**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent the development of and worsening of pressure ulcers for 3 residents (Resident #15, Resident #25, Resident #33) of five residents reviewed for pressure ulcers resulting in the development of facility-acquired pressure ulcers, including a Stage 3 pressure ulcer, and the worsening of pressure ulcers. Findings include: Resident #25 (R25): R25 is [AGE] years old and admitted to the facility on [DATE] with diagnosis that include encephalopathy, cerebral infarction and pressure ulcer of unspecified buttock, unspecified stage. R25 has a Brief Interview for Mental Status (BIMS) score of 3 as of 09/10/24 indicating severe cognitive impairment. On 10/07/24 at 09:30AM, R25 was observed lying supine in bed, a wedge cushion was noted to be at the end of the bed but not currently in use. R25 had protective boots on both feet. On 10/07/24 at 12:00PM, R25 was observed lying supine in bed, there was a wedge cushion noted on the bed but still not in use. On 10/08/24 at 10:12AM, R25 was observed lying supine in bed. R25 was also observed to have protective boots on both feet. On 10/08/24 at 01:30PM, an interview was conducted with Certified Nursing Assistant (CNA) K. CNA K was asked why R25 was positioned on their back so often during the day. CNA K stated that R25 often refuses to be turned off of their back and even when they try to place pillows under their sides for positioning R25 will throw them on the floor. CNA K stated they try to reposition him often while they are working. On 10/08/24 at 02:44PM, an interview was conducted with the DON (Director of Nursing). The DON was asked if R25 had all of their wounds present on admission or if any developed in the facility. The DON stated that the wounds were present on admission. The DON was asked if they feel the wounds have improved, worsened or remained stable. The DON stated they feel that some of the wounds have remained the same and fairly stable. On 10/09/24, R25 was observed to be discharged from the facility. On 10/09/24, record review revealed that R25 had developed an in-house acquired pressure ulcer on their left ischial tuberosity(an area on the buttocks) on 10/02/24 measuring: length 2.31cm, width 0.61cm, depth 1.0cm and was categorized as MASD(Moisture Associated Skin Damage). On 10/09/24, record review revealed that on 10/08/24 the same pressure ulcer measured: length 2.13cm, width 2.11cm and depth 3.0cm and was categorized as a Stage 3 wound (indicating full thickness tissue loss). On 10/09/24, record review revealed that R25 was admitted with a wound on the peri-anal area, classified as unstageable. On 10/02/24 the wound measured length 1.59cm, width 1.04cm and depth 1.04cm. On 10/08/24 the wound measured length 9.74cm, width 7.03cm and depth 4.0cm and was classified as unstageable. On 10/09/24, record review of R25's care plan titled, Skin Management revealed an intervention, please help me get turned and repositioned every 2 hours as allowed. Resident #15: An interview on 10/07/24 at 02:36 PM with Resident #15 revealed that her right heel had a sore on it and that she did not recall/remember how it developed/started. Record review of Resident #15's Minimum Data Set (MDS) dated [DATE] section M: Skin conditions- had no unhealed pressure ulcers noted. Record review of Resident #15's electronic medical record (EMR) revealed an admission skin assessment dated [DATE] revealed no skin issues with bilateral feet/heels. Record review of Resident #15's 'Wound Evaluation' form dated 2/21/2024 at 7:50AM revealed a pressure ulcer unstageable (slough and/or eschar) located on the right heel, as new, and in-house (in facility) acquired. Dimensions/measurements: area 3.45cm, length 2.01cm x width 2.05cm. Observation of wound photo located in the medical record revealed a dark/blackened area of good size to Resident #15's right heel. Record review of Resident #15's Minimum Data Set (MDS) dated [DATE] section M: Skin conditions- noted one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. Record review of Resident #15s 'Skin & Wound- Total Body Skin Assessment' dated 2/20/2024 revealed skin assessment with good turgor, normal skin color, warn temperature, normal moisture, normal condition and no new wounds. Record review of Resident #15's nurse progress note dated 2/22/2024 noted blood-filled blister to right heel. 10/08/24 02:54 PM Record review of the skin care plan noted to observed skin daily and report to nurse any findings dated 2021. How did the right heel blood blister start if it would have been pink/red before it became blackened. Record review of the Point Click Care wound definitions: Suspected Deep Tissue Injury- Purple or Maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Observation and interview on 10/08/24 at 01:02 PM with Resident #15 and Licensed Practical Nurse (LPN) F revealed observation of Resident #15's right heel wound heeled with scar tissue noted. Resident #15 stated that it (right heel wound) would hurt and burn something awful and that it was a big old hole in my foot/heel. In an interview and record review on 10/09/24 at 09:56 AM with the Director of Nursing (DON) of Resident #15's admission date of 1/23/24 skin assessment was good with no concerns of bilateral feet/heels. Record review of Resident #15's electronic medical record 'Wound Evaluation' tab on 2/21/24 revealed the right heel with eschar with dead necrotic skin The DON was asked what happens or when the blackened cap falls the wound? The DON stated that the wound becomes an open wound, and potential for infections. The state surveyor in quired about care plan intervention of Certified Nurse Assistance's are to review skin daily, was it done? DON stated that Both Resident #15 and Resident #33's right heel pressure ulcers were preventable, with floating heels, prafo boots, repositioning, and getting the resident out of bed for few hours. Venous wounds would have done a doppler at the time development of the wounds, not months later. Resident #33: In an interview on 10/07/24 at 11:31 AM with Resident #33 revealed that when she came into the facility, she did not have a right heel sore. Observation on 10/07/24 at 11:31 AM the state Surveyor observed right foot/heel dressing of gauze wrap that soaked through the dressing and onto the sheets with brown ring, dressing dated 10/6/2024. Record review of Resident #33's admission Skin Assessment form dated 5/30/2024 revealed skin concerns to chest of implanted port, left hand blister, right neck old access site, coccyx redness, right arm bruising. There was no skin concern related to bilateral foot heels noted. Record review and Interview on 10/7/2024 with Resident #33 revealed that she does hemodialysis on Mondays/Wednesdays/Fridays and was waiting to go to dialysis. Observation and interview on 10/07/24 at 12:21 PM with the Director of Nursing (DON) was requested to observed Resident #33's right foot/heel dressing dated 10/6/2024. Observation of drainage tan to brown in color was noted onto sheets through the dressing. The DON stated that Resident #33's dressing is to be changed daily in the mornings by the night shift nurse before leaving their shift, yes, she would have gone to dialysis with that dressing if you hadn't brought me into see the dressing. The DON stated that the facility Wound Care nurse/Infection Preventionist had resigned Friday, she took photos every Wednesday, and on admission. We just ordered soft boots for the resident; we don't have them yet. The state surveyor observed no boots in the closet or in the room. In an interview on 10/07/24 at 12:25 PM with Resident #33 with the DON present stated that the right foot/heel dressing was not changed this morning. The DON stated that Licensed Practical Nurse (LPN) F will be in to dress the wound before she goes to dialysis. Observation on 10/07/24 at 12:32 PM with Licensed Practical Nurse (LPN) F and Director of Nursing (DON) applied spray derma cleanse with 4x4 gauze, wiped the surface of the wound. The state surveyor observed an open wound with puss drainage noted by the DON, treatment of Santyl (debride). Wound measurement with tape measurement revealed a 1cm X 0.5cm open wound with hole in the back of resident's heel measurement. Santyl ointment into the opening, covered with a telfa non-stick 3x2 dressing gauze and gauze wrap. In an interview on 10/08/24 at 10:08 AM with Licensed Practical Nurse (LPN) F Observation of Resident #33's right heel dressing was changed at 6:00AM the dressing was clean and intact; a smaller brown ring was noted again on the sheet under the heel. no drainage noted on dressing. Sheet was not changed after dressing. In an interview and records review on 10/09/24 at 09:42 AM with Director of Nursing (DON) of Resident #33's electronic medical record revealed the admission assessment on 5/30/24 did not have any foot heel skin concerns. Wound/skin tab revealed Right heel wound started on 7/17/24 as a blacked eschar unstageable before anyone found it? Director of Nursing (DON) stated that Resident #33 was originally in her room on the 100 hall and the Certified Nursing Assistant (CNA) did skin assessment and found the wound as eschar and reported it to the nurse. The CNAs are to check skin each day and report, they should have reported a reddened area before it became eschar. Eschar is a blackened skin, necrotic and dead. We could have placed an intervention prior to the eschar. In an interview and record review on 10/09/24 at 10:09 AM with the Registered Nurse (RN) Clinical Care Coordinator B performed a record review of the wound & skin tab in electronic medical record to review right heel wound progression. RN B stated that the heel would have start out getting boggy/soft, redden and turn white, then we gradually start to see the breakdown of the tissue until it starts to die, when it dies it becomes eschar blackened. Unstageable. cap falls off under then it broken down and open, seeping a smell. The Certified Nursing Assistant (CNA) are to review skin daily, and report to nurse skin changes. While reviewing a photo of Resident #33's right heel wound RN B stated depending on the resident and their circulation that wound would take 2-3 weeks to develop into eschar.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation has two Deficient Practice Statements. Deficient Practice Statement 1: This Citation Pertains to Intake Numbers MI00137515 and MI00141236. Based on interview and record review, the facility failed to ensure that timely and appropriate care was provided, per professional standards of practice and Health Care Provider orders, for one resident (Resident #802) of three residents reviewed for assessment and monitoring, resulting in a lack of accurate infection control surveillance, Resident #802 not receiving medications as ordered for Covid-19, a lack of comprehensive assessment, documentation, and a timely response to an acute change in condition, and death. Findings include: Resident #802: Review of intake documentation dated received [DATE] revealed concerns that Resident #802 had contracted Covid-19 and that the facility did not notify the family, and did not implement appropriate infection control procedures related to Covid-19. The intake detailed, On Wednesday, (Resident #802) complained to the nurse about difficulties breathing, but (facility staff) didn't call 911. (Licensed Practical Nurse [LPN] D) gave (Resident #802) albuterol (inhaled medication used to prevent and treat bronchospasm in individuals with obstructive airway diseases), then left the room for an hour or so, when (LPN D) returned, (Resident #802) was unresponsive. Per the intake, Resident #802 died in the facility. Review of a separate intake for the facility revealed concerns that appropriate infection control precautions to prevent the spread of Covid-19 were not being implemented and/or followed. Facility Infection Control (IC) data was requested from the facility Administrator and Corporate Registered Nurse (RN) W on [DATE] at 11:03 AM. Upon request for infection control data from [DATE], RN W revealed the facility (IC) angrily quit employment with the facility the prior week and were unsure of the location of prior data. Record review revealed Resident #802 was originally admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis (MS), paraplegia (paralysis of the lower body), neuromuscular disfunction of the bladder, and depression. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed the Resident was cognitively intact and required limited-to-total assistance to complete Activities of Daily Living (ADL). Per the Electronic Medical Record (EMR), Resident #802 died in the facility on [DATE]. Any Incident and Accidents (I and A) and/or concern forms pertaining to Resident #802 were requested from the facility Administrator on [DATE]. On [DATE] at 9:00, the Administrator stated there were no I and A and/or concern forms for Resident #802. A review of Resident #802's EMR revealed the Resident made their own medical decisions but preferred to have their family involved in their care. Witness F was listed as Resident #802's Emergency Contact # 1. A form dated [DATE], entitled, Authorization List for PHI (Personal Health Information) included Witness F and specified to Please release medical information to whomever asks for it. A Code Status Form dated [DATE] was present in the EMR. The form specified Resident #802 was full code and wanted to receive Cardiopulmonary Resuscitation (CPR). Further review revealed a Physician . Progress Note dated [DATE] which specified the Health Care Provider (HCP) discussed code status with Resident #802 and the Resident wants everything to be done. The note indicated the (HCP) explained in detail what everything being done entails, and that Resident #802 wanted all resuscitation efforts made in a medical emergency. Review of progress note documentation in Resident #802's EMR revealed the following: - [DATE] at 3:07 PM: Nurses Note . Nursing staff was having a conversation with this resident it was noticed that responses were delayed and had a dry cough. A rapid covid test was performed and the Resident tested positive for Covid-19 this am. (Physician E) and family notified. New orders were monitor and follow protocols. - [DATE] at 4:10 PM: Nurses Note . Resident isolated in room and PPE staged. - [DATE] 12:37 AM: eMar (Electronic Medication Administration Record) -Medication Administration Note . Ventolin (albuterol) HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for Shortness of Breath for 14 Days PRN (as needed) - [DATE] 12:37 AM: eMar-Medication Administration Note . Acetaminophen (Tylenol) Tablet 325 mg (milligram) Give 2 tablet by mouth every 4 hours as needed for Generalized discomfort. Resident c/o (complain of) of discomfort. - [DATE] at 2:23 AM: Nurses Note . Walked into resident room around 1:10 AM, (Resident #802) was unresponsive performed OPR (sic) (CPR- Cardiopulmonary Resuscitation). Called 911. EMS took over. DON (Director of Nursing) and family called. EMS pronounced resident (deceased ) at 1:59 AM. - [DATE] at 4:03 AM: eMar -Medication Administration Note . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for Shortness of Breath for 14 Days PRN (as needed) Administration was: Ineffective - [DATE] at 4:03 AM: eMar-Medication Administration Note .Give 2 tablet by mouth every 4 hours as needed for Generalized discomfort PRN Administration was: Unknown. - [DATE] at 4:21 AM: Nurses Note . family was here to visit around 3:30 AM . (Funeral Home) here to pick up body. A review of assessment documentation in Resident #802's EMR revealed no assessments had been completed related to the Resident testing positive for Covid-19, a change in condition, and/or to the Resident's death in the facility on [DATE]. A review of Resident #802's EMR revealed no HCP visit notes and/or documentation indicating the Resident was assessed by the Physician/HCP after testing positive for Covid-19 and before their death in the facility. Review of Census documentation revealed Resident #802 was moved from the 400 hall of the facility to a room on the 200 hall of the facility on [DATE] at 9:15 PM. Review of Resident #802's Health Care Provider Orders in the EMR revealed the following: - Covid Test PRN (as needed) (Ordered: [DATE]) - Normal Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush). Use 75 milliliter (mL) intravenously (IV) one time only for COVID . 1 liter to infuse at 75mL/hr . (Ordered: [DATE]) - Resident was actively assessed for symptoms of COVID - 19 (fever, shortness of breath, cough, sore throat, chills/shaking, loss of tastes/smell, muscle aches, headaches confusion, nausea, vomiting and diarrhea) three times a day. The patient did not display any of these symptoms during my shift. Document in a nurse's note if the patient experienced any of these signs or symptoms of COVID every shift for Monitoring (Ordered: [DATE]) - Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for Shortness of Breath for 14 Days (Ordered by Phone: [DATE]). The order was signed by Physician E on [DATE] at 8:53 PM. - Paxlovid (300/100 [mg]) Oral Tablet Therapy Pack (antiviral medication used to treat Covid-19 - treatment should be initiated as soon as possible after Covid diagnosis) . Give 3 tablet by mouth two times a day for COVID 19 for 5 Days . (Ordered by Phone: [DATE]; Start Date: [DATE]; Discontinued: [DATE]) - Paxlovid (300/100 [mg]) Oral Tablet Therapy Pack (antiviral medication used to treat Covid-19 - treatment should be initiated as soon as possible after Covid diagnosis) . Give 3 tablet by mouth two times a day for COVID 19 for 5 Days . (Ordered by Phone: [DATE]; Start Date: [DATE]). The order was signed by Physician E on [DATE] at 8:53 PM. - Monitor patient for side effect r/t Paxlovid: anaphylaxis type reaction, hives, rash, diarrhea, high blood pressure, muscle aches, changes in smell. Three times a day for Paxlovid Therapy for 7 Days (Ordered by Phone: [DATE]; Start Date: [DATE]) - CBC (Complete Blood Count- blood test), BMP (Basic Metabolic Panel - blood test), CRP (C-Reactive Protein- blood test to identify inflammation in body) to be drawn next lab draw (Ordered and Discontinued: [DATE]) - Chest X-Ray 2-view .: (Ordered and Discontinued: [DATE]) Review of Resident #802's HCP orders revealed no orders related any type of Transmission Based Precautions (TBP) pertaining to Covid-19 diagnosis on [DATE]. However, discontinued orders for specific type of TBP were noted in the orders for 2020, 2021, and 2022. Further review revealed the Resident had not previously had an order for an inhaler and did not have an order for supplemental oxygen. A review of Resident #802's EMR revealed no results for the laboratory testing ordered on [DATE]. A Chest X-Ray was completed on [DATE] at 8:39 PM. The report detailed, Results . The lungs demonstrate no consolidation, masses or effusions . no evidence of significant pneumothorax (collapsed lung) . No focal airspace disease (abnormalities) . The report was signed by the facility Physician on [DATE]. Results of Covid-19 testing, including a PCR (polymerase chain reaction - more reliable/accurate test often used to confirm positive Point of Care [POC]/rapid test) were not present in Resident #802's EMR. Review of Resident #802's Electronic Medication Administration Record (eMAR) for [DATE] revealed the following: - Acetaminophen (Tylenol) 650 mg was administered on [DATE] at 2:06 PM and on [DATE] at 12:37 AM. A pain level of four (out of 10) was documented for both administrations. - Ventolin Inhaler was administered one time on [DATE] at 12:37 AM. - The ordered Paxlovid was never administered to the Resident. An interview was completed with Family Member Confidential Witness F on [DATE] at 9:15 AM. When queried regarding Resident #802, Witness F stated, On Sunday, Mother's Day 2023 ([DATE]), (Resident #802) tested positive for Covid. Witness F revealed they, along with other family members, went to visit the Resident in the afternoon on Mother's Day ([DATE]) and were informed by the nurse that (Resident #802) tested positive for Covid and they were unable to see them. Witness F stated, We asked why they (facility) didn't tell us that. When asked what the staff said in response, Witness F replied, The one nurse said, well you can probably go in there (Resident #802's room). Witness F verbalized the staff weren't wearing no masks or nothing in the hallways even though there were multiple residents who were Covid positive. When asked if Resident #802 was in the same room they had been in, Witness F replied, Yeah. (Resident #802) was in the same room so we stuck our head in there and (a female staff member) was in there feeding (Resident #802). Witness F revealed the staff member in Resident #802's room told them they could not come in and expressed confusion related to why one nurse said they could visit, and another said they could not. When asked what they did, Witness F replied, So we left. With further inquiry, Witness F revealed Resident #802 was moved to the Covid hall of the facility finally on Tuesday [DATE]th, 2023. When asked if they were saying Resident #802 tested positive for Covid-19 on Sunday [DATE] but was not moved to the Covid hall of the facility until Tuesday ([DATE]), Witness F confirmed. When queried if they knew why the Resident was not moved to the Covid unit [DATE], Witness F revealed they were unsure. Witness F then stated they were contacted by Licensed Practical Nurse (LPN D) in the evening, I wanna say 10:00 or 11:00 (PM) O'clock at night on [DATE]. Witness F revealed LPN D called to inform them that Resident #802 was having difficulty breathing and they were going to give them albuterol. With further inquiry regarding the phone call, Witness F stated they asked LPN D to keep an eye on (Resident #802) and send them to the ER if needed. When asked if they knew what type of albuterol, Witness F replied, Inhaler, like for asthma. Witness F continued, (LPN D) gave (Resident #802) albuterol and I don't even know if they even called the Doctor to approve (albuterol administration) or to inform them that (Resident #802) was having difficulty breathing. Witness F then stated, (Resident #802) shouldn't have died. You don't leave a patient who is having difficulty breathing, give them albuterol, and not go back to check and see if they are okay. (LPN D) didn't go back until an hour later. When asked to clarify if LPN D told them Resident #802 was short of breath, Witness F replied, Yes. (LPN D) called and said that (Resident #802) was complaining of shortness of breath and they were going to give them albuterol. Witness F was asked if Resident #802 contacted them and replied, No (Resident #802) can't call, can't use their phone (without assistance). Witness F revealed the Resident had limited mobility and could not use their hands very good. Witness F continued, Then (LPN D) called me and told me (Resident #802) passed. Witness F divulged they were shocked and asked LPN D what they were talking about. LPN D responded, (Resident #802) complained about having breathing problems, I gave them albuterol and then about an hour or so later I went back and (Resident #802) was unresponsive. Witness F indicated they had worked in the medical field and immediately had concerns regarding the care Resident #802 received. Witness F stated, You don't leave a patient who is having respiratory failure or a respiratory problem for over an hour, you just don't do that. Witness F verbalized further concerns that LPN D did not check to see the effectiveness of the albuterol in a timely manner and did not do their job. Witness F stated, It should be an RN (Registered Nurse) doing that stuff. When asked what they meant, Witness F revealed they did not think LPN's were able to complete assessments. Witness F revealed they went to the facility after informing other family members. When asked what happened when they got to the facility, Witness F revealed they were able to see the Resident when they arrived. When queried if they spoke to the nursing staff at the facility, Witness F indicated they spoke to LPN D and asked them why they did not call 911 and get the Resident to the hospital right away when they couldn't treat Resident #802 there after they started having difficulty breathing. Witness F was asked if LPN D responded and replied, Just to say they were sorry and (LPN D) started crying. Witness F stated they asked LPN D why they did not call 911 and LPN D responded, Well I did. Witness F verbalized they replied, Yeah after the point that (Resident #802) was unresponsive and (LPN D) said yes. LPN D then told them that Resident #802 didn't meet criteria to be critical to send them to the hospital. When queried if they asked LPN D what the criteria for critical was, LPN D verbalized they did but did not answer them. Witness F then stated, I asked how long (Resident #802) was unresponsive for and (LPN D) said I don't know. When queried if they had any additional concerns, Witness F stated, At that time, we were in the Covid (hall) and (LPN D) was walking around and not even wearing a mask. Witness F indicated they were concerned that the facility staff's lack of appropriate use of Personal Protection Equipment (PPE) contributed to the spread of Covid-19 in the facility. Review of Resident #802's EMR revealed a care plan entitled, Actual Infection r/t Covid Positive . [DATE] (Initiated: [DATE]; Revised: [DATE]). The care plan included the interventions: - Precautions other than standard: Transmission Based Precautions (Initiated and Revised: [DATE]) - Labs/diagnostics as ordered (Initiated: [DATE]; Revised: [DATE]) - Monitor and document response to treatment (Initiated: [DATE]; Revised: [DATE]) - Monitor me for s/sx (signs/symptoms) of an Adverse drug reaction every shift (Initiated: [DATE]; Revised: [DATE]) A second care plan in Resident #802's EMR entitled, Resident is at risk for psychosocial wellbeing concern r/t medically imposed restrictions r/t COVID-19 precautions . (Initiated: [DATE]; Revised: [DATE]) included the interventions: - Educate staff, resident, family and visitors of COVID-19 signs and symptoms and precautions (Initiated: [DATE]) - Follow facility protocol for COVID-19 Screening/Precautions (Initiated: [DATE]) A review of Resident #802's documentation in the EMR revealed the Resident was on Room Air and not receiving supplemental oxygen. An interview was completed with Certified Nursing Assistant (CNA) A on [DATE] at 11:45 AM. When queried if they recalled Resident #802, CNA A verified they did. CNA A was asked if they recalled the Resident being diagnosed with Covid-19, CNA A stated, I didn't even know he had it the last time until when I came in and they said (Resident #802) had passed. When asked if Resident #802 had a history of breathing difficulties and if they wore oxygen, CNA A replied, No and stated they were a pleasant person. On [DATE] at 4:35 PM, LPN D was contacted via phone. When queried if they recalled Resident #802, LPN D verbalized they did. LPN D was then asked if they were working the night Resident #802 passed and replied, Yeah. When queried what happened, LPN D stated, I can't talk to you know. LPN D was asked if there would be a more convenient time for them to talk and replied, I don't know. A review of LPN D's Human Resource file was completed on [DATE] at 4:50 PM with Staff G. LPN D's last Annual check off competency was dated [DATE]. When queried if they had a more recent annual competency, Staff G reviewed the file and verbalized they did not. When queried if annual competency education is supposed to be completed, Staff G confirmed it should be and was unable to provide further explanation. The facility schedule/assignments for [DATE] and [DATE] were requested from LPN D at this time. Review of a facility-provided schedule for [DATE] revealed CNA H, CNA I, CNA V, LPN D and LPN J were working when Resident #802 passed. On [DATE] at 7:56 AM, RN W provided a Monthly Infection Control Analysis form for [DATE]. The form did not provide Resident specific information but detailed 10 residents developed facility acquired Covid-19 infection. The line listed data was requested again at this time. CNA H was attempted to be contacted via phone on [DATE] at 8:18 AM. A voicemail message was unable to be left and a text message requesting a return phone call was sent. At 8:23 AM on [DATE], CNA I was contacted via phone. A voicemail and text message requesting a return phone call was left. On [DATE] at 8:26 AM, CNA V was attempted to be contacted via phone and a voicemail message was left requesting a return phone call. LPN J was attempted to be contacted via phone on [DATE] at 9:20 AM. A voicemail message was left requesting a return phone call. Return phone calls were not received from CNA H, CNA I, and CNA V. On [DATE] at 9:41 AM, an interview was completed with LPN D. When queried if they recalled Resident #802, LPN D confirmed they did and were the Resident's assigned nurse the night they passed. When asked what happened, LPN D stated, I remember when I went in the room, (Resident #802) said they had a headache. When asked, LPN D revealed they gave (Resident #802) Tylenol for their headache. LPN D continued, When I went back to check on their headache, (Resident #802) appeared short of breath. When asked how the Resident appeared short of breath, LPN D indicated the Resident appeared to be having trouble breathing. When asked if Resident #802 verbalized they felt short of breath, LPN D replied they did. LPN D stated, I gave (Resident #802) their inhaler then. When asked if they gave the inhaler because the Resident was having difficulty breathing, LPN D confirmed they did. When queried if the contacted the Physician/HCP, LPN D indicated they did not contact them at that time. When queried if they assessed the Resident's vital signs, LPN D replied, SPO2 (oxygen saturation) was okay. When asked what they did then, LPN D indicated they left Resident #802's room after administering the inhaler. LPN D then stated, Went back to check on (Resident #802) and put the SPO2 and vital sign machine on and it read something, not sure what, then it went to zero. LPN D was asked if Resident #802 responded when they put the blood pressure cuff and SPO2 monitor on them and stated, I don't remember. When asked to clarify what they were referring to when they said the monitor read something, LPN D indicated the monitor lit up like it was working. When queried if it was just the machine turning on, LPN D revealed they were unsure. When queried regarding the length of time following the inhaler administration until they went back to check on Resident #802, LPN D revealed they were not completely sure but around and hour maybe. LPN D continued, I left and had the CNA go get the other nurse. When asked where the CNA was, LPN D verbalized they were at the nurses' station. LPN D was asked how far the nurses' station was from Resident #802's room and revealed Resident #802's room was midway down the hall. When queried if they were wearing Personal Protective Equipment (PPE) in Resident #802's room, LPN D indicated they were. LPN D was then asked if they removed the PPE prior to exiting the room and stated, Yes, of course. When queried what specific type of TBPs were in place, LPN D specified they did not recall. When asked if they checked Resident #802 for a pulse or respirations prior to exiting the room, LPN D replied, No, I went to get help. When asked why they did not use the call light in the room, LPN D replied, I don't know. When asked what happened when they left Resident #802's room, LPN D stated, I went to the CNA and told them that I need your nurse now and went back to (Resident #802). (LPN J) came in, tapped (Resident #802) and started compressions. When queried if Resident #802 was breathing or had a pulse at that time, LPN D stated, I don't know, I don't know. When queried if they or LPN J checked for a pulse or breathing, LPN D revealed they did not check for a pulse and were unaware of LPN J checking for a pulse. LPN D was asked about the Resident's color and temperature but was unable to provide a response. When queried what happened next LPN D stated, EMS came and took over. They kept doing compressions. LPN D stated, They were down there a long time. When asked if they stayed in the room with the Resident, LPN D revealed they did not as EMS had taken over. LPN D then stated, Once it was all said and done, they (EMS) pronounced them (deceased ). LPN D revealed the contacted the family to inform them that Resident #802 had passed. When queried regarding the conversation with Resident #802's family went, LPN D verbalized the family was very upset. LPN D asked if they document medication administration in the eMAR at the time they remove a medication from the medication cart or when they return to the cart after administering the medication to the Resident takes the medication and replied, I go give it and then document. When queried if that was what they did when they administered Resident #802's medications on [DATE], LPN D stated, I don't know if I immediately documented it and indicated they recalled being busy and may not have documented the medications immediately following administration. When queried regarding the times on Resident #802's eMAR specifying the Tylenol and Ventolin inhaler were administered at the same time, LPN D stated, Yeah and they wasn't given at the same time. When asked to clarify if they were saying they did not administer the Tylenol and Ventolin inhaler at the same time but documented the medications were administered at the same time, LPN D verbalized confirmation. When queried if they listened to Resident #802's lung and heart sounds and/or completed a physical assessment when the Resident complained of shortness of breath, LPN D stated, I don't know. LPN D articulated that assessment findings such as lung sounds would be in a (progress) note. When queried why they did not document that Resident #802 was experiencing difficulty breathing and why no assessment documentation was completed, Resident #802 did not provide an explanation. When queried if supplemental oxygen was initiated for Resident #802 due to their difficulty breathing, LPN D replied that Resident #802 already had supplement oxygen in place via nasal cannula. When queried why there was no order for supplemental oxygen and vital sign documentation specified the Resident was on room air, LPN D was unable to provide an explanation. On [DATE] at 12:28 PM, RN W provided the IC Line Listing for [DATE]. The line list detailed Resident #802's onset date for Covid-19 was [DATE]. The line listing indicated the Resident did not have any orders and/or receive any medications for Covid-19 infection and did not move to the Covid hall of the facility. The signs and symptoms on the line list included, Cough, Resp > 25, Hoarseness or loss of voice, Difficulty breathing / Shortness of breath, Sore throat, Fatigue / Malaise, s/s (signs/symptoms) of common cold. Note: There was no documentation of Resp > 25, Hoarseness or loss of voice, sore throat, and/or Difficulty breathing / Shortness of breath in Resident #802's EMR. An interview was conducted with the DON on [DATE] at 1:45 PM. When queried regarding assessment and intervention expectations for a resident who develops difficulty breathing, the DON stated, I would expect a lung assessment and oxygen saturation. The DON stated they would attempt to sit them up, positioning, and apply oxygen if needed to improve oxygenation. The DON was then asked to review Resident #802's documentation in the EMR. When queried why there was no documentation related to the Resident having trouble breathing, the DON confirmed the lack of assessment and documentation. When asked, the DON verbalized documentation should have been completed. The DON was informed of interview completed with LPN D. When queried regarding the appropriateness of the care provided for Resident #802, the DON stated, If (a resident is) very short of breath, should pull call light to get the other nurse and call the Doctor to get an order to send out (to hospital). When queried regarding Ventolin inhaler administrator, the DON stated, I probably wouldn't give it they were short of breath because it is past that (medication being effective) When queried regarding facility policy/procedure related to TBPs and if there should be an order in the EMR specifying the specific type of precautions, the DON replied, Yes. When queried if there was an order in Resident #802's EMR, the DON reviewed and stated there was no order. When asked why there was not an order, the DON communicated that they did not work at the facility during Resident #802's stay and were unable to provide an explanation. The DON was then asked when Paxlovid should be initiated for an individual diagnosed with Covid-19 and indicated as soon as possible. When queried why Paxlovid was not ordered for Resident #802 until [DATE] when they tested positive for Covid-19 on [DATE], the DON was unable to provide an explanation. The DON was then asked to review Resident #802's eMAR. When queried if Resident #802 received any doses of Paxlovid, the DON replied, Never administered. When queried why Resident did not receive the ordered medication, the DON stated, I can't answer that because there is no note. When queried if the Resident's Physician/HCP should come to see and assess them following a change in condition, such a being diagnosed with Covid-19, the DON replied, Yeah. The DON was then asked if Resident #802 was assessed by their Physician/HCP following their diagnosis. The DON reviewed Resident #802's EMR and confirmed they were not. When asked, the DON verified concerns related to Resident #802's assessment, monitoring, and treatment. Resident #802's Certificate of Death was obtained and reviewed. Per the Death Certificate, Resident #802 died on [DATE] AM at 1:59 AM due to a. Covid-19 . Approximate Interval Between Onset and Death > 3 day; b. Respiratory Failure Approximate Interval Between Onset and Death 5-10 minutes . The Manner of Death was listed as Natural and the Medical Examiner was not contacted. Facility Physician E is listed as the Certifying Physician on the Death Certificate. An interview was competed with the facility Administrator on [DATE] at 8:45 AM. Resident #802's change in condition, lack of medication administration as ordered, nursing assessment, timely response, and death in the facility were reviewed. When queried, the Administrator stated, I'm not sure what happened. On [DATE] at 12:00 PM, the Administrator provided an investigation folder pertaining to Resident #802. The folder contained the following: - Typed Statement specifying, (LPN D): After receiving vitals and report from the nursing assistant at 12:15 AM or a little later, I went to assess. Resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, the facility failed to ensure quality of care for nursing assessment for two residents (Resident #17, Resident #62), resulting in infections for Resident's #17 peritoneal catheter site and Resident #62 being sent to the hospital for septic shock requiring antibiotic therapy and prolonged illness. Findings include: Record review of the facility provided 'Assessment, Nursing, Policy Number: NRS-114 and dated 07/01/2008, revealed that the purpose of the policy was to ensure adequate assessment of resident care needs in order to develop and comprehensive plan of care. Assuring the goals are directed at attaining the highest practical level of wellness based on residents' choices. Record review of the facility-provided 'Dialysis: Peritoneal', Policy Number: NRS-148 and dated 07/01/2008 revealed safe and accurate therapy to osmotically remove fluids Procedure: (#19.) Inspect the catheter site. If dressing is reapplied, apply clear transparent occlusive dressing. (#22.) Documentation in the clinical record: (c.) Temperature and status of the catheter sire. (e.) Condition of catheter dressing or if new dressing applied. Record review of the facility-provided 'Activities of Daily Living (ADL)', Policy Number NRS-102 and dated 07/01/2008, revealed that the purpose was to assist residents as needed in achieving maximum functional ability with dignity and self-esteem to improve quality of life. Resident #17: Record review of Resident #17's quarterly Minimum Data Set (MDS), dated [DATE] revealed an elderly male with cognitive skills for daily decision-making skills as severely impaired. Record review of Resident #17's medical diagnosis list included dementia, schizophrenia, bipolar depression, end stage renal disease and anxiety. Record review of Resident #17's electronic profile noted admission date was 5/18/2023. An interview on 10/17/23 at 02:15 PM with Resident #17's family members at bedside identified that the resident had a peritoneal dialysis catheter/tube in his abdomen since admission and has not used the peritoneal dialysis catheter for the 7 months the resident has resided in the facility. Observation on 10/17/23 at 02:16 PM of Resident #17's peritoneal catheter/tube to the abdomen showed that it was red and appeared inflamed at the opening site. Resident #17 stated that it hurts, when his family member touched the area. the state surveyor observed no split gauze dressing to the area, the family member stated the site was warm to the touch who touched the area. In an observation and interview on 10/17/23 at 02:20 PM, Registered Nurse (RN)/Infection Control Preventionist (ICP) A stated that she was not aware that the resident had a peritoneal catheter in place to his abdomen. Observation by RN/ICP A of Resident #17's abdomen peritoneal catheter/tube site revealed redness and painful to touch noted by facial expression. RN/ICP stated that the site did look infected and would follow-up with the physician. Record review on 10/17/23 at 2:27 PM of Resident #17's Care Plans, pages 1 through 24, revealed on page 21 a care plan, dated 05/19/2023, for Renal insufficiency related to end-stage renal disease. Interventions included: 05/19/2023; Notify physician if signs and symptoms of fluid imbalance such as neck vein distention, difficulty in breathing, increased heart rate, edema, elevated blood pressure, or adventitious breath sounds. 5/19/2023; Observe for adverse medication effects to decreased renal clearance. There were no interventions or care plan related to skin for peritoneal catheter site monitoring. An interview on 10/18/23 at 11:35 AM with Registered Nurse (RN)/Infection Control Preventionist (ICP) A revealed that Resident #17 was placed on Keflex (antibiotic) for the perineal catheter site that was infected. RN/ICP A stated that Resident #17 has been at the facility for 6 months with no care to the area. The facility made an appointment for a nephrology consultation, as well as an antibiotic for 7 days. In an interview and record review on 10/19/23 at 08:21 AM, the Director of Nursing (DON) revealed that a record review of the skin care plan did not mention a peritoneal catheter or to monitor the site for infection, cleaning, or dislodgement. Resident #62: Record review of Resident #62's admission Minimum Data Set (MDS), dated [DATE], revealed an elderly male with Brief Interview of Mental Status (BINS) 8 out of 15, cognitive impairment. Record review of Resident #62's medical diagnosis list included dementia, renal insufficiency, obstructive uropathy, septicemia, urinary tract infection, diabetes. Record review of Resident #17's progress note revealed an admission date of 09/20/2023. Interview and observation on 10/17/23 at 09:31 AM of Resident #62's showed bladder scan results of 1343 ml dated 10/17/2023 at 8:23 AM in room with no attendant present. Resident #62 stated that they just scanned his bladder. Resident #62 stated that his bladder felt full, he did not feel well, and also he could not eat his breakfast because his stomach felt different. In an interview on 10/17/23 at 09:52 AM, Licensed Practical Nurse (LPN) K revealed the resident was going out to hospital because he has a milky yellow discharge from the penis area. He is uncircumcised. LPN K revealed that she did a bladder scan of 1343 ml, he had a change of condition from yesterday by registered Nurse (RN) C, so LPN K stated that she was sending Resident #62 out. Mobile Medical Response went into the room to get the resident. LPN K gave a report of Resident #62 having tenting skin and appearing dehydrated. An interview on 10/17/23 at 09:55 AM with Licensed Practical Nurse (LPN) K about Resident #62 revealed going out to hospital he has not had any urine output in 12-24 hours. LPN K revealed that she did straight catheter of Resident #62 with no output this morning and needs to go out to hospital. In an interview on 10/19/23 at 09:46 AM with Physical Therapy Assistant (PTA) J revealed that Resident #62 had needed more assistance during therapy (two people) whereas he had been a one- person assist. PTA J revealed that she reported to the Director of Nursing (DON) a change with increased assistance with transfers/bed mobility. It was a significant decline from previous levels. The change was reported around 10:00 AM in the morning. PTA J brought the progress note from that day for the State Surveyor. In the therapy notes for Friday for the prior week, Resident #62 refused to ambulate because he was feeling weak. Record review of Resident #62's 'Physical Therapy Treatment Encounter Notes', dated 10/11/2023, at 2:33 PM revealed that Resident #62 required frequent voice cues to stay on complete treatment session. Resident #62 was noted to refuse gait training today with complaint of felling weak. Physical therapy notes on 10/16/2023 at 9:43 AM revealed that Resident #62 required lying to sitting at the edge of bed with maximum assist. Static sitting balance at edge of bed with moderate assist, stand/pivot transfer bed to wheelchair with maximum assist with voice cues needed for upright posture. An interview on 10/19/23 at 09:11 AM with the Director of Nursing (DON) revealed that for Resident #62 was admitted with Urinary Tract Infection, sepsis, and diabetes. Record review of the care plans addressed: Infection related to sepsis; urinary tract infection dated 9/22/2023. Interventions included: Antibiotic as ordered, Labs/diagnostics as ordered, monitor for sign & symptoms of adverse drug reaction each shift, Report to physician any adverse effects or non-resolving symptoms such as fever, nausea, vomiting, acute change of mental status, vital signs outside of normal parameter of resident. Renal Insufficiency related to Acute Kidney Injury care plan interventions included: Notify physician if signs and symptoms of fluid imbalance such as neck vein distention, difficulty breathing, increased heart rate, elevated blood pressure, or adventitious breath sounds. There were no interventions to monitor output of urine with insufficiency diagnosis. Surveyor requested peri-care staff education/in-servicing for the last 10 months. Quality of care policy requested, diabetic monitoring policy requested, nursing assessment policy and documentation policy. Record review on 10/18/2023 of Resident #62's 'Change of Condition' form, dated 10/16/2023 at 5:38 PM, noted a functional decline, that started in the morning, additional pertinent diagnosis included dementia and diabetes. Blood pressure 105/66, pulse 76, respirations 17, temperature 97.7 degrees, pulse oxygen level 97% on room air blood sugar was 122, was taken on 10/16/2023 at 10:10 AM, there were no other vital signs taken for the day. Record review of Resident #62's nursing progress notes revealed that there was no change of condition progress note found. An interview and record review on 10/18/23 at 12:49 PM with Registered Nurse (RN) C revealed that Resident #62 on Monday (10/16/2023) therapy came out and said that he was really weak, and not acting like himself. RN C revealed that he did a 'Change of Condition' form on 10/16/2023 and ordered a UA and gave report to night shift nurse. Record review of progress notes revealed there was no note for change of condition. RN C stated that he would put a late entry since the state surveyor did not find a progress note today (10/18/2023). A record review of Resident #62's Hospital record, dated 10/18/2023 at 10:38 AM, revealed that the resident was treated for: (1.) Urinary Tract Infection. (2.) Septic shock. (3.) Hyperglycemia. (4.) Metabolic Acidosis.