**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to honor the resident representative's request to ensure, 1 of 3 sampled residents reviewed for Choices, Resident #71, received a shower on the scheduled shower days. The findings included: Record review documented Resident #71 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment done on 12/27/24 documented Resident #71 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment and the resident is dependent for all care needs. During an observation in the room of Resident # 71, there was a white sheet of paper posted on the bulletin board with the following handwritten message: please see that she (Resident #71) get a shower on her shower days. Review of the orders shows the resident's shower schedule is every Monday and Thursday on the 3 PM - 11 PM shift. Review of the documentation on the Certified Nursing Assistant (CNA) task list from 02/27/25 to 03/24/25 showed Resident #71 received 4 bed baths and 3 tub baths on the scheduled shower days. An interview was conducted on 03/26/25 at 4:39 PM, Staff C, CNA, who stated she provided a bed bath to Resident #71. An interview and observation were conducted with Staff D, Licensed Practical Nurse (LPN) in the room of Resident # 71. The LPN stated that the note on the bulletin board was written by the resident's sister who is involved in her care. A side-by-side review of the record and interview on 03/27/25 at 10:54 AM with the Director Of Nursing (DON), who confirmed the lack of shower documentation on the task list for Resident #71. She also confirmed the facility does not have a tub.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document the discharge status of 1 of 3 sampled residents reviewed as closed records, Resident #100. The findings included: Record review documented Resident #100 was admitted to the facility on [DATE] and discharged home on [DATE]. Resident #100's diagnoses upon admission included: Anemia, Hypertension, Hip fracture, Spondylopathy in lumbar region, Muscle wasting and atrophy, Abnormalities of gait and mobility, Obesity, and Chronic pain syndrome. Review of Resident #100's care plan for discharge, dated 01/14/25, documented, The resident wishes / or Responsible Party wishes to: return home. The goal of the care plan was documented as, Safely discharge to a lower level of care (Home, Home with Home Health Aide, Assisted Living Facility, Independent Living Facility, other) when rehab goals are met. Reivew of a progress note, dated 01/24/25, documented, Resident discharge from [name of facility] to home at 300 pm, VIA PRIVATE CAR accompanied, 2-persons food / medication administered as ordered before leaving the facility one of the staff accompanied resident to the lobby skin warm / intact / dry, lung sound clear no SOB [shortness of breath] or distress noted, vs WNL [vital signs within normal limits]. Discharge instruction reviewed with resident voice understood the explanation; med list / medication provided, follow-up with MD [medical doctor] within 3-5 days post discharge. Review of a Social Services progress note, dated 01/24/25, documented, Discharge Summary note. Res [resident] is A&Ox3 [alert and oriented times three], independent with decision making, requested to speak with this writer yesterday as she would like to d/c [discharge] home today. Res informed this writer yesterday that the hospital was planning to d/c her spouse home today thus she wanted to be at home, plus res feels she can manage safely at home and prefers being at home. DME [durable medical equipment] ordered thru [through] [name of company] DME yesterday. Review of Resident #100's discharge Minimum Data Set (MDS) assessment, dated 01/24/25, documented Resident #100's discharge status as 'Short-Term General Hospital. An interview was conducted on 03/26/25 at 9:59 AM with the MDS Coordinator, who when asked about Resident #1's discharge status, confirmed that the resident was discharged home. The MDS Coordinator stated that she would update and resubmit the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to follow physician orders for 2 of 6 sampled residents, as evidenced by the topical cream for Resident #5 was not applied as ordered, and the blood pressure medication was not given as needed for Resident #58; and failed to follow physician orders to obtain a urology consultation as ordered for 1 of 2 sampled residents reviewed for catheters, Resident #63. The findings included: 1. Record review revealed Resident #5 was readmitted to the facility on [DATE]. Review of the current Minimum Data Sheet (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 05, on a 0 to 15 scale, indicating severe cognitive impairment. Review of a physician order dated [DATE] instructed the staff to apply an antifungal cream to the areas affected with a rash (skin condition) on the day (7 AM to 3 PM) and evening (3 PM-11 PM) shifts. Review of the care plan dated [DATE], documented Resident #5 was at risk for potential or actual impairment of the skin related to itching, rash with a goal that the resident's skin impairment will be healed with an intervention that the nurse will administer medication as ordered. An observation on [DATE] at 10:08 AM revealed Resident #5 was scratching her arms and shoulders profusely. Further observation revealed Resident#5 had scattered bumpy and reddened areas on her arms, shoulders and chest. An observation on [DATE] at 3:23 PM in Resident #5's room revealed Resident #5 had her eyes closed, scratching her arms and shoulders. During an interview on [DATE] at 10:08 AM, when asked how she was doing, Resident #5 stated, I have all these bites. When asked how long she has had the rash, Resident #5 stated, I just came from the hospital, but I had the rash before. When Resident #5 was asked if the nurse was aware of the rash, she stated I think so, I will let them know. When asked if any cream had been applied to the rash, Resident #5 stated, No. During an Interview on [DATE] at 3:25PM, when asked if any treatment was provided to Resident #5, Staff D, Licensed Practical Nurse (LPN), reviewed Resident #5's orders in the computer and stated Triamcinolone (corticosteroid ointment for the skin). Staff D went into the clean utility room, where the treatment cart was stored. Staff D looked throughout the treatment cart and did not find the triamcinolone ointment. Staff D stated, I used the last of the cream this morning on the resident and I threw the tube away. I will have to order a new one. She was in the hospital, and she came back. When asked if that was the only treatment that was to be provided to Resident #5, Staff D stated Yes. During an interview on [DATE] at 9:15AM, when asked if an antifungal cream was ordered for a resident what medication is used, the Unit Manager stated, It's a stock medication that comes in a tube. When asked to show the antifungal cream that was ordered for Resident #5, the Unit Manager looked in the treatment cart and she picked up a jar of triamcinolone ointment and stated, This is for that resident. When asked if the triamcinolone ointment is the medication that would be used if the order was for an antifungal cream the Unit Manager stated, No. Sometimes the antifungal cream comes in small packets. I will go get some from the supply room. During an interview on [DATE] at 9:40 AM, when asked if there was any antifungal cream in stock, Staff F, Central Supply staff, stated, We are out of it. I'm in the process of ordering it now. When asked how long they had been out of the antifungal cream, Staff F stated, We've been out since Tuesday. When asked if she meant yesterday on Tuesday, Staff F stated, No, last week I had two tubes of the cream on the shelf that were expired on Friday, so I threw them out, but I forgot to reorder it at that time. If I order it today, it will come tomorrow. During an interview on [DATE] at 10:06 AM, the Unit Manger stated, I'm trying to figure out which nurse used the last of the antifungal cream for the resident and did not reorder it. I called central supply to see if there was any cream and she said the ones she had were thrown out on Friday because they were expired. During an interview on [DATE] at 10:50 AM, when asked how long Resident #5 had the rash, Staff D, LPN) stated, She has a rash off and on. She has seen a dermatologist in the past. I think a few months ago. During an interview on [DATE] at 10:56 AM, when ask how Resident #5's skin looked when she provided care, Staff G, Certified Nursing Assistant, stated, She has a rash that she has had for a while. Review of [DATE] Treatment Administration Record (TAR) for Resident #5 documented that the nurses had signed off on the order for the administration of the antifungal cream, but the medication had not been available. 3. Record review documented Resident #63 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and was dependent on staff for activities of daily living (ADLs). The assessment further documented the resident had an indwelling catheter (urinary catheter). Resident #63 was readmitted to the facility on [DATE] after a hospitalization. Resident #63's had care plan for using a urinary catheter with a documented risk for an infection and/or complications. Review of Resident #63's physician orders revealed an order dated [DATE] to follow up with urology for hemorrhagic cystitis (an inflammation of the bladder lining that leads to bleeding). Further record review revealed the resident had not followed up with urology, and there was no documentation of the resident refusing follow up with urology. An interview was conducted with the Director of Nursing (DON) on [DATE] at 10:00 AM, who acknowledged the above finding. 2. Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses to include essential primary Hypertension (high blood pressure). Review of the current MDS assessment dated [DATE] documented Resident #58 had a BIMS score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented a current diagnosis of Hypertension. Review of the current care plan initiated on [DATE] documented the resident had hypertension and staff were to administer medications as ordered and monitor vital signs as ordered. Review of the current orders revealed Resident #58 was receiving three routine blood pressure medications. These medications included Metoprolol which was originally ordered at 50 milligrams (mg) daily and increased to 100 mg twice daily on [DATE], Hydralazine 10 mg three times daily, and Amlodipine 5 mg twice daily was added to the regimen as of [DATE]. The orders also included for staff to administer Catapres 0.1 mg every eight hours as needed for a systolic blood pressure reading greater than 150. This order did not include any time frame in which staff were to measure the resident's blood pressure. The only active order for the monitoring of vital signs was to complete a set once during the night shift (11 PM to 7 AM). There was one discontinued order to monitor vital signs every shift for three days only upon return from a brief hospitalization. During an interview on [DATE] at 9:56 AM, Resident #58 stated his only concern was that his blood pressure was running high. Review of the [DATE] Medication Administration Record (MAR) for Resident #58 revealed the following high blood pressures with no 'as needed' Catapres administered: a) On [DATE] on the night shift, the resident's blood pressure was 161/96. b) On [DATE] on the night shift, the resident's blood pressure was 155/87. c) On [DATE] on the night shift, the resident's blood pressure was 166/91. Further review of the record revealed staff were not documenting the blood pressure for Resident #58 every eight hours, or with each shift, in order to know when the 'as needed' Catapres was needed. Review of the blood pressure readings from [DATE] through [DATE] revealed a lack of three daily blood pressure readings every day except on [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 3:32 PM, when asked the process for blood pressure monitoring, Staff A, Licensed Practical Nurse (LPN), stated she takes the blood pressure of her residents on blood pressure medications every morning upon arrival and documents them in the electronic medical record (EMR) at the end of her shift. The LPN provided a handwritten paper with documented blood pressures for several residents and stated she was getting ready to document the readings from this morning at the time of the interview. Further review of the [DATE] MAR and blood pressure readings for Resident #58 on [DATE], revealed Staff A, LPN had cared for the resident on [DATE], [DATE], [DATE], [DATE], and [DATE], but only documented his blood pressure on [DATE] and [DATE]. During an interview on [DATE] at approximately 4:15 PM, when asked the process for blood pressure monitoring, Staff B, Registered Nurse (RN), stated she takes the blood pressure for her residents who are on blood pressure medications at the beginning of the shift. When asked about documentation, the RN stated she might document them in the vital sign section of the EMR, or she may just document, OK to give in the electronic MAR. When asked specifically about Resident #58, the RN stated she had just taken his blood pressure, and it was 177/96. The RN volunteered, I told him to hang loose for a bit and I'd bring back his meds. Further review of the [DATE] MAR and blood pressure readings lacked any documented blood pressure reading of 177/96 for Resident #58 on [DATE]. During an interview on [DATE] at 9:51 AM, when asked the process for blood pressure monitoring for Resident #58 who had an 'as needed' order for Catapres, the Director of Nursing (DON) stated she would expect staff to check the resident's blood pressure at least once a shift and document the reading. During a side-by-side review of the record, the DON agreed with the concern of the lack of blood pressure monitoring and provision of Catapres for Resident #58. The DON confirmed the physician recently increased his routine blood pressure medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide adequate hydration for 1 of 1 sampled resident, as evidenced by not ensuring that Resident #16 was able to have the fluids she was allowed. The findings included: Record review revealed Resident #16 was admitted to the facility on [DATE]. Review of current Minimum Data Sheet (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 05, on a 0 to 15 scale, indicating severe cognitive impairment. Review of the physician order dated 02/27/25 instructed the staff that Resident #16 was on a 1200 milliliters per day fluid restriction with 900 milliliters to be given by dietary daily and 300 milliliters to be given by nursing daily. During an interview on 03/24/25 at 10:42 AM, Resident #16 stated, I was put on liquid restriction. I get 2 juices, 4 ounces at lunch and dinner. I leave it on my table to sip on it throughout the day and the aides always take it away. They have been asked not to, but they still dump it. When asked if she had fluids this morning, Resident #16 stated, Yes, but they dumped it. They aren't supposed to just take my food. It's so depressing to me, because I like to sip on it. My lips are so dry. An observation on 03/26/25 at 10:44 AM in the hallway, revealed Resident #16 was in the hallway complaining to the MDS coordinator about her juice being taken away from her room. She stated [Name], Licensed Practical Nurse (LPN) poured one 4 ounce cup of juice in my ice and they took it away. I did not even have coffee. My mouth is so dry. Why do they keep doing this. Staff D stated, I will go get you another 4-ounces of juice since they took it away. Resident #16 asked Why can't we put up a sign or something, so they know not to take it. Staff D stated, I will just inform the aides not to take your juice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure physician visits in a timely manner for 1 of 2 sampled residents reviewed for catheters, Resident #63. The findings included: Record review revealed Resident #63 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and was dependent on staff for activities of daily living (ADLs). The record revealed Resident #63 was hospitalized on [DATE], and readmitted to the facility on [DATE]. Review of Resident #63's physician progress notes revealed a progress note dated 11/07/24. There was no further evidence the resident was seen or evaluated by a physician between 08/24/24 through 11/07/24. An interview was conducted with the Director of Nursing (DON) on 03/27/25 at 10:00 AM, who acknowledged the above finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Fracture of Unspecified Part of Neck of Left Femur Subsequent Encounter for Closed Fracture with Routine Healing, Pressure-Induced Deep Tissue Damage of Sacral Region, and Unspecified Dementia. The Minimum Data Set (MDS) assessment for Resident #3 dated 10/24/23 revealed in Section C, a Brief Interview of Mental Status Score of 7, indicating severe cognitive impairment. In Section H it was documented that the resident had an indwelling catheter. Review of the Physician's orders for Resident #3 revealed an order entered on 11/29/23 with an effective date of 11/27/23 to D/C (Discontinue) Foley cath (catheter). Photographic Evidence Obtained. Review of the Nursing Progress Note for Resident #3 dated 11/27/23 included: Resident son made aware of above mention. [linked]. Review of the Nursing Progress Note for Resident #3 dated 11/27/23 included: Called place to hospice requesting for admission to come to facility for resident. Per Nurse [name], she will send message to admission department. MD [physician] made aware, new order received to D/C F/C [Discontinue Foley / Catheter], monitor for voiding. An interview was conducted on 11/28/23 at 2:45 PM with Staff E, Registered Nurse Unit Manager (RNUM) who stated she has worked at the facility for about 16 months always as the Unit Manager. When asked about the indwelling urinary catheter (Foley) for Resident #3, she stated the resident's Foley was taken out yesterday. When asked by whom, she stated she did it after talking to the doctor (Primary) who gave her the order, and notifying Resident #3's son. During a telephone interview conducted on 11/29/23 at 12:56 PM with the son of Resident #3 who was asked if the resident had an indwelling urinary catheter in place when he was admitted to the facility, he said yes. When asked if any physician or staff member of the facility informed him of the removal of the indwelling urinary catheter, he said 'no, one told him about that, someone called the other day to talk to him about hospice for his father'. Based on observations, interviews and record reviews, the facility failed to provide notification to the residents' representative after a change in condition for 2 of 23 sampled residents, Residents #31 and #3. The findings included: Review of the facility policy, titled, Fall and Injury Reduction Policy, effective March 2023, documented, in part, Notify the resident representative of the fall, new intervention, and/or care given, or location transferred. The facility's policy titles, Notification of Resident/Patient Change in Condition, effective October 2021, documented, in part: Policy: Nurses will notify the resident / resident representative, if there is a crucial / significant change in the resident condition. If the change int eh resident's condition is not crucial or significant, the resident's Physician, resident representative or legal representative will be notified at the earliest convenient time during regular business hours. Procedure: 1. Notify the Physician resident/resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day. 2. Document the Nurse's Notes, the time notification was made and the names of the person(s) to whom you spoke. 1. Record review documented Resident #31 was admitted to the facility on [DATE]. According to an admission Minimum Data Set (MDS), dated [DATE], Resident #31 had a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. The MDS documented the resident required 'Substantial / maximal assistance' for toileting and transferring and was 'occasionally incontinent' of urine and bowel. Resident #31's diagnoses at the time of the assessment included: Anemia, Hypertension, Urinary Tract Infection (UTI) (on admission), Hyponatremia, Non-Alzheimer's Dementia, Encephalopathy, difficulty walking, Cognitive communication deficit, Muscle weakness, and Urinary incontinence. Review of the facility's grievance log showed that the resident had an unwitnessed fall on 11/07/23. An 'Event Note' documented an unsuccessful attempt at notification on 11/07/23 at 23:00 (11:00 PM). Review of the Progress note, dated 11/07/23 at 23:43 (11:43 PM), documented by Staff A, Licensed Practical Nurse (LPN), Note Text: Resident was observed on the floor by the bathroom door around 2100 (9:00 AM). Resident states that he was going to the bathroom. Resident was observed on his side with his head up. Resident is very weak; he couldn't get himself back the bed. Transfer resident back to bed with Hoyer lift. Safety precaution maintained, call light within reach, bed at lowest position. No injuries noted; No complaint of pain. Resident is resting comfortably. Resident #31 was unable provide details of the incident /event and was not interviewable. During an interview, on 11/28/23 at 10:11 AM, with Resident #31's daughter, when asked about the details of the resident's fall, the resident's daughter stated, I haven't noticed any changes in him. They didn't tell me about it. During an interview, on 11/30/23 at 7:48 AM, with Staff B, Registered Nurse (RN) on Suites unit since 2020, when asked about the incident, Staff B replied, I wasn't in that day, when I came in the next day, they told me they found him sitting on the floor in his room. Staff A was the nurse on the floor that day, she would have been responsible to call the family and the doctor. 11-7 [11 PM - 7 AM] didn't do the follow up and did not inform me. When they have the morning meeting, they see everything on the 24-hour report. Staff B reviewed the progress note and stated, there is nothing that says that she called the daughter (referring to Staff A). During an interview, on 11/30/23 at 7:56 AM, with Staff C RN/UM (Unit Manager) on Suites unit, when asked about notifying Resident #31's daughter about the fall, Staff C replied, I would have been coming in and going over the reports and we would go over the 24-hour report in the morning meetings. It would have been reviewed during the morning meeting. If she notified the daughter, she should have put it in the nurse's notes. Staff C confirmed that there was no progress note regarding notifying the resident's family. During an interview, on 11/30/23 at 9:02 AM, with Staff A, when asked about Resident #31's fall on 11/07/23, Staff A replied, I don't know. I was working and I found him on the floor and I asked for help. When asked about notifying Resident #31's representative about the fall, Staff A replied, there was no answer, you have to let the family know. I put the note of what happened, it is protocol to notify the family I leave a note and the facility will follow up. During an interview with the Director of Nursing (DON) on 11/30/23 at approximately 11:00 AM, the DON stated that Resident #31's daughter was in the facility regularly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and policy review, the facility failed to provide necessary treatment and services to prevent worsening of a pressure ulcer for 1 of 2 sampled residents sampled for pressure ulcers (Resident #254). The findings included: The Policy and Procedure, titlesd, Treatment Protocols for Stage III and Stage IV Pressure Area or Full Thickness Wounds with No Drainage (Shallow or Deep), effective October 2021, documented, Review support surface guideline to ensure the Resident / Patient receives the benefit of a therapeutic bed surface when clinically necessary. Review of the record revealed Resident #254 was initially admitted to the facility on [DATE]. The resident had multiple hospitalizations during her residence at the nursing home and was transferred to the hospital on [DATE] and did not return to the facility. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 04/01/23 documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The resident had diagnoses that included Acute Kidney Failure, Unspecified Dementia, and Diabetes Mellitus. Review of the care plan for Activities of Daily Living (ADLs), initiated on 02/06/23 and revised 04/24/23, documented the resident needed the assistance of one staff member for turning and repositioning, a glide sheet for bed mobility with the assistance of two staff members, and a mechanical lift to transfer the resident to a chair. On 12/21/22, the resident was admitted from another nursing facility. Review of the resident's record revealed she was treated for a stage 2 sacral pressure wound at the previous facility and the wound had resolved prior to being admitted to this facility. Review of the resident's Electronic Health Record (EHR), from 12/21/22 through a readmission from the hospital on [DATE], revealed the resident did not have a sacral wound but had treatment of skin cream to the buttocks. Review of the readmission data collection evaluation dated 03/20/23 revealed a skin evaluation of coccyx pressure. An admission summary note dated 03/30/23 noted sacral redness to coccyx and a dry dressing applied. On 03/31/23, a wound note revealed a sacral wound with a length of 7.5 centimeters (cm), width of 4.5 cm and a depth of 0.2 cm. The wound note revealed the daughter was notified of the wound. On 04/04/23, a skin and wound evaluation revealed the resident had a stage 3 pressure wound located on her sacrum. The wound measurements were 3.4 centimeters (cm) in length, 0.9 cm in width and 0.3 cm in depth. The resident was seen by a wound care specialist on 04/04/23. The wound was debrided (necrotic tissue removed by a scalpel) and the primary dressing was calcium alginate. On 04/11/23, the wound physician evaluated the sacral wound. The wound measured at 1.4 cm in length, 0.7 cm in width and 0.3 cm in depth. The physician noted the importance of repositioning every 2 hours or as needed and consistent use of offloading devices. On 04/18/23, the wound physician evaluated the sacral wound. The wound measured at 6 cm in length, 2.2 cm in width and 0.3 cm in depth. The clinical stage of the wound continued at a stage 3. The physician noted that the wound was not improved and had increased in volume. The wound was again debrided and the treatment was changed to calcium alginate with silver and repositioning often. On 04/21/23, the resident was transferred to the hospital and returned to the facility on [DATE]. On 04/25/23, the wound physician evaluated the resident. The sacral wound now had a length of 8.2 cm, a width of 4.3 cm and a depth of 0.6 cm estimate. The wound was now an unstageable pressure injury per physician notes. The wound was debrided. Per physician note, the staff was educated on the importance of offloading the area and consistent use of offloading devices. Continued treatment of calcium alginate with silver. On 04/30/23, the resident was transferred to the hospital and did not return to the facility. Review of the nursing notes and record lacked any documentation of the resident being turned or repositioned. Interview with Certified Nursing Assistants (CNAs) during the 4-day survey revealed they could not recall the specifics related to turning and repositioning this resident. On 11/29/23 at 12:54 PM, an interview was conducted with Staff E, Registered Nurse and Unit Manager (RN/UM). Staff E was asked what a pressure reducing device to the chair and bed was. Staff E replied they have gel cushions for the chair and special mattresses for the bed if the sacral wound is stage 3 or above or if the family asks for a special mattress. In a phone interview with the family member of the resident, she revealed that on 04/14/23, she asked for an air mattress and was told the resident did not qualify for it. An interview was conducted with the Director of Nurses (DON) on 11/30/23 at 10:56 AM. She stated the resident was assessed at a stage 3 on 03/31/23. When asked about the mattress that was on Resident # 254's bed, she replied that all the residents have a special mattress for pressure reduction. A review of the mattress description provided by the Administrator revealed the mattresses in the facility are support mattresses that are pressure reduction and help decrease skin problems in moderate to high risk residents. In a subsequent interview with the DON on 11/30/23 at 12:36 PM, she stated the facility does not have a policy for when a resident has a stage 3 sacral wound that they (the residents) are put on an alternating pressure relief mattress but that is what they do. The DON stated they rent those mattresses. She stated that they did not rent an alternating pressure relief mattress for Resident #254 but the resident should have had an alternating pressure relief mattress. The offloading that was planned by the wound care physician was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain accuracy of records for 3 of 23 sampled residents, Residents #3 #79, and #95. The findings included: Review of the facility's policy, titled, Late Entry, Addendum, Corrections and Clarification, with an effective date of June 2022, included: The facility will utilize the following procedures when documentation problems or mistakes occur, and changes or clarifications are necessary. Late Entry: At times it will be necessary to make an entry that is late (out of sequence) to provide additional documentation to supplement entries previously written. When a pertinent entry was missed or not written in a timely manner, a late entry will be used to record the information in the medical record. Guidelines Late Entry 1. Document the late entry as soon as possible timeframe. 2. Record the late entry on the next available chronological line of the applicable form. 3. State Late Entry at the beginning of the documentation. 4. Enter the current date and time. 5. Identify date and time (if known), for which the late entry is written. 6. Document the late entry. 7. Draw a line from the end of your entry to your signature. 8. Sign your name and title at the end of the line. 1. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Fracture of Unspecified Part of Neck of Left Femur Subsequent Encounter for Closed Fracture with Routine Healing, Pressure-Induced Deep Tissue Damage of Sacral Region, and Unspecified Dementia. The Minimum Data Set assessment (MDS) for Resident #3 dated 10/24/23 revealed in Section C a Brief Interview of Mental Status Score of 7, indicating severe cognitive impairment. In Section H, it was documented that the resident had an indwelling catheter. Review of the Physician's orders for Resident #3 revealed an order dated 10/22/23 for Urinary Catheter: Urinary catheter care daily and as needed every day shift for Preventative Measure and as needed for preventative measure with a discontinued date of 11/28/23. Review of the Physician's orders for Resident #3 revealed an order dated 10/22/23 for Urinary Catheter: Drain urinary catheter bag every shift and prn [as needed] every shift and as needed with a discontinued date of 11/28/23. Review of the Physician's orders for Resident #3 revealed an order dated 11/28/23 as S/P (Status / Post) Foley catheter removal, monitor for voiding if not voiding in 6-8 hours, reinsert Foley and notify MD [physician] every shift for 2 days. (The actual verbal order was received on 11/27/23). Review of the Physician's orders for Resident #3 revealed an order entered on 11/29/23 with an effective date of 11/27/23 to D/C (Discontinue) Foley cath. Photographic Evidence Obtained. Review of the Treatment Administration Record (TAR) for Resident #3 included an order as S/P Foley catheter removal, monitor for voiding if not voiding in 6-8 hours, reinsert Foley and notify MD every shift for 2 Days revealed documentation as being completed from 11/28/23 starting with the evening shift (3:00 PM to 11:00 PM) until night shift (11:00 PM to 7:00 AM) on 11/29/23. Review of the TAR for Resident #3 printed on 11/29/23 at 2:11 PM did not reveal an order to remove / discontinue indwelling urinary catheter (Foley). Review of the TAR for Resident #3 printed on 11/30/23 at 11:05 AM revealed the order dated 11/27/23 to D/C foley cath was documented as signed off by Staff E RNUM on 11/27/23. Review of the time stamped TAR for Resident #3 revealed the order to D/C foley cath was actually entered on 11/29/23 at 7:25 AM and signed off on 11/29/23 at 7:27 AM by Staff E RN/UM. On 11/27/23 at 10:49 AM, an observation was made of Resident #3 lying in bed with no catheter drainage bag seen. On 11/27/23 12:50 PM, a second observation was made of Resident # 3 lying in bed with no catheter drainage bag seen. During an interview conducted on 11/27/23 at 10:49 AM, Resident #3, who was asked if he has a urinary catheter, said I don't know what you are talking about. During an interview conducted on 11/28/23 at 2:22 PM with Staff D, Registered Nurse, who stated she has worked at the facility for about 5 years. When asked if Resident #3 had an indwelling urinary catheter she stated no, it was removed today or yesterday by the Unit Manager. When asked was it was documented that the indwelling urinary catheter was removed, she said it should be documented in the nurse's notes by the nurse who removed it. During an interview conducted on 11/28/23 at 2:45 PM with Staff E, Registered Nurse / Unit Manager (RNUM), who stated she has worked at the facility for about 16 months always as the Unit Manager. When asked about the indwelling urinary catheter (Foley) for Resident #3, she stated the resident's Foley was taken out yesterday (11/27/23). When asked by whom, she stated she did it after talking to the doctor (Primary) who gave her the order. When asked if she documented in the resident's chart that she removed the indwelling urinary catheter, she said she was not sure if she put a note in. When asked when she removed the indwelling urinary catheter, she said it was in the late afternoon yesterday but could not remember what the time was. When asked if she communicated this to the day shift (7:00 AM-3:00 PM) nurse, she said no, she told the evening shift nurse (3:00 PM-11:00 PM). She acknowledged she did not document the Foley being taken out until today (11/28/23). She stated she put in a late entry into the resident's electronic chart to document the Foley being removed. When asked if she had put in an order to remove the indwelling urinary catheter, she said she forgot to do that as well and was informed by the day nurse today that there was no order to remove the Foley. She put the order in the resident's chart today (11/28/23) to remove the Foley. When the RN/UM showed this surveyor the order she put into the chart to remove the Foley, it also included to monitor for voiding if not voiding in 6-8 hours, reinsert Foley and notify MD. The RN/UM then acknowledged there was no documentation of the resident voiding. The RN/UM stated that she was told by the night shift (11:00 PM-7:00 AM) nurse that the resident had voided. An interview was conducted on 11/28/23 at 3:30 PM with Staff F, Registered Nurse (RN), who stated she has worked at the facility since March of 2023. When asked if a resident has an indwelling urinary catheter (Foley) where do they document the care, the RN stated it would come up as an alert in the Treatment Administration Record (TAR) to document. When asked where and who would document any urine output for a resident, she stated it would be the nurse and it would depend on how the order is written, they would document under order for urinary catheter drainage or the actual amount voided if the order is written like that, both ways would be documented in the TAR. When asked if the resident had an order for an indwelling urinary catheter and if the indwelling urinary catheter was removed but the order was not discontinued, the RN stated the Unit Manager is responsible for discontinuing the orders. When asked about Resident #3 and if he had an indwelling urinary catheter, she said he did not have a Foley when she worked yesterday (11/27/23 on the Evening Shift 3:00 PM to 11:00 PM). The Unit Manager informed her the Foley had been removed and the resident had already voided. When asked why she documented on the TAR for Resident #3 that he had an indwelling urinary catheter and a leg strap in place for the urinary catheter, she said it was probably because the order was not discontinued, and it alerted her it needed to be addressed. When asked if it may have been better to indicate in the TAR under urinary catheter a code indicating see nurses note and make a note that the resident did not have an indwelling urinary catheter, she said that probably should have been what she should have done. During a telephone interview conducted on 11/29/23 at 1:15 PM with Resident #3's Primary Physician, he was asked if he had seen the resident, and he said yes. When asked about the indwelling urinary catheter for Resident #3, he asked what room he was in, and it was provided to the physician. The Primary Physician then stated that he gave an order to discontinue the Foley catheter verbally over the phone and the staff informed him that the resident refused to have the Foley removed. When asked what the current status of the Foley catheter for Resident is #3, he said he still has it (Foley) in. 2. Resident #79 was admitted to the facility on [DATE] with diagnoses that included Hydrocephalus, Personal history of other malignant neoplasm of the skin and Atrial Fibrillation. Resident #79 had a Brief Interview of Mental Status (BIMS) score of 9 according to the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/24/23, indicating the resident had moderate cognitive impairment. On 11/27/23 at 12:17 PM, an observation was made of the resident sitting in his room. The resident had a IV (intravenous) site on his left upper arm covered with a clear occlusive dressing which was covered with a gauze wrap. The resident was unable to verbalize if he was currently on an antibiotic or not. Review of a physician order, dated 11/22/23, revealed an order to Change IV Dressing on right arm every 7 days as well as PRN (as needed) for soiling and/or dislodgement. There was no IV in the resident's right arm, only the left arm. An interview was conducted with the Director of Nurses (DON) on 11/27/23 at 3:30 PM, who stated the resident pulled out the IV on his right arm and on 11/23/23, it had to be replaced and was put in the left arm. When asked about the order that stated the IV was still on the right arm, she stated that it was never changed when the IV site was changed. 3. Resident #95 was admitted to the facility on [DATE], hospitalized on [DATE], then readmitted on [DATE]. Resident #95 diagnoses included Osteomyelitis of vertebra, cervical region, Type 2 Diabetes Mellitus, and Pressure ulcer of sacral region stage 4. The resident's BIMS score was 15, according to the 5-day MDS with an ARD of 11/14/23, indicating the resident was cognitively intact. Review of the Electronic Health Record (EHR) revealed the resident had a physician order dated 11/11/23 for wound care for the coccyx wound. The order was to clean the wound with Dakins 0.5%, pat dry, apply calcium alginate and collagen powder to wound bed and cover with foam dressing every evening shift for wound to buttock. The Treatment Administration Record (TAR) was signed by a nurse as completed from 11/11/23 to 11/27/23. The EHR also revealed an order for negative pressure wound therapy to coccyx. Negative pressure wound therapy dressing was to be completed on Tuesday and Friday. The order was dated 11/13/23 and discontinued on 11/29/23. It was marked as completed on the TAR on 11/14/23, 11/17/23, 11/21/23, 11/24/23 and 11/28/23. On 11/28/23 at 4:01 PM, an interview was conducted with Registered Nurse / Unit manager, Staff C. Staff C stated when she came in this morning the wound vac was not responding and was malfunctioning. She stated Resident #95 said the nurse came in and had to reset it from about 3:00 AM through the rest of the night. Staff C stated that she tried to fix it when she came in at 6:00 AM but could not. She called the physician around 8:30 AM and received an order for a wet to dry dressing so the resident could go to a doctor visit. When asked about the order for the calcium alginate dressing, Staff C stated that she was unaware of that order and maybe she should have used that order. Staff C could not determine why the resident had 2 orders for the same wound and stated that it might have been a backup order for the wound vac or a dressing that is put under the wound vac. The observation for the wound vac therapy dressing was conducted on 11/29/23 at 5:45 PM. On 11/29/23, the order for wet to dry dressing was discontinued. The wound vac was discontinued. A new order was received to revert back to: cleansing the wound with normal saline, apply collagen powder, to wound bed, pack with alginate dressing cover with island or foam dressing. On 11/29/23, the DON was made aware the resident had 2 orders for the sacral wound and verbalized understanding that there should not have been 2 orders for the same wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Facility Policy, titled, Dialysis Management dated October 2021, documented, The facility will coordinate care and services for hemodialysis residents. Daily assessment and documentation of shunt or access site for bleeding, signs and symptoms of infection, redness/pain. Notify physician of abnormal findings. Facility Policy, titled, admission Orders, dated October 2021, documented, admitted from Hospital. Review the transfer orders. Obtain further orders as appropriate. Dialysis is a treatment of removing waste products, toxins, and extra fluids in the blood of a person whose kidneys are not working normally. The blood is removed from the body and filtered through an artificial kidney. The filtered blood is then returned to the body with the help of a dialysis machine. Arteriovenous graft (AV graft) is a type of access used for hemodialysis. An AV graft is the connection of a vein and an artery that utilizes a hollow synthetic tube under the skin. This allows needles to be placed into the graft providing high enough blood flow for hemodialysis. Central Venous Catheter (CVC) is a type of dialysis access used in which a long tube is threaded through the skin into a central vein in the chest. A CVC is typically intended as a temporary access until an AV graft or fistula is placed. Some of the possible disadvantages of a CVC are damage to the central vein from prolonged use, possible increased length of dialysis treatment from lower blood flow and increased risk of infection. On 08/03/22 at 10:00 AM, Resident #82 was observed to have a right CVC and a left antecubital incision with five black sutures. Resident #82 stated that they only use the catheter in her chest for dialysis. She said that they are not using her AV graft for dialysis because she still has her sutures from surgery. She stated that she had her surgery two months ago and has never gone back for follow-up or to have her sutures removed and does not know why. Record review on 08/03/22 for Resident #82 documented an admission date of 06/17/22 with diagnoses that included: Stroke with Left Sided Weakness, End Stage Renal Disease on Dialysis, and Heart Disease. A Minimum Data Set (MDS) assessment, dated 07/07/22, documented Resident #82 as being cognitively intact and requiring extensive assistance for all activities of daily living except eating which requires limited assistance. No physician orders for AV graft follow up care, surgical incision care or suture care were noted. The Baseline care plan, dated 06/17/22, documented a left antecubital surgical incision. Surgical notes, reviewed from an acute care hospital, documented placement of an AV Graft left arm on 06/01/22 with nylon suture used for skin closure. On 08/03/22 at 10:10 AM, the Director of Nurses (DON) was questioned by the surveyor regarding follow up care for Resident #82's AV Graft incision. The DON stated she was unable to find any orders for care or follow-up for the surgical AV graft site. On 08/03/22 at 10:20 AM, the Regional Nurse Consultant stated that she was unable to locate notes for Resident #82's AV Graft care or orders for follow up. She said the sutures and incision were documented on admission and on a skin assessment on 06/20/22. On 08/04/22 at 9:08 AM, Staff A stated she felt bad because she missed that Resident #82 had sutures all this time. She said she did not see them because they are not to take blood pressure readings in that arm. On 08/04/22 at 12:00 PM, the DON stated they are looking at their admission process to ensure something else like this does not happen again. She stated they should have followed up on Resident #82's surgical incision, sutures, and post op care. On 08/04/22 at 12:36 PM, the Nurse Manager of the Dialysis Center stated that the nursing home facility handles the post op care and management of appointments. The dialysis center provides the dialysis. He stated that they do not use graft sites that still have sutures. Based on observation, interview, record review and policy review, the facility failed to accurately assess and reassess the efficacy of interventions for skin rash for 1 of 1 sampled resident, reviewed (Resident #92); and failed to provide post-op surgical care for 1 of 1 sampled resident, reviewed (Resident #82). The findings included: 1. During the initial screening of residents on 08/01/22 at 1:50 PM, Resident #92 was observed to have a reddened raised rash on both his arms, as well as linear scratches in the same areas. Record review on 08/02/22 revealed Resident #92 was admitted on [DATE] with a primary diagnosis of Osteomyelitis, non-healing pressure ulcers, Diabetes, and the relevant diagnosis of Pruritis. The admission comprehensive assessment documented the BIMS (Brief Interview of Mental Status) exam score of 15/15 showing no cognitive decline. Known allergies to heparin, penicillin and sulfa were also noted. The admission summary, dated [DATE] at 11:54 PM, noted a general body rash and multiple dry scabs to both legs. On 07/18/22 at 2:55 PM, a progress note read: Torso and upper back covered in hives, with associated itching, presenting as an allergic response to something. Legs clean, no hives, Communicated with Attending physician, awaiting feedback regarding treatment plan. Evening nurse to follow. (Written by Staff C, a Registered Nurse). No follow up documentation or new orders were found. Review of the resident's physician orders showed a previous order for an 'as-needed' antihistamine from 07/01/22 to 07/15/22. The ketoconazole cream 2% was originally ordered on 07/05/22 to apply to groin/peri area every day and evening shift. A different order, dated 07/02/22, read: 'cleanse generalized area with normal saline and dry area. Apply antifungal cream to affected area. Reapply twice a day, treat rash for 14 consecutive days even if rash has improved, every day and evening shift for wound healing for 14 days. If no improvement in 14 days, consider treatment change.' The treatment began on 07/05/22 and continued until it was discontinued on 08/02/22 after surveyor intervention. No documentation reassessing the efficacy of the treatment at any time over the 28 days was found in the medical record. Review of the resident's care plan revealed a focus area of RASH: The resident has Rash to groin/peri/generalized body, (not initiated until 07/26/2022) with the following interventions: 1) The resident's rash will heal by review date; 2) Administer medication as ordered by MD. Monitor/document side effects and effectiveness; 3) Avoid scratching and keep hands and body parts from excessive moisture and 4) Monitor skin rashes for increased spread or signs of infection. On 08/02/22 at 3:15 PM during an interview, Resident #92 was asked if the visible rash itched. He responded, Boy, does it ever! The resident lifted his clothing to expose his torso which was also covered in the same reddened and raised rash. He said the worst is on his back, he has some rash on his legs, and he sweats a lot. He believed it started in the previous facility as an allergic reaction to antibiotics. He then demonstrated how he relieves the itching by rubbing skin to skin with his hands or rubbing his clothing on the abdomen and added that sometimes it burns. He said the cream they (nurses) put on doesn't really work, so I guess I'll just have to suffer. Immediately following the interview, at 3:25 PM, the Director of Nursing (DON) was brought to the room to observe the rash and the resident verbalized to her that he was itching all over. The DON then reported she spoke to the physician and received an order to discontinue the ketoconazole because it was not effective and to start hydroxyzine 10mg every 8 hours as needed for paraneoplastic rash. On 08/03/22 at 09:15 AM, during an interview with Staff B, Licensed Practical Nurse (LPN), assigned to care for Resident #92, she said he had received one dose of the antihistamine earlier in the day (7:31 AM) and he had reported less itching. This was verified with the resident at 11:45 AM. Record review revealed the resident had not received any doses of the antihistamine between 08/02/22 at 3:35 PM when it became available and the dose given the next morning on 08/03/22 at 7:31 AM, further delaying relief. The DON was made aware and contacted the physician to report improvement of the itching. The order of hydroxyzine was changed from as needed to routine three times daily. On 08/04/22 at 9:50 AM, during an interview with Staff C, RN, she reported the resident's itching had diminished. On 08/04/22 at 2:20 PM, during an interview with Resident #92, he was asked whether he had reported the itching or asked for treatment from the staff on any previous occasions. He said he believed the cream they were using was cortisone and that nothing more could be done. He stated, I am grateful for whatever I can get.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to document the location of pain for 1 of 1 sampled resident reviewed as a closed record (Resident #96); and failed to document a change in condition for 1 of 5 sampled residents reviewed for Covid-19 (Resident #21). The findings included: 1. Resident #96 was admitted to the facility on [DATE], with diagnosis that included right femur fracture. A comprehensive assessment, dated [DATE], documented the resident had mild cognitive impairment, and required extensive 1-2 person assist with activities of daily living. Resident #96 was care planned for pain or a potential for pain related to a history of fall with a fractured femur. An intervention included to observe and report signs and symptoms of pain and worsening of pain. Report changes in pain location, type, frequency, and intensity. A review of Resident #96's physician orders revealed an order, dated [DATE], to monitor pain every shift and report pain number on a 0-10 scale for pain monitoring. A review of Resident #29's Medication Administration Record (MAR) revealed the resident had a pain level of 3 on the evening shift on [DATE], a 3 on day shift on [DATE], and a 3 on evening shift on [DATE]. A physician order, dated [DATE], documented to apply a lidocaine patch to the resident's right hip daily for pain. A physician order, dated [DATE], documented for oxycodone 5 milligrams every 6 hours as needed for pain. A review of Resident #29's MAR revealed the resident received oxycodone on [DATE] at 11:09 AM, [DATE] at 6:48 PM, and [DATE] at 10:24 AM. Further review of Resident #29's record did not reveal the location of the resident's pain, intensity, or effectiveness of pain medication. Resident #29 expired on [DATE]. 2. An observation of room [ROOM NUMBER], on [DATE] at 1:00 PM, revealed isolation signage on the door, with a personal protective equipment cart outside of the room door. It was noted 2 resident's were located in the room. An observation of room [ROOM NUMBER] was observed on [DATE] at 10:00 AM, with the same isolation signage on the door. It was noted only one resident remained in the room [ROOM NUMBER] A, Resident #21. An interview was conducted with Staff A, Licensed Practical Nurse (LPN), on [DATE] at 10:15 AM. Staff A stated Resident #21 exhibited signs and symptoms of Covid-19, coughing, therefore the roommate was moved. A review of Resident #21's record did not reveal any documentation of any signs and symptoms. An interview was conducted with the Infection Control Preventionist (ICP) on [DATE] at 10:00 AM. The ICP stated she was not aware of Resident #21 having any signs or symptoms of Covid-19. The ICP acknowledged there was no supporting documentation in the resident's chart. There was no documentation that the physician or family member had been notified of possible exposure to Covid-19. The ICP stated all residents were tested for Covid-19 on [DATE] for recent outbreak. The ICP acknowledged the non-existing documentation of Resident #21's condition.