**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that, for 4 of 47 sampled residents, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the residents' choice. Specifically, a resident with an identified mass was not evaluated as requested by the resident representative; a resident was hospitalized after a failure to identify a change of condition in a timely manner; a resident's blood sample was not obtained per protocol which resulted in an emergency room visit; and a resident received medication in error and one medication rectally when oral medication was available. The deficient practice identified for residents 22 and 36 were found to have occurred at a harm level. Resident identifiers: 22, 36, 64 and 121. Findings include: HARM 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included dementia, moderate intellectual disabilities, atherosclerotic heart disease, asthma, and hypertension. Resident 22's medical record was reviewed from 11/27/23 through 12/6/23. A review of the face sheet indicated that a Family Member (FM) was resident 22's responsible party and POA (Power of Attorney). A Nursing Note dated 8/7/23 at 11:20 AM indicated, Noted lump at right breast during shower. Right nipple is inverted as well. NO drainage is noted. Immovable lump approx [approximate] size of 50 cent coin. Contacted sister [name redacted] and informed her. Notified UM [Unit Manager]/DON [Director of Nursing] /Provider as well. No discoloration is noted. Resident without s/sx [signs or symptoms] [sic] pain. WCTM [will continue to monitor]. A Social Services note dated 8/8/23 at 12:18 PM indicated, Spoke with family today. they have decided that [resident 22] needs to stay here because they cannot get 24 hour care at home, and sisters cannot take care of her. They have requested we get a diagnosis and prognosis for the breast issue, and if it is cancer, they are thinking about going on Hospice are in the facility. A [name of facility] document dated 8/17/23 indicated the chief complaint was dementia and breast mass. It also indicated, She further stated that if a lump is found the nurse management and the provider should be notified and, we will get an ultrasound and mammogram. there is a high likelihood this is cancerous. making high complexity. We spoke with the family and they would at least like to have some information. They did not think they will do anything heroic. There was no physician orders regarding breast mass located in resident 22's medical record. A Physician/Practitioner note dated 11/30/23 at 8:35 PM indicated, I was asked to see [resident 22] today because of a breast mass which is described as getting bigger. It is hard to determine how long this has been there. She has a firm mass in her right breast about 4 cm which is caused some puckering just laterally and inferior to the nipple. There is no discoloration or inflammation. This is almost certainly malignant mass. We will talk with the family about desired treatment or evaluation of this. She has no other new complaints. She is up in her wheelchair and is pleasant but a little resistant to being examined. The nurse [name redacted] was present with me during the exam. On 11/28/23 at 10:24 AM, an interview was conducted with resident 22's FM. The FM stated that resident 22 had a large lump on her right breast that had increased in size, and nothing had been done about it. On 12/4/24 at 2:55 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that a skin assessment was focused on the resident's skin and included the entire body. LPN 4 stated a lump was something that could be identified during a skin assessment and should be documented in the medical record. LPN 4 stated that if a lump was found, nurse management and the provider should be notified. LPN 4 stated resident 22's lump was, right here, as she pointed to her own lateral side of the right breast. LPN 4 stated the lump had been there for longer than a month and they were watching it for changes. LPN 4 stated the family of resident 22 was aware of the lump and they did not want her to go through an invasive procedure. LPN 4 stated she had not observed the resident touching the mass or any other indication that the mass was causing resident 22 pain. On 12/6/23 at 10:05 AM, an interview was conducted with the DON. The DON stated that Social Work (SW) had helped make appointments in the past, but the SW was not comfortable doing that, so it became the responsibility of the Unit Managers. The DON stated the Unit Manager was expected to look for needed follow up appointments. The DON stated resident 22's mass was diagnosed but the family decided not to treat it and the nurse manager would be expected to follow up with that if the resident needed a referral. The DON further stated she thought there was documentation of resident 22's family refusing treatment for the breast mass. No documentation of resident representative refusing treatment for the breast mass was provided. 2. Resident 36 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included rheumatoid arthritis, type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, pressure ulcer of unspecified site, repeated falls, and major depressive disorder. Resident 36's medical record was reviewed on 12/5/23. Resident 36's progress notes documented the following: On 9/26/23 at 6:21 AM, a nurses note revealed, Pt [patient] increase lethargic, he struggled taking his meds which I put in pudding. he was not able to take water through a straw and he has some chest congestion. I tested patient for COVID twice and both were negative. notified MD [medical doctor]. On 9/26/23 at 10:41 AM, a nurse note revealed, pt is lethargic but arousable. wet cough noted. pts VS [vital signs] stable and WNL [within normal limits] at T [temperature] 36.4 C [Celsius], BP [blood pressure] 124/80, HRR [heart rate] 69, RR [respiratory rate] 16, O2 sat [oxygen saturation] 98% on 3L [liters] via. chest Xray requested from MD. orders pending. On 9/27/23 at 5:21 AM, a nurse note revealed, Day shift nurse got orders for CBC [complete blood count], CMP [complete metabolic panel], Xray and UA [urinalysis]. I put orders in. [Note: No orders were located for the CBC or CMP to indicated if the provider wanted the labs orderd as routine or stat.] On 9/28/23 at 12:55 AM, nurse note revealed, Pts lethargic sx [symptoms] continue. The patient is alert and oriented but has difficulty speaking. Had difficulty swallowing after being given crushed meds that were in applesauce. Was unable to sip water out of a straw. Did not look interested in eating his dinner. Is now sleeping well. On 9/28/23 at 10:04 PM, a nurse note revealed, Aide went into the pt room to change pt brief, Pt was unresponsive, shallow breathing, and pt was sating at 58% on 2L of oxygen, increased oxygen to 5L and pt started sating in the 90's but still unresponsive. Called [local hospital] ambulance pt was transferred to the hospital . Also tiger texted [MD name removed],[Director of nursing], on call manager. On 10/12/23 at 7:36 PM, a Physician - admission history and physical note documented resident 36 had been hospitalized on [DATE] due to acute respiratory failure with hypoxia and hypercapnia. It stated, he was recently hospitalized for sepsis likely secondary to UTI [urinary tract infection] as well as respiratory failure. On 9/27/23, a chest x-ray was obtained and read. The results became available to be reviewed on 9/27/23 at 4:32 PM. It was noted that the doctor reviewed the results on 10/2/23. A statement on the x-ray results read as followed, patient discharged on 9/28/23. Please forward to ordering provider or pcp [primary care provider]. [Note: There was a 6 day delay in the provider reviewing the x-ray results.] A laboratory report with a collection date of 9/27/23 at 6:25 AM, documented the results had been printed on 9/28/23 at 4:29 PM. The CBC and CMP resulted with abnormal low and high lab values. A statement written on the laboratory report documented, At hospital with a date of 10/2/23. It should be noted that a UA was not collected or ordered by the physician as indicated by the progress note made on 9/27/23. Resident 36 presented with a change of condition on 9/26/23 and was sent to the hospital 3 days later on 9/28/23 due to becoming unresponsive. Imaging and lab work were collected on 9/27/23 but it was unclear whether the m want all this done urgently or routinely. Ultimately, there was a delay in the physician provider reviewing the results and getting the resident the care, they required based upon their initial presentation on 9/26/23. On 12/6/23 at 5:05 PM, an interview was conducted with the Licensed Practical Nurse (LPN) 2. LPN 2 stated they recalled resident 36 had to go to the hospital a couple of months ago because he was septic. LPN 2 stated they were concerned about resident 36's condition on 9/26/23, so the physicians was contacted. LPN 2 stated they remembered resident 36 had not been doing well the day before and the night of and that was why she contacted the doctor that day. LPN 2 stated they were able to obtain orders from the doctor. LPN 2 stated if the doctor ordered anything stat, then results were supposed to be reported to the provider as soon as they were available. LPN 2 stated if blood work was ordered stat then it needed to be collected within 4 hours of being ordered and results were made available within a few hours. LPN 2 was unable to locate an order for the CBC and CMP that was collected on 9/27/23 and was unable to determine if the labs were to be ordered stat or routinely. On 12/6/23 at 5:25 PM, an interview was conducted with the DON. The DON stated if a resident had a change of condition, a change of condition form needed to be filled out and the physician needed to be informed. The DON stated based on the progress notes made on 9/27/23 by the night shift staff, it indicated the day shift nurse had received orders from the doctor to obtain a CBC, CMP and UA. The DON stated they were able to locate the x-ray order. The DON was unable to locate any order's for a CBC, CMP and UA on 9/26/23 or 9/27/23 in resident 36's medical record. The DON stated if the nurse received a verbal order, it was supposed to be entered in the medical record. The DON stated the purpose in entering a physician's order in the computer was to have the physician review what they had ordered and then acknowledge it by signing it. The DON stated resident 36's lab results had been printed on a Thursday and the doctor had already been in that day. The DON stated the next day the doctor came into the facility would have been on 10/2/23 and that was why it had been signed that day. The DON was unsure if the provider had been notified of resident 36's results before 10/2/23 since there was no documentation to indicate otherwise. The DON stated there were some out of range lab values present on the CBC and CMP but there was no blaring sign to indicate an infection. The DON stated the doctor was responsible for reviewing all lab work and decided what needed to be done next based on the results. 4. Resident 64 was admitted to the facility on [DATE] with diagnoses which included diabetes type 2, anxiety, and depression. On 11/27/23 at 2:56 PM, an interview was conducted with resident 64. Resident 64 stated that she was admitted because she had a recent toe amputation and had to be on IV (intravenous line) antibiotics and would need frequent blood draws. Resident 64 stated that she had a nurse provide a lab draw and knew that with her PICC (peripherally inserted central catheter) lab draws the nurses needed to first flush her picc line then remove blood and throw that blood away, then take another sample of blood after and use that fresh draw to be used for the lab levels. Resident 64 stated that a nurse was doing a lab draw and noticed the nurse did not flush her PICC line and just took a blood sample for an upcoming lab. Resident 64 stated that when the lab results came to the facility, she was told her levels were critical and was immediately taken to the hospital. Resident 64 stated that she was very upset and scared. Resident 64 stated she requested to have her PICC line removed so that mistake could not happen again, but that without the PICC for easy access to lab draws it was difficult to have her labs drawn. Resident 64's medical record was reviewed 11/27/23 through 12/6/23. Resident 64 had an order for labs to be drawn weekly. One time a day every Tuesday pull labs from picc line and call courier for pick up. Resident 64 had an order that documented, PICC/Central- Flush accessed lumen(s) with 10ml [milliliter] NS [normal saline] before blood draw, discard 5ml of blood, draw labs then flush with 20ml NS after blood draw. Change needleless connector after complete. As needed for Blood draws. On 11/1/23 a nursing note documented, Received a critical lab result for pt. Potassium of 10. MD [medical director] notified, received order to send pt out to ED [emergency department]. Pt notified and pt sister said she would take her to the ED. Pt left the facility around 1845 [6:45 PM]. This nurse called the hospital around 2045 [8:45 PM] for an update and ED nurse stated they rechecked her levels and it was at a 4. He also stated the pt had left the ED and was on their way back to the facility. Pt arrived back to the facility around 1900 [7:00 PM]. On 12/6/23 at 10:40 AM, an interview was conducted with LPN 2. LPN 2 stated that only nurses could draw labs from a PICC line and that there were specific protocol to follow with PICC line draws. On 12/6/23 at 10:44 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that PICC line lab draw were done by nurses. RN 1 stated the process to draw from a picc line included wiping the area with an alcohol wipe, flush the line with normal saline, draw 7-10 mL of blood and waste, then draw the lab, then flush the line with 10 mL's of normal saline. RN 1 stated that if the process was done incorrectly it could result in an incorrect lab value. RN 1 stated that was the protocol for PICC line draws and if a nurse was unfamiliar with how to do that they could either ask another nurse or there was instructions in the residents medical record. POTENTIAL FOR HARM 3. Resident 121 was admitted to the facility 7/1/23 and discharged on 7/8/23 with diagnoses which included congestive heart failure, chronic kidney disease, monoclonal gammopathy, transient cerebral ischemic attack, pulmonary fibrosis, and respiratory disorder. A form titled exhibit 358 was submitted to the State Survey Agency (SSA) on 9/1/23 at 12:03 AM. The form revealed there was an allegation of Deprivation of Goods and Services by Staff. The form revealed what was reported On the morning of August 31sr [sic], 2023, aroujd [sic] 10:30am, I [ADM 1] rece]ived [sic] a call from [name removed]/APS [Adult Protective Services]; She informed me of an allegation her office had received regarding [resident 121], and concerns with her 8-day respite stay from July 1st to 8th. [Name removed] provided the list of concerns regarding her care at [name of facility] during this period. Facility Administrator, following-up on requests for recorde [sic], etc. [Name removed] reported that the patient has improved, walking on own. Nurse, [initials removed]. placed on Admin. [Administrative] Leace [sic] pending further investigation details and findings. There was no exhibit 359 submitted to the SSA with the investigation results. Resident 121's medical record was reviewed 12/4/23 through 12/6/23. A Physician's Order dated 6/30/23 at 1:30 PM revealed to admit resident 22 to facility on 7/1/23 and discharge date [DATE]. The form revealed to Administer the following medications as directed: There were no medications listed. A form titled Patient Medication Record printed 6/21/23 and signed by a hospice nurse dated 5/19/23 revealed the following physician medication orders: a. Bumetanide Oral 2 MG (Milligram) by mouth once daily for diuretics. b. Potassium Chloride Extended Release (ER) 20 MEQ (Milliequivalent) by mouth once daily for diuretic. c. Acetaminophen 325 MG 2 tablets as needed for pain. d. Morphine Sulfate Oral Solution 20 MG/5ML (milliliters) every 2 hours if needed for anxiety. e. Lorazepam Intensol Oral Concentrate 2 MG/ML every 2 hours if needed for anxiety. f. Ondansetron 4 MG every 4 hours if needed for nausea/vomiting. An order summary report for resident 121's medication dated 7/3/23 revealed the following orders: a. Acetaminophen Suppository 650 MG insert 1 suppository rectally every 4 hours as needed for pain. b. Biscodly Rectal Suppository insert 1 suppository rectally every 24 hours as needed for constipation c. Bumetanide (Diuretic Medication) Oral 1 MG give 1 tablet by mouth every 24 hours as needed for edema. d. Escitalopram (anti-depressant) 20 MG by mouth in the morning for depression. e. Haloperidol (antipsychotic) Lactase give 0.5 ml by mouth every 4 hours as needed for nausea agitation. f. Hyscyamine Sulfate give 0.125 mg by mouth every 4 hours as needed for excessive secretions. g. Lorazepam 2 MG/ML 0.5 ml by mouth every 2 hours as needed for anxiety. h. Morphine Sulfate solution 20 MG/ML. Give 0.25 ml by mouth every 1 hour as needed for shortness of breath (SOB)/pain. i. Morphine Sulfate Solution 20 MG/ML. Give 0.5 ml by mouth every 1 hours as needed for pain SOB. j. Morphine Sulfate Solution 20 MG/ML. Give 0.75 ml by mouth every 1 hours as needed for pain SOB. k. Morphine Sulfate Solution 20 MG/ML. Give 1 ml by mouth every 1 hours as needed for pain/SOB. l. Ondansetron tablet disintegrating. Give 4 mg by mouth every 4 hours as needed for nausea. m. Potassium Chloride ER table 10 MEQ. Give 10 MEQ by mouth every 12 hours as needed for supplement. n. Senna Plus oral tablet 8.6-50 MG. Give 1 tablet by mouth every 24 hours as needed for constipation. o. Senna Plus oral tablet 8.6-50 MG. Give 2 tablets by mouth every 24 hours as needed for constipation. p. Senna Plus oral 8.6-50 MG. Give 3 tablets by mouth every 24 hours as needed for constipation. q. Senna Plus oral 8.6- 50 MG. Give 4 tablets by mouth every 24 hours as needed for constipation. A physician's visit dated 7/4/23 revealed This is an [AGE] year-old here on hospice respite. The patient most recently was at [name of local hospital] in the fall. Patient does have significant dementia, congestive heart failure, pulmonary fibrosis, and now has transitioned to hospice care. The patient did not have any particular complaints today. She denies any problems with pain that is not controlled she is not having trouble breathing there are no issues with her chest as far as pain. The following medications were listed: a. Escitalopram (anti-depressant) 10 mg every day b. Escitalopram (anti-depressant) 20 mg every day b. Furosemide (diuretic) 20 mg once daily. Can increase to 2 tablets daily if needed. Use as needed for swelling. c. Metolazone (diuretic) 5 mg. One tablet by mouth every other day. d. Omeprazole 20 mg. Table 1 capsule once daily. e. Potassium Chloride ER 10 MEQ. One capsule orally three times a day by oral route once daily with food. f. Synthroid 88mcg every day. Take 1 tablet by oral route once daily. The physician documented under Assessment/Plan: .1. Unspecified diastolic (congestive heart failure) .Comments: we will have her continue her current medications. A form titled Client Medication Report dated 7/6/23 revealed the following medication orders: a. Acetaminophen 325 MG. Take two tablets by mouth every 6 hours as needed for pain. b. Acetaminophen 650 MG rectal suppository. Place 1 suppository rectally every 4 hours as needed for pain and fever. c. Bisacodyl 10 MG rectal suppository. Administer one suppository rectally daily as needed for constipation. d. Bumetanide 2 MG. Take one tablet by mouth daily for diuretic. e. Depakote 500 MG. Take 1 tablet by mouth twice daily for agitation. f. Escitalopram 20 MG. Take one tablet by mouth daily for depression. g. Hyoscyamine 0.125 MG sublingually tablet take 1 tablet by mouth every 6 hours as needed for secretions. h. Lorazepam 2 MG/ML oral concentrate. Give 0.5 ML by mouth or sublingually every 2 hours as needed for anxiety or agitation. i. Morphine Concentrate 100 MG/5ML oral solution. Take 0.25 ML by mouth or sublingually every hour as needed for pain and dyspnea. j. Ondansetron 4 MG Disintegrating tablet . One tablet on tongue or in mouth every 4 hours as needed for nausea or vomiting. k. Potassium Chloride ER 20 MEQ. Take one tablet by mouth daily for supplement. l. Senna 8.6 mG-50 MG tablet. 1-4 tablets by mouth daily as needed for constipation. Resident 121's July 2023 Medication Administration Record (MAR) revealed resident 121 was Administered the following medications: a. Escitalopram Oxalate Oral tablet 20 MG daily for depression. Administered daily from 7/1/23 through 7/8/23. b. Acetaminophen Suppository 650 MG. Administered 7/6/23 with a pain score of 3. Resident 121 had as needed (prn) orders according to the July 2023 MAR for the following medications: a. Bumetanide Oral tablet 1 MG. Give 1 tablet by mouth every 24 hours as needed for edema. b. Potassium Chloride ER tablet 10 MEQ. Give 10 MEQ by mouth every 12 hours as needed for supplement. c. Lorazepam oral concentrate 2MG/ML. Give 1 ml by mouth every 2 hours as needed for anxiety. It should be noted the above medications were not administered 7/1/23 through 7/8/23. A Nursing Admission/readmission Medication Regimen Review dated 7/1/23 revealed No, medication inconsistencies have not been identified. Nursing progress notes were reviewed and there was no information why resident 121 was administered Acetaminophen Suppository 650 MG on 7/6/23 with a pain score of 3. There were other pain medications available orally for resident 121. On 12/6/23 at 11:36 AM, an interview was conducted with LPN 3. LPN 3 stated medication scripts were faxed to pharmacy when a resident was admitted . LPN 3 stated medications were doubled checked by nursing staff. LPN 3 stated that the double check process included a nurse entering the medication into the medical record. LPN 3 stated then the medications were checked by a nurse manager. LPN 3 stated that when a resident with hospice services was admitted , medication orders came from the hospice company. LPN 3 stated the double check process was the same for a hospice respite resident as other admissions. On 12/6/23 at 11:40 AM, an interview was conducted with LPN 2. LPN 2 stated that the admission process for orders was recently changed. LPN 2 stated that the Assistant Director of Nursing (ADON), Unit Manager (UM), or Director of Nursing (DON) entered the medications into the electronic medical record, the floor nurse checked the medications that were entered into the medical record, then the nurse managers rechecked the medication orders. LPN 2 stated the admission orders were scanned into the medical record after they were inputted into the medical record. On 12/6/23 at 11:43 AM, an interview was conducted with the DON. The DON stated there was a nursing evaluation to double check admission orders. The DON stated usually the UM put the physician's orders in the medical record from the hospital orders. The DON stated the nurse reviewed the order to determine if the orders were accurate, then the medications were activated in the medical record. The DON stated that the orders were then faxed to the pharmacy. The DON stated that the pharmacy completed a review when the orders were sent to the pharmacy. The DON stated if there were concerns with the medication orders, the pharmacy called the facility staff. The DON stated admission paper work was sent to the central admission office to review and upload into the the electronic medical record. The DON stated if a resident was admitted from home, medication orders were brought with the resident when admitted . The DON stated the physician orders the nurse used for resident 121 upon admission were from the form titled Patient Medication Record that was printed 6/21/23 and signed by a hospice nurse on 5/19/23. The DON stated the medications from that form and the ones in the MAR were different. The DON stated there was no Depakote ordered, the potassium was as needed, and the Furosemide was as needed. The DON stated no Depakote could cause increase in behaviors because it was an anti-depressant. The DON stated not receiving the Furosemide would cause increase in weight gain and concerns with the heart. The DON stated that the potassium was administered with the Furosemide so there was not as much of a concern that it was not administered during admission. The DON stated that administration of medications orally was the preferred route. The DON stated there should have been documentation as to why resident 121 was administered Acetaminophen rectally verses orally. On 12/6/23 at 2:27 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated that upon admission resident 121's medications were entered as needed and not scheduled. RNC 1 stated that medications should have been administered daily. RNC 1 stated resident should be administered medications orally, unless there was a reason they were unable to swallow. RNC 1 stated resident 121 should have been administered Acetaminophen orally verses rectally.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 6 of 47 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident with previous falls from falling and sustaining a head laceration and neurological (neuro) checks were not completed as indicated. This deficiency was identified to have occurred at a harm level for resident 27. In addition, a resident who had fallen was moved before an assessment was completed by qualified personnel; the facility had hot water. In addition, facility environment disrepair identified resident accident hazards. Resident identifiers: 25, 27, 44, 47, 51 and 58. Findings Include: HARM 1. Resident 27 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, type 2 diabetes, anxiety disorder, major depressive disorder, obstructive sleep apnea, and vascular dementia. Resident 27's medical record was reviewed from 11/29/23 to 12/6/23. On 9/24/23, a quarterly Minimum Data Set (MDS) documented resident 27 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated resident 27 had moderate cognitive impairment. Resident 27's functional status documented resident 27 was an extensive one person assist with toilet use and was one person supervision assist with ambulation. Resident 27's progress notes, facility incident reports and neuro checks were reviewed and documented the following falls: a. On 8/9/23 at 6:19 PM, a nurse note stated, Pt [patient] was transferring [sic] herself from her wheelchair to her bed unassisted when she lost her balance. pt stated that she hit her head when she fell. she also hit her right shoulder. bruising noted to right shoulder skin tear note to upper right arm. skin tear cleansed with wound cleanser and and tegaderm applied. md [medical doctor] notified. 2 view xray right shoulder ordered. results pending. family notified of fall. Vs [vital signs] stable and neurochecks intact PERRLA [pupils are equal, round, and reactive to light and accommodation]. wctm [will continue to monitor]. The neuro checks were not completed as indicated. The Incident report documented the fall happened due to resident 27 being weak and not calling for assistance. Interventions included a room change, a physical therapy and speech language evaluation and staff was to assist resident 27 to the restroom at 11:00 AM and 5:00 PM before meals and she was to be assisted to get up for dinner. b. On 8/26/23 at 10:05 AM, a nurse note stated, This RN [registered nurse] was standing at med [medication] cart just outside resident's room when there was a loud crash. This RN went into room and observed resident laying on the floor with her head next to her roommates bed. Resident's lunch tray/dishes was on the floor behind her. A large hematoma observed to R [right] forehead with a drop of blood laterally to her R eye on cheek. Unable to tell this RN what she was doing at the time, but did deny hitting head on room mates bed. The roommate stated that she didn't see what happened. ROM [range of motion] assessed with no deficits. Skin assessed with no new bruising or wounds to report. Ice applied to hematoma for < [less than] 20 min [minutes] for comfort and swelling. PRN [As needed] Tylenol administered for headache post fall. Site cleansed to lateral right cheek and left OTA [open to air]. Daughter [name removed] notified. MD [medical doctor] notified. Neuro checks initiated. VSS [vital signs stable] post fall. No increased confusion to report at this time. The neuro checks were not completed as indicated. The facility incident report documented resident 27's fall was due to a diagnosis of leukemia and increased risk and weakness. No new interventions were identified. c. On 9/11/23 at 8:56 AM, a nurse note stated, Pt found on floor. Pt is unable to tell me what happened. She appears to have hit her head as she has a raised/bruised area to her right forehead. Pt VS at time of fall was BP [blood pressure] 131/84, P [pulse] 102, T [temperature] 97.2, RR [respiration rate] 24, O2 [oxygen] Sat [saturation] 97%RA [room air]. Pt eyes are reactive to light however she is unable to track. Her grip is equal bilaterally. Pt able to move all extremities. Pt does c/o [complain of] Pain stating 'yes' when I asked if she was in pain. She again stated yes when I asked if her pain was in her head. PRN pain meds given. MD notified of fall. Family, [name removed], notified of fall. No neuro check were located to indicated resident had any neuro's checks done on the day she fell. The facility incident report determined resident 27 had fallen because she was unable to transfer herself. Identified interventions included resident 27 was to be assisted to bed after dinner and staff were to help resident 27 become more comfortable. It documented resident 27 was not to try to get up by herself. d. On 9/15/23 at 10:38 AM, an orders administration note stated, .Fall Charting: No adverse effects noted or reported. Continues to have an elevated bump on upper right forehead. Her face is now pale yellow . e. On 9/26/23 at 10:00 PM, a nurse note stated, Resident slid out of bed at 22:00 (10:00 PM), no head injury reported by resident, the patient was smiling and was assisted back to the bed, Vitals BP174/89, HR 92, O2 96%, R18. Resident refused vitals check every 15 minutes, wanted to go back to sleep. Call lightwithin [sic] reach. No neuro checks were located. The facility Incident report documented resident 27 had fallen due to getting up unattended. Identified interventions included attaching a light cord to the call light, an update in the toileting schedule to include 10:00 PM and educating the resident on how to call light. f. On 10/8/23 at 6:14 PM, an alert note stated, Was informed by Noc [night shift] staff that pt fell at 0500 this morning. VSS and have been monitored all day. No injuries noted. pt stated she feels fine. husband notified. The neuro checks were not fully completed as indicated. No incident report was located about this fall. No new interventions were identified to prevent resident 27 from further falls. g. On 10/11/23 at 4:33 PM, a nurse note stated, The resident fell from her bed and was found in a sitting position on the floor. The nurse assessed the resident and the resident has no new bruise and she is WNL condition for her baseline assessment. No neuro checks were located to indicate resident 27 was monitored after her fall. The facility incident report documented that wheelchair safety was reviewed with resident 27 and another Physical Therapy (PT) evaluation was made. h. On 10/23/23 6:28 AM, a nurse note stated, the resident was found sitting on the floor in massive diarrhea. The nurse got done with counting carts with the night nurse and the resident's husband came to the nurse and he asked for help to put her back on bed. The resident is not aware to let the nurse know if she fell or was she just sitting on the floor. No neuro checks were located to indicate resident 27 neurological status had been monitored after being found on the floor. No incident report was located. i. On 10/24/23 at 2:38 PM, a nurse note stated, the resident was found sitting on the bathroom floor today at 1220 pm [12:20 PM]. the nurse assessed the patient there is no bruise and no complaints of pain. the nurse addressed the issue to the doctor and DON [Director of Nursing] and suggested that they change her room so at least wecan [sic] keep an eye on her. No neuro checks were located to indicate resident 27 neurological status was monitored after her fall. An identified intervention was a room change further away from the nurse's station. j. On 10/24/23 at 11:46 PM, an Event note stated, Nurse assessed pt because day shift nurse reported that pt was found on the floor several times today before noc nurse came on duty. Pts hand grips are equal, leg and hand strength equal and strong, pts pupils are 3mm [millimeters], PERRLA, alert and oriented, no visible s/s [signs/symptoms] injury r/t [related to] incidents apparent. Aides reported that pt will not ask for help and will get up alone to toilet so they are rounding frequently. Pts call light and personal items are within reach, adequate lighting in room, pt wearing non-slip socks, bed in lowest position, walker is nearby, pt given education and reminders to call for help. No neuro checks were located to indicate resident 27 neurological status was monitored after her fall. No incident report was located. k. On 10/26/23 at 5:32 AM, an alert note stated, Resident had a fall this shift where she received a laceration to her head and a skin tear to her right forearm. sent to hospital where she received stitched to her forehead . There were no neuro checks located to indicate resident 27's neurological status had been monitored post fall. No incident report was located. l. On 10/29/23 at 4:51 PM, a nurse note stated, Found resident sitting on the floor in front of her wheelchair. Assisted back to her wheelchair per two assist and taken to the bathroom. Neuros started. No apparent new injuries noted. No neuro checks were located. The interventions identified on the incident report included an update in resident 27's toileting schedule and making sure resident 27 had no skid foot wear on. m. On 10/30/23 at 2:14 PM, a physician note stated, Nursing requested visit after another recent fall. Patient was found in room, seated up in bed, alert and cooperative, NAD. Patient's husband is also present. Bruising left side of forehead improving after fall approximately 1 week ago. She denies any new pain or injury after fall yesterday. She denies headache, dizziness, near syncope. Patient's husband attributes falls to patient's impulsive behavior and stroke related cognitive and physical disabilities. We discussed plan to continue fall precautions with frequent toileting, fall mat at bedside, call light within reach, and frequent checks. n. On 11/2/23 at 4:57 AM, a nurse note stated, Pt keeps falling, doing frequent checks. and education on how to use call light, she can't really show how to use, just repeats yes. Neuro checks started notified MD and oncall manager. An Incident report documented resident 27 had a witnessed fall on 11/1/23. The neuro checks were not fully completed. o. On 11/24/23 at 3:41 AM, a nurse note stated, Pt had a fall at approximately 0300 [3:00 AM]. On call doctors were called and the person who picked up the phone stated, 'I don't think I am the one on call tonight but use your best judgement.' Due to the size of the goose egg on the pt's head and delayed speech from baseline, I believe it is in the patient's best interest to be evaluated by a doctor in the emergency dept at [name of local hospital]. Pt c/o headache and tenderness to palpation. Goose egg is soft and pt's blood pressure was elevated at 152/94, RR 22, pupils reactive and responsive to light, but are slightly delayed. EMS [emergency medical service] was contacted and arrived. Initial assessment of the pt was performed by EMS. Fall was unwitnessed. Pt was transferred from the w/c [wheelchair] to the stretcher via stand and pivot with nursing and EMS assistance. Pt was secured to the stretcher via straps times three and side rails times two. Pt was transported outside with paramedics and taken to [name of local hospital]. Pt's daughter was notified. The neuro checks were not fully completed. The facility incident report documented it was unknown why resident 27 had fallen. Documented interventions included an update to resident 27 toileting schedule, educating resident 27 in using the call light, a medication review and labs were requested. p. On 11/24/23 at 5:42 AM, a nurse note stated, [name of local hospital] called and stated the pt had a head CT [computed tomography scan] that was negative for any brain injury or brain bleed. Pt is being discharged and is going to be transported back to this facility. Pt has a right frontal scalp hematoma. q. On 11/27/23 at 1:17 PM, a physician/practitioner note stated, [Resident 27] is seen and examined for an acute visit today regarding recent multiple falls .Nursing reported that patient has had more than one recent fall due to getting up to the bathroom by herself. Pt has decreased mobility and is unable to ambulate to the bathroom without assistance. r. On 11/28/23 at 4:16 PM, a nurse note stated, regarding recent multiple falls. contusion/ bruising to the right side of forehead continues to heal routinely. bruising turning from purple to yellowish in color. md orders to collect ua [urinalysis] with c&s [culture and sensitivity] as indicated . On 12/5/23 at 11:46 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated resident 27 was considered a high fall risk and could not be left unattended. CNA 5 stated resident 27 had memory issues and was unable to safely stand by herself. CNA 5 stated resident 27 fell all the time. CNA 5 stated intervention they had in place included having the bed in the lowest position and a bed mat. CNA 5 stated they check on resident 27 about every hour when her husband was not here. On 12/6/23 at 10:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated resident 27 was a one person transfer and believed staff assisted her to the restroom. LPN 5 stated resident 27 had an abnormal gait and was a fall risk. LPN 5 stated resident 27 believed she was capable of doing things on her own and but was not safe to do so because she was only oriented to herself. LPN 5 stated interventions they had in place included doing frequent rounding. LPN 5 stated other intervention they were able to implement for resident safety included restraints to prevent them from falling. LPN 5 stated resident 27 toileting schedule was the CNA rounding. LPN 5 stated resident 27 knew how to use her call light. On 12/6/23 at 2:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated resident 27 had an over inflated idea of what she can do versus what she can actually do. LPN 3 stated resident 27 was reminded to not walk on her own but stated she still did anyways. LPN 3 stated resident 27 was a fall risk and she recently had a fall that sent her to the emergency room. LPN 3 stated it was another nurse that had found her on the floor that night. LPN 3 stated that other nurse was also an emergency medical technician and stated the nurse was concerned with how resident 27 presented after the fall that they sent her to the hospital. LPN 3 stated they have signs posted in her room to reminded her to call if she needed to get up. LPN 3 stated resident 27 was located a little further away then what they liked from the nurses station. LPN 3 stated the neuro checks were a group effort between the aids and nurses. LPN 3 stated neuro checks were put in place to monitor for acute changes post fall such as a subderal hematoma. LPN 3 stated a subderal hematoma took hours to manifest and it was considered the silent killer post falls. On 12/6/23 at 2:23 PM, an interview was conducted with Certified Nursing Assistant (CNA) 7. CNA 7 stated the aids checked on resident 27 often to make sure she was not getting up on her own. CNA 7 stated every time they walked by her room, they checked on her to avoid any percarious situation. CNA 7 stated they had a note posted on her call that reminded her to call to avoid falls. CNA 7 stated there was no official toileting schedule but they had a routine in place. CNA 7 stated resident 27's call light was the first one to be answered because of her history. CNA 7 stated resident 27 was considered a high fall risk and stated one of the interventions they had in place was lowering her bed to the lowest position she allowed. CNA 7 stated resident 27 communication had been hampered from a previous stroke so her communication was not the most precise. On 12/6/23 at 3:07 PM, an interview was conducted with the Director of Nursing (DON). The DON stated a registered nurse needed to do the initially assessment when a resident fell. The DON stated the registered nurse could then be the one to determine if the LPN performed the indicated neuro checks. The DON stated if the registered nurse determined something abnormal during the neuro checks then they notified to the doctor. The DON stated the purpose of the neuro checks was to monitor resident's for a certain amount of time for any abnormal outcomes after a fall. The DON stated they expected neuro checks to be completed as ordered and any resident refusals to be documented. The DON stated head injuries were less likely to happen and less risky for a resident the longer out they were from the fall. The DON stated an incident report needed to be done after every fall. The DON stated they expected to be notified of every fall. The DON stated incident reports were a way of tracking falls and it helped with the investigation and adding interventions for the residents to prevent future falls. The DON stated they tried to determine the cause of the fall. The DON stated that for one resident 27's intervention, they ordered pain medication to address her pain post fall. The DON stated they had added toilet times on the CNA task to reminded them when resident 27 needed to be toileted. The DON stated the toilet times included 3:00 AM, 9:00 AM, 11:00 AM, 4:00 PM, 7:00 PM, and 11:00 PM. The DON was unable to located where the CNA's were consistently documenting resident 27's toileting times. POTENTIAL FOR HARM 2. Resident 51 was admitted to the facility on [DATE] with diagnoses which included prediabetes, hypertension, major depressive disorder, anxiety disorder, lack of coordination, and alcohol abuse with alcohol-induced psychotic disorder with delusions. On 12/6/23 at 9:05 AM, the DON was observed to enter the secured unit. An observation was made of resident 51 in the dining room sitting in a chair with LPN 6 wiping blood off the left side of his face. There was blood observed on the floor. Resident 51's left hand was observed to have shake when LPN 6 wiped his face with a wash cloth. There was a laceration to the right eye and bruising observed to resident 51's right cheek. Resident 51 was observed with non-slip socks. The DON was observed to obtain resident 51's vital signs. Resident 51's medical record was reviewed 12/6/23. A care plan dated 8/31/22 and updated on 9/15/22 revealed a focus of resident 51 .is at risk for falls: Confusion. The goal was [Resident 51 will be free of falls through the review date. An intervention included to Anticipate and meet the resident's needs. On 12/6/23 at 9:20 AM, an interview was conducted with LPN 6. LPN 6 stated she worked the 400 hallway on Tuesday and Wednesdays. LPN 6 stated that resident 51 had behaviors of walking with his eyes closed. LPN 6 stated that Certified Nursing Assistant (CNA) 4 was in assisting resident 51 off the floor when she entered the dining room. LPN 6 stated that resident 51 had a head wound. LPN 6 stated that LPN's were unable to assess residents after a fall and needed a an RN to assess the resident. LPN 6 stated that the DON assessed resident 51 after the fall. LPN 6 stated after a resident fell with a head wound, the RN assessed the resident, neurological assessments were done, and the nurse was instructed what to do from the RN. LPN 6 stated that the physician was notified and documentation was completed. LPN 6 stated staff kept an eye on him for the next few days. LPN 6 stated resident 51 was bleeding everywhere and she asked him to squeeze her hands. LPN 6 stated that resident 51 was observed to be in pain and needed pain medication. LPN 6 stated that resident 51 should have been left on the ground until the RN was there to assess the resident prior to moving him. On 12/6/23 at 9:21 AM, an interview was conducted with the DON. The DON stated after a fall, the nurse identified what the resident was doing, was trying to do, what help that was provided prior, figure out what they were trying to do previous to the fall. The DON stated the family and physician were notified. The DON stated an incident report was completed by the nurse after every fall. The DON stated the resident was then monitored for a few days, assessed for increased pain, injuries or any adverse side effects. The DON stated the CNA was to notify the nurse and help the resident if the resident was in immediate harm. The DON stated for example the CNA needed to get the resident a blanket or pillow. The DON stated she would like vital signs to be done right away before moving the resident. The DON stated CNA's should wait to move the resident until after the nurse had assessed for injuries, pain, and neurological. The DON stated after the resident was assessed with no injuries then the resident was to be moved. The DON stated resident 51 should have been left until the RN was able to assess. The DON stated if a resident was moved prior to the nurse assessing, it could cause more damage if there was a head injury or a fracture. On 12/6/23 at 9:25 AM, an interview was conducted with CNA 4. CNA 4 stated resident 51 stood up a lot and wandered. CNA 4 stated that resident 51 stood up and fell sideways on his right side. CNA 4 stated that CNA 1 and her helped resident 51 off the floor when they noticed blood. CNA 4 stated resident 51 was placed into a chair in the dining room. CNA 4 stated she usually left the resident on the floor until nurse assessed but since resident 51 was bleeding, the CNA's thought it was better to get him up into a chair. CNA 4 stated usually have nurse assess before moving resident. On 12/6/23 at 5:22 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated resident's should not be moved until the resident was assessed by an RN. 3. On 12/4/23, hot water temperatures were observed through out the facility. The following temperatures were observed: [Note: All temperatures were in degrees Fahrenheit.] a. At 10:36 AM, an observation was made of the 100 hallway bathroom at the nurses station. The water temperature was 125.2. b. At 10:39 AM, room [ROOM NUMBER]'s bathroom water temperature was 124.8. Resident 47 resided in room [ROOM NUMBER]. Resident 47 was interviewed and stated the water was hot but he knew how to add cold water. c. At 10:44 AM, room [ROOM NUMBER]'s bathroom water temperature was 126.3. Resident 58 resided in room [ROOM NUMBER]. Resident 58 was interviewed and stated the water was hot but he knew to use cold water when it was too hot. d. At 10:47 AM, room [ROOM NUMBER]'s bathroom water temperature was 131.9. e. At 10:56 AM, the Secured Unit/400 hallway dining room sink had a water temperature of 122.9. f. At 11:01 AM, room [ROOM NUMBER]'s sink temperature was 119.6. Resident 25 resided in room [ROOM NUMBER]. Resident 25 was observed to be ambulatory through the Secured Unit. g. At 11:07 AM, room [ROOM NUMBER]'s sink water temperature was 123.5. h. At 11:09 AM, room [ROOM NUMBER]'s sink water temperature was 119.4. i. At 11:19 AM, the sink in the shower room of the Secured Unit water temperature was 120.1. j. At 11:32 AM, room [ROOM NUMBER]'s sink water temperature was 121.2. k. At 11:35 AM, room [ROOM NUMBER]'s sink water temperature was 124.0. Resident 44 resided in the room and was interviewed. Resident 44 stated she liked how hot her sink water was because she was able to make a cup of coffee. Resident 44 stated that she touched the spout to see how hot the water was because if she put her finger under the water it would get burned. On 12/4/23 at 11:17 AM, an interview was conducted with CNA 4. CNA 4 stated resident 25 was able to use the restroom independently and able to wash his hands independently. CNA 4 stated the water had been hot and had to be adjusted with showering residents. CNA 4 stated she worked on all the units at the facility and residents had stated Too hot when being showered. CNA 4 stated they could not remember who the residents were and the water was easily adjusted. CNA 4 stated there were no residents that had sustained burns from the water. On 12/4/23 at 11:40 AM, an interview was conducted with CNA 5. CNA 5 stated the water was warm but no residents had complained it was too hot. On 12/4/23 at 11:53 AM, an observation and interview was conducted with Regional Plant Operations 1. The hot water heaters were observed to be set at 158 degrees Fahrenheit. Regional Plant Operations 1 stated that the hot water heaters were set to 158. There was no observed mixing valve. Regional Plant Operations 1 stated he was unable to find the mixing valve. Regional Plant Operations 1 stated the mixing valve was usually set to 110 and not above 115 which made the resident rooms around 110. Regional Plant Operations 1 stated that the Maintenance Director was to check water temperatures daily Monday through Friday. On 12/4/23 at 2:32 PM, an interview was conducted with Regional Plant Operations 2. Regional Plant Operations 2 stated he checked water temperatures and the temperatures were 120.3, 119.0, and 122.0 in the 100 hallway. Regional Plant Operations 2 stated he turned the hot water heater temperature down to 152 from 158. Regional Plant Operations 2 stated that 152 would then make the water temperatures 113 in the hallways. Regional Plant Operations 2 stated that he could not find a mixing valve and was unable to locate water temperatures documented by the previous Maintenance Director. 4. On 11/30/23 at 1:44 PM, a facility tour was conducted. The following was observed: a. A handrail was loose near the maintenance door and the double doors. There was a broken metal beam along the bottom of the door that projected out towards the hallway. b. A counter was broken off and had sharp edges were exposed in the dining area near the microwave. c. Near the exit doors and room [ROOM NUMBER], a metal piece was bent and protruding out, along the bottom of the door. d. The bathroom in room [ROOM NUMBER] had two sets of toilet paper holders. The sets were missing parts which created a projection from the wall. e. In room [ROOM NUMBER], there was a floor vent that had missing metal pieces which created sharp edges at the foot of bed. f. A wire shelf located at the head of the bed in room [ROOM NUMBER]B was loose. On 12/5/23 at 11:09 AM, an interview was conducted with Regional Plant Operations 1. Regional Plan Operations 1 stated that he had probably not seen anything that needed repair because the facilities maintenance staff was no longer employed at the facility as of 11/30/23. On 12/5/23 at 11:09 AM, a facility walk through was completed with Regional Plant Operations 1. Regional Plant Operations 1 observed the items listed above and had no additional information. No documentation was provided that indicated the facility had previously made an attempt to address the identified concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 51 was admitted to the facility on [DATE] with diagnoses which included dementia, hypertension, depression, anxiety, alcohol abuse, and cognitive communication deficit. On 11/27/23 at 11:04 AM, an observation was made of resident 51. Resident 51 was observed laying in bed with a food tray next to him on the bedside table. On 11/27/23 at 1:33 PM, an observation was made of resident 51. Resident 51 was observed alone in his room, laying in bed with a food tray on the bedside table next to the bed. The main dish was covered with a lid and the drink cups were full and covered. On 11/28/23 at 10:10 AM, an observation was made of resident 51. Resident 51 was observed alone in his room sitting in his bed with the head of the bed about 75% raised, he had his breakfast in front of him on the bedside table. Resident 51 had a bowl of cereal with milk in his hand and rested on his chest. Soggy cereal was observed on his clothes. Resident 51 slowly spooned milk towards his mouth, he spilled the milk on his chest, and failed to get any cereal or milk in his mouth. His food tray was observed to have approximately 90% of scrambled eggs; 80% of cereal and half of a cup of milk in his cereal bowl, with 10% of cereal on his chest; one whole sausage patty; two glasses of milk, one cup was empty; 50% of one vanilla mighty shake; and 100% of one glass of orange juice with saran wrap on top was on the food tray. Resident was staring straight and did not react when spoken to. On 11/29/23 at 8:31 AM, an observation of resident 51 was made. Resident 51 was laying in his bed with his eyes closed, there was no food tray in his room. On 11/29/23 at 8:35 AM, an observation of resident 51 was made. A food tray was delivered to resident 51 in his bed. Staff raised the head of the bed to about 75% degrees. Staff opened the resident's mighty shake and removed the covers of the plate of food, orange juice, and milk. Resident 51's eyes were closed, and he was not eating. On 11/29/23 at 8:45 AM, an observation of resident 51 was made. Resident 51 was alone in his room with the breakfast tray sitting in front of him, untouched. Resident 51 was staring straight with his eyes half open. He did not respond when spoken to. On 11/29/23 at 8:58 AM, an observation of resident 51 was made. Resident was sitting up and awake, his food remained untouched. Certified Nurse Assistant (CNA) 1 was observed at bedside taking resident's blood pressure. The Director of Nursing (DON) entered the room and assisted CNA 1 with obtaining vital signs. On 11/29/23 at 9:06 AM, an observation was made of resident 51. Resident 51 was alone in his room and his food remained untouched. On 11/29/23 at 9:09 AM, an observation was made of CNA 1. CNA 1 was observed to go into resident 51's room and ask him if he was done eating. No response from the resident was heard and CNA 1 left the resident's room. On 11/29/23 at 9:14 AM, an observation of CNA 9 was made. CNA 9 was observed in resident 51's room assisting resident eat breakfast. CNA 9 told CNA 1 that resident 51 was not reacting or taking any food. CNA 1 asked CNA 9 if resident 51 was spitting his food out. CNA 1 told CNA 9, he'll be up and moving around later. After I am done with breakfast, I will get him up and get him ready and he will wake up more. CNA 1 was assisting other residents in the dining room. On 11/29/23 at 9:51 AM, an observation was made of resident 51's room. It was observed that the resident was not in his room and there was an open mighty shake on the tv stand that was approximately 50% full. On 11/29/23 at 12:07 PM, an observation was made of resident 51. Resident 51 was observed to be in his bed, his eyes were open, and he had no response when he was spoken to. A mighty shake was on the tv stand that was approximately 50% full. On 11/29/23 at 12:32 PM, an observation was made of resident 51. Resident 51 was observed to walk out of the dining room and stood next to the door, stared, and drank a tan liquid from a cup that was approximately half full. A concurrent interview with CNA 1 was conducted. CNA 1 stated that resident 51 was drinking a med pass because he had not eaten breakfast. On 11/29/23 at 12:45 PM, an observation was made of resident 51. Resident 51 was in his bed laying on his stomach. He was propping his head up and holding the med pass cup that was approximately 35% full. CNA 1 walked resident 51 back to the dining room and had him sit at the table while she encouraged him to eat. On 11/29/23 at 1:03 PM, an observation was made of resident 51. Resident 51 walked out of the dining room. Resident 51's tray was then observed in the dining room to have a vanilla mighty shake that was approximately 25% full, 35% of a taco, 35% of a serving of zucchini, one full glass of tan liquid, 70% of a glass of milk, and 70% of a glass of orange juice was left on the resident's tray. On 11/30/23 at 8:59 AM, an observation was made of resident 51. Resident 51 was in his room alone. He is sitting up in bed holding a cereal bowl, he was not moving or eating. On 11/30/23 at 9:12 AM, an observation was made of the Activities Director (AD). The AD entered resident 51's and encouraged him to eat. Resident 51 was observed to be feeding himself cereal with a plastic fork. The AD then left the resident's room. The AD returned to his room at 9:16 AM and left again. Resident was alone in his room and slowly ate his cereal with a spoon, cereal was observed to be spilled on his tray. No mighty shake was observed on his meal tray. The AD returned to the room at 9:22 AM and encouraged the resident to eat. On 11/30/23 at 9:27 AM, an observation was made of resident 51 in his room, alone eating cereal. The AD returned to the resident's room and encouraged him to eat. At 9:50 AM, the AD removed resident 51's breakfast tray from his room. The meal tray was observed which had two empty milk cups, a combined total of approximately 1 cup of milk was in cereal bowls; 25% of orange juice; eggs had been eaten; 100% of breakfast potatoes and toast on plate; two bowls of cereal had 25% of cereal in each bowl; and no magic shake container was on the tray. A concurrent review of resident 51's meal card that was on his tray indicated that resident 51 was on a fortified, regular diet, and regular food texture with thin liquids. It further indicated that eight ounces of milk, a mighty shake, an assorted juice, choice of hot or cold cereal, cheese and egg casserole, o'brien potatoes, toast, margarine or jelly, milk or beverage with notes that indicated to serve two raisin bran cold cereals and to send milk with all meals. On 11/30/23 at 9:53 AM, an interview was conducted with CNA 3. CNA 3 stated resident 51 did not eat unless he was prompted. CNA 3 stated he did not know how much resident 51 had eaten for breakfast and that the RD took his tray and he would ask her. CNA 3 stated he did not know if resident 51 had a mighty shake on his tray and that that was taken care of by the kitchen. He stated that the staff who delivered the tray should have checked that resident 51 received his mighty shake and that he was unsure why resident 51 needed a mighty shake. Resident 51's medical record was reviewed from 11/27/23 through 12/6/23. The Annual MDS Section G- Functional Status Activities of Daily Living (ADL) Assistance dated 8/26/23 indicated, Eating- how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. 1. Supervision. 2. One person physical assist. The Functional Abilities, Self-Care quarterly dated 11/26/23 indicated, Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident .Substantial/maximal assistance. The physician orders indicated: 1. Mirtazapine Tablet 15 mg (milligrams) Give 0.5 tablet by mouth at bedtime for appetite related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, start date 11/10/23 at 7:00 PM 2. Mirtazapine Tablet 15mg Give 1 tablet by mouth at bedtime for appetite related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, start date 9/26/23 at 7:00 PM and discontinued 11/10/23 at 1:52 PM 3. Mighty Shakes three times a day for nutrition support and to, Offer with meals. Start date 9/21/23 at 3:00 PM 4. Snack of Choice two times a day for nutrition support, start date 8/17/23 at 3:00 PM 5. Regular Diet diet, Regular texture, Thin consistency Add fortified foods started 8/12/23 at 6:57 AM 6. Weight monthly 10th in the afternoon starting on the 10th and ending on the 11th every month for weight, started 11/10/22 at 3:00 PM, discontinued 11/30/23 at 2:12 PM. 7. Folic Acid Oral Tablet 1 mg by mouth in the morning for SUPPLEMENT, start date 9/1/22 at 7:00 AM Weights were reviewed and documented: 7/31/23 184; 8/28/23 175; 9/28/23 166.5; 10/27/23 170; 11/27/23 155.5. A Nursing Skin and Nutrition Review dated 8/24/23 at 7:04 AM indicated that resident 51's level assistance needed was supervision and was to have had encouragement of intake at mealtimes in the dining room. It further indicated, Significant wt (weight) change of -14.6% in 6 months. BMI: 26.5. Encourage intake at meal time. No wounds or edema noted at this time. Added snack of choice BID (two times a day) for nutrition support. Will continue to monitor and review in a week. A Nursing Skin and Nutrition Review dated 9/28/23 at 8:42 AM indicated, Significant wt change of -7.2% in a month, -9.5% in 3 months and -18.4% in 6 months. BMI: 24.7. Encourage intake at meal time. No wounds or edema noted at this time. Receiving snack of choice BID and Mightyshake TID for nutrition support and fortified foods. Will continue to monitor and review in a week. A Nursing Skin and Nutrition Review dated 11/14/23 at 9:48 AM indicated the resident's level of assistance needed was, Supervision. It indicated the resident was to be encouraged to eat at mealtimes. The document further indicated, Significant wt (weight) change of 6.1% in a month, -9.8% in 3 months and -14.6% in 6 months. A Nutritional Screen dated 11/24/23 indicated, No wt change in the last week but significant wt change of -6.5% in a month, -9.1% in 3 months, and -16.1% in 6 months and, [Resident 51] has had significant wt change in the last 6 months, several interventions have been implemented and he is currently on Mirtazapine (a medication) to increase appetite. Continue to offer foods [Resident 51] prefers. RD (Registered Dietitian) will continue to monitor PO (by mouth) intake and weight and make diet recommendations PRN (as needed). The care plan indicated, [Resident 51] has an ADL (activities of daily living) performance deficit related to dementia s/s (signs and/or symptoms), forgetfulness with a goal of, [Resident 51] will improve current level of function through the review dated was initiated on 9/1/22, revised on 11/17/22, with a target date of 9/18/23; Interventions were listed as, Eating: [Resident 51] is set up with eating. Needs reminders and cuing to start meal at times/mimics others initiated 9/1/22 and revised on 9/15/22. An interview on 11/29/23 at 12:55 PM, was conducted with CNA 1. CNA 1 stated resident 51 needed to be supervised when he ate, but the level of supervision changed throughout the day. CNA 1 stated resident 51 needed set-up and supervision, but sometimes he needed total assistance to eat. The CNA stated supervision meant staff needed to stay with the resident when they ate. An interview on 12/6/23 at 10:28 AM, was conducted with the Director of Nursing (DON). The DON stated the facility had been working with resident 51 for awhile with the dietitian; we had tried different supplements and diet plans. The DON stated staff had been trying to spoon feed him, but he would not open his mouth. The DON stated placing a feeding tube was discussed but the resident's family did not want to do that. The DON stated resident 51 needed to be monitored while he ate and that when he wanted to eat, he could. The DON stated that mighty shakes were ordered and the CNA's knew which resident's received shakes and that it is also on the meal ticket. The DON stated that the CNA's should have made sure that a mighty shake was on his tray. 4. Resident 31 was admitted to the facility on [DATE] with diagnoses which included dementia, bipolar disorder, history of gastric bypass, hyperglycemia, and chronic respiratory failure. Resident 31's medical record was reviewed 11/27/23 through 12/6/23. Resident 31's care plan dated 2/18/23 with a revision on 8//28/23 included a focus area of nutritional problems related to increased energy needs due to bipolar disorder and current mania, being very active and constantly moving. Goals for resident 31 included, the resident will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx [signs and symptoms] of malnutrition through review date. The interventions list included: Provide and serve diet as ordered. RD[registered dietitian] to evaluate and make diet change recommendations PRN [as needed]. Weight per facility policy. Resident 31's diet order dated 2/17/23 documented a regular diet, fortified with large protein. [Note: Residents in the facility were not receiving the proper fortified diets.] Resident 31's weights revealed the following: a. On 2/18/23 resident 31's admission weight was 191.0 Lbs (pounds). b. On 3/23/23 resident 31's weight was 158.6 Lbs. [Note: A possible weight loss of 32 lbs was documented with out a reweigh.] c. On 6/16/23 resident 31's weight was 159.0 Lbs. [Note: The next documented weight after the potential weight loss was taken more than 3 months later.] Resident 31's skin and nutrition notes revealed the following: a. On 4/6/23, a skin and nutrition review documented, most recent wt [weight] 158.6 # [lbs] (3/23). Wt loss 32.4 # . Questioning accuracy- current wt was wheelchair, and previous wt was standing . Recommend to review again in one week to determine accuracy of wts. b. On 4/26/23, a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. The previous weight documented 191 lbs, dated 2/18/23. The comments documented, Most most recent wt [weight] 158.6 # [lbs] (3/23). Wt loss 32.4 # . Questioning accuracy- current wt was wheelchair, and previous wt was standing . Recommend to obtain new wt and review again in one week to determine accuracy of wts . c. On 5/2/23, a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. The comments documented, Most most recent wt [weight] 158.6 # [lbs] (3/23). Wt loss 32.4 # . Questioning accuracy- current wt was wheelchair, and previous wt was standing . [Note: No recommendation were made.] d. On 5/12/23 a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. The comments documented, Most most recent wt [weight] 158.6 # [lbs] (3/23). Wt loss 32.4 # . reported in the month prior to most recent wt (191 #, 2/18). Questioning accuracy- current wt was wheelchair, and previous wt was standing . Recommend to obtain new wt when possible/ once off isolation to determine additional interventions needed. e. On 5/19/23, a nutritional screen documented, the most recent weight as 156.8 lbs dated 3/23/23. A screening question included, Has the resident had unintended weight loss over the past 7 days? The answer marked documented, Does not know. f. On 5/26/23, a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. [Note: There were no comments or recommendations documented.] g. On 6/2/23, a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. [Note: There were no comments or recommendations documented.] h. On 6/15/23, a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. [Note: There were no comments or recommendations documented.] I. On 6/22/23, a skin an nutrition review documented, the most recent weight as 159.0 lbs taken on 6/18/23. [ Note: This is the first re-weigh done since 3/23/23.] The comments documented, significant wt loss triggered . Doctor notified. 5. Resident 121 was admitted to the facility 7/1/23 and discharged on 7/8/23 with diagnoses which included congestive heart failure, chronic kidney disease, monoclonal gammopathy, transient cerebral ischemic attack, pulmonary fibrosis, and respiratory disorder. Resident 121's medical record was reviewed 12/4/23 through 12/6/23. A physician's order dated 6/30/23 and discontinued 7/9/23 revealed Encourage fluids to ensure adequate hydration and minimize uti [Urinary Tract Infection] risk. Offer 120 mls [milliliters] at least qid [four times a day] for hydrational support four times a day for offers fluids for hydrational support. A physician's order dated 6/30/23 and discontinued 7/9/23 revealed Mightyshakes every 24 hours as needed for [sic] offer mighty shakes for nutritional support. Resident 121's July Medication Administration Record (MAR) revealed that resident was administered fluids four times a day of 120 mls. The MAR further revealed mighty shakes were not administered from 7/1/23 through 7/9/23. An assessment titled Nutrition Screen dated 7/4/23 revealed no estimated fluid needs were calculated. Additional notes revealed [Resident 121] appears to be meeting nutritional needs at this time with intake of [greater than] 75% at meals and mighty shakes given daily. Fluids offered meets estimated needs. A nursing progress note dated 7/4/23 at 1:01 AM, the nutrition section was blank. A nursing progress note dated 7/7/23 revealed Called [name and phone number removed] with urine sample for [name of lab removed] to process. Hospice Company. It should be noted there was no follow-up information or laboratory values located in resident 121's medical record. On 12/6/23 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she was not sure how fluid needs were calculated and stated she did not know if that was enough fluid to maintain resident 121's hydration status. Based on interview, observation and record review, the facility did not ensure that 5 of 47 sample residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, current weights were not being obtained to allow staff to appropriately assess the residents' nutritional status. In addition, interventions were not being implemented in a timely manner, residents were not being provided with the appropriate supplements, and were not assisted with meals . The findings for resident 53 were determined to have occurred at a harm level. Resident identifiers: 30, 31, 51, 53 and 121. Findings include: HARM 1. Resident 53 was admitted to the facility on [DATE] with diagnoses that included crushing injury of right shoulder and upper arm, hemolytic anemia, congestive heart failure, vitamin B12 anemia, osteoporosis, epilepsy, atrial fibrillation, and prediabetes. Resident 53's medical record was reviewed from 11/27/23 through 12/6/23. On 8/8/23, resident 53 had a diet order for double portions. On 8/9/23, resident 53 weighed 218 pounds (lbs). On 8/11/23, resident 53 weighed 220 lbs. On 8/31/23, facility staff completed a Skin and Nutrition Review (SNR) for resident 53. The most recent weight used for the SNR was from 8/11/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 9/7/23, facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 8/11/23. The facility did not use the current weight taken on 9/7/23 listed in the Electronic Health Record (EHR) of 181.8 lbs. On 9/8/23, a physicians order was written for resident 53 to receive a mighty shake supplement twice daily. On 9/13/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/7/13. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Significant wt change of -17.4% in a month from weight 9/7. BMI (Body Mass Index): 23.6. Need udpated weight for this week. no wounds or edema noted at this time. Meal intake [about] 75%. Recommend adding double portions. Will continue to monitor and review in a week. (Note: Resident 53 had already receiving double portions since admission, so this was not a new intervention.] On 9/21/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/7/13. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 9/22/23, resident 53 weighed 179.8 lbs. On 9/28/23, facility staff completed a SNR for resident 53. The SNR indicated Significant wt change of -17.7% in a month from wt taken 9/28. BMI: 23.3. No wounds or edema noted at this time. Meal intake >75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID (twice daily). Will continue to monitor and review in a week. On 9/29/23, a physicians order indicated resident 53 was to be administered Mirtzapine 15 milligrams at bedtime for an appetite stimulant. On 10/5/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Significant wt change of -17.7% in a month from wt taken 9/28. BMI: 23.3. No wounds or edema noted at this time. Meal intake >75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID. Will continue to monitor and review in a week. On 10/12/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Need updated weight for this week. BMI: 23.3. No wounds or edema noted at this time. Meal intake ~75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID. Will continue to monitor and review in a week. On 10/19/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Need updated weight for this week. BMI: 23.3. No wounds or edema noted at this time. Meal intake >75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID. Will continue to monitor and review in a week. On 10/26/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Need updated weight for this week. BMI: 23.3. No wounds or edema noted at this time. Meal intake ~75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID. Will continue to monitor and review in a week. On 11/2/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Need updated weight for this week. BMI: 23.3. No wounds or edema noted at this time. Meal intake ~75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID. Will continue to monitor and review in a week. On 11/2/23, a nursing progress note indicated that resident 53 had been seen by his cardiologist, and had given orders to . 3. Discuss having the pt (patient) have a protein drink to increase his weight. 4. Set a goal for the pt to gain 10-15 lbs over the next few months . 5. Pt should eat 3000 calories a day, encouraged pt to follow up with a nutritionist. On 12/3/23, resident 53 weighed 184.4 lbs. It should be noted that despite weight loss over several months, and multiple interventions, resident 53 did not have a care plan developed to address his nutritional needs. On 12/6/23 at 4:30 PM, an interview was conducted with the facility Dietary Manager (DM). The DM was asked how the facility was ensuring that resident 53 received 3000 calories a day. The DM stated that he provided extra milk to provide double protein. The DM provided surveyors with a calorie breakdown of the menu. Per review of the menu, an extra milk would add 8 grams of protein. On 11/29/23 at 3:30 PM, an interview was conducted with the facility RD. When asked why current weights were not being used for the SNR meetings, the RD stated we've been struggling to keep up to date on the weights. There's not enough staff to have CNAs (Certified Nursing Assistants) get weights. I've talked to them multiple times about it. POTENTIAL FOR HARM 2. Resident 30 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, dysphagia, impulse disorder, mental disorders due to known physiological condition, major depressive disorder, mild protein calorie malnutrition, hemiplegia, alcohol dependence, avoidant personaility disorder, acute kidney failure, and history of a traumatic brain injury. Resident 30's medical record was reviewed from 11/27/23 through 12/6/23. On 7/10/23, resident 30 weighed 148.6 lbs. On 9/22/23, resident 30 weighed 138.8 lbs. This was a 6.6 percent weight loss in 2.5 months. Resident 30 had not been weighed since 7/10/23, nor had any refusals to be weighed been documented. On 9/24/23, a physicians order was written for resident 30 to receive a Boost supplement twice daily. On 9/28/23 facility staff completed a SNR for resident 30. The SNR indicated that facility staff would serve an egg salad sandwich with resident 30's meals. Review of resident 30's orders revealed that this was not implemented until 10/16/23. On 10/19/23 facility staff completed a SNR for resident 30. The most recent weight used for the SNR was from 10/10/23. The facility did not have a current weight in order to help assess resident 30's nutritional status. On 10/26/23 facility staff completed a SNR for resident 30. The most recent weight used for the SNR was from 10/10/23. The facility did not have a current weight in order to help assess resident 30's nutritional status. On 11/2/23 facility staff completed a SNR for resident 30. The most recent weight used for the SNR was from 10/10/23. The facility did not have a current weight in order to help assess resident 30's nutritional status. On 11/6/23 resident 30 weighed 141.2 lbs. On 11/16/23 resident 30 weighed 137.4 lbs.

On 12/06/23 at 4:42 PM, an interview was conducted with Administrator (ADM) 2. ADM 2 stated he is the covering administrator right now. QAA was done every month. ADM 2 stated the Director of Nursing (DON), Medical Director, and other staff attended the QAA meeting. ADM 2 stated nurses and Certified Nurse Assistants (CNA) rotated into the meetings. The ADM stated that the QAA reviewed quality measures, CASPER reports, and documents pulled from CMS based on the Minimum Data Set (MDS). ADM 2 stated he had not seen the QAA process for this building yet and that the facility would be instituting the corporate QAPI program for standardization. ADM 2 stated the standard for QAA was to have it monthly. ADM 2 stated he would look for the logs. ADM 2 stated that he did not know if the facility had found the systematic areas that needed improvement. ADM 2 stated a food committee and a dietitian, who worked with the DON, met to address weight loss immediately. ADM 2 stated, last week, the facility had started weighing everyone in the facility and was working on improving that process. ADM 2 stated he did not know if abuse reporting was done, but it would be done now. ADM 2 stated administration was pulled into a training in October about abuse reporting and follow up. Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance for the same deficiencies identified in the last annual recertification survey. Resident identifiers: 22, 25, 27, 30, 31, 36, 44, 47, 51, 53, 58, 64 and 121. Findings included: 1. An annual recertification survey was completed on 2/28/22. During that survey F559, F609, F656, F661, F677, F684, F692, F755, F757, F812, F867, F880, F908, F880, F883, F908. F910, F912 and F915 were cited. 2. A recertification survey was completed on 12/6/23. During that survey F609, F656, F677, F684, F692, F755, F812 and F867 were were identified as repeat deficiencies. 3. Based on observation, interview, and record review it was determined that, for 4 of 47 sampled residents, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the residents' choice. Specifically, a resident with an identified mass was not evaluated as requested by the resident representative; a resident was hospitalized after a failure to identify a change of condition in a timely manner; a resident's blood sample was not obtained per protocol which resulted in an emergency room visit; and a resident received medication in error and one medication rectally when oral medication was available. The deficient practice identified for residents 22 and 36 were found to have occurred at a harm level. Resident identifiers: 22, 36, 64 and 121. [Cross refer to F684] 4. Based on observation, interview, and record review it was determined, for 6 of 47 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident with previous falls from falling and sustaining a head laceration and neurological (neuro) checks were not completed as indicated. This deficiency was identified to have occurred at a harm level for resident 27. In addition, a resident who had fallen was moved before an assessment was completed by qualified personnel; the facility had hot water. In addition, facility environment disrepair identified resident accident hazards. Resident identifiers: 25, 27, 44, 47, 51 and 58. [Cross refer to F 689] 5. Based on interview, observation and record review, the facility did not ensure that 5 of 47 sample residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, current weights were not being obtained to allow staff to appropriately assess the residents' nutritional status. In addition, interventions were not being implemented in a timely manner, residents were not being provided with the appropriate supplements, and were not assisted with meals . The findings for resident 53 were determined to have occurred at a harm level. Resident identifiers: 30, 31, 51, 53 and 121. [Cross refer to F692]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility did not ensure a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 32 sampled residents, a resident was not provided with the necessary services related to incontinence care, which resulted in the resident acquiring Moisture Associated Skin Damage (MASD). Resident identifier: 167. Findings included: Resident 167 was admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, Coronavirus Disease-2019 (COVID-19), unspecified dementia, dehydration, retention of urine, muscle weakness, chronic kidney disease (stage 3), hyperlipidemia, hypertension, difficulty walking, and protein-calorie malnutrition. On 2/22/22 at 12:43 PM, resident 167's family member was interviewed. Resident 167's family member stated they would come to visit resident 167 everyday for about three hours near lunch time. Resident 167's family member stated they were concerned about the amount of care resident 167 had received, and stated resident 167 had been in the same clothes as yesterday. The family member was nervous staff were not providing resident 167 with assistance at meals or with drinking fluids regularly, and resident 167's family member stated this was why they would come visit at lunch time. Resident 167's family member stated they had not seen staff enter resident 167's room every two hours to reposition him or provide incontinence care. Resident 167's family member stated if resident 167 needed to be provided cares they would have to ask staff to come assist resident 167. When asked about resident 167's care, the family member responded, it depends on who is here if they will take care of him. On 2/22/22 at 2:29 PM, resident 167 was observed to work with a Physical Therapist (PT) and Occupational Therapist (OT) who assisted resident 167 to the bathroom. At 2:37 PM, the PT and OT staff assisted resident 167 into his bed. Resident 167 was not on an air mattress at this time, and resident 167 was positioned flat on his back with the head of his bed slightly elevated. Resident 167's family member was observed to exit the facility. At this time a continuous observation began regarding resident 167's assistance from staff. On 2/22/22 at 4:04 PM, Certified Nursing Assistant (CNA) 1 entered resident 167's room. Resident 167 stated they would like to go to the bathroom, and CNA 1 stated to resident 167 that he had already been up for the day, and resident 167 was in a brief, so he could just go in that. CNA 1 did not reposition resident 167 or look to see if resident 167 may have needed a brief change at that time. On 2/22/22 at 5:01 PM, the continuous observation of resident 167's care was completed. [Note: Resident 167 was not provided with incontinence care, offered fluids, or repositioned for at least 2 hours and 24 minutes. The most recent care provided to resident 167 was from the PT and OT during this observational period.] On 2/28/22, a review of resident 167's medical record was completed. Resident 167 had a Care Plan with a Focus, initiated on 2/4/22, which read, The resident has potential for impairment to skin integrity r/t (related to). [Note: This Care Plan Focus did not include a related to statement.] There were no interventions put into place regarding this Care Plan Focus. Resident 167 had a Care Plan with a Focus, initiated on 2/22/22, which read, The resident has a Urinary Tract Infection results for c & s (culture and sensitivity) pending. Some interventions related to this Care Plan Focus read, Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas .Encourage adequate fluid intake .Give antibiotic therapy as ordered . Resident/family/caregiver teaching should include: Good hygiene practices: Females to wipe and cleanse from front to back, Clean peri area well after BM (bowel movement) in order to help prevent bacteria in urinary tract, cranberry juice or prune juice to help keep urine acidic, Void at first urge. Do not hold urine for extended amount of time, Wear clean underwear daily, Take the full course of antibiotic therapy even if much improved after a few days of therapy. A Nursing Admission/readmission Evaluation dated 2/4/22, documented the reason resident 167 required skilled care was due to their need for help with activities of daily living. Resident 167 required extensive assistance by one staff to turn and reposition in bed. Resident 167 required limited assistance of one staff for eating. Resident 167 required extensive assistance of two staff for toilet use and total dependence on two staff for transferring. Resident 167's skin assessment documented cancer on top of scalp, missing left third and fourth finger, and neck skin cancer. [Note: Resident 167 was noted to not have any issues with MASD on admission.] A Braden Scale for Predicting Pressure Sore Risk assessment was completed on 2/4/22. Resident 167 was assessed at a score of 14, which indicated resident 167 was at MODERATE RISK for development of a pressure sore. A Skilled Nursing Note dated 2/5/22, documented that resident 167 was incontinent of bowel and brief dependent. Resident 167 had a urinary Foley catheter. Resident 167 was weak and requested two to three staff to transfer and maximum assistance for showers. Resident 167 was dependent with bed mobility, transfers, eating, toileting, walking, and locomotion. [Note: Resident 167 was identified as incontinent of bowel and brief dependent. Resident 167 would need staff assistance regarding brief changes due to his ADL assistance of dependent with bed mobility and toileting.] A Braden Scale for Predicting Pressure Sore Risk assessment was completed on 2/11/22. Resident 167 was assessed at a score of 12, which indicated resident 167 was at HIGH RISK for development of a pressure sore. [Note: Resident 167's score on the Braden Scale indicated resident 167 was at higher risk of pressure sore development on 2/11/22, than when resident 167 was admitted .] A Skilled Nursing Note dated 2/12/22, documented that due to general fatigue, resident 167 was unable to vocalize his needs when spoken to during his medication administration. Resident 167 was very fatigued and spent his time sleeping. Resident 167 was incontinent. Resident 167 did not demonstrate motor skills this shift. At baseline resident 167 was able to independently move extremities. Resident 167 required extensive assistance with bed mobility, transfers, and toileting. Resident 167 required supervision with eating. [Note: At the time of this assessment, resident 167 was noted to be very fatigued, incontinent of bowel, and unable to vocalize his needs when spoken to. Resident 167 remained extensive assistance with most ADLs particularly bed mobility, toileting, and transfers.] A Skilled Nursing Note dated 2/16/22, documented Resident 167 was alert and oriented to self and unable to make needs known. Resident 167 was checked by nurse and CNA every hour to make sure resident 167 was comfortable. Resident 167 was incontinent of bowel movement and every 2 hour (q2h) brief changes performed by CNAs with proper peri care. Resident 167 had an indwelling catheter in place. Resident 167's skin assessment documented a rash. Resident 167 was dependent with bed mobility, eating, and toileting. [Note: Resident 167, at the time of this assessment, was assessed to now be dependent on staff for bed mobility, eating, and toileting. Per this Skilled Nursing Note, staff were aware of resident 167's need for, every hour checks, and, q2h brief changes due to incontinence. Resident 167 was also not noted to have skin issues of MASD.] A Skilled Nursing Note dated 2/18/22, documented Resident 167 was alert and oriented to self and able to make needs known. Resident 167 was incontinent of bowel and had an indwelling Foley catheter in place. Resident 167 was dependent with bed mobility, eating, and toileting. A Skin and Wound Total Body Assessment was completed on 2/18/22, and indicated resident 167 had no new wounds at the time of the assessment. A Braden Scale for Predicting Pressure Sore Risk assessment was completed on 2/19/22. Resident 167 was assessed at a score of 10, which indicated resident 167 was at HIGH RISK for development of a pressure sore. [Note: Resident 167's score on the Braden Scale indicated resident 167 was at higher risk of pressure sore development on 2/19/22, when compared to the previous assessments completed on 2/4/22 and 2/11/22.] A Nursing Note dated 2/22/22 at 6:34 PM, read Note Text: [name of Resident 167 removed] had BM WNL (within normal limits), while changing res (resident), noticed skin break break (sic) down around coccyx area. Cleaned and dry area cont.(continue) to monitor. An Alert Note dated 2/23/22 at 4:47 PM, read Note Text: family notified of excoriation to coccyx, advised that pt (patient) will have an air mattress, will be turned more and assisted, and calmoseptine ordered for coccyx cares. care plan placed . Within resident 167's Treatment Administration Record (TAR) was an order placed on 2/23/22 at 6:00 PM, which read air mattress; every shift for check air mattress function q (every) shift. [Note: Resident 167 was noted to have acquired the excoriation to the coccyx prior to this Physician Order.] Within resident 167's TAR was an order placed on 2/23/22 at 6:00 PM, which read turn q 2 hrs (hours) and prn (as needed); every 2 hours for turn patient q 2 hrs regardless of with visitors. [Note: Resident 167 was noted to have acquired the excoriation to the coccyx prior to this Physician Order.] A Skin and Wound Evaluation, completed by the facility's Wound Nurse, was documented on 2/24/22. The assessment read, Type: Moisture Associated Skin Damage . Location: Right buttocks; Acquired: Present on Admission; How long has the wound been present: unknown . [Note: On admission resident 167 was not noted to have MASD present; the MASD present on the skin evaluation from 2/24/22, was acquired while the resident was within the facility, and MASD was first noted in resident 167's chart on 2/22/22 at 6:34 PM.] A Skilled Nursing Note from 2/25/22, documented Resident 167 was responsive and able to make needs known. Res is bed changed incont. (incontinent); Resident 167 could sit up at the edge of the bed slowly. Resident 167 required limited assistance with bed mobility and eating, extensive assistance with transfers, and was dependent with toileting, and walking. [Note: The nursing assessment near after discovery of excoriation on resident 167's coccyx indicated resident 167 was incontinent, and resident 167 required limited assistance from staff for bed mobility and was dependent on staff with toileting.] An Interdisciplinary Team (IDT) Note from 2/25/22, read, Note Text: Skin excoriation to coccyx was discussed in IDT meeting. Air mattress applied, Skin Tx (treatment) in place with wound nurse following and routine repositioning assistance and toileting needs addressed routinely and as needed. Within resident 167's TAR was an order, started on 2/28/22, which read, For wounds to the bilateral buttocks: Cleanse well with Ns (normal saline) or wound spray. Gently pat dry. Apply skin prep to the peri wound and allow to dry. Warm hydrocolloid between hands for approx. (approximately) 30 seconds. Apply wound wounds. If hydrocolloids are well adhered and not saturated, leave in place for 7 days. May also change PRN. WHEN REMOVING HYDROCOLLOID, PLEASE BE EXTREMELY SLOW AND GENTLE TO AVOID MORE TEARING OF THE SKIN. USE NS TO HELP LOOSEN IT BEFORE REMOVING. every day shift every Monday. On 2/23/22 at 2:52 PM, Licensed Practical Nurse (LPN) 3 was interviewed. LPN 3 stated resident 167 had been declining. LPN 3 stated staff had noticed resident 167's urine was a dark wine color and a Urine Analysis had been ordered to identify if resident 167 had suffered a urinary tract infection. LPN 3 stated resident 167 was started on Bactrim for 7 days while the physician was awaiting final test results. LPN 3 stated resident 167 had been changed to soft/puree foods with thickened liquids on 2/22/22. LPN 3 stated they were unaware if resident 167 had an open area on their skin. LPN 3 stated if resident 167 did have an open area LPN 3 would have read or heard about the open area during report at the beginning of their shift. [Note: The Nursing Note from 2/22/22 at 6:34 PM, indicated resident 167 had skin break down present around his coccyx area.] On 2/23/21 at 2:54 PM, the COVID-19 Unit Manager (UM) was interviewed. The COVID-19 UM stated resident 167 had been cleared from a COVID-19 standpoint, but the facility was working with the family to determine discharge placement. The COVID-19 UM stated resident 167 had needed total assistance with most of his ADLs recently. The COVID-19 UM stated just within the past three to four days resident 167 had been more attentive. The COVID-19 UM stated resident 167 still needed at least extensive assistance with transferring, standing, personal hygiene and pericare. The COVID-19 UM stated they had tried to train nurses to complete an e-Interact assessment whenever a resident had a change in condition like new antibiotics, cognitive change, a fall, new infection, a medication change, or a new open skin area. The COVID-19 UM stated this form helped to remind the nurses to notify family of changes in condition. [Note: No e-Interact Assessment was completed for resident 167's skin breakdown noted on 2/22/22 at 6:34 PM.] On 2/23/22 at 3:17 PM, the COVID-19 UM was interviewed. The COVID-19 UM stated the facility physician completed telehealth visits with the residents on the COVID-19 unit every Tuesday and Thursday. The COVID-19 UM stated the physician did not come over to the COVID-19 unit, but the nursing staff would round on the residents with the physician joining via telehealth. The COVID-19 UM stated it was not ideal, but the unit made it work. The COVID-19 UM stated it was hard to find reliable staff for the COVID-19 unit. The COVID-19 UM stated there was a high turnover with staff, so the unit had trouble developing continuity of staff. The UM stated some agency staff that could be consistent were wonderful, but once the agency staff started to understand what the UM expected the agency staff were leaving to begin a different posting. The COVID-19 UM stated the turnover and lack of ability to have consistent staff made the difference between excellent care versus less than stellar. On 2/23/22 at 3:44 PM, LPN 3 and the COVID-19 UM were interviewed further. LPN 3 stated incident reports were developed when a resident had a fall, when there was a resident to resident or resident to staff altercation, or if there was a skin change. The COVID-19 UM stated the Wound Nurse did become notified of skin issues and the Wound Nurse would evaluate and track the progress and treatment. The COVID-19 UM stated they would communicate with the Wound Nurse via Tiger Text or an email, and the COVID-19 UM stated the communication between the COVID-19 unit and the wound nurse could be better. On 2/23/22 at 3:48 PM, the COVID-19 UM was interviewed. The COVID-19 UM stated resident 167 should be turned and repositioned and checked for incontinence care every two hours. The COVID-19 UM stated staff should know to provide this service, and the UM stated they wondered if staff were nervous to go into a room when family was there. The COVID-19 UM stated staff would need to be re-educated that when family were visiting staff should, be the super aide, and enter the resident rooms to provide cares or ensure the resident did not need anything. On 2/24/22 at 3:25 PM, CNA 2, who was an agency CNA, was interviewed. CNA 2 stated when they had a resident who needed extensive assistance with cares and was incontinent CNA 2 would round on the resident every two hours to reposition and provide or check for the resident's need of incontinence care. On 2/24/22 at 3:27 PM, CNA 3, who was an agency CNA, was interviewed. CNA 3 stated resident 167 had definitely declined since he got here. CNA 3 stated resident 167 was a one person assistance with activities like transfers when he admitted , but now he required two staff members. CNA 3 stated they did not typically work with resident 167 because they took the other side of the unit, but CNA 3 stated resident 167 was a Q2 check even prior to the order. [Note: On 2/23/22, resident 167 had an order placed within his medical record for, turn q 2 hrs and prn; every 2 hours for turn patient q 2 hrs regardless of with visitors.] CNA 3 stated the CNA should check on resident 167 every 2 hours, provide repositioning, and determine if resident 167 needed a brief change. CNA 3 stated, it could have been hard to get to him because of staffing, but I can't say. I wasn't his CNA. On 2/24/22 at 3:39 PM, Registered Nurse (RN) 1 was interviewed regarding resident 167's status and the use of Braden Scales. RN 1 stated they were an agency RN and had not worked with resident 167 often. RN 1 stated the Braden Scale assessment took into account what a resident's risk was for developing a wound. RN 1 stated the assessment took into account a residents incontinence, nutrition and physical ability. RN 1 stated the assessment could help staff to assess how often a person may need to be turned or changed to prevent wounds. RN 1 stated the change in resident 167's Braden Scale scoring indicated resident 167 was at a higher risk for a pressure ulcer. RN 1 stated the change in resident 167's Braden Score Assessment would indicate staff need to monitor resident 167 more to get him moving, provide incontinence care, or provide encouragement with eating. On 2/28/22 at 9:09 AM, the Wound Nurse was interviewed. The Wound Nurse stated they were informed of resident 167's wound and had completed an assessment with a treatment for resident 167's wounds. The Wound Nurse stated resident 167's, wounds looked like MASD. The Wound Nurse stated the wounds were incontinence related and resident 167 definitely needed incontinence care more often to heal his wounds. On 2/28/22 at 9:51 AM, CNA 4, who was an agency CNA, was interviewed about resident 167's care. CNA 4 stated resident 167 was, pretty dependent, with cares. CNA 4 stated they provided resident 167 with catheter care on 2/26/22, and CNA 4 stated they noticed resident 167's catheter care had not been getting done completely. CNA 4 stated they had pulled back resident 167's foreskin to clean beneath, and it, looked like it hadn't been done in a long time. CNA 4 stated resident 167 had never refused care from them, and CNA 4 stated resident 167 did rely on brief changes versus going to the toilet. CNA 4 stated they would provide resident 167 with a brief change, Usually once a day. More in the evening. At least every other day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 1 out of 32 sampled residents, a resident that was dependant on renal dialysis missed a day of dialysis and had two critical potassium lab values with no interventions which resulted in death. Resident identifier: 111. Findings included: Resident 111 was admitted to the facility on [DATE] with diagnoses which included Coronavirus Disease-2019, severe protein-calorie malnutrition, diabetes mellitus type 2, end stage renal disease, hypertensive heart, chronic kidney disease with heart failure and with stage 5 chronic kidney disease, anemia in chronic kidney disease, mild cognitive impairment, metabolic encephalopathy, essential hypertension, congestive heart failure, hypoxemia, pain, and dependence on renal dialysis. Resident 111's medical record was reviewed on 2/23/22. A review of the Nurse to Nurse Forms dated 1/11/22, documented that resident 111 had dialysis that morning, 1/11/22. [Note: Resident 111 went to dialysis the day prior to admission.] A care plan Focus initiated on 1/12/22 and revised on 1/18/22, documented [Name of resident 111 removed] needs dialysis hemodialysis r/t (related to) renal failure. The goals initiated on 1/12/22 and revised on 1/18/22, included [Name of resident 111 removed] will have immediate intervention should any s/sx (signs or symptoms) of complications from dialysis occur through the review date and [Name of resident 111 removed] will have no s/sx of complications from dialysis through the review date. The interventions initiated on 1/12/22 and revised on 1/18/22, included Check and change dressing daily at access site. Do not draw blood or take B/P (blood pressure) in arm with graft. Monitor intake and output. Monitor VITAL SIGNS . Notify MD (Medical Doctor) of significant abnormalities. Monitor/document/report PRN (as needed) any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Resident is on Dialysis. Work with resident to relieve discomfort for side effects of the disease and treatment. (Cramping, fatigue, headaches, itching, anemia, bone demineralization, body image change and role disruption.) The Blood Pressure Summary and the Pulse Summary were reviewed and the following were documented: [Note: The blood pressure (BP) measurements were taken in millimeters of mercury and heart rate (HR) measurements were taken in beats per minute. A normal blood pressure for most adults was defined as a systolic pressure of less than 120 and a diastolic pressure of less than 80. A normal resting heart rate for adults ranges from 60 to 100 beats per minute.] a. On 1/12/22 at 12:56 PM, BP 136/78 and HR 76 regular b. On 1/12/22 at 1:59 PM, BP 137/73 and HR 70 regular c. On 1/13/22 at 3:59 AM, BP 120/59. At 4:00 AM, HR 97 regular d. On 1/13/22 at 3:30 PM, BP 161/79. At 3:31 PM, HR 95 regular e. On 1/14/22 at 4:23 AM, BP 180/93. At 4:24 AM, HR 93 unable to determine f. On 1/14/22 at 8:33 AM, 178/94 and HR 93 regular g. On 1/14/22 at 3:56 PM, 180/85. At 3:57 PM, HR 93 regular h. On 1/15/22 at 4:14 AM, 150/87 and HR 99 regular On 1/12/22 at 1:08 AM, a Skilled Nursing Note documented . Color appears slightly jaundiced . On 1/12/22 at 1:28 PM, an Alert Note documented labs (Laboratory) order placed for admit labsd (sic) for tomorrow cbc (complete blood count) cmp (comprehensive metabolic panel) hga1c (hemoglobin A1c) and renal panel and lft's (liver function test) pt (patient) has esrd (end stage renal disease) and will need dialysis will check w (with) social worker for times/ (and) days On 1/13/22 at 5:08 AM, a Skilled Nursing Note documented . colour (sic) jaundiced slightly does have esrd waiting on lab results; . A review of the January 2022 Medication Administration Record (MAR) documented on 1/13/22, COMPLETE and PRINT the Pre-Dialysis Assessment and Communication Form and ensure it is sent to dialysis with the resident. every day shift every Tue [Tuesday], Thu [Thursday], Sat [Saturday] for pre dialysis assessment. On 1/13/22, the MAR was coded Other/See Progress Notes. (Note: There were no progress notes corresponding with the code on the MAR.) A CMP collected on 1/13/22 at 12:20 PM, documented a potassium level of 5.8 millimoles per liter (mmol/L). The reference range for potassium was noted to be between 3.5 and 5.0 mmol/L. The lab value was documented as high. The lab results were printed on 1/13/22 at 3:10 PM. [Note: MD notification and response was unable to be located in the medical record. According to the Mayo Clinic, a normal range of potassium is between 3.6 and 5.2 mmol/L of blood. A potassium level higher than 5.5 mmol/L is critically high, and a potassium level over 6 mmol/L can be life-threatening. Small variations in ranges may be possible depending on the laboratory.] A Telemedicine visit by the MD dated 1/13/22, documented that resident 111 had a diagnosis of end stage renal failure and continue with dialysis Monday, Wednesday, and Friday. There was no documentation regarding the CMP lab draw. [Note: It was documented in the medical record that resident 111 be sent to dialysis on Tuesday, Thursday, and Saturday.] On 1/14/22 at 6:04 AM, an Order - Administration Note documented Zofran Tablet 4 MG [milligrams] Give 4 mg by mouth every 6 hours as needed for nausea / vomiting Pt c/o (complains of) nausea. A review of the January 2022 MAR documented that Zofran was administered to resident 111 and it was effective. [Note: According to https://medlineplus.gov/ency/article/001179.htm a symptom of hyperkalemia would include nausea and vomiting.] A CMP collected on 1/14/22 at 3:30 PM, documented a potassium level of 6.9 mmol/L. The reference range for potassium was between 3.5 and 5.0 mmol/L. The lab value was documented as high. It was noted on the form critical value notification and read back at: 1957 (7:57 PM) to [name of medical assistant removed] with [name of doctor removed] on 1/14/2022. A hand written note on the form documented Notified MD [name of MD removed] 1/14/22 check The Note. The lab results were printed on 1/15/22 at 11:28 AM. [Note: The critical value notification and read back was made by the lab. The hand written note on the form was made by a facility staff member and the MD notification and response was unable to be located in the medical record. According to https://www.mayoclinic.org/symptoms/hyperkalemia/in-depth/sym-20050776 Having a blood potassium level higher than 6.0 mmol/L can be dangerous and usually requires immediate treatment.] A Re-occurring Dialysis Form from a local transportation company documented that resident 111 had a pick up appointment and pick up time at 5:00 AM. Resident 111 had an appointment time at the local dialysis center at 5:45 AM on Tuesdays, Thursdays, and Saturdays. The schedule start date was to begin on 1/15/22. On 1/15/22 at 5:32 AM, an Alert Note documented Note Text: pt was transferred to [name of local hospital removed] by ambulance this morning at 0515 (5:15 AM). ambulance came to take pt to dialysis this morning. while entering pts room team noticed pt had removed oxygen cannula from nose. the team put oxygen back on pt and called pt and asked pt his name, the pt stated his name was [unidentified name removed]. we then prepared the pt to be transferred from his bed to the gurney. while transferring the pt he then went unconscious. the team elected to send him to the ER (Emergency Room) in [name of local hospital removed]. we called the administrator on call and informed him of what was being done. contacted doctor and we are trying to find pt family information On 1/15/22 at 12:14 PM, a Nursing Note documented Res (resident) family stopped by to pick up charger and phone. Asked res family for update. Res's family stated that res passed away. The local hospital Emergency Department note dated 1/15/22, documented [AGE] year-old male presents to the emergency department as a critical patient with ongoing CPR (cardiopulmonary resuscitation). Was supposed to have dialysis today and had not had any dialysis since Monday [1/10/22]. Initially presumed likely hyperkalemic as source of his cardiac arrest and patient was therefore given 2 g (grams) of calcium gluconate and 1 amp of bicarbonate. ABG (arterial blood gas) was obtained demonstrating a metabolic acidosis with pH (potential hydrogen) of 6.970. His potassium was elevated to 8.7 and his lactate was 6.0, no other abnormalities. After receiving calcium gluconate and ABG rhythm was noted to change to ventricular tachycardia and had pulses. We were unable to restore pulses but we did obtain repeat VBG (venous blood gas) has (sic) we were unable to obtain an ABG. This demonstrated a pH of 6.935, potassium of 4.9, and lactate of 4.2. Despite the improving potassium and lactate patient remained pulseless. At 0623 (6:23 AM) resuscitative efforts were halted and patient was declared deceased . The diagnoses included hyperkalemia, metabolic acidosis, cardiac arrest, and deceased . On 2/24/22 at 1:26 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated the residents who needed dialysis had their dialysis chair time and transportation scheduled by the Social Worker. LPN 4 stated the Social Worker was no longer employed at the facility but the administrator was responsible for that now. LPN 4 stated there was a calendar put out when the resident went to dialysis and when they came home. LPN 4 stated the schedule depended on the chair time what medications were sent with the resident. LPN 4 stated the nurse completed the pre-dialysis assessment form. LPN 4 stated when the resident came back from dialysis the nurse completed the post dialysis assessment, vital signs, check their access fistulla, pain, and check the dressing for drainage. LPN 4 stated the residents were sent to dialysis with a face sheet, list of medications, and a dialysis sheet. LPN 4 stated then the dialysis center would fill out their part and send the dialysis sheet back with the resident. LPN 4 stated the resident would be sent with food or snacks if they did not eat a meal before dialysis. LPN 4 stated when the resident returned from dialysis they would get a snack. On 2/24/22 at 2:10 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated it had been less than a year ago since the facility stopped doing dialysis at the facility. The ADON stated the social worker set up the dialysis appointments. The ADON stated the social worker would find a chair before the resident was admitted to the facility, so it was taken care of. The ADON stated the social worker set up the chair time and then she set up the transportation. The ADON stated it was possible that a resident missed their chair time because of transportation not being scheduled. On 2/28/22 at 11:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated this morning (2/28/22) he had called the previous Long Term Care Facility (LTCF) where resident 111 resided. The DON stated that resident 111 had been dialyzed on the Tuesday prior to admission [DATE]). The DON stated that he had called the prior social worker that had worked at the facility and the social worker had stated that the dialysis center was unable to fit resident 111 in for dialysis on Thursday (1/13/22) and that was why resident 111 had missed dialysis. The DON stated the next scheduled dialysis for resident 111 was on Saturday (1/15/22). The DON stated the social worker was in charge of transportation and scheduling. On 2/28/22 at 12:24 PM, an interview was conducted with a staff member at the local dialysis center. The staff member stated that resident 111 did come to dialysis on 1/11/22. The staff member stated that resident 111 was expected for dialysis on 1/13/22, but the staff member did not know why resident 111 did not show up. The staff member stated that resident 111 was scheduled to come to dialysis on 1/15/22, but resident 111 did not make it. On 2/28/22 at 1:12 PM, an interview was conducted with LPN 3. LPN 3 stated resident labs were drawn by staff from the local lab. LPN 3 stated if the labs were ordered urgent the facility staff would draw the lab and the local lab picked up the sample. LPN 3 stated she would send the doctor a secured text message or call him if the lab was critical value. LPN 3 stated the doctor response was documented in a progress note and any new orders were entered into the electronic medical record. On 2/28/22 at 1:15 PM, a follow up interview was conducted with the DON. The DON stated the local lab called the MD directly and the local lab did not call the facility. The DON stated if the lab called the facility, the staff would notify the MD. The DON stated he was told not to add notes to the medical record after the resident went out and did not return. On 2/28/22 at 2:06 PM, an additional interview was conducted with the DON. The DON stated that he was unsure of when the critical lab was faxed to the facility without making several phone calls. The DON verified that the facility staff noted on the critical lab form that the MD was contacted but the DON was unable to verify who the staff member was. The DON stated that he wished the staff member had initialed the lab note. On 3/1/22 at 8:30 AM, an interview was conducted with the MD. The MD stated that he did not recall being notified about the critical lab on 1/14/22. The MD stated he had looked in his office system yesterday (2/28/22) to see if there was a note that would indicate that he had been contacted and what was said but there was nothing. The MD stated the labs were drawn through a local lab and he was unsure how those were communicated with the facility. The MD stated he had instructed the DON yesterday (2/28/22) to look at the nurses notes and vital signs to see how resident 111 was responding to the critical lab value. The MD stated he was aware of the critical lab the day prior when resident 111's potassium was at 5.8. The MD stated there would have been an intervention for the high potassium. The MD stated he would have questioned if the sample was a good sample or was resident 111 hemolyzed. The MD stated that the potassium lab was a sensitive lab. The MD stated an electrocardiogram would have been ordered for resident 111 and something would have been done dependant on resident 111's other clinical findings. Additional information was provided by the Administrator on 3/2/22 at 10:34 AM. The additional information included the following statement: The statement from the DON documented . Wednesday, 1/12/22 The resident admitted to the facility from [name of local LTCF removed] at about 1240 PM. He was assessed by nursing staff who noted his ESRD and need for dialysis and recognized the lack of a dialysis time and transportation arrangements. The appointment made with dialysis was for 9am (9:00 AM) Thursday morning, and facility staff where (sic) aware of the dialysis chair time. [Note: The transportation agreement with the local transportation company documented a schedule start date to begin on 1/15/22, Saturday. There was no documentation located in the medical record regarding the appointment made Thursday morning at the dialysis center.]