**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview, the facility failed to ensure a resident with a history of poly substance overuse smoked safety when under the influence for 1 of 1 (Resident #1) residents reviewed for smoking safety. The facility reported a census of 70 residents. Findings include: Review of the Minimum Data Set (MDS) assessment tool dated 4/10/25 revealed Resident #1 admitted to the facility on [DATE]. A score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicated intact cognition. The MDS list of diagnoses included anxiety, asthma and respiratory failure. Review of the document Smoking Program assessed the following areas to determine if a resident is an unsafe smoker of cigarettes. Per the instructions the assessor to evaluate or observe the resident in the following areas. Any check will make the resident unsafe smoker using a cigarette: a. Unable to comprehend facility-smoking policy? b. Smokes in unauthorized areas? c. Careless with smoking materials? d. Burn holes observed on clothing or wheelchair? e. Inappropriately extinguishes cigarettes or matches? f. Provides smoking materials to others? g. Unaware of surroundings? h. Poor judgement or decision-making skills? i. Inability to control movements or maintain control of cigarette? j. Inability to follow instructions? k. Unable to safety light cigarette? l. Falls asleep while smoking? m. Other physician limitations or behaviors that interfere with safe smoking? n. None of the above. Review of the Smoking Program assessments completed on 4/16/25 and 6/3/25 revealed no areas checked. The section Program Independent Smoking Program listed a Focus area: Tobacco use, with the Goal: Resident will adhere to smoking policy. Intervention: Independent Smoker: May smoke without assistance. The 6/3/25 assessment added the Intervention: Independent Smoker: Must smoke only in designated areas/designated times (unless able to independently get to and from the designated areas). The Smoking Program assessments completed on 4/16/25 and 6/3/25 did not address if Resident #1 unsafe smoker using cigarettes when under the influence. Review of the Care Plan, dated 4/2/25, revealed a Focus area to address Tobacco Use. Interventions included, in part: a. Independent Smoker: May smoke without assistance. Date Initiated: 4/17/25. b. Independent Smoker: Must smoke only in designated areas/designated times (unless able to independently get to and from the designated areas). Date Initiated: 6/3/25. Review of the Care Plan, dated 6/3/25, revealed a Focus area to address History of poly substance overuse that may impact psychosocial functioning. Interventions did not address general safety or safety when smoking. Review of a facility self-report, dated 5/31/25 at 8:21 AM revealed, in part: The morning of 5/31/25 at approximately 7 am DON [name redacted] was called to this facility as the police department was contacted due to a noise complaint related to residents on the smoking patio. When DON arrived at facility approximately 7:15 resident [name redacted, Resident #1] was on the smoking patio being very loud and belligerent. During an interview on 6/12/25 at 2:43 p.m., Staff A, Registered Nurse (RN) stated on the evening of 5/30/25 Resident #1 left with his family and returned between 10:15 p.m. - 10:30 p.m. Staff A stated when he first returned he was pleasant and did not act that intoxicated. She stated as the night progressed he became increasingly belligerent, extremely loud, and uncooperative. Staff A stated he was drunk, and demanded to smoke. She explained he was out on the smoking patio for several hours during the night shift. She stated she had gone out to check on him, at least 3 times, encouraged him to come inside so she could check his oxygen levels. She stated he allowed her to check one time between 3:30 a.m. and 4:00 a.m. Staff A stated Resident #1 was loud and yelling when out on the patio, despite her asking him to keep it down and lower his voice. She stated the resident was unable to be reasoned with. While on the patio Resident #1 had a can of beer, which he surrendered when she requested. Staff A stated there was less than an ounce of beer left in the can. She stated around 5 a.m., a neighbor called the facility and reported a resident was yelling loudly outside and asked if there was anything the facility could do to make the resident stop yelling. Staff A stated she notified the Director of Nursing (DON) at that time, and the police did come to the facility. During an interview on 6/19/25 at 3:10 p.m., Staff D, Licensed Practical Nurse (LPN), stated she did not think the resident was safe to smoke independently when he was intoxicated. Staff D stated but try telling him that, he does whatever he wants. Staff D state had not observed Resident #1 dropping a cigarette when outside or burning a hole in clothing, but had heard this had happened. During an observation on 6/19/25 at 3:18 p.m., Resident #1 in his room with two staff members. Resident #1 had returned to the facility after a family outing. Resident #1 yelled loudly, speech appeared slurred, and demanded to go outside to smoke. The staff were unable to calm the resident or get him to lower his voice. During an interview on 6/19/25 at 3:20 p.m., the Administrator stated the Smoking Program assessments reflected one point in time. She stated a resident's condition could vary, someone who could smoke independently today may not be able to smoke independently tomorrow if their condition changed. When asked if she thought Resident #1 should smoke independently in his current condition per the observation at 3:18 p.m., the Administrator stated she would have to assess further and went to the resident's room During an interview on 6/19/25 at 4:51 p.m., Staff A, RN stated Resident #1 was under the influence he was not safe to smoke. She stated when he is intoxicated there is no reasoning with him. Staff A stated there were times when he was intoxicated that he would let the cigarette burn down to his fingers, she wasn't aware of any injury from that. She heard that he burned a hole in one of his jackets when smoking outside and he probably needed to wear a smoking apron (a fire-retardant garment worn to protect clothing from burning ashes/cigarettes). During another interview on 6/23/25 at 8:07 a.m., the Administrator stated that she put a new plan in place for Resident #1. She explained he would be supervised when smoking at all times, and there was a staff member assigned on each shift to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility policy review and staff interviews, the facility failed to ensure urinary catheter bags and tubing placed off the floor to minimize the risk of urinary tract infections for 2 of 4 residents reviewed (Resident #37 and Resident #121) with indwelling catheters. The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15 for Resident #37, which indicated intact cognition. The MDS listed diagnoses included: neurogenic bladder (lose of control of bladder function due to nerve damage) and urinary tract infection. The MDS assessed Resident #37 dependent on staff for all activities of daily living with the exception of eating. The MDS indicated the resident had an indwelling urinary catheter. Review of the Care Plan, Date Initiated: 5/8/24 revealed a Focus area to address Resident requires the use of a indwelling catheter related to neurogenic bladder. Interventions included, in part: Ensure dignity bag remains in place, monitor tubing for kinks and leaks and ensure tubing remains off the floor. Date Initiated: 5/8/24. Review of a Discharge Summary from the Internal Medical provider, dated 12/23/24 Reason for admission: Septic Shock Secondary to Urinary Tract Infection. During observations: a. On 3/16/25 at 11:21 AM, Resident #37 laid in bed with the dignity cover flap and tubing of the urinary catheter bag resting on the floor. b. On 3/16/25 at 2:06 PM, resident sitting up in bed, watching television with catheter bag and tubing resting on the floor. Staff D, Certified Nursing Assistant (CNA) in room and then exited without repositioning the bag and tubing. sat up in bed watching television. Foley bag and tubing remained on floor, Staff D, CNA left the room without repositioning bag and tubing. c. On 3/17/25 at 7:30 AM, the resident lying in bed with the collection bag, with a dignity cover, resting on the floor. d. On 3/17/25 at 7:37 AM, the Director of Nursing (DON) left the room after bringing the resident water. The collection bag remained on the floor. e. On 3/17/25 at 8:18 AM, Staff B, CNA entered the room with breakfast tray. Staff B exited the room without repositioning the collection bag off the floor. 2. Review of the admission Record for Resident #121 revealed an admission date of 3/7/25. Review of the Medical Conditions listed on the March 2025 Medication Administration Record included, in part: type 2 diabetes mellitus, benign prostatic hyperplasia (BPH, meaning an enlarged prostate), and obstructive and reflux uropathy (blockage of urinary tract that hinders urine flow). Review of the Care Plan, Date Initiated: 3/7/25 revealed a Focus area to address Resident requires use of a (indwelling, catheter related to BPH w/Obstructive Uropathy. Intervention included, in part: Endure dignity bag remains in place, monitor tubing for kinks and leaks and ensure tubing remains off the floor. Date Initiated: 3/7/25. During observations: a. On 3/16/25 at 11:35 AM, while Resident #121 in bed, catheter bag and tubing rested on the floor. b. On 3/17/25 at 7:30 AM, while resident slept in be, the catheter bag and tubing rested on floor. c. On 3/18/25 at 6:15 AM, while resident slept in bed, catheter bag and tubing rested on the floor. During an interview on 3/18/25 at 10:10 AM, Staff D, CNA stated if she saw a resident's catheter bag and/or tubing on the floor, she would report it to the nurse so the nurse could change the bag and tubing. During an interview on 3/18/25 at 2:08 PM, Staff A, Registered Nurse stated if a staff member saw a resident's catheter bag or tubing on the floor, she would expect them to pick it up off the floor, perform catheter care and if needed change the bag out. Staff A stated CNAs can change the bag. During an interview on 3/18/25 at 3:46 PM, the Director of Nursing reported if a nurse or CNA found a resident's catheter bag or tubing on the floor, he would expect them to pick it up off the floor and inform the nurse. A review of the facility policy titled: Catheter Care: Indwelling Catheter, reviewed on December 2023 directed staff to: a. Check that tubing is not kinked, looped, clamped, or positioned above the level of the bladder b. Validate drainage bag is off the floor and in a dignity bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #37 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 14 and had the following diagnoses: neurogenic bladder (lose of bladder control due to nerve damage), septicemia (blood infection), and urinary tract infection. The MDS also identified Resident #121 had an indwelling urinary catheter. Review of Resident #37 Order Summary Report, dated 3/16/25 revealed an order for Gentamacin Sulfate External Ointment 0.1% (Gentamicin Sulfate (Topical)). Apply to left ischium topically every day and evening shift for Ischial Wound Cleanse with NS (normal saline), paint peri-wound betadine, apply gentamicin to wound bed, cover with alginate AG, cover with gauze dressing, secure with tape. Start Date 1/9/25. During an observation of wound care on 3/17/25 at 1:56 PM, Staff A, Registered Nurse (RN ) cleansed the wound to the left ischium, and dabbed with gauze. Without completing hand hygiene or changing gloves, Staff A then used a betadine swab to paint the wound. Staff A then open a package of cotton applicators, and without completing hand hygiene or changing gloves applied gentamicin ointment to the applicator and applied to wound. During an interview on 3/18/25 at Staff A, RN stated when performing wound care she would complete hand hygiene and change gloves in between cleaning the wound bed and applying treatments. Staff A stated she did not do this during the wound care observation on 3/17/25 with Resident #37. During an interview on 3/18/25 at 3:46 PM, the Director of Nursing (DON) stated completing wound care he would expect nursing staff to complete hand hygiene and change gloves when going from cleansing wound and then applying the prescribed treatment, or when going between two different wounds. A review of the facility policy titled: Dressing Change, reviewed November 2023, included a Procedure, which directed, to complete hand hygiene and apply (or change) gloves after: setting up area with supplies and assisting resident to a comfortable position, removing soiled dressing, preparing dressing if needs to be cut to use, after cleaning wound, and after completing the treatment. 3. Review of the admission Record for Resident #121 revealed an admission date of 3/7/25. Review of the Medical Conditions listed on the March 2025 Medication Administration Record included, in part: type 2 diabetes mellitus, benign prostatic hyperplasia (BPH, meaning an enlarged prostate), and obstructive and reflux uropathy (blockage of urinary tract that hinders urine flow). Review of the Care Plan, Date Initiated: 3/7/25 revealed a Focus area to address Resident requires use of a (indwelling, catheter related to BPH w/Obstructive Uropathy. Intervention included, in part: Endure dignity bag remains in place, monitor tubing for kinks and leaks and ensure tubing remains off the floor. Date Initiated: 3/7/25. During an observation on 3/16/25 at 7:30 AM, a lack of a sign on door or within the room to indicate the need for Enhanced Barrier Precautions noted. Gloves noted to be available in the room. Lack of protective gowns outside or inside room noted. During an observation on 3/17/25 at 7:43 AM Staff B, Certified Nursing Assistant (CNA) and Staff C, CNA entered Resident #121 with mechanical lift to transfer the resident from his bed to his wheelchair. Neither staff donned a gown prior transferring the resident. During an observation on 3/16/25 at 2:07 PM, Staff D, CNA entered Resident #121 room. Staff D completed hand hygiene and donned gloves prior to emptying Resident #121 urinary catheter bag. Staff D did not don a gown prior to emptying the bag. During an interview on 3/18/25 at 10:10 AM, Staff D, CNA stated that Enhanced Barrier Precautions (EBP) should be in place for anyone who has catheters. She stated EBP required the use of gown and gloves when providing care. Staff D stated no on reported to her that Resident #121 would require gowns and gloves for cares. During an interview on 3/18/25 at 3:46 PM, the Director of Nursing stated EBP should be used for any resident that has a direct line for infection, such as larger wounds, intravenous access, and catheters. He stated should be aware of the need for EBP if they saw a blue caddy on the door with PPE and a sign. A review of the facility policy titled: Enhanced Barrier Precautions, last reviewed March 2024 included a Purpose statement, which declared: To minimize risk of transmission of novel or targeted Multi-Drug Resistant Organisms (MDROs) during high contact resident care activities for residents requiring enhanced barrier precautions (EBP). Procedure directed: 1. EBP will be used in conjunction with standard precautions for residents with any of the following (if/when Contact Precaution requirements are not in place): a. Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply; b. Wounds and/or indwelling medical devices (even if the resident is not known to be infected or colonized with a targeted MDRO). NOTE: Wounds generally include chronic wounds including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. This would not include shorter-lasting wounds, such as skin breaks/tears covered with an adhesive bandage or similar dressing. NOTE: Indwelling medical devices include: central lines/PICC, urinary catheters, feeding tubes, tracheostomy/ventilator (a peripheral intravenous line would not be considered indwelling device for purpose of EBP). Based on observation, record review and staff interviews, the facility failed to utilize proper infection control methods during the change of a resident's colostomy bag/wafer (Resident #2) for one of one residents reviewed with a colostomy and during wound care for one of three residents reviewed for wound care (Resident #37) and failed to initiate and follow precautions for one of four residents reviewed for Enhanced Barrier Precautions (Resident #121). The facility reported a census of 66 residents. 1. The Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed a diagnosis of paraplegia identified a colostomy. The Brief Interview for Mental Status (BIMS) score was 15 that suggested an intact cognition. The Care Plan for Resident #2 directed staff to utilize Enhanced Barrier Precautions (EBP) by wearing a gown and gloves while performing high-contact care activities such as colostomy care due to colonized multidrug-resistant organism (MDRO). A Physician Order, dated 1/19/25 for Resident #2 revealed a colostomy bag and to change the pouch twice a week and as needed (PRN). The General Progress Note, dated 3/14/25 for Resident #2 revealed the resident was noted to have a right abdomen urostomy patient with clear colored urine and noted to have on the left side, a colostomy with brown, semi soft stool. During an interview on 3/17/25 at 1:32 PM, Resident #2 stated the colostomy bag had come off and the nurse was to change it. During an observation on 3/17/25 at 3:02 PM, Staff K Licensed Practical Nurse (LPN) entered Resident #2's room and put on personal protective equipment (PPE), a gown and gloves, and proceeded to gather supplies out of the resident's bed side stand to change his colostomy wafer and bag. Staff K removed the towel covering the colostomy to Resident #2's left abdomen. The previous colostomy wafer was partially pulled away for the resident's stoma (an artificial surgical opening into the body for the purpose of waste removal or drainage) and a small amount of soft bowel movement was coming out. Staff K removed the old wafer and bag and placed in the trash, then pulled wipes from a bag to wipe away the bowel movement. Staff K removed the gloves and put new gloves on then proceeded to place a new wafer on. Staff K then proceeded to replace the urostomy bag (surgical opening to the divert urine from the kidneys to an external bag). Staff K failed to hand hygiene before putting on the PPE, after changing gloves during the procedure, or after securing the colostomy bag and adherence of the ostomy bag. A document titled Treatment Administration Record dated March 2025 for Resident #2 revealed the colostomy bag was marked as changed on 3/17/25. During an interview on 3/17/25 at 4:02 PM, The Director of Nursing (DON) stated his expectation was that the nurse would perform hand hygiene before, during and after procedures such as colostomy cares.

Based on observations, record review and staff interviews, the facility failed to label and date opened food items in the refrigerator, freezer and dry storage areas in an effort to prevent foodborne illness. The facility reported a census of 66 residents. Findings Include: During the initial kitchen tour with Staff G, [NAME] on 3/16/25 at 10:10 AM, observations included: a. In the cooler, apple sauce, cheese, cabbage, and ranch dressing observed open. No label present or open date indicated. b. In the ice freezer, breadsticks, biscuits and slider rolls observed open. No label present or open date indicated. c. In the 3-door freezer, waffle fries and breaded fish fillets observed open. No label present or open date indicated. d. In the 2-door freezer, two packages of vegetables observed open. No label present or open date indicated. e. In the dry storage room, a box of fruit flavored cereal and bag of toasted flake cereal observed open. No label or open date indicated. When queried about storage of opened food items, Staff G stated food items that had been opened should have been labeled and dated. During an interview on o 3/19/25, the Dietary Manager stated any food item opened should be labeled and dated. He stated this it is his expectation that kitchen staff indicate the name of a food item and date opened is clearly written on the packaging. Review of the facility policy titled Labeling and Dating, revised on 12/2023 included a Purpose statement which declared To ensure foods stored will be properly labeled according to guidelines. Procedures included, in part: Date Marking for dry storage food items: 2. Once a case is opened, the individual food items from the case are dated with the date the items was received into the facility and placed in/on the proper storage unit . Date marking for refrigerated food items: 3. Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date. Date marking for freezer storage food items: 3. Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date .

Based on the Center of Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (for October 1st to December 31, 2024) review, facility staffing assignments review and staff interview, the facility failed to submit accurate agency staffing data for the PBJ Staffing Data Report. The facility reported a census of 66 residents. Findings include: The PBJ reported for the first fiscal year (FY) 2025, triggered for Excessively Low Weekend Staffing. The Daily Nursing Staffing Schedule for 9/2024, showed a consistent number of staff from the week and the weekends. The Daily Nursing Staffing Schedule for 10/2024, showed a consistent number of staff from the week and the weekends. The Daily Nursing Staffing Schedule for 12/2024, showed a consistent number of staff from the week and the weekends. Review of the Audit for PBJ 10/2024 through 12/31/2024, revealed 20 agency staff not submitted to the BPJ. On 3/19/25 at 3:43 PM, the Administrator reported the data submission for the PBJ and staffing reports were completed by the corporate office. On 03/20/2025 at 8:45 AM, the Administrator revealed she identified twenty nursing staff from agencies that were not included in the PBJ data. On 3/20/25 at 11:52 AM, the Administrator reported the facility failed to use a policy or procedure for the PBJ process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, the facility failed to follow physician orders for wound care and positioning for 1 of 3 resident records reviewed for wound care (Resident #2). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 9/20/24, revealed Resident #2 diagnoses listed included osteomyelitis (infection of the bone) of the vertebra, sacral and sacrococcygeal region, hypertension (high blood pressure), peripheral vascular disease (restricted blood flow), paraplegia (paralysis of the lower body), and hemiplegia (paralysis of one side of the body). Resident #2's Brief Interview for Mental Status score of 15 out of 15 indicated intact cognition. The MDS assessed the resident dependent on staff to roll left and right, and for a chair/bed-to-chair transfer. The MDS indicated the resident at risk for developing pressure ulcers. The MDS identified Resident #2 with two Stage 4 pressure ulcers. A review of the electronic health record Medical Diagnosis list indicated Resident #2 diagnosed with: a. Pressure ulcer of left lower back, Stage 4 on 3/22/23. b. Pressure ulcer of sacral region, Stage 4 on 3/22/23. The Care Plan, date initiated 7/22/24, included a Focus area to address SKIN: At risk for alteration in skin integrity related to impaired mobility, pvd (peripheral vascular disease), refusal of repositioning. Non-compliance with preventative measures, dry skin, hld (high cholesterol), vit([NAME]) d deficiency, h/o (history of) cachexia (condition that causes loss of muscle and fat mass); healing prognosis is poor, h/o and risk of malnutrition, anemia, edema. Interventions included, in part; Administer treatment per physician orders, date initiated 1/11/24. A Wound Care Progress Note dated 11/12/24, Plan directed, in part; a.Limit time in chair to 1 hour (or less as tolerated by patient0, and reposition every 30 minutes while in chair. b. Use betadine to the peri wound (skin around the wound), gentamicin ointment, silver alginate covering with gauze and tape to the sacrum and left ischium ulcers changing twice daily and as needed with the assistance of facility nurses. Topical lidocaine 4% to aid in pain relief twice daily and as needed with dressing changes. Saline or wound cleanser of choice with dressing changes. Continue dressing orders until next office visit. A review of Physician Orders in the resident's electronic health record revealed an order transcribed 11/21/24 by Staff A, Registered Nurse (RN) and the facility's Wound Nurse, directed staff to apply Gentamicin Sulfate 0.1 percent ointment to the left ischium wound topically twice daily. Apply Betadine to peri wound, apply Gentamicin ointment to wound bed, cover with alginate, cover with gauze, secure with tape and apply to left ischium topically as needed for wound care if loose or soiled. The November, 2024 Treatment Administration Record (TAR) revealed the resident had no documented wound care of the left ischial pressure ulcer from 11/13/24 through 11/20/24 (7 days without treatment), and the physician directive to limit the resident's time up in chair to 1 hour or less at a time was not listed in the treatment orders. When reviewed on 11/25/24, the resident's [NAME] (a brand name for an informational system that is used as a quick reference for nursing staff) directed staff to Encourage resident to minimize time up in wheelchair. Wound clinic recommends no longer than 2 hours 3 times a day. During an observation on 11/20/24 at 12:57 p.m., Resident #2 in bed, with the door to the room open. The door to the room closed at 1:10 p.m. Staff C, Certified Nursing Assistant (CNA) opened the door at 1:14 p.m., and Resident #2 seated in his wheelchair. During an interview on 11/2024 at 1:44 p.m., Resident #2 while in his wheelchair, stated he was supposed to go to bed, and was not to be up for more than 30 minutes. He stated he could not access his call light from his current position. The call light was activated, and Staff D, CNA responded at 1:47 p.m. Staff D stated she was unaware the resident had a restriction on how long he could be up in his wheelchair, her coworker Staff C, CNA, was currently on break and she would return with Staff C when she was back from break to lay the resident down. At 2:05 p.m., the resident remained seated in his wheelchair in his room, Staff D in the hall near the Nurse's Station and stated they (Staff D and Staff C) had just completed care on another resident and would lay Resident #2 down next. During an interview on 11/20/24 at 1:22 p.m., Staff A, RN, and facility Wound Nurse, stated Resident #2's current physician orders for the left ischial wound was to apply Betadine to the peri wound, Gentamicin ointment to the wound bed, followed by a calcium alginate wafer, covered with a 4 inch by 4-inch gauze dressing secured with tape, or a border gauze dressing, applied twice daily. Staff A stated the physician's recommendation was the resident was not to be up in a chair for more than 2 hours at a time. Staff A stated either she or the nursing staff on duty normally transcribed the Wound Center's physician orders upon the resident's return from the appointment, and as the facility Wound Nurse, she reviewed the Wound Center physician progress notes and assessed and measured resident wounds at least weekly. During an interview on 11/25/24 at 11:06 a.m., Staff A stated she realized the 11/12/24 physician orders for the left ischial wound care had not been transcribed when she was interviewed on 11/20/24, and entered the physician orders in the computer at that time.

Based on observations, maintenance record review, resident and staff interviews the facility failed to provide dignified care to residents when the water temperature unpredictably changed from a comfortable temperature to a cold temperature for 6 of 6 resident reviewed for dignity. The facility reported a census of 66 residents. Findings include: During interview on 11/19/24 at 2:40 p.m., the facility Administrator stated she became aware shower water temperatures were not hot enough on 11/12/24 when a resident informed her of the concern. She contacted a local plumbing company at that time for service. The Administrator stated the plumbing company was on site the same day, and identified the 2nd floor central shower required a new cartridge. She stated the plumbing company returned on 11/15/24 and replaced the cartridge. On 11/20/24, the State Agency took water temperatures from the identified location with the following results: a. At 9:57 a.m., the 2nd floor central shower measured at 107.8 Fahrenheit (F). b. At 10:59 a.m., the 1st floor central shower measured at 109.7 F. c. At 11:30 a.m., the 1st floor central shower measured at 112.4 F. d. At 11:34 a.m., the 2nd floor west shower measured at 62.8 F, the shower room floor was wet upon entry, used towels and wash cloths were in the hamper (indications the room was recently in use). e. At 11:39 a.m., the 2nd floor central shower measured at 111.5 F. A review of the facility's water temperature log completed by Staff E, Maintenance Director, revealed water temperatures recorded throughout the 1st floor on 10/22/24, 10/29/24, 11/5/24 and 11/15/24 revealed a temperature range of 110 F to 115 F. Water temperature for the 2nd floor were not recorded. During an interview on 11/20/24 at 11:34 a.m., Staff F, Licensed Practical Nurse (LPN) stated they had warm water today so they were able to do a few showers. She stated other days they could not get showers done if the water didn't get warm enough. During an interview on 11/20/24 at 11:56 a.m., the Administrator stated after speaking to maintenance staff she had been told you had to run both the sink and the shower at the same time in the 2nd floor west shower to get the temperature up. During an observation on 11/20/24 at 12:04 p.m. Staff E, Maintenance Director and the Administrator took water temperatures of the 2nd floor west shower room. While running the sink and shower at the hottest possible setting the first temperature taken measured at 89 F, then 93 F, then 97.9 F, then back down to 94.1 F within a 2-minute time period. Staff E stated because it was upstairs you had to leave the water run for a while to get the temperature up. During an interview on 11/20/24 at 11:49 a.m., Resident #2 (BIMS of 15 out of 15, intact cognition) stated water in the showers was never warm enough. The resident stated he had refused too many showers to count over the last 3 to 4 months due to the water temperatures. Resident #2 stated he has been in the shower when the water cools down and had staff hurry to finish as there was no assurance that the water temperature would get warmer again. During an interview on 11/20/24 at 6:11 p.m., a family member and Power of Attorney for Resident #1 stated the water in the sink in the resident's room has been cold since she was admitted to the facility 5 weeks ago. The family member stated the water never got warm or hot, and they spoke to different staff about it since the resident was admitted . They stated the standard response was we are working on it, but nothing changed. The family member stated Resident #1 had refused several showers because the water was cold, and she had a hard time to get warm after that. During an interview on 11/21/24 at 9:44 a.m., Resident #5 (BIMS of 15 out of 15, intact cognition) stated he received his shower in the 1st floor central shower room and there has been a problem for several months with the water not being hot enough to shower. The resident stated had to wait 20 minutes while in the shower for the water to get warm enough again to continue. During an interview on 11/21/24 at 9:50 a.m., Resident #7 (BIMS OF 15 out of 15, intact cognition) stated they have to run the water for a while to get it warm enough. He explained they can't have showers when the dishwasher is running. He stated the water has cooled down during his shower a couple of times, that wasn't comfortable and he hoped they could fix the problem. During an interview on 11/21/24 at 9:52 a.m., Resident #8 (BIMS of 13 out of 15, intact cognition) stated he had been in the shower when the water got cool. He stated staff had to flush the toilet to make it warmer but it still was not warm enough. Resident #8 stated it seemed like they were having problems with the water temperatures for a while. During an interview on 11/21/24 at 10:12 a.m., Resident #6 (BIMS of 15 out of 15, intact cognition) stated they had problems with the water temperature in the shower for at least a few months. She stated the water isn't hot enough and will cool down during the shower. Resident #6 stated when you are all lathered up they have to finish and rinse that off with cool water and it was uncomfortable. Everyone here knows there is a problem with the water temperature in the shower. Resident #6 stated she has refused showers when the water isn't warm enough at least 3 to 4 times in the last couple months. During an interview on 11/21/24 at 10:02 a.m., Staff H, Certified Nursing Assistant (CNA), stated the hot water had to run for 10 to 15 minutes to get it warm enough for resident showers, the sink water had to be running at the same time to help get the temperature up. Staff H stated when she worked on the evening shift they couldn't do showers after supper because when the dishwasher ran it took all the hot water. During an interview on 11/21/24 at 10:36 a.m., Staff E, Maintenance Director when asked where the 2nd floor water temperatures were recorded for the 10/22/24 and 11/15/24 time period, stated he had given the log to Staff G, Maintenance staff that worked on the weekend to complete. He stated the temperatures he recorded on the form was after the water had ran for 10 to 15 minutes because that is what he had to do to get the temperature as hot as it would get. Staff E stated the water temperatures had been an issue since he started working there in January [2024]. Staff E stated he had consulted with the corporation about service providers and when there are water temperature issues at the facility it is more of an immediate need and difficult to get providers at the time to address the issue. During an interview on 11/26/24 at 6:56 a.m., Staff I, CNA, stated the hot water/shower temperatures had been a problem for a while. She stated there had been different companies there to try to fix it but the water temperatures continued to be low. Staff I stated the best time to shower a resident with the best chance for warmer water was right before breakfast She stated you have to keep the sink on when you give the shower, has been in the middle of a shower when the water temperature drops, it could be 15 minutes before the water temperature gets high enough to resume the shower so you have to cover the resident and wait for the water temperature to go back up, there wasn't anything else you could do. On 11/26/24, the State Agency, with the Director of Nursing present obtained the following water temperatures from the shower on the 1st floor west shower after the sink and shower faucets turned to the highest hot water setting, while running at the same time: a. 7:10 a.m. 56.5 F b. 7:14 a.m. 76.1 F c. 7:16 a.m. 75.4 F d. 7:17 a.m. 83.4 F e. 7:19 a.m. 81.7 F f. 7:21 a.m. 78.4 F g. 7:24 a.m. 96.0 F h. 7:27 a.m. 97.2 F i. 7:29 a.m. 96.1 F j. 7:30 a.m. 92.2 F The hot water in the Therapy Room (located near the 1st floor central shower room) on 11/26/24 at 7:35 a.m. revealed hot water at the sink at 117.9 F within 1 minute of turning the faucet on, the water as high as 119.0, and fluctuated between 116.3 F and 119.0 F without loss of hot water temperature. During an observation on 11/26/24 at 7:40 a.m., the 1st floor central shower room steamy upon entrance, had a shower temperature measurement of 117.2 F. During an interview on 11/26/24 at 7:04 a.m., Staff G, Housekeeping and Maintenance, stated he has never taken a water temperature at the facility. Staff G stated he had not been instructed to take water temperatures, and did know about the water temperature logs.

Based on observations, maintenance record review, and resident and staff interviews the facility failed to maintain essential equipment in acceptable operating condition to maintain water temperatures in resident showers between 110 degrees Fahrenheit (F) and 120 degrees F as required. The facility reported a census of 66 residents. Findings include: During interview on 11/19/24 at 2:40 p.m., the Administrator stated on 11/12/24 a resident informed her the shower water temperatures were not hot enough on 11/12/24. She stated she contacted local plumbing company A at that time for service. She stated the repair company was on site the same day. The plumber identified the central shower on the 2nd floor required a new cartridge. The cartridge was replaced on 11/15/24. The Administrator stated maintenance staff monitored water temperatures. She stated the facility had 1 boiler and 2 water heaters in use. During an interview on 11/20/24 at 11:34 a.m., Staff F, Licensed Practical Nurse (LPN) stated the facility had warm water today so they were able to do a few showers. During an interview on 11/20/24 at 11:56 a.m., the Administrator stated after she spoke to the Maintenance staff, she had been told to get the water temperature up on the 2nd floor, west shower room both the sink and the shower had to be ran at the same time. During an observation on 11/20/24 at 12:04 p.m., Staff E, Maintenance Director and the Administrator took water temperatures on the 2nd floor, west shower room. While running the sink and shower at the hottest possible setting the first temperature taken measured at 89 F, then 93 F, then 97.9 F, then back down to 94.1 F within a 2-minute time period. Staff E stated because it was upstairs you had to leave the water run for a while to get the temperature up. A review of the facility's water temperature log completed by Staff E, Maintenance Director, revealed recorded temperatures for the 1st floor showers recorded on 10/22/24, 10/29/24, 11/5/24 and 11/15/24 revealed a temperature range of 110 F to 115 F. Water temperatures for the 2nd floor showers were not recorded in the log. During an interview on 11/21/24 at 10:36 a.m., Staff E stated the water temperatures had been an issue since he started working there in January [2024]. Staff E stated he had consulted with the corporation about service providers and when there are water temperature issues at the facility it is more of an immediate need and difficult to get providers at the time to address the issue. During an interview on 11/21/24 at 11:20 a.m., the Administrator stated local plumbing company A had returned to assess the hot water at the facility. She stated the facility is getting estimates on a new boiler a few weeks ago as a local plumbing company B informed her the boiler leaked and required replacement. The hot water in the Therapy Room (located near the 1st floor central shower room) on 11/26/24 at 7:35 a.m. revealed hot water at the sink at 117.9 F within 1 minute of turning the faucet on, the water as high as 119.0, and fluctuated between 116.3 F and 119.0 F without loss of hot water temperature. During an interview on 11/21/24 at 10:02 a.m., Staff H, Certified Nursing Assistant (CNA), stated the hot water had to run for 10 to 15 minutes to get it warm enough for resident showers, the sink water had to be running at the same time to help get the temperature up. Staff H stated when she worked on the evening shift they couldn't do showers after supper because when the dishwasher ran it took all the hot water. During an interview on 11/21/24 at 9:50 a.m., Resident #7 (BIMS OF 15 out of 15, intact cognition) stated they have to run the water for a while to get it warm enough. He explained they can't have showers when the dishwasher is running. He stated the water has cooled down during his shower a couple of times, that wasn't comfortable and he hoped they could fix the problem. On 11/26/24, the State Agency, with the Director of Nursing present obtained the following water temperatures from the shower on the 1st floor west shower after the sink and shower faucets turned to the highest hot water setting, while running at the same time: a. 7:10 a.m. 56.5 F b. 7:14 a.m. 76.1 F c. 7:16 a.m. 75.4 F d. 7:17 a.m. 83.4 F e. 7:19 a.m. 81.7 F f. 7:21 a.m. 78.4 F g. 7:24 a.m. 96.0 F h. 7:27 a.m. 97.2 F i. 7:29 a.m. 96.1 F j. 7:30 a.m. 92.2 F During an interview on 11/26/27 at 1:00 p.m., the Administrator stated local plumbing company B is scheduled to return to further diagnosis the issue with maintaining hot water temperatures on the 2nd floor.

Based on observation, clinical record review, resident and staff interviews the facility failed to treat residents with dignity and respect, in full regard of the resident's stated needs and right to refuse a shower, for 1 of 8 resident's reviewed (Resident #5). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) Assessment tool, dated 7/23/24, revealed Resident #5 scored 13 out of 15 points possible on the Brief Interview for Mental Status (BIMS) Cognitive assessment, indicating intact cognition. Diagnoses listed on the MDS included: adult failure to thrive, anxiety, depression, and contractures in left hand, and feet. The resident required substantial/maximal staff assistance for personal hygiene, bathing and dressing the upper body, completely dependent on staff for dressing the lower body, toileting/hygiene, and unable to stand or ambulate. The MDS indicated the residents speech is clear, usually understood by others and usually understands others. A review of the Care Plan, dated 7/17/24, revealed a Focus Area to address Resident requires assistance with ADL's (Activities of Daily Living). Interventions, dated 7/17/24, included in part: to assist the resident with showering/bathing per schedule, prior to initiating an ADL task, staff will explain the task to resident, provide sufficient time for completion of ADL tasks, and allow resident independence to the best of their ability with ADL task. The Care Plan, dated 7/17/24, also included a Focus Area to address Resident is at risk of pain related to low back pain, contractures of multiple of multiple sites, constipation, HTN (hypertension) and depression. Interventions, dated 7/17/24, included in part: Administer pain medication per physicians order, Encourage/assist to reposition frequently to position for comfort, Evaluate pain level as ordered, Implement non-pharmacological interventions massage, relation techniques, counseling, warm/cool compress, positioning as indicated, and Observe for non-verbal signs of pain. Documentation in the resident's record revealed she received bed baths on 7/29/24 and 7/31/24, and no history of a shower bath. A Nursing Progress Note transcribed at 7:13 p.m. on 7/31/24 by Staff A, Licensed Practical Nurse (LPN) stated: Resident was assisted into the Hoyer lift and transferred onto the reclining shower chair. Resident continued to yell out and shout profanities to staff during shower. Resident is currently on the phone with her family at this time about how upset she is about getting a shower. An observation on 8/27/24 at 11:21 a.m. revealed Resident #5 positioned on her back in bed, head of the bed elevated approximately 15 degrees, awake and alert, with a cell phone in her right hand, all fingers of her left hand very contracted and the resident would not have been able to hold the phone or grasp anything with it. During an interview on 8/27/24 at 11:22 a.m., the resident stated prior to admission to the facility, she lived in her home, completely dependent on family for care, she hadn't been out of bed for around 2 years. When she came to the facility staff provided bed baths for her, then 1 day staff came and told her she was getting a shower, she told them no, she didn't want a shower, but they got her up anyway. She stated she had horrible pain in her legs when they had her up in the air with the lift, and was afraid. During an interview 8/27/24 at 12:34 p.m., Resident #5 stated on the day that staff showered her, she never agreed to a shower, staff came with the mechanical lift and said I was getting up and going to get a shower. When they started lifting her with the mechanical lift it really hurt and she started yelling/screaming due to the pain. They never offered to lay her back down, or not to have the shower she would have accepted a bed bath but staff didn't offer that option. During an interview on 8/27/24 at 11:31 a.m., the Director of Nursing stated he had been unaware of Resident #5 having a problem with a shower, would have to look into it, and stated the resident had bed baths on 7/29/24 and 7/31/24. During an interview on 8/27/24 at 11:38 a.m., the Administrator stated she heard there was an issue with the resident having a shower, she spoke to the resident, her Power of Attorney (POA), and the staff involved, it was Staff B, Certified Nursing Assistant (CNA). The resident told the Administrator she agreed to the shower until she became uncomfortable, then she wasn't in agreement. The resident reported staff offered to stop but she agreed to continue with the shower, and didn't want a shower again. The resident told her she called the Elder Abuse hotline about it. They have changed her care plan to bed baths only since then. During an interview on 8/27/24 at 11:56 a.m., the resident's POA stated the resident called her on the telephone her right after she was showered and was very upset. The resident was bedridden, completely dependent for all care, the resident said staff made her take a shower even though she said no and screamed because the mechanical lift hurt her knees. It caused the resident mental distress, and the POA spoke with Staff E about it, they agreed that if the resident refused a shower staff should have honored the resident's wishes. During an interview on 8/28/24 at 2:48 p.m., Staff B, CNA, stated 1 day when she worked, staff from the evening shift, Staff C, CNA, went in to change the resident after she had been incontinent with bowel. Staff B stated she did not think if was possible to clean up the resident with wet wipes and they felt the resident required a shower. Resident #5 said she hadn't had a shower for a long time, Staff B stated she tried to reassure the resident, that she would make it as quick as possible, and the resident was okay with it until they got her up in the air with the mechanical lift and transferred her to the recumbent shower chair, that's when she started screaming that she didn't want a shower, and didn't want to be at the facility any more. Once in the shower, as she washed her perineal area the resident yelled that Staff B was degrading her. Staff B stated she completed the shower as quickly as she could and notified the nurse of the events afterward. During an interview on 8/28/24 at 4:36 p.m., Staff C, CNA, stated she assisted Staff B to transfer the resident to the shower chair with the mechanical lift, the resident didn't say she didn't want a shower until they had her up in the air and were in the process of moving her to the shower chair, that's when she screamed/yelled and cursed at them and said she didn't want a shower. Staff C stated Staff B did try to reassure the resident, she remained present in the shower room as she was showered, the resident continued to yell profanities at them during the shower, stopped after the shower was completed and they returned her to her room. During an interview on 8/28/24 at 1:58 p.m. Staff D, LPN, stated Staff B told her after she showered the resident that the resident said she didn't want a shower, and once in the shower room she said staff washed her inappropriately. When Staff D spoke to the resident she said she never got out of her house, never took showers and was upset that she got a shower, she didn't say that she was hurt by the mechanical lift or anything like that. During an interview on 8/28/24 at 11:55 a.m., Staff E, facility Social Worker, stated when the resident came to the facility she hadn't bathed for some time and had an odor. When they showered the resident she could hear the resident's screams when she was in her office, approximately 50 feet away and separated by several walls. After the shower the resident agreed she felt better but didn't want to have a shower again, she only wanted bed baths.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to obtain a physician order to obtain Lorazepam from the facility's Med Bank for one of six residents reviewed, (Resident #30). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #30 with a BIMS (Brief Interview for Mental Status) score of 15, intact cognitive status and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Peripheral Vascular Disease, Anxiety Disorder and Chronic Obstructive Pulmonary Disease. The MDS also identified Resident #30 required only set up or clean up assistance with most activities of daily living. In an interview on 5/20/24 at 11:08 AM, Resident #30 reported he had trouble getting his Lorazepam. When he had trouble breathing, he got anxious. When he no longer received hospice services, the nurses told him he could not get the Lorazepam until he saw the doctor tomorrow. He reported he was afraid to sleep as he was afraid he would stop breathing. On 2/12/24, the Care Plan identified Resident #30 with the problem of using Psychoactive medications related to adjustment disorder with anxiety and depression and directed staff to: a. Administer the medications as ordered. b. Monitor for adverse or allergic reaction; Call the Physician for any changes in condition. c. Monitor for any ill effects related to medication. A review of the May 2024 Medication Administration Records (MARs) revealed the following: 5/4/24 Ativan (Lorazepam) Oral Tablet 0.5 milligrams (mg) Give one tablet by mouth one time only for anxiety for one day and no documentation to show the dose had been given. A review of the Progress Notes revealed the following: On 5/18/24 at 8:59 AM The Med Aide reported the resident is having a panic attack and insists on being given a PRN (give as needed) Lorazepam at this time. The Night Nurse reported speaking with pharmacist who told her to take two 0.5 mg Lorazepam tablets from the med bank (to equal 1 mg). The Nurse was not able to pull the medication from med bank. The Nurse called pharmacy representative and left a voicemail with request for return call to obtain medication necessary. On 5/19/24 at 3:04 AM Call placed to Hospice to request Ativan (Lorazepam) prescription, stated they would work on getting one sent as soon as possible. On 5/19/2024 at 4:16 AM Call received from hospice stated will work on resident Ativan. On 5/19/2024 at 8:49 PM The resident requested Lorazepam and none in facility. Nurse spoke on phone with pharmacy and there was no quantity remaining on script. Unable to send and unable to pull from med bank. The Nurse spoke on phone with the facility Nurse Practitioner to request a prescription, she reported she would not write a script for Lorazepam since Resident #30 was now off hospice and stated the primary care physician needed to see Resident #30 and review his medications. On 5/20/24 at 1:54 PM Call placed to Resident #30's primary care physician to request an order for Ativan to be sent to the pharmacy. She was under the impression that he was still under Hospice Care. She would send in the prescription. An observation on 5/21/24 which began at 7:50 AM revealed Resident #30 turned on his call light. Staff G, RN and Staff J, CMA stood outside Resident #30's room discussed that Resident #30 was asking for Lorazepam which Staff J stated he no longer had in the medication drawer. At 7:53 AM, the Social Worker entered room and Resident #30 asked for his Lorazepam. Staff J, CMA stated it had to be re-ordered by the doctor and they did not have any. The Social Worker informed Resident #30 that they needed to talk to the doctor about the Lorazepam since he is no longer on hospice. Resident #30 appeared to be very upset about it. At 8:02 AM, Staff G, RN walked into Resident #30's room. Resident #30 asked for his Lorazepam and a box of tissue. Resident #30 stated, that's 4 times now. At 8:04 AM Staff G gave Resident #30 a box of tissue and said, here's this, I'm working on the rest At 8:06 AM Staff G asked Staff J if Resident #30 had a med card for Lorazepam because he checked the MAR and he still has an order for it and he said he would get it from the med bank. At 8:25 AM Resident #30 stated he was very upset that its been 6 days since he's been able to get his Lorazepam. When surveyor asked Staff J, CMA if he could have Benadryl, she said he doesn't have an order for it and that Staff G was still working on getting the Lorazepam. At 12:39 PM Resident #30 reported he still had not received his Lorazepam A review of the May 2024 MARS revealed Lorazepam 1 mg orally had been given on 5/21/24 at 12:51 PM. In an interview on 5/23/24 at 10:15 AM, the Director of Nursing (DON) reported the following: Resident #30 was discharged from hospice services on 5/17/24 and the facility Nurse had notified the Nurse Practitioner (NP) of the concern that he needed a refill for the Lorazepam. The NP reported Resident #30's Primary Care Physician would need to write the order. The facility Nurse contacted the Primary Care Physician and received a one time order initially and later another order to re-instate the PRN order for Lorazepam. The DON also reported he would have expected the Nurse to check the order to make sure it was an active order. The nurse should have been able to pull it from our med bank as that is a medication that the facility had available. Resident #30's specific dose was not in the facility Med Bank. The Nurse can only pull what the prescription is for. The facility's available stock was for 0.5 mg and his order was for 1 mg. The nurse should have contacted the provider for an order for that specific dose in order to pull it from the Med Bank. A review of the Facility Policy titled: Medication Administration dated as last reviewed May 2023 did not address the process of obtaining medication from the Med Bank if the resident did not have the medication ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to follow the care plan and transfer the resident with the use of the stand lift for one of one resident reviewed, (Resident #55). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #55 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Diabetes Mellitus, Multiple Sclerosis and Depression. The MDS also identified Resident #55 was totally dependent on staff for all transfers. On 3/21/24, the Care Plan identified Resident #55 required assistance with ADL's (Activities of Daily Living) related to immobility, Multiple Sclerosis with impaired range of motion and directed staff to transfer with the stand lift. A review of the Progress Notes dated 3/29/24 at 3:32 PM had documentation of the following: Was informed by staff that resident had fallen and was on the floor. Upon entering the resident room, resident was laying on her back with a pillow under her head. Resident #55 had a red mark on her left cheek which she said a fist sized crystal rock had fallen off her bedside table and hit her in the face during the fall when she fell into the bedside table and knocked it over. Resident #55 was lifted off the floor with a hoyer and assist of 3. Resident #55 refused to have an x-ray done and denied pain at the time. In an interview and observation on 5/20/24 at 11:45 AM, Resident #55 reported Staff F, CNA had transferred her from the bed to the wheelchair without anyone helping her, did not use a lift or use a gait belt. Staff F grabbed Resident #55's arm and they locked arms. Resident #55 stood up and Staff F tried to transfer Resident #55 to the wheelchair which she did not lock. Resident #55 reported she fell on her knees and hit her head on the front side on the bottom of the tray table. The care plan was not updated with any new interventions after the fall on 3/29/24. In an interview on 5/21/24 at 4:54 PM, the Administrator reported the following regarding the facility's investigation of Resident #55's fall on 3/29/24: On 3/29/24 at 2:47 PM, Staff F, CNA transferred Resident #55 without any staff assistance into a wheelchair. Resident #55 started to slide onto floor and aid lowered her to the floor at that time. Resident #55 fell to her left side from a kneeling position into her bedside table which caused a rock from on top of the bedside table to fall and hit her on her right cheek. Staff G, RN assessed Resident #55 who denied the need for any treatment or x-ray. The assessment and vitals were normal. Resident #55 was care planned to transfer with assist of two using Sara lift. Staff F did not correctly transfer Resident #55 and was educated on following correct transfer protocol. The Physician was notified of fall and intervention and no new orders were received. The family were notified of fall and plan, verbalized understanding and agreement. In an interview on 5/22/24 at 3:48 AM, Staff B, CNA reported before the fall on 3/29/24, Resident #55 was care planned to be transferred with the assist of two using the Hoyer lift. In an interview on 5/22/24 at 3:56 AM, Staff C, LPN reported Resident #55 was care planned to be transferred with the assist of two using either a stand lift or Hoyer lift. In an interview on 5/22/24 at 4:36 AM, Staff D, LPN reported before the fall on 3/29/24, Resident #55 was care planned to be transferred with the assist of one using a gait belt and now should be transferred with the assist of one using the stand lift. In an interview on 5/22/24 at 5:00 AM, Staff E, CNA reported before the fall on 3/29/24, Resident #55 was care planned to be transferred with the assist of one using a gait belt and now should be assist of one using the stand lift. In an interview on 5/22/24 at 11:02 AM, Staff F, CNA reported the following: a. When Resident #55 fell in March 2024, it happened because she could not get help in time. She did not have another staff member on the floor, there wasn't a gait belt in the room, and she did not have a gait belt on her. b. The other CNA that was supposed to be there, left before 2nd shift staff came. This happened a couple times a week. c. Every staff person should have their own gait, but that day she left her gait belt at home. d. That day she helped Resident #55 sit up at the edge of the bed. She assisted her to stand to move to the wheelchair, but her left leg wouldn't turn, she said she was going to fall, she lowered her down to the floor. Resident #55 fell on her knees when she left the room to get help. When she came back, Resident #55 was laying on her side and her face hit the bottom of the tray table. In an interview 5/22/24 at 11:18 AM, Staff G, RN reported the following: a. When Resident #55 fell in March 2024, one of the CNA's told him Resident #55 fell. He could not recall the name of the CNA. When he arrived to the room, he saw a Sara lift (sit to stand lift) in the room and the aide had tried to transfer Resident #55 by herself. b. Resident #55 was laying on her back by the bed, on the side of the bed. He did not see any bleeding. When she fell, she said she had a large crystal which fell off her bedside table and hit her on the left side of her cheek. The distance from the table to her face would be 1.5 to 2 feet. c. There should have been 2 CNA's helping with the transfer with the Sara lift. The CNA should have pulled the call light for help. d. He was not sure how Resident #55 had been care planned to be transferred, but thought she was supposed to be transferred using the [NAME] (stand lift). In an interview on 5/23/24 at 9:25 AM, the Director of Nursing reported the following: a. When Resident #55 fell on March 2024, she was being transferred and staff lowered her to the floor. There was one CNA in the room with the resident. The Incident Report did not specify that she put a gait belt on the resident. b. When he did the investigation, therapy had already been working with her on transfers. c. Before the fall, Resident #55 was care planned to have two staff transfer her using a Sara lift. d. Based on the documentation, Staff F, CNA did not use a Sara lift or a gait belt, it is not documented. When she fell, Resident #55 fell onto the bedside table which the salt lamp fell off the table (about the size of a fist) and dropped possibly 2 to 3 feet before it hit her right cheek. There was no bleeding. She did report pain to her face. e. The nurse came in to assess her and denied the need for x-rays to her face. She was able to move all extremities. She was alert and oriented per baseline. Vital signs were within normal limits. f. The staff used a hoyer lift to assist her back to bed. g. He would expect an intervention to be added to the care plan after a fall within 24 hours. h. The fall could have been prevented if the staff would have checked the [NAME] first on the electronic record. The aide should have had another staff member in the room with her and should have had a lift with her. i. Staff F thought that Resident #55 was a pivot transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview the facility failed to date feeding tube equipment, flush for patency with the correct water amount, and confirm correct settings on a feeding tube pump in order to follow physician orders for 1 of 1 resident reviewed, (Resident #4). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #4 identified the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating no cognitive impairment. The MDS reported diagnoses including: sarcoidosis of the lung (lung cancer), paraplegia (inability to voluntarily move lower parts of the body), and pneumonia. The Care Plan updated 2/2/24 documented the resident's risk for altered nutritional status related to his inability to eat or drink by mouth, and a PEG tube (feeding tube directly into the stomach) due to dysphagia (difficulty swallowing). It instructed staff to provide nutrition through the PEG tube. The Physician Order dated 3/7/24 instructed staff to flush the G-tube with 60 mL of water every shift for G-tube care. The order dated 4/27/24 instructed staff to administer Pivot 1.5 feeding solution at 50 mL per hour continuously until 1200 mL is reached per day; water flush at 40 mL per hour until 960 mL is reached. Staff may turn the pump off during cares and as needed. During an observation on 5/22/24 at 2:32 PM Staff H, Licensed Practical Nurse (LPN) donned a gown, performed hand hygiene, and applied gloves. Staff I, LPN brought in a covered tray with a Pivot 1.5 feeding solution bottle, a flush syringe, a new water flush bag, and a graduated cylinder. Staff I donned a gown, completed hand hygiene, and put on gloves. Staff H listened to the resident's abdomen with a stethoscope and assessed the site dressing. She then unhooked the feeding tube and placed it on a clean towel on the resident's abdomen. She used the syringe to check for residual fluid and got less than 5 mL out. She discarded it into the graduated cylinder. The Director of Nursing (DON) conducted hand hygiene, dated the cylinder, rinsed it, and filled it with water for flushing. Staff H used 40 mL to flush the feeding tube and check for patency. She then dated the feeding bottle. Hand hygiene was performed and gloves changed. Staff H opened the bottle and hooked it to new tubing. Staff I filled the cylinder with water and filled the new bag for the water flush. Staff H then hung the feeding solution and water bag. Staff failed to date the water bag and tubing. Staff H and I struggled to connect the tubing for the pump and did not ask for assistance. The DON intervened and connected the tubing to the pump. Staff H primed the water into the garbage after entering the settings into the pump. She could not get the feeding solution to prime down the tube and did not ask for assistance. The DON donned gown and gloves and intervened. Staff H then connected the tube to the resident and started the pump. Both Staff H and I removed gowns and gloves and left the room. Staff H failed to check the settings on the pump prior to exiting. The settings read: feeding 50 mL per 1 hour, flush 0mL per 0 hrs. During an interview on 5/21/24 at 3:07 PM Staff H explained the feeding is usually changed on third shift. This was her first time doing this. She does the morning flush and medications but never had to hook up a new feeding. She expressed she did not know how to connect the tubing to the pump correctly and didn't want to ask for help. She explained she put the 40 mL flush setting in and hit run but it kept saying hold. She thought the 50 mL feeding and 40 mL flush were set when she walked out. During an interview on 5/22/24 at 1:46 PM the DON explained he would have expected staff to contact someone for assistance when staff were struggling in this situation. There is a manager on-call in the evenings. He noted once set up is complete staff need to make sure the pump is set to the correct settings before exiting the room. He expressed he knew Staff H said she checked it so he was not sure what went wrong. He noted he felt Staff H got caught up with the hourly flushing of 40 mL instead of using the 30 mL for the patency check. The facility policy titled Enteral Tubes: Intermittent/Continuous (Pump) Feedings dated 2/2024 instructed staff to: Verify physician's order for formula, rate, and frequency. Label syringe and plastic bag with patient name and date. Label container and tubing with resident name, date, formula, rate, and time feeding is initiated. Verify enteral tube placement and check residuals. Check for patency by flushing with 30ml of tap water. Hang closed system of prescribed formula on IV pole. Prepare per manufacturers guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The MDS dated [DATE] for Resident #22 identified a BIMS score of 15/15 indicating no cognitive impairment. The MDS indicated diagnoses including: diabetes mellitus, seizure disorder, and malignant neoplasm of upper lobe, left bronchus or lung (lung cancer). The admission Record indicated an admission date for Resident #22 on 3/29/24. The Care Plan updated 3/29/24 instructed staff to administer pain medication per the physician orders. The Physician Order dated 3/29/24 at 12:57 PM instructed the resident to receive Lyrica 75 mg capsule (antiseizure medication), 1 capsule by mouth two times per day for pain. The Progress Note dated 3/29/24 at 10:42 PM noted medications had not yet been delivered from the pharmacy. On 3/30/24 at 8:56 AM nursing reported Lyrica was on order from the pharmacy. At 5:28 PM the note indicated the medication was still on order from the pharmacy. On 3/31/24 the note indicated Lyrica was still unavailable and the pharmacy was notified. At 5:51 PM the note indicated the medication was still unavailable and pharmacy was notified. On 4/1/24 the note indicated Lyrica was not available from the pharmacy to administer. The Registered Nurse (RN) was made aware. At 8:16 PM the note indicated the medication was still unavailable. The RN and physician were notified. On 4/2/24 at 11:17 AM the note indicated Lyrica was still not available. The pharmacy was called and the medication was to be sent. The physician, resident, and family were notified. At 9:03 PM the physician and family were notified the medication was still not present. On 4/3/24 at 8:38 AM the physician was notified that Lyrica had not arrived at the facility. The Medication Administration Record (MAR) for March 2024 showed the resident did not receive scheduled Lyrica the evening of 3/29/24, the morning and evening of 3/30/24, or the morning and evening of 3/31/24 as it was unavailable. The MAR for April 2024 reported the resident did not receive his schedule Lyrica the morning and evening of 4/1/24, the morning and evening of 4/2/24, and the morning of 4/3/24 due to the medication being unavailable. This resulted in 10 missed doses of the pain medication spanning 6 days. Based on clinical record review, staff interviews and facility policy review the facility pharmacy failed to deliver medications ordered to the facility in a timely fashion for 4 out of 4 residents reviewed, (Resident #22, #30, #47, and #70). The facility reported a census of 70 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 included diagnoses of stroke, and hypercholesterolemia. The Medication Administration Record (MAR) for Resident #47 dated 4/25/24, lacked documentation of administration for the medication, ticagrelor (help prevent blood clot). The MAR directed to see Nurses Notes. The Medication Administration Nurses Note for Resident #47 dated 4/25/2024 at 11:03 PM reflected ticagrelor 90 mg unavailable. 2. The MDS for Resident #70 dated 4/27/24 reflected his admission date as 4/27/24. The MDS dated [DATE], listed diagnoses of coronary artery disease (CAD), high blood pressure, Alzheimer's disease, and psychotic disorder and post traumatic stress disorder (PTSD). The MDS identified short and long term memory problems with severely impaired decision making. The MAR for Resident # 70 dated April 27, 2024 revealed see Nurses Note for five of the medications scheduled bedtime medication. The Progress Notes dated 4/27/24, reflected waiting on the pharmacy for the missed medication that included an antipsychotics, cholesterol medication, heart medication, eye drop, and an antidepressant. On 5/22/24 at 10:39 AM, Staff I, Registered Nurse (RN) reported one time a week something ordered won't come from the pharmacy. She said she called the pharmacy and they told her the medication, it's in the next delivery, and it won't show up. She stated that she called the pharmacy again and then they told her it's too soon to replace or that they needed the prescription. She stated the Director of Nursing (DON) knew medications not delivered from the pharmacy is a problem. On 5/23/24 at 7:42 AM, Staff H, Licensed Practical Nurse (LPN) confirmed at times the pharmacy failed to bring the medication the nurses ordered. She said the pharmacy told them they required a prescription, it may be too soon, or it's on the next trip. She reported if it failed to come the next time they get the Director of Nursing (DON) involved. 4. The MDS dated [DATE] identified Resident #30 with a BIMS score of 15 and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Peripheral Vascular Disease, Anxiety Disorder and Chronic Obstructive Pulmonary Disease (COPD). The MDS also identified Resident #30 required only set up or clean up assistance with most activities of daily living. On 2/12/24, the Care Plan identified Resident #30 with the problem of being at risk for ineffective breathing pattern related to COPD, Chronic Respiratory failure with hypoxia and episodes of shortness of breath. The Care Plan failed to direct staff to administer the inhalers as ordered by the physician. A report from the Veteran's Administration revealed Resident #30 did not receive his inhalers as ordered on 4/19/24 and on 4/20/24. A review of April Medication Administration Records revealed an order written 2/12/24 for Tiotropium Bromide-Olodaterol Inhalation Aerosol Solution 2.5-2.5 Mcg - 2 puffs inhale orally one time a day for shortness of breath, COPD (Chronic Obstructive Pulmonary Disease). On 4/19/24 the dose had been marked as UV (unavailable) and on 4/20/24 it had been marked as H (held). A review of the Progress Notes dated 4/1/24 through 4/30/24 did not have documentation to explain why the above two doses were unavailable and held. In an observation and interview on 5/20/24 at 11:08 AM, Resident #30 sat up in bed with continuous oxygen maintained at 4 liters per nasal cannula running per concentrator. He reported when he has trouble breathing, he gets anxious. He was afraid to sleep because he was afraid he would stop breathing. On 5/23/24 at 8:00 AM, the DON confirmed knowledge related to some delivery difficulty related to the pharmacy. The facility provided a policy titled Medication Administration - Medication Pass dated 5/2023, listed the purpose: To safely and accurately prepare and administer medication according to physician order and patient needs. The facility provided a Pharmacy Order Guide undated that reflected new orders and refill orders received before 11 am will arrive with the 1st scheduled delivery. New orders received after 11 PM (M-F) and after 4:30 PM on Sat/Sun/Holidays) will arrive on the first scheduled delivery the following day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and staff interview the facility failed to maintain a sanitary kitchen, ensure the disinfectant solution was within proper test range, label food appropriately for storage, wear hair restraints appropriately and dispose of expired food items. The facility identified a census of 70 residents. Findings include: 1. The initial tour of the kitchen on 5/20/24 at 10:10 AM revealed the following: a. The Vulcan stove backsplash and sides by griddle were 50% covered with black/brown residue, both handles to oven doors with sticky residue, doors on outside with scattered areas of brown and white residue. b. The floor to all areas of kitchen with debris. c. The Hoshizaki ice machine with dispenser. Housing units with white debris noted along seams. d. The [NAME] dishwasher with debris noted along seams of outer doors. e. At 10:18 AM, the Dietary Director filled a bucket with water and sanitizer and put test strip in it and it read zero. The Dietary Director had run chemical directly from a dispenser, he placed another strip in to the solution and again the reading was 0. The Dietary Director reported these were new strips that start out as yellow and should turn a light green and should test from 200 to 400 ppm (parts per million). He emptied the bucket and refilled with water running from the Sunburst Sanitizer dispenser. He obtained another package of test strips which had not been opened before and submerged x 10 seconds and no color change noted on strip. He placed another strip into bucket and no change in color noted again. He reported there might be an issue with the strips and he will contact Sunburst to troubleshoot. 2. On 5/21/24 at 7:29 AM an observation on the 2 [NAME] kitchenette revealed the following: a. The Hoshizaki ice machine with white residue to right side of dispensing tray, splatters of red residue to housing unit under dispensing spout. b. The Frigidaire refrigerator did not have thermometer inside. It contained one ½ gallon of white skim milk outdated 5/3/24 and another ½ gallon jug of white skim milk outdated 5/8/24. It also contained one uncovered plastic container with cake without a date. On 5/22/24 starting at 6:17 AM, the following observations revealed: a. Staff K, cook, ran test strip in a bucket of sanitizer which tested at 1000 ppm. b. The top of the stove with side and backsplash portions remain 50% covered with black/grown residue around the griddle. The floor to the kitchen still with scattered white particles. c. Staff K had a long braid down to middle of her back which had not been properly covered by the hair restraint. d. The housing unit to the Hoshizaki ice machine not cleaned from yesterday. The [NAME] dishwasher remains with crusty gray residue to bottom of the doors. e. The Vulcan oven with red panel on right side with brown residue noted to outer panels, Accutemp steamer with white residue streaks underneath the door. f. At 7:37 AM, during the breakfast meal service, Staff K donned new pair of gloves then began plating food again when her braid fell out of the hair restraint. g. At 7:52 AM, Staff K's braid fell out of the hair net again. She began plating more meals for residents in the dining room. Then went to the dried food storage room to remove her hairnet and pull up her braid and into hairnet. In an interview on 5/22/24 at 10:14 AM, the Dietary Director reported the following: a. Equipment such as the stove top, ice machine and ovens should be cleaned at least once a week. b. There is a deep cleaning schedule which happens once a month and as needed. c. There is a cleaning chart which is posted, however, it is not signed off on the schedules to show it had been done. d. All staff in the kitchen should have their hair completely covered by a hair net when in the kitchen. e. When asked who had the responsibility to check the kitchenette refrigerators for outdates, he reported he was not sure. He has had problems with items that are not labeled with dates or what the item is. f. There was no clear designation as to who had the responsibility to check the refrigerators A review of the facility policy titled: Sanitizing and Disinfectant Solutions dated 2020 had documentation of the following: a. If a dispensing system is used, appropriate concentration level will be tested at least daily. b. Sanitizing solutions are changed in accordance with manufacturer instructions or when they become visibly soiled. In general each shift should prepare fresh solutions. A test paper/strip should be used to verify the concentration. A review of the facility policy titled: Kitchen Sanitation dated as last reviewed October 2023 had documentation of the following: Purpose: To maintain the sanitation of the Food and Nutrition Services Department through compliance with written cleaning schedules developed by the Director of Food and Nutrition Services or other clinically qualified nutrition professional. Procedure: a. The Director of Food and Nutrition Services or other qualified nutrition professional shall record cleaning and sanitation tasks for the Food and Nutrition Services Department. b. A cleaning schedule shall be posted with tasks designated to specific positions in the department. c. Tasks shall be addressed as to frequency of cleaning. d. The Director of Food and Nutrition Services or other clinically qualified nutrition professional should check off assignments completed by using the employees initials to validate the task is completed.

Based on clinical record review, staff interviews and facility policy review, the facility failed to follow accepted practices for enteral (feeding tube formula bags) feeding supplies, and to follow a Physician's Order to continue clopidogrel (Plavix, the brand name of the medication. The medication purpose is to keep platelets from sticking together) for 1 of 3 residents in the sample (Resident #1). The facility reported a census of 66 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 2/14/24, listed diagnosis for Resident #1 included hemiplegia (one sided paralysis) following a stroke affecting the right dominant side, dysphagia (difficulty swallowing), and aphasia (difficulty with communication). The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 8 out of 15, indicating severely impaired cognition. A review of Hospital Discharge Records, dated 2/7/24, indicated during the hospitalization Resident #1 had a Foley catheter inserted, and developed hematuria (blood in urine). During the hospitalization, a consulting Urologist placed clopidogrel bisulfate 75 milligrams (mg) on hold until the hematuria cleared. The 2/7/24 Hospital Discharge Instructions included an order to restart clopidogrel 75 mg 1 tablet daily. A review of the Electronic Health Record (EHR) revealed the facilities Physician's Order, dated 2/7/24, for clopidogrel bisulfate 75 mg 1 tablet by feeding tube one time daily. A review of Urology Progress Notes, from a follow up appointment on 2/21/24, revealed a concern with hematuria. The Urology notes indicated a plan to await recommendations from the doctor managing the patients anticoagulants (clopidogrel). During an interview on 2/27/24 at 3:02 PM, Staff A, Licensed Practical Nurse (LPN) stated after Resident #1 returned from the follow up appointment on 2/21/24, a nurse from the Urologist office called the facility. Staff A stated the nurse asked for the contact information for the facility Physician. Staff A stated the nurse stated she wanted to follow up with the Physician regarding the hematuria and management of the anticoagulants. Staff A stated she did not hear back from the facility Physician prior to the end of her shift, and denied calling the Physician for follow up as the Urology Nurse was to call. Staff A reported she did not change the clopidogrel order. Staff A stated she documented the conversation with the Urology Office in the EHR, and passed the information on to the next nurse during the shift report. A review of the February Electronic Medication Administration Record (EMAR) revealed a hold order placed for clopidogrel 75 mg 1 tablet by feeding tube one time daily on 2/22/24, and 2/23/24. Per the EMAR, the clopidogrel order restarted on 2/24/24. During an interview on 2/28/24 at 1:51 PM, Staff B, LPN stated the night of 2/21/24 during report the previous nurse informed her Resident #1's clopidogrel was placed on hold due to hematuria. Staff B stated she checked the EHR and noted clopidogrel had not been placed on hold, and reported she then placed the medication on hold. Staff B stated she placed an order to restart the clopidogrel effective 2/24/24, after reading a Fax sent by the facility Physician. Staff B stated the note stated the Physician needed to do a Telehealth appointment with Resident #1 before changing the clopidogrel order. A review of the paper Medical Record revealed a fax sent by the facility provider on 2/22/24 at 11:36 AM. The provider wrote I need to do a Telehealth appointment with Resident #1 to decide if I can take him off Plavix (clopidogrel) temporarily for Urology. During an interview on 2/28/24 at 2:45 PM, Staff C, LPN stated on 2/24/24 she contacted the facility Physician to report gross hematuria noted in the Resident #1 Foley bag. Staff C stated the Physician informed her she did not want to change the clopidogrel order until she had a Telehealth appointment with the resident. During an interview on 2/29/24 at 12:34 PM, the Director of Nursing (DON) stated the clopidogrel order should not have been placed on hold, given the Physician's Note on the 2/22/24 fax. The DON stated if staff had questions or were unclear about the note on the Fax they should have called the Physician and asked for clarification. A facility policy, dated 7/2023, titled Physician Orders/Transcription of Orders revealed a purpose statement to correctly and safely receive/transcribe Physician's Orders so correct order can be followed/administered. To ensure that patient medications, treatments and plan of care are in accordance with the licensed providers orders. The Care Plan, dated 2/8/24, identified a Focus Area related to tube feeding due to dysphagia. A review of the EHR revealed a Physician's Order dated 2/8/24 for the resident to receive Jevity 1.5 at 50 ml(milliliters) per hour, with a total volume of 1200 ml in 24 hours, and water flush 25 ml/hr. Further review of the EHR revealed a Physician Order, dated 2/22/24 to ensure a new feeding bottle [bag] is hung daily, with date and initials. During an interview on 2/29/24 at 9:54 AM, Staff C, Licensed Practical Nurse (LPN) stated Resident #1's family voiced concern with the formula bag for the enteral feeding not being changed every 24 hours. Staff C stated the family reported this occurred on 2/19/24. She stated she does not recall the date on the bag, but does know it was more than 24 hours. Staff C stated she changed the bag immediately, and explained formula bags should be changed every 24 hours, with the date and time noted. During an interview on 2/29/24 at 12:40 PM, the DON stated a bag for feeding tube formula should be changed every 24 hours if the bag is opened to be filled. The DON stated he expected staff to change the bag every 24 hours and put a date and time on the bag. A facility policy, dated 10/2023, titled Enteral Tubes, Intermittent (Pump) Feedings directed staff in Step #7 of the Procedure to Hang open top tube feed system on IV pole and add prescribed formula, Prepare per manufacturer's guidelines. NOTE: Hang times for open systems are 8-12 hours, tubing and bag changed every 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review the facility failed to notify the Resident Representative/Emergency Contact of a hospital transfer for 1 of 3 residents reviewed for transfers out of the facility (Resident #3). The facility reported a census of 72 residents. Findings Include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed the resident discharged to the hospital on 1/17/24. A readmission MDS dated [DATE] documented the resident re-admitted back to the facility The Care Plan initiated 4/5/23 documented Resident #3 with altered cardiovascular status, heart disease, congested heart failure and history of cerebral vascular accident (stroke). The Notice of Transfer Report to the Ombudsman for January 2024 identified resident #3 transferred for hospitalization on 1/17/2024. The Progress Note dated 1/17/24 at 5:49 PM, documented Resident #3's family notified via phone call by Staff A, Licensed Practical Nurse (LPN), regarding the transfer to the hospital The Hospital Report dated 1/18/24, documented the resident confused on admit 1/17/23 with some improvement on 1/18/23, no connection with family was made. An interview on 2/14/23 at 10:20 PM with LPN, Staff A revealed there was no answer from the family member's phone, documented as Emergency Contact #1 and reported she did not recall trying additional family/Emergency Contacts listed for Resident #3 to notify of the transfer to the hospital on 1/17/23. Staff A stated, she expected the next shift to contact family. In an interview on 2/14/23 at 11:20 AM, the Administrator acknowledged the expectation is that the responsible party, family, or Emergency Contact be notified when a resident is transferred to the hospital. The Administrator explained the Progress Notes should give name and identify who is contacted to support who was notified. The Facility Policy titled Notification for Change of Condition, revised 6/2023 included, the facility will provide care to residents and provide notification of resident's change in status. The facility must immediately inform the resident's Legal Representative or interested family member when there is a significant change, and or a decision to transfer from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, and Dietician Job Description review, the facility failed to ensure Registered Dietician (RD) involvement for consultation, education, Care Plan updates for nutritional interventions to address protein needs and nutritional deficits for promotion of chronic wound healing of 1 of 3 residents reviewed (Resident #1). In addition, the Dietician lacked participation of expectations in Quality Assurance and Performance Improvement (QAPI) meetings. The facility reported a census of 72. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for resident #1 included diagnoses of paraplegia and malnutrition. The MDS revealed 3 pressure ulcers and coded for protein and/or calorie malnutrition, risk for malnutrition. A Brief Interview for Mental Status (BIMS) Assessment scored 15 out of 15 indicating no cognitive impairment. Review of Resident #1's Care Plan revealed the following Focus Areas: a. A Focus Area initiated on 1/14/24 encourage good nutrition and hydration in order to promote healthier skin. b. A Focus Area on 3/22/23 for skin, identified pressure wound to right ischium with intervention to encourage good nutritional and hydration. c. The Focus Area titled Nutritional Status initiated 3/24/23 documented nutritional status goals to tolerate diet as evidenced by weight. Interventions included to administer Vitamin/mineral supplements as ordered, encourage and assist as needed to consume, honor preferences, regular diet, goal to heal skin impairments without complications. d. A Focus Area for the wound to the left ischium updated 7/20/23 documented focus to educate and good nutrition. e. The Focus Area for the coccyx /sacrum wound updated 7/20/23 revealed at risk for alteration in skin integrity, due to malnutrition, vitamin D deficiency and history of cachexia (illness causing muscle loss). The [Hospital Name Redacted] Assessments on 2/9/24 for Resident #1 while hospitalized from [DATE] to 2/14/23 documented status of chronic wounds included presence of chronic pressure wounds: coccyx pressure injury, lower right flank pressure injury, right heel pressure injury, Left ischium pressure injury and right Ischium pressure injury. The Progress Notes from Staff B, Registered Dietician, (RD) revealed on 11/15/23 at 12:39 PM, Resident #1 continues to refuse all recommended nutritional supplements and modulars for wound healing. Staff B documented on 10/18/23 at 2:30, resident continues to refuse all nutritional supplements recommended for wound healing. Staff B documented on 9/15/23, Dietician documented Resident #1 continues to refuse all offered and recommended nutritional supplements for wound healing. In an interview with Resident #1 on 2/15/24 at 9:40 AM, reported having chronic wound complications with the coccyx wound for over two years. Resident #1 did not recall ever meeting with a RD at the facility. Resident #1 stated he did try nutritional supplements in the past, sometime last year and got tired of them. Resident #1 stated he would be willing to go back to them and would be willing to meet with the RD. In an interview on 2/15/23 at 1:30 PM, Staff B, Registered Dietician (RD), revealed she had been working strictly remotely since Resident #1's January admission Assessment and individual follow up is in the facility usually weekly depending on changes, reassessments and quarterly notes and special needs. Staff B, acknowledged Resident #1 had special needs, needed frequent reassessments due to wounds. Staff B stated she did a Wound Note under the Progress Notes section, on 10/18/23 and 11/15/23 and is working on one today 2/15/23. Staff B explained she would expect Dietary Wound Notes to be at a minimum of monthly. Staff B, reported Resident #1 refused past nutritional supplements, and other alternatives, attempts and refusals. Staff B stated she would be back in the facility first week of March and realized improvements needed in regards to Resident #1 wounds to be reviewed a minimum of twice a month. In an interview on 2/19/24 at 12:26 PM, Staff C, Food Services Director reported he primarily works with Staff B via email or text correspondence. Staff C stated he use to see her more often but over the last year Staff B worked more remotely, and does not have a set schedule on when comes in person. Staff C confirmed Resident #1 with a supplement order back in August and relayed it is primarily the Dietician's role to visit with a resident for education. Staff C remarked the last time he saw Staff B in the facility was sometime in January but not certain of when. Staff C looked at Resident #1's history and thought the nutritional shake was ordered in August and stopped in December but could not be certain since the system that did not give dates or detailed information. Staff C reported on other brands and options for nutritional supplements, did not know if other alternatives were offered. Staff C commented at times he received feedback from Staff B on specifics but, not always. In an interview on 2/19/24 at 3:00 PM, the Director of Nursing (DON) reported aware of Resident #1's chronic wounds and protein needed for healing. The DON stated on 8/21/23 the Wound Clinic recommended increased protein that was implemented by alerting the kitchen to give increased meats and eggs, and would be monitored by looking at percentages of food intake documented after meals. The DON acknowledged the percentage does not address specific protein intake, and the RD would follow up regarding the effectiveness. In an interview on 2/15/24 at 3:00 PM, the Administrator, reported Staff B had been working remotely and unsure about recent attempts for Resident #1's dietary interventions after August 2023 and if options discussed related to noted refusal of supplements. The Administrator unaware if tried any other options. The Administrator relayed she would expect Dietary involvement due to chronic wound healing needs, and documentation of follow up would include education and attempts of other interventions. The administrator voiced, more time by the RD in the facility would be beneficial In a follow up interview on 12/19/23 at 4:50 PM, the Administrator confirmed Staff B failed to attend the Departmental/QAPI meetings. The Administrator relayed, attendance is part of the RD's expectation. Review of the Quality Assurance and Performance Improvement Sign-In monthly sheets reviewed, Meetings held in in March, April May, June, July, August, Sept. Oct, in 2023, Staff B failed to attend the 2023 QAPI meetings. Review of the January 2024 attendance sheet in January revealed Staff B did not attend the meeting. The facility provided the Clinical Dietician Job Description, revised 12/1/19 included objective of providing nutritional care through monitoring, Care Planning and education. Essential function to evaluate, interpret, monitor and document the nutritional status and needs, identify and provide nutritional counseling, support the individual Care Plan process, make recommendations, communicate and interact effectively, attend and participate in departmental meetings, support QAPI efforts and recognize role as part of QAPI efforts of the organization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and facility policy review, the facility failed to provide services that met professional standards regarding medication administration, weight documentation, catheter care documentation and wound treatment completion for 4 of 12 residents observed (Residents #2, #6, #15, and #16). The facility reported a census of 53 residents Finding Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #2 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15 points. The MDS also identified Resident #2 with the following diagnoses: Type 2 diabetes mellitus with diabetic neuropathy, heart failure and hypertension (high blood pressure). The MDS documented Resident #2 required extensive staff assistance with most activities of daily living. On 7/3/23, the Care Plan identified Resident #2 with the problem of cardiovascular dysfunction related to hypertension and failed to include the Physician Orders with parameters to hold Isosorbide and Lisinopril if the systolic blood pressure was less than 100 and to hold Metoprolol if the systolic blood pressure was less than 100 and if heart rate was less than 58. A review of the August 2023 Physician Orders and MARs (Medication Administration Records) revealed the following: a. Isosorbide Mononitrate ER (Extended Release) oral tablet 30 milligrams (mgs), give one tablet by mouth one time a day for Hypertension (HTN) - high blood pressure. Hold for Systolic Blood Pressure (SBP) of 100 or less b. Lisinopril oral tablet 10 mg, give 1 tablet by mouth one time a day for HTN. Hold for SBP 100 or less. Isosorbide Mononitrate ER and Lisinopril were signed out as given on the following dates with the following blood pressures (BP): a. On August 3rd: BP of 93/54. b. On August 12th: BP 99/50. c. On August 13th: BP 98/52. d. On August 15th: BP 94/58. Metoprolol Tartrate oral tablet 25 mg, give 0.5 tablet by mouth two times a day for HTN. Hold for SBP of 100 or less or HR (Heart Rate) of 58 or less Metoprolol Tartrate was signed out as given on the following dates with the following blood pressures (BP) and/or Heart Rates (HR): a. On August 1st at 6:00 PM: HR of 52. b. On August 2nd at 8:00 AM: HR of 50. c. On August 3rd at 8:00 AM: BP 93/54, HR of 52. d. On August 3rd at 6:00 PM: HR of 54. e. On August 4th at 8:00 AM: HR of 56. f. On August 4th at 6:00 PM: BP 96/52. g. On August 8th at 6:00 PM: BP 92/59. h. On August 9th at 6:00 PM: BP 98/53. i. On August 13th 8:00 AM: BP 98/53. j. On August 15 at 8:00 AM: BP 94/58. A review of the Progress Notes revealed the following: On 8/14/23 at 8:40 AM, Physician notified of low blood pressures over the weekend. No changes in orders at this time. Physician aware Isosorbide which was administered Saturday and Sunday for BP of 99/50 but Lisinopril held. Isosorbide and Lisinopril administered Sunday for BP of 98/52. In an interview on 8/23/23 at 1:23 PM, the Nurse Consultant reported she had become aware on 8/14/23 that there were numerous problems with staff not following guidelines set forth by the Physician. She stated she started auditing residents with parameters daily on 8/15/23 and has been providing education to the Nurses and Certified Medication Aide's (CMA's) regarding following physician orders per their policy which included noting that active orders should be followed and carried out as written/transcribed. She included education on reading orders with parameters. 2. The MDS dated [DATE] identified Resident #6 as cognitively intact with a BIMS score of 13 out of 15 points. The MDS also identified Resident #6 with the following diagnoses: coronary artery disease, heart failure and diabetes mellitus. The MDS documented Resident #6 required extensive staff assistance with bed mobility, transfers, toileting and bathing. A review of the Physician Order dated 12/12/22 revealed an order to weigh Resident #6 three times a week every day shift on Monday, Wednesday and Friday. Notify Physician of significant weight changes. On 7/11/23, the Care Plan identified Resident #6 with the problem of altered cardiovascular status related to chronic kidney disease with heart failure and failed to address the need to notify the physician of a significant weight gain with parameters. A review of the August 2023 Treatment Administration Records (TAR's) revealed an order to weigh Resident #6 three times a week every Monday, Wednesday and Friday. No weights were documented on July 28, and August 21. A review of the Progress Notes revealed no documentation to show the Physician was notified of the weight gain of 7.7 pounds in a week. 3. MDS dated [DATE] identified Resident #15 as cognitively intact with a BIMS score of 13 out of 15 points. The MDS also identified Resident #15 with the following diagnoses: spinal stenosis, peripheral vascular disease and neurogenic bladder. The MDS documented Resident #15 required extensive staff assistance with bed mobility, transfers, dressing, toileting and bathing. A review of the Physician Orders revealed an order dated 7/13/23 to maintain indwelling Foley 16 french 10 cc (cubic centimeter or milliliter) and perform catheter care every shift for catheter care. A review of the August 2023 TAR revealed an order dated 7/13/23 to maintain indwelling Foley 16 french 10 cc and perform catheter care every shift for catheter care. The TAR failed to have documentation to show the treatment had been completed on the evening shift on August 2 and on the night shift on August 19. On 3/24/23, the Care Plan identified Resident #15 with the problem of use of indwelling urinary catheter needed due to neurogenic bladder and directed staff to provide catheter care, however, failed to address the frequency to complete once a shift. 4. MDS dated [DATE] identified Resident #16 with moderate cognitive impairment with a BIMS score of 11 out of 15. The MDS also identified Resident #16 with the following diagnoses: thrombosis of the right and left femoral vein, hypertensive heart disease, chronic kidney disease, dementia, schizophrenia, anxiety disorder, seizure disorder, and moderate intellectual disabilities. The MDS documented Resident #16 required extensive assistance with bed mobility, transfers, toileting and bathing. Review of the TAR for August 2023 revealed Resident #16 had the following orders: a. Buttocks: Cleanse with foam cleanser, apply a thin layer of stomahesive powder to buttocks, and then cover with a layer of Z-guard paste. Apply at least three times a day, after each episode of incontinence and as needed (PRN) three times a day for buttocks wound -start date 07/27/2023 -discontinue (D/C) date 08/02/2023 b. Left hip: cleanse with NS, cover with a single layer of Xerofoam and silicone foam, daily and PRN every day shift for left hip -start date 07/29/2023 -D/C date 08/01/2023. c. Heel boots to bilateral feet while in bed every shift for skin protection -start date- 07/31/2023. d. Wound left buttocks: cleanse with normal saline (NS), apply Xerofoam to the denuded area and cover with foam. Change daily PRN every day shift for wound care -start date 08/03/2023 -discontinue (D/C) date 08/09/2023. e. Wound right buttocks: cleanse with NS, apply Xerofoam to denuded areas and cover with foam. Change daily and PRN every day shift for wound care -start date 08/03/2023. f. Wound left buttocks: apply moistened domeboro compress on for 15 minutes, then place foam for protection. Change daily every day shift for wound care -start date 08/10/2023. g. Domeboro External Packet (Aluminum Sulfate & Calcium Acetate), apply to buttocks topically every day shift for wet compress topically 15 min prior to treatment -start date 08/10/2023. Record review of the August 2023 TAR revealed the following: a. Heel boots to bilateral feet while in bed every shift for skin protection -start date- 07/31/2023. The facility failed to document completion of order on: Days: 8/15, 8/19, 8/20, 8/21, and 8/23, Evenings: 8/2, and Nights: 8/14, 8/18, 8/19, and 8/21. b. Wound left buttocks: cleanse with NS, apply Xerofoam to the denuded area and cover with foam. Change daily and PRN every day shift for wound care -start date 08/03/2023 -D/C date 08/09/2023. The facility failed to document completion of the treatment on: 8/9/23. c. Wound right buttocks: cleanse with NS, apply Xerofoam to denuded areas and cover with foam. Change daily and PRN every day shift for wound care -start date 08/03/23. The facility failed to document completion of the treatment on: 8/15/23, 8/19/23, 8/20/23, and 8/21/23. d. Wound left buttocks: apply moistened Domeboro compress on for 15 minutes, then place foam for protection. Change daily every day shift for wound care -start date 08/10/2023. The facility failed to document completion of the treatment on: 8/15/23, 8/19/23, 8/20/23, and 8/21/23. e. Domeboro External Packet (Aluminum Sulfate & Calcium Acetate): apply to buttocks topically every day shift for wet compress topically 15 min prior to treatment -start date 08/10/2023. The facility failed to document completion of the treatment on: 8/15/23, 8/19/23, 8/20/23, and 8/21/23. On 7/27/23, the Care Plan identified Resident #16 with a problem of impaired skin integrity of buttocks and bilateral peri area related to incontinence, moisture, and chronic discoloration to buttocks/coccyx and directed staff to identify/document potential causative factors, monitor location, size and treatment of skin alteration, skin checks during shower/bed bath, report skin alteration to the nurse, and turn and reposition at regular interval with cares as needed. In an observation on 8/24/23 at 6:55 AM, Staff A, Registered Nurse (RN) with Staff B, Licensed Practical Nurse (LPN) assisting, completed the wound treatment to Resident #16's buttocks. Staff used good hand hygiene, donning and doffing gloves throughout the process. Staff A and Staff B assisted the resident from his back to roll onto his right side and positioned him for the treatment. Staff A asked the resident about pain and if he needed any medication prior to the treatment and the resident declined any pan or need for medication. The old dressing was removed from the resident's bottom (dressing was dated with yesterday's date and initials. Resident's bottom area was noted to be dry, red and scaly with a few open areas with a small amount of frank blood. Areas were cleansed with NS soaked 4 x 4's. Domeboro solution soaked 4 x 4's were applied to resident buttock cheeks and left in the area for 15 minutes. Resident was covered with a sheet and remained on the right side. In an observation on 8/24/23 at 7:20 AM, Staff A with Staff C, Certified Nursing Assistant (CNA) assisting, returned to complete the treatment. Staff used good hand hygiene, donning and doffing gloves throughout the process. Staff A removed the Domeboro soaked 4 x 4's then applied a foam dressing that was dated and initialed to his left buttock area. Staff A then applied a small piece of Xerofoam and covered it with a foam dressing that was dated and initialed to the right buttock. In an interview on 8/24/23 at 2:12 PM, the Director of Nursing (DON) stated it was the expectation Nurses and Medication Aides read Physician Orders in their entirety prior to giving a medication to ensure they understand what they are giving. The DON expected an assessment of a resident with a noted weight gain and the Physician be updated. The DON also expected catheter care to be done as directed, and wound treatments to be completed as ordered. If staff were not able to complete for some reason they should let the Physician know and document it. Facility provided policy titled Following Physician Orders/Transcription of Orders revised 5/2023 stated orders must contain specific and clear parameters if parameters indicated by Medical Doctor/Nurse Practitioner/Physician Assistant (MD/NP/PA). Active orders should be followed and carried out as written/transcribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to document assessments/interventions for a resident with low blood pressure (Resident #2), failed to document wound assessments for one resident (Resident #4) and failed to document a complete assessment when a wound was identified for one resident (Resident #8). The facility reported a census of 50 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] identified Resident #2 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15 points. The MDS also identified Resident #2 with the following diagnoses: Diabetes Mellitus with Neuropathy, Heart Failure and Hypertension (high blood pressure), and identified the resident required extensive staff assistance with most activities of daily living. The Physician Order Summary report dated 6/27/23 documented an order dated 5/10/23 for Metoprolol 25 milligrams (mg), give one half tablet by mouth two times a day for Hypertension (high blood pressure) and do not give if the systolic blood pressure (the top number of the blood pressure) is 100 or less or if the heart rate is 58 or less. The May 2023 Medication Administration Record (MAR) did not include a field to enter the resident's heart rate. The following doses were administered at 6:00 PM on the following dates with the following blood pressures (BP): a. On May 18 BP 99/51. b. On May 25 BP 81/55. c. On May 28 BP 95/26. d. On May 31 BP 94/45. The June 2023 MARs did not include a field to enter the resident's heart rate. The following doses were administered at 6:00 PM on the following dates with the following blood pressures (BP): a. On June 5 BP 77/41. b. On June 6 BP 85/52. c. On June 8 BP 90/49. d. On June 10 BP 98/52. e. On June 11 BP 87/47. f. On June 12 BP 94/51. g. On June 18 BP 97/49. h. On June 19 BP 98/51. The Care Plan with the target date of 7/25/23 did not identify Resident #2 with the problem of Hypertension and did not address the interventions as ordered to hold the Metoprolol if the systolic blood pressure was less than 100 or if the heart rate was less than 58. The blood pressures recorded in the Electronic Medical Record (EMR) under the section titled: Weights/Vital Signs had documentation of the following: a. On 6/21/23 at 9:01 AM BP 84/57, at 9:03 AM BP 84/51 and at 9:05 AM BP 84/51. The Nurse's Notes did not have documentation to show any of the above blood pressures had been called to the Physician or Nurse Practitioner. The Progress Notes documented by the Physician or Nurse Practitioner on the following dates and times did not include documentation they had been notified of the above low blood pressures: a. On 5/16/23 at 1:39 PM. b. On 5/23/23 at 3:07 PM. c. On 6/20/23 at 2:23 PM. Observations of the Resident #2 revealed no episodes of hypotension, rested comfortably in his wheelchair, properly positioned and appeared comfortable on the following dates and times: a. On 6/19/23 11:55 AM, 1:03 PM, and 3:51 PM. b. On 6/20/23 7:51 AM and 9:32 AM. c. On 6/21/23 8:06 AM and 6/21/23 10:15 AM. In an interview on 6/28/23 at 2:33 PM, Staff A, Registered Nurse (RN) reported if a resident had orders for Metoprolol and had a systolic BP of below 100, she would hold the dose and recheck the BP again within 30 minutes. In an interview on 6/29/23 at 10:47 AM, Staff G, Licensed Practical Nurse (LPN) reported if a resident had orders for Metoprolol and had a systolic BP of below 100, she would hold the dose and recheck the BP within an hour. Upon review of the MAR, Staff G verified the MAR did not have a field to document the resident's heart rate and it should have. In an interview on 7/3/23 at 10:10 AM, the Director of Nursing (DON) reviewed Resident #2's MARs and verified there was an option in the EMR that should have warned nurses to hold the Metoprolol with low blood pressures as ordered. She would expect the nurses to recheck the blood pressure within an hour and notify the physician. She would not expect the order to hold the Metoprolol to be addressed on the care plan. In an interview on 7/3/23 at 2:16 PM, Staff L, LPN reported when she entered the order for Metoprolol on the MAR, she forgot to add the field to include documentation of the heart rate and could not recall why. If the resident had a BP of 84/50, she would recheck the BP in 30 minutes, hold the Metoprolol and notify the doctor. 2. The MDS dated [DATE] identified Resident #4 as cognitively intact with a BIMS score of 13 out of 15 points. The MDS also identified Resident #4 with the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Coronary Artery Disease, Diabetes Mellitus and Heart Failure. The MDS documented Resident #4 required extensive staff assistance with all activities of daily living except for locomotion off the unit which he had been totally dependent on staff for. The MDS also identified Resident #4 at risk for developing pressure ulcers, however did not have any current unhealed pressure ulcers. The Nurse's Note dated 6/1/23 at 2:00 PM documented the following: during cares this evening staff reported a small red open area to right buttock. The nurse completed an assessment, cleansed the right buttock and covered it with dry gauze. The nurse also notified the Physician and waited for new orders. A Physician Order dated 6/2/23 directed staff to provide wound care every day shift to the right buttock, cleanse it with normal saline, apply Xeroform and cover with Optiform daily and as needed (PRN)if it became soiled or dislodged. The June 2023 TARs revealed an order dated 6/2/23 for wound care to the right buttock, cleanse with normal saline, apply Xeroform and cover with Optiform daily and PRN if becomes soiled. The TAR lacked documentation the wound care completed on June 4, 13 and 18. The Care Plan failed to have documentation showing the Care Plan updated after the wound identified 6/1/23. The Skin Alteration Record with the first assessment dated [DATE] did not document the location of the wound or the date of onset. The Record documentation of the wound was 0.3 centimeters (cm) long, 0.4 cm wide and 0.1 cm deep. The Record failed to have documentation for the next 12 days until 6/14/23 where no measurements documented. Observations of the resident revealed the resident laid in his bed on his back with the head of the bed elevated and with the air mattress in place and inflated on the following dates: a. On 6/19/23 at 11:23 AM, at 12:34 PM, and at 3:58 PM. b. On 6/20/23 at 7:30 AM, at 9:30 AM, at 12:50 PM, at 12:54 PM, and at 12:55 PM. c. On 6/21/23 at 7:50 AM, and at 10:18 AM. 3. The MDS dated [DATE] identified Resident #8 as cognitively impaired with a BIMS score of 0 out of 15 points and with the following diagnoses: Unspecified Dementia, Coronary Artery Disease and Benign Prostatic Hyperplasia. The MDS also identified Resident #8 required extensive staff assistance with bed mobility and dressing and totally dependent on staff for assistance with transfers, locomotion on and off the unit, toileting, personal hygiene and bathing. A review of the facility Skin Alteration Records revealed on the left third toe - the Initial Assessment did not have documentation when the date of onset for the wound. The assessment dated [DATE] did not have the depth documented. On 6/13/23, there was no documentation of measurements. In an observation of wound care on 6/21/23 at 1:13 PM, Staff K, RN and the facility Nurse Practitioner (NP) entered the room, washed their hands and donned gloves. Staff K removed the dressings from Resident #8's left foot. The NP measured wound to top of left foot with the length of 0.75 cm and width of 1.0 cm. The wound bed appeared pink and did not have drainage or signs of infection. The NP changed gloves and measured the wound to 3rd toe with the length of 0.75 cm and .75 cm wide. The wounds did not show signs of infection. Resident #8 denied pain during the wound care. In an interview on 6/28/23 at 10:29 AM, Staff B, LPN reported measurements and assessments should be documented weekly. In an interview on 6/28/23 at 2:33 PM, Staff A, RN reported measurements and assessments should be documented weekly. In an interview on 7/3/23 at 10:10 AM, the DON reported the location and date of onset of the wound should be recorded on the top right corner of the Skin Alteration Record and expected nurses to document measurements and assessments weekly. The facility policy titled: Skin Quick Reference dated February 2022 had documentation of the wound evaluation should include components of wound evaluation: Location, Wound etiology, Measurements - length, width, depth, Stage (if pressure injury), Wound bed, Wound edges / border, Peri-wound appearance, Tunneling, Undermining, Exudate (drainage), Signs/symptoms of infection, Pain, Odor, Wound status, Signs/symptoms of healing, Response to treatment and Goal of care. When asked for the facility policy on Assessment/Intervention, the Administrator provided the Care Path on dehydration which directed the staff if the resident had a blood pressure lower than 90 systolic or heart rate less than 50 to take the following actions: a. Notify the Physician or Nurse Practitioner or Physician Assistant. b. Evaluate Symptoms and Signs for with the following Requires Immediate Notification** o Acute mental status change. o Not eating or drinking at all. o Acute decline in ADL abilities. o New cough, abnormal lung sounds. o Nausea, vomiting, diarrhea. o Abdominal distension or tenderness. o Inability to stand without severe dizziness or light headedness. o New or worsened incontinence, pain with urination, blood in urine. o Very low urinary output. o New skin condition (e.g. rash, redness suggesting cellulitis, signs of infection, around existing wound/pressure ulcer). c. Consider notifying Physician to obtain orders for any further orders for evaluation. d. Monitor vital signs, fluid intake/urine output every 4-8 hrs for 24-72 hrs. e. Offer frequent fluids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to document complete assessments of the pressure ulcer for one resident (Resident #3) and failed to prevent the development of a new pressure ulcer for another resident (Resident #5). The facility reported a census of 59 residents Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #3 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 of 15 points and had the following diagnoses: Cancer, Peripheral Vascular Disease and Malnutrition. The MDS also identified Resident #3 required extensive staff assistance with most activities of daily living and with one Stage 2 pressure ulcer and four venous/arterial ulcers. A review of the facility Skin Alteration Records revealed on 5/20/23, the facility identified wounds as the following: a. The tip of the right great toe: the form had documentation of: 5/20/23 Length (L) of 0.2 centimeters (cm), Width (W) or 0.2 cm, no documentation of Depth (D), eschar with heavy serous clear drainage, extremity weeping with maceration, pain at site. The form lacked further documentation of assessments after 5/20/23. b. The sole of right foot, ball of great toe had documentation of: 5/20/23 L= 1 cm W=2 cm depth = no documentation. The form lacked further documentation of assessments after 5/31/23. c. The 3rd toe of the right foot: the form documentation on 5/20/23 of the following: no measurements documented, 20% toe at tip with eschar, heavy serous clear drainage, surrounding skin with maceration. The form lacked further documentation of assessments after 5/20/23. A review of the facility Nurse's Notes revealed the following: a. On 6/6/23 at 5:35 PM, this nurse assisted the Hospice Nurse with wound care. Resident #3's right foot soaked per Hospice Physician and apply betadine cover with alginate, entire foot darkened with all toes on foot necrotic and disarticulate of right fifth toe. This entry lacked documentation of the presence of maggots. b. On 6/6/23 at 11:28 PM, Hospice Nurse in facility this shift following report from previous shift that patient has maggots in the wound on his right foot. Dressing change to both legs performed by Hospice Nurse who stated she drowned the maggots by submerging patient's foot in water. Recommends submerging patient's feet in water prior to dressing change for the next couple days. Recommended toes on patient's right foot be wrapped/covered by dressing/kerlix. Maggots were located between patient's toes. She also reported Resident #3's overlay mattress was deflated and the roho cushion in his wheelchair was not inflated. A review of the Hospice Nurse's Notes revealed the following by Staff C, Hospice Registered Nurse (RN) revealed the following: a. On 6/6/23 started at 5:35 PM, RN Visit ended 7:30 PM. There was no documentation of wound care, appearance of wound or the presence of maggots in wound. In an interview on 6/19/23 2:15 PM, a nurse from the Veteran's Administration (VA) reported the following: The VA Nurse and Physician observed the dressing change. The VA Physician informed the facility nurse that Resident #3 should be premedicated. He had received Morphine earlier, however, it was short acting. By the time the facility nurse did the dressing, an hour had passed and by then Resident #3 was in agony and the doctor told her to give him pain medication. Even after the Floor Nurse had medicated the resident again, he still looked like he was in pain. The VA nurse saw the maggots, but did not take any photos. In an interview on 6/20/23 at 2:28 PM, Staff A, RN reported when she charted Resident #3 had maggots in the wound, the nurse on first shift had reported it to her. Staff A did not personally observe the maggots. She reported Staff C, Hospice Nurse and the Director of Nursing (DON) observed the maggots in the wound. Resident #3 had a history of going outside very frequently to smoke which may have created an environment for the maggots. In an interview on 6/20/23 at 2:42 PM, Staff B, Licensed Practical Nurse reported she did observe the maggots in Resident #3's wound, however, could not recall the exact date. There were one or two that she noticed them at the tip of his 2nd and 3rd toes. Staff B did not document it in the Nurse's Notes as she was not sure what is was. She saw white worms, and was not sure what to document. She reported it to the second shift. In an interview on 6/21/23 at 11:54 AM, Staff C, Hospice RN reported that she saw 3 maggots in the wound on 6/7/23 and could not explain why she did not chart it. In an interview on 6/22/23 at 8:07 AM, DON reported the following: Resident #3 had total necrosis from the knee down, on the right 5th digit. She actually visualized 2 maggots between his toes. The Hospice Doctor instructed us to soak his foot and we did not see them since. We only saw them that day. The DON stated when nurses first visualize any kind of insects in a wound, she expected the nurse to call the doctor and get an order for treatment. Staff B did say she notified Hospice. The DON would expect the nurse to document the appearance of the wound and interventions, and chart any infestation. The DON could not explain why there was no documentation on the nurse's notes or the skin sheets of the presence of the maggots in the wound. 2. The MDS dated [DATE] identified Resident #5 as cognitively intact with a BIMS score of 13 out of 15 and had the following diagnoses: Chronic Hepatic Failure, Cirrhosis, Diabetes Mellitus and Seizure Disorder. The MDS also identified the resident required extensive staff assistance with bed mobility and dressing. The MDS documentation showed the resident with one Stage 3 pressure ulcer that he had on admission. The Nursing admission assessment dated [DATE] identified Resident #5 had pressure ulcers to the following areas: a. Coccyx Length (L)=2 cm, Width (W)=1 cm, Depth (D)=0.1 cm (not staged, marked as N/A). b. Right buttock L=0.2 cm, W=0.1 cm, D= 0.1 cm (not staged, marked as N/A). c. Left buttock L=0.1 cm, W=0.1 cm, D= 0.1 cm (not staged, marked as N/A). d. Left heel unstageable L=6 cm, W=4 cm, D= 0 cm (not staged, marked as N/A). e. Left elbow L=1.5 cm, W=1.5 cm, D= 0 cm staged as suspected deep tissue injury. A review of the Wound Care Center Progress Notes revealed the wound to the left medial plantar foot developed 5/12/23 after admission to the facility. The wound measured as L= 1.1 cm W= 1.0 cm D= 0 cm. On 5/12/23 the Care Plan identified the resident with the problem of wound #4- Left, medial plantar foot (other distal) and directed staff to: a. Apply left heel protector as needed (PRN) in bed as he will allow. b. Avoid mechanical trauma: Constrictive shoes, Cutting and trimming corns and calluses, Adhesive tapes, Improper shaving, Vigorous massage. In an observation of wound care on 6/21/23 at 10:35 AM, the above wound to the left medial plantar area had already healed. Staff B, LPN washed her hands, donned gloves and used a clean scissors to cut the soiled dressing from the Resident #5's left foot, used the correct technique to cleanse the wound to the left heel. The wound bed appeared cream colored in the center and pink to the outer edges without signs of infection, odor or drainage. The surrounding skin did not appear to have signs of infection. Staff B did not disinfect the scissors prior to cutting the new Vaseline gauze or the new package of gauze. A review of the June Treatment Administration Records revealed an order dated 6/12/23 and directed staff to Wound # 1 Left Heel: Cleanse wound and peri wound with normal saline, pat dry and apply silver alginate to wound bed and cover with dry gauze, apply foam, kerlix and secure with tape. Avoid excessive contact of tape with skin. Change dressing three times per week and as needed. Once a week on Friday at the clinic and twice a week at the facility on Monday and Wednesday. The facility policy titled: Skin Quick Reference dated February 2022 had documentation of wound evaluation should include components of wound evaluation: Location, Wound etiology, Measurements - length, width, depth, Stage (if pressure injury), Wound bed, Wound edges / border, Peri-wound appearance, Tunneling, Undermining, Exudate (drainage), Signs/symptoms of infection, Pain, Odor, Wound status, Signs/symptoms of healing, Response to treatment and Goal of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to utilize proper infection control techniques during wound care for two of five residents reviewed with wounds. (Residents #4 and #5) and failed to prevent an indwelling urinary catheter bag and tubing from touching the floor for one of two residents with catheters. (Resident #10). The facility reported a census of 59 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #4 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 points and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Coronary Artery Disease, Diabetes Mellitus and Heart Failure. The MDS documented the resident required extensive staff assistance with all activities of daily living except for locomotion off the unit which he had been totally dependent on staff for. The MDS also identified him at risk for developing pressure ulcers, however did not have any current unhealed pressure ulcers. The Nurse's Note dated 6/1/23 at 2:00 PM, documented the following: during cares this evening staff reported a small red open area to right buttock. The nurse completed an assessment, cleansed the right buttock and covered it with dry gauze. The nurse also notified the physician and waited for new orders. A Physician Order dated 6/2/23 directed staff to provide wound care every day shift to the right buttock, cleanse it with normal saline, apply Xerofoam and cover with optiform daily and as needed if it became soiled or dislodged. The June 2023 Treatment Administration Records revealed an order dated 6/2/23 for wound care to the right buttock, cleanse with normal saline, apply Xerofoam and cover with Optiform daily and prn if becomes soiled. The TAR lacked documentation the wound care completed on June 4, 13 and 18. The Care Plan lacked documentation to show the Care Plan updated after the wound was identified 6/1/23. The Skin Alteration Record with the first assessment dated [DATE] did not have documentation on the location of the wound or the date of onset. The Record documented the wound was 0.3 centimeters (cm) long, 0.4 cm wide and 0.1 cm deep. The Record lacked documentation for the next 12 days until 6/14/23 where there were no measurements documented. An observation of wound care which began 6/20/23 at 1:29 PM, Staff B, Licensed Practical Nurse (LPN) entered the room, washed her hands and donned gloves. Staff D, Certified Nurse Aide (CNA) assisted Resident #4 to turn to his left side. When Staff B removed the incontinent brief, Resident #4 noted incontinent of a moderate amount of soft stool. Staff B removed the dressing to his wound which was dated 6/19 and used the correct technique to cleanse his rectal crease using disposable wipes. The wound noted to the right side of coccyx with a scant amount of serous drainage without odor or signs of infection to surrounding skin and wound. Staff B removed her gloves, washed her hands and donned new gloves and used the correct technique to cleanse the wound. Staff B failed to change gloves before she used the scissors to cut the Xerofoam dressing which she then applied to the wound. In an interview on 6/28/23 at 10:29 AM, Staff B, LPN reported when completing wound care, she should change gloves whenever they become soiled, after removing the old dressings and before putting on new dressings. In an interview on 7/3/23 at 10:10 AM, the Director of Nursing (DON) reported when completing wound care, she expected nurses to change gloves in between clean and dirty. 2. The MDS dated [DATE] identified Resident #5 as cognitively intact with a BIMS score of 13 out of 15 points and had the following diagnoses: Chronic Hepatic Failure, Cirrhosis, Diabetes Mellitus and Seizure Disorder. The MDS documented the resident required extensive staff assistance with bed mobility and dressing. The MDS also identified the resident with one Stage 3 pressure ulcer that he had on admission. On 3/8/23, the Care Plan identified Resident #5 with the problem of a left heel pressure ulcer and directed staff to administer treatments as ordered and monitor for effectiveness. A review of the June TAR's revealed an order dated 6/12/23 and directed staff to Wound #1 Left Heel: Cleanse wound and peri wound with normal saline, pat dry and apply silver alginate to wound bed and cover with dry gauze, apply foam, kerlix and secure with tape. Avoid excessive contact of tape with skin. Change dressing three times per week and as needed. Once a week on Friday at the clinic and twice a week at the facility on Monday and Wednesday. In an observation of wound care on 6/21/23 at 10:35 AM, Staff B, LPN washed her hands, donned gloves and used clean scissors to cut the soiled dressing from the Resident #5's left foot, used the correct technique to cleanse the wound to the left heel. The wound bed appeared cream colored in the center and pink to the outer edges without signs of infection, odor or drainage. The surrounding skin did not appear to have signs of infection. Staff B failed to disinfect the scissors prior to cutting the new Vaseline gauze or the new package of gauze. In an interview on 6/28/23 at 10:29 AM, Staff B, LPN reported when completing wound care, she should disinfect the scissors before wound care and each time she used it to cut through dressings. In an interview on 6/28/23 at 2:33 PM, Staff A, Registered Nurse (RN) reported during wound care nurses should disinfect scissors before and after each use. A review of the facility policy titled: Clean Dressing Change with the last revision date of April 2016 documented the following: a. Perform hand hygiene and apply latex-free non-sterile gloves. b. Remove soiled dressing and discard in trash bag. c. Remove soiled gloves, discard and perform hand hygiene. d. Prepare dressing supplies on clean field. e. Perform hand hygiene and apply latex-free non-sterile gloves. f. Cleanse wound per physician orders. g. Remove soiled gloves, discard and perform hand hygiene. h. Perform hand hygiene and apply latex-free non-sterile gloves. i. Apply dressings per physician orders. The policy failed to direct staff to disinfect scissors before and after scissors when coming in touch with soiled dressings and before and after wound care. 3. The MDS dated [DATE] identified Resident #10 as cognitively intact with a BIMS score of 12 out of 15 points and had the following diagnoses: Cancer, Cerebrovascular Accident (stroke) and Non-Alzheimer's Dementia. The MDS also identified Resident #10 required extensive staff assistance with most activities of daily living and had a history of falls one month prior to admission to the facility. On 6/26/23, the Care Plan identified Resident #10 with the problem of having a catheter and failed to direct staff to keep the tubing off the floor. Observations of the resident with the indwelling catheter bag and tubing found on the floor on the following dates and times: a. On 6/19/23 at 3:45 PM, as he laid in bed with the spigot side of the bag facing the floor. b. On 6/19/23 at 3:48 PM, assessment unchanged. c. On 6/20/23 at 7:47 AM, with bag and tubing lying on the floor. d. On 6/21/23 at 8:01 AM, with tubing lying on the floor. e. On 6/21/23 at 12:36 PM, assessment unchanged. f. On 6/21/23 at 12:42 PM, assessment unchanged. In an interview on 6/28/23 at 11:17 AM, Staff I, CNA reported Aides should make sure that any indwelling catheter tubing does not touch the floor. In an interview on 6/28/23 at 11:35 AM, Staff J, CNA reported Aides should make sure that any indwelling catheter tubing does not touch the floor. In an interview on 6/28/23 at 12:54 PM, Staff K, RN reported Aides should make sure that any indwelling catheter tubing should never touch the floor. A review of the facility policy titled: Catheter Care dated June 2021 had documentation of the following: Check that tubing is not looped, kinked, clamped or positioned above the level of the bladder and off the floor - place bag in catheter bag holder if appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interview, and facility policy review, the facility failed to update the Care Plans as changes occurred for five of six residents reviewed (Residents #2, #4, #6, #7 and #9). The facility reported a census of 59 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #2 as cognitively intact with a Brief interview for Mental Status (BIMS) of 14 out of 15 points. The MDS also identified Resident #2 with the following diagnoses: Diabetes Mellitus with Neuropathy, Heart Failure and Hypertension (high blood pressure), and the resident required extensive staff assistance with most activities of daily living. The Physician Order Summary report dated 6/27/23 documented an order dated for 5/10/23 for Metoprolol 25 milligrams (mg), give one half tablet by mouth two times a day for Hypertension and do not give if the systolic blood pressure (the top number of the blood pressure) is 100 or less or if the heart rate is 58 or less. The May 2023 Medication Administration Record (MAR) did not include a field to enter the resident's heart rate. The following doses were administered at 6:00 PM on the following dates with the following blood pressures (BP): a. On May 18 BP: 99/51. b. On May 25 BP: 81/55. c. On May 28 BP: 95/26. d. On May 31 BP: 94/45. The June 2023 MARs did not include a field to enter the resident's heart rate. The following doses were administered at 6:00 PM on the following dates with the following blood pressures (BP): a. On June 5 BP: 77/41. b. On June 6 BP: 85/52. c. On June 8 BP: 90/49. d. On June 10 BP: 98/52. e. On June 11 BP: 87/47. f. On June 12 BP: 94/51. g. On June 18 BP: 97/49. h. On June 19 BP: 98/51. The Care Plan with the target date of 7/25/23 did not identify Resident #2 with the problem of Hypertension failed to address the interventions as ordered to hold the Metoprolol if the systolic blood pressure was less than 100 or if the heart rate was less than 58. The blood pressures recorded in the Electronic Medical Record (EMR) under the section titled: Weights/Vital Signs had documentation of the following: a. On 6/21/23 at 9:01 AM BP 84/57, at 9:03 AM BP 84/51 and at 9:05 AM BP 84/51. The Nurse's Notes did not have documentation to show any of the above blood pressures had been called to the Physician or Nurse Practitioner. The Progress Notes documented by the physician or nurse practitioner on the following dates and times did not include documentation they had been notified of the above low blood pressures: a. On 5/16/23 at 1:39 PM. b. On 5/23/23 at 3:07 PM. c. On 6/20/23 at 2:23 PM. Observations of Resident #2 revealed no episodes of hypotension, rested comfortably in his wheelchair, properly positioned and appeared comfortable on the following dates and times: a. On 6/19/23 at 11:55 AM and at 1:03 PM and at 3:51 PM. b. On 6/20/23 at 7:51 AM, at 9:32 AM. c. On 6/21/23 at 8:06 AM and 6/21/23 at 10:15 AM. In an interview on 6/28/23 at 2:33 PM, Staff A, Registered Nurse (RN) reported if a resident had orders for Metoprolol and had a systolic BP of below 100, she would hold the dose and recheck the BP again within 30 minutes. In an interview on 6/29/23 at 10:47 AM, Staff G, Licensed Practical Nurse (LPN) reported if a resident had orders for Metoprolol and had a systolic BP of below 100, she would hold the dose and recheck the BP within an hour. Upon review of the MAR, Staff G verified the MAR did not have a field to document the resident's heart rate and it should have. In an interview on 7/3/23 at 10:10 AM, the Director of Nursing (DON) reviewed Resident #2's MARs and verified there was an option in the EMR that should have warned nurses to hold the Metoprolol with low blood pressures as ordered. She would expect the nurses to recheck the blood pressure within an hour and notify the physician. She would not expect the order to hold the Metoprolol to be addressed on the care plan. In an interview on 7/3/23 at 2:16 PM, Staff L, LPN reported when she entered the order for Metoprolol on the MAR, she forgot to add the field to include documentation of the heart rate and could not recall why. If the resident had a BP of 84/50, she would recheck the BP in 30 minutes, hold the Metoprolol and notify the doctor. 2. The MDS dated [DATE] identified Resident #4 as cognitively intact with a BIMS of 13 out of 15 points. The MDS also identified Resident #4 had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Coronary Artery Disease, Diabetes Mellitus and Heart Failure. The MDS identified the Resident #4 required extensive staff assistance with all activities of daily living except for locomotion off the unit, which he had been totally dependent on staff for. The Physician Order dated 3/14/23 directed staff to weigh Resident #4 weekly on Wednesday on day shift. The following weights were documented in the EMR under the section titled: Weights/Vital Signs did not have weights documented on the following dates: a. March 15, 22 and 29. b. April 5, 19 and 26. c. On May 10, 17, 24, and 31. d. On June 14 and 21. On 1/12/23 the Care Plan identified the resident with the problem of nutritional status as evidenced by actual/potential weight loss/gain related to potential for variable oral intake due to depression. The new order for weekly weights dated 3/14/23 was not addressed on the Care Plan. The April 2023 Treatment Administration Records (TARs) revealed the following: a. An order dated 3/15/23 to weigh weekly on Wednesday on day shift and did not have documentation of weights for April 5 and 19 The May 2023 TARs revealed the following: a. An order dated 3/15/23 to weigh weekly on Wednesday on day shift and did not have documentation of weights for the entire month. In an interview on 6/28/23 at 9:37 AM, Staff E, Certified Nurse Aide (CNA) reported the CNA's are responsible for weighing the residents. The nurse will give a list to the aides, the aides will weigh the resident and return the list to the nurse who will then enter it into the EMR. When asked why weights were not documented weekly, he reported the resident could have had family visiting and should have been passed on to the next shift. In an interview on 6/28/23 at 10:12 AM, Staff H, CNA reported the Nurse Aides and sometimes the nurses are responsible for weighing the residents. When the aides weigh the residents, they will record it on a piece of paper, give it to the nurse who will then enter it into the EMR. She could not explain why the weights had not been documented weekly. In an interview on 6/28/23 at 10:29 AM, Staff B, LPN reported the CNAs should weigh the resident, record it on a piece of paper and the nurse will document it on the electronic TAR. She also reported the order should have been addressed on the Care Plan and that any nurse can update the Care Plan. In an interview on 6/28/23 at 2:33 PM, Staff A, RN reported the nursing staff is responsible for weighing the residents and should document in the EMR under the vitals section. When asked why the weights were not documented weekly as ordered, she reported he had refused to stand or sit in the wheelchair to be weighed. If the resident refused to be weighed, it should be documented in the Progress Notes. In an interview on 7/3/23 at 10:10 AM, the Director of Nursing (DON) reported the nurses should tell the aides which residents need to be weighed. Sometimes the resident is not available at the time the aides are ready to weigh the resident, or there is a miscommunication between the nurse and CNA. If there was an order for weekly weights, she would not expect it to be addressed on the Care Plan. In an interview on 7/3/23 at 1:04 PM, the MDS Coordinator reported if there was an order for daily weights, she would expect the nurses to check the physician orders. She also reported it would not need to be addressed on the Care Plan. Observations of the resident during the investigation revealed the resident was always in bed and in no distress and able to feed himself meals without problems. 3. The Minimum Data Set, dated [DATE] identified Resident #6 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 13 out of 15 points and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Coronary Artery Disease and Heart Failure. The MDS also identified Resident #6 required extensive staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing, and identified the resident had 2 or more falls without injury since admission. An incident report dated 4/4/23 at 2:45 PM identified Resident #6 fell trying to get into bed and did not have an injury. On 2/17/22, the Care Plan identified Resident #6 with the problem of activities of daily living (ADL) deficit and directed staff to transfer with one staff member assist with a gait belt. On 2/22/22, the Care Plan identified the resident with the problem of being risk for falls due to unsteady gait, vertigo (dizziness), self-transfer attempts, however, it did not address the fall Resident #6 had on 4/4/23 and did not have new interventions on how to prevent future falls. Observations revealed the resident up in his power chair, properly positioned and did not make any attempts to stand up on his own on the following dates/times: a. On 6/19/23 at 11:47 AM. b. On 6/19/23 at 12:41 PM. c. On 6/19/23 at 3:45 PM. d. On 6/20/23 at 7:46 AM. e. On 6/20/23 at 9:33 AM. f. On 6/21/23 at 8:00 AM. g. On 6/21/23 at 10:13 AM. h. On 6/21/23 at 12:34 PM. In an interview on 6/28/23 at 12:54 PM, Staff K, RN reported any resident fall should be addressed on the Care Plan with new interventions added. The MDS Coordinator usually updates the Care Plans, however, any nurse can update the Care Plans. In an interview on 6/28/23 at 2:33 PM, Staff A, RN reported any resident fall should be addressed on the Care Plan with new interventions added and usually updated by the MDS coordinator. In an interview on 6/29/23 at 10:47 AM, Staff G, LPN reported any resident fall should be addressed on the Care Plan with new interventions added. The MDS coordinator usually updates the Care Plans, however, any nurse can update the Care Plan. In an interview on 7/3/23 at 10:10 AM, the DON reported any resident fall should be addressed on the Care Plan with new interventions added, or add a note to the Care Plan stating it had been reviewed. 4. The MDS dated [DATE] identified Resident #7 as cognitively intact with a BIMS of 15 out of 15 points and with the following diagnoses: Atrial Fibrillation, Peripheral Vascular Disease and Benign Prostatic Hyperplasia. The MDS also identified Resident #7 required extensive staff assistance with most activities of daily living and was totally dependent on staff for assistance with transfers, toileting and bathing. A review of the Nurse's Notes revealed an entry dated 6/13/23 at 6:18 PM with documentation the resident had a new open area identified after debridement by the podiatrist and had new orders to cleanse with sterile water, apply Aquacel slightly larger than the wound and cover with light gauze dressing and secure with tape daily. On 6/14/23, the Care Plan identified the resident admits with legs having dark discoloration and growths- areas debrided at a doctor's appointment on 6/14/23, however, it did not include new interventions to address the new open areas and assess/measure at least weekly. The Skin Alteration Record labeled callous debridement dry failed to have documentation of location or date of onset, however, the left foot circled on the body on the form. The first assessment was dated 6/14/23 documented the wound measured 3 centimeters (cm) long, 5 cm wide and 0.1 cm deep. The area with pale pink tissue, scant amount of serosanguineous drainage, surrounding skin normal in color, firm/hard, with edema, no pain at site. Further assessments and measurements completed June 23 and 27. During an observation of wound care on 6/21/23 1:33 PM, Staff K, RN utilized the correct techniques to remove soiled dressings to the second and third toes to Resident #7's left foot and to cleanse the wounds. The wound beds and surrounding skin did not have drainage or signs of infection or odor. Staff K utilized the correct techniques to apply the new dressings In an interview on 7/3/23 at 10:10 AM, the DON reported she would expect any new open areas to be addressed on Resident #7's Care Plan. 5. The MDS dated [DATE] identified Resident #9 as severely cognitively impaired with a BIMS score of 0 out of 15 points and had the following diagnoses: Dementia, Coronary Artery Disease and Benign Prostatic Hyperplasia. The MDS did not identify the resident with pressure or venous stasis ulcers. On 5/5/22 the Care Plan identified Resident #9 with the problem of chronic wounds to his left foot related to plasmocytic perivascular spongiotic dermatitis to the left heel, foot and toes. The left great toe callus (scab off and treated 6/20/23). The Care plan failed to direct the staff to offer the resident analgesics (used to relieve pain) prior to wound care. A review of the June 2023 MAR and Physician Order Summary revealed an order dated 3/17/20 for Acetaminophen (Tylenol) 325 mg tablet, give 2 tablets orally every 4 hours as needed for pain related to right foot. The MAR did not have documentation to show any doses had been administered for the entire month. During an observation/interview on 6/19/23 at 11:30 AM, Resident #9 sat up in bed with the air mattress inflated and Prevalon boots to both feet (to relieve pressure and help prevent ulcers). Resident #9 reported when the nurses change his dressings and touch a spot on his left heel, it causes a lot of pain and none of the nurses had offered to medicate him prior to the dressing changes. During an observation of wound care on 6/20/23 at 1:01 PM, Staff B, LPN and Staff D, CNA both washed their hands, donned gloves and assisted Resident #9 to turn to his left side. After Staff B removed the dressing to Resident #9's coccyx area, he yelled Ow! I tell you what! At 1:18 PM, as Staff B wrapped a dressing around Resident #9's left foot, the resident flinched with a facial grimace of pain when Staff D lifted his leg. At 1:21 PM, when Staff B left the room for more dressings, Resident #9 reported he was not given any pain medication prior to the dressing change and rated his pain level as 9. In an interview on 6/28/23 at 9:37 AM, Staff E, CNA reported he had helped nurses turn Resident #9 during wound care and 9 times out of 10 Resident #9 will look like he is having pain and will let the staff know this when they turn him. In an interview on 6/28/23 at 10:12 AM, Staff H, CNA reported she has helped nurses turn Resident #9 during wound care and has observed him complain of pain when the staff are too rough when turning him. In an interview on 6/28/23 at 10:29 AM, Staff B, LPN reported Resident #9 did not like being turned over on his side too long and had complained that she took too long to clean him up during wound care. When asked if there was a reason why he was not being pre-medicated prior to his wound care, she reported she never thought of it. In an interview on 6/28/23 at 2:33 PM, Staff A, RN reported Resident #9 had complained of pain when they cleansed his wound. When asked if he was being pre-medicated prior to his wound care, she said no, however, that would be a great idea. She also reported she thought the intervention of pre-medicating Resident #9 prior to wound care should be addressed on his Care Plan and felt the Nurse Practitioner should consider writing an order to pre-medicate. In an interview on 7/3/23 at 10:10 AM, the DON reported Resident #9 had complained during wound care when repositioned or when staff lifted his leg. When asked why he was not being pre-medicated prior to wound care, she reported Resident #9 will say he did not want it, the nurse will ask and he will refuse. She also reported they should be documenting when he refuses. She also reported she felt the need to offer to pre-medicate did not need to be addressed on the Care Plan. A review of the facility policy titled: Care Plan and dated November 28, 2017 had documentation of the following: After the Comprehensive Assessment (State/Federal-required MDS) is completed, the facility will put in place person-centered Care Plans outlining care for the resident within 7 days. These will be periodically reviewed and revised by a team of qualified person after each assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to follow Physician Orders for four of six residents reviewed (Residents #2, #4, #5 and #6). The facility reported a census of 59 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #2 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15 points. The MDS also identified Resident #2 with the following diagnoses: Diabetes Mellitus with Neuropathy, Heart Failure and Hypertension (high blood pressure), and identified the resident required extensive staff assistance with most activities of daily living. The Physician Order Summary report dated 6/27/23 documented an order dated 5/10/23 for Metoprolol 25 milligrams (mg), give one half tablet by mouth two times a day for Hypertension (high blood pressure) and do not give if the systolic blood pressure (the top number of the blood pressure) is 100 or less or if the heart rate is 58 or less. The May 2023 Medication Administration Record (MAR) did not include a field to enter the resident's heart rate. The following doses were administered at 6:00 PM on the following dates with the following blood pressures (BP): a. On May 18 BP 99/51. b. On May 25 BP 81/55. c. On May 28 BP 95/26. d. On May 31 BP 94/45. The June 2023 MARs did not include a field to enter the resident's heart rate. The following doses were administered at 6:00 PM on the following dates with the following blood pressures (BP): a. On June 5 BP 77/41. b. On June 6 BP 85/52. c. On June 8 BP 90/49. d. On June 10 BP 98/52. e. On June 11 BP 87/47. f. On June 12 BP 94/51. g. On June 18 BP 97/49. h. On June 19 BP 98/51. The Care Plan with the target date of 7/25/23 did not identify Resident #2 with the problem of Hypertension and did not address the interventions as ordered to hold the Metoprolol if the systolic blood pressure was less than 100 or if the heart rate was less than 58. The blood pressures recorded in the Electronic Medical Record (EMR) under the section titled: Weights/Vital Signs had documentation of the following: a. On 6/21/23 at 9:01 AM BP 84/57, at 9:03 AM BP 84/51 and at 9:05 AM BP 84/51. The Nurse's Notes did not have documentation to show any of the above blood pressures had been called to the Physician or Nurse Practitioner. The Progress Notes documented by the Physician or Nurse Practitioner on the following dates and times did not include documentation they had been notified of the above low blood pressures: a. On 5/16/23 at 1:39 PM. b. On 5/23/23 at 3:07 PM. c. On 6/20/23 at 2:23 PM. Observations of the Resident #2 revealed no episodes of hypotension, rested comfortably in his wheelchair, properly positioned and appeared comfortable on the following dates and times: a. On 6/19/23 11:55 AM, 1:03 PM, and 3:51 PM. b. On 6/20/23 7:51 AM and 9:32 AM. c. On 6/21/23 8:06 AM and 6/21/23 10:15 AM. In an interview on 6/28/23 at 2:33 PM, Staff A, Registered Nurse (RN) reported if a resident had orders for Metoprolol and had a systolic BP of below 100, she would hold the dose and recheck the BP again within 30 minutes. In an interview on 6/29/23 at 10:47 AM, Staff G, Licensed Practical Nurse (LPN) reported if a resident had orders for Metoprolol and had a systolic BP of below 100, she would hold the dose and recheck the BP within an hour. Upon review of the MAR, Staff G verified the MAR did not have a field to document the resident's heart rate and it should have. In an interview on 7/3/23 at 10:10 AM, the Director of Nursing (DON) reviewed Resident #2's MARs and verified there was an option in the EMR that should have warned nurses to hold the Metoprolol with low blood pressures as ordered. She would expect the nurses to recheck the blood pressure within an hour and notify the physician. She would not expect the order to hold the Metoprolol to be addressed on the care plan. In an interview on 7/3/23 at 2:16 PM, Staff L, LPN reported when she entered the order for Metoprolol on the MAR, she forgot to add the field to include documentation of the heart rate and could not recall why. If the resident had a BP of 84/50, she would recheck the BP in 30 minutes, hold the Metoprolol and notify the doctor. 2. The MDS dated [DATE] identified Resident #4 as cognitively intact with a BIMS score of 13 out of 15 points. The MDS also identified Resident #4 with the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Coronary Artery Disease, Diabetes Mellitus and Heart Failure. The MDS documented Resident #4 required extensive staff assistance with all activities of daily living except for locomotion off the unit which he had been totally dependent on staff for. The Physician Order dated 3/14/23 directed staff to weigh Resident #4 weekly on Wednesday on the day shift. The following weights were documented in the EMR under the section titled: Weights/Vital Signs did not have weights documented on the following dates: a. March 15, 22, and 29. b. April 5, 19, and 26. c. May 10, 17, 24, and 31. d. June 14, and 21. On 1/12/23 the Care Plan identified the resident with the problem of nutritional status as evidenced by actual/potential weight loss/gain related to potential for variable oral intake due to depression. The new order for weekly weights dated 3/14/23 was not addressed on the Care Plan. The April 2023 Treatment Administration Record (TAR) revealed the following: a. Order dated 3/15/23 to weight weekly on Wednesday on day shift and did not have documentation of weights for April 5 and 19 The May 2023 TAR revealed the following: a. Order dated 3/15/23 to weight weekly on Wednesday on day shift and did not have documentation of weights for the entire month. In an interview on 6/28/23 at 9:37 AM, Staff E, Certified Nurse Aide (CNA) reported the CNA's are responsible for weighing the residents. The nurse will give a list to the aides, the aides will weigh the resident and return the list to the nurse who will then enter it into the EMR. When asked why weights were not documented weekly, he reported the resident could have had family visiting and should have been passed on to the next shift. In an interview on 6/28/23 at 10:12 AM, Staff H, CNA reported the Nurse Aides and sometimes the nurses are responsible for weighing the residents. When the Aides weigh the residents, they will record it on a piece of paper, give it to the nurse who will then enter it into the EMR. She could not explain why the weights had not been documented weekly. In an interview on 6/28/23 at 10:29 AM, Staff B, LPN reported the CNAs should weight the resident, record it on a piece of paper and the nurse will document it on the electronic TAR. In an interview on 6/28/23 at 2:33 PM, Staff A, RN reported the nursing staff is responsible for weighing the residents and should document in the EMR under the vitals section. When asked why the weights were not documented weekly as ordered, she reported he had refused to stand or sit in the wheelchair to be weighed. If the resident refused to be weighed, it should be documented in the progress notes. In an interview on 7/3/23 at 10:10 AM, the DON reported the nurses should tell the aides which residents need to be weighed. Sometimes the resident is not available at the time the aides are ready to weigh the resident, or there is a miscommunication between the nurse and CNA. If there was an order for weekly weights, she would not expect it to be addressed on the Care Plan. In an interview on 7/3/23 at 1:04 PM, the MDS Coordinator reported if there was an order for daily weights, she would expect the nurses to check the physician orders. She also reported it would not need to be addressed on the Care Plan. Observations of the resident during the investigation revealed the resident was always in bed and in no distress and able to feed himself meals without problems. 3. The MDS dated [DATE] identified Resident #5 as cognitively intact with a BIMS score of 13 out of 15 and had the following diagnoses: Chronic Hepatic Failure, Cirrhosis, Diabetes Mellitus and Seizure Disorder. The MDS identified the resident required extensive staff assistance with bed mobility and dressing. The MDS documented the resident with one Stage 3 pressure ulcer that he had on admission. On 3/8/23, the Care Plan identified Resident #5 with the problem of a left heel pressure ulcer and directed staff to administer treatments as ordered and monitor for effectiveness. The Physician Order Summary revealed an order dated 4/12/23 directed staff to paint the left heel with betadine, allow to dry for 2 minutes. Cover with Alginate (a natural polymer obtained from brown seaweed), 4 x 4 (gauze dressings) ABD (a highly absorbent dressing) and Kerlix (roll gauze). Change on day shift on Monday, Wednesday and Friday. The April 2023 TAR documented the following: On 4/19/23 6:00 AM, Wound # 1 Left Heel: Cleanse wound and peri wound with saline, Apply Double layer of Xerofoam. Apply ABD pad (a highly absorbent type of dressing) if necessary for drainage, secure with roll gauze and tape. Change dressing once a week at the clinic on Friday and twice weekly at the facility every day shift every Monday and Wednesday for left heel wound dressing. Treatments had been documented as completed on April 19, 21, 24, 26, 28. A review of a progress note from the Wound Care Center dated 4/27/23 revealed Resident #5 presented for treatment of wounds to the left heel. The facility nurses have been doing dressing changes and changing every other day. Resident #5 did not have appropriate dressings on today and instead of the silver alginate that was ordered, presented to the clinic with Xerofoam and ABD to wound bed. In an observation of wound care on 6/21/23 at 10:35 AM, Staff B, LPN washed her hands, donned gloves and used a clean scissors to cut the soiled dressing from the Resident #5's left foot, used the correct technique to cleanse the wound. The wound bed appeared cream colored in the center and pink to the outer edges without signs of infection, odor or drainage. The surrounding skin did not appear to have signs of infection. Staff B did not disinfect the scissors prior to cutting the new Vaseline gauze or the new package of gauze. In an interview on 6/28/23 at 10:29 AM, Staff B, LPN reported the Wound Clinic changed orders on wound treatments frequently and that nurses should check the orders each week after Resident #5 returns from the Wound Care Center. If there were new orders, the nurse should write this in the Communication Book and in the Progress Notes. When the nurse transcribes the order to the TAR, she should note the order which would mean she transcribed the order. In an interview on 7/3/23 at 10:10 AM, the DON reported she would expect the nurses to check Resident #5's orders each week when he returns from the Wound Care Center. 4. The MDS dated [DATE] identified Resident #6 as cognitively intact with a BIMS score of 13 out of 15 points and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Coronary Artery Disease and Heart Failure. The MDS identified Resident #6 required extensive staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The MDS documented the resident has had 2 or more falls without injury since admission. The Physician Order dated 12/12/22 directed staff to weigh Resident #6 three times a week, every Monday, Wednesday and Friday. A review of the weights documented in the EMR showed weights not documented on the following dates: a. In December 2022 - 23,26,28, and 30. b. In January 2023 - 9, 13, 16, 18,23, 25, 27,and 30. c. In February 2023 - 1, 3, 6, 8, 13, 17, 20, 22, 24, and 27. d. In March 2023 - 1, 3, 6, 8, 10, 13, 17, 24, 27, 29, and 31. e. In April 3, 5, 10, 19, and 26. f. In May 3, 5, 8, 10, 12, 17, 19, 22, 24, and 26. g. In June 9, and 12. A review of the TARs revealed weights not documented: a. December 2022 for the entire month b. January 2023 for the entire month c. February 2023 for the entire month d. March 2023 for the entire month e. April 2023 on 3, 5, 7, 10, 12, 14, 24, and 26. f. May 2023 on 3, 5, 8, 10, 12, 15, 17, 19, 22, 24, and 26. g. June 2023 on 2, 9, and 12. On 2/17/22, the Care Plan identified Resident #6 with the problem of cardiac disease related to coronary artery disease and directed staff to obtain weights as needed and report significant changes. On 2/27/22, the Care Plan identified Resident #6 with the problem of nutritional status as evidenced by actual/potential weight loss/gain and directed staff to review weights and notify physician and responsible party of significant weight changes. Observations of Resident #6 revealed he sat up in his power chair and able to feed himself without problems on the following dates/times: a. On 6/19/23 at 11:47 AM. b. On 6/20/23 at 7:46 AM. c. On 6/21/23 at 8:00 AM. d. On 6/21/23 at 12:34 PM. A review of the undated policy titled: Medication Administration had documentation of the following: Open EMAR to Patient Record and review Physician Medication Order against medication label 1. Read transcribed physician order on EMAR: patient name, medication name, dosage, route and interval ordered a. Remove medication from cart. b. Compare EMAR with medication label for accuracy. 2. If medication is unfamiliar or physician order is questioned: a. Read original physician order. b. Compare original physician order with EMAR for accuracy. c. Remove medication from cart. d. Compare EMAR with medication label for accuracy. e. Verify allergy status. f. Contact Physician for clarification, if needed. 3. Read special medication administration instructions. 4. Obtain vital signs, if applicable, and record results on EMAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow Physician Orders for topical patch medications for 2 of 2 residents reviewed. (Resident #6, Resident #43) The facility reported a census of 57. Findings Include: 1. The Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #6 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognitively intact. The MDS documented the resident had received scheduled pain medication at any time in the last 5 days. The MDS showed Resident #6 had a diagnosis of Acute Transverse Myelitis (a demyelinating disease of the Central Nervous System Lymphomas). The Care Plan dated 1/4/23 revealed Resident #6 had Neurological deficiencies related to transverse myelitis and neurosarcoidosis. The interventions included to administer medications per the physician orders initiated on 3/4/22. The Physician Orders dated 10/19/22 for Resident #6 revealed an order for Lidoderm External Patch 5%- Apply to the right hip topically one time a day at 8:00 AM for right hip pain and remove at bedtime. Observation on 2/9/23 at 7:45 AM revealed Staff A, Registered Nurse (RN) removed the Lidoderm Patch dated 2/8/23 on the right outer hip and applied a new Lidoderm patch to the right outer hip dated 2/9/23. During an interview on 2/9/23 at 8:33 AM, queried Staff A if there was a reason the Lidoderm patch from 2/8/23 was still applied from yesterday and Staff A stated they leave it on for 24 hours and she just knew she removed it every morning and didn't know if there was an order on 2nd shift to remove it. Staff A queried if it was standard practice to leave medication patches on for 24 hours and Staff A stated she didn't know and she removed a lot of patches on the next day unless they fell off in bed. Staff A was queried if there were orders to remove patches after 12 hours and Staff A responded she did not think so but she didn't work the other shifts. During an interview on 2/13/23 at 1:41 PM, queried the Director of Nursing (DON) on the expectations of removing Lidoderm and/or fentanyl patches after they are applied and DON stated the Lidoderm patches would be put on in the morning and removed at night unless they are ordered for 24 hours and then they would take one off and place a new one. DON informed Lidoderm patch observed on Resident #6 on 2/9/23 at 7:45 AM and she stated he liked it on all the time and she would talk to the doctor about it. 2. The MDS Assessment Tool dated 1/3/2023, listed diagnosis for Resident #43 included: Dependence on renal dialysis (severe kidney disease), congestive heart failure, and Type 2 diabetes mellitus. The MDS assessed the resident required extensive assistance of one staff for dressing, and personal hygiene. The MDS listed the Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating Intact cognition. A record review revealed the resident admitted to the facility directly from the hospital for skilled care on 12/30/22. The 12/30/22 Hospital Discharge Summary included an order for a Fentanyl Patch 25 micrograms per hour (mcg/hr) 1 patch every 72 hours. A review of the electronic health record (EHR) revealed a physician's order, dated 12/30/22, directing staff to apply a Fentanyl 25 mcg/hr transdermal (on skin) patch every three days (72 hours) for pain. An Admit Note, dated 12/30/22, stated the resident admitted from a local hospital, and orders clarified with the Charge Nurse and noted. The Admit Note stated a Fentanyl Patch escript (electronic prescription) at the Pharmacy and should be delivered to the facility. The admission Evaluation, dated 12/30/22, revealed the resident reported a pain level of 6 out of 10 due to cellulitis in his foot. The evaluation lacked documentation regarding use of a Fentanyl Patch, and if the resident had a patch on from the hospital. A Progress Note dated 1/2/23 revealed the resident reported he had two Fentanyl Patches on his body. One patch, dated 12/28/22 placed on the resident's ankle under a gauze dressing. The other patch, dated 12/31/22 found on the residents shoulder. The December 2022 Electronic Medication Administration Record (EMAR) lacked documentation of a Fentanyl Patch administered on 12/31/22. The January 2023 EMAR documented a 9 for the Fentanyl Patch due on 1/2/23. Per the EMAR chart code, a 9 means other/see nurses notes. The EHR lacked a Progress Note on 1/2/23 explaining the reason for the 9 documented on the EMAR. A general Progress Note, dated 1/5/23, revealed the Fentanyl Patch had not been available or applied on 1/2/23. On 1/5/23 the Fentanyl Patch had been applied. Prior to the application, the resident reported pain as a 7 out of 10. During an interview on 2/14/23 at 2:41 PM, the Director of Nursing (DON) stated she would expect an admission Evaluation would include a head to toe assessment of a resident, and the results be indicated on the Evaluation Tool used in the EHR. The DON stated she did the admission Assessment for the resident on 12/30/22. She recalled finding the Fentanyl Patches dated 12/28/22, and 12/31/22 during the Assessment, and completed the Progress Note documenting this information at the time of the Assessment. The DON stated she can not explain why the Fentanyl Patches found on 12/30/22 were not documented in the admission Evaluation head to toe assessment. The DON stated she can not explain why the Progress Note documenting the two Fentanyl Patches found on the resident on 12/30/22 is dated 1/2/23. The DON stated the December 2022 MAR did not have a Fentanyl order added upon the resident's admission and the facility did not apply a patch on his admission or on 12/31/22. The DON stated she can not explain why the resident had a Fentanyl Patch dated 12/31/22 on his shoulder as documented in the 1/2/23 progress note. The facility policy, dated 5/20/2022, tiled Transdermal Patch Application directed staff to: a. The Implementation Section directed staff to verify the practitioner's orders. b. The Clinical Alert Section directed staff to remove and discard any previously applied patch, and wash and dry any remaining medication from the site, as necessary. The facility policy, dated 5/20/2022, titled Admission, Long Term Care directed staff to perform a physical assessment, focusing on the resident's complaints. The policy also directed staff to document the results of the physical assessment.

Based on observation, electronic record review, resident and staff interviews the facility failed to follow physician orders to treat a non-pressure foot wound and for 1 of 1 residents (Resident #21) in the sample. The facility reported a census of 57 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 12/17/22, listed diagnosis for Resident #21 included: Right below the knee amputation, Type 2 diabetes mellitus, and cellulitis of left lower limb. The MDS assessed the resident required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use. The MDS listed the Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. During an interview on 2/6/23 at 11:51 AM, the resident stated things are not good, and is concerned he will lose his left foot due to a wound. The resident stated he has asked to go to a Wound Clinic but has yet to be informed of an appointment. The resident shared a picture of his left foot. The picture revealed a wound on the lateral aspect of the resident's left foot. The wound appeared dark and surrounded by red, peeling skin. The admission Evaluation, dated 12/13/22, Clinical Evaluation Integumentary (skin) section noted the following skin integrity issues: a. Other - umbilical hernia. b. Right antecubital - puncture wound from IV. c. Other - Right below the knee amputation staples intact. Resident refuses to remove pants, unable to assess the stump. d. Other - Dry skin to face, forehead. The admission Evaluation lacked documentation of skin integrity concerns for the resident's left foot. The facility Skin Alteration Report, dated 1/3/23, documented a 2.5 centimeter (cm) x 2 cm x 0.1 cm pale, pink tissue with scant serosanguineous (watery fluid with pink appearance due to the presence of blood) drainage, and surrounding skin having swelling and maceration (skin softened due to fluid) appearance on the side of residents left foot. The report indicated an alteration type of other, specifying vascular. A Nurse Practitioner (NP) Progress Note dated 1/3/23 revealed the resident reported having a chronic wound on his left foot he has had for the past 8 to 10 years. On 1/3/23 the NP measured the left foot laterally with a result of 2 x 3 with 50% slough, 50% granulation tissue with firm callus at edges, and non tender. On 1/3/23 a Physician Order directed staff to cleanse the left lower extremity and left foot with normal saline, apply Xeroform gauze (type of dressing) to the wound bed and cover with a foam dressing every 48 hours. A record review of the January 2023 Treatment Administration Record (TAR) lacked documentation of completed wound care on 1/3/23 and 1/6/23. The order had a discontinue date of 1/6/23. The facility Skin Alteration Report, dated 1/6/23, documented 2.5 cm x 2 cm x 0.1 cm pale, pink tissue with scant serosanguineous drainage, and surrounding skin having swelling and maceration appearance present on the side of the residents left foot. The report indicated an alteration type of other, specifying vascular. A review of the EHR revealed a Physician Order, dated 1/8/23, directing staff to apply Xeroform oil emulsion external pad to left foot topically on the evening shift every other day for a vascular wound, The January 2023 Medical Administration record (MAR) documented the completion of the 1/8/23 wound care order. The EHR also revealed an NP Order on 1/10/23 directing wound care to residents left foot, cleansing with normal saline, apply alginate to wound bed, cover with foam dressing, change every other day. The January 2023 MAR and TAR lacked a scheduled order for the 1/10/23 order, and accompanying documentation regarding the completion status of the order. A review of the EHR revealed a lack of documentation seeking clarification of the 1/8/23 and the 1/10/23 wound care orders. The facility Skin Alteration Report, dated 1/10/23, documented 2 cm x 3 cm x 0.1 cm dark pink/red tissue, and slough with scant serosanguineous drainage, and surrounding skin having a reddened appearance present on the side of the residents left foot. The report indicated an alteration type of other, specifying vascular. The EHR Census revealed the resident's hospitalization from 1/15/23 to 1/18/23. The facility Skin Alteration Report, dated 1/18/23 documented 3 cm x 3 cm x 0.0 cm pale, pink tissue with no drainage and the surrounding skin having a maceration appearance present on the side of the residents left foot. The report indicated an alteration type of other, specifying vascular left lateral foot, heel ankle area. The EHR Census revealed the resident's hospitalization from 1/22/23 to 1/25/23. The facility Skin Alteration Report, dated 1/25/23, documented 4 cm x 5 cm x 0.4 cm intact skin pale, pink tissue with no drainage and the surrounding skin having a maceration appearance present on the side of the residents left foot. The report indicated an alteration type of other, specifying vascular/diabetic left lateral pedal surface. A second facility Skin Alteration report, dated 1/25/23, documented 3 cm x 2.5 cm x 0.0 cm as white tissue, pale, pink tissue with no drainage, and surrounding skin with a maceration appearance present near the heel of the residents' left foot. The report indicated an alteration type of other, specifying vascular, left lateral foot. The report also contained a notation of change to diabetic status post hospital. A review of the EHR revealed a Physician Order, dated 1/26/23, directing staff to apply silver sulfadiazine external cream 1% to left foot wounds topically every evening shift for wound care. The January 2023 EMAR lacked documentation of wound care occurring on 1/27/23. The January 2023 EMAR documented a 9 for wound care on 1/29/23. Per the EMAR chart code, a 9 means other/see nurses notes. The EHR lacked documentation to explain the 9. The February 2023 EMAR documented a 9 for wound care on 2/2/23. The EHR lacked documentation to explain the 9. The facility Skin Alteration Report, dated 2/1/23 documented 5 cm x 4.5 cm x 0.1 cm dark pink/red tissue, with scant serous (clear) drainage. Appearance of surrounding skin alteration not indicated. The report indicated an alteration type of other, specifying vascular/diabetic left pedal surface. A second facility Skin Alteration report, dated 2/1/23 per the Nurse Practitioner, noted a 3 cm x 2.5 cm x 0.0 cm intact skin, with no drainage and surrounding skin maceration in appearance present near the heel of the resident's left foot. The report indicated an alteration type of other, specifying vascular, left lateral foot. The report also contained a notation of change to diabetic status post hospital. The facility Skin Alteration Report, dated 2/7/23 documented 6.25 cm x 7 cm with no depth noted. The report noted the wound sites merged together. The wound described as 90% eschar, and 10% slough, with no drainage. The appearance of the surrounding skin described as firm/hard. On 2/8/23, the provider sent an order for the resident to go to the local hospital emergency room (ER) for the deteriorating wound. An observation of wound care on 2/13/23 at 11:00 AM, revealed the left foot to have a dark wound bed starting on the top of the left 5th toe, down towards the middle of the lateral aspect of the foot and around to the bottom of the foot. The wound did not have an odor and no observable drainage. The resident denied experiencing pain. On 2/13/23 at 11:05 AM, Staff C, Registered Nurse (RN)/Unit Manager stated the facility Nurse Practitioner (NP) completes measurements as she is the residents Wound Care Provider. Staff C stated the NP will see the resident either on 2/14/23 or 2/15/23 and the wound will be measured at that time. During an interview on 2/14/23 at 3:08 PM, the Director of Nursing (DON) stated the wound on the resident's left foot deteriorated since the assessment on 1/3/23 noting an open area. The DON stated the facility NP monitored the wound weekly, and the resident had two hospitalizations with no new orders for wound care with either discharge. The DON stated after the resident returned from the facility on 1/25/23 the left foot wound had become necrotic The DON stated she can not explain why the 1/25/23 Skin Alteration Report described the wound as pale, pink, with no documentation of necrotic tissue. The DON stated every one who saw the resident did what they could for the wound, and she did not believe an appointment at the Wound Care Clinic would happen any sooner than the care the resident received or change the care received. The DON stated she expects staff to follow all Doctors Orders as prescribed for wound care. She stated if wound care had not been completed she would expect a completed Progress Note in the EHR explaining. The undated facility policy, titled Medication and Treatment Administration Guidelines, Long Term Care directed staff to immediately document the medication and treatment administered. The policy directed staff to report medications or treatments not administered as ordered to the provider. The staff should also document in the clinical record the name, dose of medication and reason why the medication or treatment was not administered.

Based on Clinical record review, policy review and staff interviews the facility failed to coordinate care with a Dialysis provider for one of one residents (Resident #43) sampled. The facility reported a census of 57 residents. 1. The Minimum Data Set (MDS) Assessment Tool, dated 1/3/2023, listed diagnosis for Resident #43 included: Dependence on renal dialysis (severe kidney disease), congestive heart failure, and Type 2 diabetes mellitus. The MDS indicated the resident received dialysis while not a resident and while a resident. The MDS listed the Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating Intact cognition. The clinical record review revealed an order dated 12/30/22 for the resident to receive Dialysis three times per week. A review of the electronic and paper clinical record reviewed the facility had attempted coordination with the Dialysis provider on two dates 1/2/23, and 2/6/23. During an interview on 2/13/23 at 11:15 AM, when asked how the facility coordinates care with a Dialysis provider, Staff C, Registered Nurse stated the Dialysis Center does not send back the sheets we send them. Staff C stated the facility does not call the Dialysis provider to facilitate communication, and assumes when the resident comes back everything is okay. During an interview on 2/14/23 at 2:41 PM, the Director of Nursing (DON) stated the staff do coordinate care with the Dialysis Center, but we could do a better job. The facility policy, dated 2023, titled Dialysis Guidelines stated it is the center and the Dialysis Provider are responsible for shared communication regarding patients receiving Dialysis services, either off site or on site.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review the facility failed to screen residents for eligibility of the pneumococcal and influenza vaccines for 2 of 9 residents reviewed. (Resident #17, Resident #52) ) The facility reported a census of 57 residents. Findings Include: Review of the Facility's Immunization Report revealed Resident #17 and Resident #52 had unknown status for the influenza and pneumococcal vaccines, and documented the following admission dates: a. Resident #17 admitted to the facility on [DATE]. b. Resident #52 admitted to the facility on [DATE]. During an interview on 2/9/23 at 10:56 AM, Infection Preventionist queried about unknown status for vaccinations for Residents #17 and #52 and she stated she was not able to find any documentation on their vaccine status and had even called the hospital. The Infection Preventionist queried about Iowa Registry Immunization System (IRIS) for vaccine look up and she stated she will start to utilize IRIS now. During an interview on 2/13/23 at 1:41 PM, queried the Director of Nursing (DON) on what the expectation of residents being vaccinated for pneumococcal and influenza and the DON stated they offered the influenza and pneumococcal every fall. The DON queried on the time period after a resident admitted for their vaccines to be completed or documented and the DON stated it would depend on whether they refused or not and there was not a real time frame. The DON queried if residents were admitted in November 2022 should there vaccine status be updated and she stated they should have asked them in the fall if it was not in their written paperwork or in the clinical records. The Facility Policy titled Infection Control Manual Chapter 10: Screening and Vaccination Policy dated 5/22 revealed in part, the following: a. Influenza- offer upon admission to eligible residents if they have not been vaccinated for the current influenza season and annually thereafter. b. Pneumonia- offer upon admission to eligible residents who have never been vaccinated for pneumonia or unknown vaccination history.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review the facility failed to screen residents for eligibility of the COVID-19 vaccines and/or failed to document refusal or acceptance of the COVID-19 vaccines for four of nine residents reviewed. (Resident #4, #17, #51, and #52) ) The facility reported a census of 57 residents. Findings Include: Review of the Facility's Immunization Report revealed the COVID-19 Vaccines Consent Status for Residents #4, #17, #51, and #52 stated TBD (To Be Determined), and Administered Information had been left blank. Documentation revealed the following admission dates: a. Resident #4 admitted to the facility on [DATE]. b. Resident #17 admitted to the facility on [DATE]. c. Resident #51 admitted to the facility on [DATE]. d. Resident #52 admitted to the facility on [DATE]. During an interview on 2/9/23 at 10:56 AM, Infection Preventionist queried about unknown status for vaccinations for Residents #17 and #52 and she stated she was not able to find any documentation on their vaccine status and had even called the hospital. The Infection Preventionist queried about IRIS (Iowa Registry Immunization System) for vaccine look up and she stated she will start to utilize IRIS now. The Infection Preventionist queried about the COVID-19 vaccine status for Resident #4 and #51 and she stated they have both refused up to this point but she wanted to ask them one more time before she put them down as a refusal. During an interview on 2/13/23 at 1:41 PM, queried the Director of Nursing (DON) on what the expectation of residents being vaccinated for COVID-19 and the DON stated they just completed the second clinic for the Bivalent booster and offer the COVID vaccine to the skilled residents who haven't had their COVID vaccines. The DON queried on the time period after a resident admitted for their vaccines to be completed or documented and the DON stated it would depend on whether they refused or not and there was not a real time frame. The DON queried if residents were admitted in November 2022 should there vaccine status be updated and she stated they should have asked them in the fall if it was not in their written paperwork or in the clinical records. The Facility Policy titled Infection Control Manual Chapter 10: Screening and Vaccination Policy dated 5/22 revealed in part, the following: a. COVID-19- offer upon admission either the single dose COVID-19 vaccine or one of the 2 dose vaccines with the second dose administered per manufacturer's recommendations to eligible residents who have never received or who had previously refused the COVID-19 vaccines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident bath documentation review, Facility Grievance Book review, resident and staff interviews, the facility failed to aide residents with bathing or shower needs twice a week for five of six residents reviewed. (Residents #2, #6, #7, #8 and #9). The facility reported a census of 53 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 identified a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident had been cognitively intact. Review of Resident #2's October 2022 Shower record shown Monday and Thursday assigned as the resident's days of the week to have had a shower. Further review of the October 2022 Bath Record shown the resident had completed one shower for the entire month on 10/27/22. The dates of 10/3, 10/10, 10/13, 10/17, 10/20, 10/24, and 10/31 lacked documentation as evidenced by blank boxes indicating no shower had been given. The date of 10/6/22 had documentation that Resident #2 had refused a shower on the date aforementioned. Review of Resident #2 November 2022 Shower Documentation shown Monday and Thursday as the resident's assigned shower days of the week. Review of the November 2022 Bath Record shown Resident #2 had not received one shower the entire month as evidenced by no documentation had been recorded on 11/3, 11/7, 11/10, 11/14, 11/17, 11/21, 11/24, and 11/28. Each of the aforementioned dates had been left blank. Review of Resident #2's Shower Documentation record shown during December 2022, the resident assigned Monday and Thursday for showers. Further review of the record shown Resident #2 received a total of two showers on the dates of 12/15 and 12/26. Documentation had shown the dates of 12/1 and 12/5 were blank which had indicated no shower given and on 12/8/22 shown documentation of resident refusal. During an interview on 12/27/22 at 4:15 PM, Resident #2 stated that during a shower on 12/26/22 the hot water had run out and he had finished the shower in cold water. The resident remarked this is not the first time this had happened, and he had gone up to three weeks without a shower. 2. Review of the MDS dated [DATE] for Resident #6 recorded a BIMS total score of 14 out of 15, indicating intact cognition. Review of Resident #6 Shower Documentation for October 2022 shown the resident assigned Wednesday and Saturday for shower days. During October 2022 Resident #6 received two showers total on the dates of 10/1 and 10/8. Documentation shown the resident not available on 10/5, 10/12, 10/15 and 10/19, 10/20 and 10/25. There had been no documentation on 10/ 22 as evidenced by a blank checkbox. Review of the November 2022 Shower Documentation shown the resident had switched to Monday and Thursday for shower days. Further review of the November documentation for showers indicated the resident received one shower for the entire month which had been on 11/14/22. On 11/7, 11/24, and 11/28 documented as resident refused. Further review shown 11/3, 11/10, and 11/21 with no documentation as evidenced by blank boxes indicating no shower completed. Review of December 2022 Shower Documentation shown Resident #6 received a total of five showers in December on either a Monday or Thursday. On 12/1 documented as no shower due to resident unavailable. No documentation noted on the dates of 12/12, and 12/26 as evidenced by blank check boxes indicating a shower not completed. During an interview on 12/27/22 at 2:39 PM, Resident #6 stated he does not always get a shower every week. The resident stated this happens because of a problem with the water system. Further review of the record shown no documentation of any as needed showers outside of scheduled shower days of the week for the months of October, November and December 2022. 3. Review of the MDS assessment dated [DATE] for Resident #7 identified a BIMS score of 15 out of 15, indicating the resident had intact cognition. Review of the Facility Grievance Report Book shown Resident #7 asked Therapy Staff to complete a Grievance Form on 11/21/22 which stated the resident had no shower or bath offered since having been admitted to the facility on [DATE]. Resident #7 admitted to a room on the first floor. Review of Resident #7's Shower Document shown the resident should have had a minimum of nine showers or baths for the month of November 2022, instead the record shown Resident #7 received a total of two showers. Five of the November 2022 shower dates noted with no documentation as evidenced by a blank check box. Two of the November 2022 shower dates marked as the resident refused. Review of the December 2022 Shower Record on 12/28/22 shown the resident completed a shower and had washed hair for two of four scheduled Mondays. The two Monday evening showers not completed were marked Resident #7 refused. Resident #7 scheduled on Thursday evenings in December 2022 and review of the Shower Record shown the resident did not receive a shower out of four opportunities. One of the Thursday evening boxes contained no documentation. Three of the Thursday evening dates had been marked Resident #7 refused. On 12/28/22 at 10:20 AM an interview completed with Resident #7. When asked about the facility showers and water temperature the resident had stated showers had not been offered twice a week. The resident had stated once the right lower leg boot had been removed and the wound vac discontinued then he had been independent with wrapping and taping a bag to his right lower leg. During an interview with Resident #7 on 12/28/22 at 11:00 AM the Shower Activity Documentation discussed in further detail and Resident #7 informed of documentation stating resident's refusal of shower on December 22. Resident #7 stated refusal of a shower had been one time during the evening due to a medication taken that had previously caused altered physical balance issues. Resident #7 further stated that morning showers are preferred due to retiring at 8:00 PM for sleep. The resident went on to state facility staff had been made aware of morning shower preference. Resident #7 stated when asking staff for help getting to the shower that staff would verbalize the particular day as not being the assigned shower day. Resident #7 reported having to wash hair in the room sink had been frustrating and stated not having body odor due to having had to 'get on-it' (washing up) at the sink within room. Observation of the sink area had shown several personal hygiene products sitting upon the sink counter. 4. Resident #8 documented as admitted to the facility 12/8/22 for short-term care. Resident #8's MDS completed on 12/14/22 shown a BIMS score of 12 out of 15, indicating a moderate mental impairment. Review of a Care Plan dated 12/9/22 shown Resident #8 identified to have bladder incontinence. During an interview on 12/28/22 at 10:00 AM, Resident #8, stated the shower water needed to be warmed up for awhile sometimes to get hot. Review of the Bathing Schedule for Resident #8 documented Tuesday and Friday as bath days. During December 2022 Resident #8 completed a total of one shower with hair washing on 12/27. Further review of the December documentation shown staff documented the resident refused on 12/16, 12/20, and 12/23. 5. The MDS for Resident #9 dated 12/8/22 documented a BIMS score of 14 out of 15, indicating the resident had intact cognition. Records shown Resident #9 admitted to the facility 6/23/22. Review of the most recent MDS shown Resident #9 depends extensively on staff for physical assistance with bathing activity. Review of the Care Plan dated 7/6/22 shown a revision to the bladder incontinence area due to Resident #9 having increased incontinence. On 8/29/22 the Care Plan updated to include the resident being at risk for skin integrity issues related to urinary incontinence and immobility. Review of the December 2022 Shower Record Activity shown Resident #9 with four opportunities on Fridays during the day. Resident #9 had a bed bath on 12/2/22 and one shower during December on 12/9/22. The date of 12/16/22 documented as resident refused and 12/23/22 documented as not applicable. During an interview on 12/28/22 at 1:30 PM Resident #9 stated the water temperature not warm during several showers and further stated no shower being offered for two to three weeks with hot water. Resident #9 stated on 12/2/22 during a bed bath that her hair had also been washed. During the interview, Resident #9 had been asked if the facility working on the hot water and stated had no knowledge if the facility hot water was being fixed. Resident #9 verbalized frustration of information about facility repairs and upgrades not being given.

Based on review of facility documentation, facility policy, resident and staff interviews and observations the facility failed to maintain essential equipment in safe operating mechanical condition to provide hot water needed for residents to shower. The facility reported a census of 53 residents. Findings Include: During an interview on 12/28/22 at 9:20 AM, with Staff A, Registered Nurse (RN) the number of facility showers given discussed. Staff A reported she worked at the facility for three years. Staff A explained first floor had two shower rooms however Staff A stated the [NAME] Shower on the first floor had been shut off due to cold water. On 12/28/22 at 9:30 AM, Staff A checked the water temperature of the hot water. After the hot water run for two minutes the hot water temperature was 100.5 degree. Staff A verbalized the facility replaced the hot water heater approximately one month ago. During an interview on 12/28/22 at 12:20 PM, the Maintenance Director reported being in the position for one year and been on-site five days a week, and staff call after hours for maintenance needs. When discussing the shower temperature, the Maintenance Director stated on 12/22/22 a shower had been closed on each floor. Shower One (first floor) and two (second floor) [NAME] had been closed and the water temporarily shut off to each shower. The Maintenance Director stated working with a Regional Maintenance Director and a plumbing company had been set up through a Regional support team. The Maintenance Director further stated the following completed to date: a. Hot water heater replaced. b. The boiler cleaned. c. A mixing valve added. When asked about temperature checking and if Documentation Logs kept, the Maintenance Director stated taking temperatures once or twice per week is normal. The Maintenance Director further stated water temperatures are taken on first shift one week in the morning and then on second shift the next week at 2:00 PM in the afternoon. An interview with Staff B, Licensed Practical Nurse (LPN) completed on 12/28/22 at 12:54 PM. Staff B stated the facility hot water heater had been replaced recently and further stated the second-floor [NAME] shower water shut off due to being cold water only. Staff B reported having usually worked on second floor that residents were apprehensive to transport to first floor to have a shower. Staff B further explained, the shower schedule reviewed daily to see if extra showers could be worked into the day and stated the water temperature issues had been an issue for longer than four weeks. Staff B stated that if a resident refused a shower or bed bath that a Certified Nurse Aide (CNA) notifies the nurse and the nurse would then speak with the resident and encourage the bed bath or shower. Staff B reported a resident could have a shower or bed bath as needed and the electronic clinical record had an area to chart an as needed shower. Staff B stated the shower days decided on a resident's admission however the day and time of day can be changed. During an interview on 12/28/22 at 2:05 PM, Staff C, Director of Nursing (DON) stated she had been employed at the facility for nine years. When asked about expectations for resident bed baths or showers weekly, Staff C stated each resident expected to receive a bath or shower a minimum of twice a week. Staff C further reported audits completed on the electronic shower documentation per the Medical Records staff. Staff C indicated hot water had been an ongoing issue the facility had been trying to resolve. Staff C also stated for residents going out of the facility over Christmas that water needed warmed up in the microwave for bed baths. Staff C further stated when showers had been completed on each floor in the morning and Dietary and Laundry operating, then the hot water had run out. On 12/28/22 at 2:30 PM, the facility Administrator provided a copy of the Water Management Program Plan for review. Page 11 of the plan outlined the parameters for hot water as followed: High temperature hot water (> 140 Fahrenheit (F)) is mixed with cold water in a thermostatic mixing valve (TMV) to reduce temperature to a range of 105 degree to 120-degree F to prevent potential scalding of users. VHA, 2014 indicates that for most adults, water temperature of 110-degree F at the outlet will minimize the risk of scalding. At 117 degrees, the risk of scalding is significantly increased, and at 140 degrees then 2nd degree burns may occur within three seconds of exposure. Discomfort or injury of elderly persons may occur at lower temperatures. On 12/28/22 at 3:00 PM, during an interview with Staff D, CNA, reported she worked at the facility approximately six years. When asked about the hot water and shower availability, Staff D stated there had been a problem for less than one year. Staff D verbalized residents can be taken to a shower on another floor, however they are resistive to change. Staff D stated the shower plate on the first floor had been applied incorrectly and the COLD marked on the silver diameter is the hot and vice versa. On 12/28/22 at 4:00 PM, the Administrator and the Maintenance Director each provided a one-page document which lacked dates and times the water temperature had been checked. On 12/29/22 shower water temperature checks had been observed where staff had access to one shower on the first floor. The second shower on the first floor had been shut off by the Maintenance Director. The shower located on the first floor temperature checked on 12/29/22 at 9:17 AM and the facility Administrator turned on the hot water. The Administrator had initially entered the shower room and found the Housekeeper running the hot water to check for hot water to notify nursing. After the water had run for three minutes, the water temperature was checked by the Administrator and read 96 degrees. The water continued to run on hot and at three minutes later at 9:20 AM the Administrator re-checked the temperature which read 94 degrees. After continuous hot water running the water temperature at five minutes, 9:22 AM, and checked by the Administrator then read 92 degree. The water temperature not checked at ten minutes due to the decreasing temperatures. The Administrator verbalized the facility had difficulty maintaining hot water temperatures in the morning due to kitchen water needs and the facility had laundry facilities within. The Administrator reported the [NAME] shower on the first floor had been shut off to help identify the water temperature issue. The Maintenance Director had turned the hot water on at 9:39 AM within the first-floor shower. The water temperature checked at three minutes, at 9:42 AM read 50.0 degrees. The water continued to run and the temperature checked by the Maintenance Director at five minutes at 9:44 AM, and read 40 to 42 degrees. The water temperature not checked at ten minute interval due to plummeting temperatures from the three minutes to five-minute check. The Maintenance Director turned the water on at 11:11 AM, and the water temperature checked at three minute interval at 11:14 AM and recorded at 59 degrees. The water continued to run and the Maintenance Director checked the water temperature at five minutes at 11:16 AM, and been 40 degrees. The water temperature check not completed at ten minutes due to plummeting temps. No showers had been given on the first floor on 12/29/22 due to hot water temperatures being below normal. Staff had access to one shower on the second floor as the second shower on the second floor had been shut off by the Maintenance Director. The second-floor shower hot water had been turned on at 9:50 AM by the Maintenance Director, and water temperature checked at three minutes at 9:53 AM, and read 102 degrees. The hot water continued to run and checked by the Maintenance Director at five minutes at 9:55 AM and read 101 degrees. The water continued to run and the Maintenance Director checked the water temperature at ten minutes, at 10:00 AM and read 102.7 degrees. The Maintenance Director had decided to complete a second-floor shower water temperature check at 11:20 AM. Per the facility staff in the second-floor shower room the water had been running for 30 minutes as resident showers had been given. The facility staff stated to the Maintenance Director that the hot water had been running continuously to maintain hot water. The Maintenance Director checked the water temperature at 11:20 AM, and the water temperature read 102.3 degrees. The Maintenance Director checked the water temperature at 11:23 AM at the three minute interval and read 102.6 degrees. The five-minute water temperature checked by the Maintenance Director at 11:25 AM read 102.6 degrees. The water temperature at ten minutes not completed due to a resident waiting to shower.