**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #60) reviewed for accidents, the facility failed to provide feeding assistance according to the physician's order to ensure a dignified dining experience. The findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses that included dementia, cognitive communication deficit, and diabetes. A physician's order dated 1/18/24 directed Resident #60 to receive hospice services. The quarterly MDS dated [DATE] identified Resident #60 had severely impaired cognition, was always incontinent of bowel and bladder and required set up for meals and substantial assistance from staff with dressing, bathing and toileting. The care plan dated 10/29/24 identified Resident #60 had the potential for alteration in nutritional status related to dementia. Interventions included advanced meal set up, assistance with feeding, and offering individual parts of a meal at once (i.e. yogurt, then sandwich, etc.). A physician's order dated 11/1/24 directed a regular diet. A physician's order dated 12/18/24 directed Resident #60 have 1:1 feeding with all meals. Observation on 1/27/25 at 8:50 AM identified NA #3 assisted Resident #60 to a seat at a table in the dining room. NA #3 retrieved a meal tray from the food truck, placed the tray directly in front of Resident #60, which included yogurt. NA #3 opened the yogurt, placed a spoon in it, and offered it to Resident #60, and all other food items on the tray, including a main entrée, remained covered. NA #3 walked away from Resident #60 and assisted with delivering a meal to another resident at a different table, approximately 6 - 7 feet away from Resident #60, with her back turned 180 degrees from Resident #60. During this time, Resident #60 was observed making multiple attempts to self-feed, first by attempting to partially insert his/her lower face and mouth into the yogurt and attempting to lick the yogurt from the container. At 8:52 AM, Resident #60 inserted his/her right index and middle fingers into the yogurt and attempted to scoop the yogurt into his/her mouth. At 8:53 AM, Resident #60 was observed attempting to use the spoon, which had remained in the yogurt container during these attempts and began to self-feed with the spoon. NA #3 turned to look at Resident #60 and left the dining room. From 8:53 AM - 8:55 AM, Resident #60 remained unsupervised in the dining room with the meal tray position directly in front of him/her self-feeding the yogurt. At 8:55 AM, LPN #3 entered the dining room, removed Resident #60's yogurt from his/her hand, placed the yogurt on the meal tray, and removed the meal tray from the dining room and brought it to the unit pantry. During this time, NA #3 was observed entering the dining room and assisting another resident at the same table as Resident #60 and setting up the resident's meal tray, while Resident #60 remained seated at the table. Resident #60 was observed without a meal tray, with 2 other residents seated and eating in the dining room, from 8:55 AM - 8:58 AM. Interview with LPN #3 immediately following this observation identified she removed Resident #60's meal tray because the resident required 1:1 feeding assistance. LPN #3 identified that she was unsure why NA #3 would have left the tray with Resident #60. Observation on 1/27/25 at 8:59 AM identified a male staff member bringing Resident #60's meal tray back to his/her table, setting the tray up including removal of the entrée lid, drink lids, and then sat directly next to Resident #60 and provided feeding prompts and assistance by offering food items. The male staff member remained with Resident #60 for the duration of his/her meal. Interview with NA #3 on 1/27/25 at 9:55 AM identified she was aware that Resident #60 had an order for 1:1 feeding with meals, however this was not a strict rule if Resident #60 was given one item at a time. NA #3 identified she believed that Resident #60 was okay to eat some items independently, while other items required 1:1 feeding, and yogurt was an item Resident #60 was fine to eat independently but other items on his/her tray required feeding assistance. Interview with the Dietitian on 1/27/25 at 10:00 AM identified Resident #60 had an order for 1:1 feeding with all meals due to his/her continued cognitive decline and need for supervision and prompts with meals. The Dietitian identified Resident #60 was on hospice services due to advanced dementia, and due to the advanced stage of cognitive decline, Resident #60 would often forget how to eat, including how self-feed and use utensils. The Dietitian identified due to the decline, Resident #60 required 1:1 assistance to have a staff member remind him/her how to use a fork, for example, and that staff should also be setting Resident #60's meal tray, including removing the lids and covers from food and drink items. The Dietitian identified that Resident #60 did not have any selective 1:1 food item list, and while Resident #60 can self-feed, he/she required a staff member to sit with him/her for the entire meal and to provide multiple prompts and reminders through the duration of the meal. Interview with the DNS and ADNS on 1/27/25 at 10:05 AM identified Resident #60 required 1:1 feeding assistance due to cognitive deficits with self-feeding and not due to risk of aspiration. The DNS identified that Resident #60 can self-feed with each meal, but a staff member must sit with him/her for the duration of the meal. The ADNS identified that someone should have been sitting with Resident #60 during his/her meal, and that she and the DNS would speak with the staff on Resident #60's unit to determine the issue. The facility policy on resident rights directed that residents of the facility had the right to a dignified existence and to be treated with respect, kindness, and dignity. The facility policy on assistance with meals directed that residents should receive assistance with meals in a manner that meets the individual needs of the residents. The policy further directed that facility staff would serve resident trays and help residents who required assistance with eating and residents who required feeding assistance would be treated with attention to safety, comfort and dignity. The facility policy on dignity, respect and neglect of care directed that facility staff could provide dignified care of residents by always checking on residents to assist with their needs during the shift and providing care in a dignified manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #48) reviewed for advance directives, the facility failed to ensure the physician's orders were consistent with the resident's wishes for code status. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, diabetes, and muscle weakness. The Resident/Patient Health Care Instructions for signed and dated by Resident #48's representative at admission on [DATE] identified Resident #48's advance directive choice was do not resuscitate (DNR). Physician's order dated 5/2/24 directed Resident #48 was a full code. Review of the clinical record identified Resident #48 was hospitalized from [DATE] - 11/21/24 for pneumonia. The Resident/Patient Health Care instructions form identified Resident #48 requested do not resuscitate (DNR). The form was signed and dated by Resident #48's representative on 11/21/24. The form further indicated it was not a physician's order and should be reviewed and a physician's order written. A physician's order dated 11/21/24 directed Resident #48 was a full code. Review of Resident #48's face sheet identified Resident #48's advance directive choice as DNR/DNI. The 5-day MDS dated [DATE] identified Resident #48 had severely impaired cognition. Review of the clinical record failed to identify a care plan related to Resident #48's advance directive choice. A resident care conference note dated 12/10/24 identified Resident #48's code status as DNR. Review of Resident #48's face sheet dated 1/27/25 identified Resident #48's advance directive choice as DNR/DNI. Interview with LPN #5 (Regional Nurse) on 1/27/25 at 10:39 AM identified that the admitting nurse is responsible to reconcile the resident's signed advance directive choices outlined on the health care instruction form and reconcile the choices against the physician's orders in the clinical record. LPN #5 identified she was unsure why the physician's order did not match Resident #48's choice of DNR but that it should have. Interview with LPN #1 on 1/27/25 at 10:55 AM identified that she was the admitting nurse for Resident #48 on 11/21/24. LPN #1 identified she was unsure why the physician's order directed full code when the resident's choice was DNR. LPN #1 identified that Resident #48's order did not match Resident #48's advance choices indicated on the health care instructions form. Although requested, the facility failed to provide a policy related to a clear and accurate clinical record. The policy on Advance Directives directed that information about whether or not a resident had executed an advance directive would be displayed prominently in the clinical record, and the plan of care for the resident would be consistent with the resident's documented treatment preferences and/or advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #56 and 84) reviewed for a specialty medical treatment and/or nutrition, for Resident #56 the facility failed to notify the physician and/or and the specialized treatment center when the resident was over the fluid restriction and for Resident #84 the facility failed to ensure the physician and resident representative were notified when the resident had a weight loss. The findings include: 1. Resident #56 was admitted to the facility in May 2024 with diagnoses that included end stage renal disease requiring peritoneal dialysis and a stroke affecting the right dominant side. A monthly physician's order dated 11/8/24 directed a fluid restriction of 1000 ml per day. The quarterly MDS dated [DATE] identified Resident #56 had intact cognition and required moderate assistance with toileting and personal hygiene. The care plan dated 11/29/24 identified Resident #56 receives peritoneal dialysis for end stage renal disease. Interventions included to monitor fluid intake, 1000 ml within 24 hours. Review of the Fluid Intake Report dated 12/1/24 to 12/31/24 identified Resident #56 had gone over the fluid restriction 28 out of 31 days. Review of the Fluid Intake Report dated 1/1/25 to 1/28/25 identified Resident #56 had gone over the fluid restriction 26 out of 28 days. Review of the nursing and physician progress notes dated 12/1/24 to 1/28/25 failed to reflect that the physician had been notified that Resident #56 had gone over fluid restriction 54 days out of 59 days. Interview with LPN #4 on 1/29/25 at 9:40 AM indicated Resident #56 was on a 1000 ml fluid restriction per physician order. LPN #4 indicated that the charge nurse is responsible to document the fluid intake into the EMR every shift. LPN #4 indicated that the 11:00 PM to 7:00 AM supervisor was responsible for adding up the 24-hour totals of fluid intake to see if a resident goes over their fluid restriction and notify the physician and dialysis center. Interview with RN #4 (7:00 AM to 3:00 PM day supervisor) on 1/29/25 at 10:17 AM indicated that the 11:00 PM to 7:00 AM RN supervisor was responsible to add the 24-hour intakes for residents on a fluid restriction. RN #4 indicated that if Resident #56 went over the fluid restriction, the supervisor is responsible to notify the dialysis center and the physician and document it in the medical record. Interview with the DNS on 1/29/25 at 10:22 AM indicated that if a resident on a fluid restriction goes over the fluid restriction more than 5 - 10 ml's the APRN or physician must be notified and the nurse must write a progress note indicating such. The DNS indicated that the 11:00 PM to 7:00 AM RN supervisor was responsible to add up each day's fluid totals for residents on fluid restrictions. The DNS indicated that if the resident went over the fluid restriction the night supervisor would inform the day supervisor to call or inform the APRN that day. After review of the progress notes the DNS indicated the notes failed to reflect the dialysis center or the APRN had been notified that Resident #56 had gone over the fluid restriction. Interview with MD #1 on 1/29/25 at 10:53 AM indicated that if a peritoneal dialysis resident is on a 1000 ml fluid restriction every day nursing was responsible to calculate the 24-hour totals. MD #1 indicated that if Resident #56 went over the fluid restriction he should be notified that day and documented in the clinical record. Review of the Change in a Resident's Condition or Status identified the facility will promptly notify the resident, physician, and the resident's representative of changes in the residents medical/mental condition and/or status. The nurse will notify the residents physician if there has been a significant change in the resident's physical, emotional, or mental condition or need to alter the resident's medical treatment. Notifications will be made within 24 hours of a change occurring in the resident's medical condition or status, except in medical emergencies. The nurse will record in the medical record information related to changes. Although requested, a facility policy for dialysis residents on fluid restrictions was not provided. 2. Resident #84 was admitted to the facility in July 2024 with diagnoses that included stroke, dysphasia, and dementia. Review of the weight record dated 7/24/24 identified Resident #84 weighed 156 lbs. A physician's order dated 8/13/24 directed to weigh the resident daily and if weight loss is greater than 2 lbs. in a day or 5 lbs. in 7 days notify the physician/APRN. A physician's order dated 8/14/24 directed to provide a dysphasia puree diet but allow ground meats and soft sandwiches and thin liquids. Additionally, provide house supplement 237 ml twice a day. The quarterly MDS dated [DATE] identified Resident #84 had severely impaired cognition, was independent to eat, did not have a weight loss of 5% in the last month or loss of 10% in the last 6 months. The care plan dated 9/24/24 identified Resident #84 has the potential for alteration in nutritional status related to dementia. Interventions included evaluating the nutritional status on admission, per the MDS schedule and as needed and report any concerns or changes to the physician and resident representative. Review of the weight record dated 10/4/24 identified the resident weighed 150 lbs., (a 6 lbs. weight loss in 3 months). Review of the weight record dated 11/10/24 identified Resident #84 weighed 138 lbs., (a 12 lbs. weight loss in 1 month, 18 lbs. in 4 months). Review of the nurse's progress notes, APRN, and physician notes dated 11/10/24 - 12/11/24 failed to reflect that the APRN, physician, or resident representative were notified of the resident's weight loss. Further, review of the clinical record dated 11/10/24 to 12/11/24 failed to reflect that Resident #84 was seen by the dietitian subsequent to the weight loss. Review of the weight record dated 12/2/24 identified Resident #84 weighed 133 lbs., (a 5 lbs. weight loss in 1 month). Review of the nurse's progress notes, APRN, and physician notes dated 12/2/24 - 12/12/24 failed to reflect that the APRN, physician, or resident representative were notified of the continued weight loss. Review of the clinical record dated 12/2/24 to 12/11/24 failed to reflect that Resident #84 was seen by the dietitian for a weight loss. The dietitian progress note dated 12/12/24 at 11:19 AM identified a significant weight loss trend. Recommendations included orders for house supplement 237 ml twice daily, and liquid protein 30 ml daily remain appropriate to maximize protein and caloric intake. The APRN progress note dated 12/13/24 at 9:44 PM identified Resident #84 was seen for a significant weight loss of 11 lbs. over the past month. Resident #84 is tolerating diet order without difficulty. Resident #84 has variable oral intakes of 50-100% of meals. Assessment and plan resident has poor oral intake decreased, poor appetite, will have speech therapy evaluate resident for a diet upgrade, dietitian evaluated resident, food preferences upgraded, monitor intakes and weights. Interview with the Dietitian on 1/27/25 at 10:30 AM indicated that she had seen Resident #84 in August 2024, and not again until the quarterly MDS assessment on 12/12/24. The Dietitian indicated that it was nursing's responsibility to notify her when a resident had a weight loss right away so she could evaluate the resident. The Dietitian indicated she was not aware of the significant unplanned weight losses on 11/10/24 and 12/2/24 until she reviewed the clinical record on 12/12/24. Interview with MD #1 on 1/27/25 at 10:48 AM indicated when Resident #84 had a significant weight loss the APRN or physician, and the resident representative, and dietitian should have been notified. Further, the notification should be documented in the clinical record. Interview with the DNS on 1/27/25 at 11:07 AM indicated that when a resident has a weight loss the nurse is responsible to notify the dietitian, physician, and residents' representative. After clinical record review, the DNS indicated that Resident #84's weight loss the physician, dietitian, and resident representative should have been notified. The DNS indicated that she did not see a progress note of anyone being updated. Review of the Change in a Resident's Condition or Status identified the facility will promptly notify the resident, physician, and the resident's representative of changes in the residents medical/mental condition and/or status. The nurse will notify the residents physician if there has been a significant change in the resident's physical, emotional, or mental condition or need to alter the resident's medical treatment. A significant change of condition is a major decline or improvement in the resident's status requires interdisciplinary review and/or revision to the care plan. Notifications will be made within 24 hours of a change occurring in the resident's medical condition or status, except in medical emergencies. The nurse will record in the medical record information related to changes. Review of the Weight Monitoring Policy identified nursing was responsible for notifying the dietitian of any significant weight changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #70) reviewed for pre-admission screening and resident review (PASARR), the facility failed to ensure the State-designated authority was notified when the resident was diagnoses with a new mental health diagnosis (10/20/21) and again when the physician discontinued the mental health diagnosis on 10/13/23. The findings include: Review of a PASARR Level 1 screen dated 8/5/21 identified no level 2 required. Resident #70 has anxiety and depression and was receiving Klonopin (anxiety medication), Lexapro (antidepressant medication), and Wellbutrin (antidepressant). If changes occur or new information refutes these findings, a new screen must be submitted. Resident #70 was admitted to the facility on [DATE] with diagnoses that included anxiety, depression, and dysthymic disorder (mild but long-term depression). The admission MDS dated [DATE] identified Resident #70 had intact cognition, no delusional or hallucinating thoughts and no physical or verbal behaviors. A physician's order dated 8/26/21 directed to administer Abilify 5 mg (anti psychotropic medication) once daily at bedtime. A PASARR Level 1 screen dated 9/22/21, conducted because the resident came off insurance on 9/4/21 identified Resident #70 has diagnosis of depressive disorder, unspecific mood disorder, anxiety, and dysthymic disorder. Approved for long-term care based on information provided. If medical conditions improve to the point that the resident can safely return to the community, the facility should assist with discharge planning with appropriate support services. The effective date is 9/4/21. The psychiatric evaluation and consultation, written by MD #3, dated 10/20/21 at 1:23 PM identified given history of symptoms it would be appropriate to add the diagnosis of schizoaffective disorder to the diagnosis list. Tapering of psychotropic medication will lead to worsening of symptoms. The Psychiatric Evaluation and Consultation, written by MD #3, dated 10/13/23 (2 years later) identified based upon symptoms, etiology of current disease, and response to recent medication trials, it would be prudent to discontinue the diagnosis of schizoaffective disorder. Will recommend a gradual dose reduction trial of antipsychotics as tolerated and if indicated. Interview with the SW #1 (Director of Social Services) on 1/27/25 at 7:20 AM indicated she was responsible to oversee all PASARRs starting with admission. Further, she was also responsible to track Level 2 PASARRs, update as needed and ensure all Level 2 recommendations are followed and care planned. SW #1 indicated that when the psychiatric provide adds or discontinues a diagnosis it is their responsibility to notify her so she can update State-designated authority. SW #1 indicated that if she was notified of the new diagnosis or discontinuation of the diagnosis of schizoaffective disorder for Resident #70, she would have notified State-designated authority. Review of the Coordination with PASARR Program Policy identified the facility coordinates assessments with the pre-admission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental health disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. PASARR Level 1 is the initial pre-screening that is completed prior to admission. Negative Level 1 Screen permits admission to proceed and ends the PASARR process. Positive Level 1 Screen necessitates a PASARR Level 2 evaluation prior to admission. PASARR Level 2, a comprehensive evaluation by the appropriate state-designated authority, (cannot be completed by the facility) that determines the appropriate setting for the individual and recommends any specialized services and/or rehabilitation services the individual needs. The facility will only admit individuals with a mental disorder or intellectual disability who the State-designated authority has determined as appropriate for admission. Recommendations, such as any specialized services, from a PASARR Level 2 determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transition of care. Any Level 2 resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. Any resident who exhibits a newly evident or possible serios mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual authority for a level 2 resident review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #24, 81 and 312) reviewed for nutrition and/or choices, for Resident #24 the facility failed to ensure the air mattress was set per the physician's order, for Resident #81 the facility failed to ensure the resident had close supervision during meals and for Resident #312 the facility failed to ensure that weights were obtained per the physician's order The findings include: 1. Resident #24 was re-admitted to the facility in September 2024 with diagnoses that included stroke and a stage 4 pressure ulcer. The annual MDS dated [DATE] identified Resident #24 had severely impaired cognition and was dependent requiring total assistance for dressing, toileting, and personal hygiene. Resident #24 was always incontinent of bladder and frequently incontinent of bowel and at risk for developing a pressure ulcer. A physician's order dated 12/3/24 directed to utilize a specialty mattress with the setting at 210 lbs. Check function and settings every shift from 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM The care plan dated 12/12/24 identified Resident #24 was at risk for a pressure ulcer due to impaired mobility and incontinence. Interventions included having a pressure-reducing mattress, a cushion to bed and wheelchair as ordered. Review of the weight report dated 12/5/24 identified Resident #24's weighed 210 lbs. Review of the weight report dated 1/8/25 identified Resident #24's weighed 208 lbs. Observation on 1/26/25 at 8:43 AM and 2:00 PM identified Resident #24 was lying in bed on an air mattress in a semi upright position. The air mattress was set to 270 lbs. Observation on 1/27/25 at 8:00 AM and 8:30 AM identified Resident #24 was lying in bed on air mattress in a semi upright position. The air mattress was set to 270 lbs. Interview with LPN #2 on 1/27/25 at 8:45 AM indicated that according to the physician's order, the air mattress was to be set at 210 lbs., and the nurse on each shift must check the setting and then sign off that it had been checked in the EMR that the setting was accurate. LPN #2 indicated that the air mattress is to be set according to the resident's weights to be therapeutic to prevent skin breakdown. LPN #2 indicated that Resident #24 would not be able to state if the air mattress was too soft or too hard. Observation with LPN #2 on 1/27/25 at 8:47 AM indicated that Resident #24 was lying in bed on the air mattress that was set at 270 lbs. LPN #2 indicated that the setting of 270 lbs., was not correct, and she would re-set it to the 210 lbs. as ordered by the physician. Interview with the DNS on 1/28/25 12:34 PM indicated that the air mattress is set based on the resident's weight and the physician's order. The DNS indicated that the nurses are to check the setting every shift and make sure it is set according to the physician order. The DNS indicated there is a sticker with the resident's weight and what the setting should be located on the face of the machine. The DNS indicated that the charge nurse was responsible to check the air mattress every shift to make sure the setting was the same as the physician's order and resident's weight and then sign off in the EMR. Review of the manufacturer manual for air mattress identified the pump and mattress system is indicated for the prevention and treatment of all pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. Turn the machine on and determine the resident's weight and set the control knob to that weight setting on the control unit. Although requested, a facility policy for use of air mattress was not provided. 2. Resident #81 was admitted to the facility in December 2021 with diagnoses that included dementia and a stroke affecting the right dominant side. The annual MDS dated [DATE] identified Resident #81 had severely impaired cognition and was totally dependent on staff for toileting, dressing, and personal hygiene. Additionally, Resident #81 needed partial assistance with eating. A physician's order dated 12/5/24 directed a dysphagia puree diet with ground meats and soft sandwiches with close supervision during meals. The care plan dated 12/12/24 identified Resident #81 was at risk for weight loss. Interventions included to use a sippy cup with meals, diet mechanical soft with thin liquids. Aspiration precautions and monitor eating closely. Encourage to use feeding skills as much as he/she could and assist times 1 as needed. Observation on 1/26/25 at 9:00 AM identified Resident #81, who was in a semiprivate room, by the window with the curtain pulled from the head to the foot of the bed, (not able to be seen from the door) was lying in bed in upright position with breakfast tray in front of him/her with closed eyes. The breakfast tray was untouched and contained a scoop of puree eggs and scoop of puree bread. There was a built-up spoon on the side of the tray not used, the coffee was in a brown cup (not a sippy cup) and a carton of milk was opened. The orange juice cup had the metal cover peeled back halfway. NA #1 had dropped off the tray and continued passing trays. Interview with NA #1 on 1/26/25 at 9:10 AM indicated that she had given Resident #81 his/her breakfast meal this morning and indicated Resident #81 eats breakfast in his/her room daily with the privacy curtain pulled all the way and is not visible from the doorway. NA #1 indicated that Resident #81 was responsible for feeding him/herself and did not require supervision. Interview with RN #3 on 1/26/25 at 9:17 AM indicated that Resident #81 feeds him/herself to start and just needs cueing during the meal. RN #3 indicated that the nurse aides were to provide supervision and after the resident has a chance to feed him/herself then provide assist with eating to finish meal. RN #3 identified Resident #81 was behind the pulled privacy curtain and not visible from the doorway while left with the breakfast tray. RN #3 indicated that the nurse aide will come back and assist Resident #81 with eating after resident has had time to eat independently. Observation on 1/27/25 at 8:20 AM identified NA #2 entered the room with the breakfast tray. Resident #81 was sitting upright in bed with eyes closed. The breakfast tray had a flat plate with a scoop of puree eggs and a scoop of puree bread per the meal ticket. NA #2 removed the cover from the main meal and placed the weighted spoon in it. NA #2 did not uncover the hot liquid cup, did not open the 8oz milk cartoon, and did not open the disposable container of orange juice. NA #2 left the room. Resident #81's privacy curtain was pulled completely between the beds so Resident #81 was not visible from doorway. Interview with NA #2 on 1/27/25 at 8:45 AM identified she had delivered Resident #81's breakfast tray. NA #2 indicated Resident #81 could eat by him/herself and just needed to be set up. NA #2 indicated that she does not know why she did not open the drinks and set up the meal tray. NA #2 indicated that she was planning on going back after passing the rest of the breakfast trays and a resident wanted his/her coffee heated in the microwave. NA #2 indicated that Resident #81 was to have supervision during meals and eats breakfast in bed and lunch in the dining room. NA #2 indicated that the privacy curtain was pulled and Resident #81 was not visible from the hallway, but she was planning on going back to assist Resident #81 with breakfast. Interview with LPN #2 on 1/27/25 at 8:50 AM indicated that Resident #81 needed to be set up for meals. LPN #2 indicated that Resident #81 will start to feed him/herself but then staff need to assist. LPN #2 indicated that Resident #81 needed to be supervised for all meals, but staff can do that from the hallway when they pass by the room. LPN #2 identified the privacy curtain was pulled and Resident #81 was not visible from the hallway and the curtain would need to be pulled back. Interview with the Rehab Director on 1/28/25 at 10:53 AM indicated that Resident #81 required self-feeding with supervision and or cueing with meals which means the resident must be visually seen by a staff person during the meal. Interview with OTA #1 on 1/28/25 at 11:55 AM indicated that Resident #81 was last seen for therapy related to eating in December 2021, but she had worked with Resident #81 in September of 2024. OTA #1 indicated that Resident #81 must have close supervision will all meals because he/she needs cueing to eat due to dementia. OTA #1 indicated that supervision means the nurse aide must be able to visually observe the resident for entire meal. OTA#1 indicated that Resident #81 cannot be in bed with the curtain pulled for meals unless the nurse aide stays in the room behind the curtain with the resident throughout the whole meal. Interview with the DNS on 1/28/25 at 12:26 PM indicated her definition of supervision with meals means the resident would have to eat in the dining room so the nurse aides can visually see the resident. Review of the Resident Meal Pass Policy purpose is to provide appropriate assistance for residents who choose to receive meals in their rooms. Review the residents care plan and provide the special needs of the resident. Check the meal tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. Ensure that the necessary non-food items are on the tray. Report or replace missing items such as silverware, napkins, special devices, etc. 3. Resident #312 was admitted to the facility in January 2025 with diagnoses that included hemiplegia following stroke, urinary tract infection, and chronic kidney disease. The physician's order dated 1/16/25 directed to obtain weights on admission and consecutively for 2 days and then to obtain monthly weights on the 3rd Monday of every month. Review of the clinical record identified Resident #312 had an admission weight of 94.6 lbs. on 1/16/25. A physician admission note dated 1/17/25 identified Resident #312 had a developmental disability, was nonverbal at baseline and admitted from the hospital due to urinary tract infection requiring daily antibiotics via a PICC line. Resident #312 had a history of diabetes requiring Insulin, and had a low grade hypernatremia with concern for malnutrition thought to be related to oral intake. The care plan dated 1/17/25 identified Resident #312 required mechanically altered diet due to dysphagia and stroke. Interventions included providing diet and supplements as ordered. The January 2025 TAR identified licensed staff signed that weights had been obtained on 1/17, 1/18 and 1/20/25 however, the clinical record failed to identify the weights for 1/17, 1/18 and 1/20/25. The admission MDS dated [DATE] identified Resident #312 had severely impaired cognition, was dependent on staff to assist with eating, bathing, and toileting. A physician's order dated 1/23/25 directed to obtain weekly weights x 4 weeks every Monday at 9:00 AM. Interview with Person #2 on 1/26/25 at 12:47 PM identified that he/she notified facility staff that Resident #312 was very picky regarding food choices. Review of the January TAR on 1/27/25 at 2:00 PM identified the weekly weight ordered to be obtained on 1/27/25 at 9:00 AM was signed off as obtained, however, no weight could be found. Review of the clinical record identified LPN #3 as the nurse who signed off that the weights on 1/16, 1/17, 1/20, and 1/27/25 had been obtained. Interview and review of the clinical record with LPN #3 on 1/27/25 at 2:21 PM identified she initially could not recall signing off the TAR for Resident #312's weights on 1/17 and 1/20/25. LPN #3 identified that while she had signed off Resident #312's weight for 1/27/25 at 9:00 AM as obtained, she had not obtained the resident's weight and identified that since Resident #312 required a hoyer lift for transfers to a motorized wheelchair, she was waiting until Resident #312 was going to be transferred back to bed to obtain the weight. LPN #3 identified she worked the 7:00 AM - 3:00 PM shift and indicated Resident #312 probably would not be transferred back to bed prior to the end of her shift. LPN #3 identified that she typically signed off the weight orders in the TAR and then made a note to herself to obtain the weight at a later time during the shift and document the weight in the clinical record. Subsequent to surveyor inquiry, Resident #312 was weighed 1/27/25 at 2:29 PM and had a weight of 98 lbs. Interview with the DNS on 1/29/25 at 12:05 PM identified it was her expectation that when a physician's order was in place related to obtaining weights, that the nurse who signs off in the MAR or TAR that the weight had been obtained, had actually obtained the weight and documented it in the clinical record. The facility policy on weight assessment and intervention directed that the nursing staff would measure and obtain weights on admission, the next 2 days, weekly for 4 weeks and then monthly if no concerns. The policy further directed that the weights would be recorded in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #37) reviewed for pressure ulcers, the facility failed to complete the Braden Scale (a tool used to assess a resident's risk of developing a pressure ulcer) weekly after admission per the physician's order, failed to ensure that a wound care physician's recommendation was implemented, and failed to ensure that a thorough RN assessment of the residents pressure ulcers was completed following re-admission. The findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, muscle weakness, and anemia. A physician's order dated 11/14/22 directed to complete a Braden Scale weekly for 4 weeks. A Braden Scale dated 11/14/22 identified Resident #37 had a score of 20, indicating the resident was not at risk for the development of pressure ulcers. a. Review of the clinical record failed to identify any additional weekly Braden scale documentation following Resident #37's initial assessment on 11/14/22. A nurse's note dated 11/14/22 at 1:44 PM identified the admission skin audit indicated Resident #37 had a scar on the coccyx and discoloration on the buttocks. The care plan dated 11/16/22 identified Resident #37 was at risk for skin breakdown related to bowel and bladder incontinence. Interventions included keeping the skin as clean and dry as possible and minimizing skin exposure to moisture. The admission MDS dated [DATE] identified Resident #37 had severely impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder and required moderate staff assistance with bathing, toileting, and dressing. The MDS further identified Resident #37 was at risk to develop pressure ulcers. A wound care note, written by MD #4, the Wound Care Physician, dated 11/21/22 identified Resident #37 was seen for wound evaluation of coccyx and buttocks related to moisture. The note identified a wound to the coccyx had resolved and recommendations included to apply Dermaseptin (a zinc oxide-based barrier cream) daily and as needed. The plan of care was discussed with LPN #1 (Wound Care Nurse). b. Review of the clinical record failed to identify the Dermaseptin, or any other zinc-based barrier cream, according to MD #4's recommendation, had been implemented. Review of clinical record identified Resident #37 was sent to the hospital on 1/18/23 related to a possible gastrointestinal bleed. A weekly skin assessment dated [DATE] by LPN #1, completed while Resident #37 was hospitalized and outside of the facility, identified Resident #37 had clean, dry and intact skin with no alterations observed. The hospital discharge paperwork identified Resident #37 was discharged from the hospital on 1/21/23 following a gastrointestinal hemorrhage. The hospital discharge paperwork identified Resident #37 was found to have a stage IV pressure ulcer to the coccyx and deep tissue injury to the left buttock with recommendations including multiple treatments and to continue cleansing the wound with normal saline, daily dressing changes and with soiling, Silvadene ointment to the coccygeal wound bed, 40 % zinc oxide paste to the peri wound and left buttock, and to cover the coccyx/buttocks with bordered foam. A physician's order dated 1/21/23, following readmission to the facility, directed to complete a Braden Scale weekly for 4 weeks. A Braden Scale dated 1/21/23 identified Resident #37 had a score of 20, indicating the resident was not at risk for development of pressure ulcers. A nursing admission assessment, completed by LPN #2, on 1/21/23 at 1:55 PM, identified Resident #37 was always continent of urine and bowel and was observed to have an open area to the coccyx that measured 1.0 cm x 0.3 cm with no depth. The note further identified no wound care observation was performed and failed to identify documentation or an assessment of the left buttock DTI identified in the hospital discharge documentation. A nurse's note dated 1/21/23 at 3:08 PM by RN #7 identified Resident #37 was readmitted to the facility at 11:30 AM following hospitalization for GI bleed. The note further identified Resident #37 was observed to have an open area to the coccyx with treatment in place. c. Review of the clinical record failed to identify an RN assessment of Resident #37's left buttock deep tissue injury and stage IV pressure ulcer to the coccyx, including wound measurements and appearance, which had been noted in the hospital discharge paperwork had been completed on admission. Interview and clinical record review with LPN #1 on 1/28/25 at 11:24 AM identified that she completed weekly wound rounds with MD #4 after she became the wound care nurse in September 2022. LPN #1 identified that she was present when MD #4 evaluated Resident #37 on 11/21/22 and he ordered Dermaseptin to be started. LPN #1 identified it was her responsibility to place the order in the clinical record as a telephone order to ensure that the treatment was started. Review of the clinical record with LPN #1 identified the treatment was not in place following the 11/21/22 wound rounds. LPN #1 identified she also worked as a unit manager and that the new additional role of wound care nurse at that time was very overwhelming, which may have been why the order was not placed, but she should have taken care of it. LPN #1 identified she did not know why she documented a skin assessment on 1/20/23 while the resident was out of the facility and in the hospital and identified the volume of her workload in multiple roles at the facility as a possible cause. Interview with RN #7 (RN Supervisor) on 1/28/25 at 2:14 PM identified that she documented her RN admission assessments under the nurse's notes in the clinical record. RN #7 identified she usually reviewed the hospital discharge paperwork for all residents who are admitted or re admitted to the facility and ensured all orders are in place including reviewing medications. RN #7 identified that she did not remember Resident #37 having any wound treatments following the re admission, but due to the amount of time that had passed, she was not sure. RN #7 identified that she would have placed wound measurements in the note if she had assessed and measured the wounds when Resident #37 was readmitted to the facility on [DATE]. RN #7 identified that she should have reviewed Resident #37's hospital discharge paperwork from 1/21/23 and noted any pressure ulcers and treatments identified in the documentation present upon readmission and if that she did not document the details in her nurse's note, she did not complete a full assessment of the wounds. Interview with LPN #5 (Regional Nurse) on 1/29/25 at 8:15 AM identified that the facility utilized non medicated barrier creams that did not require a physician's order. LPN #5 identified that any barrier cream that was medicated, including zinc oxide-based barrier creams, required a physician's order and were to only be administered by a licensed nurse. LPN #5 identified that the order would populate on the TAR and the nurse would sign off the cream as administered based on the order in place. Interview with MD #4 on 1/29/25 at 9:48 AM identified that he had been treating Resident #37 for several years related to recurrent pressure ulcers of the coccyx and that when he saw and evaluated Resident #37 on 11/21/22, Resident #37 had a healed closed area on the coccyx from a previous pressure injury. MD #4 identified that he specifically ordered Dermaseptin daily and as needed for Resident #37 related to his/her history of being very incontinent and identified that a zinc oxide based barrier cream was needed to protect Resident #37's skin from moisture and breakdown to prevent further pressure injuries. MD #4 identified he was not aware the treatment had not been implemented. Interview with the DNS on 1/29/25 at 12:05 PM identified that it was the responsibility of the RN supervisor to review the hospital discharge paperwork and complete the initial physical exam of any resident newly admitted or readmitted to the facility. The DNS identified that the LPN assigned to care for the resident would also document following admission and readmission. The DNS identified that a resident who was admitted with a pressure ulcer or wound should have a wound assessment completed on admission under the wound observation assessment in the electronic record which would include the measurements and wound appearance at the time of admission. The DNS identified the Braden Scale assessments were ordered weekly for 4 weeks on admission by the physician and she would expect the nursing staff to ensure that the assessments were completed per the order and identified any resident with a pressure ulcer present on admission should have a risk of pressure ulcers per the Braden Scale if entered correctly. The DNS also identified it was the responsibility of LPN #1 to ensure that any treatment orders added to the resident's wound were entered into the physician's orders in the electronic record to ensure treatment was initiated. The facility policy on pressure ulcers/skin breakdown directed that incidence of new pressure ulcers would be minimized and healing of existing pressure ulcers would be optimized to the extent possible. The policy also directed that nursing staff would assess and document an individual's risk factors for developing pressure ulcers and examine the skin of newly admitted residents for evidence of existing pressure ulcers and other skin conditions. The policy further directed that the physician would help identify contributing factors to skin breakdown, including macerated or friable skin, and would order pertinent treatment for treating a wound including the application of topical agents. The facility policy on resident examination and assessment directed the purpose of the policy was to examine and assess the resident for any abnormalities in health status. The policy further directed that the skin assessment should include assessment findings related to intactness, color, texture and the presence of any pressure ulcers and all assessment data should be recorded in the resident's medical record. The facility policy on physicians' orders directed that verbal orders must be recorded immediately in the resident's chart by the person receiving the order, and must include the name and strength of the drug, the dosage, route and frequency of administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 (Resident #84) reviewed for nutrition, the facility failed to address a weight loss according to professional standards and facility policy. The findings include: Resident #84 was admitted to the facility in July 2024 with diagnoses that included stroke, dysphasia, and dementia. Review of the weight record dated 7/24/24 identified Resident #84 weighed 156 lbs. A physician's order dated 8/13/24 directed to weigh the resident daily and if weight loss is greater than 2 lbs. in a day or 5 lbs. in 7 days notify the physician/APRN. A physician's order dated 8/14/24 directed to provide a dysphasia puree diet but allow ground meats and soft sandwiches and thin liquids. Additionally, provide house supplement 237 ml twice a day. The quarterly MDS dated [DATE] identified Resident #84 had severely impaired cognition, was independent to eat, did not have a weight loss of 5% in the last month or loss of 10% in the last 6 months. The care plan dated 9/24/24 identified Resident #84 has the potential for alteration in nutritional status related to dementia. Interventions included evaluating the nutritional status on admission, per the MDS schedule and as needed and report any concerns or changes to the physician and resident representative. Review of the weight record dated 10/4/24 identified the resident weighed 150 lbs., (a 6 lbs. weight loss in 3 months). Review of the weight record dated 11/10/24 identified Resident #84 weighed 138 lbs., (a 12 lbs. weight loss in 1 month, 18 lbs. in 4 months). Review of the nurse's progress notes, APRN, and physician notes dated 11/10/24 - 12/11/24 failed to reflect that the physician was notified of the resident's weight loss. Further, review of the clinical record dated 11/10/24 to 12/11/24 failed to reflect that Resident #84 was seen by the dietitian subsequent to the weight loss. Review of the weight record dated 12/2/24 identified Resident #84 weighed 133 lbs., (a 5 lbs. weight loss in 1 month). Review of the nurse's progress notes, APRN, and physician notes dated 12/2/24 - 12/12/24 failed to reflect that the APRN, physician, or resident representative were notified of the continued weight loss. Review of the clinical record dated 12/2/24 to 12/11/24 failed to reflect that Resident #84 was seen by the dietitian for a weight loss. The dietitian progress note dated 12/12/24 at 11:19 AM identified a significant weight loss trend. Recommendations included orders for house supplement 237 ml twice daily, and liquid protein 30 ml daily remain appropriate to maximize protein and caloric intake. The APRN progress note dated 12/13/24 at 9:44 PM identified Resident #84 was seen for a significant weight loss of 11 lbs. over the past month. Resident #84 is tolerating diet order without difficulty and has variable oral intakes of 50 - 100% of meals. Will have speech therapy evaluate for a diet upgrade, dietitian evaluated resident, food preferences upgraded, monitor intakes and weights. The dietitian progress note dated 12/12/24 identified significant weight loss trend for 30 days and 90 days for 11 lbs. noted over past month. Resident status post antibiotic for urinary tract infection. Suspected weight loss due to acute illness. History of recent stroke and variable oral intakes at times. Tolerating dysphasia puree diet order without difficulty swallowing. Appropriate for speech therapy referral. Staff set up and give encouragement with meals in room or small dining room. Orders for house supplement 237 ml twice daily and liquid protein 30 ml daily remain appropriate to maximize protein and caloric intake the physician, APRN, and A physician's order dated 12/16/24 directed to obtain bloodwork (CBC, CMP, lipid panel, A1C, TSH with reflex, Free T4, Vitamin D 250H, B12). Interview with the Dietitian on 1/27/25 at 10:30 AM indicated that she had seen Resident #84 in July 2024 after admission and again in August 2024 after readmission. The Dietitian indicated that in August Resident #84 had gone to the hospital for a few days because of another stroke and she noted a weight loss. The Dietitian indicated on readmission 8/14/24 she started Resident #84 on the supplement and therapy had downgraded the diet to puree. The Dietitian indicated she had not been notified of the weight loss at the beginning of November or beginning of December and indicated had she been notified she would have seen Resident #84 right away because she is in the facility 4 days a week. The Dietitian indicated that for the 11/10/24 weight loss and the weight loss on 12/2/24 she would have done a complete evaluation and looked at the whole picture to determine what interventions were in place and to determine if it was dietary or medical issue causing the weight loss. The Dietitian indicated that the nurses should have communicated the weight loss. The Dietitian indicated that she did not see or evaluate resident's weights until she went to see Resident #84 to do the quarterly MDS assessment on 12/12/24 and noted the undesired weight loss. Interview with MD #1 on 1/27/25 at 10:48 AM indicated that when a resident has a weight loss of 5% in a month, he would expect the provider and dietitian to be notified that day. MD #1 indicated that he would expect the nurse to document in the progress notes who was notified. After clinical record review, MD #1 indicated that Resident #84 had a 10 lbs. weight loss or over 5% based on the weight 11/10/24, and a 17 lbs. weight loss on 12/2/24. MD #1 indicated that on 11/10/24 and 12/2/24 he should have been notified so he/she could do an evaluation to determine if this unplanned weight loss was a dietary or medical issue. MD #1 indicated that the provider was only notified based on documentation of Resident #84 weight loss on 12/13/24 and seen by APRN for the weight loss. Interview with the DNS on 1/27/25 at 11:07 AM indicated that when a nurse takes a weight and there is a discrepancy by 2, 3, or 5 lbs. based on the physician's order they are responsible to notify the physician. The DNS indicated if a reweight is needed it should be done the same day but no later than the next day to verify the weight loss then notify the dietitian, physician, and residents' representative. After clinical record review, the DNS indicated that Resident #84's weight loss on 11/10/24 and 12/2/24 were verified and the physician and dietitian should have been notified however, there was no documentation to reflect notification had taken place. Interview with LPN #2 on 1/27/25 at 12:14 PM indicated that she had taken Resident #84's weight on 12/3/24 and 12/4/24 and she was not aware that it was a weight loss because the computer did not trigger it as it only shows the last 3 daily weights. LPN #2 indicated that she would have had to go to the vital sign section to pull up the last months weights to identify a weight loss and she does not do that. LPN #2 indicated that if she was aware of the weight loss she would have notified the APRN, resident representative, and the dietitian. Interview with Dietitian on 1/28/25 at 8:10 AM indicated that she sees all new admission, readmissions, quarterly, and if nursing notifies her of weight loss, or if the physician puts in for a consult. The Dietitian indicated that she had not been notified prior to seeing Resident #84 to do the quarterly assessment on 12/12/24 of a weight loss. Review of the Weight Assessment and Intervention Policy identified the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our resident's. The nursing staff will measure resident's weights on admission, and next 2 days, and weekly for 4 weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in the resident's medical record. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. The Dietitian will evaluate resident after notification of identified weight discrepancy. The Dietitian will review the unit's weight record by the 15th of the month to follow individuals weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change have been met. The threshold for significant unplanned and undesirable weight loss will be based on the following criteria a 5% weight loss in 1 month is significant, if greater than 5% is severe, 7.5% weight loss in 3 months is significant, if greater than 7.5% is severe, 10% weight loss in 6 months is significant, if greater than 10% is severe. The physician and interdisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss, for example cognitive or functional decline, chewing or swallowing abnormalities, pain, medications, environmental factors like noise or distractions, etc. Review of Nutritional Assessment Policy identified as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change of condition that places the resident at risk for impaired nutrition. Review of the Weight Monitoring Policy identified staff should obtain timely and accurate weights to maintain acceptable nutritional parameters. Weights will be documented in the EMR by the unit manager or unit assistant. If there is a 3 or more-pound difference a reweight is to be performed immediately. Nursing is responsible for notifying the dietitian of any significant weight changes. The dietitian may change resident back to weekly weights if oral intake has been noted to be a concern, change in medical status, weight loss or potential for weight loss is suspected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #56) reviewed for a specialized medical treatment and who had orders for a 1000 ml fluid restriction, the facility failed to consistently monitor fluid intake to ensure the resident was within the fluid restriction and implement measures according to professional standards. The findings include: Resident #56 was admitted to the facility in May 2024 with diagnoses that included end stage renal disease requiring peritoneal dialysis. The quarterly MDS dated [DATE] identified Resident #56 had intact cognition and required moderate assistance with toileting and personal hygiene. The care plan dated 11/29/24 identified Resident #56 receives peritoneal dialysis for end stage renal disease. Interventions included monitoring fluid intake and a fluid restriction of 1000 ml per 24 hours. Review of the December 2024 monthly physician's order directed a fluid restriction of 1000 ml per day and to provide a 2-gram sodium renal diet. Review of the fluid intake record dated 12/1/24 to 12/31/24 identified Resident #56 had gone over the fluid restriction 28 out of 31 days. Review of the fluid intake record dated 1/1/25 to 1/28/25 identified Resident #56 had gone over the fluid restriction 26 out of 28 days. Review of the nursing and physician progress notes dated 12/1/24 to 1/28/25 failed to reflect that the physician, APRN, or resident was notified that Resident #56 had gone over the physician's order for the 1000 ml fluid restriction. Interview with LPN #4 on 1/29/25 at 9:40 AM indicated Resident #56 was on a 1000 ml fluid restriction per physician order. LPN #4 indicated that the charge nurses every shift document the fluid intake into the EMR. LPN #4 indicated that the 11:00 PM to 7:00 AM supervisor was responsible for adding up the 24-hour totals and if the resident goes over the fluid restriction, she would notify the RN supervisor. Interview with RN #4 (7:00 AM to 3:00 PM day supervisor) on 1/29/25 at 10:17 AM indicated that the 11:00 PM to 7:00 AM RN supervisor was responsible to add the 24-hour intakes for residents on a fluid restriction. Interview with the DNS on 1/29/25 at 10:22 AM indicated that if a resident on a fluid restriction goes over the fluid restriction more than 5 - 10 ml's the APRN or physician must be notified, and the nurse must write a progress note to indicate such. The DNS indicated that the 11:00 PM to 7:00 AM the RN supervisor was responsible for adding up each day's fluid totals for residents on fluid restrictions. The DNS indicated that if the resident went over the fluid restriction the night supervisor would inform the day supervisor to call or inform the APRN that day. The DNS indicated that the resident would be educated about going over the fluid restriction and it would be documented by the nurse in the progress notes. After review of the clinical record the DNS was not able to identify that the dialysis center or the APRN were notified that Resident #56 had gone over the fluid restriction or that the resident had been educated on the fluid restriction. Interview with MD #1 on 1/29/25 at 10:53 AM indicated that if a peritoneal dialysis resident is on a 1000 ml fluid restriction, nursing was responsible to calculate the 24-hour totals. MD #1 indicated that if Resident #56 went over the fluid restriction he should be notified that day and that notification be documented in the clinical record. MD #1 indicated that if the resident was about 1000 ml over the fluid restriction that was more serious and the APRN would do an assessment and the dialysis center should be notified that day, because they would have to take more fluid off through the next dialysis cycle. MD #1 indicated that if Resident #56 continuously goes over the fluid restriction he/she may need to have an extra exchange of the peritoneal dialysis during the day not just at night. Review of the Encouraging and Restricting Fluids Policy identified the purpose of this procedure is to provide the resident with the number of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Verify there is a physician's order. Be accurate when recording fluid intake. Record fluid intake in ml's. When a resident has been placed on a restricted fluid, remove the water pitcher and cup from the room. Review of the Intake, Measuring, and Recording Policy identified the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. Verify the physician's order. Inform the resident and his/her representatives and visitors that the resident is on intake and output. 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 has consumed. Post an intake and output record form in the resident's room. Although requested, a facility policy for dialysis residents on fluid restrictions was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #70) reviewed for unnecessary medications, the facility failed to attempt continued gradual dose reductions (GDR) according to professional standards, after the diagnosis of schizoaffective disorder had been discontinued and failed to ensure a comprehensive care plan had been developed for the use of an antipsychotic medication. The findings include: Resident #70 was admitted to the facility on [DATE] with diagnoses that included anxiety, depression, and dysthymic disorder. The admission MDS dated [DATE] identified Resident #70 had intact cognition, no delusional or hallucinating thoughts and no physical or verbal behaviors. A physician's order dated 8/26/21 directed to administer Abilify (antipsychotic medication) 5mg daily at bedtime. The psychiatric evaluation and consultation dated 10/20/21 at 1:23 PM identified given history of symptoms it would be appropriate to add schizoaffective disorder diagnosis to the diagnosis list. Tapering of psychotropic medications will lead to worsening of symptoms. The Psychiatric Evaluation and Consultation dated 10/13/23 (2 years later) identified based upon symptoms, etiology of current disease, and response to recent medication trials, it would be prudent to discontinue the diagnosis of schizoaffective disorder. Will recommend a gradual dose reduction trial of antipsychotics as tolerated and if indicated. Review of the psychiatric note written by APRN #1 dated 11/10/23 recommended per diagnosis of schizoaffective disorder, stop Abilify 5mg and start Abilify 2mg. A physician's order dated 11/10/23 directed to decrease Abilify to 2mg daily at bedtime. Review of psychiatric notes written by APRN #1 dated 11/21/23, 12/21/23, 3/21/24, 4/23/24, 5/23/24, 6/25/24, 7/25/24, 8/27/24, 9/26/24, 10/25/24, and 11/26/24 identified that Resident #70 was receiving Abilify for schizoaffective disorder. Interview with SW #1 on 1/27/25 at 8:57 AM identified there was no care plan for the diagnosis of schizoaffective disorder because she thought the diagnosis had been discontinued in October 2023. SW #1 indicated that she does see in the psychiatric visits during 2024 that the schizoaffective diagnosis and Abilify were still in place, but in October 2023 she had asked for the psychiatric group to see Resident #70 and maybe discontinue that diagnosis. SW #1 indicated that she did not follow up on it in October 2023, she just assumed it was discontinued. After surveyor inquiry, the diagnosis of schizoaffective disorder was discontinued on 1/27/25. Interview with APRN #1 on 1/28/25 at 10:03 AM identified she had been contacted yesterday by her company's head of management CEO notifying her that the state agency was looking into Resident #70's diagnosis of schizoaffective disorder and that her documentation should not reflect that diagnosis. APRN #1 identified she reviewed Resident #70's clinical record and noted that MD #3 had diagnosed Resident #70 with the diagnosis of schizoaffective disorder on 10/20/21. APRN #1 indicated that she was not aware until yesterday that the diagnosis had been discontinued by MD #3 on 10/13/23. APRN #1 indicated she started seeing Resident #70 on 9/7/23 and the Abilify was already in place for the diagnosis of schizoaffective disorder. APRN #1 indicated that she was not verbally informed by MD #3 or staff that the diagnosis of schizoaffective disorder had been discontinued. APRN #1 indicated that on 11/21/23 she had decreased the Abilify to 2mg and indicated that if she were aware that the diagnosis had been discontinued, she would have weaned Resident #70 completely off the Abilify. APRN #1 indicated since November 2023 she should have stopped the Abilify because Resident #70 no longer had the diagnosis. Although attempted, an interview with MD #3 was not obtained. Review of the Antipsychotic Medication Use policy identified antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period and are subject to gradual dose reduction and re-review. Antipsychotics medications shall generally be used only for the following conditions/diagnosis as documented in the record, consistent with the definition in the Diagnostic and Statistical Manual of [NAME] Disorders for schizophrenia, schizoaffective disorder, delusional disorder, mood disorder (bipolar disorder, depression with psychotic features, and treatment refractory major depression). Diagnosis alone does not warrant the use of antipsychotic medications. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: the behavioral symptoms present a danger to the resident or others and the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations, delusions, paranoia, or grandiosity). : or behavioral interventions have been attempted and included in the plan of care, except in an emergency. All antipsychotic medications will be used within the dosage guidelines, or clinical justification will be documented for dosages that exceed the listed guidelines for more than 48 hours. The physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting based on assessing why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #81) reviewed for nutrition, the facility failed to provide adaptative equipment with meals according to physician's orders and the plan of care. The findings include: Resident #81 was admitted to the facility in December 2021 with diagnoses that included dementia and a stroke affecting the right dominant side. A Therapy Communication to Nursing form dated 12/24/21 identified Resident #81 needed to be given a scoop plate, built up utensils, and a 2 handled sippy cup with every meal. The monthly physician's order dated 7/1/24 to 7/31/24 directed a dysphasia mechanical diet and can have soft bread. Sippy cup with breakfast, lunch and dinner. Additionally, close supervision during meals. Review of the Electronic Health Records (EMR) identified that in August 2024, the facility transitioned to a new EMR. Review of monthly physician's orders (in the new EMR) dated 9/1/24 to 12/31/24 failed to reflect the order for the sippy cup with breakfast, lunch and dinner. The annual MDS dated [DATE] identified Resident #81 had severely impaired cognition and needed partial assistance with eating. The care plan dated 12/12/24 identified Resident #81 was at risk for weight loss. Interventions included using a sippy cup with meals, providing a mechanical soft diet with thin liquids, aspiration precautions and monitor eating closely. Encourage the resident to use feeding skills as much as he/she could and assist as needed. Observation on 1/26/25 at 9:00 AM identified Resident #81's breakfast tray was in front of the resident without the benefit of a scoop dish and a 2 handled sippy cup. The entrée was on a flat plate, orange juice cup had the metal cover peeled back halfway, coffee was in a brown cup, and milk in the carton. The meal ticket dated 1/26/25 identified Resident #81 needed a sippy cup. Interview with NA #1 on 1/26/25 at 9:10 AM indicated that she had given Resident #81 the breakfast meal this morning and indicated she does not read the meal tickets because it was the kitchens responsibility to make sure the meal trays are correct. NA #1 indicated that she did not read Resident #81's meal ticket when providing breakfast today. After reading the meal ticket, NA #1 indicated that she was not aware that Resident #81 needed the sippy cup. NA #1 indicated that the kitchen was responsible for making sure the sippy cup and scoop plates were on the tray. Interview with RN #3 on 1/26/25 at 9:17 AM indicated that the nurse aides were responsible to read every resident meal ticket when delivering the meal tray and making sure the meal is correct based on the meal ticket. RN #3 indicated she can see Resident #81 did not have the scoop dish or sippy cup and indicated that NA #1 should have called the kitchen to make sure Resident #81 had the sippy cup to be able to drink his/her liquids. Observation during the lunch meal on 1/26/25 at 1:00 PM identified Resident #81 was sitting in his/her wheelchair in the small dining room without the benefit of the scoop dish or a 2 handled sippy cup. Observation on 1/27/25 at 8:20 AM identified NA #2 entered room with Resident #81's breakfast tray. Resident #81 was sitting upright in bed with eyes closed. The breakfast tray had a flat plate with a scoop of puree eggs and a scoop of puree bread per the meal ticket. NA #2 removed the cover from the main meal and placed the weighted spoon in it and walked away. NA #2 did not uncover the hot liquid cup, did not open the 8oz milk cartoon, and did not open the disposable container of orange juice. There was no sippy cup or scoop dish on the tray. Meal ticket dated 1/27/25 breakfast identified Resident #81 needed weighted silverware and a sippy cup. Interview with NA #2 on 1/27/25 at 8:45 AM identified she had delivered Resident #81's breakfast tray. NA #2 indicated Resident #81 could eat by him/herself just needed to be set up. NA #2 indicated that she does not know why she did not open the drinks and set up the meal tray for Resident #81. NA #2 indicated that she was planning on going back after passing the rest of the breakfast trays including heating another resident's coffee heated in the microwave. NA #2 indicated that she did not read Resident #81's meal ticket when she delivered the tray. NA #2 indicated that she was not aware the meal ticket stated Resident #81 needed built up utensils and a sippy cup. NA #2 indicated that the kitchen was responsible for making sure all adaptive equipment is on the meal trays if they are needed. Interview with LPN #2 on 1/27/25 at 8:50 AM indicated that Resident #81 needed to be set up for meals. LPN #2 indicated that the kitchen staff and the NA #2 were responsible for making sure Resident #81 had the right meal consistency and the adaptive equipment needed. LPN #2 indicated that Resident #81 will start to feed him/herself but then staff will need to cue and provide assistance. Interview with Director of Dietary on 1/27/25 at 9:30 AM indicated that the dietary aide at the end of the tray line was responsible to make sure the meal tray was accurate matching the meal ticket. Director of Dietary indicated that he has plenty of sippy cups and Resident #81 should have had the sippy cup on the meal tray every meal. Director of Dietary indicated that he did not know why Resident #81 did not have the sippy cup for the last 2 days, but he will make sure for lunch today that Resident #81 gets a sippy cup. Interview with the Dietitian on 1/27/25 at 10:20 AM indicated that the dietary staff in the kitchen were responsible to make sure trays are accurate prior to leaving the kitchen and then the nurse aides are responsible on the unit as they pull the tray off the carts to verify the meal ticket and the tray match prior to bringing the tray to the resident. The Dietitian indicated that the dietary aides on the tray line were responsible to make sure the adaptive equipment was on the meal tray, but the nurse aides are the last check before bring the tray to the resident. The Dietitian indicated that if a piece of adaptive equipment was not on a tray the nursing staff can call the kitchen, and the kitchen staff will bring it right up to the unit. Interview with Rehab Director on 1/28/25 at 10:53 AM indicated that Resident #81 was seen 9/16/24 in discharge summary from occupational therapy indicated resident was self-feeding with supervision and or cueing with assistive device. Interview with OTA #1 on 1/28/25 at 11:55 AM indicated that Resident #81 was last seen for therapy related to eating was in December 2021, but she had worked with Resident #81 in September of 2024 for his/her wheelchair. OTA #1 indicated that at that time she did not change the orders for Resident #81 to have a scoop dish, weighted utensils, and a 2 handled sippy cup because she felt Resident #81 would benefit from continuing to use the adaptive equipment to maintain as much independence as possible. OTA #1 indicated that the 2 handled cup is needed to prevent spillage onto the resident. Interview with the DNS on 1/28/25 at 12:26 PM indicated that the kitchen staff were responsible to make sure that every meal tray based on the meal ticket was correct before leaving the kitchen, and nursing was responsible to make sure the resident was getting the correct diet and adaptive equipment on the tray. The DNS indicated that if anything was wrong or missing the nurse's aide or nurse were to call the kitchen staff right away. Interview with OTA #1 on 1/29/25 at 11:16 AM indicated that Resident #81 should currently have the order for the adaptive equipment including the 2 handled sippy cup and scoop dish because therapy had not discontinued that order. Interview with the Chief Nursing Officer on 1/29/25 at 12:18 PM indicated that on 8/9/24 the facility started a new computer program for the meal tracker. The Chief Nursing Officer indicated that was when the EMR would talk to the meal ticket tracking system. The Chief Nursing Officer indicated that prior to that date, the adaptive equipment was in the same order as the diet but with the new system the diet order went under dietary, and the adaptive equipment order would go under the general physician orders. The Chief Nursing Officer, after review of Resident #81's clinical record, indicated that when the system changed over it only took the diet order but not the adaptive equipment order for Resident #81. The Chief Nursing Officer indicated that someone would have had to separately enter the order for the adaptive equipment under general physician orders. The Chief Nursing Officer indicated that it was an importing glitch when the system changed over. The Chief Executive Officer indicated that they would have to do a house wide audit to make sure this did not happen to any other residents. Interview with the DNS on 1/29/25 at 12:40 PM indicated that moving forward Resident #81 would be out of bed for all meals and in the dining room to be supervised for meals. Interview with Corporate Manager on 1/29/25 at 1:00 PM indicated that they would have to do a house audit to see if any other residents with orders for adaptive equipment and supervision had dropped off and were not in place subsequent to the change to the meal tracker program. Review of the Resident Meal Pass Policy identified the purpose was to provide appropriate assistance for residents who choose to receive meals in their rooms. Review the residents care plan and provide the special needs of the residents. Check the meal tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. Ensure that the necessary non-food items are on the tray. Report or replace missing items such as silverware, napkins, special devices, etc. Although requested, a facility policy for adaptive equipment was not provided.

Based on review of the facility documentation, facility policy, and interviews the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention. The findings include: The Infection Preventionist (RN #1) was hired on 11/30/2015. During entrance conference on 1/26/24 at 7:45 AM the facility failed to provide documentation that RN #1 had been awarded the certification for Nursing Home Infection Preventionist with contact hours. Upon review of facility documentation, it was identified that RN #1 had completed the Nursing Home Infection Preventionist Training Course on 4/23/24 but had not completed the final test to obtain the Infection Preventionist certificate. The facility provided documentation that the ADNS had been awarded the certification for Nursing Home Infection Preventionist on 9/4/2020. Interview with RN #1 on 1/28/25 at 8:20 AM identified that she had served as the facility's Infection Preventionist (IP) for 10 months, and that she had completed the Nursing Home Infection Preventionist Training Course and obtained a certification of training course completion on 4/23/24, which she thought fulfilled all the IP requirements. RN #1 indicated that it was subsequent to surveyor inquiry on 1/26/25 that she learned that she also had to take a final test after completing the modules in order to be certified as an IP; RN #1 attempted to take the test, but she did not pass. RN #1 indicated that her last day as the facility's full time IP was 1/27/25, but she would remain at the facility, part-time and assist with training a new IP once one was hired; the ADNS would oversee the day-to-day infection control duties, in the interim. Interview with the DNS on 1/28/25 at 1:20 PM identified that RN #1's certificate reads that RN #1 had successfully completed the Nursing Home Infection Preventionist Training Course on 4/23/2024, and she thought that certificate indicated that the IP requirements had been met. The Infection Preventionist Job Description document directs the minimum qualifications of the IP was to have any combination of education and experience that would likely provide the required knowledge, skills, and abilities; as well as any required licenses or certifications. Education: primary professional training in nursing, medical technology, microbiology, epidemiology, or related field; and have completed specialized training in infection prevention and control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical records, facility documentation, facility policies, and interviews for 6 of 10 residents (Resident #2, 18, 79, 87, 88, and 100) reviewed for immunizations, the facility failed to ensure consented residents received the 2024-2025 Covid vaccination, in a timely manner. The findings include: Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's clinical record identified a signed Annual Vaccinations form dated [DATE] which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty 2024-25 (a vaccine that helps prevent the Covid-19 virus); 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] identified Resident #2 received the Covid-19 vaccination on [DATE], subsequent to surveyor inquiry. Resident #18 was admitted to the facility on [DATE]. Review of Resident #18's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty 2024-25; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] identified Resident #18 received the Covid-19 vaccination on [DATE], subsequent to surveyor inquiry. Resident #50 was admitted to the facility on [DATE]. Review of Resident #50's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had declined to the Covid-19 vaccine. Resident #58 was admitted to the facility on [DATE]. Review of Resident #58's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had declined to the Covid-19 vaccine. Resident #60 was admitted to the facility on [DATE]. Review of Resident #60's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directing the administration of Comirnaty 2024-25; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] identified Resident #60's resident representative declined the Covid-19 vaccination on [DATE] because Resident #60 was on hospice care. Resident #79 was admitted to the facility on [DATE]. Review of Resident #79's clinical record identified a signed Annual Vaccinations form dated [DATE] which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty 2024-25; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] failed to identify Resident #79 had received the Covid-19 vaccine. Resident #87 was admitted to the facility on [DATE]. Review of Resident #87's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty 2024-25; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] identified Resident #87 received the Covid-19 vaccination on [DATE], subsequent to surveyor inquiry. Resident #88 was admitted to the facility on [DATE]. Review of Resident #88's clinical record identified a signed Covid Vaccine Consent form dated [DATE], which identified he/she or the responsible party had consented the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty 2024-25; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] identified Resident #88 received the Covid-19 vaccination on [DATE], subsequent to surveyor inquiry. Resident #100 was admitted to the facility on [DATE]. Review of Resident #100's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty 2024-25; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] failed to identify Resident #100 received the Covid-19 vaccination. Resident #109 was admitted to the facility on [DATE]. Review of Resident #109's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had declined to the Covid-19 vaccine. Interview and clinical record review with the Infection Preventionist (RN #1) on [DATE] at 8:20 AM failed to provide surveillance data on resident Covid-19 vaccinations but indicated that she pulls her reports from the electronic health record system when needed. RN #1 indicated that 2 of the 5 residents (Resident #60 and #87) initially reviewed for immunizations had consented for the Covid-19 vaccination but had not yet received the Comirnaty 2024-25 vaccine. RN #1 indicated that Resident #60 and Resident #87 were scheduled to receive their Covid-19 vaccination on the upcoming Monday. RN #1 further indicated that the pharmacy dispenses Covid-19 vaccines in quantities of 10 at a time, and the next order of 10 vaccines was expected to be delivered by Monday. RN #1 was unable to provide a policy indicating that there was a limit to how many Covid-19 vaccines could be received from the pharmacy; RN #1 indicated that was the directive she was told by the pharmacy. RN #1 identified that the following residents were scheduled to receive the Covid-19 vaccine on Monday: Residents #2, 18, 50, 58, 60, 79, 87, 88, 100, and 109. RN #1 further identified that she had been the facility's Infection Preventionist (IP) for 10 months, and her last day as the facility's full time IP was [DATE], but she would remain at the facility in a part time capacity until a new IP was hired and trained. Interview with the pharmacy manager (Person #1) on [DATE] at 11:49 AM indicated that, last year during a medication review, it was identified that the facility had multiple expired Covid-19 vaccinations in the medication refrigerator. Person #1 indicated that Covid-19 vaccines have a shorter shelf life than other vaccines, and once defrosted it must be administered within 30 days. Person #1 identified that representatives from the pharmacy had a conversation with facility management and it was determined that 10 vaccines would be supplied at a time to devoid waste. Person #1 further identified that the pharmacy was not rationing Covid-19 vaccines and there was no policy in place to limit quantities supplied to the facility; if the facility had a need for more than 10 vaccines, the pharmacy would provide a larger quantity. Observation with the DNS of the medication refrigerator on [DATE] at 10:37 AM identified 5 Covid-19 vaccinations in a bag dated [DATE] and 10 Covid-19 vaccinations in a bag dated [DATE]. Interview with the Administrator on [DATE] at 10:57 AM identified that he never learned that there was a limit on ordering Covid-19 vaccinations. Interview with the DNS on [DATE] at 11:51 AM identified that she was aware that Covid-19 vaccines were routinely being supplied 10 at a time; while she was unable to recall where that directive came from, the DNS indicated that more could have been ordered if there was a need. The DNS further indicated that she was unaware that there were multiple residents that were consented to receive the Covid-19 vaccine but had not yet received it, and she was also unaware that there 15 Covid-19 vaccines in the refrigerator that were available to be given to consented residents. The DNS identified that it was her expectation that a Covid-19 vaccination would be administered right away, once you receive the vaccinations. Interview and clinical record review with the ADNS on [DATE] at 12:22 PM identified that the expectation is that once consent is obtained, if the vaccine is available then it would be administered, unless there was an issue or the resident was sick. The ADNS further identified that she had been unaware that there were Covid-19 vaccinations available at the facility while there were consented residents that had not yet received the vaccine. The ADNS indicated that Residents # 50, 58, and 109 declined the Covid-19 vaccination, and she was unsure why RN #1 had identified them as receiving the vaccination on Monday, Resident #60's resident representative declined the Covid-19 vaccination on [DATE] because he/she was on hospice care, Resident # 79's vaccine was on hold because he/she was not feeling well, Resident #100 was out of the facility on an LOA and would receive the vaccine upon his/her return, and Residents #2, 18, 87, and 88 received the Covid-19 vaccine on [DATE]. The Preventative Health Care Report dated [DATE] identified 9 residents received the Covid-19 vaccine on [DATE], subsequent to surveyor inquiry. Although attempted a second interview was not obtained with RN #1, and RN #1 was unavailable for majority of the survey process. The facility's Covid-19 Vaccination policy directs that all residents will be offered the Covid-19 vaccination. The IP will maintain surveillance data on all Covid-19 vaccinations among staff and residents. Administration of the Covid-19 vaccine will be made in accordance with current CDC recommendations. The facility's Infection Preventionist policy directs that the IP shall coordinate the development and monitoring of the facility's established infection prevention and control policies and practices. The IP will collect, analyze and provide infection and antibiotic usage data and trends to nursing staff and health care practitioners; consult on infection risk assessment and prevention control strategies; provide education and training, and implement evidence-based infection prevention and control practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policies, and interviews for 1 of 2 residents (Resident #45) reviewed for abuse, the facility failed to speak to the resident in a dignified manner. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, and anxiety disorder. The 5-day MDS dated [DATE] identified Resident #45 had severely impaired cognition, required extensive assistance with bed mobility and transfers, and used a walker and a wheelchair for mobility. In addition, the resident's primary medical condition was debility due to cardiorespiratory conditions. The care plan dated 1/14/23 identified that Resident #45 had a history of trauma and that the resident may benefit from trauma informed care. Interventions included an approach to reassure the resident that he/she is safe. Further, the care plan indicated the resident required assistance with mobility and self-care due to impaired cognition related to Alzheimer's dementia. Interventions included to allow extra time to perform tasks as needed, praise resident for her efforts to participate, and sequence tasks as needed. Observation on 1/23/23 at approximately 10:00 AM identified PTA #1 was walking Resident #45 using a walker and the wheelchair following behind the resident. PTA #1 was overheard to say in a harsh tone to Resident #45 Which way did I tell you to go yesterday? Which way are you going to go? This was said harshly and loudly in the hallway, in front of staff and 2 other residents. When Resident #45 replied inaudibly, PTA #1 loudly replied no, that is not the right way, that is not what I told you to do yesterday. Resident #45 became short of breath and stopped walking. PTA #1 squatted by the side of the wheelchair, repeatedly looked at her watch, and asked Resident #45 no less than 3 times if he/she was ready to go. Resident #45 stated yes and stood, with assistance and continued walking down the hallway. Interview with the Therapy Director on 1/23/2023 at 1:25 PM identified that therapy staff use pathways to focus the discussion with the resident to the degree the resident can understand, but that residents are to be treated with dignity and respect. Interview with the RN Supervisor (RN #1) on 1/23/23 at 2:07 PM identified that PTA #1 was removed immediately from the facility pending an investigation. In addition, it was noted that PTA #1 was not an employee of the facility but that of the therapy contractor. Although attempted, an interview with PTA #1 was not obtained. Review of the resident rights policy indicated that employees shall treat all residents with kindness, respect, and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, and interview for 1 resident (Resident #82), the facility failed to ensure that the resident's floor mat was maintained in good condition. The findings included: Resident #82 's diagnoses included vascular dementia with behavioral disturbance, transient cerebral ischemic attack, and repeated falls. The quarterly MDS dated [DATE] identified Resident #82 had moderately impaired cognition and required assistance with bed mobility and transfers. The care plan dated 11/15/22 identified Resident #82 was at risk for falling due to being unsteady on his/her feet, impulsive, and history of falls. Interventions included the use of floor mats next to the resident's bed. Observation on 1/19/23 at 10:55 AM identified that the floor mat on the right side of Resident #82's bed was in disrepair, had severe separation between the outer layer and inner of foam at all four corners, and the corners of the outer covering of the floor mat rolling inward towards the center of the mat. The exposed inner foam layer was also observed tattered and broken. Review of the maintenance log for the unit at that time failed to reflect staff requested the floor mat be repaired or replaced. A physician's order dated 1/20/23 directed that the resident has floor mats in place. Observation on 1/24/23 at 9:23 AM identified the damaged floor mat was in the resident's room in the original observed location on the right side of the resident's bed. Review of the maintenance log for the unit at that time failed to reflect staff requested the floor mat be repaired or replaced. Interview and observation with the Infection Control Nurse (RN #2) on 1/24/23 at 9:46 AM identified the floor mat was in disrepair and that the resident could slip and fall on the mat. RN #2 indicated she completes monthly environmental rounds with the Administrator and Director of Maintenance and most recently rounded on 12/30/22. RN #2 identified she was not aware of any issues with the floor mat prior to today's observation. Subsequent to surveyor inquiry, RN #2 replaced the damaged floor mat. Interview with the Administrator on 1/24/23 at 12:32 PM identified he rounds the entire facility daily, however, he completed spot checks of the resident rooms. The Administrator also identified that he rounds with the Maintenance Director, and he also kept a list of documented issues with the facility in a separate maintenance log book which he kept in his office. The Administrator also identified, after reviewing the log book, the floor matt in Resident #82's room was not in the book. The Administrator failed to identify why the floor mat was in Resident #82's room in poor condition and identified that the mat should have been replaced. Interview with the Director of Maintenance on 1/24/23 at 1:00 PM identified that he completed weekly rounds of the facility with the Administrator and identified that the issues that typically needed to be addressed included cosmetic repairs of the floors, tiles, paint, etc. The Director of Maintenance identified that he was in charge of delivering the floor mats to the resident rooms, however he was not in charge of monitoring if they needed replacement or repair; rather this would be up to the nursing staff to notify him via the maintenance log book on the unit. The Director of Maintenance reported this book was checked by the maintenance staff every morning and he had not received any notice that the mat was damaged or needed replacement. He further identified a floor mat in disrepair would be a fall risk for the resident. The facility policy Homelike Environment directed that the residents of the facility would be provided a safe, clean, comfortable and homelike environment. The policy further identified that the facility staff and management would maximize the characteristics of the facility to reflect a personalized homelike setting which included a clean, sanitary and homelike environment. Although requested, the facility failed to provide a policy on damaged equipment or durable medical equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 5 residents (Resident #35 and 97) reviewed for unnecessary medications, for Resident #35, who was receiving an antipsychotic medication, the facility failed to monitor the behaviors the antipsychotic medication was being used to treat, and for Resident #97 the facility failed ensure as needed (PRN) psychotropic drugs were limited to 14 days. The findings include: 1. Resident #35's diagnoses included schizoaffective disorder, anxiety, dysthymic disorder, and unspecified dementia. A physician's order dated 3/30/22 directed to administer Risperidone (antipsychotic medication) 0.5mg twice daily. A Drug Regimen Review dated 10/18/22 directed behavioral monitoring due to the use of psychotropic medications. The annual MDS dated [DATE] identified Resident #35 had intact cognition and required assistance with toileting, hygiene, bathing, and dressing. The care plan 11/25/22 identified Resident #35 had schizoaffective disorder, depression and insomnia. Target behaviors included insomnia, restlessness, agitation, and anxiety. Interventions included to administer medications as ordered, refer to psychiatry for drug/behavior review, monitor and document for side effects and effectiveness, and monitor for and report any sedation, or anticholinergic signs and symptoms. A physician's order dated 11/21/22 directed to administer Risperidone 1mg, daily. Review of psychiatric notes dated 8/1/22 through 12/12/22 identified the resident had a diagnosis of schizoaffective disorder and was on Risperidone 1mg. A Drug Regimen Review dated 1/13/23 directed behavioral monitoring for the use of psychotropic medication. Interview with DNS on 1/25/23 at 11:25 AM indicated that residents on antipsychotic medications are to be monitored for behaviors. Review of the Psychotropic Drug Use Policy directs the interdisciplinary team to help identify the behavioral target symptoms and specific behavioral concerns that warrant the use of an antipsychotic drug, the monitoring of the resident's behavior, and the tracking and documentation of the number of behavioral episodes or number of hours per behavioral episode. 2. Resident #97 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. The admission MDS dated [DATE] identified Resident #97 had severely impaired cognition, exhibited no behaviors and required assistance with bed mobility and transfers. The care plan dated 11/13/22 identified the resident has the potential for complications related to psychotropic medication use. Interventions included encourage diversional activities, medication as ordered, refer to psychiatry as needed and report changes to the physician. Physician's order dated 1/2/23 directed to administer Trazodone (anti-depressant medication) 25mg PRN 3 times daily for agitation, anxiety and insomnia. Review of the facility psychotropic drug use policy failed to direct that residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and that PRN orders for psychotropic drugs are limited to 14 days.

Based on review of the facility documentation, facility policy, and interviews the facility failed to ensure 5 of 5 staff nurse aides had annual performance evaluations in accordance with facility policy. The findings include: 1. NA #2 was hired 7/25/2005 and the last annual performance evaluation was completed on 12/9/19, over 3 years ago. 2. NA #3 was hired 9/19/12. Although the last annual performance evaluation was completed 11/17/22, annual performance evaluations were not completed for 2019 and 2021. 3. NA #4 was hired 8/8/16. Although the last annual performance evaluation was completed 12/9/22, annual performance evaluations were not completed for 2019 and 2021. 4. NA #5 was hired 4/28/12 and the last annual performance evaluation was completed on 2/27/20, 3 years ago. 5. NA #6 was hired 3/2/08 and the last annual performance evaluation was completed on 1/16/20, 3 years ago. Interview with Director of Human Resources on 1/23/23 at 2:50 PM indicated she had started in April 2022 and audited the files for the annual performance evaluations and the 60-day evaluations after being hired. HR #1 indicated she made a spread sheet of employee's names, date of hire, and when the evaluations were due and provided a copy to all the department heads so they would know what evaluations were past due and the evaluations that were do each month. HR #1 indicated she did her part, and the department heads had the responsibility to get the evaluation completed and return them to her to be filed in the employee's file. HR #1 indicated as she receives a completed evaluation, she updates the list and hands it out again. Interview with the Administrator on 1/23/23 at 3:30 PM identified each department head was responsible to do their employee evaluations. The Administrator indicted HR #1 had informed him prior that they were behind in doing the evaluations. Review of facility Performance Reviews Policy identified employees were required to have performance evaluations annually.

Based on review of the clinical record, facility documentation, facility policy, and interviews the facility failed to ensure environmental rounds with corrective action forms were completed per facility policy and failed to ensure the infection control policy and procedure manual was reviewed annually by the required administrative staff. The findings include: 1. Review of the 2022 environmental rounds identified September and October 2022 were not completed. Interview with Infection Preventionist, (LPN #3) on 1/25/23 at 10:55 AM indicated she was responsible to do environmental rounds monthly per facility policy but identified she did not have or use a corrective action form when she did rounds, she just assumed the department heads would follow up on the identified areas to be corrected. LPN #3 indicated when follow up was required, she would go with each department head and then follow up with the department head to make sure issues where addressed. LPN #3 indicated she did not use a corrective action form or any other form to document on concerns or things that needed to be corrected during environmental rounds. Review of the Environmental Rounds Policy identified environmental rounds will be performed regularly throughout the entire facility with detailed reporting to all units and departments as needed. Additionally, a selection of individual units as well as dietary, laundry, and housekeeping departments be specifically identified for closer scrutiny each month. The infection preventionist will generate reports identifying areas of noncompliance. This report and a corrective action form will be distributed to the supervisors of each area. The corrective action form will be completed by the supervisor and will outline the corrective actions taken ant the anticipated completion dates. 2. Medical Staff Meeting dated 1/19/22 - 1/18/22 failed to reflect the Infection Control policy/procedure manual had been reviewed. Interview with LPN #3 on 1/25/23 at 9:45 AM indicated she had not reviewed the entire infection control manual herself nor did she review it with the medical director in the last year. LPN #3 identified she was not aware of any changes in the infection control policies and procedure manual but it had not been signed off by the Medical Director. LPN #3 indicated there were 2 infection control manuals and the signature sheets in the front of the manuals were both blank. LPN #3 indicated the signature form in front of the infection control manuals required the date the policies and procedures were reviewed and signatures with dates signed off as reviewed and if there were any changes by the governing board (Medical staff), the Administrator, Medical Director, and the committee chairperson (the IP). LPN #3 indicated the Medical Director was responsible to review the infection control policies and procedures to approve the manual. Although attempted, an interview with Medical Director was not obtained. The Infection Control Policy and Procedure Manual Part 1 and Part 2 identified a form requiring that the facility accepts the policies and procedures outlined in this manual. Such policies have been reviewed by the board, Medical Director, and the Quality Assessment and Assurance Committee and found to be adequate in meeting the day to day operational needs of this facility and our residents. The Administrator has been delegated the administrative authority, responsibility, and accountability of assuring that all personnel, residents, and the community are made aware of these policies and procedures though established orientation and/or in-service training program. The form required signatures and dates from the Administrator, Governing Board, Medical Director, QAA Committee and Committee Chair Person. Although requested, a facility policy for annual review of the Infection Control Policy and Procedure Manual was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 of 5 residents (#2, 35, 45, 69, and 97) reviewed for vaccines, the facility failed to ensure the resident and resident representative were educated and offered the pneumococcal vaccines per facility policy and CDC guidelines. 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included pneumonia, heart failure, and cerebral infarction. The Informed Consent Form for Pneumococcal Vaccines identified the following were offered Pneumococcal 15, Pneumococcal 20, and Pneumococcal 23. The form identified Resident #2's representative signed consent on 12/9/22 and 1/12/23 for the resident to receive the pneumococcal vaccines. Review of the MAR for December 2022 and January 2023 and the vaccine record identified Resident #2 did not receive the Pneumococcal Vaccine. 2. Resident #35 was admitted to the facility on [DATE] with diagnoses that included dementia and heart failure. The Informed Consent Form for Pneumococcal Vaccines was blank. The Vaccine Record, last updated on 10/13/22, identified that Resident #35 had not received a pneumococcal vaccine. 3. Resident #45 was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses that included Influenza and chronic obstructive pulmonary disease, and dementia. The Informed Consent Form for Pneumococcal Vaccines was blank. The Vaccine Record, last updated on 10/14/22, identified that Resident #45 had not received the pneumococcal vaccine. 4. Resident # 69 was admitted to the facility on [DATE] and readmission on [DATE] with diagnoses that included dementia and heart disease. A physician's order dated 9/3/19 directed to give the Pneumovax every 5 years. The last dose was not identified. The Informed Consent Form for Pneumococcal Vaccines was blank. The Vaccine Record, was last updated on 10/13/22, identified that Resident #69 had not received a pneumococcal vaccine. 5. Resident #97 was admitted to the facility on [DATE] and readmission on [DATE] with diagnoses that included late onset Alzheimer's Disease and displaced fracture of left hip. The Informed Consent Form for Pneumococcal Vaccines was blank. The Vaccine Record, last updated on 11/22/22, identified that Resident #97 had not received the pneumococcal vaccine. Interview with the Prior IP, LPN #3, on 1/25/23 at 11:17 AM indicated the infection control nurse was responsible to offer and administer vaccines, including the Pneumococcal vaccines. LPN #3 indicated she and RN #2 had just started to audit the vaccine status of the residents. LPN #3 noted she would give the pneumococcal vaccine depending on the residents need. Subsequent to review of the clinical records, LPN #3 identified that Resident #2, 35, 45, 69, and 97 had no record of being offered or receiving the Pneumococcal Vaccine. Interview with IP, RN #2, on 1/25/23 at 9:23 AM indicated after admission, she will speak with the resident or call the family regarding the vaccine status. RN #2 indicated she would educate the resident or family member and get consent or declination from the resident or representative. RN #2 indicated she will also look at the hospital discharge paperwork to see if it indicated any vaccine status and will confirm hospital paperwork with the resident or family. RN #2 indicated once the consents were done she will put in the physician order and then give the vaccine the same day. RN #2 indicated nursing or herself should get vaccine status and consent within a day or 2 of admission, and the resident should receive the vaccine within 24 - 48 hours after admission. Review of Pneumococcal Vaccine policy identified prior to or upon admission residents will be assessed for eligibility to receive the pneumococcal vaccine series. Residents will be offered the vaccine series upon admission to the facility unless contraindicated or had already had the vaccine. Assessment of the resident's pneumococcal vaccine status will be conducted on admission. Before receiving the vaccine the residents representative shall receive information and education regarding the benefits and the potential side effects of the pneumococcal vaccines. Provision of such education will be documented in the resident's medical record. Pneumococcal vaccine will be administered to residents per our facilities physicians approved protocol. Residents have the right to refuse but appropriate entry will be documented in the medical record indicating the date of refusal for the pneumococcal vaccine. Residents that receive the vaccine will document the date of vaccine, lot number, expiration date, person administering, site of vaccine given and document in residents medical record. Administration of the pneumococcal vaccines will be made in accordance with current CDC (Center for Disease Control and Prevention) recommendations at the time of the vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, interviews, and review of facility documentation, for one of thirty-two residents residents reviewed for Advanced Directives, (Resident #32), the facility failed to ensure appropriate orders were maintained for a resident selecting no cardiopulmonary resuscitation/Do Not Resuscitate (DNR). The findings include: Resident #32 was admitted prior to 2016. The Resident Health Care Instructions form signed by Resident #32, a facility staff member and a physician, and dated [DATE] regarding Code status, directed No, do not attempt CPR, allow death to occur naturally (DNR). Resident #32 diagnoses included anxiety disorder and kidney disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 had no cognitive impairment. The care plan dated [DATE] and [DATE] identified Resident # 32 had an advanced directive of Do Not Resuscitate (DNR) with an intervention to check for valid order. Physician's orders dated [DATE] directed full code. Interview and record review with the Director of Nurses (DNS) on [DATE] at 11:54 AM identified Resident #32 had completed a Resident Health Care Instructions form dated [DATE] which directed No, do not attempt CPR, allow death to occur naturally (DNR). The DNS further identified the physician's orders dated [DATE] directed full code. Interview and record review with the DNS on [DATE] at 1:33 PM identified that the order for full code was entered into the record in error when the facility changed to an electronic record in September of 2019 and this should have been reviewed at least quarterly by nursing. The DNS further identified that subsequent to surveyor inquiry, the DNS met with Resident #32 regarding advanced directives, and then obtained orders for DNR. The facility policy for Health Care Decision Making identified that upon admission, quarterly, and with a change in condition, the physician, in collaboration with designated Center staff, will meet with the resident or healthcare decision maker to complete or review advance directives, and define and clarify medicl issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews, for 2 of 2 Residents (Resident #66 and #362) reviewed for incontinent care and positioning, the facility failed to provide incontinent care/checks or repositioning at least every 2 hours and/or provide care according to the plan of care and/or failed to consistently document weekly wound monitoring and/or identify and implement measures in a timely manner to prevent the development of or promote the healing of a wound. The findings include: a. Resident #66 was admitted to the facility on [DATE] with diagnoses that included dementia with Lewy Bodies and benign lipomatous neoplasm of skin and subcutaneous tissue of the trunk. The Nursing Assistant Care Card dated 7/18/19 directed to toilet resident with one staff member and assist of 1 staff member. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #66 had severely impaired cognition, was always incontinent of bowel and bladder, and required extensive assistance for personal care, toilet use, eating, dressing, and bed mobility. Additionally, Resident #66 was a mechanical lift transfer with assist of 2 to a wheel chair. A physician's order dated 1/6/20 directed to transfer with an assist x 2 out of bed to tilt in space wheel chair with a calf pad in place. A physician's order dated 1/7/20 directed to turn and reposition resident 4 times a shift on day shift, evening shift, and night shift. The nurse's note dated 2/7/20 at 8:26 AM identified that fluids were encouraged and incontinent care and turning and repositioning frequently provided. The Treatment Administration History for January 2020 indicated nurse's signed off 4 times every shift that Resident #66 was turned and repositioned. The nurse's note dated 2/8/20 at 2:19 AM identified that fluids were encouraged and incontinent care and turning and repositioning frequently provided. Observation on 2/13/20 at 10:30 AM identified Resident #66 was in a recreation activity in the dining room across from nurse's station sitting with legs sideways in the wheel chair with a seat belt on and calf pad on. At 12:00 PM, Resident #66 was moved from the dining room into the lounge for lunch. At 12:26 PM, Resident #66 was noted to be sitting in the lounge at a table slouched down with the meal tray in front of him/her without the benefit of the items opened for consumption. At 12:30 PM, 2 Nurse Aides (NA's) boosted Resident #66 up in the chair. At 1:04 PM, Resident #66 was brought out of dining room and was sitting in front of nurse's station. From 1:04 PM - 1:52 PM Resident #66 was sitting in front of nurses' station in a row of 4 residents. At 2/13/20 01:52 PM Recreation Staff #1brought resident into the dining room for a sensory group. At 2:05 PM Resident #66 was noted to be sitting in the dining room for recreation. An interview with Registered Nurse (RN) #5 on 2/13/20 at 1:58 PM indicated the residents should be checked and changed at least every 2 hours. RN #5 further identified that the nursing assistants had not brought forward any issues or reasons why the check and change would not have been done that day. Observation and interview on 02/13/20 at 2:10 PM after surveyor inquiry to the LPN #4 and RN #5 indicated Nurse Aide (NA) #6 was on lunch break and left at 1:50 PM for 30 minutes. RN #5 and LPN #4 and NA #7 used a hoyer lift to transfer Resident #66 onto the bed. Observation at 2:19 PM (approimately 3 hours and 50 minutes later) identified Resident #66 was transferred to the bed via the hoyer lift and received incontinent care. Resident #66 was noted with a small brown bowel movement and a moderate to large amount of urine in brief. Resident #66 skin was intact and no redness noted. Interview on 2/13/20 at 2:40 PM with NA #6 indicated he/she got Resident #66 up after breakfast about 10:00 AM-10:15 AM. NA #6 indicated by the time he/she finished toileting and caring for residents on unit it was time for lunch, so the residents that were in the dining room from recreation stayed up there because the next thing he/she knew the lunch trays were there. NA #6 indicated he/she was hungry and had to take his/her lunch break and when he/she came back at 2:20 PM from lunch break he/she was then going to take care of Resident #66. b. Resident #362 was admitted to the facility on [DATE] with diagnoses that included diabetes, Alzheimer's disease, and peripheral vascular disease. The Hospital Discharge summary dated [DATE] indicated Resident #362 had a stage 2 pressure area to the left buttock, wound base was pink and periwound intact and no other wounds. The admission assessment dated [DATE] indicated the Stage 2 left buttock pressure area measured 0.9 cm x 0.3 cm x 0.1 cm, a right and left 2nd toe blister both measure 1.0 cm x 0.5 cm, and a right heel Deep Tissue Injury (DTI) measured 2.5 cm x 1.0 cm x 0 cm with the tissue identified as black, brown, and dry and wound edges are boggy. Resident #362 had a Braden Scale for Predicting Pressure Sore Risk Score of 15 which identified a high risk for skin breakdown. Additionally, the assessment indicated Resident #362 had poor bed mobility or difficulty moving to a sitting position on the side of the bed and had difficulty with balance or poor trunk control. The nurse's note dated 1/23/20 at 10:36 PM identified that Resident #362 was a new admission and had a pressure area to the left buttock, DTI to the right heel, a very boggy left heel, and discoloration areas noted to top of bilateral 2nd toes. A physician's order dated 1/23/20 directed to turn and reposition Resident 4 times a shift every shift, cleanse left buttock with normal saline followed by dermasetpine and mepilex change daily, document wound measurements under wound management every Wednesday, monitor DTI to right heel every shift until resolved, off load heels at all times while in bed, skin prep every shift x 14 days (end date 2/6/20) and re-evaluate, skin prep to right and left top of second toe every shift x 14 days (end date 2/6/20) and re-evaluate, and zinc oxide apply small amount to buttocks and groin with each incontinent episode every shift. The Initial Care Plan dated 1/23/20 directed to provide incontinent care every 2 hours and as needed. The Braden Scale for Predicting Pressure Sore Risk dated 1/23/20 identified a score of 15 indicating Resident was at risk for developing a pressure sore. The Braden Scale completed on 1/30/20 indicated a score of 12 with a high risk for pressure sores, and 2/7/20 indicated a score of 12 with a high risk for pressure sores. The Nursing Assistant Daily Care Card dated 1/23/20 indicated Resident #362 was incontinent of bowel and bladder and was at high risk for pressure ulcers. Apply barrier cream with each incontinent care and off load heels. The Wound Management Report dated 1/23/20 indicated there was a left buttock stage 2 pressure area 0.9 cm x 0.3 cm x 0.1 cm. On 2/3/20 the left buttock measured 1.0cm x 1.0 cm x 2.0 cm. On 2/10/20, the left buttock measured 1.0 cm x 1.0 cm x 0.2 cm. The Wound Management Reports for these dates failed to reflect the right heel DTI, the left heel bogginess, or the left or right toes. The Wound Physician note dated 1/27/20 indicated the first time he/she saw Wound #1 the left buttock measuring 1.0 cm x 1.0 cm x 0.1 cm treatment, cleanse with normal saline and apply alginate and change daily and as needed for soiling. The Wound Physician reclassified this area as a moisture associated dermatitis not a stage 2 as noted from admission. The Brief Interview for Mental Status (BIMS) evaluation dated 1/29/20 at 8:32 AM indicated Resident #362 had severe cognitive impairment. The admission Minimum Data Set (MDS) assessment dated [DATE] which was partially completed on 2/14/20 identified Resident #362 was always incontinent of bowel and bladder and required extensive assistance for dressing, toilet use, personal hygiene, and bed mobility. Additionally, Resident #362 was dependent for meals and needed to be fed. Resident #362 was a mechanical lift for transfers from bed to wheel chair. Furthermore, Resident #362 had a stage 2 pressure ulcer and a Deep tissue injury (DTI) and had a pressure reducing device for chair and bed, turning and repositioning program, nutrition and hydration intervention to manage skin problems, and pressure ulcer and injury care. The care plan dated 1/30/20 identified a pressure ulcer. Interventions directed to consult with wound physician (MD) as indicated and weekly. Resident #362 may exhibit nonverbal signs of pain related to left buttock pressure injury and interventions included monitor and record and nonverbal signs of pain. The Wound Report for 2/7/20 did not reflect Resident #362 on this report for pressure or non-pressure areas. The report did not reflect the right heel DTI, the boggy left heel, the left 2nd toe, the right 2nd toe, or the left buttock area. The Treatment Administration Record dated 2/1/20- 2/14/20 indicated the treatment for the right and left 2nd toe treatment stopped on 2/6/20 and was not renewed. Additionally, the order for skin prep every shift for 14 days stopped and was not renewed (did not indicate where the skin prep is to be applied). An Observation on 2/10/20 at 11:30 AM Resident #362 lying in bed flat on his/her back with heels in bunny boots. Resident #362's legs were on top of a flat pillow, however the heels were without the benefit of being elevated and were touching the bed. The Wound Physician note dated 2/10/20 indicated evaluation of Wound #1 left buttock as a stage 1 pressure Ulcer. The area was noted to be red and tender with no drainage and there was no change noted in the wound progression. Treatment was demaseptin change daily and as needed. The New Wound #2 on the Coccyx was a Stage 2 Pressure Ulcer 1.0 cm x 1.0 cm x 0.2 cm with moderate amount of serous drainage noted. Cleanse with normal saline followed by alginate, cover with a border foam, and change daily and as needed for soiling. Observations on 2/11/20 at 1:30 PM with Licensed Practical Nurse (LPN) #4 identified the Right heel had a DTI on the medical aspect of the right heel and he/she put skin prep on it that morning. The left heel was noted to be severely boggy up around the heel and the heel base and bottom of heel to the almost center of the foot, 100% of heel. LPN #4 pointed to the top of the right second toe first knuckle area which was noted to be bright shinny skin with center 50% red with pink edging. Resident #362's bilateral feet had a bunny boot on both feet and legs from calf and feet were on the flat pillow. Heels were in the boots and on flat pillow without the benefit of being elevated. The nurse's note dated 2/11/20 at 2:09 PM identified that treatment completed as ordered to left buttocks, skin prep applied to right heel, and let 2nd toe, left heel noted to be boggy, supervisor/unit manager updated of left heel bogginess. Observation and interview with RN #3, the Infection Control Nurse (ICN), on 2/11/20 at 2:40 PM indicated the right heel was not a DTI and the left heel was not boggy. RN #3 indicated the bunny boots help to elevate the heels off the bed and the pillow was to low not allowing the heels to be elevated and RN #3 moved the pillow from under the heels to up higher underneath the bilateral calf indicating the proper position of the pillow should be under the calves to float the heels. The right 2nd toe was noted to be shiny and red in color. RN #3 stated Physician #1 said don't worry about the right heel as it is not a DTI and the left buttock was healed and the staff were using barrier cream. An interview and observation with Director of Nursing Services (DNS) on 2/11/20 at 3:00 PM indicated to elevate the heels the pillow needs to be higher under the calves to elevate the heels but the resident also has these boots. Observation of bunny boots on bilateral feet. The DNS then removed Resident #362's brief and there was no dressing on the left buttock or the coccyx. The DNS identified a dressing should have been present. The DNS indicated the left buttock stage 2 area was new measuring 5.0 cm x 6.5 cm x 0.1 cm and appeared that it was a blister that popped by looking at the edges and it is not the same area as the one from admission. Additionally, the DNS indicated the coccyx was unstageable or a stage 3 due to the white appearance measuring 1.0 cm x 1.0 cm x 0.1 cm. The DNS indicated RN #3 would notify the Physician and get a new treatment order and the DNS would add an air mattress to Resident #362's bed. An interview with Physician #1 on 2/11/20 at 3:50 PM indicated he/she saw Resident #362 on 1/27/20 for a left buttock open area and then again on 2/10/20 for a new coccyx stage 2 area. Physician #1 indicated he/she was not aware nor asked to look at Resident #362's heels or toes. Physician #1 indicated he/she was not aware Resident #362 had a DTI on his/her right heel, a boggy left heel, or altered skin integrity on the toes. The dietary note dated 2/11/20 at 5:09 PM identified that the facility will provide Resident #362 with liquid protein 30 cc 2 times a day for additional nutrition support as patient has increased nutritional needs to aid in pressure injury healing. A physician's order dated 2/11/20 directed to cleanse open blister to left buttocks with normal saline, pat dry, followed by xeroform, and covered with a foam dressing 2 times a day and as needed for soiling. Additionally, increase liquid protein to 30 cc 2 times a day. The care plan dated 2/11/20 identified alteration in skin integrity, wound to buttock. Interventions included turn and reposition every 2 hours, specialty mattress, skin assessment weekly, and treatment to left buttock. A physician's order dated 2/12/20 directed to transfer using a mechanical lift out of bed to tilt in space wheel chair with pressure relief cushion. The nurse's note dated 2/12/20 at 3:54 PM identified that the air mattress in place for pressure relief. Patient turned and repositioned every 2 hours while in bed, treatment changed as ordered to left buttocks, skin prep applied to right heel and left 2nd toe, off load boots in place. A physician's order dated 2/13/20 directed to apply air mattress setting at 140 pounds and check function and setting every shift. Observation on 2/13/20 at 10:25 AM identified a new air mattress was now on bed set at 140 lbs. and there was a new calf pad/bolster dark blue on top and light blue on bottom. Observation on 2/13/20 at 10:30 AM identified Resident #362 sitting in the dining room for a recreation activity with new blue boots on bilateral feet. At 11:50 AM after the recreation program, staff noted Resident #362 was leaning forward from the back of the wheel chair at a 90 degree angle and leaning to the left. Staff adjusted Resident #362's upper body but did not move his/her lower half and moved his/her wheel chair to a different table for lunch. At 12:06 PM Resident #362 was noted to be sitting in the dining room for lunch. At 12:20 PM a nursing assistant brought over Resident #362's meal. When the nursing assistant went to feed Resident #362 she had to move the resident's upper body because Resident #362 was leaning forward and to the left. The nursing assistant adjusted the upper half of Resident #362's body but did not move the lower half. From 1:03 - 1:28 PM Resident #362 still sitting in dining room after lunch. Observation on 2/13/20 at 1:30 PM identified Resident #362 was brought out of dining room to sit in front of nurses station in the center of a row of Residents. Observation at 1:49 PM identified staff brought Resident #362 into the dining room by Recreation Staff #1 for a program at 2:00PM. An interview with RN #5 on 2/13/20 at 1:58 PM indicated dependent residents should be checked and changed at least every 2 hours. He/She further identified that the nursing assistants had not brought forward any issues or reasons why this would not have been done for Resident #362 that day. Interview on 2/13/20 at 2:40 PM with NA #6 indicated he/she got Resident #362 up after breakfast about 10:00 AM-10:15 AM. NA #6 indicated by the time he/she finished providing care for residents on unit it was time for lunch, so the residents that were in the dining room for recreation stayed there because the lunch trays were there. NA #6 indicated he/she then went to his/her lunch break and when he/she came back from break at 2:20 PM , he/she was then going to take care of Resident #362. Observation on 2/13/20 at 2:45 PM (approximately 4 hours later) identified Resident #362 was brought to his/her room and transferred to the bed for care. Resident #362 was noted with a small amount of urine in the brief and a small amount of brown stool. No redness was noted around the left buttock dressing or the coccyx dressing. An interview with the DNS on 2/13/20 at 2:50 PM indicated Resident #362 should be checked for incontinence and repositioned every 2 hours. The DNS indicated to check to see if the residents are incontinent the nursing assistants would have to take the resident to their room or into the shower room for privacy. Additionally, the DNS indicated Resident #362 had a wound and should be assisted to bed every 2 hours to reposition and if he/she was incontinent to be able to change him/her. An interview with LPN #4 on 2/13/20 at 2:55 PM with DNS present indicated that after the morning recreation program and before he/she moved Resident #362 to a different table for lunch, LPN #4 and a nursing assistant NA #7 adjusted the upper half of Resident #362 because she/he was leaning forward and off to the side but did not move his/her lower half. Additionally, LPN #4 indicated when Resident #362's tray came for lunch, the nursing assistant sat the resident back in the chair (back to the upright position) straightening his/her upper body but did not move the resident's lower half. The Wound Report for 2/14/20 reflected Resident #362 had a stage 2 pressure ulcer on the coccyx indicating it was community acquired on 1/23/20 and has gotten slightly larger in size from last week until this week. (Resident #362's admission assessments do not indicate there was a pressure ulcer to the coccyx on admission nor did the Wound Physician report dated 1/27/20.) Additionally, the Wound Report dated 2/14/20 identified the stage 2 left buttock pressure ulcer was facility acquired with a new onset of 2/11/20 measuring 5.0 cm x 6.5cm x 0.1 cm. This report did not reflect the original left buttock area, the right heel DTI, the left boggy heel, the top of the left 2nd toe, or the top of the right 2nd toe. An interview with Dietician #1 on 2/14/20 at 11:20 AM indicated Resident #362 had increased calorie needs and protein needs due to the DTI on his/her right heel. An interview with RN #3 on 2/14/20 at 1:30PM indicated the admission nurse does the skin assessment and the admission and if a new resident had a skin issue he/she will put the resident's name on Physician #1's clip board and get an initial treatment until resident is seen by Physician #1. RN #3 indicated he/she does review admission charts for infections and wounds. RN #3 indicated if a resident had an area on the coccyx or buttock the resident should be repositioned at least 4-5 times a shift if in bed and every hour if the resident is in a chair because it is worse for the resident's skin when they are in the chair. RN #3 indicated all wounds should be measured at least weekly. RN #3 indicated he/she does weekly wound rounds on Mondays with Physician #1 and if Physician #1 doesn't come in he/she will do rounds him/herself. RN #3 indicated a Resident with a DTI on his/her heels should be measured weekly and if the heels are boggy should also be checked weekly. The bunny boots are used for protection not prevention and the blue heel lift boots have a whole were the heel goes. RN #3 indicated Resident #362 received the blue heel lift boots and the heel lift bolster on 2/12/20. An interview with RN #4 on 2/14/20 at 1:50 PM indicated that Resident #362 had the bunny boots to bilateral heels because when resident was admitted the facility did not have any of the blue heel lift boots available. RN #4 indicated Resident #362 received the air mattress on 2/11/20 and the blue heel lift boots and a heel bolster on 2/12/20. RN #4 indicated they used the bunny boots for protection until nursing got the blue heel lift boots for prevention with her wounds. RN #4 is unable to recall or remember if he/she did the weekly wound measurements on 1/27/20. An interview with Advanced Practice Registered Nurse (APRN) #1 on 2/14/20 at 2:30 PM indicated the right DTI appears a little smaller (but did not measure it), and the left heel continues to be boggy since admission. Additionally, APRN #1 indicated it was the first time he/she was seeing the stage 2 area on the left buttock and the 2 areas on the coccyx were new to her. Additionally, APRN #1 indicated nursing should be measuring all wounds at least weekly. The APRN note dated 2/14/20 indicated resident noted to have boggy heels bilaterally on admission, they remain slightly boggy that day. Also, Resident #362 had a right DTI to heel which was improving at the time. Also, APRN evaluated wounds to left buttock measuring 6.5cm x 5.0 cm x 0.1 cm, distal coccyx measuring 0.8cm x 1.0 cm x 0.1 cm, and proximal coccyx measuring 1.2 cm x 1.0 cm x 0.1 cm. Skin noted with areas of flakiness and scales. The Pressure Ulcer and Skin Break down Policy indicated the incidence of a new pressure ulcer will be minimized to the extent possible and the healing of existing pressure ulcers will be optimized to the extent possible. The Prevention of Pressure Ulcers Policy indicated, conduct a comprehensive skin assessment upon admission. Prevention is to keep the skin clean and free of exposure to urine and fecal matter. Also, monitor the resident for weight loss and intake of food and fluids. Repositioning at least every hour, reposition residents who are chair bound or bed bound with the head of the bed elevated 30 degrees or more. At least every 2 hours, reposition residents who are reclining and dependent on staff for repositioning and repositioning more frequently as needed, based on the condition of the skin and the residents comfort. The Wound Care Policy indicated to provide guidelines for the care of wounds to promote healing. Documentation for wound care provided includes date and shift the wound care was provided. The name and title of the staff member doing the wound care. Document the assessment of the wounds bed color, size, amount of drainage, how did the resident tolerate procedure and the signature and title of the person recording the data. Repositioning of a Resident Policy indicated is to provide a guidelines for the evaluation of residents repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Repositioning is a common, effective intervention for preventing of skin breakdown, promoting circulation, and providing pressure relief. Positioning a resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue already compromised and may impede healing. For residents with a Stage 1 or greater pressure ulcer, an every 2 hour repositioning schedule is inadequate. Residents who are in a chair should be on an every 1 hour repositioning schedule. Assist the resident to change his/her position in the chair and monitor the need for toileting or incontinence care when changing position. The facility failed to ensure Resident #362's skin integrity was comprehensively assessed and monitored on an ongoing basis and failed to ensure measures were in place and implemented in a timely manner to prevent skin breakdown and promote skin healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews, for 1 resident (Resident #362) reviewed for pressure ulcers, the facility failed to consistently document weekly wound monitoring and/or identify and implement measures in a timely manner to prevent the development of or promote the healing of a pressure ulcer. The findings include: Resident #362 was admitted to the facility on [DATE] with diagnoses that included diabetes, Alzheimer's disease, and peripheral vascular disease. The Hospital Discharge summary dated [DATE] indicated Resident #362 had a stage 2 pressure area to the left buttock, wound base was pink and periwound intact and no other wounds. The admission assessment dated [DATE] indicated the Stage 2 left buttock pressure area measured 0.9 cm x 0.3 cm x 0.1 cm. Resident #362 had a Braden Scale for Predicting Pressure Sore Risk Score of 15 which identified a high risk for skin breakdown. Additionally, the assessment indicated Resident #362 had poor bed mobility or difficulty moving to a sitting position on the side of the bed and had difficulty with balance or poor trunk control. The nurse's note dated 1/23/20 at 10:36 PM identified that Resident #362 was a new admission and had a pressure area to the left buttock and a very boggy left heel. A physician's order dated 1/23/20 directed to turn and reposition Resident 4 times a shift every shift, cleanse left buttock with normal saline followed by dermasetpine and mepilex change daily, document wound measurements under wound management every Wednesday and apply small amount of zinc oxide to buttocks and groin with each incontinent episode every shift. The Initial Care Plan dated 1/23/20 directed to provide incontinent care every 2 hours and as needed. The Braden Scale for Predicting Pressure Sore Risk dated 1/23/20 identified a score of 15 indicating Resident was at risk for developing a pressure sore. The Braden Scale completed on 1/30/20 indicated a score of 12 with a high risk for pressure sores, and 2/7/20 indicated a score of 12 with a high risk for pressure sores. The Nursing Assistant Daily Care Card dated 1/23/20 indicated Resident #362 was incontinent of bowel and bladder and was at high risk for pressure ulcers. Apply barrier cream with each incontinent care and off load heels. The Wound Management Report dated 1/23/20 indicated there was a left buttock stage 2 pressure area 0.9 cm x 0.3 cm x 0.1 cm. On 2/3/20 the left buttock measured 1.0cm x 1.0 cm x 2.0 cm. On 2/10/20, the left buttock measured 1.0 cm x 1.0 cm x 0.2 cm. The Wound Physician note dated 1/27/20 indicated the first time he/she saw Wound #1 the left buttock measuring 1.0 cm x 1.0 cm x 0.1 cm treatment, cleanse with normal saline and apply alginate and change daily and as needed for soiling. The Wound Physician reclassified this area as a moisture associated dermatitis not a stage 2 as noted from admission. The Brief Interview for Mental Status (BIMS) evaluation dated 1/29/20 at 8:32 AM indicated Resident #362 had severe cognitive impairment. The admission Minimum Data Set (MDS) assessment dated [DATE] which was partially completed on 2/14/20 identified Resident #362 was always incontinent of bowel and bladder and required extensive assistance for dressing, toilet use, personal hygiene, and bed mobility. Additionally, Resident #362 was dependent for meals and needed to be fed. Resident #362 was a mechanical lift for transfers from bed to wheel chair. Furthermore, Resident #362 had a stage 2 pressure ulcer and a Deep tissue injury (DTI) and had a pressure reducing device for chair and bed, turning and repositioning program, nutrition and hydration intervention to manage skin problems, and pressure ulcer and injury care. The care plan dated 1/30/20 identified a pressure ulcer. Interventions directed to consult with wound physician (MD) as indicated and weekly. Resident #362 may exhibit nonverbal signs of pain related to left buttock pressure injury and interventions included monitor and record and nonverbal signs of pain. The Wound Report for 2/7/20 did not reflect Resident #362 on this report for pressure or non-pressure areas. An Observation on 2/10/20 at 11:30 AM Resident #362 lying in bed flat on his/her back with heels in bunny boots. Resident #362's legs were on top of a flat pillow, however the heels were without the benefit of being elevated and were touching the bed. The Wound Physician note dated 2/10/20 indicated evaluation of Wound #1 left buttock as a stage 1 pressure Ulcer. The area was noted to be red and tender with no drainage and there was no change noted in the wound progression. Treatment was demaseptin change daily and as needed. The New Wound #2 on the Coccyx was a Stage 2 Pressure Ulcer 1.0 cm x 1.0 cm x 0.2 cm with moderate amount of serous drainage noted. Cleanse with normal saline followed by alginate, cover with a border foam, and change daily and as needed for soiling. Observations on 2/11/20 at 1:30 PM with Licensed Practical Nurse (LPN) #4 identified the left heel was noted to be severely boggy up around the heel and the heel base and bottom of heel to the almost center of the foot, 100% of heel. Resident #362's bilateral feet had a bunny boot on both feet and legs from calf and feet were on the flat pillow. Heels were in the boots and on flat pillow without the benefit of being elevated. The nurse's note dated 2/11/20 at 2:09 PM identified that treatment completed as ordered to left buttocks and supervisor/unit manager updated of left heel bogginess. Observation and interview with RN #3, the Infection Control Nurse (ICN), on 2/11/20 at 2:40 PM indicated the right heel was not a DTI and the left heel was not boggy. RN #3 indicated the bunny boots help to elevate the heels off the bed and the pillow was to low not allowing the heels to be elevated and RN #3 moved the pillow from under the heels to up higher underneath the bilateral calf indicating the proper position of the pillow should be under the calves to float the heels. RN #3 stated Physician #1 said don't worry about the right heel as it is not a DTI and the left buttock was healed and the staff were using barrier cream. An interview and observation with Director of Nursing Services (DNS) on 2/11/20 at 3:00 PM indicated to elevate the heels the pillow needs to be higher under the calves to elevate the heels but the resident also has these boots. Observation of bunny boots on bilateral feet. The DNS then removed Resident #362's brief and there was no dressing on the left buttock or the coccyx. The DNS identified a dressing should have been present. The DNS indicated the left buttock stage 2 area was new measuring 5.0 cm x 6.5 cm x 0.1 cm and appeared that it was a blister that popped by looking at the edges and it is not the same area as the one from admission. Additionally, the DNS indicated the coccyx was unstageable or a stage 3 due to the white appearance measuring 1.0 cm x 1.0 cm x 0.1 cm. The DNS indicated RN #3 would notify the Physician and get a new treatment order and the DNS would add an air mattress to Resident #362's bed. An interview with Physician #1 on 2/11/20 at 3:50 PM indicated he/she saw Resident #362 on 1/27/20 for a left buttock open area and then again on 2/10/20 for a new coccyx stage 2 area. The dietary note dated 2/11/20 at 5:09 PM identified that the facility will provide Resident #362 with liquid protein 30 cc 2 times a day for additional nutrition support as patient has increased nutritional needs to aid in pressure injury healing. A physician's order dated 2/11/20 directed to cleanse open blister to left buttocks with normal saline, pat dry, followed by xeroform, and covered with a foam dressing 2 times a day and as needed for soiling. Additionally, increase liquid protein to 30 cc 2 times a day. The care plan dated 2/11/20 identified alteration in skin integrity, wound to buttock. Interventions included turn and reposition every 2 hours, specialty mattress, skin assessment weekly, and treatment to left buttock. A physician's order dated 2/12/20 directed to transfer using a mechanical lift out of bed to tilt in space wheel chair with pressure relief cushion. The nurse's note dated 2/12/20 at 3:54 PM identified that the air mattress in place for pressure relief. Patient turned and repositioned every 2 hours while in bed, treatment changed as ordered to left buttocks. A physician's order dated 2/13/20 directed to apply air mattress setting at 140 pounds and check function and setting every shift. Observation on 2/13/20 at 10:25 AM identified a new air mattress was now on bed set at 140 lbs. and there was a new calf pad/bolster dark blue on top and light blue on bottom. Observation on 2/13/20 at 10:30 AM identified Resident #362 sitting in the dining room for a recreation activity with new blue boots on bilateral feet. At 11:50 AM after the recreation program, staff noted Resident #362 was leaning forward from the back of the wheel chair at a 90 degree angle and leaning to the left. Staff adjusted Resident #362's upper body but did not move his/her lower half and moved his/her wheel chair to a different table for lunch. At 12:06 PM Resident #362 was noted to be sitting in the dining room for lunch. At 12:20 PM a nursing assistant brought over Resident #362's meal. When the nursing assistant went to feed Resident #362 she had to move the resident's upper body because Resident #362 was leaning forward and to the left. The nursing assistant adjusted the upper half of Resident #362's body but did not move the lower half. From 1:03 - 1:28 PM Resident #362 still sitting in dining room after lunch. Observation on 2/13/20 at 1:30 PM identified Resident #362 was brought out of dining room to sit in front of nurses station in the center of a row of Residents. Observation at 1:49 PM identified staff brought Resident #362 into the dining room by Recreation Staff #1 for a program at 2:00PM. An interview with RN #5 on 2/13/20 at 1:58 PM indicated dependent residents should be checked and changed at least every 2 hours. He/She further identified that the nursing assistants had not brought forward any issues or reasons why this would not have been done for Resident #362 that day. Interview on 2/13/20 at 2:40 PM with NA #6 indicated he/she got Resident #362 up after breakfast about 10:00 AM-10:15 AM. NA #6 indicated by the time he/she finished providing care for residents on unit it was time for lunch, so the residents that were in the dining room for recreation stayed there because the lunch trays were there. NA #6 indicated he/she then went to his/her lunch break and when he/she came back from break, he/she was then going to take care of Resident #362. Observation on 2/13/20 at 2:45 PM (approximately 4 hours later) identified Resident #362 was brought to his/her room and transferred to the bed for care. Resident #362 was noted with a small amount of urine in the brief and a small amount of brown stool. No redness was noted around the left buttock dressing or the coccyx dressing. An interview with the DNS on 2/13/20 at 2:50 PM indicated Resident #362 should be checked for incontinence and repositioned every 2 hours. The DNS indicated to check to see if the residents are incontinent the nursing assistants would have to take the resident to their room or into the shower room for privacy. Additionally, the DNS indicated Resident #362 had a wound and should be assisted to bed every 2 hours to reposition and if he/she was incontinent to be able to change him/her. An interview with LPN #4 on 2/13/20 at 2:55 PM with DNS present indicated that after the morning recreation program and before he/she moved Resident #362 to a different table for lunch, LPN #4 and a nursing assistant NA #7 adjusted the upper half of Resident #362 because she/he was leaning forward and off to the side but did not move his/her lower half. Additionally, LPN #4 indicated when Resident #362's tray came for lunch, the nursing assistant sat the resident back in the chair (back to the upright position) straightening his/her upper body but did not move the resident's lower half. An interview with Dietician #1 on 2/14/20 at 11:20 AM indicated Resident #362 had increased calorie needs and protein needs. The Wound Report for 2/14/20 reflected Resident #362 had a stage 2 pressure ulcer on the coccyx indicating it was community acquired on 1/23/20 and has gotten slightly larger in size from last week until this week. (Resident #362's admission assessments do not indicate there was a pressure ulcer to the coccyx on admission nor did the Wound Physician report dated 1/27/20.) Additionally, the Wound Report dated 2/14/20 identified the stage 2 left buttock pressure ulcer was facility acquired with a new onset of 2/11/20 measuring 5.0 cm x 6.5cm x 0.1 cm. This report did not reflect the original left buttock area. An interview with RN #3 on 2/14/20 at 1:30PM indicated the admission nurse does the skin assessment and the admission and if a new resident had a skin issue he/she will put the resident's name on Physician #1's clip board and get an initial treatment until resident is seen by Physician #1. RN #3 indicated he/she does review admission charts for infections and wounds. RN #3 indicated if a resident had an area on the coccyx or buttock the resident should be repositioned at least 4-5 times a shift if in bed and every hour if the resident is in a chair because it is worse for the resident's skin when they are in the chair. RN #3 indicated all wounds should be measured at least weekly. RN #3 indicated he/she does weekly wound rounds on Mondays with Physician #1 and if Physician #1 doesn't come in he/she will do rounds him/herself. RN #3 indicated the bunny boots are used for protection not prevention and the blue heel lift boots have a whole were the heel goes. RN #3 indicated Resident #362 received the blue heel lift boots and the heel lift bolster on 2/12/20. An interview with RN #4 on 2/14/20 at 1:50 PM indicated that Resident #362 had the bunny boots to bilateral heels because when resident was admitted the facility did not have any of the blue heel lift boots available. RN #4 indicated Resident #362 received the air mattress on 2/11/20 and the blue heel lift boots and a heel bolster on 2/12/20. RN #4 indicated they used the bunny boots for protection until nursing got the blue heel lift boots for prevention with her wounds. RN #4 is unable to recall or remember if he/she did the weekly wound measurements on 1/27/20. An interview with Advanced Practice Registered Nurse (APRN) #1 on 2/14/20 at 2:30 PM indicated it was the first time he/she was seeing the stage 2 area on the left buttock and the 2 areas on the coccyx were new to her. Additionally, APRN #1 indicated nursing should be measuring all wounds at least weekly. The APRN note dated 2/14/20 indicated APRN evaluated wounds to left buttock measuring 6.5cm x 5.0 cm x 0.1 cm, distal coccyx measuring 0.8cm x 1.0 cm x 0.1 cm, and proximal coccyx measuring 1.2 cm x 1.0 cm x 0.1 cm. Skin noted with areas of flakiness and scales. The Pressure Ulcer and Skin Break down Policy indicated the incidence of a new pressure ulcer will be minimized to the extent possible and the healing of existing pressure ulcers will be optimized to the extent possible. The Prevention of Pressure Ulcers Policy indicated, conduct a comprehensive skin assessment upon admission. Prevention is to keep the skin clean and free of exposure to urine and fecal matter. Also, monitor the resident for weight loss and intake of food and fluids. Repositioning at least every hour, reposition residents who are chair bound or bed bound with the head of the bed elevated 30 degrees or more. At least every 2 hours, reposition residents who are reclining and dependent on staff for repositioning and repositioning more frequently as needed, based on the condition of the skin and the residents comfort. The Wound Care Policy indicated to provide guidelines for the care of wounds to promote healing. Documentation for wound care provided includes date and shift the wound care was provided. The name and title of the staff member doing the wound care. Document the assessment of the wounds bed color, size, amount of drainage, how did the resident tolerate procedure and the signature and title of the person recording the data. Repositioning of a Resident Policy indicated the facility is to provide guidelines for the evaluation of residents repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Repositioning is a common, effective intervention for preventing of skin breakdown, promoting circulation, and providing pressure relief. Positioning a resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue already compromised and may impede healing. For residents with a Stage 1 or greater pressure ulcer, an every 2 hour repositioning schedule is inadequate. Residents who are in a chair should be on an every 1 hour repositioning schedule. Assist the resident to change his/her position in the chair and monitor the need for toileting or incontinence care when changing position. The facility failed to ensure Resident #362's skin integrity was comprehensively assessed and monitored on an ongoing basis and failed to ensure measures were in place and implemented in a timely manner to prevent skin breakdown and promote skin healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews, for 1 resident (Resident #362) reviewed for hydration, the facility failed to monitor hydration intake to ensure a resident met his/her fluid intake needs. The findings include: Resident #362 was admitted to the facility on [DATE] with diagnoses that included diabetes, Alzheimer's disease, and peripheral vascular disease. The Initial Care Plan dated 1/23/20 directed to provide incontinent care every 2 hours and as needed, encourage fluids, and monitor Intake and Output as ordered. The Nursing Assistant Daily Care Card dated 1/23/20 indicated Resident #362 was incontinent of bowel and bladder, on aspiration precautions, and totally dependent with a puree diet. The Nutrition Initial assessment dated [DATE] at 9:26 AM indicated Resident #362's total fluid required to meet needs was 1420-1700 ml (25-30ml/kg) and had a stage 2 pressure ulcer and a DTI to right heel. The The Brief Interview for Mental Status (BIMS) evaluation dated 1/29/20 at 8:32 AM indicated Resident #362 had severe cognitive impairment. The admission Minimum Data Set (MDS) assessment dated [DATE] which partially completed on 2/14/20 identified Resident #362 was always incontinent of bowel and bladder and required extensive assistance for dressing, toilet use, personal hygiene, and bed mobility. Additionally, Resident #362 was dependent for meals and needed to be fed. Resident #362 was a mechanical lift for transfers from bed to wheel chair. Furthermore, Resident #362 had a stage 2 pressure ulcer and a Deep tissue injury (DTI) and had a pressure reducing device for chair and bed, turning and repositioning program, nutrition and hydration intervention to manage skin problems, and pressure ulcer and injury care. The care plan dated 1/30/20 identified Resident #362 was at risk for constipation and at risk for dehydration related to dependency on staff to provide fluids. Interventions included to provide and assist as needed to consume fluids with and between meals. Observation on 2/10/20 at 11:25 AM identified Resident #362 was lying flat on his/her back with no water pitcher in room or on the over bed table. Resident #362's lips appeared dry and his/her hands had cracked lines on the posterior side indicating they were dry. Observation on 2/11/20 at 1:30 PM and 3:00 PM identified Resident #362 was lying in bed on his/her back with no water pitcher in room or on the over bed table, his/her lips appeared dry and Resident #362 smacked his/her lips. Resident #362 hands had cracked lines on posterior side indicating they were dry. The dietary note dated 2/11/20 at 5:09 PM identified that staff will provide with liquid protein 30 cc twice daily for additional nutrition support as patient had increased nutritional needs to aid in pressure injury healing. The Advanced Practice Registered Nurse (APRN) note dated 2/11/20 indicated asked to see resident for low grade fever and increased lethargy. Upon assessment Resident #362 was noted to have dry mucous membranes and noted to have crusting to bilateral eyes as well as yellow drainage x 2 days. APRN ordered lab work and for staff to encourage fluids. The Hematology Report dated 2/12/20 at 12:01 PM indicated Resident #362 had a hemoglobin and hematocrit were low at 10.9/35.8. Review of the fluid intake from 1/23/20- 2/13/20 Resident #362 was ranging from no fluid intake to 570 cc fluid intake per day for 22 days. The Daily Intake Report from 1/23/20-2/13/20 indicated Resident #362 was not meeting his/her total fluid requirements (1420-1700 ml (25-30ml/kg)) . An interview with Registered Nurse (RN) #4 on 2/14/20 at 9:30 AM indicated all new admissions are placed on Intake and Output (I+O) for the first 3 days then the Dietician will check the I+O's and the night shift looks at the I+O's if a resident is on an Antibiotic or Intravenous fluids for the length of the antibiotic or the IV fluids. RN #4 indicated if the night supervisor sees a resident did not meet the estimated goals she/he will pass the information to the day nurse and puts the information in the APRN book for them to look at it and let the Dietician know. RN #4 indicated all I+O's are done in the computer and nothing is done on paper. RN#4 indicated that Resident #362 was not in the APRN book for dehydration since admission after reviewing the book. An interview with the Director of Nurses (DNS) on 2/14/20 at 9:50 AM indicated new admissions are monitored for intake and output for 3 days and the Dietician, nursing supervisor, or unit manager can estimate the fluid needs for a new admission but mostly the Dietician does it when they do their admission note. The DNS indicated the fluid intakes are in the computer under fluids or in a nursing note and once the facility started using the computerized program, they stopped using paper to monitor intake and output. The DNS indicated in the computer the hydration/dehydration assessments are under observation but the DNS was not able to find a 3 day admission assessment for Resident #362. The DNS indicated after the 3 days if a residnet does not met the fluid goals the resident would continue on intake and output. An interview with APRN #1 on 2/14/20 at 10:15 AM indicated he/she was not notified by the nursing staff at any time that Resident #362 was potentially dehydrated. APRN #1 indicated he/she was asked to see Resident #362 for increased lethargy and a low grade temperature on 2/11/20. APRN #1 indicated when he/she went to assess the resident he/she noted Resident #362 looked a little dehydrated with dry mucous membranes and his/her lips were dry, so she ordered lab work and for staff to encourage fluids. An interview with Dietician #1 on 2/14/20 at 11:20 AM indicated Resident #362 fluid needs were between 1420-1700 ml per day. Dietician #1 indicated Resident #362 had increased calorie needs and protein needs due to the Deep Tissue Injury (DTI) on his/her right heel. Dietician #1 indicated nursing is responsible to review new admissions 3 day intake and output and if a resident is not meeting the fluid goals then nursing with notify the Dietician and physician and the resident will stay on Intake and Output for a longer period of time. Dietician #1 indicated nursing had not informed him/her that Resident #362 had not met the fluid goals since admission. An interview with the DNS on 2/14/20 at 2:50 PM indicated that nursing staff may not have recorded all the fluids that the resident may have drank even though they should have, but the Lab drawn on 2/12/20 indicated the BUN was 12 so Resident #362 was not dehydrated. The Intake and Measuring and Recording policy indicated the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24 hour period. The Resident Hydration and Prevention of Dehydration Policy indicated the facility will strive to provide adequate hydration and to prevent and treat dehydration. The minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments using the current Standard of Practice. Nursing will monitor and document fluid intake and the dietician will be kept informed of status. The dietician, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. The interdisciplinary team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved. The facility failed to monitor the fluid intake to ensure a resident met their identified fluid needs.