**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes M100151387 and M100151421. Based on observation, interview and record review, the facility failed to prevent hospitalization, monitor, assess, intervene, document, and provide appropriate care of nephrostomy tubes for 2 (R1 and R2) of two residents reviewed for nephrostomy care, resulting in hospitalization and infection. Findings include: Resident #1 (R1) Review of a Face Sheet revealed R1 originally admitted to the facility on [DATE] and readmitted to the facility after a hospitalization on 3/31/25. Pertinent diagnoses include hydronephrosis (urine build up on kidney) with renal and ureteral calculous (kidney stones) obstruction (1/14/23), infection and inflammatory reaction due to nephrostomy catheter (3/31/25), acute pyelonephritis (kidney infection) (3/31/25), urinary tract infection (3/31/25), and Escherichia coli (E. coli, a bacterium that causes infection, 3/31/25). Review of the Minimum Data Set (MDS) dated [DATE] for R1 revealed she is cognitively intact had an assessment for mood/depression score of 00. No behaviors documented and required substantial/maximum assistance with lower body dressing and toileting. In an interview on 4/15/25 at 1:30 PM, the Registered Nurse (RN) A reported R1 had been in the hospital several times in the last few months to have her nephrostomy tube (catheter) replaced and expressed concern the facility is not competently providing nephrostomy care. On 3/20/25, R1 went to the hospital and the 3-way stopcock on the nephrostomy tube was in the off position and not draining. The exit site was red and had some drainage as well. Once the stopcock was opened, they were able to drain about a half liter of puss like drainage that later tested positive for E. coli bacterial infection. R1 was then transferred to another hospital for an inpatient stay for antibiotic therapy and monitoring. RN A reported R1 had a nephrostomy tube placed on 10/27/24 and exchanged on 11/20/24, exchanged again on 12/4/24, new replacement on 1/11/25 because it may have been pulled out, on 1/16/25 it was checked, changed and repositioned, on 2/5/24 it was dislodged, and 2 sutures were put in place. On 2/25/25 the facility called them about a suture not being intact with redness at the exit site and she had low urine output and was to go to Big Rapids and not sure if R1 went. On 3/11/25 the nurse at the facility called with concerns about the nephrostomy tube for R1 and then R1 was sent to the hospital on 3/20/25. The resident could not speak. Review of the Hospital Medical Records for R1 revealed: History of Present Illness: . chronic severe right hydronephrosis who had an IR (Interventional) appointment today to look at her nephrostomy tube which was found to not be draining, they replaced it and had 548 mL (milliliters) of purulent urine. Apparently, there was some concern about a possible fistula between the renal pelvis and duodenum and was sent to the emergency department for limited CT scan. Interventional Radiology documented: Findings: The stitches holding the nephrostomy catheter are noted to be intact. The stopcock was in the off position and purulent drainage was noted around the catheter. Aspiration yielded 540 cc (cubic centimeters) of green, purulent fluid. A sample was sent for culture. Impression: The nephrostomy tube was noted to be in the off position with purulent material draining from around the catheter. A large volume of purulent fluid was evacuated from the kidney. Contrast injection revealed a possible fistula between the renal pelvis and duodenum. Pictures provided revealed R1 had redness and drainage at the exit site upon arrival to the hospital. R1 had a low blood pressure of 98/43 and afebrile. (Not documented in the facility medical records.) Review of Hospital medical records for R1's hospital stay from 3/20/25 to 3/31/25 revealed: In regards to her pyelonephritis, she has a heavily infected kidney with frank purulence. She was identified to have ESBL (Extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales are resistant to common antibiotics and may require complex treatments) producing E coli. She was seen in consultation with the infectious disease team and was started on meropenem as well as micafungin. The interventional radiology team, recommended flushing the tube, to help with drainage. Given the extent of infection as well as the concern for renal duodenal fistula, Urology was consulted, ultimately it was decided from Urology standpoint the patient was not felt to be a surgical candidate. Infectious Disease recommended changing from meropenem (broad spectrum antibiotic) and micafungin (antifungal) to ertapenem (antibiotic for severe infections). They recommended therapy through 3/31. There was discussion about PICC (peripherally inserted central catheter) line and outpatient IV (intravenous) ertapenem, but given limited access with HD (hemodialysis), she was kept inpatient to complete her abx (antibiotics) therapy. This was done without complication. No further concerns about fistula. Patient clinically improved with abx. Review of the Electronic Medical Records (EMR) for R1 revealed no ongoing assessing, monitoring, or output of nephrology tubing and exit site care. Review of the January Medication/Treatment Administration Record (MAR/TAR) for R1 revealed an order for a nephrostomy dressing change dated 11/20/24 to 2/6/25 25 Change Nephrostomy drain dressing daily, clean site with soap and water, apply a small amount of triple antibiotic, Cover with gauze. May shower-do not bath or submerge tube underwater. Change tube attachment or tape as needed to keep from pulling on tube. in the evening for Nephrostomy care. Care was documented/not documented as done on 1/7 (sleeping), 1/10 (no data entry), 1/11 (hospital), 1/13 (no data entry), 1/16 (other see nurses notes), 1/23 (other, see nurses notes), 1/24 (sleeping). Review of the Nursing Progress notes revealed no documentation to reflect 1/13, on 1/16 the nurse documented R1 was sleeping at this time and no follow up, and 1/23 no follow up documentation. Review of the Nursing Progress notes dated 1/10/25 for R1 revealed the resident went to dialysis and pulled out her nephrostomy tubing. On 1/11/25 R1 had it replaced. Review of the February Medication/Treatment Administration Record (MAR/TAR) for R1 revealed an order dated 11/20/24 to 2/6/25 Change Nephrostomy drain dressing daily, clean site with soap and water, apply a small amount of triple antibiotic, Cover with gauze. May shower-do not bath or submerge tube underwater. Change tube attachment or tape as needed to keep from pulling on tube. in the evening for Nephrostomy care. Care was documented/not documented as done on 2/7, 2/10, 2/11, 2/13, 2/16, 2/23, and 3/7. -An order for R1 dated 11/20/25 and discontinued on 2/6/25 to Empty and record nephrostomy drain and record output every shift. No documentation indicating the nephrostomy output was being monitored. No follow up documentation in the EMR to show any concerns of drainage or redness at the exit site before hospitalization on 3/20/25. Review of the March MAR/TAR for R1 revealed a continued order from February for dressing changes every other day and was discontinued on 3/11/25. A new order started on 3/12/25 to: Change the right Nephrostomy dressing, Do not pull on the tube. Do not use scissors for the dressing because you could cut the tube or the stitch. Wash the area with mild soap and water, rinse, and pat dry with a clean Washcloth. Look at the site after your dressing is removed. Check for redness around the tube exit site. Check for any discolored or odor. Inspect the suture to verify that it is still anchored in the skin. Place gauze around the tube where it exits the body and cover Tegaderm (sic) in the evening every other day. On 3/10 (sleeping, no follow up documentation or reapproached). After the dressing change on 3/8/25, the next dressing change was 3/12/25. -No orders to document or monitor the output from the nephrostomy tubing. Review of the April MAR/TAR for R1 revealed she had an order for a nephrostomy dressing change every other day and received a dressing change on 4/1/25 after readmission from the hospital. On 4/3 (refused), no documentation as to why and if reapproached, 4/5 (see nursing notes) and no nursing progress notes documented, 4/7 (sleeping) and no progress notes reflecting the resident was reapproached. R1 did not receive any dressing changes after 4/1/24 until 4/9/25. On 4/11 no dressing change was done, and the nursing progress notes reflected the nephrostomy tubing was out about 5 centimeters on 4/9/25 and 10 cm by 4/10/25 and documented as dislodged by the end of the day. No root cause documented, no anchoring or securing devices was documented as used and no frequent supervision of cares. -An order 4/1/25 to Record output to nephrostomy. Notify MD (physician) any abnormal urine output and change in Urine (cloudy, foul-smell, or bloody) every shift. Between 4/1 and 4/17 there were 30 shifts of 0 output and on 4/14 it is documented as n/a, See Nurses Notes. There were no nursing notes for 4/14/25. Review of a Nursing Progress note dated 4/9/25 for R1 revealed: nephrostoy (sic) tube appears to be pulled out approx. 5 cm (centimeters) as stitch is approx. that far out. Drng (dressing) (sic) is the bag, approx. 5 ml. Nephrologist paged via number on (R1's chart at this time. (R1) has no c/o (complaints of) pain, no bleeding, drng (sic) or redness at nephrostomy site. Review of a Nursing Progress note for R1 dated 4/9/25 revealed the on-call facility provider was notified her nephrostomy tube concerns and requested to watch closely and if the tube dislodges or has any drainage to call them immediately. Review of a Nursing Progress note dated 4/10/25 for R1 revealed advanced radiology was notified her nephrostomy tubing is out about 10 cm now and the sutures are no longer intact with no c/o (complaints of) pain or discomfort and very little output. Radiology to get an appointment as soon as possible. No more nursing progress notes addressing concern or if the resident was sent out to have her nephrostomy tube replaced. No follow up assessments. Review of a Skilled Daily-Medically Complex document dated 4/10/25 for R1 revealed: nephrostomy output appears clear to turbid light. without obvious red. resident denies pain. site without redness or site drainage. (sic) Review of a Medicare Coverage Evaluation for R1 dated 4/16/25 revealed: Dressing change ordered to nephrostomy site. Monitor amount of drainage. Nephrostomy tube became dislodged on 4/10/25, sent out to have it replaced in GR (Grand Rapids hospital). During an observation and an interview on 4/16/25 at 1:30 PM, RN C went to R1's room and reported her nephrostomy bag was draining because the pigtail of the stopcock was pointing towards the injection/flushing port even though we just saw another resident who had her nephrostomy stopcock pigtail pointing towards the drain bag tubing. RN C reported R1's dressing (which was an undated 22 gauze with tape and the tubing was not secured) and RN C reported her stitches securing the tubing was fine. The resident was lying in bed, and her pants were partially over the nephrostomy, but under the exit site potentially tugging on the tubing. In an interview on 4/16/25 at approximately 1:40 PM, RN B reported she has not heard of any concerns with R1 having her nephrology tubing displaced or replaced recently. RN B reported she did not know who last changed the nephrostomy dressing and acknowledged there was no date on it. RN B reiterated an earlier conversation of staff not getting treatments done as ordered and at times they are documenting they are done even if they did not complete them. RN B reported management is aware of concerns. In an interview on 4/16/25 at 3:33 PM, Unit Manager/Licensed Practical Nurse (UM/LPN) H reported R1 has pulled out her nephrostomy catheter several times because she has OCD (obsessive compulsive disorder, not listed as a diagnosis for R1 on her Face Sheet). UM H continued alleging R1 is non-compliant. UM H reported R1 had her nephrostomy tubing dislodged on 4/10 and went to [name of another city where second hospital was located] on 4/11 to have her tubing replaced. When asked if anchoring her tubing would help, UM H reported there is no order for one and did not think it would help. When queried about the hospitalization in March, UM H reported she did not know why R1 went into the hospital and started looking into the computer. UM H reported she is the Unit Manager but gets pulled to the floor to work often implying that is why she did not know what is going on with R1 and reiterated she has had her catheter dislodged several times but didn't know all the details. When asked about the lack of charting of care, assessments, and transfers outside the facility for R1 in the EMR, UM H reported she herself would put in a progress note and verified there was no transfer form in the computer when R1 went to the hospital on 3/20/25 and 4/11/25. UM H reported residents do not get a transfer form for outside appointments, but the MAR and the Face Sheet will get with the resident and the last set of vital signs. When asked about the standards of care for nephrostomy's, UM H reported the doctors do not usually order output monitoring unless the nurses ask for them and elaborated that after this last hospitalization, she did add the output monitoring to the nurses charting. UM H was questioned about the 0 output documented in the MAR and said they did not have parameters to notify the physician but expected nurses to know when to notify the physician for anything abnormal. When asked about the nurses being educated on nephrostomy care, UM H reported they get educated but thinks they may need more. When questioned about the stopcocks on the nephrostomy bags for R1 and R2, UM H reported that if there are instructions, they will put those instructions in the order as what needs to be done or will put them in an education binder for the nurses. During an observation and an interview on 4/16/25 at 3:35 PM, the Unit Manager/Licensed Practical Nurse (LPN) H was asked about the nephrology tubing for R1 and reported the pig tail of the stop cock was pointing toward the flushing/irrigation port. At this time, UM H did not know if the stopcock was opened or closed to draining. Resident #2 (R2) Review of a Face Sheet revealed R2 originally admitted to the facility on [DATE] and readmitted after a hospitalization on 4/6/25 and has pertinent diagnoses of Urinary tract infection, bacteremia (blood infection), methicillin resistant staphylococcus aureus infection, multiple sclerosis, hydronephrosis. During an observation and an interview on 4/16/25 at 11:35 AM, R2 was in bed and her nephrostomy tube was on her right side and R2 reported that hardly anything comes out. RN B reported the stopcock on the nephrostomy tube was draining and can tell the tubing is stable. The pigtail of the stop cock was facing the tubing of the drain bag. During an observation and an interview on 4/16/25 at 1:30 PM, RN C went to R2's room and reported the nephrostomy bag was draining because the pigtail of the stopcock was pointing toward the tubing of the drain bag which means it is on. During an observation and an interview on 4/16/25 at 3:25 PM, the Unit Manager/Licensed Practical Nurse (LPN) H was asked about the nephrostomy tubing for R2 and asked this surveyor if the attending nurse was questioned. When UM H was asked to look at R2's nephrostomy tubing, UM H looked at the stopcock and verified the pigtail of the stopcock was pointing toward the drain bag and said she would have to get her bifocals to read if it says it is in the off position because she was not sure at this time. When asked what a typical assessment would include, UM H reported the drainage and any color, pain, discomfort, sediment, and would look at the exit site. When asked what an abnormal reporting for this resident would be and what the expectations of staff would be, she reported she would document her findings, look at the history. UM H did report there was some scant sediment in the drain bag and small amount of blood fluid in the tubing, but no measurable amount of body fluid at this time. Review of the April MAR/TAR for R2 revealed an order to Empty nephrostomy bag and enter amount every shift dated 4/7/25 revealed until 4/17/25 there are 22 shifts of 0 output from the nephrostomy bag and one shift with no documentation. The highest output was 40 ml (milliliters) on 4/7/25 when the monitoring began post hospitalization. On the 4/17/25 night shift, after questioning the nephrostomy care, 575 ml of fluid output was documented. In an interview on 4/16/25 at 5:00 PM, UM H reported that stopcock for R1 which had the pig tail pointing towards the irrigation port was not in the right position and will educate her staff on the correct position which is towards the drain bag like it was for R2. Review of the Care Plan for R2 revealed no nephrostomy care plan or interventions. In an interview on 4/17/25 at 1:21 PM, the Director of Nursing (DON) reported they educated the nurses yesterday and all the nurses today before they start their shift on nephrostomy care and reported the nurses could demonstrate the appropriate positioning of a nephrostomy stopcock. The DON reported R1 has a history of pulling out her nephrostomy tubing and is always fidgeting with it. R1 and R2 are dialysis patients, and it is hard to know how much urine output they will have. The DON reported R1 is OCD with her tubes and other devices she has and just cannot leave them alone. The UM H made sure her dressing was secured with a Tegaderm, and the tubing was anchored well yesterday. The DON verified the dressing is to be secured with a Tegaderm and acknowledged it was not. The DON reported she thought there was an order to anchor the nephrostomy tubing in place but could not find it. When asked if dressings should be dated, the DON reported it is preferred. When asked if there were concerns that staff reported dressing changes were not being done but were charting, they were? The DON reported it had been a while but did not have anything solid to prove the nurses were doing this. When asked what was included in the nephrostomy care education the day before, the DON was to provide the information and reported the staff know which position the stopcock should be in to drain the nephrostomy. During an observation on 4/17/25 at 1:45 PM, Licensed Practical Nurse (LPN) I and surveyor went to R2's room and verified the stopcock was pointing towards the drain bag which meant that it is draining. Afterward, LPN I verified the stopcock was pointed toward the drain bag and said it was draining, but not confidently, with a little blood-tinged urine noticed in the bag. In an interview on 4/17/25 at 2:00 PM, the RN A reported the pigtail of the stopcock is the off position. Wherever that pigtail is pointing, that means it is blocking the flow to that area. It should always be pointing toward the irrigation port so the nephrostomy tubing can drain to the bag. RN A then reported if it is pointing toward the drain bag, it is not draining. In an interview on 2/17/25 at 2:19 PM, the DON reported she went to R2's room and saw the pigtail of the stopcock was pointed towards the drain bag and R1's pigtail was pointed towards the port. The DON reported UM H misunderstood what position the stopcock needed to be in and is going around re-educating staff right now. In an interview on 2/17/25 at 2:30 PM, the facility Staff Educator/RN U reported the staff were educated yesterday on the correct positioning of the stopcock for R1 and R2 and the pigtail should be pointing towards the flushing port. RN U reported she knew this yesterday and educated the staff by showing them a picture. RN U reported she went to R1's room yesterday and the stopcock was in the correct position, but today it was pointing towards the drain bag indicating it is not open. RN U reported she educated the staff and the Unit Manager by reviewing the policy and talking about it. The Unit Manager misunderstood and those she educated, were informed wrong. Today, the started to re-educate staff again with pictures of the stopcock and that the pigtail should always be pointed toward the flushing port for draining into the bag. Review of a policy titled Nephrostomy and Cystostomy Tube Care and Maintenance last revised on 1/1/22 revealed: Residents with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1.As part of the comprehensive assessment and care planning process, the type of tube will be clearly documented in the resident's medical record. When the type of tube is not clear, the nurse will call the surgeon, other physicians, family members, or other individuals, as needed, to make the determination. 2.The care and maintenance of nephrostomy/cystostomy tubes shall be in accordance with physician orders. The orders shall specify the type and frequency of dressing changes and emptying of collection bags along with any special instructions. 3.Nephrostomy/cystostomy tubes shall be managed by licensed nurses. Nurse aides may handle the collection bags in accordance with facility procedures for handling urinary drainage bags. 4.The resident's goals and preferences for care and treatment of the tube(s) will be used to formulate a plan of care (i.e. self-care, dependent care, family caregiver). Interventions may include but are not limited to: a. Frequency of dressing changes and emptying of collection bags. b. Self/family care instructions, where applicable. c. Monitoring for and responding to any signs of resident's discomfort associated with the tube(s). d. Interventions to prevent complications or promote dignity associated with the tube(s). I. Fluid preferences, and need for increased fluid intake. ii. Monitoring for symptoms of blockage (reduced or absent urinary output), urinary tract infection (fever, chills, back pain, new onset delirium, foul smelling or cloudy urine), or dislodgement (tube falls out, leaking urine around tube, increase in tube length). iii. Monitoring for skin breakdown or signs of infection (redness, warmth, swelling, abnormal exudate) around the insertion site(s). iv. Physical management of tubing and collection bags to prevent infection or dislodgement. 6. Considerations for care: a. Check tube(s) frequently for kinks or obstructions. These are likely to occur if the resident lies on the insertion site. b. Keep the drainage bag below the level of the kidney at all times. Keep bags covered for dignity. c. Monitor output for changes in amount, color, clarity, or odor. d. Monitor for signs of urinary tract infection or infection of insertion site. e. Monitor resident for discomfort associated with the tube(s) or procedures. f. Record output from each tube. Specify location of output. g. Document abnormalities and report to physician immediately. According to Corona, L., [NAME], K., Lucas-[NAME], C., United Ostomy Associations of America, Inc. (UOAA), [NAME], Z. L., [NAME], S. C., [NAME], H. C., Advent Health Medical Group Urology, Kaiser Santa [NAME], & Double Nephrostomate. (n.d.). NEPHROSTOMY. https://www.ostomy.org/wp-content/uploads/2024/01/UOAA_Nephrostomy_Facts_Booklet_2024-01a.pdf, If your nephrostomy tube has a 3-way stopcock valve (the longest port is labeled off) (p. 9) . Tube blockage/obstruction: Signs and symptoms o Drainage has decreased or stopped, greater than 2 hours o Leakage of urine around insertion site If you think your tube is blocked or obstructed o Check to make sure the tube is not kinked - use a mirror to assess your back o Check to make sure the valve is open so urine can flow into the bag o Check to make sure the collection bag is not damaged. If it is, change it. o Attempt to flush the tube with no more than 10 cc of sterile water or sterile normal saline. Do not withdraw fluid after irrigation. If fluid does not go in easily you can try to gently pull back on the syringe to dislodge any obstructing particles. Reattempt flushing using gentle pressure. If you have any pain while attempting this intervention, stop. (See tube flushing) If none of these interventions produce normal urine flow, contact your physician or interventional radiologist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00133465. Based on interview and record review, the facility failed to appropriately assess, monitor, document, implement treatment/ resources, and notify the physician promptly for changes in condition for 2 (Resident #1 and Resident #4), resulting in both residents being hospitalized and one resident receiving pain medications potentially masking underlying condition. Findings include: Review of a policy titled Notification of Changes last reviewed [DATE] revealed The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. Resident #1 (R1) Review of a Face Sheet revealed R1 was a [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnoses of paraplegia, pressure ulcers, open wounds, history of bariatric surgery, and bipolar. Review of the Minimum Data Set (MDS) dated [DATE] revealed R1 was cognitively intact and required extensive assistance of two staff for transfers and extensive assistance of one staff for bed mobility. She had limited range of motion on one side of her upper extremity and impairment on bilateral lower extremities. She had 2 stage III pressure ulcers upon admission and one stage IV pressure ulcer upon admission. In an interview on [DATE], the complainant reported R1 complained of her stomach hurting really bad around [DATE] or [DATE] and had told several of the staff at the facility and family members several times. Concerned she was just given pain medications to cover the pain, but the root cause of her pain was not addressed. She was sent to the hospital and found out she had a bowel obstruction and died. She also had several pressure sores and a septic infection that spread. Concerned staff were nice but not doing appropriate care. Review of the Hospital Medical Records dated [DATE] revealed R1 went to the hospital emergency room around 6:30 PM with pertinent diagnoses of small bowel obstruction, peristomal hernia, and lactic acidosis. When she arrived, she had an elevated heart rate (tachycardic) in the 140s (60-100 is normal) and rapid breathing (tachypneic) and sweating (diaphoresis). She had abdominal pain with decreased colostomy output. Given patient's comorbidities and current critical illness it was recommended that patient be transferred to a higher level of care. However, general surgery at the higher level of care felt patient needed operative intervention sooner and recommended exploration prior to transfer in assessment for transfer postoperatively. In an interview on [DATE] at 1:13 PM, Licensed Practical Nurse (LPN) C reported the day R1 went to the hospital ([DATE]), she was the day shift nurse for her that day and was told in report that morning that R1 had some stomach aches which was normal for her and R1 wanted to see the doctor. Her vital signs were normal with the exception of a lower-than-normal temperature, and she just seemed to be acting out of sorts more than normal. She did have some bowel sounds, seemed weak and chilled. She had some pain but could not rate it because she was just kinda out of it. LPN C reported she called the doctor around 9-10:00 AM that day and had to leave a message for the doctor who did not return her call. The doctor came late that day around 5:00 PM or so. LPN C reported the doctor did not call back because she was going to be in later that day. LPN C reported she had not worked with R1 for a couple of days and does not always work in the same halls with the same residents to always know how the residents were during that week but reported R1 has not always been right. LPN C remembers R1 had some vaginal discharge that was an infection and sure the doctor did a vaginal swab. She also had a foley catheter. She had a colostomy that had different consistencies in her (fecal) output and would try different things to get her colostomy to flow nice. She did not have any output in her colostomy the day she went to the hospital and not sure what her output if any the day before. When the doctor saw R1, she didn't see any true problems, but LPN C insisted that this was not normal for the resident and that is when the doctor ordered the resident to be sent to the emergency room. Review of Physician Orders for R1 revealed on [DATE] an order for Norco 7.5-325 mg (milligrams) was ordered as needed twice a day for pain but not specifically indicated for what pain. On [DATE] one dose was given for pain rated 5/10 and discontinued on [DATE]. Acetaminophen 500 mg X 2 tablets was ordered to be given twice a day for pain (unspecific) starting [DATE] and discontinued on [DATE] when the resident was discharged . Another order for Acetaminophen 500 mg X 2 tablets as needed was ordered on [DATE] and given on [DATE] for pain rated 4/10 with no indication where or what the pain was. Review of Physician orders for R1 revealed on [DATE] an order for Norco (narcotic) 7.5-325 mg to be given one time a day for pain around 4:00 PM. This order discontinued on [DATE]. No indication what pain. Review of the Medication Administration Record (MAR) for [DATE] through [DATE] revealed she had an average pain rated at 0-6 when given Norco or acetaminophen. On [DATE] a pain rated 9/10, [DATE], pain 8/10. No follow up documentation or assessments as to where or what the pain was. Review of Physician orders for R1 revealed on [DATE] an order for Norco (narcotic) 7.5-325 mg to be given three times a day for pain around 4:00 PM and discontinued on [DATE]. Specific pain was not indicated, and neither was the times. R1 did receive 2 doses on [DATE] for pain rated 2/10. Review of Physician Orders for R1 revealed on [DATE] an order for Norco 7.5-325 mg was ordered once a day as needed for pain and discontinued [DATE]. Not specifically indicated for what pain. No doses of this order were given. Review of Physician Orders for R1 revealed on [DATE] an order for extra strength Tylenol (500 mg tablets X 2) was scheduled twice a day for pain but not specific to what pain. Review of a Physician Assistant Progress note for R1 dated [DATE] revealed the resident was seen for ulcers on her bilateral ischium and coccyx and stated the wounds on her bottom are painful at times. She offers no other complaints today. Resident is also noted to have vaginal discharge with an odor again, resident has recurrent vaginitis, will refer her to gynecology as the discharge makes it difficult for the dressings to be able to adhere. Review of a Physician Assistant Progress note for R1 dated [DATE] revealed the resident was seen for ulcers on bilateral ischium and coccyx only. Review of a Physician Progress note dated [DATE] for R1 revealed it was a Federal Regulatory Visit and there were no documented complaints of abdominal concerns or pain being addressed. Review of the Electronic Medical Records (EMR) for R1 revealed no Nursing Progress notes on [DATE] addressing R1s pain that was rated at an 8/10 or any follow up assessments and/or physician notifications. Review of a Physician Progress note dated [DATE] for R1 revealed: She's complaining of nausea and abd pain today. Not wanting to eat or take any meds. She had a vaginal ID test done and shows some BV, but that shouldn't cause these symptoms. By the time I could see her this evening, she was feeling much worse. Severe abd (abdominal) pain. I recommend send to ER. Review of an Order Summary for R1 revealed an order for a referral to Gynecology for recurrent vaginitis that was discontinued on [DATE]. Review of the EMR revealed no assessment, labs, or appointments for Gynecology or vaginitis. Pressure Ulcers Review of the September Medication Administration Record (MAR) for R1 revealed orders for bilateral ischial wounds dressing changes ordered [DATE] revealed 5 treatments not documented, Zinc oxide cream to coccyx every shift ordered [DATE] not documented done 4 times, and Prevalon boots to bilateral feet at all times not documented as done 4 times. Review of the October MAR for R1 revealed an order for Bilateral ischial wound treatment orders dated [DATE] and discontinued on [DATE] revealed 8 treatments were not done. Review of the November MAR for R1 revealed an order on [DATE] for Bilateral ischial wounds treatment once a day and the resident did not get treatment for 8 days. An order for the left medial thigh wound treatment ordered daily on [DATE] and discontinued [DATE] missed 2 days of treatments. Zinc oxide cream to coccyx every shift and as needed missed 6 treatments. Prevalon boots to bilateral feet every shift missed 6 opportunities. Review of a Care Plan for R1 revealed Focus: The resident has/is at risk for [chronic] pain related to paraplegic, osteomyelitis, chronic ulcer of back, pressure ulcers, osteoarthritis, impingement disorder of shoulder, calculus of ureter, chronic pain syndrome last revised [DATE] (after discharge). Interventions: Administer pain medications as ordered. 1. Give ½ hour before treatments or care, initiated [DATE], last revised and canceled on [DATE]. 2. Evaluate the effectiveness of pain interventions on the following frequency. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, last revised and canceled on [DATE]. 3. Monitor/document/report to physician any side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls last revised and canceled on [DATE]. 4. Monitor/record/report to Nurse any signs or symptoms of non-verbal pain, last revised and canceled on [DATE]. 5. Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss last revised and canceled [DATE]. 6. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment, initiated [DATE] and last revised and canceled [DATE]. 7. NON-MEDICATION INTERVENTION FOR PAIN: offer repositioning to resident when having pain/discomfort, initiated [DATE] and last revised and canceled [DATE]. 8. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain, initiated [DATE], last revised and canceled on [DATE]. 9. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease movement or range of motion, withdrawal or resistance to care. 10. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease movement or range of motion, withdrawal or resistance to care, last revised and canceled [DATE]. 11. Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences, last revised and canceled [DATE]. 12. Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain-relieving methods (i.e., positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound), last revised and canceled [DATE]. 13. Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to (signs or symptoms) or (complaints of) pain or discomfort, last revised and canceled [DATE]. Review of a bacterial vaginitis care plan for R1 initiated on [DATE] and resolved on [DATE]. In an interview on [DATE] at 2:37 PM, the DON reported R1 went to the resident council meeting the day before she was hospitalized , then on the morning of [DATE] she complained of not feeling well. The doctor came in around 10:00 AM and the resident kept progressing and feeling worse with generalized stomach pain. When the doctor came in, she said her pain was greater than a 10. Resident #4 (R4) Review of a Face Sheet revealed R4 is a [AGE] year-old female who originally admitted to the facility on [DATE] with pertinent diagnoses of end stage renal disease, diabetes, recent diagnoses of pulmonary embolism, hemiplegia, and hemiparesis (one sided weakness), and convulsions. Review of the MDS for R4 dated [DATE] revealed she was moderately cognitively impaired and required extensive assistance of 2 staff for bed mobility and totally dependent on staff for transfers. She had limited range of motion on the upper and lower extremity on one side. Review of hospital records dated [DATE] for R4 revealed she had an altered mental status, with 1. acute encephalopathy, 2. hypoglycemia, 3. Severe sepsis, 4. Seizures, 5. Hyperammonemia, 6. Hepatic steatosis and a bloody nose. Patient apparently had skipped dialysis on Friday, 3 days ago, because she did not want to go. When the nursing home went to wake her up for dialysis this morning, she had minimal responsiveness, and it was thought she may have had a seizure. They noticed blood around her mouth without any obvious trauma. EMS states the patient's blood sugar was in the 80s per their glucometer. Concern at this time is intracranial hemorrhage as she is on Eliquis, new liver disease, nonspecific sepsis but concerning for CNS disease, urinary tract infection, drug intoxication, or drug effect leading to the above etiology. Review of the December MAR for R4 revealed an order for 5 mg of Eliquis (anticoagulant) to be given twice a day for pulmonary embolism started on [DATE]. Buspirone 5 mg twice daily ordered [DATE] and again on [DATE]. Escitalopram 10 mg ordered [DATE] and again on [DATE]. Review of an Order Note for R4 revealed a severe drug interaction warning for Buspirone 5 mg twice daily and Escitalopram Oxalate 10 mg increasing the risk for serotonin syndrome. Another warning for 81 mg of aspirin concurrently taken with Escitalopram 10 mg has a moderate risk of an increase in upper gastrointestinal bleeding. No indication the physician was notified and addressed the interactions. Review of Nursing Progress Notes dated [DATE] revealed R4 refused to go to dialysis (a treatment to remove waste, chemicals, and fluid from your blood when the kidneys no longer function well.) Review of the EMR for R4 revealed no assessments done since refusals of dialysis or indication the social worker was notified. Review of a Nurses Progress note dated [DATE] at 5:10 AM for R4 revealed she was found unresponsive except to pain/sternal rub. Dried blood around mouth, she also had blood from her mouth yesterday afternoon but unsure where it came from in her mouth. No documentation indicating the resident was assessed and the physician was notified the of blood coming from her mouth the day before. In an interview on [DATE] at 1:13 PM, LPN C reported R4 went to the hospital earlier in December because she had a stroke and then was found unresponsive at 5:00 AM on [DATE] when they went to get her up for dialysis. The week before she went out, she was very upset with the passing of her roommate earlier that month because they were very close and felt her roommate gave her a purpose. She started to refuse care, dialysis, and activities. In an interview on [DATE] at 1:54 PM, the dialysis center reported the last dialysis treatment R4 received was on [DATE] at their facility. In an interview on [DATE] at 2:10 PM, Social Worker (SW) D reported she had not been at the facility since [DATE] when she found out that R4s roommate had passed away. SW D reported she was not aware of R4 not adjusting well after the passing of her roommate and was not sure who would have followed up with the resident after such a loss. In an interview on [DATE] at 2:37 PM, the Director of Nursing (DON) reported she expects nurses to document in the progress notes any changes in a resident and noted there are different assessments they can do. If a resident was found bleeding from her mouth, she would expect it to be documented so it would pull over on an interdisciplinary (IDT) note and put it in the doctors note. Would also expect an assessment to be done. If it is unknown where the bleeding was coming from, the DON would expect the physician to be called. If a resident refuses to go to dialysis, she would expect that an alternate day be arranged, and informing the physician of her refusals. The DON reported it would be great if the nurses would document when a resident refuses to go to dialysis. The medical record is a legal document and is used to protect the patient as well as the professional practice of those in healthcare. Documentation of the care you give is proof of the care you provide .Charting is objective, not subjective. This means chart only what you see, hear, feel, measure, and count - not what you infer or assume. All nurses know that if it wasn't charted, it wasn't done the patient's complete and accurate medical record the most reliable source of information on the care of that patient. Proper nursing documentation prevents errors and facilitates continuity of care. https://www.asrn.org/journal-chronicle-nursing/341-charting-and-documentation.html The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). Nursing assessment is the deliberate and systematic collection of data of the residents' health and functional status and is the first step in Nursing Process. The data obtained in the assessment is communicated to other care givers and health professionals and is used to diagnose the problem and plan and implement care ([NAME], P. A. & [NAME], A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According to Legal and Ethical Issues in Nursing, 4th Edition, ([NAME], G, 2006), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete. A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. ([NAME] & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved [DATE], from http://www.hgexperts.com/article.) Nursing judgment is critical when medications that are ordered PRN (as needed) are given. The nurse documents the assessment made and the time of medication administration. The nurse should make frequent evaluation of the effectiveness of the medication and record findings in the appropriate record ([NAME], P. A. & [NAME], A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00128848 and MI00132982 This citation has 2 Deficient Practice Statements (DPS) DPS 1 Based on interview and record review, the facility failed to accurately perform post fall assessments for 2 residents (Resident #57, and #218) reviewed for falls, resulting in the potential for neurological changes to go undetected and a delay in treatment. Findings: Resident #57 (R57) Review of an admission Record revealed R57 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's Disease. Review of R57's Incident Report dated 10/19/22 revealed, Un-witnessed .Nurse heard resident yelling, nurse found resident sitting on her bottom in the bathroom in front of her WC (wheelchair), in front of sink .States she was trying to blow her nose cause it was bleeding and slipped . Review of R57's Progress Note dated 10/19/22 revealed, Resident was in bathroom after lunch, lost her footing and slipped onto floor, landed on her bottom; no inuuries, (sic). Review of R57's Fall-Initial assessment dated [DATE] at 1:34 PM revealed a neurological assessment was completed. (Neurological Assessment/neurological examination is completed to ensure no trauma/damage occurred following a fall). Review of R57's Fall-Follow-up assessment dated [DATE] at 7:57 PM revealed a neurological assessment was completed. Review of R57's Fall-Follow-up assessment dated [DATE] at 3:53 AM revealed a neurological assessment was completed. Review of R57's Fall-Follow-up assessment dated [DATE] at 9:18 PM revealed a neurological assessment was completed. Indicating a neurological assessment for R57 was not completed every shift x72 hours following a fall. (Neurological assessments were complete on all 3 shifts on 10/22/22). Review of R57's Incident Report dated 11/11/22 revealed, Un-witnessed .staff gathering residents for dinner noted resident sitting on her bathroom floor with back against the wall .resident stated 'I had to pee in the toilet. Review of R57's Progress Notes revealed no documentation of R57's fall on 11/11/22. Review of R57's Fall-Initial assessment dated [DATE] at 6:03 PM revealed a neurological assessment was completed. Review of R57's Fall-Follow-up assessment dated [DATE] at 11:03 AM revealed a neurological assessment was completed. Review of R57's Fall-Follow-up assessment dated [DATE] at 12:57 AM revealed a neurological assessment was completed. Review of R57's Fall-Follow-up assessment dated [DATE] at 12:57 PM revealed a neurological assessment was completed. Indicating a neurological assessment for R57 was not completed every shift x72 hours following a fall. No additional Fall-Follow-up assessments for R57 were received prior to survey exit. Resident #218 (218) Review of an admission Record revealed R218 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and unsteadiness on feet. Review of R218's Incident Report dated 8/11/22 revealed, Resident fell out of his wheelchair onto the floor. The fall was witnessed. He did not hit his head .Resident unable to give description . Review of R218's Progress Notes revealed no documentation of R218's fall on 8/11/22. Review of R218's Fall-initial dated 8/11/22 at 10:35 AM revealed a neurological assessment was completed. Review of R218's Fall-Follow-up dated 8/11/22 at 11:24 PM revealed, Follow up to fall that occurred on: 7/26/22. R218's neurological assessment was completed. Review of R218's Incident Report dated 8/12/22 revealed, Resident in the hall in his W/C (wheelchair) and slid out of his chair reaching down to get something. Witnessed by Cena (Certified Nursing Assistant) . Review of R218's Progress Notes revealed no documentation of R218's fall on 8/12/22. Review of R218's Fall-initial dated 8/12/22 at 9:46 AM revealed a neurological assessment was completed. Review of R218's Fall-Follow-up dated 8/12/22 at 6:24 PM revealed a neurological assessment was completed. Review of R218's Fall-Follow-up dated 8/13/22 at 10:24 AM revealed, Follow up to fall that occurred on: 7/26/22. R218's neurological assessment was completed. Indicating a neurological assessment for R218 was not completed every shift x72 hours following a fall on 8/11/22 and 8/12/22. No additional Fall-Follow-up assessments for R218 were received prior to survey exit. During an interview on 12/12/22 at 2:51 PM, Unit Manager (UM) L reported that following a witnessed or unwitnessed fall, neurological assessments are completed every shift for 72 hours unless ordered more frequently by the physician. During an interview via email on 12/13/22 at 11:21 AM, Regional Director of Operations (RDO) K reported that per the risk management program, any resident that experienced a fall/head injury would have neurological assessments completed every shift for 72 hours whether the incident was witnessed or unwitnessed. RDO K reported that facility nurses are required to complete the neurological assessments and document the assessment in the Fall-Initial assessment and the Fall-Follow-up assessments. RDO K reported that neurological assessments are completed every shift for 72 hours unless the physician orders the neurological assessments to be completed more frequently. Review of the facility policy Fall Prevention Program last revised 1/1/22 revealed, Policy: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate the resident's all risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program. 5. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 6. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of an injury. On 12/12/22 at 2:47 PM requested Fall Prevention Program policies in their entirety. No additional policies were provided prior to survey exit. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The health care record provides a way for members of the interprofessional health care team to communicate about multiple aspects of patient care, including patient needs and response to care and therapies; clinical decision making; and the content and outcomes of consultations, patient education, and discharge planning. Information communicated in the health care record allows health care providers to know a patient thoroughly, facilitating safe, effective, timely, and patient-centered clinical decision making. The health care record is the most current and accurate, continuous source of information about a patient's health care status, allowing the plan of care to be clear to anyone who accesses the record. To enhance communication and promote safe patient care, you document assessment findings and patient information as soon as possible after you provide care (e.g., immediately after providing a nursing intervention or completing a patient assessment) . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 366). Elsevier Health Sciences. Kindle Edition. DPS 2 Based on observation, interview, and record review the facility failed to provide quality care to one resident (R58) resulting in a fall, poor communication, unmet needs, unfulfilled choices and psychosocial harm for R58 and the potential for all facility residents to not have their needs met and choices honored. Findings: Review of the facility admission Record reflects R58 was admitted to the facility 8/8/22 with pertinent diagnosis that included: Amyotrophic Lateral Sclerosis (ALS), Adult Failure to Thrive, and Cognitive Communication Deficit. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R58 was cognitively intact. Section G of the MDS reflected that R58 required 2+ staff for bed mobility and was non-ambulatory. Section G0300 reflected that when moving on and off the toilet R58 was not steady and could only stabilize with staff assist. Review of the Facility Reported Incident (FRI) received by the state agency on 11/13/22 reflected an allegation of neglect against CNA (Certified Nurse Aide) giving care. CNA was immediately suspended pending investigation. The FRI reflected that on 11/12/22 at approximately 7:15 PM R58 fell off the toilet. The FRI reflected a CENA (Competency Evaluated Nurse Aide, a term used in the industry for those trained and certified to provide direct care to residents in a health care setting) had transported R58 to the bathroom and toilet by herself using a mechanical lift. The FRI reflected that the CENA unhooked R58 from the mechanical lift and left him unattended on the toilet. The FRI alleged that R58 had told the CENA he wanted privacy. The FRI reflected the CENA was interviewed and acknowledged the fall but revealed that an Orientee had assisted her in using the mechanical lift to transport R58 to the toilet. Onsite review of documents provided by the facility reflected a summary of the incident after an investigation had been completed. The facility document titled Investigation Summary reflected a repeat of the information of the actions of the CENA and the orientee about the fall of R58. Further review of facility documents revealed the CENA and the orientee were not certified staff. The facility staff schedule reflected that the CENA involved was a Hospitality Aide and that the Orientee was orienting as a Hospitality Aide. Review of the undated Job Description for Hospitality Aide reflected, Note: The hospitality aide may not provide or assist with resident care. The facility document reflected no Experience was listed or Licenses/Certification for the position. The document did not list that Essential Functions included transferring residents, toileting residents or the use of mechanical lifts. The document reflected the entirety of listed Knowledge/Skills/Abilities for the position of Hospitality Aide were: Ability to communicate effectively with residents and their family members. Ability to learn infection control techniques. Ability to be patient and polite. The document provided by the facility revealed that the staff members that transferred and left R58 unattended were not qualified to perform the actions documented that occurred on 11/12/22. Review of the FRI and Investigation Summary submitted by the facility to the state agency did not include or attempt to convey information that the staff members involved in the fall of R58 were not trained or certified to perform the actions documented. On 12/7/22 at 2:53 PM an observation and interview were conducted with R58 in his room. R58 was observed in bed with both hands curled at the wrists toward his forearms. No splints or braces were observed on the Resident or in the room. No wheelchair was observed in the room. R58 was observed to be nonverbal and two communication boards about the size of large placemats were observed on an over-the-bed table. The communication boards had phrases, pictures, letters, and numbers that could be used to communicate with R58. R58 attempted to point towards characters on the communication board but the curled wrists made it unclear what R58 was pointing to. Communication was achieved through the nodding and shaking of the head for yes and no. R58 communicated that he remembered the fall from the toilet on 11/12/22. R58 communicated that the staff that transferred him at the time of the incident had done so several times before but not since the incident. R58 communicated that he did not want to be left alone on the toilet and fell because he could not support himself. R58 communicated that no call light was in reach. R58 also communicated other care issues. These included being left wet and soiled for extended periods. R58 indicated that although initial call light response may have been prompt staff would turn off the call light and may or may not return later. R58 communicated that staff did not perform range of motion (ROM) exercises with him and that he did not have splints or braces for his wrists and hands. R58 indicated that he gets shaved, and his nails cut but the rest of him does not get cleaned well. R58 conveyed that he would like a shower. R58 communicated that he would like to get out of bed occasionally. R58 communicated that the biggest problem that he has is communicating with staff. R58 indicated that he communicated well with only a few staff but that he is not able to communicate his needs or preferences to most staff. R58 indicated that most of his concerns could be resolved with improved communication with staff. Review of the MDS dated [DATE], Section G - functional status reflected that R58 required 2+ staff for bed mobility and was non-ambulatory. Section G0300 reflected that when moving on and off the toilet R58 was not steady and could only stabilize with staff assist. Review of the EMR at risk for falls Care Plan for R58 revealed that while in bathroom staff must be stand-by assist at all times was not implemented until 11/13/22 despite the findings documented in Section G of the MDS of 8/14/22. Review of the EMR documentation of Task - ADL (activities of daily living) toilet Use from 11/9/22 to 12/8/22 reflected documentation of 29 incidents of Total Dependence on staff for toilet use. Review of the Electronic Medical Record (EMR) for R58 reflected a Doctor's Order dated 10/14/22 for Restorative Nursing Program for 1) ROM, 2) Eating. No documentation was found in the EMR that ROM had been performed with R58. Review of the EMR Task ADL Bathing (showers Mon and Thurs AM) with a 30-day look-back period prior to 12/5/22 reflected no showers had been given. The documentation reflected in the 30-day time period reviewed 5 bed baths had been performed, and no resident refusals were documented. Review of the EMR revealed a Quarterly Social Services Review had been conducted on 11/28/22. The documentation reflected that R58 understands and is independent with daily decision-making skills, and documented that R58 is only sometimes understood. The Social Services Review reflected that in the section for Things that make you become anxious/agitated was documented Resident is nonverbal and does not reflect that an attempt was made to query R58 to complete this section. The section for Things that calm or soothe you was blank as are the sections for ADLs and Mobility. Section I for the topic of Social Services Intervention Status is also blank and does not identify the area of communication as a Problem to specifically address in this section despite documentation in this review that R58 is non-verbal, understands but is only sometimes understood. Review of the handwritten Quarterly Care Conference note dated 11/16/22 reflected that R58 is showered on Sundays and Thursdays despite EMR documentation of only bed baths. The Care Conference note reflects Activities are with the pad. The Care Plan note did not reveal active Resident involvement in the Care Conference despite that R58 is cognitively intact and, per the Social Services Review, is independent with daily decisions. On 12/7/22 at 4:47 PM an interview was conducted with Social Worker (SW) J. SW J reported that she, Hospice, and the Guardian for R58 were present for the Care Conference. SW I acknowledged that it was tough to communicate with R58. SW I reported that the Guardian had brought in an iPad (the pad) to assist R58 with communication. SW I indicated that R58 could not use the device and got disgusted with it. Review of the MDS dated [DATE] revealed Section C - cognitive patterns was not completed. Section G - functional status, reflected R58 had full range of motion of both upper and lower extremities and used a wheelchair for mobility. On 12/7/22 at 4:23 PM an interview was conducted with MDS Registered Nurse (RN) I who reported that the information for Section C of the 11/14/22 was not provided to her in time to be included in this MDS. MDS RN I was informed of the curled wrist of R58 observed throughout the survey and the findings of section G of this MDS. MDS RN I was informed that no wheelchair was found in the room of R58. MDS RN I reported that she doesn't always do in-person assessments of the residents when completing an MDS. MDS RN I reported she will visit a resident only if she is not able to complete the MDS by reviewing the documentation in the medical record. The interview continued at 5:07 PM when MDS RN I reported she went to the room of R58 and stated I saw what you saw about the curled wrists of R58. MDS RN I reported that she was able to do passive ROM with the hands and wrists of R58. The MDS RN reported she did find the Residents wheelchair as it had been stored in another room. On 12/8/22 at 2:12 PM a telephone interview was conducted with the Director of Nursing (DON) The DON was informed that R58 had conveyed that he did not want to be left alone on the toilet, that he wanted to get out of bed occasionally, that he wanted showers instead of bed baths. and that staff were turning off his call light and leaving him wet and soiled for extended periods. The DON was informed that R58 had conveyed that most staff do not communicate well with him, and that often his needs were not met. The DON was informed that R58 had conveyed that most of his concerns could be resolved with improved communication with staff. The DON was informed that the wrists of the Resident had been observed to be curled throughout the survey and that no braces or splints were observed to be in use. Also, that R58 indicated that staff do not do ROM with him. The DON reported that after the fall of 11/12/22 R58 had been able to point with his finger at the communication board and that the curled wrists was a change for him. The DON was informed that the EMR did not reveal documentation of this change. As of exit no further pertinent information was provided by the facility.