Every finding on record at Friendship Village of Dublin

Based on interviews, facility record review, review of Centers for Disease Control and Prevention (CDC) guidance, and facility policy review the facility failed to ensure hot water storage tanks were maintained at a safe temperature to prevent legionella growth. This had the potential to affect all residents residing in the facility. The census was 45. Findings include: Review of the facility's monthly domestic hot water system temperature readings revealed gas water heater #1 return flow temperature reading was found to be reading at 130 degrees Fahrenheit (F), output reading was found to be 129 degrees F on 01/27/25. A work order was placed on 01/27/25. A return flow reading was 130 degrees F and output reading was 130 degrees F on 02/28/25 and a work order placed on 02/28/25. Temperature checks noted as outflow temperature reading of 130 degrees F and return flow temperature reading of 110 degrees F. Return flow reading of 125 degree F and output flow reading of 130 degrees F on 03/28/25.Review of the facility's monthly domestic hot water system temperature readings revealed gas water heater #2 return flow reading of 125 degrees F on 03/28/25. A return flow reading of 125 degrees F and output flow reading of 130 degrees F on 05/02/25, and a work order was placed.Review of the facility's monthly domestic hot water system temperature readings revealed gas water heater #3 return flow temperature reading was found to be 125 degrees F and output flow reading of 130 degrees F on 03/28/25. A return flow reading of 125 degrees F and output flow reading of 130 degrees F on 05/02/25, and a work order was placed. Interview on 06/04/26 at 2:47 P.M. with Life Safety Specialist #338 and Director of Facilities #239 confirmed hot water heaters should be set at minimum 140 degrees F. Review of the facility's policy titled Water Management Plan Alderwood Health and Rehab revised on 06/2024 revealed the hot water heater (HWH) outgoing water should be at least 140 degrees F. Monthly hot water temperature readings - output and return temperature revealed hot water heaters should be set to greater than or equal to 140 degrees F, increase hot water settings and confirm output temperature, temperature should be 140 degrees F or more.Review of the facility's policy titled Water Management Plan dated 01/05/24 revealed hot water tanks should be set to operate and maintain hot water temperatures of 140 degrees F or more. Hot water presenting outside of the control limits will receive corrective action. Those actions may include adjustment to hot water heaters, adjustment to Thermostatic Mixing Valves (TMVs), adding insulation to pipework, increase facility flush frequency, increasing secondary disinfection, and/or contacting a qualified professional to assist with correct action.Review of CDC guidance titled Controlling Legionella found at https://www.cdc.gov/control-legionella/php/guidance/monitor-water-guidance.html dated 03/15/24 revealed under Monitoring Building Water, store hot water at temperatures above 140 degrees F. Allow water in pipes to remain hot enough to limit Legionella growth.

Based on staff interviews, record review, and review of facility policy, the facility failed to ensure a resident's advance directive status was addressed accurately in the medical record. This affected one (Resident #8) of three residents reviewed for advanced directives. The facility census was 45 residents.Findings include:Review of Resident #8's medical record revealed an admission date of 06/27/23. Diagnoses included Parkinson's disease with dyskinesia, delusional disorder, and dementia. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had impaired cognition. Review of the care plan initiated 07/06/23 indicated Resident #8's code status was Do Not Resuscitate (DNR) Comfort Care.Review of Resident #8's advance directive in the electronic medical record revealed a DNR order form signed 07/01/24 indicating the resident's code status was DNR Comfort Care - Arrest.Review of Resident #8's advance directive in the resident hard chart kept at the nurse's station revealed a second DNR order form signed 08/21/25 indicating the resident's code status was DNR Comfort Care - Arrest.The physician orders dated 06/05/25 revealed an order for DNR Comfort Care.Interview on 06/02/26 at 12:15 P.M. with Licensed Practical Nurse (LPN) #125 confirmed the signed DNR forms for Resident #8 do not match the physician orders in the electronic medical record.Interview on 06/02/26 at 2:45 P.M. with Quality Assurance Nurse #133 revealed the facility would use the DNR order form attached to Resident #8's paper chart if a copy was needed.Interview with Director of Nursing on 06/03/26 at 3:56 P.M. confirmed Resident #8's code status should be DNR Comfort Care.Review of the undated facility policy titled 'Advance Directives' revealed if the resident or the resident's representative has executed one or more advance directive(s), copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff.

Based on observations, resident and staff interviews, medical record review, and review of the Certified Nursing Assistant (CNA) job description, the facility failed to ensure the residents who were dependent on staff for activities of daily living received the assistance with personal hygiene and facial hair removal. This affected one (#38) of two residents reviewed for activities of daily living (ADL). The facility census was 45 residents. Findings include:Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of brain, carcinoma in situ of unspecified bronchus and lung, melanoma in situ, acute respiratory failure with hypoxia, anxiety disorder, and aphasia.Review of Resident #38's ADL care plan dated 01/02/26 revealed there was no mention of resident's need for assistance with shaving facial hair.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively impaired and required partial to moderate assistance from staff with personal hygiene.Review of the personal hygiene documentation from 05/05/26 to 06/02/26 revealed Resident #38 required extensive assistance or was totally dependent on staff for personal hygiene care.Observations on 06/02/26 at 10:34 A.M. and 06/03/26 at 9:49 A.M. revealed Resident #38 had facial hair on her upper lip and chin.Observation on 06/03/26 at 11:35 A.M. revealed the hospice aide was at bedside to provide a bed bath and personal hygiene for Resident #38.Observation and interview on 06/03/26 at 2:30 P.M. revealed Resident #38 had facial hair to the upper lip and chin. Resident #38 stated she did not like the facial hair and required assistance removing the hair.Interview with Certified Nursing Assistant (CNA) #225 confirmed the presence of facial hair on Resident #38 and confirmed the resident required assistance removing the facial hair. XNA #225 stated she was unsure if it was the responsibility of the facility staff or hospice staff to provide the personal hygiene care.Interview on 06/03/26 at 7:20 A.M. with the Director of Nursing confirmed the facility CNAs should assist Resident #38 with shaving and removal of facial hair.Review of the job description titled '[Certified Nursing Assistant [CNA]' dated February 2020 revealed the essential duties of the [CNA] include bathe, shave, dress and undress, care for hair, finger nails, eyes and ears (cleaning, eyeglasses, etc.), perform daily dental care, perineal care, as well as any other customary daily activities of living.

Based on staff interviews and record review, the facility failed to ensure post fall follow up notes were completed every shift for 72 hours after fall as ordered by the physician. This affected one (Resident #2) of two residents reviewed for falls. The facility census was 45. Findings include:Review of the medical record for Resident #2 revealed an admission date of 12/28/26. Diagnoses included low back pain, repeated falls, transient ischemic attack and psychophysiological insomnia.Review of the care plan dated 01/13/26 revealed Resident #2 was at risk for falls. Review of the Morse Fall Scale dated 01/23/26 revealed Resident #2 was at a high risk for falls.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was moderately cognitively impaired.Review of an unwitnessed fall event dated 04/10/26 at 11:00 P.M. revealed Resident #2 was found lying on their back and was conscious. The resident reported rolling out of bed. The resident denied pain. One skin tear was noted on the left knee; the area was cleansed and a dressing applied. Neuro checks were initiated, and the physician, son, and Director of Nursing (DON) were notified. Review of a physician order dated 04/13/26 revealed a follow up note was to include the condition of the resident, pain, treatments, intervention effectiveness, and neuro checks (if applicable) every shift for 72 hours for the incident event for three days until completed.There were only two documented follow-up notes written following the physician order dated 04/13/26. The progress note dated 04/13/26 at 5:51 P.M. revealed Resident #2 was on fall day two and denied any complaint, pain, or discomfort. Treatment was applied to bilateral extremities, dressings were clean and dry. The resident continued to walk with a walker from the common area to their room even with reminders from staff to ask for assistance. The progress note dated 04/14/26 at 5:48 P.M. revealed the resident follow up for the fall with treated skin tear. The resident denied pain. All safety measures were in place as tolerated by the resident.Review of an unwitnessed fall event dated 04/16/26 at 5:45 A.M. revealed Resident #2 was found on the bedroom floor. The resident had attempted to go to the restroom without assistance, lost balance, and fell. Pain in the shoulder was noted. A physician evaluation with an order for an X ray was requested. The resident sustained a right eyebrow skin tear. Review of a physician order dated 04/16/26 revealed a follow up note was to include the condition of the resident, pain, treatments, intervention effectiveness, and neuro checks (if applicable) every shift for 72 hours for the incident event for three days until completed.There were only two documented follow-up notes written following the physician order dated 04/16/26. The progress note dated 04/16/26 at 5:32 P.M. revealed follow up on the fall; no new visible injuries were noted and all interventions were in place. The progress note dated 04/18/26 at 1:35 P.M. revealed the resident follow up on the fall with injury. A sling was in place. The resident was up in common areas for activities and social time. Staff continued to assist with toileting and ADLs. All safety measures were in place as tolerated by the resident.Interview on 06/04/26 at 3:57 P.M. with the Administrator and Director of Nursing (DON) revealed the requested information would be recorded in various areas of the resident's medical record. Interventions implemented would be marked as completed in the Treatment Administration Record however, no documentation pertaining to effectiveness would be recorded. Resident pain would be available for review in the vital sign tab. Treatments completed would also be documented in the treatment record.Interview on 06/04/26 at 3:41 P.M. with Registered Nurse (RN) #208 confirmed interpretation of the physician order would be to place a nurse's progress note every shift with evaluation of interventions, resident pain, and documentation of any treatments completed or injuries noted post incident.

Based on interview and record review ,the facility failed to ensure physician ordered laboratory services were collected. This affected one (Resident #3) of one resident reviewed for antibiotics. The facility census was 45. Findings include:Review of the medical record for Resident #3 revealed an admission date of 03/20/26. Diagnoses included paraplegia, hypertensive chronic kidney disease, type two diabetes mellitus, neuromuscular dysfunction of bladder, and neurogenic bowel.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired and did not exhibit rejection of care.Review of a physician order dated 04/22/26 revealed weekly laboratory testing including a complete blood count (CBC) with differential, comprehensive metabolic panel (CMP), sedimentation rate, and C reactive protein (CRP). The order specified that results were to be faxed to infectious disease every Wednesday.Review of the laboratory results dated [DATE] revealed the weekly CBC with differential, CMP, sedimentation rate, and CRP completed on 05/01/26 were the most recent labs on file.Review of the Treatment Administration Record (TAR) dated 05/13/26 revealed the weekly CBC with differential, CMP, sedimentation rate and CRP were documented as completed. A second TAR entry for 05/13/26 documented these same labs as other/progress note.Review of a progress note dated 05/13/26 at 3:24 P.M. revealed laboratory services did not come to the facility on that date.Review of a progress note dated 05/13/26 at 10:22 P.M. again documented laboratory services did not come to the facility and stated the labs would be completed on 05/15/26.Review of the infectious disease after visit summary dated 05/13/26 requested infectious disease requested the most recent set of laboratory values (CBC, CMP, ESR, and CRP) be sent to the office. The summary noted the last completed labs were from 05/01/26 and stated these labs were required weekly. The resident had a history of postoperative spine infection with retained hardware following a T9-S1 laminectomy and fusion on 01/28/26, complicated by hematoma evacuation on 02/23/26, a fluid collection identified on 03/11/26, and wound irrigation and debridement with purulence on 04/03/26 with cultures growing methicillin-susceptible Staphylococcus aureus (MSSA).Review of the care plan dated 06/02/26 revealed the resident was on chronic antibiotic therapy. Interventions included administering antibiotics as ordered and reporting pertinent lab results to the physician.Interview on 06/04/26 at 11:54 A.M. with the Administrator and Director of Nursing revealed they were unable to locate the missing weekly CBC with differential, CMP, sedimentation rate, and CRP results ordered for Resident #3.Interview on 06/04/26 at 3:52 P.M. with the Administrator and Director of Nursing revealed laboratory services reported the resident was no longer active in their system due to a service transition. The Director of Nursing confirmed the medical record did not contain evidence that the laboratory was contacted for collection or that laboratory staff attempted to obtain the samples. The Director of Nursing confirmed the most recent laboratory collection was on 05/01/26, and therefore Resident #3 missed two weekly laboratory collections as ordered.

Based on observations, staff interviews and policy review the facility failed to prepare, distribute and serve food in a safe, sanitary manner. This had the potential to affect all residents. The census was 40. Findings Include: Observation on 11/13/24 at 11:30 A.M. of the lunch meal preparation revealed [NAME] #501 and Dietary Aid #502 preparing food for the meal and neither worker were observed to have beard covers on, to cover their cheeks, upper lip, and chin hair while working in the kitchen . This observation was verified by Director of Dietary Quality Assurance #700. Interview on 11/13/24 at 11:45 A.M. with [NAME] #501 confirmed he should have had a beard cover on while cooking the food. Review of facility policy titled Employee Sanitary Practices, dated 04/04/19 and 03/01/19, revealed employees will wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food.

Based on record review, staff interviews, review of the facility's water management program, review of facility policy and review of the Centers for Disease Control and Prevention's (CDC) guidance, the facility failed to ensure adequate monitoring of the water management program to control the spread of waterborne pathogens. This had the potential to affect all 40 residents. The census was 40. Findings include: Interview on 11/14/24 at 9:01 A.M. with the Facilities Director #450 confirmed the facility had performed a Legionella (bacteria that can cause a severe type of pneumonia) risk assessment in April of 2024. Review of the facility's binder titled Water Management, no date, on 11/14/24 at 9:01 A.M. revealed a list of team members and their responsibilities in the water management program, and a map to describe the water filtration system. There was no documented evidence provided to show the facility monitored physical controls, documented water temperatures, monitored disinfectant level controls, completed visual inspections, or environmental testing for waterborne pathogens in the calendar years of 2023 or 2024. Interview on 11/14/24 at 10:20 A.M. with the Facilities Safety Specialist #455 it was confirmed there was no documented evidence of Legionella monitoring from 2023 to present. Interview on 11/14/24 at 10:34 A.M. with the Facilities Director #450 he stated he was hired in December of 2023, and had no documented evidence of Legionella monitoring from 2023 to present. Review of the facility's policy and procedures document on 11/14/24 at 11:30 A.M. titled Water Mitigation Program dated November of 2023, revealed the facility's policy was to contract with a water mitigation system provider to ensure adequate facilitation of the water management program to control the spread of waterborne pathogens. The procedures were listed as follows:. Water will be tested in accordance with the facility's contracted water mitigation and management program. The Facilities Director is the responsible party for overseeing the facility's water mitigation and management program Regular testing of the water mitigation and management program is reported and reviewed through the monthly quality assurance and performance improvement committee, including Legionella surveillance and compliance. Review of the CDC guidance titled Overview of Water Management Programs, dated 03/15/24, revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Further review revealed the seven key elements of a Legionella water management program included: establish a water management program team, describe the building water systems, identify areas where Legionella could grow and spread, decide where control measures should be applied and how to monitor them, establish ways to intervene when control limits are not met, ensure the program runs as designed and is effective, and document and communicate all the activities.

Based on medical record review and staff interview, the facility failed to complete a preadmission screening and record review (PASRR) document in a timely manner. This affected one (Resident #29) of one reviewed for PASRR. The census was 40. Findings Include: Resident #29 was admitted to the facility on [DATE]. Her current diagnoses were nontraumatic intracranial hemorrhage, osteoporosis, dementia, morbid obesity, polyosteoarthritis, atrial fibrillation, congestive heart failure, anxiety disorder, hyperlipidemia, occlusion and stenosis of carotid artery, acute kidney failure, chronic kidney disease (stage III), post traumatic stress disorder, osteoarthritis, and major depressive disorder. Review of her minimum data set (MDS) assessment, dated 10/10/24, revealed she had a mild cognitive impairment. Review of Resident #29's progress notes, dated 09/12/24, revealed she was admitted to the facility from the hospital. Review of Resident #29's hospital documentation found the hospital completed a hospital exemption form for admission to the long term care/skilled care facility. This form allows the resident to remain in the facility for up to 30 days, without the facility having to complete a PASRR document. Review of Resident #29's PASRR document, dated 11/13/24, revealed this was the only PASRR document completed. The PASRR document should have been completed and submitted to the appropriate state agency by 10/12/24, which it was not. Interview with Social Worker (SW) #317 on 11/13/24 at 2:30 P.M. confirmed the hospital exemption form was completed on 09/12/24. She also confirmed a hospital exemption form was completed on 10/03/24 and thought that was acceptable for her to remain in the facility. She confirmed the only PASRR completed for Resident #29 was on 11/13/24. SW stated she didn't know she would have to complete a PASRR if they went into the hospital multiple times within the first 30 days.

Based on observation, staff interview, and record review the facility failed to ensure medications were administered according to the prescribing physician's orders. This affected two (#4 and #7) of four residents reviewed for medication administration. The census was 40. Findings include: 1. Resident #4 had an admitted [DATE] with diagnoses including: falls, depression, overactive bladder, hyperlipidemia, rosacea, abnormal gait/mobility, Parkinson's disease, and anxiety. Observation on 11/14/24 at 8:56 A.M. revealed Licensed Practical Nurse (LPN) #329 administered Carbidopa-Levodopa (used to treat symptoms of Parkinson's disease), extended release (ER), 25-100 mg, one tablet by mouth to Resident #4. Review of the electronic medication administration record (eMAR) on 11/14/24 at 8:57 A.M. revealed an order for Carbidopa-Levodopa ER, 25-100 mg, one tablet by mouth, give at 7:00 A.M. Review of the order summary report for Resident #4 on 11/14/24 at 10:00 A.M. revealed the following orders for Resident #4: Carbidopa-Levodopa ER, oral tablet 25-100 mg, give one tablet by mouth in the evening for Parkinson's disease, give at 8:00 P.M., dated 01/31/24. Carbidopa-Levodopa oral tablet, 25-100 mg, give two tablets by mouth three times a day for Parkinson's disease, dated 12/29/23. Interview with LPN #329 at 10:15 A.M. on 11/14/24 confirmed that the wrong dose of Carbidopa-Levodopa ER, was administered at the wrong time for Resident #4. 2. Resident #7 had an admitted [DATE] with diagnoses including: hypothyroidism, allergic rhinitis, anxiety, depression, dementia, Alzheimer's disease, hypertension, pain, and insomnia. Observation on 11/14/24 at 9:13 A.M. revealed LPN #329 administered Depakote Sprinkles (mood stabilizer anticonvulsant), Delayed Release (DR)125 mg, one capsule by mouth to Resident #7 at 9:15 A.M. Review of the eMar on 11/14/24 at 9:15 A.M. revealed an ordered administration time for Depakote Sprinkles DR, one capsule, of 7:30 A.M. Review of the order summary report for Resident #7 on 11/14/24 at 10:00 A.M. revealed the following orders for Resident #7: Depakote Sprinkles, oral capsule, DR, 125 mg, give one capsule by mouth two times a day for dementia with agitation. Depakote Sprinkles, oral capsule, DR, 125 mg, give two capsules by mouth in the evening for agitation with dementia. Interview with LPN #329 at 10:15 A.M. on 11/14/24 confirmed that the administered dose of Depakote Sprinkles DR was given at the wrong time for Resident #7.

Based on medical record review, staff interview, and facility policy, the facility failed to ensure pressure injury interventions were implemented in a timely manner for one (Resident's #11) of two resident's reviewed for pressure ulcers. Additionally, the facility failed to complete skin measurements and monitoring in a timely manner for two (Residents #11 and #29) of two residents reviewed for pressure ulcers. The facility census was 40. Findings include: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including fracture of left femur, disruption of wound, edema, type II diabetes, chronic diastolic heart failure, osteoarthritis, paroxysmal atrial fibrillation, rosacea, bilateral primary osteoarthritis of knee, anxiety, chronic pain, chronic kidney disease stage III, thrombophilia, gastro esophageal reflux disease, hypertension, hyperlipidemia, and irritable bowel syndrome. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #11 had impaired mobility, required the use of a walker or wheelchair for ambulation and required moderate to maximal assistance with acclivities of daily living. The resident was coded to have a stage three pressure ulcer present at the time of admission and a nutrition risk. Review of the skilled nursing assessments for Resident #11, from 10/04/24 to 11/12/24, revealed the facility did not document any measurements for the stage III pressure ulcer until 10/10/24 even though pressure ulcer was documented as present at time of admission. Review of the physician orders for Resident #11 revealed use of a Prevalon boot with a start date of 10/02/24. Review of the treatment administration record (TAR) reveaeld the resident had a treatment order for the left heel of change foam dressing to the left heel three times a week and as needed dated 10/07/24 and 10/08/24. No wound treatment intervention was implemented until 10/07/24. Review of the care plan for Resident #11 revealed the facility will administer treatments as ordered and monitor for effectiveness. Additionally, the facility was to assess, record, and monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. Review of the progress notes for Resident #11 revealed on 10/11/24 at 4:13 P.M. Assistant Director of Nursing (ADON) placed call to the resident's daughter regarding current wound treatment for pressure injuries present on admission. Medication review complete and orders for labs to be drawn on Monday. All questions answered and verbalized understanding. Interview on 11/13/24 at 1:44 P.M. with ADON #345 confirmed pressure ulcers should be addressed promptly upon admission and confirmed that the interventions were not initiated until 10/07/24. Interview on 11/14/24 at 2:16 P.M. with RN #347 verified a head to toe assessment is completed the day of admission and if a pressure ulcer or skin alteration is present they notify the Director of Nursing (DON) and Nurse practitioner (NP). RN #347 stated the Nurse Practitioner will examine the pressure ulcer the same day. RN #347 also stated the staff, including the NP, ADON, or nursing staff, will measure the wound the same day as admission and the wound nurse will measure again on Thursday when they are at the facility. 37100 2. Resident #29 was admitted to the facility on [DATE]. Her current diagnoses were nontraumatic intracranial hemorrhage, osteoporosis, dementia, morbid obesity, polyosteoarthritis, atrial fibrillation, congestive heart failure, anxiety disorder, hyperlipidemia, occlusion and stenosis of carotid artery, acute kidney failure, chronic kidney disease (stage III), post traumatic stress disorder, osteoarthritis, and major depressive disorder. Review of her minimum data set (MDS) assessment, dated 10/10/24, revealed she had a mild cognitive impairment. Review of Resident #29 progress notes, dated 11/01/24, revealed she was readmitted back to the facility after an acute hospital stay. Review of Resident #29 skin observation tool, dated 11/01/24, revealed staff documented that she had Moisture Associated Skin Damage (MASD) on her right and left buttocks. There were no measurements or description documented for this skin alteration. Review of Resident #29 Skin Provider Consultation report, dated 11/05/24, revealed the nurse practitioner assessed the wound and determined it to be a stage III pressure ulcer to her buttocks with the measurements of 3.0 centimeters (cm) by 3.5 cm by 0.1 cm. The report also documented this wound was present upon admission. Interview with Assistant Director of Nursing (ADON) #345 on 11/13/24 at 1:44 P.M. and 11/14/24 at 9:05 A.M. confirmed Resident #29 skin injury/pressure ulcer was not officially measured and monitoring was not started until 11/05/24, which was four days after she was readmitted to the facility from the hospital. She confirmed the skin injury was not present when she left for the hospital, so it was only present upon readmission. She confirmed they have started new procedures of having each new skin injury assessed and measured upon admission, instead of waiting until the wound nurse arrives to the facility on ce a week. Review of the Pressure Ulcers/Skin Breakdown - Clinical Protocol revealed, the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions and the physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. Additionally, the clinical protocol indicated treatments such as pressure-reducing surfaces and appropriate wound care measures should be initiated immediately.

Based on medical record review, interviews, and review of facility policy, the facility failed to ensure resident weights were obtained as per dietician recommendations. This had the potential to affect two (#36 and #37) out of four reviewed for nutrition. The census was 40. Findings Include: 1. Review of the medical record for Resident #37 revealed an admitted [DATE] diagnoses include severe fracture of the left femur, history of falling, dementia, severe cognitive deficits, and anemia. Resident required one person assist with activities of daily living. Review of Resident #37's plan of care revealed the resident will maintain adequate nutrition support as evidenced with no significant weight changes. Review of Resident #37's Nutrition/Dietary Note dated 09/18/24 revealed Resident #37 weighed 140.2 pounds triggering him for significant weight loss of 5.7% weight loss in one month. This was related to his decreased intakes and appetite. Medications to increase appetite have been ordered. Dietician will continue to monitor Resident #37's weight trends via weekly weights to review effectiveness of interventions . Review of Resident #37's physician orders for 09/22/24 to 11/14/24 did not indicate resident was to be weighed weekly. Review of Resident #37's documented weights revealed a weight was obtained on 9/22/24 of 141.8 pounds and on 10/23/24 137.6 pounds. No additional weights were obtained. Interview with Dietician #380 on 11/14/24 at 10:50 A.M. revealed she did see the resident on 9/18/24 and recorded in his progress notes to monitor the resident's weight trends and indicated the resident was to be weighed weekly. She notified Resident #37's doctor to order the weekly weights. 2. Resident #36 was admitted to the facility on [DATE], diagnoses include collapsed vertebra, history of falling , pacemaker, severe cognitive deficits, and unspecified dementia with agitation. Review of Resident #36's plan of care revealed Resident #36 will maintain adequate nutrition support as evidenced by no significant weight changes. Weigh resident as ordered and in similar manner for accuracy. Review of Resident #36's Quarterly Nutrition Review note on 10/04/24 at 10:16 A.M. Resident #36 weighed 115.2 pounds indicating she has had a decline in the last three months. Dietician to order weekly weights for close monitoring for four weeks. Review of Resident #36's physician orders for 10/04/24 to 11/14/24 did not indicate resident was to be weighed weekly. Review of Resident #36's documented weights revealed on 09/01/24 she weighed 115.2 pounds and on 10/30/24 she weighed 111.4 lbs. Resident #36 had no other documented weights. Interview with Dietician #380 on 11/14/24 at 11:30 A.M. revealed she did see the resident on 10/04/24 and stated in progress notes to monitor the residents weight trends and indicated the resident was to be weighed weekly. She notified Resident #36's doctor to order the weekly weights. Review of facility policy titled Interventions for Unintended Weight Loss , dated 03/01/2019, revealed Unintended weight loss or gradual weight loss will be monitored so that appropriate and individualized intervention can be implemented. Residents will be weighed upon admission or readmission , weekly for the first four weeks after admission, and at least monthly thereafter to help identify and document weight trends. Weekly weights may be ordered due to significant change in condition or altered nutritional status.

Based on medical record review, staff interview, policy review and review of medication information from Medscape, the facility failed to ensure a resident was free from unnecessary psychotropic medications by ensuring there was an adequate indicate for use for the use of an antipsychotic medication. This affected one (#7) of five residents reviewed for unnecessary medications. Additionally, the facility failed to adequately monitor behaviors for residents that were prescribed psychotropic medications. This affected two (Residents #7 and #29) of five reviewed for unnecessary medications. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Her diagnoses were Alzheimer's disease, insomnia, dementia, hypothyroidism, allergic rhinitis, depression, hypertension, intervertebral disc degeneration lumbar region, gastro-esophageal reflux disease without esophagitis, pain, pure hypercholesterolemia, and postnasal drip. Review of the Minimum Data Set (MDS) assessment, dated 05/08/24, revealed a brief interview of mental status (BIMS) score of 02 indicating significant cognitive impairment. Resident #7 was not coded as having any psychotic disorder. Review of the physician orders for antipsychotic medications used in Resident #7's care from 10/08/24 to present revealed the following orders: Seroquel (antipsychotic) oral tablet 25 milligrams (mg) one tablet by mouth every 24 hours as needed for Alzheimer's dementia with psychosis for 14 days with a start date of 11/12/24 and an end date of 11/26/24. Seroquel oral tablet 25 mg one tablet by mouth two times a day for agitation for seven days with a start date of 11/4/24. Seroquel oral tablet 25 mg by mouth one time a day for agitation for seven days with a start date of 10/27/24 and an end date of 10/29/24. Seroquel oral tablet 25 mg by mouth in the evening for agitation for seven days with a start date of 10/18/24 and an end date of 10/25/24. Seroquel oral tablet 50 mg by mouth one time a day for agitation for seven days with a start date of 10/19/24 and an end date of 10/26/24. Seroquel oral tablet 50 mg by mouth one time a day for dementia with psychosis and give 50 mg by mouth one time a day and give 50 mg by mouth at bedtime for dementia with psychosis with a start date of 10/8/24 and an end date of 10/18/24. Seroquel oral tablet 25 mg by mouth one time a day for dementia with psychosis give at noon with a start date of 10/8/24 and an end date of 10/18/24. Review of the progress notes revealed on 11/06/24 at 11:18 A.M., medication review team which included the Certified Nurse Practitioner (CNP), Medical Director, Pharmacy, Director of Nursing (DON), Assistant Director of Nursing (ADON) but did not indicate clear evidence or outcomes of the review that supported ongoing use of Seroquel for Resident #7. The note does not specify whether behavioral management strategies other than pharmacological interventions were considered and there was insufficient evidence in the record that other non-pharmacologic interventions were attempted or that the family was involved in discussions about the medication changes. There was no clear documentation present in the record of the need for continued use of psychotropic medications and justification for such use. The use of Seroquel was not sufficiently documented as being aligned with the goals of treatment. There was no evidence of specific documentation regarding the resident's response to Seroquel or any assessments regarding the risks and benefits of its use. Interview on 11/13/24 at 8:51 A.M. with ADON #345 and DON confirmed the diagnoses for ordering Seroquel were not appropriate for the medications use. Documentation provided no clear rationale for the ongoing use of the medication and its effectiveness in managing the Resident's symptoms. Interview on 11/14/24 at 9:24 A.M. the Nurse Practitioner verified Seroquel was initially prescribed to address agitation related to Alzheimer's disease, but the plan to taper off Seroquel was discussed. Review of medication information from Medscape at: https://reference.medscape.com/drug/seroquel-xr-quetiapine-342984?_gl=1*5jj9fp*_gcl_au*MTU0MDAzODMxNC4xNzI2NTk1Nzgz revealed Seroquel is an antipsychotic medication used for schizophrenia, bipolar and major depressive disorder. Seroquel is not approved for dementia-related psychosis; elderly patients with dementia-related psychosis who are treated with antipsychotic drugs are at increased risk of death, as shown in short-term controlled trials; deaths in these trials appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (eg, pneumonia) in nature. 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Her diagnoses were Alzheimer's disease, insomnia, dementia, hypothyroidism, allergic rhinitis, depression, hypertension, intervertebral disc degeneration lumbar region, gastro-esophageal reflux disease without esophagitis, pain, pure hypercholesterolemia, and postnasal drip. Review of the Minimum Data Set (MDS) assessment, dated 05/08/24, revealed a brief interview of mental status (BIMS) score of 02 indicating significant cognitive impairment. Additionally, Resident #7 was not coded as having a psychotic disorder. Review of Resident #7's current orders revealed the resident had the current psychotropic medications used in her care: Seroquel (antipsychotic) oral tablet 25 milligrams (mg) one tablet by mouth every 24 hours as needed for Alzheimer's dementia with psychosis for 14 days with a start date of 11/12/24 and an end date of 11/26/24. Rexulti (Serotonin-Dopamine Activity Modulator used for schizophrenia, depression, and agitation associated with Alzheimer's dementia) oral tablet three mg one tablet by mouth one time a day for Alzheimer's dementia with agitation with a start date of 11/19/24. Depakote sprinkles (mood stabilizer anticonvulsant) oral capsule delayed release sprinkle 125 mg, two capsules by mouth in the evening for agitation with dementia start date 10/30/24. Review of the care plan for Resident #7 revealed that the nursing staff was responsible for monitoring and documenting any behavioral symptoms that occur while the resident is receiving psychotropic medications. This includes tracking any changes in behavior (e.g., increased agitation, aggression, confusion) and evaluating whether the antipsychotic medications are effective or if dosage adjustments are necessary. There was no evidence behavioral symptoms (such as agitation, aggression, or confusion) were systematically monitored or documented on a shift-by-shift basis as required by the care plan. Review of the progress notes revealed no evidence that behavioral symptoms (such as agitation, aggression, or confusion) were systematically monitored or documented on a shift-by-shift basis as documented in the care plan. Despite changes in medication orders there was no clear documentation of the effectiveness of these medications in managing the resident's behavioral symptoms over time. Interview on 11/13/24 at 12:12 P.M. with the Administrator, verified behavior documentation for the facility would be in the skilled notes. Interview on 11/14/24 at 9:43 A.M. with the DON confirmed the facility documents by exception and would document behaviors in the progress notes if they occur and then discuss the behaviors at their daily/weekly meetings with the nurse practitioner and staff. 37100 3. Resident #29 was admitted to the facility on [DATE]. Her current diagnoses were nontraumatic intracranial hemorrhage, osteoporosis, dementia, morbid obesity, polyosteoarthritis, atrial fibrillation, congestive heart failure, anxiety disorder, hyperlipidemia, occlusion and stenosis of carotid artery, acute kidney failure, chronic kidney disease (stage III), post traumatic stress disorder, osteoarthritis, and major depressive disorder. Review of her minimum data set (MDS) assessment, dated 10/10/24, revealed she had a mild cognitive impairment. Review of Resident #29's current physician orders revealed she was ordered Duloxetine (anti-depressant) 40 milligrams (mg) for depression. Review of Resident #29 current care plan revealed she was prescribed Duloxetine for depression and anxiety. An intervention for this care plan stated the facility was to, monitor/document/report as needed adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in activities of daily living (ADL) ability, continence, no voiding, constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, nausea/vomiting, dry mouth, and dry eyes. Review of Resident #29 progress notes and behavior tracking documentation, dated 09/12/24 to 11/14/24, revealed no behaviors documented. Also, there was no documentation to support behaviors were being tracked in general. Interview with Administrator on 11/13/24 at 12:12 P.M., via email revealed the behavior documentation for residents are completed in progress notes as each behavior occurs. They do not keep logs for specific behaviors for each resident. Interview with DON on 11/14/24 at 9:43 A.M. stated they document by exception for behaviors. She confirmed the staff would document behaviors in the progress notes if they occur, and then discuss the behaviors at their daily/weekly meetings with the facility nurse practitioner if changes to their medication regimen needs to occur. Review of the behavioral assessment, intervention and monitoring policy revealed if the resident is being treated for altered behavior or mood, the interdisciplinary team (IDT) will seek and document any improvements or worsening in the individuals behavior, mood, and functioning. Additionally, the IDT will monitor the progress of individuals with impaired cognition and behavior until stable with new or emergent symptoms being documented and reported. Finally, interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment.

Based on record review, staff interview, and policy review the facility failed to ensure residents had an appropriate indication for the use of antibiotics. This affected one resident (#26) of five residents reviewed for antibiotic stewardship. The census was 40. Findings include: Review of medical record for Resident #26 revealed the resident was admitted on [DATE], diagnoses included: vitamin D deficiency, myocardial infarction, hypertension, osteoporosis, obstructive sleep apnea, heart disease, and abnormal weight loss with a body mass index (BMI) of 19.9 or less, (normal healthy weight rage is BMI 18.5-24.9). Review of Resident #26's physician orders for January of 2024 revealed an order for Macrobid (antibiotic) oral capsule, 100 milligrams (mg), give one capsule by mouth, two times a day, for urinary tract infection (UTI), for five days. The order start date was 01/04/24, with a stop date of 01/09/24. The order was listed as completed. Review of Resident #26's Infection Report Form based on The McGeer Criteria (set of surveillance tools used to identify health care-associated infections), dated 01/04/24 on 11/14/24 at 1:30 P.M. revealed Resident #26 was hallucinating with increased incontinence. Documentation on the form stated Resident #26 was not experiencing fever, pain, hematuria, urgency, frequency, dysuria, or tenderness, and no urinalysis or urine culture was completed. No subcriteria, nor microbiologic criteria were met to support the use of an antibiotic for a urinary tract infection. Resident #26 was prescribed Macrobid, 100 mg, twice a day, for five days, with an ordered start date of 01/04/24 and a stop date of 01/09/24 for a urinary tract infection. Interview with the Assistant Director of Nursing (ADON) #345 on 11/14/24 at 2:09 P.M. confirmed Resident #26 completed a course of antibiotics for a urinary tract infection that did not meet The McGeer Criteria for a UTI from 01/04/24 - 01/09/24. Review of the policy titled Antibiotic Stewardship dated 2001 revised 12/2016 revealed: Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.

Based on observation, facility policy and procedure review and interview the facility staff failed to ensure the hood and filter system in the main kitchen and serving kitchen food production areas were maintained in a clean and sanitary manner to prevent the contamination of food. This had the potential to affect all 45 residents residing in the facility who consumed food prepared in the two areas. Findings include: On 05/31/22 at 8:45 A.M. observations during the kitchen tour revealed the main kitchen hood and filters above the stove were very dusty. Interview with Executive Chef #101 at the time of the observation verified the dust on the hood and filters and revealed they were last cleaned by a contracted company on 02/01/22. On 05/31/22 at 8:55 A.M. observation of the serving kitchen area revealed the hood and filters above the stove were very dusty. Interview with Dietary Director #100 at the time of the observation verified the areas were very dusty and indicated the hood and filters were last cleaned by a contracted company on 02/01/22. Review of the undated policy titled Weekly Cleaning Schedule Legacy revealed the hood filters were removed and cleaned weekly. The hood interior and exterior were to be cleaned with a stainless steel cleaner weekly.

Based on observation, facility policy and procedure review and interview the facility staff failed to ensure trash was covered in the main kitchen storage and production areas. The had the potential to affect all 45 residents residing in the facility. Findings include: On 05/31/22 at 8:45 A.M. observations during the kitchen tour revealed the main kitchen dry stock areas had a trash can full of trash with no lid near the sugar and flour storage bins. Interview with Executive Chef #101 at the time of the observation verified the trash can was full of trash with no cover and was not being currently used by staff. Continued observation in the main kitchen revealed a trash can half full of trash with no cover near the ovens in the food production area that was not in use by staff. Interview with Dietary Director #100 at the time of this observation verified the trash can was half full of trash with no cover near the ovens in the food production area. Review of the policy titled Waste Disposal, dated 2019 revealed that prior to disposal, all waste was kept covered in a leak-proof container when not in use.

Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #3 was properly transferred to prevent a fall. This affected one resident (#3) of three residents reviewed for accidents. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, major depressive disorder, and [CONDITION(S)]. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 04/28/22 revealed Resident #3 had cognitive impairment. The MDS revealed the resident required extensive assistance of two staff for transfers. Review of a nurse's note, dated 05/29/22 at 10:30 A.M. revealed the nurse heard Resident #3 scream out. The nurse found the resident lying on the floor under a sit-to-stand mechanical lift. The note revealed the State tested Nursing Assistant (STNA) said Resident #3 would not hold on or sit still during the transfer. No visible injuries were noted. The STNA was educated on the use of the sit-to-stand mechanical lift since the resident did not have an order for sit-to-stand transfers at the time of the incident. Review of the Post Fall Evaluation, dated 05/29/22 revealed contributing factors for Resident #3's fall included the sit-to-stand lift being used by only one staff member. On 06/02/22 at 10:08 A.M. interview with Licensed Practical Nurse (LPN) #162 revealed the STNA stated she had seen other staff use the sit-to-stand by themselves with Resident #3 and felt she could transfer the resident without assistance. On 06/02/22 at 12:46 P.M. interview with the Director of Nursing verified Resident #3's medical record revealed the resident required extensive assistance of two staff for transfers and there was only one staff member transferring the resident on 05/29/22 at the time the resident fell . Review of the Safe Lifting and Movement of Resident Policy and Procedure, revised July 2017 revealed nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident needs for transfer assistance on an ongoing basis. Assessments should include the residents mobility, size, weight-bearing ability, cognitive status and whether the resident was usually cooperative with staff.

Based on observation, record review, facility policy and procedure review and interview the facility failed to provide oxygen as ordered for Resident #13 and failed to ensure oxygen/respiratory supplies were dated to maintain proper use. This affected one resident (#13) of one resident reviewed for oxygen. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 03/23/22 revealed Resident #13 had impaired cognition. Review of the April 2022 and May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care, dated 04/05/22 revealed Resident #13 had oxygen therapy related to terminal prognosis, comfort measures, chronic respiratory failure, chronic pleural effusion and chronic heart failure. Interventions included oxygen through nasal prongs at three liters, monitoring for signs of respiratory distress, providing medications as orders and positioning the resident to facilitate ventilation. On 05/31/22 at 11:50 A.M. and 12:00 P.M. Resident #13 was observed receiving oxygen via a nasal cannula. The oxygen was set at two liters and there was no date on the tubing. On 05/31/22 at 12:00 P.M. interview with Licensed Practical Nurse (LPN) #134 confirmed the above observation. LPN #134 confirmed Resident #13's orders were for three liters of oxygen and she was receiving two liters. LPN #134 revealed Resident #13's daughter had been in to visit with her on 05/30/22 and stated the daughter may have adjusted the concentrator. LPN #134 reported oxygen tubing was to be changed weekly and confirmed there was no documentation to indicate the last time Resident #13's tubing had been changed as the tubing was not dated and there was no documentation of such on the administration records. On 06/01/22 at 1:07 P.M. interview with the Director of Nursing (DON) revealed residents who received oxygen continuously should have their tubing changed weekly. The DON indicated staff should document the tubing changes on the administration record also. Review of the policy titled Oxygen Administration, dated October 2010 revealed that unless otherwise ordered the flow of oxygen should be started at two to three liters. After completing oxygen setup or adjustment the nurse should document the date and time the procedure was performed, the rate of oxygen flow, route, and rationale, the reason for the administration and all assessment data obtained.

Based on interview and record review the facility failed to provide a [MEDICATION(S)] patch as ordered for pain management and correctly document the administration of the patch for Resident #33. This affected one resident (#33) of one resident reviewed for pain management. Findings include: Record review revealed Resident #33 had a plan of care, dated 07/08/21 related to risk for alteration in comfort related to generalized discomfort, arthritis, limited mobility, [CONDITION(S)], [CONDITION(S)], hypertension, [CONDITION(S)], [CONDITION(S)] and additional diagnoses. The care plan revealed Resident #33 was noted to scratch and pick at her transdermal pain patch at times. Interventions included applying ice 20 minutes per hour and after activities as needed, attempt non-medication interventions, ensure transdermal pain patch was securely in place, medication as ordered, monitor for pain every shift and notify physician of any new or worsening changes in pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/18/22 revealed the Resident #33 had impaired cognition. The MDS revealed she received a scheduled pain medication regimen and had not experienced pain during the assessment reference period. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 05/11/22 at 8:46 A.M. by Licensed Practical Nurse (LPN) #149 and on 05/13/22 at 7:30 A.M. Review of the progress note, dated 05/13/22 at 7:10 A.M. revealed LPN #134 noted during shift to shift change that Resident #33's [MEDICATION(S)] patch that was in place, was dated 05/08/22. The note indicated orders in the electronic medical record stated to change every 72 hours; the Director of Nursing (DON) and Hospice were notified. Review of the progress note, dated 05/13/22 at 7:19 A.M. revealed Hospice returned the phone call and gave a verbal order to take off Resident #33's patch, dated 05/08/22 and replace it with a new patch, the start date changed in the MAR for 72 hours from 05/13/22. On 06/02/22 at 12:45 P.M. interview with the Director of Nursing (DON) revealed following the incident, the [MEDICATION(S)] patch count (sign out sheet and supply on hand) were never off and she had determined the medication had not been properly administered during this time period as opposed to the medication being misappropriated or misused by staff. On 06/02/22 at 1:21 P.M. interview with LPN #149 revealed she had not administered the [MEDICATION(S)] patch on 05/11/22 as ordered. She reported she had been waiting for the oncoming nurse and had been checking off things she had completed on the MAR. LPN #149 reported she was supposed to change the patch with another nurse, however, by the time the nurse arrived she had forgotten. Review of the controlled drug receipt, record, and disposition form revealed Resident #33 did not receive a [MEDICATION(S)] patch as ordered on 05/11/22.

Based on record review and interview the facility failed to ensure medications were not administered to Resident #27 when outside of the parameters set by the physician for medication administration. This affected one resident (#27) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/11/22 revealed Resident #27 had mildly impaired cognition. Review of the plan of care, dated 05/15/22 revealed Resident #27 was on diuretic therapy related to chronic heart failure and fluid management. Interventions included administering diuretic medications as ordered by physician, monitor for interactions and adverse consequences. An additional intervention to monitor dose as it may require modification to achieve desired effects while minimizing adverse consequences, especially when multiple antihypertensives were prescribed simultaneously. Review of the May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #27's systolic blood pressure was below 110 mm Hg. This included on 05/02/22, 05/05/22, 05/06/22, 05/09/22, 05/10/22, 05/13/22, 05/14/22, 05/15/22, 05/16/22, 05/24/22, 05/27/22, and 05/29/22. Review of the May 2022 MAR for Resident #27 revealed [MEDICATION(S)] was administered in the evening on eight occasions when Resident #27's systolic blood pressure was below 110 mm Hg. This included on 05/05/22, 05/09/22, 05/10/22, 05/20/22, 05/22/22, 05/23/22, 05/24/22, and 05/30/22. Further review revealed [MEDICATION(S)] was administered when an evening blood pressure was not obtained and marked as 'vitals outside of parameters' on three occasions on 05/02/22, 05/27/22, and 05/29/22. Review of the progress notes from 05/02/22 to 05/29/22 for Resident #27 revealed no notes indicating a physician was contacted about administering medications outside of parameters. Additionally, there were no progress notes to indicate medication was not administered when indicated on the MAR. On 06/01/22 at 1:07 P.M. and 1:51 P.M. interview with the Director of Nursing (DON) confirmed generally a check mark in the MAR meant the medication was administered unless otherwise stated in the progress notes. She confirmed the medications were held at times due to the vitals being outside of the parameters and were administered at other times when they were outside of the ordered parameters. The DON confirmed blood pressure was obtained at the time of medication administration. When asked if nurses should be documenting if they were calling the physician prior to administering medications outside of parameters she stated she was not sure, but probably. On 06/01/22 at 1:51 P.M. interview with Physician #165 revealed Resident #27 had beta blockers for her chronic heart failure. He reported a desire to drive her heart rate down. Physician #165 reported when a resident admitted on beta blockers and diuretics the standard order was to hold for a systolic blood pressure below 110 mm Hg. However, the physician revealed this was not always necessary in the case of Resident #27's beta blockers, but he was not able to speak to the diuretic. Physician #165 reported he was unsure about every documented incident of the medication being administered outside of parameters, however, at times the nurses would call him and ask prior to administering it. He reported the hold order probably should have been discontinued but confirmed it was still in place.

Based on medical record review, resident, staff, Physician and pharmacist personnel interview, review of the emergency medication box receipt and policy review, the facility failed to effectively manage Resident #2's pain upon admission to the facility. This resulted in Actual Harm when Resident #2 was not provided with a pain assessment and/or sufficient pain medications following admission and the resident experienced excruciating pain requiring physician evaluation/treatment. This affected one (#2) of three residents reviewed for pain medications. Facility census was 41. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. Resident #2 required extensive assistance of two staff members for transfers and bed mobility. Resident #2 was frequently incontinent of bladder and continent of bowels. Resident #2 had a surgical wound present upon admission. Resident #2's pain assessment revealed she has had pain in the last five days, occasionally that has limited her day-to-day activities and on a scale of zero to ten, Resident #2 rated her pain a 10 as the worst pain she experienced in the previous five days. Review of the plan of care dated 10/21/21 revealed Resident #2 has a self-care performance deficit with weakness and pain. Interventions include staff assistance with activities of daily living. Resident #2 has acute and chronic pain with interventions including to provide medication as ordered, anticipate residents pain and respond immediately to complaints of pain, evaluate pain interventions for effectiveness, explore non-pharmacological interventions for pain relief, and notify the physician if interventions are unsuccessful. Review of an admission timestamp revealed Resident #2 was admitted on [DATE] at 2:52 P.M. Review of a physician note dated 10/20/21 revealed the facility physician reviewed Resident #2's condition and medications and revealed no concerns. Review of the physician orders on 10/20/21 to 11/03/21 identified orders for Acetaminophen tablet 325 milligrams (mg) with instructions to give two tablets by mouth every six hours as needed for pain. On 10/20/21 to 10/29/21 there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/25/21 there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/29/21 there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record (MAR) revealed upon admission Resident #2 had two pain medications (Acetaminophen every six hours and Oxycodone every four hours) ordered as needed for pain control. According to the MAR document for October 2021, Resident #2 received the first pain medication, Acetaminophen after admission on 10/21/21 at 7:12 A.M. after rating pain at 10 out of 10. Resident #2 was given the second dose of pain medication, Oxycodone on 10/21/21 at 9:00 A.M. after rating pain at eight out of 10. Review of the progress notes dated 10/21/21 at 12:51 P.M. by Licensed Practical Nurse (LPN) #59 revealed the first progress note mentioning the residents was experiencing pain indicated the resident had complaints of pain rated at eight out of 10. Review of the hospital discharge summary revealed prior to discharge, Resident #2 was given one dose of Oxycodone five mg at 9:38 A.M. and was given two doses of acetaminophen 650 mg at 5:17 A.M. and 9:37 A.M. The document was printed from the hospital at 10:49 A.M. to be sent to the facility. It is not documented if the resident received any additional doses of pain medications from the time this document was printed and until the resident's transport arrived to transport Resident #2 to the facility around 2:30 P.M. Interview on 11/09/21 at 11:18 A.M. with State tested Nursing Assistant (STNA) #51 revealed Resident #2 was calling out in pain when she started her day shift on 10/21/21 so STNA #51 went to check on the resident. STNA #51 stated Resident #2 was calling out in pain and requesting pain medications. STNA #51 revealed she informed the day shift LPN #59 of Resident #2's complaints of pain. Interview on 11/09/21 at 11:40 A.M. with Resident #2 revealed concerns with pain medications during the first day and night of her admission at the facility. Resident #2 revealed she was given pain medication at the hospital before she was transferred to the facility on [DATE] and went until the next morning, 10/21/21 without getting any pain medications. Resident #2 revealed the nurse informed her the facility did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 revealed she was in excruciating pain and just wanted to die. Resident 2 stated the pain was in her left hip from a fall requiring hip surgery. Interview on 11/09/21 at 12:20 PM with LPN #53 revealed when Resident #2 arrived to the facility she was not in any pain. LPN #53 revealed she completed the initial assessment for Resident #2 without any concerns. LPN #53 revealed if any medication was needed the nurses would obtain it from the emergency medication box. LPN #53 stated she did not provide any medications during her shift on 10/20/21 until 7:00 P.M. and stated Resident #2 did not have any complaints of pain during the shift. Interview on 11/09/21 at 12:40 P.M. with RN #58 revealed she did not remember the details of the shift in question but revealed Resident #2 was given one dose of pain medication during the night shift. RN #58 revealed an estimated time this medication was given was between 11:00 P.M. and 1:00 A.M. RN #58 was unable to recall why this medication was not documented on the MAR. RN #58 revealed Resident #2 has since had behaviors of yelling out when her pain medications are delayed. RN #58 revealed Resident #2 had a timer set and would put her call light on as soon as the pain medications were allowed. RN #58 revealed there were times she was 60 to 90 minutes late in getting Resident #2 her medications and informed Resident #2 she had other priorities. Interview on 11/09/21 at 3:00 P.M. with the Director of Nursing (DON) revealed one dose of Oxycodone five mg was pulled from the emergency medication box on 10/20/21 at 11:37 P.M. by RN #58 and LPN #60. The DON confirmed the Oxycodone pulled from the emergency medication box was not signed out on the MAR as administered and/or there was no documentation regarding the pain medication or a pain assessment in Resident #2's medical record. The DON confirmed Resident #2 had complaints of 10 out of 10 pain on 10/21/21 at 7:12 A.M. according to the MAR and Tylenol was administered. The DON further confirmed there was no further assessment or description of Resident #2's pain and there was no documentation of a pain assessment in Resident #2's medical record/progress notes until 10/21/21 at 12:51 P.M. Interview on 11/09/21 at 3:30 P.M. with Physician #105 revealed the morning of 10/21/21, LPN #59 reached out to the physician's office regarding Resident #2 being in significant pain to the left hip. Physician #105 examined Resident #2 that morning and in addition to the pain medications already ordered, the physician placed a new order for a muscle relaxant. Physician #105 revealed she ensured Resident #2 the facility will stay on top of her pain medications. Physician #105 reviewed the hospital paperwork which revealed prior to leaving the hospital, pain was tolerable and controlled except when moving and stated, I would assume she was in a decent amount of pain. Physician #105 revealed nursing staff in the morning truly advocated to get her pain under control. Interview on 11/09/21 at 3:57 P.M. with LPN #59 revealed Resident #2 was upset and in excruciating left hip pain upon arrival to her room in the morning of 10/21/21 and Resident #2 was exhibiting non-verbal signs of pain including facial griming. LPN #59 provided a dose of Acetaminophen on 10/21/21 at 7:12 A.M. and contacted the physician regarding pain concerns. LPN #59 revealed she also provided one dose of Oxycodone at 9:00 A.M. LPN #59 revealed from nursing report, the night nurse gave Resident #2 one pain medication during the night shift. Interview on 11/09/21 at 4:11 P.M. with the Administrator revealed the facility has had issues with the pharmacy tote arriving by its scheduled time of midnight. On 10/20/21 Resident #2's medications were ordered around 3:00 P.M. to 4:00 P.M. and they were not delivered until 10/21/21 at 6:15 A.M. Interview on 11/09/21 at 4:51 P.M. with Pharmacy Staff #100 confirmed that Oxycodone five mg one tablet was approved for removal for Resident #2 from the emergency medication box on 10/20/21. Review of the emergency medication box receipt revealed the pharmacy approved the medication withdrawal on 10/20/21 at 11:37 P.M. for one dose of Oxycodone. RN #58 and LPN #60 signed as witnesses for the narcotic medication. Review of the facility policy titled Administering Medications, dated 04/2019, revealed medications are administered in accordance with prescriber orders, including any required timeframe. The policy revealed medication administration times are determined by resident need and benefit, not staff convenience with considered factors including enhancing therapeutic effect of the medication and honoring resident choices and preferences, consistent with the care plan. The policy revealed medications errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee. The policy revealed the individual administering the medication, records in the medical record the date and time of administration, the dosage, and a signature of the staff administering the medication. Review of the facility policy titled Pain Management Clinical Program, dated 01/2021, revealed if a clinical change occurs pain will be screened and if pain is present a new assessment will be completed. A change in status includes a new onset or significant increase or change in pain status. This deficiency substantiates Complaint Number OH 194.

Based on observation, medical record review, review of facility investigation, review of staff statements, review of a facility policy, family interview and staff interview, the facility failed to ensure residents were provided adequate assistance during transfers. Actual harm occurred on 01/08/19 when Resident #8, who required extensive assistance from two staff using a Hoyer lift was pivot transferred and subsequently repositioned in a Broda (specialized chair) by one staff resulting in a femur fracture requiring surgical repair. In addition, the facility failed to ensure Resident #32 had interventions in place to ensure she can safely transfer to and from her wheelchair, which placed the resident at risk for potential harm. This affected two residents (#8 and #32) of three residents reviewed for accidents. Findings include: 1. Review of Resident #8's medical record revealed an original admission date of [DATE] with the latest readmission of 01/13/19 with re-admitting [DIAGNOSES REDACTED]. Record review revealed the resident was receiving Hospice services. Review of the resident's plan of care, dated 01/10/17 revealed the resident had a self-care performance deficit related to impaired mobility and cognition. An intervention, initiated on 01/29/18 revealed the resident was totally dependent on staff for transferring with a Hoyer (mechanical) lift. The care plan did not include any other methods for transferring the resident. Review of Hospice plan of care documentation, dated 05/01/18 revealed staff were to assist with transfers. The plan did not specify the level of assistance needed or how staff were to assist. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/08/18, revealed the resident was non-ambulatory, required extensive assistance from two staff for bed mobility and transfers and had functional limitation in range of motion to the upper and lower extremities on both sides. Review of the 01/08/18 discharge MDS 3.0 assessment revealed the resident had severely impaired cognition, was non-ambulatory and required extensive assistance from two staff for bed mobility and transfers. Review of a progress note, dated 01/08/19 at 5:35 P.M. and authored by Registered Nurse (RN) #13 revealed she was summoned to the resident's room by a State tested Nursing Assistant (STNA). The STNA stated, she transferred the resident from her bed to her Broda chair and when she was repositioning her she heard a crack sound on her right leg. Upon assessment the resident's right leg was internally rotated and the resident was grimacing and verbalized pain. The resident was given as needed Tylenol for pain. The resident's physician was notified and an order was obtained for an x-ray. The results of the x-ray revealed acute mid shaft fracture. The resident was sent to the local emergency room (ER) and was admitted for treatment. Hospital documentation reflected the resident had sustained a displaced comminuted fracture of shaft of right femur (a displaced fracture occurs when the bone snaps into two or more parts; if the bone is in many pieces it is called a comminuted fracture) Review of the facility incident report dated 01/08/19 at 5:03 P.M. and revised on 01/09/19 at 9:31 [NAME]M. revealed under the nursing description was the progress note dated 01/08/19 at 5:35 P.M. by RN #13. The report indicated the immediate action taken was the squad was called to transport the resident to the local emergency room for treatment. The incident report indicated no injuries were observed at the time of the incident and the resident had negative vocalizations, facial expressions, body language and consolability indicating pain. However, this was not consistent with the nursing progress note which documented the resident's right leg was internally rotated and the resident was grimacing, verbalized pain and was medicated with Tylenol. Review of an undated signed hand written statement completed by STNA #5 revealed, I, (STNA #5) was helping the resident with transfers from bed to her broda chair, when I tried to reposition her in the broda, I heard a crack sound and I called the nurse. Review of the typed statement with a drawing dated 01/08/19 and titled, Statement of Event revealed, STNA #5 was getting Resident #8 up for lunch. It was after 11:00 [NAME]M. She was in bed. The STNA changed her brief and finished dressing her. The statement documented the resident normally stands up and will bear weight on her feet and pivot. The STNA sat the resident up on the side of the bed and the resident put her arms around the STNA's neck. The STNA hugged her and pivoted her into the Broda chair. The STNA documented the resident and herself transferred body to body. This statement revealed the resident did not indicate any pain at that time. After the STNA sat her in the chair she reclined the back of the chair and then positioned the resident's legs. The STNA documented she heard a pop sound and it wasn't the chair. The STNA started looking, and the resident said, Oh my foot. The STNA then went to get RN #13. The statement was signed respectfully submitted STNA #5 and had the STNA's signature. Review of the acute care hospital documentation dated 01/10/19 revealed the resident was seen for right leg pain and according to her family the resident was being transferred from her bed to her wheelchair when the facility heard a pop and a deformity to the right leg was observed. The resident was seen, evaluated and was diagnosed with [REDACTED]. The hospital documentation revealed the resident's baseline was bed bound and non-ambulatory. Record review revealed a physical therapy evaluation was completed following the incident on 01/17/19. The evaluation reflected the resident sustained [REDACTED]. The evaluation form revealed At baseline Pt completed SPT with max A (assist) or used Hoyer lift for transfers. The evaluation did not contain any additional information as to how the resident's baseline was determined or provide any additional information as to when staff should be using a Hoyer lift versus a stand pivot transfer. Review of a Progressive Discipline Form, dated 01/19/19 revealed STNA #5 received a final written warning for substandard performance. The form documented the STNA failed to follow the care guide while delivering resident care resulting in injury to the resident (Resident #8). Review of the resident's most current MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of five. The assessment revealed the resident required extensive assistance of two staff for transfers. On 10/15/19 at 11:44 [NAME]M. Resident #8 was observed sitting in a Broda chair with her legs elevated and bilateral heel protectors in place. The resident was observed with bilateral hand contractures. Attempts to interview the resident at this time were unsuccessful as the resident would not communicate with the surveyor. On 10/15/19 at 2:26 P.M., an interview with Resident #8's family member revealed the resident had limited ability to respond to questions due to her cognition but at times could answer yes/no questions. During the interview a concern regarding a fracture the resident sustained [REDACTED]. During the interview, the family member revealed the resident required the use of a Hoyer lift to transfer and staff normally used the Hoyer lift. However, an STNA had transferred her by pivot transfer instead of using the Hoyer lift and the resident ended up with a femur fracture which required surgery resulting in screws and a rod to repair it. On 10/16/19 at 3:07 P.M., an interview with the Director of Nursing (DON) revealed at 9:30 [NAME]M. on 01/08/19 Resident #5 was being transferred by one STNA, STNA #5 using a pivot type transfer. The DON verified at the time of the incident the resident had a plan of care in place that reflected the use of a Hoyer lift for transfers. The DON indicated during the transfer process while repositioning the resident in the Broda chair, the STNA lifted the resident's legs and felt that something wasn't right with her leg and she notified the nurse immediately. She said she was not the DON at the time of the incident but reviewing the investigation, this is what she felt had occurred. On 10/17/19 at 10:50 [NAME]M., an interview with the Administrator revealed prior to the incident on 01/08/19 the resident had a plan of care in place which reflected she required a Hoyer lift for transfers. The Administrator revealed the assignment sheet for Resident #5 documented the resident required extensive assistance of one or two staff on the top line and Hoyer lift under it. The sheet failed to provide any guidance as to when staff should use what type of transfer assistance. The Administrator revealed she believed STNA #5 interpreted the sheet as the resident was either a one or two person assist. She said after the incident on 01/08/19 the care guide was update to reflect one or two assist using a Hoyer (mechanical) lift. 2. Review of the medical record of Resident #32 revealed an initial admitted d of 11/22/16. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/24/19, revealed Resident #32 was cognitively intact and required the extensive assistance from one person for transfers. The resident used a walker and wheelchair and was participating in physical therapy. Review of the nursing progress notes, dated 06/13/19, revealed Resident #32 was being transferred to the wheelchair by a State tested Nurse Aide (STNA) and hit her left lower leg on the wheelchair. Resident #32 had two small skin tears measure 2.5 centimeters (cm.) in length by 1.5 cm. in width and 1.5 cm. by 1.5 cm. and there was a moderate amount of bleeding. The wounds were cleaned and steri-strips were placed on both wounds. Further review of the nursing note revealed an intervention to add wrapped padding to the upper parts of the wheelchair to prevent any further injury. Review of the Health Center Wheelchair Check List, dated 06/13/19, revealed the resident was evaluated for a new wheelchair. Review of the care plan, dated 08/14/19, revealed the resident had an activity of daily living (ADL) self-care performance deficit, impaired mobility and impaired safety with interventions to assist the resident with showers, staff to turn and reposition in bed and the resident required the extensive assistance of staff for transfers. Review of the nursing progress note, dated 10/13/19, revealed the resident was being transferred into the wheelchair by an STNA and the resident received a skin tear to the left lower leg. The resident stated she was being transferred and something on the wheelchair gave her a skin tear. The note further revealed the wound was cleansed and the physician was notified for an order for [REDACTED].>Review of a work order, dated 10/13/19, revealed the wheelchair was being placed in an office to check for any sharp surfaces. Review of the physician's orders [REDACTED]. Review of the undated weekly non-pressure ulcer tracking log revealed Resident #32 had two skin tears on 10/13/19. The first skin tear was located on the left shin and documented to be 3.2 cm. x 2.2 cm. and the second tear was located on the distal shin measuring 2.25 cm. x 1.0 cm. and a small amount of serosanguineous discharge was noted. Interview and observation with Resident #32 on 10/15/19 at 3:30 P.M. revealed there was white gauze wrapped and taped on her left shin area. The resident stated she hit her leg on the wheelchair when getting out of bed. The resident confirmed that the STNA was present and assisting her during the transfer. Observation of Resident #32 on 10/16/19 at 2:31 P.M. revealed the resident was in her wheelchair being pushed down the hallway with no padding noted to the wheelchair to prevent further skin tears. Interview with the Director of Nursing (DON) on 10/17/19 at 2:29 P.M. revealed Resident #32's wheelchair was changed out by physical therapy as they felt the new chair was a better fit. The DON verified there was no padding on the new wheelchair as the brake on the new wheelchair was in a higher location than the old chair. The DON confirmed that the resident was in the new wheelchair when the second skin tear incident occurred on 10/13/19 and the wheelchair was not padded to prevent further injury and no new intervention was in place to prevent further injury after the 10/13/19 incident. Interview with the Administrator on 10/17/19 at 3:32 P.M. revealed Resident #32's old wheelchair was still locked up in an office and verified there was no padding on the wheelchair Resident #32 was using. Review of the facility's policy titled Event Management Program, dated 10/16/19, revealed there is a summary of each event with root cause and intervention to prevent reoccurrence in the clinical record and new interventions are put in place to prevent reoccurrence.

Based on observation, medical record review, staff interviews, physician interview and review of the facility policy for pressure ulcer prevention and management, the facility failed to ensure a resident received the necessary care and services to prevent development of an avoidable, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) to such an extent that the full depth of the wound cannot be appreciated) pressure ulcer. This resulted in actual harm for Resident #50, who was assessed at high risk for pressure ulcer development, who had severe cognitive impairment and who required assistance of staff for all activities of daily living, when the facility failed to monitor the skin integrity beneath the resident's knee immobilizer and the resident was found to have an 8.4 centimeter (cm) x 3.5 cm unstageable pressure ulcer to the lateral aspect of the left calf from the immobilizer device. This affected one (Resident #50) of four residents reviewed for pressure ulcers. The facility identified two residents currently residing in the facility utilizing a brace or a sling. The facility census was 51. Findings include: Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge physicians order dated 01/07/16 revealed Resident #50 may bear weight on her left leg as tolerated with the knee immobilizer on, and do not bend the knee for two weeks. Review of the Nursing Admission Evaluation dated 01/07/16 revealed Resident #50 was at high risk for skin breakdown. Review of the admission nurses note dated 01/07/16 at 6:46 P.M. revealed that a skin assessment was completed. The resident was identified as having a pressure ulcer to the left heel that appeared as black/dark purple which measured 0.5 centimeter (cm) by (x) 0.3 cm. The nurse's note revealed no evidence the brace was removed for visual skin inspection of the left lower extremity upon admission. Review of Resident #50's physician orders dated January 2016 revealed an order for [REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified the resident as being severely cognitively impaired as identified by a brief interview for mental status (BIMS) of 03. The MDS revealed the resident required staff assistance with activities of daily living, including bed mobility, was frequently incontinent and was admitted with a Deep Tissue Injury (DTI) to her left heel. Review of Resident #50's care plan (undated) identified Resident #50 as being at risk for impaired skin integrity due to the use of the left leg immobilizer with interventions which included: use pillows, pads or wedges to reduce pressure on pressure points, weekly skin assessments, check skin for redness, skin tears, swelling or pressure areas and report any signs of skin breakdown. Review of the Resident #50's treatment administration record (TAR) for January 2016 revealed Resident #50's skin was assessed as being intact. There was no indication from the TAR that the immobilizer had been removed from Resident #50's leg at any time for hygiene or for visual skin inspection beneath the device. Review of the physician progress notes [REDACTED].#50 had a left patellar fracture, a knee immobilizer in place, and weight bearing as tolerated. Review of the nurse's notes from 01/08/16-02/02/16 revealed that the immobilizer to the left leg was in place. There was no indication from the nurse's notes that the immobilizer had been removed from Resident #50's leg at any time for hygiene or for visual skin inspection beneath the device. Review of the nurse's note dated 02/03/16 revealed during skin checks there was an unstageable pressure ulcer area identified to the back of the mid left calf region. The physician and the responsible party were notified. Review of the wound review note dated 02/03/16 revealed the wound was assessed as an unstageable pressure ulcer to the left medial lower leg measuring 8.4 centimeters (cm) by (x) 3.5 cm. The wound bed was moist yellow with eschar; the surrounding tissue was documented as blanchable, moist, pallor/gray/white with a small amount of foul serosanguineous drainage. Review of the physicians order dated 02/03/16 revealed a new order in place to remove Resident #50 ' s left knee immobilizer and to perform skin assessments every shift. Further review of the physicians order dated 02/03/16 revealed to clean the left lower leg back of calf with 0.9% normal saline, pat dry and apply calcium alginate to wound bed , cover with Abdominal dressing (ABD) and change daily. Review of the facility's investigation note dated 02/03/16 revealed that on 01/31/16, STNA #1 observed drainage on Resident #50's pillow case and reported it to LPN #2. LPN #2 never went to assess Resident #50 despite reports of the drainage noted. Review of the physician progress notes [REDACTED].#50 had a left calf wound that measures 9 cm x 5 cm with overlying eschar, secondary to the metal bar from the leg immobilizer. The resident denied pain. Review of the Orthopedic physicians progress note dated 02/05/16 revealed Resident #50 had a partial thickness wound over the posterior aspect of the distal third of the calf where she obtained a pressure sore from her knee immobilizer posterior metal bar. The bar was removed from the immobilizer during this visit. Review of the wound review note dated 02/11/16 revealed the wound was assessed as an unstageable pressure ulcer to the left lower leg that measured 7.8 cm x 3.0 cm. The wound bed had eschar and the skin surrounding the wound was pink and intact. Review of the physicians progress note dated 03/11/16 identified the left calf wound measuring 7.5 cm x 5.0 cm ulceration with central eschar with foul odor with central eschar movable. It further revealed that the eschar currently covering the middle of the wound was excised due to detachment and delaying of the wound healing; the wound bed was covered in yellow fibrous slough. Interview with Licensed Practical Nurse (LPN) # 2 on 04/20/16 at 10:42 A.M. revealed that Resident #50 had a brace on her left leg that had a metal rod in the back and that was how she developed the pressure sore. LPN #2 revealed that Resident #50 had a dressing change to her left knee from an abrasion that needed to be completed daily, but during the dressing changes the immobilizer was un-velcroed but not removed, and the back of Resident #50's knee was never examined to check for pressure. LPN #2 revealed that the pressure sore was found due to an STNA who had noted an odor and drainage. LPN #2 voiced that she felt that the pressure sore could have been avoided if there would have been daily visual skin check completed to Resident #50's left lower extremity. Interview with Assistant Director of Nursing (ADON) #444 on 04/20/16 at 10:51 A.M. revealed that Resident #50 was admitted to the facility with a [MEDICAL CONDITION], had a knee immobilizer in place and the metal on the back of the immobilizer caused a pressure sore to the back of the resident's calf. ADON #444 revealed that on admission, as like all residents, it was ordered to have a weekly skin assessment completed. ADON #444 revealed that the nurses were supposed to remove the brace every shift to assess the skin and she verified that this was not being completed. She revealed that she felt that the pressure sore was avoidable. She revealed that on 02/05/16, Resident #50 was seen by her orthopedic physician and the metal bar was removed from the immobilizer. Further interview with ADON #444 on 04/21/16 at 8:35 A.M. revealed that the discharge orders from the hospital included the resident could bear weight on the left leg as tolerated with the knee immobilizer on and do not bend the knee for two weeks. She revealed that the facility had left Resident #50's immobilizer in place at all times due to the resident's cognitive status. ADON #444 revealed that her immobilizer should have been removed for hygiene and voiced that during the scheduled weekly skin checks, the nurses were supposed to and she would have expected them to remove the brace to perform a skin check. ADON #444 further revealed that she was unsure if the physician was called for a clarification order regarding the removal of the immobilizer. ADON #444 revealed that based on the investigation that was conducted it was identified that when the resident was to have her dressing changed to her left knee, the nurses had just opened up the immobilizer brace and did not lift the leg to assess the area. Observation with ADON #444 on 04/21/16 at 10:10 A.M. of Resident #50's dressing change to her left lateral calf revealed there was a small amount of yellow drainage on the old dressing that had been removed, there was no odor. The wound bed was pink with less than 25% slough noted. ADON #444 cleansed the area with normal saline, applied calcium alginate, covered the area with a dry clean dressing and used paper tape to secure the dressing. Interview with the Licensed Nursing Home Administrator (LNHA) on 04/21/16 at 11:34 A.M. revealed that the facility does not have a policy on the application or the removal of braces or slings. She revealed that all braces and slings come with different guidelines, so they get their directions from the physicians order or the physical therapy orders. Phone interview with the Orthopedic Patient Care Coordinator (PCC) #3 on 04/21/16 at 11:45 A.M. revealed that on 01/04/16 there were orders written for Resident #50 to continue the knee immobilizer and to be weight bearing as tolerated and to follow up in two weeks. She confirmed that there was no order to leave the immobilizer in place at all times. Phone interview on 04/21/16 at 1:45 P.M. with Orthopedic Physician (OP) #5 revealed that if the facility staff would have called for a clarification order in regards to Resident #50's immobilizer, he would have told them to remove the brace for hygiene and bathing and to keep the knee straight. He revealed that he normally doesn't write orders for skin checks to be completed because the facility usually does that and that he would have to be more specific in the future. OP #5 revealed that he would have expected the staff to remove the brace and inspect the skin or to have called for a clarification order. Interview on 04/22/16 at 3:50 P.M. with Medical Director (MD) #10 revealed that when he first saw the pressure ulcer it was approximately 9 cm x 6 cm with eschar covering the wound bed. He voiced that the eschar was removed on 03/11/16 and the wound bed had scant amount of slough and nice granulation tissue present. MD #10 revealed that prior to Resident #10 developing the pressure ulcer to her left calf he would have expected the staff to remove the brace and to do skin checks as long as it was not contraindicated. MD #10 confirmed he was unsure if the orthopedic physician was called for a clarification order regarding the knee immobilizer. Review of the undated facility policy titled Pressure Ulcer Prevention and Management included that each resident's skin condition was assessed upon admission and was documented in the clinical record, a standardized assessment for skin risk, skin assessments are completed and documented by licensed staff, all new facility acquired pressure areas will be investigated and include both the clinical/medical component and facility process, annual training was documented for all nursing personnel related to the skin management program. It revealed that at the time of admission all residents will be accessed for pressure ulcer risk at time of admission using a standardized scale (Braden/Norton), and all resident will have a complete evaluation of skin condition and tissue tolerance. A head to toe skin assessment is to be completed during the first shift.