Every finding on record at Center for Advanced Rehab at Parkside, The

Based on observations, staff and resident interviews, record review, a review of the facility's policies titled Medication Administration and Pain Management, and a review of the the facility's Standing Orders, the facility failed to ensure nursing staff provided appropriate pain management during care for one of six sampled residents (R) (R66) with suprapubic catheters reviewed for catheter care related to adhereing to the physician orders and ensureing safe medication administration practice. Harm was identified to have occurred on [DATE], when resident (R) 66 experienced unrelieved acute pain during suprapubic catheter care and received a medication without a valid physician order and at an incorrect dose, resulting in ineffective pain control. Findings included:During an observation on [DATE] at 11:02 am, Licensed Practical Nurse (LPN) CC was observed providing suprapubic catheter care for R66. R66 was lying in bed receiving oxygen therapy when the nurse initiated care. LPN CC first cleansed the suprapubic catheter insertion site using gauze with a soapy solution, followed by gauze with warm water, in repeated strokes. With each cleansing stroke, R66 immediately cried out in pain, stating, Ouch, that hurts. A visible amount of blood was observed on the gauze with each stroke, coinciding with the resident's expressions of pain. The resident turned away from the nurse, pulled his body inward, and guarded his lower abdomen. Despite these responses, the nurse continued the procedure and repeatedly attempted to reposition the resident toward her to continue care. The nurse acknowledged the resident's pain by stating, I know, I'm almost done, but did not stop the procedure or assess the resident's pain.The resident's pain responses occurred consistently with each cleansing stroke and manipulation of the catheter site. With each contact, the resident vocalized pain and attempted to protect the area by withdrawing and curling his body. As the nurse proceeded to manipulate and cleanse the catheter tubing, which occurred as the final step of the procedure, including pulling on the tubing, the resident cried out loudly and exhibited increased signs of distress, further guarding the area.At that time, the surveyor asked the resident if the procedure was painful, during manipulation of the catheter tubing, and the resident responded yes while continuing to vocalize pain. When asked if this level of pain was typical, the nurse stated, he does cry out in pain during care, indicating this occurs with catheter care, which is ordered to be performed daily. When asked about the frequency of pain management, the nurse stated the resident is medicated for pain maybe once a week, despite daily catheter care. When asked about the presence of bleeding at the site, the nurse stated, Yes, it bleeds sometimes.Only after the nurse completed the procedure did the nurse ask the resident if he wanted something for pain. The resident responded, Yes, I'm hurting. The nurse then left the room to obtain medication without performing a pain assessment, including no use of a pain scale or assessment of location, severity, or characteristics of pain. The nurse returned and administered an acetaminophen 325 mg (milligram) tablet, two tablets (650 mg total).A review of the facility's Standing Orders revealed that LPN CC failed to follow the current standing order instructions, did not enter the order into the Medication Administration Record (MAR), and administered an incorrect dose. As a result, the medication was administered without a verified active order and not in accordance with the current physician orders, as follows:A standing order dated [DATE] authorized 1. Tylenol 650 mg (by mouth) (every six hours) for (temperature) greater than 100 F (degrees Fahrenheit). This was identified as an older, obsolete standing order and was no longer the current directive for administration. A more current standing order was later provided to the surveyor for review.A more recent standing order dated [DATE] authorized Tylenol Extra Strength two tablets by mouth (every six hours) (as needed) (pain or fever). Further review of the order included instructions TO ENTER-Go to Orders-select BATCH UPDATE, in the drop-down menu select ADD ORDER SET, then select CONGESTION/COUGH STANDING ORDER and edit as needed.During an interview on [DATE] at 11:23 am, LPN CC confirmed that she did not stop the procedure to assess the resident's pain, did not utilize a pain scale, and did not complete a formal pain assessment during care. The nurse stated she proceeded with care by cleaning easier and completing the task quickly while informing the resident she was almost finished. The nurse further stated she was unable to determine the cause of the resident's pain and indicated that appropriate pain assessment should include speaking with the resident and asking what can be done to help, as well as assessing how the pain feels, where it is located, and what it feels like; however, these assessments were not performed during the procedure. The nurse also stated that pain assessments should be documented in the progress notes, but were not completed at that time. The nurse confirmed that any medication order should have been entered into the MAR before administration. The nurse further confirmed that the standing orders referenced were intended for fever management and not for pain control.A review of the electronic medical record (EMR) revealed R66 was admitted on [DATE] and pertinent diagnoses, including but not limited to obstructive and reflux uropathy with the presence of a urogenital implant/suprapubic catheter, recurrent urinary tract infections, chronic kidney disease, and acute kidney injury.A review of R66 Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. Section GG, functional status, indicated impairment in both lower extremities with substantial to maximal assistance required for activities of daily living (ADLs). Section H, bowel and bladder, indicated an indwelling urinary catheter, with the resident always being incontinent. Section I revealed diagnoses including renal insufficiency, renal failure, end-stage renal disease (ESRD), obstructive uropathy, and a urinary tract infection within the past 30 days.A review of R66 care plan dated [DATE] indicated a problem of suprapubic catheter care with risk for urinary tract infection and pain management needs. Goals included but were not limited to prevention of signs and symptoms of infection and the resident verbalizing adequate pain relief. Interventions included but were not limited to providing catheter care each shift, maintaining catheter site hygiene, securing tubing, monitoring and documenting urinary output, observing and reporting signs and symptoms of infection, assessing pain each shift, administering pain medications as ordered, providing non-pharmacological pain interventions, and notifying the physician of ineffective pain management or changes in condition.A review of the Physician's Orders for R66 included, but was not limited to: Order dated [DATE] at 11:46 am for Acetaminophen (Tylenol) Tablet 325 mg, give two tablets by mouth every six hours as needed for pain or elevated temp greater than 101 F (order entered into the MAR following administration). Order dated [DATE] for Change suprapubic catheter (20 Fr 30 mL) monthly and (as needed) for malfunction. Order dated [DATE] for Clean suprapubic catheter site every shift and apply split gauze. Order dated [DATE] for Supra pubic catheter care every shift with dressing application. Order dated [DATE] for Monitor output of catheter and document every shift. Order dated [DATE] for Supra pubic catheter connected to bedside drainage every shift. Order dated [DATE] for assessing the resident for pain every shift. Order dated [DATE] for Clean suprapubic catheter site with warm soap and water or wound spray every shift. Order dated [DATE] for Enhanced Barrier Precautions for catheter/ESBL history/wound.A review of R66's progress notes dated [DATE] at 11:30 am revealed an order for acetaminophen 325 mg tablet, give two tablets by mouth every six hours as needed for pain or temperature greater than 101 F was entered following administration. Progress note dated [DATE] at 12:09 pm revealed nursing contacted the physician to obtain an order for acetaminophen for reported pain and tenderness during suprapubic catheter care, and the order was obtained after the medication had already been administered.During an interview on [DATE] at 12:19 pm, the Director of Nursing (DON) revealed that, per facility expectations for pain assessment and management during treatments such as catheter or wound care, nursing staff are expected to stop the procedure when a resident expresses pain, assess the resident, and determine appropriate interventions or medications. The DON stated that nurses should assess pain during care, including observing for verbal and nonverbal indicators and, when able, asking the resident to rate pain on a scale of 1 to 10. The DON further stated that pain assessments should occur before, during, and after procedures as part of standard nursing practice. When asked about the observed incident, the DON confirmed she was aware of the situation and stated she would expect the nurse to stop the procedure, assess the resident's pain, and review the MAR and any applicable orders prior to proceeding. The DON indicated she was not fully familiar with standing orders but acknowledged that appropriate verification of orders should occur before medication administration. When asked about determining harm, the DON stated that pain should always be assessed and confirmed that this situation would trigger an internal review and investigation, which was in progress at the time of the interview. The DON reported concerns under investigation, including that the nurse administered medication without first ensuring it was properly entered into the MAR and may have administered an incorrect medication based on standing orders. The DON further reported that a wound care nurse would be consulted for additional assessment of the resident.Follow-up interview with the DON revealed that R66 previously had pain medication orders, which had dropped off the MAR following a recent hospitalization.A review of the facility policy titled Pain Management, revised [DATE], revealed, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Review of the section Recognition revealed item 1. In order to help a resident attain or maintain his/her highest practical level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain and the cause(s). c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Item 3. Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain. Further review of section Pain Assessment item 1. The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. Section Pain Management and Treatment item 1. Based upon the evaluation, the facility, in collaboration with the attending physician/prescriber, other health care professionals, and the resident and/or the resident's representative, will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission.A review of the facility policy titled Medication Administration dated [DATE] revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Further review of item 10. Review MAR to identify medication to be administered. Item 12. Identify expiration date. If expired, notify nurse manager. Item 14. Administer medication as ordered in accordance with the manufacturer's specifications. Item 17. Sign MAR after administered. Item 20. Correct any discrepancies and report to the nurse manager.

Based on observations, staff interviews, and review of the facility policy titled Physical Environment: Electrical Equipment, the facility failed to ensure the environment was maintained in a safe, sanitary, and functional condition in three of 15 rooms (Rooms 134, room [ROOM NUMBER], and room [ROOM NUMBER]) on the [NAME] Hall related to the Packaged Terminal Air Conditioner (PTAC) air filters containing a significant amount of gray, fuzzy particulate matter. This deficient practice had the potential to contribute to respiratory problems for residents due to unclean air filters.Findings included:During an observation on 4/21/2026 at 11:20 am, the PTAC air filters in room [ROOM NUMBER] of the [NAME] Hall contained a significant amount of gray, fuzzy particulate matter. During an observation on 4/21/2026 at 11:37 am, the PTAC air filters in room [ROOM NUMBER] of the [NAME] Hall contained a significant amount of gray, fuzzy particulate matter.During an observation on 4/21/2026 at 12:23 pm, the PTAC air filters in room [ROOM NUMBER] of the [NAME] Hall contained a significant amount of gray, fuzzy particulate matter.During an observation on 4/22/2026 at 11:47 am with the Maintenance Director, he confirmed that the PTAC air filters in rooms [ROOM NUMBER] were soiled with a significant accumulation of particulate matter. The Maintenance Director acknowledged that the filters required cleaning and stated that the PTAC filter cleaning is assigned to the Environmental Services Director (ESD). He stated that the task should be completed during the room deep-cleaning process. However, he was unable to specify the exact frequency of these cleanings. He further stated that he maintains oversight responsibility for ensuring the task is completed and indicated that the cleaning schedule may need to be reviewed and adjusted to ensure consistency. He confirmed that failure to properly maintain PTAC filters may impact system functionality and potentially compromise indoor air quality, which could affect the air that residents breathe. During an interview on 4/23/2026 at 12:19 pm, the Director of Nursing (DON) stated that the PTAC filters should be serviced and cleaned, as respiratory issues can arise from breathing dirty air filters.During an interview on 4/24/2026 at 3:08 pm, the EVS Director revealed that the air filters in the identified resident rooms have now been cleaned. He stated that, before this, filter cleaning was not performed on a routine schedule because no specific staff member had been assigned responsibility. Instead, filters were only cleaned during room deep cleaning, which occurred intermittently when rooms became vacant, ranging from approximately one week to up to three months or more. The EVS Director further stated that a corrective action has been implemented, with a designated staff member now assigned to clean air filters on a monthly basis to ensure ongoing maintenance.A review of the facility policy titled Physical Environment: Electrical Equipment, undated, revealed that the facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition. Further review revealed that the Maintenance Director shall maintain schedules for routine inspection and maintenance of all mechanical, electrical, and patient care equipment and that documentation of inspection, testing, and maintenance of electrical equipment shall be maintained for a minimum of three years.

Based on observations, interviews, record reviews, and the facility policy titled Oxygen Administration, last revised on 1/20/2025 the facility failed to ensure proper maintenance and monitoring of oxygen equipment, in accordance with professional standards of practice for one of 41 sampled residents (R) (R50) reviewed for respiratory care related to maintaining a clean oxygen concentrator filter and ensuring the appropriate setup of oxygen equipment, including the presence of a humidifier bottle. This deficient practice had the potential to result in decreased oxygen delivery, increased risk of respiratory compromise, and exposure to contaminants, which could adversely affect the resident's health and safety. Findings included: During an observation on 4/21/2026 at 1:11 pm, the resident was observed lying in bed receiving oxygen via nasal cannula at 4 liters per minute (L/min). Observation of the oxygen concentrator revealed the filter to be visibly soiled with an accumulation of dust. The nasal cannula tubing was not dated, and no humidification device was observed in use with the oxygen delivery system.During a second observation on 4/22/2026 at 11:00 am, the resident was again observed receiving oxygen via nasal cannula. The oxygen flow rate was observed at 3 L/min, and the tubing was dated. However, the oxygen concentrator filter remained visibly dirty, with no evidence of cleaning or replacement.During an interview on 4/22/2026 at 2:00 pm, a Certified Nursing Assistant (CNA) stated that she ensures oxygen tubing is clean and that oxygen is set at the correct flow rate as ordered. She reported that oxygen supplies are stored in a plastic bag in the resident's room.During an interview on 4/22/2026 at 2:20 pm, the Unit Manager (RN) stated that oxygen concentrators are monitored daily for proper function. She reported that concentrator filters are checked weekly and that tubing is changed and dated by night shift staff.During a third observation on 4/23/2026 at approximately 9:30 am, the resident was observed in bed receiving oxygen via nasal cannula at 3 L/min. The tubing was intact and dated appropriately. The resident appeared alert, with respirations even and unlabored, and no signs of acute respiratory distress were noted. The oxygen concentrator was functioning without alarm; however, the filter remained visibly soiled with accumulation of dust, indicating continued lack of maintenance.During an interview on 4/23/2026 at 9:30 am, a Licensed Practical Nurse (LPN) stated that oxygen tubing is changed weekly and as needed, with routine changes completed by night shift staff who also date the tubing. She further stated that oxygen concentrators should include a humidifier bottle when indicated and that water levels should be monitored. When shown the oxygen concentrator in use without a humidifier bottle and with a visibly soiled filter, the LPN confirmed that the humidifier bottle was not present and that the filter required cleaning.During an interview on 4/23/2026 at 1:15 pm, the Director of Nursing (DON) confirmed that staff are expected to ensure oxygen is administered as ordered and that oxygen concentrators are maintained in proper working order. She further stated that tubing is to be changed and dated weekly and that filters are to be checked, cleaned, or replaced on a weekly basis. When shown the condition of the oxygen concentrator filter, the DON confirmed that it was dirty and required cleaning or replacement.A review revealed the resident had diagnoses, including, but not limited to, Chronic Obstructive Pulmonary Disease (COPD), shortness of breath, and dependence on supplemental oxygen. Physician orders directed oxygen administration at 3 L/min via nasal cannula and included monitoring for respiratory distress and maintaining oxygen therapy as ordered.Care plan interventions included monitoring for signs and symptoms of respiratory compromise, including shortness of breath, changes in oxygen saturation, restlessness, confusion, and other indicators of respiratory insufficiency, as well as ensuring oxygen was administered as ordered. Further review revealed facility practice required oxygen tubing to be changed and dated weekly, and oxygen concentrator filters to be checked, cleaned, or replaced on a routine basis.A review of the Oxygen Administration policy dated 4/1/2023 and last revised 1/20/2025 revealed that oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences.

Based on record review, staff and resident interviews, and review of facility policy titled Resident Assessment-Coordination with PASARR Program, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II was submitted for two of four sampled residents (R) (R3 and R7) reviewed for PASARR II. This deficient practice had the potential to place residents at increased risk of not receiving the required behavioral health support to meet their daily needs. Findings included:1. During an observation and interview on 4/21/2026 at 12:23 pm with R3 revealed she was admitted to the facility following a lithium overdose related to her diagnosis of bipolar disorder and reported a need for better medication regulation. R3 stated that during her stay, she recalls only one interaction related to her mental health, describing it as a one-time psychiatric evaluation/consult. She reported that she is not currently receiving ongoing mental health services and does not see a mental health provider regularly. R3 further stated that she previously received regular mental health support and expressed that she would benefit from ongoing mental health services to address her current needs. A review of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] and pertinent diagnoses, including but not limited to bipolar disorder, unspecified; manic episode, unspecified; dementia with behavioral disturbance; altered mental status; disorientation, unspecified; cognition communication deficit. A review of R3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Section I (Active Diagnoses) documented diagnoses including bipolar disorder and non-Alzheimer's dementia, and Section N (Medications) indicated the resident was receiving antipsychotic, antidepressant, and anticonvulsant medications. A review of R3's care plan dated 4/6/2026 identified problems, including bipolar disorder with mood instability, behavioral symptoms (agitation, verbal aggression, and confusion), cognitive impairment/dementia with impaired decision-making, use of psychotropic medications, wandering/elopement risk, insomnia, and pain management needs. Goals included maintaining psychiatric stability with no depressive or manic episodes, reducing maladaptive behaviors such as agitation, verbal aggression, and confusion, improving coping skills, ensuring safety and preventing elopement, maintaining adequate sleep patterns, and supporting communication of basic needs while minimizing behavioral escalation. Interventions included administering mood stabilizers and psychotropic medications as ordered, with monitoring for effectiveness and adverse effects, identifying and addressing behavioral triggers, and implementing de-escalation techniques and calm redirection strategies. Additional interventions included maintaining a structured and low-stimulation environment, using simple and consistent communication techniques, reorienting and cueing the resident as needed, ensuring basic needs such as pain, toileting, and hunger are addressed promptly, and reinforcing participation in care. Wandering precautions were implemented through monitoring, redirection, and safety interventions. Psychosocial and psychiatric supports included psychiatric consultation and pharmacy review as needed. Medication management interventions included ongoing monitoring of psychotropic medications for side effects and effectiveness, and implementation of non-pharmacological behavioral interventions to support overall mental and behavioral stability. A review of the Physician Orders for R3 included, but was not limited to: Order dated 2/24/2026 for Depakote Delayed Release (Divalproex Sodium) 250 milligrams (mg): give one tablet two times a day for bipolar manic symptoms. Order dated 3/19/2026 for Olanzapine 5 mg: give one tablet at bedtime for manic depression. Order dated 3/26/2026 for Citalopram 10 mg: give one tablet one time a day for depression. Order dated 3/25/2026 for Trazadone 50 mg: give 0.25 at bedtime for depression, anxiety Order dated 11/26/2025 for Behavior-monitoring Order dated 11/26/2025 for antipsychotic medication monitoring. Order dated 11/26/2025 for psychiatric services to evaluate and treat as indicated A review of R3's psychiatric consults dated 4/1/2026 and 4/21/2026 (with prior visits on 3/17/2026 and 4/14/2026) revealed ongoing bipolar disorder management with psychotropic medications and continued monitoring needs due to mood instability, cognitive impairment, and history of confusion and falls, supporting the need for ongoing psychiatric oversight. A review of the facility's PASARR tracking documentation and census listing for PASARR Level II determinations revealed R3 was not included on the facility's PASARR Level II tracking list. A review of the EMR also failed to reveal evidence that a PASARR Level II evaluation or determination had been completed for R3. During an interview on 4/23/2026 at 1:06 pm with the Social Services Director regarding PASARR (Level I and Level II), it was revealed that Social Services may submit PASARR requests when there is a change in condition after admission, and indicated that the facility is currently refining its PASARR process with a formalized procedure expected to be implemented within the next week. The Director further stated that residents requiring a PASARR Level II evaluation must be identified and evaluated. He confirmed that R3 requires submission for a PASARR Level II, noting the resident has been in the facility since November 2025 and that the request would be submitted on the date of the interview. An interview on 4/23/2026 at 2:42 pm with the Director of Nursing (DON) revealed that a PASARR Level II is required for residents with qualifying diagnoses such as bipolar disorder or other serious mental illnesses. She stated that Social Services is responsible for evaluating residents for PASARR Level II upon admission, and that this process is also reviewed during interdisciplinary meetings. The DON provided the surveyor with documentation confirming that a PASARR Level II request for R3 was submitted on the date of the interview. A review of the facility policy titled Resident Assessment-Coordination with PASARR Program, revised April 2026, item 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. Further review of item 5. If a resident who was not screened.and the resident remains in the facility longer than 30 days: b. The Level II resident review must be completed within 40 calendar days of admission. Item 6. The Social Services Director shall be responsible for keeping track of each resident's PASSAR screening status and referring to the appropriate authority. Item 7. Recommendations, such as any specialized services, from a PASARR Level II determination and/or PASSAR evaluation report, will be incorporated into the resident's assessment, care planning, and transitions of care. 2. A review of the EMR revealed R7 was admitted to the facility on [DATE] and pertinent diagnoses, including but not limited to mood disorder, major depressive disorder, anxiety disorder, and altered mental status. A review of R7's quarterly MDS assessment dated [DATE] revealed a BIMS score of four, indicating severe cognitive impairment. Section E (Behavior) documented physical behavioral symptoms directed towards others: behavior of this type occurred one to three days. A review of R7's care plan identified problems, including verbal aggression towards staff members and impaired cognitive function due to intellectual disability. Interventions included Psychiatric/Psychogeriatric consult as indicated; monitor/document/report PRN (as needed) any changes in cognitive function, specifically changes in: decision making ability, memory, recall, and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Medication management interventions included ongoing monitoring of antidepressant medications for side effects and effectiveness. A review of the Physician Orders for R7 included, but was not limited to: sertraline HCl Oral Tablet 50 mg (Sertraline HCl) - Give one tablet by mouth one time a day for Depression Apixaban Oral Tablet 5 mg (Apixaban) - Give 1 tablet by mouth two times a day for atrial fibrillation Seroquel Oral Tablet 50 mg (Quetiapine Fumarate) - Give 1 tablet by mouth at bedtime for refractory depression Psychiatric services to evaluate and treat as indicated A review of R7's psychiatric consults dated 4/14/2026 (with prior visit on 2/17/2026) revealed ongoing mood disorder management with antidepressant medications and continued monitoring due to mood and behavior instability. A review of the facility's PASARR tracking documentation and census listing for PASARR Level II determinations revealed R7 was not included on the facility's PASARR Level II tracking list. A review of the EMR also failed to reveal evidence that a PASARR Level II evaluation or determination had been completed for R7. During an interview with the Social Services Director (SSD) on 4/23/2026 at 1:50 pm confirmed that R7 had qualifying diagnoses for a PASARR Level II evaluation and should have been assessed accordingly. The SSD stated that the facility recently received PASARR training the prior week and was still in the process of determining the appropriate procedures. The SSD further revealed that a request for a PASARR Level II evaluation for R7 had not been submitted promptly and would be submitted on 4/23/2026.

Based on observations, staff interviews, record review, and review of the facility's policies titled, [name of facility owner] Antibiotic Stewardship Program and Infection Prevention and Control Program, the facility failed to properly establish/implement a surveillance plan for identifying, tracking, monitoring and/or reporting of infections and antibiotic (ABT) use among residents and staff. This failure had the potential to delay detection of infection and care for all residents and increase the risk of infection transmission among staff and residents. The deficient practice had the potential to affect all residents residing in the facility. The facility census was 120 residents. Findings include: Review of the undated facility's policy titled [name of facility owner] Antibiotic Stewardship Program, revealed under Policy Explanation and Guidelines: . 4. a. i. Nursing staff shall assess residents who are suspected to have an infection and complete an SBAR form prior to notifying the physician. ii. Laboratory testing shall be in accordance with current standards of practice. b. i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made. ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness, iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. On page 2, under 5. Nursing will monitor the initiation of antibiotics based on the residents and conduct an antibiotic timeout within 48- 72 of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be based on the findings. Review of the facility's policy titled Infection Prevention and Control Program revealed under Policy Explanation and Guidelines: . 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. c. The RNs and LPNs participate in surveillance through assessment of residents and reporting changes in condition to the residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. Interview on 3/12/2025 at 1:44 pm with the Infection Preventionist (IP) revealed that the Infection Prevention and Control Program (IPCP) was initiated due to Quality Assurance and Performance Index (QAPI). The IP stated that he looked daily for new antibiotic orders in the electronic medical record (EMR) and added the resident to his running list. The IP stated that antibiotic orders were not reconciled with the pharmacist or the doctor (MD) and admitted that labs or other cultures were not closely monitored nor reviewed to avoid unnecessary antibiotic use or discontinuation if required. The IP stated that residents generally continue the ABT ordered until the medication was completed or discontinued by the doctor. The IP further stated that they do not have an active monitoring of the ABT stewardship program, and that the documentation wasn't accurate so it's not currently being used. He admitted to not having a system set up to monitor and follow lab/culture results, or ABT use and monitoring for effective intervention. He admitted to keeping a list for [NAME] ordered and adding new residents when they were admitted with ABT orders along with any labs and removed them when it was completed. He stated, I monthly review the EMR to monitor for ABT and sensitivity to inform the MD. The IP revealed he was unable to complete the ABT surveillance process due to the nurses not doing their part. He stated, I spoke to our Director of Nursing (DON) to complete in-services and educate the nurses about making a case in the EMR when ABT was ordered for it to notify me. Interview on 3/12/2025 at 2:45 pm with the DON, they stated, I have only been here for six weeks and was only told by the IP about educating the nurses on creating a case for ABT use in the EMR on 3/11/2025. It was explained to me that when the resident was placed on an ABT, the nurse should be triggering a case in order for the IP to pick up the resident for monitoring. I am not familiar with the system as I came from another state that did not have this and therefore, I have to research and educate myself before educating the nurses about it. It is my understanding that the nurses inform the MD of the resident's symptoms and then the MD decides if he wants to put the resident on ABT as well as order labs and then the IP tracks it. My expectation is that IP is pulling records on a daily basis to get the ABT info but I'm not sure how it's being done.

Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration, the facility failed to maintain a medication error rate below five percent for two residents (R) (R93 and R51). Three medication errors of 42 opportunities were observed during medication administration resulting in a medication error rate of 7.14%. Findings include: Review of the undated facility's policy titled Medication Administration revealed under the Policy section: .11. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects .14. Administer medication as ordered in accordance with manufacturer specifications 17. Sign MAR (medication administration record) after administered. Review of the facility's undated policy titled Insulin Pen, revealed the Policy section included 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. 11 .H. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not repeat until at least one drop appears. Review of the manufacture instructions for use of manufacturer of insulin pen revealed the Instructions section included Priming your Pen. Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Review of the manufacture instructions for use of diclofenac sodium gel revealed the Instructions section included Use enclosed dosing card to measure a dose For each lower body (foot, ankle, or knee)- squeeze out 4.5 inches (4 grams).Store enclosed dosing card with your Diclofenac Sodium Topical Gel 1% product. The dosing card is re-usable. On 3/12/2025 at 9:30 am, the surveyor observed Licensed Practical Nurse (LPN) BB administering diclofenac gel 1% to R93 on both knees. The surveyor noted that LPN BB squeezed an unmeasured amount of the gel into a small medicine cup and brought it to the resident's room. She applied the gel liberally to both knees. When interviewed immediately after administering the gel, the surveyor asked LPN BB how she ensured she was administering the prescribed 4 grams (gr) of the gel. LPN BB admitted that she did not know how to measure it correctly, stating that the pharmacy had not provided guidance on measurement. The surveyor then suggested that LPN BB retrieve the diclofenac gel from the medication cart and locate the measuring card in the packaging box. LPN BB retrieved the ruler from the box and admitted that she should have used it to measure the prescribed dosage before administering the medication. In an interview with the Director of Nursing (DON) on 3/12/2025 at 3:00 pm, she stated that the correct way to measure diclofenac gel was by squeezing the prescribed amount onto a measuring card to ensure accurate dosage administration. On 3/12/2025 at 8:35 am, the surveyor observed LPN AA performing a medication pass for R51. During the observation, the nurse administered manufacturer name of insulin pen insulin subcutaneously but did not prime the insulin pen before administration. Immediately after administering the insulin, the surveyor asked LPN AA whether she typically primed the insulin pen. LPN AA stated that she did, but since this was a newly opened pen, she did not think it was necessary, and she was also nervous. In an interview with the DON on 3/12/2025 at 3:00 pm, she stated that insulin pens must always be primed before use. On 3/12/2025 at 8:37 am, the surveyor observed a medication pass performed by LPN AA for R51. During the medication pass, ten medications were administered. Afterward, when the surveyor compared the administered medications against the MAR, it was noted that fluticasone nasal spray 50 mcg/act (micrograms per actuation)-one spray in each nostril for allergies-had been documented as given but was not actually administered to the resident. In an interview with LPN AA on 3/12/2025 at 2:10 pm, she admitted that she had marked the medication as given but forgot to administer it. She stated that she would administer it immediately.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Hand Hygiene, Medication Administration, and Cleaning and Disinfection of Resident-Care Equipment, the facility failed to consistently perform hand hygiene procedures while providing care to two of 42 sampled residents (R) (R57 and R32) and to sanitize shared medical equipment between residents' use for two of 42 sampled residents (R66 and R93) during medication pass observations. This failure had the potential to increase the risk of infection transmission among staff and residents. Findings include: Review of the undated facility policy titled Hand Hygiene revealed under Policy . section 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table revealed the following conditions when hand hygiene is necessary to perform: .between resident contacts, before applying and after removing personal protective equipment (PPE), including gloves, before and after handling medications, .before performing resident care procedures, .when in doubt. Review of the undated Medication Administration policy revealed under Policy section 4. Wash hands prior to administering medications per facility protocol and product. Review of the undated facility policy titled Cleaning and Disinfection of Resident-Care Equipment revealed under Policy section 3. B. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident D. Multiple-resident use equipment shall be cleaned and disinfected after each use. 1. On 3/12/2025 at 8:25 am, the surveyor observed Licensed Practical Nurse (LPN) AA performing a medication pass for R57. LPN AA began preparing medications on the medication cart but did not sanitize her hands before starting the task. She then realized that the nasal spray she needed for the resident was missing from the cart, prompting her to stop and step out to the medication room to retrieve a new bottle. Upon returning to the cart, she did not sanitize her hands again and continued preparing the medications for the resident. When she entered the resident's room, she again failed to sanitize her hands before proceeding with medication administration. She only sanitized her hands upon leaving the room. Immediately after the medication pass, the surveyor asked LPN AA whether she should have performed hand hygiene before preparing the medications, upon returning to the medication cart with the nasal spray, and upon entering the resident's room. She admitted that she should have but stated that she was nervous and forgot to do so. 2. On 3/12/2025 at 4:50 pm the surveyor observed LPN CC performing a blood glucose check on R32 followed by the administration of insulin, as per MD order. There were no concerns regarding the execution of these tasks, except for infection control practices related to hand hygiene. LPN CC was observed sanitizing her hands after leaving a previous resident's room but did not sanitize them before beginning care for a new resident (R32). She gathered all necessary supplies, entered the room, and donned (putting on) gloves without first sanitizing her hands before performing the blood glucose check. After removing her gloves, she again failed to sanitize her hands before stepping out of the room to prepare the insulin. Upon returning, she donned a new pair of gloves without sanitizing her hands and proceeded with insulin administration. LPN CC only washed her hands after completing the task and removing her gloves. Immediately after the observation, the surveyor asked LPN CC whether she should have sanitized her hands before and after donning gloves. LPN CC was unsure and stated that she had washed her hands after completing the previous resident's care. 3. On 3/12/2025 at 9:05 am, LPN BB was observed during a medication pass for R66. The nurse entered the resident's room for medication administration. She checked the resident's blood pressure (BP) before administering the medications and placed the BP monitor on the bedside table without using a barrier. She proceeded with medication administration. Upon completing the medication administration, she put the BP monitor in her pocket and then returned it to the medication cart without cleaning it. She then proceeded with the medication pass for another resident, R93. She prepared medications for the resident at the medication cart and placed the uncleaned BP monitor in her pocket again. She entered the resident's room without sanitizing the BP monitor and her hands. After checking the resident's BP, she returned the monitor to her pocket and administered the medications. Although she sanitized her hands before leaving the room, she did not sanitize the BP monitor upon returning to the medication cart. When interviewed immediately after the medication pass about whether she was supposed to sanitize her hands upon entering the room and clean shared equipment before and after each resident's use, LPN BB acknowledged that she should have done so but stated that she was nervous and failed to do that. In an interview with the Director of Nursing (DON) on 3/12/2025 at 3:00 pm, she stated that staff were expected to practice frequent hand hygiene, especially when providing resident care, and that the use of gloves does not replace handwashing. She emphasized that staff were required to follow facility policies. Regarding shared equipment, the DON repeated that staff were expected to adhere to facility policies and ensure proper cleaning of shared equipment between residents' use.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, The name of corporation Nutritional Management, the facility failed to provide one of 42 sampled residents (R) (R77) with food and drink that was palatable, attractive, and at a safe and appetizing temperature. This failure had the potential to worsen the current condition of abnormal weight loss and low body mass index (BMI) of 19.9 or less. Findings include: Review of the facility's policy titled, The name of corporation Nutritional Management undated revealed under: Compliance Guidelines: 2.Identification/ assessment: .b. The dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay. c. A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow up assessment will be completed as needed. Review of electronic medical record (EMR) for R77 revealed admission to the facility with diagnoses that include but not limited to weakness, acquired absence of other specified parts of digestive tract, BMI (body mass index) 19.9 or less, adult, hypo-osmolality dilution of solutes in the blood) and hyponatremia (a condition where sodium levels in the blood are abnormally low), hypocalcemia (A condition where calcium levels in the blood are abnormally low), muscle wasting and atrophy, difficulty in walking, muscle weakness, abnormal weight loss. Review of admission Minimum Data Set (MDS) for R77 dated 2/21/2025 documented BIMS score of 15, indicating R77 had intact cognition. Section GG (Functional Abilities and Goals) documented R77 with an upper extremity of impairment on one side, lower extremity with impairment on one side, uses a walker, needs partial/ moderate assistance with shower/bathe, lower body dressing, toilet transfer, walking and putting on and taking off footwear. Section O (Special Treatments and Programs) documented R77 needing ongoing physical therapy (PT). Review of the care plan for R77 revealed focus, goals and interventions documented, the resident has potential nutritional problem related to (r/t) variation by mouth (po) intake, gastroesophageal reflux disease (GERD), will maintain adequate nutritional status, fluid restriction is free water only. Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors . Give appetite stimulant as ordered. Observe/document/report as needed basis (PRN) any signs and symptoms (s/sx) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Observe/record/report to physician (MD) PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% (percent) in 1 month, >7.5% in 3 months, >10% in 6 months. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide vitamins and serve supplements as ordered. Provide, serve diet as ordered. Monitor intake and record every (q) meal. Registered Dietician (RD) to evaluate and make diet change recommendations PRN. Weights as ordered. Review of the physician's orders for R77 revealed, Thiamine 100 milligrams (mg) q day times 2 weeks. Begin ensure (nutritional supplement) vanilla or strawberry bid (twice daily). Begin promod (liquid protein) or similar daily. Ask patient if she will consider Marinol (synthetic form of THC-marajuana) 2.5 MG q day trial times 3 week for appetite stimulation. Weigh on admission then weekly x 4 weeks then monthly if stable. every day shift starting on the 1st and ending on the 2nd for 30 Days weigh monthly. Calcitriol Oral Capsule 0.25 microgram (mcg) (Calcitriol) Give 1 capsule by mouth one time a day every other day for Low Calcium level. Cyanocobalamin Oral Tablet 500 MCG (cyanocobalamin) Give 1 tablet by mouth one time a day for Supplements for 30 Days. Magnesium Oral Tablet (magnesium) Give 400 mg by mouth one time a day for Supplements. Nu-Iron Oral Capsule 150 MG (polysaccharide iron complex) Give 1 capsule by mouth one time a day every Mon, Wed, Fri (Monday, Wednesday, Friday) for Anemia for 30 Days. Potassium Chloride ER (extended release) Tablet Extended Release 10 MEQ Give 2 tablet by mouth two times a day for Supplements. Vitamin Deficiency System-B12 Injection Kit 1000 MCG/ milliliters (ML) (cyanocobalamin) Inject 1 ML intramuscularly one time a day every Fri for Supplement for 21 Days. Interview on 3/11/2025 at 11:19 am with R77 revealed R77 stated that the food was horrible at times, and she did not eat it. She stated that she ate mostly cheerios when the food was bad. She stated that she was never offered anything else to eat when she didn't eat the food but took what she liked off the tray. R77 stated that the tray was taken away after dinner, but no one ever asked why she hadn't eaten or offered her anything else to eat. R77 stated that she did not know what else they had available since they never got a menu, so she just asked for cheerios. Interview on 3/12/2025 at 12:30 pm with R77 revealed she did not eat dinner the night before. R77 stated she ate the chocolate pudding off the tray and ate cheerios from her drawer. She stated that again she was not offered anything different, nor did she ask. R77 stated that she did eat breakfast and lunch today but always kept a box of cheerios just in case. Interview on 3/12/2025 at 1:08 pm with the Registered Dietician (RD) revealed that the staff usually reported any food complaints to her or the dietary manager. The RD stated that she announced the alternates at morning meetings and the managers sometimes called or came by her office to inquire. The RD stated that on admission she met with the resident and went through the food preference sheet with them. She stated that there was a handwritten section for the residents to write if their choice was not preprinted on the sheet already. The RD stated that each resident's food likes and dislikes was then documented in the system. She further stated that if she visited a resident on admission and the resident wasn't available, she documented it and left herself a note to revisit another time. The RD also stated that she visited the resident daily until the interview was conducted. The RD denied ever being told R77 refused any meals but could not confirm the date she completed R77's admission interview. Interview on 3/13/2025 at 8:43 am with Certified Nursing Assistant (CNA) DD revealed that R77 sometimes did not eat meals, and she would ask if there was something else she could get the resident, and then got it. CNA DD stated that when a resident refused a meal, she often tried to offer something else and if they refused then it got reported to the nurse and she documented the refusal in the EMR. CNA DD stated, I can't remember a situation where the resident didn't eat; however, if she asked for a replacement, it would have been given to her. CNA DD admitted that she didn't always work on [NAME] Hall and was not sure if other CNAs were offering alternate meal choices to residents who refused their meal. Interview on 3/13/2025 at 2:30 pm with License Practical Nurse (LPN) BB revealed that she was not aware of R77 refusing meals or not eating. LPN BB stated that the CNAs would usually offer a sandwich or something if a resident did not eat the meal provided.

Based on observations, staff interviews, record review, and review of the facilies policies titled, Medication Administration: General Guidelines and Insulin Pen, the facility failed to adhere to accepted standards of quality care for three Residents (R) (R93, R51, and R66) reviewed during medication administration. Specifically, the facility failed to give the correct dosage of medicated ointment, to prime an insulin pen, and have residents rinse their mouth after inhaler use. Findings include: Review of the undated facility's policy Medication Administration revealed under Policy section 11 a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects .14. Administer medication as ordered in accordance with manufacturer specifications 16. If using a corticosteroid, allow resident to rinse and gargle with water if desired, to remove medication from mouth and back of throat. 17. Sign MAR (medication administration record) after administered. Metered dose inhalers-follow manufacture's product information for administration instructions Review of the facility's undated policy titled Insulin Pen revealed under the Policy section 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. 11.H. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not repeat until at least one drop appears. Review of the manufacturer's instructions for use of diclofenac sodium gel (medicated gel for pain and inflammation) revealed the Instructions section included Use enclosed dosing card to measure a dose For each lower body are (foot, ankle, or knee)-squeeze out 4.5 inches (4 grams).Store enclosed dosing card with your Diclofenac Sodium Topical Gel 1% product. The dosing card is re-usable. Review of the manufacture instructions for use of the manufacturer's name insulin pen revealed in the Instructions section included Priming your Pen. Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each use, you may get too much or too little insulin. Review of the manufacturer's instructions Patient information Breztri aerosphere (brez-TREE), (an inhaled medication used to treat chronic obstructive pulmonary disease (COPD) that contains a corticosteroid.) revealed the Instructions section included How should I use BREZTRI AEROSHERE? .Rinse your mouth with water and spit the water out after each dose (2 puffs) of BREZTRI AEROSPHERE. Do not swallow the water. This will help to reduce the chance of getting a fungus infection (thrush) in the mouth and throat. 1. On 3/12/2025 at 9:30 am, the surveyor observed Licensed Practical Nurse (LPN) BB administering diclofenac gel 1% (percent) to R93 on both knees. LPN BB squeezed an unmeasured amount of the gel into a small medicine cup and brought it to the resident's room. She applied the gel liberally to both knees. When the surveyor asked LPN BB how she ensured that she was administering the prescribed 4 grams (gr) of the gel, LPN BB admitted she did not know how to measure it correctly, stating that the pharmacy had not provided guidance on measurement. The surveyor then suggested that LPN BB retrieve the diclofenac gel from the medication cart and locate the measuring card in the packaging box. LPN BB retrieved the ruler from the box and admitted that she should have used it to measure the prescribed dosage before administering the medication. In an interview with the Director of Nursing (DON) on 3/12/2025 at 3:00 pm, she stated that the correct way to measure diclofenac gel is by squeezing the prescribed amount onto a measuring card to ensure accurate dosage administration. 2. On 3/12/2025 at 8:35 am, the surveyor observed LPN AA performing a medication pass for R51. During the observation, the nurse administered manufacturer's name insulin subcutaneously but did not prime the insulin pen before administration. Immediately after administering the insulin, the surveyor asked LPN AA whether she typically primed the insulin pen. LPN AA stated that she did, but since this was a newly opened pen, she did not think it was necessary, and she was also nervous. In an interview with the DON on 3/12/2025 at 3:00 pm, she stated that insulin pens must always be primed before use. 3. On 3/12/2025 at 9:05 am, LPN BB was observed performing a medication pass for R66. During the med pass, LPN BB administered Breztri Inhaler, However, the nurse did not offer the resident water to rinse their mouth and spit after use. In an interview with LPN BB following the medication administration, the surveyor asked what she should have done after administering the Breztri but failed to do. LPN BB admitted that she should have instructed the resident to rinse their mouth after use but forgot. In an interview with the DON on 3/12/2025 at 3:00 pm, she stated that rinsing the mouth after using an inhaler was important.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Activities of Daily Living (ADLs), the facility failed to provide two of five residents (R) (R77 and R97) who were dependent on staff for ADLs. Findings include: Review of the undated facility policy titled Activities of Daily Living (ADLs) documented under, Policy Explanation and Compliance Guidelines, . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the electronic medical records (EMR) for R77 revealed admission to the facility with diagnoses that include but not limited to weakness, retention of urine, unspecified, personal history of other (healed) physical injury and trauma, other chronic pain, low back pain, unspecified fall, repeated falls, body mass index [BMI] 19.9 or less, adult, hypo-osmolality and hyponatremia, pain, hypocalcemia, muscle wasting and atrophy, difficulty in walking, not elsewhere classified, muscle weakness (generalized), polyneuropathy, neuromuscular dysfunction of bladder, spinal stenosis. Review of admission Minimum Data Set (MDS) assessment for R77 dated 2/21/2025 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R77 had intact cognition. Section GG (Functional Abilities and Goals) documented R77 with an upper extremity of impairment on one side, lower extremity with impairment on one side, uses a walker, needs partial/ moderate assistance with shower/bathe, lower body dressing, toilet transfer, walking and putting on and taking off footwear. Section O (Special Treatments and Programs) documented R77 needing ongoing physical therapy (PT). Review of care plan for R77 revealed focus, goals and interventions documented, the resident has an ADL self-care performance deficit related to (r/t) impaired balance, weakness, deconditioning. The resident requires assistance of staff for bathing and showering, resident requires assistance with bed mobility, dressing, set up for meals, oral care, personal hygiene, bed mobility, repositioning, and toilet use. Further review of care plan documented, resident has urinary retention, bladder dysfunction, has one kidney, order to assist with self in and out catheter, risk for constipation, continent at all times, uses incontinence briefs, clean peri-area during rounds with incontinence episode, observe and document for UTI (urinary tract infection), pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and staff to provide in and out catheters as ordered. Review of physician's orders for R77 revealed, Straight cath (insert catheter to drain urine from bladder) resident while lying down r/t postural difficulty four times a day for neurogenic (lack of bladder control due to brain, spinal cord, or nerve problems) bladder, Diflucan oral tablet 100 milligrams (MG), give 1tablet by mouth in the afternoon for fungal infection for 2 days on 3/11/2025, and 3/13/2025. Interview and observation on 3/11/2025 at 11:19 am with R77 revealed her sitting on the side of her bed talking with her roommate. R77 stated she sometimes had accidents on her clothes due to straight catharizing herself at night and awakened in the morning with dried urine on her and her bed because no one came when she rang the bell for help. R77 stated, on the weekends and at night there is only one floor tech and one nurse, and they have a lot of other residents to care for. Sometimes I help my roommate because the staff takes so long to come. When I turn on my light and no one comes, then they tell me that they were busy with someone else. I believe that it is because of the urine staying on me for hours has caused me to have an itch in my private area. I saw the doctor today and informed him about the itch and he ordered something for it. Interview on 3/12/2025 at 11:00 am with R77 revealed her sitting on her bed talking to her roommate. R77 stated that nothing had changed and the staff still took a long time to come when she rang the call bell. She stated she fell asleep last night waiting on someone to come and assist and wasn't sure what time they came. She stated that she started the medication that the doctor ordered and hoped it would help her with the itch. She stated she can't wait to go home. Review of EMR for R97 revealed that she was admitted to the facility with diagnoses that include but not limited to unspecified fracture of lower end of right tibia, subsequent encounter for closed fracture with routine healing, unspecified fall, encounter for other orthopedic after care, generalized anxiety disorder, hypertensive heart disease with heart failure, chronic systolic (congestive) heart failure, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the quarterly MDS for R97 dated 12/31/2024 documented in Section C (Cognitive Status) a BIMS score of 14, indicating little or no cognitive decline. Section F (Preferences for Customary Routine and Activities) documented very important for R97 to choose what clothes to wear, to choose between a tub bath, shower, bed bath, or sponge bath. Section GG Functional Abilities) documented R97 uses a walker and a wheelchair, needs partial/ moderate assistance with shower/bath, tub/shower transfer, needs substantial/ maximal assistance with lower body dressing, and toilet transfer. Section O (Special Treatments, Procedures, and Programs) documented R97 not currently receiving physical therapy. Review of care plan for R97 dated 4/26/2024 revealed focus, goals and interventions documented, The resident has an ADL self-care performance deficit r/t (related to) weakness, deconditioning, right tibia fracture, will improve current level of function in ADLs through the review date, resident would prefer female care only for all toileting hygiene and bathing. The resident requires assistance of staff for bathing and showering, resident requires assistance with bed mobility, dressing, set up for meals, oral care routine, personal hygiene, bed mobility, assist rails up to aid with bed mobility repositioning, toilet use, PT/ occupational therapy (OT) evaluation and treatment as per MD orders. Review of the physician's orders for R97 documented, Air mattress with alternating pressure for comfort related to cancer diagnosis and Sertraline HCl (hydrochloride) oral tablet 50 MG (milligrams), give 1.5 tablet by mouth at bedtime for depression. Interview and observation on 3/11/2025 at 11:51 am with R97 revealed her lying in bed with TV on and muted. R97 stated that she was a bit upset about her showers always being off, especially on the weekends. R97 stated, my Certified Nursing Assistant (CNA) was pulled from shower duty because she said they were short staffed, and now my showers have been put off three times and this upsets me. One time I went 9 days before I was given a shower. The last time they skipped my shower was this weekend. I told several people about it because I was upset, but then they gave it to me on Monday after I made them know I was upset. The CNA told me that the reason I got a shower on Monday instead of my regular scheduled shower day was because I told on them. Well, when you can't get out of bed, and you pee and poop on yourself, you need your shower. Interview on 3/12/2025 at 11:30 am with R97 revealed her lying in bed watching TV. She revealed she was waiting on her CNA to give her to assist her with care but would not be having a shower again till Thursday. R97 revealed that her CNA informed her that because she had gotten a shower on Monday, she would not be getting another one till her regular scheduled day which would be on Thursday. Interview on 3/13/2025 at 8:30 am with R97 revealed her lying in bed with the TV off. She stated she was waiting on her CNA as she should be getting a shower today, but no one had come in the room yet to inform her of a time for her shower. Review of the shower log and documentation in their electronic health record (EHR) revealed for 30 days, no documentation of showers given nor resident's refusal for dates 2/15/2025, 2/22/2025 and 3/8/2025. Review of two weeks staffing schedule grid indicated no staffing shortages for the last 30 days. Interview on 3/13/2025 at 8:43 am with CNA DD revealed she worked mostly on [NAME] Hall but works on other halls as well. She stated that most of the time she was R77 and R97's CNA and confirmed R97's shower schedule was on Tuesdays, Thursdays and Saturdays. CNA DD stated that she was not on [NAME] Hall this past Tuesday and was not sure if R97 got a shower, but admitted to giving R97 a shower the previous Thursday as scheduled. CNA DD stated, R97 usually receives her shower between 9:30 and 10:00 am and is scheduled to receive one today. She normally does not refuse her shower but if R97 try to refuse, then I give her some time to rest and reapproach her again later which she then takes it. CNA DD also stated that she assisted R77 with ADL care in the mornings but that most of the time R77 helps herself. Interview and record review on 3/13/2025 at 9:02 am with Registered Nurse (RN) EE mentioned she was the Unit Manager on [NAME] Hall and confirmed that R97 shower days were Tuesdays, Thursdays and Saturdays. RN EE stated that she knew that R97 received a shower on 3/7/2025 but admitted that there was no documentation confirming this activity. RN EE confirmed that in nursing when it's not documented, It's not done. Record review with RN EE confirmed that on 2/15/2025, 2/22/2025 and 3/8/2025 there were no signatures confirming R97 received showers on those days and that there was no documentation of refusal or other reason why the activity was not performed. RN EE admitted that the weekend CNA was responsible for giving R97 showers on the weekends. Interview on 3/13/2025 at 9:41 am with the Director of Nursing (DON) and RN FF revealed that it was their expectation that all residents were receiving the care they deserve on all shifts each day. The DON stated that the facility had a shower team who provided showers during the week and sometimes on the weekends, but when they were not on staff, the CNAs were expected to give the shower. The DON admitted that all CNAs received indicators on the EHR in their task section when a resident was scheduled for a shower along with all other tasks. RN FF stated that all staff were expected to document on the EHR when a resident refused their shower and then notify the nurse. RN FF stated that it was then that the nurse on the floor would speak with the resident and try to either convince them to take their shower or offer them a bed bath.

Based on observation, interview, and review of policies titled Medication Storage and Administering Medications, the facility failed to ensure that one of six medication carts (200 Hall Medication Cart) was secured when unattended; failed to date and label seven open multi-dose containers of opened ophthalmic drops in one of six medication carts (Mauve Hall); and failed to discard one expired multi-dose container of ophthalmic drops in one of six medication carts (Mauve Hall). Findings include: Review of the undated policy titled Medication Storage revealed all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to keys to locked compartments. During medication pass, medications must be under the direct supervision of the person administering medications or locked in the medication storage area/cart. 1. Observation on [DATE] at 1:38 p.m. on 200 Hall revealed one medication cart located against the wall next to room [ROOM NUMBER] facing the hallway, to be unlocked and unattended. There were no residents in the immediate area. At 1:40 p.m., Registered Nurse (RN) AA approached the cart and verified she was responsible for the cart and that she left it unattended and unlocked. RN AA asked surveyor if it was a problem if cart was unattended for a minute. Interview on [DATE] at 4:50 p.m. with the Interim Director of Nursing (DON) revealed her expectation is for medication carts to be locked and secured when unattended regardless of the length of time. She revealed she provided an inservice to medication cart nurses covering the importance of locking unattended medication carts on [DATE] and she plans further education on medication storage. Review of the policy titled Administering Medications revision date [DATE], revealed that medications are administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation number 12 stated: The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 2. Observation on [DATE] at 2:45 p.m. of a medication cart on Mauve Hall with Licensed Practical Nurse (LPN) BB revealed the cart to contain six open containers of ophthalmic drops and one open container of ophthalmic ointment without open dates and one container of ophthalmic drops without an open date and with an expired manufacturer's date. The following were open and without an open date: 1. [MEDICATION(S)] 1% ophthalmic drops 2. [MEDICATION(S)] 1% ophthalmic drops 3. [MEDICATION(S)] 0.005% ophthalmic drops 4. [MEDICATION(S)] 0.05% ophthalmic drops 5. [MEDICATION(S)] 0.1% ophthalmic drops 6. Artificial Tears ophthalmic drops 7. [MEDICATION(S)] 0.5% ophthalmic ointment 8. [MEDICATION(S)] 0.2% ophthalmic drops without open date and with expiration date of ,d+[DATE]. LPN BB verified the ophthalmic drops and ointments should be labeled with an open date when opened and she verified the eight containers were not labeled. She verified the one container of [MEDICATION(S)] 0.2% ophthalmic drops was past the manufacturer's expiration date. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on [DATE] at 3:50 p.m. with the Interim DON and the Administrator verified the Mauve Hall medication cart to contain seven containers of open and undated ophthalmic medications and one open container of [MEDICATION(S)] 0.2% ophthalmic drops undated and past the manufacturer's expiration date. The Interim DON stated the pharmacy label on the [MEDICATION(S)] 0.2% ophthalmic drops stated may order after [DATE] and she thought the ophthalmic drops were in date until that date. The Interim DON verified the ophthalmic medications should be dated when opened.

Based on observation, record review and staff interview, the facility failed to ensure that two foods served from the steam table were held at 135 degrees or higher; that a fan mounted over a drink preparation area was free of dust; and that the amount of sanitizer used in the low temperature dish machine was 50 parts per million (PPM) to prevent potential chemical contamination of food on two of two observations. There were 123 residents that consumed an oral diet. Findings include: 1. During the initial tour of the kitchen on 8/20/18 beginning at 12:00 p.m., a light to moderate build-up of dust was observed on the wall-mounted fan over the drink preparation area. This same observation was made on 8/21/18 at 3:50 p.m. During interview with the Dietary Manager on 8/23/18 at 9:03 a.m., she stated that Maintenance was responsible for cleaning the fans in the kitchen, and that they did so weekly or every other week. She verified during further interview that the wall-mounted fan over the drink preparation area had a light to moderate dust build-up, would contact Maintenance to clean it, and thought they last cleaned it on Friday (six days ago). During interview with Maintenance Technician II on 8/23/18 at 12:36 p.m., he stated that he cleaned the fan over the drink machine today per the Dietary Manager's request, and that he had no documentation of the last time the fan had been cleaned. 2. During observation of the preparation of pureed foods on 8/21/18 at 3:33 p.m., the food processor parts were observed to be washed in the low-temperature dish machine between and after foods prepared, which was connected to a container of sodium hypochlorite sanitizer. Dietary Aide GG was observed to check the chemical concentration of the final rinse water after running the food processor equipment through using a chlorine test strip, and she stated she would interpret the result as 75 (PPM). She stated during further interview that she was trained that the result should not be less than 50 (PPM). On 8/23/18 at 8:56 a.m., the Dietary Manager was observed checking the sanitizer level in the low-temperature dish machine that was currently in use washing resident breakfast dishes. She stated during interview that she would record the chlorine level as 100 (PPM), and stated she thought the level should be 100. She verified during further interview that the Dish Machine Warewashing log specified a concentration of 50 PPM of the chlorine sanitizer, and stated that a level over 50 was OK as it just meant that more sanitizer was coming out. Review of a Dish Machine Warewashing log for (MONTH) (YEAR) revealed that the Chlorine Sanitizer PPM range was listed as 50 PPM, and the results obtained from 8/1/18 through 8/23/18 at noon revealed concentrations between 75 and 100 PPM recorded 65 of 68 times. Review of the facility policy Sanitization revised (MONTH) 2008 revealed: Low-Temperature Dishwasher (Chemical Sanitization): Final rinse with 50 parts per million hypochlorite (chlorine) for at least 10 seconds. Review of the facility policy Dishwashing Machine Use revised (MONTH) 2010 revealed: Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine: Minimum Concentration 50-100 ppm. 3. During observation of steam table temperatures taken at supper by Cook HH on 8/21/18 at 5:25 p.m. using the facility's calibrated thermometer, all of the foods were observed to be greater than 135 degrees Fahrenheit (F), except for the meatballs which did not register above 120 degrees F after several checks, and the Prince Edward blend vegetables temperature was 110 degrees F. This was verified during interview with the Dietary Manager at this time, who instructed staff to remove the two foods and place them back in the steamer to reheat. The Dietary Manager further stated that two residents had already received the meatballs. During interview with the Dietary Manager on 8/23/18 at 9:03 a.m., she verified that both the meatballs and the mixed vegetables were below the required holding temperature of 135 degrees at supper on 8/21/18. She further stated that about six residents had already been served the mixed vegetable. She stated during continued interview that food for supper was usually placed on the steam table around 5:00 p.m., and that most of the juices had gone out of the pan by the time the temperatures were checked on 8/21/18. The Dietary Manager further stated that the meatballs were usually held in a smaller pan than they were on 8/21/18. Review of the facility's Food Preparation and Service policy with a revised date of (MONTH) 2014 revealed: Food Preparation, Cooking and Holding Temperatures and Times: 1. The danger zone for food temperatures is between 41 degrees F and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. 3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF (potentially hazardous foods) must be maintained below 41 degrees F or above 135 degrees F.

Based on observation, record review, and staff interview, the facility failed to perform perineal care in a manner to prevent potential urinary tract infections [MEDICAL CONDITION] to the extent possible for one resident (R) (R#25). The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [MEDICAL CONDITION] (paralysis on one side of the body) following a stroke, urine retention, and a history of UTIs. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she was always incontinent of urine, and needed extensive assistance for toilet use. Review of R#25's urine cultures revealed infections with the following organisms: 11/14/17: Proteus mirabilis 3/20/18: Proteus mirabilis 5/10/18: [MEDICATION NAME] raffinosus During an observation of incontinence care with R#25's permission by Certified Nursing Assistant (CNA) BB on 8/20/18 at 4:13 p.m., the CNA was observed to obtain and place several wet washcloths on top of the resident's bed rail before removing her incontinent brief, which had a moderate amount of urine in it. Further observation revealed that the CNA asked R#25 if she wanted to wipe herself and she responded yes, and was given one of the wet washcloths. The resident was observed to wipe her right eye with the washcloth, and the CNA instructed her to wipe between her legs at which time she reached between her legs and wiped herself several times from the rectal area towards the urethra (back to front). Continued observation revealed that the CNA did not stop and instruct her the proper way to wipe. CNA BB was then observed to get another one of the wet washcloths on the bed rail, and cleaned the resident's perineal area properly from the front towards the back, and then turned her to her side and washed her buttocks with another wet washcloth from the bed rail. Further observation revealed that CNA BB did not dry the resident's skin before putting a clean incontinent brief on her. During interview with CNA BB on 8/20/18 at 4:35 p.m., he stated that he usually got a bath basin with water and peri-wash to perform incontinence care, but that R#25 liked to wipe herself, so he just used the wet washcloths. During an observation of a shower with R#25's permission on 8/22/18 at 7:25 a.m., she was observed in the common shower room in a shower chair with a large circular opening in the seat of the chair, and was placed in the shower stall by CNA CC. After washing the rest of her body, CNA CC obtained a clean soapy washcloth and first wiped R#25's inguinal areas, and then used the same washcloth to wipe the perineal and rectal area from underneath the opening in the chair in a circular and back and forth motion, and then rinsed her off. During interview with the Licensed Practical Nurse (LPN) Infection Control Nurse on 8/22/18 at 10:34 a.m., she stated that her expectations were that the staff wipe from the front to the back when doing perineal care, and that a separate section of the washcloth be used for each stroke. She stated during further interview that if a resident was allowed to wipe themselves and was doing it incorrectly, that the staff should educate them on why it was important to go from the front to the back due to the possible increase in urinary tract infection, and if they needed assistance to do so. The LPN Infection Control nurse further stated that a bath basin should be used for perineal care with warm water and soap and plenty of washcloths, and that it was not acceptable to place the washcloths on the bed rail, as there may be microbes on the rail. She further stated that the resident should be dried before a clean brief was applied. During continued interview, she stated that perineal care should be done in the same manner when a resident was in a shower chair and the staff reaching up from the opening in the chair, with a clean washcloth used and the resident cleaned from the front to the back with a different area of the washcloth for each stroke. Review of the facility's Perineal Care policy revised (MONTH) (YEAR) revealed: The following equipment and supplies will be necessary when performing this procedure: 1. Wash basin . Steps in the Procedure: 1. Place the equipment on the bedside stand . 3. Fill the wash basin one-half full of warm water. Place the wash basin on the bedside stand within easy reach. 8. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (4) Gently dry perineum.

Based on observation, record review and staff interview, the facility failed to provide privacy of one resident's (R) body (R#25) during incontinence care and a shower. The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 9 (a BIMS score of 8 to 12 indicates moderate cognitive impairment); was extensive assistance for personal hygiene and toilet use; and needed physical help in part of bathing activity. On 8/20/18 at 4:13 p.m., Certified Nursing Assistant (CNA) BB was observed performing incontinence care for R#25 with her permission. CNA BB was observed to remove the resident's pants and incontinent brief, had the resident wipe herself with a washcloth, and then the CNA further cleaned the resident's perineal area and buttocks, before placing a clean brief back on her. Further observation revealed that R#25 was in a semi-private room in a bed closest to the window, and the bottom of the window blinds were raised approximately eight inches. Continued observation revealed that her room looked out to the front of the facility, and there was a car parked parallel to the building outside of her window. Further observation revealed that the door to the hallway had never been closed, and the privacy curtain between the two beds in the room had been not been pulled the entire length from wall to wall, leaving an opening of approximately 24 inches. On 8/22/18 at 7:25 a.m., R#25 was observed receiving a shower with her permission in the common shower room on the Mauve Hall by CNAs CC and DD. Continued observation revealed that R#25 pulled up on the grab bar just inside the shower room door, so that the CNA could remove her incontinent brief and pants, and then she sat back down on the shower chair (her shirt was still on). During further observation, another CNA was heard to knock on the shower room door, and CNAs CC and DD responded patient care. Continued observation revealed that this third CNA opened the hallway door into the shower room, and left it open with her head and upper body leaning inside the shower room with R#25 directly ahead, for approximately 15 seconds while she talked to CNAs CC and DD. Continued observation revealed that there was a privacy curtain available between the hallway door and the grab bar where R#25 was seated, but it had not been pulled. During interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 8/23/18 at 10:34 a.m., they stated that the blinds to a room should be completely lowered when incontinence care was being provided. The ADON stated during further interview that as long as the resident was covered enough from being seen that the privacy curtain did not necessarily have to be pulled the entire way, but that the hallway door should be closed during perineal care. Review of the facility's Perineal Care policy revised (MONTH) (YEAR) revealed to avoid unnecessary exposure of the resident's body.

Based on observation, record review, resident and staff interview, the facility failed to evaluate the risk of leaving one resident (R) (R#25) unattended while sitting on the side of the bed, resulting in a fall from the bed. The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 9 (a BIMS score of 8 to 12 indicates moderate cognitive impairment); she needed extensive assistance of two or more persons for transfers; was not steady, only able to stabilize with staff assistance for surface to surface transfer; had functional limitation in range of motion on one side of upper and lower extremities; and had one fall with no injury since prior MDS assessment. During interview with R#25 on 8/20/18 at 4:24 p.m., she stated that she had a fall today when staff was in the room with her. She further stated that she fell off the side of the bed onto the fall mat, and that the staff tried but were unable to catch her from falling. Observation at this time revealed that R#25 was in a bed lowered to the floor with an alarm, a bed rail up on both sides of the mattress, and she had a brace on her left leg. During interview with R#25 on 8/21/18 at 8:38 a.m., she stated that when she was receiving therapy in her room yesterday, the therapist sat her up on the side of the bed and then turned around, and she fell off the bed. During further interview, R#25 stated that she had left arm, back and right-sided facial pain after this fall. Review of incident reports revealed that R#25 had a fall from the wheelchair during a staff transfer on 11/25/17; unwitnessed falls from bed on 2/1/18, 3/30/18, and 6/26/18; and a fall from the bed during therapy on 8/20/18. During an observation of a transfer by Certified Nursing Assistants (CNA) CC and DD on 8/22/18 at 7:25 a.m., the tops of R#25's knees were both noted to be reddened and have skin tears. During interview with CNA CC at this time, she stated that R#25 had a fall on Monday (8/20/18), and she thought it was from that. R#25's left arm and leg were observed to be paralyzed, and she was not able to use them to assist with the transfer. Continued observation revealed that the CNAs placed a gait belt around R#25's waist after sitting her up on the side of the bed, and when CNA CC turned around to prepare the wheelchair and CNA DD did not have a firm grasp on the gait belt, the resident started to drift backwards on the bed before being caught supported by CNA DD. During interview with Physical Therapist Assistant (PT-A) EE on 8/22/18 at 12:43 p.m., she stated that she had heard that R#25 had a fall recently when a therapist was working with her, and that she was sitting on the side of the bed and was left unattended. During interview with Occupational Therapist-Registered (OT-R) FF on 8/22/18 at 1:03 p.m., she stated that on 8/20/18 she was working with R#25 on transfers, range of motion to her left arm and neck, and postural control. She further stated that she sat the resident up on the side of the bed, and that the resident's sitting balance on the side of the bed was fair. She stated during continued interview that she got up to move R#25's wheelchair closer to her, which was about two feet away, and had to go around the back of the wheelchair to unlock it. She further stated that she saw from her peripheral vision that the resident was falling, but was not able to get around the wheelchair and back to her before she fell . She stated during continued interview that the resident's whole body fell on to the fall mat at one time, as she had no protective reflexes from the stroke, and the only thing she complained of was that her head hurt just a little bit. During interview with the Physical Therapy (PT) Rehab Director on 8/22/18 at 1:16 p.m., he stated that R#25 had been assessed by PT and OT as Mod/3 for bed mobility supine to sitting, which meant one-person assist. He stated during further interview that one-person transfer assist would have been sufficient, but that he would have had the wheelchair positioned closer to R#25 and would have let go of the resident when she was sitting up. Review of an Occupational Therapy Treatment Encounter Note(s) for R#25 dated 8/20/18 revealed: This OT positioned this pt (patient) EOB (edge of bed) with pt demonstrating F- (fair minus) balance utilizing RUE (right upper extremity) to maintain balance, OT went to position w/c (wheelchair) to bed in preparation for t/f (transfer). Pt lost balance to left and fell from bed onto floor mat on floor beside bed.

Based on observation, record review and staff interview, the facility failed to perform hand hygiene after performing incontinence care for one resident (R) (R#25). The sample size was 34 residents. Findings include: On 8/20/18 at 4:13 p.m., Certified Nursing Assistant (CNA) BB was observed performing perineal care, including the rectal area and buttocks, for R#25 after she had been incontinent of a moderate amount of urine. After the perineal care was completed, the CNA did not remove their gloves, and placed the resident's pants back on, and pulled the bed sheet and quilts back over her. CNA BB was then observed to place the call pad over the resident's abdomen, and used the motorized controls to lower the bed height, then repositioned the pillow under R#25's head before removing their gloves. During interview with the Licensed Practical Nurse (LPN) Infection Control Nurse on 8/22/18 at 10:34 a.m., she stated that staff should remove their gloves and wash their hands immediately after the soiled linen is placed in a bag following perineal care, before they touched the resident or did any other care. Review of the facility's Perineal Care policy revised (MONTH) (YEAR) revealed: 8b. Wash perineal area, wiping from front to back. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. Review of the facility's Handwashing/Hand Hygiene policy revised (MONTH) (YEAR) revealed: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents. j. After contact with blood or bodily fluids.

Based on the facility's Storage of Medications policy, observations, staff interviews, and review of manufacturer's instructions the facility failed to ensure medications were: 1) dated appropriately when opened in 1 of 2 medication storage rooms, and 2) removed expired medication and biologicals from use in 1 of 2 medication storage rooms. The facility census at the time of the survey was 122 residents. Findings include: 1. Review of the policy titled Storage of Medications last revised on April 2007, revealed in number 4, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. a. Failure to Appropriately Date Medications Once Opened. An audit of the Subacute Care (SAC) medication room refrigerator was conducted on 9/20/17 at 11:45 a.m. in the presence of Registered Nurse (RN) Unit Manager (UM). The audit revealed two opened and used multiuse vials of Tuberculin Purified Protein Derivative (PPD) solution (lot number 4). The containers and used vials of PPD solution were not dated when opened. The manufacturer's instructions on the side of the medication container revealed the medication should be discarded 30 days after being opened. During an interview with RN UM on 9/20/17 at 12:16 p.m. RN UM acknowledged the two used vials of PPD solution were not dated when opened. RN UM stated the medication should be dated when opened and the medication was only good for 30 days after being opened. RN UM removed the two opened and undated multiuse vials of PPD solution from use. b. Expired Medication and Biologicals An audit of the Subacute Care medication room cupboards were conducted on 9/20/17 at 11:50 a.m. in the presence of RN UM. The audit revealed: 1. Gericare Vitamin B-6, Dietary Supplement 100 tablets, 100 milligram (mg) unopened with an expiration date of 5/17. 2. Major Geravim liquid (lot number 0710B) 16 ounces unopened with an expiration date of 8/17. 3. Magnesium-oxide 400 mg tablets (lot number 39) 120 tablets unopened with an expiration date 3/31/17. 4. Magnesium-oxide 400 mg tablets (lot number 8042-6006) 60 tablets unopened with an expiration date of 3/31/17. 5. Magnesium-oxide 400 mg tablets (lot number 8042-6010) 60 tablets unopened with an expiration date of 8/31/17. 6. Benadryl 25 mg capsules of 30 capsules unopened with an expiration date of 2/2017. 7. Dextrose 5 in Lactated Ringer's injection (lot number J4N456) 1000 milliliter (ml) x 2 container unopened with an expiration date of 4/17 During an interview with RN UM on 9/20/17 at 12:16 P.M., RN UM acknowledged the expired drugs and intravenous liquids and she removed them from the cabinets. The UM stated she was responsibly to check for expired drugs but the unit was so busy with admissions she did not check. Interview on 9/21/17 at 5:03 p.m. with Assistant Director of Nursing (ADON) revealed the Unit Manager on SAC shoud be checking on all the medications for expiration dates every two weeks. She stated there is no signed sheet for documenting when the checks are done.

Based on observation, record review and staff interviews, the facility failed to establish and maintain an infection control program to help prevent transmission of disease and infection, failed to practice consistent infection control principles to prevent cross contamination in the laundry facility and failed to label and store personal care equipment in a sanitary manner on four (4) of four (4) halls (Blue, Brown, Green and Mauve). Findings include: 1. A review of the Infection Control Log for 2015 revealed listings of identified infections and antibiotic therapy only. There was no evidence of tracking, trending, follow up or infection control related in-services for staff. An interview conducted on 10/8/15 11:30 AM with the Infection Control Nurse AA confirmed there is no evidence of any in-services provided to the staff related to infection control and all she does is documents antibiotics. An interview conducted on 10/8/15 at 12:15 PM with the Infection Control Partner EE revealed she works mainly at the hospital but partners with the facility. The Nursing Home partner AA is responsible for providing in-services to the Nursing Home Staff. She confirmed at this time there is no evidence of in-service sign in sheets related to infection control practices. Further, she said there used to be an Infection Control Book which contained all the infection data, in-services and infection control audits but she does not know what happened to it. 2. An observation conducted of the laundry facility conducted on 10/8/15 at 11:00 AM revealed one very small room with one (1) washer and one (1) dryer. There was no separate entrance of area for soiled clothing. The dirty bin for the incoming soiled clothing was just inside the doorway to the left right next to the clean hanging clothes. The table for separating and folding the clean clothes is approximately three (3) to four (4) away from the dirty linen barrel. (See photo) An interview conducted on 10/8/15 at 11:05 AM with the laundry aide II revealed only the residents personal clothing is washed in this facility. All personal clothing is handles the same. Resident clothing that comes from an isolation room is kept in a yellow barrel in the resident's room but it is transported to laundry in a regular clear bag and washed with all the other clothing. She confirmed, once the clothing leaves the isolation room and enters the laundering room, there is no way to identify that it came from an isolation room. Interview conducted on 10/8/15 at 11:30 AM with the Infection Control nurse (Debbie Oliver/LPN) revealed she does not include the laundry services as part of her infection control monitoring but as the Infection Control Nurse the expected standard of practice for the handling of clothing coming from residents in isolation should be red bagged and washed separately from all other clothing. Interview conducted on 10/8/15 at 11:40 AM with the Director of Environmental Services JJ revealed she just took over this position about one week ago. She confirmed the laundry facility is very small, there is no separate entrance or area for the soiled linen and that the clean clothing is extremely close to the dirty/soiled laundry bin and should not be. 3. During a tour of the facility conducted on 10/5/15, improper storage and labeling of personal care equipment was found in the following bathrooms: Blue Hall: At 12:45 PM in the bathroom of room [ROOM NUMBER] revealed two (2) unlabeled urinals sitting on a hand rail behind the toilet, one (1) unlabeled denture cup on the sink, two (2) unlabeled wash basins stacked inside one another on the floor under the sink area and one (1) bagged but unlabeled bedpan, soiled with feces and a handful of toilet paper soiled with feces, hanging of the handrail to the left side of the toilet, for which two (2) residents share. At 1:05 PM in the bathroom of room of 105 revealed a bagged but unlabeled wash basin hanging on the handrail, for which two (2) residents share. Brown Hall: At 1:40 PM in the bathroom of room [ROOM NUMBER] revealed one (1) unlabeled, un-bagged wash basin in a geri- chair, one (1) unlabeled, un-bagged wash basin on the floor under the sink area and two (2) unlabeled oral basins one with a toothbrush and paste on the sink shelf, for which two (2) residents share. Green Hall: At 2:08 PM in the bathroom of room [ROOM NUMBER] revealed one (1) cup with an unlabeled tooth brush and paste in it and two (2) unlabeled wash basins stacked one inside the other on the bathroom floor, for which two (2) residents share. At 2:10 PM in the bathroom of room [ROOM NUMBER] revealed one (1) unlabeled denture cup sitting on the shelf above the sink and one un-bagged, unlabeled bedpan on the floor for which two (2) residents share. At 2:25 PM in the bathroom of room [ROOM NUMBER] revealed one (1) unlabeled wash basin with personal items in it on the floor and one un-bagged, unlabeled wash basin propped on the hand rail for which two (2) residents share. Mauve Hall: At 2:30 PM in the bathroom of room [ROOM NUMBER] revealed 2 un-bagged and unlabeled bed pans, for which two (2) residents share. At 2:32 PM in the bathroom of room [ROOM NUMBER] revealed 2 unlabeled wash basins with personal items in them on the floor for which two (2) residents share. Interview conducted on 10/8/15 at 3:21 PM with the Director of Nursing (DON) revealed there is no written policy for personal care equipment storage but the expectation and standard of practice is to label and bag all bed pans and urinals and hang them form the railing in the bathrooms. All wash basins are to be labeled and can hold personal items in them and stored in the resident ' s closet. All denture cups should be labeled and can be stores on the shelf above the bathroom sink. At no time should and personal care equipment be on the floor.

Based on review of resident trust fund accounts, and interviews, the facility failed to ensure that acceptable accounting principles were maintained for seven (7) residents (#137, # 31, #24, #35, #97, #75, #74 ) from twenty-five (25) fund accounts managed by the facility. Findings Include: An Interview with the Administrator, Director of Nurses and PP was conducted on [DATE] at 5:15 pm while reviewing the twenty-five (25) resident fund accounts managed by the facility. Discrepancies were identified in the following accounts. 1. Patient liability for Resident #137 was $406.00 in [DATE]. Resident liability was charged in [MEDICAL CONDITION] at $390.00, [DATE] $235.00 and [DATE] at $425.00. On [DATE] the resident was billed again $375.00 for [DATE] to [DATE]. $375.00 for [DATE] to [DATE]. $375.00 for [DATE] to [DATE]. $375.00 for [DATE] to [DATE]. $375.00 [DATE] to 5 /,[DATE] and [DATE] to [DATE] for $375.00 after liability was previously paid in those months. PP is not aware of why different amounts of liability was charged or why resident was charged twice for the months of January, February, March, April, May and June of 2015. 2. Resident #31's Patient liability for [DATE] was $1098.00. On [DATE] this resident was charged twice in the amount of $6045.00 for [DATE] to [DATE] room charge and [DATE] to [DATE] room charge. There is no evidence of past due liability. PP believes there was a time when the resident was charged private pay. There is no supporting evidence that the resident or responsible party was made aware of past due amounts or adjustments to the account. 3. Resident #24's patient liability on [DATE] was $650.00. The residents account was charged on [DATE] $620.00 and $680.00 on [DATE]. PP was not aware of why differences in liability was charged. 4. Patient liability for Resident #35 on [DATE] was $702.00. Liability was charged on [DATE] for $500.00, [DATE] for $485.00 and [DATE] for $475.00. PP indicated the resident also had other needs paid for and did not always have enough for liability and she did not want to leave him without a balance. 5. Resident #97's liability is $1616.00 in [DATE]. The resident was charged $1646.00, $1633.00 and $1635.00 for July, August and September of 2015. 6. Resident #75's liability was $1535.00 in [DATE]. PP revealed this resident did not always have enough funds to go to the beauty shop so she sometimes charged less liability. ,[DATE] liability was charged for $1530.53. ,[DATE] for $1501.90 and ,[DATE] for $1516.90. 7. PP was not able to determine Resident #74's liability for 2015. It was withdrawn as $1271.00 from 2014. After residents death on [DATE] her remaining balance of $59.15 was written as payment to the facility to be applied to her$ 32,718.00 balance due. PP revealed there are many accounts in which they do not receive payments correctly and have a balance upon death that is used towards the balance due. After completion of resident trust fund account review on [DATE] at 6:00 p.m. the Administrator revealed it is her expectation that the resident accounts be managed correctly with appropriate accounting techniques. No facility policy regarding resident trust funds was provided.

Based on observations, record reviews and interviews, the facility failed to ensure residents were free from the use of side rails to prevent mobility without assessment and/or physician's order reflecting the medical condition requiring use of side rails for six (6) residents (#39, #52, #122, #144, # 101 and #213) from a sample of fifty (50) residents. Findings include: 1. Observations conducted on 10/5/15 at 4:30 p.m. revealed resident #39 in bed with four (4) one-half (1/2) side rails in the up position. Interview conducted on 10/5/15 at 2:31 p.m. with the Licensed Practical Nurse (LPN) QQ responsible for providing direct care for the resident revealed that bilateral full side rails are used every now and then for safety when the resident tried to climb out of bed. Review of medical record reveals Physicians orders dated 2/1/2015 for side rails ½ x 2 aid with bed mobility and define parameters of bed. An order on 8/26/2015 Side rails x 2 to aid in bed mobility and define parameters of the bed. The care plan dated 5/24/2014 indicated the resident has a risk of falls and an intervention in place to assure side rails up x 2. 2. Observation conducted on 10/5/2015 at 1:05 PM and 4:20 p.m. revealed resident # 52 in bed with four (4) one-half (1/2) side rails in the up position. Interview conducted on 10/5/2015 at 2:28 PM with QQ revealed four (4) one-half (1/2) side rails are used to prevent falls because the resident climbs out of bed. The resident is capable of getting in and out of bed and the full rails do prevent her from voluntarily getting out of bed. Review of medical record revealed a Physicians order dated 9/28/2015 with NO side rail orders. Review of the residents most recent care plan did not include a plan of care for restraints or use of side rails. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Minimum Status (BIMS) score of two (2). 3. Observations conducted on 10/5/15 at 1:40 PM and 10/6/15 at 2:25 PM revealed resident #122 in bed with four (4) 1/2 side rails in the up position. Interview conducted on 10/5/15 at 2:20 PM with LPN RR responsible for the direct care for resident #122 revealed four (4) 1/2 rails or full side rails are used for safety. RR further revealed the resident wiggles and the rails prevent her from falling out of the bed. Review of medical record revealed a physician ' s order for side rails ½ x 2 aid with bed mobility and define parameters dated 10/1/2015. Resident is care planned for use of two (2) side rails up to define parameters. 4. Observation conducted on 10/7/15 at 9:18 AM revealed resident #144 in bed with the bed in the lowered position. Three (3) one-half (1/2) rails were observed in the up position. One (1) on the left side and two (2) on the right side of the bed. Further observation revealed the resident had one (1) leg hanging over the right side of the bed between the two (2) raised rails on that side. Review of the medical record revealed resident #144 was re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment dated [DATE] assessed the resident with a BIMS of ten (10) and required limited assistance of one-person assist with bed mobility, transfers and locomotion and walking. Section P Coded the resident as not having Physical restraints. History of falls 2-6 months Review of the Care Plan dated 9/12/14 revealed no care plan for the use of restraints or side rails. Review of Physician's orders revealed an order for [REDACTED]. 5. Observation conducted on 10/08/2015 at 6:16 AM revealed resident #101 in bed asleep with two (2) full side rails in up position. Interview conducted on 10/8/15 at 7:18 AM with LPN FF revealed resident #101 has two rails at the head of the bed to help him/her get out of the bed. FF further acknowledged she was not aware of the doctor orders for side rails. Review of medical record revealed physicians orders for two (2) side rails to define parameters for this resident dated 10/7/2015. He was care planned for the use of two (2) side rails to define parameters. 6. On 10/7/2015 at 10:00 AM and interview was conducted with the Director of Nurses (DON) during chart reviews of residents with accidents. On 9/28/2015 at 0030 it was documented resident #213 was found in bedrails. Assisted resident in removing legs from rails. Bruising to Right Lower Extremity noted. Physicians and responsible party notified. This resident ' s admission and interim care plan dated 9/24/2015 revealed resident requires side rails. The updated care plan after 9/28/2015 accident requires and intervention of padded side rails x 2. No new physicians orders for side rails on 9/28. There is no evidence of admission orders [REDACTED]. An observation of resident #213 was made with the DON on 10/7/2015 at 1:30 PM. The resident was in bed with four (4) one-half (1/2) rails in the up position and padded with bed length blue pad on the right and left sides of bed secured with Velcro. Review of the facility policy Use of Physical restraints with the Director of Nurses and Administrator on 10/7/2015 at 4:15 PM reveals A. Residents have the right to be free from any restraint imposed for the purposes of discipline or convenience and not required to treat the resident ' s medical symptoms. 1. Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident ' s body that the individual cannot remove easily which restricts freedom of movement or normal access to one ' s body. 2. Full side rails used on both sides of the resident ' s bed are considered restraints and are prohibited unless they are necessary to treat a resident ' s medical symptom or used as an enabler or to assist in mobility and transfer of a resident or by the resident ' s request. D. Before a resident is restrained the resident must have a specific medical symptom that would require the use of restraints and how the use of restraints would treat the cause of the symptom and assist the resident in reaching his or her highest level of physical and psychosocial well-being must be demonstrated. F. Prior to using restraints a systematic process of evaluation and care planning will be followed. 1. The presence of a specific medical symptom that would require a restraint. 2. A pre restraining assessment 3. Use of the least restrictive restraint. 4. Education of the restraint/representative. 6. Physicians written order for the use of [REDACTED]

Based on record review, hospital Emergency Department Physician's Documentation form review, hospital Emergency Department Order Results Final Report review, staff interview, and physician interview, the facility failed to immediately consult with the physician of one (1) resident (#115), upon the resident's return to the nursing facility after the resident was transferred to the hospital due to a fall, diagnosed with [REDACTED]. The survey sample size was fifty-six (56) residents. Resident #115 subsequently developed a Deep Tissue Injury (DTI) to the right outer ankle measuring 8 cms by 1.5 cm, a DTI on the top of the right foot measuring 8 cms by 2 cms, a DTI to the outside of the right foot measuring 7 cms by 2 cms, a DTI to the right inner ankle measuring 6.5 cms by 4.5 cms, a 7 cm by 7 cm by 1 cm pressure sore to the right foot Achilles Tendon, and an unstageable area to the top of the right foot measuring 6 cms by 5 cms. Findings include: Resident #115's Quarterly Minimum Data Set assessment of 08/01/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Hypertension, [MEDICAL CONDITION], and Dementia. A 10/20/2014, 4:00 p.m. Nurses Notes (NN) entry documented Resident #115 was lying on the floor and a bump to the back the head was noted. This NN documented that when notified, the physician gave an order to send Resident #115 to the hospital. A 10/20/2014 hospital Emergency Department (ED) Physician's Documentation form documented Resident #115 reported he hit his head and injured his right ankle during a fall, and physician's orders [REDACTED]. A 10/20/2014 hospital ED Order Results Final Report documented Resident #115's right ankle X-ray revealed no fracture. However, a hospital ED Physician Documentation form documented that Resident #115 was discharged from the hospital on [DATE] with Discharge Instructions identifying that he did have an ankle sprain, with Velcro Splint application, and specified follow-up with the resident's physician in one (1) to (2) days. A 10/20/2014, 8:15 p.m. nursing facility NN entry documented Resident #115's return to the facility, and documented a brace on the right ankle due the [DIAGNOSES REDACTED].#115's medical record, to include review of this 10/20/2014, 8:15 p.m. NN entry, revealed no evidence to indicate that Resident #115's physician was consulted, upon the resident's return from the hospital, regarding either the resident having sustained a sprained right ankle or the use of an ankle splint. Additionally, further review of Resident #115's record, to include NN entries of 10/20/2014 at 9:30 p.m. and 11:00 p.m., 10/21/2014 at 11:30 p.m., 10/22/2014 at 3:00 p.m., and also 10/22/2014 at 11:51 p.m. (which documented the continued use of the right ankle splint), revealed no evidence to indicate that the resident's physician had been consulted regarding the sprained right ankle or the continued use of an ankle splint. This was despite Resident #115's 10/20/2014 ED Physician Documentation form referenced above which documented the splint application in the hospital and specified physician follow-up one (1) to (2) days after nursing facility transfer. Additionally, further review of Resident #115's medical record, including NN entries of 10/23/2014 and 10/25/2014, both documented to be for the 7:00 p.m. to 7:00 a.m. shift, continued to reveal no evidence to indicate that Resident #115's attending physician was notified that the resident's right ankle sprain or that the resident was wearing a right ankle splint. Then, a 10/29/2014, 9:00 a.m. Late Entry NN entry documented that on 10/26/2014 at approximately 6:00 p.m., a facility nurse spoke with a family member of the resident about the right ankle splint, but noted the absence of splint management orders. This NN entry documented that the nurse removed Resident #115's ankle splint and noted a blister on the anterior foot, and documented possible deep tissue injuries on the medial and lateral aspects of ankle. Further record review, however, revealed no evidence to indicate that Resident #115's physician was consulted at that time regarding the identification of these pressure sores to the resident's right foot and ankle. Record review for Resident #115 revealed 10/27/2014 Weekly Wound Assessment Record forms documenting that Resident #115 was assessed to have the following pressure sores: a Deep Tissue Injury (DTI) to the right outer ankle measuring 8 cms by 1.5 cm, dark purple in color and tender to touch, with a 30 percent fluid filled area; a DTI on the top of the right foot measuring 8 cms by 2 cms, purple in color; a DTI to the outside of the right foot measuring 7 cms by 2 cms, dark purple in color; a DTI to the right inner ankle measuring 6.5 cms by 4.5 cms, purple in color; a 7 cm by 7 cm by 1 cm pressure sore to the right foot Achilles Tendon area; and an unstageable area to the top of the right foot measuring 6 cms by 5 cms, 50 percent covered with Eschar, dark purple in color, and tender to the touch. A notation in the Progress Notes section of Resident #115's Weekly Wound Assessment Record Form of 10/27/2014 documented the physician was notified of these pressure sores, and that treatment orders were received. During an interview with Licensed Practical Nurse (LPN) Treatment Nurse "CC" conducted on 12/10/2014 at 11:10 a.m., LPN "CC" acknowledged that Resident #115 returned from the hospital on [DATE] with a splint on the right foot. LPN "CC" acknowledged that the ER Discharge Instructions had indicated to follow-up with the attending physician within one (1) to two (2) days of the resident's return to the nursing facility, but also acknowledged that no follow-up with the resident's attending physician had been done. During an interview conducted on 12/11/2014 at 11:41 a.m. with the Physician "KK", who was Resident #115's attending physician, Physician "KK" stated he was not notified when the resident returned from the ER visit on 10/20/2014. He stated that if he had been notified, then he would have come and assessed Resident #115, especially, if he was wearing a splint, to evaluate the resident's injury. Physician "KK" further stated that it was possible that his partner, Physician "JJ", could have been notified of the application of the ankle splint for Resident #115. However, during interview with Physician "JJ" conducted on 12/11/2014 at 4:05 p.m., Physician "JJ" stated he was not notified that Resident #115 was readmitted to the facility with an ankle splint after the fall that occurred on 10/20/2014. Physician "JJ" further stated that the first time he was contacted regarding Resident #115's ankle injury was on 10/27/2014 when the Treatment Nurse reported to him the pressure sores on Resident #115's foot after the ankle splint had been removed. This physician stated that it was his expectation that staff would call to notify him of the splint and obtain an order to either manage the splint or remove the splint. Cross refer to F314 for more information regarding Resident #115.

Based on medical record review, staff interview, physician interview, hospital Emergency Department Nurses Notes review, hospital Emergency Department Physician Documentation form review, facility Policy and Procedure for Casts/Splints review, and National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, the facility failed to ensure that care was provided in accordance with professional standards of quality regarding the ongoing assessment for one (1) resident (#115) who was at risk for altered skin integrity after the application of an ankle splint, and regarding the administration of [MEDICATION NAME] drug therapy as ordered for two (2) residents (#58 and #101). The total survey sample was fifty-six (56) residents. This resulted in harm for Resident #115 who, after the failure of staff to monitor the resident's right foot and ankle after splint application, subsequently developed a Deep Tissue Injury (DTI) to the right outer ankle measuring 8 centimeters (cms) by 1.5 cm, a DTI of the right foot measuring 8 cms by 2 cms, a DTI to the outside of the right foot measuring 7 cms by 2 cms, a DTI to the right inner ankle measuring 6.5 cms by 4.5 cms, a 7 cm by 7 cm by 1 cm pressure sore to the right foot Achilles Tendon, and an unstageable area to the top of the right foot measuring 6 cms by 5 cms. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice, Section 2.3.2(c) - Standards Related to Licensed Practical Nurse/Vocational Nurse Responsibilities for Nursing Practice Implementation, specified the nurse demonstrates attentiveness and provides resident surveillance and monitoring. In addition, Section 2.3.2.(i)(3) of Chapter 2 of these Model Nursing Administrative Rules specified that the nurse administers medications accurately, and Section 2.3.2(k) specified that the nurse communicates relevant and timely resident information with other health team members. 1. Record review for Resident #115 revealed a Quarterly Minimum Data Set (MDS) assessment of 08/01/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. A 10/20/2014, 4:00 p.m. Nurses Notes (NN) entry for Resident #115 documented the resident was lying on the floor with a bump to the head, and documented a physician's orders [REDACTED].#115 to the hospital. A hospital Emergency Department (ED) NN entry documented Resident #115's 10/20/2014 hospital transfer. A 10/20/2014 hospital ED Physician's Documentation form documented Resident #115 had sustained a fall and reported hitting his head and injuring his ankle, and documented orders including an X-ray of the right ankle and a Velcro Splint. Resident #115's ED Physician Documentation form also documented an ankle sprain and application of a Velcro Splint, documented a 10/20/2014 discharge back to the nursing facility, and specified follow-up with the physician in one (1) to (2) days. A 10/20/2014, 8:15 p.m. facility NN entry then documented Resident #115 had returned from the hospital wearing a brace on the right ankle due to a sprain. The facility's Policy and Procedure (P&P) for Casts/Splints specified that upon splint application, nursing staff were to assess fingers/toes every 2 hours for 24 hours or until stable, then every 4 hours, for signs of decreased circulation/movement such as increased pain/pressure, decreased peripheral pulses, and changes in color/skin temperature. However, even though Resident #115 returned to the facility from the hospital on [DATE] wearing a right ankle splint (per the 10/20/2014, 8:15 p.m. NN entry referenced above), and even though the Casts/Splints P&P referenced above required that nursing staff assess the fingers/toes of the extremity every four (4) hours for signs of decreased circulation, further review of Resident #115's clinical record revealed no evidence to indicate that nursing staff assessed the resident's right foot and ankle every four (4) hours, or at all, for signs of decreased circulation on 10/20/2014 after his return to the facility, or on 10/21/2014, 10/22/2013, or 10/23/2014. This was in violation of nursing standards of practice, as outlined in the Model Nursing Administrative Rules, Standards Related to Licensed Practical Nurse/Vocational Nurse Responsibilities for Nursing Practice Implementation referenced above, which specified that the nurse demonstrate attentiveness and provide monitoring to residents. A weekly Skin Audits form of 10/24/2014 document that on that date, Resident #115 was noted to have normal ankles and warm, soft and mushy feet and heels. However, further review of Resident #115's clinical record revealed no evidence to indicate that nursing staff monitored the resident's right foot and ankle for circulation every four (4) hours, as required by the Cast/Splint P&P referenced above, or at all, on 10/24/2014, 10/25/0214, and 10/26/2014. This was in violation of nursing standards of practice, as outlined in the Model Nursing Administrative Rules, Standards Related to Licensed Practical Nurse/Vocational Nurse Responsibilities for Nursing Practice Implementation referenced above, which specified that the nurse demonstrate attentiveness and provide monitoring. Review of Resident #115's medical record also revealed no evidence to indicate that the resident's physician was notified of the right ankle splint upon the 10/20/2014 nursing facility return through 10/26/2014, even though the 10/20/2014 hospital ED Physician Documentation form referenced above specified physician follow-up in one (1) to (2) days after facility return. This was in violation of nursing standards of practice, as outlined in the Model Nursing Administrative Rules, Standards Related to Licensed Practical Nurse/Vocational Nurse Responsibilities for Nursing Practice Implementation referenced above, which specified that the nurse communicate relevant, timely resident information with other health team members (to include the physician). A 10/29/2014, 9:00 a.m. Late Entry NN entry then documented that on 10/26/2014, a facility nurse removed Resident #115's splint and noted a blister on the anterior foot and possible deep tissue injuries (DTIs) to the medial/lateral aspects of the ankle. A 10/27/2014 wound care assessment for Resident #115 documented on Weekly Wound Assessment Record forms revealed that Resident #115 was assessed to have a DTI to the right outer ankle measuring 8 cms by 1.5 cm, dark purple in color and tender to touch, with a 30 percent fluid filled area; a DTI on the top of the right foot measuring 8 cms by 2 cms, described as purple in color; a dark purple DTI to the outside of the right foot measuring 7 cms by 2 cms; a DTI to the right inner ankle measuring 6.5 cms by 4.5 cms, described as purple in color; a 7 cm by 7 cm by 1 cm pressure sore to the right foot Achilles Tendon; and an unstageable area to the top of the right foot measuring 6 cms by 5 cms, 50 percent covered with Eschar, dark purple in color, and tender to the touch. A 10/27/2014 Physician's Telephone Orders (PTO) form documented physician's orders [REDACTED].#115's right foot twice daily. During an interview with Licensed Practical Nurse (LPN) Treatment Nurse "CC" on 12/10/2014 at 11:10 a.m., LPN "CC" acknowledged that, after Resident #115's return from the hospital on [DATE] wearing the right ankle splint, facility nursing staff failed to monitor the resident's right foot and ankle until 10/26/2014. LPN "CC" stated that nursing staff should have assessed the condition of Resident #115's ankle and foot after splint application, and acknowledged the pressure sores of the right foot and ankle. Additionally, during interviews with Physician "KK" conducted on 12/11/2014 at 11:41 a.m., and with Physician "JJ" (Physician "KK"'s partner) on 12/11/2014 at 4:05 p.m., both physicians stated they were not notified of Resident #115's return from the hospital on [DATE] wearing the right ankle splint. Cross refer to F157 and F314 for more information regarding Resident #115. 2. Resident #101's Quarterly MDS assessment of 09/12/2014 documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. An 11/10/2014 Physician's Telephone Orders (PTO) form for Resident #101 specified to hold the current dose of [MEDICATION NAME] (ordered at 7 milligrams (mgs) at bedtime) for two (2) days, then to administer [MEDICATION NAME] five (5) mg at bedtime. However, Resident #101's November 2014 Medication Administration Record [REDACTED]. This was despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above which specified that the standard of practice required the nurse to administer medications accurately. During an interview on 12/11/2014 at 8:32 A.M., the Director Of Nursing acknowledged the error involving Resident #101 receiving the wrong dose of [MEDICATION NAME] drug therapy. Cross refer to F309, example 1, for more information regarding Resident #101. 3. Resident #58's 09/09/2014 Quarterly MDS assessment documented [DIAGNOSES REDACTED]. A PTO form dated 11/12/2014 for Resident #58 specified to hold [MEDICATION NAME] (ordered at a dose of 7 mgs at bedtime) for two (2) days, then to give [MEDICATION NAME] six (6) mgs daily. However, despite the PTO of 11/12/2014 ordering to hold Resident #58's [MEDICATION NAME] for 2 days, the resident's November 2014 MAR indicated [REDACTED]. This was despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above which specified that the standard of practice required the nurse to administer medications accurately. During interview conducted 12/12/14 at 10:50 A.M., LPN "AA" acknowledged that Resident #58's [MEDICATION NAME] should have been held on 11/12/2014, but that the resident received [MEDICATION NAME] on that date, and then [MEDICATION NAME] 6 mgs was started on 11/14/14. Cross refer to F309, example 2, for more information regarding Resident #58.

Based on medical record review, staff interview, hospital Emergency Department Physician Documentation form review, and Policy and Procedure for Casts/Splints review, the facility failed to provide skin assessments, in accordance with the Care Plan, to monitor the skin integrity of one (1) resident (#115) after the application of a right ankle splint, and failed to administer [MEDICATION NAME] anticoagulant drug therapy as ordered, as specified by the Care Plans of two (2) residents (#58 and #101). The total survey sample was fifty-six (56) residents. The facility's failure to monitor the skin integrity of Resident #115 as specified by the resident's Care Plan resulted in actual harm, in that Resident #115 developed a Deep Tissue Injury (DTI) to the right outer ankle measuring 8 centimeters (cms) by 1.5 cm, a DTI on the top of the right foot measuring 8 cms by 2 cms, a DTI to the outside of the right foot measuring 7 cms by 2 cms, a DTI to the right inner ankle measuring 6.5 cms by 4.5 cms, a 7 cm by 7 cm by 1 cm pressure sore to the right foot Achilles Tendon, and an unstageable area to the top of the right foot measuring 6 cms by 5 cms. Findings include: 1. Resident #115's Significant Change Minimum Data Set (MDS) assessment of 02/01/2014 documented [DIAGNOSES REDACTED]. Section M - Skin Conditions documented that Resident #115 had no pressure sores at that time, but was at risk of pressure sore development. The Care Plan of Resident #115 identified a Problem, originally dated 02/22/2014, indicating that the resident was at risk for an alteration in skin integrity related to reasons which included, but were not limited to, fragile and thin skin and limited mobility, with a [DIAGNOSES REDACTED].#115's Care Plan to address the resident's risk for an alteration in skin integrity included, but were not limited to, skin audits to be conducted both weekly and, in addition, on an as-needed basis, and to report any open areas or areas of redness to the charge nurse. A 10/20/2014, 4:00 p.m. Nurses Notes (NN) entry documented Resident #115 was on the floor with a bump on the head, and that the physician ordered hospital transfer. A 10/20/2014 hospital Emergency Department Physician's Documentation form documented Resident #115's fall and that after evaluation, Resident #115 was discharged from the hospital having an ankle sprain and with a Velcro Splint having been applied. A 10/20/14, 8:15 p.m. NN entry documented Resident #115's return to the nursing facility with a brace on the right ankle. A weekly Skin Audits form for Resident #115 dated 10/24/2014 (four days after the 10/20/2014 nursing facility readmission after right ankle brace application) documented that assessment revealed normal ankles and warm, soft, mushy feet/heels. This weekly Skin Audits form was done in accordance with Resident #115's Care Plan Approach referenced above which specified weekly skin audits in relation to his increased risk for alteration in skin integrity. However, as noted above, Resident #115's Care Plan Approach for the risk of alteration in skin integrity also specified that, in addition to weekly skin audits, skin audits were to be conducted on an as-needed basis to ensure adequate, ongoing assessment of the resident's skin integrity. The facility's Casts/Splints Policy and Procedure (P&P) specified that for a resident having a splint, staff were to assess for decreased circulation/movement in the fingers/toes of the extremity every two (2) hours for 24 hours or until stable, then every four (4) hours. As referenced above, Resident #115 returned to the facility on [DATE] post hospital transfer after having had a right ankle splint applied. However, despite the application of this right ankle splint on 10/20/2014, despite Resident #115's Care Plan specifying as-needed skin assessments (in addition to weekly skin assessments) to monitor his skin integrity, and despite the Splint/Case P&P referenced above specifying inspection of the extremity (right ankle and foot) every 4 hours after splint application to monitor for decreased circulation/movement, there was no evidence (other than the 10/24/2014 weekly Skin Audits form referenced above) to indicate that facility nursing staff provided monitoring every 4 hours (per Policy), or provided any monitoring, of the resident's right ankle and foot on 10/20/2014, 10/21/2014, 10/22/2014, 10/23/2014, 10/24/2014, 10/25/2014, and 10/26/2014 to assess the integrity of the skin. A 10/29/2014, at 9:00 a.m. Late Entry NN then documented that on 10/26/2014, a nurse removed Resident #115's splint and noted an anterior foot blister and possible DTIs on the medial/lateral ankle. A 10/27/2014 Weekly Wound Assessment Record for Resident #115 documented a dark purple DTI to the right outer ankle measuring 8 cms by 1.5 cm which was tender to touch and had a 30 percent fluid-filled area; a purple DTI on the top of the right foot measuring 8 cms by 2 cms; a dark purple DTI to the outside of the right foot measuring 7 cms by 2 cms; a purple right inner ankle DTI measuring 6.5 cms by 4.5 cms; a 7 cm by 7 cm by 1 cm pressure sore of the right Achilles Tendon; and a dark purple 6 cms by 5 cms unstageable area on top of the right foot which was 50 percent covered with Eschar and tender to touch. During an interview on 12/10/2014 at 11:10 a.m., Licensed Practical Nurse (LPN) Treatment Nurse "CC" acknowledged that after Resident #115's facility readmission 10/20/2014, the ankle splint was in place but that staff failed to assess the right lower extremity until 10/26/2014, at which time the ankle/foot pressure sores were identified. Cross refer to F314 for more information regarding Resident #115. 2. Resident #101's Quarterly MDS assessment of 09/12/2014 documented diagnoses, in Section I - Active Diagnoses, including, but not limited to, Hypertension, Heart Failure, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A 10/27/2014 physician's orders [REDACTED]. A subsequent 11/10/2014 Physician's Telephone Orders (PTO) form specified to hold [MEDICATION NAME] for two (2) days, then restart [MEDICATION NAME] 5 mgs at bedtime. The Care Plan for Resident #101 identified a Problem, originally dating from 12/24/2013, indicating the resident was at risk for bleeding, excessive bruising, and drug interactions related to routine [MEDICATION NAME] therapy. A Care Plan Approach related to Resident #101's identified risk for bleeding, bruising and drug interactions regarding [MEDICATION NAME] drug therapy specified that medication was to be administered as ordered by the physician. However, despite Resident #101's PTO form of 11/10/2014 referenced above specifying that [MEDICATION NAME] drug therapy be resumed at a dose of 5 mgs (after [MEDICATION NAME] was held on 11/10/2014 and 11/11/2014, per this PTO), and despite the resident's Care Plan specifying that medication (including [MEDICATION NAME]) be administered as ordered by the physician, Resident #101's November 2014 MAR indicated [REDACTED]. During a 12/11/2014, 8:32 A.M. interview, the Director Of Nursing acknowledged Resident #101's [MEDICATION NAME]'s dose was incorrect on 11/12/2014 and 11/13/2014. Cross refer to F309, example 1, for more information regarding Resident #101. 3. Resident #58's Quarterly MDS assessment of 09/09/2014 documented in Section I - Active [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#58 receive [MEDICATION NAME] 7 mgs at bedtime, but a PTO dated 11/12/2014 specified to hold the resident's [MEDICATION NAME] for 2 days, then give [MEDICATION NAME] 6 mgs daily. The Care Plan for Resident #58 identified a Problem, originally dating from 06/19/2014, indicating that the resident was at risk for bleeding and drug interactions related to the routine [MEDICATION NAME] drug therapy, with a Care Plan Approach which specified that medication be administered as ordered by the physician. However, despite Resident #58's Care Plan specifying that [MEDICATION NAME] drug therapy be administered in accordance with physician's orders [REDACTED]. Additionally, Resident #58's November MAR indicated [REDACTED]. During a 12/12/2014, 10:50 a.m. interview, LPN "AA" acknowledged that Resident #58 received the dose of [MEDICATION NAME] on 11/12/2014 in error, and that the [MEDICATION NAME] drug therapy was held only one day, on 11/13/2014, instead of 2 days as ordered. Cross refer to F309, example 2, for more information regarding Resident #58.

Based on observation, record review, staff interview, physician interview, hospital Emergency Department form review, hospital Emergency Department Order Results Final Report review, hospital Emergency Department Physician Documentation form review, Policy and Procedure for Casts/Splints review, the facility failed to perform skin assessments and monitoring of the right lower extremity, per facility policy, of one (1) resident (#115) after the application of an ankle splint. The survey sample size was fifty-six (56) residents. This failure resulted in actual harm to Resident #115, who developed a Deep Tissue Injury (DTI) to the right outer ankle measuring 8 centimeters (cms) by 1.5 cm, a DTI on the top of the right foot measuring 8 cms by 2 cms, a DTI to the outside of the right foot measuring 7 cms by 2 cms, a DTI to the right inner ankle measuring 6.5 cms by 4.5 cms, a 7 cm by 7 cm by 1 cm pressure sore to the right foot Achilles Tendon, and an unstageable area to the top of the right foot measuring 6 cms by 5 cms. Findings include: Review of the facility's Policy and Procedure (P&P) for Casts/Splints, having an Effective Date of 02/2011, revealed the documented Purpose of the P&P was to outline management in the care of a resident with a cast/splint. This P&P specified, in the Assessment section, that after cast/splint application, staff were to assess a resident's finger/toes of the involved extremity every two (2) hours for the first 24 hours or until stable, then continue assessing every four (4) hours, to assess and report any signs of decreased circulation or movement. The P&P specified that this assessment was to include, but was not to be limited to, assessing for an increase in pain or pressure, decreased peripheral pulses distal to the site of injury, and changes in the color and skin temperature of the extremity. Record review for Resident #115 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Referenced Date of 08/01/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns documented that Resident #115 had a Brief Interview for Mental Status Summary Score of 06, thus indicating severe cognitive impairment. Section G- Functional Status documented that Resident #115 had functional limitation in Range of Motion due to impairment of one lower extremity. A Nurses Notes (NN) entry of 10/20/2014 timed at 4:00 p.m. for Resident #115 documented the nurse was called to the resident's room to observe the resident lying on the floor in front of the wheelchair, and assessment revealed a bump to the back of Resident #115's head. This NN documented the physician was contacted and an order was received to send Resident #115 to the hospital emergency room . A NN entry of 10/20/2014 timed at 4:40 p.m. for Resident #115 documented the transport service had arrived and that the resident left the facility for transport to the hospital. A hospital Emergency Department (ED) NN entry for Resident #115 documented the resident's 10/20/2014, 4:45 p.m. hospital arrival. This ED NN documented, in the Presentation Section, that Resident #115 had presented with a hematoma to the back of the head, and documented, in the General Assessment Section, that the resident appeared in no apparent distress. An ED Physician's Documentation form of 10/20/2014 for Resident #115 documented the resident had sustained a fall and reported having hit his head and injuring his right ankle. This ED Physician's Documentation form further documented orders for the resident to receive a Computed Tomography (CT) scan of the brain and an X-ray of the right ankle, and for the application of a Velcro Stirrup Splint. A hospital ED Order Results Final Report of 10/20/2014 for Resident #115 documented, in the Findings section, the resident's CT Brain scan revealed no evidence for acute hemorrhage, stroke, or subdural fluid collection, and that the bone windows showed no fracture. This ED Order Results Final Report also documented Resident #115's right ankle X-ray revealed no fracture. Resident #115's ED Physician Documentation form referenced above documented, in the Disposition section, that the resident was being discharged from the hospital on [DATE] at 6:40 p.m. The Discharge Instructions section of this Physician's Documentation form documented Resident #115 had an ankle sprain, and specified a follow-up with Resident #115's physician in one (1) to (2) days. This ED Physician's Documentation form also documented that a Velcro Stirrup Splint had been applied on 10/20/2014, prior to Resident #115's hospital discharge, and documented that the resident's skin exam while in the hospital was negative for any acute changes. A nursing facility NN entry of 10/20/2014 timed at 8:15 p.m. for Resident #115 documented the resident had returned from the hospital ER, where a CT scan of the head revealed no head injury, but also documented the presence of a brace on the resident's right ankle due the [DIAGNOSES REDACTED]. A Monthly Evaluation Summary form for Resident #115 dated 10/20/2014 documented, in the Notes section, the resident's hospital transfer, and also noted, in the Skin Condition section, Resident #115 to have no pressure ulcers or other skin problems on the 10/20/2014 date of the resident's return from the hospital having a brace on the right ankle. A NN entry for Resident #115 of 10/20/2014, timed at 9:30 p.m., documented the resident had complained of pain in the right hip and ankle, and that medication had been given for the complaint of pain. A NN entry of 10/20/2014, timed at 11:00 p.m., documented that Resident #115 was resting and that the medication given for the complaint of pain in the right ankle and hip had been effective. However, despite a splint having been applied to Resident #115's right ankle upon his 10/20/2014 hospital transfer, as referenced above, despite the facility's P&P for Casts/Splints, also referenced above, specifying assessment of the resident's fingers/toes of the involved extremity for signs of decreased circulation (an increase in pain, pressure, color and/or skin temperature), and despite Resident #115's 10/20/2014, 9:30 p.m. NN entry referenced above documenting the resident's complaint of ankle pain, record review revealed no evidence to indicate that licensed nursing staff assessed the resident's right lower extremity for pressure (as specified by the Splint P&P referenced above) on 10/20/2014 after his return from the hospital. Resident #115's record revealed a NN entry of 10/21/2014, timed at 11:30 p.m. (approximately 24 hours after the previous 10/20/2014, 11:00 p.m. NN entry referenced above), which documented that the resident had requested pain medication due to a complaint of pain in the right ankle and hip. However, record review revealed no evidence to indicate that licensed nursing staff assessed Resident #115's right lower extremity for decreased circulation at that time, as specified by the Splint P&P. Record review also revealed no evidence of any assessment of Resident #115, to include assessment of the right lower extremity, between the 10/20/2014, 11:00 p.m. and 10/21/2014, 11:30 p.m. NN entries referenced above, representing an approximate 24 hour period during which nursing staff failed to assess the resident for decreased circulation after the 10/20/2014 application of the right ankle brace. This was despite the Splint P&P referenced above which specified that, after application of a splint, nursing staff were to staff were to assess the resident's toes every four (4) hours for any signs of decreased circulation. After Resident #115's 10/21/2014, 11:30 p.m. NN entry referenced above, the next documented assessment/monitoring of the resident was documented in a 10/22/2014, 3:00 p.m. NN entry, which documented the resident had been medicated for a complaint of pain in the right hip and ankle. However, despite Resident #115's complaint of ankle pain for which he received medication, per this 10/22/2014, 3:00 p.m. NN entry, there was no evidence of licensed nursing staff assessing the resident's right lower extremity for decreased circulation at the time. Record review also revealed no evidence of any assessment of the status of Resident #115 between the 10/21/2014, 11:30 p.m. and 10/22/2014, 3:00 p.m. NN entries referenced above, representing a period of approximately fifteen and one-half hours during which nursing staff failed to monitor Resident #115's right lower extremity for decreased circulation, as specified by the Splint P&P. A subsequent NN entry of 10/22/2014, timed at 11:51 p.m., for Resident #115 documented that the resident continued to have the splint applied to the right ankle status/post sprain. However, further record review for Resident #115, including review of this 10/22/2014, 11:51 p.m. NN entry, revealed no evidence to indicate that licensed nursing staff assessed the resident's right lower extremity for signs decreased circulation, per Policy. Review of Resident #115's medical record, including NN review, revealed no evidence to indicate that licensed nursing staff conducted any monitoring of the resident's status, including assessing the resident's right lower extremity every four (4) hours for signs of decreased circulation per Policy, on 10/23/2014 or 10/24/2014. A weekly Skin Audits form for Resident #115 dated 10/24/2014 did document that on that date, Resident #115 was noted to have pedal pulses, normal ankles, and warm, but soft and mushy, feet and heels. Review of Resident #115's medical record, including NN review, revealed no evidence to indicate that, after the 10/24/2014 Skin Audit referenced above, licensed nursing staff conducted any monitoring of the resident's status, including assessing the resident's right lower extremity every four (4) hours for signs of decreased circulation per Policy, on 10/25/2014 or 10/26/2014. Additionally, review of Resident #115's medical record revealed no evidence to indicate that the resident's attending physician was notified that the resident was wearing a splint to the right ankle upon his 10/20/2014 return to the nursing facility from the hospital, nor was there evidence that the physician was notified that the resident continued to wear the ankle splint from 10/20/2014 through 10/26/2014, as documented above. This was despite Resident #115's 10/20/2014 ED Physician Documentation form referenced above which documented the resident's ankle sprain and the application of the ankle splint, and which also specified follow-up with Resident #115's physician in one (1) to (2) days after return to the nursing facility. Then, a NN entry of 10/27/2014, noted to be for the 7:00 a.m. to 7:00 p.m. shift, then documented that Resident #115 was resting in bed, but also documented that the resident's wounds to the right foot had been treated per the wound care nurse. Further record review for Resident #115 revealed no evidence of any reference, prior to this 10/27/2014 NN entry, regarding the resident having wounds to the right foot. A subsequent NN entry for Resident #115 dated 10/29/2014, timed at 9:00 a.m. and labeled as being a Late Entry, documented that on 10/26/2014 at approximately 6:00 p.m., a facility nurse had spoken with the resident's family member about the splint on the resident's right ankle. This NN entry documented that no splint management orders were noted on Resident #115's discharge plan from the hospital or on admission to the nursing home. The nurse documented, via this NN entry, that she removed Resident #115's splint and noted a blister on the anterior foot, with treatment ordered per Protocol. This NN entry also documented possible deep tissue injuries on Resident #115's medial and lateral aspects of ankle from the splint and from the resident keeping his legs crossed, and documented that a wound care evaluation was requested for the next morning. Review of the wound care evaluation for Resident #115, dated as being conducted on 10/27/2014 and documented on Weekly Wound Assessment Record forms, revealed that on that date, Resident #115 was assessed to have the following pressure sores: a Deep Tissue Injury (DTI) to the right outer ankle measuring 8 cms by 1.5 cm, assessed to be dark purple in color and tender to touch, with a 30 percent fluid filled area; a DTI on the top of the right foot measuring 8 cms by 2 cms, assessed as purple in color; a DTI to the outside of the right foot measuring 7 cms by 2 cms, assessed as dark purple in color; a DTI to the right inner ankle measuring 6.5 cms by 4.5 cms, described as purple in color; a 7 cm by 7 cm by 1 cm pressure sore to the right foot Achilles Tendon area; and an unstageable area to the top of the right foot measuring 6 cms by 5 cms, 50 percent covered with Eschar, dark purple in color, and tender to the touch. A notation in the Progress Notes section of Resident #115's Weekly Wound Assessment Record Form of 10/27/2014 documented the physician was notified of these pressure sores, and that treatment orders were received. A Physician's Telephone Orders (PTO) form dated 10/27/2014 for Resident #115 documented physician's orders [REDACTED]. This 10/27/2014 PTO also specified a second physician's orders [REDACTED].#115's right foot with wound spray and pat dry, then apply Santyl, and cover with gauze and secure with tape daily and as needed. A subsequent NN entry of 11/03/2014 documented that Resident #115's physician had given an order for [REDACTED].#115 then specified to discontinue all previous treatments to the right foot, and to clean the right foot wounds with antibacterial soap, rinse with water, apply Santyl ointment to the wounds, cover with [MEDICATION NAME] Dressing and and secure with tape daily and as needed. During an observation of pressure sore treatment for [REDACTED]. foot, and the following pressure sores were observed: one (1) Stage III pressure sore on the right Achilles Heel; three (3) unstageable pressure sores with yellow Eschar; one (1) unstageable pressure sore with black/yellow Eschar; and one (1) unstageable pressure sore with black Eschar. LPN "CC" was observed wash her hands and apply gloves, clean Resident #115's right foot pressure sores with wound cleanser, and pat the wounds dry. The nurse then removed the soiled gloves, washed her hands and applied clean gloves, applied Santyl ointment and covered with [MEDICATION NAME] Non-Stick dressing, and wrap the foot with a Kerlix bandage and secure with tape (in accordance with the physician's PTO pressure sore treatment order referenced above). During an interview with LPN Treatment Nurse "CC" conducted on 12/10/2014 at 11:10 a.m., LPN "CC" acknowledged that Resident #115 returned from the hospital on [DATE] after a fall with a wrapped splint on the right foot. She further confirmed the 10/22/2014 NN entry (referenced above) which indicated Resident #115's wrapped splint remained in place and that no assessment was done. She stated that on 10/26/2014, the nurse on duty realized Resident #115 had a wrapped splint on the right foot, but that there was no order for the splint. Nurse "CC" stated that when the nurse removed Resident #115's ankle splint on 10/26/2014, she found the pressure sores. LPN "CC" stated she then evaluated Resident #115 on 10/27/2014. Treatment Nurse "CC" stated that nurses should have unwrapped Resident #115's ankle splint to assess the condition of the foot and the skin, but acknowledged the splint remained wrapped on the resident's ankle from 10/20/2014 to 10/26/2014, before the splint was removed or the skin assessed. LPN "CC" further stated that she had conducted staff in-service training on 11/05/2014, entitled Caring for a Splint or Cast, that was directly related to the incident involving facility nursing staff failing to provide assessment of Resident #115 after the application of the right ankle splint.