Every finding on record at Elmhurst Healthcare (The)

Based on observations, interviews, policy review, and record review the facility failed to promote and facilitate resident self-determination through support of resident choice for one Resident (#18) out of 12 total sampled residents. Specifically, the facility failed to allow Resident #18 to use a urinary catheter drainage bag instead of a urinary catheter leg bag. Findings include: Review of the facility policy titled 'Resident Rights', revised 1/2024, indicated: - Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to self-determination. Resident #18 was admitted to the facility in June 2024 with diagnoses including multiple fractures of pelvis. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/18/24, indicated Resident #18 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #18 required an indwelling urinary catheter. Review of Resident #18's plan of care related to his/her suprapubic catheter, revised 7/9/24, indicated: - Resident prefers to utilize drainage bag not leg bag. The surveyor made the following observations: - On 7/9/24 at 12:22 P.M., Resident #18 was laying in bed wearing a urinary catheter leg bag half filled with clear yellow urine. - On 7/9/24 at 1:50 P.M., Resident #18 was laying in bed wearing a urinary catheter leg bag half filled with clear yellow urine. - On 7/10/24 at 7:15 A.M., Resident #18 was laying in bed wearing a urinary catheter leg bag that was completely filled with clear yellow urine, and the urine continued to fill entire length of visable tubing. Resident #18 said he/she does not like this leg bag and wanted to have a larger urinary catheter drainage bag that hangs from the side of the bed, but staff told him/her he could not have one because department of public health surveyors were in the building. Resident #18 said he/she really doesn't like wearing a leg bag beacause it fills up to quickly and it's not comfortable. During an interview on 7/10/24 at 7:18 A.M., Certified Nurse Assistant (CNA) #1 said she was assigned Resident #18 during the 11:00 P.M. to 7:00 A.M. shift that night. CNA #1 said Resident #18 should not have a urinary catheter leg bag when in bed, but that the larger urinary catheter drainage bags that hang from the side of the bed were locked in the storage room that only the nurses have access to, so she expected the nurse would change it. During an interview on 7/10/24 at 7:25 A.M., Nurse #1 said he was assigned Resident #18 during the 11:00 P.M. to 7:00 A.M. shift that night. Nurse #1 said he assumed the 3:00 P.M. to 11:00 P.M. nurse had changed the leg bag to a side hanging drainage bag, but never checked. Nurse #1 said if Resident #18 did not want to wear a leg bag, he should have been allowed to use a urinary drainage bag that hangs from the side of the bed. Nurse #1 then asked Resident #18 if he/she wanted a urinary catheter drainage bag that hangs from the side of the bed and he/she said yes, so he changed it to as requested by Resident #18. During an interview on 7/10/24 at 9:30 A.M., the Administrator said she knew staff had previously been aware that Resident #18 did not want to wear a leg bag and that he/she wanted to use a side hanging urinary catheter drainage bag because they had recently inserviced the staff on this. The Administrator said this was part of Resident #18's care plan and staff should not have made him/her wear a urinary catheter leg bag since he/she did not want to wear one. During an interview on 7/10/24 at 10:07 A.M., the Director of Nursing (DON) said if Resident #18 did not want to wear a urinary catheter leg bag he/she should have been provided a urinary drainage bag that hangs from the side of the bed.

Based on observations, interviews, policy review, and record review, the facility failed maintain professional standards in the managing and caring for urinary catheter devices for one Resident (#18), out of a total sample of 12 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was maintained below level of bladder, failed to ensure the urinary catheter drainage bag was not placed directly touching the floor, and failed to ensure urinary catheter care was provided every shift as ordered by the physician. Findings include: Review of the facility policy titled 'Foley Catheter Insertion, Male Resident', revised 12/2020, indicated: - Secure the drainage bag below the level of resident's bladder and off the floor. Resident #18 was admitted to the facility in June 2024 with diagnoses including multiple fractures of pelvis. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/18/24, indicated Resident #18 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #18 required an indwelling urinary catheter. Review of Resident #18's active physician's orders indicated the following orders: - Supra Pubic Care [sic], every shift, initiated 6/12/24. - Supra Pubic [sic] 16R [sic] (french scale)/10 ML (milliliters) continuous to drainage bag, initiated 6/12/24. Review of Resident #18's plan of care related to his/her suprapubic catheter, revised 7/9/24, indicated: - Keep drainage bag below level of bladder. - Provide catheter care per policy. - Resident prefers to utilize drainage bag not leg bag. On 7/9/24 at 7:57 A.M., the surveyor observed Resident #18 in bed with a urinary catheter drainage bag hanging from the side of the bed and directly touching the floor without a barrier. The surveyor made the following additional observations: - On 7/9/24 at 12:22 P.M., Resident #18 was laying in bed wearing a urinary catheter leg bag on his/her right thigh near the knee, which was half filled with clear yellow urine. The Resident's legs were elevated, placing the urinary catheter leg bag above the level of the bladder. - 07/09/24 at 1:50 P.M., Resident #18 was laying in bed wearing a urinary catheter leg bag on his/her right thigh near the knee, which was half filled with clear yellow urine. The Resident's legs were elevated, placing the urinary catheter leg bag above the level of the bladder. - On 7/10/24 at 7:15 A.M., Resident #18 was laying in bed wearing a urinary catheter leg bag on his/her right thigh near the knee, which was completely filled with clear yellow urine and the urine continued to fill entire length of visible tubing. The Resident's legs were elevated, placing the urinary catheter leg bag above the level of the bladder. Resident #18 said he/she does not like this leg bag and wanted to have a larger urinary catheter drainage bag that hangs from the side of the bed, but staff told him/her he could not have one because department of public health surveyors were in the building. Resident #18 said the urinary catheter leg bag fills up too quickly and that staff had not emptied it since he/she went to bed last night. During an interview on 7/10/24 at 7:18 A.M., Certified Nurse Assistant (CNA) #1 said she was assigned Resident #18 during the 11:00 P.M. to 7:00 A.M. shift that night. CNA #1 said Resident #18 should not have a urinary catheter leg bag when in bed, but that the larger urinary catheter drainage bags that hang from the side of the bed were locked in the storage room that only the nurses have access to, so she expected the nurse would change it. CNA #1 said she did not empty the urinary catheter leg bag during the 11:00 P.M. to 7:00 A.M. shift. CNA #1 said urinary drainage bags should never be directly touching the floor. During an interview on 7/10/24 at 7:25 A.M., Nurse #1 said he was assigned Resident #18 during the 11:00 P.M. to 7:00 A.M. shift that night. Nurse #1 said Resident #18 should not have a urinary catheter leg bag when in bed because the drainage bag should be below the level of the bladder. Nurse #1 said Resident #18 should only wear a urinary catheter leg bag when he/she is in common areas for privacy. Nurse #1 said he did not visualize or empty the urinary catheter drainage bag during his shift because Resident #18 is learning to manage the catheter him/herself in anticipation of discharge, but he should have checked to ensure it was completed. Nurse #1 said he assumed the 3:00 P.M. to 11:00 P.M. nurse had changed the leg bag to side hanging drainage bag, but never checked. Nurse #1 then asked Resident #18 if he/she wanted to urinary catheter drainage bag that hangs from the side of the bed and he/she said yes, so he changed it to as requested by Resident #18. During an interview on 7/10/24 at 10:07 A.M., the Director of Nursing (DON) said Resident #18 should not use a urinary catheter leg bag when in bed because it should be below bladder level. The DON said urinary catheter drainage bags should not be directly touching the floor.

Based on record review and interviews, the facility failed to maintain accurate medical records by ensuring ADL (Activities of Daily Living) documentation was completed on every shift for three Residents (#275, #225 and #226) out of a total sample of 12 residents. Findings include: 1.) Resident #275 was admitted to the facility in July 2024 with diagnoses including vertigo. Review of Resident #275's medical record indicated the following documentation was not completed for the month of July. - 7 out of 16 shifts failed to document the dressing, bathing and additional fluids documentation sections. - 17 out of 26 shifts failed to document the bed mobility, behavior monitoring, bladder and bowel continence, locomotion on unit, preventative skin care, skin observation, toilet use, transferring, walk in corridor, walk in room and wheelchair mobility documentation sections. - 8 out of 9 shifts failed to document the evening snack documentation section. - 8 out of 17 shifts failed to document the locomotion off unit documentation section. - 9 out of 26 shifts failed to document the amount eaten documentation section. - 8 out of 26 shifts failed to document the eating documentation section. - 53 out of 88 opportunities to document were left blank in the turn and positioning documentation section. During an interview on 7/10/24 at 11:34 A.M., the Nursing Supervisor said the expectation is that staff documents all care provided on all shifts prior to leaving the building for the day. The Nursing Supervisor said incomplete documentation has been an ongoing issue at the facility. During an interview on 7/10/24 at 8:43 A.M., the Administrator said the Nursing Assistants are expected to document all care provided on all shifts. The Administrator said missing documentation has been an ongoing problem at the facility. 2.) Resident #225 was admitted to the facility in July 2024 with diagnoses including end stage renal disease. Review of Resident #225's medical record indicated the following documentation was not completed for the month of July: - 2 out of 2 night shifts failed to document the bed mobility, behavior monitoring, bladder or bowel continence, locomotion on unit, preventative skin care, toilet use, skin observation, transferring, walk in corridor, walk in room or wheelchair mobility documentation sections. During an interview on 7/10/24 at 11:34 A.M., the Nursing Supervisor said the expectation is that staff documents all care provided on all shifts prior to leaving the building for the day. The Nursing Supervisor said incomplete documentation has been an ongoing issue at the facility. During an interview on 7/10/24 at 8:43 A.M., the Administrator said the Nursing Assistants are expected to document all care provided on all shifts. The Administrator said missing documentation has been an ongoing problem at the facility. 3.) Resident #226 was admitted to the facility in July 2024 with diagnoses including bladder cancer. Review of Resident #226's medical record indicated the following documentation was not completed for the month of July: - 4 out of 13 shifts failed to document the bathing, dressing, locomotion off unit, personal hygiene and additional fluids documentation sections. - 1 out of 7 shifts failed to document the evening snack documentation section. - 11 out of 20 shifts failed to document the bed mobility, locomotion on unit, behavior monitoring, bladder and bowel continence, preventative skin care, skin observation, toilet use, transferring, walk in corridor, walk in room and wheelchair mobility sections. - 38 out of 68 opportunities to document were left blank in the turn and positioning documentation section During an interview on 7/10/24 at 11:34 A.M., the Nursing Supervisor said the expectation is that staff documents all care provided on all shifts prior to leaving the building for the day. The Nursing Supervisor said incomplete documentation has been an ongoing issue at the facility. During an interview on 7/10/24 at 8:43 A.M., the Administrator said the Nursing Assistants are expected to document all care provided on all shifts. The Administrator said missing documentation has been an ongoing problem at the facility.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: 1.) Ensure healthcare personnel remove gloves and perform hand hygiene before leaving a resident room. 2.) Ensure healthcare personnel appropriately don (put on) a precaution gown while caring for a Resident on enhanced barrier precautions (EBP). Findings include: Review of United States Centers for Disease Control and Prevention's (CDC) guidance titled 'Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs)', updated July 12, 2022, indicated: - Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. - Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: device care or use of urinary catheter. Review of the facility policy titled 'Handwashing/Hand Hygiene', revised 11/2020, indicated: 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: m. After removing gloves. 1.) On 7/9/24 at 7:01 A.M., the surveyor observed Certified Nurse Assistant (CNA) #2 wearing a glove on her left hand at the bedside of a resident room. CNA #2 exited the resident room, without removing the glove or performing hand hygiene, and entered another resident room still wearing the glove on her left hand and continued to assist the other resident in bed. The Assistant Director of Nursing (ADON) then intervened and told CNA #2 she had to remove the glove and sanitize her hands. During an interview on 7/10/24 at 11:33 A.M., the ADON said she had asked CNA #2 to remove the glove and wash her hands when she noticed CNA #2 had left a resident's room without removing her glove or performing hand hygiene. The ADON said staff should remove gloves and perform hand hygiene before leaving a resident's room and should never care for more than one resident wearing the same glove. On 7/10/24 at 7:21 A.M., the surveyor observed CNA #1 at the bedside of a resident room wearing gloves. CNA #1 exited the resident room, without removing the gloves or performing hand hygiene, and walked down the hall to get a new trash bag out of a cabinet. CNA #1 used her gloved hands to open and close the cabinet. CNA #1 then re-entered the resident room and resumed providing urinary catheter care without changing gloves or performing hand hygiene. At 7:25 A.M., CNA #1 exited the room again holding a filled trash bag with her gloved hands and walked down the hall. CNA #1 had not removed or changed gloves and did not perform hand hygiene upon exit of the resident room. During an interview on 7/10/24 at 7:37 A.M., CNA #1 said she had been emptying a resident's urinary catheter bag during the surveyors observation. CNA #1 declined to answer the surveyors questions regarding glove use in the hallway. CNA #1 said she was supposed to wash her hands when leaving a resident room after providing care. During an interview on 7/10/24 at 7:40 A.M., Nurse #1 said staff is not supposed to wear gloves in the hallway and that hand hygiene should be performed before leaving a resident's room after providing care. During an interview on 7/10/24 at 9:30 A.M., the Administrator said staff need to remove gloves and clean hands before leaving a resident's room. The Administrator said staff should never provide care for more than one resident wearing the same gloves. During an interview on 7/10/24 at 10:07 A.M., the Director of Nursing (DON) said staff need to remove gloves and clean hands before leaving a resident's room. The Administrator said staff should never provide care for more than one resident wearing the same gloves. 2.) On 7/10/24 at 7:21 A.M., the surveyor observed CNA #1 emptying a urinary catheter drainage bag. CNA #1 was wearing gloves, but was not wearing a precaution gown. There was a sign posted at the doorway that indicated the Resident was on enhanced barrier precautions (EBP) and that everyone must wear gloves and gown for high-contact resident care activities including device care or use of urinary catheter. During an interview on 7/10/24 at 7:37 A.M., CNA #1 said a precaution gown and gloves must be worn when emptying a urinary catheter drainage bag of a Resident on EBP. During an interview on 7/10/24 at 7:40 A.M., Nurse #1 said a precaution gown, in addition to gloves, must be worn when emptying a urinary catheter drainage bag of a Resident on EBP. During an interview on 7/10/24 at 9:30 A.M., the Administrator said the facility does not have a policy on Enhanced Barrier Precautions, but that the facility follows the CDC guidance on Enhanced Barrier Precautions. During an interview on 7/10/24 at 10:07 A.M., the Director of Nursing (DON) said CNA #1 should have worn a precaution gown, in addition to gloves, when emptying a urinary catheter drainage bag of a Resident on EBP.

Based on observations, record review and interviews, the facility failed to ensure a surgical brace was worn correctly to prevent possible further injury for 1 Resident (#34) out of a total sample of 15 residents. Findings include: Resident #34 was admitted to the facility in April 2023 with diagnoses including patella (knee) fracture. Review of Resident #34's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 which indicates he/she has moderate cognitive impairment. The MDS also indicates Resident #34 requires limited assistance with activities of daily living. On 5/9/23 at 8:49 A.M., Resident #34 was observed ambulating in his/her room. The Resident was observed wearing a brace on his/her left leg. The Brace was a knee extension brace with a locking mechanism on both sides of the brace. The brace was below his/her knee and resting on the top of his/her foot. The Resident's left knee was slightly bent while ambulating. On 5/9/23 at 12:00 P.M., 1:30 P.M., and 2:00 P.M., and on 5/10/23 at approximately 9:30 A.M., Resident #34 was observed ambulating in the hallway with his/her left knee slightly bent. The Resident was wearing a brace on his/her left leg and the brace was below his/her knee and resting on top of his/her foot. During several of these observations, the Resident was ambulating past the nursing staff who did not stop him/her to adjust the brace. Review of the discharge summary from the acute care hospital prior to admission indicated the following: *Resident #34 had sustained a left patella fracture requiring surgical intervention. *The Resident was prescribed a knee brace to be worn at all times and locked in extension (preventing knee from bending). Review of Resident #34's physician orders indicated the following order: *Keep knee brace locked in extension at all times, every shift, written 4/27/23. Review of the physical therapy evaluation dated 4/26/23 indicated Resident #34 had a precaution to wear a left lower extremity immobilizer at all times with no left knee range of motion allowed. Review of the medical record failed to indicate Resident #34 adjusts the brace on his/her own or is resistive to wearing the brace in a manner to prevent knee flexion. During an interview on 5/10/23 at 12:12 P.M., the Physical Therapy Assistant (PTA) said Resident #34 is ordered to wear a knee brace all times to prevent the knee from bending. The PTA said the brace has a locking mechanism on both sides and the locking mechanism should be at the level of the knee to prevent the knee from bending. The PTA said the brace has the potential to slip down, but both nursing and therapy have the skills to adjust the brace, so it is in the correct position on the Resident's leg. The PTA said he often adjusts the brace but is unsure if nursing does. During an interview on 5/10/23 at 1:24 P.M., the Director of Nursing (DON) said Resident #34's brace should be worn in a manner to prevent the knee from bending. The DON said nursing should be adjusting the brace as needed because if not worn correctly, the brace becomes ineffective.

Based on observations, record reviews and interviews, the facility failed to ensure a call light was within reach for 1 Resident (#19) out of a total sample of 15 residents. Findings include: Resident #19 was admitted to the facility in March, 2022 with diagnoses including traumatic brain injury and aphasia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #19 was unable to complete a Brief Interview for Mental Status assessment. Further review of the MDS indicated Resident #19 is a one person extensive physical assist with bed mobility, and supervision with eating. During an observation on 5/9/23 at 12:21 P.M., Resident #19 was using his/her left hand to point to the call bell which was hanging off of the right side of his/her bed near the floor. When asked, the Resident was unable to reach his/her call bell or move his/her right arm more than an inch. During an observation on 5/10/23 at 8:22 A.M., Resident #19 was observed in bed, with his/her call light hanging off of the right side of the Residents bed. Review of a Nurse Practitioner Note, dated 5/1/23 indicated Resident #19 has right sided weakness related to his/her traumatic brain injury. During an interview on 5/10/23 at 8:39 A.M., Certified Nursing Assistant (CNA) #2 said the CNAs check that call bells are within reach during daily rounds, and that the CNAs will adjust the call bells to be within reach using clips if needed. During an interview on 5/10/23 at 10:48 A.M., the Director of Nursing (DON) said the call bell should be placed within reach of each resident, and if a resident has unilateral weakness the call bell should be placed on the side of the bed which allows the resident to utilize their highest functioning upper extremity to reach the call-bell.

Based on record reviews and interviews, the facility failed to obtain weights in order to accurately assess the nutritional status of 3 Residents (#188, #2 and #12) out of a total sample of 15 residents. Findings include: Review of the policy titled, Weight Management, dated 4/4/19, indicated the following: *Nursing will obtain a residence weight within 24 hours of admission. This will be recorded in the residence medical record. All further weights will also be documented in the residence medical record. 1. Resident #188 was admitted to the facility in May 2023 with diagnoses including dementia and left knee wound. Review of Resident #188's electronic medical record failed to indicate a weight was obtained upon admission or subsequently. The admission weight checklist was blank in the paper medical record. Review of the dietary assessment dated [DATE] failed to include Resident #188's weight. During an interview on 5/09/23 at 1:07 P.M., Certified Nursing Assistant (CNA) #2 said the nursing staff obtain an admission weight upon a resident's admission to the facility. CNA #2 said weights are then obtained as ordered and are entered into the computer. CNA #2 said there are no weights taken on paper. Review of the facility's weekly risk meeting notes failed to indicate Resident #188's missing weights were discussed. The medical record failed to indicate Resident #188 refused being weighed. During an interview on 5/09/23 at 1:24 P.M., the Nursing Supervisor said a weight should be obtained for all residents upon admission and then as ordered. During an interview on 5/10/23 at 10:04 A.M., the Dietitian said all residents should have a weight obtained on admission. The Dietitian said she ensures an admission nutrition assessment is completed within 3 days of a resident's admission. The Dietitian said she was able to complete an admission assessment for Resident #188 without a weight by looking at other factors but would need weights to be obtained to ensure interventions are effective. The Dietitian said weights being obtained are an issue in the facility and she spoke with the nursing staff and administration about the missing weight for Resident #188 and the need for the staff to obtain a weight. 2. Resident #2 was admitted to the facility in April 2023 with diagnoses including fracture of the lumbar vertebrae, muscle weakness and back pain. Review of Resident #2's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating he/she is cognitively intact. The MDS also indicated Resident #2 requires limited assistance for staff for activities of daily living. Review of Resident #2's physician orders indicated and order for daily weights written on 5/5/23. Review of Resident #2's medical record indicated only 1 weight was recorded since the order was put into place. The medical record also failed to indicate Resident #2 refused being weighed. Review of the facility's weekly risk meeting notes failed to indicate Resident #2's missing weights were discussed. During an interview on 5/10/23 at 10:04 A.M., the Dietician said weights being obtained are an issue in the facility and she spoke with the nursing staff and administration about the missing weights for Resident #2 and the need for the staff to obtain a weight. 45763 3. Resident #12 was admitted to the facility in March 2023 with diagnoses including muscle weakness and diabetes. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #12 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates moderate cognitive impairment. Review of Resident #12's electronic medical record failed to indicate a weight was obtained on admission. Review of Resident #12's electronic medical record indicated the Resident returned from a hospitalization on [DATE], but failed to indicate a weight had been obtained upon re-admission or subsequently. Review of Resident #12's physicians orders indicated the following order: *Monitor weight weekly every day shift every Tuesday - initiated 3/21/23. Review of Resident #12's weight summary report indicated only one weight was obtained, on 4/1/23, out of the 8 weeks since the initiation of the weekly weights order. During an interview on 5/09/23 at 1:24 P.M., the Nursing Supervisor said a weight should be obtained for all residents upon admission and then as ordered. During an interview on 5/10/23 at 10:04 A.M., the Dietitian said all residents should have a weight obtained within 24 hours of admission, and that she would have expected a weight to also be obtained after re-admitting to the facility. The Dietitian said she was concerned that Resident #12 has not been getting weighed and that she has shared this concern with nursing. The Dietitian also said Resident #12 has not been refusing getting weighed.

Based on observations, record reviews and interviews, the facility failed to accurately assess and treat a pressure ulcer for 2 Residents (#34 and #29) out of a total sample of 15 residents. Findings include: Review of the facility policy titled, Pressure Ulcer/Injury Risk Assessment, dated 4/2018, indicated the following: *The purpose of a structured risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed and which will take time to modify. *Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries. *The risk assessment should be conducted as soon as possible after admission, but no later than 8 hours after admission is completed. *Repeat the risk assessment weekly for the first 4 weeks, if there is a significant change in condition, or as often as is required based on the residence condition. *Once inspection of skin is completed, document the findings on the facility approved skin assessment tool. * If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. *Notify attending MD if new skin alteration is noted. Resident #34 was admitted to the facility in April 2023 with diagnoses including patella (knee) fracture and muscle weakness. Review of Resident #34's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 which indicates he/she has moderate cognitive impairment. The MDS also indicates Resident #34 requires limited assistance with activities of daily living. During an observation with the Minimum Data Set (MDS) and Nurse #2 on 5/10/23 at 11:25 A.M., the surveyor, MDS Nurse and Nurse #2 observed Resident #34 coccyx area. Resident #34's coccyx area was red and open. The MDS nurse measured the area and said that the wound was a Stage 1 pressure wound, measuring at 2 cm x 1 cm. Resident #34 said he/she has pain when he/she sits down on this area. Review of Resident #34's discharge summary from his/her hospitalization prior to admission from the facility indicated the following: *Skin: patient admitted with pressure ulcer to the coccyx, are cleaned and Mediplex (a wound treatment) changed today, 4/23/23. Review of Resident #34's assessment dated [DATE], indicated the Resident had a pressure wound on the coccyx, however failed to indicate the size or stage of the wound. Review of Resident #34's medical record indicated the following: *Review of all nursing progress notes failed to indicate any notes regarding the Resident's pressure injury to the coccyx. *Review of all nurse practitioner notes written since admission failed to indicate the nurse practitioner was aware of Resident #34's coccyx wound. *Review of Resident #34's physician orders failed to indicate there were any treatments in place to treat the Resident's coccyx wound. Physician orders for weekly skin check were present, however no skin checks after admission had been completed. *Norton Skin Assessments dated 4/27/23 and 5/8/23 indicating the Resident is at moderate risk for pressure ulcer development. During an interview on 5/10/23 at 12:37 P.M., the Director of Nursing (DON) said all residents have an initial skin assessment completed on admission and then weekly thereafter. The DON said the skin assessments should list any skin alterations and, if there is a wound present, should have staging and measurements of the wound. The DON said if a wound is present on admission, the physician would need to be notified so a treatment can be put into place immediately. The DON said she was unaware Resident #34 had a coccyx wound. 2. Resident #29 was admitted to the facility in April 2023 with diagnoses of muscle weakness, abnormality of gait and mild protein-calorie malnutrition. Review of Resident #29's most recent Minimum Data Set (MDS), dated , 4/23/23, indicates the Resident has a Brief Interview of Mental Status (BIMS) score of 9 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicates Resident #29 requires extensive assistance from staff for activities of daily living. During an observation with Nurse #2 on 5/10/23 at 11:20 A.M., Resident #29's coccyx area was red, and an open area was observed. Resident #29 did not have a dressing on his/her coccyx. Review of the nursing assessment dated [DATE] indicated Resident #29 has a stage 3 coccyx wound. Review of the Norton Skin Assessments completed on 4/25/23 and 5/8/23 indicated Resident #29 is at high risk for pressure ulcer development. Review of Resident #29's physician orders indicated the following order written on 5/3/23: *Santyl Ointment (a wound treatment) 250 unit/gm. Apply to coccyx topically every day shift for wound care alginate calcium, santyl, f/b (followed by) bordered gauze daily. During an interview on 5/10/23 at 11:22 A.M., the Nursing Supervisor said Resident #29 has a pressure wound on his/her coccyx and there is a physician order to treat the wound. The Nursing Supervisor said Resident #29 did not have the wound treatment is place and the treatment should have been completed as ordered. During an interview on 5/10/23 at 12:37 P.M., the Director of Nursing (DON) said she expects any physician order for wounds to be followed. The DON was unaware Resident #29 did not have his/her wound treatment completed.

Based on observation, interviews and record review, the facility failed to identify and assess visible bruising for 1 Resident (#10) out of a total sample of 25 residents. Findings include: Review of the facility policy titled, Pressure Ulcer/Injury Risk Assessment, dated 4/2018, indicated the following: * If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. Resident #10 was admitted to the facility in April, 2023 with diagnoses including mild cognitive impairment. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #10 scored a 05 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates severe cognitive impairment. Further review of the MDS indicated Resident #10 requires limited physical assistance of one person for transferring, walking, and toilet use. During an observation on 5/9/23 at 8:34 A.M., Resident #10 had bruises on the left, outer forearm, and above the left elbow. The Resident was wearing a short sleeve medical gown and the bruises were visible to any staff entering the room. Review of Resident #10's nursing admission assessment, dated 4/17/23, indicated the Resident had an old bruise on the forearm and wrist, but failed to indicate any other bruising. Review of Resident #10's physician orders indicated the following order: *Weekly skin check every evening shift every Monday - initiated 4/24/23 Review of Resident #10's medical record failed to indicate that any skin checks were completed for a total of three weeks after the order was placed. Review Resident #10's nursing notes failed to indicate any bruising or skin alterations on his/her arms. During an interview on 05/09/23 at 1:47 P.M., the Nursing Supervisor said he was unaware of the bruising on Resident #10's arm. The Nursing Supervisor said the bruising was likely from blood draws during the Resident's hospitalization , however the facility could not provide an investigation into the cause of the bruises. The Nursing Supervisor acknowledged that no skin checks were performed for three weeks, and that any skin abnormalities should have been documented in the nursing progress note.

Based on observations, record review, interviews and policy review, the facility failed to 1) provide assistance with grooming tasks for 1 Resident (#2) and 2) provide assistance during self-feeding tasks for 2 Residents (#1 and #19) out of a total sample of 15 residents. Findings include: Review of the facility's policy titled Activities of Daily Living (ADLs), dated 9/2019, indicated Residents will be provided with care, treatment and services as appropriate to maintain or improve as able their ability to carry out ADLs. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. 1. Resident #2 was admitted to the facility in April 2023 with diagnoses including fracture of lymphedema. Review of Resident #2's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating he/she is cognitively intact. The MDS also indicated Resident #2 requires limited assistance for staff for activities of daily living. On 5/09/23 at 8:18 A.M., Resident #2 was observed lying in bed. He/she had significant chin hair and his/her nails were long with a brown substance under all 10 fingernails. Resident #2 said he/she would prefer not to have facial hair and would love to have his/her nails cleaned and cut and no staff have offered to do so. On 5/10/23 at 12:00 P.M., Resident #2 was observed lying in bed. He/she had significant chin hair and his/her nails were long with a brown substance under all 10 fingernails. Review of Resident #2's activity of daily living care plan last revised on 5/8/23 indicated Resident #2 requires assistance of 1 staff for all grooming tasks. During an interview on 5/10/23 at 9:36 A.M., Certified Nursing Assistant #2 said staff remove all unwanted facial hair as well as clean and cut fingernails of any resident who is unable to do so themselves. During an interview on 5/10/23 at 12:37 P.M., the Director of Nursing said she expects all residents to have unwanted facial hair removed and nails to be cleaned during daily care. 43846 2. Resident #1 was admitted to the facility in April 2023 with diagnoses including fibromyalgia, diabetes and hypertension. Review of Resident #1's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 14 out of a possible 15 on the Brief Interview for Mental Status which indicated he/she was cognitively intact. Further review of the MDS indicated Resident #1 needed one person physical assist and supervision by a staff member for eating. During an observation on 5/9/23 from 8:00 A.M. to 8:08 A.M., the surveyor observed Resident #1 sitting at the edge of bed and he/she was observed to be falling asleep, leaning back and not eating his/her breakfast tray. There no staff were present in the room to provide supervision or assistance with the meal. During an observation on 5/9/23 from 12:24 P.M. to 12:30 P.M., the surveyor observed Resident #1 in his/her wheelchair in his/her room with no staff present. Resident #1 was observed with their tray table pushed away from him/her and was using a knife to try to eat. Resident #1 was also using their hands at times. During an observation on 5/10/23 from 8:19 A.M. to 8:22 A.M., the surveyor observed Resident #1's privacy curtain pulled past the Resident's bed, unable to visualize the Resident from the hallway or the doorway. The surveyor entered Resident #1's room and rounded the bed to visualize him/her. There no staff were present in the room or hallway to provide supervision or assistance with the meal. Resident #1 was observed to be falling asleep while eating breakfast. Review of Resident #1's Activity of Daily Living (ADL) care plan, dated 5/2/23, indicated the following: *Eating: continuous supervision. Review of Resident #1's Occupational Therapy Plan of Treatment, dated 4/27/23, indicated Resident #1 required supervision or touching assistance for self-feeding tasks. During an interview on 5/10/23 at 8:26 A.M., Certified Nursing Assistant (CNA) #1 and the MDS Nurse reviewed Resident #1's CNA Plan of Care (POC) with the surveyor. The POC indicated Resident #1 was continuous supervision for eating. CNA #1 and the MDS Nurse acknowledged that the privacy curtain was pulled and staff were unable to visualize the Resident until you reached the foot of the bed. The MDS Nurse acknowledged that the care plan says the Resident needs continuous supervision. When asked if she was aware Resident #1 required supervision for meals, CNA #1 said she never looks at the care plans for the residents. 45763 3. Resident #19 was admitted to the facility in March, 2022 with diagnoses including traumatic brain injury, and aphasia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #19 was unable to complete a Brief Interview for Mental Status. Further review of the MDS indicated Resident #19 requires supervision with eating. During an observation on 5/9/23 at 8:22 A.M., Resident #19 was eating in his/her room without staff present, unsupervised. During an observation on 5/9/23 at 12:18 P.M., Resident #19 was eating in his/her room without staff present, unsupervised. Review of Resident #19 ' s activity of daily living care plan, last revised 6/9/2022, indicated Resident #19 requires supervision with eating. During an interview on 5/10/23 at 8:39 A.M., Certified Nursing Assistant (CNA) #2 said residents should be provided the level of assistance for eating that is outlined in their care plans.

Based on record review, observation and interview the facility failed to ensure they provided a dignified experience by providing privacy for a Foley catheter (drains urine from the bladder) for 1 Resident (#30) out of a total sample of 15 residents. Findings Include: Resident #30 was admitted to the facility in April 2023 with diagnoses including spondylosis, hydronephrosis, and displacement of other urinary catheter. Review of Resident #30's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she was cognitively intact. Further review of the MDS indicated Resident #30 had an indwelling catheter. During an observation on 5/9/23 from 7:44 A.M. to 8:45 A.M., the surveyor observed Resident #30 in bed with his/her Foley catheter with 500 cc of urine, was facing the doorway, not in a privacy bag. During an observation on 5/9/23 from 12:00 P.M. to 12:22 P.M., the surveyor observed Resident #30 in his/her wheelchair with his/her Foley catheter attached to the underside of the wheelchair. It was facing the doorway, not in a privacy bag. During an observation on 5/9/23 at 2:34 P.M. the surveyor observed Resident #30 in his/her wheelchair with his/her Foley catheter attached to the underside of the wheelchair. It was facing the doorway, not in a privacy bag. During an interview and observation on 5/10/23 at 7:41 A.M., the Minimum Data Set (MDS) Nurse acknowledged that Resident #30's Foley catheter was not in a privacy bag and was facing the doorway. The MDS Nurse said it should absolutely be in a privacy bag for dignity reasons. Resident #30 was observed in bed with the urine side of the catheter visible from the doorway. During an interview on 5/10/23 at 7:44 A.M., Nurse #1 said Resident #30's Foley catheter should be in a privacy bag.

Based on record review and interview the facility failed to 1) ensure they developed a hospice care plan for 1 Resident (#26), 2) failed to develop an edema management care plan for 1 Resident (#2) and 3) failed to develop a wandering/elopement risk care plan for 1 Resident (#10) out of a total sample of 15 Residents. Findings Include: 1. Resident #26 was admitted to the facility in April 2023 with diagnoses including End Stage Renal Disease, Dysuria, and Hypertension. Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated he/she scored a 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she was cognitively intact. Review of Resident #26's Physician Orders dated 4/11/23, indicated an order may admit to hospice. Review of Resident #26's Nurses Note, dated 4/18/23, indicated he/she was seen by the hospice nurse today, no new recommendations. Review of Resident #26's Evaluation Summary Note, dated 4/19/23, indicated he/she is currently on hospice services through the Hospice of MA. Review of Resident #26's Nurse Practitioner Note, dated 4/26/23, indicated he/she was being followed by hospice. Review of Resident #26's hospice Visit Documentation Log, indicated hospice visits were made on 4/25/23 and 5/4/23. Review of Resident #26's hospice Service Recommendations, dated 5/4/23, indicated recommendations for pain management. Review of Resident #26's medical record failed to indicate that a plan of care was developed for hospice services. During an interview on 5/9/23 at 2:31 P.M., the Director of Nurses (DON) said the expectation would be that a plan of care should have been developed by now for Hospice for Resident #30. During an interview on 5/10/23 at 7:38 A.M., the MDS nurse said the Resident should have had a care plan in place for hospice services prior to today. 41456 2. Resident #2 was admitted to the facility in April 2023 with diagnoses including fracture, lymphedema and congestive heart failure. Review of Resident #2's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating he/she is cognitively intact. The MDS also indicated Resident #2 requires limited assistance for staff for activities of daily living. During an interview on 5/09/23 at 8:18 A.M., Resident #2 was observed lying in bed and both legs had significant edema and his/her nonskid socks were digging in to his/her legs leaving marks. When asked, Resident #2 said his/her legs are painful, especially in the area where the socks are tight. Resident #2 said he/she receives a diuretic for the fluid in his/her legs, but staff do not measure his/her legs to see if the swelling has increased. Resident #2 said staff do not ask him/her about the swelling in his/her legs. Review of Resident #2's care plans failed to indicate a care plan for the management of his/her lymphedema. During an interview on 5/10/23 at 12:01 P.M., the Nursing Supervisor said he would expect a care plan to be put in place for any medical condition a resident is admitted with, and the facility is treating. The Nursing Supervisor said Resident #2 should have a care plan to address his/her lymphedema and does not. During an interview on 5/10/23 at 12:37 P.M., the Director of Nursing said she would expect a a care plan to be in place for any resident with the diagnosis of edema or lymphedema with interventions on how to monitor the condition. 45763 3. Resident #10 was admitted to the facility in April, 2023 with diagnoses including mild cognitive impairment. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #10 scored a 05 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates severe cognitive impairment. Review of Resident #10's Nurse Practitioner notes indicated the Nurse Practitioner acknowledges the Resident's wandering behavior on the following dates: 4/21/23 4/24/23 4/25/23 4/26/23 5/1/23 5/4/23 5/5/23 5/8/23 5/9/23 5/10/23 Review of Resident #10's progress notes indicated the Resident was sent to the emergency roiagnom on [DATE] due to increase in agitation, attempting to elope, and wandering in other patient's room. Review of Resident #10's care plans failed to indicate that a care plan for wandering or elopement was ever developed. During an interview on 5/10/23 at 11:18 A.M., the Director of Nursing (DON) said that a care plan for Resident #10's wandering behaviors should have been developed.

Based on record review and interview, the facility failed to develop and implement an effective baseline care plan and provide the resident with a summary of the baseline care plan within 48 hours from admission to the facility for 1 Resident (Resident #188) out of a total sample of 15 residents. Findings include: Review of the facility policy titled, Care Plans - Baseline, dated 11/2017, indicated the following: *A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours (48) of admission. *The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Resident #188 was admitted to the facility in May 2023 with diagnoses including dementia and left knee wound. Review of Resident #188's care plans indicated his/her care plan was developed on 5/8/23, over 48 hours after admission to the facility. During an interview on 5/09/23 at 1:24 P.M., the Nursing Supervisor said he completes all admissions for the facility along with the floor nurse. The Nursing Supervisor said the care plan should be created upon a resident's admission to the facility. During an interview on 5/09/23 at 2:24 P.M., the Director of Nursing said she expects a baseline care plan to be created with the first 3 shifts (24 hours) that a resident is at the facility.

Based on record review, facility policy review and interviews, the facility failed to obtain consent for the use of psychotropic medications for 1 Resident (#188), out of a total sample of 15 residents. Findings include: Review of the facility policy titled, Psychoactive Medication, dated 4/2018, indicated the following: *The interdisciplinary team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via resident care plan review. The resident, and when indicated, the family or responsible person, will be included in this process prior to administration of dose Resident #188 was admitted to the facility in May 2023 with diagnoses including dementia and left knee wound. Review of Resident #188's physician orders indicated the following order: *Trazadone (an anti-depressant medication) Give 25 mg (milligrams) by mouth at bedtime for insomnia. Review of Resident #188's medical record failed to indicate the Resident or his/her representative signed a consent for the use of this medication. During an interview on 5/09/23 at 2:24 P.M., the Director of Nursing said consents for the use of psychotropic medications are obtained at the time of admission. The Director of Nursing said she was unaware Resident #188 did not have consents obtained.

Based on observation and policy review the facility failed to ensure medications were stored properly in the medication cart on the second floor. Findings Include: Review of the facility's policy titled Storage of Medications, dated 8/2020, indicated medications and biological's are stored safely, securely, and properly, following manufacturer's recommendations or the of the supplier. During an observation on 5/10/23 at 11:47 A.M., the surveyor observed the second floor medication cart. In the medication cart was 4 medicine cups with pre-poured medications in the top drawer. During an interview on 5/10/23 at 11:47 A.M., Nurse #3 said she should have given the medications right after she poured them to the resident they were intended for. During an interview on 5/10/23 at 11:51 A.M., the Administrator and the Regional Nurse said their expectation is that medications are given right after they are poured and said they should not leave pre-poured medications in the medication cart.

Based on observation, interview, and record review, the facility failed to maintain proper sanitation practices related to labeling and dating of food items in the kitchen. Findings include: Review of the facility policy titled, Food and Supply Storage, revised 06/2018, indicated the following: *Food, non-food items, and supplies used in food preparation and service shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption outlined in the Federal Drug Administration Food Code, state regulations, and city/county health codes. *Food products that are opened and not completely used; transferred from it's original package to another storage container; or prepared at the facility should be labeled as to its contents and use-by dates. *Discard food that exceeds their use-by date or expiration date, is damaged, is spoiled, has the time and temperature zone requirements, or incorrectly stored such that it is unsafe or its safety is uncertain. During an initial walk through of the kitchen on 05/09/23 at 7:04 A.M., the following observations were made: *An unlabeled container of what appears to be a cooked dough *A container of pudding labeled 4/26 *A used/opened piping bag of whipped cream labeled 4/13 *A jar of [NAME] harissa, opened but undated. *A container of tuna salad labeled as prepared on 4/28 with a use-by date of 5/5 *A container of egg salad labeled as prepared 4/26 with a use-by date of 5/5 *An open bag of hot dogs, wrapped but undated. *An unlabeled and undated container of an unidentified yellow food item *A container of tomato soup labeled as prepared on 4/29 with a use-by date of 5/5 *A bag of raisin bran cereal, opened but undated. During an interview on 05/09/23 at 7:12 A.M., the Food Service Director (FSD) said food items should be labeled and dated as they are prepared or opened, and should be discarded 6 days after that date. The FSD also said that dairy and cream food items, including whipped cream, should be discarded 3 days after the prepared/opened date.

Based on record review and interview the facility failed to maintain practices to prevent the potential spread of infection on 1 of 2 resident care units. Findings include: Review of the facility's policy, entitled, Infection Control for All Nursing Procedures, last reviewed 2/2023 indicated the following: *Policy: To provide guidelines for general infection control while caring for residents. *General guidelines: Standard precautions are the minimum infections prevention practices that apply to all patient care, regardless of suspected or confirmed infection status or the patient in any setting where health care is delivered. these practices are designed both to protect the DHCP and prevent DHCP from spreading infections among patients. Standard precautions include: a Hand hygiene, b. Use of personal protective equipment (PPE) (e.g., gloves, masks, eyewear)/ c. respiratory hygiene/cough etiquette d. sharps safety Transmission-Based precautions will be used whenever measures more stringent than standard precautions are needed to prevent the spread of infection. Employees must wash their hands before and after direct contact with resident, after removing gloves, hygiene prior to donning and post doffing gloves, On 5/10/23 the following observations were made by the surveyors on the second-floor resident care unit: *At 10:09 A.M., the Nursing Supervisor came out of a room, identified by door signage as requiring transmission based precautions, wearing gloves and a gown. He removed the gown and gloves in the hall and threw them into a covered waste basket across from the room. *At 11:15 A.M., Nurse #3 was at the medication cart in the hall, wearing gloves on both hands, she touched her pocket, keys, the medication drawer contaminating the gloves, and then without hand hygiene, prepared medication with her gloved hands. *At 11:35 A.M., Certified Nursing Assistant (CNA) #2 exited a resident room, identified as requiring transmission-based precautions, with one gloved hand carrying trash. CNA #2 did not perform hand hygiene upon exiting the room, proceeded down the hall and entered the soiled utility room. *At 11:40 A.M., Nursing Supervisor had his face covering mask down at the desk centrally located near residents. During an interview on 5/10/23 at approximately 1:00 P.M., the Director of Nursing said staff should perform hand hygiene upon exiting a resident's room and should not be wearing gloves in the hallway. The DON said staff should not be wearing PPE in the hall and should doff the doff PPE prior to exiting a resident room.

Based on record review and interview the facility failed to 1) assess for the eligibility and obtain consent or refusal for the administration of Pneumococcal or Prevnar 13 vaccine for 3 Residents (#1, #2, and #15), and 2) failed for to assess for the eligibility and obtain consent or refusal for the influenza vaccine for 1 Resident (#19), out of 5 resident records reviewed, out of a total sample of 15 residents. Findings include: Review of the facility's policy entitled, Pneumococcal Vaccine, dated last revised 2/2020 indicated the following: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Under Policy Interpretation and Implementation, the policy indicated: a) Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series when indicated, will be offered the vaccine unless medically contraindicated, refusal by the resident or health care representative, or the resident has already been vaccinated. Review of the facility's policy entitled, Influenza Vaccine, dated last revised 11/2020 indicated the following: All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccination against influenza. Guidelines, a) Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents unless the vaccine is medically contraindicated, or the resident has already been immunized. The facility staff may obtain resident's influenza vaccines history form their primary care physicians prior to admission. Documentation of previous vaccination should be provided by the facility. On 5/10/23 at 8:50 A.M., the following resident records were reviewed for immunizations. 1. a) Resident #1 was admitted to the facility in April 2023. Review of the immunization tab, in Resident #1's electronic medical record indicated no immunizations found. Review of Resident #1's medical record (paper chart) indicated the following: A document entitled, Massachusetts, Resident Immunization Consent or Refusal Form. The areas next to pneumococcal and Prevnar 13 were circled refused in ink. The document failed to have the name of the resident, a signature of the resident or resident representative, a signature of the witness, or a date. 1. b) Resident #2 was admitted to the facility in April 2023. Review of the immunization tab, in Resident #2's electronic medical record indicated no immunizations found. Review of Resident #2's medical record indicated the following: A document entitled, Massachusetts, Resident Immunization Consent or Refusal Form. All areas of the form were blank, including the area to circle consent or refuse for pneumococcal and Prevnar 13 vaccination, nor was it signed by a resident or resident representative or witness, or dated. 1. c) Resident #15 was admitted to the facility in April 2023. Review of the immunization tab, in Resident #15's electronic medical record indicated no immunizations found. Review of Resident #15's medical record indicated the following: A document entitled, Massachusetts, Resident Immunization Consent or Refusal Form. All areas of the form were blank, including the area to circle consent or refuse for pneumococcal and Prevnar 13 vaccination, nor was it signed by a resident or resident representative or witness, or dated. 2. For Resident #19 the facility failed to determine eligibility, obtain consent or refusal for the influenza vaccine during the most recent influenza season. Resident #19 was admitted to the facility in March 2022. Review of the immunization tab in Resident #19's electronic medical record indicted the following: historical: influenza vaccine dated 1/15/21. No further information regarding Resident #19's status of assessment/consent or refusal of the influenza vaccine for the recent influenza season was present. Review of Resident #19's medical record failed to reveal a Resident Immunization Consent or Refusal Form was in the record. During an interview on 5/10/23 at 10:07 A.M., Nurse #3 reviewed the Immunization Consent or Refusal Form in Resident #2's record and verified it was the form used for all residents to determine a resident's eligibility, consent or refusal for immunizations including pneumococcal/Prevnar 13 and influenza. Nurse #3 said the form was blank and not completed for the resident. Nurse #3 said the admission nurse reviews all consents when a resident is admitted to the facility, including the immunization consent/refusal form. During an interview on 5/10/23 at 10:23 A.M. with the Director of Nursing (DON) and the Administrator, the DON said the admission nurse is to review the immunization consent or refusal form with a resident on admission, to determine if the resident is eligible for the pneumococcal or Prevnar 13 vaccine. The DON said the nurse should also review the influenza vaccine with the resident if admitted during the influenza season. The DON said she would need to look for information as to why Resident #19, who is identified as a long-term resident, did not have information in the record regarding either consenting or refusing the influenza vaccine during the most recent influenza season. On 5/10/23 at approximately 1:30 P.M., the Minimum Data Set Nurse, said she looked through Resident #19's record and could not locate any information regarding whether Resident #19 consented or refused the influenza vaccine.

Based on observation, record review and interviews, the facility failed to ensure oxygen was administered correctly for 1 Resident (#29) out of a total sample of 15 residents. Findings include: Resident #29 was admitted to the facility in April 2023 with diagnoses of chronic obstructive pulmonary disease (COPD). Review of Resident #29's most recent Minimum Data Set (MDS), dated , 4/23/23, indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicates Resident #29 requires extensive assistance from staff for activities of daily living. On 5/09/23 at 8:58 A.M., Resident #29 was observed sitting on the edge of his/her bed wearing oxygen. The oxygen was set to 2L (liters). On 5/9/23 at 12:18 A.M., Resident #29 was observed sitting in his/her wheelchair. He/she was not wearing any oxygen. On 5/9/23 at 1:39 P.M., Resident #29 was observed sitting in his/her wheelchair. The Resident was wearing oxygen and the oxygen was set to 3L. Review of Resident #29's physician orders indicated the following order: *Oxygen at 1 Liters/minute via nasal cannula, continuously, every sift. During an interview on 5/09/23 at 1:24 P.M., the Nursing Supervisor said he expects residents to be receiving oxygen at the rate ordered by the physician. During an interview on 5/09/23 at 2:24 P.M., the Director of Nursing said oxygen should be provided and worn at the level prescribed by the physician. The Director of Nursing said Resident #29 may move the oxygen level on his/her own. Review of Resident #29's medical record failed to indicate any behavior notes or care plan interventions that Resident #29 changes the oxygen setting him/herself.

Based on record review and interview the facility failed to ensure the accurate coding of the Minimum Data Set assessment, (MDS) for 4 Residents (#1, #2, #15 and #19) out of a total sample of 15 residents. Specifically, the MDS assessment for 3 residents inaccurately indicated the pneumococcal and influenza vaccine was offered and refused, and for 1 Resident the MDS inaccurately indicated the influenza vaccine was received outside of the facility. Findings include: 1. Resident #1 was admitted to the facility in April 2023. Review of Resident #1's MDS with an Assessment Reference Date of 5/1/23 indicated Resident #1 was offered and declined the influenza vaccine and was offered and declined the pneumococcal vaccine. Review of Resident #1 medical record indicated an incomplete immunization consent or refusal form. 2. Resident #2 was admitted to the facility in April 2023. Review of Resident #2's MDS with an Assessment Reference Date of 4/27/23 indicated Resident #2 was offered and declined the influenza vaccine and was offered and declined the pneumococcal vaccine. Review of Resident #2's medical record indicated the immunization consent or refusal form was entirely left blank. 3. Resident #15 was admitted to the facility in April 2023. Review of Resident #15's MDS with an Assessment Reference Date of 5/3/23 indicated Resident #15 was offered and declined the influenza vaccine and was offered and declined the pneumococcal vaccine. Review of Resident #15's medical record indicated the immunization consent or refusal form was entirely left blank. 4. Resident #19 was admitted to the facility in March 2022. Review of the MDS with an Assessment Reference Date of 4/12/23, indicated for this year's influenza season that Resident #19 was not administered the vaccine by this facility and coded as the reason, received the vaccine outside of this facility. Review of Resident 19's medical record failed to indicate evidence that Resident 19 was administered an influenza vaccine. During an interview on 5/10/23 at 10:32 A.M., the MDS nurse said she uses the information from the immunization consent or refusal forms to code the MDS. The surveyor told the MDS nurse that for Resident #1, #2 and #15 the immunization forms were blank or incomplete, she acknowledged that a blank or incomplete immunization consent or refusal form is not considered an offer or refusal of the vaccines. The MDS nurse said she also asks the nursing supervisor for the information for vaccination status. For Resident #19, the MDS nurse said she would need to look further into the Resident's record to determine if the Resident received the influenza vaccine outside of the facility. During an interview on 5/10/23 at approximately 1:30 P.M., the MDS Nurse said she looked through Resident #19's record and could not locate any information on either consent or refusal for the influenza vaccine or administration elsewhere.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who complained of right hip pain, the Facility failed to ensure care and treatment by nursing met professional standards of practice. On 08/03/22 Nurse #2 notified a covering Nurse Practitioner (NP) that Resident #1 complained of right hip pain and a verbal telephone order was obtained for an x-ray of his/her right hip. Nurse #2 did not transcribe the order onto Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #2 decided Resident #1 did not require the x-ray. Resident #1 continued to complain of right hip pain, over the course of several days, however this was not reported to his/her Physician or NP, and as a result, Resident #1's right hip was not x-rayed until 08/09/22, at which time he/she was diagnosed with a right hip fracture. Findings Include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Facility Policy titled physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was admitted to the facility on [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Nurse #2's written Statement, undated, indicated that on 08/03/22 during the 3:00 P.M. to 11:00 P.M. shift, Resident #1's Health Care Agent (HCA) reported that he/she was complaining of hip pain. The Statement indicated that when he went to check on Resident #1, he observed him/her holding his/her left lower stomach. The Statement indicated Resident #1 had advanced dementia and could not properly make his/her needs known. The Statement indicated that Nurse #2 called the covering NP to report Resident #1's situation and the NP ordered an x-ray be obtained of Resident #1's right hip. The Statement indicated that because Resident #1's pain was relieved after an enema was administered, he (Nurse #2) thought Resident #1's pain had been related to constipation and did not obtain the x-ray that had been ordered by the NP. Review of Resident #1's Nurse Progress Note, dated 08/04/22, indicated that he/she complained abdominal pain (on 08/03/22), was holding his/her stomach, had not moved his/her bowels in days, and an enema was given with positive effect. The Note indicated that Resident #1 also complained of right hip pain, the NP (covering) was notified, and a new order was obtained for a right hip x-ray. Review of Resident #1's Medical Record indicated that there was no documentation to support that Nurse #2 wrote the order for Resident #1's right hip x-ray, scheduled the x-ray, or notified the covering NP who had ordered the x-ray that he had not obtained it. During an interview on 09/06/22 at 2:43 P.M. and on 09/08/22 at 12:29 P.M., Nurse #2 said he worked a double shift from 08/03/22 at 3:00 P.M. through 7:00 A.M. on 08/04/22. Nurse #2 said he could not recall the time, but that sometime between 3:00 P.M. and 11:00 P.M. on 08/03/22, Resident #1 was crying and holding his/her stomach. Nurse #2 said Resident #1's HCA was there and told him that he/she was complaining of right hip pain. Nurse #2 said although he looked at Resident #1's right hip, he did not attempt to move it because he/she was touching his/her stomach and not his/her hip. Nurse #2 said he called the (covering) NP and notified her that he thought Resident #1 was constipated and said he also notified her that he/she complained of right hip pain. Nurse #2 said the NP gave him an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 said he never transcribed the order into Resident #1's Medical Record and did not obtain the x-ray ordered by the covering NP because after he gave Resident #1 an enema, he/she seemed to feel better. Nurse #2 said he did not call the NP back to discuss whether or not she wanted to discontinue the order for Resident #1's x-ray. Review of Resident #1's Nurse Progress Note, dated 08/07/22, indicated that his/her family reported to Nurse #4 that he/she complained of right hip pain with touch and movement. The Note indicated Nurse #4 assessed Resident #1's right hip to be slightly swollen, pain medication was administered and he/she tried to go to sleep. During an interview on 09/13/22 at 8:45 A.M., Nurse #4 said that, on 08/07/22, she was told that Resident #1 had right hip pain by his/her family member and said she went to assess him/her and observed his/her right hip to be swollen. Nurse #4 said Resident #1's family member asked him/her if he/she was in pain, and said he/she verbalized pain. Nurse #4 said she did not notify Resident #1's Physician of his/her right hip swelling or complaints of pain. Review of Resident #1's Nurse Progress Note, dated 08/08/22, indicated that he/she acknowledged less pain, had slept some, and kept turning himself/herself horizontally in the bed. Review of Resident #1's Nurse Progress Note, dated 08/09/22, indicated the Director of Nursing (DON) had a discussion with Resident #1's HCA concerning Resident #1's care. The Note indicated that Resident #1 had complained of right hip pain with movement for two days. The Note indicated that Resident #1's HCA told the DON that an x-ray had been ordered for him/her. The Note indicated there was no order for an x-ray in the computer system, his/her NP was notified, and that the NP said she would be in to see Resident #1. Review of the Resident #1's Nurse Practitioner Note, dated 08/09/22, indicated that he/she was seen for complaints of right hip pain for several days and that the pain was worse with movement. The Note indicated that Resident #1's range of motion in his/her right hip was limited by pain. The Note indicated to obtain an x-ray due to right hip pain to rule out a fracture. Review of Resident #1's Radiology Report, dated 08/09/22, indicated that he/she had a right hip fracture. Review of Resident #1's Nurse Progress Note, dated 08/10/22, indicated that he/she was transferred to the Hospital Emergency Department for further evaluation of a hip fracture. During an interview on 08/31/22 at 11:50 A.M., Resident #1's NP said she saw him/her on 08/09/22 due to complaints of right hip pain and said she ordered an x-ray that day. The NP said she did not know that Resident #1 had complained of right hip pain on 08/03/22 or that an x-ray had been ordered that day but never obtained. During an interview on 08/31/22 at 1:29 P.M., the Director of Nursing (DON) said Nurse #2 should have followed the NP orders and obtained Resident #1's x-ray or he should have called the NP to discuss the situation and allow the NP to decide if Resident #1 still needed the x-ray. The DON said it was not Nurse #2's responsibility to make the clinical decision not obtain the right hip x-ray for Resident #1.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who complained of right hip pain, the Facility failed to ensure Nurse Practitioner's (NP) orders were followed in accordance with professional standards of practice in order to prevent a delay in treatment. On 08/03/22 Resident #1 complained of right hip pain, the covering NP was notified and an order was given for a right hip x-ray but not obtained. Resident #1 was noted to again complain of right hip pain on 08/07/22 and was assessed to have a swollen right hip and his/her Physician was not notified. It was not until 08/09/22, six days after he/she first complained of right hip pain, that the x-ray was obtained, which revealed that Resident #1 had a right hip fracture, he/she was transferred to the Hospital Emergency Department where he/she was admitted to the Hospital and underwent surgical repair. Findings Include: The Facility Policy titled physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility Policy titled Change in a Resident's Condition or Status, dated as revised on 04/04/19, indicated that the professional staff will communicate with Physician, participant, and family regarding changes in condition. The Policy indicated that the nurse will notify the resident's attending Physician/Nurse Practitioner (NP) or the Physician or NP on call, when there has been a change in a resident's condition which included, but was not limited to, the need to alter a residents medical treatment significantly. Resident #1 was admitted to the facility on [DATE], he/she had a Brief Interview for Mental Status Score (BIMS) of 9 (scores of 8-12 indicate moderately impaired cognition) and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Nurse Progress Note, dated 08/04/22, indicated that he/she complained abdominal pain, was holding his/her stomach, had not moved his/her bowels in days, and an enema was given with positive effect. The Note indicated that Resident #1 also complained of right hip pain, the NP (covering) was notified, and a new order was obtained for a right hip x-ray. Review of Nurse #2's written Statement, undated, indicated that on 08/03/22 during the 3:00 P.M. to 11:00 P.M. shift, Resident #1's Health Care Agent (HCA) reported that he/she was complaining of hip pain. The Statement indicated that Nurse #2 observed Resident #2 holding his/her left lower stomach and indicated he/she had advanced dementia and could not properly make his/her needs known. The Statement indicated that he called Resident #1's covering NP to report the situation and the NP ordered an x-ray. The Statement further indicated that because Resident #1's pain was relieved after an enema was administered, he (Nurse #2) thought his/her pain had been related to constipation and he (Nurse #2) did not obtain the x-ray that had been ordered by the NP. During an interview on 09/06/22 at 2:43 P.M. and on 09/08/22 at 12:29 P.M., Nurse #2 said he worked a double shift on 08/03/22 at 3:00 P.M. through 7:00 A.M. on 08/04/22. Nurse #2 said he could not recall the time, but that sometime during the 3:00 P.M. and 11:00 P.M. shift on 08/03/22, Resident #1 was crying and holding his/her stomach. Nurse #2 said Resident #1's HCA was there and told him that he/she had complained of right hip pain. Nurse #2 said Resident #1 was touching his/her stomach and not touching his/her hip and said although he observed Resident #1's hip, he never attempted to move his/her hip to further assess it. Nurse #2 said he called the NP about concerns that Resident #1 was constipated and also notified her that he/she complained of right hip pain. Nurse #2 said the NP gave him an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 said he never transcribed the order into Resident #1's Medical Record and did not obtain the x-ray because after he gave Resident #1 an enema, he/she seemed to feel better. Nurse #2 said he did not call the NP back to discuss whether or not she wanted to discontinue the order for Resident #1's x-ray. Review of Resident #1's Nurse Progress Note, dated 08/07/22, indicated that his/her family stated Resident #1 kept complaining of right hip pain with touch and movement. The Note indicated Nurse #4 assessed Resident #1's right hip to be slightly swollen, pain medication was administered and he/she tried to go to sleep. Review of Resident #1's Medical Record indicated there was no documentation to support that his/her Physician/NP was notified of his/her right hip swelling and complaints of pain on 08/07/22. Review of Resident #1's Nurse Progress Note, dated 08/08/22, indicated that he/she acknowledged less pain, had slept some, and kept turning himself/herself horizontally in the bed. Review of Resident #1's Nurse Progress Note, dated 08/09/22, indicated the Director of Nursing (DON) had a discussion with Resident #1's HCA concerning Resident #1's care. The Note indicated that Resident #1 had complained of right hip pain with movement for two days. The Note indicated that Resident #1's HCA told the DON that an x-ray had been ordered for him/her. The Note indicated there was no order for an x-ray in the computer system, his/her NP was notified, and that the NP said she would be in to see Resident #1. Review of the Resident #1's Nurse Practitioner Note, dated 08/09/22, indicated that he/she was seen for complaints of right hip pain for several days and that the pain was worse with movement. The Note indicated that Resident #1's range of motion in his/her right hip was limited by pain. The Note indicated to obtain an x-ray due to right hip pain to rule out a fracture. Review of Resident #1's Radiology Report, dated 08/09/22, indicated that he/she had a right hip fracture. Review of Resident #1's Nurse Progress Note, dated 08/09/22 and timed at 10:52 P.M., indicated that Resident #1's x-ray revealed he/she had a right hip fracture, the NP was notified, an order was obtained to transfer him/her to the Hospital Emergency Department. The Note indicated that after his/her HCA was notified, the HCA preferred that Resident #1 be transferred to the Hospital Emergency Department in the morning. Review of the Emergency Department Provider Note, dated 08/10/22, indicated that Resident #1 presented with right leg tenderness and that his/her right leg was externally rotated and mildly foreshortened (observation of hip rotated outward and leg shortening are common clinical presentations of a hip fracture). Review of the Hospital Discharge Summary Note, dated 08/15/22, indicated Resident #1 was admitted with a right hip fracture for which he/she was evaluated by orthopedics and underwent surgical correction. During an interview on 09/13/22 at 9:38 A.M., Certified Nurse Aide (CNA) #4 said when she worked on the 11:00 P.M. to 7:00 A.M. shifts from 08/05/22-08/09/22, that at the beginning of her shifts during shift report, she had been told Resident #1 was in pain when he/she was provided with personal care. CNA #4 said she usually provided personal care for Resident #1 at the beginning and end of her shift and said he/she would flinch and make a facial expression when she moved him/her. During an interview on 08/31/22 at 11:50 A.M., Resident #1's NP said she saw him/her on 08/09/22 due to his/her complaints of right hip pain and said she ordered an x-ray that day. The NP said she was not aware that on 8/03/22 the covering NP had ordered an x-ray for Resident #1 because of his/her complaints of right hip pain. The NP said she was not notified by nursing of Resident #1's complaints of hip pain on 08/07/22. During an interview on 08/31/22 at 1:29 P.M., the Director of Nursing (DON) said that while doing clinical rounds on 08/08/22, Resident #1's HCA told her that his/her right hip was bothering him/her over the weekend and said the HCA was concerned because Resident #1's right leg continued to hurt and he/she could not move it. The DON said she checked on Resident #1 and asked him/her to raise his/her right leg and said Resident #1 verbalized that he/she was in pain as he/she raised his/her leg and told her that it hurt when he/she moved it. The DON said she called Resident #1's NP on 08/08/22 after she had spoken with his/her HCA and said the NP gave no new orders at that time, but said she would be in to assess him/her the following day. The DON said she had later discovered that Nurse #2 had written a progress note on 08/04/22 that indicated Resident #1 had right hip pain and a new order for an x-ray had been obtained at that time. The DON said Nurse #2 did not schedule Resident #1's right hip x-ray on 08/03/22 because after he gave Resident #1 an enema he/she seemed better. The DON said Nurse #2 should have called the NP to let the NP decide whether the x-ray should still have been obtained and said it was not his responsibility to make the clinical decision not obtain the right hip x-ray for Resident #1. During an interview on 09/19/22 at 9:26 A.M., the DON said Nurse #4 should have notified Resident #1's Physician/NP about his/her right hip swelling and complaints of right hip pain to obtain any necessary orders.

Based on record review and interviews, the Facility failed for one of three residents (Resident #1) to ensure that changes in Resident #1's left ankle and calf were identified, documented, and reported to a physician until Resident #1 presented with symptoms [MEDICAL CONDITION] and was transferred to the emergency department. Resident #1 was admitted to the Facility following surgical intervention to the left ankle and required the use of a removable cast to the left ankle. Resident #1's plan of care included that staff were to assess the condition of Resident #1's left ankle and incisions every shift for symptoms of infection and for changes in the surgical incisions and perform diabetic foot care every evening. Though staff documented they completed an assessment of the left foot and performed diabetic foot care, they failed to monitor or identify when Resident #1 developed a wound on the left calf. After approximately one week at the Facility, Resident #1 was transferred to the emergency department where it was determined that the left ankle incisions had obvious symptoms of infection, Resident #1 was septic, and Resident #1 was noted to have a calf wound which was infected and not previously noted by the Facility nursing staff. Findings included: The Hospital discharge record, dated 8/31/11, indicated that Resident #1's [DIAGNOSES REDACTED]. The Hospital discharge record indicated that Resident #1 was discharged to the Facility with an air cast on the left lower extremity. The record indicated that Resident #1 was to return to the Hospital or notify a physician for a fever greater than 101.5 degrees Fahrenheit (F), redness or drainage at the incision, sutures to be removed at follow-up appointment, and that no dressing was needed if the incisions remained free of drainage. Review of the nurse's note, dated 8/31/11, indicated that Resident #1 was admitted on this date following a hospitalization for a left ankle fracture that required surgical intervention. The skin assessment and wound care assessment, dated 8/31/11, indicated that nursing staff assessed Resident #1's wounds and noted that Resident #1 had redness under both breasts, had sutures in place to two incisions noted on the left ankle. The assessment of the left ankle surgical sites indicated that Resident #1's left ankle was without symptoms of infection, and had no redness, warmth, or drainage. The skin assessment indicated that Resident #1 had a left buttock sore which measured 1.5 centimeters in size and was free of symptoms of infection; and Resident #1 had a scab on the right ankle. No other skin abnormalities, wounds, rashes, or sores were noted at the time Resident #1 was assessed. Nurse #2 was interviewed at 11:43 AM on 10/20/11. Nurse #2 said that Nurse #2 completed the admission wound and skin assessment, which included an assessment of Resident #1's left ankle and incisions. Nurse #2 said that dressings were over the incisions and Resident #1 wore a boot over the foot, but could not recall whether Resident #1 used a cast or splint. Nurse #2 said that Resident #1's incisions were free of infection when observed on 8/31/11. Nurse #2 said that after the incisions were assessed, Nurse #2 reapplied a dressing over the ankle incisions. Nurse #2 said that Resident #2 did not have any calf wounds when assessed on admission and if Resident #1 had such a wound or sore, its existence would have been documented on a wound evaluation form, the skin assessment, and the nurse's notes. The Director of Nurses was interviewed at various times on 10/4/11 and at 3:40 PM on 10/26/11. The DON said that after the date of survey, it was determined that though Nurse #2 applied a dressing on 8/31/11, it was removed the same day by another nurse because there was no order for the application of a dressing unless there was drainage. The DON said that since the incisions were free of drainage, the dressing was not needed. The admission physician order, dated 8/31/11, indicated that nursing staff were to monitor Resident #1's left ankle incision for increased pain, swelling, drainage, warmth, every shift; that Resident #1 was to maintain touch down weight bearing on the left lower extremity and use an air cast boot to the left extremity. The orders included that staff were to perform diabetic foot care every evening. There were no orders regarding the application and removal of dressings to Resident #1's left ankle incisions. The treatment records indicated that the nursing staff documented in the form of their initials every shift. No narrative description of the condition of the incisions were included on the treatment records. The 9/1/11 to 9/7/11 treatment record entries indicated that the nursing staff signed that they had completed an assessment of resident #1's ankle incision. The 9/7/11 entry was signed by Nurse #1 on 9/7/11. The DON said that the Facility normally documented in a narrative form when there was a change in condition or at least once a week for wounds. The nurse's notes, dated from 9/1/11 to 9/7/11, indicated that on 9/1/11 Nurse #1 documented that Resident #1 had a cast on the left ankle and had positive CSM (circulation-sensation-motion).The 9/2/11 note indicated that Resident #1 was noted to be wearing a "Darko boot" on the left foot. There was no documentation of a narrative description of the condition of Resident #1's left ankle incisions; an assessment of the condition of Resident #1's skin under the removable cast/splint, or that staff monitored and documented the outcome and response to prescribed treatment interventions. The 9/7/11 nurse's note indicated that on this date, Resident #1 had twitching and changes in mental status and was transferred to the emergency department for an evaluation. Nurse #1 was interviewed at 9:50 AM and 10:35 AM on 10/4/11. Nurse #1 said that Nurse #1 was assigned to complete the prescribed treatments for residents including Resident #1. Nurse #1 said that though Nurse #1 documented that Nurse #1 had assessed Resident #1's left ankle incisions for symptoms of infection, an assessment of Resident #1's left ankle was not done, per physician's orders [REDACTED]. Resident #1's Health Care Agent was interviewed at 11:03 AM on 10/20/11. The Health Care Agent said that s/he was informed that the staff were sending Resident #1 to the Hospital for twitching and a high fever. The Health Care Agent said that after Resident #1 arrived at the emergency department, the boot and dressings were removed from Resident #1's left ankle. The Health Care Agent said that Resident #1's ankle was obviously infected because a foul odor was emitted from the cast and dressing, and there was drainage from the incisions, and a new calf wound which had foul drainage from the area. The Health Care Agent said that it was obvious given the condition of Resident #1's ankle that the staff were not monitoring the area for infection. The Health Care Agent said that after admission, it was determined that Resident #1 had an infection in the wounds as well [MEDICAL CONDITION]. Review of the emergency department record, dated 9/7/11, indicated that Resident #1 arrived at the emergency department at 3:13 PM on this date. The record indicated that staff at the Facility arranged for transfer of Resident #1 because Resident #1 was noted to be twitching and then became unresponsive. The records indicated that Resident #1's temperature was elevated at 103 degrees Fahrenheit (F). The Hospital record indicated that at 6:15 PM Resident #1's left boot and dressings were removed and it was at this time that Resident #1 was noted to have a three centimeter by eight centimeter area of skin breakdown on the medial aspect of the left calf. The note indicated that the hospital staff noted discoloration, discharge, and odor from both incisions of the ankle and that wound cultures were obtained and dressings were applied. The emergency department treating physician's note, dated 9/7/11, indicated that Resident #1 arrived from the Facility with an orthopedic boot on the left foot. The record indicated that when the boot was removed, Resident #1 was noted to have macerated skin with cloudy mucous around the wound and yellow colored discharge. The admitting [DIAGNOSES REDACTED]. The Physician was interviewed at 4:25 PM on 10/26/11. The Physician said that Resident #1 was at high risk for infection. The Physician said that the the Physician was contacted by the emergency department treating physician who was appalled at the condition of Resident #1's dressings and incisions. The Physician said that the emergency department treating physician informed the Physician that the dressings were "saturated" with drainage, there was a foul odor from the incisions, and the incision was open, leaving the bone visible. The Physician said that was suspicious regarding how long the infection had been present given the condition of Resident #1 and the fact that no one at the Facility stated they had applied the dressing. The Physician said that it was possible however, given Resident #1's risk for infection and lack of feeling in the affected foot, that there was a pocket of foul drainage under the skin that expelled once the incision separated. The Physician said that the condition of the calf wound however, would not have occurred over night and more likely it was an area of redness that deteriorated over time. The DON said that nursing staff interviewed insisted they assessed the incisions as ordered, but was unable to identify any staff member who would state that they applied the dressing to Resident #1's left ankle incisions or when the dressings were applied.