**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #22 (R22) R22 was first admitted to the facility on [DATE] and had diagnoses including dementia, anxiety disorder, depression and cognitive communication deficit. A review of the most recent MDS assessment, dated 3/21/2025, revealed R22 was coded as always incontinent and was dependent for toileting hygiene (helper does ALL of the effort. Resident does none). The routine medication regimen included Senna (herbal bowel supplement) Plus (containing colace-additional bowel laxative) Oral Tablet 8.6-50 MG (milligrams) . Give 1 tablet by mouth two times a day for Constipation which was ordered 2/2/25. The MAR indicated R22 regularly accepted this constipation medication twice per day for the month of April 2025. The EMR task list was reviewed on 4/29/25 and revealed R22 had not had a bowel movement (BM) on 4/17/25, 4/18/25, 4/19/25, 4/20/25, and not until 11:43 PM on 4/21/25. The EMR physician's orders and administration of these orders for R22 included: - Milk of Magnesia Oral Suspension (Magnesium Hydroxide) Give 30 ml (milliliters) by mouth as needed for Constipation. Start date 10/12/24. - MiraLax (Powdered Bowel Laxative) Oral Powder 17 GM (gram)/SCOOP Give 1 scoop by mouth every 24 hours as needed for Constipation. Start Date 2/28/2025. - Bisacodyl Rectal Suppository 10 MG (Bisacodyl) Insert 1 suppository rectally every 96 hours as needed for constipation Start (ordered on) Date 07/02/2024. The April 2025 MAR indicated these medications were not given when the resident had not had a bowel movement for 5 days from 4/17/25 until the end of day 4/21/25. - Bisacodyl EC (enteric coated) Oral Tablet Delayed Release 5 MG Give 5 mg by mouth every 72 hours as needed for constipation Start Date 07/02/2024. The April 2025 MAR indicated this medication was not given for the entire month. Resident #44 (R44) R44 was admitted on [DATE] and had diagnoses including dementia, chronic kidney disease, cognitive communication deficit and constipation. The routine medication regime included Senna Plus Oral Tablet 8.6-50 MG (milligrams) . Give 2 tablets by mouth at bedtime related to CONSTIPATION which was ordered 10/13/24. The Medication Administration Record (MAR) indicated R44 regularly accepted the constipation medication every day for the month of April. A review of the EMR revealed the care plan included a focus of (R44) has an impaired gastrointestinal status related to history of constipation. Date Initiated: 10/01/2024. The interventions for this focus included in part: - Medications as ordered Date Initiated: 10/01/2024 - Observe for abdominal pain, abdominal cramping, increase in abdominal girth, hyperactive/hypoactive bowel sounds, frequency, urgency and loose stools Date Initiated: 10/01/2024 - Observe for no BM in 3 days Date Initiated: 10/01/2024 . A review of the EMR task list on 4/29/25 revealed R44 had not had a bowel movement for four days from 4/17/25 at 1:59 PM and then not until 1:59 PM on 4/21/25. The EMR physician's orders for R44 included: - Milk of Magnesia Oral Suspension (Magnesium Hydroxide) Give 30 ml by mouth every 64 hours as needed for Constipation. Start date 04/12/2022. The April 2025 MAR indicated this medication was not given for the entire month. During an interview on 4/30/25 at 8:21 AM, the DON stated the facility did not have a policy/protocol or standing orders to treat constipation. The DON said their EMR dashboard included an alert after three days without a BM. The nurses and DON receive the alerts and should follow up by checking individual orders and if none are written they should contact the physician for actions to be taken. When asked about the order for R44 which included Milk of Magnesia (MOM) to be given every 64 hours as needed for Constipation, the DON did not know why the order was written for that time frame. She stated MOM orders were usually given every 24 hours. Based on observation, interview and record review the facility failed to assess, monitor and treat changes in respiratory, skin and bowel patterns for four Residents (#55, #10, #22 and #44). This deficient practice resulted in a decline in transfer ability, eating, and alertness and ultimately delayed response including hospitalization for treatment of pneumonia for Resident #55, delayed assessment, diagnosis and treatment of a potentially cancerous skin lesion for R10, and the potential for bowel complications from delayed treatment for Resident #55, #22 and #44. Findings include: Respiratory Care Resident #55 (R55) Review of the Minimum Data Set (MDS) assessment, dated 1/22/2025, revealed R55 was admitted to the facility on [DATE] and had diagnoses including Parkinson's Disease, dementia, and dysphagia (difficulty swallowing). R55 scored 6/15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS assessment revealed R55 was transferred to an acute care hospital on 1/30/2025 and returned to the facility on 2/1/2025. On 4/29/2025 at 10:35 a.m., R55 was observed being transferred from a wheelchair to his bed by Certified Nursing Assistant (CNA) N and CNA P. R55 appeared weak, with his head hung down toward his chest with his eyes closed as CNA P placed a gait belt around his torso in preparation for a stand and pivot transfer. CNA P stated to CNA N, He's awfully tired, is he going to be able to transfer? CNA N replied, He [R55] gets like this sometimes. CNA P then left the room and returned with a mechanical sit-to-stand lift and sling. CNAs N and P proceeded to transfer R55 to the bed with minimal participation from R55. R55's eyes remained closed, and his head hung toward his chest during the transfer. Review of R55's electronic medical record (EMR) revealed a physician progress note, dated 2/10/2025 at 9:40 a.m., that read in part, . He is reported to have increased difficulty swallowing. [Speech Therapy] is working with him on this. He has been hospitalized and treated for pneumonia repeatedly . Further review of the EMR revealed a nurse's note, dated 1/30/2025 at 3:10 a.m., that read in part, Resident was complaining of back pain to CNA. Nurse went to see if resident could have anything for pain. When nurse came in resident was grunting and having difficulty breathing. O2 [oxygen level] was at 69% and resident was taking quick shallow breaths . Resident was complaining of chest pain and was holding his left hand over the right side of his chest. [Physician] called and ordered resident to be sent to ER for evaluation . EMS [emergency medical services] arrived and resident was breathing faster, grunting louder and O2 was 81% on 4 L [4 liters per of oxygen per minute] . Review of the hospital H&P [History and Physical], dated 1/30/2025 at 5:24 a.m., revealed the following: . [R55] with Parkinson's disease and recurrent pneumonia felt to be secondary to aspiration . sent from [facility] after complaining of right-sided chest pain and having a pulse ox of 80% on room air . He was seen by speech therapy last time and was discharged on a modified diet . SpO2 100% on 6 L/min supplemental oxygen via BiPAP [a non-invasive ventilator to assist in breathing] . He has rhonchi [abnormal lung sound indicative of fluid in the lung] in the right middle field and right lower field . Further review of the H&P revealed, Imaging Study Results . XR Chest . Impression: Interval development of a moderate to large area of airspace disease/pneumonia of the right lung. Recommend follow-up upon completion of any anticipated therapy . Assessment & Plan: Acute hypoxic respiratory failure . Sepsis secondary to pneumonia . Right lower lobe pneumonia, fairly dense consolidation, suspect aspiration . Review of the assessments section of R55's EMR revealed an SBAR (Situation, Background, Assessment, Response) Communication Form, dated 12/25/2025 at 9:42 p.m. that read in part: Situation: increased audible bronchial secretions, refusal to get out of bed, increased lethargy . Mental Status Changes . decreased consciousness . Functional Status Changed (compared to baseline) . needs more assistance with ADLs, decreased mobility, weakness . Respiratory . abnormal lung sounds . possible aspiration, wet vocals and increased [sic] in dysphagia that could lead to infection . Further review of the SBAR Communication Form, revealed, RN spoke with Resident's [daughter] via phone call. Discussed decline in condition, resident receiving food from family in bed, current wet rattle/gurgle during insp [inspiration] and expirations . [daughter] decided to monitor resident in facility and to follow up with necessary testing tomorrow . It was noted physician notification of the concerns was documented as 12/26/2025 at 9:00 a.m., nearly 12 hours after the change in condition was identified. Review of the physician note for R55, dated 12/27/2024 at 8:20 a.m., revealed the following: Patient is seen for therapies, however he has missed several treatments due to sleepy/lethargy per nursing . given patients continued decline and repeated hospitalizations a discussion with family regarding hospice/palliative care is warranted. It was noted R55 maintained the status of Full Resuscitation, as of the survey date of 5/1/2025. Further review of R55's EMR, including progress notes, assessments, scanned documents, vital signs and the Medication and Treatment Administration records, for the period of 12/25/2024 through the date of R55's most recent hospitalization on 1/30/2025, revealed no follow-up testing, including a chest x-ray, was ordered for R55 in response to the suspected aspiration, increased lethargy and abnormal lung sounds documented on 12/25/2024. Review of the EMR revealed no pertinent charting for change in condition was initiated in response to the SBAR documentation of R55's change in condition on 12/25/2024. Continued review of the EMR revealed R55's condition continued to decline after 12/25/2024. Review of a nurse's note, dated 12/28/2024 at 3:54 p.m., read in part: Notified daughter of resident refusing meals and meds (medications). Resident preferring to sleep and minimal responses. Review of a Skilled Daily, nursing note, dated 12/30/2024 at 11:52 a.m., read in part: Resident has had increased lethargy . decreased po (oral) intake per staff report. Review of the Skilled Daily, nursing note, dated 12/31/2024 at 11:51 a.m., read in part: He did not eat or drink today. Refused his meds. Would not open mouth. [Physician] informed of how his condition is been declining. He just sleeps most of the time. Physician documentation for the period of 12/28/2024 through R55's hospitalization on 1/30/2025, revealed the resident was evaluated as follows: 12/31/2024 at 11:01 a.m., Patient is seen for continued decline. Staff state patient has not been eating or drinking for the last week and spends most of this time in bed . Assessment: weakness, AMS [altered mental status]. 1/16/2025 4:26 p.m., Assessment: weakness. 1/22/2025 10:49 a.m., Assessment: weakness. It was noted in review of the EMR, the required skilled nursing care charting ended on 12/31/2024. No further respiratory assessments were documented by nursing until 1/30/2025 when R55 was found with right sided chest pain and an oxygen saturation level of 69% on room air, as documented in the nursing note previously referenced and dated 1/30/2025 at 3:10 a.m. Further review of R55's EMR revealed he was previous hospitalized on [DATE] and returned to the facility on [DATE] after being treated for pneumonia and acute encephalopathy (decreased brain function). Review of EMR for the period of 12/1/2024 through 12/9/2024, prior to the resident's transfer to the hospital, revealed the following: 12/4/2024 at 10:30, Change identified . Would not respond to me verbally when trying to find out what was wrong . combative with care . he has been this way before when he is not getting enough sleep or when he had aspiration pneumonia . Assessment: His vss [vital signs stable]. Lung sounds CTA [clear to auscultation]. His moaning stopped when he was put back to bed and he went to sleep . 12/09/2024 at 10:43, Transcribed Physician Progress Note: Patient is seen for report of general decline. He is obtunded upon exam. He has been refusing medications and [has] mental status changes . Assessment: weakness, AMS . Orders given to transfer to ED for AMS. It was noted in review of the physician note, R55's pulmonary exam was negative for cough, dyspnea, and congestion. During an interview on 5/01/2025 at approximately 10:45 a.m., the B-Hall Unit Manager, Registered Nurse (RN) O reviewed R55's EMR and confirmed there were no comprehensive nursing assessments after the skilled daily nurse charting ended on 12/31/2024 until R55 was transferred to the hospital on 1/30/2025. RN O reported the documentation in the skilled nursing and physician notes indicated a change in condition but the pertinent charting for monitoring for infection or change in condition was not initiated. RN O was asked why R55 did not have a follow-up chest x-ray to assess response to treatment following his return from hospitalization for pneumonia on 12/16/2024, to which she reported a repeat x-ray was only ordered if abnormal findings were identified on assessment. During an interview on 5/1/2025 at 1:25 p.m., the Director of Nursing (DON) was queried regarding the process staff were expected to follow when assessment revealed abnormal findings. The DON reported staff were to complete an SBAR note and notify the physician. The DON reported completion of an SBAR note indicated the need to initiate the pertinent charting for change in condition to ensure completion of comprehensive assessments each shift for monitoring. The DON reported she was aware of the concern related to R55's change in condition remaining undiagnosed prior to his hospitalization on 1/30/2025. The DON reviewed R55's EMR during the interview and when asked if a chest x-ray should have been completed after the identification of abnormal lung sounds, increased lethargy and suspicion of aspiration on 12/25/2024, the DON responded, yes and chest x-ray was warranted at that time. The DON confirmed changes in condition do not always present clearly in the elderly and staff should be documenting resident condition consistently and clearly to ensure continuity of care and recognition of acute changes. Skin/Wound Care Resident #10 (R10) Review of the MDS assessment, dated 3/18/2025, revealed R10 was admitted to facility on 12/9/2020 and had diagnoses including diabetes and dementia. Further review of the MDS assessment revealed R10 required partial/moderate assistance with most ADLs (activities of daily living) and scored 9/15 on the BIMS, indicating she had moderate cognitive impairment. Section M - Skin Conditions, revealed R55 was assessed as having no Other Ulcers, Wounds and Skin Problems. On 4/29/2025 at 9:52 a.m., R10 was observed seated in a wheelchair in the doorway of her room. R10 had a black scab noted on the left side tip of her nose. When asked what caused the wound, R10 reported I just have a small sore, it bleeds sometimes. Review of R10's EMR for the period of 1/2/2025 through 5/1/2025, revealed no treatment ordered or wound evaluations documented in relation to the wound on R10's nose. During an interview on 4/30/2025 at 8:11 a.m., RN L reported the wound on R10's nose was not being treated. RN L reported the wound was not caused by an injury and at times was only a small scaly patch of skin that opens when R10 picks at it. On 4/30/2025 at 8:24 p.m., R10 was observed self-propelling from the main dining room toward her room. The wound on the right side of the tip of R10's nose was devoid of the scab. Closer observation revealed an open lesion with slightly raised edges and a marbled appearance to the wound bed. During an interview on 5/1/2025 at 8:04 a.m., the DON was asked about the open lesion on R10's nose. The DON reported the wound appeared to be chronic and had been present for at least six months. The DON stated she would check with the B-Hall Unit Manager, RN O for information related to the wound. The DON reported she checked the EMR for documentation related to the wound but was unable to find any. When asked if the non-healing wound should initiate a concern of skin cancer or an infection with a multi drug-resistant organism (MDRO), the DON reported staff should always be aware of non-healing wounds and report to the physician for further assessment. On 5/1/2025 at 10:17 a.m., RN O was interviewed and reported the condition of the wound on R10's nose was discussed at a care conference on 1/9/2025. Review of the, Care Plan Conference Summary, dated 1/9/2025 at 3:04 p.m., revealed, Nursing concerns with scab on her nose that [R10] continues to pick at out of habit . The Summary included no further information related to R10's wound. When asked if the wound had been reported to the physician for evaluation, RN O was unable to provide an answer. RN O stated she thought she remembered a provider looking at the wound but was unable to find documentation of the event or any orders provided, therefore, R10 was placed on the list for the provider to assess during the next provider rounds. RN O reported she phoned R10's patient advocate who reported the wound was present prior to admission. R10's patient advocate agreed a referral to dermatology was warranted for evaluation for skin cancer. Bowel Care Resident #55 (R55) Review of the MDS dated [DATE], revealed R55 was admitted to the facility on [DATE] and had diagnoses including Parkinson's Disease, dementia, and dysphagia (difficulty swallowing). Further review of the MDS revealed R55 scored 6/15 on the BIMS, indicating severe cognitive impairment. Further review revealed R55 required substantial/maximal assistance with toilet transfers and toileting hygiene. Review of R55's point of care documentation for Bowel Elimination for the period of 4/3/2025 through 4/30/2025 revealed documentation of No bowel movement, as follows: 4/3/2025 at 1:59 p.m. through 4/8/2025 at 9:59 p.m., a total of more than five days with no bowel movement. Review of R55's April 2025 Medication Administration Record (MAR) revealed the following active physician orders and administration documentation: Milk of Magnesia Suspension [MOM] 400 MG [milligrams]/5 ML [milliliters] . Give 30 ML by mouth as needed for constipation if no BM [bowel movement] in 3 days. Start Date: 2/01/2025. Documented as administered on 4/8/2024 at 9:19 p.m., the fifth day of no bowel movement for R55. Bisacodyl Suppository 10 MG. Insert 1 suppository rectally as needed for constipation daily if no results for MOM. Start Dated: 4/07/2025 . Documented as administered on 4/7/2025 at 6:33 a.m. the fourth day of no bowel movement for R55. It was noted no administration of the ordered MOM was administered prior to administration of the bisacodyl suppository per physician order. During an interview on 5/1/2025 at 1:25 p.m., the DON reported it was a standard of practice for nursing staff to review bowel elimination patterns for residents daily to allow for the identification abnormalities and to allow for initiation of appropriate interventions for constipation. The DON confirmed prolonged constipation can cause severe discomfort and serious adverse consequences such as bowel obstruction, especially in residents with decreased mobility. When asked when treatment for constipation should be initiated, the DON reported treatment should be initiated after three days without a bowel movement.