Every finding on record at Advanced Health Care of Summerlin

Based on observation, interview, record review and document review, the facility failed to ensure 1) a peripheral intravenous (IV) access was not inserted without a physician order 2) and complications to the IV access which resulted in incomplete administration of an IV medication was communicated to the physician and documented in the resident's electronic health record (EHR) for 1 of 13 sampled residents (Resident 61). The deficient practice had the potential to place the resident at risk for other IV-related complications such as pain and unresolved dehydration.Findings include:Resident 61 (R61) was admitted on [DATE], with diagnoses including paralytic syndrome following cerebral infarction and dehydration.On 01/27/2026 in the morning, R61 was lying in bed, alert, with a peripheral IV access on right hand with the dressing dated 01/16/2026. IV tubing was looped around an IV pole where a half empty bag of normal saline (NS) hung by the right side of the resident's bed. R61 explained the IV access was placed yesterday because the resident was not drinking enough but verbalized not knowing why the IV tubing was disconnected and NS bag was half empty.A physician order dated 01/26/2026 (12:02 PM), documented to give Dextrose D5 %- 0.45 percent (%) sodium chloride at 50 cubic centimeters per hour (cc/hr.) times two liters for hydration.The medical record lacked documented evidence a physician order was obtained for the insertion of the peripheral IV access and documentation of the insertion procedure such as site location, needle gauge, number of attempts, patient response and complications which may have resulted in the incomplete administration of the prescribed IV medication.On 01/28/2026 at 12:30 PM, a charge nurse indicated receiving a telephone order from R61's provider to administer two bags of D5-0.45% NS at 55 cc/hr. until completed. The charge nurse indicated receiving the order on 01/26/2026 between 10:00 AM to 11:00 AM. The charge nurse acknowledged an order for IV access insertion was not obtained nor transcribed in the resident's EHR. The charge nurse indicated an IV medication order automatically meant IV access would have been needed.The facility's Medication Order policy (undated), documented telephone orders were promptly entered into the resident's EHR.On 01/28/2026 at 12:35 PM, the Director of Nursing (DON), who was present during the interview with the charge nurse, interrupted stating a separate order was required for an IV access insertion. The DON indicated telephone orders were written on a physician order form or entered directly into the resident's EHR prior to the insertion procedure. The DON acknowledged personally entering the physician orders for the peripheral IV access insertion and care into R61's EHR after noticing the IV line on R61's right hand during morning rounds on 01/27/2026 at 7:20 AM.The medical record lacked a documented reason to explain why R61's IV medication was interrupted, and evidence a physician was notified of complications to R61's IV access. On 01/28/2026 at 12:52 PM, the charge nurse and DON confirmed there was no documentation explaining why R61's IV fluid administration was interrupted, and whether the physician was notified.On 01/28/2026 at 12:57 PM, a registered nurse (RN) recounted inserting R61's peripheral IV access on 01/26/2026 at approximately 5:00 PM and initiated IV fluid administration related to the resident's dehydration status. The RN indicated being aware a physician order was required prior to the insertion but assumed the order had already been entered by the charge nurse who had instructed the RN to insert the IV access and initiated IV fluids to R61.On 01/28/2026 at 1:00PM, the RN indicated starting the shift at 6:00 AM and receiving report from night shift that R61's IV access was patent with no issues. The RN noticed R61's IV access started leaking mid-morning which resulted in discontinuing the IV medication and disconnecting the tubing. The RN acknowledged documentation of the IV access complication and interruption of treatment should have been reported to the provider immediately and documented in the resident's EHR but became busy with other patient care. The facility's Patient Care policy (undated) documented entries to the medical record were made at the time the action occurs.On 01/28/2026 in the afternoon, the DON indicated only one-half of the first NS bag had been administered to R61 since receiving the physician order on 01/26/2026 in the morning and there was no documentation explaining the IV complication which resulted in incomplete administration of R61's fluids along with no evidence of physician notification.The facility's IV Access Device policy (undated) documented the facility ensured IV accesses were managed safely to protect residents from complications and improper device management, allowing continuity of treatment. A physician order was required for device insertion, assessment was documented and the provider was notified immediately when complications were detected.

Based on observation, interview, record review and document review, the facility failed to ensure physician orders for pain medications were followed for 1 of 13 sampled residents (Resident 9). The deficient practice had the potential to place the residents at risk for inadequate pain control. Findings include:Resident 9 (R9) was admitted on [DATE], with diagnoses including hemicolectomy (surgical removal of part of the colon) and malignant neoplasm of the colon.On 01/27/2026 in the morning, R9 pulled up their gown revealing a surgical scar in the abdominal area. R9 indicated severe unrelenting pain caused them to present to the hospital where the resident was diagnosed with colon cancer which had spread.A hospital Discharge summary dated [DATE], documented R9 presented with abdominal pain which worsened over the past week. A mass was identified in the middle ascending colon which was confirmed as colon cancer with metastasis to the liver and nodules throughout the peritoneum.A physician order dated 12/31/2025, documented to give Acetaminophen 650 milligrams (mg) for moderate pain level four to six out of 10 (4-6/10) in the pain scale. A physician order dated 12/31/2025, documented to give Oxycodone 5 mg for severe pain seven to 10 (7-10/10) in the pain scale.The medication administration record (MAR) for January 2026, revealed R9 was given Acetaminophen when the resident expressed severe pain on:-01/14/2026 at 6:38 PM at pain level 7/10-01/15/2026 at 2:06 PM at pain level 7/10-01/16/2026 at 4:36 PM at pain level 8/10-01/16/2026 at 8:22 PM at pain level 7/10-01/18/2026 at 6:03 PM at pain level 7/10-01/20/2026 at 10:41 AM at pain level 7/10-01/21/2026 at 5:57 PM at pain level 7/10-01/22/2026 at 2:24 PM at pain level 10/10On 01/28/2026 at 11:51 AM, a registered nurse (RN) assigned to R9 indicated being familiar with the resident's pain issues which were related to cancer. The RN explained R9 had two pain medication orders: Acetaminophen for moderate pain and Oxycodone for severe pain. The RN explained when R9 complained of pain, the resident's pain was assessed for location, description and intensity using the pain scale and the appropriate medication was administered. After reviewing R9's MAR, the RN confirmed Acetaminophen was administered when the resident complained of severe pain rated at 7 to 10 on the pain scale. The RN indicated not giving the appropriate pain medication placed the resident at risk for inadequate pain control.On 01/28/2026 at 12:03 PM, the Director of Nursing (DON) indicated being familiar with R9 who was admitted to the facility following a diagnosis of colon cancer with metastasis which was the reason pain management was a top priority for this resident. The DON indicated there were two pain medications ordered for R9, Acetaminophen for moderate pain (4-6/10) and Oxycodone (7-10/10). The DON reviewed R9's MAR and confirmed physician orders were not followed when Acetaminophen was administered for severe pain on: 01/14/2026, 01/15/2026, 01/16/2026, 01/16/2026, 01/18/2026, 01/20/2026, 01/21/2026, and 01/22/2026. The DON indicated this placed R9 at risk for inadequate pain control.The facility's Pain Management policy (undated) documented that all residents were assessed for pain upon admission and educated regarding pain management and current orders. Residents were assessed for intensity of pain utilizing a standard pain scale of zero to10. Pain medications were administered according to the pain assessment, location and intensity.

Based on interview, record review and document review, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 of 4 sampled residents (Resident 1). The deficient practice had the potential for failure to ensure the resident's safety and prevent further abuse from occurring. Findings include:Resident 1 (R1) was admitted on [DATE] and discharged on 05/27/2025, with diagnoses including intervertebral disc degeneration, morbid obesity, and long term use of opiate analgesic. The Nurse's Notes (progress notes) dated 05/18/2025 at 4:10 PM, documented (Name of R1) complained that a few nights ago, three nurses came in to reposition me at night, They pulled my arm and as a result, I developed bruises on my left arm and the inner side of my elbow. 2 spots around 3 cm dark decolorization noticed. No s/sx of infection or pain. Pt couldn't remember the exact date. DON reported. There was no documented evidence of the facility's investigation regarding R1's allegation. On 09/24/2025 at 11:38 AM, Registered Nurse 1 (RN1) explained an allegation of abuse from a resident, family, or staff, should have been reported immediately to the Administrator. RN1 would have initiated the investigation right away by interviewing the staff, residents, and family about the allegation. RN1 explained notifying the Director of Nursing (DON) and Administrator about the details and results of the initial investigation conducted. RN1 would also notify the resident's physician. RN1 indicated documenting the reported allegations of abuse in the progress notes and the actions taken to address the allegation. RN1 confirmed reporting to the DON the allegation made by R1 as documented in the nurse's notes dated 05/18/2025 at 4:10 PM. RN1 requested to review the notes and R1's medical record to verify the actions taken regarding the resident's reported allegation of abuse. On 09/24/2025 at 11:48 AM, RN2 revealed R1's complaint documented in the nurse's notes dated 05/18/2025 at 4:10 PM was an allegation of abuse and should have been reported and investigated right away. RN2 explained if such complaint was received from a resident or staff, RN2 would have reported the allegation to the Administrator. RN2 would have initiated the investigation right away. RN2 explained the reported allegation and actions taken should have been documented in the nurse's notes. On 09/24/2025 at 11:55 AM, RN1 revealed working as a Charge Nurse on 05/18/2025, Sunday. RN1 confirmed R1 reported an allegation of abuse as documented in the nurse's notes and notifying the DON about the allegation. RN1 explained not knowing the staff involved because R1 reported the incident happened few nights ago. RN1 indicated an investigation of the allegation of abuse was not initiated because RN1 did not know which staff to interview or suspend. On 09/24/2025 at 12:07 PM, a Charge Nurse explained if an allegation of abuse was received from a resident, similar to the allegations made by R1, the Charge Nurse would have completed a head-to-toe skin assessment, interviewed the resident, and notified the physician, DON and Administrator. The Charge Nurse would have documented the assessment in the nurse's notes including the allegation and actions taken by the Charge Nurse to address the allegation. The Charge Nurse would have initiated an investigation immediately or right after the resident reported the allegation. On 09/24/2025 at 1:01 PM, a Certified Nursing Assistant (CNA) indicated being assigned to R1 when the resident was still at the facility. R1 required two to three person assist and maximum assistance in turning and repositioning. The CNA revealed on two occasions while the CNA was changing the resident in bed with another CNA, R1 requested the CNA to be gentle because the resident was in a lot of pain. R1 claimed other people, especially on night shift, were rough with the resident. R1 was always in pain and complained when being turned and repositioned. On 09/24/2025 at 1:26 PM, the DON explained the staff were expected to notify the DON or the Administrator right away for an allegation of abuse, even if it was a hearsay. The DON and the Administrator would have initiated an investigation immediately which included interviewing the residents and staff or possible witnesses. The alleged perpetrator, if a staff member, would have been suspended pending investigation. The facility would ensure the resident's safety. The Administrator would have reported the incident to the State. The DON explained a head-to-toe skin assessment would have been completed for an allegation of physical abuse and documented the assessment in the progress notes. The DON confirmed not being aware of the alleged incident documented in the nurse's notes dated 05/18/2025 at 4:10 PM. The DON acknowledged R1's allegation was not reported to the DON. The DON revealed there was no documentation in the progress notes about the follow-up made regarding the R1's allegation. The DON indicated RN1 was the supervisor on 05/18/2025 and should have done an investigation such as determining the staff involved and reported to the DON. The DON confirmed the allegation was not followed through and investigated because the DON was not aware of the allegation. The DON acknowledged R1 made an allegation of physical abuse based on the nurse's notes. If the DON was made aware of the alleged incident, the DON would have conducted an investigation right away and notified the Administrator. The DON would have asked the Administrator to review the closed-circuit television (CCTV) to find the staff members who went inside R1's room prior to 05/18/2025. R1 and other residents who were possible witnesses should have been interviewed. R1's family should have been informed regarding the abuse allegation. The DON explained the staffing schedule should have been reviewed to determine the CNAs and nurses who were assigned to R1 prior to 05/18/2025, then interviewed the nursing staff identified in the schedule. The DON acknowledged these actions were not done and the abuse allegation was not investigated. On 09/24/2025 at 1:47 PM, the Administrator confirmed not being informed of the alleged incident documented in the nurse's notes dated 05/18/2025 at 4:10 PM for R1. The Administrator acknowledged there was no investigation conducted regarding R1's allegation. The facility policy titled Abuse Policy and Procedure (undated), documented the Administrator and Director of Nursing would be immediately called for any suspected or reported abuse. The Administrator or Director of Nursing would then ensure the safety of the residents, begin the investigation, and if necessary, report the information to the police, Department of Health and Welfare, family, physician, and/or any other appropriate agency. The charge nurse would complete an Incident Report when indicated. The Incident Report would be reported to the Administrator and/or Director of Nursing immediately. The Administrator and/or Director of Nursing would complete an investigation of the incident including a written summary of the findings no later than five working days of the reported occurrence. The summary would include interview notes, incident report, and written, signed, and dated statements from the accused, and witnesses, and the person reporting the incident. Complaint 2297619

Based on observation, interview, record review and document review, the facility failed to properly discuss and provide documentation of resident's discharge planning and appeal rights for 1 of 14 sampled residents (Resident 95). The deficient practice had a potential for a resident to not be able to exercise the right to appeal a discharge decision from the Managed Medicare (MA) Plan and have the necessary planning for discharge. Findings include: Resident 95 (R95) R95 was admitted on [DATE], with diagnoses including Parkinson's disease without dyskinesia and acute respiratory failure. On 08/21/2024 at 12:10 PM, R95 verbalized being discharged tomorrow (08/22/2024). The resident voiced concerns regarding the continuation of care proposed by the facility and the quality of care to be received with the Home Health Agency (HHA). The resident had reservations the current functional capacity might not be fitting to be downgraded to a lower level of care. The resident verbalized signing a discharge notice and was sure no option to appeal was mentioned during the discussion with the Case Manager (CM). The resident did not have a copy of the Notice of Medicare Non-Coverage (NOMNC) and confirmed signing the document and no copy was provided. Observed R95 go thru documents received from the facility and only admission documents were in possession. On 11/21/2024 at 12:31 PM, the CM indicated the resident signed the NOMNC and a copy was placed at the discharge packet to be sent home with the resident. The CM confirmed the resident was not provided a copy and the appeal option was discussed upon signing the NOMNC. The CM agreed a copy should have been left with the resident to be reviewed at a later time. The CM acknowledged having a copy would be good for the resident to have if in case a decision to appeal the discharge come into mind, the resident would have the appeals contact number. The CM agreed the resident had now passed the deadline to have an expedited independent review from the Quality Improvement Organization (QIO- an independent reviewer to ensure NOMNC was issued according to MA guidelines) and an insurance appeal was the only available option which was not expedited and could lead to a financial risk if the insurance appeal was not successful. R95's MDS completed on admission had a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 reflects: 13 - 15 points: Cognitively intact. R95's electronic health care records revealed one entry from Care Coordination. The documentation lacked the necessary details of discharge planning for the resident's continuation of care needs or any discussion with regards to the notice of discharge appeal rights. On 11/21/2024 at 2:41 PM, the Director of Nursing (DON) and interim DON confirmed CM and discharge planning department was under nursing services. The DONs confirmed all documents signed by a resident and the representative; a copy of the signed document should be provided for further reference. The DONs expectation for discharge documentation was to document all the necessary discharge planning provided to the resident. R95 had a BIMS of 15 and the DONs agreed the resident was capable to fully express any desire of wanting to appeal if discussed or the resident had the capacity to read and digest any information on the NOMNC if provided. The DONs acknowledged R95 had missed an opportunity to have an independent review from the QIO due to the lack of provision of document material to further reference resident rights. The facility policy titled Patient Discharge (undated), documented when the facility transfers or discharges a resident under any circumstances, the facility will ensure that the transfer or discharge is documented in the resident's medical record. #9. All other necessary information, as applicable to ensure a safe and effective transition of care. The facility policy titled Resident Rights - facility version A0717, documented the resident has the right to receive notices orally (meaning spoken) and in writing (including braille) in a format and a language he or she understands, including: 1. Required notices: The facility must furnish to each resident a written description of legal rights which includes: state and local advocacy organizations.

Based on observation, interview, record review, and document review, the facility failed to ensure: 1) visitors were educated on the proper use of PPE and wore PPE inside the contact isolation precaution room (Resident 145) and 2) signage for Enhanced Barrier Precaution (EBP) was posted for a resident with a draining wound, personal protective equipment (PPE) was available, and staff used gowns when providing direct care to residents on precautions (Resident 146). The deficient practice could have the potential to increase cross-contamination and transmission of multidrug-resistant organisms (MDROs) and the spread of infectious agents, including multidrug-resistant organisms (MDROs), increasing the risk of healthcare-associated infections (HAIs) among residents, staff, and visitors. Findings include: Resident 145 (R145) R145 was admitted on [DATE], with diagnoses including surgical care aftercare following surgery on the digestive system and sepsis. A physician order dated 11/07/2024, documented R145 was on strict contact isolation for Vancomycin-Resistant Enterococci (VRE) wound. On 11/19/2024 at 10:44 AM, contact precautions signage was posted by the entrance, and PPE supplies were available. The signage indicated to perform hand hygiene and wear PPE upon room entry. R145 was in bed with eyes closed with R145's family, who had not been wearing PPE, at the bedside. A staff member was present inside the room. On 11/21/2024 in the afternoon, R145's family was at bedside with no PPE. The family indicated the staff did not say anything about wearing PPE. On 11/21/2024 at 2:37 PM, the Infection Preventionist (IP) indicated R145 was admitted with a VRE wound infection and was placed on contact isolation. The IP indicated the PPE should have been worn before entering the room, including the staff and visitors. The IP indicated the family should have been provided education regarding the importance of wearing PPE in the contact isolation room to prevent cross-contamination. Resident 146 (R146) R146 was admitted on [DATE], with diagnoses including cardiogenic shock, acute kidney failure, lymphedema, and localized edema (swelling). The Observation Detail List Report dated 11/15/2024, documented a brief interview of mental status score of 15/15, which indicated R146's cognitive status was intact. On 11/19/2024 at 11:07 AM, R146 was seated in the wheelchair, alert and verbally responsive. Severe weeping edema (water retention that occurs when fluid leaks through the skin due to swelling) on the bilateral lower legs and a soiled and wet wound dressing were noted on R146's left lower leg. R146 indicated had a chronic open wound on the leg and on the thigh prior to admission. R146 indicated the peripheral IV access was placed a few days ago by the licensed nurse. There was no EBP signage posted and no PPE available by the entrance door. On 11/19/2024 at 11:27 AM, the Clinical Care Manager (CCM), the Wound Nurse Practitioner and the Wound Care Treatment Nurse (WCTN) entered R146's room, assessed, and treated the wound on the left lower leg and other parts of R146's body without wearing a gown. The wound NP indicated it was the first time R146 was seen and described the left lower lateral leg wound as non-pressure, but it was opened and draining. The NP indicated the dressing was wet and noted a scant amount of serous (clear to yellow fluid) drainage. On 11/20/24 at 11:13 AM, the WCTN confirmed there was no EBP signage posted by the door and no PPE available in R146's room. The WCTN indicated a gown should have been worn to protect self, especially during direct contact for wound treatment, regardless of whether the resident was on precautions or not. On 11/21/2024 at 8:10 AM, a Certified Nursing Assistant (CNA) provided direct care to R146 in the room without a gown, wheeled R146 to the dining room, and entered back into the room and fixed R146's bed without wearing a gown. The CNA confirmed was not wearing a gown and was aware R146 was on EBP. The CNA explained EBP protocol should have been followed to prevent contamination. On 11/21/20 at 1:28 PM, the IP indicated there should have been an EBP signage and available PPE by the door to prompt the staff and visitors due to R146's open wound. The IP indicated regardless of what kind of wound it was, EBP protocol was required. The IP explained the admission nurse and the floor nurse were responsible for initiating the precautions upon the resident's admission. The IP indicated the staff were expected to follow the protocols by putting in an order, putting up signage, performing hand hygiene, and wearing the PPE to prevent cross-contamination. A facility policy titled Enhanced Barrier Precautions (undated), documented the facility adhered to guidance by the Centers for Disease Control and Prevention (CDC) regarding the prevention of the spread of multidrug-resistant organisms through the use of Enhanced Barrier Precautions (EBP). Residents were placed on EBP for the following conditions: wounds, the presence of an indwelling medical device, or infection or colonization with a CDC-targeted multidrug-resistant organism. Staff members donned gowns and gloves during high-contact resident care activities, including changing linens, performing wound care, and providing hygiene. Signage was posted outside the resident's room indicating the type of precautions, the required personal protective equipment (PPE), and high-contact resident care activities.

Based on observation, interview, record review and document review, the facility failed to ensure residents had physician orders and assessment for self-medicating; and medications were properly secured in the resident's room for 2 of 14 sampled residents (Resident 98 and 102). The deficient practices had a potential for a resident to improperly administer and store medications. Findings include: Resident 98 (R98) R98 was admitted on [DATE], with diagnoses including fracture of left lower leg and end stage renal disease on hemodialysis. On 11/19/2024 at 10:34 AM, observed at R98's bedside table was a Family Wellness brand Stomach Relief, Maximum Strength, bismuth subsalicylate 1050 milligram bottle. R98 indicated bringing in the medication from home just in case of needing it. R98 indicated taking the medication for upset stomach or hyperacidity. The resident confirmed placing the medication at the bedside table ever since arrival and none of the staff had questioned its presence. On 11/20/2024 at 11:45 AM, the nurse caring for R98 was not aware of the medication at the resident's bedside. The nurse confirmed all medications should be secured and if there was one, a Self-Administration assessment should be completed. The nurse confirmed R98 did not have a self-administration assessment completed. R98's progress notes had an entry from the nurse dated 11/20/2024 at 12:01 PM, The nurse's note documented: noted patient had Pepto Bismol in room that family had brought in, the patient does not have an order for this medication and states not using it, reminded patient that medication cannot be kept in room per policy, and was in agreement to take med out of the room and place in med cart to give back to the family when they visit. On 11/20/2024 at 12:59 PM, the Unit Manager (UM) indicated the nurse made an entry into the progress note indicating the presence of an unsecured medication and the resident had no self-administration assessment or physician's order. The UM confirmed a self-administration assessment should have been completed and the medication should have been secured. Resident 102 (R102) R102 was admitted on [DATE], with diagnoses including malignant neoplasm of the bronchus and open wound of the left lower leg. On 11/19/2024 at 9:41 AM, R102 indicated having lung cancer and taking supplemental medications. Observed at R102's bedside table were bottles of supplemental medications: 1) [NAME] Vegetable Supplement, 2) [NAME] Energy - Oxygen, 2) [NAME] Energy - Lungs, 3) [NAME] Energy - Colosil Plus, 4) [NAME] Energy - VirX. R102 indicated bringing the meds from home and has been taking it religiously. R102 indicated the medication was given by a friend living in Canada and was informed the medications should be good in fighting for cancer. On 11/20/2024 at 11:45 AM, the nurse caring for R102 was aware of the medication at the resident's bedside. The nurse indicated completing the self-administration assessment and confirmed not having an actual physician's order. The nurse also confirmed medications should be kept secured even when inside the resident's room. R102's electronic healthcare record had a Self-Medication Administration Assessment completed on 11/19/2024. R102's admitted was 11/12/2024. On 11/20/24 at 12:59 PM, the UM indicated the nurse should have completed the self-assessment since admission and medications should be kept secured. The UM confirmed all medications a resident will be taking should have a physician's order. The facility policy titled Self Medication Administration (Undated), documented as part of their overall evaluation, staff will assess each patient's mental and physical abilities to determine whether a patient is capable of self-administering medications. In addition to general evaluation of decision-making capacity, staff will perform a more specific skills assessment utilizing the Self-Medication Administration Assessment form. For self-administering patients, the nursing staff will be responsible for documenting that medications were taken on the eMAR. Self-administered medications must be stored in a safe and secure place, which is not accessible to other patients.

Based on observation, interview, record review, and document review, the facility failed to ensure the peripheral intravenous (IV) access was identified, flushed, and monitored, and a physician order was obtained or removed when not in use for 1 of 14 sampled residents (Resident 144). This deficient practice could have the potential to result in complications such as infection, infiltration, and phlebitis, or other adverse outcomes. Findings: Resident 144 (R144) R144 was admitted on [DATE], with diagnoses including anemia and altered mental status. On 11/19/2024 at 10:09 AM, R144 was in bed alert, verbally responsive but hard of hearing. A peripheral IV access was on the right arm; the dressing was undated, and skin redness was observed around the insertion site and had dried blood-like residue. R144 was unaware of the reason for the IV access placement and could not remember when it was inserted. R144's Admission Skin assessment dated [DATE], lacked documented evidence the peripheral IV access was identified. On 11/19/2024 at 2:42 PM, R144's family was at bedside, indicating R144's IV access was inserted in the hospital prior to admission at the facility. The family indicated R144 had been admitted 11 days ago, and the family was told by the facility staff the peripheral IV access would be removed for non-use. R144's medical records lacked documented evidence of the peripheral IV access, peripheral intravenous (IV) access was identified, flushed, monitored, and a physician order was obtained or removed when not in use. On 11/19/2024 at 2:44 PM, a Registered Nurse (RN) verified and indicated R144's peripheral IV should have been removed for non-use. The RN confirmed there was no order in place for the utilization and management of R144's peripheral IV access. The RN indicated there should have been an assessment upon R144's admission; IV should have been flushed, monitored for signs and symptoms of infection, or discontinued for non-use. The RN proceeded to remove the peripheral IV and confirmed redness surrounding the insertion site. On 11/20/2024 at 11:32 AM, the Clinical Care Manager (CCM) indicated the resident should have been assessed upon admission, and the admission Licensed Nurse should have completed the skin assessment. The CCM indicated any IV access should have been flushed, and the insertion site would be monitored for s/s of infection, and if not in use, should have been discontinued to prevent infection. A facility policy titled Admission Skin Assessment (undated), documented upon admission the resident would be examined to identify current issues. The physician would be contacted to initiate appropriate treatment orders if not addressed in the physician admit orders. The admission skin assessment would be uploaded into resident documents. The admitting nurse was responsible for ensuring the selected interventions were initiated, appropriate equipment was placed, and monitoring was placed on the treatment record and baseline-centered care plan as indicated. A facility policy titled Intravenous Access (undated), documented to appropriately maintain intravenous access devices.

Based on observation, interviews, record reviews, and document reviews, the facility failed to ensure the fluid restriction was followed, or the physician's order was clarified and communicated for 1 of 14 residents (Resident 146). This deficient practice had the potential to result in fluid overload, which could lead to complications such as edema, hypertension, or congestive heart failure, compromising the resident's overall health and safety. Findings include: Resident 146 (R146) R146 was admitted on [DATE], with diagnoses including cardiogenic shock, chronic obstructive pulmonary disease, cardiomyopathy, hypertensive heart disease with heart failure, acute kidney failure, lymphedema, and localized edema. The Observation Detail List Report dated 11/15/2024, documented a brief interview of mental status score of 15/15, which indicated R146's cognitive status was intact. The physician progress note dated 11/17/2024, documented R146 presented to the hospital with severe leg swelling and was unable to ambulate. R146 was found to be in acute exacerbation of chronic congestive heart failure. A physician order dated 11/17/2024, documented low sodium (NAS) diet: texture: soft and bitesize. Liquids: thin, Fluid restriction: 1000 milliliters (ml) per day (Nursing: 640 ml; kitchen 360 ml breakfast 120 ml, lunch 10 ml, dinner 120 ml). A physician order dated 11/19/2024, documented NAS diet: texture: soft and bitesize. Liquids: thin, Fluid restriction: 1000 ml/day (Nursing: 260 ml; kitchen 840 ml breakfast 360 ml, lunch 24 ml, dinner 240 ml). The Medication Administration Record from 11/15/2024-11/20/2024, documented fluid restriction of 1000 ml/day (Nursing 640 ml; Kitchen 360 ml (breakfast-120 ml, lunch 120 ml, and dinner 120 ml). The meal tickets dated 11/19/2024 and 11/20/2024, documented R146 was on fluid restriction and the fluid or beverages being served: -Breakfast: 360 ml -Lunch: 240 ml -Dinner: 240 ml On 11/19/2024 at 11:07 AM, R146 was seated in the wheelchair, alert and verbally responsive. Severe edema on bilateral lower legs was noted and legs were not elevated. A 355 ml bottle of water was at bedside with a straw. On 11/20/2024 at 8:35 AM, R146 was in bed with eyes open. The breakfast tray was on the table, containing scrambled eggs, sausage, yogurt, and a glass of cranberry juice with a straw. The meal ticket, dated 11/20/2024, indicated breakfast included 360 ml of cranberry juice. A 355 ml bottle of water was on the table, with approximately 100 ml remaining. The Clinical Care Manager (CCM) confirmed the observation and indicated R146's fluid restrictions should have been timely communicated to staff and the kitchen to prevent fluid overdose, especially since R146 had severe edema. On 11/20/2024 in the morning, the Wound Care Treatment Nurse (WCTN) was at bedside to provide wound care treatment to R146. R146 requested water, and the 355 bottled water was provided to R146, and then the WCTN proceeded to provide the wound care. On 11/20/2024 in the afternoon, the WCTN confirmed R146 was given water as requested but was unaware R146 was on fluid restriction. The WCTN indicated previously the residents on fluid restriction had a log inside their room, but with R146, no indicator was noted the resident was on fluid restriction. On 11/20/2024, at 11:35 AM, the dietary manager indicated the fluid restrictions orders would be obtained from the matrix, or the registered dietitian would provide the information. The dietary manager confirmed the fluids were provided to R146 on 11/19/2024: breakfast-360 ml, dinner-240 ml, and dinner-240 ml. The dietary manager confirmed there was no advice or order communicated to change the order distribution. On 11/20/2024 at 11:37 AM, the Registered Dietitian (RD) indicated R146 was not evaluated yet since R146 was just admitted on [DATE]. The RD indicated the hydration was standard per policy to be distributed during breakfast-360 ml, dinner-240 ml, and dinner-240 ml. The RD verified R146 had a fluid restriction for 1000 ml due to edema. The RD confirmed the process; the fluid order restriction should have been communicated to the kitchen. The RD indicated there was a new diet order on 11/19/2024. On 11/20/2024 at 1:30 PM, R146 was seated in the wheelchair with a lunch tray with 240 ml of colored juice. R146 indicated was aware of the fluid restriction but uncertain how much fluid daily would be allowed. R146 indicated the licensed nurse administered the medication with drinking water in a cup. On 11/20/2024 at 1:41 PM, Licensed Practical Nurse (LPN) verified and confirmed R146 was on a fluid restriction of 1000 ml/day. The LPN indicated during each medication administration, R146 was given 120 ml of water and took a few sips. On 11/20/24 in the afternoon, the Director of Nursing (DON) confirmed R146 was on fluid restriction for 1000 ml/day. The DON indicated the order should have been communicated to the kitchen in writing for proper distribution as prescribed, or the order should have been clarified if needed more. The DON indicated the order should have been matched with what was provided and the fluid intake should have been documented. A facility policy titled Fluid Restriction (undated), documented fluid restrictions would be followed as per physician's orders and following the procedures: The amount of fluid per 24 hours would be specified in a written physician's order and sent to the food and nutrition service department in writing. The food and nutrition services department and the nursing department would determine how much fluid would be provided at meals and medication passes. Water provided at the bedside would be calculated into the daily total fluid restriction.

Based on observation, interview, record review, and document review, the facility failed to ensure the resident's edema (swelling) was appropriately assessed following admission and interventions implemented for 1 of 14 sampled residents (Resident 146). This deficient practice had the potential to result in delayed treatment, worsening edema, increased risk of skin breakdown or infection, and compromised overall health and well-being. Findings include: Resident 146 (R146) R146 was admitted on [DATE], with diagnoses including cardiogenic shock, chronic obstructive pulmonary disease, cardiomyopathy, hypertensive heart disease with heart failure, acute kidney failure, lymphedema and localized edema. The Observation Detail List Report dated 11/15/2024, documented a brief interview of mental status score of 15/15, which indicated R146's cognitive status was intact. The Observation Detail List Report dated 11/15/2024, documented R146 had no edema. The Admission Skin assessment dated [DATE], documented R146 had no edema. An admission Physician order dated 11/15/2024, documented to assess edema every shift and apply interventions to include the following: elevate extremities, diet, compression, diuretics and to record edema amount. The Medication Administration Record (MAR) from 11/16/2024 to 11/19/2024, showed inconsistencies in the documentation of edema, with alternating entries indicating both the presence and absence of edema on different days. The Physician Progress Note dated 11/17/2024, documented R146 presented to the hospital with severe leg swelling and unable to ambulate. R146 was found to be in acute exacerbation of chronic congestive heart failure. The Nursing Progress Notes dated 11/17/2024, documented R146 had bilateral lower extremities edema. On 11/19/2024 at 11:07 AM, R146 sat in a wheelchair, alert and verbally responsive. The lower extremities showed weeping edema (water retention that occurs when fluid leaks through the skin due to swelling), legs were not elevated and had no compression stockings. The wound dressing on the left lateral lower leg was wet. R146 reported experiencing edema for a long time and mentioned multiple heart issues. R146's medical records lacked documented evidence the edema was assessed, and interventions implemented following R146's admission. On 11/19/2024 at 11:27 AM, the wound Nurse Practitioner (NP) indicated it was the first time R146 had been seen and noted R146 had severe edema, with the left lower extremity leaking fluid. On 11/20/2024 at 11:13 AM, the Wound Care Treatment Nurse (WCTN) indicated the wound dressing had been removed, it was wet, and a chuck had been placed to prevent the area from being left open due to R146's severe weeping edema. On 11/20/2024 in the afternoon, the Clinical Care Manager (CCM) confirmed the edema was not identified upon admission, and no compression stockings were applied. The CCM indicated there was an order to assess and to implement the interventions but was not implemented except for diuretics, which were discontinued. The CCM indicated if the interventions were not appropriate, the physician should have been notified and the order clarified. The CCM confirmed the edema was present on admission based on the hospital transfer summary. On 11/21/2024 at 3:30 PM, the Director of Nursing (DON) indicated the process was to completely assess the resident upon admission, including the skin or edema. The DON confirmed the edema was present on admission, but it was not appropriately assessed, and the Licensed Nurses documented in the MAR, R146 had no edema while others documented the presence of edema. A facility policy titled Admission Skin Assessment (undated), documented upon admission, the resident would be examined to identify current issues. The physician would be contacted to initiate appropriate treatment orders if not addressed in the physician admit orders. The admission skin assessment would be uploaded into resident documents. The admitting nurse was responsible for ensuring the selected interventions were initiated, appropriate equipment was placed, and monitoring was placed on the treatment record and baseline-centered care plan as indicated.

Based on observation, interview, record review, and document review, the facility failed to ensure a baseline person-centered care plan to manage a resident's edema (swelling) following admission was completed for 1 of 14 sampled residents (Resident 146). This deficient practice had the potential for delayed interventions, worsening edema, increased risk of skin breakdown or infection, and compromised resident's overall health and well-being. Findings include: R146 was admitted on [DATE], with diagnoses including cardiogenic shock, chronic obstructive pulmonary disease, cardiomyopathy, hypertensive heart disease with heart failure, acute kidney failure, lymphedema and localized edema. The Physician Progress Note dated 11/17/2024, documented R146 presented to the hospital with severe leg swelling and unable to ambulate. R146 was found to be in acute exacerbation of chronic congestive heart failure. The Nursing Progress Notes dated 11/17/2024, documented R146 had bilateral lower extremities edema. On 11/19/2024 at 11:07 AM, R146 sat in a wheelchair, alert and verbally responsive. The lower extremities showed weeping edema (water retention that occurs when fluid leaks through the skin due to swelling), legs were not elevated and had no compression stockings. The wound dressing on the left lateral lower leg was wet. R146 reported experiencing edema for a long time and mentioned multiple heart issues. R146's medical records lacked documented evidence a baseline person-centered care plan to manage R146's edema following admission was completed. On 11/20/2024 at 11:13 AM, the Wound Care Treatment Nurse (WCTN), indicated the wound dressing had been removed, it was wet, and a chuck had been placed to prevent the area from being left open due to Resident 146's severe weeping edema. On 11/20/2024 in the afternoon, the Clinical Care Manager (CCM) confirmed the edema had not been identified upon admission, no care plan had been created, the legs were not elevated, and no compression stockings were in place. The CCM acknowledged the edema was present on admission. On 11/21/2024 at 3:30 PM, the Director of Nursing (DON) confirmed the resident's edema was present but had not been identified upon admission, and a baseline care plan should have been completed within 48 hours. The DON emphasized the importance of the care plan in establishing goals and interventions to ensure timely and appropriate care. A facility policy titled Baseline Person-Centered Care Plan (undated), indicated the baseline care plan was developed during the admission process to guide resident care before creating the comprehensive care plan. The baseline care plan was prepared at the time of admission, including the care to be provided, goals to be achieved, and actions necessary to reach those goals. The admitting nurse was responsible for utilizing and completing the baseline person-centered care plan.

Based on interview, record review, and document review, the facility failed to transcribe and implemented a wound treatment per physician order for 1 of 4 sampled residents (Resident 1). The deficient practice resulted in no follow up treatment and could potentially have led to a concern of an infection. Findings include: Resident 1 (R1) R1 was admitted on [DATE] with diagnosis including dementia. A discharge Minimum Data Set (MDS) dated [DATE] documented resident assessed with Brief Interview for Mental Status of 05, indicating severe cognitive impairment. A progress note dated 01/27/2024 documented a CNA notified nursing staff the resident had a skin tear to right lateral shin. Measurements were obtained and found skin tear to be 1 cm x 1.5 cm with scant amount of sanguineous drainage. Provider made aware and orders were obtained for new wound. Weekly skin assessments conducted and documented with negative skin issues identified on the following dates: -01/07/2024 -01/14/2024 -01/21/2024 -01/28/2024 The medical record lacked documented evidence of a transcribed treatment order and any follow up treatment. On 03/21/20204 at 1:05 PM, the Clinical Nurse Manager/Wound Care explained new skin concerns were reported to nurses or wound care staff to follow up and assess for treatment if needed. Wound care had standing orders for treatment, however, would consult with a physician and follow orders accordingly when in doubt and document in progress notes. Weekly skin assessments are conducted on all residents regardless if receiving wound care treatments. The Clinical Nurse Manager/Wound Care would have expected the skin tear to be documented on the weekly assessment, however confirmed the weekly assessments documented negative skin issues. The Clinical Nurse Manager/Wound Care was not familiar with R1 indicating R1 did not receive regular wound care treatments while at the facility. The Clinical Nurse Manager/Wound Care acknowledged documentation of identified skin tear and physician order obtained in progress note dated 1/27/24, however, indicated the medical records lacked documented evidence of a physician order for treatment, completed follow-up treatments, or additional documentation related to the skin tear in progress notes. The Clinical Nurse Manager/Wound Care indicated the concern of the treatment order not being documented, staff would not be notified for follow-up treatment, and could potentially lead to a risk of an infection. On 03/21/2024 at 1:43 PM, a Wound Care staff member recalled being informed about the skin tear, contacted a physician, and obtained orders after reviewing the progress note. The Wound Care staff member acknowledged a treatment order was not transcribed and without an order, upon starting shift, the resident would not be identified to be followed up with. If the resident was not followed-up with, the potential consequence may lead to an infection, or the skin tear could worsen. The facility policy titled Care of Skin Tears and Abrasions (undated) documented to verify there was a physician order for treatment, and to check the treatment record.

Based on observation, interviews, and document review the facility failed to ensure Aplisol (tuberculin solution) was dated when opened and the discontinued intravenous medication for a discharged resident was taken out from the active supply. The deficient practice had the potential to put staff and residents at risk for inaccurate test results and improper medication administration. Findings include: On 12/29/2023 at 1:44 PM, in the medication room the refrigerator contained one open bottle of Aplisol solution used for tuberculosis testing which was not dated when opened. On 12/29/2023 at 1:46 PM in the medication room there were intravenous (IV) medications hanging on the wall for current resident treatments. The IV medication for a discharged resident was still among the active medications. On 12/29/2023 at 1:48 PM, a Registered Nurse (RN) indicated when a resident was discharged the medications would be reconciled by the nurse completing the discharge on unit. All oral medications would be given to the resident, any medications left over should be put in bin located in the medication room for destruction. The RN acknowledged the Aplisol solution was opened and should be dated, confirmed resident was discharged for the IV medication hanging in medication room. On 12/29/2023 at 2:06 PM, the Director of Nursing (DON) indicated the case manager would contact physician and would obtain orders to release remaining oral medications. The DON verbalized staff would place the medications which were discontinued in bin for destruction. The DON explained when using multidose vial it would be dated when the vial was opened. The undated facility policy titled Medication Storage documented all multi-dose bottles must be dated upon opening.

Based on observation, interview, and document review, the facility failed to ensure a medication dosage was specified or clarified for 1 of 15 sampled residents (Resident 16). The deficient practice could potentially lead to medication errors, improper administration, and adverse effects. Findings include: Resident 16 (R16) was admitted on [DATE], with diagnoses including a pressure ulcer. On 12/28/2023 at 8:44 AM, during medication pass, a Licensed Practical Nurse (LPN) prepared R16's medications. The Liquacel liquid protein order had no dosage specified. The LPN explained normally, the Liquacel dosage would be 30 milliliters (ml) and the LPN proceeded to administer the medications. On 12/28/2023, at 9:10 AM, the LPN explained the Liquacel liquid protein order was incomplete due to the lack of dosage specification. The LPN indicated the order should have been clarified before administering the medication. On 12/29/2023 at 2:32 PM, the Director of Nursing (DON) confirmed Liquacel had no indicated dosage, and it should have been clarified. The DON indicated the staff were expected to verify the completeness of the medication order for safe administration. A facility policy titled Administration of Medication dated 07/25/2023, documented the Licensed Professional, following professional standards of practice, would appropriately administer prescribed medications. The policy emphasized the verification of the six medication administration rights, including the right dosage.

Based on observation, interview, record review, and document review, the facility failed to ensure the correct size of the Foley catheter was inserted as ordered, appropriately documented and care planned for 1 of 15 sampled residents (Resident 21) and the nephrostomy flushing order was followed for 1 of 15 sampled residents (Resident 15). The deficient practice could have the potential to develop urethral trauma, infections, discomfort, inadequate drainage and compromised renal function. Findings include: A facility policy titled Indwelling Foley Catheter Continued Use dated 07/25/2023, documented the nurse would obtain and follow through with the physician order regarding the indwelling urinary catheter following respective facility protocol. 1) Resident 21 (R21) was admitted on [DATE], with diagnoses including pressure ulcer. On 12/27/2023 at 10:00 AM, R21 was seated in the wheelchair, verbally alert and oriented. R21 had an indwelling catheter, the Foley catheter in place was 20 French (Fr) times (x) 10 cubic centimeters (cc) water balloon, the Foley bag was empty, tubing was kinked. A Physician Order dated 11/15/2023, documented insert Foley catheter 18 French (Foley size) times 10 cc water balloon for urinary retention. On 12/28/2023 at 3:47 PM, the Clinical Care Manager (CCM) verified R21's Foley size order of 18 Fr and confirmed the Foley size in place was 20 Fr. The CCM indicated the Foley order was dated 11/15/2023 and inserted the same day for urinary retention. The CCM indicated R21 was retaining urine with distended abdomen and bladder scan was ordered. The CCM indicated the Foley was changed on 11/24/2023 with 16 Fr. The CCM indicated there was no care plan in place, no documentation when it was last changed using 20 French. On 12/29/2023 at 1:37 PM, the Director of Nursing (DON) confirmed the Foley order size was 18 French and the Foley catheter in place was size 20 French which was a bigger size. The DON indicated the nurses were expected to verify and follow the orders for the resident's safety. 46265 2) Resident 15 (R15) was admitted on [DATE] with diagnoses including obstructive and reflux uropathy, and acute kidney failure. A Physician Order dated 11/17/2023 documented to flush nephrostomy tube with 10 milliliters (mL) of normal saline every shift. The physician order included a discontinuation date of 12/14/2023. Nursing progress notes documented having flushed the nephrostomy tube on the following dates: - 12/15/2023 - 12/16/2023 - 12/20/2023 - 12/21/2023 A care plan dated 12/17/2023 documented to monitor nephrostomy site including interventions to complete treatment as ordered by physician. On 12/28/23 at 12:36 PM, a Certified Nursing Assistant (CNA) verbalized the CNA staff was only allowed to report to a nurse any concerns found with nephrostomy tube such as leaking, soiled dressing, collection bag full. The CNA indicated the nurse was responsible for changing the dressing and monitoring and emptying the collection bag. On 12/28/23 at 12:41 PM, a Licensed Practical Nurse (LPN) verbalized the nurse provided all care for nephrostomy tube. If the CNA noticed a concern the CNA would notify the nurse and the nurse would assess and provide care if needed. The LPN indicated the nurses would provide the dressing changes and empty the collection bag when needed. The LPN explained there was no current order for flushing the nephrostomy tube. The order to flush the nephrostomy tube was discontinued on 12/14/2023 and the nephrostomy tube should not be flushed without an order. If there was something wrong with the tube and collection bag the resident would be sent to nephrologist to have tube and bag changed. On 12/28/23 at 1:28 PM, the Director of Nursing (DON) verbalized the order to flush the nephrostomy tube was discontinued on 12/14/2023 when a new tube was placed. The DON indicated an order to flush tube should have been obtained after 12/14/2023 if the nephrostomy tube required to be flushed by the nurse.

Based on observation, interview, record review, and document review, the facility failed to ensure a heel riser was implemented as ordered for 2 of 15 sampled residents (Residents 19 and 141). The deficient practice had the potential to cause a pressure ulcer to develop. Findings include: A facility policy titled Pressure Ulcer Prevention dated 09/11/2023, documented the residents would receive care consistent with professional standards of practice to prevent pressure ulcers, and or ensure the residents do not develop pressure ulcers unless unavoidable. A resident with a pressure ulcer received the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. 1) Resident (R19) was admitted on [DATE], with diagnoses including difficulty walking, body malaise, and weakness. The Observation Detail Report dated 11/12/2023, documented a Braden scale score of 13-17, which indicated moderate risk and had a problem of impaired mobility. The interventions included offloading or elevating heels. A Physician Order dated 11/12/2023, documented to place the heel riser while in bed and verify placement every shift. The Post-Admission Skin assessment dated [DATE], documented R19's heels were intact and there were no skin issues. A Progress Note dated 11/26/2023, documented a fluid-filled blister on R19's right heel was identified. The Wound Care Progress Note dated 12/07/2023, documented right heel blister and open wound abrasions. A Care Plan dated 12/07/2023, documented R19 had impaired tissue integrity related to a right heel open blister. The interventions included providing treatment as ordered and elevating legs with a heel riser. A Wound Care Progress Note dated 12/11/2023 documented a with a length of 2 centimeters (cm) and a width of 2.5 cm. A Progress Note dated 12/13/2023, documented the right heel blister status post-debridement to continue foam dressing. The Attending Physician Progress Note dated 12/13/2023, documented R19's heel with pressure injury. The Weekly Wound Care Note dated 12/16/2023 and 12/21/2023, documented right heel chronic ulcer, with a length of 1.2 cm and a width of 1.4 cm, moist with redness, scant amount of serous drainage, no pain, no signs, and symptoms of infection, and changed treatment to Medihoney. On 12/27/2023 at 11:05 AM, R19 was lying in bed in a supine position, with no heel riser in place. R19 heels were flat against the bed mattress. The Medication Administration History from 12/01/2023 to 12/27/2023 documented R19's heels were offloaded or elevated, and the placement of a heel riser was verified. On 12/28/2023 at 1:41 PM, WCN2 confirmed R19 had impaired mobility and could barely walk. WCN2 explained upon R19's admission, bilateral heels were intact and there were no issues but R19 developed a fluid-filled blister on 11/26/2023. WCN2 indicated was familiar with R19 and confirmed there was an order to place a heel riser even before the development of the blister. WCN2 further confirmed the heel riser had not been in place since, although the documentation indicated the placement was verified. WCN2 indicated the pressure ulcer on R19's right heel could have been avoided if the wound protocol had been implemented. On 12/28/2023 at 2:25 PM, the CCM confirmed the existence of a heel riser order for offloading R19's heels but observed it was not in place during rounds. A single pillow was noted under R19's feet, yet R19's heels were flat against the bed mattress. The CCM explained the heel riser made of foam material was designed to offload the heels, preventing pressure. The CCM emphasized one pillow alone could not effectively offload the heels. The CCM confirmed R19's right heel pressure ulcer was a facility-acquired wound and could have been prevented if the wound protocol had been followed. On 12/29/2023 in the morning, during a telephone interview, the Wound Physician indicated a heel riser could effectively offload heels and prevent pressure ulcers. The physician emphasized the importance of staff adherence to the wound prevention protocol, and staff were expected to follow the orders diligently. On 12/29/2023 in the afternoon, WCN1 indicated the heel riser order should have been followed for pressure prevention. WCN1 indicated R19's pressure ulcer on the right heel was avoidable and could have been prevented if proper offloading measures had been implemented. 46265 2) Resident 141 (R141) was admitted on [DATE] with diagnoses including sacral pressure ulcer, multiple wounds, methicillin resistant staphylococcus aureus in wounds (wound infection resistant to antibiotics). A Physician Order dated 12/18/2023 documented heel riser while in bed, verify placement every shift. On 12/27/2023 at 10:15 AM, R141 was lying in bed with eyes closed, no offloading of the heels was noted. On 12/27/2023 in the afternoon, R141 was sitting up in bed with heels flat against the bed mattress. On 12/28/2023 at 2:39 PM, R141 lying in bed, no heel riser in place. A Certified Nursing Assistant (CNA) on the unit confirmed there was no heel riser in place. On 12/28/2023 at 11:11 AM, a Licensed Practical Nurse (LPN) verbalized physician orders should be followed and if order was not carried out physician should be contacted, and order clarified or updated.

Based on observation, interview, record review, and document review, the facility failed to ensure a physician order for the use of Oxygen (O2) was obtained, transcribed and care planned for 1 of 15 sampled residents (Resident 9) and the O2 liter flow order was specified or clarified for 1 of 15 sampled residents (R83). The deficient practice could have the potential to compromise resident's respiratory care, leading to inadequate O2 administration, potential respiratory distress, and an increased risk of adverse respiratory events. Findings include: 1) Resident 9 (R9) was admitted on [DATE], with diagnoses including multiple rib fractures and chronic kidney disease. On 12/27/2023 at 10:30 AM, R9 was seated in the wheelchair, verbally alert and oriented. O2 was flowing at 2 liters per minute (LPM) through nasal cannula. R9 indicated was on O2 continuously but was unsure how many liters per minute. There were no signs of respiratory distress. R9's medical record lacked documented evidence; a physician order for O2 use and care management was obtained and transcribed. There was no care plan in place. On 12/28/2023 at 3:31 PM, the Clinical Care Manager (CCM) indicated an order for O2 was necessary, specifying details such as the prescribed liters, titration instructions, tubing change schedule, guidelines for humidifier replacement, and a care plan should have been initiated. The CCM confirmed there were no existing orders for oxygen utilization and no established care plan. On 12/29/2023 at 11:00 AM, a Registered Nurse (RN) confirmed R9 was on O2 flowing at 2 LPM through nasal cannula but there was no physician order in place. On 12/29/2023 at 11:26 AM, the Director of Nursing (DON) indicated O2 would require an order. Nurses were expected to verify the orders, and if there was no order in place, the physician should have been called to obtain an order and implemented. 2) Resident 83 (R83) was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. A Care Plan dated 11/21/2023, documented R83 had ineffective airway clearance related to COPD. The interventions included administering O2 as ordered. On 12/27/2023 at 11:33 AM, R83 was seated in the wheelchair, verbally alert and oriented. O2 was flowing at 2 LPM through nasal cannula. R83 indicated having been on O2 continuously more than a year ago. R83 had shortness of breath. A Physician Order dated 12/06/2023, documented Oxygen per nasal cannula to maintain O2 saturation at more than 90 percent (%). Document liters per minute every shift. May titrate or discontinue O2 LPM as tolerated, maintaining O2 saturation of more than 90%. On 12/28/2023 at 3:20 PM, the CCM verified and confirmed R83's O2 order was incomplete and confusing. The CCM indicated the O2 liter flow and titration parameter should have been indicated for a clear direction. A facility policy titled Oxygen Administration dated 07/25/2023, documented to verify there was a physician's order for administering Oxygen. The physician's order must include liter flow parameters, frequency, and duration of O2 treatment. If the order was unclear or incomplete, clarify the order with the physician. Review the physician's orders and the resident's care plan to identify any special needs of the resident. A facility policy titled Physician Orders dated 09/28/2022, documented the medications and treatments were administered only upon a clear, complete, and signed order. The medication and treatment orders should have specified the dose and dosage form.

Based on interview and record review, the facility failed to provide documented evidence of the assessment of the insertion site, and the date and time when a midline catheter (intravenous line) was removed for 1 of 4 sampled residents (Resident 1). The deficient practice had the potential for the facility failing to provide timely interventions for possible complications of the removal of the intravenous line. Findings include: Resident 1 Resident 1 was admitted on [DATE], with diagnoses including surgical aftercare following surgery on the circulatory system and abdominal aortic aneurysm. The Nurse's Progress Notes dated 10/11/2022, documented R1's left upper arm midline was dislodged and pressure dressing applied. The physician's order dated 10/11/2022, documented removal of R1's dislodged midline. R1's medical record lacked documented evidence of the assessment of the insertion site, and the date and time when the resident's midline catheter was removed. On 07/20/2023 at 1:40 PM, the Director of Nursing (DON) confirmed the findings and explained the nurses were expected to monitor and assess the insertion site when an intravenous line was removed. The DON acknowledged the nurses should have documented in the progress notes the site assessment, and the date and time when R1's midline catheter was removed.

Based on interview and record review, the facility failed to ensure a pain medication was administered per the physician's order for 1 of 4 sampled residents (Resident 3). The deficient practice had the potential to cause adverse effects and psychosocial consequences for the resident of concern. Findings include: Resident 3 Resident 3 was admitted on [DATE], with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease and age-related osteoporosis. On 07/20/2023 at 11:00 AM, Resident 3 was lying in bed, alert and oriented. R3 indicated having right lower back pain and was waiting on a new patch for pain relief. R3 stated a Lidocaine patch was to be administered twice daily, but the resident had missed receiving the medication on certain days. The staff told the resident the medication was not available. R3's care plan dated 07/06/2023, documented the resident was on a pain management regimen. The physician's order dated 07/06/2023, documented Lidocaine Adhesive Patch 4% one patch topical, to be applied to affected area twice daily for pain. R3's Medication Administration Record (MAR) for July 2023, documented Lidocaine Adhesive Patch was not administered to the resident on 07/08/2023 and 07/17/2023, per the physician's order. The MAR documented the medication was not administered to R3 due to drug (medication) not being available. On 07/20/2023 at 2:30 PM, the Director of Nursing (DON) confirmed the findings and acknowledged the nurses were expected to administer the medications as ordered. The DON explained the nurses should have reordered the medication if only one remaining dose was available.

Based on interview, record review, and document review the facility failed to have a physician order for a resident being transferred out to the hospital for 1 of 3 sampled closed records (Resident #24). The failed practice had the potential to lead to an inappropriate and unsafe transfer. Findings include: Resident #24 (R24) R24 was admitted on [DATE] with medical diagnoses including surgical amputation (removal) of the right great toe, Parkinson's disease (affecting the central nervous system), diabetes, and heart failure. A Nursing Progress Note dated 09/10/2022, revealed the Director of Nursing gave orders from a provider to send R24 to the hospital. There was no documented evidence a physician order was obtained and signed by the physician to transfer the resident to the hospital on 09/10/2022. On 12/09/2022 in the morning, the Director of Nursing (DON) indicated there was not a physician order to transfer the resident out to the hospital. The DON stated there needed to be a physician order to transfer the resident out to the hospital in an emergent or non-emergent situation. A review of the facility's policy titled Physician Orders undated revealed treatment orders were documented in the resident's medical record with the date, time, and signature of the person receiving the order. The policy indicated verbal, or telephone orders were promptly entered into the electronic administration system.

Based on interview, record review, and document review the facility failed to follow the resident's choice for life-sustaining treatment for 1 of 3 sampled closed records (Resident #23). The failed practice had the potential to revive the resident and not allow for a natural death as desired by the resident. Findings include: Resident #23 (R23) R23 was admitted on [DATE] with medical diagnoses including encephalopathy (alteration in brain function), dementia, diabetes, and heart failure. An Acknowledgement of Information on Advanced Directives dated [DATE], revealed R23 wanted to be kept comfortable and allowed a natural death. R23 did not want any life-sustaining treatment or other medical interventions to extend life. A Physician Order for Life-Sustaining Treatment (POLST) dated [DATE], revealed if the resident did not have a pulse (heartbeat) or stopped breathing, an attempt to resuscitate would not be made and R23 would be allowed a natural death. The POLST was not signed by the physician, only signed by the family of R23. A Physician Order dated [DATE] indicated R23 had a code status of Do Not Resuscitate (DNR) which reflected in the Electronic Medical Record (EMR). On [DATE] at 1:00 PM, a Licensed Practical Nurse (LPN) confirmed R23 had a code status of Do Not Resuscitate in the Electronic Medical Record (EMR). A Nursing Progress Note dated [DATE] revealed the resident became nonresponsive, code status was verified, and Cardiopulmonary Resuscitation (CPR) was started. When Emergency Medical Services (EMS) arrived, CPR was continued by the paramedics. On [DATE] in the afternoon, the Director of Nursing (DON) indicated the Physician Order for Life-Sustaining Treatment (POLST) needed to be signed first since it was a legal document and then the Physician Order was signed in the Electronic Medical System (EMR). The DON confirmed for R23 there was a physician order for code status of Do Not Resuscitate (DNR), however, there was not a Physician Order for Life-Sustaining Treatment (POLST) signed by the Physician. A review of the facility's policy titled Advanced Directives revised on [DATE] was reviewed. The policy revealed nursing staff was to inform emergency medical personnel of the resident's advanced directive.