**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents were free of any significant medication errors for 1 of 1 resident (R57) reviewed for significant medication errors. R57 did not receive scheduled insulin at 8:00AM on 7/24/24 and did not have blood glucose monitoring in place. R57 was hospitalized on the evening of 7/24/24 with acute hyperglycemia (a medical emergency that occurs when blood sugar levels are extremely high) requiring treatment with insulin drip (administration of insulin through intravenous line.) Evidenced by: Facility policy entitled Medication Administration, dated 05/2024, states in part: Policy: Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice . 20. Sign MAR (Medication Administration Record) after administered . R57 admitted to the facility on [DATE] with diagnoses that include, in part: Type 2 Diabetes Mellitus without complications (a condition that occurs when the body doesn't produce enough insulin or can't use insulin properly, resulting in high blood sugar levels.) Of note, R57 was admitted from the hospital after being treated for hyperglycemia. R57's MDS (Minimum Data Set) dated 8/7/24 indicates that R57 has a BIMS (Brief Interview of Mental Status) of 15, indicating R57 is cognitively intact. R57's physician orders dated 7/23/24, state in part: insulin glargine (Lantus) 20 units subcutaneous once a day (in the morning). It is important to note there were no physician orders for monitoring blood glucose levels. R57's MAR (Medication Administration Record) for July 2024 shows: 7/24/24 8:00 AM--Medication not administered. Important to note: R57's TAR (Treatment Administration Record) for July 2024 shows no record of blood glucose monitoring on 7/23/24 or 7/24/24. R57's SBAR (Situation, Background, Assessment, and Recommendation) Communication Form and Progress Note dated 7/24/24 8:00PM states, in part: .resident yelled out for help, writer went to resident's room. Resident stated he did not feel well. Resident diaphoretic (sweating), shaking, cold to touch, BP (blood pressure) low. Glucometer (device to test blood sugar level) reads HI (reading beyond the level which the machine can report). R57's Nephrology Consult Note dated 7/25/24, states, in part: .sent back to the ED (emergency department), where his BS (blood sugar) was noted to be in the 900's. Was started on an insulin drip. R57's hospital Discharge summary dated [DATE], states, in part: Discharge Diagnosis: acute hyperglycemia . On 09/10/24 at 8:03 AM, Surveyor interviewed R57, who indicated being hospitalized after admission to facility due to blood sugar issues. On 09/12/24 at 8:26 AM, Surveyor interviewed LPN O (Licensed Practical Nurse) and asked what interventions would be expected for a new admission with a diagnosis of diabetes. LPN O stated accu checks (blood glucose checks / monitoring), insulin or oral meds as needed, parameters, glucagon gel or injection, diet. Surveyor asked what the process would be if there were no blood glucose checks ordered for a new admission. LPN O stated call the physician and double check to ensure it wasn't missed. Surveyor asked if medications are signed for on the MAR when they are administered. LPN O said yes. On 9/12/24 at 9:19 AM, Surveyor reviewed the July 2024 MAR with LPN O and asked if the Lantus ordered for R57 at 8:00AM on 7/24/24 was given. LPN O stated no, it isn't signed out. On 9/12/24 at 8:37 AM, Surveyor interviewed LPN E and asked if blood glucose checks / monitoring would be expected for a new admission with diagnosis of diabetes. LPN E stated yes. Surveyor asked what the process would be if there were no blood glucose checks ordered. LPN E stated check with the doctor. Surveyor asked if medications are signed for on the MAR when they are administered. LPN E stated yes. On 09/12/24 at 9:33 AM, Surveyor interviewed DON B (Director of Nursing) and asked if staff is expected to follow physician orders. DON B stated yes. Surveyor asked if nurses should be signing out meds at the time they are given. DON B stated yes. Surveyor asked if a medication is not signed out on the MAR has it been administered. DON B stated no. Surveyor reviewed July 2024 MAR with DON B and asked if the Lantus had been administered on 7/24/24. DON B said no, that was not given. Surveyor asked if DON B would expect Lantus to be administered if ordered? DON B stated yes. Surveyor asked DON B if blood glucose checks would be expected to be ordered and checked for a resident on Lantus? DON B stated yes, if there is no order, ask the doctor for orders. Surveyor asked DON B is it possible that if R57 had received his Lantus at 8am that the hospitalization would have been avoided. DON B stated yes. On 9/12/24 at 3:18 PM, Surveyor interviewed NP N (Nurse Practitioner) and asked would you expect the facility to administer medications as orders? NP N stated yes. Reviewed MAR indicating that R57 had not received his insulin on 7/24/24 and asked if NP N would expect the facility to have administered this insulin? NP N stated yes. Surveyor asked NP N is it possible that if the facility had administered his AM insulin, his blood sugar would not have been registering high. NP N stated it is not a yes or no, potentially. Surveyor asked NP N if administration of the Lantus may have prevented the need for the insulin drip. NP N stated yes, it is possible. Surveyor asked NP N if the facility had been monitoring blood glucose checks on a regular basis if the need for hospitalization may have been prevented. NP N stated yes. Surveyor asked if NP N would expect that the facility would inquire about doing blood glucose monitoring if R57 was admitted without orders and was on Lantus. NP N stated yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure they followed their Antibiotic Stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 6 sampled residents (R16 and R34) and 1 supplemental resident (R612) reviewed for antibiotic stewardship. R16 is being cited at severity level 3 (actual harm). R34 and R612 are being cited at severity level 2 (potential for more than minimal harm). The facility did not follow Standards of Practice for Antibiotic Stewardship: R16 has a history of antibiotic resistance and was prescribed antibiotics without meeting criteria. R16 was prescribed antibiotics for five events between March 26, 2024 and July 5, 2024, for asymptomatic bacteremia (presence of bacteria that does not cause symptoms thus not requiring antibiotic treatment). The facility did not thoroughly review R16's urine culture and sensitivities, and therefore, did not recognize R16 had developed resistance to a prescribed antibiotic. R34 was prescribed an antibiotic for Urinary Tract Infection (UTI) twice in the month of July without meeting criteria. R612 was prescribed and received an antibiotic for Acute Kidney Injury (AKI). R612 did not meet criteria for the prescribed antibiotic. Evidenced by: The facility policy titled Antibiotic Stewardship Program with a date of 12/23/22, states in part: It is the policy of this facility to implement and Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use . 4. The program includes antibiotic use protocols and a system to monitor antibiotic use . ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility uses the (CDC's NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections. iv. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. v. All prescriptions for antibiotics shall specify the dose, duration, and indication for use. vi. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized . Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness . According to National Institutes of Health (NIH), Asymptomatic bacteriuria is very common in clinical practice and its incidence increases with age .most patients with asymptomatic bacteriuria will never develop symptomatic urinary tract infections and will have no adverse consequences from asymptomatic bacteriuria . most patients will not benefit from treatment (www.ncbi.nlm.nih.gov). The facility form titled Infection Report Form is used for the facility's infection control program. The Infection Report Form identifies criteria that must be present to meet surveillance criteria for an infection. Example 1 R16 was admitted to the facility on [DATE]. R16's medical diagnoses list does not indicate any diagnoses related to UTI or Multidrug-Resistant Organism (MDRO). R16's admission Minimum Data Set (MDS) assessment dated [DATE] states in part, Section I Active Diagnoses Infections does not have a check mark for I1700. Multidrug-Resistant Organism (MDRO), I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS). This indicates R16 does not have an MDRO and does not currently have a UTI and has not had a UTI in the previous 30 days. Event 1 R16's 3/22/24 Urine Culture and Sensitivity Report states, in part: >100,000 cfu/ml Methicillin-Resistant Staphylococcus aureus (MRSA) isolated. 30,000 cfu/ml Mixed flora (multiple species present). Resistant to Oxacillin, Penicillin G, and Tetracycline (antibiotics). R16's 3/21/24 Infection Report Form (facility form used for antibiotic stewardship) does not have any criteria marked under the UTI section, indicating R16 has no symptoms of UTI. Of note, R16 does not meet criteria. In the follow up section the report states Resident returned from appt (appointment) - order for UA (urinalysis)/microalbum, creatinine. Asymptomatic bacteremia [sic] (presence of bacteria that does not cause symptoms). Of note, the follow up section indicates the urinalysis was obtained as a routine lab from a consulting provider. R16's March 2024 Medication Administration Record (MAR) indicates R16 received 4 doses of Bactrim DS oral tablet 800-160 for asymptomatic bacteremia. Event 2 R16's 4/4/24 Urine Culture and Sensitivity Report states, in part: >100,000 cfu/ml Enterococcus faecalis isolated. Resistant to Gentamicin and Tetracycline. 30,000 cfu/ml Methicillin-Resistant Staphylococcus aureus isolated. Of note, this is the same bacteria as the previous event. Resistant to Oxacillin, Penicillin G, and Tetracycline. R16's 3/26/24 Infection Report Form, in section two of UTI criteria, has marked At least 105 cfu/ml or no more than 2 species of microorganisms in a voided urine sample. Of note, section one of the UTI criteria has no marks, indicating R16 does not meet criteria. R16's 4/5/24 physician order states, Bactrim DS 800-160 give one tablet by mouth two times a day for UTI until 4/11/24. R16's April 2024 MAR indicates R16 received 12 doses of Bactrim DS 800-160 for asymptomatic bacteremia. R16's 4/24/24 Urine Culture and Sensitivity Report states, in part: >100,000 cfu/ml Enterococcus faecalis isolated. Resistant to Gentamicin and Tetracycline. 20,000 cfu/ml Methicillin-Resistant Staphylococcus aureus isolated. Resistant to Oxacillin, Penicillin G, and Tetracycline. Of note, these are both the same bacteria as the previous event. Event 3 R16's 4/24/24 Infection Report Form does not have any criteria marked under the UTI section, indicating R16 has no symptoms of UTI. Of note, R16 does not meet criteria. In the follow up section the report states, switched to this after report next to Nitrofurantoin (antibiotic) 100 mg po (by mouth) BID (twice a day), indicating the Amoxicillin (antibiotic) order was discontinued and changed to Nitrofurantoin. R16's 4/25/24 physician order states Amoxicillin 500 MG give 1 tablet by mouth four times a day for UTI. R16's physician order on 4/29/24 states Nitrofurantoin Macrocrystal oral capsule 100 MG give one capsule by mouth two times a day for UTI for 14 days. R16's April 2024 and May 2024 MAR indicates R16 received 13 doses of Amoxicillin 500 MG and 27 doses of Nitrofurantoin 100 MG. R16 received antibiotics for a total of 18 days. Of note this is the 3rd time R16 was treated and had asymptomatic bacteremia. A 5/2/24 Urology note states in part; Recent MRSA (Methicillin Resistant Staph Aureus and Enterococcus UTI known to be a MRSA carrier-probably the MRSA is could be [sic] primary source in the bladder or could be secondary and seeding from somewhere else staff [sic] is known to do that. Event 4 R16's 6/4/24 Urine Culture and Sensitivity Report states, in part: >100,000 cfu/ml Proteus mirabilis isolated. Resistant to Ampicillin, Gentamicin, Nitrofurantoin, Tetracycline, and Trimethoprim/Sulfa (is also known as Bactrim DS). Of note, R16 is now resistant to Bactrim DS and Nitrofurantoin. R16's 6/5/24 Infection Report Form, in section two of UTI criteria, has marked At least 105 cfu/ml or no more than 2 species of microorganisms in a voided urine sample. Of note, section one of the UTI criteria has no marks, indicating R16 does not meet criteria. In the follow up section the report states Asymptomatic Bacteremia [sic]. R16's 6/5/24 physician order states Keflex Oral Capsule 500 MG (antibiotic) give 500 mg by mouth four times a day for UTI for 5 days. R16's June 2024 MAR indicates R16 received 20 doses of Keflex. Event 5 R16's 7/2/24 Urine Culture and Sensitivity Report states, in part: >100,000 cfu/ml Proteus mirabilis isolated. Of note, this is the same bacteria as the previous event. Resistant to Ampicillin, Gentamicin, Nitrofurantoin, Tetracycline, and Trimethoprim/Sulfa. R16's 7/2/24 Infection Report Form does not have any criteria marked under the UTI section, indicating R16 has no symptoms of UTI. Of note, R16 does not meet criteria. In the follow up section the report states Asymptomatic Bacteremia [sic]. R16's 7/2/24 physician order states Nitrofurantoin 100 MG give 1 capsule by mouth two times a day for UTI for 10 days. Of note, R16's previous culture and sensitivity noted R16 was resistant to Nitrofurantoin. R16's 7/5/24 physician order states Cipro oral tablet 500 MG (broad spectrum antibiotic) give 1 tablet by mouth two times a day for UTI for 10 days. R16's July 2024 MAR indicates R16 received 6 doses of Nitrofurantoin and 20 doses of Cipro. On 9/12/24 at 8:33AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she oversees and participates in the infection prevention program. DON B indicated R16 has had no symptoms for these five events. Surveyor asked DON B if R16's asymptomatic bacteriuria should be treated. DON B indicated if a resident is asymptomatic, not showing signs of UTI, the facility should not treat. DON B indicated she expects antibiotic stewardship to be followed. Surveyor asked DON B if the prescribing physicians have been educated on antibiotic stewardship for R16's asymptomatic bacteriuria. DON B could not present evidence that the facility has educated the physicians regarding treating asymptomatic bacteremia. Example 2 R34 was admitted to the facility on [DATE] with diagnoses that include neuromuscular dysfunction of bladder (bladder muscles are not functioning properly, causing problems with urination) and paraplegia (affects the ability to move or feel the lower half of the body). R34's 7/11/24 Urine Culture and Sensitivity Report states >100,000 cfu/ml Mixed flora (multiple species present). Suggest appropriate recollection if clinically indicated. Of note, mixed flora is indicative of a contaminated urine sample. R34's 7/11/24 Infection Report Form does not have any criteria marked under the UTI section, indicating R34 has no symptoms of UTI. Of note, R34 does not meet criteria. R34's 7/11/24 physician order states Cefpodoxime Proxetil oral tablet 200 MG (antibiotic) give 1 tablet by mouth every 12 hours for 10 days for UTI. R34's July 2024 MAR indicates R34 received 5 doses of Cefpodoxime Proxetil 200 MG. On 9/12/24 at 8:33AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she oversees and participates in the infection prevention program. DON B indicated the facility did not obtain a recollection of urine for R34 per the recommendations of the 7/11/24 Urine Culture and Sensitivity Report. Example 3 R612 was admitted to the facility on [DATE] with diagnoses that include benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate). R612's 6/29/24 Urine Culture and Sensitivity Report states 70,000 cfu/ml Mixed flora (multiple species present). R612's 6/27/24 Infection Report Form does not have any criteria marked under the UTI section, indicating R612 has no symptoms of UTI. In the follow up section, the report indicates the antibiotic ordered was for an acute kidney injury. Of note, R612 does not meet criteria. R612's 6/29/24 physician order states Macrobid Oral Capsule 100 MG (antibiotic) give 1 capsule by mouth two times a day for UTI for 5 days. R612's June 2024 and July 2024 MARs indicate R612 received Macrobid for 4 days (8 doses). On 7/2/24, after R612 received 4 days of Macrobid, physician discontinued the order. Nurses progress notes dated 7/2/24 at 14:19 (2:19PM) states in part Dr. (Doctor's name) responded back to the UA (Urinalysis) stating that it does not appear that R612 has a UTI .you may discontinue this medication. On 9/12/24 at 8:33AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she oversees and participates in the infection prevention program. DON B agreed R612 did not meet criteria for an antibiotic and should not have received the antibiotic. The facility treated R16's asymptomatic bacteriuria five times. R16 now has resistance to Nitrofurantoin. R34 and R612 received treatment for UTIs that did not meet criteria. DON B indicated the facility did not follow antibiotic stewardship.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not immediately consult with a resident's physician when there was a need to alter treatment for 1 of 7 residents (R63) that resulted in actual harmy, and 1 of 7 residents (R61) that had potential for minimal harm. The facility did not consult with R63's Medical Doctor (MD) per Physician Orders and as her condition changed resulting in actual harm when R63 was hospitalized and aggressive diuresis. Evidenced by: Facility policy, entitled Notifications of Change, date implemented 12/2022, states in part .the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . the facility must inform the resident, consult with the residence physician and or notify the resident's family member or legal representative when there is a change requiring such notification: circumstances requiring notification include: significant change in the resident's physical, mental or psychosocial condition . circumstances that require a need to alter treatment . it's for our discharge of the resident from the facility . Example 1: R63 was admitted to the facility on [DATE] with diagnoses including asthma, Chronic Obstructive Pulmonary Disease (COPD), acute and chronic respiratory failure, dependence on supplemental oxygen, Nonrheumatic aortic valve stenosis (narrowing of a valve between the left lower chamber of heart and a major blood vessel/aorta), and Heart Failure with preserved ejection fraction (a type of heart failure that affects the left side of the heart, especially the lower chamber called the left ventricle. It occurs when the left ventricle is stiff and cannot relax and fill with blood properly. This causes high pressure inside the heart and reduces the blood flow to the rest of the body.) R63's Hospital Discharge Summary and discharge instructions, dated [DATE], include, in part: . Heart Failure Care: Weigh yourself daily. Call your physician for any weight gain of more than 2 lbs (pounds) in 24-hour period or 5lbs in one week. Take your weight record to your doctors on your follow up . Notify your physician of any of the following and/or seek attention immediately if develop: . swelling in your legs, feet, or ankles, increased shortness of breath with activity or SOB (shortness of breath) at night while lying flat, weight gain of 2lbs in 24-hour period or 5lbs in one week, nausea, feeling more tired or weaker than usual . Go to the emergency room or call 911 if you have new or increased chest pain or moderate to severe shortness of breath to the point that you cannot speak, weakness, or numbness of extremity, not able to speak or have difficulty finding words, change in vision, or confusion. R63's Physician Orders, for 4/5/23-4/30/23, include in part: daily weight every day shift for CHF (Congestive Heart Failure) . call physician for any weight gain more than 2 lbs in 24 hours . (It is important to note this does not include 5lbs weight gain in one week as the discharge instructions stated.) R63's Medical Record included the following: R63's Nurses Note, dated 4/5/2023, includes: .Resident admitted to facility per stretcher via ambulance. Resident is alert and oriented. States she is here for strengthening . ambulates with assist of one and a walker. Resident walked to the toilet, SOB (Shortness of breath) noted on rest and exertion. Resident is oriented to room and controls . able to make needs known . All cares complete per care plan. No signs or symptoms of distress noted. R63's weight, 4/5/23, 310.0 Lbs. R63's Heart Failure Clinic (HFC) Note, dated 4/13/23, includes in part: If weight gain is 3 or more pounds in one day or 5 pounds in one week, call Heart Failure Clinic .Check swelling in your feet, legs, abdomen - call HFC if you notice increase in swelling . Are you experiencing SOB? Call HFC if you notice worsening shortness of breath with activity or shortness of breath when you are lying down . If you are having trouble breathing while sitting or at rest, go to ER or call 911. If you notice tiredness, weakness, lightheadedness, call HFC. R63's Nurse Note, dated 4/13/23, includes: . returned from medical appt . was seen by Cardiology. R63's weight, 4/13/23, 311.2 Lbs. R63's Nurse Note, dated 4/14/23, includes: .writer called R63's MD (Medical Doctor) regarding critical lab value of Carbon Dioxide level 44 . left message with clinical staff . awaiting return call. (It is important to note the facility did not provide evidence of a return call by R63's MD to consult about critical lab values.) R63's weight, 4/14/23, No weight recorded. (It is important to note the facility did not provide evidence of R63's weight being recorded for this date.) R63's weight, 4/15/23, 309.9 Lbs. R63's weight, 4/16/23, 310.4 Lbs. R63's Nurse Notes, dated 4/16/23, include: .alert with baseline mentation . uses oxygen continuous at 4L/minute via nasal canula to maintain oxygen saturation level greater than 90% . becomes SOB and easily fatigued with physical activity. Breath sounds diminished throughout bilateral lungs. No cough or congestion . lacks motivation to assist with cares . spends day in room lying in bed or sitting on chair watching tv. No increased edema noted to bilateral lower extremities . has a fluid filled blister to top of left foot . R63's Nurse Note, dated 4/17/23 includes: Resident with 4+ edema in her feet and lower legs. States I wish I could get rid of this fluid, but does not want to elevate her feet while in bed and is not compliant with her fluid restriction. Reported that when she got up to the bathroom a few minutes ago her left foot was wet and she believed it was weeping. No weeping noted by this writer at this time . Writer received call from R63's MD office. Writer informed MD . fluid filled blister, elevated Carbon Dioxide level, noncompliance . staff to continue to educate and encourage. R63's weight, 4/17/23, 311.6 Lbs. R63's weight, 4/18/23, 311.8 Lbs. R63's weight, 4/19/23, 313.8 Lbs. (Note this is a 2lb weight gain in 24 hrs with no MD notification). R63's Nurse Notes, 4/19/23, includes: . alert with baseline mentation . uses oxygen continuous at 4 L/minute via nasal canula to maintain oxygen saturation level greater than 90% during the day hours and 5 L at night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout bilateral lungs . No cough or congestion . lacks motivation to participate in cares . spends day in room lying in bed or sitting in chair watching tv. R63's Consultation Report, dated 4/19/23, includes: change Lasix to after lunch, please avoid processed meat and canned foods . (The facility did not provide evidence of R63's weights being reviewed or her increased edema being addressed with the MD.) R63's Nurse Notes, 4/20/23, includes: . alert with baseline mentation . uses oxygen continuous at 4 L/minute via nasal canula to maintain oxygen saturation level greater than 90% during the day hours and 5 L at night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout bilateral lungs . No cough or congestion . lacks motivation to participate in cares . spends day in room lying in bed or sitting in chair watching tv. R63's weight, 4/20/23, 315.0 Lbs. (It is important to note this weight gain of 5 Lbs. since 4/15/23. The facility failed to consult with R63's MD regarding this weight increase.) R63's Nurse Notes, 4/21/23, include: The patient is alert and oriented x 3. She is cooperative with nursing interventions and consumes meals in her room per her choice. She is on a fluid restriction and is non-compliant drinking extra fluids in her room. BMP (Basic Metabolic Panel - a blood test for metabolism) completed this am and faxed to clinic; awaiting response. VS taken; BP 140/68, resp 20, pulse 88, temp 97.6. R63's weight, 4/21/23, 317.0 Lbs. (It is important to note R63's weight has increased by 2 Lbs. in 24 hours and 7 pounds since 4/15/23 and the facility did not provide evidence of notifying R63's MD regarding this weight increase.) R63's weight, 4/22/23, 319.4 Lbs. (It is important to note R63's weight increase of 2 additional pounds in 24 hours and 9 Lbs. in one week with no evidence R63's MD was consulted with regarding this.) R63's weight, 4/23/23, 320.8 Lbs. (It is important to note R63's weight continues to go up. The facility provided no evidence of MD notification.) R63's weight, 4/24/23, 319.8 Lbs. R63's Nurse Notes, dated 4/24/23, include: . alert with baseline mentation . uses oxygen continuous at 4L/minute via nasal canula to maintain . greater than 90% during day hours and 5L at night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout . No cough or congestion . lacks motivation to assist with cares . spends day in room lying in bed or sitting on chair watching tv. Increased edema to bilateral lower extremities and bilateral upper extremities . (it is important to note the increase in edema to R63's lower and upper extremities.) R63's weight, 4/25/23, 320.8 Lbs. R63's Nurse Notes, dated 4/25/23, include: . alert with baseline mentation . uses oxygen continuous at 4L/minute via nasal canula to maintain . greater than 90% during day hours and 5L at night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout . No cough or congestion . lacks motivation to assist with cares . spends day in room lying in bed or sitting on chair watching tv. Increased edema to bilateral lower extremities and bilateral upper extremities .Today's BMP results received. Results faxed to heart failure clinic per MD instructions along with today's weight. (It is important to note the facility did not provide evidence of R63's heart failure clinic or MD consulting with facility regarding R63's increased edema, increased weight, or lack of motivation.) R63's Nurse Notes, dated 4/26/23, include: Patient is alert with baseline mentation . uses oxygen continuous at 4L/minute via nasal canula to maintain oxygen saturation greater than 90% during the day hours and 5L at night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout . No cough or congestion . lacks motivation to assist with cares . Increased edema to bilateral lower and upper extremities . MD updated with today's CBC (complete blood count- blood test) results. R63's weight, 4/26/23, 321.8 Lbs. R63's Nurse Note, 4/27/23, includes: Patient currently out of building on her way to cardiologist appointment. Pt alert with baseline mentation. Pt uses O2 continuous @ 4L/min via NC to maintain POX > 90% during day hours and 5L t night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout . No cough or congestion . lacks motivation to assist with cares . Increased edema to bilateral lower and upper extremities . Resident admitted to hospital from cardiologist doctor appointment admitted for fluid overload. History: Writer spoke with R63's daughter, on 4/27/23, patient has had a weight gain of 0.5 Lbs. per day, increased edema in lower bilateral extremities, and increased shortness of breath. Today's weight is 319.0 Lbs . Telephone encounter by Cardiologist: on 4/24/23 spoke with facility RN to increase furosemide to 40 mg twice daily. BMP and see me on 4/27/23 R63's Cardiology Follow Up Note, dated 4/27/23, includes: The patients daughter who works in the emergency room called a few days ago complaining of a 10 pound plus weight gain. I doubled her furosemide dose to 40mg twice daily. This has not made a difference. She has gained about 15 pounds since discharge from the hospital (4/5/23). The patient also admits to worsening shortness of breath and orthopnea. She has conversational dyspnea. Assessment: The patient is grossly volume overloaded. She is not doing well on an increased dose of oral loop diuretic therapy. She will need inpatient management for aggressive diuresis. Extremities: Gross bilateral lower extremity pitting edema . Weight 322Lbs. R63's Hospital Summary, dated 5/14/23, includes: admission 4/27/23 .discharged [DATE] with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) and CHF (Congestive Heart Failure) Exacerbation and was found to be in Atrial Fibrillation with RVR (rapid ventricular rate). She spent a couple weeks in the hospital and was on Lasix drip . IV Lasix 5cc through continuous infusion . On 6/14/23 at 3:14 PM, during an interview, RN Y (Registered Nurse) indicated when R63's weight gain reached 5 Lbs. in one week the nurse on the unit should have consulted the Heart Failure Clinic and/or R63's MD. RN Y also indicated staff should have called and consulted R63's physician regarding her increased edema. On 6/14/23 at 4:55 PM, ADON C indicated R63's daughter called the Cardiologist regarding R63's weight gain, lack of motivation, and worsening edema on 4/24/23. ADON C indicated the facility should not have relied on R63's daughter to contact R63's MD and should have kept the HFC and R63's MD apprised of her changing condition and should have followed MD orders of when to update. ADON C indicated the facility should have updated R63's MD on her changing condition. On 6/15/23 at 9:29 AM, NHA A, DON B, and ADON C indicated R63 was non-complaint with her fluid restrictions, elevating her lower extremities, and wearing her compression stockings. NHA A, DON B, and ADON C indicated the nurse on the unit should have consulted with R63's MD with her weight gain of 5 Lbs. in one week and her increase in edema when it was noted. Of note, there is no evidence the facility provided risks and benefits to R63 regarding following fluid restriction and elevation of lower extremities. The facility failed to notify the HFC and MD of R63's weight gain per physician's orders. R63 was hospitalized and required intravenous diuretic therapy. R1's physician was not updated when resident had a change of condition. This example is at a level 2 potential for harm/isolated. Example 2 R61's Nurse's Notes document the following: 12/9/2022 21:29 (9:29 PM) Note Text: Res (Resident) sleeping very soundly at start of shift. vitals and bgm (blood glucose monitoring) taken and res did not wake. Res was on room air o2 (oxygen) was at 76 (%). O2 applied at 2l (liters) via NC (nasal cannula) O2 came up to 85 (%). O2 bumped up to 3liters. o2 in 90s. Res awake and was told these findings also res had periods of apnea. This writer explained to res it would be wise ro keep o2 while in bed. Res agreed as well as husband on the phone. Res in stable condition, all cares complete per care plan. No s/s (signs and symptoms) of distress noted. [SIC] On 6/14/23 at 11:40 AM, Surveyor interviewed LPN H (Licensed Practical Nurse). Surveyor asked LPN H when a resident has a change in their oxygen level, when should the Provider be updated; LPN H stated, at the time it happens. Surveyor asked LPN H how she would inform the Provider of a change in oxygen level, LPN H said call, it is a change of condition. On 6/14/23 at 2:36 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B should a Provider be updated if the residents' oxygen level changes, DON B stated yes. Surveyor asked DON B when would you expect staff to inform a provider of a change in a residents' oxygen level, DON B said they should have updated the on call Physician and sent an update to the Primary Care Provider. It is important to note that there was no documentation in R61's medical record that a provider was ever made aware of this change in her oxygen level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not offer and/or administer the influenza immunization to each resident, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza and immunization for 1 of 6 (R64) residents reviewed for immunizations that resulted in actual harm, and 2 of 6 residents (R34 and R27) reviewed for immunizations that resulted in the potential for harm. R64 consented to have the influenza immunization upon admission to the facility. R64 did not receive the immunization and then contracted Influenza A which resulted in a complex hospitalization. Evidenced by: The facility's policy titled Influenza Vaccination dated 12/2022, states in part: Policy: it is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. Policy Explanation and Compliance Guidelines: .7. Individuals receiving the influenza vaccine< or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record .9. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal . According to the Center for Disease Control and Prevention (CDC) article titled Flu Vaccine Provided Substantial Protection This Season dated 2/22/23, This year's flu vaccine reduced the risk of influenza A-related hospitalization among adults by nearly half according to the CDC Flu vaccine effectiveness against circulating influenza A (H1N1) viruses was 56% .Adults 65 years and older were 35% less likely to have flu-related hospitalization . Example 1: R64 was re-admitted to the facility on [DATE] with diagnoses that include: Parkinson's Disease, Type 2 Diabetes Mellitus, asthma, history of COVID-19, and congestive heart failure. R64's Minimum Data Set (MDS) dated [DATE] states that R64 has a Brief Interview of Mental Status (BIMS) of 15 out of 15 indicating that R64 is cognitively intact. On 10/3/22, the facility's former ADON (Assistant Director of Nursing) obtained verbal consent from R64 to receive the influenza vaccine and co-signed the Vaccine Administration Record (VAR) - Informed Consent for Vaccination form. It is important to note that the back of the form that typically includes the vaccine specific information, date given, and signature of the person administering the vaccine is missing on R64's form. On 10/4/22, the facility held a flu clinic to administer the influenza vaccine. The facility's ADON kept track of resident's vaccinations on a resident roster. That roster indicates that R64 received the influenza vaccination. R64's Wisconsin Immunization Registry (WIR) states that R64 received the influenza vaccine on 2/8/23. (Of note, this was after R64 contracted Influenza A and was hospitalized .) The facility's nurse's notes state the following: 12/4/22 at 10:55 AM: Resident requesting PRN (as needed) geri-tussin for non-productive cough .faxes sent to communicate all concerns. 12/4/22 at 7:30 PM: R64 stated that she didn't feel great. T-97.4, P-84, R18, O2 sat (oxygen saturation) 97% on room air. Noted an occasional dry cough. She also stated that she could not taste. Episodes of flushed face .Lungs clear with occasional expiratory wheezes. COVID rapid test completed, results negative . 12/5/22 at 10:51 AM: .Resident c/o (complained of) increased congestion and cough. COVID test negative. SPO2 96% on room air. Call placed to MD regarding symptoms . 12/5/22 at 9:23 PM: New orders obtained for labs and STAT chest x-ray. Orders to send to ER (Emergency Room) for eval (evaluation) if symptoms worsen or at resident request. Resident had PRN acetaminophen, remains afebrile. Resident continues to c/o (complain of) malaise but denies increased symptoms. Slept intermittently throughout the shift. Non- productive cough noted. Refused to go to the ER for eval, wanting to wait here for chest x-ray. 12/5/22 at 9:44 PM: Technician arrived at facility for chest x-ray. 12/6/22 at 7:11 AM: Chest x-ray results negative and sent to [MD] for review. Requesting orders for flu testing . 12/6/22 at 9:54 AM: Writer called [MD] office requesting to test and treat for the flu, awaiting response. 12/6/22 at 2:21 PM: New orders for COVID PCR, Influenza A/B and RSV swab. Swab taken to [hospital] for processing . 12/6/22 at 11:05 PM: Resident alert and cooperative. Resident lying in bed and appears lethargic. Audible wheezing heard at bedside. Temp. 96.7, b/p (blood pressure) 151/77, HR (Heart rate) 72 PsO2[sic] 90-94%, R (respirations) 18 and resident reports S.O.B (shortness of breath), wheezing, diminished lung sounds not [sic] to right upper lobe. Resident able to cough and clear some congestion. Resident agreed at this time to be seen in the ER and was sent to [hospital] for eval and treat. Call placed to ER for an update and resident was found positive for the flu and admitted . Hospital H&P (History and Physical) dated 12/12/22 states in part: . presented with SOB, wheeze, and chest discomfort on 12/6/22. Initially diagnosed with exacerbation of asthma. Influenza A positive in ED (Emergency Department). Started on Tamiflu (anti-viral) and Solu-Medrol (steroid) and azithromycin (antibiotic). On presentation, mild elevation of troponin thought secondary to demand ischemia from dyspnea. On presentation patient was afebrile, normotensive, normal heart rate, normal O2 sat, no leukocytosis . On 12/8/22, patient noted to be hypoxic and lethargic- ABG (Arterial Blood Gas) with hypoxemia, started on supplemental O2, CXR (Chest x-ray) with new perihilar infiltrates (suggestive of pneumonia) . Patient required increasing O2 supplementation and then placed on BiPAP with no significant improvement- transferred to ICU (Intensive Care Unit) for continued monitoring. Patient was intubated on 12/9/22, at approximately 3:00 AM after intubation, patient went into VT (Ventricular Tachycardia/irregular rapid heartbeat that leads to cardiac arrest if not corrected) arrest, achieved ROSC (Return of Spontaneous Circulation) within 2 minutes. Sputum and blood cultures taken on 12/8/22 have grown MSSA (Methicillin Sensitive Staph aureus- a type of bacteria). Antibiotics changed to Cefazolin on 12/9/22 . R64 remained on the ventilator until 12/18/22 and was finally discharged from the hospital on [DATE]. On 6/14/23 at 10:20 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the facility's process is when a resident consents to receiving the influenza vaccine, DON B stated that the resident should get it. Surveyor asked DON B how the nurse is made aware of the consent, DON B stated that the consent should be in the admission packet, they get the consent signed, and then they place an order for the influenza vaccine. DON B also reported that last year, the facility had the pharmacy come into the facility on October 4, 2022, for vaccination administration. Surveyor asked DON B to explain why R64 did not receive the vaccine, DON B stated that she thought that R64 had received it and that she would have to get back to this Surveyor. Surveyor asked DON B if she was aware or recognized that R64 did not receive the vaccine, DON B stated no. It is important to note that the facility was also unaware that the pharmacy (from Illinois) did not submit the vaccination records to WIR. On 6/14/23 at 11:06 AM, DON B reported to Surveyor that R64 approached the former ADON Z asking for the vaccine and that his tracking sheet indicates that she received the vaccination. On 6/14/23 at 11:09 AM, Surveyor interviewed former ADON Z. Surveyor asked ADON Z if he administered the influenza vaccination to R64, ADON Z stated that R64 returned from an appointment after the pharmacy's flu clinic was over, so he administered the vaccination to R64. Surveyor asked ADON Z where he documented the administration of the vaccine, ADON Z stated that he thought he wrote it on the back of one of the forms. Surveyor asked ADON Z if he documented it in the nurse's notes, ADON Z stated probably not. On 6/14/23 at 11:15 AM, Surveyor called the pharmacy that held the flu clinic at the facility. Surveyor spoke with PT AA (Pharmacy Tech). Surveyor asked PT AA if they have any documentation of R64 receiving the influenza vaccination, PT AA stated that she couldn't see anywhere that R64 received it from them and that they didn't have any forms scanned into their system. On 6/14/23 at 11:35 AM, Surveyor interviewed R64. Surveyor asked R64 if ADON Z had given her the influenza vaccination, R64 stated that she had asked for it several times, but they just kept putting her off. R64 stated that she never received the influenza vaccination while at the facility. On 6/14/23 at 12:15 PM, Surveyor met with ADON C. Surveyor asked ADON C if they were able to find the back side of the form or if they had received any documentation from the pharmacy, ADON C reported that the pharmacy didn't have anything, and that ADON Z had given it after they had left, so they wouldn't have the form anyway. The facility was unable to provide any documentation showing that R64 received the influenza vaccination. R64 states she did not receive the vaccine prior to contracting Influenza A. R64 contracted Influenza A which resulted in being placed on a ventilator, and subsequently having a cardiac arrest. R64's hospitalization lasted 23 days. R34 did not have the influenza immunization offered and no declination and risks and benefits were documented. R27 did not have the influenza immunization offered and no declination and risks and benefits were documented. These examples rise to a level 2 potential for harm/isolated. This is evidenced by: The facility policy entitled, Infection Prevention and Control Program, dated 5/16/23, states, in part. 7. Influenza and Pneumococcal Immunization: a. Residents will be offered the influenza vaccine each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere during that time . c. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. d. Residents will have the opportunity to refuse the immunizations. e. Documentation will reflect the education provided and details regarding whether the resident received the immunizations . Example 2 R34 was admitted to the facility on [DATE], and has diagnoses that include: Acute and Chronic Respiratory Failure with Hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), sarcoidosis of lung (growth of tiny collections of inflammatory cells in the lungs causing dry coughing, shortness of breath, wheezing, and chest pain), asthma (a condition in which airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), and pneumonia. There is no documentation that R34 was provided education on the risks and benefits of the influenza immunization or that the immunization was offered, received, or declined for 2022. Example 3 R27 was admitted to the facility on [DATE] and has diagnoses that include: systemic lupus erythematosus (an inflammatory disease caused when the immune system attacks its own tissues, affecting the joints, skin, kidneys, blood cells, brain, heart, and lungs), heart failure, and cardiomyopathy (an acquired or hereditary disease of the heart muscle making it hard for the heart to deliver blood to the body). There is no documentation that R27 was provided education on the risks and benefits of the influenza immunization or that the immunization was offered, received, or declined. On 6/15/23 at 9:26 AM, Surveyor interviewed DON B (Director of Nursing) and asked if R34 was offered the influenza immunization in 2022. DON B indicated there was no documentation that R34 was provided education on the risks and benefits of the influenza immunization or that the immunization was offered, received, or declined for 2022. Surveyor asked DON B if there should be documentation in R34's medical record and DON B indicated yes. Surveyor asked DON B when R27 was admitted to the facility and DON B indicated 8/14/19. Surveyor asked DON B if R27 had been offered the influenza immunization and DON B indicated she would have hoped so. Surveyor asked DON B if R27 was provided education on the risks and benefits of the influenza immunization or that the immunization was offered, received, or declined. DON B indicated no. Surveyor asked DON B how often the influenza immunization should be offered to residents and DON B indicated yearly. Surveyor asked DON B if there should be documentation in R27's medical record regarding the influenza immunization and DON B indicated yes and there is not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure Residents maintained acceptable parameters of nutritional and hydration status for 1 of 3 Residents (R2) reviewed for nutritional status. R2's nutritional and fluid intakes were not monitored to ensure he was meeting his estimated daily nutritional and fluid needs, resulting in 2 hospitalizations for dehydration. This is evidenced by: Facility policy titled Nutrition and Hydration Guideline dated 10/3/22, states in part, Purpose: The intent of this requirement is that the resident maintains, to the extent possible, acceptable parameters for nutritional and hydration status through: Providing nutritional and hydration care and services consistent with the nutritional comprehensive assessment. Recognizing, evaluating, and addressing the needs of every resident, including but not limited to, those at risk or already impaired nutrition and hydration .Process: Accurately and consistently assess a resident's nutritional status on admission and as needed thereafter: Identify a resident at nutritional risk and address risk factors for impaired nutritional status .Obtain weights upon admission, weekly x 4, monthly .Identify, implement, monitor, and modify interventions (as appropriate), consistent with the resident's needs, choices, preferences, goals, and current professional standards of practice, to maintain acceptable parameters of nutritional status. Notify the physician as appropriate in evaluating and managing causes of the resident's nutritional risk and impaired nutritional status. Identify and apply relevant approaches to maintain acceptable parameters of nutritional status, including fluids .Offer sufficient fluid intake to maintain proper hydration and health. Facility policy titled Notification of Change Guideline dated 10/3/22 states in part, .Requirements for notification of resident, the resident's representative, and their physician: A significant change in the resident's physical, mental, or psychosocial status. A significant change includes deterioration in health, mental, or psycho-social status . R2 was admitted to the facility on [DATE] with diagnoses that include right hip fracture with repair, hemiplegia, and hemiparesis following cerebral infarction (stroke) affecting the left side, Major Depressive Disorder, and hypertension. R2's admission Minimum Data Set (MDS) dated [DATE] states that R2 has a Brief Interview for Mental Status (BIMS) of 3 out of 15, indicating that R2 is severely cognitively impaired. R2 requires extensive 2 person assist for bed mobility and is independent with eating, requiring setup help only. R2's Physician Orders state: Daily weight upon admission x 3 days, then weekly x 4 weeks, then monthly. R2 also had an order dated 11/3/22 for Ensure Clear with meals, changed to Ensure Regular with meals on 11/10/22. There is no documentation showing that R2 received the Ensure or how much he consumed. R2's weights were documented as follows: 11/2/22: 147.2 lbs. (pounds). 11/7/22: 156 lbs. 11/18/22: 130.2 lbs. 11/19/22: 131.3 lbs. 11/20/22: 130.0 lbs. 11/21/22: 129.6 lbs. 11/28/22: 129.0 lbs. It is important to note that the facility did not complete daily weights for the first 3 days after admission (11/3 and 11/4), nor did they obtain a re-weigh when documentation showed that R2 had gained 9 lbs. Based on the documented weights, R2 had lost 26 lbs. from 11/7/22 to 11/18/22. Additionally, facility staff only entered the weights from 11/2/22 and 11/18/22 into the Electronic Health Record (EHR), the others were documented on the paper Medication Administration Record (MAR). There is no documentation indicating that the Physician was updated on R2's significant weight loss. R2's meal intake documentation is as follows: 11/2: RU (Resident Unavailable) 11/3: no documentation 11/4: 2 (51-75%), 1 (26-50%), no documentation for supper 11/5: no documentation 11/6: no documentation 11/7: no documentation 11/8: 3 (76-100%), 3, no documentation for supper 11/9: RR (Resident Refused), RR, 2 11/10: RR, 2, no documentation for supper 11/11: 0 (0-25%), 0, 0 (R2 Tested positive for Covid-19) 11/12: 0, 2, no documentation for supper 11/13: 0, 0, 0 11/14: 3, 0, 0 11/15: 2, 2, no documentation for supper 11/16: 3, RU, RU (hospital) 11/17: in hospital 11/18: no documentation- R2 returned from the hospital at 4:15 PM 11/19: 0, 0, RR 11/20: 0, RR, 0 11/21: 0, 1, RU 11/22: 0, 3, 0 11/23: 3, no documentation for lunch, 0 11/24: 0, RR, no documentation for supper 11/25: 0, 1, 0 11/26: 0, 0, 0 11/27: 0, RR, RR 11/28: 0, 0, 1 11/29: 2, 1, no documentation for supper 11/30: RR, 1, RR R2's fluid intake (in milliliters) documentation (by shift) is as follows: 11/2: AM: NA (Not applicable) PM: RU (Resident unavailable) NOC: no documentation 11/3: AM: no documentation PM: no documentation NOC: 0 11/4: AM: 300 PM: no documentation NOC: no documentation 11/5: AM: 120 PM: no documentation NOC: 0 11/6: AM: no documentation PM: 120 NOC: NA (Not Applicable) 11/7: AM: no documentation PM: no documentation NOC: NA 11/8: AM: 480 PM: no documentation NOC: 120 11/9: AM: 240 PM: no documentation NOC: 120 11/10: AM: 120 PM: no documentation NOC: 120 11/11: AM: 50 PM: 250 NOC: no documentation (R2 Tested positive for Covid-19) 11/12: AM: 600 PM: 240 NOC: 0 11/13: AM:240 PM: 240 NOC: 240 11/14: AM:600 PM: 120 NOC: 150 11/15: AM: 360 PM: no documentation NOC: 200 11/16: AM:240 PM: RU NOC:120 11/17: in hospital 11/18: AM: no documentation PM: no documentation NOC: RU 11/19: AM:120 PM:0 NOC: 200 11/20: AM:480 PM:0 NOC: no documentation 11/21: AM: 120 PM:240 NOC: 0 11/22: AM: 600 PM: 480 NOC: 0 11/23: AM: 240 PM: 360 NOC: NA 11/24: AM: 500 PM: no documentation NOC: 0 11/25: AM: 480 PM: 720 NOC: no documentation 11/26: AM: 480 PM: 480 NOC: 200 11/27: AM: 240 PM: 240 NOC: 200 11/28: AM: 120 PM: 120 NOC: 200 11/29: AM: 240 PM: 120 NOC: 0 11/30: AM: 200 PM: 120 NOC: 120 Surveyor reviewed the Nurse's Notes, and there is no documentation stating that the Physician was updated regarding R2's poor appetite or poor fluid intake. Facility staff did not total daily intakes to ensure that R2 was receiving an adequate amount of fluids. On 11/11/22, R2 was positive for Covid-19. On 11/16/22, R2 had an unwitnessed fall and was sent to the emergency department. The hospital's History and Physical (H&P) states in part, On exam, frail elderly male with right sided weakness and expressive aphasia, dry mucous membrane noted. Patient admitted for UTI (Urinary Tract Infection) and AKI (Acute Kidney Injury) in setting of dehydration and recent COVID-19 infection. Plan: continue gentle hydration . Abnormal lab values include Sodium 147 (H), BUN (Blood Urea Nitrogen) 32 (H). R2 received IV (Intravenous) fluids. R2's Discharge MDS dated [DATE] states that R2 now requires supervision - oversight, encouragement or cueing with eating. R2 returned to the facility on [DATE]. Facility did not complete a dehydration assessment on R2. R2's Nutrition Risk Care Plan dated 11/27/22 states in part, At nutritional risk r/t (related to): Consumes <75%, weight loss - down 17 lbs. x 2 weeks. Goal: Weight will remain stable 130 lbs., Resident will be free of dehydration AEB (As Evidenced By) good skin turgor, labs, etc., Resident will meet 75-100% est (estimated) needs. Interventions: Provide diet as ordered .honor food preferences .supplements as ordered: TID (Three Times a Day) Ensure, monitor weights: as ordered, monitor for signs of dehydration. R2's Nutritional assessment dated [DATE] states in part, .Needs staff to cut up food- indicated on meal ticket. Usually requires supervision- at times may need assistance. Est. needs: 1700-2070 kcal/day, 1480-1780 ml/day. Est. needs increased d/t (due to) low BMI (Body Mass Index) and R (Right) hip fx (fracture) with surgical site .No new recommendations at this time. Reweight requested . It is important to note that the facility's Registered Dietician (RD) did not see R2 until R2 had been at the facility for 25 days. R2 went from being independent with set-up to now needing staff to cut up food, requiring staff supervision, and needing assist at times. R2's Quarterly MDS dated [DATE] states that R2 now requires extensive 1 person physical assist for bed mobility, eating, and toilet use. On 12/2/22, R2 went to see his Primary Care Physician (PCP) due to making suicidal remarks and the facility's request to increase his mirtazapine (anti-depressant.) R2 was found to be hypotensive (low blood pressure) with blood pressure readings of 60/40 and 80/52. Clinic notes state that R2 was ill-appearing and pale. The Physician discussed options with family, fluids were started, and R2 was sent to the ED (Emergency Department) and was subsequently admitted to the hospital for 5 days with the diagnoses of dehydration, elevated lactic acid level, hypotension, and failure to thrive. Abnormal lab values include Hemoglobin 8.4 (L), Lactic Acid 3.9 (H), Cortisol 31.0 (H), Creatinine 1.3 (H), and Albumin 3.3 (L). (Albumin test measures the amount of protein in the clear liquid portion of the blood. Low albumin levels can be a sign of malnutrition.) On 12/13/22 at 1:52 PM, Surveyor interviewed CNA J (Certified Nursing Assistant). Surveyor asked CNA J how often residents are weighed? CNA J stated that everyone gets weighed on the 1st of the month, but new admissions are weighed 3 days straight. Surveyor asked CNA J what they do with the weights after they have obtained them? CNA J stated that they give them to the nurse, and they put them in the computer. On 12/13/22 at 1:55 PM, Surveyor interviewed LPN I (Licensed Practical Nurse). Surveyor asked LPN I what do the nurses do with the weights when the CNAs give them to them? LPN I stated that they put them in the computer or on the MAR. Surveyor asked LPN I, how are the nurses alerted to weight loss in a resident? LPN I stated by looking at it and that the computer also updates them when there is weight loss. Surveyor asked LPN I what steps she takes after noticing or being alerted to a weight loss? LPN I stated that they inform the dietician, the doctor, and the family. Surveyor asked LPN I where they would document this communication? LPN I stated in the nurse's notes. On 12/13/22 at 2:40 PM, Surveyor interviewed DON B (Director of Nursing) and ADON F (Assistant Director of Nursing.) Surveyor asked DON B what the facility's policy is for weighing new admissions? DON B stated that they are weighed on admission and then depending on the MD (Medical Doctor) orders. Surveyor asked DON B what her expectations were when a nurse notices a weight loss or gain? DON B stated that she would expect the nurse to let her and ADON F know, and he will update the dietician. Surveyor asked DON B if the MD should be updated; DON B stated yes. Surveyor asked DON B if she would expect that communication to be documented; DON B stated yes. Surveyor asked DON B if by reviewing the documentation, she could tell if the MD was updated on R2's weight loss; DON B stated no. Surveyor asked DON B if she would expect that the RD (Registered Dietician) see R2 before 11/27/22? DON B stated yes, he should have been seen when he was newly admitted . Surveyor asked DON B who is responsible for totaling daily fluid intakes? DON B stated that it is usually dietary. Surveyor asked DON B who reviews the intake totals? DON B stated that before it was dietary, but she is unsure at this time. Surveyor asked DON B if she expected the CNAs to document every day and shift; DON B stated yes. Surveyor asked DON B if staff were aware of R2's poor appetite, would she expect that R2 be weighed more frequently; DON B stated yes. Surveyor asked ADON F if at any point he updated the MD regarding R2's weight loss? ADON F stated he receives and reviews the dietary notes and then sends them to the MD. Surveyor asked ADON F if at any point during the 9 days from when the weight loss was documented, until the RD saw R2 was the MD updated? ADON F stated that he was not sure. On 12/14/22 at 8:25 AM, Surveyor interviewed RN G (Registered Nurse (MD office)). Surveyor asked RN G if they had received any updates from the facility regarding R2's poor appetite and decreased fluid intake? RN G reviewed the clinic documentation and reported that they received faxes on: 11/2 regarding admission paperwork, 11/9 requesting to change Ensure from clear to regular, 11/15 requesting an order for Mucinex and to schedule oxycodone, and 11/18 request orders for an antibiotic for UTI. RN G stated that they also received a call on 12/1 to request an increase to mirtazapine. Surveyor asked RN G if the clinic/MD was made aware the R2 had a 17-pound weight loss? RN G stated that they were not made aware of that. RN G reported to Surveyor that the MD required R2 to come into the clinic to be assessed before increasing his mirtazapine, and then was sent to the hospital for hypotension and dehydration on 12/2/22. On 12/14/22 at 9:35 AM, Surveyor interviewed RD H. Surveyor asked RD H what her timeline is for seeing new admissions? RD H stated 14 days. Surveyor asked RD H if R2 was seen within 14 days of admission? RD H stated no and that she must have been late with that one. Surveyor asked RD H if the facility updated her regarding R2's 17-pound weight loss; RD H stated no, but that she noticed it in the computer and sent an email to the ADON and DON requesting a reweigh. Surveyor asked RD H if a reweigh was completed? RD H stated that she was unsure because some are documented on paper and others are in the EHR (Electronic Health Record.) Surveyor asked RD H if she reviews daily fluid intakes? RD H stated no. Surveyor asked RD H if R2 was meeting his daily fluid intake needs? RD H stated no. Surveyor asked RD H if she knew how much of R2's Ensure he was consuming daily? RD H stated no. Surveyor asked RD H if the dietary staff was documenting how much Ensure is consumed? RD H stated no, nursing should be documenting that. On 12/14/22 at 10:04 AM, Surveyor interviewed DON B. Surveyor asked DON B how they know if a resident is receiving the Ensure if no one is documenting on it? DON B stated that it should be documented on the MAR. DON B reviewed R2's MAR and stated that it's not on there. Surveyor asked DON B how does the nurse know if the Ensure has been given? DON B stated that they would have to check with staff. Surveyor asked DON B if she would expect that to be documented; DON B stated yes. Surveyor asked DON B if they currently have a process to track how much Ensure is being consumed and therefore tracking the calories from the Ensure? DON B stated no. Surveyor asked DON B if they have a Dehydration assessment for R2; DON B stated no. R2 had weight loss due to a decline in fluid and nutritional intake, staff were not monitoring R2's weights or intakes to ensure he was meeting his estimated daily needs. R2 went from being independent to supervision to needing assist of 1 with eating within 28 days of being admitted . R2 became ill with Covid-19 which increased his daily nutritional and fluid requirement while ill. R2 was not assessed for dehydration at any time during his stay by the facility and was hospitalized two times with dehydration. R2 did not return to the facility after his 12/2/22 hospitalization.