Every finding on record at Stonecroft Health Campus

Based on interview and record review, the facility failed to ensure a resident's choice of code status was documented accurately for 1 of 2 residents reviewed for advanced directives. (Resident 13) Finding includes: On [DATE] at 2:34 p.m., Resident 13's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, acute respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body), and chronic kidney disease (condition where the kidneys are damaged and can't properly filter waste and fluid from the blood). An Out of Hospital Do Not Resuscitate declaration and order, a choice of treatment document, dated [DATE], was signed by the Resident's POA (power of attorney) and the resident's physician, the document indicated no CPR (cardiopulmonary resuscitation) to be performed. The CPR consent, dated [DATE], indicated to perform CPR while the resident was in the facility. The CPR consent was obtained by verbal phone consent of the Resident's POA and witnessed by two nurses on [DATE]. A review of the physician orders indicated the following: On [DATE] Code Status: Full Code (all possible life-saving measures taken in the event of a medical emergency, such as cardiac or respiratory arrest, including CPR). The order was discontinued on [DATE]. On [DATE]: Code Status: DNR (Do Not Resuscitate). The order was discontinued on [DATE]. On [DATE]: Code Status: DNR. The order was discontinued on [DATE]. On [DATE]: Code Status: DNR. A Social Service Comprehensive Note, dated [DATE], indicated the resident was a full code. A Social Service Comprehensive Note, dated [DATE], indicated the resident was a DNR. A Resident First Meeting Minutes Note, dated [DATE], indicated the Resident's code status remained a DNR. A Resident First Meeting Minutes Note, dated [DATE], indicated the Resident's code status remained a DNR. A Hospital History and Physical, dated [DATE], indicated the resident was a full code. No additional documentation was in the clinical record to reflect the change in advanced directive. During an interview with the DON (Director of Nursing) on [DATE] at 11:55 a.m., she indicated she was unsure why the advanced directive order was changed. The DON indicated there was no further documentation in the record that indicated a request from the POA to change the resident's advanced directive. On [DATE] at 11:45 a.m., the Administrator provided the facility's admission packet, dated [DATE]. The Administrator indicated this was the current admission packet used by the facility. The document indicated .Out of Hospital Do Not Resuscitate Declaration and Order .is used to state your wishes .The declaration may be canceled by you at any time by a signed and dated writing .or by communicated to health care providers at the scene the desire to cancel the order . On [DATE] at 1:08 p.m., the DON provided the Guidelines for DNR Order policy. The policy was dated, [DATE], the DON indicated this was a current policy used by the facility. The policy indicated, .2. A Do Not resuscitate Form shall be completed and signed .and placed in medical record .5. The interdisciplinary care planning team will review advance directives with the resident during quarterly Resident First Conference to determine if the resident wishes to make changes in such directives . 3XXX,d+[DATE](f)(5)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 1 residents reviewed for Resident Assessment. (Resident 55) Findings includes: On 5/19/25 at 11:21 a.m., Resident 55's clinical record was reviewed. The diagnoses included, but were not limited to, lung cancer and lupus (disease when your body's immune system attacks your own organs and tissue). The progress notes, dated 4/18/25 at 3:01 p.m., indicated Resident 55 was discharged home with her husband. The discharge MDS assessment, dated 4/18/25, indicated Resident 55 was discharged to a short term general hospital. During an interview on 5/19/25 at 3:07 p.m., the Social Services Director (SSD) indicated Resident 55 was discharged home. During an interview on 5/20/25 at 10:52 a.m., the MDS nurse indicated Resident 55 was discharged home. The MDS was coded wrong. During an interview on 5/20/25 at 12:24 p.m., the MDS Consultant indicated they did not have a MDS coding policy. The facility followed the RAI (Resident Assessment Instrument) manual. 3.1-31(d)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was given to the resident and the resident representative for 5 of 5 residents reviewed for hospitalization . (Resident 4, Resident 48, Resident 14, Resident 25, Resident 41) Findings include: 1. On 6/19/23 at 11:42 a.m., Resident 4's clinical record was reviewed. The diagnosis included, but was not limited to, elevated white blood cell count. Resident 4's progress notes indicated the resident was sent to the hospital on 4/27/23. The Notice of Transfer or Discharge forms, dated 4/27/23, lacked documentation the resident and the resident's representative had been notified of the transfer in writing and provided the appeal rights information in writing including the contact information of the the Office of the State LTC (Long Term Care) Ombudsman, after the resident was sent out to the hospital. 34848 2. On 6/19/23 at 11:17 a.m., Resident 48's clinical record was reviewed. The diagnoses included, but were not limited to, atrial fibrillation with RVR (rapid ventricular rate), pulmonary embolism (blood clot in the lung), and deep vein thrombosis and embolism (blood clot in the lower extremities). The resident's progress notes indicated he was sent to the hospital on 4/14/23. The Notice of Transfer or Discharge forms, dated 4/14/23, lacked documentation the resident and the resident's representative had been notified of the transfer in writing and provided the appeal rights information in writing including the contact information of the the Office of the State LTC (Long Term Care) Ombudsman, after the resident was sent out to the hospital. 36912 3. On 6/16/23 at 11:15 a.m., Resident 14's clinical record was reviewed. The diagnoses included, but were not limited to, pneumonia and Parkinson's disease. The resident was transferred to the hospital on 6/10/23. There was no documentation to indicate the resident and the resident's representative were notified of the transfer in writing. 4. On 6/16/23 at 11:35 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to, urinary tract infection and pneumonia. The resident was transferred to the hospital on 5/23/23. There was no documentation to indicate the resident and the resident's representative were notified of the transfer in writing. 38312 5. On 6/19/23 at 10:37 a.m., Resident 41's clinical record was reviewed. The diagnoses included, but were not limited to, urinary tract infection, Parkinson's disease, and kidney failure. Resident 41's progress note dated, 3/16/23 at 1:35 p.m., indicated he was very agitated and was slurring his speech. He was transferred to the emergency room for evaluation and treatment. The Notice of Transfer or Discharge form, dated 3/16/23, lacked documentation of a written notification of the Notice of Transfer or Discharge form was given to Resident 41 and his resident representative. During and interview on 6/20/23 at 3:10 p.m., the Director of Nursing (DON) indicated the clinical record lacked the written notifications were given to the residents or the resident representatives. On 6/21/23 at 1:50 p.m., the Administrator provided the facility policy, Guidelines for Transfer and Discharge, dated 5/3/17 and indicated this was the policy currently being used by the facility. A review of the policy lacked information of Notice of Transfer or Discharge form being given to the resident and the resident representative. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii)

Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for residents who transferred to the hospital was provided in writing to the resident or the residents representative for 5 of 5 residents reviewed for hospitalization . (Resident 4, Resident 48, Resident 14, Resident 25, Resident 41). Findings include: 1. On 6/19/23 at 11:42 a.m., Resident 4's clinical record was reviewed. The diagnosis included, but was not limited to elevated white blood cell count. Resident 28's progress notes indicated the resident was sent to the hospital on 4/27/23. There was no documentation that a written notice that specified the facility's bed-hold policy was provided to the resident or the resident's representative. 34848 2. On 6/19/23 at 11:17 a.m., Resident 48's clinical record was reviewed. The diagnoses included, but were not limited to, atrial fibrillation with RVR (rapid ventricular rate), pulmonary embolism (blood clot in the lung), and deep vein thrombosis and embolism (blood clot in the lower extremities). Resident 48's progress notes indicated the resident was sent to the hospital on 4/14/23. There was no documentation that a written notice that specified the facility's bed-hold policy was provided to the resident or the resident's representative. 36912 3. On 6/16/23 at 11:15 a.m., Resident 14's clinical record was reviewed. The diagnoses included, but were not limited to, pneumonia and Parkinson's disease. The resident was transferred to the hospital on 6/10/23. There was no documentation to indicate the resident or the resident's representative were notified of information regarding the facility's bed-hold policy in writing. 4. On 6/16/23 at 11:35 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to, urinary tract infection and pneumonia. The resident was transferred to the hospital on 5/23/23. There was no documentation to indicate the resident or the resident's representative were notified of information regarding the facility's bed-hold policy in writing. 38312 5. On 6/19/23 at 10:37 a.m., Resident 41's clinical record was reviewed. The diagnoses included, but were not limited to urinary tract infection, Parkinson's disease, and kidney failure. Resident 41's progress note, dated 3/16/23 at 1:35 p.m., indicated he was very agitated and was slurring his speech. He was transferred to the emergency room for evaluation and treatment. The clinical record lacked documentation the facility's bed-hold policy was provided to the resident or the resident's representative. During and interview on 6/20/23 at 3:10 p.m., the Director of Nursing (DON) indicated the clinical record lacked the documentation the facility's bed-hold policy was provided to the resident or the resident's representative. On 6/21/23 at 1:50 p.m., the Administrator provided the facility policy, Guidelines for Transfer and Discharge, dated 5/3/17 and indicated this was the policy currently being used by the facility. A review of the policy indicated . c. In cases of emergency transfers, the notice of the bed-hold policy under the State plan and facility's bed-hold policy should be provided to the resident or resident's representative with 24 hours of the transfer . 3.1-12(a)(25) 3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to ensure food was not stored beneath a water line on which water had condensed for 1 of 2 observations of the kitchen. Findings include: During a tour of the facility's walk-in freezer on 5/9/22 at 10:20 A.M., food was observed to be stored beneath the freezer condenser water line, upon which water had condensed and ice had formed. Beneath the freezer condenser were three pot roasts covered in ice that originated from the condenser water line. During an interview on 5/9/22 at 10:25 A.M., the Dietary Manager indicated the food should not have been kept under the freezer condenser. During an interview on 5/11/22 at 10:50 A.M., the Dietary Manager indicated the facility used the Indiana State Department of Health Retail Food Establishment Sanitation Requirements, effective date, November 13, 2004, as the facility policy and procedure regarding food storage. A review of the policy indicated, .410 IAC 7-24-178 Food storage; prohibited areas Sec. 178. (a) Food may not be stored as follows: .(2) Under the following: .under lines on which water has condensed . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure a sanitary and comfortable environment. Resident walls were not free from damage for 2 of 12 rooms reviewed and the facility failed to ensure sit to stand lifts were clean for 5 of 5 residents who use the sit to stand lifts. (Resident 6, Resident 8, Resident 12, Resident 16, Resident 17, Resident 20, Resident 29) Findings include: 1. On 5/5/22 at 12:35 P.M., the wall behind Resident 12's bed headboard was observed to have damage to the drywall and was without paint. 2. On 5/5/22 at 3:00 P.M., the wall left of Resident 16's bedroom window was observed to have damage to the drywall and was without paint. 3. On the following dates and times, the motorized sit to stand lift was observed in the hallway between Room 212 and Room 214 with the foot platform containing food crumbs and debris: - 5/6/22 at 12:30 P.M. - 5/6/22 at 2:30 P.M. - 5/9/22 at 10:00 A.M. - 5/9/22 at 2:15 P.M. - 5/10/22 at 10:45 A.M. - 5/11/22 at 9:45 A.M. - 5/11/22 at 2:50 P.M. 4. On the following dates, times, and locations, a non-motorized sit to stand lift was observed with the foot platform containing food crumbs and debris: - On 5/6/22 at 2:36 P.M., between Room 230 and Room 232. - On 5/9/22 at 10:10 A.M., next to Room 208. - On 5/10/22 at 10:50 A.M., next to the equipment storage room in the 200 unit hallway. - On 5/11/22 at 9:50 A.M., next to Room 216. On 5/11/22 at 11:25 A.M., the Director of Health Services provided a list of residents who currently use the motorized and non-motorized sit to stand lifts which included, Resident 6, Resident 8, Resident 17, Resident 20, and Resident 29. During an interview on 5/11/22 at 10:00 A.M., the Administrator indicated the walls were damaged and in need of repair, and the sit to stand lift foot platforms were dirty and in need of regular cleaning. 3.1-19(f)

Based on interview and record review, the facility failed to provide specific information on what COVID-19 vaccine the employee should be medically exempted from, a clinically recognized contraindication, and failed to obtain proof of vaccination status for a contracted vendor. (Employee 1 and Employee 2) Findings include: 1. On 5/11/22 at 11:30 a.m., a review of the Medical Exemptions for vaccinated/exempted employees revealed the following: -lack of documentation for what specific COVID-19 vaccine Employee 1 and Employee 2 should not receive. -lack of documentation to identify a clinically recognized contraindication for Employee 1 and Employee 2. During an interview on 5/11/22 at 2:15 p.m., the Clinical Support Nurse indicated the facility had been updating its forms for the current guidelines but had not put them into practice yet. On 5/11/22 at 11:30 a.m., the Interim Administrator provided the facility's policy,COVID-19 Health Care Staff Vaccination dated 2/1/22, and indicated it was the policy currently being used by the facility. A review of the policy did not indicate identifying what specific COVID-19 vaccine the employee should be exempted from nor that a medical exemption should contain a clinically recognized contraindication. 2. On 5/11/22 at 11:00 a.m., a document shredding vendor was observed inside of the facility collecting documents. During an interview on 5/11/22 at 2:52 p.m., the ED (Executive Director) indicated the facility did not have record of the vaccination status for the shredding vendors which worked inside of the facility. Upon entrance, all vendors were required to use the electronic screening device which asked individuals if they were vaccinated for COVID-19. During an interview on 5/11/22 at 3:10 p.m., the ED indicated if someone would answer a screening question which prevented their entry, a stop sign would alert the individual to wait for employee assistance. They indicated no other alerts were sent to the facility staff when someone was told to wait for assistance, and one could freely walk about the facility if no one was at the desk. On 5/11/22 at 3:15 p.m., the ED provided the facility policy, COVID-19 Health Care Staff Vaccination, dated 2/1/22, and indicated it was the policy currently being used. A review of the policy did not indicate instruction to obtain outside vendors' vaccination status. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure admission physician orders were obtained for a resident with a Foley catheter (flexible tube which passed through the urethra and into the bladder) for 1 of 3 residents reviewed for urinary catheter. (Resident 29) Finding includes: On 5/4/22 at 3:25 p.m., Resident 29 was observed to be awake in her room with the Foley catheter (F/C) drainage bag hanging on the side of bed. On 5/5/22 at 11:00 a.m., Resident 29 was observed to be awake in her room with the F/C drainage bag attached to the side of her leg. Resident 29's clinical record was reviewed on 5/5/22 at 11:23 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment, dated 4/18/22, indicated Resident 29 had an indwelling urinary catheter. A care plan, initiated on 4/24/22, and current through target date 8/31/22, for Resident 29 indicated, . Problem: Resident uses a F/C for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approach: . Provide assist with catheter care and change F/C per physician orders. The physician orders, dated 5/9/22, lacked documentation of Resident 29 having an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/11/22 at 10:46 a.m., the Director of Nursing indicated there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/11/22 at 12:35 p.m., the Clinical Support nurse provided the facility's policy,Guidelines for the Use of Indwelling Catheter with a revised date of 11/15/21, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . An indwelling catheter is not used unless there is a valid medical justification . 3.1-30(a)

Based on observation, interview, and record review, the facility failed to ensure staff wore Personal Protective Equipment (PPE), as indicated by facility policy, while working on a COVID positive isolation unit for 1 of 1 isolation unit reviewed for infection control. This deficiency had the potential to affect 17 residents who resided on the isolation unit of 48 residents who resided in the nursing facility. Findings include: During an interview, on 12/22/2020 at 12:57 p.m., Registered Nurse (RN) 1 indicated she had observed staff not donning (putting on) and doffing (taking off) Personal Protective Equipment (PPE) and not wearing shoes while having worked on the COVID unit. The unit was a designated COVID unit and full PPE was required to be worn while coming in and out of resident rooms. During an interview, on 12/22/2020 at 1:45 p.m., Licensed Practical Nurse (LPN) 1 indicated she had observed staff not donning and doffing PPE and not wearing shoes while having worked on the COVID unit. During an interview, on 12/22/2020 at 2:00 p.m., Certified Resident Care Associate (CRCA) 1 indicated she had observed staff not donning and doffing PPE and not wearing shoes while having worked on the COVID unit. During an observation, on 12/22/2020 at 3:15 p.m., of facility video surveillance for the COVID unit, dated 12/15/2020 at 7:00 p.m. through 12/16/2020 at 6:00 a.m., the following was observed: -LPN 2 was observed coming in and out of multiple resident rooms without donning or doffing PPE. -CRCA's 2, 3 and 4 were observed coming in and out of multiple resident rooms without donning or doffing PPE. -CRCA 2 was observed multiple times walking down the hall while not wear a face mask or shoes. -RN 2 was observed walking down the hallway and coming in and out of multiple resident rooms while wearing the same gown. The resident rooms were observed on the video to have PPE stations outside each resident room which included gowns, gloves and hand sanitizer. On 12/23/2020 at 2:00 p.m., the Clinical Support Liaison provided the facility's policy, Standard of Practice (SOP)-Guidelines for COVID-19 with a revised date of 3/11/2020, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 2. e. Appropriate PPE should be used by healthcare personnel when interacting with the resident . The Indiana State Department of Health Toolkit dated, 10/19/2020, included, . COVID-19 Positive (Red). These are residents who are confirmed COVID-19 positive and who, based on Center for Disease Control (CDC) criteria still warrant transmission based precautions. Health Care Provider (HCP) will wear a single gown with each resident, glove, N95 (or approved KN95) mask and eye protection. Gowns and gloves should be changed after every resident encounter . This Federal tag relates to Complaint IN 899. 3.1-18(b)

Based on observation, interview, and record review, the facility failed to ensure food was stored unopened and not stored beneath a water line on which water had condensed. This had the potential to affect 52 of 52 residents who were served from the facility kitchen. Findings include: During a tour of the facility's walk-in freezer, on 1/6/20 at 10:20 [NAME]M., food was observed to be stored beneath the freezer condenser water line, upon which ice had formed. The food included 1 box of cod filets and 1 bag of cod loins. The filets were in a bag within the box. The box and bag were both opened, exposing the cod filets to air and ice. The cod loins were in a bag, which was open, exposing the loins to air and ice. On a shelf, not beneath the freezer condenser, was 1 open box of sausages and 1 box of pastry dough. The sausages were in a bag within the box. The box and bag were both opened, exposing the sausages to air. The pastry dough was within a bag within the box. The box and bag were both opened, exposing the pastry dough to air. During an interview, on 1/6/20 at 10:35 [NAME]M., the Dietary Manager indicated the cod filets, cod loins, sausages, and pastry dough were exposed to air and should have been closed. The cod filets and cod loins were stored beneath the condenser water line, upon which ice had formed and should have been stored elsewhere. During an interview, on 1/8/20 at 2:20 P.M., the facility Administrator indicated the facility uses the Indiana State Department of Health Retail Food Establishment Sanitation Requirements, effective date, (MONTH) 13, 2004, as the facility policy and procedure regarding food storage. A review of the policy indicated, .410 IAC 7-24-177 Food storage Sec. 177 . food shall be protected from contamination by storing the food as follows: .(5) In packages, covered containers, or wrappings ., and .410 IAC 7-24-178 Food storage; prohibited areas Sec. 178. (a) Food may not be stored as follows: .(2) Under the following: .under lines on which water has condensed . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a [DIAGNOSES REDACTED]. Findings include: Resident 31's clinical record was reviewed on 1/9/2020 at 10:34 a.m. [DIAGNOSES REDACTED]. Physician orders, dated (MONTH) 2020, indicated Resident 31's medications included, but were not limited to: [MEDICATION NAME] (an antidepressant) 10 mg (milligrams), 2 tablets once a day for depression. The medication start date was 9/11/2019. Resident 31's Quarterly Minimum Data Set (MDS) assessment, dated 11/21/2019, indicated an antidepressant was taken 7 out of 7 days. The MDS did not have a [DIAGNOSES REDACTED]. During an interview, on 1/10/2020 at 11:15 a.m., the MDS Coordinator indicated the Quarterly MDS for Resident 31 was coded incorrectly and should have been checked for depression. On 1/10/2020 at 1:43 a.m., the MDS Support person indicated the facility did not have a policy related to correctly coding the MDS. They follow the RAI (Resident Assessment Instrument) manual. A review of the RAI Version 3.0 Manual, Section I indicated, . Code diseases that have a documented [DIAGNOSES REDACTED]. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure licensed staff remained in the room during medication administration for 1 of 1 randomly observed resident (Resident 150). Findings include: On 1/8/2020 at 9:41 a.m., two medication administration containers were observed to be on Resident 150's bedside table. One contained several pills and the other contained a liquid medication. The resident was lying in bed awake. There was no nurse present in the room, at that time. On 1/8/2020 at 9:42 a.m., Registered Nurse (RN) 1 was observed to enter Resident 150's room and indicated she was sorry for leaving the room. Resident 150's clinical record was reviewed on 1/8/2020 at 10:34 a.m. [DIAGNOSES REDACTED]. Interview, on 1/8/2020 at 10:15 a.m., RN 1 indicated she left the room to take Resident 150's breakfast tray out. Interview, on 1/8/2020 at 12:01 p.m., The Director of Health Services (DHS) indicated the nurse should have stayed with the resident until all the medications were gone. Review, on 1/10/2020 at 3:00 p.m., of the RN job description, undated, indicated, . Nursing Care Functions . Comply with written procedures for the administration, . of medications . On 1/8/2020 at 12:45 p.m., the DHS provided the facility's policy, untitled with a date of 3/2015, and indicated it was the policy currently being used by the facility for medication administration. A review of the policy indicated, . II. During the medication pass . monitor resident, make sure medication is taken, leaving no medications at bedside. 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure a Foley catheter (a flexible tube inserted into the urethra and drains urine from the bladder) drainage collection bag and tubing were positioned off of the floor for 1 of 2 residents reviewed for urinary catheter use (Resident 7). Findings include: On 1/7/2020 at 11:50 a.m., Resident 7's Foley catheter urine collection bag and tubing were observed attached to a bed lift handle while the tubing and drainage bag rested on the floor. Interview, at that time, the resident indicated someone recently emptied the bag and he often had UTIs (urinary tract infections). On 1/7/2020 at 2:30 p.m., Resident 7's Foley catheter collection bag and tubing were observed resting on floor. On 7/9/2020 at 10:00 a.m., Resident 7's clinical record was reviewed. [DIAGNOSES REDACTED].) and type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. Review of Resident 7's, January, 2020, current physician's orders [REDACTED]. Medical reason: Obstructive and reflux [MEDICAL CONDITION], 8/15/2018 (start date). A care plan, initiated on 11/26/2019 and current through 2/26/202, for Resident 7 indicated, Problem State Date: 11/26/2019 . I have an indwelling catheter because I have a dx (diagnosis) of [MEDICAL CONDITION] . Goal: I do not want to have an infection . because of my catheter use . The care plan did not address keeping the drainage bag nor tubing off of the floor. Review of Resident 7's progress notes indicated the following: 11/6/2019 at 7:27 p.m., . NP (nurse practitioner) ordered [MEDICATION NAME] (injected antibiotic medication) . to be given daily for positive urine culture. Bactrim (antibiotic medication) to be continued. 12/6/2019 at 10:30 a.m., . UTI review. Resident complaints of lower flank pain (pain in the upper abdomen or back which can signify kidney problems) . resident continues [MEDICATION NAME](antibiotic medication). Interview, on 1/7/2020 at 2:38 p.m., the Director of Health Services indicated Resident 7 recently received a new bed which could be why the drainage bag was on the ground. She would get a dignity bag (a bag which conceals urine in the drainage bag to improve patient dignity) to lift and hang up the bag. On 1/10/2020 at 3:03 p.m., the Director of Health Services provided the facility policy, Urinary Catheter Care, dated 5/11/2016, and indicated it was the policy currently being used. A review of the policy indicated, Overview To prevent infection of the resident's urinary tract . 11. Be sure the catheter tubing and drainage bag are kept off the floor . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident received oxygen (O2) as indicated on the physician order [REDACTED]. Findings include: 1. On 1/7/20 at 10:15 a.m., Resident 44 was observed to be resting in her bed with O2 on at 2.5 liters (L) per nasal cannula (tube which delivers O2) (NC). On 1/8/20 at 1:57 p.m., Resident 44 was observed to be resting in bed with O2 on at 2.5 L per NC. On 1/9/20 at 9:39 a.m., Resident 44 was observed to be resting in bed with O2 on at 2.5 L per NC. On 1/9/20 at 10:04 a.m., Resident 44's clinical record was reviewed. The [DIAGNOSES REDACTED]. A care plan initiated on 12/18/19 and current through 4/10/20, for Resident 44 indicated: Problem: .Potential for SOB (shortness of breath) while lying flat r/t (related to): Asthma .GOAL: Resident will be free of complications from SOB .INTERVENTIONS .Administer oxygen per MD (medical doctor) order and as needed . Resident 44's Skilled Documentation indicated the following: -On 1/6/20 at 1:02 a.m., refer to physician orders [REDACTED]. -On 1/7/20 at 2:52 a.m., refer to physician orders [REDACTED]. -On 1/8/20 at 7:34 a.m., refer to physician orders [REDACTED]. Resident 44's, (MONTH) 2020, physician orders [REDACTED].>Interview, on 1/9/20 at 10:28 a.m., Licensed Practical Nurse (LPN) 1 indicated Resident 44 had a [DIAGNOSES REDACTED]. Interview, on 1/10/20 at 2:28 p.m., the Director of Health Services (DHS) indicated the chart lacked documentation of a physician order [REDACTED]. On 1/10/20 at 3:03 p.m., the DHS provided the facility policy, Guidelines for the Administration of Oxygen, dated 9/17/18, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .1. Verify physician's orders [REDACTED]. 2. On 1/7/20 at 11:19 a.m., Resident 249 was observed to be sitting in his wheelchair in his room with oxygen (O2) on at 3 liters (L) per nasal cannula (NC). On 1/8/20 at 12:21 p.m., Resident 249 was observed to be sitting in the front lobby in his wheelchair with O2 on at 3 L per NC. On 1/9/20 at 10:19 a.m., Resident 249 was observed to be participating in therapy with O2 on. On 01/9/20 at 10:30 a.m., Resident 249's clinical record was reviewed. The [DIAGNOSES REDACTED]. A care plan initiated on 12/18/19 and current through 3/18/20, for Resident 249 indicated: Problem: .Potential for SOB (shortness of breath) while lying flat r/t (related to): resp (respiratory) failure .GOAL: Resident will be free of complications from SOB .INTERVENTIONS .Administer oxygen per MD (medical doctor) order and as needed . Resident 249's Skilled Documentation indicated the following: -On 1/6/20 at 12:35 a.m., refer to physician orders [REDACTED]. -On 1/7/20 at 2:43 a.m., refer to physician orders [REDACTED]. -On 1/8/20 at 2:37 a.m., refer to physician orders [REDACTED]. Resident 249's, (MONTH) 2020, physician order [REDACTED].>Interview, on 1/9/20 at 10:28 a.m., Licensed Practical Nurse (LPN) 1 indicated Resident 44 had a [DIAGNOSES REDACTED]. Interview on 1/10/20 at 2:28 p.m., the Director of Health Services (DHS) indicated the chart lacked documentation of a physician order [REDACTED]. On 1/10/20 at 3:03 p.m., the DHS provided the facility policy, Guidelines for the Administration of Oxygen, dated 9/17/18, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .1. Verify physician's orders [REDACTED]. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure supervision of a resident assessed to be at risk for falls 1 of 1 resident reviewed for accidents which resulted in repeated falls with the most recent fall resulting in emergency room care and stitches (Resident 43). Findings include: On 12/4/18 at 11:00 a.m., Resident 43 was observed self-propelling down the hallway by himself. Staff were not observed to be near the resident, nor supervising. On 12/5/18 at 10:00 a.m., Resident 43 was observed self-propelling down the 200 hall by himself. Staff were not observed to be near the resident, nor supervising. During an interview, on 12/5/18 at 12:02 p.m., Resident 43's family member indicated the resident has fallen multiple times and they were very concerned for his well-being. They further indicated he wandered in and out of rooms all the time. On 12/6/18 at 3:25 p.m., Resident 43's clinical record was reviewed. [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. The 30-day Minimum Data Set (MDS) assessment, dated 11/5/18, indicated Resident 43 was cognitively intact, required limited assistance of one with transfers, supervision of one with walking, and had 2 falls since admission: one with injury and one without. A care plan, initiated on 10/30/18 and current through target date 1/30/18, for Resident 43 indicated, Problem State Date: 10//30/18. Resident is at risk for falling R/T (related to) [MEDICAL CONDITION]. Goal: Resident will remain free of falls with major injury. Approach: Labs as ordered. Created 12/6/18. Redirect resident as needed. Offer snacks while awake at night. Created 12/6/18. Remove mattress from bedside. Created 12/3/18. Scoop mattress to provide bed boundaries. Created 12/3/18. UA (urinalysis) as ordered. Created 12/3/18. Staff to offer to assist to toilet after lunch. Created 12/3/18. Staff to offer to assist with toileting during the night. Created 12/3/18. Mattress at bedside (removed). Edited on 12/4/18. Orthostatic BP's (blood pressures) for one week. BID (twice daily) accuchecks (blood sugar monitoring) for one week to determine if falls are related to medical complication. Created 11/26/18. Ensure resident to utilized non skid footwear and encourage to use call light when assistance is needed. Created 11/20/18. Staff to assist to the bathroom during the night and resident encouraged to use call light for assistance. Created: 11/12/18. Educate resident to call for assistance with going to the bathroom. Created 10/31/18. Encourage resident to assume standing position slowly. Created 10/31/18. Ensure the floor is free of liquids and foreign objects. Created 10/30/18. Keep call light within reach. Created 10/30/18. Keep personal item and frequently used items within reach. Created 10/31/18. Provide non-skid footwear. Created 10/30/18. Staff to assist resident with transfer as needed. Created 10/30/18. Therapy eval (evaluation) and treat as needed. Created 10/30/18. The care plan lacked documentation of staff supervision to implement. Resident 43's Admission assessment indicated the resident had a fall in the last month prior to admission and he had a fall in the last 2-6 months prior to admission. The assessment did not identify his fall risks. A review of Resident 43's Event Reports indicated the following: On 10/24/18 at 1:20 p.m., the resident fell in his bedroom and obtained a skin tear on front of his left elbow. The resident got up to go to the bathroom and a new intervention was implemented for the resident to request assistance with going to the bathroom. On 10/26/18 at 4:30 p.m., the resident fell in the day room and obtained a skin tear on the back of his left elbow. The resident stood up and things 'got black' and a new intervention was implemented for the resident to rise slowly from sitting or lying to standing. On 11/7/18 at 2:00 a.m., the resident fell in his bedroom and obtained a cut above his right eye and a cut to the right side of his nose. The resident was self toileting and intervention was implemented for staff to offer assistance to the bathroom during the night and staff were instructed to perform 2 hour safety checks. On 11/15/18 at 8:35 p.m., the resident fell in his bedroom. The resident was trying to walk unassisted and a new intervention was implemented for the resident encouraged to use the call light for when needing assistance and to utilize non-skid foot wear. On 11/20/18 at 6:56 a.m., the resident fell in his bedroom and obtained an abrasion on the left elbow and left knee. The resident was up walking in his room by himself and a new intervention was implemented for the resident to have orthostatic blood pressure (low blood pressure that happens when you stand up from sitting or lying down) readings for one week. On 11/30/18 at 11:40 a.m., the resident fell out of his bed. A new intervention was implemented for a mat to be placed next to the bed. On 12/2/18 at 1:22 p.m., the resident fell in his bedroom while self toileting. He was walking with his walker and a new intervention was implemented for staff to offer assistance to toilet after lunch. On 12/2/18 at 4:40 a.m., the resident fell in his bedroom and obtained a small scratch on his right ear and a small scratch on his right great toe. The resident was noted to be more confused and incontinent (lack of voluntary control over urination) and new interventions were implemented for staff to collect a UA (urinalysis is used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes), side mat removed, and a scoop mattress placed on bed for boundaries. On 12/3/18 at 3:25 a.m., the resident fell in his bathroom while self toileting. On 12/5/18 at 10:59 p.m., the resident fell in another resident's bedroom. The resident was in another resident's room and a new intervention was implemented for staff to redirect the resident and offer snacks when up at night. New orders were received for labs related to increased confusion. On 12/6/18 at 3:30 p.m., the resident fell in the common area after he attempted to walk. On 12/6/18 at 7:01 p.m., the resident fell in another resident's bedroom. On 12/6/18 at 8:06 p.m., the resident fell and hit his head on a counter in the common area. The resident attempted to stand from the wheelchair in the common area and was sent to the emergency room which resulted in the resident obtaining stitches. A review of progress notes indicated the following: 10/31/18 at 12:29 p.m., IDT (interdisciplinary team) review for falls that occurred on 10/24 and 10/26. On 10/24 resident got up to go to the bathroom and fell from bed. New intervention added for resident to request assist with going to bathroom. On 10/26 resident stated he got up and thing got black and he fell . Resident was educated to rise slowly from sitting or lying to standing . 11/12/18 at 11:07 a.m., IDT (interdisciplinary team) review for the fall that occurred 11/7 . Root cause: Resident noted on floor beside bed, he had attempted to self transfer to the bathroom. New intervention: Staff to offer assist to the bathroom during the night and resident encouraged to use call light for assistance . 11/15/18 1:27 a.m., At 1 am, resident walked out of his room and went right to the side door next to his room. He trying (sic) to push the door open because he saw a woman outside that needs help. After redirected, resident sit at the nurse station for coffee . 11/20/18 at 7:45 a.m., Resident found in floor by CRCA (certified resident care assistant) in front of the room's door at 6:56 a.m. Resident stated he was trying to walk around when he fell . Resident has abrasion on L (left) elbow and L knee . Resident did not use call light fir (sic) assistance. 11/20/18 at 3:54 p.m., IDT (interdisciplinary team) review for fall that occurred on 11/15. Resident stated he was trying to walk around when he fell in the floor . Root cause: Resident attempting to walk unassisted without non-skid foot wear. New intervention: Resident educated to use call light when needing assistance and to utilized non-skid food wear . 11/21/18 2:54 p.m., Res (resident) ambulated X 1 from his rm (room) into hallway to another res rm w/o (without) assist . This writer then asked RCA (resident care assistant) if she could provide 1:1 (one-on-one) with res. Res is currently with therapy . 11/26/18 at 12:08 a.m., Resident had not been sleeping at night. This evening, resident seen walking shirtless into room across the hall from his, then walking out of the room. Resident redirected. Resident not sleeping during the night is common occurrence. Often seen up at nurse's station, sitting in w/c (wheel chair) and watching television or wandering around the facility asking for breakfast . 12/2/18 at 5:07 a.m., Found resident sitting on floor without his pants on. Resident was sitting on hop of his comforter, which was soaked in urine. There was also a large wet spot on resident bottom sheet. Resident had wet brief, which he had placed in trash can. Pants were also saturated and were hanging on the side of his walker. Resident was unable to verbalize the reason he ended up in his position, though it is presumed to be r/t (related to) incontinent episode . 12/2/18 at 1:23 p.m., Answered resident's call light to find him on the floor by his restroom with his walker on top of him. States that he was going to the bathroom when he got dizzy and fell over . 12/2/18 at 3:48 a.m., Resident was in bathroom and ended up on floor earlier this shift. Resident with increased confusion and increased episodes of incontinence . Resident did have positive [MEDICATION NAME] test (a diagnostic tool used to determine pathological changes in urine) so urine is to be sent to the lab this AM (morning). Resident currently at the nurses station eating a donut . Resident has poor safety awareness. He is mobile and had a bedside mattress next to bed. Resident has been seen walking on mattress and scooting it around, causing more of a safety hazard than it prevented. Mattress removed from room. Resident toileted. More frequent checks in place. 12/2/18 at 10:15 p.m., Resident was wandering into room across the hall from him numerous times this shift and was difficult to redirect. Insisted he was trying to wake up the resident who was in the room . 12/3/18 at 2:17 p.m., Res (resident) continues to transfer self without asking for help . 12/3/18 at 10:40 p.m., Resident walking in hall alone with no walker in depend (incontinence brief) and t-shirt trying to get outside to smoke cigarette . resident to get dressed and brought to nurses station for snack . 12/6/18 at 8:09 p.m., Resident attempted to stand from w/c (wheelchair) in common area and fell forward hitting his head on the LPN (Licensed Practical Nurse) counter, resident sent to (Hospital Name) as per family request. resident has been unable to follow commands, when asked to stay seated, the resident is persistent on self ambulating out of his w/c, compromising his own safety. resident has fallen multiple times in the past 72 hours. 12/7/18 at 1:44 a.m., 0120 (1:20 a.m.) Staff called this nurse over to evaluate res (resident) d/t (due to) res statements of wanting to harm himself. Upon arrival to unit, res had a staff member by the arm twisting it and would not let go. Res had a blank stare on his face and his speech was a little mumbled. Res then tried to stand up and throw himself to the right trying to throw himself to the floor. I informed res I was going to call his daughter and he responded by saying tell her to bring all the guns. 0125 (1:25 a.m.) I notified NP (nurse practitioner) on-call and she said to send him out for evaluation. I placed call to 911 . IDT notes and care plan lacked implementation of intervention(s) of supervision to prevent recurrence of falls. During an interview, on 12/11/18 at 3:00 p.m., Director of nursing indicated she was unsure of the facility's policy, but did not believe they were able to provide one-on-one care for residents. If someone needed one-on-one care, the facility would talk to the family members about providing this need. On 12/11/18 at 3:52 p.m., the Corporate Nurse Consultant provided the facility policy, Fall Management Program Guidelines, revised on 5/31/17, and indicated it was the policy currently being used. A review of the policy indicated the policy did not address the need for increased supervision. On 12/11/18 at 4:00 p.m., the Corporate Nurse Consultant provided the facility policy, Resident Rights, undated, and indicated it was the policy currently being used. A review of the policy indicated, 9. Safe Environment. The resident has a right to a safe . environment, including but not limited to receiving treatment and supports for daily living safely . 3.1-45(a)(2)

Based on interview and record review, the facility failed to document the daily assessment of the [MEDICAL TREATMENT] AV shunt (connection between a vein and an artery) and the monitoring of the thrill (a vibratory sensation felt on the skin overlying an area of turbulence) and bruit (an audible vascular sound associated with turbulent blood flow) for 1 of 1 resident reviewed for [MEDICAL TREATMENT] care. (Resident 15) Findings include: On 12/11/2018 at 10:35 a.m., Resident 15's clinical record was reviewed. [DIAGNOSES REDACTED]. On 12/11/2018 at 10:45 a.m., a review of the (MONTH) and (MONTH) (YEAR), [MEDICAL TREATMENT] treatment sheets for Resident 15 indicated the resident received [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday. A care plan, initiated on 10/24/2018, for Resident 15 indicated: PROBLEM: . Resident has [MEDICAL CONDITION] resulting in need for [MEDICAL TREATMENT] . GOAL: Resident will be free from complications associated with [MEDICAL TREATMENT] . APPROACH: Assess access site for signs of localized infection such as swelling, redness, pain or tenderness, heat at the area, purulent drainage, bloody/malodorous [MEDICATION NAME] . The care plan did not address monitoring for a thrill and bruit daily. The Medical Record Administration (MAR) and treatment sheets for October, November, and (MONTH) (YEAR), lacked documentation which indicated the access site was being assessed and the thrill and bruit was being monitored daily for Resident 15's [MEDICAL TREATMENT] site. During an interview, on 12/11/2018 at 10:58 a.m., Licensed Practical Nurse (LPN) 1 indicated Resident 15 had lost an access site in the past so they watched the access site and checked for a thrill and bruit every day. On 12/11/2018 at 2:47 p.m., The Director of Health Services (DHS) indicated they do not have the documentation to support the access site had been assessed and the thrill and bruit had been monitored daily. On 12/11/2018 at 2:06 p.m., the DHS provided the facility's policy, Guidelines for [MEDICAL TREATMENT] with a review date of 5/22/2018, and indicated it was the policy currently being used by the facility. Review of the policy indicated, 7. Monitor the AV fistula . daily and document in resident medical record . 8. Monitor the AV shunt daily for bruit and thrill . 3.1.37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's request for incontinence care was immediately provided for 1 of 1 resident randomly observed for dignity. (Resident 94) Findings include: On 11/14/2017 at 3:45 p.m., the call light for Resident 94 was observed to be lit up and making a buzzing noise throughout the hallway. License Practical Nurse (LPN) 1 and LPN 2 were observed sitting at the nurses desk. No other staff was observed in the hallway. On 11/14/2017 at 3:58 p.m., the call light for Resident 94 was observed to continue to be lit up and making a buzzing noise throughout the hallway. LPN 1 and LPN 2 were observed sitting at the nurses desk. No other staff was observed in the hallway. On 11/14/2017 at 4:03 p.m., the call light for room [ROOM NUMBER] was observed to continue to be lit up and making a buzzing noise throughout the hallway. LPN 1 and LPN 2 were observed sitting at the nurses desk. No other staff was observed in the hallway. On 11/14/2017 at 4:10 p.m., Certified Nursing Assistant (CNA) 1 was observed to enter Resident 94's room, turn the call light off and immediately exit the room. During an interview on 11/14/2017 at 4:15 p.m., Resident 94 indicated she had been incontinent of bowel and after CNA 1 answered the call light CNA 1 informed the resident she was going to get some help, a wash cloth and would return in a few minutes. Resident 94 indicated she felt humiliated to be incontinent for so long. On 11/14/017 at 4:22 p.m., CNA 1 was observed taking resident's to the dining room to prepare for dinner. CNA 1 was observed to not return to Resident 94's room after she answered the call light. On 11/14/2017 at 4:25 p.m., the call light for Resident 94 was observed to be lit up again and making a buzzing noise throughout the hallway. CNA 2 was observed to yell into the room, I will be right there. LPN 1 and LPN 2 were observed to be sitting at the nurses desk. On 11/14/2017 at 4:27 p.m., Resident 94's call light was observed to be answered by CNA 3. On 11/14/2017 at 4:33 p.m., CNA 3 indicated Resident 94 had been incontinent of bowel and she had gotten her cleaned up. Resident 94's clinical record was reviewed on 11/16/2017 at 11:00 a.m. [DIAGNOSES REDACTED]. Review of Resident 94's Admission Minimum Data Set (MDS) Assessment, dated 9/5/2017, indicated a BIMS (Brief Interview for Mental Status) score of 12, with a score of 8 to 12 being interviewable and moderately cognitively impaired. The MDS further indicated the resident as always incontinent of bowel and required extensive assistance of two staff with Activities of Daily Living (ADL's). On 11/14/2017 at 5:00 p.m., The Director of Health Services (DHS) indicated the staff failed to prioritize the resident's needs and should have attended to Resident 94 as soon as possible. On 11/16/2017 at 11:53 a.m., the DHS provided the facility's policy, Resident Rights Guidelines with a revised date of 8/11/2016, and indicated it was the policy currently being used by the facility. The policy indicated, . 2. Our residents have a right to . a. Be treated with dignity and respect . 3.1-3(t)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) skin assessment for 1 of 27 residents reviewed for accuracy of the MDS (Resident 94). Findings include: On 11/14/17 at 11:33 a.m., Resident 94's clinical record review was reviewed. [DIAGNOSES REDACTED]. A review of Resident 94's November, 2017, Treatment Administration Record indicated the resident had an old skin impairment assessed on 11/6/17 and on 11/13/17. Resident 94's MDS assessment, dated 11/12/17, indicated, Other Ulcers, Wounds and Skin Problems . None of the above were present . On 11/16/17 at 10:48 a.m., the MDS Coordinator indicated the MDS coding of no skin problems was inaccurate. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to develop a dental care plan for 1 of 1 resident reviewed for dental. (Resident 5) Findings include: On 11/9/17 at 11:03 a.m., Resident 5 was observed to have some lower teeth missing. On 11/14/17 at 11:58 a.m., Resident 5's clinical record was reviewed. The [DIAGNOSES REDACTED]. A review of Resident 5's admission Minimum Data Set (MDS) assessment dated [DATE], indicated obvious or likely cavity or broken natural teeth. A review of Care Area Assessment (CAA) summary dated 10/27/17, indicated to proceed to care plan due to the potential dental problems. A review of Resident 5's care plans lacked a care plan to address dental problems. During an interview on 11/16/17 at 10:25 a.m., the MDS nurse indicated there was no dental care plan to address assessed dental problems. On 11/16/17 at 2:30 p.m., the Director of Health Services (DHS) indicated the facility did not have a care plan policy. 3.1-35(c)(1)

Based on observation, interview, and record review, the facility failed to ensure staff followed physician's orders for the prevention of skin tears (partial or complete separation of the outer skin layer) for 1 of 3 residents reviewed for skin observation. (Resident 32) Findings include: Resident 32's clinical record was reviewed on 11/8/2017 at 2:30 p.m. [DIAGNOSES REDACTED]. A review of Resident 32's November, 2017, Physician's orders indicated the following: Skin sleeves to BUE (bilateral upper extremities) at all times except skin assessments and hygiene. On 11/9/2017 at 11:11 a.m., Resident 32 was observed sitting in a wheelchair next to the nurses station, dressed in day clothing with multiple bruises and scabs on bilateral upper extremities. Resident 32 was observed to not be wearing skin sleeves. On 11/9/2017 at 2:09 p.m., Resident 32 was observed sitting in a wheelchair next to the nurses station, dressed in day clothing with multiple bruises and scabs on bilateral upper extremities. Resident 32 was observed to not be wearing skin sleeves. On 11/14/2017 at 10:00 a.m., Resident 32 was observed sitting in a wheelchair next to the nurses station, dressed in day clothing which included a long sleeved sweatshirt. Multiple bruising and scabs were observed on bilateral hands. Resident 32 was observed to not be wearing skin sleeves. On 11/14/2017 at 2:22 p.m., Resident 32 was observed attending an activity of crafts, dressed in day clothing which included a long sleeved sweatshirt. Multiple bruising and scabs were observed on bilateral hands. Resident 32 was observed to not be wearing skin sleeves. On 11/14/2017 at 3:50 p.m., Resident 32 was observed sitting in a wheelchair next to the nurses station, dressed in day clothing which included a long sleeved sweatshirt. Multiple bruises and scabs were observed on bilateral upper extremities. Resident 32 was observed to not be wearing skin sleeves. On 11/14/2017 at 4:30 p.m., License Practical Nurse (LPN) 2 indicated Resident 32 is to wear the skin sleeves at all times and she does not have them at this time. LPN indicated the skin sleeves were possibly being laundered. On 11/15/2017 at 11:00 a.m., Certified Nursing Assistant (CNA) 4 indicated during an interview that Resident 32 often refuses her skin sleeves however, she does not need to wear the skin sleeves if she has a long sleeved shirt on. The staff will chart in Care Tracker and/or progress notes on the dates when she refuses. On 11/16/2017 at 11:21 a.m., The Director of Health Services (DHS) and the Director of Social Services indicated there were no behaviors of refusal to wear the upper extremity skin sleeves charted by the CNA's in Care Tracker or by the nurses in progress notes on 11/9/2017 and 11/14/2017. During an interview on 11/16/2017 at 4:00 p.m., a representative from the skin sleeve manufacturer indicated, A shirt sleeve will not provide the same protection as the geri (skin) sleeve. The geri sleeve can be used with a long sleeved shirt and will still provide the protection to the skin as indicated. A careplan with a start date of 8/16/2017, and edited on 11/15/2017, for Resident 32 indicated: . Problem: Skin Integrity. I have multiple skin tears r/t (related to) fragile skin . GOAL: My cut, skin tear, etc. will heal without complications . APPROACH: Apply geri sleeves to arms and legs for protection . On 11/16/2017 at 11:59 a.m., the DHS indicated the facility does not have a policy related to following physician orders. 3.1-37(a)