**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to monitor and assess blood sugar levels for residents with diabetes, for 1 of 3 residents (R2) were reviewed for quality of care in the sample of 14. This failure resulted in R2 requiring emergency intervention for blood glucose level 24 and hospitalization. Findings include: R2's Face Sheet, undated, documents she was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, vascular dementia, diabetes, and unspecified calorie protein malnutrition. R2's Minimum Data Set (MDS) dated [DATE] documented that she was cognitively alert and oriented. R2 has an active diagnosis for diabetes. R2's Care Plan, dated 8/12/24, documents, Problem: I have a diagnosis of diabetes mellitus, which places me at risk for medical complications. The goal for this care plan documents, I will experience no medical complications related to their diabetes through the next review. Interventions for this care plan include HgbA1c (Hemoglobin A1c is a blood test that measures the average blood sugar level over the past 2-3 months) as ordered by a physician, follow protocol per facility for low blood sugars, administer my medications as ordered MD (medical doctor), and accu checks as ordered by a physician. R2's Physician's Order, dated 8/12/2024, documented that R2 is to receive Humalog (lispro) insulin 20 units subcutaneously before meals three times per day. R2's Medication Administration Record (MAR), dated 12/1/24-12/27/24 documented R2 did not receive the scheduled insulin ordered by the physician 13 times in a six-day span including 12/1/24 (morning), 12/1/24 (afternoon), 12/1/24 (evening), 12/2/24 (morning), 12/2/24 (afternoon), 12/2/24 (evening), 12/3/24 (morning), 12/5/24 (morning), 12/5/24 (afternoon), 12/5/24 (evening), 12/6/24 (morning), 12/6/24 (afternoon) and 12/6/24 (evening). The reason documented that these insulins were not given is documented as Not Administered: Other or Not Administered: another comment with the blood glucose level documented. R2 also did not receive her scheduled insulin on 12/7/24 (morning), and the reason was that R2 was sleeping. R2's Progress Notes did not document that R2's Physician, V22, was not notified when R2's insulin was not given as ordered on the above dates. R2's Progress Note, dated 12/8/24 at 4:33 PM, documents, Resident was sent out to the (local) hospital at 4:33 PM for Change of condition. The resident was not responding to verbal cues. Vitals 98% (oxygen saturation level), 86 (pulse), 86/56 (blood pressure), 20 (respirations). POA (Power of Attorney) notified, Left message with (V22's, medical doctor) on-call nurse. R2's progress notes and December 2024 Medication Administration Record (MAR) did not document that R2's blood glucose level was checked at the time of condition change. R2's Emergency Medical Services (EMS) report printed on 2/18/25 documents that EMS arrived at the facility on 12/8/24 at 4:41 PM to find R2 unresponsive with an altered level of consciousness (LOC). Per this report, EMS obtained R2's vital signs and noted her blood glucose level was 24. The report also documented that EMS administered Glucagon to treat R2's critically low blood glucose level and transported her to the local hospital. R2's Hospital Record, dated 12/8/24 - 12/12/24, document under Assessment and Plan, Type 2 Diabetes Mellitus with hypoglycemia- long term (current) use of insulin: Status: acute; Assessment and Plan: HgbA1c 5.6%, blood sugar in 20's in nursing home, 60 on arrival to the ER (emergency room), currently trending 70-100. Hold insulin for now; she may not need insulin with her A1C. On 2/18/25 at 10:30 AM, V2, Director of Nursing (DON), provided a document that she stated was V22's standing order for his residents in the facility. This document stated that for residents with the following diagnoses/conditions: Endocrine: Diabetes Mellitus. The standing orders documented that glycated hemoglobin (HgbA1C) is to be drawn every three months, hold insulins if blood sugar levels are below 80 (Recheck in one hour), call provider for any blood sugar above 350, and hypoglycemic protocol: May use fingerstick glucose checks as needed (PRN) for signs and symptoms of hypoglycemia. Give a glass of orange juice (OJ) with sugar or glucose gel, 1 ounce, squeezed into mouth PRN hypoglycemia. If unable to give OJ, give one glucagon injection subcutaneously (SQ) or intramuscularly (IM). On 2/13/25 at 11:15 AM, V10, Registered Nurse (RN), stated that the physician was made aware of a resident's blood sugar by the staff calling him. V10 noted that if a resident is to receive insulin, there should be a range of blood sugars for when the insulin should be given and when it should be held. If there is not a range of blood sugars listed, V10 stated that the physician should be called. On 2/13/25 at 11:20 AM, V11, a Licensed Practical Nurse (LPN), stated that she remembers R2's blood sugars being fine. V11 stated that R2 typically did not receive her scheduled insulin because her blood sugars weren't high enough. V11 stated that she would document this, but the physician was not always notified. On 2/13/25 at 2:50 PM, V13, LPN, stated that she had only worked at the facility for two weeks. V13 does not remember taking R2's blood sugar prior to sending her out with emergency services. She stated that she kind of remembers that R2 was seated in a high-back reclining chair. V13 stated that she did remember the EMS checking R2's blood sugar. On 2/13/25 at 3:09 PM, V14, LPN, stated that she was vaguely familiar with R2. V14 stated that she usually worked on the B hall, and R2 resided on the C hall. V14 remembered working with the nurse who sent her out. V14 thought she may have been an agency nurse, and she remembers printing the face sheet for her. V14 doesn't remember R2 being unresponsive or any blood sugars that may have been taken. On 2/18/25 at 8:50 AM, V2 stated that if a resident's blood glucose is out of range or if the Resident's insulin is not given as ordered, the nurse should call or text the physician. V2 would expect this to be documented in the progress notes. V2 stated that staff are not good at documenting this in the progress notes, but she said they are getting better. On 2/18/2025 at 2:00 PM, V11 was shown a copy of R2's December 2024 MAR documentation regarding R2's insulin administration. V11 reviewed R2's original insulin order in the presence of surveyors and stated that there were not any parameters included in the insulin order of when the insulin should be held. V11 stated that she uses nursing judgment when deciding to hold a resident's insulin. V11 stated that she was not comfortable giving that amount of insulin with a blood sugar that was 90-100. V11 stated that each time she holds the insulin is very situational and dependent on the individual Resident and the amount of insulin they are supposed to receive. V11 stated anytime a resident's insulin is held, the physician should be notified. V11 stated she did not notify the physician when she held R2's insulin, but she should have. V11 stated that she has not had any conversation with any physician or nurse practitioner regarding the frequency with which she held R2's insulin on the days prior to R2 being sent to the hospital with low blood sugars. V11 stated that she had never seen any real change in R2's condition, which she had recalled. V11 stated that the physician should be notified when the insulin is held, especially when it is being held as often as R2's was being held. On 2/18/25 at 2:30 PM, V2 was shown the hard copy of the standing orders that she had provided. V2 stated that these orders are entered into the computer when the nurses need to use them. She stated that the nurses all have access to these at the desk. V2 stated that standing orders are not entered until the physician says to use them. V2 stated that these orders can be used as soon as the Resident is admitted . On 2/18/25 at 3:00 PM, V11 was shown V22's standing orders and asked if she was familiar with these. V11 stated that she was and that they were available in the nursing binder at the desk. V11 stated that if a resident's blood sugar is low, she would pull out the standing orders and follow them. She stated she would hold the insulin based on the standing order. Still, she would not necessarily enter that standing order into the resident's orders into their Electronic Medical Record (EMR) because she has the standing order hard copy to follow. On 2/19/25 at 8:23 AM, V21, Nurse Practitioner (NP), stated that she was not aware that R2's insulin was held 13 times in a six-day span from 12/1/24 to 12/6/24 due to the nurse determining R2's blood sugar was too low to receive that much insulin. V21 stated she remembered receiving a couple of texts from the nurse caring for R2 informing her that she had held the dose of insulin, and V21 stated she told the staff that it was okay. V21 added that she is aware that sometimes a resident may not eat and will have random low blood sugar. V21 stated that the nurses should notify her every time a dose of insulin is held. V21 stated that she had seen R2 in October, and no changes were made to her insulin. V21 stated that if she is notified that the insulin is being held frequently and is aware of this, she can make the necessary changes to the ordered insulin dose. V21 stated that R2 should have had a HgbA1C in November, three months after she was admitted , but there was no HgbA1C result found in the R2's EMR for November 2024. V21 stated she would have adjusted the current insulin dose based on a recent A1C result. She also stated that if she was made aware of multiple insulin doses being held, she would have ordered an HgbA1C. V21 stated that if an HgbA1C had been done as ordered in November 2024, the results may have resulted in a decreased insulin dose if appropriate. V21 stated that if the HgbA1C result had been lower, there was no way she would have continued the current insulin dose. V21 added that she cannot adjust the Resident's insulin based on a couple of texts or calls that a nurse had held the insulin. Still, if she had been aware that they had held the insulin 13 times in six days, she would have ordered an HgbA1C and adjusted R2's insulin according to the results. V21 stated that the standing orders provided to the facility are based on current evidence-based practice and diabetic, heart health, and specific diagnoses recommendations. The standing orders are reviewed annually according to these guidelines. The labs in the standing orders are essential because they are based on these guidelines. V21 expects that on admission, the pertinent standing orders should be entered for each Resident. V21 stated she couldn't guestimate (guess/estimate) what is happening when they have only received a couple of notifications that insulin has been held on the Resident. V21 stated that when they are in the facility, she and V22 review the physician order sets for the last couple of months, along with any lab results available. V21 stated that they depend on the staff to notify them if the blood glucose results are abnormal. V21 also stated it should be documented in the progress notes every time a nurse contacts the physician/ nurse practitioner. V21 was asked if she was aware that R2 had a significant weight loss from 170 pounds to 136 pounds in a four-month period. V21 stated she was not aware of the weight loss, and if V22 was aware of it, he would have addressed it in his progress notes. V21 stated she last saw R2 in October 2024. V21 stated this weight loss would have most definitely influenced the hypoglycemia as the weight loss has a direct effect on the metabolic system. There was no documentation in R2's EMR that R2 was seen by V21 or V22 after October 2024. The facility's undated policy, Medication Administration, documents, Purpose: To provide practice standards for safe administration of medications for residents in the facility. Whenever a medication is held for any reason, the licensed nurse will initial the appropriate area on the MAR and circle their initials. The licensed nurse will document the reason the medication was held on the back of the Mar. If medication is not given, licensed personnel should document the medication was not given, notify the MD (medical doctor), and make a note in the resident's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to implement interventions to address a significant weight loss for 1 of 3 residents (R2) who were reviewed for weight loss in a sample of 14. This failure resulted in R2 experiencing a significant weight loss of 20% over a four-month period. Findings include: R2's Face Sheet, undated, documents she was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, vascular dementia, diabetes, and unspecified calorie protein malnutrition. The R2 medical record did not document how the facility obtained R2's initial weight upon admission on [DATE]. R2's Care Plan, dated 8/12/2024, documents the problem: Adult failure to thrive related to anorexia. The goal for this care plan documents (R2) will not exhibit signs of malnutrition or dehydration. The interventions for this care plan include assess for dehydration (dizziness on sitting/standing change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation fever, infection, electrolyte imbalance), encourage and record intake of food and fluids, monitor and record output, monitor for signs of malnutrition (pale skin; dull eyes; swollen lips; swollen and/or dry tongue with [NAME] or magenta hue; poor skin turgor; cachexia; bilateral edema; muscle wasting. R2's care plan was not updated to address her significant weight loss. R2's Physician's Order (PO), dated 8/13/2024, documented an order for pureed diet with thin liquids. R2's Nutrition Assessment, dated 9/12/2024, documented R2 being observed turning her head as staff attempted to feed her oral intake of less than 50% at most meals. R2 is taking fluids well. Her weight and body mass index (BMI) indicate obesity. Recent glycated hemoglobin (HgbA1C) is at a good level for diabetes. R2 is at high risk for weight loss. Continue the Pureed diet. Recommend Health Shake with all meals. R2's weight record, dated 9/12/24, documented her weighing 170 pounds. On 10/12/24, she weighed 168 pounds. On 10/28/24, she weighed 162 pounds. On 11/6/24, she weighed 152 pounds, and on 12/5/24, she weighed 136 pounds. These weights calculate a 20 % weight loss in three months from 9/12/24 to 12/5/24 and a 10.5 % weight loss over the last month from 11/6/24 to 12/5/24. R2's PO, dated 10/18/24, documented that R2 should receive health shakes with all meals. This was 36 days after V23; the Dietician recommended that R2 receive health shakes. R2's PO, dated 11/21/24, documented monthly weights to be performed on the fifth of the month to monitor weight loss. R2's meal intake record from 8/20/24 to 12/1/24 documented that of the 52 meals where the intake was recorded, 30 meals had an intake of none to 25%. There was no documentation in R2's medical record that the Dietician assessed R2 after the initial assessment of 9/12/25 or that the facility implemented any interventions to address R2's insidious weight loss after 10/18/24. On 2/13/25 at 11:25 AM, V2, Director of Nursing, DON, stated once the weights are obtained and these fluctuate from the normal for the resident, either herself or the nurse caring for the resident will notify the physician. V2 stated that they have until the tenth month to obtain the weights. V2 stated she would pull a weight report and review back to when the resident was admitted , and if there were any variations, she would notify the physician. V2 stated that the dietitian can obtain the report and view the weights. On 2/18/25 at 12:12 PM, V19, a Certified Nursing Assistant (CNA), stated that R2 was fed her meals, and she would usually eat about 25% of the meal. V19 stated that R2 liked her health shakes and would drink all of them. On 2/18/25 at 1:10 PM, V20, the CNA, stated she remembered assisting R2 with eating her meals and that she ate horrible. V20 stated that R2 always ate less than 25%, but she would always drink her health shakes or any beverage offered. On 2/19/25 at 8:23 AM, V21, Nurse Practitioner (NP), was asked if she was aware R2 had a significant weight loss from 170 pounds to 136 pounds in a four-month period. V21 stated she was not aware of R2's weight loss, but she only saw her in October and did not see her again. She stated that V22, R2's medical doctor, was aware of R2's weight loss; he would have addressed it in his progress notes. A review of R2's electronic medical record (EMR) did not include documentation that R2 was seen by V21 or V22 after V21 saw her on October 23, 2024. There was no documentation or plan in V21's progress notes regarding R2's weight loss, and there was no documentation in R2's progress notes that V21 or V22 had been notified of R2's significant weight loss. V21 stated this weight loss would have most definitely influenced the hypoglycemia as the weight loss has a direct effect on the metabolic system. On 2/20/25 at 11:19 AM, V23, the Registered Dietitian, stated she is rarely notified by the facility when a resident needs to be seen. She stated that she would run her own reports- like tube feedings and weight records, which tell her a lot. V23 stated that a resident should be weighed 24-48 hours after admission. She stated that she has not been contacted regarding new admissions or significant weight changes but figured it out herself. V23 stated that if a resident has a substantial weight change, they should notify her. V23 reviewed the initial nutritional assessment performed on 9/12/24 for R2. V23 stated she didn't know why R2 did not receive orders for the recommended health shake until over a month later. V23 stated that the process followed her recommendation to V1, Administrator; V2, Director of Nursing; and V5, Dietary Manager. From there, the recommendation should be sent to the physician for an order, placed in the resident's physician's orders, and implemented by the dietary staff. V23 stated this process should not take over a month. V23 stated she doesn't know why R2 was not seen and reviewed regarding her weight loss at the facility. V23 added she could not explain it. She doesn't understand why she missed it. V23 added that in comparison to her other facilities, this facility does not reach out to her with concerns. The facility's undated policy, Significant Weight Gain or Loss, documents, Purpose: To ensure that insidious/significant weight gain or loss will be identified so that nutritional needs can be evaluated, and appropriate intervention provided. Standards: All admissions will have a baseline weight obtained. If weight loss is noted, the family and resident will be notified in addition to the physician. Interdisciplinary Team (IDT) team will review monthly to assure appropriate plan of care and interventions for those with significant weight gain or loss.

Based on observation, record review, and interview, the facility failed to assess and provide medication for pain management for 2 of 3 residents (R4 and R7) reviewed for pain in the sample of 9. This failure resulted in R4 being in pain and R7 being unable to participate in therapy. Findings include: 1. On 11/13/2024 at 1:17 PM, R4 stated he did not receive pain medication for several days after admission. R4 stated, That was not good for me, as my pain was at an 8. R4 stated they were administered Tylenol, but that was not effective. R4's Medication Administration Record(MAR) History dated 11/1/2024-11-13-2024 documents Hydrocodone -acetaminophen -Schedule 2 table 5-325 Milligram (mg) administer 1 tablet every 8 hours as needed (prn). R4's MAR history documents start date 11/1/2024. R4's MAR history does not document R4 receiving pain medication until 11/8/2024. R4's Face sheet dated 10/29/2024 documents a diagnosis in part of low back pain, and pressure ulcer of sacral region stage 4. R4's progress notes dated 10/29/2024 at 10:51 AM document R4 arrived at the facility per ambulance. R4's progress notes dated 10/30/2024 at 1:53 PM documents a call placed to the hospital regarding the hard script required for the Norco order that was sent with R4 upon discharge. R4's progress notes document the hospitalist that discharged R4 on 10/29/2024 is not available. R4's progress notes document order will be entered once a hard script is provided or hospital escribes. R4's progress notes dated 11/1/2024 at 1:10 PM document a call placed to the hospital about the Norco script. 2. On 11/13/2024 at 2:21 PM, R7 was sitting in the dining room in a wheelchair, moaning. R4 stated being in pain. R4 described pain at a 7 on a scale of 1-10. R7 indicated his pain was in his belly. R7 said he gets pain medication once in a while. On 11/13/2024 at 2:50 PM, R7 was being pushed into the therapy room in a wheelchair, moaning. 2:54 PM, V9, COTA (Certified Occupational Therapy Aid) has a heat pack on his abdomen in the therapy room. Stated trying to relieve cramping stated they gave him pain medication before I brought him down. R7 continues to moan in pain. On 11/13/2024 at 2:55 PM, V9 pushed out of the therapy room to his room R7, continually moaning in pain. On 11/13/2024 at 2:58 PM, V9 reported to the nurse R7 reported pain 7 out of 10. the nurse enters the room and asks if in pain R7 says belly. And asks if R7 needs to go to the Bathroom or wants a drink. No type of abdominal assessment was performed when the surveyor asked if the nurse had done any assessment and stated that I had been in there a couple of times. I gave him Tylenol 30 minutes ago. 3:03 PM remains up in wheelchair in room moaning in pain. The nurse then goes to the nurses' station where (V16), the Medical Director, is across from the station. nurse is V11, LPN. 3:12 PM placed in bed by mechanical lift by V12, Certified Nursing Assistant (CNA), V13 CNA, V12, and V14 CNA. V13, CNA stated, He is yelling for no apparent reason. R7's care plan dated 1/26/2023, documents R7 has the potential for pain related to diagnosis of polyneuropathy, interstitial pulmonary disease, venous insufficiency, Gastroesophageal Reflux Disease (GERD), Pulmonary Vascular Disease (PVD), old meniscus bucket tear, derangement of unspecified lateral meniscus due to an old tear or injury, and chronic. R7's Care plan documents the following interventions 10/27/2024 administer pain medications as per orders 10/27/2024 Assess for pain every shift and document results, observe and report to the nurse changes in the usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care, record/report to nurse any signs/symptoms of non-verbal pain. Changes in breathing (noisy, deep/shallow, labored, fast/slow; vocalizations (grunting, moans, yelling out, silence); mood/behavior changes(more irritable, restless, aggressiveness, squirmy, constant motion, refer to physician for adjustment in pain management as needed. R7's undated medication list documents hydrocodone0acetaminiophen 5-325mg i tab twice daily, starting on 11/8/2024. However, the list fails to document the last dose administered. R7's prescription order Norco 5/325 one by mouth twice a day script documents faxed 11/13/2024 with note at top of script please fil. On 11/13/2024 at 2:15 PM, V2, DON stated (R7's) pain medication was not available as the script had not been received from a physician. On 11/13/2024 at 1:20 PM, V2, the Director of Nursing (DON), stated she expected residents to have pain medication as ordered. The facility policy for pain management undated policy documents the purpose of ensuring accurate assessment and management of the resident's pain. The policy documents that facility staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. The policy documents the licensed nurse will administer pain medication as ordered, and documents medication administered on the Medication Administration Record (MAR). The policy documents that if there is a new onset of pain or if the pain has changed, the licensed nurse will notify the physician to review the medication. The policy documents that nursing staff will implement timely interventions to reduce the increase in the severity of pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer medications as ordered for residents (R1, R2, R3, R12) of 4 residents reviewed in a sample of 12. This failure resulted in R1 and R3 experiencing severe pain. Findings include: R1's face sheet, dated 5/23/24, documented that R1 was admitted on [DATE] with diagnoses of quadriplegia, hypertension, COPD (Chronic Obstructive Pulmonary Disease), spinal stenosis, intervertebral disk degeneration, osteoarthritis, and cirrhosis of the liver. R1's MDS (Minimum Data Set) dated 5/27/24 documented R1 is cognitively intact. On 5/23/24 at 6:40 AM, R1 stated that at the beginning of the week B hall did not have a nurse and that he did not receive any of his morning or noon medications. R1 stated that he went to the facility Administrator around 2 PM on this day and informed her that he had not received any medications all day. R1 stated that (V1) informed him she was aware of that hall not having a nurse and that the other nurses would administer his medication, or they will get fired. R1 stated he never did receive his morning or noon medications on this day. R1 stated he normally takes pain pills every 6 hours and that he had to go from 3:00 AM until 4:00 PM without pain medication. R1 stated that his pain rating was at a level of 10 by the time he finally received the pain medication at 4 PM. R1's MAR (Medication Administration Record) dated 5/23/24 documented that R1 has physician orders to receive the following medications between 7 AM and 10 AM: budesonide-formoterol aerosol inhaler 8-4.5 mcg (micrograms) 2 puffs inhalation, vitamin b-12 250 mcg , fibercon 625 mg (milligrams), finasteride 5mg, baclofen 5mg, arginine-glutamine-calcium 1.5 grams, lidocaine patch 5%, omeprazole 20mg, oxycodone 10 mg every 6 hours as needed, polyethylene glycol 17 grams, senna 8.6 mg, toprol XL 25 mg, venlafaxine 37.5 mg, and vitamin D3 25 mcg. The MAR (Medication Administration Record) does not have a nurse's initials documented for these medications on 5/20/24 indicating they were not administered as ordered by R1's physician. R1's MAR, dated 5/23/24, documented that R1 is to receive gabapentin 600 mg between 11 AM and 1 PM. R1's MAR does not have a nurse's initials documented as administered for this medication on 5/20/24. R1's MAR documented an order for a pain assessment to be completed every shift and as needed. The MAR did not document a pain assessment was completed on the day shift on 5/20/24. R1's MAR did document a pain assessment was completed on the evening shift of 5/20/24 and R1 rated his pain at a level of 10. R2's face sheet, dated 5/28/24, documented R2 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, COPD, generalized anxiety disorder, depression, anemia, and tachycardia. R2's MDS, dated [DATE], documented that R2 is cognitively intact. On 5/23/24 at 7:40 AM, R2 stated that on Monday, 5/20/24 he did not receive any of his medications all day. R2 stated that he was concerned because he is on a lot of medications, and it is essential he receives them for his high blood pressure and chronic liver disease. R2 stated he asked a nurse on another hall for his medications and that she stated she was not allowed to help him. R2 stated he then went to the Administrator's office and informed (V1) Administrator that he needed someone to give him his morning medications and that she replied okay. R2 stated he never did receive any of his morning nor noon medications. R2's MAR dated 5/23/24 documented that R2 has physician orders to receive the following medications between 7 AM and 10 AM: lidocaine adhesive medicated patch 4% and a steroid inhaler. The MAR does not have a nurse's initials documented for these medications on 5/20/24 indicating they were not administered. R2's MAR dated 5/23/24 documented that R2 has physician orders to receive the following medications every day at 11 AM: aspirin 81 mg, folic acid 1 mg, Lasix 20 mg, spironolactone 50 mg, tamsulosin .4 mg, iron 325 mg, and lactulose 20 mg. R2's MAR does not have a nurse's initials documented for these medications on 5/20/24 indicating the medications were not administered as ordered. R3's face sheet, dated 5/23/24, documented R3 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, generalized anxiety disorder, neuromuscular dysfunction of bladder, low back pain, chronic kidney disease, major depressive disorder, cerebral infarction, dementia, hyperlipidemia, anemia, diabetes, and chronic pain. R3's MDS, dated [DATE], documented R3 is moderately cognitively impaired. On 5/23/24 at 8:15 AM, V11, daughter of R3, stated that she received a call from her mother, (V12) on 5/20/24 at noon and that (V12) stated (R3) has not had any medications all day and that no one had checked (R3's) blood sugar. V11 stated that her dad, (R3) was in pain because he had not received any pain medication all day on 5/20/24. On 5/23/24 at 8:25 AM, V12, wife of R3, stated that her husband (R3) did not receive any medications on Monday, 5/20/24. V12 stated that (R3) has chronic back pain and has had 3 failed back surgeries. V12 stated her husband needs pain pills every 6 hours to control his pain and that he didn't receive any pain medication all day on 5/20/24. V12 stated that she went to the Administrator's office after lunch and the Administrator, (V1) stated the nurses out there can pass meds. V12 stated she informed (V1) that the nurses said they can't pass the medications on the B hall. V12 stated (V1) just shrugged her shoulders in response. R3's MAR, dated 5/23/24, documented R3 has physician orders for the following medications to be administered every day between 7 AM and 10 AM: ascorbic acid 1000 mg, Dulcolax 5 mg, duloxetine 30 mg, Eliquis 5 mg, finasteride 5 mg, furosemide 40 mg, guaifenesin 600 mg, hydralazine 25 mg, novolog insulin pen 100 unit/ml amount to administer per sliding scale, tamulosin .4 mg, and protonix 20 mg. R3's MAR does not have a nurse's initials documented as administered on 5/20/24 nor is there a blood sugar documented as ordered for the insulin administration. R3's MAR, dated 5/23/24, documented R3 has physician orders for the following medications to be administered every day between 11 AM and 1 PM: Ativan .5 mg, hydralazine 25 mg, hydroxyzine 25 mg, novolog insulin pen 100 unit/ml administer per sliding scale, and oxycodone 5 mg. R3's MAR does not document that these medications were administered on 5/20/24 nor does it document that a blood sugar test was completed as ordered for the insulin administration. R3's nurses note dated 5/22/24 at 3:38 PM documented We encountered a staffing challenge 5/20/2024. In this case residents' medications ran later than normal. MD (Medical Director) and POA (Power of Attorney) are aware. Crisis management and Inservice education in place. Additional CNA added to B hall for monitoring, VS (Vital Signs) q4 hrs until 5/24/2024. Additional leadership rounding in place. Staff will continue to mx residents for any concerns. This note was signed by V2, Interim Director of Nursing. R12's face sheet, dated 5/28/24, documented R12 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, congestive heart failure, history of embolisms, hypertension, anemia and chronic kidney disease. R12's MDS, dated [DATE], documented R12 is cognitively intact. R12's MAR, dated 5/23/24, documented R12 has physician orders for the following medications to be administered everyday between 7 AM and 10 AM: amlodipine 10 mg, entrestro 24 mg, famotidine 40 mg ferrous sulfate 324mg, flonase allergy relief spray 50 mcg, folate 1 mg, Humalog insulin 13 units, insulin glargine 60 units, Jardiance 10 mg, Lasix 40 mg, magnesium oxide 400 mg, metformin 50 mg, toprol 100 mg, aspirin 81 mg, and spironolactone 25 mg. R12's MAR does not have these medications documented as administered on 5/20/24. R12's MAR documents an order for blood sugars to be tested every morning between 6 AM and 8 AM. R12's MAR does not document a blood sugar result for 5/20/24 between the times of 6 AM and 8 AM. R12's MAR, dated 5/23/24, documented R12 has an order to receive 13 units of Humalog insulin every day between 11 AM and 12 PM. R12's MAR does not document this insulin was administered on 5/20/24. R12's progress note, dated 5/22/24, documented we encountered a staffing challenge on 5/20/24. In this case residents' medications ran later than normal. MD notified. Resident is own POA and is aware. Crisis management and in-service education in place. Additional CNA added to B hall for monitoring, VS q4 hrs until 5/24/2024. Additional leadership rounding in place. Staff will continue to mx residents for any concerns. On 5/23/24 at 1:45 PM, Administrator, V1 stated she was not made aware of the B hall not having a nurse assigned to it until 10:30 AM on 5/20/24. V1 stated the Interim DON (Director of Nursing) was scheduled to work the floor on 5/20/24 but that she got called in on the evening shift on 5/19/24 so she did not come in on 5/20/24. V1 stated she attempted to call a nurse in but was unsuccessful and that the facility does not have a contract with a staffing agency because the current owner has not paid the bill with the staffing agency. V1 stated on 5/20/24 she called the two floor nurses to her office and told them that this isn't ideal, but she needed them to pass medications to the residents on B hall and that the nurses refused to do so. On 5/28/24 at 10:23 AM, V17, Regional Director stated that she would have expected a licensed nurse to pass the medications to the residents on B hall on 5/20/24. On 5/28/24 at 2:35 PM, V1, Administrator stated that if there are no initials on the MAR then the medications were not administered. The facility's Administering Medications Policy, dated April 2019, documented medications are administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time from. It continues, 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe beverage serving temperatures to prevent thermal burns and adequate supervision to prevent falls for 3 of 9 residents (R60, R62, and R68) reviewed for accidents/hazards in the sample of 42. These failures resulted in R62 and R68 sustaining second degree abdominal burns and R60 falling and sustaining nasal fracture. Findings include: 1.R62's Face Sheet documents R62 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, essential primary hypertension, chronic obstructive pulmonary disease, type 2 diabetes mellitus with hyperglycemia, anxiety, encephalopathy, stage 3 chronic kidney disease, and obesity. R62's Minimum Data Set (MDS) dated [DATE] documented R62 was severely cognitively impaired and required substantial assistance rolling in bed and transferring. R62's 11/2/23 Care Plan documents R62 obtained a burn to her abdomen after spilling hot tea on her abdomen. The Facility's Incident Initial Report sent to IDPH (Illinois Department of Public Health) on 11/2/23 documents, On 11/2/2023 at 9a (9:00 AM) it was reported to (V1, Administrator) from Nurse that (V19, Certified Nurse's Aide/CNA/ Coordinator) went to give (R62) hot tea in the dining room. (R62) asked (V19) for a hug, as (V19) went to hug (R62) she accidentally tapped cup with her elbow as she was hugging resident which made the cup of hot tea spill on the resident's abdomen. Nurse immediately took (R62) to her room and assessed (R62) and noted a blister on (R62)'s abdomen. (R62) was not upset and told (V19) she knew it was an accident and was okay. Nurse contacted MD/POA (Medical Doctor/Power of Attorney). Investigation initiated. R62's Progress Note by V17, Registered Nurse (RN), on 11/2/23 at 9:22 AM documents, resident was sitting in dinning [sic] room when staff member and resident hugged knocking over hot tea onto resident abd (abdomen) and staff arm. Resident taken to room assessed and given first aide to abd are [sic]. skin noted to be red with slight blistering. md (Medical Doctor) and poa (Power of Attorney) notified. n.o. (New Order) for ssd (Silver Sulfadiazine) cream and to keep area covered. On 1/23/24 at 1:00 PM, V17, Registered Nurse/RN, stated she did not witness R62's accident in the dining room. She stated, I guess (R62) had a Styrofoam cup of hot tea, and she went to hug (V19), and their hands kind of got tangled up, and it ended up getting spilled on her. (V19) came and got me. It was red. It was a decent sized area to the lower abdomen. It hurt her. The tea was steaming out of the cup. I very rarely work on that hall, but I notified the daughter and the doctor. V17 stated It got pretty nasty after the first few days and (R62) was seen by (Wound Consultant Company) for quite a while. I can't say if the coffee was always that hot. The Facility had gone back and forth over the coffee; it was too hot for a while, then it was too cold. V19, Certified Nursing Assistant (CNA)'s Hand-Written Statement dated 11/2/23 documents, At breakfast (R62) ask me to get her some hot tea. I went to get (R62) some hot tea took it back to her and sat it in front of her and she reach out to give me a hug forgetting the hot tea for her, and I went to hug he (her) back and my right arm hit the cup of hot tea and it spilled on my arm and also (R62) stomach and I reported to the nurse. On 1/23/24 at 11:12 AM, V19 stated, (R62) asked for a cup of hot tea, so I went and got it for her and set it down on the table. She reached her arms out to hug me and it got her stomach and my right elbow. I got (V17) and we pulled (R62) out (of the dining room) to the shower room. Her stomach was red but didn't blister. I think (V17) got Silvadene for her stomach and also for my arm. I felt so bad, I cried. On 1/23/24 at 11:15 AM, R62 stated, It was an accident. One of the girls dumped hot tea on me and it was steaming hot. It was nasty for a while. It is all healed up now. She felt terrible, she did not mean to do it. The Facility's Incident Final Report submitted to IDPH on 11/2/23 documents, On 11/1/2023 at 9a (9:00 AM) it was reported to (V1) from (V17) that (V19) went to give (R62) hot tea in the dining room. (R62) asked (V19) for a hug, as (V19) went to hug (R62) she accidentally tapped cup with her elbow as she was hugging (R62) which made the cup of hot tea spill on (R62)'s abdomen. (V17) immediately took (R62) to her room and assessed (R62) with interventions in place. (R62) remains at baseline. (V17) contacted MD/POA. Upon investigation, (V17) had applied silver sulfadiazine cream to (R62)'s abdomen. In conclusion, the quality assurance team met, new interventions were discussed: silver sulfadiazine to be applied 2x day to abdomen covered with dry dressing. Kitchen informed to offer lids for hot drinks. R62's Physician Order Report documents 11/3/23 order, Cleanse burn to abdomen with NS (Normal Saline) or wound cleanser, apply SSD (Silver Sulfadiazine) cream and calcium alginate, cover with silicone bordered foam dressing. Change twice daily and PRN (as needed) if soiled. R62's (Wound Consultation Company) documentation dated 11/8/23 documents, Nursing requests that I examine her abdomen, which was noted on 11/2 to have a burn on her abdomen from a spill of hot tea, currently treating with silvadene. The burn to R62's abdomen measured 14 cm (centimeters) x 17cm x 0.3cm and required mechanical debridement. On 1/23/24 at 8:40 AM, V7, Dietary Aide, stated they were previously writing down the temperatures of hot beverages, but she was off work for a couple days and they might have stopped. She stated, It's supposed to be no more than 140° Fahrenheit (F). I didn't calculate it today. On 1/23/24 at 8:43 AM, V5, Dietary Manager, stated, I thought it was supposed to be 145-150°F. V5 stated You want it a little hotter going in to the hall trays, because if you put them on at 140-145°F here (the cart) it'll be down to 120°F when it gets to them, and they are going to complain that it's too cold. 145°F is the goal. On 1/23/24 at 9:52 AM, V7, Dietary Aide, said the department stopped tracking temperatures almost two months ago. On 1/23/24 at 9:56 AM, V1, Administrator, stated the Facility added hot beverage temperatures to QAPI (Quality Assurance Performance Improvement). On 1/23/24 at 10:02 AM, V5, Dietary Manager, provided QAPI notes from 11/8/23 and stated, Apparently they were only supposed to take the temperatures for four weeks. She was unsure if there is a policy on hot beverage temperatures but will check on it. On 1/23/24 at 1:43 PM, V2, Director of Nursing (DON), stated, (R62) had a decent size wound and was treated by (Wound Consultant Company). She was on prophylactic antibiotics. When it first happened, it was not open and had just started to blister at the time. I didn't realize it would be hot enough to cause burns like that. It should be under 140°F. I was not told dietary was no longer checking the temperatures. I thought that was a process they put in place here. On 1/25/24 at 2:39 PM, V1, Administrator, stated she was unaware that staff was no longer taking hot beverage temperatures and would expect staff to be aware of safe serving temperatures and provide beverages to residents at safe temperatures. She stated, The Facility Policy for serving temperatures states staff will follow the guidelines, so I provided the list of our guidelines. For hot beverages, they have to temp at 140°F or below. The Facility's undated Serving Temperatures for Hot and Cold Foods documents, Staff will follow the guidelines below when serving hot and cold beverages and food. It documents hot beverage temperatures are per Facility Guidelines. The Hand-Written document signed by V1, Administrator, on 1/25/24 documents, For hot beverages, they have to temp at 140°F or below. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities documents a water temperature 155°F can cause a third-degree burn in one second. It documents burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. 3. R60's Face Sheet, undated, documented R60 was admitted on [DATE] with diagnosis of Congestive Heart Failure, Type 2 Diabetes Mellitus, Idiopathic Progressive Neuropathy, Chronic Kidney Disease, Malignant of Prostrate. R60's MDS, dated [DATE] documents R60 uses manual wheelchair. R60's MDS documents R60 requires substantial/maximum assist with toilet transfers and partial/moderate assist with toilet hygiene. R60's Care Plan with problem start date of 11/12/23, documents R60 is at risk for falls due to diagnosis of idiopathic progressive neuropathy. The Care Plan Interventions include provide individualized toileting interventions based on needs/patterns, order comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk, implement exercise program that targets strength, gait, and balance. All Intervention start dates are 11/12/23. R60's Care Plan updated 12/15/2023 documents I have experienced an actual fall on 2/21/2022, 6/26/23, 12/13/23. The Care Plan Interventions include provide me with follow up care as indicated related to my injury until healed, nonskid socks applied to feet, complete post fall assessments and monitoring per facility protocol, notify my provider if any change in condition is observed, Dycem applied to wheelchair, physical/Occupational therapy referral, interdisciplinary team to review fall and provide interventions. R60's Fall Risk assessment dated [DATE] documents R60 has visual impairment, has balance and gait problem while walking, has impaired mobility, and is at risk for falls. The facility's incident report form dated 12/13/2023 at 12:30PM, Nurse advised Administrator that resident was found to be on floor in resident bathroom face first. Nurse immediately assessed Resident. Resident was noted with laceration to nose. Resident stated he was trying to move up on toilet and lost his balance. Nurse immediately called 911 and sent to (local hospital ER) for evaluation. MD (medical doctor)/POA (Power of Attorney notified). Investigation initiated. R60's Progress Note, dated 12/13/2023 at 12:46PM documents Writer heard crash in resident's bathroom. Resident noted to be on floor, face first. Resident able to answer questions and respond appropriately. Laceration noted to nose. Blood coming from nose. Bump noted to forehead. Numerous skin tears noted to BUE (bilateral upper extremities). Resident laying on left arm. Pain noted to left arm. 911 called. R60 transported to (local hospital) ER (Emergency Room). R60's Progress Note, dated 12/13/2023 at 6:30PM documents R60 returned at this time from local hospital. The Note documented R60 returned via ambulance stretcher with x2 emergency medical technicians, EMTs, present. The Note documented R60 had a hematoma noted to forehead, lacerations noted to bridge of nose, and left arm. The Note documented Computerized Tomography (CT) scans note frontal scalp hematoma, fractures to nasal bones, nasal septum, and frontal and ethmoid sinuses. Resident was started on amoxicillin-potclavulanate 875-125mg Q (every) 12 hours for 10 days. Discharge report from hospital ER nurse states resident does have sutures to nasal lacerations which will need to be removed in 7-10 days. R60's CT scan report dated 12/13/2023 at 2:11PM documents Findings: Maxillofacial CT: There is a frontal scalp hematoma. There is a laceration of the nose. There are fractures of the nasal bones, nasal septum, and frontal and ethmoid sinuses including the medial walls of the orbits and the anteroinferior aspect of anterior cranial fossa. There is a small focus of pneumocephalus There is mucosal thickening in the paranasal sinuses. The mastoid air cells are normal. There is extensive dental disease. On 1/24/2024 at 10:45AM V29, Certified Nursing Assistant, CNA, stated I put (R60) on the toilet. I did leave the bathroom. He was able to adjust himself and had the call light. I heard the nurse yell and (R60) was on the floor. He had landed on his face and there was a lot of blood. I'm not sure what he was trying to do. On 1/24/2024 at 11:20AM V30, Licensed Practical Nurse, LPN, stated The day (R60) fell I was out passing meds in the hallway, and I heard him yell out. He was left in the bathroom by himself and fell face first into the sink. (R60) was known to readjust himself when sitting. We called 911 and he went to the hospital. On 1/24/2024 at 3:10PM V3, Assistant Director of Nursing, ADON, stated I would expect a resident with a history of falls to be supervised while in bathroom and not left unattended. On 1/25/2024 at 9:09AM V41, Medical Director, stated If (R60) has history of falls and is at risk for falls I would expect (R60) to need supervision. Fall policy with a revision date of 2018 states University Care Center will provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. All resident falls that occur within the facility will be tracked, analyzed, and trended. This information will be used to assist facility management and direct care staff in maintaining a safe environment. It is the responsibility of the facility to assure that all residents are assessed to determine fall risk and history or falls. Individualized preventative approaches should be provided to assist with fall prevention. 2. R68's Event Report dated 11/7/23 at 8:15 PM documents, Resident states that hot tea was spilled on her abdomen at breakfast. States it may have happened a day or so ago. She states she can't remember how it got spilled. States she might have bumped her cup. Burn is on right mid quadrant of abdomen, approximately 1.5-inch x (by) 1 inch with popped blister mid region. The Event documents, Partial thickness burn (Second Degree) extend through the epidermis and into the dermis. These burns are typically very painful, red, blistered, moist, soft and blanch when touched. Examples include burns from hot surfaces, hot liquids or flame. On 1/23/24 at 9:33 AM R68 stated the burn on her abdomen is healed now. She stated it happened when the CNA was putting her tray down on the table at breakfast. She stated she could not remember if the CNA had handed her the cup of tea or if it was on the table, but it spilled on her. R68 stated the tea was very hot but it didn't hurt too bad and V15, CNA told her to have the nurse look at it. R68 stated after breakfast she went to the nurse's station and showed the burn to V17, Registered Nurse (RN) who was her nurse that day. R68 stated V17 told her, Yeah, that's a burn but didn't do anything at that time. R68 stated nobody did anything about her burn until V16, RN, came to work that night and looked at it and put a dressing on it and then the wound nurse started seeing her. R68 stated the wound nurse told her she had a third degree burn on her abdomen. R68 stated it seems like the tea is always too hot and she has to wait for it to cool down before she can drink it. She stated she doesn't want to act like she knows more than she does, but she has worked as a dietary aide in the past and she knows they have to check the temperatures of the food and drinks. R68 stated after she was burned the staff did start taking temperatures of the drinks for a while, but she doesn't know if they still do them. She stated the temperatures were cooler for a while, but they are hotter again lately. R68 stated when the incident happened, V15 asked her right away if she was alright, but it didn't hurt too bad, so she kept her same shirt on. R68 stated V17 was standing right there and didn't do anything. R68 stated V17 didn't look at it until she wheeled herself to the nurse's station after she was done with breakfast. On 1/25/24 at 9:00 AM R68 was lying in bed and pulled her blanket back and lifted her shirt to show writer a light pink quarter-sized faint scar that she stated was from her burn that happened when the hot tea spilled on her. R68's MDS dated [DATE] documents she is alert and oriented. R68's Physician Order dated 11/8/23 documents she may be seen by the specialized wound consultant. R68's Wound Consultant progress note dated 11/8/23 documents this was the initial consult for R68 who suffered a burn of her abdomen on 11/5/23. The note documented wound consultant ordered a treatment of: cleanse with normal saline or wound cleanser, apply Santyl and calcium alginate and cover with dry dressing; change daily and as needed. R68's Care Plan dated 11/5/23 documents, I obtained a burn to my abdomen related to spilled hot tea. Interventions for this care plan document, Assess my burn and document weekly on my condition including the size, color, drainage, odor until healed; Avoid giving me warm liquids in cups without a lid. Cool my liquids before providing them to me. May substitute chocolate milk for hot chocolate; Observe my burn for signs and symptoms (s/s) of healing or lack of healing and send report to providers COC (change of condition) if observed; Observed for s/s of pain related to my wound and treat my pain as indicated; Wound nurse to monitor, consult with NP, MD, and hospice (R68 not on hospice). Treat as ordered until healed. On 1/23/24 at 10:00 AM V15, CNA stated on the day R68 was burned with hot tea she was giving R68 her breakfast tray in the dining room. V15 stated she had set the cup of hot tea down on the table and the nurse, V17, spoke to her and she turned around to face the nurse, and when she turned back around, she thinks she may have bumped the table, or R68 bumped the table and the hot tea spilled onto R68's abdomen and thigh. V15 stated she grabbed the bib off the table and blotted the hot tea off R68's shirt and pants right away. She stated the hot tea was in a coffee cup. V15 stated the nurse was standing right there and said she would look at R68's skin after she was finished with breakfast. V15 stated she looked at R68's skin when it happened and her abdomen was very red where the hot tea had spilled on her, and her thigh was red, but not as bad. V15 stated she did not know if the nurse looked at it or not and she (V15) looked at it again before the end of her shift and it was still very red, but she was not sure if there was a blister or not on the area. V15 stated after the incident they (facility) had a meeting about it, and they started checking the temperatures of the hot drinks before they put them out for the CNAs to use. V15 stated they started using different containers to pour from but then residents were complaining the coffee and tea was not hot enough. She stated the kitchen checks the temperatures before they put the water for tea and the coffee out, but she has not seen them actually do it, but the dietary aides had told her they have to check the temperatures now before they put them out. V15 stated she has not known any other residents who have been burned by hot liquids, more often they complain the coffee and tea is not hot enough. On 1/23/24 at 1:03 PM V17, RN stated she was told about R68's burn on a day she was not working. V17 stated she did not know about R68's burn and was not told about it when it happened. V17 stated she wrote a statement that she was not aware of R68's burn and turned it into the Director of Nursing. V17 stated it was a few days later that she heard about the burn on a chat group that was between the nurses, including the DON and Assistant Director of Nursing (ADON). She stated she had never seen R68's burn, but then stated she may have done the treatment a couple of times. She stated the last time she saw it, there was no longer a treatment in place. On 1/23/24 at 1:40 PM V2, Director of Nursing (DON), stated she does not know exactly when R68's burn occurred but she thinks it happened on 11/5/23 but nothing was reported to her until 11/7/23 when the night shift nurse called her. V2 stated the Medical Doctor (MD) was also notified of R68's burn at that time. V2 stated R68's burn was small on her abdomen. She stated she was not even aware that the temperatures of the tea were hot enough to cause that type of burn. On 1/23/24 at 1:50 PM during phone interview, V16, RN stated she works night shift and documented finding R68's burn on 11/7/23. V16 stated she was giving R68 her nighttime insulin and when she pulled her shirt up to give her the injection, she saw the burn on R68's right abdomen. V16 stated R68's answers were vague and iffy about when it occurred. V16 stated she notified the physician of the burn right away but was not sure if he gave her the order that night or the next day for the treatment. V16 stated the burn was open and scabbed over. She stated it was just a little smaller than a half dollar. V16 stated the wound did not look infected but looked like a blister that had popped and was drying up. V16 stated besides the MD, she also reported the burn to the DON and ADON. 01/24/24 10:50 AM V24, Wound Nurse Practitioner returned call and stated she had assessed and treated both R68's and R62's burns and would have considered them both to be second degree burns because they were both blistered and then opened. She stated they both healed without problem. V24 stated she does not know off the top of her head what temperature of hot liquid would cause these second-degree burns, but she knows the facility reconciled the problem with the hot water temperatures because she was concerned other residents could be hurt. V24 stated she discussed concerns with V2, DON and V3, ADON while they were making rounds. On 1/25/24 at 9:06 AM V41, Medical Doctor stated he is familiar with R68 and remembers when she had the burn from the hot tea. He stated sometimes when a person has a burn, they don't have pain right away, but he would expect to be notified right away of the incident. V41 stated the area should be assessed to monitor for changes in the burn.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to adequately assess and ensure a resident receiving continuous Gastrostomy tube (G-tube) feeding did not experience significant weight loss for 1 of 2 residents (R13) reviewed for nutrition in the sample of 42. This failure resulted in R13 having an insidious significant weight loss of 12 pounds in three months while receiving nutrition via G-tube. Findings include: R13's Face Sheet, undated, lists her diagnoses to include Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Aphasia following unspecified cerebrovascular disease, Dysphasia following cerebral infarction, and Gastrostomy status. R13's Minimum Data Set (MDS) dated [DATE] documents her weight as 198 even though her weight documented under vital signs in her electronic medical record (EMR) documents her weight as 189# on 11/4/23, which was the last weight documented before the MDS was done. According to the MDS, R13 has a feeding tube, and incorrectly documents R13 had no significant weight loss/ gain. R13's Care Plan documents the problem dated 10/12/20: I am at risk for alteration in nutrition r/t (related to) other specified nutritional deficiencies, specified depressive episodes, pure hypercholesterolemia, gastrostomy status, unspecified dementia without behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting left, dysphagia following cerebral infarction, Type 2 diabetes mellitus with hyperglycemia, NPO (Nothing by mouth) status. The goal for this care plan with target date of 4/25/24 documents, I will maintain my weight +/- 5 pounds (lbs) through next review date. The interventions for this care plan include the following: Administer medications as ordered; allow me time to perform task of eating a meal-assist as needed, (R13 is unable to eat anything by mouth); Gastrointestinal tube feeding (Glucerna 1.2 80 ml/hr (milliliters per hour); R13's Physician Order dated 1/4/24 documents, Diet: NPO Glucerna 1.2 65 ml/hr continuous 22 hrs (hours) *hold 2 hrs per day*. Flush with 300 ml H2O every 4 hours. Special instructions: 50 ml before and after each medication administration; Observe and report to MD (medical doctor) s/s (signs and symptoms) of malnutrition: emaciation, muscle wasting, significant weight loss which is 3 pounds in a week, over 5% in one month, over 10% in 3 months, over 10% in 6 months; Observe/document/report to MD (Medical Doctor) if I have signs of dysphagia: (i.e. (for example): pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appearing concerned. (R13 is NPO); RD (registered dietician) to evaluate and make diet change recommendations prn. Weight to be completed monthly and prn. R13's Physician Order dated 1/4/24 document: Diet: NPO Glucerna 1.2 65 ml/hr continuous 22 hrs (hours) *hold 2 hrs. per day*. Flush with 300 ml H2O every 4 hours. Special instructions: 50 ml before and after each medication administration. R13's Registered Dietician (RD) progress note dated 10/31/2023 at 9:11 AM documents Readmit/TF status. readmitted to facility 10/27 from hospital dx (diagnoses) COVID/UTI (Urinary Tract Infection). Weight (10/12)-189 lbs, BMI-30.5. Noted weight has had trend down -2 lbs x 1 month, -4 lbs x 3 months, -7 lbs x 6 months. NPO with Glucerna 1.2 55 ml/hr continuous with 300 ml water flush Q4 and 50 ml flush before/after meds. Provides: 1518 kcals, 76 g pro, and 1018 ml fluid (2818 ml total with flushes). Prostat 30 ml daily ordered. No skin concerns noted at this time. [NAME] meds: mvi (multivitamin), levemir, levetiracetam, reglan, senna, folic acid. Weekly weights in place to monitor nutritional status closely. Current tube feeding fluids/water flushes exceeding estimated fluid needs. RECOMMEND: 1. d/c (discontinue) prostat 30 ml daily as no skin concerns at this time 2. Suggest increase tube feeding to Glucerna 1.2 65 ml/hr continuous (hold 2 hours/day for ADLs) to better meet estimated energy needs. Monitor weights, tube feeding tolerance, and labs as available. R13's last Registered Dietician (RD) progress note was dated 11/16/23 at 3:07 PM and documented: RD consulted due to weight loss. Current weight 182# (pounds), showing trend down. NPO with Glucerna 1.2 55 ml/hr continuous with 300 ml water flush every 4 hours and 50 ml flush before/after meds. Provides: 1518 kcals, 76 g (grams) protein, and 1018 ml fluid (2818 ml total with flushes). Prostat 30 ml daily ordered. No skin concerns noted at this time. Weekly weights in place to monitor nutritional status closely. Recommend: 1. Suggest increase tube feeding to Glucerna 1.2 65 ml/hr continuous (hold 2 hours/day for ADLs (Activities of Daily Living) to better meet estimated energy needs. Monitor weights, tube feeding tolerance, and labs as available. RD to follow up as needed. There were no further RD progress notes documented in R13's EMR after 11/16/23 as of 1/23/24. On 1/25/24 at 10:45 AM V2, Director of Nursing (DON) provided an email document dated 1/2/24 that documents she notified the facility's RD that R13 receives tube feedings for nutrition, her weight was 183# and now it's 177#, and that weight was verified with a re-weight. In the document V2 asks the RD, Is this an intentional decrease in her weight? and requested the RD review and advise with any recommendations she has. On 1/25/24 at 10:45 AM V2 provided a document titled, Weight dated 1/4/24 from the facility's RD that documented, I had noticed that her (R13's) weight was trending down. I also noticed that her TF (tube feeding) was decreased. Here are my recommendations to prevent further weight loss: Increase tube feeding to Glucerna 1.2 65 ml/hr continuous (hold 2 hours/day for ADLs) to better meet estimated energy needs. Monitor weights, tube feeding tolerance, and labs as available. The RD recommendations dated 10/31/23 and 11/16/23 to increase R13's tube feeding to 65 ml/hr was not followed until after another RD recommendation was received on 1/4/24 to increase the tube feedings to 65 ml/hr after R13's Medical Doctor V41 was notified of R13's continued weight loss. On 1/25/24 at 10:45 AM V2 provided a copy of a photocopied text message to V41, Medical Doctor (MD) dated 1/2/24 that documented, (R13) receives tube feeding for nutrition. Was 183 now 177, verified with second. Another message at 1:30 PM documented, The dietician to review. She shouldn't have weight loss with tube feeding. V2 stated this was V41's response to her notification of R13's weight loss and she notified the RD of the need to review R13 for weight loss. V2 stated she could not find any other notifications that V41 had been notified of R13's weight loss prior to this date. R13's Electronic Medical Record was reviewed for weights. R13's weights were documented as: 7/23 (195#); 8/8/23 (192#); 9/12/23 (191#); 10/3/23 (197#); 11/4/23 (189#), 12/23/23 (183#), and 1/4/23 (177#). These weights represent R13 having a 4% weight loss in one month, and 10% weight loss (significant) at both 3 and 6 months. On 1/23/24 at 4:10 PM V3, Assistant Director of Nursing (ADON) provided R13's reweight taken just now as 176.4#. On 1/24/24 at 9:00 AM V2 stated they just got a new dietician, so she does not know if she is aware of R13's additional weight loss. V2 stated she does not know why R13 was not weighed in December as she is just learning the electronic system. V2 stated when tube feeding is running using a generic bag for the formula, the bag should be labeled with the date and time it was hung and the name of the formula should be included since there is no label on a bottle with this information. On 1/25/24 at 9:06 AM V41, MD, stated he was looking back in his notes/emails from the facility and does not see where the facility notified him that R13 continued to lose weight. V41 stated he would expect the facility to notify him of changes and recommendations from the Registered Dietician and would not expect a resident who is consistently receiving tube feeding to have significant weight loss. On 1/25/24 at 11:10 AM V2 stated she does have documentation of some of R13's weekly weights and provided paperwork. She also provided a copy of emails to V41 dated 1/2/24 when facility reported R13's weight loss to him. V2 also provided documentation of assessment by RD dated 1/4/24 that recommends increasing tube feeding to Glucerna 1.2 to 65 ml/hr continuous (hold 2 hours/day for ADLs) to better meet estimated energy needs. Monitor weights, tube feeding tolerance, and labs as available. Writer asked V2 if she was aware that the dietician had recommended these changes on 10/31/23 and again on 11/16/23 and it was not done. V2 stated she was not aware of those recommendations. The facility's policy, Weight Assessment and Intervention, revised September 2008, documents, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 5. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. 2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: f. Increased need for calories and/or protein; h. Fluid and nutrient loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refill medications timely for 1 of 3 (R2) residents reviewed for medication administration in a sample of 10. This failure resulted in R2 being admitted to the hospital for breakthrough seizure activity. Findings include: On 10/17/2023 at 11:30 AM, R2 stated that she was sent to the hospital because she was having seizures. She continued to state they didn't give her seizure medicine to her for at least a day or 2 and it sent her into full active seizures. She stated that they told her that they didn't have it and it was unacceptable to her. She continued to state that she was on top of her medication and it has happened before when they have run out of different medications for her. R2's Minimum Data Set, dated [DATE], documented that her cognition was intact. R2's Physicians order sheet, dated 10/2023, documented an order for Clonazepam 3 mg, oral, Twice A Day, by mouth twice a day. R2's Care Plan, dated 02/27/2023, documented, Approach: Medications as ordered by MD. R2's Medication Administration Record (MAR), dated, October 2023, documented, that on 10/3/2023 at 8:00 AM, R2 was given 3 milligrams (MG) of Clonazepam. R2's Controlled Substance record dated 10/3/2023 at 8:00 AM R2 received 2 mg of Clonazepam. R2's Medication Administration Record, dated October 2023, documented on 10/3/2023 at 7:28 PM Clonazepam 3mg was not administered/drug item unavailable. R2's Medication Administration Record, dated October 2023, documented on 10/4/2023 at 10:27 AM Clonazepam 3mg was not administered/drug item unavailable. R2's MAR, dated October 2023, documented, that on 10/4/2023 at 7:27 PM, Clonazepam 3mg was not administered/drug item unavailable. The facility's electronic notification application, dated 10/3/2023 at 1:24 PM, documented, (R2) (date of birth ) 07/03/1983 need a script for clonazepam 1 mg tablets, give 3 tablets (twice a day.) It continues, She is completely out. The facility's electronic notification application, dated 10/3/2023 at 5:13 PM, documented, Clonazepam 1mg (by mouth) (twice a day) one hundred eighty #180. It was signed by V6, R2's Physician. R2's Nurses Note, dated 10/04/2023 at 09:15 PM, Called to resident room, resident is in active seizure. Resident laid to left side head is free from clutter. Resident lasted in seizure for 30 seconds. Is now awake and oriented x3. States she had a few seizures earlier in the day but came out of them quickly, doctor notified. (Vital Signs)-120/78, 112 (heart rate), 22 (respirations), 98.4 and 95% (room air). Resident states she feels okay now. Frequent checks initiated. Call light within reach. R2's Nurses notes, dated 10/04/2023 at 09:27 PM, documented, Called to resident room. Resident is having another seizure at this moment. Resident is noted to have emesis on bed, resident is laying on side provided by staff. This nurse calls 911 for transport and (transfer) to (local hospital). doctor and (Power of Attorney) notified. R2's Local Hospital History and Physical, dated 10/5/2023, documented, Plan: (R2) is a [AGE] year-old female with a history of intractable epilepsy presenting for increased seizure frequency. Likely provoked by medication non-compliance and underlying UTI, (Urinary Tract Infection). It continues, Patient takes several anti-seizure medications and resides in a nursing home. Recently they ran out of patient's Klonopin, so she had not been receiving it. She presented yesterday due to increase in baseline seizures. (Emergency Medical Staff) was called and patient received 2 milligrams (MG) Versed en route. On arrival to (local hospital emergency department) she continued to have seizures (described as (Right upper extremity) and right facial twitching.) R2's Regional Hospital History and Physical, dated 10/11/2023, documented, Hospital Course: (R2) is a 40 (year old) woman who presents with provoked seizures in setting of benzodiazepine withdrawal (did not receive Klonopin at her nursing home). Her past medical history is most significant for focal epilepsy and cerebral hemi atrophy . It continues, Provoked seizures (secondary to) benzodiazepine withdrawal (no longer occurring.) Resident Council Meeting minutes, dated 07/05/2023, documented, Resident complained that she has ran out of meds for a few days. On 10/17/2023 at 11:15 AM, V5, Licensed Practical Nurse, (LPN), stated, that there were no issues with getting medications refilled from the pharmacy and that R2 does not refuse her medications. On 10/17/2023 at 11:20 PM, V3, LPN stated, they have no issues with getting refills from the pharmacy. She continued to state that she will call the pharmacy for a refill, she will fax the order for the resident and if she doesn't have a medication, they do have an emergency medication kit and she would check to see if the medication would be in there but not all medications are in there. On 10/17/2023 at 1:15 PM, V3, Assistant Director of Nurses, LPN, stated, that the pharmacy sent a 1/2 card of R2's clonazepam because there was a shortage of that medication. She continued to state that R2 missed the PM dose on Tuesday (10/3/2023) and the AM dose on Wednesday (10/4/2023) she had 2 seizures, and she was sent out to the hospital that night. On 10/17/2023 at 1:39 PM, V2, Director of Nurses, (DON), stated, that R2's Doctor was notified for a new order through the texting application the facility uses. On 10/17/2023 at 4:00 PM, V9, Order Entry Supervisor from the Facility's Contracted Pharmacy, stated, that there was only a shortage of Clonazepam 0.25 mg tablets and that it did not affect R2 because she was dispensed 1 mg tablets. She continued to state that the last supply of 15 days' worth of medication was dispensed on 10/11/2023 but prior to those 60 tablets of 1mg Clonazepam was sent to the facility on 9/14/2023 and that Clonazepam was not refilled until 10/11/2023. On 10/17/2023 at 4:25 PM, V2, DON, stated, that she would expect the nurses to reorder resident medications from the pharmacy in time before the medications run out. The facility's policy, Medication and Treatment Orders, dated 07/2016, documented, 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing Pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide resident bariatric equipment/bedside commode needed to promote resident dignity for 1 of 1 resident (R185) reviewed for accommodation of needs in a sample of 35. This failure resulted in R185 having feelings of embarrassment regarding being made to urinate/defecate in an adult incontinent brief instead of toileting. Findings include: R185's Undated Face Sheet, documents he was admitted to the facility on [DATE]. R185's Electronic Medical Record, dated 3/6/2023 at 2:14 PM documents R185 weighed 540.2 pounds and is 5 foot 11 inches tall. R185's admission Minimum Data Set (MDS) dated [DATE] documents R185 is alert, frequently incontinent of bladder and occasionally incontinent of bowel. R185's MDS documents R185 requires supervision with setup assistance for toileting. On 3/16/2023 at 10:00 AM R185 was sitting in his wheelchair. He stood up, leaned against his dresser and showed an incontinence brief under him. R185 stated, I have a wound on my buttocks and staff put cream on it several times a day. There isn't a place for me to poop because I can't fit on the toilet in the bathroom in this room, and the facility doesn't have a bedside commode (BSC) that's big enough for me. When I have to poop staff told me to go in my {adult incontinence brief} and they will clean me up. I push my call light after I am done pooping and staff assist to clean me up within 20 minutes. I know when I have to poop and to have to go in my {adult incontinence brief} and have staff clean me up is embarrassing. No staff have offered to take me to the shower room to poop. I wouldn't be able to walk or propel myself to the shower room. I've talked to the facility social worker and nursing about the need to get a bariatric bedside commode, no one is responding to me. I just want to poop like a regular person, on a toilet/BSC. On 3/16/2023 at 1:50 PM V6 *(Certified Nursing Aide/CNA) stated, I have asked (V28/Maintenance Director), (V27/Housekeeper) and (V12/Social Worker) and they told me to look in the storage room for a BSC for (R185), and I have looked for one in the storage room. There were some there, but not a bariatric one. (R185) has to lay in bed and poop in a {adult incontinence brief} and we clean him up afterwards. (R185) doesn't want to have to poop in a {adult incontinence brief} or even wear a {adult incontinence brief}, but he won't fit on the toilet in his room, and they don't toilet residents in the shower rooms on the halls. On 3/16/2023 at 3:00 PM V24 (CNA) stated, (R185) always gets upset when he has to have a bowel movement. He doesn't have a BSC that fits him and (R185) doesn't fit in his bathroom because he is obese, so he has to lay in bed with a brief on, have a bowel movement, then we get him cleaned up. V24 stated R185 told her time and time again that he wanted a BSC that was big enough for him and she told nurses about it (names unknown), but he had to go potty in his brief because there wasn't a toilet/BSC big enough for R185's use. On 3/16/2023 at 2:30 PM V2 (Director of Nursing/DON) stated at one point R185 had a bariatric BSC but it went missing. V2 stated they have ordered R185 one and put a toilet riser in his bathroom in his room today. V2 wasn't aware R185 was told by staff to have a bowel movement in his pants because the facility didn't have the proper equipment for him. On 3/16/2023 at 3:30 PM R185 was sitting up in his wheelchair playing a video game. (R185) stated staff put a rise over his toilet but he won't fit to sit on it because he is wider than the toilet riser, and he attempted to sit on it already. R18 stated it wasn't wide enough for him; it poked him on both sides, and he was afraid it would cause skin breakdown on both sides. On 3/17/2023 at 9:00 AM V12 (Social Worker) stated no one reported to her that (R185) didn't have a toilet so he could have a bowel movement. V12 stated she ordered a bariatric BSC for him when she became aware of the issue on 3/16/2023. R185's Equipment Invoice, dated 3/16/2023 at 4:39 PM, documents a bariatric commode was ordered. A Written Statement, undated, written by V2 (DON) documents, (V12) and I spoke with (R185) on 3/16/2023 to inform him we had ordered him a larger bedside commode that could accommodate him. Resident was very pleased. Stated he did have a bedside commode when he arrived in facility, but it was removed because it was not large enough. Stated he tried using that toilet, but it was too close in proximity to the wall. He was also given a toilet riser but said it would be too small and therapy felt a bedside commode would be better. Resident stated he uses bedpan and said he has bedside commode; he will still need help cleaning up because he can't reach his buttocks. At home he used a toilet but there was more room in bathroom, and he still needed help wiping. Resident stated he is actively trying to lose weight so he can do these things himself. He said he is pleased with the care and is very outspoken. He stated, 'If there is a problem with care that I will let you and (V12/Social Worker) know myself.' On 3/17/2023 at 12:00 PM V28 (Maintenance Director) stated, (R185) had a BSC when he was initially admitted to the facility. At one point (R185) asked for staff to remove the BSC from his room. V28 stated he didn't know why R185 didn't want the BSC anymore or what size the BSC was. On 3/17/2023 at 1:10 PM, V27 (Housekeeping Director) stated when R185 was initially admitted he had a bariatric bed and a BSC in his room; she didn't know what size it was but one day it was no longer in his room. V27 stated R185 didn't tell her he needed a bigger BSC commode, and no staff told her he needed one either. On 3/17/2023 at 1:48 PM V23 (Nurse Practitioner) stated, It is not dignified to tell a resident to have a bowel movement in his pants because the facility didn't have a bariatric BSC to fit the resident. The Facility's Accommodation of Needs policy, revised 1/2020, documents Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. In order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the residents' wishes. Staff will interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity. Staff will help to keep adaptive devices clean and in working order for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess, monitor, treat per standards of practice and implement interventions to prevent the formation and/or worsening of pressure ulcers for 2 of 9 residents (R68 and R282) reviewed for pressure ulcers in the sample of 35. This failure resulted in R282 developing two new unstageable pressure ulcers to bilateral heels. Findings include: 1. R282's Face Sheet, undated, documents diagnoses including Parkinson's disease, pressure ulcer of sacral region, unstageable, dysphagia, oropharyngeal phase, pressure ulcer of left hip, unstageable, mild protein calorie malnutrition, and dementia in other diseases classified elsewhere, severe, with agitation. R282's Minimum Data Set (MDS) dated [DATE] documented R282 was moderately cognitively impaired, required limited 1+ person assistance for bed mobility, required extensive 2+ person assistance with transfer, activity of walking activity did not occur over the previous 7-day period, and had one unstageable pressure ulcer that was present on admission. R282's Care Plan last revised 2/28/23 documents, I was admitted with a pressure ulcer to left hip. My co-morbidities include: malnutrition, repeated falls, atherosclerotic heart disease, dementia. The Care Plan interventions, dated 2/28/23, documented the following: Administer medications as ordered; Administer treatment as ordered and monitor for effectiveness; Assess/record/monitor wound healing, measure length, width, and depth where possible; Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD (Medical Doctor); Education resident /family/caregivers as causes of skin breakdown including transfer/positioning requirement, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, follow facility protocols for prevention/treatment of skin breakdown; if resident refuses treatment, confer with resident, IDT (Interdisciplinary Team) and family to determine why and try alternative methos to gain complaint; Monitor/document/report to MD PRN changes in skin status such as appearance, color, wound healing, signs and symptoms of infection, wound size and state, obtain and monitor lab/diagnostic work as ordered, and RD (Registered Dietitian) to review and make recommendations PRN. The Care Plan did not include any new interventions for wound care after 2/28/23. R282's Weekly Skin assessment dated [DATE] documented existing skin conditions/wounds to left hip, buttocks, and bilateral heels that were healing. There were no new skin conditions/wounds listed at that time. R282's Progress Note dated 3/5/23 at 3:18 PM documented, Resident is new to facility. Wound to coccyx. Low air loss mattress with bolsters to help with wound. Areas to skin changed daily. Will monitor. R282's Specialty Physician Wound Evaluation & Management Summary dated 3/7/23 documented, Chief Complaint: This patient has multiple wounds. This summary documented a total of five wounds to include the coccyx, upper left sacrum, right lower buttock, left hip, and left dorsal hand. V22 (Wound Specialist) documented treatment orders and recommended dietary consult, pre-albumin level, and culture of stage 4 pressure ulcer on coccyx. R282's Physician Order dated 3/9/23 documents, Dietitian to evaluate as needed for nutritional interventions. R282's Weekly Skin assessment dated [DATE] documented resident had existing skin conditions/wounds on left hip, buttocks and bilateral hands that were healing. There were no new skin conditions listed at that time. R282's Progress Note dated 03/14/23 at 10:49 AM documented, Coccyx pressure ulcer measuring 5cm (centimeters) x (by) 5 x 2cm. left hip pressure measuring 6 x 4 x 0.2. Left upper sacrum measuring 2 x 1 x UTD (unable to determine). R282's Specialty Physician Wound Evaluation & Management Summary dated 3/14/23 documented the resident had previous wounds to coccyx, upper left sacrum, right lower buttock, left hip, and left dorsal hand. In addition, there was a Focused Wound Exam (Site 6) - unstageable (due to necrosis) of the right heel, full thickness measuring 2.5 cm (centimeters) x 3.5 cm x not measurable cm and a Focused Wound Exam (Site 7) - unstageable DTI (deep tissue injury) of the left heel partial thickness measuring 1.5 cm x 1.5 cm x not measurable cm. R282's Weekly Skin assessment dated [DATE] documented resident had existing conditions/wounds on buttocks, left hip and bilateral hands. There was documentation of new pressure ulcers on R282's bilateral heels. On 3/16/23 at 1:58 AM, R282 was in his wheelchair in the therapy gym wearing tennis shoes with his shoes on the foot pedals of his wheelchair. On 3/16/23 at 1:25 PM, V3 (Assistant Director of Nursing/ADON) stated, (R282) stated he will only allow surveyors to observe wound care if they pay him. On 3/17/23 at 8:00 AM, R282 was sitting in his wheelchair in his room wearing tennis shoes with shoes on the foot pedals of his wheelchair. On 3/17/23 at 8:03 AM, V3 (ADON) stated, (R282)'s pre-albumin is pending. His wound culture is ordered for today. I thought it was done, but the lab said they didn't have it, so it is being done today. It doesn't really look infected, but it has that kind of chronic slough, so I think the doctor wanted to order the culture just to be sure. I could have sworn the heel wounds were here on admission, but it was not on the previous notes, and it was on Tuesday's notes, so I'm treating them as new. I put in orders for the Betadine which is now being treated. Our dietitian usually comes at the end of the month but does work remotely. I will see if she has any documentation for (R282). On 3/17/23 at 10:00 AM, V23 (Nurse Practitioner) stated, If a resident came in with wounds and is at high risk for developing wounds, I would expect preventative measures to be in place. This could include floating heels, heel boots, barrier cream, special mattresses, and things like that. I would expect those to be documented in the Progress Notes. Dietitian consults are important because they review the patient and estimate their nutritional needs. Sometimes they will recommend supplements, vitamin C, (arginine supplement), and extra protein to help rebuild healthy skin tissue. Poor nutrition can cause continued skin breakdown and abscesses. I would expect the dietitian to see the resident on their next visit to facility. If it is going to be a while, I would expect the facility to contact the dietitian, because these interventions need to be implemented right away. On 3/17/23 at 11:45 AM, V3 (Director of Operations/Infection Prevention Nurse Consultant) stated, I don't have any documentation that we did anything to prevent (R282's) wounds. On 3/17/23 at 12:25 PM, V1 (Administrator) stated she would expect facility to take preventative measures to prevent wounds and document all preventative measures. As of 3/17/23 at 2:00 PM, no Registered Dietitian (RD) documentation was received from Facility. The Facility's Nutritional Assessment Policy revised October 2017 documents, As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition. Increased need for calories and/or protein - onset or exacerbation of diseases or conditions that result in a hypermetabolic state and an increased demand for calories and protein (e.g., cancer, COPD, liver disease; hyperthyroidism, wounds). The Facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol Policy revised April 2018 documents, The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. The Facility's Wound Care Policy revised October 2010 documents, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Apply treatments as indicated. 2. R68's Undated Face sheet documents she was admitted to the facility on [DATE]. R68's Hospital Discharge Paperwork, dated 1/27/2023 documents, VRE (Vancomycin -Resistant Enterococci) onset 1/6/2023 in resident's bone on buttocks. R68's Braden Scale for Predicting Pressure Sore Risk, dated 1/28/2023 at 1:58 AM documents, High risk. R68's admission Minimum Data Set (MDS), dated [DATE] documents R68 was severely cognitively impaired, total dependence of two persons physical assist for bed mobility, transfers, dressing, toilet use and personal hygiene. R68's MDS documents R68 is at risk for pressure ulcers and had a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) present upon admission. R68's MDS documents skin and Ulcer/injury treatments pressure reducing device for chair and bed, pressure ulcer care and application of ointments/ medications. R68's Care Plan, dated 1/31/2023 documents R68 was admitted with stage IV pressure area to coccyx. Goal: pressure ulcer will show signs of healing through the review date. Approaches: administer medications and treatments as ordered, assess/record/monitor wound healing, measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the MD (medical doctor), follow facility protocols for the prevention/treatment of skin breakdown, if the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance, document alternative methods, inform the resident/family of any new area of skin breakdown, observe the (s/s) signs and symptoms of pain or discomfort, pain management as per MD orders PRN (when necessary), observe for s/s of infection or pain, notify MD/NP (nurse practitioner) as needed, obtain lab/diagnostic testing as ordered and report results to MD/NP, pressure relieving mattress to bed, RD (registered dietitian) to review and make recommendations PRN, sees wound physician wound care specialist and turn and position when providing care as needed or requested. Problem: diagnosis of coccygeal osteomyelitis (VRE) and at risk for medical complications due to this diagnosis. Goal: will have no s/s of complications from my osteomyelitis through the next review. R68's Physician's Order Sheet (POS), dated 1/2023 documents diagnoses included pressure ulcer of sacral region, stage IV. R68's Nursing Progress Note, dated 1/27/2023 at 4:59 PM, documents, Resident arrived via EMS (emergency medical services) from a local hospital. Alert and oriented x1. Per EMS she knows her name and DOB (date of birth ). Assisted from stretcher to bed by nursing staff and EMS. At this time, this nurse assisted CNA (Certified Nursing Aide) in skin check and rolled resident from side to side with little difficulty to remove hospital linens. Resident C/O (complained of) generalized pain. Large sacral wound with slough noted to sacrum. Dressing intact. MD (physician) aware of resident arrival. R68's Focused Observation (admission nursing assessment) dated 1/27/2023 at 6:26 PM written by V3, Assistant Director of Nurses (ADON) documented, alterations in skin? Yes. No assessment of the Stage IV pressure ulcer on R68's coccyx was documented including location, length, width, depth, and drainage and odor. R68's Electronic Medical Record, documents no skin assessment dated [DATE] through 2/2/2023. R68's Nursing Progress Note, dated 2/3/2023 at 3:49 PM, documents, Wound physician here this week to see resident for stage 4 pressure to sacrum measuring 11.5 centimeters (cm) x (by) 12.0 cm x 0.9 cm. moderate serous exudate. 30% necrotic tissue, 20% slough and 50% granulation tissue. post-surgical wound of left lower back measuring 1.0 cm x1.0 cm x 0.6 cm. moderate serous exudate with 100% slough. continue current treatment orders. POA (power of attorney) aware. R68's Nursing Progress Note dated 2/10/2023 at 12:31 PM, documents Wound physician here this week to see resident. stage 4 pressure ulcer to sacrum measuring 10.0 cm x 13.0 cm x 0.9 cm. moderate serous exudate with 30% necrotic tissue, 20% slough and 50% granulation tissue. all tx (treatment) orders are ssd (silver sulfadiazine) cream mix with collagen particles and apply to wound bed, cover with calcium alginate, and dry dressing. continues on LAL (low air loss) mattress. Hospice, MD and POA aware. wounds present on admission. R68's Nursing Progress Note, dated 3/3/2023 at 12:55 PM documents, Wound physician here to see resident this week. sacrum wound measures 7.0 cm x 13.0 cm x 0.9 cm with moderate serous exudate, 20% slough and 50% granulation tissue wound has improved. R68's March 2023 POS documents 3/9/2023 cleanse sacral wound daily with wound cleanser and 4 x 4 gauze. Pat dry. Mix compound (streptomycin, flucytosine, vancomycin) capsules with 15 pumps of [NAME]-gel into mixing container provided. Apply collagen particles to wound bed, cover with calcium alginate, apply silicone bordered dressing daily. May change as needed. On 3/16/2023 at 10:30 AM there was an isolation sign was on R68's door. V25 (Licensed Practical Nurse/LPN) entered R68's room wearing gown, gloves, booties, and gloves. When V25 entered (R68's) room, no handwashing or hand sanitize was observed. When V6 (CNA) turned R68 to her right hip, there was a large wound dressing on R68's sacrum/coccyx and left buttocks. All dressings were saturated with drainage and were not intact. V25 removed the old dressings and stated she's not good at describing the wound drainage, but it was bloody. V25 stated she's not good at describing wound bed, but that it had blood on it. V25 then removed multiple pieces of 4 x 4 gauze from R68's coccyx wound bed. V25 cleansed R68's coccyx wound bed with wound cleanser and patted dry with gauze. V25 dropped the coccyx foam border dressing on the floor. V25 removed her gloves and left the room. She reentered R68's room with gloves on, touching the door and R68's bedside table, then applied collagen wound filler (powder) to same gloved hands and applied the powder directly to the coccyx wound bed. V25 didn't wash her hands or use hand sanitizer when she reentered R68's room. V25 then applied calcium alginate to the coccyx pressure ulcer bed, then covered it with a large silicone foam dressing. V25 removed the non-intact dressing on R68's left lower buttock that had moderate amount of serous drainage and stated she needed to get the wound treatment clarified. V25 didn't cover the pressure ulcer at that time. This area was approximately the size of a quarter. V25 left the room at that time. R68's Nursing Progress Note, dated 3/16/2023 at 12:11 PM, documents Resident seen by (V22) Wound Physician for wound care. Sacral wound measures 8.0 cm x 12.0 cm x 0.9 cm with moderate amount of serous exudate. 30% necrotic 20% slough and 50% granulation. No change to wound. Per MD he believes it is a [NAME] Ulcer. Resident is terminally ill and continues on hospice. There was no assessment of left buttock wound/open area. On 3/16/2023 at 2:00 PM, V6 (CNA) and V25 (LPN) entered R68's room to complete wound treatment. V6 turned R68 to her right hip which showed R68's left lower buttocks pressure ulcer didn't have a wound dressing on it. Observation of the pad under R68 showed serous drainage on it from the left lower buttock open area. V25 cleansed the open area with wound cleanser and gauze. V25 applied SSD ointment, collagen particles mixed in a medication cup and applied it with a q tip applicator. V25 put calcium alginate over the wound bed then applied a silicone foam bordered dressing. The coccyx dressing was lifted on the edges in two sides, and the wound could be seen through the lifted edges at that time. On 3/16/2023 at 2:15 PM, V25 stated she had to get the lower left buttock wound treatment clarified and so she had to wait to get a physician's order for it. When she did the wound treatment on 3/16/2023 morning, the coccyx pressure ulcer and the lower left buttock dressings were not intact, no staff told her the wound dressings were not intact until V6 told her until at approximately 10:30 AM. V25 stated she thinks the dressing aren't intact because of the amount of drainage from the pressure ulcers. V25 stated she noted the wound on R68's left lower buttocks was open but the wound physician would be the one to assess it. V25 stated she always applies the collagen wound filler (powder) with gloved hands, she changes gloves and either uses hand sanitizer and washes her hands before and after pressure ulcer treatment. She didn't recall entering R68's room with gloved hands and applying the collagen wound filler to the wound bed with the gloved hand without washing her hands or using hand sanitizer first. R68's Electronic Medical Record, dated 3/17/2023, did not include documentation or assessment of the open area on R68's lower left buttocks. On 3/16/2023 at 2:30 PM, V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) were interviewed. V2 stated she expected staff to follow physician's orders for pressure ulcer treatments and to notify the resident's physician if the dressing isn't staying on and intact due to the amount of drainage. If staff found a pressure ulcer's dressing was not on or intact, they expected staff to notify the nurse and the dressing should be redone, so it is intact at all times. V3 stated this is to control the infection, control drainage and benefit wound healing. V3 stated staff are expected to sanitize their hands before entering the resident's room and then wash their hands prior to providing pressure ulcer treatment. V3 stated when staff need to get skin/wound care orders clarified, a dry dressing should be applied to the area and a physician's order should be on the POS within 1-2 hours. V2 and V3 stated they didn't know the initial pressure ulcer dressing was done at 10:30 AM and the resident didn't have a dressing on the lower right buttocks until 2:00 PM today. They also were not aware R68's coccyx wound dressing was not intact on all edges. V3 stated if the pressure ulcer dressing isn't intact, and the correct pressure ulcer treatment isn't administered per the POS it would ultimately cause the pressure ulcer to deteriorate. On 3/17/2023 at 10:00 AM, V23 (Nurse Practitioner/NP) stated upon admission a through skin assessment should be documented in the resident medical record including pressure ulcer size, tunneling/undermining, pain, drainage, appearance of the wound bed. This skin assessment should be documented in the resident's medical record within 24 hours so the facility has a baseline of what the pressure ulcer looked like on admission and if the pressure ulcer was facility acquired or if it was present upon admission. V23 stated she expected physician's orders to be followed and if a pressure ulcer dressing isn't intact, she expected staff to replace the dressing as soon as possible. V23 stated if the nurse needed to get pressure ulcer treatment clarification, she expected staff to apply a dry dressing over the area until the physician clarification is obtained because if the pressure ulcer was on the buttocks, that would keep feces out of it and help keep infection out. V23 stated she expected staff to wash their hands or use hand sanitizer prior to starting pressure ulcer treatment. V23 stated entering a resident's room with gloves on and touching items along the way, then providing pressure ulcer treatment (putting powder directly on the dirty gloves and applying it directly to the wound bed) is definitely improper infection control technique and can lead to infection to the wound bed because who knows what was on the items the nurse touched prior to applying the powder to the wound bed. The Facility's Wound Care Policy revised October 2010 documents, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound .Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Apply treatments as indicated.