Every finding on record at Sun Health Grandview Care Center

Based on a review of clinical records review, resident and staff interviews, and policy review, the facility failed to ensure that medications were not left at the resident's bedside for 2 of 61 sampled residents (#36, #39). The deficient practice could result in the overmedication or undermedication of residents.-Regarding Resident #36Resident #36 was admitted to the facility on [DATE] with diagnoses that included fracture of the right femur, unspecified fall, acute post hemorrhagic anemia, and hypotension.An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicating intact cognition.During an initial observation of Resident #36's room on July 29, 2025 at 1:40 p.m., a container of Refresh lubricant eye drops 0.5 fl oz (fluid ounce) medication was observed lying on the resident's bedside table.Review of provider orders, revealed no evidence of orders for the Refresh lubricant eye drops. An interview was conducted on July 29, 2025, at 1:40 p.m. with Resident #36, who stated that she brought the eye drops with her and uses them twice a day, both morning and night.A follow-up interview was conducted with a Registered Nurse (RN/staff #46) on July 29, 2025 at 3:17 p.m. as she was entering the resident's room to perform vitals. The RN stated that she observed Refresh tears lubricant eye drops medication on the resident's bedside table, and that she was not aware whether the resident had been assessed for self-administration of medications. The RN then reviewed the resident's clinical record and stated that there was no evidence of a a provider order for the Refresh eye drops.Further review of the clinical record revealed a new physician's order dated July 30, 2025, for the Systane Pro PF Ophthalmic Solution 0.6%, 1 drop in both eyes four times a day for dry eyes for 1 day may have at bedside and self-administration.A progress note dated July 31, 2025, at 5:43 p.m., revealed that the resident had an eye appointment on July 30, 2025, and the physician recommended artificial tears 1 gtt (drop) QID (four times a day) OU (both eyes) as needed for dryness or irritation, may leave at bedside and self-administer eye drops.An interview was conducted on August 1, 2025 at 9:43 a.m. with the Director of Nursing (DON/Staff# 108), who stated that if a resident preferred to self-administration medications, the IDT (interdisciplinary team) would assess the resident and get a physician order for medication self-administration. The DON then stated that Resident #36 had not been assessed for the self-administration of medication because Resident #36 did not ask to self-administer the medication. The DON further stated that the Refresh eye drops found at the resident's bedside was absolutely concerning, and she will educate the staff.-Regarding Resident #39Resident #39 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, muscle weakness, injury of the head, and low back pain.A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition.During an initial observation of Resident #39's room on July 29, 2025 at 2:54 p.m., the following medications were observed lying on the resident's bedside table: -Refresh Lubricant Eye Drops 0.33 fl oz (fluid ounce) -Systane Lubricant Eye DropsThere was no evidence of a provider order in Resident #39's clinical record regarding eye drops.An interview was conducted on July 29, 2025, at 2:54 p.m. with Resident #39 who stated that her mother bought the eye drops in about a month ago, but she had not yet used them.Review of the clinical record revealed no evidence that a Medication Self-Administration Assessment had been performed. Further review of Resident #39's clinical records revealed no evidence in the progress notes of an Interdisciplinary Team (IDT) meeting related to medication self-administration.An interview was conducted on July 29, 2025 at 3 p.m., with a Licensed Practical Nurse (LPN, Staff #182) regarding Resident #39, who stated that she observed the eye drop medications on the resident's bedside table. The LPN then stated that Resident #39 was incapable to self-administer medication due to her limited mobility and range of motion. The LPN further stated that, as per facility policy, residents should not have any kind of medication on the bed side table. The LPN also stated that when medications are observed at a resident's bedside, staff educate the resident. The LPN then reviewed the resident's clinical record and stated that she did not see a physician's order for the eye drops.An interview was conducted on August 1, 2025 at 9:43 a.m. with the Director of Nursing (DON/Staff# 108), who stated that Resident #39 had not been assessed for the self-administration of medication because the resident did not ask for it. The DON further stated that the medication found on the resident's bedside table was absolutely concerning, and she did not know how long eye drop medications had been there, but she will investigate and educate the staff.Review of the facility's policy titled, Medication Administration, revised in April, 2024, revealed that medications should be administered as ordered.Review of the facility's policy titled, Resident Self-Administration of Medication, revised in July, 2024, revealed that each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. The policy then revealed that bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The policy also revealed that all nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or the responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary.

Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure two (#21 and #104) of 61 sampled residents' privacy was respected.Findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, urinary tract infection, and unspecified dementia. The Minimum Data Set, dated [DATE] included a brief interview for mental status score of 4 indicating the resident severe cognitive impairment. The care plan dated July 17, 2025 revealed that resident #21 has impaired cognitive function/dementia or impaired thought processes related to dementia. Interventions included to ask yes/no questions in order to determine the resident's needs and present just one thought, idea, question or command at a time. -Resident #104 was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses that included acute kidney failure, chronic kidney disease, and sepsis due to escherichia. The MDS dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. During the initial interview process, a certified nursing assistant (CNA/staff #12) entered the room without knocking or asking the resident if it was okay to enter, walked past the surveyor, and told the resident that she was getting her water. The interview process stopped while the staff emptied the resident's gray plastic cup of water in the sink and left the room. Then staff #12 returned and entered the room a second time without knocking or asking the resident if she could enter the room. The staff placed the resident's cup on her tray and left. Then CNA #12 was observed saying hi to a resident (#104) in the room across the hall as she walked into the room without asking the resident if it was okay to enter or waiting to be asked to enter. An interview was conducted on July 31, 2025 at 12:52 p.m. with (CNA/staff #12), who stated that she had received training on resident's rights, which included the resident's right to refuse treatment, the right to do what he or she wants, to be treated with dignity and respect, and the right to privacy. She stated that residents have the right to meet with family and guests in private/alone. She stated that she was trained to knock on the resident's door before entering, even if the door is open, to signal to the resident that she is there, and does it most of the time. She stated that most of the time, the resident will say, come in. The CNA stated that sometimes she peeks in and if the resident is busy, she will come back later. The CNA further stated that the reason for knocking and waiting for the resident to respond is to allow the resident privacy and it also shows respect for the resident's privacy. She stated that residents have the right to say that she cannot come into the room. The CNA stated that she remembered entering the resident's room when the surveyor was in the room, and thought the resident was being interviewed, but wasn't aware that the interviews were private and it was possible that she could overhear something confidential. She stated that usually when she does ice water, she has a habit of walking in, so needs to be more aware. The CNA acknowledged that she also walked into the room across the hall without knocking, explaining why she was there, or waiting for the resident to say it was all right to come in. An interview was conducted on July 31, 2025 at 1:46 p.m. with the Director of Nursing (DON/staff #1), who stated that residents have the right to be treated with dignity, respect, and the right to privacy. The DON stated that staff are trained to knock on the door and wait for a response before entering, and if appropriate, staff may need to announce themselves because the patient may not be able to respond. The Resident Handbook, revised 2024, revealed that the resident has the right to privacy and confidentiality: personal privacy includes accommodations, personal care visits, and meetings of family and resident groups. A policy titled, Resident Rights, reviewed/revised April 2024, revealed that the facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on residents' rights and the facility's responsibility to properly care for them. The policy included that all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression.

Based on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure proper infection control was followed and maintained regarding placement of the catheter bag for one of 1 sampled residents (#23). The deficient practice could result in development and transmission of infections.Findings include:Resident #23 was admitted to the facility on [DATE], with diagnoses that included acute kidney failure, retention of urine, type 2 diabetes mellitus with a foot ulcer, and depression.The admission minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident had intact cognition. The assessment also included that the resident had an indwelling catheter.The foley catheter care plan initiated on July 6, 2025, included interventions to maintain a closed drainage system with the drainage bag lower than the bladder at all times and on a privacy bag.During an interview with Resident #23 conducted on July 23, 2025, at 2:10 p.m., the resident stated that CNA's (certified nursing assistant) generally do all sanitary things, wear personal protective equipment, and empty the catheter bag. An observation was conducted on July 29, 2025, at 2:10 p.m., Resident #23 was sitting in a wheelchair in his room, with his indwelling catheter bag placed under the wheelchair and the bag was touching the floor.During a second observation conducted on July 31, 2025, at 12:17 p.m., Resident #23 was in his room sitting in a wheelchair with the indwelling catheter bag under the wheelchair, touching the floor.During another observation conducted with a CAN (staff #109) on July 17, 2025, at 12:24 p.m., Resident #23 was sitting in a wheelchair eating his lunch and his catheter bag was touching the floor. The CNA stated that the resident's catheter bag was touching the floor, and it shouldn't be. The CNA then hung the catheter bag to the resident's wheelchair and stated that the facility had temporary staff and they generally did not hang the catheter bag. She further stated that risk could result in the resident developing a urine infection because the facility floors may not be clean or disinfected.An interview was conducted with a Registered Nurse (RN/staff #213) on July 17, 2025, at 12:47 p.m., who stated that catheter bags should be below the bladder and placed on side of the bed to prevent falls, of under the wheelchair so that the catheter bag is below the bladder and not touching the floor. The RN further stated that the risks due to a catheter bag touching the floor could result in the resident running over the tubing/bag, and could cause trauma (bleeding, pain) to the resident. The RN further stated that if a catheter bag touches the floor there is an infection issue because the floor may not be disinfected.In an interview conducted with the Director of Nursing (DON/staff #108) on August 1, 2025, at 9:55 a.m., who stated that catheter bags should be placed in a covered bag and secured to the side of the bed or under the wheelchair. The DON further stated that the indwelling catheter bag should not be resting on the floor, and should be elevated at least a centimeter above the floor to prevent the risk of infection.A facility policy titled, Catheter Care, revised on April 4, 2024, revealed that if a foley catheter drainage bag or tubing touches the floor, it is considered contaminated and should be replaced as soon as possible. If immediate replacement is not feasible, the contaminated external surfaces should be disinfected with a facility- approved disinfectant wipe and allowed to air dry. The bag should be securely elevated off the floor to prevent further contamination. Staff must change the system as soon as possible.

Based on observation, staff interviews, and policy review, the facility failed to ensure food was stored in accordance with appropriate temperature guidelines for facility refrigerators and the kitchen freezer. The universe was 57. The deficient practice could increase the risk for foodborne illness. Findings include: An observation was conducted on July 29, 2024 at approximately 7:40 A.M on the third floor of the facility. The refrigerator temperature log identified with the location of Canyon revealed that on July 22, 2024, the refrigerator had a temperature of 44 degrees Fahrenheit at 8:00 A.M. Per the temperature log, there was not documented evidence that any corrective action had taken place or that the manager had reviewed the temperature log for that day. A further review of refrigerator temperature logs, revealed that for the Red Rock location on July 7, 2024 and July 20, 2024 the refrigerator was outside of designated parameters. The temperature noted for July 7, 2024 at 4:28 P.M. was noted to be 45 degrees Fahrenheit and the temperature noted on July 20, 2024 at 4:31 was noted to be 50 degrees Fahrenheit. Both instances documented that the door was open; however, there was no evidence that the temperature had been rechecked or that any corrective action had taken place. It was noted that both instances were reviewed by the manager. A review of the temperature log for the Kitchen location for July 24, 2024 at 6:00 A.M. revealed a temperature of 42 degrees Fahrenheit. The log further revealed no evidence of corrective action or that the manager had reviewed the log. A review of the freezer temperature logs for July, 2024 revealed that on July 13, 2024, July 23, 2024 and July 26, 2024 at 6:00 P.M. the temperature was noted to be 2 degrees Fahrenheit. The log showed no evidence of corrective action or that it was reviewed. An interview was conducted with staff #201 (Nutrition Mgr) on July 29, 2024 at approximately 7:40 A.M. Staff #201 stated that she did recall the occurrance on July 22, 2024 of 44 degrees Fahrenheit on the Canyon location refrigerator. She stated that maintenance had looked at the refrigerator and repaired it. She stated that she thought the food items, in the refrigerator at the time, were temperature checked, but that the facility did not maintain a log of food temperature checks if a refrigerator or freezer are outside of temperature zones for food safety guidelines. She stated that her expectation is that all temperature are re-checked and documented and that food temperatures are taken. She stated that if the food is outside of the safety zone, over 41 degrees for the refrigerator and over 0 degrees for the freezer, that it should be discarded. An interview was conducted on July 31, 2024 at 1:49 P.M. with staff #205 (Maintenance Technician). Staff #205 stated that he could not find any July 2024 work orders for the refrigerators or freezer prior to July 29, 2024. He stated that the first time he had heard of a concern regarding the refrigerator temperatures was on July 29, 2024. Staff #205 stated that he tries to ensure that the refrigerators are kept below 38 degrees Fahrenheit. He stated that he was not aware what happened to the food items in the refrigerators or freezer when they were outside of the safety zone, since he was only notified of the issue on Monday, July 29, 2024. An interview was conducted on July 31, 2024 at 8:37 A.M with staff #208 (Facilities Director). Staff #208 stated that they try to keep the refrigerators set to 38 degrees Fahrenheit. He stated tha he was aware of a refrigerator that outside of food safety parameters. He stated that they cleaned the condensor and that the fan was running without issue. He stated that he was not aware if temperatures were initially re-checked or what had happened to the food in the unit. Staff #208 stated he was not made aware of any issues until Monday, July, 29, 2024. An interview was conducted on July 31, 2024 at approximately 8:45 A.M. with staff #201(Nutrition/kitchen Mgr). Staff #201 stated that maintenance had been notified but sometimes she or staff would just verbally alert maintenance when they are in the area and not always put in a formal work order. She stated that on Monday, July 29, 2024 maintenance had conducted a deep clean of the vent area and vacuumed out the coils, but stated that she had no evidence of prior documentation addressing the refrigerator and freezer temperature concerns. She stated that refrigerators outside of the kitchen are temperature checked by the dining room staff, who should put in a work order, document the action they took on the log and notify her, but stated that this had not occured for the dates in question. She stated that her expectation is that refrigerator temperatures are maintained under 41 degrees and freezer temperatures are maintained at 0 degrees Fahrenheit or below. Upon review of the logs, she stated that there was no evidence that the temperatures had been rechecked when temperatures were outside of parameters, nor was there evidence of the action that staff took regarding the food items in the refrigerators or freezer, or that any notifications had taken place. Staff #201 stated that if any food items tested within a refrigerator or freezer were outside of the safety zone and potentially served to residents, the process would be that the administrator and director of nursing would be notified. She stated she was uncertain what food items may have been outside of safety guidelines, or whether they were served to residents. She stated that post observation on the 3rd floor on July 29, 2024 at 7:40 A.M., she did notify the administrator and DON. She stated that no adverse outcomes had been reported for the dates in question. Staff #201 stated that the risk is when temperatures are taken and are outside of parameters, it needs to be documented what transpired, otherwise no one knows what follow-up actually happened. She stated that going forward everything will be documented to ensure proper communication. An interview was conducted on July 31, 2024 at 2:13 P.M. with staff #935 (administrator). Staff #935 stated that the expectation is that refrigerators and freezers are at the correct temperatures at all times. Furthermore, that staff notify their supervisor when temperatures are out of range, which she stated did not happen. Staff #935 stated that food needs to be re-checked when the refrigerator or freezers are out of range. She stated that the risk could include formation of bacteria on the food. A review of the cold temperature storage policy revised January, 2024 revealed that frozen storage temperatures are to be maintained at 0 degrees Fahrenheit or below and refrigerated storage is to be maintained at 41 degrees of below. The policy further notes that prompt corrective actions are to be taken to preserve the wholesomeness and quality of foods exposed to improper storage temperatures and that any deviant readings on the log are to be circled and temperatures should be rechecked in an hour and documented.

Based on clinical record reviews, staff interviews, the Resident Assessment Instrument (RAI) manual, and facility policies, the facility failed to develop and complete a Discharge Minimum Data Set (MDS) assessment within the required timeframe for Resident # 11. The deficient practice could result in delayed identification of potential risks and care needs of the residents. Findings include: Resident # 11 was admitted into the facility on [DATE] at 09:05 PM with diagnoses that included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, acute respiratory failure with hypoxia, and unspecified chronic kidney disease. Review of the MDS assessment history, revealed an Admissions MDS Assessment was completed and accepted March 01, 2024. Resident # 11 was discharged on [DATE] at 11:00 AM; however, medical records revealed no discharge MDS was completed at this time. An interview was conducted on July 30, 2024 at 08:55 AM with MDS Coordinator (Staff #970) who stated the MDS Coordinator role was to complete admission entry records including long-term care admission, quarterly, annual, and discharge assessments. Staff #970 (MDS Coordinator ) stated admission and discharge MDS assessments are due on the 14th day from day of event. Staff #970 (MDS Coordinator) confirmed through electronic medical review that discharge MDS assessment was not created nor completed for Resident # 11. Staff #970 (MDS Coordinator) stated she was confused that no discharge MDS assessment was completed because MDS Coordinators receive reports of all discharges. Staff #970 (MDS Coordinator) stated the discharge MDS assessment for Resident # 11 would be completed, however would be considered late. Staff #970 (MDS Coordinator) stated the risks were that section GG 'functional abilities and goals', would be unavailable for review, there would be no quality measures in place, and that, it's like the discharge never happened. An interview was conducted on July 30, 2024 at 12:31 PM with Director of Nursing (Staff #385/DON) who stated that after learning about Resident # 11 not having a discharge MDS assessment completed -- initiated an audit. Staff #385 (DON) stated risks were that whenever MDS assessment are incomplete, federal and state government would not be updated of quality measures. Staff #385 (DON) stated not having completed an discharge MDS assessment did not meet facility's expectations. Review of the facility's Policy titled, Resident Assessment - Resident Assessment Instrument, (revised July 2024) revealed, facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by Centers for Medicare & Medicaid Services (CMS). The current version of the RAI (MDS 3.0) will be utilized when conducting a comprehensive assessment of each resident in accordance with the instruction found in the RAI Manual. The assessment will include at least the following: identification and demographic information; customary routine; cognitive patterns; communication; vision; mood and behavior patterns; psychological well-being; physical functioning and structural problems; continence; disease diagnosis and health conditions; dental and nutritional status; skin conditions; activity pursuit; medications; special treatments and procedures; discharge planning. Facility will maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessment to develop, review and revise the resident's comprehensive care plan.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure that a physician order for the use of a foley catheter was in place for one resident (#20). The sample size was 15. The deficient practice could result in inappropriate use of a catheter. Findings include: Resident #20 was admitted on [DATE] with diagnosis including sepsis, UTI (urinary tract infection), klebsiella pneumoniae, hypertension and hypothyroidism. A review of the admission MDS (minimum data set) dated July 24, 2024 revelaed that resident #20 had a BIMS (brief interview of mental score) of 14, suggesting that the resident was cognitively intact. A review of the physician orders in the electronic health records revealed no evidence of a physician order for a catheter or catheter care. A review of the TAR (treatment administration record) since admission of the resident, revealed no evidence of an order for catheter care or that catheter care was being tracked or that input or output were being tracked for the resident. A review of the care plan revealed of focus are of urinary track infections and sepsis that were being tracked and noted interventions included encouraging fluid intake, providing antibiotic therapy as ordered as well as antipyretics, analgesics and antispasmodics as ordered. The interventions further noted to track for signs and symptoms of worsening sespis and UTI, lab work as ordered, reporting of results to the physician as well as teaching of good hygiene practices; however the care plan made no mention that the resident had a catheter in place or was receiving catheter care. A review of the clinical admission progress notes dated July 18, 2024 revealed, under the genitourinary subsection, a notation that a catheter was in place due to urinary retention, size 18 french. A further progress note notation dated July 19, 2024 also documented that the resident had an indwelling catheter. A progress note entry on July 20, 2024 revealed that the resident had a catheter in place; however, on this entry the catheter size is noted as 16 french. An interview was conducted on July 31, 2024 at 9:41 A.M. with staff #620 (LPN-licensed practical nurse). Staff #620 stated that daily Foley catheter care involves washing and cleaning the peri area and checking to make sure that the catheter is draining and reinserting as required. Staff #620 stated that catheter care always includes measuring the resident's fluid intake and output. Staff #620 stated that orders would be needed for catheter care. Staff #620 reviewed the resident record and stated that there was no evidence of an order for catheter care. Staff #620 stated that the expectation is for the orders to be in place and that the risk could include infection as no direction is given to staff regarding the catheter care. An interview was conducted on July31, 2024 at 9:58 A.M. with staff #385 (DON-director of nursing). Staff #385 stated that her expectation is that catheter care should be done every week. Staff #385 stated that for catheter care there should be a standard order in place or it should be on the cardex. Staff #385 reviewed the residents' record and stated that she did not see an order in place for the catheter and associated care. She stated that she would be contacting the physician to ensure the procedural orders are in place. Staff #85 stated that risk could include infection and lack of communication with staff. A review of the facility policy entitled catheter care revised March, 2024 revealed that residents with indwelling catgheters are to receive appropriate catheter care when indwelling catheters are in place.

Based on observations, clinical record review, interviews and policies and procedures, the facility failed to ensure one resident was appropriately supervised to prevent a fall with major injury. The deficient practice can contribute to residents being injured during a fall. Resident #19 was admitted to the facility December 7, 2023 and discharged to the hospital December 17, 2023. Resident #19 was readmitted to the facility December 21, 2023 with diagnoses to include displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, transient cerebral ischemic attack, unspecified, weakness. The MDS (minimum data set) dated December 13, 2023 indicate a brief interview for mental status was conducted revealing a BIMS score of 15suggesting resident is cognitively intact. The resident was assessed to be partial to moderate assist with upper dressing, substantial to maximal assist with lower dressing and partial to moderate assist with sit to stand and with toilet transfers. The MDS also revealed the resident is frequently incontinent of bowel and bladder. A review of the care plan initiated on December 7, 2023 revealed that resident #19 was noted to be at risk for falls related to weakness, dehydration, use of antidepressant medication and anemia. The care plan further noted that resident #19 is to be provided assistance from nursing staff as needed to complete activities of daily living toileting, and hygiene needs. A review of the progress note, entered by staff #76 LPN (licensed practical nurse) revealed an entry for December 17, 2023 noting that staff had responded to noise from the bathroom of resident #19 and found the resident lying on the floor. The entry further noted that staff helped the resident to use the toilet , reminded to pull the string/light when done, per resident he stood up without calling the staff to pull his pants, night staff interrupted us while giving report to the oncoming night staff that the resident fell , found resident in bathroom floor with the right legs rotated, right thumb finger had a cut and bleeding, resident is responsive when found , V/S was checked BP 154/65, HR 74, RR 21, T 97.5, Oxygen stat 98 %, sent to ED for possible hip fracture, MD notified, family was notified by night staff and DON , night staff to follow up. Further review of the nursing progress notes dated December 17, 2023 revealed an entry stating while receiving report day shift aide walks up and reports resident is on the floor. Grabbed /V/S equipment, neuro chart and went to assess. Sitting up with legs bent below him in shower stall. Gait belt and 3 assist to w/c as there was no room to extend completely out. Obvious Fx R hip unable to flex extend or move leg-rotated. This writer supported legs up while other two moved w/c into room. Rt hand dorsal aspect purplish and edematous blood on shower floor. V/S taken This writer called 911, daughter and son. Resident remains alert and verbal has bilateral hearing aids in place. Day nurse had notified Dr. Lakshmipathy and DON. Aide remained with resident in room until paramedics arrived -this writer gave report to paramedics from door to elevator. Printed med list and face sheet handed to them. Left the building at 1845. Spoke with family, DIL came in and removed all belongings, pad, w/c, walker charger for HA's, she has charger for phone, clothing. ASH, [NAME] [PHONE NUMBER]. A review of the Fall Risk Assessment completed on December 8, 2023 revealed resident #19 assessment score of 9, indicating resident is a low risk and should have call light within reach for help. Low bed, referral for therapy. Resident scored a 15-post fall risk assessment and upon re-admission. An interview was conducted with resident #19 on May 24, 2025 at 1:16pm. The resident stated he was in his wheelchair when one of the CNA's helped him into the bathroom. The resident stated the CAN told him to ring when he was done and left the bathroom. Resident #19 stated the CAN did not help him to pull down his pants. Resident #19 stated he pulled himself up at the grab bar and let go of the grab bar to pull his pants down and fell forward. Resident #19 stated he hit the back of his head and broke his hip when he fell . Resident #19 stated he ended up in a position where the call light was too far to reach, so he grabbed his cushion from his wheelchair and tried hitting the pull-down rope. He stated he was on the floor for approximately 10 minutes when was finally able to reach the call light and several people came. He stated he had falls previously and that the that and they were aware further stating the facility had asked him when he first arrived and had the dates documented of his previous falls. An interview was conducted on May 24, 2024 at 1:41 P.M. with staff # 47 LPN (licensed practical nurse) who stated the resident fell during the evening shift and had been taken to the hospital due to his fall. Staff #47 stated the resident was initially admitted with a fall risk score of 9 which is considered a low risk, which would include making sure the residents call light is in reach, assistance to the bathroom. She further stated assistance to the bathroom would include ensuring the resident was assisted with their clothing onto the toilet and that the call light was within reach. Staff #47 stated a 10 or more on the fall risk assessment is considered a high risk. A telephonic interview was conducted on May 24, 2024 at 5:29 P.M. with staff #126 CAN (certified nursing assistant). Staff #126 stated she had taken the resident to the bathroom, locked the wheelchair and left to attend to another resident. She stated she had understood he was able to be left alone in the bathroom, until he was done. She stated she told him to call if he needed help when he was done. She stated she heard the resident yelling for help and went into the bathroom to find him on the floor. She stated his clothing was still on and may have fallen when trying to pull his clothing up or down. She stated he had gone to the bathroom on his own previously and did not think there was a problem with him going on his own and had not been told he was a fall risk. An interview was conducted on May 24, 2024 at 2:29pm with staff #130 (Director of Nursing, DON) She stated that residents deemed as a low or high fall risk are have interventions customized for each resident. Stating high risk protocols would ensure the resident and staff are educated, resident is given safety reminders, low bed, floor mats and increase of supervision. Low risk protocol would involve assessing the resident's impulsivity, assist to the toilet, making sure they are seated and making sure they know where and how to use the call light. Staff #130 stated when the facility five-day report was completed the resident had not been interviewed due to his hospitalization and that the registry CNA story appeared consistent. Staff #130 further stated she was unaware of the resident's recollection of his fall until interviewed by Adult Protective Services (APS) post operatively. Review of facility policy titled Fall Policy (revised 3/2024) states each resident will be assessed for the risks of falling and will receive care and services in order to minimize the likelihood of falls.

Based on clinical review, staff interviews, and the facility policy and procedures, the facility failed to update the fall care plan for one resident (#13). The deficient practice could result in more falls. Findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses that included age related osteoporosis, dementia, cellulitis of left lower limb, and muscle weakness. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. It also included that the resident needed a two-person extensive assist with bed mobility, transfers, and toileting and a one-person extensive assist with locomotion on the unit. Review of the fall risk assessment dated [DATE] revealed that the resident's last fall was on July 1, 2023 and was a high risk for falls. The care plan dated July 7, 2023 revealed the resident was at risk for falls related to recent and history of falls, left hip pain, her left leg is shorter than the right leg, hypertension, Parkinson's', dementia, urinary incontinence, use of anxiety medication as needed, osteoporosis, recent infection, and pain. Review of the interventions revealed that there were no new interventions added to the care plan after July 7, 2023. Review of a progress note dated July 10, 2023 revealed that the resident was found kneeling on the side of the bed by the outgoing nurse around 6:10 AM, assessment was done by two nurses, no complaint of pain, and the resident said that she was trying to get to the recliner and feels that her knees are weak and just kneeled on the floor. Bed was in the low position, the resident was holding onto the rails and claimed that she did not hit her head. No visible injuries noted. Review of a progress note dated July 12, 2023 revealed that the resident was found on the floor calling out for help and the call-light was not engaged. A certified nursing assistant (CNA) found the resident on the floor lying on her right side. Resident stated repeatedly that she did not fall or hit her head. However, the incident was not witnessed. A physical head to toe assessment was done and visible injuries were identified. The resident decided that she wanted to go to the emergency room (ER) to be evaluated for pain to the lower hip. 911 was called and the resident was transferred to the ER. Review of the physician's note dated July 16, 2023 states the resident fell and was found kneeling on the floor. No major injuries noted. Review of the fall risk assessment dated [DATE] revealed that the resident's last fall was on July 12, 2023, the resident was a high risk for falls, and the fall prevention protocol was initiated or updated. Review of a progress note dated August 1, 2023 revealed the resident was found on the floor in the bedroom. The resident complained of pain to right side. The physician was notified and the resident was sent to the ER for increased pain. An interview was conducted on October 18, 2023 at 10:47 AM with the MDS Coordinator (staff #100), who stated that fall risks may be care planned when the resident has a high risk of falling and a history of falls. She stated that if a resident falls, the care plan should be updated and the interdisciplinary team (IDT) team decides what interventions should be included on the plan. Staff #100 reviewed the resident's clinical record and stated that the care plan was initiated on July 7, 2023 and there were no new interventions added after that date. She stated that the resident had fallen on: July 10, 12, 23, 2023 and on August 1, 2023. An interview was conducted on October 18, 2023 at 12:36 PM with the Director of Nursing (DON/staff #150), who stated that a care plan for falls is developed when a resident is at risk for falling. She stated that when a resident falls, the facility reviews the incident, completes the incident report, and updates the care plan interventions if it is appropriate. She stated that the facility staff prevent falls by acting and, but the intervention may not be care planned. She stated that there may have been a floor mat in the resident's room, but it was not care planned. The facility's, Fall Policy dated May 2022 stated that each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions well be monitored for effectiveness. When any resident experiences a fall, staff will review the resident's care plan and update as indicated.

Based on closed clinical record review, interviews, and policies, the facility failed to ensure skin assessment was conducted as ordered by the physician for one resident (#1). The deficient practice could result in skin issues not identified and treated as appropriate. Findings include: Resident #1 was admitted on [DATE] with diagnoses of unilateral primary osteoarthritis, cognitive communication deficit, and type 2 diabetes. An undated care plan included that the resident was at risk for skin breakdown and poor skin integrity related to limited mobility. The goal was for the resident to maintain skin integrity and resident's problematic areas will improve or be healed. Interventions included to monitor for and report all red areas. A physician orders dated October 14, 2022 included the following: -Braden Scale Risk Assessment every one week for four weeks; -Braden Scale Risk Assessment quarterly and as needed; and, -Weekly skin assessment. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The assessment included the resident was at risk of developing pressure ulcer/injuries, had a pressure ulcer/injury and a scar over a bony prominence and had one or more unhealed ulcer injuries that was stage 1. Despite the order, review of the clinical record revealed no evidence that Braden Scale Risk Assessments and weekly assessments were completed as ordered. The Weekly Skin assessment dated [DATE] included that the resident had a bruise and redness. However, the documentation did not include the location of these skin findings. Further review of the clinical record revealed that there was no other weekly skin assessment completed for the resident. The Treatment Administration Records (TARs) for October and November 2022 revealed that the Braden Scale Risk Assessments were not documented as completed as ordered. An interview with an MDS nurse (staff #5) was conducted on September 19, 2023 at 2:11 p.m. The MDS nurse stated that skin checks were completed daily and weekly and were documented in the daily nursing and weekly skin assessment forms. The MDS nurse also stated that the certified nursing assistants (CNAs) conducts skin check during showers, documents on shower sheets. Staff #5 said that wound treatment are documented on the Treatment Administration Record (TAR); and, if the resident has a wound then a skin assessment is conducted and staff will complete a weekly wound report. The MDS nurse also said that weekly in reference to treatment, depended on the admitted for the week range. Regarding resident #1, the MDS nurse said that part of basic intervention was a Braden assessment when admitted and then weekly; and that, resident #1 was not seen until day 14 with her risk factors identified and care planned. The MDS nurse also stated that if the order for skin assessment was placed on October 14, then it should have been done and documented either on October 14 or 15. Further, the MDS nurse stated that treatment should have been done, skin assessed and documented. In an interview with a CNA (staff #10) was conducted on September 22, 2023 at 1:02 p.m., the CNA said that residents were repositioned every 2 hours; but, depending on the workload, she tries to go in every 30 minutes to an hour to check that residents were okay. The CNA said that she also checks in on her residents prior to going on breaks. The CNA stated that she places a pillow underneath the heels if the resident does not have a floating boot for residents who were susceptible to skin breakdowns/pressure injury/ulcer; and, she ensures that linens were not wet and the resident was not soiled. She said that as a CNA, her portion of the skin assessment is done during shower; and that, residents were provided showers 3 times a week. The CNA said that during showers she checks the body for any skin changes, documents them and notify the nurse. An interview was conducted on September 22, 2023 at 12:36 p.m. with a registered nurse (RN/staff #15) who stated that upon admission of the resident, a full body assessment is conducted; and if the resident has a wound, it is documented in the clinical record, the provider will be notified and treatments are ordered. The RN stated that dressing is changed if soiled, wound round is done every Wednesday and weekly skin assessment is completed for all residents. The RN said that there should be no reason why the weekly skin assessment was not done. He also said that the CNAs do skin checks during showers to see any skin changes, document the change on the shower sheet and inform the nurse. The RN also said that the residents gets a shower every other day; and, if the resident refuses then the nurse will talk to the resident and the refusal will be documented. A review of the clinical record was conducted with the RN during the interview. The RN stated that based on the order, the first Braden Risk Assessment should have been done on admission and then a week after the order date going forward; and, the weekly skin assessment should have been done on admission and weekly thereafter. The RN further stated that if these assessments were only done once then the physician order was not followed. During an interview with the Director of Nursing (DON/staff #20) conducted on September 22, 2023 at 1:31 p.m. the DON stated that upon resident admission, an initial physical assessment is completed by the nurses followed by the nurse manager then weekly thereafter. Regarding resident #1, the DON stated that resident #1 was diabetic; and that, the resident's mobility should have been a factor in her not getting a deep tissue injury. The DON said that for diabetic residents' wounds had been known to show up within 4-6 hours of injury. She stated resident #1 returned to the facility on [DATE] and there should have been an initial nursing assessment. However, there was none found in the clinical record for resident #1. The facility policy on Resident Assessment and Documentation reviewed/revised January 2018 included that each resident will have a full assessment upon admission. A full assessment consists of completion of the standard nursing assessment form/tool, a skin breakdown assessment such as the Braden scale, a pain assessment and a fall risk assessment. Additionally, the policy noted that all assessments will be maintained in the medical record per the medical record guidelines. The facility policy titled, Skin Assessments revised October 2019 revealed that a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to oxygen was administered according to professional standards of practice for one resident #1. The sample size was 3. The deficient practice could result in resident not receiving needed treatment and care. Findings include: Resident #1 was admitted on [DATE] with diagnoses of multiple rib fractures, traumatic hemopneumothorax, traumatic subcutaneous emphysema, flail chest, atrial fibrillation, and congestive heart failure. The Nursing Admission assessment dated on July 4, 2023 revealed the respirations were not labored, lung sounds were clear bilaterally and had diminished in the left upper and lower lobes. The documentation did not include whether or not the resident was receiving oxygen therapy. The admission physician orders did not include orders for oxygen. Review of the baseline care plan revealed focus of care and intervention developed and implemented related to the administration of oxygen. The vital sign report dated July 5, 2023 at 6:58 a.m. revealed resident had oxygen saturation of 90% oxygen on room air. The nurse practitioner (NP) note dated July 5, 2023 revealed the resident's breathing was unlabored and regular and there was no cyanosis noted. Review of the occupational therapy (OT) daily note dated July 5, 2023 revealed the resident had an oxygen saturation (O2 sat) of 80% on room air and a heart rate 63. According to the documentation, the nurse was notified that the resident's oxygen level was desaturating. The vital sign report on July 5, 2023 at 4:30 p.m. oxygen saturation of 94% with oxygen at 2-3 liters per minute (lpm) via the nasal cannula (NC). Review of the daily nursing assessment dated [DATE] revealed that oxygen (O2) was added via by nasal cannula due to shortness of breath (SOB) and oxygen saturation at 80's on pulse oximeter. Per the documentation, oxygen saturation was 94% at 2 liters of oxygen via nasal cannula. There was no evidence found in the clinical record that the physician was notified of the resident's change in condition, low oxygen levels and initiation of oxygen therapy. During an interview with the Director of Nursing (DON/staff #49) conducted on July 25, 2023 at 10:30 a.m., the DON stated she was not aware that resident #1's oxygen had desaturated while in therapy; and that, she had not read the therapy notes. The DON said that if a resident's O2 saturation dropped into the 80's and the resident did not have an order for oxygen, she would expect the nurse to start oxygen to bring saturation up to 90% and notify the physician for orders. In an interview with registered nurse (RN/staff #17) conducted on July 25, 2023 at 1:31 p.m., the RN stated he had admitted resident #1 on July 4, 2023; and, he thought the resident was always receiving oxygen. He stated that each time he had checked oxygen saturation for resident #1, it was always in the 90's; and that, no one had notified him that the resident's oxygen saturation went down to 80%. The RN said that if the therapist had, he would have jumped on that. The RN said he would sit the resident up, administer a breathing treatment if ordered, call the physician and report his findings and the resident's response and ask for changes in oxygen orders. An interview was conducted with the OT (staff #50) on July 25, 2023 at 2:15 p.m. The OT stated she completed the therapy evaluation with resident #1 on July 5, 2023; and that, during the evaluation, the resident was attempting to reposition himself and his oxygen level dropped to 80%. The OT said that she tried to sit the resident up and have him breathe slower and deeper but the resident could not tolerate it probably because of the rib fractures. The OT further stated that she then notified the nurse who brought oxygen and sat the resident up. During an interview with a licensed practical nurse (LPN/staff #51) conducted on July 25, 2023 at 2:30 p.m., the LPN stated she was the nurse for resident #1 on the nights of July 4, and 5, 2023; and that, the resident was receiving oxygen his entire stay at the facility. The LPN said that the resident had multiple rib fractures and received routine breathing treatments; and that, the certified nursing assistants (CNAs) took the resident #1's vital signs and oxygen levels which were fine on both nights. In an interview with a CNA (staff #37) conducted on July 25, 2023, the CNA stated she had not been assigned to the care of resident #1; but, she helped him get positioned on the bed several times. The CNA stated that she believed resident #1 was always receiving oxygen; and that, she remembered staff getting an oxygen concentrator when resident #1 was admitted . Review of the facility policy on Oxygen Administration included for staff to notify the physician if a resident is unable to maintain oxygen saturations as specified, as ordered.

Based on observations, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen, failed to maintain refrigerator temperature, failed to ensure food items were labeled, and failed to ensure expired food items were not available for use. The deficient practice could result in a potential for food borne illness. Findings include: During an initial walk through of the kitchen conducted with kitchen manager (staff #42), on [DATE] at 10:30 am, there was a tub of sour cream with expiration date of [DATE], a jug of lemon juice with expiration date of [DATE], a red onion wrapped in saran wrap with expiration date of [DATE], and a package of sliced swiss cheese with expiration date of [DATE]. Continued observation revealed that testing of the sanitizing solution in the two (Sani) buckets that were in use was conducted and revealed that neither buckets changed the color of the test strip. The kitchen staff who was present during the observation stated that they had filled the buckets up at the sink. The kitchen manager (staff #42) then used the same spigot to fill another bucket; however, it failed the test. Staff #42 submerged the testing strip 3 times, before it started to faintly change colors around the edges. She stated that she had put in a work order and provided the printout that showed the sanitizer dispenser tested on ly at 100ppm on [DATE]. In another observation conducted on [DATE] the resident refrigerator behind the nurse station showed the temperature log had only been completed on [DATE] and 3, 2023; and, there was an open can of chicken without a lid. The canned chicken did not have an open date or which resident it belonged to. During an interview with a registered nurse (RN/staff #76) on [DATE] at 12:45 p.m., the RN stated the items in refrigerator at the nurse station were for residents only and the canned chicken found in the refrigerator was for a resident/s. The kitchen manager who was also present during the interview stated that the refrigerators on the units were not part of the kitchen duties and she believed it was for housekeeping staff to follow up. An interview with a licensed practical nurse (LPN/Staff #4) was conducted on [DATE] at 10:22 a.m., the LPN stated that there had been some confusion about who was responsible for resident refrigerator located at the nurse station; however, the LPN said that it was the responsibility of the nursing staff. She stated staff would complete the temperature logs on each shift. Staff #4 stated if a resident has personal food items the nursing staff who received it must label and date it before placing in the refrigerator. In an interview conducted with staff #42 on [DATE] at 10:30 a.m. staff #42 stated that the expectation for sanitization in the kitchen was to keep a high standard of cleanliness. Staff #42 said that the Sani buckets that were observed in the kitchen were not in compliance; and that, the sanitization standards were to keep people from getting sick and avoid cross contamination. An interview was conducted with the Director of Nursing (DON/ Staff #36) on [DATE] immediately following the interview with staff #42. The DON stated that she previously thought dining was in charge of the unit refrigerator; however, after some clarification it was determined that housekeeping cleans the refrigerator and the night shift nurses completes the temperature logs. Review of the Sanitizer Solution from Dispenser revealed that the corrective action for the dispenser being out of order, as evidenced by the sanitizer solution concentration not being in ,d+[DATE]ppm range, is to post a sign Out of Order and do not use it until it is repaired. Sanitizer will be mixed manually until dispenser is repaired. The facility policy on food storage for cold foods revealed that all time/temperature control foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. The policy also included all foods will be in covered containers or wrapped, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on clinical record review, resident and staff interviews, facility documentation and policy reviews, the facility failed to ensure restorative nursing assistance (RNA) program was provided to one resident (#23) as ordered by the physician. The deficient practice could result the resident unable to improve their ability to carry out the activities of daily living (ADL). Findings include: Resident #23 was admitted on [DATE] with diagnoses of polymyalgia rheumatica, and anxiety disorder. A physician order dated November 20, 2020 included for continuous RNA program 3x weekly to increase strength and mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Per the assessment, the resident required extensive assistance with one staff for transfer, dressing, bathing and toileting. The undated and current ADL care plan included the resident required assistance with ADLs and care related to impaired functional mobility due to muscle spasm and history of CVA (cardiovascular accident) with left nondominant hemiparesis. It also included that the resident was on RNA program and used a [NAME] lift for transfers as indicated. Interventions included RNA as ordered and tolerated by the resident. A physician progress note dated January 20, 2023 revealed the resident was alert and oriented, was on RNA at times and needed PT (physical therapy)/OT (occupational therapy) due to worsening weakness. The restorative referral note signed March 7, 2023 revealed the resident continued with outpatient therapy and required 1-person assist for ADLs. Goal was to maintain current functional status with ADLs and mobility. Program recommendation included ambulation with hemi-walker, stand pivot transfers, left upper extremities (LUE) passive range of motion (PROM), right upper extremities (RUE) exercises with 2 lbs. (pounds) hand weight and bilateral lower extremities exercises and ROM. Frequency was for 3-5X per week for 6 weeks. Review of the RNA documentation from January 20 through April 20, 2023 revealed that RNA program was not provided 3x weekly as ordered. The clinical record revealed no evidence of the reason why RNA was not provided 3x weekly as ordered; and that, the physician was notified. Further review of the clinical record revealed no evidence that the resident refused RNA program. In an interview with resident #23 conducted on April 18, 2023 at 12:30 p.m., the resident stated that she had not been receiving RNA service as ordered. The resident stated that the assigned RNA staff told her the facility was understaff and her RNA service was put on hold because of this. An interview conducted on April 20, 2023 at 1:07 p.m. with the restorative nurse assistant (RNA/staff #53) who stated that the expectation was to do RNA program with the residents as needed and as ordered by the physician. However, staff #53 stated that sometimes due to staffing shortages RNA services were not provided to residents as they are instructed by management to assist as a certified nursing assistants (CNAs). Staff #53 said that because of staffing issues, RNA services will often be put on hold. Staff #53 also stated that there are only two RNA staff at the facility and they both work Monday through Friday from 8:00 a.m. to 4:00 p.m. and rotating weekends. Further, staff #53 stated that if one of the RNA staff was not on the schedule then the expectation was for a CNA to assist with RNA service for that day. During an interview with the Director of Nursing (DON/staff #36) conducted on April 20, 2023 at 1:27 p.m., the DON stated that her expectation was for the RNA to complete the RNA service for the resident as ordered by the physician. The DON said that if the RNAs are short staffed then the expectation was for the CNAs to assist with RNA service that day. In an interview with staffing coordinator (staff #32) conducted on April 20, 2023, staff #32 stated that RNAs were scheduled Monday through Friday, 8:00 a.m. - 5:00 p.m. and rotating weekends. Staff #32 stated that if one or both RNA call out sick for that day then the expectation was for the CNA to fill in as an RNA. Review of the facility policy on Restorative Nursing Programs revised on March 2016, stated residents will be provided with maintenance and restorative services designed to maintain or improve the resident's abilities to the highest practicable level. The policy also stated that RNA is to assist the residents in adjustment to their disabilities and use of any assistive device and help residents with range of motion exercises, perform passive range of motion for resident who are unable to participate. The policy also included that all residents will receive maintenance restorative nursing service as needed by a certified nursing assistant. A resident's ability will be identified during the comprehensive assessment with the support from the interdisciplinary team with the support and guidance from the physician.

Based on clinical record review, resident and staff interviews, and policy and procedure, the facility failed to ensure the opportunity to choose and accommodate the preferred use of undergarment was provided to one of two sampled residents (#386). The deficient practice could result in the residents not able to exercise autonomy on things important to them. Findings include: Resident #386 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission nursing note dated May 9, 2022 included the resident was admitted for therapy for increased strength and mobility. The documentation also included the resident was alert and oriented x 3 (to person, place, and time) and was able to make needs known. The daily nursing assessment dated [DATE] included the resident was alert and oriented x 4 (to person, place, time, and situation) and had a soft, nontender abdomen with bowel sounds present in four quadrants. The [CONDITION(S)] assessment revealed the resident was continent. The occupational therapy plan of care dated May 9, 2022 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 13 indicating the resident was cognitively intact. Per the assessment, the resident required maximum assistance with toileting. The undated active care plan included the resident required assistance with ADLs (activities of daily living) and care related to weakness and s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included giving the resident choices in care and providing set-up and cueing as needed. The daily nursing assessments from May 10 through May 17, 2022 revealed the resident was continent with bowel and bladder. The ADL verification worksheet from May 9 through May 19, 2022 revealed that the resident was incontinent of bladder from May 9 through May 12. The documentation also revealed the resident was continent of bladder from May 12 through May 19. Further review of the worksheet revealed that the resident was continent of bowel from May 9 through 19, 2022. In an interview conducted with the resident on May 16, 2022 at 1:41 p.m., resident #386 stated she was told she had to wear incontinent briefs/pull ups because that was the only kind the facility has. The resident stated she did not want to wear incontinent brief/pull up. The resident stated that she can use regular underwear with a pad on it. The resident stated she would have to pay for the pad and she can only use what the facility provides. In another interview conducted with the resident on May 18, 2022 at 11:30 a.m., resident #386 stated she was continent, knows and can tell when she wants to go to the bathroom to use the toilet. The resident stated the pull up she was wearing was a French cut and she never wore a French cut undergarment in her life and she will not wear one now. Further, the resident stated that she was not given an option or choice to wear regular underwear and she did not like wearing incontinent briefs/pull ups. An interview was conducted with a certified nurse assistant (CNA/staff #67) on May 18, 2022 at 1:52 p.m. The CNA stated that if a resident was continent, does not want to wear an incontinent briefs/pull ups and wants to wear regular underwear, then the resident has the right to wear regular underwear if the resident chooses to. The CNA stated that resident #386 is alert and oriented and can verbalize or express needs and wants. She also said that the resident was continent with bowel and bladder and wears a pull up which are provided by the facility. Further, the CNA stated that she was not aware of any issues regarding the resident's use of incontinent briefs or pull ups. During an interview with a registered nurse (RN/staff #72) conducted on May 18, 2022 at 2:07 p.m., the RN stated that incontinent briefs or pull ups are used for residents who are incontinent with bowel or bladder, has limited mobility, and cannot tell staff their needs and wants. He said that if a resident is alert and oriented, can tell staff when they have to go to the bathroom, is continent, ambulatory or has some limitation in mobility, the resident does not need an incontinent brief or pull ups. He said if the resident is continent and has limitations in mobility, the resident is encouraged to call for help and the staff could offer the use of a bedpan or urinal or the staff will assist the resident to the bathroom if the resident chooses to do so. The RN said that the only time an alert, oriented and continent resident may use an incontinent brief or pull is at night when there is a possibility of an accident or if the resident chooses to wear one. The RN further stated that staff should not let or force the resident to wear an incontinent brief or pull up or tell the resident that this is all the facility has. He said that residents have rights and forcing them or letting them wear something that the resident does not want to wear is a violation of their rights. An interview was conducted on May 19, 2022 at 1:31 p.m. with the interim Director of Nursing (DON/staff #77) with the MDS (minimum data set) coordinator (staff #31) present. The DON stated that a resident who is alert, oriented, continent do not necessarily have to wear incontinent briefs or pull ups if the resident chooses not to. She stated that the facility's goal on admission when it comes to resident ADLs is for the resident to be more independent and to get rid of the use of incontinent briefs/pull ups if not needed. The facility's policy on Residents Rights included that the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has the right to exercise his or her rights as a resident of the facility. The resident has a right to be treated with respect and dignity including the right to retain and use personal possessions including clothing. Further, the policy included that the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice including but not limited to the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure one of two sampled residents (#387) was administered oxygen as ordered by the physician. The deficient practice could result in residents not receiving oxygen as ordered. Findings include: Resident #387 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician treatment order dated May 2, 2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An undated nutritional care plan revealed the resident was at risk for altered hydration status with [CONDITION(S)] and pneumonia. Interventions included medications as ordered. The nursing admission clinical notes dated May 2, 2022 indicated that the resident was alert and oriented. The note also included the resident was receiving 2 liters per minute of supplemental oxygen. The Physician Admission Clinical Notes dated May 5, 2022 revealed the resident was placed on oxygen but did not indicate dosage or frequency. Review of the Flow Sheet dated May 12, 2022 revealed the resident's oxygen saturation was at 93% with oxygen via nasal cannula <2 liters. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was receiving oxygen treatment prior to and while at the facility. Review of the Flow sheet signed on May 16, 2022, revealed the resident's oxygen saturation was at 97% with oxygen via nasal cannula at 2-3 liters. The order for oxygen at 2 liters per minute per nasal cannula as needed (PRN) was transcribed onto the Treatment Administration Record (TAR) for May 2022. Per the TAR, PRN oxygen was administered only once on May 17, 2022 which was also the discontinued date. Another physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing clinical note dated May 19, 2022 revealed the resident reported that she had been on oxygen at 0.5 liter per minute via nasal cannula all day and had been doing well but was unsure whether the oxygen was working. Additionally, the note revealed the nurse verified that there was no order to wean resident #387 from oxygen and that without an order the nurse had to put the oxygen at 2 liters via nasal cannula. An interview conducted with resident #387 on May 16, 2022 at 9:39 a.m. The resident stated that she had been using oxygen since she had the [CONDITION(S)] infection. The resident and family member said that the oxygen is supposed to be 1 liter per minute. During the interview, the resident was observed sitting in the wheelchair receiving oxygen connected to a concentrator via nasal cannula at 1.5 liters per minute (LPM). Another observation was conducted on May 17, 2022 at 9:45 a.m., the resident was observed in the wheelchair receiving oxygen via nasal cannula at 1 LPM. Another observation was conducted on May 18, 2022 at 1:49 p.m., the resident was observed in bed receiving oxygen via nasal cannula at 1 LPM. In an interview conducted with a registered nurse (RN/staff #72) on May 18, 2022 at 2:08 p.m., staff #72 said that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN said the oxygen flow for the resident was 0.5 liters and that the resident was tolerating it. In another interview with staff #72 conducted on May 19, 2022 at 1:01 p.m., he said there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #72 stated the physician forgot to inform the nurse about it and forgot to write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, he stated he administered 2 LPM of oxygen to the resident today. Staff #72 said he notified the physician of the lack of order to wean the resident but the physician had not responded yet. An interview was conducted on May 19, 2022 at 1:31 p.m. with the Interim Director of Nursing (DON/staff #77) and an LPN (staff #31). The DON stated oxygen flow has to be followed as directed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During the interview, a review of resident #387's clinical record was conducted with staff #77 who stated that there was no order found to wean the resident from oxygen. Further, the DON stated that the current order was for 2 LPM of oxygen. Review of the facility Oxygen Administration policy revealed the purpose is to administer oxygen to the resident when the blood is carrying insufficient oxygen to the tissues. Check the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A facility policy regarding the Administration of Medication revealed that medications must be administered in accordance with the attending physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on clinical record review, observations, resident and staff interviews and policy review, the facility failed to ensure one resident (#23) with pressure ulcers received the necessary treatment and services consistent with professional standards of practice. The deficient practice could result in worsening of residents' pressure ulcers. Findings include: -Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the comprehensive nursing admission assessment dated [DATE] revealed documentation that the resident did not have a pressure ulcer and noted under other skin problems was that the resident's right heel was purple. The Braden Scale for Predicting Pressure Sore risk dated October 4, 2019 revealed a score of 11 indicating the resident was high risk. The physician's orders [REDACTED]. needs two times a day; and for weekly skin assessments. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15 which indicated the resident had intact cognition. The assessment included the resident required extensive assistance for bed mobility, transfers, and toilet use; and had functional limitation in range of motion impairment to one side of the lower extremities. The assessment also included the resident had 3 unstageable suspected deep tissue injuries (SDTI) that were present upon admission. The assessment revealed the resident had a pressure reducing device for the chair and bed, and pressure ulcer care. The current undated care plan revealed the resident had bilateral SDTI to the heels and right Achilles upon admission. The goal was that the resident's skin would remain intact with minimal risk of incidence of breakdown. Interventions included assisting and/or reminding the resident to turn and reposition frequently and as needed, pressure relieving devices as indicated-pressure reducing mattress, wheelchair cushion, floating the heels, and treatments per orders. Regarding the pressure ulcer to the right Achilles: Review of the comprehensive nursing admission assessment dated [DATE] revealed no documented concerns regarding the right Achilles area. Review of the nurse progress note dated October 5, 7 and 10, 2019 revealed documentation regarding the resident's heels but did not include any documentation regarding an alteration in skin integrity to the right Achilles area. Review of the wound team notes dated October 9, 2019 revealed the resident had right and left heel wounds but did not include an alteration in skin integrity to the right Achilles area. A nurse progress note dated October 11, 2019 revealed there was a scab to the posterior right lower extremity, the surrounding skin was pink, and it was open to air. A physician's orders [REDACTED]. Review of a physician progress notes [REDACTED]. The plan was to offload and increase nutrition. Review of the wound note dated October 16, 2019 revealed the resident had a deep tissue injury to the Achilles that was present on admit that measured 4 centimeters (cm) by 1 cm and was drying. The documentation did not include if it was the right or left Achilles or any other description of the deep tissue injury. A nurse progress note dated October 16, 2019 revealed for an addendum to the October 7, 2019 note that the right Achilles had a dark scabbed area and included for an addendum to the October 10, 2019 note that the right Achilles dark, scabbed area had not changed. Review of a wound note dated October 17, 2019 revealed the wound was now a blackish linear ulceration that was present on admission in the posterior aspect above the heel. The note did not indicate if the wound was on the right or left. A nurse progress note dated October 18, 2019 revealed the note was a late entry for the wound assessments on October 7, 8, 11, 12, and 13 which should include red area on lower leg and also on the Achilles. The note did not include whether it was the right or left Achilles. A nurse progress note dated October 19, 2019; an addendum to the October 5, 2019 note, revealed there was a red scab to the right Achilles. Review of a progress note revealed the resident transferred to and returned from the emergency roiagnom on [DATE] for an unrelated issue. A progress note dated October 21, 2019 revealed the Achilles wound had a moderate amount of purulent drainage on the dressing, had signs and symptoms of worsening and the resident reported increased discomfort. Review of another progress note dated October 21, 2019 revealed the right Achilles was open with slough to the wound bed. The wound team notes for October 23, 2019 revealed the right Achilles wound was unstageable, measured 2.6 cm by 1.4 cm, and was open with drainage and slough to the wound bed. Review of the Treatment Administration Record (TAR) for October 2019 revealed an entry for a one time treatment ordered October 23, 2019 and discontinued October 24, 2019 to apply [MEDICATION NAME] cream to the right Achilles and cover with foam dressing. The TAR did not reveal documentation the treatment was provided. Further review of the October 2019 TAR revealed monitoring of a posterior lower extremity wound was being done but did reveal documentation treatment was being provided to the right Achilles wound. Review of the wound team notes dated October 30, 2019 revealed the right Achilles wound was free of slough and was a stage 2. The note included the wound measured 3.5 cm x 1 cm and had moderate bloody drainage. The wound team note for November 6, 2019 revealed a stage 2 to the Achilles that measured 3.5 cm x 1 cm and had dry scabbing, no slough, and bloody drainage. Review of the November 2019 TAR from November 1-12, 2019 did not reveal treatment was provided to the right Achilles. Review of the wound notes dated November 13, 2019 revealed the ulcer to the Achilles measured 3.5 cm x 1.5 cm with yellow slough. The note included the resident reported the wound was painful when touched. A physician's orders [REDACTED]. The TAR for November 2019 revealed the treatment was provided was provided as ordered. A progress note dated November 20, 2019 revealed the wound was a stage 4 and the tendon was exposed. The noted included the wound measured 2.5 cm by 2 cm with yellow slough and rolled edges. The physician's orders [REDACTED]. A progress note on November 21, 2019 revealed the resident had non healing wounds in spite of care and that the resident was unsure if she wanted to see a specialist due to her age. Further review of the clinical record revealed no evidence the right Achilles wound was consistently thoroughly assessed. An interview was conducted with the acting Director of Nursing/wound care nurse (staff #31) on January 30, 2020 at 1:27 p.m. She stated the right Achilles wound was present when the resident was admitted [DATE] and that it is expected the wound would be thoroughly accessed upon admission and weekly thereafter. She stated that she did not see, nor was she notified of the wound to the right Achilles area at the time of admission. Staff #31 also stated that treatments should be provided as ordered. Review of the clinical record revealed the resident was transferred to the hospital on November 21, 2019 for an unrelated issue. Regarding the pressure ulcer to the right heel: Review of the comprehensive nursing admission assessment dated [DATE] revealed the right heel was purple. A physician order [REDACTED]. A nurse progress note dated October 5, 2019 revealed the right heel was purple and had the appearance of a deep tissue injury. Review of a physician order [REDACTED]. A nurse progress note dated October 7, 2019 revealed the right heel had purple discoloration noted, was intact, and non blanchable. A nurse progress/wound round note dated October 10, 2019 revealed the right heel deep tissue injury was present on admission, purple and intact, and measured 3.5 cm by 5 cm. Review of the TAR for October 2019 revealed the order dated October 16, 2019 to apply form dressing to the right heel daily was provided as ordered. A wound team note dated October 16, 2019 revealed the deep tissue injury to the right heel was purple and measured 3.5 cm by 4.3 cm. Review of the nurse progress notes revealed the resident discharged to and returned from the emergency roiagnom on [DATE]. A nurse progress note dated October 20, 2019 revealed the right heel wound had a fluid filled blister, moderate purulent drainage on the dressing, signs and symptoms of worsening, and the resident reported increased discomfort. The physician order [REDACTED]. Review of the TAR for October 2019 revealed the treatment was provided as ordered. Review of the wound team progress note dated October 23, 2019 revealed the right heel deep tissue injury measured 3.3 cm by 4.5 cm, was purple with a puncture to the side of the wound draining minimal serosanguinous drainage. The note included pain was noted on assessment. The October 2019 TAR revealed an order dated October 23, 2019 and discontinued October 24, 2019 to apply [MEDICATION NAME] cream to the right heel and cover with foam dressing one time a day. The TAR revealed no documentation the treatment was provided. Review of the wound team progress note dated October 30, 2019 revealed the right heel deep tissue injury measured 3.3 cm by 4.5 cm, was purple and dark in color, drying, and it was noted the resident had less pain. Review of the wound team progress note dated November 6, 2019 revealed the right heel deep tissue injury was purple and dark in color and measured 3.5 cm by 4.4 cm with no drainage. Review of a physician's orders [REDACTED]. Review of the TAR dated November 2019 revealed the treatment was provided as ordered. Review of the wound team progress note dated November 13, 2019 revealed the right heel deep tissue injury was purple with an open mushy pinkish center and measured 3.3 cm by 3 cm with no drainage. A Physician's progress note dated November 15, 2019 revealed the right heel wound had black eschar and a new open area. Review of the wound team progress note dated November 20, 2019 revealed the right heel suspected deep tissue injury was purple with a mushy pink center that was sore and painful to touch and measured 2 cm by 3.2 cm with no drainage. Review of a Physician's progress note dated November 21, 2019 revealed the right heel wound had black eschar and an open area. Additional review of the clinical record revealed no evidence the right heel pressure ulcer was thoroughly accessed. Review of the clinical record revealed the resident was transferred to the hospital on November 21, 2019 for an unrelated issue. -Resident #23 was readmitted to the facility on [DATE]. A Braden Scale for Predicting Pressure Sore risk dated November 23, 2019 revealed a score of 17 indicating the resident was at risk. Regarding the right Achilles pressure ulcer: The comprehensive nursing admission assessment dated [DATE] revealed the resident had a wound to the right Achilles. Review of the TAR for November 2019 revealed an order dated November 23, 2019 and discontinued November 27, 2019 to cleanse the right Achilles wound with wound cleanser or mild soap and water, pat dry, apply skin protectant to skin around wound, apply a cut to fit piece of Xeroform to the wound bed, cover with an abdominal dressing or a few gauze for padding and wrap with gauze lightly daily and as needed if the dressing is soiled or removed. The TAR dated November 23, 2019 revealed the treatment was provided as ordered. A progress note dated November 24, 2019 revealed the right Achilles wound measured approximately 5.3 cm by 4.6 cm, had a red wound bed creamy color, and the surrounding skin was pink/red and tender to touch. The note did not include the stage of the pressure ulcer or whether exudate was present or not. Review of a wound note dated November 27, 2019 revealed the stage four wound measured 6.2 cm by 3.5 cm and the tendon was exposed. The noted included the surrounding wound bed was pink and bumpy and that the wound was painful to touch. Review of the November 2019 TAR revealed an entry for dressing change to the right Achilles, apply silver cream, cover with calcium alginate and form dressing daily ordered November 27, 2019. The TAR did not reveal evidence the treatment was provided November 27-28, 2019. Continued review of the November 2019 TAR revealed to use silver foam to the open Achilles tendon wound three times a week, Monday Wednesday Friday, starting November 27, 2019. There was no documentation this treatment was provided November 27-28, or 30 2019. The resident refused on November 29, 2019. A weekly skin assessment dated [DATE] revealed the right Achilles wound had slough. Review of a progress note dated [DATE] revealed the stage 4 wound measured 5.0 cm by 5.1 cm, tendon was exposed with areas of black on the tendon, and there was moderate amount yellow drainage present on old the dressing. The note included the wound was painful to touch. The TAR for December 2019 revealed no evidence the silver foam treatment to the Achilles tendon was provided December 1- 4, 2019. Review of the wound clinic notes dated December 5, 2019 revealed the wound to the right posterior leg/Achilles was an unstageable pressure ulcer that measured 4.5 cm by 3.5 cm by 0 cm depth with the tendon exposed. The assessment included there was moderate amount of serosanguinous drainage with no odor, pain level of 8/10, well defined wound margins, 76 to100% eschar and 26 to 50% slough, and that the periwound skin had maceration and [DIAGNOSES REDACTED]. Dressing was applied. A provider note dated [DATE] revealed the stage 4 wound measured 5 cm by 5.1 cm, the tendon was exposed, and there was moderate amount of yellow drainage. The note included the resident was non-compliant with floating instructions and that the ulcer was larger than at the wound clinic. Review of the December 2019 TAR revealed an order dated [DATE] to remove the old dressing, cleanse with normal saline, apply endoform (cut to fit), apply [MEDICATION NAME] blue ready, cover with gauze and wrap with [MEDEQUIP] three times a week. The order did not include a location. Continued review of the TAR for December 2019 revealed the treatment scheduled for December 9, 2019 was not provided. Review of a homecare company Registered Nurse (RN) visit note report dated December 10, 2019 revealed the unstageable right Achilles tendon wound measured 4.7 cm by 4 cm by 0.1 cm, full thickness, distinct edges, round in shape, small amount of serosanguinous drainage, no odor, less than 25 % [MEDICATION NAME] with 26 to 50% slough and 0 to 25% eschar, no maceration to surrounding tissue, and pain associated with the wound. The note included to cleanse with wound cleanser, apply endoform, [MEDICATION NAME] blue heel foam, cover with gauze, and tape with x span size 6 using clean technique every 3 days and as needed. The note also included there were no supplies, so the wound was cleaned with wound cleanser, foam and gauze and x span was applied. A physician order [REDACTED].*to be done by home health company*. The order did not include the location of the wound or how often to change the dressing. Review of the clinical record from December 6 to 16, 2019 revealed no treatment specified to the right Achilles wound. Continued review of the clinical record revealed resident #23 was discharged to the hospital on December 16, 2019 for hip surgery and debridement of the tendon wound. Regarding the pressure ulcer to the right heel: Review of the comprehensive nursing admission assessment dated [DATE] revealed the right heel was purple, the resident had no foot problems, no open [MEDICAL CONDITION] on the foot, and no dressings to the foot. Review of a physician's orders [REDACTED]. Review of the November 2019 TAR revealed the treatment was provided as ordered. A nurse progress note dated November 24, 2019 revealed the resident's right heel had 2 open areas. The first area measured approximately 0.8 cm by 0.8 cm, white skin surrounded the area and there was a dark area in the center. The second area measured 2.6 cm by 2 cm, had a dark circle in the center and the area was a creamy color. The right heel area was red and blanchable. The wound team progress note dated November 27, 2019 revealed the right heel suspected deep tissue injury was irregular in shape with dark purple areas, scant amount of yellow pink drainage, and measured 2.7 cm by 3 cm. The note included the resident stated the wound was painful to touch. Review of the November 2019 TAR revealed an order dated November 27, 2019 to apply silver cream and heel cup dressing to the right heel daily and to apply [MED] to the right heel wound three times a week. Further review of the TAR for November 2019 revealed no documentation the treatments were provided November 27-28, and 30, 2019. The resident refused on November 29, 2019. A wound team progress note dated [DATE] revealed the right heel suspected deep tissue injury was irregularly shaped and open with yellow and dark purple areas and slough. The note included there was a scant amount of yellow/pink drainage and the wound measured 3.2 cm by 3 cm and was painful to touch. Review of the December 2019 TAR did not reveal documentation December 1-4 that [MED] was applied to the right heel wound. The wound clinic notes dated December 5, 2019 revealed the stage 3 right heel pressure ulcer had moderate amount of serosanguinous drainage, no odor, well defined wound margin, wound bed had 76-100% slough, 1-25% pink granulation, and normal periwound skin. The note included the wound measured 2 cm length by 3.5 cm width by 0.1 cm depth and wound pain was 0/10. A nurse progress note dated December 5, 2019, revealed the son stated the wound clinic physician will be faxing orders for wound care and did not want the current orders to be followed. A physician's progress note dated [DATE] revealed the resident was non-compliant with floating instructions. Review of the December 2019 TAR revealed an order dated [DATE] to remove the old dressing from the right heel, cleanse with normal saline, apply endoform and [MEDICATION NAME] blue ready, cover with gauze and [MEDEQUIP] three times a week. Further review of the TAR for December 2019 revealed no documentation the treatment was provided on December 9, 2019 as scheduled. A home health visit note dated December 10, 2019 revealed the right heel stage 3 full thickness pressure ulcer measured 2.5 cm by 3.4 cm by 0.2 cm, less than 25% [MEDICATION NAME] tissue, 26 to 50% slough and 0 to 25% eschar. The note included the skin surrounding the wound was normal and the resident had a wound pain level of 4/10. The note included to cleanse with wound cleanser, apply endoform, apply [MEDICATION NAME] blue heel foam, cover with gauze, and tape with x span size 6 using clean technique every 3 days and as needed. The note also included that due to no supplies, the wound was cleansed with wound cleanser and foam, gauze and x span was applied. A physician's orders [REDACTED].*to be done by home health*. The frequency for the dressing change was not included in the order. Review of the clinical record revealed thorough assessments of the right heel were not consistently done. Continued review of the clinical record revealed resident #23 was discharged to the hospital on December 16, 2019 for hip surgery and debridement of the tendon wound. -Resident #23 was readmitted to the facility on [DATE]. A Braden Scale for Predicting Pressure Sore risk dated December 20, 2019 revealed a score of 17 indicating the resident was at risk. The comprehensive nursing admission assessment dated [DATE] revealed documentation that the resident had no pressure ulcers and no pressure ulcers on prior assessment. Regarding the pressure ulcer to the right Achilles: A physician order [REDACTED]. Review of the progress note dated [DATE] revealed the resident had a 5 cm long right Achilles wound with exposed tendon. Review of the team wound notes dated December 26, 2019 revealed the stage 4 wound measured 6 cm by 2.6 cm with a description of tendon/rolled edges. Review of the wound clinic notes dated January 2, 2020 revealed the wound to the right posterior leg/Achilles was a stage four pressure ulcer that measured 5.7 cm by 3 cm by 0.1 cm. The assessment included a small amount of serosanguinous drainage, no odor, a wound pain level of 5/10, wound margin well defined, wound bed with 51% to [AGE]% slough and 1% to 25% bright red granulation, weak local pulse, and the surrounding skin had maceration. A provider note January 5, 2020 revealed the resident had a non-healing Achilles ulcer with slough. Review of a wound team note dated January 8, 2020 revealed two sets of measurements for the stage 4 Achilles wound: 9.7 cm by 3 cm by 0.1 cm and 6.5 cm by 2.5 cm, with a description of tendon/rolled edges. There was no explanation as to why 2 measurements were documented. Review of the TAR for January 2020 revealed the treatment was not provided on January 8, 2020 because wound supplies were not available. A wound team note dated January 15, 2020 revealed the right Achilles stage four pressure ulcer measured 6 cm by 2.5 cm with a description of tendon/rolled edges. Review of a physician's progress note dated January 16, 2020 revealed the patient had a foul smelling wound and was more lethargic with increased confusion. The documentation included the resident had a severe decline in condition with poor prognosis and non-healing wound and a wound infection. The note also included the physician spoke to the family about hospice and the family chose hospice. A progress note dated January 16, 2020 revealed the right stage 4 Achilles pressure ulcer measured 6 cm by 2.5 cm, had a foul odor, and the tendon was exposed. Review of a wound round progress note dated January 22, 2020 revealed the stage 4 right Achilles wound measured 6.5 cm by 3.5 cm and the tendon was exposed. A progress note dated January 28, 2020 revealed that due to the resident's end stage condition, hospice, poor mobility, the resident was at high risk for further ulcers. An observation of the wound was conducted on January 29, 2020 at 8:17 a.m. with a Registered Nurse (RN/staff #24) and the acting Director of Nursing (DON/staff #31). Staff #31 identified the wound as a stage four pressure ulcer. The wound measurements were 5.5 cm by 2.9 cm. Staff #31 stated that she was unable to measure depth due to the protrusion of the elevated tendon. The wound bed was red with surrounding yellow tissue and exposed tendon, serosanguinous drainage was present, no odor, wound edges were rolled and the surrounding skin was within normal limits. An interview was conducted with the acting DON/wound care nurse (staff #31) on January 30, 2020 at 1:27 p.m. After reviewing the TAR, staff #31 stated that treatments are to be administered as ordered and that if there is no documentation a treatment was provided, she is unable to provide evidence it was done. Regarding treatment supplies not being available, staff #31 stated they did a wet to dry dressing and notified the physician that they did not have supplies. Staff #31 also stated that if supplies were not available they should contact the physician for an interim treatment. -Regarding the pressure ulcer to the right heel: The comprehensive admission nursing assessment dated [DATE] revealed the resident had no pressure ulcer and no pressure ulcers on prior assessment, had no foot problems, had no open [MEDICAL CONDITION] on the foot, and had no application of dressings to the foot. A physician orders [REDACTED]. Review of the wound team progress note dated December 26, 2019 revealed the unstageable right heel wound measured 2.8 cm by 3 cm and that the resident complained of pain, wincing at times. This was the first assessment of the right heel wound since readmission. A wound clinic note dated January 2, 2020 revealed the stage four right heel pressure ulcer had a small amount of serosanguinous exudate, maceration to surrounding skin, no odor, 5/10 pain, well defined wound margin, 51-[AGE]% slough, 1-25% bright red granulation and measured 2.3 cm by 3.4 cm by 0.2 cm. The documentation included a dressing was applied and there was a weak local pulse. A physician's progress note dated January 5, 2020 revealed the wound to be non-healing and to have slough. The January 2020 TAR revealed the treatment was not provided on January 8, 2020 because wound supplies were not available. Review of the wound round notes dated January 8, 2020 revealed the right heel deep tissue injury measured 2.3 cm by 3.4 cm by 0.2 cm and had eschar. Review of the wound round notes dated January 15, 2020 revealed the unstageable wound to the right heel was mushy and with eschar and measured 3.5 cm by 3 cm. A physician's progress note dated January 16, 2020 revealed hospice was discussed with the family and the family chose hospice. The wound round notes dated January 16, 2020 revealed the right heel appeared unstageable, eschar was mushy, and the wound measured 3.5 cm by 3 cm. A physician's orders [REDACTED]. The order did not include the frequency. Review of the January 2020 TAR revealed the treatment was provided two times a week. The wound round notes dated January 22, 2019 revealed the unstageable right heel had black eschar and measured 3.4 cm by 3 cm. Further review of the clinical record did not reveal evidence a thorough assessment of the right heel was consistently done. A wound observation was conducted on January 29, 2020 at 8:17 a.m. with an RN (staff/#24) and the acting DON (staff #31). The dressing was observed to stick to the wound with removal of old dressing. The right heal wound was identified by staff #31 as an unstageable pressure ulcer that was drying with eschar present with no drainage or odor. The wound measured 2.4 cm x 3.1 cm. The wound was cleansed and a new dressing applied as ordered. -Regarding the pressure ulcer to the right lower Achilles: Review of a wound round note dated December 26, 2019 revealed the resident now had a suspected deep tissue injury above the unstageable wound on her left heel and below the Achilles wound that measured 2 cm by 1.8 cm and was dark purple in color. The note included the resident was readmitted with this wound. However, this was the first documentation regarding this wound since readmission on December 20, 2019. The wound team notes dated January 15, 2019 revealed the deep tissue injury between the right heel wound and Achilles wound was purple and measured 1.4 cm x 1.2 cm. A wound round progress note dated January 22, 2020 revealed the deep tissue injury above the unstageable wound on the resident's right heel and below the Achilles wound measured 1 cm x 1 cm, was purplish and resolving. An observation of the wound was conducted on January 29, 2020 at 8:17 a.m. with a RN (staff #24), and the acting DON (staff #31). The wound was cleaned with wound cleanser, appeared purple red in color, measured 0.2 cm by 0.2 cm, and was identified by staff #31 as a deep tissue injury. Staff #31 applied a clean dressing to area. Review of the clinical record from December 20, 2019 to January 29, 2020 did not reveal thorough assessments of this wound, no order for treatment or that treatments were done specific to this wound. An interview was conducted with the acting DON/wound care nurse (staff #31) on January 30, 2020 at 1:27 p.m. She stated that the wound between the right heel wound and the Achilles wound was present on re-admission from the hospital December 20, 2019. Staff #31 stated that if this wound was not thoroughly assessed at re-admission and weekly thereafter, her expectations were not met. -Regarding the pressure ulcer to the right lateral foot: A nurse progress note dated January 14, 2020 revealed there was a red, round non-blanchable area to the outer aspect of the right foot. A wound team note dated January 15, 2020 revealed the red non-blanchable area to the right outer foot measured 1.6 cm by 0.8 cm. A nurse progress note for wound rounds dated January 22, 2020 revealed the resident had a new suspected deep tissue injury to the right lateral midfoot that measured 1.8 cm by 1 cm, was dark purple in color, and the cause unknown. Review of the physician's orders [REDACTED]. Additional review of the clinical record did not reveal a thorough assessment of this wound. An observation of the wound was conducted on January 29, 2020 at 8:17 a.m. with a RN (staff #24), and the acting DON (staff #31). The nurse removed the old dressing. The wound was identified as an unstageable pressure ulcer, measured 1.1 cm by 1.3 cm, oval in shape with a dark edge and a yellow and red center. An interview was conducted with the acting DON/wound care nurse (staff #31) on January 30, 2020 at 1:27 p.m. She stated that the right foot wound was facility acquired. Staff #31 stated her expectati (TRUNCATED)

Based on clinical record review, family and staff interviews, and policy review, the facility failed to ensure one resident (#36) who required [MEDICAL TREATMENT] care received such services, consistent with professional standards of practice. The deficient practice could result in residents who require [MEDICAL TREATMENT] having complications. Findings include: Resident #36 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview Mental Status (BI[CONDITION]) score of 12, indicating the resident had moderate cognitive impairment. The care plan dated January 23, 2020, revealed the resident was at risk for infected access area due to the need for [MEDICAL TREATMENT] due to End Stage [MEDICAL CONDITION]. One outcome goal was that the resident would remain free from signs and symptoms of infection to the access area. Interventions included monitoring the shunt site for signs/symptoms of complication, documenting and reporting as needed; checking the site for bruit and thrill as ordered, and monitoring the shunt site for active bleeding and if present notifying the physician. Review of the physician order [REDACTED]. Review of the Treatment Administration Record (TAR) for January 2020, revealed the left arm [MEDICAL TREATMENT] fistula was being monitored for symptoms of infection and for bruit/thrill two times daily as ordered but did not indicate whether bruit/thrill was present. The TAR also revealed the resident received [MEDICAL TREATMENT] on January 24, 2020. Review of the [MEDICAL TREATMENT] for January 24, 2020 revealed the resident went out for [MEDICAL TREATMENT] at 11:20 a.m. on January 24, 2020. The Follow-up Instructions for Health Care Institutions form from the [MEDICAL TREATMENT] center dated January 24, 2020 revealed instructions to observe for bleeding every 30 minutes for 4 hours, palpation of thrill/auscultation of bruit of the permanent [MEDICAL TREATMENT] access every 8 hours, and that the Band-Aid/bandage on the permanent [MEDICAL TREATMENT] access can be removed in 12 hours unless otherwise directed. Review of the [MEDICAL TREATMENT] form dated January 24, 2020 revealed the resident returned from [MEDICAL TREATMENT] at 4:15 p.m. The form included vital signs were obtained on return to the facility and that assessment of the [MEDICAL TREATMENT] fistula revealed bruit was present. The assessment of the [MEDICAL TREATMENT] fistula did not include any documentation regarding a dressing to the access site. The form included for vital signs to be done in four hours following return from [MEDICAL TREATMENT], however, no vital signs were documented for this time frame. The form also included instructions to use this form for each day of [MEDICAL TREATMENT]. This form eliminates the need for reference to [MEDICAL TREATMENT] on nurses' notes. Further review of the clinical record revealed no evidence if the resident was observed for bleeding every 30 minutes from the [MEDICAL TREATMENT] for 4 hours upon returning from [MEDICAL TREATMENT] on January 24, 2020 and whether the Band-Aid/bandage was removed from the [MEDICAL TREATMENT] 12 hours after returning from [MEDICAL TREATMENT] as instructed on January 24. Additional review of the physician order [REDACTED]. Review of the TAR dated January 2020 revealed the dressing from the [MEDICAL TREATMENT] was removed on January 27, 2020 between 6:00 p.m. to 6:00 a.m. There were no instructions on the TAR regarding the removal of the dressing prior to January 27, 2020. Review of the [MEDICAL TREATMENT] form dated January 27, 2020 revealed the resident left the facility for [MEDICAL TREATMENT] at 11:30 a.m. The form included vital signs were obtained prior to the resident leaving along with documentation that bruit was not present. The form did not reveal any documentation in the section designated for the resident's return to the facility. Additional review of the clinical record did not reveal a Follow-up Instructions for Health Care Institutions form dated January 27, 2020 from the [MEDICAL TREATMENT] center. Review of the TAR dated January 27, 2020 indicated the resident had received [MEDICAL TREATMENT]. Review of the [MEDICAL TREATMENT] form dated January 28, 2020 revealed no bruit was present to the [MEDICAL TREATMENT] pre-[MEDICAL TREATMENT]. The TAR dated January 28, 2020 indicated that the resident did not receive [MEDICAL TREATMENT]. A nursing note dated January 28, 2020 revealed the resident had returned from a procedure for declotting the [MEDICAL TREATMENT]. Orders were received from the physician at the [MEDICAL TREATMENT] center to keep the area intact with band aid and to not remove suture from the area. The note also revealed the resident was scheduled to have [MEDICAL TREATMENT] in the a.m. (January 29, 2020). Review of the [MEDICAL TREATMENT] form dated January 29, 2020 revealed the resident left the facility at 11:30 a.m. for [MEDICAL TREATMENT]. The pre [MEDICAL TREATMENT] section of the form revealed no documentation the access site was assessed. A nursing note dated January 29, 2020 at 2:37 p.m. revealed the resident was unable to receive [MEDICAL TREATMENT] because the [MEDICAL TREATMENT] center staff stated that when they attempted there was no back flow and there was no bruit or thrill. The note included the physician wanted the resident to go to the surgery center on January 30, 2020 and after that receive [MEDICAL TREATMENT]. The note also included that if [MEDICAL TREATMENT] is still unable to be given to the resident, send the resident to the hospital. The resident was transferred to the hospital on January 30, 2020. On January 27, 2020 at 12:54 p.m., an interview was conducted with the resident's family member, who stated the resident's [MEDICAL TREATMENT] was kept covered and not checked after the resident received [MEDICAL TREATMENT] on Friday, January 24, 2020. The family member stated the dressing to the [MEDICAL TREATMENT] was supposed to be removed and it was not removed until Monday morning, January 27, 2020. The family member further stated the facility did not provide care to the [MEDICAL TREATMENT] and that resulted in a blood clot developing at the site. Another interview was conducted with the family member on January 29, 2020 at 10:10 a.m. The family member stated that staff are supposed to check the [MEDICAL TREATMENT] when the resident comes back from [MEDICAL TREATMENT], but that they did not check it and left the dressing on Friday through Monday. The family member stated that when the family member called the facility Monday morning, January 27, 2020, a Licensed Practical Nurse (LPN/staff #62) said that she removed the bandage from the [MEDICAL TREATMENT] that morning (January 27). The family member stated the resident was sent to a center on January 28, 2020 to have the site declotted. The family member stated it took over 3 hours and the resident experienced pain and had to be sedated. The family member also stated the nephrologist had told them the [MEDICAL TREATMENT] bandage needs to be removed and that when it is left on, it causes rings in the skin. On January 29, 2020 at 11:30 a.m., an interview was conducted with a Certified Nursing Assistant (CNA/staff #48), who stated that when a resident comes back from [MEDICAL TREATMENT], she takes the resident's vital signs, and obtains the vital signs again 4 hours later. She said that she reports the results to the nurse. During an interview conducted with a Registered Nurse (RN/staff #54) on January 29, 2020 at 11:57 a.m., the RN stated that after [MEDICAL TREATMENT] a post check is done, which includes vital signs, weight, and checking for bruit, and then 4 hours later vital signs are checked again. The RN said the dressing can be removed from the [MEDICAL TREATMENT] after 4 hours. She said she would assess the [MEDICAL TREATMENT] to ensure the bruit is still present. She said if there is no bruit she would notify the physician because it is an indication there may be a blood clot. On January 29 2020 at 1:35 p.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #62), who stated that she checked for the bruit on Monday (January 27) and there was no bruit, so she reported it to [MEDICAL TREATMENT]. She said the [MEDICAL TREATMENT] clinic said to bring the resident to the clinic. The LPN stated the resident was not dialyzed on Monday, because of a blood clot in the access site. She said that an appointment was scheduled for Tuesday, January 28, to have the site de-clotted. She said the resident was not able to be dialyzed on Wednesday (January 30) due to the site still being clotted. The LPN stated that a reason for blood clotting is due to the dressing being left on for too long. She stated that the [MEDICAL TREATMENT] clinic's order was the dressing could stay on for up to 12 hours. The LPN stated that the dressing was left on from Friday until Monday morning, which was more than 12 hours. She also stated that she reported the dressing being left on until Monday morning to the Administrator. The LPN stated the nephrologist was contacted and said to bring the resident in for [MEDICAL TREATMENT], and gave an order to remove the dressing from the [MEDICAL TREATMENT] 2 to 4 hours after [MEDICAL TREATMENT]. The LPN also stated the resident had not had [MEDICAL TREATMENT] since Friday and consequences of missing [MEDICAL TREATMENT] could be buildup of fluids and becoming toxic. On January 31, 2020 at 8:13 a.m., an interview was conducted with the Director of Quality Management (staff #31) who stated that she was acting Director of Nursing. She stated the resident had [MEDICAL TREATMENT] on Friday, January 24, 2020 and that staff #62 told her the resident's pressure dressing to the [MEDICAL TREATMENT] was left on from Friday until Monday morning, January 27. She said staff #62 contacted the [MEDICAL TREATMENT] center for instructions and was instructed to take off the pressure dressing. Staff #31 stated that staff #62 removed the pressure dressing on Monday morning and would have documented the removal in the progress notes and not on the pre/post [MEDICAL TREATMENT] form. After reviewing the [MEDICAL TREATMENT] form dated January 24, 2020 and noting the form was not complete with the vital signs 4 hours after [MEDICAL TREATMENT], she stated that she would have to find out who had completed part of the form. Staff #62 then entered and stated that it is not standard practice to check the bruit with the dressing on, but depending on how thick the dressing is, it may be done. Review of the facility's policy regarding [MEDICAL TREATMENT] dated October 2018, revealed the facility staff will follow standard of care protocols with residents who receive [MEDICAL TREATMENT] services. The policy included that fistulas will be checked for bruit/thrill as necessary and to document and/or notify the provider accordingly. Observe the resident upon return from the [MEDICAL TREATMENT] center. Inform the provider of significant changes or abnormal symptoms. Monitor for any bleeding after [MEDICAL TREATMENT]. If the fistula graft seems to ooze/bleed for an unusually longer period than anticipated, notify the provider. The policy did not address removing the dressing from the fistula after [MEDICAL TREATMENT].

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident's (#23) advanced directive was accurate in the clinical record. The deficient practice could result in the resident receiving unwanted emergency medical interventions. Findings include: Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the resident's conditions of admitted d [DATE] revealed the resident did not want cardiopulmonary resuscitation (CPR) or intubation or drugs or electric shock to keep her heart beating. Review of the Prehospital Medical Care Directive dated [DATE] revealed that in the event of cardiac or respiratory arrest, the resident refuses any resuscitation measures including cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of advanced cardiac life support drugs and related emergency medical procedures. A review of the Face Sheet revealed the resident was a Do Not Resuscitate (DNR) and a Full Code. An interview was conducted with a Licensed Practical Nurse (LPN/staff #111) on [DATE] at 12:55 p.m. She stated that she would review the Medication Administration Record [REDACTED]. The LPN also stated that she can find a resident's code status on the report sheet and in the code status binder. She stated resident #23 is a DNR and on hospice. After reviewing the physician order [REDACTED]. The LPN further stated staff may try to resuscitate the resident even though that is not the resident's wishes. An interview was conducted with the Director of Nursing (DON/staff #31) on [DATE] at 1:23 p.m. The DON stated the expectation is that the physician's orders [REDACTED]. She stated there is a risk CPR could be performed which would be against resident #23's choice. Review of the facility's policy on advanced directives revealed the facility will ensure that a resident's choice concerning written advanced directives relative to his/her refusal of medical or surgical treatment are followed in accordance with their community's Advanced Directive policies and procedures and current state law. The policy also included the resident's nurse will notify the attending physician/practitioner of a resident's advanced directive and the attending physician/practitioner will be responsible to issuing appropriate orders that coincide with the resident's advanced directive.

Based on clinical record review, staff interview, and policy review, the facility failed to ensure the Office of the State Long-Term Ombudsman was sent a copy of one resident's (#42) transfer notice. The deficient practice could result in the ombudsman not receiving a copy of residents' transfers/discharges. Findings include: Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nursing note dated November 1, 2019 revealed the resident was discharged to home with home health. Review of a Discharge Minimum Data Set assessment dated [DATE] revealed the resident was discharged to the community with return not anticipated. However, review of the clinical record and facility documentation revealed no evidence the Long-Term Ombudsman was notified of the patient's discharge. An interview was conducted with the Administrator (staff #[AGE]) on January 28, 2020 at 12:20 p.m. She stated that she does not send the Ombudsman notification of planned resident discharges. After reviewing the Ombudsman communication of discharged residents for November 2019, she stated that she was unable to find documentation that she notified the Ombudsman of resident #42's discharge. The facility's policy on transfer and discharge revealed for non-emergent transfers or discharges initiated by the facility, return not anticipated, a copy of the transfer/discharge notice shall be provided to a representative of the Office of the State Long-Term Care Ombudsman.

Based on observations, facility documentation, interviews, and policy review, the facility failed to ensure the nursing staffing information was complete. The deficient practice resulted in information not being readily available to residents and visitors. Findings include: -During an observation conducted on January 27, 2020 at 9:05 a.m., a Daily Posted Staffing Schedule dated January 27, 2020 was observed to be posted on the 2nd floor. Further observation revealed the posting did not include the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. Behind the nursing staffing information form dated January 27, 2020, were two nursing staffing information forms dated January 25 and 26, 2020. Review of nursing staffing information revealed the actual hours worked by the licensed and unlicensed nursing staff per shift were not included for January 25 and 26, 2020. -A Daily Posted Staffing Schedule dated January 27, 2020, was observed to be posted on the 3rd floor. Review of the POS [REDACTED]. It was observed the nursing staffing information for January 25 and 26, 2020, were behind the posting for January 27, 2020. Review of these nursing staffing information forms revealed actual hours worked by the licensed and unlicensed nursing staff responsible for resident care per shift and the resident census were not included. On January 30, 2020 at 8:48 a.m., an interview was conducted with the Administrator (staff #74), who stated that the actual hours worked by the nursing staff are documented by crossing out the total hours worked and adding the number of actual hours worked. The administrator reviewed the Daily Posted Staffing Schedules for January 25, 26, and 27, 2020 that were posted on the 2nd and 3rd floor. She then pulled a Daily Posted Staffing Schedule at random, which was dated January 19, 2020. The census was not documented on the posting, but the total hours worked were crossed out and the actual hours worked were written under the column for total hours. The administrator was unable to say if the actual hours worked were being documented on the day the Daily Posted Staffing Schedule was posted. Review of the facility's policy regarding required posting revised August 2019, revealed the facility will post required postings in an area that is accessible to all staff and residents, which includes staffing information. The policy did not specify what type of staffing information needed to be posted.

Based on observation, staff interviews, and review of facility policy, the facility failed to ensure that the environment promoted maintenance or enhancement of resident's quality of life during third floor dining by not having an in-dwelling urinary catheter bag in a privacy bag on one resident. Findings Included: An observation was conducted on August 21, 2017 from 12:30 to 1:17 p.m. in the third floor dining room. One resident was seated at a dining table with a catheter bag that was not in a privacy bag. Multiple staff were in the dining room during the observation period. The catheter bag remained uncovered for the entire observation period. An interview was conducted with Certified Nursing Assistant (CNA/staff #111)) on August 23, 2017 at 9:45 a.m., she stated that the CNA's receive training on how to do catheter care. She stated that before she removes a resident from their room she will put the catheter bag in a privacy bag so that it won't be obvious. An interview was conducted with Licensed Practical Nurse (LPN/staff #85) on August 23, 2017 at 10:08 a.m., she stated that the CNA's do catheter/perineal care each shift and with brief changes. She stated that the staff promote patient dignity by placing the catheter bag in a privacy bag. She stated that if it was noted by staff that the privacy bag was forgotten, staff would notify the CNA to go get the privacy bag. She stated that she would be able to see if the privacy bag was missing with a glance down the hall. An interview was conducted with Registered Nurse (RN/staff #66) on August 23, 2017 at 2:19 p.m., she stated that if a resident had a catheter bag they would need a privacy bag to cover the catheter bag. She stated that is the policy and that is how the CNA's are trained. She stated that if the bag was uncovered she would stop and correct the issue by asking the resident to let her put the catheter bag in a privacy bag. She stated that if the resident was already out of the room and refused to have the catheter bag covered she would follow the resident wishes. She would then place the catheter bag in a privacy bag when the resident returned to the room. An interview was conducted with the Director Of Nursing (DON/staff #138) on August 8, 2017 at 2:38 p.m., she stated that the catheter bag should always be in a privacy bag. She stated that she would expect the privacy bag to go with the resident to and from the wheelchair or bed or for there to be second bag in place. She stated that she always encourages the use of the privacy bag even if the resident voices a preference to not have one. She stated that if the catheter bag was not covered, it should have been caught when staff were transferring the resident to the chair. She stated that the staff gets classroom training and hands on training for catheter care, including privacy bag use. She stated that the last training occurred before this DON started on August 2, 2017. She stated that if a nurse noted an uncovered catheter bag and the resident refused the placement of a privacy bag she (DON) would like for the nurse to make a note in the record and add the resident's preference to the care plan . She stated that if a resident refused a privacy bag the nurse would explain that the privacy bag was for infection control as well, not just for looks and the nurse would document that education. She stated that she monitors the use of privacy bags when she does rounds and if she sees an issue she would give staff cues/reminders to correct the issue. A review of the facility policy on catheter care revealed that for resident dignity, all catheter drainage bags should be covered with a privacy bag.

Based on clinical record reviews, staff interviews, hospital documentation and policy review, the facility failed to maintain the residents highest practicable well-being, by failing to provide care and treatment and adequately monitoring one resident (#312), by failing to ensure that one resident (#311) was monitored regarding skin conditions, and by failing to ensure that one resident (#309) was provided the necessary care and services following a left wrist fracture. Findings include: -Resident #312 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], January 26, 2014, and February 4, 2014, with [DIAGNOSES REDACTED]. Review of the Incident/Accident Report dated January 19, 2014, revealed a staff member noted that on Sunday, January 18, 2014, the resident had a large bruise and hematoma to her left wrist of an unknown etiology. No measurements were noted. The documentation included the physician was notified. Review of the closed clinical record revealed there was no documentation that a nursing assessment was done of the left hand/wrist which was identified on January 18. A Nurse's Note dated January 19, 2014, revealed that a cold compress was applied to the bruise on the left hand and the resident responded that it hurt when touched. Also noted was to continue to monitor. Further review of the clinical record revealed there were no physician's orders on January 19, 2014 regarding any treatment or care that was to be provided for the left hand. Review of the Nurse's Note dated January 20, 2014 at 9:45 a.m., revealed there was purplish bruising noted to the top of the left hand and wrist, with two small raised areas on the top of the left hand. The note also stated that the resident complained of pain to touch, but was unable to say what happened to her hand. The note further stated that ice was applied to the swollen area as ordered and the physician ordered an x-ray and they were to keep the left hand elevated. However, there were no physician's orders in the clinical record for the above interventions. A fax transmittal dated January 20, 2014, included that the wound nurse looked at the resident's left hand and was requesting to discontinue the cold compresses and apply warm compresses as needed until resolved, to which the physician agreed. A fax transmittal dated January 21, 2014, documented they were informing another physician that they had received a telephone order from a physician to send the resident to the emergency room , due to a large hematoma to the left hand. The documentation included that an x-ray was done and was negative for a fracture, there was swelling of the hand which was getting large, there was an open area with increased pain, and blisters were starting on the fingers. The fax also included the resident was admitted to the hospital. Despite the above information on the fax, there was no clinical record documentation that a thorough assessment of the left hand was completed on January 21, 2014. Review of the hospital Consultation Report dated January 21, 2014, revealed the resident was transferred from a care facility for left hand and left arm swelling. The note included that nobody knows if the resident had trauma or a fall, and the resident is severely demented and unable to answer any questions. The documentation also included that according to the emergency room note, the resident had a fall two days ago (although there is no clinical record documentation that the resident had a fall in January) and was seen by her primary doctor and the x-rays were negative for any acute fracture. The report also noted that there was an increase in the size of the hematoma on the dorsum of her hand, with blisters and that infectious disease was consulted. Review of another hospital Consultation Report dated January 21, 2014, revealed that the patient's clinical picture is consistent with post-traumatic hematoma. The report documented that the physician did not believe the resident had [DIAGNOSES REDACTED] given the fact that she was not toxic and her labs remain within normal limits and she is afebrile. Per the note, usually patients with [DIAGNOSES REDACTED] are febrile with systemic toxicity; however, there is significant [MEDICAL CONDITION], which could compromise her vascular supply to the hand and that the resident would benefit from decompressive surgery. According to the surgical consult, the resident underwent [REDACTED]. The resident was readmitted to the facility on [DATE]. Review of the Daily Nursing Assessment and a Nurse's Note dated January 23, 2014, revealed the resident was readmitted from the hospital with a left hand hematoma. The note stated that the left upper extremity had dark purple bruising from hand to elbow, and that the left hand was wrapped with Kerlix. The admission orders [REDACTED]. According to the January 2014 Treatment Administration Record (TAR), the above order was included, however; it was hand written that the treatment was discontinued. No date was documented. Also on the TAR, was another wound treatment dated January 24, which included to rinse the left hand with wound spray, gently pat dry, apply [MEDICATION NAME] to wound, cover with Xeroform, 4 x 4 and Kerlix, and change two times per day. However, there was no physician's order in the clinical record to discontinue the [MEDICATION NAME] AG and to apply [MEDICATION NAME] starting on January 24. A Nurse's Note by the wound nurse dated January 24, 2014, documented that the wound was unable to be measured, as the whole back of left hand and fingers had blisters and the back of the hand was black. The note included the doctor was called, and the wound orders were changed to [MEDICATION NAME] since [MEDICATION NAME] AG was not doing well and was sticking to the wound. The note also stated the nurse could feel a radial pulse and for [MEDICATION NAME] two times daily to try to salvage most of the hand. Per the TAR, there was no documentation that the treatment was done on January 24. Review of the Nurse's Note dated January 25, 2014 at 3:25 p.m., revealed the resident's dressing was changed by the wound nurse and the resident had no signs or symptoms of discomfort. There was no documentation on the January 2014 TAR that the treatment was done on January 25, as noted in the above nurse's note. A Nurse's Note by the wound nurse dated January 24/25 revealed there was extensive damage to the resident's left hand. The skin on top of the hand was black/purple and peeling, and finger tips had extensive blisters, plus there was bruising up into the left armpit. The note also stated the information was relayed to the medical director, the physician, the Director of Nursing (DON), and family. Per the note, an order was obtained to change the wound care to daily soaks with warm water and [MEDICATION NAME] two times daily, and if resident shows any signs of acute illness, may send to the hospital. However, further review of the clinical record revealed there was no physician's order for the daily soaks, nor any documentation that they were done. Review of the Nurse's Notes dated January 25, 2014 at 9:00 p.m., revealed the resident's left forearm had dark discoloration, was bruised and swollen, and was cool to the touch. A Minimum Data Set (MDS) assessment dated [DATE], included in Section I. Active Diagnoses, that the resident had [MEDICAL CONDITION]/abscess. However, there was no documented evidence that a care plan for [MEDICAL CONDITION] was developed. A Nurse's Note dated January 26, 2014 at 5:55 a.m. included the resident appeared weak, vomited a moderate amount of yellow colored secretions and had three loose, watery stools and that the a.m. nurse would be notified. A note at 8:20 a.m., documented that the physician was called and orders were given to send the resident to the hospital for evaluation and treatment. Per the note, the resident was transported by ambulance to the hospital at 9 a.m. and was admitted . Review of the emergency room Report dated January 26, 2014, revealed the resident presented with left hand hematoma, status [REDACTED]. An x-ray of the hand was done with the results noting a clinical history of left hand swelling and possible osteo[DIAGNOSES REDACTED]. The report noted that a comparison from an x-ray done on January 21, revealed diffuse severe dorsal hand and diffuse digital swelling is again noted and there is now development of soft tissue gas in the dorsum of the hand at the level of the metacarpals. The note further stated that severe soft tissue swelling of the hand with interval development of gas in the soft tissues was concerning for gangrenous infection versus abscess formation. The documentation included the following [DIAGNOSES REDACTED]. According to an Orthopedic Consultation Report dated January 27, 2014, the resident was seen by the physician and six days ago underwent unroofing of hemmorhagic blister, which occurred after a crush injury. Review of the hospital Discharge Summary dated January 31, 2014, revealed the resident had a recent left hand crush injury, with impending [DIAGNOSES REDACTED]. The summary noted that the resident had extensive bruising, extensive blood collection and required an evacuation of a large hematoma and was found to have almost impending [DIAGNOSES REDACTED] prior to surgery. The summary included that the physician recommended continuing antibiotics, as the physician could not rule out a superimposed [MEDICAL CONDITION] and given the presence of the hematoma, was concerned for possible infection. The summary also stated that the resident had significant oozing and bleeding after surgery on postoperative day two for which she underwent transfusion of packed red blood cells. Review of the hospital Discharge Summary dated February 4, 2014, revealed the resident was discharged back to the facility for occupational therapy. The clinical record revealed the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. There was no documentation that a thorough assessment of the resident's left hand was completed upon readmission on February 4. A physician's order dated February 4, 2014, included the following wound treatment: change dressing to left hand daily, remove the old dressing and soak hand in warm water for 5-10 minutes, clean area with wound cleanser after soaking and gently pat dry, cover dorsum of hand, all fingers, and thumb with Xeroform gauze, then ace wrap and keep hand elevated and flex fingers often. The above treatment order was transcribed onto the February 2014 TAR, however, there was no documentation that the treatment was provided on February 4. A Nurse's Note dated February 5, 2014, documented the top center of the left hand was black in color, and there was discoloration to the hand and fingers, with bruising and swelling. The note also included the treatment was done to the left hand (although this was not documented on the TAR). According to the Nurse's Note dated February 6 at 2:02 p.m., the resident ate very little for breakfast and started gagging, but no emesis and later refused lunch. The note included the resident's fingers were swollen with non-[MEDICAL CONDITION] and were purplish in color, with multiple scabs. The top of left hand had a large blackish wound area, which was approximately 8 x 5 centimeters and just above the wrist remains a raised lump area. Also noted was that the wound treatment was done to left hand (although this was not documented on the TAR). A Nurse's Note dated February 6 at 5:34 p.m., documented the resident tried to get up for supper, but became sweaty and wanted to go back to bed, blood pressure was 98/61 with a pulse of 71. The note included the resident was given fluids orally, the head of the bed was elevated, the resident was taking bits of crackers with no emesis and stating that she feels better. Per the note, the doctor would be in tomorrow to see the resident. physician progress notes [REDACTED]. Review of the Nurse's Note dated February 7, 2014 at 5:48 p.m., revealed the physician was in to see the resident today and orders were given for intravenous (IV) fluids, due to [MEDICAL CONDITION]; the blood pressure was 94/58 at 8:00 a.m. and at 4:00 p.m. was 108/80 after fluids were infused. The note also included the resident refused meals and continued on antibiotic therapy for left hand [MEDICAL CONDITION]. From February 7 at 6 p.m. until approximately 10:30 p.m., there were no additional assessments regarding the resident's condition, despite documentation that the resident was experiencing a change of condition. According to a hospital emergency room Report dated February 7, 2014, the resident was brought to the emergency room via ambulance at 11 p.m., with altered mental status. The report noted the resident was recently discharged and had surgery for [REDACTED]. Per the report, the left hand was swollen, red, warm, with large eschar and poor blood flow. It was also noted that the resident had a high white blood cell count, [MEDICAL CONDITION], with concern for origination from the hand. The resident was not discharged back to the facility after this date. However, in the clinical record was a Nurse's Note dated February 8, 2014 at 6:31 p.m. The entry was not noted as a late entry and appears to be referring to the events from the previous day. The note included that around noon the resident was found to be extremely lethargic; IV fluids were given and blood pressure was rechecked at an unknown time and was 114/72. Wound care was done to the left hand as ordered and hand was very cyanotic in appearance with large areas of eschar and no real warmth or pulses were able to be palpated and had increased pain during dressing change. The report included that at about 6:00 p.m. the resident seemed very lethargic and nonresponsive and an order was received to send the resident to the hospital for an evaluation. However, per the hospital emergency room documentation the resident did not arrive until approximately 11 p.m. Review of the hospital History and Physical Report revealed the resident presented to the emergency room from a care center for what was described as a syncopal episode, with necrotic left hand. The report noted that the resident was found to have a hemoglobin of 5.9 which was a critical level (normal range is 12-16) and was transfused with packed red blood cells. Review of the Infectious Disease Consultation Report dated February 8, 2014, revealed that the resident had a large necrotic lesion on the left hand and a couple from the first to fourth metaphalangeal area, very hard and also the digits are very cold. Review of the Surgical Consult Report dated February 8, 2014, revealed the resident was transferred from a care center with initially a hand injury or hematoma, which has become infected. Another Consultation Report dated February 10, 2014, revealed the resident had operations to her left hand on January 21, 2014, with a left hand hematoma decompression on the dorsal aspect that was followed by an operation on January 29, 2014, with irrigation and debridement of the left hand soft tissue necrosis and irrigation of the left dorsal hand hematoma. A surgical consult was ordered for the left upper extremity vascular evaluation. Review of the Discharge Summary Report dated February 11, 2014 noted that the resident was found to be in systemic [MEDICAL CONDITION] response syndrome, and was started on [MEDICATION NAME] and [MEDICATION NAME]. The note included the resident was made a Do Not Resuscitate (DNR) and this morning was noted to have agonal respirations and passed away, with a probable cause of septic shock secondary to a recent hand infection and necrosis. Review of the Record of Death/Human Remains Release Record dated February 11, 2014, revealed the cause of death as cardiovascular collapse/sepsis. An interview was conducted on April 22, 2015, with a Licensed Practical Nurse (LPN). The LPN stated that the resident's left hand injury started out being bruised and very swollen, but the skin was intact. She stated the resident developed blisters on the fingers of the left hand, and the swelling got worse and the resident was sent to the emergency room . The LPN also stated that the resident returned to the facility after several days, and when she came back there was discoloration to the whole left arm and chest that appeared to have poor circulation and was soon sent back to the hospital. The LPN further stated that she was not aware of any injury to the resident's left hand. An interview was conducted with another LPN on April 22, 2015. The LPN stated that this resident had a small bruise on her lower left arm which got bigger and was sent out to the hospital where she was started on antibiotics for [MEDICAL CONDITION], but the left arm and hand just kept getting worse. The LPN stated that the wound nurse was doing all of the treatments, but that wound nurse no longer worked at the facility. An interview was conducted on April 23, 2015, with the Director of Nursing (DON). The DON stated that this resident was unable to tell staff what happened to her left hand. She stated that when a resident is admitted to the facility an assessment is done upon admission, and the wound nurse assesses wounds every day and notifies the physician if there is a change in condition. The DON also stated that all assessments should be documented in the nursing notes. The DON was also unable to provide any additional clinical record documentation for this resident. Review of the facility's policy on Skin Assessments revealed .The wound nurse/designee, upon identification of a wound/pressure ulcer will complete an assessment.Identified sites will be described in the medical record.Documentation should include progress or deterioration of the wound, how resident tolerates procedure, change of treatment, etc.The assigned Wound Nurse will assess all wounds weekly. A weekly Summary Report will be submitted to the Director of Nursing, Administrator and the Dietary Manager. Review of the facility's policy on Change of Condition revealed .Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status.If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. -Resident #311 was admitted to the facility March 17, 2014, with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. The MDS assessment dated [DATE] included the resident scored a 6 on the Brief Interview of Mental Status, indicating severe cognitive impairment. Under Section G. Functional Status, the resident required extensive assistance with transfers. Regarding the skin tear: A care plan dated March 2014 addressed the resident's risk for abnormal bleeding and bruising, due to anticoagulant therapy. A review of the nurse notes dated March 21, 2014, revealed the resident had increased [MEDICAL CONDITION] to the right wrist and was found in bed with a skin tear to the right wrist, which was pumping blood into a pool on the mattress and the floor. Pressure was applied till the bleeding stopped. The skin tear was cleansed and a dressing was applied. A review of the clinical record revealed there was no documentation of any wound assessments or monitoring of the skin tear that was done from March 22 through 29, 2014, when the resident was discharged . According to the Discharge Plan of Care form dated March 29, 2014, the resident was being discharged to home, with instructions to cleanse the right arm with normal saline and apply Vaseline to area, cover with dry dressing and change daily until healed. The documentation did not indicate if this treatment was for the right wrist skin tear or another wound. Regarding the Rash: Nurses notes dated March 28, 2014 documented the resident had a rash to the abdominal area. The physician was notified and orders were obtained for Solu [MEDICATION NAME] (corticosteroid) Intravenously. The note included that the physician was in to see the resident. A review of the March 2014 physicians orders did not reveal the order for Solu [MEDICATION NAME], nor was it included on the MAR. Further review of the clinical record revealed there was no further assessment documentation regarding the rash. A nurses note dated March 29, 2014, included that cream was ordered for the resident's rash to the abdominal area and that the script was given to the family with instructions. According to the Discharge Plan of Care form dated March 29, 2014, the cream ordered was [MEDICATION NAME] (corticosteroid), and was to be applied to the affected areas twice daily until healed. An interview was conducted on April 23, 2015 with a LPN, who stated that if he had been told of a resident having a rash or a skin tear, he would assess and describe the rash or skin tear, notify the physician, follow the physicians orders and document the information. An interview was conducted on April 23, 2015, with the DON. She stated that she was one of the first persons to see the rash due to the family showing her the rash. She described the rash as possible heat rash, which was underneath the resident's breasts. The DON also stated that she did not document anything regarding the rash, since she talked to the nurse that was taking care of the resident and the physician had already been notified. An interview was conducted on April 24, 2014 with a Registered Nurse, who took care of the resident. She stated the rash was pinpoint and was on the resident's abdomen and trunk. Review of a facility policy titled Skin Assessment included the following: 1. The Wound Nurse/designee, upon identification of a wound/pressure ulcer will complete an assessment. 2. Identified sites will be described in the medical record. This includes pressure, non-pressure, venous, arterial, diabetic wounds, significant burns, skin tears, cuts and other skin conditions as deemed necessary. The policy also included the following guidelines are to be followed when completing the assessment: a. Wounds:are identified as partial or full thickness, b. Measurements, c. Wound bed of open areas, d. Exudate e. Wound related pain, f. Documentation should include progress or deterioration of the wound, how resident tolerates procedures, and change treatment if needed. -Resident #309 was admitted on [DATE], with a [DIAGNOSES REDACTED]. Review of a nursing note dated August 11, 2014 at 7:46 a.m., revealed that at 4:40 a.m., the resident's alarm sounded and the resident was found by the nurse and Certified Nursing Assistant (CNA) on the floor by the window. The resident denied hitting his head, however, a skin tear was assessed to the resident's left elbow and a [MEDICATION NAME] (non-adherent) dressing was applied, steristrips were applied to the left hand, and a [MEDICATION NAME] dressing was applied to the left lower extremity. [MEDICAL CONDITION] was also noted to the left upper extremity. Review of an incident report dated August 11, 2014, revealed the fall occurred in the resident's room, when the resident attempted to go to the bathroom. The assessed injuries included skin tears to the resident's left elbow, left hand, and left lower extremity. The report also documented that an x-ray was ordered to the left wrist. A physician's order dated August 11, 2014, included for an x-ray to the left hand and wrist. Review of the final x-ray report dated August 11, 2014, revealed there was diffuse osteopenia and soft tissue swelling. The final impression was an acute distal ulnar and radial fracture. A hand written note at the bottom right hand side of this page was dated August 11, 2014, which documented the resident's physician was informed and that the resident was to see an orthopedic physician splint needed. A nursing note dated August 11, 2014 at 4:03 p.m., documented that an orthopedic facility was contacted for an appoint for the resident's left wrist fracture. The entry revealed that there were no openings until Friday (August 15, 2014) but was informed that a sooner appointment was required. The orthopedic center was to return a call back to the facility and that the resident's physician was aware. An Occupation Therapy (OT) Daily Treatment Note dated August 11, 2014 at 6:12 p.m., documented the resident was currently on non-weight bearing (NWB) status to the left upper extremity, due to an earlier fall this day. Despite this entry, review of the clinical record did not reflect a physician's order for weight bearing status, or other interventions that were to be implemented such as; neurovascular checks to the left hand. Another nursing note dated August 11 at 7:03 p.m., reflected that an appointment was made with the orthopedic center for August 15, and the physician was made aware of the appointment. The note also included that the physician requested a splint to be ordered for the resident's left hand and a message was left with the facility's central supply and ice was provided at this time. Further review of the clinical record did not reflect an order for [REDACTED]. In addition, no care plan was developed to address the fracture and the need for interventions. An SBAR (Situation Background Assessment Request) form dated August 11, revealed worsening of the left wrist pain, noted as 10/10. Conditions which made it better were ice and medications and that any movement to the area made the condition worse. Another OT Daily Treatment Note dated August 12, 2014 at 10:36 a.m., included Met with patient and family regarding new acute L (left) wrist fracture and request of house physician to obtain splint. The entry continued that the OT therapist was called by nursing to assist with positioning of the left upper extremity. The resident had significant [MEDICAL CONDITION] and pain of 8/10 to the left wrist. The DON was notified and came to the resident's room and discussed options with the resident, as the orthopedic physician consult was unable to be scheduled until August 15. The resident and family decided to have the resident transported to the emergency department for further assessment. Continued review of the clinical record revealed there was no documentation of any ongoing assessment or monitoring of the resident's left upper extremity which was done, from the time of the fall on the morning of August 11 through the afternoon on August 12, when the resident was sent to the hospital. Review of the the emergency room Report dated August 12, 2014 at 2:56 p.m., revealed the resident presented to the emergency room due to a fall yesterday, which resulted in distal radius and ulnar fractures of the left wrist. The report included there was moderate swelling to the left upper extremity. The documentation also noted that there was no splint on at the time of admission and that one was applied. An interview was conducted on April 23, 2015 at 1:00 p.m., with the OT therapist who worked with the resident and documented the therapy note on August 12. The therapist stated that when nursing communicates to them that a resident has a fracture, therapy immediately ensures residents are placed on a NWB status during treatment in therapy. The therapist further explained that nursing would still need to contact the physician for the order of NWB status. During an interview with the DON on April 24, 2015 at 10:00 a.m., the DON stated after reviewing the clinical record that ice was applied based on an entry in the nursing notes and that a splint was being ordered through central supply. The DON stated she could not locate a physician's order for the splint. The DON could not explain why the splint was not transcribed to the August 2014 TAR, nor why there were no other interventions documented regarding the monitoring of the left wrist for circulation and [MEDICAL CONDITION], or more frequent applications of non-pharmacological interventions, such as ice. The DON stated that this would be expected as part of the standard of care, but that if nursing did not document it then it was not competed. In addition, the DON stated that she could not locate a care plan following the resident's fracture of his wrist, only explaining that one would be expected. On April 27, 2015 at 10:24 a.m., an interview with the Registered Nurse (RN), who cared for the resident on August 11 and 12, was conducted. The RN stated that in reference to the entry she made regarding the splint to be ordered through Central Supply, there should have been a physician's order for the splint that would have read splint when available. The nurse explained that it should have been transcribed onto the TAR so that when it arrived, nursing would initial that it came and was applied. The nurse further stated that there was no NWB precautions and that there should have been a weight bearing status order. The RN stated nursing interventions that do not require a physician's order include elevating the extremity, immobilizing the affected arm as much as possible, ice for [MEDICAL CONDITION], and placing the extremity on a pillow while the resident is in bed. The nurse also stated that an assessment of the extremity would include assessing for circulation, checking pulses, assessing for color, temperature, and sensation changes and that these interventions and assessments should be documented in the nurses notes, as well as in the care plan. Review of a Medication Orders Policy dated as revised on June 2013, revealed that 9.b. Telephone or verbal orders must be recorded on the Physicians' Order Sheets when received, and must be recorded by the nurse receiving the order. Review of the facility's policy on Change of Condition revealed .Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status.If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. A policy was requested with regards to caring for residents with fractures, however, the DON stated that no policies were available specific to that situation.