Based on observation, interview and record review the facility failed to provide assistance with ADL's (Activities of Daily Living). This failure resulted in R1 being left on the bed pan unattended leading to feelings of pain, frustration, panic and embarrassment. This applies to 1 of 3 residents reviewed for assistance with ADL's in a sample of 6 residents. The findings include: R1 Face sheet shows his diagnoses to include acute respiratory failure with double lung transplant, protein-calorie malnutrition, pneumonia, and type 2 diabetes mellitus. R1's 3/18/24 MDS (Minimum Data Set) shows, he is fully cognitively intact, and needs substantial/maximal assistance rolling left and right. R1's 3/12/24 POS (Physician Order Sheets) shows Physical and Occupational therapy is to evaluate and treat as indicated 3-5 times a week. R1's 3/13/24 Care Plan shows he has a self care deficit and is dependent with ADL care. The facility must provide total assistance in all aspects of hygiene/dressing. R1's 3/21/24 Progress Note, by V10 (Nurse Practitioner) shows R1 was referred to skilled therapy related to a noted functional decline. R1 has a decrease in strength, balance, transfers, mobility, and the ability to perform self-care ADL's. The same progress note shows R1 is alert and oriented to person, place, and time. On 4/2/24 at 10:00 AM, R1 said, on 3/29/24 at 11:00 AM he was placed on the bed pan, and when he was finished having a bowel movement pressed his call light to be taken off. R1 said, staff kept coming in and shutting off the call light and telling him (R1) they would be right back and never returned. R1 said, the bed pan was starting to hurt his bottom and he was feeling frustrated, R1 said, it was like he didn't matter. R1 said, he finally called 911 because he couldn't take it anymore and was starting to panic. R1 became emotional and started to weep when relaying this event. R1 said, it's embarrassing to have to use a bed pan but to be on it for 3 hours and then have a room full of EMS and staff to take him off caused more embarrassment. On 4/2/24 at 1:00 PM, V7 CNA said, she was R1's CNA on 3/29/24, the day R1 called 911. V7 said, her normal shift is 10:00 AM to 10:00 PM but she was late that day. V7 said, she put R1 on the bed pan, but she couldn't remember what time. V7 said, it was before lunch because she remembers R1 was still on the bed pan when she delivered his lunch tray. V7 said, she didn't take him off the bed pan because she got busy and thought someone else would do it. V7 said, she doesn't know what time he (R1) was taken off the bed pan. On 4/2/24 at 9:45 AM, V2 DON (Director of Nursing) said, we have video of staff going in R1's room several times, so V2 thinks R1 was put on the bed pan at 1:00 PM and taken off at 2:40 PM. V2 said, she assessed R1's bottom at 2:40 PM when EMS (Emergency Medical Service) arrived. V2 said the staff should answer the call light as soon as possible because the resident may be in distress. On 4/2/24 at 1:00 PM, V4 CNA said, R1 is alert and oriented. V4 said, staying on the bed pan for longer than 1/2 an hour is too long. V4 said the resident should come off the bed pan and try again later, because staying on the bed pan too long could cause skin break down. On 4/2/24 at 1:00 PM, V5 CNA said, R1 is alert and oriented. V5 said, staying on the bed pan for longer than 1/2 an hour is too long. V5 said, the resident should come off the bed pan and try again later, because staying on the bed pan too long could cause skin break down. On 4/2/24 at 10:15 AM, V3 (Wound Nurse) said, a 1/2 hour to 1 hour on the bed pan is too long because it might cause skin breakdown. The CNA should take the resident off the bed pan and the resident should try later to use the bed pan. A Policy and Procedure for Bed Pan use and for assistance with ADL's was requested, however V1 (Administrator) said, they did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R57's admission Record showed and original admission date of 9/22/23 with diagnoses to include cellulitis (skin infection) of left lower limb, sepsis (blood infection), diabetes, and obesity. R57's 9/29/23 admission Minimum Data Set showed moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. On 12/12/23 at 2:24 PM, R57 was alert and oriented to person, place, time, and medical condition. R57 stated he had sepsis from right leg wound. R57 stated he had a wound to his left leg that requires daily treatment. R57 stated the facility is known to not perform the dressing changes daily. R57 stated the dressing had not been changed on 12/11/23 or 12/10/23. R57's November and December 2023 Treatment Administration Record (TAR) showed an order for daily left knee wound care to include an antibacterial wound treatment. The treatment began on 11/8/23 and was discontinued on 12/13/23. During this time, 8 treatments to the left knee were not documented as being completed out of a total possible 36 treatments (22 percent of R57's treatments were not documented as being done; 12/11/23 treatment was not documented as being done.) On 12/13/23 at 4:29 PM, V2 Director of Nursing stated the purpose of wound care is to promote healing, treat the condition, and it can help prevent infection. When a nurse does a treatment it should be documented in the treatment record or a progress note. It's possible that it wasn't done if it's not documented. You could also talk to the patient and see if the treatment had been done. He should be having daily dressing changes. The facility's Dressing Non-Sterile policy (revised 2/17/20) showed the purpose of wound care is To protect open wounds from contamination and to absorb drainage. The policy states, following wound care, to Initial Treatment Administration Record electronically . 3. R24's Face Sheet shows his diagnoses to include, lymphedema, type 2 diabetes mellitus, a history of pressure and non-pressure injuries, venous insufficiency, developmental disorder of scholastic skills, and morbid obesity. R24 is alert and oriented. On 12/14/23 at 3:03 PM, during a dressing change performed by V12 RN (Registered Nurse), R24 had a unstageable pressure injury on the inside edge of his left foot, below his big toe. The sore was on a bony prominence. The pressure injury was 1 cm (centimeter) round with a scab on the top of the wound. The wound bed could not be seen because of the scab on top. On 12/14/23 at 3:03 PM, R24 said, the wound on the side of his left foot is new and he must be wearing his shoes too tight. R24 said he is to receive new shoes soon. 12/15/23 02:42 PM, V18 ( R24's wound care Physician) said, a pressure ulcer will form on a bony prominence. V18 said, if the wound bed is not visible then the wound is classified as unstageable. On 12/14/23 at 3:03 PM, V12 RN said, she wouldn't classify R24's new wound as an unstageable pressure injury. V12 said she thinks it's just a scab. V12 said she called the Physician and is waiting to get orders for what to do about it. On 12/15/23 at 12:15 PM, V17 (RN at the wound clinic) said, R24 did not come to his appointment today. On 12/15/23 at 11:52 AM, V11 (Clinical Executive Director) said, she did R24's dressing the night (12/13/23) before the new pressure injuries was found and could not recall for sure if she saw anything, V11 said it may have been a callous. V11 said, R24 did not go to his scheduled appointment at the wound care clinic today, and she was not sure why. V11 said, in order to determine if a wound is partial or full thickness the wound bed needs to be visible, if not, the wound can't be staged. V11 said, wounds should be found on a resident before reaching a unstageable level. R24's care plan (revision on 12/06/2023) shows, The resident is at increased risk for alteration in skin integrity related to venous insufficiency. R24's goal is to not develop any skin integrity issues through the next review. The interventions in place includes: Skin will be checked during routine care on a daily basis and during the weekly bath or shower schedule per resident preference. and reposition resident frequently, and off load heels as needed. R24's 12/13/23 (8:20 PM) Progress Notes, shows V11 did R24's dressing the night before the wound was discovered. There is no mention of a new wound in that progress note. The local wound care clinic notes dated 12/8/23 (the latest one available) does not mention a new wound on the left metatarsophalangeal joint. R24's Shower Sheets and the Physician Order Sheets fail to mention a new wound on his left foot between 12/12/23 and 12/14/23. The 10/2020 Pressure Ulcer and Skin Condition Assessment Policy shows, the purpose is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure, and other ulcers and assuring intervention are implemented. Each resident will be observed for skin breakdown daily during care and .the CNA (Certified Nursing Assistant) will promptly report it to a licensed Nurse who will perform the initial assessment. Based on observation, interview, and record review the facility failed to ensure a resident (R14) with congestive heart failure was weighed daily to monitor for fluid overload. The facility also failed to ensure a resident (R57) received wound care as ordered. The facility also failed to identify a wound to the foot for (R24). These failures affect 3 of 7 residents (R14, R24, R57) reviewed for quality of care in the sample of 21. This failure resulted in R14's increased weights not being reported to the physician and R14 requiring hospitalization from 11/20/23 through 11/24/23. Findings include: 1. R14's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease with acute exacerbation, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, acute on chronic diastolic (congestive) heart failure, acute and chronic respiratory failure with hypoxia, chronic kidney disease, secondary hyperparathyroidism, morbid obesity, Type 2 Diabetes, anemia in chronic kidney disease, acquired absence of right leg below knee, acquired absence of left leg above knee, major depressive disorder, and anxiety disorder. R14's facility assessment dated [DATE] showed he has no cognitive impairment. On 12/11/23 at 9:45 AM, R14 was in his room and sitting in his wheelchair. R14 stated he does not get the care he needs at the facility. R14 said, I am supposed to be weighed daily for congestive heart failure and kidney failure because I retain fluid. I end up in the hospital about once a month almost. Today they took me down to weigh me and the batteries in the scale were dead so I was sitting there waiting for them to find the batteries and I had to have them bring me back to my room because it was taking too long for me to do down there without my oxygen on. I keep my own list of my weights so you can see I wasn't weighed 12/5-12/9 and I was not weighed 12/10 or 12/11 and today now I'm still waiting. I don't know what they are writing down but these are my weights. I'm getting myself up and into bed and I get really really winded, that is when I know that I need to go to the hospital. I've been in the hospital probably 6 or more times this year. R14's care plan initiated 10/24/23 showed, The resident demonstrates a potential for fluid overload related to: . Daily weight . Administer medication per physician's orders, Assess for signs and symptoms of fluid overload and notify the physician if signs and symptoms of fluid overload are present: edema . adventitious lung sounds . Observe, assess and record signs of edema. Report changes, new edema to physician . R14's care plan initiated 10/24/23 showed, The resident presents with altered respiratory function secondary to: . Observe and report signs of congestions, lethargy, labored breathing, wheezing, etc . Notify the physician as needed . R14's October and November 2023 eMAR (electronic Medication Administration Record) showed an order for Lasix Oral Tablet 40 mg (milligrams) Give one tablet by mouth every 24 hours as needed for weight gain greater than 3 lbs (pounds) in a 24 hour period . R14's 10/26/23 weight was 277 lbs and his 10/27/23 weight was 282 lbs showing a 5 lb weight gain in 24 hours. R14's October 2023 eMAR showed no dose of Lasix 40 mg administered as a result of that 5 lb weight gain. R14's October and November 2023 eMAR (electronic Medication Administration Record) showed an order for CHF (congestive heart failure) - weight daily - if weight gain of 2 lbs or more notify MD (physician) . R14's documented weights showed his 11/8 weight was 269.9 and his 11/9 weight was 272 (2.1 lb weight gain). R14's 11/9/23 nursing progress note showed, . stated he feels like he is gaining, refuses 911 transport for evaluation, resident alert and orientated x 4 . This note does not show physician notification made of resident 2.1 lb weight gain and report of feeling like he is gaining weight. R14's 11/9/23 Skin/Wound Note showed, . swelling of hands noted. Floor nurse notified. R14's eMAR showed R14's 11/10 weight was 267.2 and his 11/11 weight was 273.2. (6 lb weight gain) R14's medical record showed no evidence of notification to the physician regarding the 6 lb weight gain identified on 11/11/23. R14's November 2023 eMAR showed no evidence of Lasix given in response to this 6 lb weight gain. R14's 11/17 weight was 258 lbs and his 11/18 weight was 274 lbs (16 lb weight gain). R14's medical record showed no evidence of notification to the physician regarding the 16 lb weight gain identified on 11/18/23. R14's November 2023 eMAR showed no evidence of Lasix given in response to his 16 lb weight gain. R14's 11/20/23 nursing progress note entered at 9:16 PM showed, Patient requested to be sent to ER (emergency room) for SOB (shortness of breath). Doctor and POA (power of attorney) was notified. [Ambulance Service] was provided for transport to [acute care hospital] . R14's 11/24/23 nursing progress note entered at 3:36 PM showed R14 was readmitted from the acute care hospital. R14's Nurse Practitioner Note dated 12/1/23 showed, . His most recent hospitalization was from 11/20/23 through 11/24/23. He presented to the emergency department with worsening shortness of breath x 2 days. Also reported a cough with increased congestion and sputum production O2 sat (saturation) 78. He was started on IV furosemide (diuretic), scheduled nebulizer treatments, prednisone (steroid), doxycycline (antibiotic). Nephrology was consulted and recommended continued diuresis without need for dialysis at that time. His weight at the time of discharge was 272 pounds . He was discharged back to the SNF (Skilled Nursing Facility) . Weight 11/28/23 263.7 lbs On 12/14/23 at 12:55 PM, V12 RN (Registered Nurse) said weights are documented on the eMAR and those flow over to the weights and vitals in each resident record. V12 said once entered they have to verify if he has had a two lb weight gain. If he has had 2 lb or more weight gain, we contact the doctor for his congestive heart failure. Physician notification gets documented in the progress notes. If [R14] has an increase in weight he could be having too much fluid building up on him. We monitor his weights to monitor his CHF. On 12/14/23 at 1:13 PM, V2 DON (Director of Nursing) said R14 is a daily weight to monitor his congestive heart failure. V2 said, In fact, he had came back to us not too long ago from a hospitalization. He still is a daily weight, came back 11/25. Monitoring for weight gain for fluid. He builds up with edema, he has been educated often to elevate extremities, and he does not lay down during the day, he sits up in his chair during the day. If there is a weight gain of 2 lbs or more the nurses contact the physician. Notification to the physician should be documented in the progress notes and also depending on if faxed over or called. If faxed it is under the misc scanned in. On 12/19/23 at 5:02 PM, V16 (Medical Director) said he is not very familiar with R14 but that he would expect daily weights to be completed as ordered for CHF (congestive heart failure) residents. V16 said the physician should be notified of weight of changes as ordered as well. V16 said increased weight would be an indicator of increased fluid. A policy and procedure for care of a resident with congestive heart failure and daily weights was requested. On 12/14/23 at 11:30 AM, V1 (Administrator) stated the facility has no policies addressing either congestive heart failure or daily weights but that the nurses are to follow physician orders as written.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident received pain medication as scheduled for 1 of 1 resident (R9) reviewed for pain in the sample of 20. This failure has resulted in R9 requesting further pain control on 7/18/23 while reporting pain at a level 10 on the pain scale and on 10/18/23 while reporting pain at a level of 8 on the pain scale. The findings include: R9's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, palliative care, cerebrovascular disease, Type 2 diabetes, rheumatoid arthritis, major depressive disorder, age related osteoporosis without current pathological fracture, and anxiety disorder. R9's facility assessment dated [DATE] showed she has moderate cognitive impairment. R9's care plan initiated 5/3/21 showed, Resident and family have opted for hospice via [hospice company] for diagnosis of weight loss and failure to thrive . Resident will be enabled to live to the limit of potential in physical, mental, emotional, and spiritual health and will be kept as comfortable and as pain free as possible . Keep resident comfortable and as pain free as possible. Monitor for symptoms of pain and/or distress (i.e. restlessness, grimaces, etc.) and anticipate and meet needs throughout the day. Provide medication as ordered for comfort . R9's care plan initiated on 2/11/21 showed, Resident is at increased risk for alteration in pain/discomfort related to compression fractures and Rheumatoid Arthritis. The resident will notify staff with onset of pain through next review . Notify MD for any new resident complaints of pain and or signs and symptoms of pain to obtain new order for medication regimen or break through pain management . R9's care plan initiated 2/21/23 showed, [R9] on hospice care related to terminal illness - alteration in comfort . Resident will have no observable indications of physical discomfort (moaning, restlessness, grimacing) . Provide cares per resident and/or family wishes to achieve acceptable level of comfort . Assess for pain and discomfort PRN. See Pain Care Plan . R9's December 2023 POS (Physician Order Sheet) showed an order for Norco (Opioid Pain Medication) 5-325 mg, Give 1 tablet by mouth every 8 hours related to Rheumatoid Arthritis. The same POS showed an order for Fentanyl Transdermal Patch, Apply 1 patch transdermally every 72 hours . R9's July 2023 eMAR (electronic Medication Administration Record) showed she did not receive any of her scheduled opioid pain medication on 7/26/23 (3 doses) and 7/27/23 (3 doses). R9 did not receive her 5:00 AM dose of Norco on 7/28/23. R9's eMAR notes showed the Norco was not available to be administered. This same eMAR showed R9 also did not receive her scheduled Fentanyl pain patch on 7/15/23, 7/18/23, and 7/24/23. R9's eMAR notes showed on 7/15/23 they were waiting for the physician to send the prescription to the pharmacy and the medication was not available for administration. R9's eMAR showed she received a dose of Morphine on 7/18/23 for pain she rated at a 10 out of 10 on the pain scale. R9's August 2023 eMAR showed she missed 2 doses of her Norco on 8/29/23. R9's eMAR notes showed the missed doses were due to the medication being on order and not available for administration. R9's September 2023 eMAR and Norco count sheet were reconciled to determine the number of doses R9 did not receive. The narcotic count sheet showed R9 ran out of Norco on 9/19/23 causing her to miss her scheduled dose at 9:00 PM. R9 missed all doses of her Norco from 9/20/23 through 9/23/23. (13 missed doses) R9's eMAR notes showed the Norco was not available. R9's October 2023 eMAR and Norco count sheets were reconciled to determine the number of doses R9 did not receive. The narcotic count sheet showed R9 ran out of Norco on 10/13/23. R9 missed all doses of her Norco from 10/14/23 through 10/19/23 (24 missed doses). R9's eMAR notes showed the Norco was on order. R9's same eMAR showed R9 did not receive her Fentanyl pain patch on 10/16/23, 10/19/23, 10/22/23, and 10/25/23. R9's narcotic count sheet for Fentanyl showed her last patch had been applied 10/13/23. R9's eMAR note showed her Fentanyl pain patch was not available. R9's 10/18/23 eMAR note showed she requested Morphine for generalized pain. R9's eMAR showed she received a dose of Morphine on 10/18/23 when she reported pain at a level 8 out of 10 on the pain scale. Additionally, a 10/18/23 Mood/Behavior note was added for R9 that showed, CNA (Certified Nursing Assistant) reported that patient was changed 14 times throughout the night. Patient repeatedly taking off brief without it being wet/soiled asking to be changed . R9's December 2023 eMAR and Norco count sheets were reconciled to determine the number of doses R9 did not receive. The narcotic count sheet showed R9 ran out of Norco on 12/11/23. R9 missed all doses of her Norco from 12/12/23 through 12/13/23 (6 missed doses). R9's eMAR notes show a new prescription was needed. On 12/14/23 at 9:41 AM, V16 CNA said R9 complains about pain all the time. V16 said R9 has been complaining more recently and the aides report this to the nurses. On 12/14/23 at 12:45 PM, V12 RN (Registered Nurse) said, I'm assuming it is [R9's] Rheumatoid Arthritis that is causing her pain. She has Norco and Fentanyl patches for pain treatment. The Norco came in today. Norco is given every 8 hours scheduled. It is not PRN (as needed). If I see that a medication is not here I call the pharmacy to find out if they need a new prescription, if they do need a new prescription, I call the doctor and ask them to send to the pharmacy. I let them know if we have none because I write NONE so they know that we don't have any. The pharmacy comes in one time a day early in the morning or you can STAT (rush) it if needed. There is a convenience box but if its a prescription issue we still can't get it. On 12/14/23 at 2:14 PM, V2 DON (Director of Nursing) said, There was an order the other day that they changed it because we needed a prescription. So we had to go through hospice for that for the refills. We would have to reach out to see if there is something available that is comparable if we run out of medications. I haven't heard anything in terms of her complaining of pain. The nurse yesterday said she was reaching out to hospice to see if they could switch her Norco to PRN . If they are out, the nurses should reach out to hospice because hospice fills the scripts . On 12/19/23 at 5:02 PM, V19 (Medical Director) said R9 could start experiencing withdrawal signs and symptoms within 6-12 hours of her missed dose of Norco or Fentanyl. V19 said R9 would present with agitation, restlessness, and increased pain. V16 said he would expect the facility to request refills and new prescriptions timely to ensure the resident does not run out of medications. V16 said if the facility nurses have difficulty getting the hospice physician to ensure prescriptions are called in and a resident is without their pain medications they would be able to contact him to call in a prescription. The facility's policy and procedure with review date of 11/2022 showed, Pain Management and Assessment . Purpose: To develop a standardized method for assessing, monitoring, evaluating, and documenting pain in both cognitively intact and impaired residents. Resident will receive necessary comfort, exercise greater independence, and enhance dignity through optimizing their ability to perform activities of daily living . 2. Assess and document pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms . 3. Evaluate for behavioral responses to pain: . crying or moaning . increase in body movements . irritability/mental confusion . 7. Evaluation of the effectiveness of analgesic pain medication will be conducted post administration . 9. If pain is not relieved, give further medication as the physician ordered. If there are no orders, notify the physician of assessment results and obtain an order. 10. The resident's care plan will reflect the individualized pain management plan, including both pharmacological and non-pharmacological interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow facility policy and failed to notify a resident's provider and provide emergency services for a resident with a change in condition, and the facility failed to follow-up with a resident's physician regarding signs and symptoms relating to a urinary tract infection. This applies to 1 of 3 residents (R1) reviewed for change in condition in the sample of 7. This failure resulted in R1 developing septic shock (Serious Condition that occurs when a body-wide infection leads to dangerously low blood pressure) and requiring hospitalization. The findings include: 1. R1's admission Record showed an original admission date of 5/20/23 with diagnoses to include major depression; nausea, and acid reflux disease. R1's 5/29/23 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 14 out 15. The MDS showed she was able to make herself understood, she was able to understand others, and she had clear speech. The MDS showed R1 was totally dependent upon two staff for bed mobility (turning in bed); transferring from bed to chair; dressing; personal hygiene; and toilet use. The MDS showed she was frequently incontinent of urine and she was always incontinent of bowel. The MDS showed she had a stage II pressure sore. R1's Care Plan showed she was a Full Code (In the event her heart or lung function would cease; resuscitation interventions should be initiated). R1's 5/20/23 admission Note from 7:50 PM showed R1 was admitted from a hospital approximately 45 minutes from the facility. R1 was alert and she was oriented to person, place, time and curent condition. R1's note showed R1 stated R1 was not able to walk due to a pinched nerved and R1 required surgery. The note showed R1 was unable to move or straighten R1's left leg. (Note was authored by V18 Licensed Practical Nurse, LPN) R1's Hospital Records (obtained from the facility) showed R1 is a [AGE] year old female admitted on [DATE]. Patient active problem list: Urinary Tract infection without hematuria (no bleeding) .and Sepsis, due to unspecified organism . The records also showed diagnoses to include Failure to thrive in adult; malnutrition; and low blood pressure. R1's 6/1/23 psychiatry note showed .there are no symptoms of mania, paranoia, or delusional thoughts elicited this visit .Appearance/Behaviors: Calm, cooperative, Good eye contact, Well groomed. Speech: Clear, normal rate, tone, and volume .Mood: Depressed; Attention: Good; Insight: Fair; Judgment: Fair. The note showed she was awake; alert; and oriented to person, place, and time. R1's Physician Notification from V22 Registered Nurse sent to V4 Medical Director/Physician on 6/1/23 showed, R1 was complaining of burning with urination, urinary urgency, and bloody discharge. V22 requested a urine analysis (Urinalysis, UA) and, if needed, catheterize the resident to obtain the sample. V4 responded on 6/1/23 to do urine analysis (UA) and catheterize the resident if needed. The same fax sheet showed, Update 6/6/23 - resident refuses straight cath (catheter that is inserted for sample then immediately removed), says she has a fear of catheters, has been refusing. R1's Fax sheet sent to V4 showed R1 had blood tinged urine and her vaginal area was swollen and she was experiencing vaginal discharge. The note showed a request for catheterization for urine analysis and to culture the urine if indicated. V4 responded, via fax, on 6/4/23 stating Ok to do above. (The nurse's signature who authored the fax was not legible; V18 LPN confirmed she sent the fax. The date box on the fax is blank; however, the fax was stamped with a date of 6/2/23. Staff schedules showed V18 worked the evening of 6/1/23 to the morning of 6/2/23.) R1's 6/4/23 Nurse's Note from 8:02 PM, showed, R1 refused straight catheterization for a UA and that she would do a bed pan for the UA. (Note authored by V18) R1's 6/6/23 Nurse's Note from 3:18 AM, showed Resident refused to be straight cathed, stated that she has a fear of catheters. R1's 6/11/23 Nurse's Note from 4:57 PM, showed R1 was experiencing a change in condition. The note showed, Altered mental status, lethargy, slow to respond. Unable to get blood pressure reading. Oxygen saturation ranging from 79 percent to 86 percent. Oxygen started at 3 liters per nasal cannula . The note showed she had a low heart rate of 38 beats per minute (Normal range is 60 to 100 beats per minute, BPM) and 911 was called. The note showed V4 was notified of the transfer. R1's Hospital records from the evening of 6/11/23 showed R1 was in septic shock, she had bladder inflammation, and a urinary tract infection. The records showed a physician note on 6/11/23 at 9:13 PM, . It is difficult to obtain history from patient but patient's mother is at bedside and stated that 2 to 3 days ago the patient started not looking so well. Patient's face appeared pale and she was having increasing her jerking movements. Patient's mother states the patient was treated for UTI 2 weeks ago . The note continued .Septic shock with acute (recent onset) organ dysfunction present on admission .Source of infection is urinary and respiratory . On 6/14/23 at 1:00 PM, V18 LPN stated she works 6:00 PM to 6:00 AM mainly on the first floor of the facility. (R1 was a first floor resident of the facility.) V18 stated, on admission, R1 was alert, oriented, and conversational. V18 said R1 was .very 'spot on' and deliberate with her statements, she could make her needs known . V18 said she worked the evening of 6/11/23. V18 said the day nurse on 6/11/23, V19 Registered Nurse, had a one hour and 45 minute drive home, therefore, she came in early so V19 could start her long drive home. V18 said she arrived at the facility between 4:30 PM and 5:00 PM. V18 said the report she received from V19 regarding her shift that day was uneventful. V18 said while she was receiving report, V20 Certified Nursing Assistant stated R1 was talking crazy .she was talking about asparagus and how the CNA had blue eyes and pretty pale skin but she (V20) is dark skinned and has dark eyes. I asked the CNA, was she saying this stuff with her eyes open and the CNA said no . V18 said the CNA reported R1 had not eaten breakfast or lunch and she had not drank any fluids that day. V18 said R1 not eating breakfast or lunch was normal for R1. V18 said, So I said send her out, she has altered mental status. If she is seeing stuff with her eyes closed, that is weird and not normal for her . V18 said V19 went to do vitals while she called for transportation. V18 said when she entered the room the staff were not able to get a blood pressure with the machine. V18 said she attempted a manual blood pressure and she could not hear anything. V18 said she attempted to feel for a pulse in R1's wrist and she was unsuccessful. V18 said R1 appeared pale; almost grey. V18 said, A week and a half ago Monday, or Sunday, I went to straight cath her for a UA because her urine was nasty smelling and blood tinged .I asked [V4] for UA and culture if indicated. She (R1) said she can't use a bed pan because of what happened at [previous long-term care facility]; then she would start crying. Then I went to straight cath her and she said no. I told her she can't use bed pan but I told her to press the call light next time she had to go and we would do the bed pan. She was not willing to do the bed pan for the UA then [V22 Registered Nurse] tried (straight catheter) and she said No again. The night they sent her to the ER, I told them (R1's family that was in the room that night) she is in bad shape; I think she has Sepsis .I think she was septic from the UTI. She had nasty foul smelling urine for 1 to 2 weeks and you don't let anyone get a UA; these UTI's don't go away on their own. I think [V22] sent him (V4) something or faxed him something that she refused straight cath or UA. I don't remember getting a fax back that he (V4) respond. If we fax and there is no response, we sometimes have to send a couple faxes . V18 said providers will not order antibiotics without a UA. V18 said the foul smelling urine was reported to her by the CNA staff. V18 said, If someone told me something is not right with her (R1), I would go down and see for myself. I don't know why [V20] didn't tell her (V19) what she told us [during report] earlier on in the shift. If I was told she was not right, I would go down there with the vitals machine and talk to her and do an assessment and see what's up and do vitals. On 6/15/23 at 10:05 AM, V18 stated she knew R1 needed to be sent out without seeing the resident. V18 said, What they were describing was a change in her mental condition and she needed to be sent out. On 6/14/23 at 9:43 AM, V20 CNA said she was scheduled to work 6:00 AM to 6:00 PM on 6/10/23 (Saturday) and 6/11/23 (Sunday.) V20 said, in regards to R1 on Saturday, She was a lot more with it, at least more than Sunday .Saturday she was not even talking in a normal conversation but she could at least talk. She asked to talk to her mom. She was trying to help us turn her on Saturday but you could tell something was going but it was not as bad as Sunday. She could say she was hurting and she really did not like to reposition. The weekend before I only saw her a little but she was a lot more alert and conversational (The weekend prior to 6/10/23 and 6/11/23) . it was a big change to the next weekend . It was painful for her when I would provide incontinence care .I even told the night CNA, if she doesn't get sent out, that he needed to check on her every hour and don't go longer than that. V20 said, in regards to R1 on Sunday 6/11/23, She was a lot worse. She was totally out of it. I tried to wake her up for breakfast and she wouldn't wake up at all, she mumbled a few things but that was it. I told her I would leave her breakfast and I would come back. I asked if she needed help, but she didn't say anything. I tried to get her a drink with a straw and the water just ran out of her mouth . Then at lunch she did nothing again. I told the nurse that she has gotten way worse; it was around lunch time. I don't know the exact time, but it was right around lunch time. Then, sometime between 3:00 PM and 5:00 PM, [V19 RN] went down there to check her (R1) vitals and they couldn't get vitals on her. I did see [V19] go down and check on her at lunch time. I don't know if she did a set a vitals on her at lunch time but, I did tell [V19] I would do a set of vitals and with everything going on I forgot to do them. (R1's Electronic Charting showed no vital signs on or about 12:00 PM on 6/11/23) When [V19] saw her at lunch time, [R1] would not have been alert and oriented. She was not alert for me at all; the entire shift. I would say her condition from Saturday to Sunday, she had a change in condition. Even on Sunday morning she already had a change in condition. I even asked what meds she was on Sunday morning because she appeared snowed (sedated) to me, and she was on Seroquel so I thought that was the cause of it but she never came around. I don't think [V19] had ever taken care of her before so I don't think she knew if this was a change in condition. [V19] would not have known this was change. The family came in later in the afternoon, they came in right before, as everybody decided she (R1) needed to be sent out The way [R1] was when she was sent out she was not in any different condition than she was in the morning. [R1] was talking about asparagus and she said I had pretty pale skin, but I am super dark and tan and I have brownish green eyes but she said I have beautiful blue eyes. She said that around lunch time, and that was when I told [V19] that she was not really waking up at all. V20 said, It wasn't until the full time employee came in on Sunday night; she came in early around 4:30 PM or so, and we told her how [R1] was acting .It was the night nurse (V18) that prompted us to send her out. I think if [V19] knew she (R1) was alert and oriented prior to Sunday, she (V19) would have sent her (R1) out earlier that day. But no one knew how she was normally and it wasn't until [V18] came in that we were aware how she was acting was not normal. [V19] didn't work Saturday either. V20 said, R1 had yellow drainage that was not urine. V20 said, in regards to the drainage, I've never seen anything like that before and I have 28 years of experience .The yellow discharge smelled like, it's hard to explain, I've never smelled anything like that before, it was not normal. I don't think it was a yeast infection, It seemed like it was vaginal discharge but I did not think it was a yeast infection. I've had residents with yeast infections and it didn't look like any of those that I have seen before. V20 said, Oh god yes, most definitely with UTI's and infections, there is a big change in cognition. I remember, I think [V18] said, they were trying to get a UA on her but she wouldn't let them straight cath her. I don't know how long they had been trying to get one. On 6/13/23 at 3:49 PM, V16 CNA stated she worked the day shift on Sunday 6/11/23. V16 said, Sunday was my first time meeting [R1]. She was really out of it. She had her eyes closed and she could not form a sentence. That was how she was at the beginning and the end of the shift .She did have a brief (incontinence brief) I didn't notice any blood but I did notice some yellow pus like discharge. The yellow pus was mixed with the urine. I didn't see any yeast like discharge when I cleaned her up. My understanding that was her normal condition .the nurse [V19] said she was out of it as well. [V19] did not say this was abnormal for her. My shift that day was 6:00 PM to 2:00 PM that day. She was definitely not alert, oriented, and answering questions when I saw her. She was the same my entire shift. If I had cared for her previously and she was alert and oriented at that time, I would have told the nurse she needed to be evaluated because the way I saw her on Sunday that would have been a change .She (R1) was just gibberish nothing that she said was understandable. I did not do the vital signs on her that day the nurses will sometimes give us a list of residents that need vitals but they did not give us a list that day. I did try talk to her and I tried to feed her both meals but she pushed them away both times. On 6/14/23 at 8:15 AM, V19 stated, prior to 6/11/23, she had never cared for R1. V19 said she saw R1 for morning medication pass, then again shortly after medication pass. V19 stated she saw R1 for less than 10 minutes during the day. V19 said during morning medication pass R1 stopped V19 from giving her medications water and she wanted to take them with soda; however, she did not really speak with R1. V19 returned to apply a cream to R1's vaginal area and R1 did not say anything. V19 stated she believed R1 was alert and oriented in the morning of 6/11/23. On 6/15/23 at 11:24 AM, V19 denied being told at lunch time on 6/11/23 of a declining condition. V19 denied requesting a CNA do vitals for R1 and denied being aware of the CNA stating she would perform vitals on R1. V19 said, I would have gone down and done an evaluation, if I had known there was a change, but that was my first time taking care of her and I know she has a history of behaviors. I told [V18] maybe she (R1) was having behaviors that afternoon. I would say when I went in in the morning she was awake and alert. I would say that not being able to make her needs known, not opening eyes, and being out of it would be a change in condition. If I had been told that, I would have gone down and done an assessment. I would expect the CNA's to tell me if the resident was having a change in condition . A change in cognition is not uncommon for residents with a UTI . On 6/14/23 at 3:01 PM, V22 RN stated he sent the fax on 6/1/23 to R1's physician. V22 said, said R1 was incontinent; alert and oriented; and she could make her needs known. V22 stated, R1 reported to him the symptoms listed on the fax sheet. V22 said the symptoms he reported are consistent with the symptoms of a UTI. V22 stated he notified the physician of R1's refusal for catheterization and he was not aware if V4 responded. V22 stated an untreated UTI can lead to sepsis. V22 said if resident is unable to provide a urine sample for UA but the resident has symptoms of a UTI, he would encourage fluids and contact the resident's physician to see if we can get an antibiotic due to the signs and symptoms of a UTI. On 6/14/23 at 12:25 PM, V3 Assistant Director of Nursing stated if a resident refuses straight catheterization the nurse should attempt alternatives such as a bedside commode or bed pan if needed. V3 said the doctor should be notified if the staff are unable to obtain a UA. V3 said there should be follow up if nursing does not hear back from the doctor and the resident continues to have symptoms. V3 said she did not interact extensively with R1; however, [R1] could respond appropriately. On 6/15/23 at 12:48 PM, V4 Medical Director/Physician stated signs and symptoms of a urinary tract infections in females are discomfort with urination and urinary frequency. V4 said UTI's are typically diagnosed based on UA results. V4 said UTI's left untreated, can resolve on their own but the infection could get worse, it could spread. A person can become septic from a UTI. It's variable but it takes longer than a day to become septic from a UTI. V4 stated he was R1's physician; however, he had not yet met her in person for an examination. V4 said he did not recall the fax messages regarding R1. V4 stated he did not recall being notified of R1 refusing to be catheterized or the facility being unable to obtain a UA for R1. V4 said the symptoms described on the fax message sent on 6/1/23 of burning with urination, urinary urgency, and bloody discharge are symptoms consistent with a UTI. V4 said he does not recall the facility notifying him of foul smelling urine and pus like discharge, which V4 stated are symptoms of a UTI. V4 said, If the staff are not able to get a UA and the resident is having symptoms, if I don't respond to the fax, I would expect the staff to do some sort of a follow up with me. V4 stated, if he had been notified of urgency with urination, burning with urination, blood tinged urine, yellow discharge, and foul smelling urine, refusal of catheterization, and staff were not able to do a hat (a hat is a urine catch device placed in a toilet) then V4 would have said lets go ahead and treat it with an antibiotic. If I had been called and she was treated with an antibiotic, it's possible that she would not have become septic. V4 said that based on the quick diagnosis of a UTI at the hospital (within a few hours of arriving at the hospital) and based on the symptoms she had at the facility; R1 had the UTI while she was living at the facility. V4 said a change in cognition is not an uncommon symptom of a UTI. V4 stated, prompt care of a UTI can be important. It is better to treat it sooner rather than later. It's not the best case scenario to let it go a week or two. V4 stated he does not recall being notified of a change in cognition for R1and he would expect to be notified of such a change. V4 stated nurses may use their best judgement and send a resident out for evaluation without notifying him. R1's Physician Order Sheet showed no orders for antibiotics during her stay at the facility. R1's Progress notes from 6/1/23 through 6/11/23 (with the exception R1's note on 6/11/23 when she was sent out for evaluation) showed no communication with R1's physician regarding an inability to obtain a UA or notification of a change in cognition. On 6/14/23 Documentation of R1's UA results, if done, was requested and not provided The facility's Change in Condition Physician Notification Overview Guidelines policy (Reviewed 4/22) showed, Theses guidelines were developed to ensure that: All significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings and is to be documented in the medical record .medical care emergency problems are communicated to attending physician and family as soon as possible. The policy continued, The nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgement requires immediate medical intervention .Any calls to or from the physician will be documented in the nurse's notes indicating information conveyed and received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R1's electronic face sheet printed on 3/9/23 showed R1 has diagnoses including but not limited to chronic respiratory failure, chronic obstructive pulmonary disease, pneumonia, congestive heart failure, acute kidney failure, fluid overload, and hypertension. R1's facility assessment dated [DATE] showed R1 has no cognitive impairment. On 3/7/23 at 7:53AM, R1 stated, I go to the hospital quite often, usually for my congestive heart failure. They used to weigh me every day but for some reason they don't anymore. They hardly ever weigh me and the doctors always tell me I need to monitor my weight to see if I'm retaining fluid. R1's weight record showed for February and March 2023 showed R1 is weighed 3-4 times per month. R1's weight record showed on 2/24/23 R1's weight was 344.8lbs (pounds) and on 3/6/23 R1's weight was 349.8lbs (5 lb. weight gain in 1 month). R1's nursing progress notes dated 2/19/23 showed, Patient complaining of shortness breath and difficulty catching his breath. Patient oxygen 89% with 4 liters per nasal cannula, desaturating ranging from 84-86%. Not able to titrate levels above 90%. Patient stated that he would like to go to the hospital to be evaluated. Patient note with elevated Blood pressure 129/102 heart rate: 110. Call placed to (local ambulance) .Patient admitted with bilateral pneumonia per (local hospital). R1's nursing care plan dated 12/18/22 showed, The resident demonstrates a potential for fluid overload related to: noncompliance. Education provided on risks of fluid overload, patient states, I do not care about diet or fluid restriction, it makes me happy and I will die happy. Physician notified of non-compliance, assess for signs and symptoms of fluid overload & notify the physician if signs and symptoms of fluid overload are present: adventitious lung sounds, observe, assess & record signs of edema. R1's local hospital discharge records dated 2/24/23 showed, Weigh yourself daily before breakfast. Notify physician if 3lb weight gain in 24 hours or 5lb weight gain in 1 week. R1's physician's orders showed an order for daily weights was discontinued in November 2022 when resident was sent to the local hospital. R1's daily weight physician's order was not reinstated when he returned back to the facility in November 2022. On 3/9/23 at 9:05AM, V4 (Certified Nursing Assistant) stated, All residents are weighed per orders and the nurse gives us a list of who needs to be weighed. If the nurse notices a discrepancy then she will have us reweigh them. (R1) is weighed monthly as far as I know. We haven't been asked to weigh him more often. He would even go down and weigh himself if we asked him to. On 3/9/23 at 9:53AM, V2 (Director of Nursing) stated, Weights should be obtained per physician's orders. Best practice for a resident with congestive heart failure is to weigh them every day to keep an eye on their fluid status and be aware of any concerns with fluid overload. Based on observation, interview, and record review the facility failed to monitor a resident's weight who had congestive heart failure; failed to provide wound care in a manner to prevent cross contamination; and failed to provide ongoing assessments for a resident readmitted following a pulmonary embolism. This applies to 4 of 5 residents (R11, R29, R54, R1) reviewed for quality of care in the sample of 23 and 1 resident (R20) outside of the sample. This failure resulted in R11 being hospitalized for an exacerbation of congestive heart failure and chronic obstructive pulmonary disease. The findings include: 1. R11's Face Sheet showed an original admission date of 9/9/2019 with numerous diagnoses to include: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, and morbid obesity. R11's 12/21/22 Minimum Data Set (MDS) showed he was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. R11's MDS showed he required limited assistance of one person for transfers and dressing as well as extensive assistance of one person for toilet use and personal hygiene. On 3/06/23 at 7:42 PM, R11 was in his room, in his wheelchair, and self-propelling in his room. R11 was using supplemental oxygen via nasal cannula set to 5 liters per minute. R11 stated, I just got back from hospital today. I was there for five days. I have CHF and I was having trouble breathing for several weeks and I just couldn't take it anymore. They (hospital) took 14 liters [of fluid] off of me. I can breathe better now. They (facility) never weigh me. I've only been weighed a few times since I've been here .I don't think the staff recognized what the problem was .Everyone knew I was having breathing difficulties. I told everybody that. I even told the activity lady. The activity lady took my oxygen saturation. It's just that no one was pushing me to go to the hospital except myself. R11's hospital discharge summary from 3/6/23 showed during his hospital stay Continue bumex (diuretic) gtt (intravenous drip) and albumin (intravenous protein) for exacerbation of CHF. The summary showed he was down 7 liters of fluid. R11's electronic health record showed he was sent to the hospital on 3/1/23. R11's progress notes showed no entries on 3/1/23. R11's electronic health record showed no documented assessment on 3/1/23. R11's 3/6/23 Nursing Progress Notes from 2:25 PM showed he readmitted to the facility at 1:45 PM (5 day hospital admission). R11's Weights and Vitals Summary from 11/1/22 through 2/31/23 showed the following (only 4 weights): on 11/30/22 he weighed 232.4 pounds; on 12/1/22 he weighed 248 pounds; on 1/26/23 (nearly two months between weights) he weighed 249.4 pounds; on 2/1/23 he weighed 250 pounds (This was the final documented weight prior to R11's hospital admission.) R11's documented weight on 3/7/23 was 271 (21 more pounds than the previous weight) pounds. (This weight is following a hospital stay in which 7 liters of fluid, or 15.4 pounds was removed.) R11's 2/26/23 Dietary progress note for 10:57 PM showed his chart was reviewed and he triggered for significant weight gain of 17.6 pounds or 7.6 percent over 3 months (From his weight of 232.4 pounds on 11/30/22 to his weight of 250 pounds on 2/1/23) The note showed R11 had a diagnosis of CHF and he was on diuretic therapy, which may be attributing to his weight fluctuations. (The note did not indicate R11's provider was notified of the weight gain. This note was documented 25 days after he was weighed on 2/1/23. Note was authored by V28 Registered Dietitian.) On 3/08/23 at 11:19 AM, V28 stated she did not recall R11. V28 stated CHF resident are .at risk for fluid gain or fluid loss from week to week typically they are weighed weekly; depending on doctor orders. I would expect the doctor to be notified [of weight gain] because they might need an increase in their diuretics. I think it's possible that maybe he (R11) would not have needed to be admitted [to the hospital] if the MD was notified and the diuretic was increased. On 3/08/23 at 3:38 PM, V2 Director of Nursing stated, she could not find any assessment or documentation regarding why R11 was sent to the hospital. V2 stated she would expect a head-to-toe assessment if a resident is complaining of shortness of breath. V2 said, They (the hospital) ended up keeping him for 5 days which, means it was fairly significant. CHF patients can get fluid around their lungs and that can cause shortness of breath. Weighing should be done weekly for CHF to monitor for fluid increase. They should have seen the weight increase way before (2/26/23). The second they (resident) put on the weight it should have been identified. V2 said if weight gain is identified, They should call the doctor as soon as it notified and assess the resident. V2 said, if weekly weights were done and the doctor was notified of R11's weight gain, she would anticipate an increase in R11's diuretic dosing or a new diuretic medication. V2 said these interventions could have prevented R11 from experiencing shortness of breath and a subsequent 5 day hospital admission. The National Library of Medicine published study titled Information Needs of Skilled Nursing Facility (SNF) Staff to Support Heart Failure Disease Management (published 1/25/21) showed, monitoring body weight, administering medication, and sodium restricted diets Improved outcomes of patient with HF (heart failure) in skilled nursing facilities .Evidence shows that performing heart failure disease management (HF-DM) practices as described by clinical guidelines can decrease mortality rates, decrease hospital admission rates, and improve quality of life for HF patients by relieving symptoms. However, within the SNF, quality of HF care is highly variable and HF-DM practices are applied inconsistently .Clinical practice guidelines recommend monitoring for changes in body weight and changes in symptoms because these early warning signs can alert staff and physicians to worsening HF, prompt early intervention, and may help patients avoid hospitalizations . 2. R29's Face Sheet showed an original admission date of 4/12/2019 with diagnoses to include: chronic ulcer of right heel and midfoot; diabetic foot ulcer; and type 2 diabetes. On 3/07/23 at 1:45 PM R29's was supine in bed with an elastic bandage and wound vacuum to his right foot. On 3/7/23 at 1:45 PM, V15 wound care nurse removed R29's dressing to his right heel by cutting the elastic bandage as well as the underlying dressings and then removed his negative pressure wound therapy NPWT (commonly referred to as a wound vac) tubing. V15 set the scissors in R29's bed. V15 then cleaned the wound and applied the NPWT dressing; during this time V15 did not change her gloves until after R29's drape dressing was applied. V15 did not sanitize her scissors prior cutting the new NPWT drape and foam dressing components (same scissors used to cut the old dressing then set in R29's bed.) On 3/08/23 at 4:09 PM, V2 Director of Nursing stated V15's gloves should have been changed after R29's dressing was removed and before the wound was cleaned. V2 said this is done to prevent cross-contamination of the wound. V2 said V15's scissors should have been disinfected prior to cutting R29's clean NPWT drape and foam. V2 said her scissors could have been contaminated from cutting the old dressing and/or setting them down in the resident's bed. 3. R54's admission Record, printed by the facility on 3/8/23, showed diagnoses including cellulitis of left and right lower limbs, morbid obesity, dyspnea and arthropathies (diseases of the joints i.e. arthritis). R54's most recent facility assessment showed she is cognitively intact (BIMS score of 15) and is independent with activities of daily living. The assessment showed R54 does require supervision for dressing and personal hygiene. R54's Admission/readmission Screener dated 11/19/22 showed Skin Integrity: 1. Current ski integrity issues: Venous or arterial ulcers. The screening document also showed R54 had +1 pitting edema to her bilateral lower extremities. R54's 11/19/22 Discharge Summary, from a local hospital, lists self neglect as one of her discharge diagnoses. On 3/6/23 at 6:08 PM, R54 was sitting in her room, in her wheelchair. Both of R54's lower legs were covered in bandages. Both of R54's feet were swollen and her right foot was very red. R54 said she has infections in both legs. R54 said she changes the bandages on her legs herself. R54 opened the drawer to her night stand and it was filled with supplies to do the dressing changes. On 3/8/23 at 11:08 AM, R54 was sitting in her wheelchair in her room, doing needlepoint. R54 put the needlepoint down and got the supplies out of the bottom drawer of her night stand to do the dressing change. R54 cut the gauze that was wrapped around her right leg and removed the gauze. R54 did not perform hand hygiene or wear gloves at any point during the wound care. R54 had oil emulsion dressings around her right lower leg. R54 said she put them on that morning so she was not going to change them as she already had and they were to be changed daily. R54 put saline on gauze and patted the oil emulsion dressing with the gauze. Then R54 put a little more saline on another piece of gauze and wiped all over the top of her right foot, going over intact skin and then the 2 open areas on her right foot (one near the arch of her foot and the other at the top by her first and second digits). R54 said I know I should use gloves, but I can't feel my fingers with them on. R54 dropped the rolled gauze onto the floor and it rolled about 8 inches from her wheelchair. R54 used a reacher bar to scoot the gauze close enough back toward her to where she could pick it up. R54 placed the rolled gauze back on her table with the other wound supplies. R54 grabbed three abdominal pads from the bedside table and placed them on her abdominal area of her shirt, with the blue line facing out. R54 taped the three abdominal pads together and then wrapped them around her right leg, with the sides of the abdominal pads that had been in contact with her shirt directly over the oil emulsion dressings. R54 grabbed the rolled gauze that had recently been on the floor and wrapped the rolled gauze around the abdominal pads on her right lower leg. R54 grabbed scissors and cut a section of the rolled gauze to tie together in order to secure the gauze to her right leg. After wound care R54 put the supplies back in the bottom drawer. R54 did not perform hand hygiene after wound care. R54's Nursing Progress Note dated 3/1/23 at 3:08 PM, showed, Late Entry: (entered on 3/3/23) Note Text: I talked to this resident about doing her legs. She stated that she can do her own legs. I told her that I could do them. She said you don't do them right anyway. I asked if the way you do your leg is how you want them done. She said yes. I reached out to the Wound Doctor, she stated that the resident will be discharged from the Wound Center because she has refused or don't want to do any of the treatment they have offered for her. I told the doctor that she stated that she likes the way that she does her own legs. She told me to get in contact with the MD. I sent him a note and told him about what was going on with the resident and how she has started doing her own legs, because she refuses a lot. The Physician gave the order to let her do her own legs if she prefers. I will monitor the legs for signs or symptoms of infection or edema. Resident told about the order. R54's Order Summary Report, listing the active orders as of 3/9/23, showed an order on 3/3/23 Resident to do her own wound dressing because of continuous (refusals). Nurse will monitor the lower legs for signs and symptoms of infection or edema one time a day, every 6 days for wound care. the report showed an active order dated 2/9/23 for right and left leg and right heel: Apply a thin layer of betamethasone valerate 0.1% over the adaptic dressing (a dressing with a specially formulated petrolatum emulsion to help protect the wound while preventing the dressing from adhering to the wound) and apply to the entire open wound from heel up on the right lower leg. Cover with a 4 x 4 gauze, Qwik (an absorbent and wicking dressing) and ABD (abdominal) pad. Secure with (rolled gauze), paper tape and a 6 inch ace wrap three times a day for wound care. The Order Summary Report also showed an order for Ciprofloxacin HCl 500 mg (milligram) tablet twice daily for leg infection until 4/9/23. R54's Unit Nurse Skin Review dated 3/7/23 showed she has open ulcers and cellulitis. R54's Skin/Wound note dated 3/2/23 showed The resident has a venous ulcer on the right and left leg. Both of the lower legs are macerated (moisture associated skin damage). The right leg venous ulcer measures 12.5 x 44.5 x 0.1 cm (centimeters) with large serous (thin, watery fluid that is produced in response to local inflammation) drainage. This wound is a full-thickness wound. The left venous ulcer measures 12.0 x 15.8 x 0.1 cm. This venous ulcer is full thickness with moderate drainage . On 3/8/23 at 1:30 PM, an assessment of R54's abilities to perform wound care on her own was requested. On 3/9/23 at 10:23 AM, V2 (Director of Nursing) said she did not see an assessment in R54's medical record to determine her ability to perform self-wound care. This surveyor's observation of R54 performing wound care to her right leg was described to V2. At 10:30 AM, V2 stated, Based on the information you just provided, it is obvious that we should be doing her wound care and she should not be doing her own wound care. 5. R20's nursing progress notes for 3/4/23 at 5:20 PM document she had complaints of flank pain and shortness of breath. Her vital signs included a blood pressure of 144/91 and pulse oximetry level of 86% on room air. R20's daughter who was present at the time requested R20 be sent to the hospital for evaluation. The notes show R20 was sent out and admitted to the hospital for a pulmonary embolism (blood clot in the lung). R20's progress note of 3/8/23 at 1:51 PM shows she returned from the hospital via stretcher at 12:46 PM, she was alert and oriented x 2. No complaints of pain and her call light was in reach. The nursing note did not include any assessment or vital signs upon her return. The assessments were reviewed for 3/8/23 and show no assessment until 10:06 PM. That assessment showed vital signs taken on 3/4/23 at 10:00 AM, before R20 was sent out to the hospital. No current vital signs are documented in the computer charting program. On 3/9/23 at 11:58 AM, V29 LPN said R20 just came back from hospital and is on a 72 hour monitor status, so the nurses document her condition and pain level every shift. Vitals are done every shift and are documented in the computer under assessments and vital signs tabs. V29 said when a resident returns from hospital the nurse should do an assessment, get vial signs notify the family and physician of their return. She said when vital signs are posted in the record, they will transfer over to the vital signs tab. V29 said she had not obtained R20's vital signs yet for her shift. On 3/9/23 at 12:24 PM, V2 said when a resident returns to the facility, they are a re-admit and should follow the same procedures as a new resident. The nurse should do a physical assessment including a set of vital signs. V2 said the manager V15 (Registered Nurse) was on duty and should have either obtained a fresh set of vitals or had an aide get them for her. V2 checked R20's record and said the last set of vital signs she sees are from 3/4/23. V2 said there is no excuse for not having the assessment and vital signs completed. The facility's 11/2022 policy for admission of a resident shows the purpose of the policy is to facilitate smooth transition into a health care environment and to gather comprehensive information as a basis for planning individualized therapeutic care. Procedure: 9. Conduct head to toe nursing assessment of body systems, parts, and surfaces identifying functional status abilities, needs, or problems. Be sure to measure any areas of redness or skin breakdown on extremities or other skin surfaces. 18. complete admission record, charting, T.P.R (Temperature/Pulse/Respirations), Blood pressure, height and weight. 20. Record in detail on nurses' notes all other pertinent information such as: a. Findings from the assessment-required to meet the residents needs, which can in turn be conveyed to the physician so the admission orders cover all aspects of required treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement interventions to promote wound healing; failed to assess a pressure injuries upon readmission; and failed to implement treatment for a pressure injury upon readmission. The facility also failed to provide care in a manner to prevent pressure injury cross- contamination. This applies to 3 of 7 residents (R51, R23, R10) reviewed for pressure ulcers in the sample of 23. This failure resulted in R51's pressure ulcers not being assessed or treated upon readmission leading to a worsening of R51's pressure injury. The findings include: 1. R51's Face Sheet showed an original admission date of 7/15/22 with diagnoses to include: Right pubic fracture (onset 12/27/22); Non-Pressure chronic ulcer of right and left lower leg; heart failure. R51's 1/8/23 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. R51's MDS showed she required extensive assistance of two staff for bed mobility, transferring, dressing, and toileting. R51's Pressure Injury Report showed she had an unstageable pressure injury to her left heal measuring 1.1 centimeters (cm) by 1.3 cm by 0.1 cm. The report showed the right heel was also unstageable measuring 0.9 cm by 1.1 cm by 0 cm. The pressure injury report showed it was identified in this condition on 2/23/23 and the last assessment was 2/23/23. (Document was provided on 3/9/23 at 11:23 AM.) R51's Skin/Wound Note from 2/23/23 at 8:26 PM showed she has blisters to the left lower leg that burst open and Eschar (dead tissue) to both heels. The note showed the same measurements as the pressure injury report from 2/23/23. The note showed she applied a betadine (antiseptic) moistened 4 inch by 4 inch gauze pad, an absorbent pad (ABD), and a gauze wrap. The note showed, I put pillows under her feet to help relieve pressure. R51's Skin/Wound note from 2/16/23 showed no heel injuries. R51's 2/27/23 Progress note from 2:24 PM showed she was sent to the local emergency department for increased confusion and swelling to her legs. R51's 3/3/23 Social Service note from 2:02 PM showed she returned to the facility. On 3/7/23 at 2:20 PM, R51 had signage on her door indicating she was in contact and droplet isolation. R51 was supine in bed. R51 had gauze wrap to her lower leg extending to the middle of her foot. The gauze wrap was covered with an elastic support bandage. R51 had a blanket folded under her ankles; however, R51's heels were touching the bed. R51's March 2023 TAR (provided 3/9/23) showed her heel treatment was discontinued on 3/2/23. R51's TAR showed no heel treatment was documented as being provided. On 3/8/23 at 11:48 AM, R51 was supine in bed. Heels in full contact with the mattress; no blanket under her ankles. On 3/9/23 at 8:34 AM, R51was supine in bed and her heels were in full contact with the mattress. On 3/9/23 at 8:34 AM, R51 stated she has not been out of bed since she returned from the hospital. R51 said, I guess I'm lucky I have water. They don't care about me here. On 3/9/23 at 9:51 AM, V7 Licensed Practical Nurse (LPN) stated if there are not orders for wound care she wouldn't know that the treatment needed to be done. On 3/9/23 at 9:55 AM, R51's heels remained in full contact with her mattress. Her room was as it was at 8:34 AM; over bed table to the side, no breakfast tray in the room. On 3/9/32 at 9:55 AM, R51 stated, I never got my breakfast. I'm starving please just get me a cracker or something. On 3/9/23 at 10:10 AM, V1 Administrator stated there is a camera on R51's hallway. (Requested V1 review video showing staff provided R51 a breakfast tray; no video proof was provided.) 03/08/23 11:19 AM, V28 Registered Dietician said proper nutrition and protein is important for wound healing. On 3/9/23 at 10:49 AM, V7 and V14 Certified Nursing Assistant (CNA, providing assistance for V7) entered R51's room for wound care. V7 removed the bandage to R51's right lower leg and stated there is no wound to the right heel. The dressing removed from R51's left heel did not include a betadine moistened gauze or an absorbent pad (ABD.) V7 removed the wrap to R51's left lower leg and said there is a heel wound and she has no orders to treat this wound. R51 refused to have her legs wrapped again. R51 stated she wanted to leave them off for a while because they make her legs hot. V7 did not provided education or encouragement to R51 regarding the importance of wound care and protecting her wounds. V7 also did not offer alternative options to protect R51's wound. At 11:03 AM V7 and V14 completed their care and left the room. R51's left heel draining pressure injury was in full contact with the bed; her heels were not off-loaded. On 3/09/23 at 10:49 AM, R51's left heel was approximately 3 inches by 2 inches (7.6 cm by 5 cm; wound is considerably larger compared to 2/23/23 assessment.) On 3/09/23 at 11:03 AM, R51 stated, If they had a pillow, I would let them get my heels off the bed. That would probably feel good. I think they are supposed to have my heels not touching the bed anyways. On 3/09/23 at 11:20 AM, V2 Director of Nursing stated, (while reviewing R51's electronic record) she could not find any treatment orders for R51's left heel. V2 stated, It (R51's left heel pressure injury) was first identified to left heel on 2/23/23 per the wound report. It was found as an unstageable pressure wound. I would expect her wound to be found prior to it having eschar, which is dead tissue. I don't see any other assessment other than 2/23/23. V2 said R51's wound should have been assessed upon her return from the hospital on 3/3/23. (R51's wound had not been assessed by the facility as of 3/9/23 at 11:20 am; 6 days later.) V2 said R51's heels should be off-loaded to promote wound healing. V2 said an indicator of a wound declining is increasing in size, smell, or pain. V2 said wound orders are important to ensure the best wound care to promote healing is put in place; ensures the physician is aware of the resident's current status; and it ensures the wound treatment is being done. V2 said the importance of wound assessments is to track the wound to determine if the wound is declining, which may warrant a change in wound care. V2 said the only location R51's wound treatment would be documented is in the wound report and/or her treatment administration record. R51's Care Plan showed, Skin will be checked during routine care on a daily basis and during the weekly bath or shower schedule per resident preference. R51's care plan showed no interventions to off-load her heels. R51's February 2023 Treatment Administration Record (TAR) showed both heels should be cleaned and dried; betadine moistened gauze applied; and then covered with gauze and an ABD pad. The TAR showed this treatment was not initiated until 2/26/23 (3 days after wound was identified.) R51's Wound Policy (Revised 2/2023) showed finding from the weekly skin assessment should be completed by the wound nurse or designee and should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues . The policy showed, Nursing staff should keep the attending physician aware of the progress of all ulcers, especially those in higher risk residents, those that do not heal as anticipated, and those that develop complications . 2. R23's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include acute on chronic congestive heart failure, chronic atrial fibrillation, difficulty in walking, unsteadiness on feet, essential hypertension, gall bladder disease, Type 2 Diabetes, and major depressive disorder. R23's facility assessment dated [DATE] showed he has severe cognitive impairment and requires extensive assistance from staff for all cares. R23's nursing note dated 11/30/22 showed, I was called to resident room. CNA was cleaning resident's toes and there is an area between great and 2nd toe. It appears to be a stage 2. Right foot. It was cleansed and protocol initiated. Wound nurse was notified. R23's Skin/Wound note dated 11/30/22 entered at 6:36 PM showed, . Resident has an opening on the top of the toe. The third toe is rubbing the skin off. Wound measures 0.9 x 1.6 x 0.1 cm . R23's November 2022 TAR (Treatment Administration Record) showed no orders for wound care to R23's 2nd toe. R23's December 2022 TAR showed an order for treatment to R23's 2nd toe on his right foot was not started until 12/6/22 (6 days after identification). On 3/8/23 at 2:33 PM, V15 (Wound Care Nurse) entered R23's room to provide wound care to the pressure sore on R23's right foot. V15 entered the room and went directly to R23's bed. V15 did not perform hand hygiene prior to starting R23's wound care. V15 applied gloves, sprayed the wound with wound cleanser, cleaned the wound with gauze, removed her gloves (did not perform hand hygiene), put on a new pair of gloves and put the new dressing on. V15 then removed her gloves, picked up the wound supplies, exited R23's room and went to the clean utility room where she washed her hands. V15's heels were not floated prior to V15 leaving the room. On 3/09/23 at 11:57 AM, V2 DON (Director of Nursing) said hands should be washed after entering the room and before touching the resident. V2 said gloves should be put on and changed after the wound is cleaned and before putting the new dressing on. V2 said gloves should be changed during the wound care but no hand hygiene is necessary due to time restrictions while performing dressing changes. V2 said V15 should have washed her hands before leaving R23's room. The facility's policy and procedure revised 11/8/22 showed, Hand Hygiene; Purpose: Provide guidelines on proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infection . Procedure: . 3. The use of gloves does not replace hand hygiene. 4. Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE) . Staff will perform hand hygiene by washing hands for at least twenty seconds with antimicrobial or non-antimicrobial soap and water under the following conditions: . c. Before applying gloves and after removing gloves or other PPE; d. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; e. After handling items potentially contaminated with blood, body fluids, or secretions; .g. After providing direct resident care . Surveyor: Gross, [NAME] 3. R10's admission Record, printed by the facility on 3/8/23, showed diagnoses including encephalopathy (a term for any brain disease that alters brain function or structure), other specified disorders of the brain, convulsions, bipolar disorder, autistic disorder, disorders of psychological development and altered mental status. R10's ADL (activities of daily living) care plan, with a revision date of 3/10/22. showed she had a self-care deficit and required total assistance of staff in all aspects of hygiene and dressing. R10's facility assessment dated [DATE] showed she had severe cognitive impairment and was dependent on staff for personal hygiene. The assessment showed R10 was always incontinent of bowel and bladder. R10's incontinence care plan, with a revision date of 1/4/21, showed she had incontinence of bowel and/or bladder. The care plan showed Administer appropriate cleansing and peri-care after each incontinent episode. Observe for signs of skin irritation and/or breakdown . R10's skin integrity care plan, with a revision date of 10/12/21, showed she is at increased risk for alteration in skin integrity and skin will be checked during routine care on a daily basis . R10's Order Summary Report, showing active orders as of 3/8/23, showed Cleanse coccyx with normal saline, pat dry. Apply foam dressing twice weekly. R10's 2/20/23 Skin/Wound note showed Resident has an open stage II to the left inner buttock cheek. The wound has a red outer edge. Full thickness wound with no drainage. Area measures 0.4 x 0.8 x 0.1 cm (centimeters) . 03/06/23 at 7:43 PM V17 and V18 (Certified Nursing Assistants-CNAs) were providing incontinence care during the bedtime care for R10. V17 cleaned R10's front, periarea, then rinsed and dried. V17 and V18 rolled R10 onto her right side. R10 had a couple small pieces of stool in her brief. V17 used the same wash cloths that she used to clean R10's periarea to wipe and rinse both of R10's buttock cheeks, then the rectal area, then wiped over the open wound on R10's left inner buttocks. V15 (Wound Nurse) came into R10's room and placed a dry dressing over the open area on R10's left inner buttocks. V15 did not clean the wound before placing the dressing on. On 3/09/23 at 9:03 AM, V29 (Licensed Practical Nurse-LPN) said it is not okay to clean a resident during pericare and then wipe over the open wound bed, it is cross-contamination. V29 said the staff should use a clean cloth to clean the wound bed. On 3/9/23 at 10:12 AM, V2 (Director of Nursing-DON) said she would expect the CNAs to use a clean wash cloth for each area during incontinence care. At 10:20 AM, V2 said staff should not clean stool and then go over any wound bed with the same cloth. V2 said staff should not use the same wash cloth to clean the front and back areas of the resident during incontinence care and then go over a wound bed because it would introduce bacteria into the wound bed. The facility's Wound Policy, with a revision date of 2/2023, showed Purpose . To promote healing of existing pressure and non-pressure ulcers. The policy showed 5. The goals of wound treatment are to; a. Keep the ulcer bed moist and the surrounding skin dry. b. Protect the ulcer from contamination, and c. Promote healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident on an enteral feeding did not experience severe weight loss, failed to provide enteral feeding per facility policy and procedure, and failed to follow the physician's order for enteral feeding for 1 of 2 residents (R9) reviewed for enteral feedings. This failure resulted in R9 experiencing a severe weight loss of 28 lbs in three months which is a 13% weight loss. The findings include: R9's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include cellulitis of bilateral lower extremities, major depressive disorder, and pressure ulcer of right buttock stage 3. R9's facility assessment dated [DATE] showed he has no cognitive impairment and is totally dependent on staff for all cares. R9's care plan initiated 1/10/23 showed, The resident is receiving a tube feeding and it has been determined to be medically necessary and the resident is at risk for complications: . inadequate calorie or protein intake, altered hydration . Goal: The resident will tolerate the tube feeding without complications thru the next review . Interventions: . The feeding tube will be utilized in compliance with current clinical standards of practice and services provided to prevent complications to the extent possible for the resident . Report the following to the MD (physician) for further medical evaluation: . changes in medical condition . weight loss . On 3/06/23 at 6:09 PM, R9 said he has lost a lot of weight since being at the facility. R9 said his pants are falling off of him. R9's record showed the first time the Registered Dietitian assessed R9 was on 1/21/23. This assessment showed, . Chart reviewed for new admission, skin review, and tube feeding follow up- noted that resident does not have orders for free water flush to meet hydration needs. RD (Registered Dietitian) to provide recommendations to clarify orders and increase protein to aid in wound healing. Tolerating TF (tube feeding), however, some noted refusals due to feeling full. Will encourage staff to notify RD if resident is not tolerating . PLAN: Continue to monitor with RD available as needed. Recommendations: 1) update TF orders to read: Jevity 1.2 bolus feed of 480 mls four times per day to Total Volume 1920 ml/24 hours; 2) Provide Free Water Flush: 200 ml four times per day to total volume 800 ml/24 hours; 3) Provide via PEG: Prostat 30 mls BID to aid in wound healing . R9's Dietary Progress note dated 2/10/23 showed, . Resident triggered for significant weight loss x 1 month [-11%, -23.6 pounds] - per nursing notes, resident has been reported to skip bedtime bolus feed resulting in decreased caloric intakes. Staff encourage resident to take bolus, however he will refuse Chart reviewed for skin review and tube feeding follow up and significant weight loss review . Plan: Continue to monitor with RD available as needed . R9's January 2023 MAR (Medication Administration Record) showed R9 refused 9 of 24 of his enteral feedings scheduled to be given at 9:00 PM. R9's February 2023 MAR showed R9 refused 20 of 28 of his feedings scheduled for 9:00 PM. R9's March 2023 MAR showed R9 refused 4 of 7 of his feedings scheduled at 9:00 PM. R9's weight record was reviewed and showed on 1/6/23 he weighed 213 pounds, on 2/6/23 he weighed 190 pounds, and on 3/8/23 he weighed 185 pounds. (This is a 13% weight loss in three months.) R9's Physician Order Sheet showed an order started 1/6/23, Enteral Feed Order, four times a day 16 ounce bolus feeding plus 21 grams protein and probiotic. The same Physician Order Sheet showed, Jevity 1.2 bolus feed of 480 mls four times a day to Total Volume 1920/ml over 24 hours. R9's physician order sheet did not include the addition of the free water flush recommended by the Registered Dietitian to meet R9's hydration needs. The same Physician Order Sheet showed an order started 1/29/23 for ProStat (protein supplement) twice daily. On 3/7/23 at 8:36 AM, V15 WCN (Wound Care Nurse) prepared R9's medications and placed them in a small drinking cup and poured water over them. V15 did not include Pro-Stat (protein supplement) with R9's medications. V15 mixed them with a spoon and entered R9's room. V15 did not wash her hands after she entered R9's room, filled a graduated cylinder with water from the bathroom and went to R9's bedside. V15 went into R9's closet and brought out a enteral feeding syringe. No hand hygiene was performed. V15 asked R9 if he wanted some protein today to which he answered yes. V15 took a scoop of protein powder from the large container of protein powder at bedside and placed a full scoop into the same cup with R9's medications and water. V15 stirred the mixture for several minutes to try and get the protein powder dissolved. The cup was full all to the top edge. V15 filled the enteral feeding syringe from the cup, opened the valve on R9's enteral tube and pushed the contents into his tube without checking placement. V15 repeated this for 15 syringe's full of medications, water, and his carton of tube feeding formula. V15 was adding water and formula to the cup to try and get all the medications and protein from the cup. No hand hygiene was performed before leaving R9's room. R9's complete medical record showed no evidence of notification to R9's physician regarding significant weight loss. On 3/09/23 at 11:57 AM, V2 DON (Director of Nursing) said in order for R9 to receive protein powder he should have an order for protein powder. V2 said ProStat is a protein supplement and since he has an order for the ProStat he should have received the ProStat. V2 said the facility has been trying with his comorbidities but he has declining rapidly. V2 said the facility has received recommendations for a continuous feeding but the family refuses. V2 said she was not aware of R9's continuous refusals for his nightly enteral feeding. V2 said she has told the nursing staff to do R9's feeding first thing in the morning because he is very hungry in the morning. V2 said R9's physician and nurse practitioner have been coming in every week for the previous month. V2 said the Nurse Practitioner and the Physician both document in the electronic record when they see a resident. V2 was unable to provide documentation to show R9 was seen by the Nurse Practitioner or the Physician since his admission to the facility. V2 said R9 goes to many physicians and all have recommended the same continuous feeding. The only documentation provided to show R9's physician visits was emergency room visit documentation. V2 said V15 (Wound Care Nurse) should have washed her hands upon entered R9's room and upon exiting after providing care. V2 said V15 should have checked placement prior to pushing the medications and tube feeding formula to ensure proper placement of the tube. V2 said R9's orders should reflect the free water flush to avoid dehydration. On 3/9/23 at 2:06 PM, V28 (Registered Dietitian) said residents who have enteral feeds are assessed monthly. V28 said they were aware of R9 refusing some of his nightly feedings but that they were not aware that he was refusing almost all of his nightly feedings. V28 said if they knew he was refusing these feedings so frequently they would have considered adjusting the other three scheduled feedings to increase his caloric intakes. The facility's policy reviewed 4/2022 showed, Tube Feeding; Purpose: To define infection control measures for the resident receiving tube feedings. Standards: 2. Wash hands before and after the procedure . 10. After each tube placement check, before and after medications and feedings, the tube is flushed with clear water (patency check) to completely clear the tube to remove all residues . The facility's policy reviewed 11/22 showed, Change in Resident's Condition . General: It is the policy of the facility, except in a medical emergency to alert the resident, resident's physician/Nurse Practitioner and resident's responsible part of a change in condition Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: . b. There is a significant change in the resident's physical, mental, or emotional status. c. There is a pattern of refusing treatment or medication. The facility's policy reviewed 11/22 showed, Weighing Residents; Purpose: To monitor weight gain or loss 1. Ease resident is weighed on admission and monthly thereafter, or in accordance with physician orders or plan of care. 5. A licensed nurse evaluates weight changes and determines if there is a 3 pound or greater weight loss/gain in one week and notified physician of unanticipated or undesired weight gain or loss. 7. Monthly weights shall be measured and recorded according to schedule. Undesired or unanticipated weight gains/loss of 5% in 30 days, 7.5% in three months, 10% in six months shall be reported to the physician, Dietary Manager and or Registered Dietitian .