Every finding on record at Franciscan Villa

Based on record review and interview, the facility failed report no later than two hours to the OSDH and other official agencies after an allegation of abuse was made for 1 (#3) of 5 sampled residents reviewed for abuse. The DON identified 101 residents resided in the facility. Findings: An undated facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, read in part, The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required. A care plan for Resident #3, dated 09/02/20, showed the resident had diagnoses which included chronic pain syndrome, rheumatoid arthritis, and major depressive disorder. The care plan showed Resident #3 needed assistance with daily care needs. A quarterly assessment for Resident #3, dated 05/14/26, showed the resident had a BIMS score of 11 which indicated they were moderately impaired cognitively. The assessment showed Resident #3 was incontinent of bowel and bladder. The assessment showed Resident #3 was dependent on staff for personal hygiene. An OSDH initial incident report, with an incident date of 05/17/26, showed an allegation of abuse for Resident #3. The report showed OSDH received the report on 05/20/26 at 11:41 a.m. There was no documentation Adult Protective Services or the Nurse Aide Registry was notified. An OSDH final incident report, with an incident date of 05/18/26, showed an allegation of abuse for Resident #3. The report showed Adult Protective Services and the Nurse Aide Registry was notified. There was no documentation Adult Protective Services or the Nurse Aide Registry was notified. On 06/26/26 at 12:33 p.m., the DON reviewed the investigative documentation for the incident for Resident #3. The DON stated the ADON reported and completed the investigation for the allegation of abuse for Resident #3. The DON stated the ADON did not report the allegation of abuse within the two-hour required time frame to the OSDH. The DON stated the ADON did not notify Adult Protective Services or the Nurse Aide Registry of the incident. The DON stated the ADON should have notified the OSDH within the two-hour time frame and the ADON did not know how to notify the Nurse Aide Registry regarding the incident. The DON stated they thought when the incident report was sent to the OSDH, Adult Protective Services was also notified. The DON stated they did not know the Adult Protective Services required a separate notification. On 06/26/26 at 2:00 p.m., the ADON reviewed the investigative documentation regarding the incident for Resident #3. The ADON stated they did not recall when or what day the allegation of abuse was reported. The ADON stated if the incident was a resident-to-resident incident or an injury was sustained the incident would be reported to the OSDH within two-hours, otherwise the incident could be reported within 24 hours. The ADON stated they did not know how to notify the Nurse Aide Registry of an incident regarding a certified nurse aide.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 2 (#1 and #3) of 5 sampled residents reviewed for abuse. The DON identified 101 residents resided in the facility. Findings: A facility policy titled Abuse, Neglect, and Exploitation, revised 11/2024, read in part, An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur.Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations . Providing complete and thorough documentation of the investigation 1.A care plan for Resident #1, revised 10/10/25, showed the resident had diagnoses which included impulse disorder, persistent mood disorder, and anxiety disorder. A quarterly assessment for Resident #1, dated 03/29/26, showed the resident had a BIMS of 13 which indicated no cognitive impairment. The assessment showed Resident #1 did not have behaviors during the lookback period. An OSDH initial incident report, with an incident date of 05/24/26, showed Resident #1 was hit in the face by another resident. The report showed there was a small open area with a small amount of blood noted. On 06/26/26 at 11:05 a.m. the DON stated there were no documented resident or staff interviews for the incident on 05/24/26 regarding Resident #1. The DON stated per the incident it was a resident-to-resident abuse allegation. The DON stated there was no investigative interview documentation to determine what had occurred for the incident. On 06/26/26 at 11:52 a.m., the administrator stated it was not their practice to keep documented interviews obtained. They stated they just documented on the state incident report the investigation was completed.2. A care plan for Resident #3, revised 10/23/25, showed the resident had diagnoses which included chronic pain syndrome, rheumatoid arthritis, and major depressive disorder. A quarterly assessment for Resident #3, dated 05/14/26, showed the resident had a BIMS of 11 which indicated moderate impaired cognition. The assessment showed Resident #3 was incontinent of bowel and bladder. The assessment showed Resident #3 was dependent on staff for personal hygiene. An OSDH initial incident report, with an incident date of 05/17/26, showed an allegation of physical abuse for Resident #3. There was no documentation regarding interviews with the person who reported the allegation of abuse, the alleged perpetrator, or others who might have had knowledge of the allegation. On 06/25/26 at 2:50 p.m., the DON reviewed the investigative documentation for the allegation of abuse on 05/17/26 regarding Resident #3. The DON stated there were no documented resident interviews or staff interviews regarding the allegation of abuse. The DON stated the investigation was completed by another staff member. The DON stated they would have investigated the allegation of abuse differently. The DON stated they would have asked more questions, dated and signed the documents obtained, and completed interviews with staff. On 06/25/26 at 3:15 p.m. the administrator stated they were the abuse coordinator for the facility. The administrator stated they were responsible for the final review for an investigation for an allegation of abuse. The administrator stated they felt like a thorough investigation had been completed.

Based on record review and interview, the facility failed to ensure that a resident's behavior was monitored and documented according to the physician's order for 1 (#1) of 1 sampled resident reviewed for behavior monitoring.The administrator identified 86 residents resided in the facility.An undated Suicide Threats, policy, read in part, If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. Staff shall document details of the situation objectively in the resident's medical record.An admission assessment for Resident #1, dated 01/11/26, showed the resident had a depression score of 8 which indicated mild depression and intact cognition.A physician order for Resident #1, dated 01/13/26, showed Oxycodone (an opioid) 10-325 mg every 6 hours for pain.A Brief Trauma Questionnaire for Resident #1, dated 01/20/26, showed the resident had denied any history of being in a war zone, a serious car accident, a major natural disaster, a life-threatening illness, physically beaten, pressured into unwanted sexual contact, violent death of someone close to them, or a situation where they feared serious injury or death to themselves or others.A quarterly RN pain assessment for Resident #1, dated 01/26/26, showed the pain medication for Resident #1 was effective and their tolerable pain level was a 3. The assessment showed Resident #1 requested to have their tizanidine (a muscle relaxer) changed to alternate with the Oxycodone (opioid) and Tylenol (pain reliever) to allow for pain medications every 3 hours.On 02/12/26, the psychiatric nurse ordered changes to Resident #1's medications. Austedo XR (for involuntary movement disorders) increased from 24 mg to 30 mg by mouth daily. Aricept (for dementia) was discontinued due to ineffectiveness and Namenda (for dementia) 5 mg twice daily by mouth was started. Effexor (major depression) decreased from 150 mg to 75 mg by mouth daily for 14 days, then discontinued. Wellbutrin XL (major depression) 150 mg to start in 7.On 02/24/26, Vraylor 1.5 mg (for mild depression) was discontinued by the psychiatric nurse.On 03/04/26 at 6:44 p.m., a behavior note written by the ADON documented the suicide hotline had notified the facility Resident #1 had called and reported feeling isolated and contemplating ending their life. The note showed the ADON was notified by the suicide hotline Resident #1 had disclosed hoarding acetaminophen with the intent to use it for self-harm. The note showed immediate interventions were conducted. The note showed Resident #1 expressed a desire to get out of bed for at least one hour after lunch, either in the common area or the activities hall, to increase social interaction. The note showed Resident #1 requested a shower, aligning with their scheduled shower day, and the aide was instructed to assist with bathing. The note showed Resident #1 acknowledged having the acetaminophen but confirmed it was unused. The note showed family member #1 was present during the discussion, was asked to take the bottle home, and was informed that acetaminophen was ordered and remained available at the facility as needed. The note showed the psychiatric nurse was notified and would visit Resident #1during the next rounding. The note showed the director of nursing had also been informed and was aware of the situation. The note showed an order for behavior monitoring was put into place.An Incident/Accident Report, dated 03/04/26 at 10:00 p.m., showed the ADON was notified by the suicide hotline Resident #1 was contemplating ending their life. The report showed during the assessment, the ADON discovered Resident #1 had a bottle of acetaminophen (a pain reliever) at the bedside and expressed a desire for more activities and a change in their shower schedule. The ADON noted family member #1 was at Resident #1's bedside. The ADON educated Resident #1 and family member #1 that medications were not permitted to be kept at the bedside, and family member #1 agreed to remove them. The ADON agreed to assist with activities and get the shower schedule changed. The ADON notified the DON and they determined Resident #1 no longer had access to means for self-harm. The psychiatric nurse was notified and behavior monitoring was ordered. The suicide hotline called again later (same day) and LPN #3 immediately went to assess Resident #1 who was found to have family member #1 at their bedside. Resident #1 and family member #1 told LPN #3 the crisis had passed and declined to go to the hospital for an evaluation. LPN #3 made sure Resident #1 had the call light. Shortly after, Resident #3 (Resident #1's roommate) reported Resident #1 was shaking a pill bottle and threatening to take them all. LPN #3 found Resident #1 with an empty pill bottle and 911 was called to transport Resident #1 to the hospital.On 03/04/26 at 10:06 p.m., an order to monitor episodes of sadness, suicidal tendencies, suicidal thoughts, agitation, document all findings and notify the provider immediately was transcribed by the ADON. The order had a start time of 7:00 p.m. A nurse progress note written by LPN #3 for Resident #1, dated 03/04/26 at 10:55 p.m., documented Resident #1 had called the crisis line and stated they were going to overdose. The note showed LPN #3 checked on Resident #1 who was in the room with family member #1 at the bedside. The note showed Resident #1 stated they were fine and did not want to go to the hospital, but they were hungry. The note showed Resident #1 was offered a snack. The note showed Resident #1 wanted to be pulled up in bed, so LPN #3 with the assistance of family member #1 pulled Resident #1 up in bed and provided the call light. The note showed LPN #3 called the crisis line back to let them know Resident #1 was okay. The note showed about 20 minutes later, Resident #1's roommate came out and told staff Resident #1 was shaking a pill bottle and talking on the phone saying they were going to take them all. The note showed LPN #3 entered the room and found the pill bottle empty. The note showed Resident #1 stated they had the acetaminophen in their table for a month. The note showed Resident #1 was sent to emergency room for evaluation and the ADON was notified.On 03/09/26 at 12:32 p.m., Resident #3 stated they went to the nursing station because their roommate had the bottle in their hand saying they were going to take them all and do whatever it took to get out of the facility. Resident #3 stated Resident #1 had never previously threatened to self-harm prior to that day. Resident #3 stated Resident #1's family member was there earlier, but not at the time Resident #1 said they were going to overdose. Resident #3 stated after LPN #3 and another staff member came and assessed Resident #1, the ambulance arrived soon after. On 03/09/26 at 3:19 p.m., family member #2 stated via phone interview Resident #1 received a bed bath around 6:00 p.m. on that night. Family Member #2 stated Resident #1 was hurting more that day and the pain medications were not cutting it. Family Member #2 stated Resident #1 had told family member #1 to bring the acetaminophen for their back. Family member #2 stated [Resident #1] did not want to live that way anymore, and had historically gone back and forth on whether they wanted to give up or stay alive for their family. Family member #2 stated I don't know if anyone in the facility knew [Resident #1] was suicidal, but before I put [Resident #1] in the facility, [Resident #1] used to say [they] was tired of it and didn't know if [they] could do it.On 03/10/26 at 8:45 a.m., the administrator stated the ADON was terminated for not following protocol. The administrator stated they were unable to find behavior monitoring documentation. The administrator stated family member #1 had been instructed to take the medication home, but they forgot. The administrator stated Resident #1 was assessed and because they were bed bound and staff believed the family member would do as they agreed and take the medication home, they believed the risk had been removed.On 03/10/26 at 10:04 a.m., CNA #1 stated they were instructed to give Resident #1 a bed bath around 5:45 p.m. and the bath took around 45 minutes. CNA #1 stated Resident #1 was not acting suicidal during the bed bath, but Resident #1 did often complain of pain and wanted to be repositioned in the bed. CNA #1 stated family member #1 returned to the room and assisted CNA #1 to move Resident #1 up in bed. CNA #1 stated Resident #1 denied further needs, so they left Resident #1 with family member #1 at their bedside. CNA #1 stated they observed a bottle of Tylenol on the bedside table but was told the family member #1 was going to take it home with them. CNA #1 stated Resident #1 always wanted more pain medications but would fall asleep mid-sentence. CNA #1 stated they believed they left the room around 6:45 p.m.On 03/10/26 at 10:31 a.m., family member #1 stated via phone Resident #1 was in a lot of pain and really depressed and had a bottle of aspirin that I forgot to take home with me. Family Member #1 stated they left to get something to eat and were notified of the overdose in less than half an hour after they left the facility. Family Member #1 stated they knew Resident #1 wasn't happy and was hurting all the time but did not have any indication they were going to try anything. Family Member #1 stated they were aware that Resident #1 had made a call to the suicidal hotline. Family Member #1 stated [Resident #1] was just really having a bad day and was in constant, constant pain and made a really bad decision. Family Member #1 stated Resident #1 had previously indicated that if they couldn't find something to help with the pain, they had seriously considered suicide, but the family didn't really think [Resident #1] would do it. Family member #1 stated Resident #1 had been in pain for a couple years and they were at the end of what the pain physician could do to help. Family Member #1 stated they were not sure if the facility was aware of Resident #1's past suicidal ideation.On 03/11/26 at 8:41 a.m., Family Member #1 stated via telephone they were unaware of Resident #1's post traumatic stress disorder diagnosis and did not know what the diagnosis was related to. Family Member #1 stated they had brought Tylenol in, and it had been in the bedside drawer always. Family Member #1 stated they were aware Resident #1 was not supposed to have medication in their room even before the nurse told them during the incident, but they did not tell the nurse about it because, yeah, I also know it takes an hour to get it from the nurse. Family Member #1 stated they did not feel threated by the situation, but they could have sworn they grabbed the Tylenol when they left.On 03/11/26 at 9:52 a.m., the ADON stated once they were notified of the suicidal ideation, they assessed Resident #1 and asked the CNA's if anyone had noticed anything different about Resident #1. The ADON stated they had a non-urgent conversation with Resident #1 because they had stated they were okay and family member #1 was in the room with Resident #1. The ADON stated Resident #1 retrieved the Tylenol from the bedside table themselves. The ADON stated they educated the resident and the family member medication was not allowed to be in the resident rooms, but the staff could give some medication when the resident asked for it. The ADON stated they planned with Resident #1 to get them up for social activities and would put them back to bed when they were ready. The ADON stated they had the CNA come provide a bed bath. The ADON stated, in my mind, I thought the issue was resolved. The ADON stated there were no prior indications of suicidal ideation and they were unaware of the Tylenol in the room until they were notified by the crisis line. The ADON stated they were not allowed to take the resident's stuff, so they told family member #1 to take it home. The ADON stated they did not know what they did wrong to get terminated.On 03/11/26 at 10:15 a.m., the administrator stated the psychiatric nurse had returned their call and stated they remembered the conversation with the ADON, had a plan to see the resident on their next rounds, and believed the ADON had it under control.On 03/11/26 at 12:04 p.m., the administrator stated the primary physician had returned the call and stated they vaguely remembered the call but knew the psychiatric nurse was notified and they were all part of the same practice.

Based on observation, record review, and interview, the facility failed to ensure the interdisciplinary team determined a resident could safely self-administer a topical medication for 1 (#2) of 6 sampled residents reviewed for medication administration.The administrator identified 86 residents resided in the facility. On 03/09/26 at 1:06 p.m., Resident #2 was observed to have antifungal cream on their bedside table.An undated Resident Self-Administration of Medication policy read in part, A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered.The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record.A physician's order for Resident #2, dated 10/12/25, showed antifungal external cream 2%. Apply to groin topically every shift for redness.A quarterly assessment, dated 12/27/25, showed that Resident #2 had a BIMS score of 13 indicating intact cognition; had diagnoses which included hemiplegia or hemiparesis and chronic kidney disease stage 3.There was no self-administration of medication assessment or physician order to self-medicate found in the electronic medical record.On 3/11/26 at 8:55 a.m., LPN #1 stated they did not know who gave Resident #2 their antifungal cream. LPN #1 stated if the residents were cognitively intact, they could get an order for the resident to apply the creams themselves. LPN #1 stated Resident #2 did not have an order to self-apply, but they could call the physician and get one. On 3/11/26 at 10:15 a.m., the administrator stated they were unable to locate a medication self-administration assessment for Resident #2.

Based on observation and interview, the facility failed to store medications within locked compartments of a medication cart on one of three halls observed for medication storage. The Director of Nursing identified three medication carts and three treatment carts which stored medications. Findings: On 12/19/24 at 10;43 a.m., an unlocked/unattended treatment cart was observed on the resident hall. From 10:43 a.m. to 10:59 a.m., multiple staff walked past the treatment cart without locking it. On 12/19/24 at 11:01 a.m., LPN #1 walked to the unlocked treatment cart and removed a pair of gloves without locking the cart. On 12/19/24 at 11:07 a.m., LPN #1 returned to the treatment cart, removed items from its drawers and walked away from the medication cart without locking it. On 12/19/24 at 11:08 a.m., LPN #1 stated the treatment cart should be locked and they did not know why it was not locked. On 12/23/24 at 1:30 p.m., an unlocked/unattended treatment cart was observed on the hall. On 12/23/24 at 1:33 p.m., LPN #2 stated the treatment cart should not be left unlocked.

Based on observation and interview, the facility failed to provide palatable meals for three (#37, #23, and #4) of three residents interviewed regarding food palatability. The dietary manager identified 88 residents who ate meals prepared in the kitchen. Findings: On 12/19/24 at 10:56 a.m., Resident #37 stated the food did not taste good. The resident stated when they ate in the dining room, the food was warm but not hot; and if they ate in their room, the food was cold. On 12/19/24 at 11:11 a.m., Resident #23 stated the food tasted bad. On 12/20/24 at 8:46 a.m., Resident #4 stated the food was served to their room cold, tasted bad, and at times was inedible. The resident stated they received items on their tray which were clearly marked on their dinner card not to be served to them and when they requested an alternative item, were told the kitchen was closed. On 12/23/24 at 11:45 a.m., a test tray was checked for food palatability. The barbecued pulled pork was barely warm, the coleslaw barely cool, and the baked beans were of a good temperature but left a vinegar like after taste. The bread was warm but chewy and tasted somewhat stale as of day old bread. On 12/23/24 at 1:00 p.m., the dietary manager was informed of the observations. The dietary manager stated the bread was left to proof too long. 41220

Based on record review, observation, and interview, the facility failed to implement dietary recommendations for interventions in weight loss for one (#62) of four residents reviewed for significant weight loss. Resident #62 experienced 20% weight loss from 03/31/22 to 07/09/22. The director of nursing identified four residents with significant weight loss. Resident #62 was not listed among those identified with significant weight loss. Findings: Resident #62 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's progress notes, dated 03/23/22; 03/25/22; 03/29/22; 03/31/22; 04/04/22; 04/14/22; 05/11/22; 05/31/22; 06/08/22; 06/15/22; 06/30/22; and 07/14/22 all documented Resident #62 displayed no signs or symptoms of fluid volume overload. The physician's progress notes documented Resident #62 denied increased [CONDITION(S)] in their legs and upon examination, did not find evidence of significant [CONDITION(S)], and no pedal [CONDITION(S)]. The progress notes documented the resident's weight was followed closely. The progress notes documented Resident #62 had protein-calorie malnutrition and to encourage protein supplementation and nutrition. The registered dietician's recommendation, dated 03/20/22, documented Resident #62 weighed 104.9 pounds, was 60 inches (five feet) tall, and had a BMI (body mass index) of 20.5 which was within normal limits for the resident's height. The recommendation documented the resident received a regular textured diet and ate 50-75% of most meals. The registered dietician recommended to offer the resident Ensure Plus twice daily at lunch and dinner meals. The physician agreed to the recommendation and the facility noted it on 03/28/22. The admission assessment, dated 03/24/22 documented the resident was 59 inches tall (4 foot 11 inches) and weighed 107 pounds. The assessment documented the resident had no weight loss or gain. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed no documentation of communication with the physician to change the Ensure Plus with the lunch and dinner meal, recommended by the registered dietician, to Ensure three times daily. A review of the weights for Resident #62 documented the following weights: 03/31/22 - 108.1 pounds; 04/07/22 - 104.3 pounds; and 05/07/22 - 93 pounds. Resident #62 experienced significant weight loss of 10.8% in one month and 14% in five weeks. The registered dietician's recommendation, dated 05/12/22, documented in part, .Significant weight LOSS .05/07/22 93# Sig wt loss 10.8% 1 mos. Reference wt 04/07/22 104.3#. Diet order continues as Regular texture w/Ensure Plus offered TID for additional cal/pro supplementation. Per recent TASK documentation, res feeds self with supervision/set-up assistance. PO intake fluctuating 25-100% most meals. RECOMMENDATION: MedPass 90cc TID = 540 cal, 22 gm Pro . The physician agreed and signed the recommendation on 05/17/22. A review of the resident's clinical record found no documentation the resident received Ensure Plus or the MedPass, as recommended by the registered dietician. A review of the weights for Resident #62 documented the following weights: 05/28/22 - 91.1 pounds; and 06/18/22 - 93.5 pounds. The quarterly assessment, dated 06/22/22 documented the resident was 59 inches tall (4 foot 11 inches) and weighed 94 pounds. The assessment documented the resident had not experienced a weight loss or gain. A review of the resident's clinical record found no documentation the facility attempted further nutritional/dietary interventions for the resident's significant weight loss. On 07/02/22 the resident's weight was documented at 88.0 pounds. Resident #62 experienced a significant weight loss of 18.5% since 03/31/22. The careplan, dated 07/04/22, documented the resident had the potential for alteration in nutrition because of their disease process. The careplan read in parts, .I have a need for monitoring of my nutrition to maintain nutritional well-being .I will continue to have adequate nutrition as shown by not having a significant weight loss or gain over the next 90 days . The careplan interventions included the use of a diuretic medication; use of medications for hypertension; limiting salt and excessive fluids in the diet; the need for set up assistance at mealtime; monitoring for increased [CONDITION(S)]; offering the resident a supplement or alternative if they ate less than 50% of the meal served or refused to eat; monitoring the resident's weight and report a loss or gain of 5% in one month, 7.5% in three months, or 10% in 180 days to the physician; and to give dietary supplements/medications as per orders. On 07/09/22 the resident's weight was documented at 87.0 pounds. Resident #62 experienced 20% weight loss from 03/31/22 to 07/09/22. On 07/18/22 at 12:41 p.m., the resident was laying in bed, leaning heavily to the left with the head of the bed near fully upright. The resident appeared asleep. The resident appeared underweight, thin, and frail. The resident's lunch was on the overbed table and did not appear to be eaten. There was no Ensure or Ensure Plus present. There was no staff present to provide encouragement and/or assistance. On 07/19/22 at 9:08 a.m., observed resident sitting up in bed with a breakfast plate of scrambled eggs and a small paper bowl of oatmeal present with a wadded up napkin on top of the oatmeal. Neither the eggs nor the oatmeal appeared to be eaten. There was no Ensure or Ensure Plus present. There was no staff present to provide encouragement and/or assistance. The resident was observed eating a butter cookie from a tin of cookies. On 07/20/22 at 12:10 p.m., observed resident sitting up in bed with noon meal present. Resident appeared to eat approximately 50% of meal. There was no Ensure or Ensure Plus present. There was no staff present to provide encouragement and/or assistance. On 07/20/22 at 4:00 p.m., Resident #62 was observed with the wound nurse. Resident #62 appeared thin and frail with the prominent outline of skeletal bones visible on the spine, coccyx, hips, rib cage, shoulders, and arms. On 07/20/22 at 5:30 p.m., the director of nursing was asked if she was aware of the dietary supplements in place for resident #62. The director of nursing reviewed the clinical record and stated they did not see where the MedPass had been started. The director of nursing stated they started employment after the supplements were ordered so could not say how the dietary recommendation was missed. The director of nursing stated there were two people who received the physician's progress notes and facility recommendations from the physician's and reviewed them for orders. On 07/20/22 at 5:50 p.m., the assistant dietary manager stated the kitchen kept Ensure and Ensure Plus stored in a refrigerator accessible to the staff on long term care. The assistant dietary manager stated they had initiated other interventions such as providing a double portion of protein at mealtime. The assistant dietary manager was asked to provide documentation of the interventions ordered and initiated for resident #62. There was no documentation provided by the end of survey.

Based on record review and interview, the facility failed to ensure a clinical rationale when a pharmacy recommendation was declined had been provided for two (#8 and #25) of five residents who were reviewed for unnecessary medications. The DON identified 89 residents who received medications. Findings: 1. Resident #25 had diagnoses which included dementia without behavioral disturbance, anxiety, and recurrent depressive disorder. A Pharmaceutical Consultant Report, dated 05/26/22, documented the pharmacist recommended a gradual dose reduction of [MEDICATION(S)] 20 milligrams daily. The physician declined the recommendation. There was no rationale provided on the form, physician's progress notes, or the resident's clinical record. 2. Resident #8 had diagnoses which included [CONDITION(S)], hypertension, and major depressive disorder. A Pharmaceutical Consultant Report, dated 05/26/22, read in parts, .Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rationale for the continued use .[MEDICATION(S)] 10mg HS .[MEDICATION(S)] 10mg HS .[MEDICATION(S)] DR 30mg BID . There was no rationale provided on the form, physician's progress notes, or the resident's clinical record. On 07/20/22 at 12:33 p.m., the DON was asked what the process was for pharmacy recommendations. They stated the pharmacy recommendations were reviewed, sent to the resident's physician, and any changes indicated by the physician were reflected in the clinical record. The DON was asked who was responsible to ensure the physician had documented a clinical rationale if they declined the pharmacy recommendation. They stated in the future themselves or the ADON would be responsible to review the recommendations. They stated they had noticed some pharmacy recommendations had not had a clinical rationale documented by the physician.

Based on observation and interview, the kitchen failed to maintain sanitary conditions in the main kitchen, including the ice machine, the microwave in the long term care satellite kitchen, and the microwave in the resident dining room. The director of nursing identified all residents ate meals prepared in the kitchen. Findings: On 07/17/22 at 11:00 a.m., an initial tour of the kitchen was performed. There was four large packages of pork loin thawing in a box on the floor of the walk in refrigerator. There were three bottles of personal drinks in resident refrigerator labeled cooler #3. The ice machine was observed to have black, brown, and pink slimy substance scattered in, under, and around the water collection tray which holds the water to be pumped up and recirculated to freeze into ice. On 07/17/22 at 10:20 a.m., the cook was asked how often the ice machine was cleaned. The cook stated they were to clean the ice machine weekly but did not know when the ice machine had last been cleaned. They stated it had obvious been awhile since the ice machine was cleaned. On 07/17/22 at 10:30 a.m., the assistant dietary manager stated the pork loin needed to be off the floor. The assistant dietary manager stated they thought as long as the personal drinks were labeled, they were allowed to store them in the refrigerator with resident food. The assistant dietary manager stated the ice machine was dirty and they would dump the ice and clean the ice machine immediately. On 07/17/22 at 1:00 p.m., a microwave in the resident dining room was observed to be dirty. The microwave was observed to be used by residents and their family members. Dried food and fluids were observed on the interior walls, door, turntable, ceiling and floor. On 07/20/22 at 12:00 p.m., a microwave in the long term care kitchenette was observed to be dirty. Dried food and fluids were observed on the interior walls, door, turntable, ceiling and floor. On 07/20/22 at 12:05 p.m., the assistant dietary manager was observed to use the microwave in the long term care kitchenette to warm the ham to serving temperatures. On 07/20/22 at 12:10 p.m., the assistant dietary manager was asked what was the condition of the microwave in the long term care kitchenette and in the resident dining room. The assistant dietary manager stated they were both dirty. The assistant dietary manager stated both microwaves were to be cleaned daily with the kitchen staff responsible for the microwave in the kitchenette but nursing staff was responsible for the microwave in the dining room.

Based on record review and interview, the facility failed to identify significant weight loss for one (#62) of 18 residents whose comprehensive assessments were reviewed. The director of nursing identified four resident with significant weight loss. Findings: The admission assessment, dated 03/24/22 documented Resident #62 was 59 inches tall (4 foot 11 inches) and weighed 107 pounds. The assessment documented the resident had no weight loss or gain. The quarterly assessment, dated 06/22/22 documented the resident weighed 94 pounds. The assessment documented the resident had no weight loss or gain. There was a significant weight loss of 11% from the admission assessment weight of 107 pounds on 03/24/22 to the quarterly assessment weight of 94 pounds on 06/22/22 (approximately three months.) On 07/20/22 at 5:30 p.m., the director of nursing was provided the recorded weights for the admission assessment and quarterly assessment for resident #62 and asked why the resident was not identified as having significant weight loss. The director of nursing stated she did not know the assessment did not identify the resident has having significant weight loss.

Based on record review, observation, and interview, the facility failed to ensure catheter care was documented, order was obtained, and a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Census and Conditions of Residents form documented five residents who had an indwelling urinary catheter. Findings: An undated policy, titled Appropriate Use of Indwelling Catheters, read in part, .The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission assessment, dated 05/23/22, documented the resident was cognitively intact for daily decision making, was frequently incontinent of urine, and did not have an indwelling urinary catheter. Review of the electronic medical record did not reveal documentation of catheter care. The Order Summary Report, dated 02/01/22 through 07/31/22, did not reveal a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The progress note, dated 07/13/22, documented the resident was readmitted to the facility from the hospital with the indwelling urinary catheter. On 07/18/22 at 12:03 p.m., the resident was observed in bed with an indwelling urinary catheter in place. The resident stated they thought they had the indwelling urinary catheter because they were too weak to utilize the commode. On 07/20/22 at 10:33 a.m., CNA #1 was asked how often catheter care was provided. The CNA stated the nurses or the CNAs provided catheter care every two hours and as needed. They were asked where catheter care was documented. The CNA stated in the electronic medical record. On 07/20/22 at 4:04 p.m., the DON was asked how long the resident had the indwelling urinary catheter. The DON stated since 07/13/22. They were asked how often catheter care was provided. They stated the CNAs and nurses performed catheter care twice per shift. They stated they were to document the catheter care in the electronic medical record. The DON was asked why a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They stated they would find out. On 07/20/22 at 5:14 p.m., the DON stated LPN #1 had called the resident's hospice and discussed the use of the indwelling urinary catheter but had not called the physician to obtain an order.

Based on observation and interview, the facility failed to ensure infection control was maintained during wound care for one (#57) of two sampled residents who were observed during wound care. The Resident Census and Conditions of Residents form identified ten residents who had pressure ulcers. Findings: Resident #57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/18/22 at 10:50 a.m., LPN #2 was observed to provide wound care to resident #57's bilateral lower extremity in the dining room. LPN #2 was observed to sit on the floor and place a piece of wax paper on the floor. The gloves were observed to hang off of the wax paper and touch the floor. The nurse was observed to cut the soiled dressing off of the resident's right leg and place the soiled scissors on top of the pile of unused gloves. The nurse was observed to leave the area and gather supplies. While the nurse was away from the resident, the resident placed their left foot onto the wax paper and dressing supplies stored on the floor atop the wax paper. LPN #2 returned and donned gloves without washing or sanitizing their hands and was observed to touch items in the treatment cart, the floor, and then the resident's leg with the same gloved hands. LPN #2 was observed to clean the resident's right leg and apply a cream/ointment without changing gloves. The LPN placed an absorbent dressing to the right leg, removed it, laid the absorbent dressing atop the soiled dressing still on the resident's left leg, removed a package of [MEDICATION(S)] from the lower drawer of the treatment cart, opened the package of [MEDICATION(S)], grabbed the absorbent dressing off of the soiled left leg dressing, placed it in position on the right leg, and secured the absorbent dressing with the [MEDICATION(S)]. LPN #2 was observed to provide treatment to the resident's left leg. The LPN was observed to sanitize their hands and change gloves. The LPN removed the resident's sock and soiled dressing from the left leg. The nurse removed their gloves, removed supplies from the treatment cart, and placed the supplies directly on the floor. The LPN sanitized their hands, donned gloves, and laid the bottle of hand sanitizer on its side to roll back and forth across the wax paper and floor. The LPN placed the resident's left leg onto the nurse's right leg, cleansed the resident's left leg, removed their gloves, and applied no sting barrier to the resident's left leg. The LPN sanitized their hands, obtained additional supplies from the treatment cart, and placed them directly on the floor. The LPN donned gloves, obtained the supplies from the floor, and in the process, touched the floor with their gloved hands. The LPN opened the packages and laid them on the wax paper. With the same gloved hands used to open the packages, the LPN applied a cream/ointment to the resident's leg, then applied the bandages. On 07/20/22 at 3:17 p.m., LPN #2 was asked when hand hygiene was to occur when wound care was provided. They stated before and after wound care and when they went from anything that was soiled to a clean item. The LPN was asked why supplies had been placed on the floor and hand hygiene had not been performed when wound care had been observed on 07/19/22. They stated they had known better and should have performed the treatment in the resident's room. LPN #2 was asked how infection control was maintained during wound treatments when wound care supplies were placed on the floor and wound care was performed in a common area like the dining room. They stated they knew they should not have placed the wound care supplies on the floor or performed the wound care in a common area.

Based on observation, interview, and record review, it was determined the facility failed to report an injury of unknown origin, that resulted in serious bodily injury, within two hours for one (#2) of three resident reviewed for reportable incidents. The facility identified 77 residents lived in the facility. Findings: The policy documented an injury of unknown origin should be reported to the Oklahoma State Department of Health (OSDH) within 24 hours. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 07/16/19, documented the resident was severely impaired for daily decision making. The assessment documented the resident required one person assistance with activities of daily living (ADLs). The care plan, dated 07/17/19, documented the resident required ADL assistance. The nurse note, dated 09/02/19 at 1:32 PM, documented the nurse assessed the resident complaining of left leg pain. The nurse notified the physician and an x-ray was ordered. The nurse notes, dated 09/02/19 at 8:00 PM, documented the x-ray report revealed the resident had a left distal femur fracture. The incident report, dated 09/02/19, documented the resident sustained [REDACTED]. The report documented the resident started to complain of left leg pain after her shower. The report documented an x-ray was obtained and the result documented a left distal femur fracture. The report documented it was faxed to OSDH on 09/03/19 at 12:52 PM. On 10/02/19 at 3:15 PM, licensed practical nurse (LPN) #1, stated after he obtained the x-ray results for resident #2 he notified the physician, director of nurses (DON), and the administrator. The LPN stated the resident was sent to the hospital. On 10/03/19 at 4:45 PM, the administrator stated she reported the incident to OSDH within 24 hours. The administrator stated she was not aware she had to report it in two hours.

Based on observation, interview, and record review, it was determined the facility failed to prepare and serve food in a sanitary manner for 82 of 83 residents who were reviewed for food service. The facility failed to: a) Clean the deep fryer. b) Ensure the staff wore hair restraints to cover exposed hair. c) Ensure the staff washed their hands before and after donning gloves and after contact with unclean surfaces while preparing food. d) Ensure the staff cleaned the food thermometer before and between food temperature checks. The facility identified 82 residents who received meals prepared by the kitchen. Findings: The facility policy for sanitization documented food service areas were to be kept clean. The policy documented the staff was to wear hair restraints to keep hair from contacting food, equipment, and utensils. The policy documented three ways to sanitize kitchen utensils and equipment. The policy documented an item should be in contact with iodine solution for at least 30 seconds, with chlorine solution for at least 10 seconds, or immersion in water at 171 degrees Fahrenheit for 30 seconds. The policy for hand-washing/hand hygiene documented the staff was to wash their hands after handing soiled equipment or utensils. The policy documented the staff was to wash their hands after removing their gloves. On 04/16/18 at 11:05 AM a tour of the kitchen was conducted. The deep fryer grease was dark brown with a large amount of white particles floating in the grease and on the edges of the deep fryer. The sides of the deep fryer had brown streaks. On 04/16/18 at 11:20 AM, the dietary manager (DM) was interviewed regarding cleaning schedules for the kitchen. The DM was unable to locate the cleaning schedule for the kitchen. The DM stated the deep fryer was cleaned weekly and was skimmer cleaned daily. On 04/16/18 at 11:35 AM, the dietary cook was interviewed regarding the cleaning schedule for the kitchen. The cook pointed to the wall and stated the assistant dietary manager (DM) posted the cleaning schedule weekly. The cook stated no cleaning schedule was posted at this time. The cook stated the deep fryer was cleaned about every eight days and the last time was six days ago. The cook stated no other cleaning tasks were performed for the deep fryer. On 04/16/18 at 11:48 AM, the assistant DM was interviewed regarding the cleaning schedule for the kitchen. The assistant DM stated the cleaning schedule was posted in the kitchen, but the staff were not assigned individual tasks. The assistant DM stated the tasks had to be completed by the end of each day. On 04/16/18 at 11:55 AM, the facility provided a cleaning schedule for the week ending 04/16/18. The schedule documented 14 tasks to be completed by the end of the week. Five of the 14 tasks were documented as completed. The task of cleaning the deep fryer was not documented as completed. On 04/17/18 at 10:35 AM, the dietary cook was observed preparing the pureed diet for the residents. The cook gathered utensils and donned a pair of gloves. The cook did not wash his hands prior to putting on his gloves. The cook blended the sweet potatoes in the mixer. With gloved hands, the cook donned oven mitts to handle a hot pot on the stove. The cook removed the oven mitts and continued to prepare the pureed food with the same gloved hands. The cook placed the pureed sweet potatoes in a pan, covered the pan with clear wrap, and placed the pan in the oven. The cook removed his gloves. After removing his gloves, the cook rinsed the mixer in the sink under running water. The cook did not use a cleaning solution to wash the mixer. The cook did not dry the mixer before returning the mixer to it's base. The cook donned a pair of gloves to prepare the mixed vegetables. The cook did not wash his hands after removing his gloves or before donning a new pair of gloves. The cook obtained a pan of mixed vegetables from another counter and a spoon from a drawer. The cook placed the mixed vegetables in the mixer and placed his gloved hand over the opening of the lid while to food blended. The cook sprayed the pan with cooking spray, placed the mixed vegetables in the pan, covered the pan with clear wrap, and placed the pan in the oven. The cook placed the spatula and mixer in a dirty sink. With same gloved hands the cook rinsed the mixer with running water and returned the wet mixer to it's base. The cook obtained a pan of turkey from another counter. The cook placed the turkey in the wet mixer. The cook pureed the turkey using the same wet gloves. The cook sprayed an empty pan with cooking spray, poured the pureed turkey into the pan, covered the pan with clear wrap, and placed the pan in the warm oven. The cook placed the used mixer bowl in a dirty sink and removed his gloves. The cook did not wash his hands after removing his gloves. The cook obtained a pan of cake from a rack and proceeded to the mixing area. The cook took the mixer in the sink and rinsed it with running water. The cook was not wearing gloves. The cook did not use a cleaning solution to wash the mixer. The cook returned the wet mixer to it's base. The cook without washing his hands, donned a pair of gloves and obtained a half gallon of milk from the refrigerator. The cook placed the cake and poured some milk in the mixer to blend. After preparing the pureed cake the cook removed his gloves and continued to prepare the meal. The cook did not wash his hands after removing his gloves. On 04/17/18 at 11:00 AM, the dietary aide was observed standing between the stove and food service table. The aide was wearing a ball cap. His hair was sticking out approximately one inch from the front, sides, and back of the cap. The dietary aide left the kitchen area and returned wearing a hair net. On 04/17/18 at 11:05 AM, the cook took a thermometer from the shelf and placed it in the cake to check the temperature. The cook removed the thermometer from the cake and dropped the thermometer on the floor. The cook picked up the thermometer and started searching for something on the shelf. On 04/17/18 at 11:07 AM, the assistant DM took the thermometer from the cook and dipped the thermometer in a bowl of clear liquid and dried the thermometer with paper towel. This process was repeated two more times while obtaining the temperature of the remaining food. The assistant DM stated the thermometer was cleaned in plain hot water. The assistant DM stated the thermometer was normally cleaned with an alcohol pads. The DM stated the kitchen was out of alcohol pads. On 04/17/18 at 11:15 AM, the dietary aide was interviewed regarding hair restraints. The dietary aide stated staff should not enter a food preparation or service area without a hair net. On 04/17/18 at 11:25 AM, the DM was interviewed regarding hand-washing. The DM stated the staff was to wash their hands with every glove change, after handling equipment, and after changing tasks. The DM stated the thermometer was to be cleaned with a cleaning solution.

Based on observation, interview, and record review, it was determined the facility failed to implement the infection control policy for one (#42) of one sampled resident reviewed for infection control. The facility failed to ensure the staff wore the correct personal protective equipment when providing care for a resident with contact precautions. The facility identified one resident with transmission based precautions lived in the facility. Findings: The facility policy and procedure for transmission based precautions documented the staff must wash their hands with soap and water before and after direct contact with a resident, after removing gloves, and when there was a chance of exposure to [MEDICAL CONDITION] spores. The policy documented alcohol based hand rubs were not effective against spore producing organisms. The policy documented the staff were to wear personal protective equipment as necessary to prevent exposure to infectious material. The policy for contact precautions documented the staff must wear a gown and gloves for all interactions that may involve contact with the resident or a potentially contaminated area in the environment. The policy documented the staff were to don personal protective equipment on entrance to the room and discard it before exiting the room. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 14 day comprehensive assessment, dated 03/01/18, documented the resident was dependent for daily decision making and required extensive assistance with the activities of daily living (ADLs). The assessment documented the resident was frequently incontinent of bowel and bladder. The care plan, dated 04/12/18 documented the resident had [MEDICAL CONDITION], was on contact isolation, and received [MEDICATION NAME] (an antibiotic). The physician orders [REDACTED]. The orders documented the resident was to receive [MEDICATION NAME] 250 milligrams by mouth for a [MEDICAL CONDITION] infection. A laboratory report, dated 04/12/18, documented the resident had a [MEDICAL CONDITION] infection. On 04/16/18 at 12:30 PM, the resident was observed. The resident's room had a sign on the door to check at the nurse's station before entering. A three drawer chest was outside the room and was stocked with personal protective equipment. Biohazard bags were placed inside the room by the door for trash and linens. On 04/16/18 at 12:30 PM, licensed practical nurse (LPN) #1 was interviewed regarding the resident's isolation. The LPN stated the resident had [MEDICAL CONDITION]. On 04/18/18 at 8:35 AM, certified nurse aide (CNA) #1 was observed serving the resident a meal in her room. The CNA donned gloves and entered the room. The CNA did not don a yellow protective gown. The CNA adjusted the resident in her recliner and repositioned the resident's pillow. The CNA removed her gloves and exited the room. The CNA did not perform hand hygiene. On 04/18/18 at 8:40 AM, the CNA was interviewed regarding contact precautions. The CNA stated she should wear a gown and gloves when a resident was on contact precautions. The CNA stated she did not put on a gown. The CNA stated she took her gloves off when she left the room but did not perform hand hygiene. The CNA stated she should have used hand sanitizer. The CNA stated the resident was on contact precautions for a [MEDICAL CONDITION] infection. The CNA stated she did not know she had to wash her hands with soap and water.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care services for five (#1, #2, #3, #4, and #5) of eight residents reviewed for activity of daily living (ADL) care. The facility failed to ensure residents were provided personal care in a timely manner. The facility identified 68 residents who required assistance with ADL care. Findings: 1. Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 09/08/17, documented the resident was independent for daily decision making. The assessment documented the resident required extensive assistance for ADLs. The assessment documented the resident had an upper and lower extremity impairment on one side. The assessment documented the resident was continent of bowel and bladder. The assessment documented the resident used a walker and a wheelchair for mobility. The assessment documented the resident had a surgical wound. The care plan, dated 09/17/17, documented the resident had an alteration in ADL function related to a recent left hip joint replacement surgery and impairment to her upper right arm. The care plan documented the resident required assistance from staff for all ADL tasks. On 02/28/18 at 1:05 p.m., the resident was interviewed. The resident stated the staff would come into her room and turn off the call light. The resident stated it would be a long time before the staff would return. The resident stated sometimes it would take 45 minutes to an hour to receive toileting assistance. The resident stated she had soiled the bed while waiting for staff assistance. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 02/14/18, documented the resident was independent for daily decision making. The assessment documented the resident required supervision to limited assistance for ADLs. The assessment documented the resident required a walker or a wheelchair for mobility. The assessment documented the resident had a prosthetic device. The care plan, dated 02/19/18, documented the resident had an ADL self care performance deficit related to dementia. The assessment documented the resident had impaired balance, chronic fatigue, and chronic pain related to a lumbar vertebra fracture. On 02/27/18 at 8:00 a.m., the resident was observed sitting in her wheelchair in her room. On 02/27/18 at 8:03 a.m., the resident was interviewed. The resident stated the daytime staff did not answer the call light well and the nighttime staff was even worse. The resident stated she had learned quickly she would have to attend to her ADL needs herself. The resident stated while waiting for staff to assist her she had urinated in her bed. The resident stated the staff would come into her room and turn the call light off. The resident stated the staff would say they would come back to assist her. The resident stated the staff might come back and they might not. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 12/20/17, documented the resident was moderately impaired for daily decision making. The assessment documented the resident required extensive assistance for ADLs. The assessment documented the resident was frequently incontinent of bowel and bladder. The assessment documented the resident required the assistance of two staff for ADL care and transfers. The assessment documented the resident used a walker or a wheelchair for mobility. The care plan, dated 12/20/17, documented the resident had a [MEDICAL CONDITION] with impairment to the left non dominant side. The care plan documented the resident required extensive assistance for most ADL functions. The care plan documented the staff would use a sit to stand device with a two person assist for transfers. The assessment documented the resident was continent of bowel and bladder. On 02/17/18 at 10:54 a.m., the resident was observed in her room sitting in her wheelchair watching television. On 02/27/18 at 10:58 a.m., the resident was interviewed. The resident stated the nighttime staff was slow to answer the call lights. The resident stated at times it had taken 1.25 to two hours for the staff to assist the resident with toileting. The resident stated at times it was midnight before she was assisted to bed. The resident stated she had soiled herself several times waiting for toileting assistance. The resident stated it made her feel terrible and was embarrassing. 4. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated 01/01/18, documented the resident was independent for daily decision making. The assessment documented the resident required supervision for most activities of daily living. The assessment documented the resident was occasionally incontinent of bladder. The care plan, dated 01/01/18, documented the resident had an ADL self care performance deficit but was able to perform most ADLs with supervision. On 02/17/18 at 10:21 p.m., the resident was observed in her room sitting in her chair watching television. On 02/27/18 at 10:26 p.m., the resident was interviewed. The resident stated she did not require a lot of assistance with ADLs. The resident stated sometimes the aids did not show up for work and it would take awhile to receive assistance. 5. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 01/22/18, documented the resident was independent for daily decision making. The assessment documented the resident required extensive assistance for ADLs. The care plan, dated 03/02/18, documented the resident had an ADL self care performance deficit. The assessment documented the resident was incontinent of bladder. The assessment documented the resident was taking a diuretic. On 02/27/18 at 10:38 a.m., the resident was observed in her room sitting in her chair. On 02/27/18 at 10:41 a.m., the resident was interviewed. The resident stated it would take up to 30 minutes to answer the call light if staff was available. The resident stated the aids did not show up to work a lot. The resident stated it could take longer to receive ADL assistance when the staff did not show up to work. The resident stated the staff did not show up quite often on both the daytime and nighttime shifts. On 02/27/18 at 10:48 a.m., certified nurse aid (CNA) #3 was interviewed. The CNA stated there was not enough staff in general. The CNA stated if everyone did their jobs she could complete her duties. The CNA stated the aids would call in a lot of the time. The CNA stated residents complained about the night shift being slow to provide ADL care. The grievance logs for the past six months were reviewed. The grievance logs documented multiple complaints related to the call lights not being answered in a timely manner. The angel round flowsheets for (MONTH) (YEAR) were reviewed. The flowsheets documented multiple complaints related to slow responses to the call lights. The flowsheets documented the night shift was worse than the day shift. On 03/01/18 at 2:25 p.m., the director of nurses (DON) was interviewed regarding call lights. The DON stated the staff carried a pager and a light would also come on above the resident's door. The DON stated the staff would have to physically go into the resident's room to turn off the call light. On 03/01/18 at 2:76 p.m., CNA #5 was interviewed regarding call lights. The CNA stated she thought every nursing home went through staffing turn overs. The CNA stated sometimes there was not enough staff. The CNA stated the residents had complained about the night shift being slow to respond to the call lights. On 03/01/18 at 3:10 p.m., licensed practical nurse (LPN) #2 was interviewed. The LPN stated there was not always enough staff to meet the resident's needs. The LPN stated he wondered about the staffs work ethics. The LPN stated they had to scramble to provide the resident's care.

Based on observation, interview, and record review, it was determined the facility failed to provide the ordered care and treatment for one (#1) of eight residents reviewed for care and treatment. The facility failed to (a) measure the circumference of the resident's ankle for [MEDICAL CONDITION], and (b) discontinue the resident's [MEDICATION NAME]. The facility identified 88 residents who lived in the facility. Findings: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 09/08/17, documented the resident was independent for daily decision making. The assessment documented the resident required extensive assistance for ADLs. The assessment documented the resident had an upper and lower extremity impairment on one side. The assessment documented the resident was continent of bowel and bladder. The assessment documented the resident used a walker and a wheelchair for mobility. The assessment documented the resident had a surgical wound. The care plan, dated 09/17/17, documented the resident had an alteration in ADL function related to a recent left hip joint replacement surgery and impairment to her upper right arm. The care plan documented the resident required assistance from staff for all ADL tasks. (a) The physician order, dated 09/02/17, documented an order for [REDACTED]. The treatment administration record (TAR), dated 09/10/17, documented an order to measure the circumference of the resident's upper ankle daily. The TAR documented the measurement would be taken one time a day for [MEDICAL CONDITION] to the left lower extremity. The TAR documented the measurement was obtained three out of the six days it was ordered. On 03/01/18 at 3:38 p.m., the director of nurses (DON) was interviewed. The DON stated the only measurements taken for the residents ankle were documented in the TAR. The DON stated no other measurements had been taken. (b) The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The physician order, dated 10/12/17, documented an order for [REDACTED]. (The order was not discontinued and the resident continued to receive the ([MEDICATION NAME]) [MEDICATION NAME] and one dose of the newly ordered medication of [MEDICATION NAME].) The nurse note, dated 10/17/17, documented the resident was seen by the physician for persistent nausea. The incident report, dated 10/18/17, documented the resident had received a discontinued medication ([MEDICATION NAME]). The incident report documented the physician was made aware of the medication order and the nurse had been spoken too. The incident report documented the resident had been discharged home. On 02/28/18 at 1:32 p.m., licensed practical nurse (LPN) #1 was interviewed. The LPN stated the resident had a lot of trouble eating related to nausea and vomiting. The LPN stated everything upset the resident's stomach. The LPN stated she had contacted the resident's physician related to the resident's nausea and vomiting. The LPN stated she was responsible for changing the order from [MEDICATION NAME] to [MEDICATION NAME]. The LPN stated she had not discontinued the order for the ([MEDICATION NAME]). The LPN stated she should have changed the order. On 03/01/18, at 4:10 p.m., the physician #2 was interviewed. The physician stated there was no way to know if the [MEDICATION NAME] would have been affective for the resident's nausea and vomiting since the resident's medication order had not been changed.

Based on observation, interview, and record review, it was determined the facility failed to provide treatment and services to promote the healing of pressure ulcers for two (#2 and #3) of four sampled residents reviewed for pressure ulcers. The facility failed to: a) Thoroughly and accurately assess pressure ulcers on admission for the residents. b) Notify the physician of pressure ulcer status and obtain orders for treatment for [REDACTED]. c) Notify the physician for changes in pressure assessment for resident #3. d) Provide a nutrition evaluation which identified the nutritional needs to aide in wound healing. Resident #2 was admitted to the facility with a skin tear to the sacrum. An assessment the day after admission documented an unstageable pressure wound to the right buttock measuring 6 centimeters (cm)X 8 cm. A wound specialist evaluation, dated 08/30/17, documented an unstageable pressure wound to the right buttock measuring 6.4 cm X 9.2 cm X not measurable depth and the report documented the wound had deteriorated. Resident #3 was admitted with a deep tissue injury to the coccyx/sacrum and was covered with a dressing. The day after admission an assessment documented the wound measured 3.0 cm X 3.0 cm was dry, dark purple, closed, and was a suspected deep tissue injury (DTI). On 09/19/17 the wound was observed and measured. The wound was larger and measured 4.0 cm X 3.8 cm and was covered with eschar. The open red area surrounding the center eschar was not measured. This area was irregular, inflamed, and was not measured. The facility identified seven residents who resided in the facility with pressure ulcers. Findings: The facility policy and procedures for pressure ulcer prevention documented the pressure ulcer prevention protocol was to be initiated when a resident was admitted with a pressure ulcer. The protocol documented the staff was to start an activities of daily living (ADL) sheet indicating the resident was being turned frequently, notify the wound nurse to monitor the resident's skin, and document clearly and accurately in the nurses notes pertaining to pressure ulcers. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A admission skin screen, dated 08/17/17, documented the resident had a dressing to left hip to stay on for two weeks, a right forearm burn site, bilateral breast has some yeast, and the sacrum had a skin tear. A weekly wound note, dated 08/18/17, documented the resident had a right buttock unstageable pressure wound measuring 6 cm X 8 cm. Thin, watery, pale red to pink drainage. The note documented the surrounding tissue was very inflamed and indurated. A physician narrative note, dated 08/21/17, documented the resident had a history of [REDACTED]. The note did not document a pressure ulcer or skin concerns. The physician order, dated 08/22/17, documented the staff was to cleanse the right buttock with normal saline, apply skin prep to surrounding tissue, and apply wnd-ebd (a debridment medication) cream to wound bed. The staff was to cover the wound with a dry dressing daily and as needed . A laboratory report, dated 08/22/17, documented the resident's white blood cell count (WBC) was 8.4 (within normal range) and hemoglobin was 9.8 (low 11.2-15.7) hematocrit was 32.7 (34.1-44.9). The order documented the physician was notified of the results and a new order was received to decrease the resident's blood pressure medication and encourage fluids. A wound care specialist evaluation, dated 08/23/17, documented the resident had an unstageable pressure ulcer to the right buttock. The evaluation documented the wound was 5.8 cm length X 9.4 cm width X not measurable depth. The evaluation documented the pressure ulcer had light serous exudate with thick adherent devitalized necrotic tissue at 100%. The evaluation documented surgical excision debridment was done. The 5 day assessment, 08/24/17, documented the resident was independent for daily decision making and required extensive assistance with the activities of daily living (ADLs). The assessment documented the resident had a surgical wound. The assessment document the resident had one unstageable pressure ulcer that was present upon admission. The assessment documented the wound measured 6.0 cm in length and 8.0 cm in width. The care plan, dated 08/25/17, documented the resident had a unstageable pressure ulcer to the right buttock. The care plan documented the resident was at risk for further skin impairment related to decreased mobility. The staff was to administer skin treatments as ordered by the physician, reposition the resident frequently, and provide a pressure reducing mattress for the resident. The staff was to monitor and document the location, size, and treatment of [REDACTED]. A weekly wound note, dated 08/25/17, documented a pressure ulcer to the right buttock measuring 5.7 cm in length X 9.4 cm in width X depth unknown. The note documented the pressure ulcer had serosanguineous, thin, watery, and pale red to pink drainage. The note documented the wound edges were firm and necrotic. A nutrition risk assessment, dated 08/29/17, documented the resident was on a regular diet with no supplements added. The assessment documented the resident's meal intake meets 76-100% of the estimated nutritional needs. The assessment documented the [MEDICATION NAME] and other nutrition related lab values were within normal limits. The assessment documented the resident's skin was intact. A wound care specialist evaluation, dated 08/30/17, documented the resident had an unstageable pressure ulcer to the right buttock. The evaluation documented the wound was 6.4 cm in length X 9.2 cm in width X not measurable depth. The evaluation documented the resident had thick adherent devitalized necrotic tissue at 100%. The evaluation documented the wound had deteriorated due to patient non-compliance with wound care and need to off-load wound more. The 14 day assessment, dated 08/31/17, documented the resident was independent for daily decision making and required extensive assistance with the activities of daily living (ADLs). The assessment documented the resident had a surgical wound. The assessment documented the resident had one unstageable pressure ulcer that was present upon admission. The assessment documented the wound measured 6.4 cm in length and 9.2 cm in width. A weekly wound note, dated 09/01/17, documented a pressure ulcer to the right buttock measuring 6.4 cm length X 9.2 cm width X depth unknown. The note documented the pressure ulcer had serosanguineous, thin, watery, and pale red to pink drainage. The note documented the wound edges were red and inflamed. A skilled nurse assessment, dated 09/01/17, documented the resident's temperature was 97.5 degree Fahrenheit (F). The assessment did not document the surgical wound to the left hip or the pressure ulcer to the buttock. A skilled nurse assessment, dated 09/02/17, documented the resident's temperature was 98.1 degree Fahrenheit (F). The assessment did not document the surgical wound to the left hip or the pressure ulcer to the buttock. A skilled nurse assessment, dated 09/03/17, documented the resident's temperature was 98.6 degree Fahrenheit (F). The assessment documented the size and area of the pressure ulcer was noted. The assessment documented wound care was provided as ordered and wound healing was monitored. A skilled nurse assessment, dated 09/04/17, documented the resident's temperature was 96 degree Fahrenheit (F). The assessment documented a pressure ulcer to the right buttock. The assessment documented the wound had purulent, thin, thick, opaque, with tan/yellow drainage covering less than 25% of the dressing. The assessment documented the wound had a foul odor. A physician progress notes [REDACTED]. The note documented the wound care physician had performed I&D (not defined) to right buttock. A Medication Administration Record [REDACTED]. A verbal physician order, dated 09/05/17, documented the resident was to receive [MEDICATION NAME] (an antibiotic) twice a day related to a [MEDICAL CONDITION] femur and subsequent encounter for a closed fracture with routine healing for 30 days. A wound care specialist evaluation, dated 09/06/17, documented the resident had an unstageable pressure ulcer to the right buttock. The evaluation documented the wound was 6.3 cm in length X 8.4 cm in width X not measurable depth. The evaluation documented the resident had thick adherent devitalized necrotic tissue at 80%. The evaluation documented the wound had improved as evidenced by decreased surface area. A skin/wound note, dated 09/06/17, documented the staff spoke yesterday with the surgical physician and reported drainage from the surgical incision and a concern related to the right buttock wound. The note documented an order was received for an antibiotic medication and physician was to see the resident the next day to examine the left hip incision. The note documented the buttock wound still had necrotic tissue, but had decreased in size since last week. The note documented the resident was to discharge home today with home health services due to insurance. A laboratory report, dated 09/06/17 at 9:33 p.m., documented the resident's white blood cell count (WBC) was 6.2 (within normal limits). The report documented the resident's hemoglobin result was 7.5 (a critical low value). An emergency department triage note, dated 09/07/17, documented the resident came to the emergency room with a complaint of generalized weakness. The record documented the patient had reported receiving a phone call today advising her to go to the emergency room due to a low blood count laboratory result. The record documented the patient reported pain in the left leg and denied issues with the surgical incision site. The record documented the bandage was clean and intact at the time. On 09/20/17 at 10:00 a.m., the wound care nurse/ licensed practical nurse (LPN) #1 was interviewed regarding notification of laboratory (lab) results for the resident on 09/06/17 to the physician. The LPN stated to lab results were received in the facility on 09/06/17 in the evening hours. The LPN stated on the morning of 09/07/17 when the lab results were reviewed the physician was notified. The LPN stated the resident was called following the conversation with the physician and was told to go to the emergency room per the physician due to low blood count. On 09/20/17 at 1:50 p.m., the wound nurse/LPN #1 was interviewed regarding wound assessments and care for the residents upon admission to the facility. The nurse stated the admitting nurse would assess the resident to determine if a skin condition exists and notify her with any concerns. The LPN stated if she was not available the staff was to notify the physician with any concerns. The nurse stated she removed a foam dressing, assessed the resident, and reapplied a foam dressing on 08/18/17. The wound nurse stated a called was placed to the physician and a message was left regarding the wound. The LPN stated the physician had not returned her message prior to leaving for the weekend. The LPN stated she should have followed up with the physician before leaving for the weekend or had the on coming staff follow up with the physician. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility standing orders, dated 04/12/16, documented an order for [REDACTED]. The hospital laboratory records for resident #3, dated 09/04/17, documented the resident's white blood cell count (WBC) was 4.3 and was within normal limits (WNL). The report documented the hemoglobin was 12.6 (WNL), the hematocrit was 27.2 (WNL), and the electrolytes were WNL. The hospital discharge record, dated 09/06/17, documented the resident had a closed femur neck fracture, had senile [MEDICAL CONDITION], had [MEDICAL CONDITION], and was on a regular diet. The record documented the resident had a stage I pressure injury to the coccyx and the area could not be assessed. The record documented the site measured 7.0 centimeters (cm) X 7.0 cm and the treatment was a [MEDICATION NAME] border dressing to the sacrum. The record documented a wound to the left buttocks which was clean and dry and the site was not able to be assessed. An admission assessment screener, dated 09/07/17, documented the resident required extensive assistance with bed mobility, transfers, dressing, and bathing. The assessment documented the resident had a deep tissue injury (DTI) to the buttocks and a surgical wound to the left buttocks. The assessment documented the resident had a large mole with a small open area where a biopsy was obtained. The assessment documented the resident was alert and incontinent one or more times, and had pain at a level three. The initial care plan, dated 09/08/17, documented the resident had a surgical wound and left hip deep tissue injury to the coccyx. The care plan documented the interventions included the staff were to educate the resident on the causative factors and measures to prevent skin injury, encourage good nutrition and hydration, place a pressure relieving mattress on the resident's bed, keep the resident's skin clean and dry, reposition frequently, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan documented the staff was to monitor and document the location, size and treatment of [REDACTED]. to the physician. The physician orders, dated 09/08/17, documented the staff were to cleanse the lift hip with normal saline, pat dry, and apply dry gauze secured with [MEDICATION NAME] daily and as needed. The orders did not document order for wound care to the DTI on the coccyx. The orders documented the resident was to receive a regular diet. The Braden scale assessment, dated 09/08/17, documented the resident was a low risk for developing pressure ulcers. The wound care records, dated 09/08/17, documented the wound to the coccyx measured 3.0 cm X 3.0 cm and was a suspected deep tissue injury. The note documented the area was dry, dark purple, and the skin was not open. A physician progress notes [REDACTED]. The note did not document the resident had a deep tissue injury or a pressure ulcer to the coccyx. The note did not document the plan for treatment for [REDACTED]. A nurse note, dated 09/13/17 at 2:54 p.m., documented the DTI to the coccyx started to have skin shear and a plan to apply a foam dressing. The note documented the purpose of the dressing was an attempt to keep skin intact. The note did not document the physician was notified. The physician orders, dated 09/13/17, documented the staff were to cleanse the coccyx DTI with normal saline and apply an [MEDICATION NAME] dressing every other day. The wound care records, dated 09/15/17, documented the wound to the coccyx measured 3.5 cm X 3.0 cm. The record documented the edges were defined and the surrounding tissue was red, firm, and indurated. The note documented the staff was to continue to offload, reposition, and support with nutrition. The treatment administration record for September 2017 documented the treatment to the DTI on the coccyx was started on 09/14/17 and was completed every other day and was started on 09/14/17. The assessment records and progress notes for September 2017 were reviewed. The assessments did not document a nutrition assessment/evaluation or dietary recommendations. On 09/18/17 at 2:35 p.m., the resident was observed with the assistance of CNA #1. The resident was lying in bed tilted to the left side and supported with pillows. The resident was clean, groomed, and had no odors. The resident had a dressing to the left hip which was clean, dry, and intact. The coccyx and sacrum had a foam dressing and was clean dry and intact. The resident had a large brown mole like lesion to her left buttocks and the lower end had a small open area. The resident was confused, thought she was at home, and was not able to answer questions very well. The resident had a small amount of fresh stool and the CNA provided peri-care using correct technique. On 09/18/17 at 2:50 p.m., the director of nurses (DON) stated the resident was on a pressure relieving mattress. On 09/19/17 at 10:30 p.m., an observation of wound care was completed. The wound care nurse provided wound care using correct technique to both the surgical wound on the left hip and wound to the coccyx. The nurse completed wound care to the coccyx. The site measured 4.0 cm X 3.8 cm over the area with eschar. The open red area surrounding the center eschar was not measured. The site had no drainage. The perimeter was irregular and inflamed. The dressing change was completed per order. On 09/20/17 at 10:05 a.m., the wound care nurse was interviewed. The nurse stated the standard care for a closed deep tissue injury was to provide a pressure relieving mattress, offload the concerned area, reposition the resident, provide nutrition and hydration, and place a protective covering to the site. The nurse stated no ointments were used since the resident's skin was closed. The nurse stated the wound was not stageable since the eschar was present. The nurse stated the wound would not be stageable till the wound bed could be assessed. The nurse stated she wrote an order for [REDACTED]. On 09/20/17 at 11:15 a.m., the resident's facility physician was interviewed regarding the wound on the coccyx. The physician stated the staff informed her the resident had a stage II pressure ulcer. The physician stated she did not assess the resident's surgical or pressure wound on 09/11/17 when she completed a physician visit for the resident. The physician stated a purple, closed area to the coccyx would not be a stage I or stage II pressure ulcer but would be a deep tissue injury. The physician stated the treatment for [REDACTED]. The physician stated other treatment would include nutrition and hydration. The physician stated she would rely on the dietitian for assistance with the provision of nutrition and hydration. On 09/20/17 at 11:40 p.m., the DON was interviewed regarding the consultations by the wound care physician. The DON stated the resident had a particular insurance which did not authorize the care of a wound care physician. The DON stated the resident's primary physician managed the treatment of [REDACTED]. On 09/20/17 at 3:15 p.m., the DON stated she and the wound care nurse could write a basic and more advanced wound care orders via the facility's standing orders.

Based on observation, interview, and record review, it was determined the facility failed to provide pharmaceutical services to meet the needs of the resident for one (#2) of three sampled residents reviewed for medication. The facility failed to provide an antibiotic medication as ordered by the physician for the resident. The facility identified 82 residents who received medications in the facility. Findings: The policy and procedures for physician medication orders documented verbal orders must be recorded immediately in the resident's clinical record. The policy documented the charge nurse or the director of nurses (DON) was to call in the order for all prescribed medications. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5 day assessment, dated 08/24/17, documented the resident was independent for daily decision making and required extensive assistance with the activities of daily living (ADLs). The assessment documented the resident had a surgical wound. The assessment documented the resident had one unstageable pressure ulcer present upon admission. The care plan, dated 08/24/17, documented the resident was admitted to the facility for rehabilitation services and care due to a left femur fracture, an artificial left hip, and iron deficiency anemia. The care plan documented the staff was to provide medication and treatment as ordered by the physician. The care plan documented the staff was to notify the physician of any changes in condition. The 14 day assessment, dated 08/31/17, documented the resident was independent for daily decision making and required extensive assistance with the activities of daily living (ADLs). The assessment documented the resident had a surgical wound. The assessment documented the resident had one unstageable pressure ulcer present upon admission. The assessment documented the resident had not received antibiotic medication. A physician order, dated 09/05/17, documented the resident was to receive Doxycycline (an antibiotic medication) twice a day for a fracture of the left femur. A skin/wound note, dated 09/06/17, documented the staff spoke to the surgical physician and reported drainage from the surgical incision and a concern related to the right buttock wound. The note documented an order was received for antibiotic medication and the surgeon was to see the resident the next day to examine the left hip incision. The note documented the buttock wound still had necrotic tissue. The note documented the resident was to discharge home that day with home health services due to insurance. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A Medication Administration Record [REDACTED]. A Medication Administration Record [REDACTED]. The note documented the medication was not available. The note documented the nurse notified the pharmacy of the new order and was waiting for the arrival of the medication. On 09/19/17 at 11:00 a.m., the director of nurses (DON) was interviewed regarding the antibiotic medication. The DON reviewed the resident's clinical record and stated the physician order [REDACTED]. The DON stated the on 09/06/17 the morning nurse documented the medication was not available and the pharmacy was notified. On 09/19/17 at 11:05 a.m., licensed practical nurse (LPN) #2 was interviewed regarding the antibiotic medication ordered. The LPN stated the medication was not available for the morning dose on 09/06/17. The nurse stated the pharmacy was notified and asked for the antibiotic to be sent stat. The LPN stated the medication arrived just prior the resident's discharge and a dose was given. The LPN stated a medication count sheet was not completed and the dose was not documented as given. On 09/19/17 at 2:25 p.m., the DON was interviewed regarding medications ordered by the physician. The DON stated the nurse receiving the physician order [REDACTED]. The DON stated the only way to know if the pharmacy received the order was to call the pharmacy for verification. The DON stated a concern related to receipt of medications was discussed in the quality assurance meeting. The DON provided a plan regarding a delay in medication delivery from the pharmacy. The plan documented a correction dated 07/18/17. The administrator was present for the interview and stated the pharmacy had reported no record had been found pertaining to an antibiotic order on 09/05/17. The administrator stated the pharmacy reported they had received a telephone order on 09/06/17.

Based on interview and record review, it was determined the facility failed to identify quality care issues and/or develop and implement appropriate plans of action to correct identified issues for two (#2 and #3) of three sampled residents reviewed for care provision. The facility failed to: a) Provide treatment and services to promote the healing of pressure ulcers for residents #2 and #3. Four sampled residents were reviewed for pressure ulcers. b) Ensure medications were ordered and received by pharmacy in a timely manner for resident #2. The facility identified 82 residents who received medication in the facility. Findings: 1. The facility to: Thoroughly and accurately assess pressure ulcers on admission for the residents. Notify the physician of pressure ulcer status and obtain orders for treatment for [REDACTED]. Notify the physician for changes in pressure assessment for resident #3. Provide a nutrition evaluation which identified the nutritional needs to aide in wound healing. Resident #2 was admitted to the facility with a skin tear to the sacrum. An assessment the day after admission documented an unstageable pressure wound to the right buttock measuring 6 centimeters (cm)X 8 cm. A wound specialist evaluation, dated 08/30/17, documented an unstageable pressure wound to the right buttock measuring 6.4 cm X 9.2 cm X not measurable depth and the report documented the wound had deteriorated. Resident #3 was admitted with a deep tissue injury to the coccyx/sacrum and was covered with a dressing. The day after admission an assessment documented the wound measured 3.0 cm X 3.0 cm was dry, dark purple, closed, and was a suspected deep tissue injury (DTI). On 09/19/17 the wound was observed and measured. The wound was larger and measured 4.0 cm X 3.8 cm and was covered with eschar. The open red area surrounding the center eschar was not measured. This area was irregular, inflamed, and was not measured. Please see F314 for details. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 08/24/17, documented the resident was admitted to the facility for rehabilitation services and care due to a left femur fracture, an artificial left hip, and [MEDICAL CONDITIONS]. The care plan documented the staff was to provide medication and treatment as ordered by the physician. The care plan documented the staff was to notify the physician of any changes in condition. The 14 day assessment, dated 08/31/17, documented the resident was independent for daily decision making and required extensive assistance with the activities of daily living (ADLs). The assessment documented the resident had a surgical wound. A physician order, dated 09/05/17, documented the resident was to receive [MEDICATION NAME] (an antibiotic medication) twice a day for a [MEDICAL CONDITION] femur. A Medication Administration Record [REDACTED]. A Medication Administration Record [REDACTED]. The note documented the medication was not available. The note documented the nurse notified the pharmacy of the new order and was waiting for the arrival of the medication. On 09/19/17 at 11:00 a.m., the director of nurses (DON) was interviewed regarding the antibiotic medication. The DON reviewed the resident's clinical record and stated the physician order [REDACTED]. The DON stated the on 09/06/17 the morning nurse documented the medication was not available and the pharmacy was notified. On 09/19/17 at 11:05 a.m., licensed practical nurse (LPN) #2 was interviewed regarding the antibiotic medication ordered. The LPN stated the medication was not available for the morning dose on 09/06/17. The nurse stated the pharmacy was notified and asked for the antibiotic to be sent stat. The LPN stated the medication arrived just prior the resident's discharge and a dose was given. The LPN stated a medication count sheet was not completed and the dose was not documented as given. On 09/19/17 at 2:25 p.m., the DON was interviewed regarding medications ordered by the physician. The DON stated the nurse receiving the physician order [REDACTED]. The DON stated the only way to know if the pharmacy received the order was to call the pharmacy for verification. The DON stated a concern related to the receipt of medications was discussed in the quality assurance meeting. The DON provided a plan regarding a delay in medication delivery from the pharmacy. The plan documented the correction plan was dated 07/18/17. The administrator was present for the interview and stated the pharmacy had reported no record had been found pertaining to an antibiotic order on 09/05/17. The administrator stated the pharmacy reported they had received a telephone order on 09/06/17.

Based on observation, interview, and record review, it was determined the facility failed to identify the use of a lap buddy as an accident hazard for one (#2) of one sampled resident who was observed standing up from the wheelchair while the lap buddy was in use. This deficient practice resulted in the likelihood of an accident for resident #2. The facility identified four residents who utilized safety devices. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual assessment, dated 07/25/10, documented the resident's cognition was moderately impaired. The assessment documented the resident needed extensive assistance of one person for ambulation. Physician orders, dated 07/28/10, documented, "May use lap buddy as a safety reminder. Resident demonstrates ability to remove it." The care plan, dated 08/02/10, documented the resident was at risk for falls. Interventions included the use of a lap buddy while in the wheelchair and a body alarm. The care plan documented the resident had four falls prior to 08/02/10 and one fall on 10/01/10. The care plan did not identify the use of the lap buddy as an accident hazard. The quarterly assessment, dated 01/17/11, documented the resident's cognition was severely impaired. The assessment documented the resident needed extensive assistance of two people for activities of daily living (ADLs). The fall risk assessment, dated 01/20/11, documented a score of 18. A score of ten or above documented the resident was high risk for falls. On 02/15/11 at 12:25 p.m., the resident was observed in the dining area. The resident stood up from the wheel chair with the lap buddy in place after the feeding assistant left the resident's side. The resident's body alarm did not go off at that time. The resident walked while pulling her wheelchair behind her with the lap buddy in place. The wheels of the wheelchair were locked. A dietary staff person urged the resident to sit down. The resident sat down. The staff member moved the resident in front of the TV and unlocked the wheels. The resident stood up again with the lap buddy in place and walked approximately 20 feet then sat back down in the wheelchair after being reminded by staff. The front wheels of the wheelchair were off the floor at times while the chair was being pulled. The alarm did not sound. The resident did not attempt to remove the lap buddy. On 02/15/11 at 12:30 p.m., licensed practical nurse (LPN) #1 was asked if the resident tried to get up out of the wheelchair with the lap buddy in place. The LPN stated, "Yes, I leave the wheels unlocked. She doesn't try to get up as often if she can move around." The LPN was asked if the alarm ever went off. The LPN stated the alarm went off a lot. On 02/15/11 at 12:40, CNA #1 was interviewed regarding the alarm not going off when the resident tried to stand. CNA #1 looked at the string to the alarm and said that it must be too long. The CNA then shortened it. On 02/16/11 at 2:18 p.m., the restorative aide (RA) was asked if the resident could take off the lap buddy. She stated, "The resident messes with it trying to get it off, but can't get it off." On 02/16/11 beginning at 2:18 p.m., the RA was observed in the dining room encouraging the resident to get up from the wheelchair and walk with her (the RA). The resident did not get up. The RA placed the lap buddy in the resident's wheelchair, locked the wheels to the chair and walked away with the resident facing the TV. At 2:25 p.m., the resident placed her hands on the arms of the wheelchair, pushed down, and stood on both feet. The chair alarm did not not alarm and the lap buddy remained in place. The resident then sat back down. At 2:27 p.m., the resident repeated the same motions. At 2:28 p.m., the resident repeated the same motions except turned chair toward the window while standing. At 2:29 p.m., the resident stood up and reached back and fingered the chair alarm string. At 2:30 p.m., the resident sat down and pulled the alarm off the back of her sweater. At 2:31 p.m., the resident stood and pulled the wheelchair behind her for 4 steps with the lap buddy in place and the alarm did not sound. After that the certified nurse aide (CNA) helped her sit back down and attached the alarm. At 2:32 p.m., the resident stood up again. The alarm did not sound. The CNA adjusted the alarm. Another CNA unlocked the wheels and took the resident to the bathroom. During this observation the resident did not try to remove the lap buddy. On 02/16/11 at 2:45 p.m., the surveyor asked resident #2 to take the lap buddy off the wheel chair. The resident did not understand. CNA # 2 then told her to take it off. The resident started talking about something else and did not take the lap buddy off. CNA #2 and LPN #1 said they have both seen her take it off at other times. On 02/16/11 at 2:47 p.m., CNA #2 and LPN #1 were asked if they thought that the lap buddy was an accident hazard when resident #2 had it on and dragged the wheelchair as she walked. CNA #2 said, "Yes, I do. She hasn't fell yet." LPN #1 did not reply. Immediate Jeopardy Identified On 02/16/11 at 4:30 p.m., an Immediate Jeopardy (IJ) situation was identified in accident hazards. The facility failed to identify the use of a lap buddy as an accident hazard for resident #2 and failed to implement measures to reduce the accident hazard. At 4:50 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ in accident hazards. At 5:20 p.m., the administrator and director of nurses (DON) were informed of the IJ in accident hazards and this placed the facility in an extended survey. 02/16/11 at 8:15 p.m., the facility submitted an acceptable plan of removal. Facility Plan of Removal for Immediate Jeopardy The facility plan of removal documented the resident would be assessed immediately for the use of a safety device and the assessment would be documented in the resident's medical record. The resident would be placed in one on one supervision and the information would be documented in the resident's medical record and care plan. The resident would be assessed by physical therapy for the appropriate fit of the wheelchair and anti-tip bars would be placed on the resident's wheelchair. A pressure sensitive alarm device would be placed on the resident's wheelchair immediately. Inservices for the nursing staff would be started immediately and would be completed for all nursing staff on or before 02/18/11. Those staff members unavailable by phone or unable to come to the facility for the inservice would be required to have the inservice prior to returning to work. All residents using any type of safety device would be assessed and the care plan would be updated immediately. The Director of Nursing would begin monitoring the effectiveness of the interventions and the concerns would be addressed in the next Quality Assurance meeting. Immediacy Removed On 02/16/11 at 6:30 p.m., the resident was observed with one on one supervision. On 02/17/11 throughout the day, the resident was observed with one on one supervision and the other interventions implemented by the facility. The IJ was removed effective 02/17/11 at 7:30 p.m., when the last employee inservice was completed. The deficient practice remained at a level of no actual harm with potential for more than minimal harm at a pattern. On 02/18/11 at 8:30 a.m., the administrator presented the survey team with copies of the inservices, assessments, resident care plans and other documents to ensure all nursing staff had been inserviced on the use of safety devices related to accident hazards. On 02/18/11 throughout the day until survey exit, the resident was observed with one on one supervision and the other interventions implemented by the facility. Staff interviews were conducted on 02/18/11 in regard to their knowledge of the inservice, to ensure their understanding of the use of safety devices and the potential for accidents with the use of those devices. All staff interviewed responded appropriately.

Based on observation, interview, and record review, it was determined the facility failed to inform/consult the physician when the facility discovered an injury for two (#1 and #5) of two sampled residents with injuries. The wound bed of resident #1's wound was down to the periosteum (the tissue surrounding the bone). The deficient practice had the potential to affect all residents at the facility who could experience an injury. Findings 1. The medical record for resident #1 documented the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. At the time of admission, the resident had an order to receive hospice services. A nurse's note, dated 12/03/10, documented the resident had bruising to her right ankle, right lower extremity and right forearm which were fading. There was not another nurse's note until 01/19/11. The hospice nurses' notes documented the following: "01/11/11 Eschar remains to R (right) knee approx 3 cm (centimeters) diam (diameter). R knee contracted @ (at) 90%." There were no physician's orders for treatment obtained at that time. The facility nurses' notes for 01/11/11 did not document the presence of a wound to the knee. A hospice nurse note, dated 01/13/11, documented, "R eschar to R knee diminishing in size from 5 cm diam to 4 X 2.5 cm." The facility nurses' notes from admission to 01/13/11 were reviewed for documentation or assessment regarding the wound with eschar. There was no documentation or assessment of a wound to the resident's right knee until 01/19/11. A nurse's note, dated 01/19/11, documented, "Has hard black tissue 3.5 X 4 cm to R knee and reddened area around wound site...santyl dressing to affected knee." There were no orders to treat the wound until 01/19/11. The physician had not been notified and an order for [REDACTED]. Diagnosis: [REDACTED]. The care plan, updated 01/19/11, documented a new problem related to the resident having [MEDICAL CONDITION] to the right lower extremity. Interventions included administering an antibiotic ([MEDICATION NAME]) three times daily, monitoring the area for redness for spreading, monitoring the skin with routine care, monitoring for changes in symptoms that may indicate worsening of the condition, and to notify the physician. A physician's progress note, dated 02/04/11, documented the resident had eschar on the right knee. The wound was documented as a pressure wound with eschar, which was unstageable. The assessment had been documented by the physician's nurse practitioner. A quarterly assessment, dated 02/08/11, documented the resident had memory problems and was rarely understood. The assessment documented the resident required extensive assist with transfers and did not ambulate. The assessment documented the resident required total assist with bathing and hygiene. The assessment did not document any skin problems. The assessment documented the resident had a pressure reducing device for her bed, had a turning and reposition program and had an application of a nonsurgical dressing. The assessment identified the resident as receiving hospice care. On 02/15/11 at 12:00 p.m., the resident was observed in the dining room in a Geri-chair. The resident was being fed by the staff. The resident was non verbal. The resident would answer questions by nodding her head in a positive or negative manner. The resident's lower extremities were covered with a lap blanket. On 02/16/11 at 12:10 p.m., hospice licensed practical nurse (LPN) #1 was interviewed regarding the wound on the resident's right knee. The LPN was asked if the wound was a stasis or pressure ulcer. The LPN reported she thought it was an injury. The LPN reported the aides had told hospice the knee was injured when the resident was pushed up to the dining room table. The LPN reported it had started out as an abrasion with a scab and advanced to eschar. On 02/16/11 at 2:00 p.m., LPN #2 (facility charge nurse), who provided care for the resident, was interviewed regarding the wound to the resident's knee. The LPN was asked how the resident had obtained the wound. The LPN reported he thought it was some kind of trauma. He stated it may have started out small. He reported he had not noticed it. The LPN was informed of the hospice nurse documenting the presence of the black eschar on 01/11/11. The LPN reported the hospice had not communicated finding the eschar to the facility. The LPN was then asked if the facility's aides, who were turning the resident and providing incontinent care for the resident, should have noticed the black area on the knee. The LPN reported they should have noticed it and should have reported it to the charge nurse. He reported that was also a lack of communication. The LPN then stated he did not know why it had not been reported. On 02/16/11 at 2:05 p.m., LPN #2 was observed providing wound care to the resident's right knee. The LPN removed the dressing from the resident's knee. The resident's right leg was observed to be contracted. The wound was observed to cover the top of the knee cap. A dark area was observed covering a portion of the wound. The wound base extended into the dermis of the wound bed. The dark area and the wound bed were dry. The LPN cleaned the wound, applied Santyl and Hydrogel, and then covered the wound with a dressing. On 02/16/11 at 3:40 p.m., LPN #3 (facility charge nurse), who provided care for the resident, was interviewed regarding the resident's wound. The LPN was asked how the wound had started. The LPN reported she did not know what had happened to cause the injury. The LPN stated whatever had happened may not have been reported to anyone. The LPN was asked why the facility aides had not reported the area of black eschar to the charge nurse on duty when it had been documented the wound was present on 01/11/10. The LPN reported the aides usually did report problems with the skin and she was not sure why it had not been reported. The LPN reported the aides may have thought it had already been reported. On 02/16/11 at 4:15 p.m., the DON was interviewed regarding the resident's wound being documented on 01/11/11 by hospice and the facility not assessing the area, obtaining a treatment, or notifying the physician until 01/19/11. The DON reported it had been a lack of communication from hospice. The DON reported the aides should have seen the wound when turning the resident and providing incontinent care. The DON reported the aides should have reported it to the charge nurse. On 02/17/11 at 3:05 p.m., the resident's physician was interviewed regarding the resident's wound. The physician reported she was not aware of what had caused the wound. The physician reported she had not been aware of the resident having sustained any injury to the knee. The physician reported the facility had not reported any injury which would have caused the wound. The physician was asked if she had seen the wound. The physician reported she had not seen the wound at that time. The physician reported she would go down and assess the resident's wound to her knee. On 02/17/11 at 3:30 p.m., the wound was observed with the physician. The physician removed the dressing. The wound was wet and the dark area was mushy and loose. The wound bed was also moist and a yellow slough had formed around the dark area. The physician reported the wound appeared to her to be a traumatic wound and the treatment should be changed. The physician reported the wound bed was down to the periosteum. The physician explained the periosteum was the tissue surrounding the bone. The physician reported she may have to check the wound for osteo[DIAGNOSES REDACTED] if there was no improvement with the new treatment. The physician then checked to see if the resident had a pulse in the foot of the right leg. The physician reported the resident did have a faint pulse in the right foot. 2. Resident #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 01/07/11, documented the resident was moderately impaired for cognition. The functional status section documented the resident required extensive assist of two persons for most activities of daily living (ADLs). The care plan, dated 01/13/11, documented the resident was at risk for skin breakdown. Interventions included to observe for skin breakdown every shift. and to report changes in skin condition to the physician and family promptly. Skin breakdown was addressed and the intervention was to inform the physician promptly. A physician's progress note, dated 02/03/11, documented the evaluation of a pressure ulcer on the top of the left 2nd toe. A physician's order, dated 02/03/11, documented wound care left 2nd toe was to spray wound care solution on the wound, pat dry, and leave open to air every day. An incident report dated, 02/06/11 at 3:00 p.m., documented the resident had been showered by the hospice aides. The incident report documented the left toe was cyanotic and bleeding. A nurse's note, dated 02/06/11 at 3:15 p.m., documented the certified nurse aide (CNA) reported the second toe on the resident's left foot was swollen, blue in color, and bleeding. A physician's telephone order, dated 02/06/11, documented an order for [REDACTED]. A nurse's note, dated 02/07/11 at 2:35 a.m., documented the left toe continued with bruising and swelling. A nurse's note, dated 02/08/11 (no time), documented the dressing to the left toe was clean, dry, and intact. The skin/wound assessment log, dated 02/08/11, documented the wound on the left 2nd toe was unstageable. The wound measured 2 centimeters (cm) by 2 cm and the depth was not measurable. A hospice nursing assessment, dated 02/08/11, documented a skin tear on the left upper arm and the left foot 2nd digit stage II ulcer. A nurse's note, dated 02/12/11 at 8:00 p.m., documented a dressing change was done on the resident's left toe, but did not include a description of the resident's toe. A physician's progress note, dated 02/13/11, documented the left toe ulcer was a stage IV and open to the bone. A new order was written on that date to change the order to [MEDICATION NAME] and gauze dressing twice daily to the area. On 02/16/11 at 10:15 a.m., the charge nurse, licensed practical nurse (LPN) #1 was asked what happened to the resident's toe. She stated the resident told the staff the hospice aides bumped the toe in the shower. On 02/16/11 at 11:30 a.m., the resident told the surveyor her toes were bumped in the shower. She couldn't remember who bumped them. On 02/16/11 at 2:00 p.m., the left 2nd toe was observed during the dressing change. The open area on the toe was oozing bright red blood between the toes. On 02/17/11 at 3:10 p.m., the physician stated to the survey team, she had not been informed of the trauma to the toe. She stated it would have made a difference in the choice of treatment.

Based on record review, observation, and staff interview, it was determined the facility failed to provide the necessary care and services to ensure residents were able to maintain the highest practicable physical well-being by failing to: a) have a system in place to identify and assess changes in skin condition, notify the physician of an alleged injury during care, seek timely medical intervention, coordinate care between hospice and the facility staff, communicate changes in skin condition between facility staff, thoroughly investigate alleged incidents of injury during care for two (#1 and #5) of two sampled residents who were on hospice with alleged injuries received while care was provided. The wound bed of resident #1's wound was down to the periosteum (the tissue surrounding the bone). This deficient practice had the potential to affect nine residents identified by the facility census and condition with hospice services. b) ensure an indwelling catheter was cleaned with soap and water as directed by the facility's policy and procedure for indwelling urinary catheter care for one (#6) of two sampled residents with indwelling urinary catheters. This had the potential to affect four residents identified by the facility as having indwelling urinary catheters. Findings: The facility policy for Hospice and Agency Caregivers documented the following: "Please provide the charge nurse with wound reports every week, and with any change of condition, including current measurements, drainage characteristics and treatments...Notify the charge nurse of treatment or scheduled changes so we can maintain continuity of care. A quick report to the charge nurses of your findings at every visit will be appreciated...All care is to be coordinated with the facility..." The facility policy and procedure for indwelling catheter care documented the purpose was to prevent infection and reduce irritation. The policy documented, "Wash perineum well with soap and arm water, taking care to wash from front to back. Cleanse area well at catheter insertion, taking care not to pull on catheter or advance further into urethra. All debris must be removed from catheter at insertion site. Rinse well with warm water and pat dry gently with clean towel." 1. The medical record for resident #1 documented the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. At the time of admission, the resident had an order to receive hospice services. The care plan, dated 11/16/10, documented the resident was at risk for skin breakdown due to incontinence and inability to position herself related to right [MEDICAL CONDITIONS]([MEDICAL CONDITION]). A nurse's note, dated 12/03/10, documented the resident had bruising to her right ankle, right lower extremity and right forearm which were fading. There was not another nurse's note until 01/19/11. The hospice nurses' notes documented the following: "01/11/11 Eschar remains to R (right) knee approx 3 cm (centimeters) diam (diameter). R knee contracted @ (at) 90%." There were no physician's orders for treatment obtained at that time. The facility nurses' notes for 01/11/11 did not document the presence of a wound to the knee. A hospice nurse note, dated 01/13/11, documented, "R eschar to R knee diminishing in size from 5 cm diam to 4 X 2.5 cm." The facility nurses' notes from admission to 01/13/11 were reviewed for documentation or assessment regarding the wound with eschar. There was no documentation or assessment of a wound to the resident's right knee until 01/19/11. A nurse's note, dated 01/19/11, documented, "Has hard black tissue 3.5 X 4 cm to R knee and reddened area around wound site...santyl dressing to affected knee." There were no orders to treat the wound until 01/19/11. The physician had not been notified and an order for [REDACTED]. Diagnosis: [REDACTED]. A Wound Record form documented the resident had a statis ulcer to the right knee. The first assessment of the wound was dated 01/19/11. The assessment documented a stasis ulcer unstageable 4 (length) X 3.5 (width) cm (centimeters). The color of the wound was documented as black with the surrounding tissue being bright red. The care plan, updated 01/19/11, documented a new problem related to the resident having [MEDICAL CONDITION] to the right lower extremity. Interventions included administering an antibiotic ([MEDICATION NAME]) three times daily, monitoring the area for redness for spreading, monitoring the skin with routine care, monitoring for changes in symptoms that may indicate worsening of the condition, and to notify the physician. The Wound Record, dated 01/25/11, documented the wound was a stasis ulcer 4 X 3.5 X 4 (depth) cm. The color was documented as black with the surrounding tissue being pink and bright red. The Wound Record, dated 02/01/11, documented the wound was an open wound "unknown" (staging not identified), 4 X 3.5 X 4 cm. The color was documented as black and yellow with the surrounding tissue being pink and bright red. A hand written addition to the care plan, dated 02/01/11, documented, "Cleanse wound to R knee c (with) wound cleanser, apply Santyl & hydrogel to wound QD (every day)." (sic) The wound to the right knee, which had been documented on the wound report as being a stasis and unknown ulcer, was not care planned until 02/01/11. A physician's progress note dated 02/04/11, documented the resident had eschar on the right knee. The assessment of the wound documented a pressure wound with eschar, which was unstageable. The progress note was documented by the physician's assistant. A quarterly assessment, dated 02/08/11, documented the resident had memory problems and was rarely understood. The assessment documented the resident required extensive assist with transfers and did not ambulate. The assessment documented the resident required total assist with bathing and hygiene. The assessment did not document any skin problems. The assessment documented the resident had a pressure reducing device for her bed, had a turning and reposition program and had an application of a nonsurgical dressing. The assessment identified the resident as receiving hospice care. The resident's monthly summaries dated 12/13/10, 01/14/11, and 02/10/11, did not document the resident had any skin problems. On 02/15/11 at 12:00 p.m., the resident was observed in the dining room in a Geri-chair. The resident was being fed by the staff. The resident was non verbal. The resident would answer questions by nodding her head in a positive or negative manner. The resident's lower extremities were covered with a lap blanket. On 02/16/11 at 12:10 p.m., hospice licensed practical nurse (LPN) #1 was interviewed regarding the wound on the resident's right knee. The LPN was asked if the wound was a stasis or pressure ulcer. The LPN reported she thought it was an injury. The LPN reported the aides had told hospice the knee was injured when the resident was pushed up to the dining room table. The LPN reported it had started out as an abrasion with a scab and advanced to eschar. The LPN was asked why there had not been any documentation before 01/11/11 which documented the eschar remained on the knee. The LPN reported she did not know but would check at the office for any missing documentation. At 12:20 p.m., the LPN provide some missing hospice notes. The notes were reviewed and there was no documentation regarding the area to the right knee prior to the note on 01/11/11. After the interview with the hospice nurse, the facility incident reports were reviewed for any documentation of an injury to the resident's knee. There was not an incident report for the resident, which would indicate the resident's knee had been injured. On 02/16/11 at 2:00 p.m., LPN #2 (the facility charge nurse), who provided care for the resident, was interviewed regarding the wound to the resident's knee. The LPN was asked how the resident had obtained the wound. The LPN reported he thought it was some kind of trauma. He stated it may have started out small. He reported he had not noticed it. The LPN was informed of the hospice nurse documenting the presence of the black eschar on 01/11/11. The LPN reported the hospice had not communicated finding the eschar to the facility. The LPN was then asked if the facility's aides, who were providing incontinent care and turning the resident should have noticed the black area on the knee. The LPN reported they should have noticed it and should have reported it to the charge nurse. He stated that was a lack of communication. The LPN then stated he did not know why it had not been reported. On 02/16/11 at 2:05 p.m., LPN #2 was observed providing wound care to the resident's right knee. The LPN removed the dressing from the resident's knee. The resident's right leg was observed to be contracted. The wound was observed to cover the top on the knee cap. A dark area was observed covering a portion of the wound. The wound base extended into the dermis of the wound bed. The dark area and the wound bed were dry. The LPN cleaned the wound, applied Santyl and Hydrogel,and then covered the wound with a dressing. On 02/16/11 at 3:40 p.m., LPN #3 (the facility charge nurse), who provided care for the resident, was interviewed regarding the resident's wound. The LPN was asked how the wound had started. The LPN reported she did not know what had happened to cause the wound. The LPN stated whatever had happened may not have been reported to anyone. The LPN was asked why the facility aides had not reported the area of black eschar to the charge nurse on duty when it had been documented the wound was present on 01/11/11. The LPN reported the aides usually did report problems with the skin and she was not sure why it had not been reported. The LPN reported the aides may have thought it had already been reported. On 02/16/11 at 4:15 p.m., the director of nurses (DON) was interviewed regarding the resident's wound being documented on 01/11/11 by hospice, the facility not assessing the area, or obtaining a treatment until 01/19/11. The DON was asked why the wound, which already had eschar present, had not been reported by the facility aides who were caring for the resident. The DON reported it had been a lack of communication from hospice. The DON reported the aides should have seen the wound when turning the resident and providing incontinent care. The DON reported the aides should have reported it to the charge nurse. During the interview on 02/16/11 at 4:15 p.m., the DON was asked how the injury had happened and if she had done an investigation and documented preventive measures to prevent further injury. The DON reported she did not know how it had happened and had not investigated the injury. During the interview on 02/16/11 at 4:15 p.m., the DON was shown the physician's progress note, dated 02/04/11, which documented the wound as a pressure wound. The DON reported she did not agree with the progress note that the wound was due to pressure. The DON reported she could not see how it could be pressure. She reported the resident draws her legs up and the resident could have bumped the knee. During the interview on 02/16/11 at 4:15 p.m., the DON was asked if an incident report had been written when the area had been found. The DON reported there was no incident report. The DON reported no one knew what had happened. On 02/17/11 at 3:05 p.m., the resident's physician was interviewed regarding the resident's wound. The physician reported she was not aware of what had caused the wound. The physician stated the facility had not reported any injury which would have caused the wound. The physician was asked if she had seen the wound. The physician reported she had not see the wound yet. The physician reported she would go down and assess the resident's wound to her knee. On 02/17/11 at 3:30 p.m., the wound was observed with the physician. The physician removed the dressing. The wound was wet and the dark area was mushy and loose. The wound bed was also moist and a yellow slough had formed around the dark area. The physician reported the wound appeared to her to be a traumatic wound and the treatment should be changed. The physician reported the wound bed was down to the periosteum. The physician explained the periosteum was the tissue surrounding the bone. The physician reported she may have to check the wound for osteo[DIAGNOSES REDACTED] (infection of the bone) if there was no improvement with the new treatment. The physician then checked to see if the resident had a pulse in the foot of the right leg. The physician reported the resident did have a faint pulse in the right foot. On 02/18/11 at 6:00 p.m., the DON was again interviewed regarding the wound and treatment not being started until eight days after it had been identified by hospice and the wound already having black eschar present. The DON reported hospice was supposed to report any changes to the charge nurse. She stated, "There is supposed to be a coordination of care." 2. Resident #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a physician's order, dated 12/24/10 to have hospice do an evaluation and treatment. A significant change assessment, dated 01/07/11, documented the resident was moderately impaired. The functional status section was documented that the resident required extensive assist of two persons for most ADLs. The assessment, dated 01/07/11, documented the resident returned from the hospital with an abrasion, a skin tear and four stageable ulcers, and one unstageable area on each heel. The care plan, dated 01/13/11, documented the resident was at risk for skin breakdown. One of the interventions was to observe for skin breakdown every shift and report changes in skin condition to the physician and family promptly. Skin breakdown was addressed for the unstageable left and right heel, and stage II left foot and coccyx. The care plan interventions did not include the order to float the heels. A physician's progress note, dated 02/03/11, had documented the evaluation of a pressure ulcer on the top of left 2nd toe. A physician's order, dated 02/03/11, documented wound care to the left 2nd toe--spray wound care solution--pat dry, leave open to air. An incident report dated, 02/06/11 at 3:00 p.m., documented the resident had been showered by the hospice aides. The incident report documented the left toe was cyanotic and bleeding. A nurse's note, dated 02/06/11 at 3:15 p.m., documented the certified nurse aide (CNA) reported the second toe on the resident's left foot was swollen, blue in color, and bleeding. A hospice nursing assessment by the registered nurse, dated 02/04/11, documented the left foot, second toe was very red with 2 x 2 x utd (unable to determine depth) due to a scab. There were no facility nurses' notes documented that day. An incident report dated, 02/06/11 at 3:00 p.m., documented the resident had been showered by the hospice aides. The incident report documented the left toe was cyanotic and bleeding. The incident report did not document how the injury had occurred or an investigation of the injury. The nurses' notes, dated 02/06/11 at 3:15 p.m., documented, ". . . L (left) toe (next to great toe) CNA's (certified nurse aides reported swollen, blue in color and bleeding. . . ." A physician's telephone order, dated 02/06/11, documented an order for [REDACTED]. A nurse's note, dated 02/07/11 at 2:35 a.m., documented the left toe continued with bruising and swelling. A nurse's note, dated 02/08/11 (no time), documented the dressing to the left toe was clean, dry, and intact. The skin/wound assessment log, dated 02/08/11, documented the wound on the left 2nd toe was unstageable. The wound measured 2 centimeters (cm) by 2 cm and the depth was measurable. A hospice nursing assessment, dated 02/08/11, documented a skin tear on the left upper arm and the left foot 2nd digit stage II ulcer. A nurse's note, dated 02/12/11 at 8:00 p.m., documented a dressing change was done on the resident's left toe, but did not include a description of the resident's toe. A physician's progress note, dated 02/13/11, documented the left toe ulcer was a stage IV, open to the bone. The treatment order was changed at that time. A nurse's note, dated 02/15/11 at 8:30 p.m., documented the resident complained of tenderness when the left toe was touched, but did not include a description of the resident's toe. On 02/16/11 at 10:15 a.m., the charge nurse, LPN (licensed practical nurse) #1 was asked what happened to the resident's toe. She stated the resident told the staff the hospice aides bumped it in the shower. The LPN was asked if the incident had been reported to her. She stated she had not been working on the day of the incident. The LPN stated hospice aides had given the resident a shower, did not report the incident to the facility nursing staff and had not written care notes for that day.. On 02/16/11 at 11:30 a.m., the resident told the surveyor her toes were bumped in the shower. She couldn't remember who bumped them. On 02/16/11 at 2:00 p.m., the left 2nd toe was observed during the dressing change. The open area on the toe was oozing bright red blood between the toes. On 02/16/11 at 3:00 p.m., the director of nursing (DON) found the incident report and presented it to the survey team. She stated nursing had reported to her about the toe but not all the details. The DON stated she was going to call the hospice manager. She returned, reported the case manager stated the hospice aides denied any incident during the shower. They did admit to failure to document their notes on 02/06/11. On 02/17/11 at 3:10 p.m., the physician stated to the survey team, she had not been informed of the trauma to the toe. "That would have made a difference." "No one notified me of an incident." On 02/18/11 at 5:20 p.m., the surveyor and the DON reviewed the incident report. She stated, "I think I should have investigated it more thoroughly. I did not understand that it was an injury." At that time the DON agreed there was a lack of communication and coordination between hospice and facility staff. 3. The medical record for resident #6 documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's comprehensive assessment and care plan had not been completed. The nursing admission assessment, completed on 02/05/11, documented the resident had a left [MEDICAL CONDITION] and pain. The assessment documented the resident was at risk for skin breakdown, to apply [MEDICATION NAME], to change incontinent briefs, and to provide indwelling urinary catheter care every shift. An Emergency Patient Care Record, dated 02/09/11, documented the resident had been sent due to abnormal labs and [MEDICAL CONDITION]. The record documented the resident had a urinary tract infection [MEDICAL CONDITION]. On 02/17/11 at 3:00 p.m., LPN #4, the care plan coordinator for the resident, was interviewed regarding the care plan. The LPN reported the admission assessment contained the initial care plan. On 02/18/11 at 3:05 p.m., certified nurse aide (CNA) #3 was observed providing indwelling urinary catheter care. The CNA placed a basin of water on the over bed table. The CNA was asked if she had any soap or peri wash in the water. The CNA reported it was just warm water. The CNA dribbled water over the peri area. The CNA then took a wet wash cloth and wiped the end of the penis, wiped once around the insertion site, and then wiped two inches down the tubing. The CNA then dried the area. After completing the catheter care the CNA was asked if she ever used soap or peri wash when doing indwelling urinary catheter care. The CNA reported she had peri wash and would use it if the catheter was real dirty. The CNA was then asked if she ever wiped any further down the tubing. The CNA reported she did not unless the tubing was dirty. On 02/18/11 at 4:45 p.m., the DON was interviewed regarding the indwelling urinary catheter care. The DON reported the CNA should have used soap and water to clean the catheter. The DON reported they did not wipe down the entire tubing, but indicated by stretching her fingers apart, the tubing would be clean down four to four and a half inches.