Every finding on record at Orchards of East Liverpool, The

Based on observation, review of insulin inserts, interview and review of the facility policy, the facility failed to label and store medication in a manner that enabled staff to know when the medication should be discarded. This affected four (Residents #12, #36, #41, and #60) of five residents who had insulin stored on the [NAME] wing medication cart. The facility census was 45.Findings include:During observations of the medication cart for rooms 21-31 in the long-term care building with Licensed Practical Nurse (LPN) #270 on 12/15/25 at 11:45 A.M., the following medication storage concerns were identified:1. Resident #60 had an open Basaglar insulin (insulin glargine) pen. The pen was not dated with the date it was opened. Review of the Basaglar insulin insert revealed instructions not to use the pen more than 28 days after the pen was first used.2. Resident #41 had an open Lantus Solostar (insulin glargine) pen with no information regarding when it was opened.Review of the Lantus Solostar insert revealed instructions to throw the pen away after 28 days.3. Resident #12 had an open Lantus pen, open insulin Lispro pen and open Liraglutide pen. None of the pens were dated when they were opened.Review of the Lantus and insulin Lispro inserts revealed the pen should be discarded 28 days after opening.Review of the Liraglutide insert indicated it should be used or discarded within 30 days.4. Resident #36 had an open insulin Lispro pen. There was no date recorded when it was opened.On 12/15/25 at 11:45 A.M., LPN #270 verified insulin pens for Residents #12, #36, #41, and #60 were not marked with the date they were opened. LPN #270 stated she believed the pens could be used for 30 days.Review of the facility's Labeling of Medications and Biologicals policy (implemented 01/22/25) revealed labels for multi-use vials must include the date the vial was initially opened or accessed. All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

Based on observation and interview, the facility did not ensure chemical sanitation was completed on kitchen dishes in the rehabilitation unit. This had the potential to affect all ten (Residents #9, #19, #20, #23, #32, #40, #42, #44, #45, and #57) residing on the rehabilitation unit. The facility census was 45. Findings include:Initial tour of the kitchen on [DATE] from 9:13 A.M. to 9:20 A.M. with Dietary Manager #310 revealed the kitchen contained a low temperature dish washer that utilized chlorine for chemical sanitation. Observation on [DATE] at 9:13 A.M. of the chemical sanitation of a dishwasher cycle revealed the test strips did not register the chlorine dilution level 50 to 100 parts per million (PPM) as required. A total of three dishwasher cycles were ran all of which failed to register any chemical dilution level.A review of the Hydrion Chlorine test strips revealed they expired [DATE]. Dietary Manager #310 verified available test strips were all expired. Interview on [DATE] at 9:40 A.M. with Dietary Manager #310 revealed Info Service who was the provider of the test strips was contacted and advised the test strips that were delivered were all expired at which time Dietary Manager #310 was informed that new test strips would be delivered. Interview on [DATE] at 11:08 A.M. with Dietary Manager #310 revealed the facility followed the state guidelines for sanitation. Interview and observation on [DATE] at 11:22 A.M. revealed an Info Service technician reported he was performing preventative maintenance when asked if he was repairing the dishwasher. Interview and observation on [DATE] at 3:10 P.M. with Dietary Manager #310 revealed the Info Service technician provided new testing strips at which time the sanitation dilution level was tested again and found to be 10 PPM. Dietary Manager #310 reported the technician advised the dishwasher was not diluting properly. Dietary Manager #310 verified test strips were provided; however, they were also expired with an expiration date of 06/25.

Based on observation, medical record review and interview, the facility failed to ensure comprehensive assessments of skin impairment were documented for one (Resident #32) of two residents reviewed for non-pressure-related skin impairment. 16 residents were screened for non-pressure skin impairment. The facility census was 45. Findings include:Review of Resident #32's medical record revealed diagnoses including necrotizing fasciitis (also known as flesh-eating disease; is a bacterial infection that affects the tissue under your skin called fascia), Methicillin-Resistant Staphylococcus Aureus (MRSA) infection (type of infection that many antibiotics don't work on), osteomyelitis (serious bone infection), displaced trimalleolar fracture (fracture of the lower leg sections that form the ankle joint and help move the foot and ankle) of the right lower extremity, fracture of the shaft of the right tibia (shin bone), peripheral vascular disease, and local infection of the skin and subcutaneous tissue. Review of Resident #32's admission assessment dated [DATE] revealed there was a [NAME] dressing (compression dressing for temporary stabilization of fractures) to the right ankle which was clean and dry. Documentation revealed staff were unable to view the surgical site related to the dressing. An order for a weekly skin assessment was discontinued on 08/13/25. On 08/22/25, Resident #32 had an appointment with the surgeon, and the [NAME] dressing was removed. A progress note from the appointment revealed dressing changes were ordered for every other day. There was no assessment of the surgical site documented. An order was written to start treatment on 08/24/25 to clean the ankle with normal saline solution and gauze, apply an ABD (abdominal) pad (dressing) and wrap with Kerlix (bandage roll) every night shift every other day for incision and wound management. A skilled nursing note dated 08/24/25 at 9:10 P.M. indicated the surgical incision was well approximated with no drainage. Staples/sutures were intact. A nursing note dated 08/25/25 at 6:55 P.M. revealed the incision was well approximated with no drainage. Subsequent nursing notes on 08/30/25, 08/31/25 and 09/01/25 revealed the incision was well approximated with no drainage noted. On 09/03/25 a skilled nursing note indicated the surgical incision was noted with warmth, redness to the site, purulent drainage and black with an odorous smell. A nursing note dated 09/03/25 at 11:13 A.M. revealed the physician was informed of the findings regarding the surgical wounds and an order was received to admit directly to the hospital. Review of a hospital history and physical dated 09/03/25 indicated there was right ankle swelling and postoperative complications including scabbing and delayed healing with drainage. The nursing facility staff called the surgeon that morning and sent photos that showed necrotic skin over the lateral ankle and dorsum (upper surface) of the foot as well as pressure ulcer on the heel. Resident #32 was admitted to the hospital for a debridement of necrotic skin and incision and drainage and exploration. The history and physical indicated there was thickened eschar over the lateral (outer) aspect of the ankle and a significant sized decubitus (pressure) ulcer over the posterior heel and a pressure ulcer over the medial (inner) aspect of the ankle. There was moderate swelling of the right foot and ankle and some drainage from the lateral incision site. The dorsum of the foot also had some scabbing. The area of the eschar on the lateral side was about 11.0 centimeters (cm) in length and the distal portion having a scab/eschar measured 5.0 cm in width. The medial side blackened skin area measured about 8.0 x 6.0 cm and the dorsum of the foot had small areas of skin necrosis measuring about 4.0 x 3.0 cm. The note indicated Resident #32 had postoperative pressure necrosis of the lateral ankle and the heel with eschar and skin necrosis of the lateral anterior and medial ankle and dorsum of the foot, but the possibility of necrotizing fasciitis was not entirely ruled out. A hospital consultation report dated 09/04/25 indicated Resident #32 was sent to the emergency room (ER) for possible infection. Initially, Resident #32 had a surgical procedure for a trimalleolar ankle fracture on 08/08/25 where the incision became infected so he was sent to the ER for admission and surgical incision and drainage. The wound was debrided 09/03/25 and cultures were in progress. Another consultant report only indicated necrotizing fasciitis of the ankle and foot. On 09/29/25 at 10:00 A.M., Resident #32 was observed with a dressing on his ankle. During an interview on 09/30/25 at 2:24 P.M., Licensed Practical Nurse (LPN) #244 stated when she changed Resident #32's ankle dressing on 09/02/25 she observed the top of his foot and outer ankle were black. LPN #244 was unable to recall if there was any impairment on the right heel, stating the whole foot was a mess. LPN #244 stated she was unsure if the condition of the foot was new onset as she had not seen the wound previously. LPN #244 stated she was unable to locate any assessments for comparison. LPN #244 stated she contacted the wound care consultant and Resident #32 was supposed to be seen the next day, which was when the orthopedic doctor was contacted and he was a direct admit to the hospital. After requesting any comprehensive assessments of the surgical site or the foot prior to 09/02/25, Registered Nurse (RN) #275 provided a typed synopsis of information included in the medical record notes on 12/15/25 at 12:35 P.M., acknowledging that was the information the facility was able to locate and it did not include ongoing comprehensive assessments. On 12/15/25 at 4:50 P.M., RN #275 and RN #309 verified no comprehensive assessments were located from the time Resident #32's [NAME] boot was removed on 08/22/25 through 09/03/25. RN #309 stated the foot was being monitored during dressing changes.

Based on medical record review, interview and facility policy review, the facility failed to ensure recommendations from pharmacy reviews were addressed in a timely manner. This affected one (Resident #40) of five residents reviewed for medication use and one (Resident #42) of two residents reviewed for antibiotic use. The facility census was 45. Findings include:1. Review of Resident #40's medical record revealed diagnoses including atrial fibrillation, stage 4 chronic kidney disease, severe protein-calorie malnutrition, and gastro-esophageal reflux disease. On 09/09/25 an order was written for protonix (pantoprazole sodium - a proton pump inhibitor that decreases the amount of acid produced in the stomach) 40 milligrams (mg) twice a day. A medication regimen review dated 10/01/25 addressed the use of pantoprazole since 09/09/25. A request was made for the physician to consider changing the frequency of administration to as necessary or changing to another class of acid reducing medication related to increased risk for osteoporosis fracture with long term use of proton pump inhibitors. A nursing note dated 10/18/25 at 2:00 P.M. indicated Resident #40 was discharged home. Further review of the medication regimen review dated 10/01/25 revealed a physician response dated 11/10/25 in which the physician provided an order to discontinue the use of the pantoprazole. On 12/15/25 at 1:20 P.M., Registered Nurse (RN) #275 stated when the pharmacy recommendations were received (and if not urgent) they were placed in a folder for the physician to review during their next visit. Resident #40's attending physician visits varied but he generally visited about every week. RN #275 was unable to state why it took until 11/10/25 for the response or why the physician wrote an order for a resident no longer in the facility. RN #275 stated the physician probably did not realize Resident #40 had been discharged when he responded to the recommendation. Review of the facility's Medication Regimen Review (implemented 01/22/25) revealed the pharmacist was responsible for communicating non-urgent irregularities to the facility via written communication to the attending physician, the facility's medical director, and the Director of Nursing (DON). The irregularities were required to be provided within ten working days of the review. Facility staff were responsible for acting upon all recommendations according to procedures for addressing medication regimen review irregularities. No time frame for non-urgent irregularities was specified. Review of the facility's Addressing Medication Regimen Review Irregularities (implemented 01/22/25) revealed the medication regimen of each resident must be reviewed by a licensed pharmacist at least once a month (or more frequently, as indicated by the resident's condition). The pharmacist must report any irregularities to the attending physician, the facility's medical director, and the DON and the reports must be acted upon. Time frames for physician response were only addressed for irregularities that required immediate action to protect a resident and in relation to residents whose anticipated length of stay was less than 30 days. 2. Review of Resident #42's medical record revealed diagnoses including diaphragmatic hernia, gastro-esophageal reflux disease, and anemia. On 09/05/25 an order was written for pantoprazole sodium 40 mg every day. A medication regimen review dated 10/01/25 addressed the use of pantoprazole since 09/06/25. A request was made for the physician to consider changing the frequency of administration to as necessary or changing to another class of acid reducing medication related to increased risk for osteoporosis fracture with long term use of proton pump inhibitors. There was no response documented. Resident #42 was discharged home on [DATE] but was re-admitted to the facility on [DATE] with the pantoprazole reordered. On 12/16/25 at 10:22 A.M., RN #275 verified there was no evidence that the pharmacist's recommendation regarding the use of pantoprazole had been addressed between 10/01/25 and the date of discharge on [DATE]. RN #275 stated Resident #42 continued to receive pantoprazole 40 mg every day since her readmission on [DATE].

Based on record review, observation, interview and facility policy review, staff failed to wear appropriate personal protective equipment (PPE) while administering medication intravenously (IV) and failed to maintain infection control practices while changing an IV access dressing. This affected one (Resident #42) of four residents observed for medication administration and one (Resident #42) of one resident observed for dressing change. The facility census was 45.Findings include:Review of Resident #42's medical record revealed diagnoses including sepsis (a life-threatening illness that develops when an existing infection triggers an extreme immune system response in the body) and osteomyelitis (infection in a bone). Physician orders included changing the Peripherally Inserted Central Catheter (PICC) line dressing every Monday (ordered 09/06/25) and Vancomycin Hydrochloride (antibiotic) 1.5 grams IV every day (ordered 09/10/25). During observation of medication administration by Licensed Practical Nurse (LPN) #244 to Resident #42 on 09/29/25 between 8:45 A.M. and 8:47 A.M., LPN #244 was observed preparing and initiating Vancomycin 1.5 grams in 500 milliliters (ml) of Normal Saline Solution (NSS) via IV route through a PICC in the left arm. No gown was worn.On 09/29/25 between 11:50 A.M. and 12:00 P.M., LPN #244 was observed changing Resident #42's PICC dressing. No gown was donned. After LPN #244 opened the sterile dressing pack, the sterile gloves were immediately applied and used to remove the old dressing dated 09/22/25, clean the site and apply a sterile dressing.On 09/29/25 at 12:02 P.M., LPN #244 verified there was no order for Enhanced Barrier Precautions (EBP) although Resident #42 had an indwelling medical device. LPN #244 verified she had not used a gown when administering medications through the IV. LPN #244 verified she had not used a mask or gown when changing the PICC line dressing, and she applied the sterile gloves prior to removing the old dressing and kept them on throughout the remainder of the dressing change. Review of the facility's EBP policy (implemented 01/22/25) revealed an order for EBP would be obtained for residents with indwelling medical devices such as central lines even if a resident was not known to be infected or colonized with a multi-drug-resistant organism. Gowns and gloves were to be made available in close proximity to the entrance of the resident's room. High-contact resident care activities included indwelling device care. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound healed or indwelling medical devices were removed.Review of the facility's PICC/Midline/CVAD Dressing Change policy (implemented 01/22/25) revealed after staff performed hand hygiene, he/she was required to don a mask, place a mask on the resident if they could not keep their head turned away, perform hand hygiene again, and set up a clean field on the overbed table with needed supplies for the dressing change. A disposable cloth or linen saver was to be placed on the overbed table then hand hygiene performed prior to opening the sterile dressing change kit and laying out supplies on the sterile field being careful not to contaminate them. The policy indicated hands should be washed again and clean gloves applied. The old dressing was to be removed beginning at the device hub and gently pulling the dressing perpendicular to the skin toward the insertion site. Prior to applying the new dressing, hand hygiene was to be performed and sterile gloves applied.

Based on medical record review, facility investigation review, facility policy review, and interviews, the facility failed to timely report an allegation of misappropriation. This affected one resident (#1) of three residents reviewed for abuse. The facility census was 42. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes mellitus, anemia, heart failure, major depressive disorder, and intermittent explosive disorder. The resident was cognitively intact. Review of complaint information received by the Ohio Department of Health (ODH) on 08/29/24 revealed on 08/27/24 at 10:27 P.M., Resident #1 reported to Licensed Practical Nurse (LPN) #40 that she checked her wallet and $60.00 was missing; the resident stated that she had $100.00 and now only $20.00. Concierge #54 confirmed she had not recently given the resident any monies from her fund. Resident #1's guardian visited on 08/27/24 and did not report any missing money. The resident has a history of confusion and diagnoses including anxiety disorder and intermittent explosive disorder. Interview on 10/04/24 at 11:15 A.M. with the director of nursing (DON) revealed she accidentally filed a complaint a with ODH rather than a Self-Reported Incident (SRI). She stated it was her first time filing and she submitted the wrong report, submitting a complaint instead of an SRI. The DON confirmed that she did not file an SRI. Review of the facility investigation revealed the allegation was unsubstantiated without evidence to support the allegation. Interview on 10/04/24 at 1:08 P.M. with the Administrator confirmed an SRI was not filed to report Resident #1's allegation of misappropriation as it should have been. Review of the facility's policy titled, Ohio Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/27/21, revealed the Administrator or his designee will notify ODH of all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property and injuries of unknown source as soon as possible, but no event later than 24 hours from the time the incident/allegation was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00157339.

Based on medical record review and staff interview, the facility failed to provide appropriate discharge instructions, education and supplies prior to a resident discharge home. This affected one resident (Resident #45) of three residents reviewed for discharge services. The facility census was 44. Findings include: Review of Resident #45's medical record revealed an admitted [DATE] with diagnoses that included rhabdomyolsis (damaged skeletal muscle breaks down rapidly), urinary tract infection, urinary retention and pressure ulcer to the sacrum. Resident #45 was admitted for therapy and intravenous antibiotic services. Additional review of the medical record revealed the use of an indwelling urinary catheter in place since admission due to urinary retention with orders to provide catheter care every shift. Admission skin and wound assessments revealed a stage three pressure ulcer (full thickness skin loss, subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) located to the coccyx. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of the Resident #45's discharge summary and instructions revealed the resident and husband were provided education on medications, home health services, medical equipment and physician follow up appointments at the time of discharge on 04/06/23. Review of the resident's progress notes, discharge summary and instructions found no evidence of education given related to the care of the indwelling urinary catheter or wound and no wound care supplies were provided. Interview with the Director of Nursing on 04/28/23 at 11:15 A.M. verified Resident #45 and/or the resident's representative were not given education regarding indwelling catheter care, wound care and not provided with supplies for wound care upon discharge. This deficiency represents non-compliance investigated under Complaint Number OH00141951.

Based on record review and interview, the facility failed to ensure Resident #10's medical record as complete and contained documentation regarding an alleged incident of abuse from a staff member. This affected one (Resident #10) of three residents reviewed for abuse. The facility census was 49. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included coronavirus (COVID-19), repeated falls, major depressive disorder, anxiety disorder, hyperglycemia, muscle weakness, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 11/21/22, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility and transfers, and extensive assistance of one staff for toileting and dressing. Review revealed no behaviors or rejection of care. Review of the Self-Reported Incident (SRI), dated 12/13/22 at 6:03 P.M., revealed Resident #10's visitor reported to a nurse, that the resident told him that a facility environmental services staff member (Housekeeper #101) told the resident to shut up and not to bother anybody. Due to this allegation, the facility modified Housekeeper #101's schedule to ensure she would have no further contact with Resident #10 or any residents. The Director of Nursing (DON) interviewed the resident who was alert and oriented and stated the older lady who cleans the halls and does laundry told her to shut up. Review of the nursing progress notes and medical record, dated December 2022 through present, revealed no documentation related to Resident #10's allegation of abuse. During interview on 12/22/22 at 11:00 A.M., Resident #10 stated Housekeeper #101 told her shut up and not to worry about what work she had left to do. During interview on 12/22/22 at 1:30 P. M., the DON stated she was notified by a nurse that a visitor stated Resident #10 told him that an environmental worker told her to shut up. The DON confirmed Resident #10's medical record did not contain any documentation related to the allegation of abuse or of any assessment of the resident or follow-up that occurred. This deficiency is cited as an incidental finding to Self-Reported Incident Complaint Number OH00138537.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure comprehensive and individualized fall safety interventions were implemented to prevent a fall with injury for Resident #37, who was identified upon admission at high risk for falls. The facility also failed to ensure adequate assistance using a mechanical (Hoyer) lift was provided to Resident #33 during a transfer to prevent a possible fall/injury. Actual Harm occurred on 11/19/22 when Resident #37 sustained a fall with injury (head injury, nausea, bilateral black eyes and leg laceration) requiring hospitalization without evidence of any type of fall/safety interventions being in place prior to or at the time of the fall. Following the fall, Resident #37 reported a decline in her condition (not having the energy or ability to walk as easily). The facility also identified the resident demonstrated a decline in functional ability following the fall. This affected two residents (#37 and #33) of three residents reviewed for accidents and hazards. Findings include: 1. Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including metabolic [CONDITION(S)], wedge compression fracture of T11 and T12, and multiple fractures of ribs on the right side. Review of fall risk observation tool completed on admission 10/14/22 and on 11/14/22 revealed Resident #37 was assessed to be at high risk for falls. Review of the admission Minimum Data Set 3.0 (MDS) assessment, dated 10/20/22 revealed Resident #37 had mild cognitive impairment. The assessment revealed Resident #37 was independent with bed mobility, required supervision with one-person physical assistance for transfers and toilet use and required extensive one-person physical assistance for dressing. A plan of care, dated 11/14/22 revealed Resident #37 would be at reduced risk of falls/injury through the next review date. However, the only intervention noted was to keep resident's call light within reach. Review of the nursing progress note, dated 11/19/22 at 6:15 A.M. revealed Resident #37 reported she fell in her room, (the fall was unwitnessed). The resident was assessed to have an open area on her right leg and reported she hit her heard. The resident was assessed, the physician and family were notified, and the resident was sent to the emergency room for evaluation and treatment. The resident returned to the facility on the same day. Review of the nursing progress note, dated 11/19/22 at 5:00 P.M. revealed Resident #37 agreed to lay down after she had been sitting up at the counter for some time. The note reported the resident was anxious, which was normal for the resident. An assessment revealed, right orbital area purplish with redness due to fall earlier today. Dressing to the right knee remained intact. Review of the nursing progress note, dated 11/19/22 at 7:15 P.M. revealed Resident #37 was found lying with her head at the foot of the bed without her oxygen on. The resident had been incontinent of stool. The resident did not answer staff questions. The only question Resident #37 did answer was telling the staff that her head hurt, and she was nauseous. The resident was assessed, cleaned up, and sent back to the emergency room . Resident #37's physician and family were notified of the transfer. Review of the nursing progress note, dated 11/19/22 at 11:50 P.M. revealed Resident #37 returned to the facility, with no new orders. The resident was yelling, oh please God help me, help me. The transport reported the resident had been chanting that since she left the hospital. The resident was placed on one on one observation for the evening. Record review revealed following the fall/incident on 11/19/22, the resident's plan of care was not updated or revised to ensure individualized and comprehensive fall/safety interventions were in place to prevent additional falls for the resident. On 11/21/22 at 9:44 A.M. Resident #37 was observed with two very large black eyes. Interview with Resident #37 at the time of the observation revealed she had fallen in her room at the facility and had not been the same since. The resident reported an increase in pain since the fall (which she stated staff did address) but indicated she had experienced a decline since the fall, stating she was not able to do what she did before, could not longer walk in the facility or talk with other residents and staff as she just didn't have any energy. On 11/21/22 at 10:30 A.M. interview with the Assistant Director of Nursing (ADON)/Registered Nurse (RN) #804 revealed she was unaware Resident #37 was assessed as a fall risk on admission. The RN verified the facility had not implemented any fall safety interventions for the resident, who exhibited mild cognitive impairment on admission and the resident sustained a fall with injury on 11/19/22. Following the fall, RN #804 revealed the facility did not complete a comprehensive fall investigation and indicated no new interventions were initiated following the fall. RN #804 revealed Resident #37 had been very active and walked the facility a lot prior to sustaining the fall. The RN revealed the resident had experienced a significant decline in condition (after the fall) and could now only sit up in the chair for a short period of time. 2. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, severe intellectual disabilities and unspecified mood disorder. Review of the physician's orders revealed an order dated 03/09/22 to transfer (resident) using a mechanical (Hoyer) lift and two staff assist every day and night shift. Review of Resident #33's fall plan of care, dated 08/26/22 revealed an intervention to transfer using a Hoyer mechanical lift and two staff assist. Review of Resident #33's MDS 3.0 assessment, dated 10/21/22 revealed the resident exhibited severe cognitive impairment. On 11/22/22 at 9:00 A.M. State tested Nursing Assistant (STNA) #805 and STNA #807 were observed providing A.M. (morning) care to Resident #33. The STNA staff were observed to provide incontinence care and then assisted the resident to sit up on the side of the bed. Each STNA then picked Resident #33 up under the arms and lifted her from the bed to the chair. The resident had one foot on the floor, was not observed to be able to fully bear weight and a gait belt was not used during the transfer. On 11/22/22 at 9:10 A.M. interview with STNA #805 revealed she was unaware Resident #33 required a Hoyer mechanical lift to appropriately transfer from the bed to the wheelchair per the physician's order. Review of the facility Transfers and Lifts policy, dated 11/2022 revealed the facility would ensure all staff members were instructed in safe transfer and lifting techniques and how to report suspected injuries.

Based on record review, facility policy review and interview the facility failed to ensure routine skin assessments were completed for Resident #28 to timely identify the deterioration of a pressure ulcer. Actual Harm occurred on 09/23/22 after the facility failed to complete routine assessments (from 09/02/22 to 09/23/22) and evaluation of treatments for skin impairment resulting in Resident #28's sustaining a deterioration in skin integrity and subsequent Stage III (full thickness skin loss involving damage or premature death of subcutaneous tissue that may extend down to, but not through, underlying connective tissue. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) pressure ulcer to the right buttocks. This affected one resident (#28) of two residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers with the exclusion of Stage I pressure ulcers (non-blanchable redness with unopened skin). Findings include: Review of Resident #28's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Braden scale assessment, dated 06/14/22 revealed Resident #28 was at low risk for pressure ulcer development with risk factors identified as having rarely moist skin, chair fast status, very limited mobility, and a potential problem with friction and shear. A care plan initiated 06/15/22 indicated Resident #28 was at risk for complications such as pressure ulcers related to heart disease, diabetes mellitus, a history of peripheral vascular disease with areas of concern to both lower extremities, [CONDITION(S)] and moisture associated skin damage. The care plan indicated Resident #28 also refused to go to bed at times. Interventions included weekly head to toe skin inspections. A nursing skin assessment, dated 08/27/22 revealed the resident had two smaller than dime sized skin tears noted to Resident #28's right gluteal fold (a prominent fold that marks the upper limit of the thigh from the lower limit of the buttock). The physician was contacted with treatment orders received to change dressing every day and as necessary until resolved. A nursing skin assessment, dated 09/01/22 revealed the area to the right gluteal fold was assessed as a Stage II(superficial ulcer that presented as an abrasion, blister or shallow crater) pressure ulcer which measured 1.5 centimeters (cm) in length by 1.5 cm width with 0.3 cm depth. The assessment indicated factors contributing to the ulcer included decreased mobility, decreased activity, decreased sensory perception, poor nutrition, non-compliance and moisture. The assessment indicated Resident #28 frequently declined to reposition, opting to sit in her wheelchair for the duration of day shift despite education being provided. Orders were received to cleanse the open area with normal saline, pat it dry, apply calcium alginate to the wound bed and cover it with a dry sterile dressing every night shift and as necessary. A wound consultation note, dated 09/02/22 revealed Resident #28 had an area which started as shearing to the right buttocks but had gotten larger. There was no assessment of the right buttocks wound documented by the wound consultant at that time and there was no treatment change. A Braden scale assessment dated [DATE] continued to indicate Resident #28 was at low risk for development of pressure ulcers. The next documented assessment of the right buttocks pressure ulcer was completed by the wound consultant on 09/23/22 when the area was assessed to be a Stage III pressure ulcer which measured 1.5 cm in length by 1.9 cm width with 0.2 cm depth with a moderate amount of serosanguineous drainage (thin, possibly pink or red-tinged). At that time, Resident #28 reported wound pain rated as a five on a scale of 0 to 10 (with 10 being the most severe pain). The treatment was changed. On 11/23/22 at 8:40 A.M., Licensed Practical Nurse (LPN) #811 was interviewed regarding the lack of assessments of the right buttock pressure ulcer between 09/01/22 and 09/23/22, although the wound clinic had documented the area had gotten larger on 09/02/22. LPN #811 stated she would look for additional information. On 11/23/22 at 10:05 A.M., LPN #811 provided nursing notes, dated 09/07/22 at 1:04 A.M. which indicated Resident #28 refused to have treatment to her gluteal fold three times, on 09/08/22 at 12:19 A.M. which indicated Resident #28 refused treatment to her gluteal fold three times and on 09/13/22 at 7:04 A.M. indicating Resident #28 did not want her dressings changed at that time. LPN #811 indicated that was all staff could find regarding possible refusal of dressing changes that would not permit observations/assessments. LPN #811 verified even if Resident #28 refused dressing changes/assessments those specific days, there was no reason assessments could not have been completed on other days to ensure ongoing monitoring and assessments were being completed to timely identify the deterioration. As of 11/23/22 the area remained a Stage III pressure ulcer. Attempts to observe the resident's pressure ulcer during the onsite annual survey were unsuccessful. The resident was up out of bed very early each day and refused to lay down for a wound observation. Treatments were scheduled and completed during the night shift and had already been completed when the surveyor entered on night shift during the survey to observe. Review of the facility policy, titled Pressure Ulcers, effective October 2022 indicated the facility would ensure a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. The Unit Nurse would track the healing progress and alter the plan of care and treatment when needed by filling out a weekly pressure ulcer status report for each resident with skin breakdown that included type of wound, location, shape, measurements, stage, color/redness/warmth/swelling, granulation/surrounding tissue/ulcer edges, odor, treatments/dressing changes/medications, presence of infection or other complications, and pain. The assessment was to be used to evaluate pressure ulcer treatment weekly for effectiveness and inform the physician of pressure ulcer status.

Based on observation, record review, facility policy review and interview the facility failed to ensure Resident #32's [MEDICATION(S)] long-acting insulin was discarded once expired. This affected one resident (#32) of one resident identified during the medication storage review who had insulin stored in the medication storage cart on the East Wing. Findings include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #32's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's Medication Administration Records (MAR) from [DATE] to [DATE] revealed staff administered the [MEDICATION(S)] insulin daily as ordered. On [DATE] at 12:10 P.M. observation with Registered Nurse (RN) #809 of the East Wing medication administration cart revealed Resident #32's [MEDICATION(S)] long acting insulin was stored in the top drawer. A date on the insulin was noted to be [DATE]. On [DATE] at 12:12 P.M. interview with RN #809 revealed Resident #32's [MEDICATION(S)] long acting insulin was only good for 42 days once opened. RN #809 confirmed the insulin was opened on [DATE], had expired on [DATE] and should have been discarded at that time. Review of the facility Medication Storage policy, dated ,d+[DATE] revealed medications would be monitored to assure they were not expired, contaminated or unusable.

Based on record review, facility policy review and interview the facility failed to ensure as needed (PRN) anti-anxiety medication ([MEDICATION(S)]) ordered for Resident #33 was not ordered longer than 14 days, had a specific duration for use and stop date. The facility also failed to ensure an appropriate indication for use of the anti-psychotic medication ([MEDICATION(S)]) for Resident #26. This affected two residents (#26 and #33) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, severe intellectual disabilities and unspecified mood disorder. Review of Resident #33's physician's orders revealed an order, dated [DATE] for the anti-anxiety medication, [MEDICATION(S)] 0.5 mg (milligrams) by mouth every twelve hours as needed for behaviors. Record review revealed the medication was discontinued on [DATE] Review of Resident #33's physician progress note, dated [DATE] indicated to continue [MEDICATION(S)] for three months for breakthrough anxiety (from [DATE] to [DATE]). Review of Resident #33's physician's orders revealed an order, dated [DATE] for [MEDICATION(S)] 0.5 mg one tablet every eight hours as needed for behaviors related to restlessness and agitation. Record review revealed no stop date or discontinuation date for the medication. Review of Resident #33's physician's progress note, dated [DATE] and psychiatric progress note, dated [DATE] revealed no information related to the use of the [MEDICATION(S)]. The notes did not include a specific duration for use or stop date. Review of Resident #33's Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #33's medication administration records (MAR) from [DATE] to [DATE] revealed staff administered the [MEDICATION(S)] on [DATE] at 1:15 P.M., [DATE] at 8:38 P.M., [DATE] at 1:31 P.M., [DATE] at 10:35 A.M., [DATE] at 12:52 P.M., [DATE] at 8:03 A.M., [DATE] at 7:42 A.M., [DATE] at 10:51 A.M., [DATE] at 12:33 P.M., [DATE] at 12:20 P.M. and [DATE] at 10:28 A.M. On [DATE] at 10:55 A.M. interview with Registered Nurse (RN)/Clinical Director of Operations #812 confirmed Resident #33's [MEDICATION(S)] anti-anxiety medication did not have a specific duration for use or stop date and was continued greater than 14 days after being ordered on [DATE]. 2. Review of Resident #26's medical record revealed an initial admitted [DATE] with diagnoses including depression and anxiety disorder. A progress note by psychiatric Nurse Practitioner (NP) #812 on [DATE] indicated nursing requested Resident #26 be evaluated for severe depression. Resident #26 was in isolation for persistent [CONDITION(S)] (C-Diff). NP #812 indicated Resident #26 reported improved sleep with the use of [MEDICATION(S)] (treats [CONDITION(S)]) and [MEDICATION(S)] (anti-anxiety). Orders were given to discontinue [MEDICATION(S)] ordered on an as necessary basis, start [MEDICATION(S)] 5 milligrams (mg) every day at bedtime, discontinue [MEDICATION(S)] ordered on an as necessary basis, start [MEDICATION(S)] 25 mg every day at bedtime, and start [MEDICATION(S)] (anti-depressant) 20 mg every day. A nursing note dated [DATE] at 5:35 A.M. indicated Resident #26 appeared frantic when staff went to her room to provide incontinence care. Resident #26 stated there was a man in the corner by her curtain then spoke of two cats in the register. A nursing note, dated [DATE] at 12:48 P.M. indicated Resident #26 had a change in mental status, experiencing hallucinations concerning people being in her room and fearing they would harm her. Resident #26 was transferred to the hospital for evaluation. Upon return from the hospital on [DATE], Resident #26 had an order for the anti-psychotic medication, [MEDICATION(S)] 25 mg at bedtime for anxiety disorder. A nursing note, dated [DATE] at 1:49 P.M. indicated a physician visited and addressed the use of [MEDICATION(S)] for anxiety. The physician referred Resident #26 to psychiatric services to address changes. On [DATE] psychiatric NP #812 documented nursing requested re-evaluation for Resident #26 since she returned from the hospital. The note indicated Resident #26 had a new order for [MEDICATION(S)]. Resident #26 was oriented with short term memory gaps. Resident #26 appeared to be in better spirits. Resident #26 indicated she had some trouble sleeping and worried a lot at night. Resident #26 denied depression. Mood had trended upwards. No delusions, hallucinations, or paranoia were noted. Orders were given to discontinue the [MEDICATION(S)] with a note to avoid anti-psychotic. Orders were given to administer [MEDICATION(S)] 25 mg every day at bedtime for anxiety/sleeplessness. Review of the [DATE] Medication Administration Record (MAR) revealed no [MEDICATION(S)] was administered on [DATE]. On [DATE] a physician order was written for [MEDICATION(S)] 25 mg every day at bedtime for [CONDITION(S)] disorder. The diagnosis was added to the diagnosis list. However, there was no documentation as to why the [MEDICATION(S)] was restarted. On [DATE] a note from psychiatric NP #812 revealed Resident #26 denied depression/anxiety. The note indicated Resident #26 was psychiatrically stable. Instructions included maintaining [MEDICATION(S)] for anxiety, mood and pain. A gradual dose reduction would likely exacerbate target signs/symptoms thus decrease quality of life. The note did not address why the [MEDICATION(S)] was re-started or address how/why the resident had a [CONDITION(S)] disorder diagnosis. On [DATE] at 4:10 P.M. Registered Nurse (RN)/Clinical Director of Operations #808 was interviewed regarding the [MEDICATION(S)] use, why it was re-started, and who gave the diagnosis of [CONDITION(S)] disorder. No additional information was provided by RN #808 On [DATE] at 7:33 A.M. Licensed Practical Nurse (LPN) #811 was interviewed regarding the new diagnosis of [CONDITION(S)] disorder when the [MEDICATION(S)] was re-started when Resident #26 had no history of the diagnosis and prior to that diagnosis the physician had been indicating the [MEDICATION(S)] was used to treat anxiety. LPN #811 indicated the facility had been unable to locate additional information. On [DATE] at 11:13 A.M. psychiatric NP #812 was interviewed regarding the order to restart [MEDICATION(S)] for [CONDITION(S)] disorder. When asked how Resident #26 met the Diagnostic and Statistical Manual (DSM) of Mental Disorders criteria for [CONDITION(S)] disorder, psychiatric NP #812 stated if she added the diagnosis she would have indicated how Resident #26 met criteria. Psychiatric NP #812 stated she doubted she would have given such a diagnosis based on Resident #26's age as the symptoms for a [CONDITION(S)] or [CONDITION(S)] diagnosis generally were exhibited when a person was in their 20's or 30's. Psychiatric NP #812 revealed she did not document any notes when the facility called to indicate if a dose reduction was ineffective as the facility should be documenting why the medication was restarted. Psychiatric NP #812 stated the [MEDICATION(S)] was probably related to anxiety or breakthrough hallucinations although she had no way of knowing due to lack of documentation. Psychiatric NP #812 indicated the DSM revealed the symptoms of hallucinations had to last longer than what Resident #26 was experiencing for a diagnosis of [CONDITION(S)] disorder. Psychiatric NP #812 stated she did not know to what extent or if Resident #26 was having hallucinations when the [MEDICATION(S)] was restarted or if Resident #26 was experiencing distress. Psychiatric NP #812 voiced she hated that [MEDICATION(S)] was even classified as an anti-psychotic because at a lower dose of 25 or 50 mg there was no [MEDICATION(S)] blockage and it acted more like an antihistamine. The NP revealed the [MEDICATION(S)] was likely ordered for the resident's anxiety. On [DATE] at 1:38 P.M. interview with Clinical Director of Operations #813 revealed the staff person who wrote the [MEDICATION(S)] order on [DATE] was an agency nurse. On [DATE] at 2:24 P.M. interview with Physician #814 revealed Resident #26 was sent to a local hospital on [DATE] then was sent to another hospital [DATE] due to seizures. Physician #814 stated he could not access records from the second hospital and it was notoriously hard to get information from that hospital. Physician #814 stated Resident #26 had a rough time as she was diagnosed with [CONDITION(S)], her son died , and she had been on isolation for C-Diff for a long time. Review of the facility Medications-Anti-psychotic policy, effective [DATE] revealed each resident was to receive only those medications, in doses and for the duration clinically indicated to treat a resident's assessed conditions. An antipsychotic medication was used only for the following conditions/diagnoses as documented in the record and as it met the definitions in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Training Revision (DSM-IV-TR) or subsequent editions: the conditions included [CONDITION(S)], [CONDITION(S)] disorder, delusional disorder, mood disorders, schizophreniform disorder, [CONDITION(S)], atypical [CONDITION(S)], brief psychotic disorder, dementing illness with associated behavioral symptoms, medical illnesses or [CONDITION(S)] with manic or psychotic symptoms and/or treatment-related [CONDITION(S)] or [CONDITION(S)]. The policy indicated the clinical condition also had to meet at least one of the following criteria: 1. The symptoms were identified as being due to [CONDITION(S)] or [CONDITION(S)] (such as auditory, visual, or other hallucinations, delusions or 2. The behavioral symptoms presented a danger to the resident or to others or 3. The symptoms were significant enough that the resident was experiencing one or more of the following: inconsolable or persistent distress, significant decline in function, and/or substantial difficulty receiving needed care. The behavioral symptoms were: 1. Not due to a medical condition or problem that could be expected to improve or resolve as the underlying condition was treated AND 2. Persistent or likely to reoccur without continued treatment AND 3. Not sufficiently relieved by non-pharmacological interventions AND 4. Not due to environmental stressors that could be addressed to improve the psychotic symptoms or maintain safety AND 5. Not due to psychological stressors or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment that could be expected to improve or resolve as the situation was addressed.

Based on observation, record review and interview the facility failed to ensure Resident #11 received medication/treatment only while necessary by failing to discontinue an antibiotic medication cream after an area to the resident's back was healed. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/22 revealed Resident #11 had severe cognitive impairment with memory problems. The assessment revealed the resident required extensive two-person physical assistance for bed mobility, transfers, dressing, and personal hygiene. The assessment noted the resident was always incontinent of urine and bowel. On 11/22/22 at 1:41 P.M. Licensed Practical Nurse (LPN) #506 was observed performing the treatment to Resident #11. At the time of the observation, there were no areas draining on Resident #11. Interview with LPN #506 at the time of the observation revealed Resident #11 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #506 was unsure why the [MEDICATION(S)] cream was still being applied to his back as of this date. On 11/22/22 at 2:53 P.M. interview with Registered Nurse (RN) #808 confirmed Resident #11 had been receiving [MEDICATION(S)] cream to his back twice a day since it was originally ordered on 05/18/22. RN #808 verified the resident did not currently have any draining purpura and the areas of concern were not reddened. The RN was unable to provide justification for the continued use of the medicated treatment for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, record review and interview the facility failed to ensure Resident #4's oxygen tubing and humidification bottle were maintained in a clean and sanitary manner and changed weekly as ordered by the physician. This affected one resident (#4) of two residents reviewed for oxygen use. Findings include: Review of the medical record for Resident #4 revealed an initial admitted [DATE] a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of admission Minimum Data Set (MDS) 3.0 assessment, dated 10/03/22 revealed Resident #4 had intact cognition. The assessment revealed Resident #4 required extensive one-person physical assistance for bed mobility, transfers, and dressing, was independent with set up help only for eating and required staff supervision with one-person physical assistance for personal hygiene. The assessment also noted Resident #4 was occasionally incontinent of urine and always continent of bowel. Review of Resident #4's Treatment Administration Record for November 2022 revealed Resident #4 was to have oxygen tubing and bottle changed on 11/20/22. The administration record revealed these tasks were documented/signed off as being completed by the nurse. On 11/21/22 at 9:00 A.M. observation of Resident #4's oxygen tubing and humidifier bottle revealed they were dated 11/13/22. On 11/21/22 at 9:10 A.M. interview with Registered Nurse #505 verified Resident #4's oxygen tubing and bottle were dated 11/13/22 and had not been changed on 11/20/22 as per order.

Based on observation, record review, and interview the facility failed to ensure Resident #41 had a medical necessity for a urinary catheter. This affected one resident (#41) of two residents reviewed for urinary catheters. The facility identified two residents with indwelling urinary catheters. Findings include: Review of Resident #41's medical record revealed diagnoses included acute nephritic syndrome (a syndrome comprising signs of [CONDITION(S)], which is kidney disease involving inflammation), infection and [CONDITION(S)] reaction due to internal right knee prosthesis and type two diabetes mellitus. An admission assessment, dated 10/22/22 indicated Resident #41 had a urinary catheter (reason for use was not indicated) and was scheduled for [CONDITION(S)] on Tuesdays, Thursdays and Saturdays. An incision on the right knee was intact with 17 steri strips present. admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated 10/22/22 indicated Resident #41 had an indwelling urinary catheter which put her at risk for complications. The care plan did not indicate the rationale for the catheter use. A nursing note dated 10/23/22 at 9:36 P.M. indicated Resident #41 had a second knee surgery performed on 09/12/22. An admission Minimum Data Set (MDS) 3.0 assessment, dated 10/28/22 revealed Resident #41 was able to understand others, able to make herself understood and was cognitively intact. The MDS assessment noted the use of an indwelling urinary catheter. A skin assessment dated [DATE] indicated Resident #41's right knee incision was healed, well approximated and with no drainage. A nursing note dated 11/11/22 at 10:55 P.M. indicated Resident #41 was non-compliant with placement of the urinary catheter bag. The note indicated Resident #41 would lay it on floor even after education. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. indicated the nephrologist would be contacted for evaluation of removal of the urinary catheter. On 11/21/22 at 12:22 P.M. Resident #41 was observed to have a urinary catheter. Resident #41 stated she had the urinary catheter for a couple months but nobody was able to tell her why she had it. Resident #41 stated she did not think she should have the catheter. The resident indicated she was having no trouble voiding prior to the catheter being inserted. A nursing note, dated 11/22/22 at 7:48 A.M. revealed Resident #41 was requesting the urinary catheter be removed. The physician on call was notified and deferred to the nephrologist. The [CONDITION(S)] clinic was contacted and indicated they would speak with the nephrologist and inform the facility of his decision. No documentation was located indicating the rationale for the urinary catheter use. On 11/22/22 at 8:15 A.M. Registered Nurse (RN) #803 was seen/overheard on the phone informing an unidentified caller Resident #41 wanted the urinary catheter removed and stating she could see no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/22/22 at 8:19 A.M. RN #803 revealed Resident #41 had the urinary catheter when she was admitted . The catheter was in place because Resident #41 was having incontinence and it put her at risk for infecting her knee incision. Since the knee incision was healed and Resident #41 wanted the catheter out, the attending physician had her contact the [CONDITION(S)] center to ensure there would be no problem with removing it. On 11/22/22 at 11:18 A.M. interview with RN #810 revealed hospital records reflected the urinary catheter was placed on 10/07/22 when Resident #41 was having kidney issues and [CONDITION(S)]. The facility did not specifically do urinary catheter assessments. RN #810 revealed if the urinary catheter was placed to prevent infection of the knee incision, there would have been no further reason for the catheter once the skin was healed on 11/06/22. RN #810 verified she did not see any follow up on the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/22/22 at 3:02 P.M. RN #803 revealed she received an order it was okay to discontinue the resident's urinary catheter on this date.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #33, who required staff assistance for activities of daily living care was provided adequate grooming and personal hygiene. This affected one resident (#33) of one resident reviewed for activities of daily living (ADL) care. Findings include: Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's Minimum Data Set (MDS) 3.0 assessment, dated 10/21/22 revealed the resident exhibited severe cognitive impairment and required extensive one person assistance for personal hygiene. On 11/21/22 at 3:35 P.M. Resident #33 was observed sitting in the dining room with multiple other residents. The resident's hair appeared dirty and she had a large amount of small facial hair on her chin area. The resident was not interviewable at the time of the observation. On 11/22/22 at 9:00 A.M. State tested Nursing Assistant (STNA) #805 and STNA #807 were observed providing A.M./morning care to Resident #33. The staff provided incontinence care and then assisted the resident from the bed to a wheelchair. When questioned, STNA #805 indicated Resident #33 was shaved on shower days but she was unaware of the exact days she was scheduled for showers. At this point, Resident #33 was not shaved but her hair was combed. Her hair still appeared dirty and the facial hair was evident on her chin. The resident was taken from her room into the dining room and placed at a table with other residents who were in the dining room. On 11/22/22 at 11:19 A.M. interview with Resident #33's sister, who was visiting the resident in the main dining room revealed the resident was to receive showers two days per week on Wednesday and Saturday. At the time of the interview, Resident #33's sister voiced concerns the resident's hair was not clean and she was concerned about the facial hair on the resident's chin area. She stated her sister required (staff assistance) to be shaved and it was not provided adequately. On 11/22/22 at 11:27 A.M. interview with Registered Nurse (RN)/Clinical Director of Operations #808 confirmed Resident #33's hair appeared dirty and she had a large amount of small dark facial hair on her chin. Review of the Shower/Tub Bath policy, dated 02/2022 revealed the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

Based on observation, record review, review of infection control monthly tracking sheets and interview, the facility failed to ensure accuracy and completeness of the logs and failed to monitor infections on an ongoing basis in order to identify patterns or trends in a timely manner. The facility also failed to implement appropriate infection control practices during cleaning of glucometers and during provision of incontinence care. This had the potential to affect all 45 residents and affected Residents #14, #19, and #242. Findings include: 1. On 11/13/19 at 11:27 [NAME]M., infection control logs were reviewed with Registered Nurse (RN) #120. RN #120 stated the (MONTH) 2019 surveillance logs had not been completed as she did not usually start the logs until the beginning of the following month. RN #120 verified the (MONTH) 2019 log indicated Resident #19 had a urine sample 09/19/19 which tested positive for extended spectrum beta lactamase (ESBL), escherichia coli, and proteus mirabilis. The log indicated Resident #19 had an elevated temperature of 101.3 on 09/17/19 and 101.1 on 09/20/19. [MEDICATION NAME] was started 09/27/19 and [MEDICATION NAME] was started 09/28/19. The log indicated the information obtained did not meet the criteria of a true infection and did not indicate Resident #19 was placed in isolation. RN #120 stated usually if residents tested positive for ESBL they were placed in isolation and she would have to review Resident #19's medical record to determine if the log was accurate. On 11/13/19 at 1:44 P.M. RN #120 provided an order dated 09/24/19 which indicated Resident #19 was placed on contact isolation on 9/23/19. 2. Observation on 11/13/19 at 11:03 [NAME]M. revealed that Licensed Practical Nurse (LPN) #400 prepared to obtain a fingerstick glucose level on Resident #242 using the facility's glucometer. LPN #400 cleansed the glucometer, gathered supplies, and entered Resident #242's room. LPN #400 then sat the glucometer, lancet, and glucometer pouch on the bedside table without placing a barrier or cleaning the table first. LPN #400 obtained the blood glucose and exited the room. LPN #400 then threw the lancet into the regular trash at his medication cart instead of placing it in the sharps container, a safety storage container used for needles. He then cleansed the glucometer with a Clorox bleach wipe for approximately five seconds before discarding the wipe and putting away the glucometer. Interview on 11/13/19 at 11:27 [NAME]M. with LPN #400 verified that he did not clean or place a barrier on Resident #242's bedside table prior to placing the supplies on the table. It was further verified that LPN #400 threw Resident #242's lancet in the regular trash and not the sharps container. It was lastly verified that LPN only cleaned Resident #242's glucometer for approximately five seconds instead of the manufacture recommended 60 seconds. Review of the manufacture recommendation for Bleach Germicidal Wipes revealed that to effectively [MEDICAL CONDITION], and blood borne pathogens the wipe must have a least one minute of contact time with the object it is disinfecting. Review of the facility policy titled Obtaining a Fingerstick Glucose Level dated 02/2019 stated, Dispose of the lancet in the sharps container and clean reusable equipment according to the manufactures instructions. 3. Observation on 11/13/19 at 12:26 P.M. of catheter care for Resident #14 revealed State tested Nursing Assistant (STNA) #11 carried an uncovered graduated container of urine that was drained from the resident's catheter out of the resident's room to the adjacent room (#20) and emptied the graduated container into the toilet. Resident #14's room did not have a bathroom. She then rinsed the graduate out in room [ROOM NUMBER]'s sink. Interview on 11/13/19 at 12:35 P.M. with State tested Nurse Aide (STNA) #11 revealed, that she stated she has always wondered if she had to cover the urine before leaving the room but did not know. STNA #11 verified that she didn't cover the urine in the graduated container when she exited the room. 4. Observation on 11/13/19 at 12:39 P.M. of Resident #14's incontinence care, STNA #11 gathered supplies, washed hands, donned gloves, and began incontinence care. After providing the care, prior to removing her gloves, she opened the closet door to obtain an incontinence brief for Resident #14. She then continued care and removed her gloves. Interview on 11/13/19 at 12:45 P.M. with STNA #11 verified that she did not remove gloves, used for incontinence care, prior to opening the closet drawer to get a brief. Review of the facility's policy titled, Handwashing/Hand Hygiene dated 02/2019 stated, Employees must wash their hands for 10 to 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin.

Based on review of survey findings and staff interview, the facility failed to ensure corrective plans were initiated and/or comprehensively evaluated in regard to identified concerns. This had the potential to affect all 45 residents. Findings include: During the survey, deficient practices were identified regarding inconsistencies in code status records, pressure ulcer assessments and care, falls, and use of [MEDICAL CONDITION] medications. On 11/14/19 at 5:40 P.M., Registered Nurse (RN) #120 stated a concern was identified in a sister facility regarding advance directives not matching so an audit was completed at this facility and no issues were identified. RN #120 stated the facility had identified concerns with pressure ulcers in (MONTH) 2019. The facility instituted weekly visits by a wound care nurse. Nurses were educated on how to complete and accurately document skin assessments. Continuing education regarding pressure ulcers was planned for nurses upon hire and annually. On 10/01/19, the Quality Assurance (QA) committee identified concerns with falls and addressed the concerns. Concerns were identified in (MONTH) 2019 regarding nurses administering [MEDICAL CONDITION] medications ordered on an as necessary basis prior to attempting non-pharmacological interventions and education was conducted. When asked how the QA committee was determining if education was effective and if identified issues had been resolved, RN #120 stated the unit managers were responsible for determining if nurses were following education or if the practice continued. Neither of the unit managers indicated the education was ineffective or that the areas remained a concern causing a need to re-evaluate or change the corrective measures. RN #120 indicated though audits had not been mandatory to evaluate effectiveness of the training of the identified concerns they would probably need to be made mandatory. Review of the facility's Quality Assurance and Performance Improvement (QAPI) plan and policy (not dated) revealed the QA committee was responsible for coordinating and evaluating QAPI program activities. The QA committee was responsible for analyzing the QAPI program performance to identify and follow up on areas of concern and/or opportunities for improvement and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.

Based on observation, interview, and record review the facility failed to ensure medication was stored, labeled and disposed to meet professional standards. This had to the potential to affect all the residents at the facility. The facility's census was 45. Findings Include: Observation on [DATE] from 2:28 P.M. to 2:52 P.M. of the facility medication storage rooms, medication cart and refrigerator revealed, an open stock bottle of Calcium with vitamin D with an expiration date of ,[DATE] in the medication room, an open bottle of eye drops being stored with an open bottle of ear drops, open nasal sprays being stored in the same bin as open eye drops in the top drawer of the medication cart, and an open undated vial of [MEDICATION NAME] that was dispensed on [DATE] in the medication refrigerator. Interview on [DATE] at 2:52 P.M. with Licensed Practical Nurse #400 confirmed the facility failed to remove the expired bottle of calcium, failed to store eye, ear, and nasal medication separately, and failed to label a vial of [MEDICATION NAME] when opened. Review of the [MEDICATION NAME] insert for the [MEDICATION NAME] revealed that vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of the facility's undated storage of medication policy revealed, medications given by different routes should be separated.

Based on observation, interview and record review the facility failed to implement the bowel protocol for Resident's #3, #8, #18 and #27 and failed to comprehensively assess a non-pressure skin area for Resident's #32 and #8. This affected four of five residents reviewed for unnecessary medications and two of two residents reviewed for non-pressure skin areas. Findings include: 1. Record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) 3.0 dated 01/13/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one or two staff including toileting. Review of the bowel movement (BM) report revealed the resident had a BM in the morning of 09/20/19. Further review revealed the resident did not have another BM until the afternoon of 09/24/19. Review of the Medication Administration Record [REDACTED]. There was no evidence of assessment for bowel sounds or fecal impaction. Review of the BM report revealed the resident had a BM in the morning of 09/28/19. Further review revealed the resident did not have another BM until the afternoon of 10/03/19. Review of the MAR for (MONTH) 2019 revealed there was no evidence of implementing the BM protocol which indicated the resident should have received MOM in the morning of 10/02/19. The resident had a BM after administration of the MOM on 10/03/19 but further review of the MAR indicated [REDACTED]. There was no evidence of assessment for bowel sounds or fecal impaction. On 11/14/19 at 1:30 P.M., interview with the Director of Nursing (DON) verified the above concerns and verified there was no further documentation to support the facility followed the BM protocol. The DON verified the facility had recently implemented an alert on the computer to inform the nurses when a resident did not have a BM in three days in order for the nurses to implement the BM protocol. 2. Record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 dated 09/24/19 revealed the resident was severely cognitively impaired and needed extensive assistance of one person for toileting. Review of the BM report revealed the resident had a BM in morning of 10/10/19. Further review revealed the resident did not have another BM until the afternoon of 10/14/19. Review of the MAR for (MONTH) 2019 revealed there was no evidence of implementing the BM protocol. There was no evidence of assessment for bowel sounds or fecal impaction. On 11/14/19 at 1:30 P.M., interview with the DON verified the above concerns and verified there was no further documentation to support the facility followed the BM protocol. Review of the physician standing orders for constipation, not dated, revealed after three days without a BM 30 cubic centimeters (cc) of MOM would be given in the morning. If no BM after use of the MOM, the nurse was to check for fecal impaction and audible bowel sounds in all four quadrants, then a [MEDICATION NAME] suppository may be inserted on the afternoon shift. If the suppository was unsuccessful and no fecal impaction was detected, the nurse on night shift may give a fleets enema. 3. Record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 dated 08/12/19 revealed the resident was severely cognitively impaired and needed extensive assistance with activities of daily living (ADL) with one or two staff. The resident was mobile in a wheelchair but was not able to stand independently. The resident was not receiving anticoagulants but had been on aspirin at 81 milligrams (mg) daily since 08/24/17. Review of the nursing note dated 07/14/19 revealed the resident was found to have a large bruise to the left forearm. The area was swollen and tender to touch. There were no further assessments related to the bruise including description, size, when the bruise was found. No incident report was completed nor was the plan of care updated to reflect the bruise. Review of the nursing note dated 09/27/19 revealed the resident was found to have a large area of bruising along the lateral right thigh. There were no further assessments related to the bruise. No incident report was completed nor was the plan of care updated to reflect the bruise. On 11/14/91 at 1:30 P.M., interview with the DON verified the above concerns and was not able to provide any additional information. Review of the care of non-pressure wounds, dated (MONTH) 2019, revealed the purpose was to provide guidelines for prevention and treatment of [REDACTED]. When inspecting the wound include all information in the assessment including if bleeding, size of wound, partial of compete tissue loss etc. Provide interventions that could prevent additional areas such as clothing to cover the arms and legs. Include the signature, title, time and date the wound was recorded. Upon discovery of an area an incident report should be completed. Record the following information on the incident report: the resident's name, name of the employee discovering the area, site and description of the area including measurements, appearance and shape of wound edges, color, odor and amount of drainage; the date and time the area was discovered, the date and time the injury occurred if known, names or employees who provided care to the resident for the previous 24 hours, site care rendered and evaluation of the incident, the name of any witnesses's to the incident, the date and time the physician and sponsor were notified and any other information relative to the incident. 4. Review of Resident #3's medical record revealed [DIAGNOSES REDACTED].#3 was at increased risk for constipation related to her gastric tube feeding, nothing by mouth status, and decreased mobility. The goal was for Resident #3 to have a normal bowel movement at least every three days. Interventions included administering medication as ordered, recording bowel movement patterns every day, and following the facility bowel protocol for bowel management. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 required extensive assistance for toilet use and was always incontinent of bowel and bladder. Physician orders [REDACTED]. Review of Resident #3's bowel movement records from 09/01/19 through 11/13/19 revealed no record of a bowel movement recorded 10/03/19-10/06/19, 10/27/19-10/31/19, or 11/09/19-11/13/19. Review of the (MONTH) 2019 and (MONTH) 2019 revealed no MOM or [MEDICATION NAME] suppository was provided during those periods. On 11/13/19 at 4:35 P.M., Clinical Operations Manager #178 verified the above recorded dates with no record of a bowel movement and verified the facility's bowel protocol was not implemented. 5. Review of Resident #27's medical record revealed [DIAGNOSES REDACTED]. A plan of care initiated 05/07/19 indicated Resident #27 was at increased risk for constipation related to decreased mobility and medication side effects. The goal was for Resident #27 to have a normal bowel movement at least every three days. Interventions included following the facility bowel protocol for bowel management and recording bowel movement pattern each day. A physician's orders [REDACTED]. Bowel protocol step one was to administer the MOM if Resident #27 did not have a bowel movement in three days. A physician's orders [REDACTED].#27 did not have a bowel movement in eight hours after the MOM was administered. A quarterly MDS dated [DATE] indicated Resident #27 required extensive assistance with toilet use and was frequently incontinent of bowel. Review of Resident #27's bowel movement records between 09/01/19 and 11/14/19 revealed there was no bowel movement recorded 09/29/19 to 10/02/19, 10/13/19 to 10/16/19, 10/21/19 to 10/30/19, and 11/10/19 to 11/13/19 without initiation of the bowel protocol/physician orders. On 11/14/19 at 3:01 P.M., the Director of Nursing (DON) was informed there was no recorded bowel movement and a lack of initiation of the bowel protocol 09/29/19-10/02/19, 10/13/19-10/16/19 with no intervention until 10/17/19, 10/21/19-10/30/19, and 11/10/19 - 11/14/19. On 11/14/19 at 3:36 P.M., Registered Nurse (RN) #120 verified no additional information was able to be located. 6. Review of Resident #32's medical record revealed an admission on 05/31/17 with [DIAGNOSES REDACTED]. Review revealed a non pressure skin impairment that was not comprehensively assessed and treated. Review of the 10/08/19 quarterly MDS revealed the resident was independent for daily decision making, with no behaviors, required extensive assist of two for bed mobility and was totally dependent of two for transfers. The Weekly Skin Integrity review revealed on 10/27/19 a treatment was in place for red area to right buttock. An old area was checked as open area. There was no description or explanation of the open area. There was no skin assessment for 11/03/19. Review of the physician orders [REDACTED]. Review of the Nurse Notes revealed a note on 11/10/19 at 2:59 P.M. including an open area to left inner buttocks measuring 0.7 centimeters x 0.9 cm x 0.2 cm depth. Cleansed and dressing applied. There was no description of color, drainage, odor, periwound, or of wound bed. The Weekly Skin Integrity review revealed on 11/10/19 a left buttock area 0.7 cm x 0.9 cm x 0.2 cm treatment in place. There was no description of color, drainage, odor, periwound, wound bed or classification. Review of the physician orders [REDACTED]. Interview on 11/13/19 at 10:18 [NAME]M. with Resident #32 revealed they had not told him what was wrong with his behind but he knew it hurt. Interview on 11/13/19 at 3:55 PM with STNA's #105 and #212 revealed the resident's soiled dressing was removed from his buttock over an hour ago during care. The aides indicated they had not told the nurse and the skin impairment remained uncovered. Observation on 11/13/19 at 4:34 P.M. of a dressing change with Licensed Practical Nurse #221 revealed the area presented as a scratch, deep initially and gradually thinning out toward the end. The wound was red and the periwound flesh color. Interview on 11/14/19 at 12:48 P.M. with Registered Nurse #120 verified there was no comprehensive assessment of the skin impairment of the buttock. The measurements did not include the character, color, wound bed, drainage and classification of the wound. The weekly skin assessment was missed for 11/03/19. Further verified the STNA's should have reported the dressing was off the impairment in a timely manner.

Based on observation, record review and interview the facility failed to provide the care and services necessary to prevent an avoidable unstageable pressure sore from developing to Resident #57's left heel. This resulted in harm when Resident #57 developed an unstageable pressure ulcer of the left heel. This affected one resident (Resident #57) of three residents reviewed for pressure ulcers. Findings include Resident #57 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #57's assessment dated [DATE] revealed the resident was readmitted with bilateral soft heals that were intact. Review of the weekly skin checks revealed Resident #57's skin was intact on 09/28/13. There were no further assessments of the resident's skin documented through 10/07/13. Review of the wound evaluation flow sheet assessment dated [DATE] revealed a left heel unstageable pressure ulcer with a length of 1.5 centimeters (cm) and width of 1.5 cm with indeterminate depth was identified. An unstageable pressure ulcer is characterized as full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough or eschar. Resident #57's wound presented with eschar (thick, leathery, frequently black or brown in color, necrotic, or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound)colored brown to dark gray). Review of the current physician orders [REDACTED].#57 was to have heel protectors on at all times while in bed. Review of Resident #57's plan of care initiated 09/13/13 revealed Resident #57 had potential for skin breakdown related to debility and an open reduction internal fixation of the left hip with decreased mobility. The care plan did not reveal any indication Resident #57 was to have left heel protectors on at all times. The plan of care indicated to inspect skin with daily care. Review of Resident #57's most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 15. A BIMS score of 15 indicated the resident was cognitively intact. Review of the weekly skin checks revealed on 01/09/14 Resident #57's skin was intact. The skin assessment dated [DATE] indicated Resident #57's skin was intact. There were no further skin assessments documented as complete through 02/09/14. Review of the physician progress notes [REDACTED]. The progress note indicated the ulceration is discolored. The progress note indicated this also was a Stage II pressure ulcer and was improved. Review of Resident #57's physician order [REDACTED]. Review of the treatment administration record (TAR) for January of 2013 revealed documentation of the treatment to apply skin prep to the left heel and leave open to air. This treatment documentation revealed no evidence of the skin prep being applied from 01/10/14 through 01/21/14, 01/22/14 through 01/24/14, 01/29/13 through 01/31/13, 02/02/13 and 02/03/13. On 02/10/14 at 11:02 A.M., Resident #57 was observed in bed with socks on and heels positioned directly on the mattress. On 02/11/14 at 8;20 A.M., Resident #57 was again observed in bed with socks on and heels positioned directly on the mattress. Observation on 02/12/13 at 2:30 P.M. revealed Resident #57 in bed with heels placed on the bed mattress. There was no evidence of heel protectors in Resident #57's room. Registered nurse (RN) #114 removed Resident #57's sock and exposed Resident #57's left heel for the surveyor to observe. Resident #57's left heel was noted to have a hard white area with a dark brown center. RN #114 measured Resident #57's wound revealing a length of 1.5 cm by a width of 0.7 cm with an undetermined depth. Interview on 02/12/13 at 2:30 P.M. with RN #114 confirmed Resident #57 was not wearing heel protectors. RN #114 verified the size of the wound during the observation and indicated the dark brown center was eschar. RN #114 indicated the wound was unstageable due to the eschar. RN #114 indicated the wound was located in the same area as the previous wound on the left heel. Interview on 02/12/13 at 2:35 P.M. with Resident #57 indicated that at one point the resident had heel protectors but they disappeared. Resident #57 indicated the heel protectors "helped a lot". Interview on 02/12/14 at 2:42 P.M. with licensed practical nurse (LPN) #115 revealed there was no documentation of heel protectors being used for the resident. Interview on 02/12/14 at 2:53 P.M. with State tested nursing assistant (STNA) #116 verified Resident #57 did not have heel protectors on while in bed on 02/12/14. STNA #116 stated "to be honest I didn't know who was supposed to have them on". Interview on 02/12/14 at 3:10 P.M. with RN #114 verified the skin prep was not applied to Resident #57's left heel as ordered. The RN also verified the wound was in the same area as the previous wound and RN #114 believed it was the same wound that had deteriorated. RN #114 verified the wound was not resolved on 01/09/14 as indicated on the wound flow sheet. RN #114 verified the skin assessments were not documented as completed weekly between 09/28/13 and 10/08/13, and were not documented as completed weekly 01/23/14 through 02/09/14. Review of the skin care prevention protocol dated 12/04/00 revealed assessment of each residents skin condition will be performed weekly by a licensed nurse who will initial the treatment record to validate the observation. This protocol indicated protective devices for example elbow and heel protectors, for bony prominence's and or proper positioning will be utilized as needed.

Based on observations, record review and interview, the facility failed to ensure appropriate interventions were implemented to maintain adequate hydration for Resident #34, who suffered severe dehydration that required hospitalized from [DATE] until 09/22/10. This affected one of nine residents that were reviewed for nutrition/dehydration. The facility's census was 43. Findings include: Resident #34 was admitted on [DATE]. Current [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] indicated the resident had short and long term memory deficits and severe cognitive impairment. A nutritional assessment dated [DATE] indicated Resident #34 required limited assistance at meals and continued with a gradual weight loss due to a poor appetite. Resident #34 was identified as confused and requiring encouragement to eat. The "Nutrition/Dehydration Risk" plan of care identified Resident #34 as a risk for dehydration related to "multiple [DIAGNOSES REDACTED]. The September 2010 physician's orders [REDACTED]. September 2010 "Diet Sheets" revealed Resident #34 refused all food and fluids on 09/12/10. On 09/13/10 at breakfast, she consumed 50 percent (%) of her food and drank 210 milliliters (ml), of fluid, which was less than one cup. Resident #34 refused lunch and dinner on that day. "Nurse's Notes" dated 09/14/10 at 8:30 A.M. revealed Resident #34 was lethargic and unresponsive. The resident's was blood pressure was low at 94/62, and her heart rate was increased at 108 beats per minute, (BPM). Resident #34 was transported to the hospital emergency room via ambulance. Clinical manifestations of dehydration include rapid pulse, and a lethargic to comatose state. Decreased blood pressure is a sign of both dehydration [MEDICAL CONDITION]. Source: Mosby's Medical Dictionary, Fourth Edition. Hospital "Physical Examination" dated 09/14/10 indicated Resident #34 presented in the emergency room with a blood pressure of 98/60 and a heart rate of 110 BPM. The hospital physician's impression indicated Resident #34 was in a state of "severe dehydration" and urosepsis. Hospital laboratory result from 09/14/10 revealed Resident #34's blood urea nitrogen (BUN) level was severely elevated at 103 mg. per deciliter (dL), with the normal range of 7-19 mg/dL. Her blood sodium level was elevated at 157 millimoles/liter ((mmol/L) with the normal range of 136-145 mmol/L. Resident #34's chloride level was elevated at 116 mmol/L with the normal range of 98-107 mmol/L. Hospital "Discharge Summary" dated 09/22/10 confirmed Resident #34 had been admitted to the hospital due to severe dehydration, and urosepsis. Elevated BUN, sodium and chloride levels are all clinical indicators of dehydration. Source: Laboratory & Diagnostic Tests, Fifth Edition. Resident #34 received intravenous (IV) fluids and IV antibiotics and was followed closely. She experienced hypokalemia (low potassium levels) which required replacement. Dehydration was listed among the discharge diagnoses. Resident #34 was observed on 11/30/10 at 11:16 A.M., 5:00 P.M., on 12/01/10 at 7:30 A.M., 10:45 A.M., 12:30 P.M. and 3:07 P.M. and on 12/02/10 at 7:42 A.M. Resident #34 remained non-verbal, making only eye contact in response to surveyor greetings. She was alert, but seemingly very confused. During an interview on 12/02/10 at 8:03 A.M., the Director of Nursing (DON) acknowledged that facility "Diet Sheets"/intake records indicated that on 09/12/10 Resident #34 refused all food and drink. She verified that on 09/13/10 Resident #34 consumed 50% of her breakfast meal with 210 ml of fluids, and refused lunch and dinner. The DON confirmed there were no "Nurses Notes" after 09/06/10 until 09/14/10 at 8:30 A.M. The DON verified there was no documentation by facility nurses of Resident #34's refusals of food and drink, nor was there evidence that any interventions were implemented to encourage the resident to eat and drink. She confirmed there was no documented evidence that Resident #34's physician was notified of her significant change in condition until she became unresponsive on 09/14/10. The DON indicated it was the expectation of the nurses to review the "Diet Sheets" daily to monitor the residents' nutritional/fluid intakes. A general guideline for determining baseline daily fluid needs would be to multiply body weight in kilograms (kg) by 30 ml. Resident #34 weighed approximately 135 pounds, or 61.4 kg. Her recommended baseline daily fluid requirement was 1,842 ml.