**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #29 was admitted to the facility in February 2023 with diagnoses including achondroplasia and hydronephrosis. Review of the Minimum Data Set (MDS) asssessment dated 12/4/24, indicated Resident #29 is cognitively intact as evidenced by a score of 14 out of a possible 15 on the Brief Interview for Mental Status exam. The MDS also indicated Resident #29 requires assistance for bathing, dressing and toileting. Review of Resident #29's physicians orders indicated: Sodium Chloride Oral Tablet 1 GM (Sodium Chloride) Give 1 tablet by mouth three times a day for Hyponatremia Repeat BMP every week until sodium level normalizes and adjust salt tablet, 10/18/24. Additional review of Resident #29's physicians orders indicated: November 2024: labs were not obtained the weeks of 11/10/24, 11/17/24 and 11/24/24. December 2024: no labs were obtained. January 2025: no labs were obtained. February 2025: labs were not obtained the weeks of 2/2/25, 2/9/25, and 2/16/25. During an interview on 3/7/25 at 11:25 A.M., the Assistant Director of Nursing (ADON) said staff should implement physicians orders. The ADON said that if the nursing staff had questions related to Resident #29's ordered weekly labs, they should have called the physician for clarification. 3. Resident #1 was admitted to the facility in February 2023 with diagnoses including peripheral vascular disease and lymphedema. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she was cognitively intact. The MDS further indicated the Resident had wounds. On 3/4/25 at 8:13 A.M., the surveyor observed Resident #1 lying in his/her bed. The air mattress was set at 10/380 lbs (pounds). On 3/6/25 at 7:59 A.M., the surveyor observed Resident #1 lying in his/her bed the air mattress was set at 10/380 lbs (pounds). On 3/6/25 at 11:00 A.M., the surveyor observed Resident #1 lying in his/her bed the air mattress was set at 10/380 lbs (pounds). Review of the medical record indicated the following physician order dated 4/18/24: - Low air loss mattress check settings and functions every shift - settings at 10/350 Lbs - every shift for preventative skin check proper function. Review of the current Treatment Administration Record (TAR) indicated the nurses had signed off that the air mattress was set at 10/350 Lbs. During an interview on 3/6/25 at 11:07 A.M., Nurse #6 said the physician order should match the air mattress setting and that nurses are responsible for ensuring the air mattress is checked for correct setting and proper functioning. During an interview on 3/7/25 at 11:10 A.M., the Assistant Director of Nursing (ADON) said the physician orders should match Resident #1's actual mattress pressure. Based on observation, record review and interview, the facility failed to meet professional standards of practice for three Residents (44, #29, and #1) out of a total of 20 sampled residents. Specifically, 1. For Resident #44, the facility failed to: a.) adequately assess, monitor, and implement a physician order for fluid restrictions (limiting the amount of fluid a person takes in) from August 2024 to March 2025. Subsequently, Resident #44 was hospitalized in February 2025, and admitted to ICU (intensive care unit) with diagnosis of acute hypoxic respiratory failure, acute renal failure and septic shock., b.) failed to follow up on physician recommendations for new prosthetic leg, and c.) failed to implement a physician order for bilateral shoulder X-ray. 2. For Resident #29, the facility failed to obtain labs as ordered by the physician. 3. For Resident #1, the facility failed to ensure the air mattress was set per the physician order. Findings include: 1. Resident #44 was admitted to the facility in August 2024 with diagnoses that include, chronic kidney disease stage 4 severe, retention of urine, type 2 diabetes mellitus, and congestive heart failure (CHF). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/17/25, indicated that Resident #44 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Further review of the MDS indicated Resident #44 requires substantial/maximal assistance for self-care and mobility, has functional limitation in range of motion to lower the extremity and has an impairment on one side requiring the use of an orthotic/ prosthetic. a. Review of Resident #44's active physicians orders indicated: No Concentrated Sweets diet- Regular texture, Thin consistency, 1500 ml/day fluid restriction 1500 ml (milliliters) Total in 24 hrs (hours): Nursing 660ml/24hr, (240 ml on 7-3, 240ml on 3-11, 180 ml on 11-7) Dietary 840ml/24 hrs) 360ml @ breakfast, 240ml lunch, 240 ml @ Dinner). Dated 8/27/24. Review of Resident #44's MAR and TAR failed to indicate monitoring of fluids and did not contain any information related to fluid restrictions. Review of Resident #44's nutrition care plan indicated: - Resident is nutritionally at risk r/t (related to) CHF, diabetes, anemia, COPD, poor dentition. Dated as revised 8/28/24. Interventions included: - Record and monitor intakes. - Continue diet as ordered. Review of Resident #44's current dietary slip failed to indicate fluid restrictions. Review of Resident #44's Kardex, (a form indicating level of care needs) failed to indicate the Resident was on fluid restrictions. Review of the nursing progress note dated 8/30/24, indicated: fluid restrictions maintained. Review of the Nutritional Risk Evaluation dated 1/13/25 indicated: Nutritional Plan: Identified at-risk for weight loss and dehydration - Yes. - Resident is on 1500ml F/R (fluid restriction). Resident had been admitted to Hospital for acute on chronic CHF and acute on chronic Renal failure. Resident had diuretics for excess water. Note that he/she is on diuretic and may experience wt.(weight) fluctuations via fluid shifts. He/she knows his nutritional expectations while on a diabetic diet with F/R. Will continue to monitor ongoing trends and adjust needs accordingly. Review of the nursing progress note dated 1/31/25 indicated: This RN was notified by this patients significant other that he/she would like this patient to be sent out to hospital. When RN asked why, he/she stated that he/she thinks he/she has pneumonia. I went to assess the patient.BP slightly low, 90/56, o2 90% on RA (room air), pulse 54. Afebrile. Patient agreeable to send out to hospital. EMS was called and patient was transferred out. Review of Resident #44's medical record indicated the following Nursing progress note dated 2/11/25, Per discharge paperwork the Resident was found to be covid positive, was admitted to ICU (intensive care unit) for management of acute hypoxic respiratory failure, acute renal failure and septic shock. Review of the hospital discharge paperwork dated 2/11/25, indicated that Resident #44 was admitted to the hospital and diagnosed with acute renal failure superimposed on stage 4 chronic kidney disease, acute hypoxic respiratory failure, hypokalemia (low potassium level), hyponatremia (low sodium level), community acquired PNA (pneumonia), and sepsis. - Disease course complicated by worsening kidney function. - AKI (acute kidney injury), hyponatremia, urinary retention. During an interview on 3/6/25 at 9:48 A.M., Certified Nursing Assistant (CNA)#6 said Resident #44 is not on fluid restrictions and said the Resident can have anything he/she wants to drink to stay hydrated. During an interview on 3/7/25 at 11:02 A.M., the assistant Director of Nurses (ADON) said Resident #44 has an order for fluid restrictions and said staff should be following the orders as written. The ADON said the care plan should indicate fluid restrictions and the order should be on the Medication Administration Record (MAR) or on the Treatment Administration Record (TAR) to track fluids. The ADON said the dietary slip should indicate the Resident is on fluid restrictions. During an interview on 3/10/25 at 10:17 A.M., Nurse Practitioner (NP) #1 said Resident #44 is very fragile and needs close monitoring due to his/her medical conditions and requires close monitoring of fluid restrictions. NP #1 said fluid restrictions should have been completed as ordered with ongoing monitoring of the fluid restrictions daily. NP #1 said staff should be following fluid restrictions as ordered especially after the recent hospitalization. b. During an observation on 3/4/25 at 9:45 A.M., Resident #44 was sitting in bed. There was a prosthetic leg on the floor next to the bedside table. During an observation on 3/7/25 at 8:40 A.M., Resident #44 was sitting in bed and said to the surveyor old leg not new one as he/she pointed to the prosthetic leg on the floor. When the surveyor asked if he/she was getting a new one, Resident #44 shook his/her head side to side and said I don't know. Review of the physician note dated 1/7/25, indicated: visit with patient today about new prosthetic. Patient stated old prosthetic is too heavy to ambulate, with increase fatigue and LE (left extremity) and low back pain. Would recommend new lighter fitting prosthetic to help increase ambulation distance and decrease pain with less caregiver asst. Review of the clinical record failed to indicate that Resident #44 had ever been evaluated for a new prosthetic leg. During an interview on 3/6/25 at 9:10 A.M., the Director of Rehab said Resident #44 may benefit from a new prosthetic leg because it is very old and he/she may have lost weight since admission and said he called the vendor last week, (approximately 2 months since the physician note recommending a newer prosthetic), but should call again to set up an evaluation. During an interview on 3/7/25 at 11:23 A.M. the Assistant Director of Nurses (ADON) said she would expect that an evaluation would be completed and said she was not aware of the recommendation. During an interview on 3/8/24 at 9:38 A.M., the Director of Nursing said that she would look into the consult for the prosthetic leg and said she would expect staff to follow up when the recommendation was made in January to start the process. During an interview on 3/10/25 at 10:28 A.M. Nurse Practitioner #1 said she would expect that recommendations would be implemented and documented in the medical chart to obtain a new prosthetic leg. c. Review of the Nurse Practitioner note dated 10/28/24, indicated, Chief complaint about shoulder pain. Assessment & Plan- bilateral shoulder pain: pt c/o (patient complained of) bilateral shoulder pain. Will order shoulder X-ray to assess for arthritis. Review of the nursing progress note dated, 11/1/24, indicated a physician order for Lidocaine patch for c/o pain to bilat (bilateral) shoulder. Review of the medical record indicated an imaging signature request form from an outside vendor dated 1/28/25, indicated, 4th request for ordering practitioner's signature. Exam date 10/29/24. Confirm this exam order by signing this document and faxing it back to imaging. The form was unsigned. During an interview on 3/7/25 11:23 A.M., the Assistant Director of Nurses (ADON) said Resident #44 should have had the X-ray completed as ordered and said she is not sure why it was not done. During an interview on 3/7/25 at 12:04 P.M., Nurse #7 said Resident #44 had an order for an X-ray but said she did not see that the X-ray was ever done. During an interview on 3/10/25 at 10:08 A.M., Nurse Practitioner #1 said Resident #44 was reporting shoulder pain and said she ordered an X-ray but was not aware that it was never done. NP #1 said the X-ray should have been obtained and followed up on and said Resident #44 has had pain in his/her shoulders and neck.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to notify the Physician of critical labs for two residents (#12, and #44) out of a total of 20 sampled residents. Specifically: 1. For Resident #12, the facility failed to alert the Physician of critically high BUN (measures how much blood urea nitrogen is in your body and can may indicated a problem with kidneys or liver) and critically low potassium (measures the electrolyte potassium in the blood that is essential for proper muscle and nerve function) results, which resulted in a delay of treatment and hospitalization for acute hypokalemia and acute kidney injury. 2. For Resident #44, the facility failed to obtain laboratory services as ordered by the Physician. Findings include: 1. Resident #12 was admitted to the facility in August 2024 with diagnoses including dementia, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #12 is moderately cognitively impaired as evidenced by a score of 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. The MDS also indicated Resident #12 requires assistance with bathing and dressing and utilizes oxygen therapy. Review of Resident #12's clinical record indicated that a blood draw was obtained on 2/26/25 at 12:20 P.M. with results reported to the facility on 2/26/25 at 4:52 P.M. that were critical: - BUN:106 (Reference range 10 - 24). Critically high. - Potassium: 2.7 (Reference range 3.3 - 5.1) Critically low. Resident #12's lab draw on 11/6/24 indicated his/her previous levels were as follows: - BUN: 19 - Potassium: 4.2 Review of the nurse progress note dated 2/26/25 at 9:09 P.M., written by Nurse #4, indicated: Resident continues on antibiotic azithromycin for PNA (pneumonia), no ill effect noted, VSS (vital signs stable). Resident compliant with meds and care, no s/sx (signs or symptoms) of hypo/hyperglycemia noted, safety maintained at all times. The nurse progress note failed to indicate Resident #12's lab results were reported to the Physician. Review of the nurse progress notes dated 2/27/25 at 10:50 A.M. written by the Director of Nursing (DON) indicated: Resident alert and able to make needs known. Continues on abx (antibiotic treatment) for pneumonia with no adverse effect. Critical lab results with BUN of 106 . Reported to provider, new order obtained from [Nurse Practitioner] to send resident to ED for evaluation. Review of the hospital paperwork dated 2/27/25 indicated the following lab results: BUN: 106 Potassium: 2.3 (a decrease from his/her potassium level on 2/26/25) Additional review of the hospital paperwork indicated Resident #12 was admitted to the hospital and diagnosed with acute hypokalemia, and acute kidney injury. During an interview on 3/6/25 at 8:14 A.M., Nurse #2 said that labs are obtained for residents on Wednesdays and Friday mornings. Nurse #2 said that labs do not usually come back until the afternoon so nurses will give report to the 3:00 P.M. - 11:00 P.M. shift to be aware of pending lab results for residents. Nurse #2 said that if labs are critical, the lab will call the facility and alert the nursing staff who will then alert the physician immediately. During an interview on 3/6/25 at 10:58 A.M., Nurse #3 said she worked the 7:00 A.M. - 3:00 P.M., shift on 2/26/25 and remembered that the lab tech arrived late that day. Nurse #3 said she told the incoming nurse (Nurse #4) that Resident #12 had pending labs. Nurse #3 said that staff would immediately call the physician if there were critical lab results for a resident. During an interview on 3/6/25 at 1:56 P.M., Nurse #4 said that he worked the 3:00 P.M. - 11:00 P.M., shift on 2/26/25. Nurse #4 said that he completely forgot to check Resident #12's labs and the DON called him on 2/27/25 and said that Resident #12's labs were critical and Resident #12 was being sent to the hospital. Nurse #4 said he did not receive a call from the lab company and he did not think that the lab faxes over results to the facility. During an interview on 3/6/25 at 11:26 A.M., the Lab Coordinator said that the lab will place three calls to the facility to alert them of any critical labs in addition to faxing over a copy of the lab results. The Lab Coordinator said that if the facility misses the call, they can still view the lab results online. The surveyor was unable to locate a physical copy of Resident #12's labs in his/her paper chart or the unit lab book. Review of the lab report indicated that calls were placed to the facility on 2/26/25 at 5:04 P.M., 5:37 P.M., and 6:29 P.M., which were unanswered. The DON was unavailable for interview. During an interview on 3/7/25 at 11:18 A.M., the Assistant Director of Nursing (ADON) said that staff should be alerting providers with critical lab results immediately. The ADON said that the DON had found that Resident #12's critical labs were not reported on 2/26/25 and she alerted Nurse Practitioner #1 on 2/27/25. During an interview on 3/10/25 at 9:36 A.M., the Nurse Practitioner said that nursing staff should immediately notify the provider with any critical lab results. The Nurse Practitioner said that she was not made aware until 2/27/25 of Resident #12's labs and she ordered the Resident be sent to the hospital. The Nurse Practitioner said that Resident #12's potassium level was too low and required hospitalization and he/she should have been sent out right away on 2/26/25. 2. Resident #44 was admitted to the facility in August 2024 with diagnoses that include, chronic kidney disease stage 4 severe, retention of urine, type 2 diabetes mellitus, and unspecified combined systolic (congestive) and diastolic (congestive) heart failure (CHF). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/17/25, indicated that Resident #44 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Further review of the MDS indicated Resident #44 requires substantial/maximal assistance for self-care and mobility. Review of the physician lab orders for Resident #44 indicated: Add TSH (thyroid stimulating hormone), T4 (thyroxine), D3 (vitamin D), B12, FOLATE, Fe tibc (total iron binding capacity) ferritin, HgA1c (glucose blood levels in diabetic patients) and FLP (fasting lipid profile), dated 11/8/2024. Review of the electronic medical record for Resident #44 failed to indicate the ordered labs were obtained. The surveyor was unable to locate a physical copy of Resident #44's labs in his/her paper chart or the unit lab book. During an interview on 3/6/25 at 11:34 A.M., Nurse #6 said Resident #44 was in the hospital recently and should have orders for labs because he/she had elevated levels that needed to be checked and said the Resident has kidney issues. Nurse #6 reviewed Resident #44's medical record and said she did not see any of the labs ordered on 11/8/24. Review of Resident #44's medical record indicated a physician progress note dated 10/29/24, indicated the following: Patient was transferred off hospice care. Remains the same condition but we need to regulate meds (medication) and labs. Review of the physician progress note dated 11/15/24, did not include information related to the labs that were ordered on 11/8/24. During an interview on 3/6/25 at 12:30 P.M., the Director of Nursing said Resident #44 did not have labs drawn as ordered and said she would expect the orders to be followed and monitored. During an interview on 3/7/25 at 11:00 A.M., the Assistant Director of Nurses (ADON) said Resident #44 had an order for lab draws but did not see that they were done. The ADON said staff should have notified the doctor to obtain a new order for labs. The Physician was unavailable for interview. During an interview on 3/10/25 at 10:14 A.M., Nurse Practitioner (NP) #1 said Resident #44 is very fragile and needs close monitoring due to his/her medical conditions and requires labs to be followed and monitored. NP #1 said labs should have been completed as ordered in November and said labs are checked to see if the resident needs to be transferred to the hospital for treatment. NP #1 said she was not aware that the labs in November were not completed and said Resident #44 should have had labs ordered when he/she returned from the hospital.

Based on interview, record and policy review, the facility failed to notify the Physician/Non-Physician Practitioner (NPP: Nurse Practitioner) of a significant change in medical condition and an elopement for two Residents (#60 and #62) out of a total sample of three closed records reviewed. Specifically, the facility staff failed to: 1. For Resident #60, identify a serious change in condition and acute decline in mental status, and notify the Physician/ NPP timely, resulting in the Resident further decompensating and being transferred to the hospital. 2. For Resident #62, notify the Physician/ NPP when the Resident with compromised medical status, and no access to prescribed medications eloped (left) the facility without a Leave of Absence (LOA) order and did not return to the facility. Findings include: 1. Review of the facility policy, Change in Resident's Condition or Status, Revised December 2023, indicated the following: The Nurse will notify the resident's attending Physician or Physician on call when there has been a (an): -Change in the resident's physical/ emotional /mental condition -Need to alter the resident's medical treatment significantly -Need to transfer the resident to a hospital/treatment center -Specific instruction to notify the physician of changes in the resident's condition Resident #60 was admitted to the facility in February 2024 with diagnoses including: Stage 4 (advanced Oxygen needs) Pulmonary Fibrosis (progressive lung disease where the lung tissue becomes damaged with fibrosis [scarring]. The thickened, stiff scar tissue makes breathing difficult for the individual, eventually resulting in shortness of breath [SOB], even at rest) and Acute on Chronic Respiratory Failure with Hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, that can trigger serious complications for the individual). Review of the February 2024 Physician's orders indicated the following: -Albuterol Sulfate (bronchodilator- relaxes and opens the airways) Nebulizer Solution (2.5 mg/3ml) 0.083% 1 vial inhale orally via nebulizer every 6 hours as needed (PRN) for SOB, start date 2/7/24. -O2 (Oxygen) via nasal cannula (NC) with humidification water at 3.5 liter per minute (LPM) to maintain saturation (SpO2 - measure of Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry) above 90% every shift related to Acute and Chronic Respiratory Failure with Hypoxia, start date 2/14/24. Review of the Occupational Therapy Treatment Encounter dated 2/20/24, indicated: -Resident had difficulty speaking -SpO2 was 95% on 4 LPM of Oxygen (O2) and heart rate (HR) was 50 -The head of bed (HOB) was elevated approximately 45°(degree) and respiratory rate (RR) was 28 bpm (breaths per minute). -When the Resident lifted his/her right foot to don (put on) their sock, the RR increased to 40, and the HR was 49 with activity. -Lying on Left side: vitals read 85% SpO2 with 1-minute recovery to 93% SpO2 on 4 LPM O2, and HR - 64. -Lying on Right side: 79% SpO2 with 5-minute recovery to 93% SpO2 [on 4 LPM O2] and non-productive cough. -Reported to nursing. Further review of the medical record did not indicate that the Physician/NP were notified of the change in the Resident's condition reported to the nursing staff by the Occupational Therapy staff on 2/20/24. Review of the Nursing Progress Notes dated 2/21/24 at 7:37 A.M., indicated the following: -Resident is alert and oriented with baseline [sic] confusion. -Resident c/o (complaint) shortness of breath, neb (Nebulizer) treatment given at 12:00 A.M., and 6:00 A.M., with good [sic] -Very anxious, increasing of respiration [sic] noted during care Review of the Nursing Progress Notes dated 2/21/24 at 8:48 A.M., indicated the following: -Resident very SOB. -Resident experiencing very shallow breathing, appears quite anxious, respirations fluctuating mid-high 20's. -Resident unable to clearly express needs. -Resident continues with O2 at 3.5 LPM via nasal cannula, SpO2 fluctuating low-high 90's -Resident's Nurse called NP and 911 for transport (to hospital). Review of the Nursing Progress Notes indicated the following medication was administered more frequently than (every 6 hours PRN) as ordered the Physician: -Albuterol Sulfate Nebulizer Solution (2.5mg/3ml) 0.083% 1 vial inhale orally via Nebulizer every 6 hours PRN for SOB: > 2/21/24 at 00:51 A.M., > 2/21/24 at 2:27 A.M., PRN effective (Treatment repeated within 1 hour, 36 minutes) > 2/21/24 at 7:35 A.M. (Treatment repeated within 5 hours, 8 minutes) > 2/21/24 at 8:29 A.M., indicated the following: PRN was ineffective (Treatment repeated within 54 minutes) Review of the February 2024 Medication Administration Record (MAR) indicated an order for Albuterol Sulfate Nebulizer Solution (2.5mg/3ml) 0.083% 1 vial inhale orally via Nebulizer every 6 hours PRN for SOB -was given on 2/21/24 at 12:51 A.M., with diminished lung sounds before and after the Albuterol treatment -was given at 2/21/24 at 7:35 A.M., with diminished lung sounds before and after the Albuterol treatment Review of the Oxygen Care Plan, initiated 2/7/24 indicated the following: -Monitor symptoms of respiratory distress and report to MD as needed (PRN) -Oxygen via nasal cannula at 3 liters (LPM) continuously (was implemented before a Physician order for 3.5 LPM of Oxygen was obtained on 2/14/24) -Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45°) Review of the Emergency Hospital Report, dated 2/22/24, indicated that Resident #60 was admitted with the following active diagnoses: -Sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection and the body's reaction causes damage to its own tissues and organs) -Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment) -Weakness and increasing Shortness of Breath (abnormal respiration often characterized by the feeling of suffocation) -Influenza (flu- contagious respiratory infection caused by influenza viruses that infect the nose, throat and lungs) -Urinary Tract Infection (UTI: bacterial infection of the urinary tract) -Pneumonia (an infection of the lungs that may be caused by bacteria, viruses, fungi or aspiration [when food or liquid is accidentally inhaled into airways and lungs] and characterized by severe cough with phlegm, fever, chills and difficulty breathing). -The patient is DNR/DNI, and the prognosis is poor. During an interview on 3/21/24 at 4:11 P.M., the Assistant Director of Nurses (ADON) said that if a resident is having a change in condition, nursing staff would perform an assessment of the resident including taking vital signs to rule out any issues with the lungs. The ADON said that a resident would need a Physician's order to titrate Oxygen to maintain the SpO2 level above a certain number. If someone got a nebulizer treatment and it did not work, the facility staff should notify the Doctor of the change in respiratory status and the results after the nebulizer treatment. During a telephone interview on 3/29/24 at 12:05 P.M., Rehabilitation Service Staff (RSS) #3 said that she provided therapy treatment to Resident #60 on the morning of 2/20/24 and documented on the Occupational Therapy Treatment Encounter. RSS #3 said that the Resident was more lethargic and seemed more deconditioned (having lost physical strength through being sick, injured, or not active) than he/she had been the previous day and could not even tolerate sitting on the edge of the bed without being SOB. RSS #3 said that Resident #60's SpO2 was 79% on 4 LPM O2 and there were no orders to increase the amount of Oxygen that could be given. RSS #3 said that she was concerned enough about the Resident's change in condition that she reported her findings to the Nurse assigned to take care of the Resident that morning. During a telephone interview on 3/29/24 at 12:15 P.M., Nurse #1 said that she was assigned to the care of Resident #60 on 2/20/24 (Day shift) and that the Resident was very anxious, his/her respiratory rate had increased with any activity and the Resident had new worsening, increased confusion and SOB. When the surveyor asked Nurse #1 if she was aware of the Occupational Therapy (OT) note from 2/20/24, Nurse #1 said that OT/RSS #3 had informed her that the Resident had increased SOB with activity during the therapy session, but she did not have access to read the OT notes. Nurse #1 said that the Resident's Oxygen was set to 4 LPM, and that was outside of the 3.5 LPM that was ordered, but she was not sure how the Oxygen got set to the 4 LPM. Nurse #1 said that she did not offer the Resident an Albuterol Nebulizer at that time or notify the Physician of the change in condition, and she should have done so based on the ongoing changes with the Resident. During a telephone interview on 3/29/24 at 12:58 P.M., Nurse # 4 said that she received the Resident shift report on 2/21/24 around 7:30 A.M., and upon entering Resident #60's room sometime later, she could tell that the Resident was in distress. Nurse #4 said that she called out for help and other staff members came to assist her. Staff also placed calls to the Physician and the family. Nurse #4 said that the Resident had SOB while talking and his/her SpO2 was around 85% and RR was 28-30 bpm, rapid and shallow. Nurse #4 said that she was unable to give an Albuterol Nebulizer as one had been given already that morning. Nurse #4 said that she went back into the MAR and documented that the (last given) Nebulizer Treatment was ineffective as the prior shift Nurse had not made any post treatment notes, as required. During an interview on 3/26/24 at 10:05 A.M., Physician #2 said that if someone required a breathing [Nebulizer] treatment and it is a change [in status] for them, she would expect to be updated. During an interview on 3/26/24 at 1:15 P.M., the DON reviewed the record for Resident #60 and said that he/she had an O2 order for 3.5 LPM and that there were no titration orders to increase the O2 and if the Resident needed more O2 the Physician should have been notified. The DON further said that it appeared the Resident had a change in status and that staff should have notified the Physician sooner. 2. Review of the facility policy titled Wandering and Elopement, revised March 2019, indicated the following: -The facility will identify Residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. -If a resident is missing, initiate the elopement/missing resident emergency procedure: >Determine if the resident is out on an authorized leave. >If the resident was not authorized to leave, initiate a search of the building and the premises, and >If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident legal representative, the attending physician, law enforcement officials and as necessary volunteer agencies. Resident #62 was admitted to the facility in December 2023, with diagnoses including Bipolar Disorder (a mental health condition that causes extreme mood swings between emotional highs and lows), Alcohol Abuse, Opioid Use, Diabetes Type 2 (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Osteomyelitis (Osteomyelitis is an infection in a bone.), left Diabetic foot ulcer (an open sore on the foot), Heart Failure (when the heart muscle doesn't pump blood as well as it should), muscle weakness and difficulty in walking. Review of the Absentee Register undated, indicated that Resident #62 signed out of the facility independently on 1/8/24. Review of the clinical record progress notes for Resident #62 indicated: -On 1/8/24 at 11:17 P.M., Patient left this morning to go visit family and has not return [sic]. -On 1/9/24 at 11:00 A.M., DON called Resident #62's family member and was informed that the Resident was currently with the family member and that Resident #62 would like to return to the facility. The DON informed the Resident that they would need a drug test from the Emergency Department before returning to the facility. -On 1/10/24 at 10:57 A.M., the DON informed the NP that Resident #62 had been discharged against medical advice (AMA) from the facility. During an interview on 3/26/24 at 1:15 P.M., the Director of Nurses (DON) reviewed the medical record for Resident #62 and said that Resident #62 had no Physician's order for an authorized leave as required and should have had one prior to leaving the facility. The DON further said that there was no completed assessment to indicate that Resident #62 could leave the building independently or with a responsible party. The DON reviewed his/her elopement score on admission and said that the elopement assessment was not completed on admission as required. The DON reviewed the nursing progress notes and said that the staff did not notify the Physician that Resident #62 did not return to the building as expected on 1/8/24 and should have returned. The DON further said that if a resident leaves the building without Physician orders it is considered elopement, and the staff should have followed the facility Wandering and Elopement policy, and notified the Physician, the Police and reported it to the Department of Public Health (DPH) timely but this was not done. Please Refer to F684.

Based on interview and record review, the facility failed to provide treatment, services and care that met professional standards of quality for one Resident (#60) out of a total sample of three discharged residents, resulting in a decline in medical status and hospitalization with sepsis (a life-threatening medical emergency that occurs when an infection triggers the body's immune system to damage its own organs and tissues). Specifically, the facility staff failed to: 1. Recognize, assess, and manage pulmonary symptoms that indicated a significant change in condition for Resident #60 who had multiple pulmonary diagnoses that required immediate and appropriate interventions for symptom management. 2. Provide needed care and services for a nephrostomy tube and manage symptoms of a change in nephrostomy tube output as required. Findings include: Review of the facility policy, Change in Resident's Condition or Status, Revised December 2023, indicated the following: The Nurse will notify the Residents attending Physician or Physician on call when there has been a (an): -Change in the resident's physical/ emotional /mental condition -Need to alter the resident's medical treatment significantly Resident #60 was admitted to the facility in February 2024, with diagnoses including: Stage 4 (advanced Oxygen needs) Pulmonary Fibrosis (progressive lung disease where the lung tissue becomes damaged with fibrosis [scarring]. The thickened, stiff scar tissue makes breathing difficult for the individual, eventually resulting in shortness of breath [SOB], even at rest) and Acute on Chronic Respiratory Failure with Hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, that can trigger serious complications for the individual) and a Nephrostomy tube (tube used to drain urine directly from the kidneys to a collection bag outside of the body). Review of the February 2024 Physician's orders dated 2/7/24, indicated the following: -MOLST (Medical Orders for Life Sustaining Treatment - document of a patient's treatment preferences concerning life-sustaining treatment) Advanced Directive - Full Code (Resuscitate), start date 2/7/24. -Albuterol Sulfate (bronchodilator) Nebulizer Solution (2.5mg/3ml) 0.083% 1 vial inhale orally via nebulizer every 6 hours as needed for shortness of breath (SOB), start date 2/7/24 Review of the Oxygen Care Plan, initiated 2/7/24 indicated the following: -Monitor symptoms of respiratory distress and report to MD as needed (PRN) -Oxygen via nasal cannula at 3 LPM continuously (was implemented before a Physician order for 3.5 LPM of Oxygen was obtained on 2/14/24) -Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45°) Review of the Nursing notes dated 2/7/24 indicated that Resident #60 was -Alert and oriented times (x) 3 [alert and oriented to person, place and time]. Review of Occupational Therapy Treatment Encounter dated 2/13/24 indicated a change in Resident #60's status from 2/7/24: -Patient was received in agitated mood and became increasingly agitated during encounter. -O2 set at 4 LPM Review of the February 2024 Physician's orders dated 2/13/24, indicated the following: -Oseltamivir Phosphate (antiviral medication) Oral Capsule 75 mg give one capsule by mouth one time a day once daily for 10 days prophylactic for flu (Influenza) for 10 administrations until finished, start date 2/13/24 -Glomerular Filtration Rate [(GFR) 71- is a measure of how well your kidneys are filtering.], start date 2/13/24 Review of Physical Therapy Treatment Encounter dated 2/14/24 indicated further decline in Resident #60's status from 2/13/24: -Patient presented with increased confusion, nursing notified. -Patient said they are feeling lethargic. Review of the February 2024 Physician's orders dated 2/14/24, indicated the following: -O2 (Oxygen) via nasal Cannula (NC) with humidification water at 3.5 liter per minute (LPM) to maintain saturation (SpO2 - measure of Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry) above 90% every shift related to Acute and Chronic Respiratory Failure with hypoxia, start date 2/14/24. Review of the most recent Minimum Data Set (MDS) Assessment, dated 2/14/24 indicated the following: -Resident makes self-understood -Resident has clear comprehension to understand verbal content -Resident had a Brief Interview for Mental Status (BIMS) of 12 out of a total 15, indicating moderate cognitive impairment -No evidence of an acute change in mental status -Respiratory Failure (a serious condition that makes it difficult to breathe on your own. Develops when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body) and a Urinary Tract Infection (UTI: bacterial infection of the urinary tract) within the last 7 days -Shortness of breath (SOB) while lying flat -Resident has an HCP- [not invoked - put into effect] Review of Physical Therapy Treatment Encounter dated 2/15/24 indicated continued decline in Resident #60's status from 2/14/24: -Multiple standing brakes [sic] due to fatigue, shortness of breath, and global weakness -Vital monitor: SP02 ranging from 80% to 97% after activity and heart rate ranging from 80 to 90 beats per minute (bpm) after all interventions. Review of the Nursing Progress Notes dated 2/17/24 indicated continued decline in Resident #60's status from 2/15/24: -Was awake at 2:30 A.M., and was confused -Pox (Pulse Oximetry/ SpO2) was 90-92% on O2 - 4 LPM via nasal cannula (higher liter flow than the 3.5 LPM ordered on 2/14/24). Review of the Nursing Progress Notes dated 2/19/24 indicated a significant change in condition for Resident #60 from 2/17/24: -Had an occasional nonproductive cough -Lung sound diminished (LSD) bilaterally -Episodes of SOB with exertion -Nephrostomy is patent 75 cubic centimeters (cc-standard unit in measuring volume), slightly dark yellow output Review of the Occupational Therapy Treatment Encounter dated 2/20/24, indicated continued decline in condition for Resident #60 from 2/19/24: -Resident had difficulty speaking -SpO2 was 95% on 4 LPM of Oxygen (O2) and heart rate (HR) was 50 -The head of bed (HOB) was elevated approximately 45°(degree) and respiratory rate (RR) was 28 bpm (breaths per minute). -When the Resident lifted his/her right foot to don (put on) their sock, the RR increased to 40, and the HR was 49 with activity. -Lying on Left side: vitals read 85% SpO2 with 1- minute recovery to 93% SpO2 on 4 LPM O2, and HR - 64. -Lying on Right side: 79% SpO2 with 5- minute recovery to 93% SpO2 [on 4 LPM O2] and non-productive cough. -Reported to nursing. Review of the Nursing Progress Notes dated 2/20/24 indicated: -The Resident was confused and wanted to get out of bed and go to his/her car. -Respirations noted to increase when getting help with morning care. Further review of the Nursing Progress Notes dated 2/20/24 indicated: -no evaluation and/or revision of interventions related to symptoms and conditions documented in the medical record from 2/13/24 - 2/20/24. -no Physician communication for alternative care options for Resident #60. Review of the Documentation of Resident Incapacitation pursuant to Massachusetts Health Care Proxy Act M.G.L.C201D, dated 2/20/24, indicated that Resident #60's HCP was invoked (allowing someone else to make healthcare decisions) due to a diagnosis of Dementia, with lifelong extent. Review of Resident #60's medical record failed to indicate any history, current or new of a diagnosis of Dementia. Review of the Nursing Progress Notes dated 2/21/24 at 7:37 A.M., indicated the following: -Resident c/o shortness of breath, neb treatment given at 12am and 6am with good [sic] -Very anxious, increasing of respiration noted during care Review of the Nursing Progress Notes dated 2/21/24 at 8:48 A.M., indicated the following: -Resident very SOB. Resident experiencing very shallow breathing, appears quite anxious, respirations fluctuating mid-high 20's. -Resident unable to clearly express needs. -Resident unable to swallow -Resident continues with continuous O2 at 3.5 liters applied via nasal cannula. -O2 sats fluctuating low to high 90's however resident still appearing very SOB, unable to get words out. -Residents' Nurse called Nurse Practitioner (NP) and 911 for transport. Review of the February 2024 Physician's orders dated 2/21/24, indicated the following: -DNR (Do Not Resuscitate)/ DNI (Do Not Intubate), may hospitalize - Health Care Proxy (HCP - an appointed individual to legally make medical decisions on a person's behalf if he/she became unable to do so) - Wife, start date 2/21/24 Review of the February 2024 Medication Administration Record (MAR) indicated the following: -Albuterol Sulfate Nebulizer Solution (2.5 mg/3 ml) 0.083% 1 vial inhale orally via nebulizer every 6 hours as needed for SOB was documented as administered on 2/21/24 at 12:51 A.M., and again at 7:35 A.M. -May send to emergency room (ER) for eval STAT (immediately) for SOB, start date of 2/21/24 at 8:17 A.M. Review of the Nursing Progress Notes dated 2/21/24 at 11:30 A.M., indicated the following: -Patient noted with increased SOB at rest and with talking, -RR 28-30 which are rapid and shallow, pox on 3.5 LPM 02 via nasal cannula (NC) - 85% -HR 102 and irregular, BP 90/58; LSD (lung sounds diminished) bilat; patient c/o SOB; -previous shift had given Albuterol nebulizer two times at 12:00 A.M., and at 6:00 A.M. -Patient having difficulty producing an effective cough Review of the Nursing Progress Notes indicated the following medication was administered more frequently than ordered: -(Albuterol Sulfate Nebulizer Solution (2.5 mg/3 ml) 0.083% 1 vial inhale orally via nebulizer every 6 hours as needed for SOB). > 2/21/24 at 00:51 A.M. > 2/21/24 at 2:27 A.M., PRN effective (given within 1 hour (hr) 36 minutes (mins) of the 00:51 A.M. treatment) > 2/21/24 at 7:35 A.M. (given within 5 hrs 9 mins of the 2:27 A.M. treatment) > 2/21/24 at 8:29 A.M., indicated the following: PRN was ineffective (given within 54 mins of the 7:35 A.M treatment). Review of the most recent Minimum Data Set (MDS) Assessment, dated 2/21/24 indicated the following: -Evidence of an acute change in mental status from the Resident's baseline -Behavior present, fluctuates (comes and goes, changes in severity) -Inattention -Disorganized thinking -Shortness of breath while lying flat, while sitting at rest, and with exertion -The Resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. During an interview on 3/21/24 at 4:11 P.M., the Assistant Director of Nurses (ADON) said that if a resident is having a change in condition nursing staff would perform an assessment of the resident including taking vital signs to rule out any issues with the lungs. The ADON said that a resident would need a Physician's order to titrate Oxygen to maintain the SpO2 level above a certain number. The ADON said if a resident got a nebulizer treatment and it did not work, the facility staff should notify the Physician/Doctor of the change in respiratory status and the results after the nebulizer treatment. During an interview 3/22/24 at 9:20 A.M., Nurse #4 said that if a resident was having any changes in respiratory status, she would look for SOB, including listening to the lung sounds checking their pulse oximetry and checking the orders for O2 to see if the liter flow can be increased. Nurse #4 further said that she would call the Physician for any change in respiratory status as the resident could have over exertion, or they could have Pneumonia, which is why the assessment piece is so important. During a follow-up interview on 3/22/24 at 9:59 A.M., Nurse #4 said if a Resident had a change in mental status and was no longer alert and oriented, the nursing staff would complete a nursing assessment and would contact the Physician to inform them about the change and then the Physician may give the order to invoke the Health Care Proxy (HCP). During a telephone interview on 3/26/24 at 10:05 A.M., Physician #2 said that if someone required a breathing (Nebulizer) treatment and it is a change for them, she would expect to be updated on the Resident's condition. During a follow-up interview on 3/26/24 at 12:58 P.M., Physician #2 reviewed Resident #60's medical record and said that the facility staff did not speak to her about a change in condition and they did not ask to increase Resident #60's oxygen from 3.5 LPM to 4 LPM. Physician #2 further said that she does not recall invoking Resident #60's HCP for a change in mental status or Resident #60 having a diagnosis of Dementia. During an interview on 3/26/24 at 1:15 P.M., the Director of Nurses (DON) reviewed the record for Resident #60 and said that he/she had an O2 order for 3.5L and no titration order was noted, so if the Resident required more Oxygen the Physician should have been notified. The DON further said that staff should have notified the Physician when Resident #60 had a change in condition on 2/20/24 and they did not. During a telephone interview on 3/29/24 at 12:05 P.M., Rehabilitation Service Staff (RSS) #3 said that she provided therapy treatment to Resident #60 on the morning of 2/20/24 and documented the Resident's status on the Occupational Therapy Treatment Encounter form. RSS #3 said that the Resident was more lethargic and seemed more deconditioned (having lost physical strength through being sick, injured, or not active) than he/she had been the previous day and could not even tolerate sitting on the edge of the bed without being SOB. RSS #3 said that Resident #60's SpO2 was 79% on 4 LPM O2 and there were no orders to increase the amount of Oxygen that could be given. RSS #3 said that she was concerned enough about the Resident's change in condition that she reported her findings to the Nurse assigned to take care of the Resident that morning. During a telephone interview on 3/29/24 at 12:15 P.M., Nurse #1 said that she was assigned to the care of Resident #60 on 2/20/24 (Day shift) and that he/she was very anxious, and his/her respiratory rate had increased with any activity and the Resident had new worsening increased confusion and shortness of breath. When the surveyor asked Nurse #1 if she was aware of the Occupational Therapy (OT) note from 2/20/24, Nurse #1 said that OT had informed her that the Resident had increased SOB with activity during the therapy session, but she did not have access to read the OT notes. Nurse #1 said that the Resident's Oxygen was set to 4 LPM, and that was outside of the 3.5 LPM that was ordered, but she was not sure how the Oxygen got set to the 4 LPM. Nurse #1 said that she did not offer the Resident an Albuterol Nebulizer at that time or notify the Physician of the change in condition, and she should have done so based on the ongoing changes noted with the Resident. During a telephone interview on 3/29/24 at 12:58 P.M., Nurse #4 said that she received the Resident shift report on 2/21/24 around 7:30 A.M., and upon entering Resident #60's room sometime later, she could tell that the Resident was in distress. Nurse #4 said that she called out for help and other staff members came to assist her and placed calls to the Physician and the family. Nurse #4 said that the Resident had SOB while talking and his/her SpO2 was around 85% and RR was 28-30 bpm, rapid and shallow. Nurse #4 said that she was unable to give an Albuterol Nebulizer as one had been given already that morning. Nurse #4 said that she went back into the MAR and documented that the Albuterol Treatment given was ineffective, as the prior shift Nurse had not made any post treatment notes, as required. Review of the Emergency Hospital Report, dated 2/22/24 indicated that Resident #60 had active diagnoses of -Sepsis -Failure to Thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction, and low cholesterol.) -Weakness and increasing Shortness of Breath (SOB: abnormal respiration often characterized by the feeling of suffocation). -Influenza (flu -contagious respiratory infection caused by influenza viruses that infect the nose, throat and lungs) -Urinary Tract Infection (UTI: bacterial infection of the urinary tract) -Pneumonia (an infection of the lungs that may be caused by bacteria, viruses, fungi or aspiration [when food or liquid is accidentally inhaled into airways and lungs] and characterized by severe cough with phlegm, fever, chills and difficulty breathing). -The patient is DNR/DNI and the prognosis is poor. 2. Review of the facility policy Nephrostomy Tube, Care of revised October 2010, indicated the following: -Check the placement of the tubing and integrity of the tape during assessments. -Drainage should be below the level of the kidneys. -There should be no kinks in the tubing. -Empty drainage bag once per shift and as needed. -Measure output every 8 hours. -Record urinary and nephrostomy output separately. -Change dressings every one to three days as ordered. -Use sterile technique during dressing changes. Review of the February 2024 Physician's orders, date 2/8/24 indicated the following: -Sodium Chloride solution 0.9% use 5 ml via irrigation in the afternoon for Nephrostomy tube -flush Nephrostomy tube with 5 ml Sodium Chloride solution 0.9% daily. Review of the Medical Record did not indicate that Physican's orders were in place for Nephrostomy site dressing changes or monitoring of the output from the Nephrostomy tube. Review of the February 2024 Medication Administration Record (MAR) indicated the following: -Sodium Chloride solution 0.9% use 5 ml via irrigation in the afternoon for Nephrostomy. -flush nephrostomy with 5 ml daily -was documented as administered from 2/9/24 through 2/20/24 Review of the Care Plan, indwelling Foley catheter and nephrostomy tube, initiated 2/7/24 indicated: -Check tubing for kinks each shift per policy -Monitor and document output as per facility policy -Nephrostomy tube dressing change as ordered. -Observe for document pain discomfort due to catheter Review of the most recent Minimum Data Set (MDS) Assessment, dated 2/14/24 indicated the following: -Urinary Tract Infection (UTI: bacterial infection of the urinary tract) within the last 7 days -Shortness of breath (SOB) while lying flat Review of the Physician Progress Note dated 2/15/24 indicated: -Nephrostomy tube draining yellow clear urine. Review of the Nursing Progress Note dated 2/17/24, indicated: -Nephrostomy tube draining yellow urine. Review of the Nursing Progress Note dated 2/19/24 indicated: -Nephrostomy is patent 75 cubic centimeters (cc-standard unit in measuring volume), slightly dark, yellow output Review of the Nursing Progress Note dated 2/21/24 indicated: -Nephrostomy tube draining 200 ml of amber urine. During an interview on 3/22/24 at 9:20 A.M., Nurse #4 said that if a resident has new or increased confusion, she would complete an assessment which would include vital signs and asking if they had burning with urination or frequency. If the resident had a Foley catheter or a Nephrostomy tube, they should be assessed for patency, drainage, sediment, cloudy urine, foul odor, and blockage by looking at their output. During a follow-up interview on 3/22/24 at 9:59 A.M., Nurse #4 said if a Resident had a change in mental status and was no longer alert and oriented, the nursing staff would complete a nursing assessment and would contact the Physician to inform them about the change and then the Physician may give the order to invoke the Health Care Proxy (HCP). During a telephone interview on 3/26/24 at 10:09 A.M., Physician #2 said that a Resident might have Dementia, or they may be sick and that could be why they were having a mental status change. When the surveyor asked about invoking the HCP for Resident #60, Physician #2 said that she would not invoke a HCP right away and that she would wait until the patient is totally incompetent, but if they are sick and are going to get better, she would not invoke the HCP as the Medical Orders for Life-Sustaining Treatment (MOLST (is one way of documenting a patient's treatment preferences concerning life-sustaining treatment) was in place already. During an interview on 3/26/24 at 1:15 P.M., the Director of Nurses (DON) reviewed the record for Resident #60 and said that Resident #60 had a nephrostomy tube in place and that she would expect to see orders for monitoring output and for administering dressing changes. She further said that she could not find evidence that there was a Physician's order for the nephrostomy tube site dressing changes or to monitor output, as expected and required. The DON further said that staff should have notified the Physician when Resident #60 had a change in condition on 2/20/24 and they did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility failed to provide necessary care and services to treat pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for two Residents (#22 and #4), out of two applicable residents, out of a total sample of 17 residents. Specifically, the facility staff failed to: 1. Offload Resident #22's heels per the Physician's Order for treatment of an existing right heel ulcer, and prevent skin decline in his/her left heel. 2. Implement a turning and repositioning schedule and apply specialized boots and/or pillows to offload Resident #4's heels per the plan of care. Findings include: Review of the facility policy titled Pressure Ulcers/Skin Breakdown, revised April 2018, indicated the following: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). -The nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (any fluid that has been forced out of the tissues or blood vessels because of inflammation or injury) or necrotic (the death of most or all organs or tissue due to disease, injury or lack of blood supply) tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses -The Physician will identify medical interventions related to wound management. 1. Resident #22 was admitted to the facility in October 2022 with diagnoses including Diabetes (condition that results in too much sugar in the blood resulting in high blood glucose[sugar]), Cerebral Vascular Accident (CVA: stroke-interruption of the blood supply to the brain resulting in damage), Protein-calorie Malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and need for assistance with personal care. Review of the Resident's clinical record indicated that he/she was transferred to the hospital on [DATE] and returned on 12/25/23. Further review of the clinical record indicated the Resident was identified as having a Deep Tissue Injury (DTI-purple or maroon localized area of discolored intact skin or fluid filled blister due to damage of underlying soft tissue from pressure) after the hospitalization, and was at increased risk for pressure ulcers related to his/her mobility status and medical conditions. Review of the Nursing assessment dated [DATE], indicated Resident #22 had a DTI to his/her right heel. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated: - Resident #22 had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 11 out of a total possible 15 - had range of motion impairments affecting bilateral (both) lower extremities - required assistance from staff with upper and lower dressing, rolling side to side, lying to sitting and with transfers - was at risk for pressure ulcers - had an unstageable [full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (yellow/white material in the wound bed) or eschar (dry/dry scab or dead skin)] pressure ulcer that was present on admission. Review of the March 2024 Physician's orders, included the following: - float heels when in bed every shift for DTI, initiated 1/4/24 - low air low mattress set at 150 every shift, initiated 3/8/24 Review of the March 2024 Treatment Administration Record (TAR) indicated the order and treatment to float Resident #22's heels while in bed every shift was administered every day, every shift from 3/1/24 through 3/21/24. Review of the current Activities of Daily Living (ADLs - tasks of everyday life including eating, bathing, dressing) Care Plan, initiated 10/5/22, indicated Resident #22 required assistance with ADLs and required the following: -Dependent on staff for grooming and hygiene -Assistance of 1-2 staff with positioning Review of the Weekly Wound assessment dated [DATE], indicated Resident #22 had the following: -Right heel DTI wound, unstageable -Preventative interventions included: > pressure distribution mattress > turning and repositioning program > elevate legs > float heels in bed and offload On 3/21/24 at 9:07 A.M., the surveyor observed Resident #22 lying in bed with the head of the bed elevated. The surveyor observed that an air mattress was in place and set to 150. During an interview at the time, Resident #22 said that he/she had an open area on the right heel which was uncomfortable when the heel was touched or moved. The Resident further said there was nothing special in place for his/her heel wound, but there was a treatment that was completed by nursing. On 3/21/24 at 9:13 A.M., Certified Nurses Aide (CNA) #6 entered Resident #22's room and showed the surveyor Resident #22's feet, which were covered with blankets. When CNA #6 lifted the bottom blankets, the surveyor observed that the Resident's heels were not offloaded, and there were no pillows or specialty devices in place to prevent the Resident's heels from laying directly on the mattress. The surveyor further observed that the Resident's feet were positioned on top of each other, that non-skid socks were in place and a gauze wrap was observed extending above the Resident's non-skid sock on the right foot. On 3/22/24 at 7:38 A.M. and 8:09 A.M., the surveyor observed Resident #22 lying in bed and the Resident's left foot was observed laying on the mattress, was not offloaded, and was further observed pressed against the foot board at the end of the bed. The surveyor observed that the Resident's right foot had a dressing wrapped around it and the right foot was laying on the mattress. On 3/22/24 at 11:38 A.M., the surveyor observed the wound dressing change of the Resident's right heel with Nurse #1 and Nurse #6. Prior to the dressing change treatment, Resident #22 was observed lying in bed on his/her right side with legs slightly bent. The Resident's left foot was bare and pressed against the foot board of the bed. Both of the Resident's feet were observed to be laying on the mattress and were not offloaded. Nurse #1 and Nurse #6 were observed to assist the Resident by shifting him/her up in bed so his/her feet were away from being positioned against the foot board of the bed, to access and complete the treatment to the right heel wound. When the surveyor asked Nurse #1 to provide an assessment of the Resident's left heel, Nurse #1 said the Resident's left heel was reddish in color compared to the bottom of his/her foot, and that the skin on the foot was dry. Nurse #6, who was still present during this time, said the Resident's heels should be offloaded and a treatment should be initiated to his/her left heel to prevent skin breakdown. Nurse #1 and Nurse #6 were observed to search the Resident's room to locate a pillow or device to offload the Resident's heels and Nurse #6 said there were no pillows present and that she would have to get one. On 3/22/24 at 12:42 P.M., the surveyor observed Resident #22 lying in bed with his/her eyes closed. The surveyor did not observe any pillows or devices offloading the Resident's heels. During an interview on 3/22/24 at 1:54 P.M., the Assistant Director of Nurses (ADON), who completed scheduled wound rounds with the Physician, said Resident #22's heels should be offloaded while in bed to prevent pressure on his/her heels. The surveyor relayed previous observations of the Resident's heels not being offloaded with the ADON who said that she would look into the matter. Review of the Weekly Wound Assessment, dated 3/22/24, indicated Resident #22 had a new suspected DTI to his/her left heel. During a follow-up interview on 3/22/24 at 3:51 P.M., the ADON said she assessed the Resident's heels, and at the time of her observation there were pillows under his/her feet to offload but that both of the Resident's feet were pressed against the foot board of the bed. The ADON said the Resident was repositioned in bed, so his/her feet were not against the foot board and a spacer was placed between the mattress and the footboard to prevent this from re-occurring. The ADON further said that the Resident's left heel was discolored and was boggy (abnormal texture of tissues characterized by sponginess), so the Physician was updated and an order was obtained for a treatment to the Resident's left heel and to implement heel protectors to both of the Resident's feet. During a follow-up interview on 3/26/24 at 1:53 P.M., the ADON said Resident #22 was unable to independently offload his/her heels when in bed and required assistance from staff to do this. 2. Resident #4 was admitted to the facility in March 2016, with diagnoses including hemiplegia (paralysis on one side of the body) affecting the left non-dominant side, CVA, abnormal posture, Adult Failure to Thrive (syndrome of weight loss, decreased appetite, poor nutrition and inactivity), pressure ulcer of the left buttock Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle), and need for assistance with personal care. Review of the MDS Assessment, dated 2/28/24, indicated: -Resident #4 had significant cognitive impairment as evidenced by a BIMS score of 4 out of a possible 15 -had no rejections of care -had range of motion impairments of upper and lower extremities on one side -was dependent on staff for dressing, personal hygiene, rolling side to side -was at risk for pressure ulcers -had one unhealed Stage 4 Pressure Ulcer which was not present on admission. Review of the ADL Care Plan, initiated 3/9/16, indicated Resident #4 required assistance with ADLs related to hemiplegia and hemiparesis and included the following interventions: -Dependent on staff for transfers and positioning, initiated 12/18/23 Review of Potential for Skin Integrity Care Plan, initiated 3/9/16, included the following interventions: -Offload Resident heels using pillows/heels up on cushion ., revised 3/9/16 -Provide 2 assist with positioning and transfers .reposition at least every 2 hours while in bed ., revised 6/30/20 Review of the Actual Skin Integrity Impairment Care Plan, initiated 8/17/20, included the following interventions initiated 9/27/21: -Encourage Resident to turn and change position every 2 hours -Offload heels Review of the Wound Evaluation and Management Summary, dated 2/1/24, indicated the following: -Resident has wounds including a Stage 4 full thickness area on his/her left ischium (curved bone forming the base of each half of the pelvis) . -The plan of care included to offload the wounds, reposition per facility protocol . turn side to side and front to back in bed every 1-2 hours if able and elevate his/her legs Review of the March 2024 Physician's orders, initiated 3/17/21, included the following: -prevalon boots (type of specialized boots to offload feet) to bilateral heels -check for placement and check skin every evening and night for DTI Review of the March 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include documented evidence that the prevalon boots were ordered and applied from 3/1/24 through 3/21/24. Review of the current CNA Care Card included the following: -Encourage Resident to turn and change position 2 hours -Offload heels using pillows/heels up on cushions as Resident allows -Dependent of two staff with positioning On 3/20/24 at 4:19 P.M., the surveyor heard the Resident calling out and observed him/her lying in bed on his/her back. The surveyor observed that an air mattress was in place and set at 200. During an interview at the time, the Resident said he/she was uncomfortable and had some pain on his/her left side. The surveyor did not observe that the Resident's heels were offloaded. The surveyor exited the Resident's room and notified Nurse #1 of the Resident's concerns, and Nurse #1 responded that she would assess Resident #4. On 3/21/24 at 7:14 A.M. through 8:58 A.M., the surveyor observed the Resident lying in bed, positioned on his/her back with eyes closed. The air mattress was observed set at 200 and the head of the bed was slightly elevated. At 8:20 A.M., two CNA's entered the Resident's room and boosted him/her up in the bed prior to breakfast. The surveyor observed the Resident's feet as he/she was being boosted, and both feet were lying on the mattress, with no devices (pillows or boots) in place to offload. On 3/22/24 at 7:25 A.M. through 7:52 A.M., the surveyor observed Resident #4 lying in bed, on his/her back with eyes closed. During an interview at 7:31 A.M., the Resident said that his/her feet bothered him/her and were uncomfortable. The surveyor did not observe offloading boots in the Resident's room and when asked, the Resident said he/she was not aware of having anything for his/her feet. The surveyor requested assistance from the ADON, who was assisting with beverage pass at the time. The ADON uncovered the Resident's feet, and the surveyor observed that both of the Resident's feet were bare and lying on the mattress. The surveyor observed that a pillow was placed under the Resident's left knee. When the ADON assisted the Resident with moving his/her left foot, the Resident cried out in discomfort and said his/her left heel hurt. The ADON assessed the Resident's left heel and said there were no open areas on the Resident's left heel, and that she was going to position the pillow under the Resident's left heel so that it was offloaded and off the mattress. When the surveyor asked the ADON if the Resident was able to move the pillow which was observed previously positioned under his/her left knee, and the ADON said the Resident was unable to move his/her left side due to hemiplegia. After the Resident's left leg was repositioned with his/her left heel elevated, the Resident smiled and said that he/she felt better. The surveyor observed that the Resident's right foot remained on the mattress and was not offloaded. On 3/22/24 from 8:39 through 11:27 A.M., the surveyor observed the following: -At 8:39 A.M., the surveyor observed Resident #4 lying upright in bed, positioned on his/her back eating breakfast -At 8:52 A.M., the breakfast tray was removed, and the Resident remained in the same position -At 10:15 A.M., the Resident remained lying on his/her back in bed with eyes closed -At 11:27 A.M., two staff members entered the Resident's room, greeted the Resident and said that the wound dressings were going to be completed and then staff would get him/her out of bed. On 3/22/24 at 12:06 P.M. through 12:45 P.M., the surveyor observed Resident #4 lying in bed, and remained positioned on his/her back with eyes closed. During an interview on 3/22/24 at 12:47 P.M., CNA #2 said that she regularly worked with Resident #4 and knew him/her very well. CNA #2 said the Resident required full care, was incontinent of both urine and bowels, and was changed at 6:30 A.M.,10:30 A.M., and around 11:15/11:30 A.M., when he/she was assisted out of bed. CNA #2 said the Resident refused to get out of bed today because of complaints of pain which was reported to the Nurse. CNA #2 said the Resident was unable to move his/her left side and was unable to move about when in bed. CNA #2 further said that the Resident required the assistance of two staff for repositioning, that the staff will change his/her position when he/she calls out but staff had no schedule for repositioning. CNA #2 said if the Resident was lying in bed without yelling out or was observed to be sleeping, that indicated he/she was comfortable so staff would not move or reposition him/her. CNA #2 said that she puts a pillow under the Resident's heels when her shift was over to elevate his/her heels, but when she returns to work in the morning for her shift, she would find that the Resident's heels are not offloaded most of the time. When the surveyor asked whether the Resident had specialized boots to offload his/her feet, CNA #2 said she did not remember. On 3/26/24 at 12:10 P.M., the surveyor and Nurse #3 reviewed the Resident's clinical record and Nurse #3 said the Resident had an order for prevalon boots since 3/17/21, but the order was just added to the TAR on Friday 3/22/24. Nurse #3 said that unless the order was designated to the MAR or the TAR, it would not show up for the nursing staff to administer and sign off. When the surveyor asked about how the repositioning of residents was documented, Nurse #3 said that the CNAs document that information. Review of the CNA documentation indicated no documented evidence that repositioning had occurred every 1-2 hours per the Resident's plan of care. During an interview on 3/26/24 at 1:44 P.M., the ADON said the Resident should be repositioned every two hours or as needed and that the CNA's would document that this occurred in the medical record. The ADON said that there has been an order for the specialized boots to offload the Resident's heels for a long time, the ADON thought that she remembered seeing the boots, but would have to check. The ADON further said that the Resident was unable to reposition him/herself and was dependent on facility staff to do this for him/her. During a follow-up interview on 3/26/24 at 3:15 P.M., the ADON said she was unable to find any indication that Resident #4 was repositioned as per his/her plan of care since October 2023.