Every finding on record at Windridge Nursing and Rehabilitation Center

Based on record review and interview, the facility failed to ensure a physician provided a rationale for the use of an antipsychotic medication when requested on a pharmacy consultant report for 1 (#5) of 5 sampled residents reviewed for unnecessary medications.The administrator identified 34 residents were prescribed psychotropic medications.Findings:A physician's medication order for Res #5, dated 09/27/24, showed the resident had been prescribed Zyprexa (antipsychotic medication) 5 mg oral tablets to be given to the resident each night at bedtime for the diagnosis of insomnia.A pharmaceutical consultant report for Res #5, dated 04/24/25, read in part, Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rationale for the continued use. The report showed Res #5 had an order for Zyprexa 5 mg to have been given at bedtime for insomnia. The report showed the pharmacist had noted insomnia was not an approved diagnosis for Zyprexa per CMS - Center for Medicare and Medicaid Services guidelines. In the section on the report where the physician was to address the medication, there was no order for a reduced dose of Zyprexa or a rationale for the continued use of the medication at the current dose.A medication administration record for Res #5, dated December 2025, showed an active order for Zyprexa 5 mg oral tablets for the diagnosis of insomnia with a start date of 09/27/24. The record showed the resident had continued to be administered the medication and received doses on 12/01/25 and 12/02/25.A facility policy and procedure titled The Use of Psychotropic Medications, revision date 12/03/25, read in part, For residents receiving psychotropic medication on admission or prescribed psychotropic medication during their stay, a gradual dose reduction will be attempted at least twice within the first year, in two separate quarters of the year, at least one month apart. The resident's response to the reduction will be documented in the medical record. If a gradual dose reduction results in a return of symptoms, the physician may return the resident to the lowest dose with symptom control. The physician will document the rationale.On 12/03/25 at 1:47 p.m., a medication order audit form was reviewed in Res #5's electronic medical record. The form showed Res #5 had been reordered Zyprexa 5 mg oral tablets on 10/22/24, 11/22/24, 12/23/24, 01/20/25, 02/20/25, 03/21/25, 04/21/25, 05/20/25, 06/18/25, 07/19/25, 08/18/25, 09/16/25, 10/15/25, and 11/11/25.On 12/03/25 at 1:15 p.m. the DON was asked to explain the process for the pharmacy consultation reports. They stated to alert the physician to any issues with the medications that were ordered such as allergies or need to attempt a GDR. The DON was shown the pharmacy consultation report for Res #5, dated 04/24/25, and was asked if the physician had addressed the pharmacist's concerns listed on the report. They stated the physician had not addressed the Zyprexa order and had not provided a rationale for the continued use of the medication. They stated it was the physician's responsibility to attempt the dose reductions per their policy or at least provide a rationale why not. They stated the physician had not followed the facility's policy regarding GDR's.

Based on observation, record review, and interview the facility failed to ensure proper infection control techniques when providing catheter care for one (#1) of one sampled residents who were reviewed for catheter care and failed to ensure enhanced barrier precautions were utilized for PEG tube care for one (#20) of one sampled residents who were reviewed for PEG tubes. The ADON identified one resident resided in the facility with a urinary catheter and one resident in the facility with a peg tube. Findings: An undated Catheter Care policy, read in part, use gloves, basin of warm water, soap or peri wash, washcloth, towel .Routine to be followed unless specific orders direct otherwise. An Enhanced Barrier Precautions policy, undated, read in part, the expanded use of PPE and refer to the use of gown and gloves during high-contact care activities that provide opportunities for transfer of Multi-Drug Resistant Organisms (MDRO) to or from staff hands or clothing or indirectly transferred. 1. Resident #1 had diagnoses which included urinary retention, neuropathy, and cellulitis. An Order Summary report documented catheter care was to be completed every shift. On 08/22/24 at 9:15 a.m., CNA #1 was observed to obtain wash cloths from a handrail in the hallway outside the room of Resident #1 to provide peri care. CNA #1 wet the wash cloths in the sink, a hospice aide assisted CNA #1 to remove the incontinent brief of Resident #1. CNA #1, using same gloves, re-wet the wash cloths in the sink. CNA #1 was observed to wipe the peri area of Resident #1 multiple times with the same wash cloth. CNA #1 returned to sink, wearing the same gloves and re-wet another cloth, returned to Resident #1 then wiped the catheter tube multiple times with the same cloth, doffed their gloves, and was not observed to sanitize their hands. On 08/22/24 at 9:43 a.m., the ADON was asked what the facility policy was on peri care with or without a catheter. They stated to use soap and water, wipe from front to back, rinse well, and clean around catheter. They were then asked if wash cloths hanging off of handrails in the hallway were considered clean. They state No. 2. Resident #20 had diagnoses which included brain cancer, dysphagia, and seizures. A physician order, dated 12/15/23, documented to change PEG tube PRN for obstruction or displacement only. A physician order, dated 12/15/23, documented to cleanse PEG tube stoma and around area with wound cleanser, pat dry with 4x4's, then secure a spilt sponge dressing daily and prn. On 08/22/24 at 9:30 a.m., no signage was posted for EBP precautions, no PPE was observed near Resident #20's or Resident #1 door. On 08/22/24 at 9:36 a.m., the administrator was asked what the facility policy was regarding Enhanced Barrier precautions. They stated the policy was included with the infection control policy and procedure. On 08/22/24 at 9:41 a.m. the ADON was asked what residents in the facility were on EBP. They stated no residents were on EBP at this time.

Based on record review and interview, the facility failed to ensure Resident Assessments were accurately coded for one (#13) of 12 residents reviewed for assessments. The Administrator identified 36 residents resided in the facility. Findings: An Assurance Of Professional Accuracy policy, undated, read in part, this facility will insure the accuracy of each resident's assessment. Resident #13 had diagnoses which included dementia, bipolar, depression, and anxiety. An Order Summary report, documented Resident #13 did not received the Antipsychotic medication Depakote and a review of discontinued orders documented Depakote was discontinued on 05/24/24. An Quarterly Resident Assessment, dated 07/12/24, document Resident #13 received a Antipsychotic medication daily. On 08/22/24 at 11:40 a.m., the ADON was asked to review the quarterly assessment for 07/12/24. The ADON reviewed and was then asked if Resident #13 received a Antipsychotic medication Depakote daily. They stated they mistook the Depakote level lab as the order for Depakote and marked the MDS inaccurately. On 08/22/24 at 12:01 p.m., the ADON was asked what the facility policy was for accuracy of resident assessments. They stated the assessments should be accurately completed.

Based on observation and interview, the facility failed to ensure equipment was maintained in a manner to prevent growth and equipment was not left in food bins. The administrator identified 36 residents who ate from the kitchen. Findings: On 08/20/24 at 10:39 a.m., scoops were observed in food bins of cake mix, sugar, flour, brown sugar and pinto beans. On 08/02/24 at 10:50 a.m., the ice machine was observed to have pink and black substances on the deflector plate which ice was observed to touch. The maintenance supervisor was asked to open the top of the ice machine. The area where ice was formed was observed to have a dark substance scattered across the plastic and along the sides of the machine. Observation of the ice revealed dark specks frozen inside of the ice. The maintenance supervisor stated the ice machine was cleaned by a contracted company every six months. On 08/21/24 at 12:46 p.m., the holding temperature of beef roast was 135.9 degrees Fahrenheit. DA #1 stated the holding temperature should be 170 degrees Fahrenheit. On 08/22/24 at 2:06 p.m., the DM stated the holding temperature of meat was to be 140 degrees Fahrenheit or higher and the food should have been reheated until it reached the proper temperature. They stated no resident had signs or symptoms of food borne illness. The DM stated the scoops should have been placed on the hook inside of the bins to prevent them from touching the food products/ingredients.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week. The Administrator identified 36 residents resided in the facility. Findings: On 08/22/24 at 1:52 p.m., Administrator, provided the requested RN hours for January, February, and March 2024. On 08/22/24 at 2:18 p.m., review of the RN time punch details and floor schedule for nurses documented, the facility did not have RN coverage for eight consecutive hours on the following dates: a. 01/06/24 - No RN hours worked, b. 01/07/24 - No RN hours worked, c. 01/20/24 - No RN hours worked, d. 01/21/24- No RN hours worked, e. 02/04/24- No RN hours worked, f. 02/20/24- No RN hours worked, and g. 02/27/24- No RN hours worked. On 08/22/24 at 2:52 p.m., Administrator was asked what the facility policy is for RN coverage 7 days a week. They stated the facility needed RN coverage 7 days a week. They were then asked were the dates above covered by RN's, they stated No.

Based on record review and interview, the facility failed to ensure a resident who received psychotropic medications received a gradual dose reduction in a timely manner for one (#4) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, documented 19 residents received psychoactive medications. Findings: A Policy and Procedure for Drug Regimen Review form, dated 04/10/17, read in part, .The physician will document in the resident's medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it. If there is no change in the medication, the physician will document his/her rationale for the decision in the resident's medical record . 1. Res #4 had diagnoses which schizoaffective disorder, major depressive disorder, and anxiety disorder. A physician order, dated 12/16/19, documented to administer trazadone 50 mg in the evening related to anxiety disorder due to known physiological condition. A physician order, dated 12/16/19, documented to administer Risperdal 2 mg twice daily related to schizoaffective disorder. A physician order, dated 12/16/19, documented to administer sertraline 50 mg daily related to major depressive disorder. A care plan, dated 11/27/20, documented the resident used psychotropic medications related to behavior management and a diagnosis of schizoaffective disorder with an intervention to consult with the pharmacy and physician to consider dose reduction when clinically appropriate at least quarterly. A MRR, dated 09/06/22, documented a request for a GDR on Res #4's Risperdal, trazadone, and sertraline. The MRR documented the chart indicated the resident's condition was stable and they had not received a gradual dose reduction previously for Risperdal since 02/13/18 and for trazadone and sertraline since 10/15/17. A physician response, dated 09/14/22, documented the physician did not wish to adjust the dosage of the Risperdal and trazadone. The physician documented the resident is stable with minimal or no side effects relating to chemical restraint. There was no documented response to the sertraline GDR request. An annual assessment, dated 11/27/22, documented the resident had severe cognitive impairment, experienced hallucinations and delusions, and received antipsychotics and antidepressants during the review period. The assessment documented a gradual dose reduction had not been attempted and had not been clinically contraindicated. A MRR, dated 03/06/23, documented a request for a GDR on Res #4's Risperdal, trazadone, and sertraline. The MRR documented the chart indicated the resident's condition was stable and they had not received a gradual dose reduction previously for Risperdal since 02/13/18 and for trazadone and sertraline since 10/15/17. A physician response, dated 03/30/23, documented the physician did not wish to adjust the dosage of the Risperdal, trazadone, and sertraline. The physician documented a previous dose reduction of the Risperdal, trazadone, and sertraline had been attempted and was not successful. Documentation of a gradual dose reduction of Risperdal, trazadone, and sertraline was not found in the clinical record. A MRR, dated 06/29/23, documented a request for a GDR on Res #4's Risperdal, trazadone, and sertraline. The MRR documented a request for the physician to document clinical rationale for continued use if a dose reduction was not desired. A physician response, dated 07/03/23, documented the physician did not wish to adjust the dosage of the Risperdal, trazadone, and sertraline. The physician did not document clinical rationale for continuance. On 08/02/23 at 9:21 a.m., the DON stated the physician did not respond to the GDR request in an appropriate manner. The DON stated a dose reduction had not been attempted for Res #4 but should have been per requirements. They stated the resident would be considered to have received unnecessary medications since no dose reduction had been attempted.

Based on record review and interview, the facility failed to ensure the physician responded to pharmacist medication reviews related to the GDR requests with a clinical rationale for five (#4, 6, 14, 19, and #28) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 34 residents resided in the facility. Findings: A Policy and Procedure for Drug Regimen Review form, dated 04/10/17, read in part, .The physician will document in the resident's medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it. If there is no change in the medication, the physician will document his/her rationale for the decision in the resident's medical record . 1. Res #4 had diagnoses which schizoaffective disorder, major depressive disorder, and anxiety disorder. A physician order, dated 12/16/19, documented to administer trazadone 50 mg in the evening related to anxiety disorder due to known physiological condition. A physician order, dated 12/16/19, documented to administer Risperdal 2 mg twice daily related to schizoaffective disorder. A physician order, dated 12/16/19, documented to administer sertraline 50 mg daily related to major depressive disorder. A care plan, dated 11/27/20, documented the resident used psychotropic medications related to behavior management and a diagnosis of schizoaffective disorder with an intervention to consult with the pharmacy and physician to consider dose reduction when clinically appropriate at least quarterly. An annual assessment, dated 11/27/22, documented the resident had severe cognitive impairment, experienced hallucinations and delusions, and received antipsychotics and antidepressants during the review period. The assessment documented a gradual dose reduction had not been attempted and had not been clinically contraindicated. A MRR, dated 09/06/22, documented a request for a GDR on Res #4's Risperdal, trazadone, and sertraline. The MRR documented the chart indicated the resident's condition was stable and they had not received a gradual dose reduction previously for Risperidal since 02/13/18 and for trazadone and sertraline since 10/15/17. A physician response, dated 09/14/22, documented the physician did not wish to adjust the dosage of the Risperidal and trazadone. The physician documented the resident was stable with minimal or no side effects relating to chemical restraint. There was no documented response to the sertraline GDR request. A MRR, dated 06/29/23, documented a request for a GDR on Res #4's Risperdal, trazadone, and sertraline. The MRR documented a request for the physician to document clinical rationale for continued use if a dose reduction was not desired. A physician response, dated 07/03/23, documented the physician did not wish to adjust the dosage of the Risperidal, trazadone, and sertraline. The physician did not document clinical rationale for continued use. On 08/02/23 at 9:21 a.m., the DON stated the physician did not respond to the GDR requests with clinical rationale to support continued use. The DON stated a dose reduction had not been attempted for Res #4 but should have been per requirements. 2. Res #14 had diagnoses which included diabetes mellitus, dementia, bipolar disorder, and hypertension secondary to other renal disorders. A care plan, dated 12/12/20, documented the resident received psychotropic medications related to bipolar diagnosis with an intervention to consult with pharmacy and the physician to consider dose reduction when clinically appropriate at least quarterly. A MRR, dated 10/04/22, documented the resident currently had 30 medications ordered. The MRR requested a physician review of the resident's medication regime and documentation of clinical risks versus benefit analysis if current drug regimen is deemed necessary for the resident's need. A physician response, dated 10/19/22, documented the physician did not wish to make changes to the resident's drug regimen. The physician did not document clinical risks versus benefit analysis rationale for continued use. An annual assessment, dated 02/12/23, documented the resident was cognitively intact, required limited assistance with ADLs, and received antidepressants, diuretics, and opioids. On 08/02/23 at 9:10 a.m., the DON stated the physician did not respond to the MRR request for Res #14 with rationale for continued use but should have. 43023 3. Res #6 had diagnoses which included anxiety and gastro-esophageal reflux disease without esophagitis. A physician order, dated 07/07/22, documented to administer Pepcid 40mg one time a day for gastro-esophageal reflux disease without esophagitis A physician order, date 07/07/22, documented to administer Carafate 1 gm two times a day for gastro-esophageal reflux disease without esophagitis A pharmacist monthly review request, dated 10/04/22, documented the resident has multiple orders for GERD (Carafate and Pepcid). The review documented to please review the orders for these medications and change, modify, or delete accordingly. The review documented if current drug regimen is deemed necessary for resident's needs, please document clinical risks versus benefit analysis. The review request was signed as declined on 10/19/22. The physician did not document a rationale for the declination on the GDR form. A rationale was not documented in the resident's clinical record. 4. Res #19 had a diagnosis which included hypertension. A physician order, dated 07/25/23, documented to administer amlodipine 10mg daily for hypertension. A physician order, dated 01/08/20, documented to administer metoprolol tartrate 50 mg twice daily for hypertension. A pharmacist monthly review request, dated 01/03/23, documented the resident has multiple orders for hypertension (metoprolol and amlodipine). The review documented please review the orders for these medications and change, modify, or delete accordingly. The review documented if current drug regimen is deemed necessary for resident's needs, please document clinical risks versus benefit analysis. The reguest form was signed as declined on 01/25/23. The physician did not document a rationale for the declination on the pharmacist review form. A rationale was not documented in the resident's clinical record. 5. Res #28 had a diagnosis which included anxiety. A physician order, dated 04/25/23, documented to administer alprazolam 0.5 mg five times a day for anxiety. A physician order, dated 04/26/23, documented to administer buspirone 15 mg three times a day for anxiety. A pharmacist monthly review request, dated 05/02/23, documented the resident has multiple orders for anxiety (alprazolam and buspirone). The review documented to please review the orders for these medications and change, modify, or delete accordingly. The review documented if current drug regimen is deemed necessary for resident's needs, please document clinical risks versus benefit analysis. The monthly review was signed as declined on 01/25/23. The physician did not document a rationale for the declination on the pharmicist review form. A rationale was not documented in the resident's clinical record. On 08/02/23 at 9:10 a.m., The DON stated it was a struggle to get the physician to respond to the GDR request with an appropriate rational. The DON stated the requests for review should have been done thoroughly but was not.

Based on record review and interview, the facility failed to ensure accurate coding of MDS assessments for anticoagulant use for three (#6, 7, and #36) of 16 sampled residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 34 residents resided in the facility. Findings: 1. Res #7 had diagnoses which included cerebral infarction, aphasia, and anxiety disorder. A quarterly assessment, dated 06/20/23, documented the resident was severely cognitively impaired, required extensive assistance with most ADLs, and received an anticoagulant seven out of seven days during the review period. On 07/31/23 at 2:00 p.m., Res #7's records were reviewed and did not document an order for an anticoagulant during the review period. On 08/02/23 at 12:10 p.m., the MDS coordinator stated the MDS assessment was coded for an anticoagulant in error. They stated the resident received aspirin and they thought it was considered an anticoagulant. 43023 2. Res #36 had diagnoses which included orthopedic aftercare, diabetes mellitus, angina, and long term use of antithombotics and antiplatelets. An admission assessment, dated 07/24/23, documented the resident received an anticoagulant 7 of 7 days of the look back period. A review of the resident's medication documented the resident had not received an anticoagulant medication during the assessment period. On 08/02/23 at 10:10 a.m., the MDS coordinator #1 reported the MDS was filled out incorrectly. 3. Res #6 had diagnoses which included acute and chronic respiratory failure, anxiety, and epilepsy. A quarterly assessment, dated 05/11/23, documented the resident received an anticoagulant 7 of 7 days of the look back period. A review of the resident's medication documented the resident had not received an anticoagulant medication during the assessment period. On 08/02/23 at 10:10 a.m., the MDS coordinator #1 reported the MDS was filled out incorrectly.

Based on observation and interview, the facility failed to ensure food was distributed in a sanitary manner. The Resident Census and Conditions of Residents form documented 34 residents resided in the facility. Findings: On 07/31/23 at 12:38 p.m., an unknown staff member was observed delivering a meal tray to room [ROOM NUMBER]. The dessert and drink were not covered. On 07/31/23 at 12:42 p.m., an unknown staff member was observed delivering a meal tray to room [ROOM NUMBER]. The drink and dessert were not covered. The staff member was observed removing the plate cover before entering the resident's room. On 07/31/23 at 12:45 p.m., an unknown staff member was observed delivering a meal tray to room [ROOM NUMBER]. None of the meal was covered. On 08/02/23 at 9:10 a.m., the DM was asked if everything on the meal tray should be covered when taking the meal from the kitchen to the resident's room. The DM reported everything should always be covered.

Based on observation, record review, and interview, the facility failed to administer medications according to physician ordered parameters for one (#14) of five sampled residents reviewed for unnecessary medications. Findings: 1. Res #14 had diagnoses which included diabetes mellitus, hyperlipidemia, and hypertension secondary to other renal disorders. A physician order, dated 12/12/19, documented to administer propranolol 40 mg twice daily for hypertension secondary to other renal disorders. The order documented to hold the medication if the systolic blood pressure was less than 100 and/or the diastolic blood pressure was less than 60. An annual assessment, dated 02/12/23, documented the resident was cognitively intact and required limited assistance with ADLs. The May 2023 MAR documented propranolol was administered when the resident's blood pressure readings were out of the physician ordered parameters on 2 out of 62 opportunities. The June 2023 MAR documented propranolol was administered when the resident's blood pressure readings were out of the physician ordered parameters on 4 out of 60 opportunities. The July 2023 MAR documented propranolol was administered when the resident's blood pressure readings were out of the physician ordered parameters on 11 out of 62 opportunities. On 08/01/23 at 4:15 p.m., CMA #1 was observed during medication pass. CMA #1 obtained Res #14's blood pressure prior to the administration of propranolol 40 mg. The CMA documented the blood pressure reading as 107/60. CMA #1 stated the resident would be given propranolol because the blood pressure reading was within the physician ordered parameters. On 08/02/23 at 9:40 a.m., the DON was asked to review the May, June, and July 2023 MAR for Res #14. The DON stated the medication should not have been given on the administration opportunities when the blood pressure reading were outside of the ordered parameters. The DON stated the CMA staff had not followed physician orders.

Based on observation and interview, the facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all residents and visitors. The Resident Census and Conditions of Residents form documented 34 residents resided in the facility. Findings: On 07/31/23 at 12:52 p.m., no nurse staffing information was posted. On 08/01/23 at 1:17 p.m., no nurse staffing information was posted. On 08/02/23 at 10:19 a.m., no nurse staffing information was posted. On 08/02/23 at 10:25 a.m., the administrator reported the daily nurse staffing information was not posted.

Based on observation, record review, and interview, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care and assure safety related to the administration of medications and enteral feedings via gastrostomy tubes for one (#22) of one resident reviewed for medication administration The Resident Census and Conditions of Residents form documented 1 resident received enteral feedings. Findings: A Technical and Nutritional Aspects of Gastrostomy/Feeding Tubes policy, dated 2011, read in parts, .draw 20 ml of air into the syringe and connect it to the tube. With a stethoscope, listen over stomach or small intestines. Inject air into the tube and listen for bubbling sound made when air is injected. The task is to be completed prior to administering formula, free water or medications . A RN/LPN Charge Nurse Orientation/Training checklist, dated 01/09/23, documented LPN #1 knew procedures for PEG or other gastrostomy tubes, including pump operation, bolus feedings, medication administration, fluid administration, verifying placement, checking residual, and changing tube if appropriate. Res #22 was admitted with diagnoses which included dysphagia, GERD, and functional dyspepsia. An admission assessment, dated 04/05/23, documented the resident was severely cognitively impaired, required extensive assistance with eating, and received 51% or more of total calories through parenteral or tube feedings. A physician order, dated 06/09/23, documented to administer Jevity 1.5 Cal via peg tube every 6 hours. Give 355.5 ml with first two feedings of the day. A physician order, dated 06/16/23, documented to administer tramadol 50 mg every 6 hours via peg tube related to pain. On 08/01/23 at 12:07 p.m., LPN #1 was observed during medication administration. LPN #1 was observed to have administered Res #22 tramadol 50 mg and Jevity 355.5ml bolus feeding via gastrostomy tube. LPN #1 did not verify placement of the gastrostomy tube with air prior to the administration of the medication or the bolus feeding. On 08/01/23 at 12:10 p.m., LPN #1 stated having verified placement of the gastrostomy tube prior to the administration of an earlier feeding of the day but having forgotten to verify placement prior to administration of the current medication and bolus feeding. LPN #1 stated they should have injected 5-10 mls of air and listened for a bubbling sound within the abdomen to verify placement prior to having administered both the medication and the enteral feeding. LPN #1 stated they had gotten into a bad habit of only verifying placement once daily but should have verified placement before every medication or enteral feeding was administered. On 08/01/23 at 12:20 p.m., the DON stated the nursing staff should verify correct placement of a gastrostomy tube before the administration of all medications or enteral feedings. The DON stated the nurse did not follow best standard practices.

Based on record review, observation, and interview, the facility failed to obtain an order to change a resident's catheter for one (#26) of one sampled residents. The Resident Census and Conditions of Residents form documented three residents who had internal or external catheters. Findings: Res #26 had diagnoses which benign prostatichyperplasia with lower urinary tract symptoms. Health status notes, dated 07/29/23, documented the resident's catheter was leaking. The note documented the catheter was attempted to be replaced two times and was unsuccessful. There was no physician order to change the catheter. On 08/02/23 at 9:16 a.m., the DON reported the catheter should not have been changed or attempted to be changed without a physician order.

Based on record review and interview, the facility failed to ensure comprehensive care plans was developed for one (#26) of 13 sampled residents. The Resident Census and Conditions of Residents form documented 34 residents resided in the facility. Findings: Res #26 was admitted to the facility on [DATE] with diagnoses of heart failure, anxiety, diabetes mellitus, and hypertension. The resident's record did not document a comprehensive care plan was developed. On 08/02/23 at 9:18 a.m., the MDS coordinator #1 reported the comprehensive care plan should have been developed.

Based on record review and interview, the facility failed to ensure baseline care plans were completed within 48 hours for one (26) of 13 sampled residents. The Resident Census and Conditions of Residents form documented 34 residents resided in the facility. Findings: Res #26 was admitted to the facility on [DATE] with diagnoses of heart failure, anxiety, diabetes mellitus, and hypertension. The resident's record did not document the baseline care plan was completed. On 08/02/23 at 9:18 a.m., the MDS coordinator #1 reported the baseline care plan should have been completed within 48 hours.

Based on observation, record review, and interview, the facility failed to ensure residents were not dressed in a hospital gown instead of their own personal clothing for one (#7) of one sampled resident reviewed for dignity. The Resident Census and Conditions of Residents report, documented 23 residents required assistance with dressing. Findings: Res #7 had diagnoses which included cerebral infarction, aphasia, and anxiety disorder. A care plan, dated 09/18/20, documented the resident had an ADL self-care performance deficit related to stroke and limited mobility with an intervention of total dependence of two staff for dressing. An annual assessment, dated 09/17/22, documented the resident was severely cognitively impaired, totally dependent with dressing, and preferred to choose daily clothing to wear. On 07/31/23 at 1:13 p.m., Res #7 was observed lying in bed wearing a hospital gown. The resident stated they preferred to wear their own personal clothes but the staff never dressed them in anything other than a hospital gown. Res #7 stated they had a closet full of their own personal clothing. The resident stated the staff had never offered or asked them if they preferred to wear their own clothing. On 08/01/23 at 8:04 a.m., Res #7 was observed lying in bed wearing a hospital gown. On 08/01/23 at 4:55 p.m., Res #7 was observed lying in bed wearing a hospital gown. Res #7 stated none of the staff had offered to dress them in their own personal clothing today. On 08/01/23 at 5:00 p.m., CNA #1 stated they had worked at the facility for a couple of months and had never observed the resident in their own personal clothing. The CNA stated the staff dressed Res #7 in a hospital gown to make bed baths and incontinent care easier for the staff and the resident. CNA #1 stated they had never asked the resident if they preferred to wear their own personal clothes because the resident had never complained about having worn hospital gowns. On 08/02/23 at 7:43 a.m., LPN #1 stated the resident preferred to wear a hospital gown most of the time for ease of positioning and baths. LPN #1 stated the resident had personal clothing but refused to get dressed often. They stated all resident refusals to dress would be documented in the progress notes or under the ADL tasks in the clinical record. LPN #1 stated they had never personally documented the resident's refusal to dress but probably should have. No documentation of Res #7's refusal to dress in personal clothing was found in the clinical record. On 08/02/23 at 9:35 a.m., the DON stated the staff should have dressed or at least offered to dress the resident in their own personal clothing daily. They stated the staff should have documented refusals in the clinical record and have not done so appropriately.

Based on record review and interview, the facility failed to ensure a physician order for oxygen contained a diagnosis for one (#26) and failed to follow physician orders for oxygen settings for one (#17) of two sampled residents reviewed for oxygen therapy. The Resident Census and Conditions of Residents form documented four residents required respiratory therapy. Findings: 1. Res #26 had diagnoses which included heart failure, anxiety, hypertension, and diabetes mellitus. A physician order, dated 07/13/23, documented may use oxygen at 2 LPM via NC continuously. The order did not document a diagnosis. On 08/02/23 at 9:14 a.m., the DON reported a diagnosis should be on all physician's orders. 2. Res #17 had diagnoses of pleural effusion, moderate persistent asthma, shortness of breath, and wheezing. A physician order, dated 04/03/23, documented oxygen at 3 lpm continuously every shift. On 08/01/23 at 8:41 a.m., the resident's oxygen was observed at 5 lpm via NC On 08/01/23 at 4:49 p.m., the resident's oxygen was observed at 5 lpm via NC. On 08/02/23 at 8:59 a.m., the resident's oxygen was at 5 lpm via NC. On 08/02/23 at 9:36 a.m., the DON was shown the physician order for the resident's oxygen. The DON was made aware of observations of the resident's oxygen set at 5 lpm. The DON reported the oxygen was at the wrong setting.

Based on observation, interview, and record review, it was determined the facility failed to: ~ perform a thorough and timely initial wound assessment; ~ promptly obtain physician orders for wound care; and ~ ensure treatments administered for wound care were appropriate and ordered by the physician for one (#47) of two residents reviewed for pressure ulcers. Resident #47 had an unstageable wound that had increased in size and had necrotic tissue present. The wound was observed for five days before a thorough wound assessment was completed, the physician was notified and physician treatment orders were obtained. The DON identified two residents in the facility who had a pressure ulcer. Findings: A policy and procedure for the prevention and treatment of [REDACTED]. .The facility will notify the physician upon the onset of the ulcer and obtain treatment orders .Orders should be specific as to type of dressing and treatment and frequency of application. The facility will notify the physician if the ulcer appears to be deteriorating or if no improvement is noted in 2-4 weeks of the initial treatment orders. An ulcer that is necrotic or has eschar will generally require debridement in order for the area to begin healing. The physician will order the specific method of debridement . Resident #47 was admitted with a [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/22/19, documented the resident was severely impaired cognitively, required extensive assistance of two staff for most ADL's, was frequently incontinent of bladder and occasionally incontinent of bowel, was at risk for pressure ulcers, had a pressure reducing device for chair and bed, was on a turning program and had nutrition or hydration intervention to manage skin problems. An annual assessment, dated 09/20/19, documented the resident was severely impaired cognitively, required extensive assistance of two staff for most ADL's, was occasionally incontinent of bladder and always continent of bowel, was at risk for pressure ulcers, had no unhealed pressure ulcers, had moisture associated skin damage, had a pressure reducing device for chair and bed, was on a turning/repositioning program, and had nutrition or hydration intervention to manage skin problems. A care plan, dated 09/24/19, documented: Problem onset: 09/24/19. Resident at risk for impaired skin integrity due to frequently incontinent of her bladder and bowels. Goal and target date: Skin would remain free from skin breakdown/irritation for 90 days through 12/24/19. Approaches: Appropriate footwear; use draw sheet for bed mobility to prevent friction and sheering; weekly skin checks; promote adequate nutrition and hygiene; incontinent care prn: adult briefs and barrier cream as indicated; therapy screen prn for positioning concerns; skin assessment quarterly and prn; notify physician, family, responsible party of changes as needed; podiatry consult and treatment as indicated; turn and reposition every 2 hours and as needed; pressure redistributing mattress and/or wheelchair cushioning. A physician's order, dated 08/31/19, documented, to monitor skin and report any skin issues to wound care nurse. A 24 hour report/change of condition, dated 10/01/19, documented under remarks/change of condition area for the night shift, open area at apex of right leg, need dressing orders. No assessment of the wound on 10/01/19 was documented. A nurse's note, dated 10/02/19 at 3:00 a.m., documented, During rounds aide noticed an open area on patients apex of thigh. Site measures 2 cm in length by 1 cm width. Site cleaned and triple antibiotic ointment with dressing applied. Will continue to monitor site. A thorough assessment of the wound was not documented. A review of the physician orders did not find documentation of the physician being notified of the resident's pressure ulcer. There was no order for triple antibiotic ointment. A 24 hour report/change of condition, dated 10/02/19, documented under remarks, change of condition for the evening shift, Calazine to right upper leg. No assessment of the wound was documented. A review of the EMAR did not show any documentation of the physician being notified nor wound care orders for calazine. A 24 hour report/change of condition report, dated 10/05/19, documented under remarks/change of condition for the night shift, (wound nurse) notified, open area to R gluteal fold, bag balm applied. A review of the physician orders did not show documentation of an order for [REDACTED].>A nurse's note, dated 10/05/19 at 1:40 a.m., documented, During rounds aide reported an open area to her R gluteal fold that appears to be bigger in size and appearance to them, now with black tissue around one side of the area. Measurements 2 cm by 2 ½ cm. Area cleansed with wound cleanser, TAO applied. Resident turned/reposition to relief pressure from area and staff to offer toilet every 2 hours to try to keep resident dry. Will report to wound nurse to assess and TX as indicated. A physician's telephone order, dated 10/05/19 and untimed, documented, Clean right gluteal fold with wound cleanser, pat dry, apply TAO. A physician's telephone order, dated 10/06/19 and untimed, documented, Cleanse open area to right gluteal fold with wound cleanser, apply [MEDICATION NAME] and cover with [MEDICATION NAME] every 3 days until resolved. A 24 hour report/change of condition report, dated 10/07/19, documented under the day shift remarks/change of condition, (Wound care nurse) to address buttocks. A physician's telephone order, dated 10/07/19 at 11:00 a.m., documented, Cleanse Right gluteal fold with wound cleanser, pat dry, Apply [MEDICATION NAME] 100% paste, Every day Cover c ABD Pad tape to secure, until resolved. Discontinue previous order. A Wound Healing Progress Report, dated 10/07/19, documented a pressure ulcer to the right buttock first identified on 10/07/19 and measured 4.00 X 2.00 X 0.00 (unstageable due to slough/eschar). A Wound Assessment Note, dated 10/07/19 at 2:15 p.m., documented, .Pressure Ulcer//Right buttock// .Right Gluteal fold 4.00 cm x 2.00 cm x 0.002 cm 25% slough, 75% eschar unable to stage. No drainage, no [MEDICAL CONDITION], no redness, surrounding tissue intact. Placed cushion in wheelchair. Reposition every 2 hours when resident will allow. Continue with TX . A nurse's note, dated 10/09/19 at 2;31 a.m., documented, Wound noted on back of right leg next to gluteal sulcus. Measures 5.5 cm lenght (sic) by 2 cm wide. Center of wound black to dark grey in color. Subcutaneous fat visible. Slough noted in center of wound. Undermining noted on right side of wound. Site cleaned with wound cleanser .Will report findings to wound nurse . A Wound Assessment Note, dated 10/09/19 at 12:19 p.m., documented, .this nurse, and (nurse's name deleted) re-assessed resident's right gluteal fold. 4.00 cm x 2.00 cm x 0.00 cm unstageable, eschar present 75% - 25% [MEDICATION NAME] tissue. The slough resolved from 10-7-19. No redness, no [MEDICAL CONDITION], no drainage noted. Has moist appearance, surrounding tissue intact, no undermining present . This note was signed by the wound nurse. A Wound Healing Progress Report, dated 10/14/19, documented the pressure ulcer to the right buttock measured 4.00 X 2.00 X 0.00 (unstageable due to slough/eschar). A physician's telephone order, dated 10/14/19 at 11:07 a.m., documented, Cleanse Right gluteal fold with wound cleanser, pat dry, Apply [MEDICATION NAME] 100% paste Cover c ABD pad PRN for soilage. A Wound Assessment Note, dated 10/14/19 at 2:55 p.m., documented, .Pressure Ulcer//Right Buttonck// .10-11-19 @1230 (p.m.) right gluteal fold 4.00 cm x 2.00 cm x 0.00 cm unstageable .slough 75% eschar 25% . small amount of serosang (serosanguinous) drainage, well defined. No redness, no [MEDICAL CONDITION], surrounding tissue intact. No tunneling noted . On 10/16/19 at 11:07 a.m., wound care was observed being done by LPN #2. The wound had black eschar in the center. The wound was cleaned with wound cleanser; [MEDICATION NAME] and dressing was applied. The LPN measured the wound and was noted as 2.5 cm X 5 cm. On 10/17/19 at 9:41 a.m., CNA #1 was interviewed. She stated she had worked at the facility for about 2 years and had worked on and off the hall the resident resided on. She stated she worked day shifts and the resident was showered in the p.m. She was asked when she first noticed the wound on the buttocks. She stated she had toileted the resident sometime early in (MONTH) and a dressing had fallen off. She stated the wound looked like a small circle spot, but it was not opened. She was asked who she told. She stated she reported it to LPN #4. On 10/17/19 at 9:52 a.m., LPN #4 was interviewed about the resident's wound on her buttocks. She stated she looked at it after CNA #1 informed her. She stated the wound looked like a pinch mark at the time, but it was not opened. She stated she did not see a dressing on it at the time. She believed she let the wound care nurse know about it. She was asked how the facility would take care of the wound if the wound care nurse was not available. She stated she would call the physician for orders. She stated they had protocols they could do until they had more orders or the wound care nurse assessed the wound. She was asked if the calazine was in the protocol for wound treatment. She stated she thought it was in the MD orders. She looked at the chart, then stated she could not find any physician orders for calazine. She stated it was a verbal discussion from the wound care nurse on how to manage it. On 10/17/19 at 10:30 a.m., LPN #3 was interviewed by telephone. She was asked about the wound description. She stated she did not remember seeing the wound before the aides had told her about it. She stated the aide said she had noticed it and it seemed larger to her. She did not see any documentation about it. She was asked what the usual protocol was when a skin break was identified. She stated they used Calazine to an area if it just looked like a pressure area, if it was an open area, they could use bag balm. She was asked how she knew to use these treatments. She stated there was a protocol the wound nurse had told them about. She stated she was not sure where the protocol was located, she just remembered being told by the wound nurse about the protocol. She was asked what she did next after learning of the wound. She stated she passed the information on to the day shift to keep the resident dry and she thought the day shift called the physician, since it was too late at night for her to contact the MD. On 10/17/19 at 11:00 a.m., LPN #2 was asked what she remembered about the wound. She stated she had gotten a report of a small wound to the resident's buttocks. She stated she had passed the information on to the wound nurse. She was asked why they notified the wound nurse. She stated it made the wound nurse aware of a new wound if they were not doing the wound treatment she thought was adequate, the wound care nurse would call the MD and get the order changed. She was asked what she did for the wound. She stated she put triple antibiotic ointment and a dressing on it. She was asked how she decided what wound care to use. She stated they had certain treatments they could do without orders. She stated their previous DON, and the wound care nurse, had told us that at one time. She stated sometimes they would use Calazine. She was asked if she needed an order for [REDACTED]. She was asked when the physician should have been notified. She stated the nurse who first saw the wound should have notified the physician. She was asked if they would have been expected to call the physician at 2:00 a.m. She stated a fax could have been sent with orders back by morning. She was asked how she knew what treatment to do that morning. She stated she used the ATB ointment. She stated she was pretty sure there was an order for [REDACTED]. She stated she did not think the wound looked open when she first saw it. She stated the area appeared to be dry, red and looked like an abrasion that needed protection. On 10/17/19 at 11:22 a.m., the wound care nurse was interviewed. She stated she had been the wound care nurse for the past 2 or 3 years and only worked three days a week. She was asked when she was first told about the wound. She stated she was first notified on 10/07/19 about the wound, as she had been out of town the first week in (MONTH) 2019. She stated when the nurses found an open area, they were to do the measurements. She was told of the interviews with several of the nurses who had stated they had been told by the wound nurse they could start treatments until the wound nurse could assess the resident. She was asked if there were standing orders for the nurses to use for wounds. She stated no. She stated she guessed she had recommended calazine or bag balm, as it was just a nursing intervention. She stated when there was an abrasion, they would use calazine if closed; if it was an open area, they would have to get an order from the MD. She was asked if it was on the wound care protocol. She stated she guessed it was, but would have to look at the protocol again. She was asked if Calazine would need an order. She stated it would. She stated it was the nurses responsibility to have obtained an order for [REDACTED]. She was asked if the nurses were to notify her if there was an open area. She stated yes. She stated the only time she would change the order would be if she found something on assessment that she thought the MD would not want. She stated if the nurses found an open area, they should call the MD, maybe put a cover over it. She was asked if she had ever told the nurses to apply a treatment on the wound before they called the MD for an order. She stated no, the MD had to give them the order. She was asked if she knew the resident had been given wound treatment without a physician's order. She stated she had talked to the nurses about what treatment was given. She was asked if she thought they should have called the physician. She stated yes, but I did not discuss it with them. She stated she knew one nurse had started triple antibiotic ointment on the wound, but was not sure if they had an order for [REDACTED].>On 10/17/19 at 12:53 p.m., the DON was interviewed. She was asked if a nurse identified a wound, what should have been done. She stated they should have assessed it, and depending on the type of wound, measured it, been able to describe it, then notified the physician to get an order to start treatment.

Based on observation, interview, and record review, it was determined the facility failed to update a care plan for a pressure ulcer for one (#47) of 18 sampled residents whose care plans were reviewed. The administrator identified 58 residents in the facility. Findings: Resident #47 was admitted with a [DIAGNOSES REDACTED]. An annual assessment, dated 09/20/19, documented the resident was severely impaired cognitively, required extensive assistance of two staff for most ADL's, was occasionally incontinent of bladder and always continent of bowel, was at risk for pressure ulcers, had no unhealed pressure ulcers, had moisture associated skin damage, had a pressure reducing device for chair and bed, was on a turning/repositioning program, and had nutrition or hydration intervention to manage skin problems. A care plan, dated 09/24/19, documented: Problem onset: 09/24/19. Resident at risk for impaired skin integrity due to frequently incontinent of her bladder and bowels. Goal and target date: Skin would remain free from skin breakdown/irritation for 90 days through 12/24/19. Approaches: Appropriate footwear; use draw sheet for bed mobility to prevent friction and sheering; weekly skin checks; promote adequate nutrition and hygiene; incontinent care prn: adult briefs and barrier cream as indicated; therapy screen prn for positioning concerns; skin assessment quarterly and prn; notify physician, family, responsible party of changes as needed; podiatry consult and treatment as indicated; turn and reposition every 2 hours and as needed; pressure redistributing mattress and/or wheelchair cushioning. On 10/15/19 at 12:00 p.m., the resident was observed in a wheelchair in the dining room of the memory care unit. A 24 hour report/change of condition, dated 10/01/19, documented under remarks/change of condition area for the night shift, open area at apex of right leg, need dressing orders. A nurse's note, dated 10/02/19 at 3:00 a.m., documented, During rounds aide noticed an open area on patients apex of thigh. Site measures 2 cm in length by 1 cm width. Site cleaned and triple antibiotic ointment with dressing applied. Will continue to monitor site. A 24 hour report/change of condition, dated 10/02/19, documented under remarks, change of condition for the evening shift, Calazine to right upper leg. A 24 hour report/change of condition report, dated 10/05/19, documented under remarks/change of condition for the night shift, wound nurse notified, open area to right gluteal fold, bag balm applied. A nurse's note, dated 10/05/19 at 1:40 a.m., documented, during rounds, aide reported an open area to her right gluteal fold that appears to be bigger in size and appearance to them, now with black tissue around one side of the area. Measurements 2 cm by 2 ½ cm. Area cleansed with wound cleanser, triple antibiotic ointment applied. Resident turned/reposition to relief pressure from area and staff to offer toilet every 2 hrs to try to keep resident dry. Will report to wound nurse to assess and treat as indicated. A physician's telephone order, dated 10/05/19 and untimed, documented, clean right gluteal fold with wound cleanser, pat dry, apply triple antibiotic ointment. A physician's telephone order, dated 10/06/19 and untimed, documented, Cleanse open area to right gluteal fold with wound cleanser, apply [MEDICATION NAME] and cover with [MEDICATION NAME] every 3 days until resolved. A physician's telephone order, dated 10/07/19 at 11:00 a.m., documented, cleanse right gluteal fold with wound cleanser, pat dry, apply [MEDICATION NAME] 100% paste, every day, cover with ABD pad, tape to secure, until resolved. Discontinue previous order. A wound healing progress report, dated 10/07/19, documented a pressure ulcer to right buttock first identified on 10/07/19 and measured 4.00 X 2.00 X 0.00 (unstageable due to slough/eschar). A wound healing progress report, dated 10/14/19, documented the pressure ulcer to the right buttock measured 4.00 X 2.00 X 0.00 (unstageable due to slough/eschar). A physician's telephone order, dated 10/14/19 at 11:07 a.m., documented, cleanse right gluteal fold with wound cleanser, pat dry, apply [MEDICATION NAME] 100% paste, cover with ABD pad, prn for soilage. On 10/16/19, a review of the resident's care plan showed no documentation on the resident's wound or wound treatment. On 10/16/19, a review of the resident's daily care plan updates sheet showed no documentation on the resident's wound or wound treatment. On 10/16/19 at 10:55 a.m., the MDS nurse was asked how she ensured the care plan for the residents were reviewed for correctness and updates. She stated she had not had the MDS position for the past two years. She stated she had started the position again in (MONTH) 2019. She stated that the care plans should have been updated every assessment period, along with any changes that occurred in between. She stated they did documentation on the daily care plan update sheet for the residents but the care plan itself had not been updated. She stated the wound and wound care was not on the care plan updates for this resident. On 10/17/19 at 9:00 a.m., the resident was observed sitting in her wheelchair with a cushion in her wheelchair.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received a written notice of the bed hold policy upon transfer to a hospital for two (#16 and #24) of three residents reviewed for transfer and discharge procedures. The administrator identified 22 residents who had transferred to an acute care hospital in the past four months. Findings: An undated, Notice of Bed Hold and Readmission and Notice Before Transfer policy, documented, It will be the policy of this facility to provide information on any individual who is to be transferred to a hospital or to go on therapeutic leave to be provided the written information at the time of his/her admission . 1. Resident #16 was admitted to the facility on [DATE]. A nurse's note, dated 10/08/19 at 4:02 p.m., documented the resident was transported to an acute care hospital emergency room . A nurse's note, dated 10/08/19 at 8:39 p.m., documented the resident's family reported to the facility that the resident had been admitted to an acute care hospital. A discharge assessment - return anticipated, dated 10/08/19, documented a discharge date of [DATE] to an acute care hospital. A nurse's note, dated 10/15/19 at 6:06 p.m., documented the resident was returned to the facility from an acute care hospital. 2. Resident #24 was admitted to the facility on [DATE]. A nurse's note, dated 09/21/19 at 1:55 p.m., documented the resident was transported to an acute care hospital emergency room . A nurse's note, dated 09/21/19 at 6:43 p.m., documented the resident was admitted to an acute care hospital. A discharge assessment - return anticipated, dated 09/21/19, documented a discharge date of [DATE] to an acute care hospital. A nurse's note, dated 09/23/19 at 7:13 p.m., documented the resident had returned to the facility. On 10/16/19 at 12:00 p.m., the administrator was asked to provide documentation that resident #16 and #24 had received written copies of the bed hold policy upon their discharge to acute care facilities on 10/08/19 and 09/21/19 respectively. At 3:57 p.m., the administrator stated the two residents had not been provided those documents upon discharge and the facility had not been routinely supplying that document to any resident or resident representative. On 10/17/19 at 8:39 a.m., resident #24 was observed in his room. He was asked if he had been given a copy of the bed hold policy upon his previous discharge. He stated he did not recall having received that document.

Based on observation, interview, and record review, it was determined the facility failed to: ~ intervene and continue to monitor and assess a resident after the resident verbalized a desire to die and who attempted suicide for one (#2) of one sampled resident who was observed for suicidal tendencies. The DON stated there had been no other residents who had attempted suicide; and ~ manage an indwelling urinary catheter based on standards of practice, including infection control for one (#5) of three sampled residents who were observed for an indwelling urinary catheter. The census and condition identified 50 residents who resided in the facility and four of the residents had an indwelling urinary catheter. Findings: A change in a resident's condition or status policy, revised February 2014, documented, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition . A suicide threats policy, revised November 2010, documented, .Resident suicide threats shall be taken seriously and addressed appropriately .Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse .After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician .All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately .If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present . 1. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 05/06/16, documented the resident was cognitively intact, required limited to extensive assistance with ADLs, and received [MEDICAL TREATMENT]. A nurse's note, dated 05/10/16 at 1:41 a.m., documented the resident had stated she did not want to go to [MEDICAL TREATMENT] anymore and she wanted to die because she was ready to die. The note documented she kept asking for help from the nursing staff to help her to die. The note documented the resident asked how long after she stopped going to [MEDICAL TREATMENT] would it take for her to die. A medicare note, dated 05/11/16, documented the resident had not wanted to go to [MEDICAL TREATMENT] and the resident's daughter had been there that morning and talked to the resident. The noted documented the resident had agreed to go to [MEDICAL TREATMENT] after her daughter had talked to her. A nurse's note, dated 05/12/16 at 5:57 p.m., documented the resident's physician had been there earlier that day and new orders had been received. A physician's progress note, dated 05/12/16, documented an order for [REDACTED]. The clinical record did not contain any documentation the physician had been notified of the resident's verbalization of wanting to die prior to the visit on 05/12/16. A nurse's note, dated 05/13/16 at 6:37 p.m., documented at 4:00 p.m. the resident had been found by staff with the call light wire wrapped around her neck and was pulling it tightly. The note documented the resident stated she was sick of being sick. The note documented the SS director and DON had been notified and the resident's family was at the bedside. A nurse's note, dated 05/13/16 at 7:00 p.m., documented the resident had been sent to the hospital for an evaluation. On 06/07/16 at 11:45 a.m., the resident was observed in bed with the head of the bed up. The resident was feeding herself lunch. On 06/09/16 at 5:16 p.m., the DON was asked what had been done for the resident to ensure her safety after she had verbalized she wanted to die. She stated the staff had taken turns sitting with her the rest of that shift. She stated the resident's sister had also been notified and had come to the facility and talked with the resident. The DON stated the resident's sister had stated the resident was just mad at her since she had told the resident she would be staying at the facility instead of going home. The DON was asked what should have been done for a resident who talked about wanting to die. She stated if the resident had said they were going to try and kill themselves they would have monitored the resident more closely. The DON was asked if expressing a desire to die would be considered suicidal ideation. The DON stated they did not feel at the time the resident's intention was to attempt suicide. The DON was asked if the physician should have been notified regarding the resident expressing a desire to die. She stated yes. The DON was asked if the psychiatric consult should have been done more timely. She stated yes. The DON was asked if the medications the physician had ordered on [DATE] had been administered to the resident. She stated she would check. At 5:28 p.m., the DON stated the resident had not received the medications because the medications had not been delivered to the facility at the time the resident had attempted suicide. A urinary catheter care policy, revised September 2005, documented, .Be sure the catheter tubing and drainage bag are kept off the floor . 2. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A laboratory urinalysis result, dated 12/11/15, documented the urine had cultured out gram negative rods, escherichia coli, and proteus mirabilis. A laboratory urinalysis result, dated 02/13/16, documented the urine had cultured out gram negative rods, escherichia coli, and proteus mirabilis. A laboratory urinalysis result, dated 04/07/16, documented the urine had cultured out gram negative rods, escherichia coli, and proteus mirabilis. A laboratory urinalysis result, dated 05/10/16, documented the urine had cultured out gram negative rods. A quarterly assessment, dated 05/18/16, documented the resident was moderately impaired cognitively, required supervision to extensive assistance with ADLs, and had an indwelling urinary catheter. A monthly physician's orders [REDACTED]. On 06/07/16 at 5:50 p.m., the resident was observed in her room sitting in a recliner with her feet elevated. An indwelling urinary catheter bag was observed hanging on the side of the trash can. The bag was uncovered and the bottom of the bag was touching the floor. The resident's urine was observed in the tubing. The urine was yellow in color and contained sediment. 06/08/16 at 11:05 a.m., CNA #3 was observed providing catheter care for the resident. Upon entering the room the resident was observed lying in bed. The resident's catheter bag was observed lying on the floor beside her bed. At 12:15 p.m., the resident was observed sitting in her recliner with her feet elevated. An indwelling urinary catheter bag was observed hanging on the side of the trash can. The bag was uncovered and the bottom of the bag was touching the floor. At 5:35 p.m., the resident was observed sitting in her recliner with her feet elevated. An indwelling urinary catheter bag was observed hanging on the side of the trash can. The bag was uncovered and the bottom of the bag was touching the floor. On 06/09/16 at 2:00 p.m., CNA #2 was asked how staff was supposed to care for a resident's indwelling urinary catheter. She stated the bag would usually have a blue dignity bag covering the urine bag. She stated the bag should never be above the resident's bladder and never touch the floor. At 2:20 p.m., the DON was asked how she would expect staff to care for a resident's indwelling urinary catheter. She stated the bag should be positioned where it will be able to drain and the bag should not be touching the floor.

Based on observation, interview, and record review, it was determined the facility failed to notify the physcian in a timely manner when a resident expressed a desire to die and later attempted suicide for one (#2) of one sampled resident who had expressed a desire to die. The DON stated there had been no other residents who had attempted suicide. Findings: Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 05/06/16, documented the resident was cognitively intact and required limited to total assistance with ADLs. A nurse's note, dated 05/10/16 at 1:41 a.m., documented the resident had stated she did not want to go to [MEDICAL TREATMENT] anymore and she wanted to die because she was ready to die. The note documented she kept asking for help from the nursing staff to help her to die. The note documented the resident asked how long after she stopped going to [MEDICAL TREATMENT] would it take for her to die. A medicare note, dated 05/11/16, documented the resident had not wanted to go to [MEDICAL TREATMENT] and the resident's daughter had been there that morning and talked to the resident. The note documented the resident had agreed to go to [MEDICAL TREATMENT] after her daughter had talked to her. A nurse's note, dated 05/12/16 at 5:57 p.m., documented the resident's physician had been there earlier that day and new orders had been received. A physician's progress note, dated 05/12/16, documented an order for [REDACTED]. The clinical record did not contain any documentation the physician had been notified of the resident's verbalization of wanting to die prior to the visit on 05/12/16. A nurse's note, dated 05/13/16 at 6:37 p.m., documented at 4:00 p.m. the resident had been found by staff with the call light wire wrapped around her neck and was pulling it tightly. The note documented the resident stated she was sick of being sick. The note documented the SS director and DON had been notified and the resident's family was at the bedside. A nurse's note, dated 05/13/16 at 7:00 p.m., documented the resident had been sent to the hospital for an evaluation. On 06/07/16 at 11:45 a.m., the resident was observed in bed with the head of the bed up. The resident was feeding herself lunch. On 06/09/16 at 4:40 p.m., the DON was asked when should you call the physician for a resident who is talking about wanting to die. She stated the physician should be called if a resident is threatening to kill themselves. The DON was asked if she thought the physician should have been notified when the resident expressed a desire to die and was asking the staff to help her die. She stated yes, the staff should have called the physician. The DON was asked if the staff had notified the physician. She stated she would have to check. At 5:16 p.m., the DON stated she could not find any documentation the physician had been notified.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident did not develop a pressure sore and failed to provide treatment and services to promote healing of a pressure sore for 1 (#12) of 3 sampled residents who were observed for pressure sores. The facility failed to turn and reposition resident #12 to prevent the development of a pressure sore and to promote the healing of a pressure sore. The assistant director of nursing identified 8 residents who had pressure sores. Findings: Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A significant change assessment, dated 10-17-13, documented the resident had modified independence in daily decision making, had no short or long term memory loss, the resident required extensive assistance with transfers and bed mobility, and had no behaviors including rejection of care. A care plan, dated 10-21-13 and updated on 07-27-14, documented the resident had a potential for impaired skin integrity as evidenced by the resident being weak and requiring staff assistance with transfers and bed mobility. The care plan goal was for the resident's skin to remain intact. The care plan interventions included to turn and reposition every two hours and as needed, use a pressure redistributing mattress and/or wheelchair cushion, use a draw sheet for bed mobility to prevent friction and sheering, and to do weekly skin checks. A quarterly assessment, dated 07-14-14, documented resident #12 was moderately impaired cognitively, required required extensive assistance with transfers, limited assistance with bed mobility, was at high risk for pressure ulcers, and had skin and ulcer treatments including turning and repositioning, and had no behaviors including rejection of care. A facility wound assessment report, dated 07-27-14, documented a new pressure ulcer located on the resident's sacrum. The report documented the wound was a stage III which measured at 1.50 centimeters (cm) in length, 1.50 cm in width and 2.00 cm in depth. A nurse's note, dated 07-27-14, documented, "...res. open area on coccyx 1.5 x 1.5 tunneled approx. 2 cm deep. placed call to (facility name deleted) and spoke to dr (physician name deleted) et (and) received order to clean apply calcium alginate with wound gel and cover with allevyn sacrum bandage daily. tx (treatment) done to coccyx..." A physician's telephone order, dated 08-06-14 at 10:50 a.m., documented to clean the wound to the coccyx with normal saline, pat dry, pack loosely with plain packing strips, cover with dry dressing, and change dressing every day. A facility wound assessment report, dated 08-07-14, documented a pressure ulcer located on the resident's sacrum. The report documented the wound was a stage III which measured at 1.00 centimeters (cm) in length, 1.00 cm in width and 0.50 cm in depth with tunneling present. On 08-13-14 at 10:50 a.m., resident #12 was observed lying on her back with the head of the bed elevated. Licensed practical nurse (LPN) #1 was observed providing wound care for resident #12. The resident's wound care was observed to be done per the physician's orders [REDACTED]. On 08-13-14 at 12:30 p.m., resident #12 was back in her bed after lunch lying on her back with the head of the bed elevated, a pillow under her legs, and a micro-air mattress on her bed. On 08-13-14 at 1:30 p.m., resident #12 was observed lying on her back with no support of pillows. On 08-13-14 at 3:20 p.m., resident #12 was observed lying on her back with no support of pillows. On 08-13-14 at 4:20 p.m., resident #12 was observed lying on her back with no support of pillows. On 08-13-14 at 5:30 p.m., resident #12 was observed in the dining room in her wheelchair with her left leg elevated. On 08-13-14 at 6:15 p.m., resident #12 was observed lying on her back in bed with no support of pillows. On 08-14-14 at 8:30 a.m., the resident was observed at the dining room table in her wheelchair with her left leg elevated eating breakfast. On 08-14-14 at 10:00 a.m., resident #12 was lying in bed on her back with the head of her bed elevated visiting with her family. On 08-14-14 at 11:40 a.m. to 1:00 p.m., resident #12 was observed at the dining room table with her left leg elevated in the wheelchair. On 08-14-14 at 1:00 p.m., resident #12 was observed returning to her bed. The resident was observed every 30 minutes until suppertime at 5:30 p.m. The resident was not turned or repositioned and no pillows were placed at the sides of her legs or behind her back from 1:00 p.m. to 5:30 p.m. On 08-14-14 at 2:25 p.m., LPN #3 was asked if resident #12 had a wound when she came back from the hospital on 07-21-14. LPN #3 stated the resident had an abrasion to her right buttock but did not have a wound on her coccyx. On 08-14-14 at 6:45 p.m., the resident's daughter was asked if the resident was repositioned during the day. The resident's daughter stated the facility had not been turning the resident. A facility wound assessment report, dated 08-14-14, documented, a pressure ulcer located on the resident's sacrum. The report documented the wound was a stage III which measured at 1.00 centimeters (cm) in length, 1.00 cm in width and 1.10 cm in depth with tunneling present. On 08-15-14 at 5:10 p.m., LPN #6 was asked about repositioning for resident #12. LPN #6 stated, "Certified nurse assistants (CNAs) should be tuning her off her bottom a little bit with a pillow." On 08-18-14 at 11:10 a.m., resident #12 was asked if the facility was turning and repositioning her. The resident stated a couple of times a day she was repositioned. On 08-18-14 at 11:35 a.m., the resident's daughter was asked about resident #12's wound. The resident's daughter stated her mother had told her either the day she got back from the hospital on 07-21-14 or the next day that her bottom hurt. The resident's daughter stated she looked at the resident's bottom and there was a "slit on her bottom and it bled." The resident's daughter stated she had informed the staff about it and LPN #3 came to the resident's room and looked at the resident's bottom and said she did not see a wound. The resident's daughter stated the LPN stood at the foot of the resident's bed where she could not really see the resident's wound. The resident's daughter stated staff put "cream" on the resident's bottom but did not treat the wound at that time. On 08-18-14 at 2:30 p.m., the director of nursing (DON) was asked about turning and repositioning a resident with a pressure sore. The DON stated residents should be turned every two hours and kept clean and dry.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' maintained their highest level of well-being for 2 (#10 and #12) of 13 sampled residents whose records were reviewed for resident well-being. The facility failed to assess, monitor, and intervene to: a. Ensure a resident who had experienced a fall received an x-ray in a timely manner for resident #12. The director of nursing (DON) identified 27 residents who had experienced falls in the last 90 days. b. Ensure a resident with a pressure sore was treated for [REDACTED]. The assistant director of nursing identified 8 residents in the facility who had a pressure sore. c. Ensure a resident with pain received pain medication in a timely manner for resident #10. The DON identified 72 residents who received as needed pain medication. Findings: A facility Pain-Clinical Protocol Policy and Procedure, dated/revised April 2007, documented, "...The staff and physician will identify the nature and severity of pain including characteristics (location, intensity, frequency, duration, etc.) b. The staff and physician will evaluate nonverbal individuals for nonspecific signs and symptoms that could reflect pain; for example, grimacing while being repositioned or having a wound dressing changed..." 1. Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07-14-14, documented resident #12 was moderately impaired cognitively, required required extensive assistance with most activities of daily living, and was continent of bowel and bladder. The assessment documented no falls since admission. The assessment documented resident #12 had occasional pain and on a scale of 1 to 10 the resident described her pain as an 8. The assessment documented the resident had received as needed (PRN) pain medications. An incident report, dated 07-15-14 at 7:50 a.m., documented staff was called to the resident's room and found the resident sitting in the bathroom floor in front of the toilet. Resident #12 stated, "...I got off the stool and sat on my wheelchair but didn't scoot back far enough and I slid out on the floor. Asked pt (patient) if she was hurt she stated 'no just my feelings' No pain or discomfort noted with AROM (active range of motion) or PROM (passive range of motion) of all ext (extremities) pelvis stable..." A physician's telephone order, dated 07-15-14 and untimed, documented, "...Mobile x-ray for R (right) knee pain..." A nurse's note, dated 07-15-14 at 5:12 p.m., documented at 4:37 p.m. resident #12 was complaining of left knee pain. A nurse's note, dated 07-15-14 at 6:40 p.m., documented the resident's daughter asked staff at 4:30 p.m. why the resident's x-ray had not been done since her fall that morning. The resident's daughter stated she did not want to wait any longer for mobile x-ray and would go ahead and take her mother by personal vehicle for an outpatient x-ray. An outpatient x-ray report, dated 07-15-14, documented, "...Left total knee arthroplasty is seen with anatomic alignment. The osseous structures are intact with no acute fractures identified. Moderate diffuse soft tissue swelling is noted..." An incident report, dated 07-16-14 at 6:20 a.m., documented, "...CNA (certified nurse assistant) assisting pt from toilet to wheelchair. Pt stated her (pt) L (left) knee "gave out." Pt leaned on w/c (wheelchair) & (and) CNA assisted pt to the floor. Pt c (with) c/o (complained of) back pain. @ (at) 0630 call to 911..." A nurse's note, dated 07-16-14 at 7:37 a.m., documented, "...0620 CNA (name deleted) called nurse to room. Pt was observed laying in bathroom floor on her back. CNA (name deleted) stated that she was assisting pt from toilet to wc pt was standing and said, 'I'm gonna try to move now' and when she did her left knee gave out...pt left knee was noted to have purplish bruising on inner and outer sides of patella. Knee had marked swelling noted and did appear to be rotated inward slightly..." A hospital discharge summary, dated 07-21-14, documented a discharge [DIAGNOSES REDACTED]. A facility wound assessment report, dated 07-27-14, documented a new pressure ulcer located on the resident's sacrum. The report documented the wound was a stage III which measured at 1.50 centimeters (cm) in length, 1.50 cm in width and 2.00 cm in depth. A facility wound assessment report, dated 08-07-14, documented a pressure ulcer located on the resident's sacrum. The report documented the wound was a stage III which measured at 1.00 centimeters (cm) in length, 1.00 cm in width and 0.50 cm in depth with tunneling present. On 08-13-14 at 10:50 a.m., LPN #1 was observed providing wound care for resident #12. While the wound was being packed with packing strips the resident stated, "That hurts so bad it feels like it is on fire." After wound care was completed the resident continued to complain of pain in her bottom area and also left leg pain. LPN #1 was asked if the resident had been pre-medicated with pain medication prior to wound care. LPN #1 stated no. On 08-13-14 at 12:30 p.m., resident #12 was observed in her bed lying on her back with the head of the bed elevated, a pillow was under her legs, and a micro-air mattress was in place on her bed. An indwelling urinary catheter was observed to be attached to the bed frame. A facility wound assessment report, dated 08-14-14, documented a pressure ulcer located on the resident's sacrum. The report documented the wound was a stage III which measured at 1.00 centimeters (cm) in length, 1.00 cm in width and 1.10 cm in depth with tunneling present. On 08-18-14 at 11:10 a.m., resident #12 was asked about her recent falls. The resident stated the first time she fell she rang her call light and nobody answered so she went to the bathroom by herself. The resident stated when she was finished, she attempted to transfer herself to the edge of the wheelchair, had not scooted back far enough, and fell to the floor catching the red emergency light as she came down. On 08-18-14 at 11:50 a.m., LPN #5 was asked about resident #12's x-ray. LPN #5 stated the resident's daughter came to them, said the resident was having knee pain, and they wanted the resident to have an x-ray. LPN #5 stated, "The next shift did whatever they did. I wasn't there." On 08-18-14 at 1:20 p.m., CNA #4 was asked what happened when resident #12 fell on [DATE]th. CNA #4 stated the resident had put her call light on and she had gone in to see what the resident needed. CNA #4 stated the resident needed to use the restroom so she transferred her to her wheelchair. CNA #4 stated when the resident was finished in the restroom, she stood up and said she was going to try to step. CNA #4 stated when she did take a step the resident's leg gave out, she caught her, and lowered her to the ground. CNA #4 was asked if she had used a gait belt to transfer the resident. CNA #4 stated she had not used a gait belt. On 08-18-14 at 1:40 p.m., LPN #4 was asked about resident #12's x-ray order. LPN #4 stated the day shift left them paperwork to get an x-ray ordered or send her out. LPN #4 stated the resident's family came up to the desk and asked when their mother was going to get the x-ray on her knee. LPN #4 told the resident's family the x-ray had not been ordered yet so the family said never mind they would take their mother themselves to get the x-ray. On 08-18-14 at 2:05 p.m., LPN #3 was observed providing wound care for resident #12. While the wound was being packed with packing strips the resident "hollered out." LPN #3 did not acknowledge the resident's expression of pain and continued the wound treatment. A departmental note, dated 08-18-14 at 2:14 p.m., documented resident #12's sacral wound measurement as 2.2 cm in length, 1.6 cm in width, and 1.3 cm in depth. On 08-18-14 at 2:34 p.m., the facility produced a fax from the x-ray company documenting the facility had ordered an x-ray for resident #12 on 07-15-14 however had no documented time of the order. On 08-18-14 at 3:50 p.m., the DON was asked about the resident experiencing pain during wound care. The DON stated she would expect if a resident complained of pain during wound treatment the nurse should assess their pain and make a plan. On 08-18-14 at 4:35 p.m., LPN #3 was asked if a resident was receiving wound care and complained of pain what would you do. LPN #3 stated, "I would tell the certified medication aid." LPN #3 was asked when she would stop the wound treatment if a resident was complaining of pain. LPN #3 stated, "I would not stop the wound care unless the pain was severe." 2. Resident #10 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A comprehensive pain assessment form, dated 07-16-14, documented resident #10 had pain almost constantly in the past 5 days. The assessment documented resident #10 rated her pain a 9 on a scale of 1-10. An admission assessment, dated 07-23-14, documented the resident was moderately impaired cognitively, required limited assistance with most ADLs, and had frequent pain rated at a 9 on a 1-10 rating scale. A Medication Administration Record [REDACTED]. A MAR, dated August 1014, documented resident #10 had been administered pain medication eleven times from 08-01-14 through 08-11-14 A discharge summary, dated 08-12-14, documented resident #10 had been admitted to the facility for intravenous antibiotic (ATB) therapy for a urinary tract infection. The summary documented the resident had completed the ATB therapy and was being discharged to home. On 08-14-14 at 12:20 p.m., licensed practical nurse (LPN) #2 was asked if residents ever complained about not getting their pain medications timely. She stated yes, occasionally on the weekends. LPN #2 stated the weekend certified medication aide (CMA) stayed very busy. She stated she felt like he stayed on top of the pain medications. LPN #2 stated she did have one resident who had complained recently about a delay in getting her pain medication. LPN #2 stated resident #10 had complained she had asked the CMA for pain medication and had been waiting 30 minutes. LPN #2 stated she obtained the pain medication for resident #10 at that time. LPN #2 stated there had been only one CMA at that time.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident received adequate supervision to prevent accidents for 1 (#5) of 4 sampled residents who were reviewed for falls. a. The facility failed to evaluate the effectiveness of interventions and implement new interventions after a fall for resident #5. b. The facility failed to document a side rail assessment to determine the risks and/or benefits of side rails for resident #5. Resident #5 fell and sustained a fractured right hip. The facility census and condition identified 53 residents resided in the facility. Findings: A facility Fall Risk/Precautions policy documented, "...Patient has displayed with poor decision making skills in regards to safe body alignment/positioning. Patient displays with unsafe mobility practices. Verbal interventions has been found to be unsuccessful in altering patients' unsafe behaviors. Therefore, it has become necessary to implement steps to attempt to insure patient safety without impeding there (sic) freedom of movement or sense of independence. Patient will be provided with a low bed with floor matt at bedside. Pressure alarm to bed to alert staff of patients' need. Personal alarm in place when pt is up in wheelchair; affixed to clothing..." A facility Proper Use of Side Rails policy documented, "...The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms...An assessment will be made to determine the resident's symptoms or reason for using side rails...The use of side rails as an assistive device will be addressed in the resident care plan...Consent for using restrictive devices will be obtained from the resident or legal representative...The resident will be checked periodically for safety relative to side rail use..." Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The clinical record documented the resident had a history of [REDACTED]. A quarterly assessment, dated 12-17-12, documented the resident was moderately impaired cognitively, had short and long term memory loss, required extensive to total assistance with activities of daily living, required extensive assistance of two staff members for transfers, and was frequently incontinent of bowel and bladder. The assessment did not document the resident had experienced falls. A care plan, dated 06-19-12, documented the resident was at risk for falls. The interventions to prevent falls were to check the environment for fall risk factors, bedrails should be sturdy and in good repair, ensure lighting was adequate, ensure gown/clothing does not cause tripping, wear nonskid shoes/slippers, keep frequently used items within easy reach, regular toileting, and to check side rails to make sure they were working properly and were in good repair. The care plan had not been updated to reflect the 12-27-12 and the 01-09-13 falls. A physicians' telephone order, dated 07-04-12, documented, "...May use 1/2 rails on bed for positioning, (and) mobility..." No side rail assessments were documented in the resident's clinical record. A facility Incident/Accident report, dated 12-27-12, documented the resident had gotten out of bed and fallen to the floor. The report documented there was no injury. Follow-up interventions included toileting schedule, position change, instructed to request assistance, call light within reach, half rails, and redirect as needed. A facility Incident/Accident report, dated 01-09-13, documented the resident had been observed on the floor beside her bed and she had complained of right hip and right elbow pain. The report documented the resident had been sent to the hospital. Follow-up interventions included position change, instructed to request assistance, and call light within reach. A report to the Oklahoma State Department of Health, dated 01-11-13, documented resident #5 had sustained a right hip fracture and required surgery. A care plan, dated 01-21-13, documented the resident was at risk for falls. There were no new interventions added to the care plan related to falls after the resident sustained [REDACTED]. A physicians' progress note, dated 01-25-13, documented, "...Very weak. Very little progress. Eats fair...She will never be a good candidate for rehab..." A quarterly assessment, dated 06-11-13, documented the resident was moderately impaired cognitively, had short and long term memory loss, required extensive to total assistance with activities of daily living, required extensive assistance of two staff members for transfers, and was frequently incontinent of bowel and bladder. The assessment did not document the resident had experienced falls. On 06-24-13 at 11:05 a.m., resident #5 was observed lying in bed with her eyes closed. Half rails were up on each side of the bed. Her call light was attached to the side rail. On 06-26-13 at 1:20 p.m., resident #5 was observed lying in bed with her eyes closed. Half rails were up on each side of the bed. Her call light was attached to the side rail. On 06-27-13 at 11:00 a.m., the director of nursing (DON) was asked what resident #5's cognitive status was. She stated the resident had moderate impairment and was not reliable with her answers when questioned. She further stated the resident had to be reminded of tasks repeatedly and had poor short term memory. The DON was asked if the resident used her call light to ask for assistance. She stated she did not know. The DON was asked if the facility had evaluated the effectiveness of the fall interventions that were presently in place. She stated the resident used the side rails for positioning and mobility. She further stated she hoped repeated instructions about calling for assistance would eventually go to the resident's long term memory. The DON was asked if the facility had implemented any new interventions after the last fall incident. She stated the resident started physical therapy after sustaining the hip fracture. She stated no further interventions were implemented. The DON was asked if a side rail assessment had been completed for resident #5's side rail use. She stated no she did not consider a half rail a restraint only a positioning device. On 06-27-13 at 3:40 p.m., resident #5 was observed lying in bed with her eyes closed. Half rails were up on each side of the bed. Her call light was attached to the side rail.

Based on observation, interview, and record review, it was determined the facility failed to provide care in a manner to maintain residents' highest physical well-being for 1 (#1) of 6 sampled residents whose physical status was observed and/or reviewed. The facility failed to monitor resident #1's urine after an indwelling urinary catheter was inserted on 11-01-10. The facility failed to address the monitoring of the resident's urine on the resident's care plan. Resident #1 was treated in the hospital for a [DIAGNOSES REDACTED]. This had the potential to affect the 6 residents the facility identified as having indwelling urinary catheters. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08-22-10, documented the resident had memory problems, had modified independence with cognitive skills for daily decision-making, required total assistance with transfers, and dressing, was continent of bowel and bladder, and had no ulcers. The care plan, last updated on 11-01-10, documented, "I have a foley." There was no further documentation related to the resident's indwelling urinary catheter. No goals, approaches, or interventions were documented on the care plan for the care of the urinary catheter. Nurse's notes, dated 11-01-10, documented the resident had a physician's orders [REDACTED]. The order for the catheter was given by the facility's medical director. Orders for comprehensive medical foot care, dated 11-08-10, documented the resident was to be given Keflex 250 mg (milligram) by mouth three times a day for five days for a [DIAGNOSES REDACTED].[REDACTED] The resident's nurses' notes from 11-02-10 through 11-18-10 did not address the resident's catheter use or the condition of the resident's urine. On 11-18-10 the resident was sent out for a visit to his primary care physician (PCP). The resident was sent from the PCP's office and was a direct admit to the hospital. The hospital history and physical (H & P), dated 11-18-10, documented by the PCP stated the following: "Patient is a [AGE] year-old male with a history significant for dementia, hypertension, CHD (coronary [MEDICAL CONDITION]), stent placement, [MEDICAL CONDITION] disorder, diabetes, who has been in a nursing home for quite a while now. Patient has not been in our clinic for almost a year. He was brought to the clinic today, noted significant altered mental status. Patient has an indwelling Foley. History is taken from patient's wife, as well as patient's daughter. Apparently has stayed in the nursing home and has not been followed up and had regular assessment by a physician. Patient has not been in our clinic for almost a year. He was noted to have progressive confusion, increase of altered mental status with generalized body weakness. Urine coming from the Foley was bloody. Patient is unable to provide history. Apparently his wife was saying that she has observed him dying in the nursing home slowly, was concerned about this, has made observation with her daughter. When seen in the clinic patient was very lethargic with an indwelling catheter with bloody urine." The hospital H & P documented the resident had altered mental status, probably secondary to acute [MEDICAL CONDITION], diabetes mellitus (DM), chronic leg [MEDICAL CONDITION], and hypertension. The resident's hospital admission orders [REDACTED]. The resident's complete blood count, dated 11-18-10 at 12:46 p.m., documented the resident's white blood count was 14.4 (normal was documented as 4.8 - 10.8). The resident's nurses' hospital adult admission history and initial assessment, dated 11-18-10 at 2:30 p.m., documented the resident had an indwelling catheter, the urine was cloudy, red/orange in color, and was "very foul smelling." The resident's urine analysis, dated 11-18-10 at 7:15 p.m., documented the urine was straw colored and cloudy, was positive for [MEDICATION NAME], had greater than 100 white blood cells, and one plus bacteria. The urine culture and sensitivity (C&S), dated 11-18-10, documented the final result of greater than 100,000 organisms of Pseudomonas Aeruginosa. The PCP hospital progress note, dated 11-19-10, documented the resident [MEDICAL CONDITION], secondary to acute [MEDICAL CONDITION], DM, chronic leg [MEDICAL CONDITION], and hypertension. On 11-23-10 at 11:33 a.m., the director of nursing (DON) was asked the reason for the insertion of the catheter. She stated the resident had developed an open area on his coccyx and had become frequently incontinent of urine. She stated the facility had attempted to contact the resident's physician by fax, but he never acknowledged the faxes. She stated the resident's PCP did not take calls from the nursing home and faxing was their only means of communication with him. When he did not respond to the fax attempts, the facility obtained the order from the medical director. On 11-23-10 at 3:57 p.m., the PCP was interviewed. When asked, the PCP stated the resident's hospital admission [DIAGNOSES REDACTED]. The resident's hospital discharge summary, dated 11-24-10, documented the resident's admitting [DIAGNOSES REDACTED]. The discharge summary documented the resident's discharge [DIAGNOSES REDACTED]. On 12-17-10 at 4:10 p.m., the DON was asked if the facility monitored the resident's catheter after it was inserted. She stated the activities of daily (ADL) sheets would have that documented. She would go check. The DON was asked if the facility had any documentation of the monitoring of the resident's urine after the catheter had been inserted. She stated they did not have that. The DON returned to the surveyor and stated the ADL sheets could not be printed out as there was a problem with their computer system.