**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, review of professional literature, and staff interview, the facility failed to ensure 1 of 5 sampled residents (Resident #23) received the services necessary to attain the highest degree of safety possible while receiving fluids. Failure to ensure staff provided proper positioning when providing water placed Resident #23 at risk for aspiration and choking. Findings include: Review of the policy titled Meal Supervision and Assistance occurred on 10/23/24. This undated policy stated, . The resident should be positioned so his or her head and upper body are as upright as possible. in bed, use wedges and pillows to achieve a nearly upright position. [NAME] B. Swigert's The Source for Dysphagia; Third Edition, LinguiSystems, Inc., Illinois, 2007, page 125 and educational handouts identified, . During the oral intake of . foods and/or liquids, it is optimal for a patient to be seated at a 90 degree angle, whether in a bed or in a chair. Review of Resident #23's medical record occurred on all days of survey. Diagnosis included dementia and difficulty swallowing. The resident's current care plan and a physician order, dated 06/08/24 stated, . 90 degrees for all intake . Observation on 10/22/24 at 10:10 a.m. showed two certified nurse aides (CNAs) (#3 and #4) transferred Resident #23 into bed. While in bed at an approximate 50 degree angle the CNA (#3) provided the resident with a drink of water. The resident coughed, held his breath, and his face turned red until the CNAs positioned him to a 90 degree angle. The resident then continued to cough and the CNAs called for the nurse. Nursing progress notes for 10/22/24 stated: *11:52 a.m. Resident was seen by [nurse practitioner] on rounds, new orders received . bedside swallow evaluation to be completed. Son, [name] at facility and updated on orders and episode of resident coughing on water. *2:51 p.m. Resident had a choking episode while laying in bed this AM. The episode was witnessed and CNA was able to repositioned [sic] to 90 degree angle and CN [charge nurse] assessed resident immediately. Resident back to baseline respiratory rate. During an interview on 10/23/24 at 4:25 p.m., an administrative nurse (#1) stated she expected staff to position Resident #23 to a 90 degree angle before providing the resident with a drink of water.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #22) observed during a dressing change. Failure to practice infection control standards related to enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions occurred on 10/23/24. This policy, dated 03/22/24, stated, . Enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific high contact care activities . High-contact resident care activities . Wound care: any skin opening requiring a dressing. Observation on 10/22/24 at 9:40 a.m. showed an EBP sign on Resident #22's door. A nurse (#2) donned gloves and changed Resident #22's heel dressing. The nurse failed to wear a gown during the dressing change. During an interview on 10/23/24 at 4:25 p.m., an administrative nurse (#1) stated she expected staff to wear a gown during a dressing change.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or resident's representative a written bed hold notice for 1 of 2 residents (Resident #21) and the notice failed to include the reserve bed payment amount for 2 of 2 residents (Resident #2 and #21) reviewed for hospital transfers. Failure to provide a written copy of the bed hold notice and include the reserve bed amount does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of the facility policy Bed Hold and Transfer Notice Policy occurred on 11/08/23. This policy, dated October 2019, stated, . The facility will have a process in place to ensure residents and/or their representatives are made aware of the facility's bed-hold and reserve bed payment amount at the time of admission to the facility and prior to transferred to the hospital . The facility will provide written information about these policies to residents and/or resident representatives . upon transfer . - Review of Resident #21's medical record occurred on all days of survey. A hospital transfer occurred on 07/03/23. The bed hold notice identified facility staff obtained verbal consent to hold the bed. The record lacked documentation the facility provided the resident and/or their representative with a written bed hold notice or the reserve bed hold amount. - Review of Resident #2's medical record occurred on all days of survey. Hospital transfers occurred on 06/30/23 and 07/19/23. The bed hold notices lacked the reserve bed hold amount. During an interview on 11/08/23 at 9:20 a.m., an administrative staff member (#1) confirmed the bed hold notices lacked the reserve bed hold amount.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policies/procedures, the facility failed to ensure staff followed standards of practice for 1 of 5 sampled residents (Resident #9) with an indwelling catheter and 1 of 2 sampled residents (Resident #229) with a dressing change. Failure to update the resident's medical record with physician's orders for an indwelling catheter and failure to follow physician's orders for a dressing change may result in delayed treatment, pain and/or worsening of resident's condition. Findings include: Review of the facility policy titled Medication Orders occurred on 11/08/23. This policy, revised 10/08/19, stated, . The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). Transcribe newly prescribed medications on the MAR or treatment record. Review of Resident #9's medical record occurred on all days of survey and included a quarterly minimum data set (MDS) dated [DATE] coded for an indwelling catheter. A Hospice Certification and Plan of Care document dated 11/01/23 identified, . Hospice nurse for insertion of foley catheter using 16 french/10cc [cubic centimeter] balloon. Change every 6 weeks and PRN [as needed] dislodgement or stoppage . Review of Resident #9's physician order report and the MAR and treatment administration record (TAR) dated 10/08/23 through 11/08/23 failed to identify an order for an indwelling catheter. Observation on 11/07/23 at 12:54 p.m. showed Resident #9 with an indwelling catheter. During an interview on the afternoon of 11/08/23, an administrative staff member (#1) confirmed the staff failed to transcribe the orders for an indwelling catheter onto the resident's orders and TAR following admit to hospice. Review of the facility policy titled Clean Dressing Change occurred on 11/08/23. This undated policy, stated, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, states, . Carrying Out a Physician's Orders . If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. - Review of Resident #229's medical record occurred on all days of survey. Current physician's orders identified, . Orders to Apply Mepilex [dressing] to open areas on Left mid back; monitor for signs/symptoms of infection; change Q72hrs [every 72 hours] and PRN . The current care plan included, . I have a potential for alteration in my skin integrity R/T [related to] my Braden Scale Assessment. I am at risk for sheering with my hoyer lift transfers and currently have an area of sheering to my back. Please follow the orders in the TAR for dressing changes and measure the area weekly with my skin assessments. A progress note, dated 11/05/23, stated, Two open areas noted to left middle back, which were noted upon CNA [certified nurse aide] washing resident up this morning; superior open area measures: 0.8cm [centimeter] x 0.3cm x 0cm; inferior area measures: 1.1cm x 0.8cm x 0cm; both areas are beefy red, with surrounding skin being blanchable light purple; small amount of sanguineous [containing blood] drainage noted on bedding. Orders to apply Mepilex and change Q72hrs and PRN . During an observation on 11/06/23 at 12:28 p.m., two CNAs (#3 and #4) performed personal cares on Resident #229. The resident's back was exposed and did not identify a Mepilex dressing on the resident's left mid back. During an observation on 11/07/23 at 1:04 p.m., two CNAs (#5 and #6) performed personal cares on Resident #229. The resident's back was exposed to show a small red sheering of the skin and did not identify a Mepilex dressing on the resident's left mid back. During an interview on 11/08/23 at 11:00 a.m., an administrative staff member (#1) stated she would expect staff to continue with current physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide treatment and services in a manner that maintained the highest practicable physical well-being for 1 of 1 resident (Resident #22) observed experiencing pain during cares. Failure to report and act on the resident's pain resulted in unresolved pain and decreased quality of life. Findings include: Review of the facility policy titled Pain Management occurred on 10/08/23. This undated policy stated, The facility must ensure that pain management is provided to residents who require such services . In order to help a resident attain or maintain his/her highest practicable level of well-being and to prevent or manage pain, the facility should: Recognize when the resident is experiencing pain and identifies circumstances when the pain is anticipated. Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice . Review of Resident #22's medical record occurred on all days of survey. Diagnoses included osteoarthritis, left ankle ulcer, and history of a pelvic fracture. A quarterly minimum data set (MDS), dated [DATE], indicated a brief interview of mental status (BIMS) score of 8 (moderately impaired cognition). A facility pain assessment, completed on 08/10/23, identified the resident experienced chronic pain almost all day, the pain rated as severe via a visual descriptor scale, and increased pain during wound treatments. The assessment also indicated pain decreases the resident's energy, socialization, and appetite and limits the resident's day-to-day activities. Resident #22's physician's orders included the following: *Wound Care: - Cleanse left ankle wound with 0.25% Dakins solution [an antiseptic], apply a small piece of iodoform [an antiseptic] gauze loosely in wound bed, and cover with foam dressing. Change daily and as needed (PRN). *Pain Medications: - Acetaminophen 650 milligrams (mg) scheduled twice a day - Oxycodone Extended Release 20 mg scheduled twice a day - Voltaren Arthritis Pain topical gel scheduled twice a day to shoulders, spine, knees, elbows, and ankles. - Acetaminophen 650 mg every 4 hours PRN. - Oxycodone 5 mg every 6 hours PRN. Observations of Resident #22 during cares showed the following: * 11/06/23 at 12:26 p.m., Two certified nurse aides (CNAs) (#6 and #8) transferred the resident from the wheelchair to the bed utilizing a full body mechanical lift. During the transfer and when rolling the resident back and forth in bed to remove the lift sling, the resident repeatedly moaned and stated, Ouch and Oh. Oh. Oh. * 11/07/23 at 1:46 p.m., Two CNAs (#3 and #6) transferred the resident from the wheelchair to the bed to prepare the resident for a bath. The resident moaned and groaned throughout the transfer process. As the CNAs lowered the head of the resident's bed, the resident repeated, Oh my back. Ohhhhh my back. The CNA (#3) stated, She has so much pain all over. We use two to work with her so we can carefully roll her. As the CNAs rolled the resident from side to side to remove the sling, the resident moaned and groaned. As the CNAs pulled down the resident's pants, the resident twice stated, Don't touch my ankle. The resident continued to express pain throughout the brief change and placement of the bath sling. As the CNAs transferred the resident from the bed to the shower chair, the resident placed her right hand to the right side of her neck and repeated, Oh My Head and Ouch Ouch while motioning her hand up and down the right side of her neck. * 11/07/23 at 2:25 p.m., following the resident's bath, a staff nurse (#2) completed the resident's left ankle wound treatment. The resident stated, Ouch Ouch and groaned throughout the treatment. Review of Resident #22's November 1-7, 2023 MAR identified the resident received the scheduled pain medications, PRN oxycodone on 7 occasions, and no PRN acetaminophen. During an interview on 11/08/23 at 7:50 a.m., an administrative staff member (#1) stated Resident #22's direct care staff failed to report the residents increased pain with cares to the nurse and agreed staff failed to effectively use PRN medications to help control Resident #22's pain. The facility failed to report and effectively manage Resident #22's pain during times of care and wound treatments.

Based on record review and staff interview, the facility failed to ensure residents' records contained the hospice election form and the certification of a terminal illness for 2 of 3 sampled residents (Resident #2 and #229) receiving hospice services. Failure to obtain these documents limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include: - Review of Resident #2's medical record occurred on all days of survey. Resident #2 elected Hospices services on 08/29/23. The medical record lacked the hospice election form and the physician's certification of the terminal illness. - Review of Resident #229's medical record occurred on all days of survey. Resident #229 elected Hospices services on 11/01/23. The medical record lacked the hospice election form and the physician's certification of the terminal illness. During an interview the afternoon of 11/07/23, an administrative nurse (#1) confirmed the medical records lacked the election form and the certification of terminal illness related to hospice.