**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #45) reviewed for activities of daily living (ADL), the facility failed to notify the physician of a change in condition. The findings include: Resident #45 was admitted in February of 2021 and had diagnoses that included chronic obstructive pulmonary disease (COPD), anxiety, and pneumoconiosis (chronic lung disease) due to asbestos and other mineral fibers. A physician's order dated 9/18/24 directed Resident #45 receive a regular diet at dysphagia level 2 (mechanically altered) texture, thin liquids, pureed vegetables, no rice, a 2 handled mug with concave lid and meal items served in individual bowls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #45 was severely cognitively impaired and required setup or clean-up assistance with eating, was dependent for personal hygiene, and required substantial/maximal assistance with transfers. The Resident Care Plan (RCP) dated 9/26/24 identified Resident #45 was at risk for alteration in nutrition related to dementia and he/she was without teeth (missing dentures since 9/16/21 that the responsible party decided not to replace). Interventions included observation of Resident #45's tolerance to the diet texture, a regular diet with dysphagia level 2 (ground) texture, and for staff to refer to the speech therapist as needed. An Interdisciplinary Referral and Rehabilitation Screen Request form submitted by Licensed Practical Nurse (LPN) #3 dated 10/23/24 identified the reason for the referral was resident choking on meats observed over two days and further identified Resident #45 was screened by the speech therapist on 10/25/24. A Speech Therapy Evaluation and Plan of Treatment dated 10/25/24 at 8:45 AM identified Resident #45 had been referred by nursing after Resident #45 had severe coughing and spitting up during oral intake of ground meat. The evaluation further identified Resident #45 had no teeth and during trials of ground textures, experienced oropharyngeal dysphagia (swallowing problem occurring in the mouth and/or throat) characterized by little to no chewing, food residue on the tongue and inner cheeks and 2 instances of an observed cough. During trials with puree texture, Resident #45 did not chew, however, there were no signs or symptoms of airway compromise. Recommendations included skilled speech therapy services for management of Resident #45's dysphagia and to downgrade to a full puree texture diet due to reduced chewing and observed signs and symptoms of oropharyngeal dysphagia. A Dietary Communication Slip dated 10/25/24 identified Resident #45 had a diet change from dysphagia level 2 (mechanically altered/ground) with thin liquids to dysphagia level 1 (puree) with thin liquids. Review of Nurse progress notes from 10/2/24 through 10/29/24 failed to identify documentation Resident #45 had had trouble swallowing, coughed while eating, choked on meats, spit up food while eating, or coughed at any time during the shift. Interview with LPN #3 on 11/26/24 at 1:53 PM identified that on 10/23/24 a nurse aide (NA) requested her to the Dining Room because Resident #45 was coughing and spitting up while swallowing meat from his/her meal. LPN #3 identified she instructed the NA to stop Resident #45 from eating the meat and LPN #3 went to the kitchen and requested a new meal without meat. LPN #3 identified she watched Resident #45 eat a few bites of the new meal and after observing him/her eating without coughing or spitting up, left Resident #45 with the NA. LPN #3 indicated she then completed a Speech Therapy Referral form and a new diet slip requesting a diet without meat textured food until further notice. LPN #3 could not identify why she did not document the incident in a progress note and could not recall if she notified the supervisor or provider of Resident #45 coughing with his/her meal. LPN #3 further identified she observed Resident #45 take a few bites of the alternate meal she requested but did no further monitoring after that. Interview with the Director of Nursing Services (DNS) on 11/26/24 at 2:50 PM identified that LPN #3 failed to write a progress note about Resident #45 coughing while eating, failed to update the supervisor and provider, and failed to monitor Resident #45 for signs and symptoms of aspiration. The DNS further identified that when filling out the speech screen referral, LPN #3 should have documented coughing rather than choking unless it was verified that Resident #45 was choking which would have required immediate emergency intervention. Interview with APRN #1 on 11/26/24 at 3:03 PM indicated he was not notified of Resident #45 having difficulty swallowing on 10/23/24, and he did not see notations in his records relating to the incident. APRN #1 identified that if he were notified, he would have inquired about Resident #45's baseline swallowing status and diet order and determined if a change in diet was required at that time. APRN #1 further identified he would have ordered a speech screen, monitoring for signs and symptoms of aspiration and if signs or symptoms of aspiration were identified, ordered a chest x-ray. Review of the Change in Condition policy directed, in part, that changes in a resident's baseline condition were monitored by nursing staff members, assessed by the Registered Nurse (RN), reported to the attending physician/APRN to determine a course of action, reported to the family representative, and documented in a progress note in the resident's medical record.

Based on clinical record review, facility documentation and staff interviews, the facility failed to provide medication administration education to a temporary agency staff nurse before starting work to meet professional standards of practice to prevent a significant medication error. The findings include: A Reportable Event Form dated 10/11/24 identified that Resident #1 received Resident #14's medications in error which included the following medications: Amlodipine 5 milligrams (mg) (lowers blood pressure), Aspirin 81mg (NSAID), Depakote 250mg (anticonvulsant), Cymbalta 120 mg (antidepressant), Gabapentin 800mg (anticonvulsant), lacosamide 100mg (antoconvulsant), Keppra 500 mg (anticonvulsant), Metoprolol 25mg (lowers blood pressure), Movantik 25mg (treats opioid induced constipation), Docusate (stool softener), Simethicone (gas relief), Vitamin D (supplement) and Vitamin B12 (supplement). Interview with LPN #1 on 11/25/24 at 1:47 PM identified that she was assigned to administer morning medications to Resident #1 on 10/11/24. LPN #1 identified that she went into the wrong room and administered Resident #14's medications to Resident #1 in error. LPN #1 identified that Resident #1 was not wearing a name identification bracelet. LPN #1 further identified that she called Resident #1 by the wrong name, Resident #1 did not respond to the name, but she assumed that she had the correct resident and administered the medications. LPN #1 identified that after administering medications to Resident #1, she realized that she administered medications to the wrong resident secondary to Resident #1 not having an ordered medical device which she would have needed to monitor. LPN #1 reported the medication error when she realized she administered medications to the wrong resident. LPN #1 identified that APRN #1 assessed Resident #1 and verbally instructed her to monitor Resident #1 every 2 hours for respiratory distress, lethargy, change in vital signs and to notify him of any change in vital signs. LPN #1 identified that Resident #1's systolic blood pressure dropped by 15 to 20 mmHg within the first two hours, which she reported to the DNS and APRN #1. Additionally, LPN #1 reported that she did not receive any form of medication administration re-education prior to continuing with her medication pass. LPN #1 indicated that she asked the DNS if she should write a statement and a progress note in the clinical record, regarding the medication error, but the DNS declined and stated he would complete the medication error statement, and a progress note for the incident. LPN #1 identified that she failed to follow the 5 rights of medication administration while administering medications to Resident #1 because she did not use any resident identifier to confirm she was administering medications to the right resident. LPN #1 identified that she should have verified the picture on electronic medical record or confirmed resident identity with another staff member when she realized Resident #1 had no name identification bracelet. Interview with the Human Resources Director (HRD) on 11/25/24 at 2:58 PM identified that the facility utilizes agency staff to fill vacant shifts. The HRD identified that prior to the initial shift worked at the facility, the agency staff would acknowledge and sign that they have received, read, and understood the facility Orientation for Pool Staff document. The document included facility policy information for Mission and Values, Confidentiality, Infection Control, Abuse and Neglect, Corporate Compliance, On-Site Hazards, Hazardous Materials, General Safety, Health Requirements, Identification, Patient's Rights, Weapons and Code of Conduct. Interview with the DNS on 11/26/24 at 10:59 AM identified that the facility does not provide orientation for agency nurses to include medication administration competency. The DNS indicated that LPN #1 was educated on the 5 rights of medication administration prior to continuing with medication administration on the day of the medication error but was unable to provide documentation that medication administration re-education was provided. The DNS provided documentation that facility staff nurses were educated on medication administration after the medication error incident, but did not implement any form of education for agency staff nurses related to medication administration and did not add the medication administration policy to the facility Orientation for Pool Staff document which is reviewed with agency nurses before working a shift in the fcaility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #58) reviewed for accidents, the facility failed to ensure that side rails were used for positioning and bed mobility resulting in a fall. The findings include: Resident #58's diagnoses included hemiplegia (paralysis) affecting the left side, dementia, anxiety and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3) and was dependent for toileting hygiene, personal hygiene, bed mobility and transfers. The Resident Care Plan (RCP) dated 10/11/24 identified Resident #58 required assistance with ADL's due to left hemiplegia, mobility deficit and self-care deficit. Interventions included using 2 quarter siderails to assist with positioning and bed mobility, assistance with personal hygiene and maintaining proper body alignment and positioning. A facility fall investigation document dated 10/28/24 by RN #7 identified a witnessed fall incident on 10/28/24 at 1:23 PM. The form identified that NA #1 and NA #2 were providing care to Resident #58 while in bed and that when Resident #58 was being turned to the side, he/she slid off the bed. NA #1 and NA #2 both identified that the side rail was down when Resident #58 was being turned. Resident #58 was only oriented to person at the time of the fall. Post Fall assessment note dated 10/28/24 at 1:27 PM by RN #7 identified that she found Resident #58 laying on the side of the bed on his/her back and no injuries were noted. A Nurse's note dated 10/28/24 at 1:45 PM by LPN #2, identified that he was called to the room by NA #1 and observed Resident #58 with his/her back on the floor and his/her legs on the bed. The note identified that Resident #58 was only wearing a T-shirt at the time of the fall, the bed side rails were in the lowered position and noted NA #1 stated Resident #58 rolled out of bed while receiving incontinence care. The note identified that LPN #2 notified RN #7 who responded to the incident and assessed Resident #58. Interview with NA #1 on 11/22/24 at 10:30 AM, identified that she and NA #2 were providing incontinence care to Resident #58 when he/she fell out of bed. NA #1 further identified that NA #2 alerted her that she was going to roll Resident #58 over to the left side. NA #1 indicated that when Resident #58 was rolled over to the left side, she was unable to support Resident #58's weight and Resident #58 slid to the floor landing on his/her shoulders first followed by his/her entire upper body. NA #1 indicated that the bed was about 3 feet high, and the side rail was down at the time of the fall. NA #1 identified that she forgot to raise the side rail which could have helped prevent Resident #58 from falling out of bed. NA #1 indicated that Resident #58 appeared shocked when he/she realized he/she was on the floor and asked why he/she was on the floor and why he/she was naked. Furthermore, NA #2 identified that Resident #58 complained of pain, which she reported to RN #7. Interview with NA #2, on 11/22/24 at 11:35 AM, identified that she and NA #1 were providing incontinence care to Resident #58 when Resident #58 fell out of bed. NA #2 identified that she informed NA #1 that she was going to roll Resident #58 over, but when she rolled Resident #58 over, NA #1 was unable to support Resident #58 ' s weight and Resident #58 landed on the floor. NA #2 indicated that the side rail, which could have helped to prevent Resident #58 from falling out of bed, was down at the time of the fall. NA #2 further indicated that NA #1 stated that she forgot to raise the side rail before Resident #58 was rolled over. NA #2 identified that when she saw Resident #58 rolling over, she tried to catch him/her from across the bed, but it happened so fast that Resident #58 ended up on the floor. NA #2 indicated that Resident #58 appeared shocked when he/she realized he/she was on the floor and asked why he/she was on the floor. NA #2 identified that Resident #58 complained of pain, which she reported to RN #7. Interview and clinical record review with RN #7 on 11/25/24 at 12:30 PM, identified that she responded to the fall and completed a fall assessment when Resident #58 fell out of bed. RN #7 identified that she found Resident #58's torso on the floor and his/her legs were still in bed. RN #7 identified that she observed and palpated Resident #58's body, checked range of motion and noted slight blanchable redness on Resident #58's buttocks. Interview with the DNS on 11/26/24 at 10:30 AM, identified that NA #1 and NA #2 should have followed Resident #58's plan of care to use 2 quarter siderails for positioning and bed mobility while providing incontinence care. The DNS was unable to explain why NA #1 and NA #2 did not use side rails while positioning Resident #58 in bed leading to a fall out of bed. The DNS identified that education related to following the plan of care was provided to NA #1 and NA #2 after the fall incident on 10/28/24. Review of facility policy titled, Fall Management Program: Policy and Procedure, identified, in part, that the fall management program is designed to provide individualized person-centered care and manage resident falls and potential for falls with resident focused interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 2 of 4 residents (Resident #22 and Resident #34) reviewed for nutrition, the facility failed to obtain a reweight as directed by provider order and failed to notify a provider of a weight change and failed to obtain daily weights as directed by a provder order. The findings include: Resident #22 was admitted to the facility in October of 2024 and had diagnoses that included periprosthetic fracture around other internal prosthetic joint, constipation, heart failure and acute prosthetic anemia. A Nutrition evaluation dated 10/16/24 at 11:57 AM identified a regular puree consistency diet with thin liquids and identified no swallowing difficulties. The evaluation identified Resident #22 had dentures but did not wear them, had 2 remaining teeth on the bottom, and had a left hip surgical site. A provider order dated 10/16/24 directed to obtain weekly weights for 4 weeks then obtain monthly weights. Instructions directed to compare current weight to previous weight and if there was a discrepancy of 5 pounds (lbs) a re-weight must be obtained for verification. The Weights and Vital Signs summary identified a weight entry on 10/16/24 at 11:57 AM of 122.4 lbs which was obtained using a mechanical lift (lifting device to obtain weight measurement). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 was moderately cognitively impaired (brief interview for mental status (BIMS) score of 12) and required set up assistance for eating, supervision or touching assistance for personal hygiene, substantial maximum assistance to dependent for bed mobility, transfer, ambulation and toileting. The MDS further identified a weight of 122 lbs, no swallowing difficulties, no weight loss and a mechanically altered diet. The Resident Care Plan dated 10/29/24 identified potential for alteration in nutrition related to a mechanically altered diet, history of low body weight and limited oral intake. Interventions included to assess likes and dislikes and offer choices, pureed diet texture with thin liquids, offer health shakes in the evening, encourage 50% of meal intake, Registered Dietician assessment as indicated and refer to speech therapy as needed. Additionally, report significant weight changes and weights as ordered. A physician's order dated 11/19/24 at 3:00 PM directed to obtain a weekly weight. The Weights and Vital Signs summary identified a weight entry on 11/19/24 at 10:58 PM of 97 lbs which represented a 20.8% weight loss. A physician's order dated 11/20/24 at 6:20 AM directed to obtain a reweight. A Dietitian note on 11/20/24 indicated a weight review was done, a reweight was pending, and weight loss was discussed with the weight committee and the charge nurse. The note further indicated Resident #22 accepted health shakes (per the medication administration record (MAR) and nursing report), that there had been no significant change in oral intake and recommended offering chocolate ice cream. Review of the Medication Administration Record for November of 2024 identified there was no weight entry on 11/20/24. Interview and record review with the Director of Nursing (DNS) on 11/26/24 at 10:20 AM, verified the order for a reweight. The DNS confirmed that the reweight was not obtained as ordered and he did not know why the reweight was not obtained. The DNS identified that the Nursing Assistants (NA) are responsible for obtaining weights on the 11:00 PM to 7:00 AM shift and then the 7:00 AM to 3:00 PM shift NA's or nurses document the weights in the electronic medical record (EMR). Additionally, the DNS reviewed the clinical record and identified the provider was not notified of the documented weight loss. Observations on 11/26/24 at 12:01 PM, identified Resident #22's lunch tray was set up on the overbed table in front of him/her with pureed meat, potatoes and vegetables, soup and ice cream. Resident #22 indicated he/she only wanted the drinks on the tray and did not want to eat. Subsequent to surveyor inquiry, the facility added a weight entry of 113 lbs (7.68% weight loss) on 11/26/24 at 12:16 PM. Interview with the DNS on 11/26/24 at 2:30 PM indicated the 11/19/24 weight entry of 97 lbs was an error. Review of the Weight Trending policy and procedure directed, in part, residents with 5% or more weight change in 30 days, 7.5% in 90 days or 10% change in 180 days will be identified. If a 5 pound weight loss/gain is noted from prior weight the NA will reweigh to verify, and inform the charge nurse of the weight change. The charge nurse will document the weight change and inform the physician, family and the weight committee. The weight committee will review the weight history, and medical information. Additionally, will implement a high calorie nourishment snack of choice. The Dietician and DNS will record in the progress notes recommendations and interventions as indicated through the meeting and policy. 2. Resident #34's diagnoses included congestive heart failure (CHF), hypertension, acute posthemorrhagic anemia and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #34 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13) and required set-up assistance with eating, maximum assistance with personal hygiene and was dependent for toileting hygiene and transfers. A physician's order dated 10/31/24 directed to administer Torsemide (diuretic) tablet 20 milligrams (mg) by mouth one time a day. A physician's order dated 10/31/24 (discontinuation date of 11/9/24) directed to obtain daily weights and report a weight gain of 2 pounds in 24 hours or 5 pounds in one week, to the provider. A physician's order dated 11/9/24 at 11:00 PM directed to obtain daily weights and report a weight gain of 2 pounds in 24 hours or 5 pounds in one week to the provider. The Resident Care Plan (RCP) dated 11/9/24 identified Resident #34 was at risk for alteration in cardiac status related to congestive heart failure (CHF), Atrial fibrillation (an irregular and rapid heartrate resulting in poor blood flow), hypertension, coronary artery disease, hyperlipidemia (high fat particles/lipids in blood), valve disease, and severe aortic stenosis. Interventions included obtaining and reporting weights as ordered, therapeutic diet as ordered, monitoring intake and output per facility policy, lab work as ordered, elevating legs above heart while in bed or recliner, monitoring vital signs as ordered and elevating head of bed for ease in breathing. Review of the Weights and Vitals Summary identified no daily weights were recorded from 10/31/24 to 11/2/24 (3 days), and from 11/9/24 through 11/20/24 (11 days). Review of Resident #34's clinical record from 10/31/24 through 11/25/24 identified no documentation for weight refusals within the progress notes or RCP. Interview and record review with RN #7 on 11/25/24 at 12:30 PM identified Resident #34's daily weight order as current and in effect. RN #7 further identified that Resident #34 was not weighed daily as directed by the provider and indicated that both nurses and NA's could obtain weights but it is the nurses' responsibility to ensure that weights are obtained and communicate weight changes to the physician. RN #7 could not explain why Resident #34 was not weighed as directed by the physician but identified that Resident #34 should have been weighed daily due to CHF. Interview and clinical record review with the DNS on 11/26/24 at 10:30 AM identified Resident #34's daily weight order as current and in effect. The DNS identified that both NA's and licensed nurses are responsible for weighing residents, but licensed nurses are responsible for ensuring that weights are obtained and updating the provider of weight changes. The DNS was unable to explain why Resident #34 was not weighed as directed by the physician but identified that he/she needed to have been weighed daily per the physician's orders due to CHF. Review of facility policy, Weight Trending Policy and Procedures, identified in part, the intent of weight monitoring as maintaining the highest practical well-being of the residents/patients by monitoring weight loss/gain.

Based on clinical record review, facility documentation and staff interviews the facility failed to provide medication administration education to a temporary agency staff nurse before starting work in the facility and failed to provide documentation of medication administration education to a temporary agency staff nurse after a significant medication error. The findings include: A Reportable Event Form dated 10/11/24 identified that Resident #1 received Resident #14's medications in error which included the following medications: Amlodipine 5 milligrams (mg) (lowers blood pressure), Aspirin 81mg (NSAID), Depakote 250mg (anticonvulsant), Cymbalta 120 mg (antidepressant), Gabapentin 800mg (anticonvulsant), lacosamide 100mg (antoconvulsant), Keppra 500 mg (anticonvulsant), Metoprolol 25mg (lowers blood pressure), Movantik 25mg (treats opioid induced constipation), Docusate (stool softener), Simethicone (gas relief), Vitamin D (supplement) and Vitamin B12 (supplement). Interview with LPN #1 on 11/25/24 at 1:47 PM identified that she was assigned to administer morning medications to Resident #1 on 10/11/24. LPN #1 identified that she went into the wrong room and administered Resident #14's medications to Resident #1 in error. LPN #1 identified that Resident #1 was not wearing a name identification bracelet. LPN #1 further identified that she called Resident #1 by the wrong name, Resident #1 did not respond to the name, but she assumed that she had the correct resident and administered the medications. LPN #1 identified that after administering medications to Resident #1, she realized that she administered medications to the wrong resident secondary to Resident #1 not having an ordered medical device which she would have needed to monitor. LPN #1 reported the medication error when she realized she administered medications to the wrong resident. LPN #1 identified that APRN #1 assessed Resident #1 and verbally instructed her to monitor Resident #1 every 2 hours for respiratory distress, lethargy, change in vital signs and to notify him of any change in vital signs. LPN #1 identified that Resident #1's systolic blood pressure dropped by 15 to 20 mmHg within the first two hours, which she reported to the DNS and APRN #1. Additionally, LPN #1 reported that she did not receive any form of medication administration re-education prior to continuing with her medication pass. LPN #1 indicated that she asked the DNS if she should write a statement and a progress note in the clinical record, regarding the medication error, but the DNS declined and stated he would complete the medication error statement, and a progress note for the incident. LPN #1 identified that she failed to follow the 5 rights of medication administration while administering medications to Resident #1 because she did not use any resident identifier to confirm she was administering medications to the right resident. LPN #1 identified that she should have verified the picture on electronic medical record or confirmed resident identity with another staff member when she realized Resident #1 had no name identification bracelet. Interview with the Human Resources Director (HRD) on 11/25/24 at 2:58 PM identified that the facility utilizes agency staff to fill vacant shifts. The HRD identified that prior to the initial shift worked at the facility, the agency staff would acknowledge and sign that they have received, read, and understood the facility Orientation for Pool Staff document. The document included facility policy information for Mission and Values, Confidentiality, Infection Control, Abuse and Neglect, Corporate Compliance, On-Site Hazards, Hazardous Materials, General Safety, Health Requirements, Identification, Patient's Rights, Weapons and Code of Conduct. Interview with the DNS on 11/26/24 at 10:59 AM identified that the facility does not provide orientation for agency nurses to include medication administration competency. The DNS indicated that LPN #1 was educated on the 5 rights of medication administration prior to continuing with medication administration on the day of the medication error but was unable to provide documentation that medication administration re-education was provided. The DNS provided documentation that facility staff nurses were educated on medication administration after the medication error incident, but did not implement any form of education for agency staff nurses related to medication administration and did not add the medication administration policy to the facility Orientation for Pool Staff document which is reviewed with agency nurses before working a shift in the fcaility.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and interviews for 15 of 70 residents (Resident #4, Resident #6, Resident #22, Resident #28, Resident #30, Resident #32, Resident #33, Resident #39, Resident #41, Resident #45, Resident #48, Resident #58, Resident #65, Resident #69, Resident #326) reviewed for preventative weekly body audits, the facility failed to perform preventative weekly body audits according facility policy and physician orders. The findings include: 1. Resident #4 was admitted to the facility in November of 2020 and had diagnoses that included cerebrovascular disease, abnormal posture, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), was at risk for developing pressure injuries and had moisture associated skin damage (MASD) with skin treatments. Resident #4 was dependent for bed mobility and transfers. The Resident Care Plan dated 10/11/24 identified Resident #4 was at risk for pressure injuries related to impaired mobility and incontinence. Interventions included to complete a weekly body audit on shower day, turn and reposition on rounds, and to monitor skin integrity during morning and evening care. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 4/8/21) which directed to perform a weekly body audit on Fridays during the 7 AM to 3 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/4/24) which directed to apply barrier cream every shift for MASD and a provider order (start date of 11/16/24) which directed to cleanse the open area to Resident #4 ' s sacrum with normal saline and apply Silvadene (topical antimicrobial) followed by a clean dressing every morning. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/11/24, 10/18/24, 11/1/24, and 11/22/24. There was no body audit performed for Resident #4 for 21 days from 10/4/24 through 10/25/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:15 PM and identified that Resident #4 had no skin issues or abnormalities. The Weekly Body Audit failed to identify MASD or an open area to the sacrum correlating to the active treatment orders in place. 2. Resident #6 was admitted to the facility in August of 2019 and had diagnoses that included congestive heart failure, rheumatoid arthritis, and anemia. The annual Minimum Data Set assessment dated [DATE] identified Resident #6 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), had abnormal posture, dementia, was at risk for developing pressure injuries and had skin treatments. Resident #6 was dependent for bed mobility and transfers. The Resident Care Plan dated 11/20/24 identified Resident #6 was at risk for pressure injuries related to severely impaired mobility and total functional incontinence. Interventions included to ensure Resident #6 had only 2 layers between his/her skin and the mattress, to turn and reposition during rounds, and to perform a weekly body audit on the scheduled shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 10/3/19) which directed to complete a weekly body audit on Fridays during the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 5/26/24) which directed to apply barrier cream to reddened buttocks 2 times a day and as needed after every incontinent episode. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/4/24, 10/18/24, 11/8/24, and 11/22/24. There was no body audit performed for Resident #6 for 14 days from 11/1/24 through 11/15/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:18 PM and identified that Resident #6 had no skin issues or abnormalities. The Weekly Body Audit failed to identify redness to the buttocks correlating to the active treatment orders in place. 3. Resident #22 was admitted to the facility in October of 2024 and had diagnoses that included a repair of a left femur fracture, muscle weakness, and anemia. The admission Minimum Data Set assessment dated [DATE] identified Resident #22 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12), was at risk for developing pressure injuries, had a surgical wound, and had skin/wound treatments. Resident #22 required substantial/maximal assistance for bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 10/28/24 identified Resident #22 was at risk for pressure injuries related to impaired mobility, incontinence and bony prominences. Interventions included to monitor for pain on or near bony prominences and pressure points, reposition in chair on rounds, and to complete a weekly body audit on shower day. The RCP further identified Resident #22 was at risk for infection related to a surgical incision to the left hip. Interventions included to document drainage, appearance of site, and signs and symptoms of infection. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 10/15/24) which directed to complete a weekly body audit on Tuesday ' s during the 7 AM to 3 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 10/18/24) which directed to monitor an area surrounding a surgical incision to the left lower extremity and report abnormal findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/22/24, 11/5/24, 11/12/24, 11/19/24, and 11/26/24. There was no body audit performed for Resident #22 for 17 days from 11/9/24 through 11/26/24. Subsequent to surveyor inquiry, a Weekly Body Audit was performed on 11/26/24 at 5:21 PM and identified Resident #22 had no documented skin issues or abnormalities. The Weekly Body Audit failed to identify documentation of a surgical incision/healed incision to the left hip correlating to the active treatment order in place. 4. Resident #28 was admitted to the facility in February of 2021 and had diagnoses that included peripheral vascular disease (PVD), diabetes, and lymphedema. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #28 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12), was at risk for developing pressure injuries and had skin treatments. Resident #28 required substantial/maximal assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 9/16/24 identified Resident #28 was at risk for pressure injuries related to impaired mobility and incontinence. Interventions included protective skin barrier with incontinent care and staff assistance to change positions in bed on rounds. The RCP further identified Resident #28 was at risk of bruises, skin tears, and skin alterations related to PVD, lymphedema and a history of cellulitis. Interventions included to moisturize legs and arms daily with morning care and to complete a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 7/28/24) which directed to apply house stock barrier cream to the buttocks every shift for skin integrity. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/5/24) which directed to complete a weekly body audit on Fridays during the 7 AM to 3 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified Weekly Body Audits were not completed on 10/1/24, 10/8/24, 10/22/24, 11/8/24, and 11/22/24. There was no body audit performed for Resident #28 for 17 days from 10/29/24 through 11/15/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:10 PM and identified Resident #28 ' s skin was clean, dry and intact. 5. Resident #30 was admitted in July of 2018 with diagnoses that included vascular dementia, osteoarthritis left shoulder, contracture right hand, and abnormal posture. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 was severely cognitively impaired and required an assist of 2 for eating, oral hygiene, toileting hygiene, showering, and upper and lower body dressing. The Resident Care Plan (RCP) dated 9/19/24 identified Resident #30 was at risk of bruises and skin tears related to dementia and fragile skin and was at risk for pressure injuries related to impaired mobility and incontinence. Interventions included to inspect skin daily with morning and evening care, to monitor skin pressure points, and perform weekly body audits on the shower day. A review of the October 2024 and November 2024 Treatment Administration Record (TAR) identified a Physician's order that directed to perform a body audit on Thursday's during the 3 PM to 11 PM shift and complete a weekly body audit form. The order was documented as completed for 11/7/24, 11/14/24, and 11/21/24. A review of Resident #30's clinical record identified the last body audit performed was on 10/31/24. Interview with RN #3 on 11/25/24 at 11:06 AM identified the last weekly body audit completed for Resident #30 was on 10/31/24, and nursing in the evenings was responsible to complete. Interview with the Director of Nursing (DNS) on 11/25/24 at 11:16 AM identified there were no weekly body audits completed for the month of November for Resident #30 and that nursing was responsible to complete. 6. Resident #32 was admitted to the facility in February of 2021 and had diagnoses that included Parkinson ' s disease and impulse disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #32 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), had muscle weakness, was at risk for developing pressure injuries and had skin treatments. Resident #32 required partial/moderate assistance with bed mobility and substantial/maximal assistance with transfers. The Resident Care Plan dated 11/07/24 identified Resident #32 was at risk for pressure injuries related to impaired mobility. Interventions included to avoid positioning Resident #32 on reddened areas and non-blanchable areas, to reposition in his/her chair on rounds, and to complete a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/08/24) directed to complete a weekly body audit on Fridays with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/11/24, 10/18/24, 11/1/24, 11/8/24, and 11/22/24. There was no Weekly Body Audit performed for Resident #32 for 21 days from 10/25/24 through 11/15/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:23 PM and identified Resident #32 had no documented skin issues or abnormalities. 7. Resident #33 was admitted to the facility in April of 2022 and had diagnoses that included Chronic Obstructive Pulmonary Disease, Dementia, Muscle Weakness, and Unsteadiness on Feet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 as moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 10), required set up assistance for eating, and was dependent for toileting and transfers. The Resident Care Plan dated 9/23/24 identified Resident #33 was at risk for pressure injuries related to impaired mobility and incontinence. Interventions included to keep skin clean, dry, and moisturized, utilization of a pressure reducing mattress, repositioning in chair during rounds, and weekly body audit on shower day. Review of the clinical record identified documentation for weekly body audits were not completed on 5/4/24, 5/18/24, 5/25/24, 6/8/24, 6/22/24, 9/14/24, 10/12/24, and 10/19/24. An Order Summary document dated 11/25/24 included a provider order (start date of 4/13/24) that directed to provide a body audit weekly on shower day. Instructions directed to complete a weekly body audit form every Saturday, inspect for altered skin integrity, changes in moles or abnormalities of skin, and report findings to MD/APRN. Interview and clinical record review with the Director of Nursing (DNS) on 11/25/24 at 11:15 AM identified that the unit nurse is responsible for completing weekly body audits and that they should have been completed for Resident #33 per physician order and facility policy. Additionally, the DNS was unable to locate documentation or explain why body audits for Resident #33 were not completed on the following dates: 5/4/24, 5/18/24, 5/25/24, 6/8/24, 6/22/24, 9/14/24, 10/12/24, and 10/19/24. 8. Resident #39 was admitted to the facility in May of 2021 and had diagnoses that included Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, emphysema, essential hypertension, and restless leg syndrome. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 as moderately cognitively impaired (brief interview for mental status (BIMS) score of 11), required set up assistance for eating, substantial/maximal assistance for toileting, personal hygiene, bed mobility and transfers. The Resident Care Plan (RCP) dated 4/29/24 identified Resident #39 was at risk for potential/actual alteration in skin, bruising and skin tears related to the aging process. Interventions included inspect skin daily with morning and evening care, observe for signs and symptoms of infection, and weekly body audits on shower day. Review of the clinical record identified documentation for weekly body audits were not completed on 4/12/24, 4/19/24, 5/3/24, 5/17/24, 5/24/24, 5/31/24, 6/14/24, 6/28/24, 7/12/24, 7/19/24, 7/26/24, 8/23/24, 9/6/24, 9/13/24, 10/18/24, 10/25/24, 11/1/24, and 11/8/24. Additional clinical record review identified there was no documentation of refusals in progress notes or the RCP. Interview and clinical record review with RN #7 on 11/25/24 at 12:30 PM, identified that weekly body audits should be done weekly on shower days. RN #7 identified that the unit nurse is responsible for completing weekly body audits and that the process includes NA ' s notifying the nurse of when a shower is provided, and the nurse completing the body audit during that time. RN #7 was unable to explain why body audits were not being completed weekly as ordered. An Order Summary document dated 11/26/24 included a provider order (start date of 6/4/21) that directed to provide a body audit weekly. Instructions directed to complete a weekly body audit form every Saturday, inspect for altered skin integrity, changes in moles or abnormalities of skin, and report findings to MD/APRN. Interview with the Director of Nursing (DNS) on 11/26/24 at 10:30 AM, identified that the unit nurse is responsible for completing weekly body audits. The DNS was unable to explain why body audits were not being completed weekly as ordered and identified that weekly body audit orders and the facility policy for weekly body audits should have been followed. Review of the Weekly Body Audit completed on 11/26/24 at 4:23 PM identified that Resident #22 had no documented skin issues or abnormalities. 9. Resident #41 was admitted to the facility in September of 2021 and had diagnoses that included polyosteoarthritis, polyneuropathy, and chronic pain. The annual Minimum Data Set assessment dated [DATE] identified Resident #41 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13) and independent with bed mobility and transfers. The Resident Care Plan (RCP) dated 11/6/24 identified Resident #41 was at risk for pressure injuries related to impaired mobility. Interventions included to turn and reposition on rounds and complete a weekly body audit on shower day. The RCP further identified Resident #41 was at risk for bruises and skin tears related to the aging process and dry flaky skin. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/30/22) which directed to complete a weekly body audit on Tuesdays during the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/1/24, 10/15/24, 10/29/24, 11/12/24, and 11/19/24. There was no body audit performed for Resident #41 for 19 days from 11/7/24 through 11/26/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:15 PM and identified Resident #41 ' s skin was clean, dry and intact. 10. Resident #45 was admitted to the facility in February of 2021 and had diagnoses that included polyneuropathy, osteoarthritis, and lumbosacral radiculopathy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #45 was severely cognitively impaired, had dementia, was at risk for developing pressure injuries and had skin treatments. Resident #45 required partial/moderate assistance with bed mobility and substantial/maximal assistance with transfers. The Resident Care Plan (RCP) dated 9/26/24 identified Resident #45 was at risk for pressure injuries related to dementia, potential for declines in mobility, and incontinence. Interventions included a pressure reducing mattress and completion of a weekly body audit on shower day. The RCP further identified Resident #45 was at risk for bruises, skin tears, and alterations in skin related to dementia, fragile skin and the aging process. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 4/12/24) which directed to complete a weekly body audit on Thursdays during the 7 AM to 3 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/3/24, 10/24/24, 11/7/24, and 11/21/24. There was no body audit performed for Resident #45 for 14 days from 10/31/24 to 11/14/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:19 PM and identified Resident #45 had no documented skin issues or abnormalities. 11. Resident #48 was admitted to the facility in October of 2021 and had diagnoses that included osteoarthritis, muscle weakness, and mild protein-calorie malnutrition. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #48 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 2), had dementia, was at risk for developing pressure injuries and had skin treatments, required substantial/maximal assistance with bed mobility and transfers. The Resident Care Plan (RCP) dated 9/23/24 identified Resident #48 was at risk for pressure injuries related to dementia, incontinence, and decline in mobility. Interventions included to keep skin clean, dry and moisturized and to complete a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 3/5/24) which directed to complete a weekly body audit on Thursdays during the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/17/24, 11/14/24, and 11/21/24. There was no body audit performed for Resident #48 for 19 days from 11/7/24 to 11/26/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:17 PM and identified Resident #48 had no documented skin issues or abnormalities. 12. Resident #58 was admitted to the facility in January of 2023 and had diagnoses that included hemiplegia and hemiparesis of the left side following a stroke, muscle weakness, and abnormal posture. The annual Minimum Data Set assessment dated [DATE] identified Resident #58 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13), was at risk for developing pressure injuries, had nonsurgical dressings and skin treatments, required substantial/maximal assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 10/11/24 identified Resident #58 was at risk for pressure injuries related to diabetes, impaired mobility and incontinence. Interventions included to keep skin clean, dry and moisturized and to provide a pressure reducing cushion in reclining chair. The RCP further identified Resident #58 was at risk for bruises and skin tears related to behaviors, dementia, and fragile skin. Interventions included to observe Resident #58 ' s position in his/her wheelchair and to complete a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 1/17/24) which directed to complete a weekly body audit on Tuesdays on the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 1/17/24) which directed to apply an optifoam dressing (protective dressing) to the left elbow every 3 days for protection, a provider order (start date of 11/13/24) which directed to cleanse a skin tear to the left forearm with normal saline and apply a dry clean dressing daily, and a provider order (start date of 11/25/24) which directed to cleanse an abrasion to the left thigh with normal saline and apply a Kerralite Cool (hydrogel) dressing every 3 days for 14 days. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/1/24, 10/15/24, 10/29/24, 11/12/24, and 11/19/24. There was no body audit performed for Resident #58 for 21 days from 11/5/24 to 11/26/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:02 PM and identified Resident #58 had a skin tear to the left forearm which measured 2.5 centimeters (cm) by 2 cm and an area to the left thigh which appeared to be resolved. The Weekly Body Audit failed to identify documentation of the skin appearance of the left elbow correlating to the active treatment order in place. 13. Resident #65 was admitted to the facility in December of 2023 and had diagnoses that included muscle weakness, venous insufficiency, and osteoarthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #58 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 8), had dementia, was at risk for developing pressure injuries and had skin treatments, and was independent with bed mobility and transfers. The Resident Care Plan (RCP) dated 9/16/24 identified Resident #65 was at risk for pressure injuries related to impaired mobility and incontinence. Interventions included to remind Resident #65 to change position in his/her chair and to complete a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 10/18/24) which directed to complete a weekly body audit on Thursdays on the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified weekly body audits were not completed on 10/17/24, 10/31/24, 11/7/24, and 11/21/24. There was no body audit performed for Resident #65 for 21 days from 10/24/24 to 11/14/24. Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 4:56 PM and identified Resident #65 had discoloration/scar tissue to an area on the buttocks previously identified with no additional skin issues or abnormalities. 14. Resident #69 was admitted to the facility in November of 2024 with diagnoses that included lung cancer with metastasis to the brain, muscle weakness, and a rotator cuff tear of the right shoulder. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 8), had dementia, had a neurological surgery, was at risk for developing pressure injuries, had surgical wound care and skin treatments, and required supervision or touching assistance with bed mobility and partial/moderate assistance with transfers. The Resident Care Plan (RCP) dated 11/20/24 identified Resident #69 was at risk for pressure injuries related to dementia, impaired mobility, and incontinence. Interventions included to monitor for pain on/near bony prominences and pressure points and complete a weekly body audit on shower day. The RCP further identified Resident #69 was at risk for infection related to a surgical incision following a craniotomy. Interventions included to document drainage, appearance of site, signs and symptoms of infection, and how the treatment was tolerated. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/1/24) which directed to monitor the incision to the left parietal scalp for signs and symptoms of infection every shift and report abnormal findings to the provider, and a provider order (start date of 11/20/24) which directed to wash the skin tear to the right lower extremity with normal saline then apply a dry clean dressing every 3 days. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/22/24) which directed to complete a weekly body audit on Wednesday on the 7 AM to 3 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified a weekly body audit was not completed on 11/22/24. There was no body audit performed for Resident #69 for 11 days (11/15/24 to 11/26/24). Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:20 PM and identified Resident #69 had an abrasion to the right lateral calf and failed to identify documentation of a surgical incision/healed incision to the parietal scalp correlating to the active treatment order in place. 15. Resident #326 was admitted to the facility in November of 2024 with diagnoses that included epilepsy, diabetes, and congestive heart failure (CHF). The Nursing admission assessment dated [DATE] identified Resident #326 was admitted to the facility from the hospital following hospitalization for seizures and CHF. Resident #326 was alert and oriented to person, place, time, situation and was cognitively intact and had moisture associated skin damage (MASD) to the coccyx which measured 3 centimeters (cm) by 3 cm and required treatment with a barrier cream and placement of an air mattress. Resident #326 required assistance with bed mobility and transfers. The Resident Care Plan (RCP) dated 11/19/24 identified Resident #326 was at risk for pressure injuries related to impaired circulation, impaired mobility, and incontinence. Interventions included protective skin barrier with incontinent care and completion of a weekly body audit on shower day. Review of the Order Summary report dated 11/26/24 included a provider order (start date of 11/19/24) which directed to complete a weekly body audit on Mondays on the 3 PM to 11 PM shift with instructions to complete the weekly body audit form, inspect for altered skin integrity, changes in moles or abnormalities of skin, and to report findings to the provider. Weekly Body Audit reports dated 11/26/24 reviewed for October 2024 and November 2024 identified a weekly body audit was not completed on 11/25/24. There was no body audit performed for 7 days (11/19/24 to 11/26/24). Subsequent to surveyor inquiry, a Weekly Body Audit was completed on 11/26/24 at 5:24 PM and identified Resident #326 had no documented skin issues or abnormalities. The Weekly Body Audit failed to identify MASD or resolution of an area of MASD to the coccyx correlating to the documentation on the Nursing admission assessment on 11/19/24. Review of the Body Audit policy directed, in part, nurses would perform a complete body audit weekly and/or more often as indicated per physician's orders, the nurse would document any abnormal findings and notify the physician.

**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 2 of 2 residents (Resident #44 and 422) reviewed for indwelling urinary catheters, the facility failed to ensure the residents dignity when the urinary drainage bags were left uncovered and visible. The findings include: 1. Resident #44 was admitted to the facility with diagnoses that included benign prostate hyperplasia and obstructive and reflux uropathy. The quarterly MDS dated [DATE] identified Resident #44 had intact cognition, required extensive assistance with transfers, bed mobility, dressing, toileting, and personal hygiene and had an indwelling catheter. The care plan dated 12/22/22 identified Resident #44 had an indwelling urinary catheter with interventions that included to use a drainage bag cover at all times. Observation on 2/7/23 at 10:45 AM identified Resident #44 was sitting in a wheelchair on the left side of the bed next to the door. The indwelling urinary catheter drainage bag was hung on the wheelchair, contained dark amber urine, and was visible from the hallway. Interview with LPN #1 on 2/7/23 at 10:52 AM indicated Resident #44 has urinary retention and has an indwelling catheter. Observation with LPN #1 indicated the indwelling urinary catheter bag was visible from the hallway while Resident #44 was sitting in the wheelchair. LPN #1 indicated she knew at 7:00 AM that morning, that Resident #44 did not have a privacy bag covering the drainage bag but was waiting to ask the infection control nurse to get her one. During interview with LPN #1 she indicated that was 2 family members had just come in to visit with Resident #44 while the resident's drainage bag was visible. 2. Resident #422 was admitted to the facility with diagnoses that included dementia, neuromuscular dysfunction of bladder, and obstructive and reflux uropathy. A physician's order dated 1/28/23 directed to give Bactrim 800/160 mg 1 tablet two times a day for urinary tract infection and sepsis for 7 days. The care plan dated 1/30/23 identified the resident had an indwelling urinary catheter with interventions to use privacy bag covers at all times. The Medicare 5-day MDS dated [DATE] identified Resident #422 had moderately impaired cognition and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Additionally, Resident #422 had an indwelling urinary catheter. The nurse's note dated 2/4/23 at 10:49 PM identified Resident #422 continues on antibiotic for a urinary tract infection and the indwelling urinary catheter is draining clear yellow urine. The nurses note dated 2/7/23 at 6:36 AM indwelling urinary catheter patent draining clear straw-colored urine. Observation on 2/7/23 at 10:19 AM identified Resident #422 was lying in bed with the bed in the low position. The urinary catheter bag was visible from the hallway, hung at bottom of the bed frame, lying flat on the floor. Visible from the hallway and without a privacy bag, yellow urine could be seen in the tubing. Interview with RN #2 on 2/7/23 at 10:25 AM identified the charge nurse and nurse aides were responsible to make sure the indwelling urinary catheter bag was not on the floor and was covered with a privacy bag. The APRN progress note dated 2/8/23 at 9:52 AM indicated Resident #422 had an indwelling urinary catheter intact, patent and draining cloudy yellow urine with sediment. Interview with the DNS on 2/14/23 at 3:05 PM indicated the nurses and nurse aides were responsible to make sure the urinary drainage bags were off the floor at all times for infection control reasons, were hung below the level of the bladder, and when transporting the resident to a common area, to ensure a privacy bag is used. The DNS indicated she was unsure if the urinary drainage bag should be covered with a privacy bag while the resident is in his/her room. Review of the Resident bill of Rights identified residents have the right to be treated with consideration, respect, and full recognition of your dignity and individuality. Review of the infection control indwelling urinary catheter use policy identified for indwelling catheters to have a privacy bag at all times ensure residents dignity and privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and interview for 1 of 2 residents (Resident #36) reviewed for positioning, the facility failed to ensure a physician's order was in place and nurse monitoring was regularly performed and documented, for a resident utilizing a positioning device, and for 1 resident (Resident #52) reviewed for accidents, the facility failed to ensure a RN assessment was completed when the resident had a change in condition. The findings include: 1. Resident #36's diagnoses included Alzheimer's disease, hypertension, and osteoarthritis. Review of the physician's order history identified a lap buddy (a positioning device) for positioning was ordered on 10/16/21 with instructions to document the resident's ability to remove the device every shift. Further review identified the lap buddy was discontinued 5 months later, on 3/24/22. The quarterly MDS dated [DATE] identified the resident had severely impaired cognition with behaviors of continuous disorganized thinking and fluctuating inattention. Further the MDS identified the resident required total 2-person assistance with transfers, extensive 1 person assistance with locomotion on and off unit, did not walk, utilized a wheelchair for mobility and had no restraints. The care plan dated 1/24/23 identified the resident had impaired ADL function related to late-stage Alzheimer's. Interventions included to transfer the resident out of bed to the adaptive wheelchair with cushion, Velcro calf positioning and leg rests in place at all times, reposition on rounds and as needed. The February 2023 monthly physician's orders directed the resident to be assisted out of bed to the adaptive wheelchair with cushion, Velcro calf positioning and leg rests in place at all times, and to reposition on rounds and as needed. Observation on 2/7/23 at 1:27 PM identified Resident #36 was up, dressed, and sitting in an adaptive wheelchair with a lap buddy in place. Observations on 2/8/23 at 10:30AM and 2/9/23 at 11:30AM identified the resident had a lap buddy positioning device in place while sitting up in the adaptive wheelchair. Review of the nurse's notes from 3/24/22 through 2/9/23 failed to reflect the use of a lap buddy positioning device or resident's ability to remove it. Review of the TAR's dated 3/24/22 through 2/9/23 (11 months) failed to reflect documentation for the use of, or monitoring of, a lap buddy positioning device. Review of the nurse aide care card failed to include the use of a lap buddy positioning device or direction on removal or reapplication. Interview with NA #1 on 2/9/23 at 9:30AM identified Resident #36 always has the lap buddy placed after being transferred out of bed to the adaptive wheelchair, indicating it remains in place until resident is assisted back to bed. Although NA #1 identified she could not recall when the resident began using the lap buddy, she indicated it has been in use for a long time. NA #1 identified the resident was able to remove the lap buddy and did so frequently during the day. Interview and review of the clinical record with the Director of Rehabilitation, (OT #1) on 2/9/23 at 12:45 PM identified although he was aware Resident #36 utilized a lap buddy positioning device, he could not recall when it was initiated or find any therapy documentation related to its use. OT #1 identified, because the resident has been under hospice services since July 2022, he thought maybe hospice had initiated the lap buddy. When review of the order history identified 10/16/21 as the original order date for the lap buddy, OT #1 indicated there should have been therapy documentation to support the initiation and use of the positioning device. OT #1 could not explain why there was none found. OT #1 indicated residents are assessed for the use of positioning devices for safety and fall prevention, either to keep them from slipping down, leaning forward or to the side. Interview and review of the clinical record with the Administrator and DNS on 2/15/23 at 9:45 AM identified they did not know why the lap buddy was discontinued on 3/24/22, because the resident continued to utilize the device since initially ordered on 10/16/21. The Administrator identified the resident had a change in condition during that time (March 2022) and perhaps the lap buddy was discontinued because the resident wasn't getting out of bed at that time, however the resident did recover and resumed utilizing the lap buddy when sitting up in wheelchair. Review of the nurse's notes failed to reflect documentation related to why the lap buddy was discontinued on 3/24/22. The Administrator and DNS identified when the lap buddy was discontinued on 3/24/22, it was removed from the TAR, care plan and nurse aide care card as well. The Administrator and DNS identified the order for the lap buddy should not have been discontinued, it should have remained in the care plan, on the nurse aide care card and on the TAR for nurse monitoring. The DNS indicated, subsequent to surveyor inquiry, the order for lab buddy for positioning, was obtained/written, and the TAR was updated to include assessing resident's ability to remove the lab buddy independently every shift. Review of the facility's Positioning Devices policy and procedures identified the interdisciplinary team will evaluate the residents need for the use of position devices to maintain body alignment and safety. The Resident Care Coordinator will be responsible for oversight of this policy. Rehab screens will be initiated to determine if devices are needed for proper positioning and body alignment. Consideration will be given to determine the effect it has on the resident to ensure it does not meet the definition of a physical restraint. (i.e. able to self-release). Additionally, nursing staff are to assess and document resident's ability to remove device daily. 2. Resident # 52 was admitted to the facility with diagnoses that included diabetes, and hemiplegia and hemiparesis following a stroke affecting the right dominant side. The admission MDS dated [DATE] identified Resident #52 had severely impaired cognition, was always incontinent of bowel and bladder and required total assistance with transfers, dressing, toileting, and personal hygiene. The care plan dated 6/10/21 identified impaired activities of daily living related to the stroke. Interventions included to transfer with a mechanical lift with 2 staff, non-ambulatory, and resident likes to get up early at 6:00 AM. Additionally, monitor skin integrity during morning and evening personal care, and check bony prominences and pressure points. a. The reportable event form dated 6/18/21 at 11:00 AM identified Resident #52 had increased pain as evidence by negative verbalization and grimacing during range of motion. APRN notified on 6/18/21 time not identified. The APRN progress note dated 6/18/21 identified the resident had increased pain, was very guarded and rigid, a significant change. Recommendations include x-ray to both hips, lumbar, spine and sacral areas. The nurse's note dated 6/18/21 at 3:57 PM, written by LPN #2, indicated resident was resting in bed, grimaces with movement and repositioning. The DNS and APRN are aware and assessed the resident. Resident is a poor historian and unable to state cause. The Radiology Report dated 6/18/21 at 10:11 PM identified an x-ray an acute left sub capital fracture with superior lateral displacement. A written statement by NA #2 dated 6/18/21 indicated that Resident #52's pain was just as bad on 6/17/21 as it was on 6/16/21. The nurse's note dated 6/19/21 at 2:58 AM identified subsequent to APRN notification, Resident #52 to the emergency room. EMS arrived at 3:15 AM for transportation. A statement written by the DNS dated 6/19/21 at 9:45 AM noted she had spoken with NA #4 who reported she provided evening care for Resident #52 on 6/14/21 during the 3:00 PM -11:00 PM shift and Resident #52 was in pain. NA #4 reported she had to go very slowly and take breaks to get Resident #52's pants off. NA #4 had reported the increased pain to charge nurse, LPN #2. A statement written by the DNS dated 6/19/21 at 10:20 AM noted she had spoken with NA #5, and he had Resident #52 on 6/17/21 during the 3:00 PM -11:00 PM shift. NA #5 reported he did not transfer the resident via a mechanical lift that shift but did provide care. NA #5 reported Resident #52 did not provide as much assistance as usual and refused the knee brace because he/she was in pain. A statement written by the DNS dated 6/19/21 at 11:05 AM noted she spoke with NA #6 who worked on 6/17/21 during the 11:00 PM - 7:00AM shift with Resident #52. NA #6 stated she was to get the resident out of bed in the morning before 7:00 AM but the resident refused because he/she was in pain. NA #6 noted she had informed the first shift nurse aide that the resident had refused to get out of bed because he/she was in pain. Interview with the DNS on 2/9/23 at 9:47 AM indicated Resident #52 required total care and could not roll him/herself over and required a mechanical lift for transfers to a wheelchair. The DNS indicated when the nurse aides reported on 6/14, 6/16, and 6/17/21 that the resident had a change in behaviors and increased pain to the charge nurses, a RN should have done an assessment to find out why, report the assessment to the APRN/MD, and document the situation in the clinical record. The DNS indicated she only had statements from the nurse aides and not the nurses so she could not explain why there were no RN assessments completed or documented on 6/14, 6/16, and 6/17/21. Review of the clinical record by the DNS identified there was no documentation from 6/14/21 - 6/17/21 by a charge nurse or RN about the residents increased pain, refusal to get out of bed, or refusal to wear the knee brace. The DNS indicated it was her expectation that when the resident experienced these changes, a head-to-toe assessment by a RN would have been done. The DNS noted on 6/18/21 when they did the head-to-toe assessment by the RN Resident #52 had increased pain noted through grimacing and had a scab on the bridge of the nose, going up to the forehead that was not reported. Interview with NA #5 on 2/14/23 at 11:59 AM indicated he was not assigned to Resident #52 on the evening shift of 6/17/21 but had Resident #52's roommate. NA #5 indicated when he had finished with the roommate, he went over to Resident #52 and offered to put the knee brace on but Resident #52 said no at approximately 9:00 PM. NA #5 indicated his/her knee hurt and the resident was in pain. NA #5 indicated he did report the residents knee pain and refusal of the knee brace to the charge nurse. b. The reportable event form dated 6/18/21 identified an abrasion noted to forehead bridge of nose with scabbed area. Additionally, the description of the event was a scabbed forehead and bridge of nose. The investigation noted a body audit was done on 6/11/21 and there were no new areas. Intervention was to ensure the resident was not wearing glasses in bed. The report noted the care plan was updated, a treatment was put into place, and the staff was educated. A written statement dated 6/18/21 by NA #3 indicated she noticed the scabs on 6/16/21 but assumed someone else had reported them. A written statement dated 6/18/21 by NA #7 identified she had noticed the scab today but did not report it because she assumed it had already been reported and did not know when or how it got there. The nurse's note dated 6/18/21 at 3:57 PM, written by LPN #2, indicated the resident was resting in bed and was identified with a 1.0 cm scab noted to forehead and a 2.0 cm x 1.0 cm scab noted to bridge of nose. The DNS and APRN aware and assessed the resident. Resident a poor historian and unable to state cause. Glasses noted slightly misshapen. Monitoring started for 72 hours and the scabbed areas to be left open to air. Interview with the DNS on 2/9/23 at 11:00 AM indicated the scab to the bridge of the nose and the forehead was not noted until the resident exhibited increased pain and was identified with a fracture on 6/18/21. The DNS could not identify when the area was first found, but noted it had to occur between 6/11/21 and 6/18/21. The DNS indicated the scab on the resident's nose may have been from wearing the glasses while in bed and being rolled side to side for care. The DNS indicated through her investigation the nurse aides thought because it was a scab, they assumed someone else had reported it, so they did not report it. The DNS indicated the intervention for the scabbed areas was for staff to take off glasses when providing care. The DNS indicated the intervention was placed in the care plan, but she did not do an education sheet with the staff. Interview and clinical record review with the DNS on 2/14/23 at 3:25 PM failed to provide documentation that when the resident was identified with a scab on the bridge of the nose, that a RN assessment was completed and documented. Although attempted, an interview with NA #2, NA #3, NA #4, NA #6, and LPN #1 was not obtained. Review of the Reportable Events Policy and Procedure identified regardless of how minor an incident may be, it must be reported to the department supervisor, and the reportable event form is to be completed on the shift that the incident occurred. An employee witnessing an incident involving a resident, must report immediately such occurrence to the supervisor. The charge nurse will evaluate the resident immediately and the RN will complete as assessment for any injury. In communication with the attending physician a course of action will be determined.

**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 resident (Resident #44) reviewed for respiratory care, the facility failed to ensure respiratory equipment was dated per facility policy. The findings include: Resident #44 was admitted to the facility with diagnoses that included acute and chronic respiratory failure with hypoxia and chronic congestive heart failure. A physician's order dated 10/27/22 directed to apply oxygen at 2 liters per minute via nasal cannula and to change the oxygen tubing weekly on Tuesday during the night shift. The quarterly MDS dated [DATE] identified Resident #44 had intact cognition, had shortness of breath with exertion, while sitting at rest, and while lying flat and did not require oxygen prior to being at the facility. The care plan dated 12/22/22 identified the resident had alteration in respiratory status with interventions that included to provide oxygen as ordered and as needed per nursing measure and physician's order. A physician's order dated 12/31/22 directed to give Xopenex Nebulizer solution 1.25 mg/3ml inhale orally via nebulizer 3 times a day. The nurse's note dated 2/4/23 at 2:00 PM noted Resident #44 was on oxygen via a nasal cannula. Observation on 2/7/23 at 10:45 AM identified Resident #44 was sitting in a standard wheelchair next to his/her bed with oxygen tubing on from a concentrator and a nebulizer mask over it. Neither the nebulizer tubing nor the oxygen tubing had been dated as to when they were last changed. Interview with LPN #1 on 2/7/23 at 10:46 AM indicated the oxygen tubing and nebulizer mask tubing are changed weekly and as needed (prn) on the 3rd shift on Sunday night shift. LPN #1 indicated the nebulizer mask had been on the floor earlier and although she had changed it, she had not dated it. LPN #1 identified both the oxygen and the nebulizer tubing should have had a piece of nursing tape attached to them indicating the date and nurse's initials when they were last changed. LPN #1 indicated she did not change the oxygen tubing and noted it was not dated when last changed. Interview with the DNS on 2/14/23 at 3:23 PM indicated the oxygen and the nebulizer tubing must be dated when changed on a weekly basis and as needed per the facility policy. The DNS indicated as soon as a nurse changes the tubing, he/she must use a piece of nursing tape and at the least date it to identify when it was last changed. The DNS indicated if LPN #1 had changed the nebulizer mask and tubing, she should have dated it before the resident had used it. Review of the Oxygen Therapy Policy identified oxygen administration requires a physician order. Oxygen tubing needs to be dated. All oxygen tubing, bubblers, and bags must be changed weekly and as needed if damaged or soiled. All new equipment must be dated for that day.

**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 1 residents (Resident #7) reviewed for hemodialysis, the facility failed to monitor a hemodialysis Arterio-Venous (AV) fistula. The findings include: Resident #7 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included end-stage renal disease, hypertension, and atherosclerotic heart disease. A Resident Care Plan dated 5/18/18 through 1/29/20 identified a problem with needing hemodialysis related to end stage renal disease. Interventions included to notify physician for change in fistula, dialysis on Mondays, Wednesdays, and Fridays, and do not draw blood or take blood pressures in the arm with the graft. The quarterly Minimum Data Set (MDS) assessment dated [DATE] and the 5 day (re-admission) MDS assessment dated [DATE] identified Resident #7 was cognitively intact and required extensive assistance of one for bed mobility, transfers, walking in the room, dressing, toilet use and personal hygiene. Additionally, the MDS identified Resident #7 received dialysis. Treatment Administration Record (TAR) identified from 8/1/19 through 8/14/19 (when Resident #7 was discharged ) Resident #7's AV fistula to the left arm was assessed for thrill/bruit every shift. TAR from re-admission on [DATE] through 1/17/20 failed to identify Resident #7's fistula to the left arm was assessed for thrill/bruit. Physician's orders from 8/15/19 through 1/17/20 failed to direct assessing Resident #7's AV fistula for thrill/bruit. Physician's order dated 1/28/20 directed to observe fistula site every shift for bruit, thrill, and signs/symptoms of infection and document every shift The nurse's notes dated 1/28/20 at 1:42 PM and 10:20 PM identified that AV fistula was monitored for thrill and bruit; no other documentation of fistula monitoring was identified in the nurses' notes for the months of December 2019 and January 2020. Interview and clinical record review with DNS on 1/30/20 at 9:09 AM failed to provide documentation that the AV fistula was performed on a daily basis. Additionally, the DNS identified prior to 8/15/19, AV fistula monitoring was completed and documented for each shift on the TAR, but not after 8/15/19. The DNS identified she did not know the reason the AV monitoring was not renewed upon Resident #7's re-admission on [DATE]. Additionally, the DNS identified it was facility expectation and standard of practice to monitor venous access devices. Review of facility Policy and Procedure for Monitoring and Surveillance of Hemodialysis Vascular Access identified a procedure was to be followed to identify abnormalities early and for early intervention when abnormalities are identified. Frequency of monitoring and documentation was not identified in the facility policy and procedure. Subsequent to surveyor inquiry, the facility policy and procedure was updated to include the monitoring of the dialysis access site will be performed on the day and evening shift.