**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R55 Review of face sheet dated 3/30/23 for R55 revealed they most recently admitted to the facility on [DATE] and previously admitted to the facility on [DATE] with diagnosis that included: cellulitis of right lower limb, pressure ulcer of sacral region, need for assistance with personal care, repeated falls and history of falling. Review of a Minimum Data Set (MDS) assessment for R55, with a reference date of 2/11/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R55 was cognitively intact. Review of R55's orders revealed an order with a start date of 3/24/23: Left Foot Wound: apply Urgotul contact layer to open wound, apply silbersorb gel/Collagen powder mixed to area covered by contact layer, cover with ABD pad, wrap with kerlix, secure with tape. **If no Urgotul, apply silversorb directly to wound bed per wound clinic** An interview was completed with R55 on 3/28/23 at approximately 11:47 AM in her room. R55 confirmed she had a wound on the top of her left foot. She stated staff change the dressing every day and it had not been changed yet today. R55 stated it was important to put ointment on the foot, keep it clean and keep it moist. R55 consented to have her wound care observed. On 3/28/23 at 1:40 PM, wound care to R55's top left foot was observed being completed by Registered Nurse (RN) L. RN L retrieved this surveyor from the conference room, knocked on the door and opened it and then continued on to the medication cart to collect her supplies that were laid out on a tray on the cart. RN L entered R55's room and placed the tray on R55's uncleaned bedside table and began donning gloves. No hand hygiene was observed. RN L sanitized scissors and directed R55 to place her foot on an unclean wheelchair pad on a wheelchair next to the bed. RN L began cutting off the bandage with the scissors. She placed the dirty scissors back on the side table, She sprayed to wound with saline and dabbed the wound with gauze. RN L then removed her gloves and placed the gauze in the gloves and went to the bathroom to wash her hands, she instructed R55 that she could put her bare foot back on the floor until she returned. After washing her hands, she donned gloves, placed the cap back on the saline container and opened a packet with a pad to place on the wound. She sanitized the scissors to begin, but then repeatedly placed the scissors back on the unclean table as the pad was trimmed and re-trimmed to fit the wound. RN L squeezed silversorb gel ointment directly on the wound and then spread with a sterile q-tip, RN L sprinkled collagen powder over the gel (versus mixing the collagen powder with the silversorb). The trimmed pad was placed on the wound and then the foot was wrapped with gauze. As RN L wrapped R55's foot, they continually dragged the gauze on the unclean wheelchair pad. RN L did not have tape, and opened the resident's side table drawer to locate some, the tape was placed and then RN L took a pen from her pocket and dated the tape. RN L then removed her gloves and went to the bathroom to wash her hands. RN L came out with a wet paper towel and wiped down R55's bedside table. RN L was asked if there was cleanser on the paper towel and she confirmed it was just water. During an interview with RN L directly after the wound care observation, she was asked if there was anything she should have done differently with the wound care and she stated I probably should have used a clean barrier on the table and a clean towel under her foot. During an observation and interview with R55 in her room on 3/30/23, the pressure ulcer on the top of her left foot was discussed. R55 was viewed to have no dressing on her left foot and the foot was in a gray fuzzy slipper, the uncovered wound was in contact with the slipper. R55 stated during the night the gauze wrap got tight and staff helped her remove it. The staff did not try to re-wrap it and stated it would be better to be open to air for the night. R55 said staff were going to rewrap her foot sometime this morning. R55 took her foot out of the slipper to show that it was completely uncovered and the wound looked very dry (standard of care would be to keep the wound moist for wound healing). R55 then placed her foot back into the slipper. R55 was asked about the wound care observation on 3/28/23. She confirmed that staff usually sprinkle the collagen powder over the ointment and do not mix it before, she stated they said it has to be that way to work the best. R55 was asked if staff generally put down a clean towel or pad before doing wound care and she stated that they do not. Based on observations, interviews, and record review, the facility failed to prevent, complete weekly assessments and treat pressure ulcers for 2 Residents (R55 and R64), resulting in R64 developing multiple pressure ulcers (including 2 unstageable ulcers) and the potential for R55's pressure ulcers to delay in healing and develop infection. Findings include: Review of R64's face sheet dated 3/30/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: cerebral palsy, abnormal posture, dementia, diabetes mellitus II, neuromuscular dysfunction of blader, need for assistance with personal care, and weakness. He was not his own responsible party. R64 was observed on 3/28/23 at 1:13 PM on his right side in bed. R64 was observed on his right side in bed on 3/29/23 at 9:00 AM. R64 was observed on 3/29/23 at 2:20 PM in bed on his right side. R64 was cooperative with rolling to his left side with the assistance of Certified Nurse Aide (CNA) J. R64's heels were in contact with his mattress (no heel float device in place). R64' left ankle was wrapped with kerlix (medical dressing) dated 3/29/23. There was a wet spot on R64's sheet where his left heel was in contact with his mattress. There were no positioning devices or heel float equipment located in R64's room at this time. CNA J said R64 prefers to stay on his right side in bed. CNA J said R64 is asked if he wants to be repositioned every 2 hours, but he wants to stay on his right side. R64 has a Foley catheter in place so he doesn't require frequent changes. R64's television and bedside table are both located on the right side of his bed. CNA J was asked if the facility had attempted to switch the television location and bedside table location when offering to turn him in bed and CNA J was not aware of any attempts to relocate items in R64's room to encourage position changes. CNA J was not aware of any devices attempted to float his heels or reposition him. During an interview with Registered Nurse (RN) M on 3/29/23 at 3:10 PM the Surveyor shared the observation and interview information obtained on 3/29/23 at 2:20 PM. RN M reviewed R64's medical records and was not able to locate any documentation that showed R64's guardian was aware of any repositioning concern, pressure ulcer concerns or any attempts using different devices or attempts to encourage R64 to stay in any position except his right side in bed. Documentation indicated there were wounds on the left buttock versus the right buttock which did not match the observation. Notes also indicated there were wounds on the right heel versus the left that did not match the observations. There were missing weekly wound measurements in the medical record during this interview. RN M said she wound investigate the wounds and provide a timeline with wound measurements, treatments and interventions attempted. On 3/30/23 at 11:00 AM, R64 was on his right side in bed. RN M and the Certified Nurse Aide instructor (CNAI) rolled R64 on his left side. R64 left buttock skin was intact. R64's right buttock had two dime size open areas over his ischium, one was covered with dark eschar and the other was partial thickness. R64's left heel had two dime size open areas, one with dark eschar covering it and the other was partial thickness. The skin on his right heel was intact. No positioning devices or pillows were in the room. Review of the facility timeline for R64's wounds revealed he was admitted to the facility on [DATE] and he had venous ulcers to both lower extremities. His skin issues resolved on 6/8/22. R64's left heel ulcer opened on 8/1/22. On 2/5/23 wound documentation revealed no skin issues. Review of the wound timeline for R64 revealed, Upon presentation of the left heel wound it was defined as unstageable. Multiple stages were given to the wound by different nurses. The wound was unstageable throughout the evolution of the wound until 1-10-23, staging of the wound should not have been considered due to sloughing with inability to view the wound bed entirely. Wound measurements on 1/10/23: ½ cm x0.4 cm x0.2 with no sloughing, clean open tissue with scant serous drainage is the appropriate stage of the wound. Review of the facility wound timeline for R64 revealed Right buttock pressure ulceration: Chart reviewed reveals this area is chronic and cycles with opening and closing due a (sp) history of pressure ulcer put him at higher risk of having the area open due to damage, injury, or pressure, because of the loss of tensile strength of the overlying tissue. Tensile strength of the skin overlying a closed pressure ulcer is 80% of normal skin tensile strength. Review of the facility wound timeline for R64 documented the right buttock was open on 8/30/22 and healed on 10/26/23 and reopened on 3/21/23. Review of R64's wound timeline revealed R64's clinical and cognitive condition reveals skin impairment is unavoidable related to his chronic IAD (incontinence-associated dermatitis) to his scrotum/testes, impaired mobility, fecal incontinence, chronic indwelling catheter, diabetes with microvascular changes with the potential for delayed wound healing, potential to decline cares and treatment, frequently scratches skin with his fingernails, and actual impairment on admission. He is dependent on the staff for all weight bearing activities including clothing management, personal hygiene, and bed mobility. He is dependent on mechanical lift for all transfers. Non-compliance is document with position changes. During encouragement and assistance with positioning notably causing him physical and emotional distress. [R64] has the propensity to physically strike out at staff during positioning and concerns, mitigate his risk factors, and promote optimal quality of life. On 3/29/23 at 2:20 PM the surveyor requested documentation of R64's notification and involvement in the concern for R64's resistance to reposition and any documentation of different approaches or attempts to reposition R64 related to his skin breakdown. Any documentation of different equipment or room arrangements to encourage repositioning as R64 is not his own responsibility party. No information was located at this time or prior to exit. R64 was cooperative with rolling in bed and with all care on all observation made during the survey. Review of R64's care plan revealed, R64's clinical condition reveals skin integrity impairment is expected and unavoidable related to chronic IAD to his scrotum/testes, impaired bed mobility, fecal incontinence, chronic indwelling catheter, diabetes with microvascular changes with the potential for delayed wound healing, potential to decline care and treatment, frequent scratches skin with his fingernails, history of actual impairment on admission, decreased understanding of the importance of eating due to intellectual disability and dementia and uses of mediation that could contribute to lethargy, date initiated 3/29/22. All interventions placed were dated 2022. There was no indication of a need to reapproach or what approach works best due to his intellectual impairment when R64 refuses. R64's heels were to be off-loaded with pillows (all observation during the survey R64's heels were in contact with the mattress and no positioning pillows were located in his room.) The care plan did not indicate R64 would not stay positioned on his left side and did not give any indication what staff should do when R64 would not allow repositioning in bed. There was no indication R64 was no longer tolerating being up in a chair. Review of R64's left heel wound measurements revealed, - 1/2/23 - 0.5 x 0.4 cm x 0.2 - stage II. - 1/10/23 - 1.2 x 0.4 x 02 - no stage given, increased in size. No change in treatment or new interventions. - 1/16/23 - 0.9 x 0.3 x 0.2 - no stage given, no new treatment or interventions. - 1/22/23 - 0.9 x 0.5 x 0.2 cm - no stage given, no new treatment or interventions. - Next measurement 2/3/23 (12 days since last measurement) 1.0 x 0.5 x 0.2, no stage, no new treatment or intervention. - Next measurement 2/13/23 (10 days since last measurement). Now has 2 open areas. 1) 1.0 x 0.8 x 0.4 and 2) 0.3 x 0.3 x 0.1 - No stages given. No indication that the second open area is new. No indication of new treatment or interventions. - 2/20/23 (documented as right heel vs left heel no wound ever actually noted on right heel since admission and no indication this was a new wound. Assume this was an error in charting). 3 x 4 and now a stage III. Note for this wound indicated this was his right heel and that the 2 previous wounds noted this is one wound now. Wound is increasing in size no new treatment or intervention documented. - 3/3/23 - 11 days since last measurement. This note was not locked until 3/29/23 during the survey. This wound was also noted to be left heel in measurement area and no clarification in the note area. Measured 1 x 2 no depth given - stage III. - 3/7/23 - This note was locked on 3/7/23. This wound was noted as left heel. 1 x 1 - No depth and no stage given. No new treatment or intervention was given. - 3/10/23 - no measurement provided, Indicated left heel wound. - 3/15/23 - noted as left heel 1 x 0.7, no stage given, no indication of new treatment or intervention. - 3/21/23 - noted as locked 3/30/23 during the survey. Again, noted as left heel 0.1 x 0.1 - Now noted as a stage II verse stage III. No new treatment or intervention given. - 3/31/23 - Left heel wound indicated but no measurements. See observation during the survey. No wounds on right heel. Left heel had two wounds that were dime size, and one was covered with eschar. Review of right buttock wound measurements: - 3/21/23 - noted on left buttock. See observation notes R64 did not have any wounds on left buttock. This is believed to be an error in documentation. This note was as locked on 3/30/23 (during the survey). It measured 0.4 x 0.4 - stage II. There was no indication this was a new wound. No indication of a new treatment or intervention. - 3/31/22, 10 day later, two wounds noted, 1) 0.5 x 0.4, no depth, but noted, suspected deep tissue injury. 2) 1.5 x 0.5 - no stage and no depth. Observation during the survey, one wound was covered with eschar.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to have clear tube placement orders, failed to track formula intake, failed to provide fluids in accordance with orders and failed to follow nursing standards of practice for 1 Resident (R51) sampled for tube feeding, resulting in weight loss, dehydration, and medication errors. Findings include: Review of R51's face sheet dated 3/30/23 revealed he initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnosis that included: dementia, epilepsy, gastronomy status, congestive heart failure, weakness, muscle wasting and atrophy, colostomy status, dysphagia (difficulty swallowing), cognitive communication deficit and need for assistance with personal care. Per review of R51's MDS (Minimum Data Set) dated 3/7/23, he coded for a weight loss of 5% or more in the last month of loss of 10% or more in the last 6 months. A care plan focus related to nutrition revealed: [R51] has an altered nutritional status .NPO with tube feed dependence to meet 100% of nutrition/hydration needs. [R51] at times does not get the full amount of TF order because he pulls his g-tube out . with a last revised date of 3/16/23. Interventions included evaluate laboratory values in relation to nutritional needs prn. There were no progress notes that revealed concerns with R51 recently pulling out his feeding tube or full tube feed order not being administered. Review of R51's MAR (medication administration record) for March revealed the tube feed is ordered Osmolite 1.5 @ 65 ml/hr. Flush every 4 hours with 220 ml. Kangaroo pump continuous feed. The MAR did not reveal any documentation of any actual amounts of tube feed formula administered. The MAR also only had entries for Day, Evening and Night instead of every 4 hours, which would be 6 times a day flushes. If the MAR is accurate and R51 is only getting flushes 3 times a day, they have a deficit of at least 660 ml of fluid a day versus what the physician and dietician have ordered. Review of R51's Enteral Nutrition Review dated 3/8/23 revealed R51's estimated Fluid Need: TOTAL / WATER VOLUME / DAY 30-35ml water/kg = 2133-2488 (ml's). Review of R51's care plan revealed he is bed bound, dependent on the staff for all aspects of care. He continues to be NPO (nothing by mouth) . with a initiated date of 1/21/23. R51's care plan also refers to a related intervention Flange Placement-5 with a last revised date of 3/6/23. Review of R51's orders revealed Check flange placement-5 prior to administering feeding or medications via PEG tube. This order was active as of 3/6/23. It was not abundantly clear what placement-5 meant. The MAR had a section to document in cm but on 3/6/23 evening no was documented, 3/6/23 night: 0, 3/9/23 Evening and 3/10/23 Day were marked 3 but review of the MAR revealed no medications or tube feeding held on those days. No corresponding progress notes were viewed that explained these entries. A progress note on 3/26/23 by charge nurse U: Gtube in place with 5 inch tube measure. On 3/29/23 at 10:00 AM, R51 was observed in bed with his eyes open. Registered Nurse (RN) K spoke to R51, but he did not respond to her. RN K had supplies ready to connect a new bottle of tube feeding formula. The feeding tube pump was running at 65 ml an hour and showed 3022 ml had been infused and 220 ml of water had been infused. RN K was asked if she reset the pump when connecting a new bottle of formula and where she documented the formula and water intake. RN K said R51 was on a continual 24-hour feed, so they did not need to record formula or water intake and she does not regularly reset the pump. The amount of 3022 ml infused at a 65 ml rate would be approximately 46.5 hours of running time. RN K placed her stethoscope on R51's lower abdomen to listen for bowel sounds while the tube feeding was connected and running at 65 ml an hour. RN K shut the feeding tube off and disconnected the tube feeding. RN K placed a paper measuring tape that measured up to 14 cm in length along R51's feed tube, starting at the portion coming from his abdomen. The tube was longer than the measuring tape. RN K said the portion of the tube showing was supposed to be 5 cm long. RN K said because it was out more than 5 cm, she would have to call the doctor. After calling the doctor, RN K said she did not have her glasses on when she measured the tube, and she was supposed to look for a mark on the tube. RN K said she measured it again and it was still out too far, so the physician wanted R51 sent to the emergency room to check his feeding tube placement. Review of R51's Physician Order dated 3/29/23 at 11:15 AM, Hold tube feed .until abdominal x-ray report read. An observation was made of R51 on 3/30/23 at approximately 8:55 AM and his tube feed was not running. An interview with RN (Registered Nurse) K at approximately 8:56 AM on 3/30/23 confirmed that R51's tube feed had been disconnected since approximately 10:30 AM the previous day. R51 had been sent to the emergency room the previous night to confirm placement of the tube but they had not completed the correct tests. RN K spoke to the physician this morning, and they were ordering another x-ray. RN K stated she had not had time to put in the order yet due to being busy passing medications on two halls. R51 had not received fluid nor nutrition or properly administered critical medications for approximately 22 hours. On 3/30/23 at approximately 9:00 AM the NHA (nursing home administrator) was informed of the concerns that R51 had not received food or nutrition for about 22 hours. The NHA stated the ER did not do an x-ray as ordered last night and they have a stat (urgent) x-ray order to get this done to verify tube placement. The NHA was informed an interview was just completed with RN K and she was too busy at this time to enter the new order for R51. The NHA stated she would check with the nurse immediately. On 03/30/2023 at 9:20 AM an interview was completed with RD (Registered Dietician) E Reported she had not been notified that R51 had been without fluids/tube feeding since 3/29/23 at approximately 10:30 AM. RD E reported she would expect to be notified if fluids/feeding had to be stopped for more than a couple of hours. RD E was asked if it was concerning that he had been without nutrition for nearly a day and she stated, you and I wouldn't go 24 hours without drinking. On 3/30/23 at 9:35AM an interview was completed with RN J and the NHA and they reported just spoke with RD E regarding R51. R N J reported the x-ray from last night showed the tubing was laying over the stomach, so they need a contrast x-ray to confirm placement, which was the point of sending him to the ER last night. R51 returned from the hospital last night without any documentation. The nursing staff that contacted the ER staff reported they flushed it and it was fine without any further diagnostic testing. The recent elevated K (Potassium) and BUN (blood urea nitrogen) was reviewed with RN J and she verified further dehydration could cause additional increase in K and BUN. RN J stated R51's nurse was communicating with physician at this time regarding possible IV for fluids if he is not sent out to the hospital. Review of R51's Medication Administration Record (MAR) with RN J revealed R51's 9:00 PM medications were administered on 3/29/23: atorvastatin (cholesterol medication) and melatonin (sleep supplement) after an order to hold peg tube at 11:15 AM on 3/29/23. Further review of the MAR revealed R51 did not receive his valproic acid for history of seizures on 3/29/23 at 3:00 PM, 3/29/23 11:00 PM, and 3/30/23 7:00 AM. R51 did not receive his eliquis (anticoagulant medication to prevent blood clots and stroke) on 3/29/23 4:00 PM and 8:00 AM on 3/30/23. Corporate Nurse J reported during the interview on 3/30/23 at 9:35 AM that R51 has not had recent seizures but verified R51 had not received his seizure medications for approximately 24 hours. Corporate Nurse J reported she had a call out to the nurse that documented she had administered the Atorvastatin and melatonin. The NHA (Nursing Home Administrator) confirmed by email on 4/4/23 at 2:50 PM that she had not yet received a return phone call from the nurse who documented administering medications on the evening of 3/29/23. Per facility provided policy Enteral Tube Feeding with a last revised date of February 2021 revealed: Assess for placement of feeding tube prior to each intermittent feed, medication administration. At 10:11 AM on 3/30/23, EMS (emergency medical services) arrived to transport R51 to the hospital. On 3/30/23 at 10:10 AM a follow up interview was completed with RD E regarding R51. RD E stated R51 did receive flushes in the ER last night, so has had some fluid and would anticipate the ER will assess him for hydration or follow-up labs would be completed when he returns. RD E stated she would recommend additional bolus flushes to be completed to ensure R51 does not become further dehydrated. RD E stated R51's initial high potassium level was 5.2 on 3/14/23 and the follow up lab was 4.9 the following week, which is still close to a high level with a normal range of 3.4-5.0. It was discussed that the BUN level was also high at 28 mg/dL (normal range is 8-20) on 3/14/23, but this lab test was not repeated. RD E stated she could not determine a dietary reason for the elevated levels and at this time the physician would need to weigh in on why these levels may be elevated and intervene. RD E stated the ordered formula nutrition, and the flushes should be adequate to maintain his nutrition and hydration status, so she was at a loss. A review of progress notes for R51 revealed a note made by RD E on 3/21/23: Assessment requested due to a high potassium level of 5.2. Unsure of cause at this time for high potassium. [R51] only receives 3139 mg of potassium daily in the full ordered amount of enteral feeding (Osmolite 1.5 60ml/hr x 24 hrs) and then an added 20 mg in his 30 ml of prostat daily. The DV of K+ is 3500-4700 mg. Sometimes low fluid volume can result in high K+ levels but [R51] gets 2414 ml of water per day between free water in his formula and the 220ml q 4 hours in flushes, This provides 34ml/kg body weight which meets his ideal hydration recommendations. waiting on repeat K+ level to re-assess. An additional follow up interview was completed with RD E on 3/30/23 at 11:47 AM. RD E had reviewed her emails and stated she did not personally contact the physician but assumed they would be reviewing her notes and the labs as well. RD E stated she had emailed the DON (Director of Nursing) on 3/21/23 about a repeat potassium lab and did not realize that they had already ordered it. R51's labs from 1/11/23 were also reviewed at this time with RD E and they revealed elevated sodium levels of 148 (normal range 134-146), Chloride level of 114 (normal range 98-112), Glucose level of 189 (normal range 70-99) and BUN of 36 (normal range of 8-20). RD E was asked if she was aware of why a repeat lab had not been done to follow up on these and she stated that R51 had been sent to the hospital due to these labs and believed they had an infection at that time. Review of a hospital Discharge summary dated [DATE] revealed that upon discharge R51 continued to have high glucose levels (113), BUN levels (21), potassium levels (6.0), and low calcium levels on 1/20/23. A follow up interview was completed with the NHA on 3/30/23 at approximately 2:30 PM regarding R51. The NHA stated R51 had returned from the hospital and the tube feed placement had been verified. The NHA was asked if any lab work had been completed and she stated that she believed just an x-ray had been done. The NHA stated labs were ordered for the next lab day for R51. At the time of exit the labs had not yet been completed for R51.