoulder blade); she documented its size and photographed the lesion. No additional wound evaluations were located in Resident 1's medical record until 10/25/24 (after amputation of his second toe on 10/15/24),) when LN B documented and photographed a diabetic lesion located on his left heel. No photo of Resident 1's necrotic toe, reportedly taken on 10/13/24, was in his medical record. Review of Resident 1's medical record revealed a Change of Condition (An acute change of condition is a sudden clinically important deviation from a patient's baseline in physical, cognitive [mental], behavioral, or functional domains [physical ability]) evaluation, dated 10/13/24 at 2:50 p.m., that indicated, .Edema (swelling) . Change in skin color .Nursing observations, evaluation, and recommendations are: Noted swelling and discoloration on left foot. Pain level 6/10 (severe pain). Noted discoloration on 2nd toe of left foot. Called (Provider Group F) after hours and spoke to advice Nurse (name) and received orders from MD . Stat X ray (immediate timeframe; photographic or digital image of the internal composition of something, especially a body part) left foot. stat CBC (blood test) and Stat uric acid level (blood test for gout). New orders Colchicine (medication for gout) twice daily for 5 days . Apply ice on left foot three times a day for 3days (sic) . During a telephone interview on 11/18/2024 at 4:20 p.m., LN C stated she was a newly graduated registered nurse who had been working at the facility a total of four months. LN C stated she was Resident 1's nurse the day he was sent to the hospital; she stated her shift began at 6:45 a.m. and a CNA told her in the morning that Resident 1 had swelling of his left foot. LN C stated she went to Resident 1's room right away and he was complaining of foot pain that was 6/10. When asked what time the CNA notified her about Resident 1's foot and she went to the room, LN C stated she did not remember. When asked what Resident 1's foot looked like, LN C stated it was swollen with discoloration. She stated the left second toe was a little bit blackish. During the same telephone interview on 11/18/2024 at 4:20 p.m., LN C stated she called Provider Group F's after-hours advice nurse (who subsequently called the on-call physician). When asked what she told the advice nurse when she called, LN C stated she told her Resident 1's foot had, swelling and discoloration. When asked if she told the advice nurse the toe was blackish, LN C stated, no. When asked why she did not notify the nurse of the black color, LN C stated she told her in a subsequent call; she stated she called and spoke to the advice nurse two separate times. During the first call, she stated she reported Resident 1 had discoloration of the toe but did not tell the on-call nurse it was black. She stated a physician from Provider Group F ordered ice (to the foot) and gout medication. During the second call, LN C stated she told the advice nurse the toe was discolored and, I think I told it was blackish. She stated a photo had been taken of Resident 1's foot and she showed the photo (to the advice nurse) during the second call. LN C stated a stat xray was ordered after the second call and Resident 1's family member requested he be sent to the hospital. When asked what the length of time between calls to the advice nurse was, LN C stated she did not remember. When asked when 911 (emergency medical responders) was called (to transport Resident 1 to the hospital), LN C stated she did not remember. LN C stated Resident 1 was still in the facility at 2:30 p.m., when her shift ended. Review of Resident 1's medical record revealed a nurse's progress note, dated 10/13/2024 at 10:58 p.m. that indicated, Res (Resident 1) was P/U (picked up) at 1634 (4:34 p.m.) to (Hospital Name) via gurney with 2EMT's (two emergency medical technicians). During the same telephone interview on 11/18/2024 at 4:20 p.m., LN C was asked how nurses documented resident skin assessments and she stated nurses perform skin assessments after resident showers and then documented in the (nurse) progress notes. During a telephone interview on 11/18/2024 at 4:45 p.m., the Director of Nursing (DON) stated Resident 1 was a very high risk for necrosis and deep tissue injury (damage to the soft tissue beneath the skin caused by pressure). She stated he had a history peripheral vascular disease and had had an amputation of the first toe on the left foot. When asked if she knew the timeframe of events on 10/13/24, the day Resident 1 was sent to the hospital, the DON stated she did not know the conversations (that occurred). When asked if she was aware LN C did not notify the advice nurse that Resident 1's toe was blackish in the initial conversation (rather that the follow-up, second call), the DON again stated she did not know the conversations. When asked what a nurse should do when she/he discovers a resident has a black toe, the DON stated they should evaluate for pain and infection and call the doctor right away. She stated necrotic toes could have bad outcomes like amputation, bleeding, infection, sepsis and even death. Review of Resident 1's medical record document titled, Braden Scale For Predicting Pressure Sore (pressure ulcer/injury: localized, pressure-related damage/injury to the skin and/or underlying tissue) Risk, dated 8/19/24, indicated he had a score of 15 (at risk of developing pressure ulcers). [The Braden Scale is an assessment tool reflecting a person's risk of developing pressure ulcers/pressure sores]. Review of Resident 1's medical record revealed multiple nurse progress notes, prior to Resident 1's hospital transfer on 10/13/24; the nurse progress notes did not indicate nursing staff were monitoring the status of his foot. A nurse's noted dated 9/10/24 at 3:27 p.m. indicated, .monitoring for skin tear on left hand . still have rashes (sic) on his back and dressing on his wound on left upper back . On 9/12/24 at 6:39 p.m., LN C documented, .Resident has recurrent rash on back. Resident got shower . LN C's note did not indicate she conducted a skin assessment after the shower. On 9/17/24 at 8:24 p.m., nursing staff documented that Resident 1 was sent to a podiatry medical appointment but did not document any skin assessments. On 9/21/24 at 10:06 p.m., LN C documented Resident 1 was complaining of, itching; she documented he had a shower but did not document a skin assessment. On 9/25/24 at 9:10 p.m., LN C documented Resident 1 received a shower, had redness and rash around the groin area, but did not document a skin assessment of his foot. The next documented nurse's progress note was dated 10/9/24 at 10:07 p.m. (reflecting a two-week period with no documented nurse progress notes). In the 10/9/24 nurse's note, LN C indicated Resident 1 received a shower, was complaining of itching, staff applied cream to arms, leg, knee and chest and an abrasion was located on the knee; LN C did not document the status of his foot. On 10/12/24 at 10:06 p.m. (the day before he was sent to the hospital), LN C documented Resident 1 refused his shower; she did not document any skin assessment. On 10/13/24 at 3:24 p.m., LN C documented, Resident (1) is alert and oriented (not confused). Noted swelling and discoloration on left foot. Pain level 6/10. Noted discoloration on 2nd toe of left foot. Called (Provider Group F) after hours and spoke to advice Nurse (name) and received orders from MD (name). Family notified. During a follow-up interview and concurrent medical record review on 11/22/24 at 1:40 p.m., the DON was asked to review the nursing progress notes, wound nurse notes, and photos located in Resident 1's medical record. When asked about the photos of his toe, reportedly taken on the morning of 10/13/24, the DON stated they had not been uploaded (into the electronic medical record) and stated, I don't know about the photos. The DON confirmed the medical record did not contain documentation of wound nurse progress notes or foot/toe photos after August 2024 and prior to 10/13/24. The DON was asked to clarify if Resident 1's medical record contained documentation of licensed nursing staff monitoring Resident 1's toe/foot the month prior to the identification of his necrotic toe. The DON stated and confirmed she could not locate foot/toe monitoring documentation in the nurse's progress notes or the treatment administration record (TAR, location of wound care and treatment notes). When asked if nursing staff should have been monitoring Resident 1's foot daily, as indicated in the Nursing Care Plan, the DON stated, yes. Review of Resident 1's nursing care plan (date initiated 02/17/2023, revised 07/03/2024) indicated, Skin: at risk for skin breakdown . The care plan goal was, Will have no skin breakdown daily x3 (for three) months . The interventions to reach the goal indicated, Daily body assessments to monitor for any skin injury . Notify MD for any skin breakdown . During an interview on 11/22/24 at 2:30 p.m., Physician D was asked about the development and outcome of Resident 1's necrotic toe. Physician D stated LN B (treatment nurse) told him she had seen Resident 1's foot on Friday (10/11/24, two days prior to being sent to the hospital) and his foot at that time was really good. When asked if he thought the necrosis could have developed quickly (between Friday and Sunday), Physician D stated it was, conceivable, but it may have taken longer. He stated everyone (medical staff) thought it was occurring (progressing) longer than a few days. During the same interview on 11/22/24 at 2:30 p.m., Physician D stated the nurse (LN C) was concerned about the change in Resident 1's toe on Sunday (10/13/24) and at some point, reported it looked black. He stated in the first call to Provider Group F, the LN C reported swelling and treatment for gout (ice and medication) was ordered. Physician D stated there was no mention of the toe's color (being black) in the first call to his provider group. Physician D stated Resident 1's family member (CF) reached out to the facility and also made a second call to an unofficial call center (related to Provider Group F) and spoke to the on-call nurse manager; Provider Group F's on-call nurse manager then arranged ambulance transfer for Resident 1 to the hospital. During the same interview on 11/22/24 at 2:30 p.m., when Physician D was asked if the failure of nursing staff to monitor Resident 1's left foot daily and notify the physician timely of any changes contributed to his necrotic toe being found (identified) at an advanced stage, he stated, yes. He stated the necrosis was found at the wet gangrene stage and was infected. When asked if Resident 1 was septic (had sepsis) when he arrived in the emergency room, Physician D stated, he met sepsis criteria. (a combination of findings/set of criteria - such as exams, tests, etc.- that providers use to identify/confirm the presence of sepsis). He stated if the issue was found when the toe was dusky (gray color; less advanced disease), he would have ordered and performed a vascular study (to assess circulation of the foot) and monitored the foot. When asked if nursing staff should have been monitoring Resident 1's toe/foot, Physician D stated, yes. Online review of the National Library of Medicine website indicated gangrene is associated with a high incidence of mortality (death), and in patients that survive, it can have a massive impact on the quality of life. (https://www.ncbi.nlm.nih.gov/books/NBK560552/). Online review of John Hopkins website indicated, Gangrene is a dangerous and potentially deadly health problem . Gangrene can spread quickly over a large area of the body .Wet gangrene is often life-threatening . (https://www.hopkinsmedicine.org/health/conditions-and-diseases/gangrene) Online review of the Mayo Clinic website indicated diabetes increases the risk of gangrene. Symptoms include changes in skin color including pale gray to blue, purple, black and red; swelling, blisters and severe pain can be present. (https://www.mayoclinic.org/diseases-conditions/gangrene/symptoms-causes/syc-20352567). Online review of the Center for Disease Control and Prevention (CDC) website indicated, Sepsis . is a life-threatening medical emergency . almost any infection can lead to sepsis . sepsis happens when an infection you already have triggers a chain reaction throughout your body . Infections that lead to sepsis most often start in the . skin . Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure and death . (https://www.cdc.gov/sepsis/about/index.html).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to assess, monitor, and provide necessary care for one of two sampled residents (Resident 1) when: 1. The facility did not provide the necessary nursing assessment for Resident 1 ' s underlying cause of vomiting; did not provide prompt intervention to prevent Resident 1 from further vomiting when Resident 1 started vomiting in the morning of 5/16/23 and was given first dose of Ondansetron (a medicine used to prevent and treat nausea and vomiting) at 8:51 p.m.; and did not monitor Resident 1 for possible complications associated with vomiting, when Resident 1 vomited three times within a 12 hour period. 2. The facility did not monitor Resident 1 ' s colostomy (a stoma [opening] in the abdominal wall allows waste to leave the body) output for signs of constipation (having a condition of the bowels in which the feces are dry and hardened and evacuation is difficult and infrequent) and did not provide Milk of Magnesia (MOM - a laxative to help loosen stools and increase bowel movements) or Dulcolax Suppository (laxative suitable for the fast relief of occasional constipation) according to the doctor ' s order to relieve Resident 1 from constipation. 3. The Facility did not monitor Resident 1 ' s urostomy (a stoma in the abdomen to collect urine outside of the body) output when there was a physician ' s (doctor) order to monitor Resident 1 ' s output every shift. 4. The facility failed to monitor and ensure Resident 1 received adequate fluid intake according to his estimated fluid needs. This failure resulted in Resident 1 ' s emergent transfer to the hospital who was found to have Septic Shock (the last and most severe stage of sepsis [an overwhelming and life-threatening response to infection]); Urinary Tract Infection (UTI - condition in which bacteria invade and grow in the urinary tract (the kidneys, ureters, bladder, and urethra); Acute Kidney Failure (also known as Renal Failure - occurs when the kidneys are suddenly unable to filter wastes from the blood) with Hyperkalemia (an elevated level of potassium [a mineral and electrolyte that conducts electricity essential for all of the body ' s functions] in the blood); and Small Bowel Obstruction (SBO - a condition in which the small intestine [part of the intestine that runs between the stomach and the large intestine] becomes blocked). Resident 1 subsequently died after one day of hospitalization. Findings: 1. During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should); Paraplegia (paralysis of the legs and lower body); and Spina Bifida (a congenital defect of the spine often causing paralysis of the lower limbs). During a record review for Resident 1, the MDS (Minimum Data Set - health status screening and assessment tool used for all residents) assessment dated [DATE] indicated, Resident 1 had a BIMS score of 14 out of 15 points (Brief Interview for Mental Status [current state of the patient during evaluation] - a 15-point cognitive (relating to the mental process involved in knowing, learning, and understanding things) screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). During a record review for Resident 1, the Progress Note titled Nurse ' s Note dated 5/16/22 at 10:48 p.m. indicated, [Resident 1] vomited x (times) 3 within 12 hours. Vomited food contents, Zofran (also known as Ondansetron) was given at 1815 (6:15 p.m.) as per MD (Medical Doctor) order. Ineffective because [Resident 1] vomited again at 2200 (10:00 p.m.). During a record review for Resident 1, the Progress Note titled Nurse ' s Note dated 5/18/22 at 9:07 a.m. indicated, at around 8:45 a.m., Resident 1 appeared drowsy but arousable; had cold extremities to both arms; abdomen was hard and distended. The Nurse ' s Note indicated the physician was notified and ordered to transfer Resident 1 to the hospital. During a record review for Resident 1, the Physician ' s Progress Note dated 5/18/22 at 12:30 p.m. indicated, Staff report [Resident 1] had 2 episodes of vomiting yesterday. [Resident 1] this morning is confused and complaining of abdominal pain. Nurses report [Resident 1 ' s] abdomen is distended and hard. During a record review for Resident 1, the hospital document titled, ED (Emergency Department) Provider Note dated 5/18/22 at 9:57 a.m. indicated Resident 1 presented to the hospital for complaint of nausea and vomiting, poor urinary output and scant to no stool output. The document indicated Resident 1 had colostomy and urostomy. During a record review for Resident 1, the hospital document titled, ED Notes dated 5/18/22 at 10:28 a.m. indicated, [Resident 1] reports no bm (bowel movement) x (for) 4 days. During a record review for Resident 1, the hospital document titled, H & P (History and Physical - formal and complete assessment of the patient and the problem) Notes dated 5/18/22 at 2:11 p.m., indicated an NGT (Nasogastric tube - a thin, soft tube that goes in through the nose, down the throat, and into the stomach; typically used for decompression (relieving pressure) of the stomach in the setting of intestinal obstruction) the tube removes fluids and gas and helps relieve pain and pressure) was placed on Resident 1 with 1.4 L (liter - basic unit of liquid volume) of dark brown output. The H & P note indicated the CT (Computed Tomography scan - a medical imaging technique used to obtain detailed internal images of the body) result for Resident 1 was consistent with Small Bowel Obstruction. The H & P indicated Resident 1 was noted to be in Acute Renal Failure with Hyperkalemia. During a record review for Resident 1, the hospital document titled, Clinical Notes dated 5/19/22 at 5:18 a.m. indicated Resident 1 ' s primary problem was Sepsis and Urinary Tract Infection. During a record review for Resident 1, the hospital document titled, Discharge Summary Note dated 5/19/22 at 9:23 a.m. indicated Resident 1 ' s admitting diagnosis was Septic Shock (the last and most severe stage of sepsis). The Discharge Summary Note indicated Resident 1 died on 5/19/22. During an interview with Licensed Staff F on 7/25/23 at 3:03 p.m., when Licensed Staff F was asked about the facility policy when a resident had vomited, Licensed Staff F stated she would complete the SBAR (Situation, Background, Assessment and Recommendation - a tool used by health care professionals to communicate with each other about critical changes in patient ' s status), initiate a care plan (contain information about a patient's diagnosis, goals of treatment, specific nursing interventions, and an evaluation plan) and give report to the incoming nurse. Licensed Staff F stated resident will be monitored and assessed every shift for seventy two (72) hours for further episode of vomiting. Licensed Staff F stated nurse ' s observation/ assessment of resident will be documented under the progress notes titled, 72 hour charting. When Licensed Staff F was asked what to assess when a resident vomited, Licensed Staff F stated she would check the color and type of the vomitus (matter that has been vomited), check resident ' s vital signs (V/S - clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure), and mental status. During a telephone interview with Family Member H on 7/25/23 at 5:20 p.m. Family Member H stated she received a call from Resident 1 ' s nurse on Sunday night of 5/15/22 to inform her that Resident 1 was throwing up. Family Member H stated when she visited Resident 1 on 5/17/22, Resident 1 complained of severe abdominal pain. Family Member H stated she told the nurse on that same day that Resident 1 had an infection and that the facility need to do something about it; however, Family Member H stated the nurse did not do anything. Family Member H stated Resident 1 was transferred to the hospital via ambulance after 20 hours from the time she visited Resident 1. Family Member H stated Resident 1 died on 5/19/22 due to sepsis from UTI. During an interview with Licensed Staff G on 8/01/23 at 3:25 p.m., Licensed Staff G was asked about her nurse ' s note on 5/16/22 at 10:48 p.m. when she indicated Resident 1 had vomited three times within a 12-hour period. Licensed Staff G stated she received a report from the morning nurse on 5/16/22 that Resident 1 had vomited once during day shift. Licensed Staff G stated Resident 1 vomited a couple more times on p.m. shift. Licensed staff G stated she obtained an order for Zofran from the doctor. After review of Licensed Staff G ' s nurse ' s notes on 5/16/22 at 10:48 p.m., Licensed Staff G verified her nurse ' s note about Resident 1 ' s vomiting did not include Licensed Staff G ' s physical assessment of Resident 1, except for checking Resident 1 ' s vital signs. When Licensed Staff G was asked what to assess when a resident vomited, Licensed Staff G stated she was a new nurse when the incident happened with Resident 1 and was not sure how to assess Resident 1. When Licensed Staff G was asked about the facility policy when a resident had vomited, Licensed Staff G stated the resident will be monitored and assessed for complications associated with resident ' s vomiting every shift for 72 hours. After review of Resident 1 ' s progress note with Licensed Staff G, Licensed Staff G verified and stated there was no nurse ' s note on 5/16/22 from day shift about Resident 1 ' s vomiting episode. Licensed Staff G stated there were no other notes after her 5/16/22 nurse ' s note about Resident 1 ' s vomiting episode until 5/18/22 when resident was transferred to the hospital. During a review of the May 2022 MAR for Resident 1 and concurrent interview with Licensed Staff G on 8/01/23 at 3:28 p.m., the MAR indicated an order written on 5/16/23 at 6:30 p.m. for Ondansetron 4 mg to be given every 4 hours as needed for nausea and vomiting. Licensed Staff G verified the MAR indicated that first dose of Ondansetron was given at 8:51 p.m. When Licensed Staff G was asked reason for giving the medication at 8:51 p.m. when she received the order at 6:30 p.m., Licensed Staff G stated she gave the medication to Resident 1 at 6:15 p.m.; however, Licensed Staff G stated she forgot to sign off the medication. Licensed Staff G stated she should have signed off the medication as soon as the medication was administered to Resident 1. Review of the document titled Certificate of Death issued on 6/07/22 for Resident 1 indicated Resident 1 died on 5/19/22. The certificate indicated, Immediate Cause (Final disease or condition resulting in death) was Septic Shock and Urinary Tract Infection. The certificate indicated Small Bowel Obstruction was the underlying cause of Septic Shock. Review of the facility policy and procedure titled, Change in a Resident's Condition or Status, revised in February 2021 indicated, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. ' Review of the facility policy and procedure titled, Documentation of Medication Administration, revised in April 2007 indicated, Administration of medication must be documented immediately after (never before), is given. 2. During a record review for Resident 1, the Colostomy Care Plan initiated on 9/13/18 indicated, Resident 1 had a colostomy for elimination of stool (feces). The Care Plan indicated interventions including but not limited to: Colostomy care every shift; Monitor Colostomy for patency, adherence, output every shift; During a record review for Resident 1, the document titled Order Summary Report for May 2022 indicated a physician ' s order written on 12/08/19 for Dulcolax Suppository to be given rectally every 72 hours as needed for constipation. During a record review for Resident 1, the document titled Order Summary Report for May 2022 indicated a physician ' s order written on 7/25/21 for Milk of Magnesia to be given every 24 hours as needed for constipation. During an interview and concurrent review of the document titled Documentation Survey Report for May 2022 with Licensed Staff A on 8/01/23 at 2:29 p.m., Licensed Staff A was asked how the nurses monitored Resident 1 to ensure he was not constipated. Licensed Staff A stated she would check Resident 1 ' s bowel record to determine if Resident 1 needed bowel care (refers to a range of activities that help maintain bowel health including but not limited to administering treatments such as enemas [the injection of liquid into the rectum and colon by way of the anus] and suppositories [relieve pain, constipation, irritation, inflammation, nausea and vomiting, fever, migraines, allergies, and sedation]). After review of the Documentation Survey Report for May 2022 for Resident 1 with Licensed Staff A, Licensed Staff A verified Resident 1 did not have colostomy output (stool from the colostomy) on May 1, 2, 4, 6, 7, 8, 12, 13, and 14. During a review of the May 2022 Medication Administration Record (MAR) for Resident 1, and concurrent interview with Licensed Staff A on 8/01/23 at 2:36 p.m., Licensed Staff A verified Resident 1 had a physician ' s order for MOM and Dulcolax suppository as needed for constipation. Licensed Staff A verified the MAR did not have licensed nurses ' initials under the MOM and Dulcolax suppository order. Licensed Staff A stated, If there was no licensed nurses initial, the medication was not given. Licensed Staff A stated physician ' s order should be followed as ordered. During an interview with Licensed Staff B on 8/01/23 at 3:17 p.m., Licensed Staff B was asked what to monitor when a resident had colostomy. Licensed Staff B stated she would check the bowel record if the resident had regular bowel movement. Licensed Staff B stated resident should be provided with ordered bowel care if constipated. Licensed Staff B stated unresolved constipation could result to resident ' s discomfort like vomiting; abdominal pain, abdominal distention, or even fecal impaction (a large, hard mass of stool gets stuck in your rectum or colon and causes a blockage). During an interview and concurrent record review of the document titled Documentation Survey Report for May 2022 with the Clinical Lead on 8/01/23 at 4:06 p.m., the Clinical Lead stated all residents had a standing order for bowel care if resident had no bowel movement for three days. After review of the of the document titled Documentation Survey Report for May 2022 for Resident 1 with the Clinical Lead, the Clinical Lead verified Resident 1 had no colostomy output on May 12, 13, and 14. During a review of Resident 1 ' s May 2022 MAR with the Clinical Lead on 8/01/23 at 4:10 p.m., the Clinical Lead verified Resident 1 had a physician ' s order for MOM and Dulcolax suppository. The Clinical Lead verified there was no licensed nurses ' initials under both medications. The Clinical Lead stated Resident 1 did not received either MOM or Dulcolax suppository when Resident 1 was constipated. Review of the Facility policy and procedure titled, Bowel Management Protocol not dated indicated, It is the policy of this facility to ensure that residents are free from complications secondary to constipation. This will be accomplished through adequate assessment, tracking and treatment as indicated. The policy indicated, The nurse will provide medication as ordered by the physician or obtain a physician's order, to residents on the bowel care list. The medication given should be recorded on the MAR and the bowel care list. 3. During a record review for Resident 1, the Urostomy Care Plan initiated on 9/13/18 indicated, Resident 1 had a urostomy for urine output. The Care Plan interventions indicated: Provide Urostomy care as ordered; change urostomy appliance per order . Monitor Urostomy every shift for complications; notify MD if any noted . Educate Resident as able regarding care of urostomy and signs/symptoms to look out for . Monitor skin integrity under and around the Urostomy [site] every shift and address any skin issues appropriately. During a record review for Resident 1, the document titled Order Summary Report for May 2022 indicated a physician ' s order written on 12/08/19 to monitor Resident 1 ' s output (the fluids that leave the body) every shift. During an interview with Unlicensed Staff C on 8/01/23 at 2:04 p.m. when Unlicensed Staff C was asked if she documented the amount of Resident 1 ' s urostomy output, Unlicensed Staff C stated, no. Unlicensed Staff C stated the POC (Point of Care - an electronic health care record for residents) did not have a place where she could document the amount of the urine output, however, Unlicensed Staff C stated she would document every time she emptied the urostomy bag and reported to the nurse if Resident 1 did not have urinary output. During an interview with Unlicensed Staff D on 8/01/23 at 2:15 p.m., when Unlicensed Staff D was asked how she documented Resident 1 ' s urostomy output, Unlicensed Staff D stated she used the urinal to measure and documented to POC. During an interview with Unlicensed Staff E on 8/01/23 at 2:20 p.m., when Unlicensed Staff E was asked how he documented Resident 1 ' s urostomy output, Unlicensed Staff E stated he used the urinal to measure and documented the amount on a separate binder. During an interview and concurrent review of the May 2022 MAR with Licensed Staff A on 8/01/23 at 2:29 p.m., when Licensed Staff A was asked how Resident 1 ' s urine output was documented, Licensed Staff A stated the CNAs (Certified Nursing Assistant) used a container to measure the urine output and the nurses would document the output in Resident 1 ' s MAR. After review of the May 2022 MAR for Resident 1 with Licensed Staff A, Licensed Staff A verified there was no documentation of Resident 1 ' s urine output in Resident 1 ' s MAR. During an interview with Licensed Staff A on 8/01/23 at 2:36 p.m., When Licensed Staff A was asked what should nurses monitor when a resident had urostomy, Licensed Staff A stated she would monitor for the amount of the urinary output, color, and odor of the urine. Licensed Staff A stated that decreased urinary output, strong urine odor, dark colored urine, and constipation could be an indication of dehydration (caused by not drinking enough fluid or by losing more fluid than you take in). During an interview and concurrent review of the document titled Order Summary Report with the DON (Director of Nursing) on 9/05/23 at 3:21 p.m., when asked about her expectations from the nurses on what to monitor when a resident had a urostomy, the DON stated she expected the nurse to monitor the resident ' s intake and output (I & O - the measurement of the fluids that enter the body [intake] and the fluids that leave the body [output]) if there was an order from the resident ' s physician. After review of the May 2022 Order Summary Report for Resident 1 with the DON, the DON verified that there was an order written on 12/08/19 to monitor Resident 1's intake and output every shift. During a review of the document titled, Documentation Survey Report for May 2022 and concurrent interview with the DON on 9/05/23 at 4:23 p.m., the DON verified the document indicated, Resident 1 ' s bladder continence (the ability to control movements of the bladder) was documented; however, the document did not indicate Resident 1 ' s urine output was measured and documented. The document indicated no data entry on the following days and shifts: AM shift: 5/1/22, 5/2/22, 5/3/22, 5/4/22, 5/11/22, 5/12/22, 5/15/22, and 5/18/22; NOC shift: 5/3/22, 5/4/22, 5/5/22, 5/6/22, 5/9/22, 5/10/22, 5/11/22, 5/13/22, and 5/17/22. When the DON was asked if the facility documented the amount of Resident 1 ' s urine output, she stated there was a physician ' s order to monitor Resident 1 ' s I & O, however, she stated the order did not indicate strict I & O where the facility had to measure and document Resident 1's urine output. When the DON was asked how would staff know if Resident 1 had adequate fluid intake or had adequate urine output, the DON stated the doctor did not want the nurses to measure Resident 1 ' s urine output, however, the DON stated, if a resident had medical condition like Congestive Heart Failure, then they would monitor the intake and measure the output of the resident. Review of the Facility policy and procedure titled, Output, Measuring and Recording revised in October 2010 indicated, The purpose of this procedure is to accurately determine the amount of urine that a resident excretes (eliminate waste matter from the body) in a 24-hour period. The policy indicated, Record the amount noted on the output side of the intake and output record. Record in mls. (milliliters - a unit of volume). 4. During a record review for Resident 1, the Nutrition Care Plan initiated on 9/14/18 indicated interventions to include but not limited to: Assess for dehydration and notify MD: change in LOC, poor skin turgor, dry mucous membranes, decreased and dark urine output change in vital signs. During a record review for Resident 1, the document titled, Order Summary Report for May 2022 indicated a physician ' s order written on 12/25/22 for Torsemide (diuretic - also called water pill, are medications designed to increase the amount of water and salt expelled from the body as urine) Tablet 20 mg. Give 40 mg by mouth one time a day for Fluid retention (buildup of fluid in the body) related to Heart Failure. During a record review for Resident 1, the document titled Nutrition Assessment dated 1/19/21 indicated Resident 1 ' s estimated fluid needs was 2400 ml. The document indicated fluid estimate was calculated based on 25 ml per kg (kilogram - a metric unit of mass) of Resident 1 ' s body weight. During a record review for Resident 1, the document titled, Weights and Vitals Summary indicated Resident 1 had a body weight of 232.8 lbs. (pounds - unit of measurement) or 105.8 kg. (to convert pounds to kilograms, divide pounds by a factor of 2.2) on 5/02/22. During an interview and concurrent review of the May 2022 MAR with Licensed Staff A on 8/01/23 at 2:29 p.m., when Licensed Staff A was asked how Resident 1 ' s intake and output was documented, Licensed Staff A stated the CNAs used a container to measure the urine output and the nurses would document the I & O in Resident 1 ' s MAR. After review of the May 2022 MAR for Resident 1 with Licensed Staff A, Licensed Staff A verified there was no documentation of Resident 1 ' s I & O in Resident 1 ' s MAR. During an interview with Licensed Staff A on 8/01/23 at 2:36 p.m., When Licensed Staff A was asked on what to monitor when a resident had urostomy, Licensed Staff A stated she would monitor for the amount of the urinary output, color, and odor of the urine. Licensed Staff A stated decreased urinary output; strong urine odor; dark colored urine; and constipation could be an indication of dehydration. During a review of the MAR for Resident 1 with Licensed Staff G on 8/01/23 at 3:36 p.m., the MAR indicated an order written on 12/25/20 for Torsemide tablet to be given to Resident 1 once a day for fluid retention. Licensed Staff G was asked about the risk for Resident 1 on diuretic. She stated Resident 1 could be at risk for dehydration and constipation due to increased urination. Licensed Staff G was asked what should the nurses monitor when Resident 1 was receiving diuretic, Licensed Staff G stated they could monitor Resident 1 ' s weight, intake, and output. During a review of the document titled Nutrition Assessment dated 1/19/21 for Resident 1 and concurrent interview with the DON on 9/05/23 at 4:02 p.m., the DON verified the document indicated Resident 1 ' s estimated fluid needs was 2400 ml. During a review of the document titled Fluid Intake for Resident 1 and concurrent interview with the DON on 9/05/23 at 4:02 p.m., the DON verified that from 5/9/22 to 5/17/22, Resident 1 ' s documented daily total fluid intake on the following days were as follows: 1640 ml on 5/09/22; 960 ml on 5/10/22; 600 ml on 5/11/22; 240 ml on 5/12/22; 480 ml on 5/13/22; 680 ml on 5/14/22; 2 ml on 5/15/22; 1740 ml on 5/16/22 and; 1440 ml on 5/17/22. The DON concurred that Resident 1 ' s documented daily fluid intake was under his estimated fluid needs; however, DON stated Resident 1 had history of refusing to drink and often times did not like the food being served in the facility. The DON stated Family Member H would bring food and drinks for Resident 1; however, the DON stated facility staff were not recording Resident 1 ' s food and fluid intake when food or drink was brought in by Family Member H. The DON was asked if Resident 1 ' s refusal to drink fluid was documented, and what interventions were put in place to ensure Resident 1 was not dehydrated, considering Resident 1 was receiving a diuretic and had a colostomy and urostomy in place. After the DON reviewed Resident 1 ' s Care Plan, she stated there was a care plan initiated on 6/26/18 which indicated Resident 1 was non-compliant (failure or refusal to comply with something) with nursing care and nursing interventions. Care Plan interventions included: Encourage resident to verbalize concerns that is making him/her to refuse care or procedures . Inform resident of procedures and purpose prior to start . Inform resident of risk and ramifications (consequence of an action) of continued non-compliance . Monitor for significant changes in condition . Respect resident rights to refuse treatment/medications/care . When refusing care, if possible, leave resident and return later to reoffer. The DON concurred the care plan did not specifically indicate Resident 1 was refusing to drink fluid and the interventions did not indicate how the facility will ensure Resident 1 ' s hydration status was maintained to prevent Resident 1 from dehydration, constipation, and urinary tract infection. Review of the Facility policy and procedure titled, Intake, Measuring and Recording revised in October 2010 indicated, The purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. Under General Guidelines of the policy indicated: - Record the fluid intake as soon as possible after the resident has consumed the fluids. - At the end of your shift, total the amounts of all liquids the resident consumed. - Record all fluid intake on the intake and output record in cubic centimeters (mls).