Based on observations, interviews, electronic medical record (EMR), and facility policy review, the facility failed to ensure the interdisciplinary team assessed and determined if a resident was capable of self-administration of medications for 2 of 23 residents sampled for self-administration of mediation. (Residents #118 and #392) The findings include: Resident #392 On 11/18/24 at 11:30 AM, Resident #392 was observed with a tube of Triamcinolone Acetonide (a cream meant to treat skin conditions such as eczema, dermatitis, and allergies) at the bed side. Resident #392 stated he uses this for general itching. He stated the nurses don't know he is using it, and he has been using this medication for 15 years. A second observation on 11/19/24 at 9:00 Am revealed the Triamcinolone cream was still at the bed side table. A review of the EMR for Resident #392 revealed diagnoses of Type 2 Diabetes Mellitus with other specified complication, presence of Cardiac Pacemaker, essential Hypertension, Hyperlipidemia, unspecified, benign Prostatic hyperplasia without lower Urinary tract symptoms, unspecified Atrial Fibrillation, Atherosclerotic Heart Disease of native Coronary Artery without Angina Pectoris, Peripheral Vascular Disease, personal history of Peptic Ulcer disease, other Asthma, Muscle weakness, and Chronic Obstructive Pulmonary Disease. A review of medication orders did not show any orders for Triamcinolone or a review by the physician on Resident #392's ability to self-administer his own medications. On 11/19/24 at 3:00 PM an interview with Staff A, a Licensed Practical Nurse (LPN) was performed. She was asked if any residents administered their own medications. Staff A stated that she did not know of any residents who self-administered medications. Staff A was shown Resdient #392's medication in his room. Staff A commented that this medication should not be there, and he does not have an order for it. She told the resident she will ask his doctor for an order. Resident #118 An observation of Resident #118 was conducted on 11/19/24 at 2:36 PM. The resident was in bed and a bottle of Osteo Biflex (a Glucosamine Chondroitin supplement) was observed on his over bed table. An interview was conducted with Resident #118 on 11/20/24 at 10:35 AM. Resident #118 stated he ordered the Osteo Biflex online, administers the medication to himself, and had previously discussed it with his physician. The bottle of medication remained on the over bed table. (Photographic evidence was obtained.) A review of Resident #118's EMR revealed no assessment for the resident to self-administer medications and no care plan for self-administration of medications. An interview was conducted with Employee G, an agency LPN, on 11/20/24 at 10:25 AM. She stated unless the physician approved otherwise, the facility should be administering and storing the Osteo Biflex. She did not know if Resident #118 had been assessed to self-administer medications. An interview was conducted with the Director of Nursing (DON) on 11/20/24 at 10:37 AM. She stated Resident #118 was not assessed to self-administer medications and he should not have the medication at bedside. She expected the staff to observe for medications at bedside and report to the nurse so the facility can screen the resident to determine if they are safe to self-administer medications. A review of the policy on Self Administration of Medication revealed, A resident may not be permitted to administer or retain any medications in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. Should the resident's attending physician permit resident to administer his/her medication(s), the following conditions will apply: The Physician's order must be given prior to self-administration Storage of medications in the resident's room must be such that it will prevent access by other residents. Only the medications permitted for self-administration shall be left at the bedside. The Interdisciplinary Care Plan Team must record in the resident's medical record that self-administration has been authorized and shall identify the name, strength, and quantity of each medication retained at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to store resident care equipment in a sanitary manner in 3 of 24 sampled resident rooms. (rooms [ROOM NUMBER]) The findings include: An observation of room [ROOM NUMBER]'s bathroom was conducted on 11/18/24 at 4:02 PM. Three wash basins (2 labeled with 64 A and one not labeled) and an unlabeled bedpan were observed to be sitting on top of the sink. Further observations of room [ROOM NUMBER]'s bathroom was conducted in the presence of Employee F, the Licensed Practical Nurse Unit Manager, on 11/20/24 at 3:00 PM. Employee F observed and confirmed 3 basins stacked on top of each other and one unlabeled bedpan on top of the sink. She stated the items should be stored in the resident's bed side drawer. (Photographic evidence was obtained.) An observation of room [ROOM NUMBER]'s bathroom was conducted on 11/18/24 at 2:50 PM. Three unlabeled wash basins were stacked on top of each other and an unlabeled urinal was sitting on top of the sink. Further observation of room [ROOM NUMBER]'s bathroom was conducted on 11/20/24 at 3:05 PM in the presence of Employee F. Employee F observed the wash basins and urinal, then confirmed the items should be labeled and stored in the resident's drawer. (Photographic evidence was obtained.) An observation of room [ROOM NUMBER]'s bathroom was conducted in the presence of Employee F on 11/20/24 at 3:08 PM. An unlabeled wash basin, unlabeled emesis basin, and unlabeled urinal was observed sitting on top of the sink. Employee F observed the items and confirmed they should be labeled and stored separately. (Photographic evidence was obtained.)

Based on observations, interviews, and record reviews, the facility failed to implement the plan of care for 2 of 2 residents sampled for falls. (Residents #46 and #3) The findings include: On 11/18/24 at approximately 11:00 AM, Resident #46 was observed sitting on the fall mat beside the bed. Resident #46 was assisted by staff to return to their wheelchair. A review of the most recent care plan for Resident #46, dated 09/16/2024, described Resident #46 as having potential for falls/injury due to impaired safety awareness, being spontaneous, not remembering to use the call light or ask for assistance, and forgetting to use a walker. Part of her plan included using a Dycem mat in her wheechair's seat to prevent slipping out of the wheelchair. On 11/18/2024 at approximately 2:05 PM, and 11/19/2024 at approximately 1:20 PM and 2:50 PM, Resident #46 was observed using her wheelchair. The seat of the wheelchair was visible during observations and a cushion was used in the seat by Resident #46. However, no Dycem mat was observed in the wheelchair either above or under the cushion in the seat. During an observation and interview on 11/20/2024 at approximately 12:45 PM, Staff D, a Certified Nursing Assistant (CNA), was asked about Resident #46's Dycem mat. After checking Resident #46's chair, CNA D confirmed there was not a Dycem mat in the chair. CNA D proceeded to Resident #3's room and revealed that Resident #3 also did not have a Dycem in his wheelchair. CNA D immediately located the Dycem mat in Resident #3's room and placed it in the wheelchair. A review of Resident #3's care plan, dated 9/13/2024, indicated Resident #3 has a potential for falls/injury due to cerumen build-up, poor balance, seizure disorder, and attempts to remain independent. Interventions include Continue Dycem to w/c seat anti-lock brakes checked. On 11/20/2024 at approximately 2:15 PM, an interview was conducted with the Director of Nursing (DON), who, after reviewing resident #46 and #3's care plans, confirmed that both residents should have a Dycem mat in their wheelchairs. The DON stated the minimum data set (MDS) coordinator reviews and updates the quarterly assessments and audits to ensure interventions are completed.

Based on interview and record review, the facility failed to provide a Notice of Medicare Non-coverage for 1 of 6 residents reviewed. (Resident #8) The findings include: A review of the medical record on 1/16/2024 found no evidence of a Notice of Medicare Non-Coverage (NOMNC) issued to Resident #8 or the resident's representative. In an interview on 1/16/2024 at approximately 2:10 PM, the Director of Nursing (DON) was asked if Resident #8 had run out of Medicare covered days. She stated that, upon admission from the resident's previous facility, they thought Resident #8 had only utilized 32 bed days while at that facility. Resident #8 would have had 8-10 days left upon her discharge in September. They had not realized she had used 62 days at the previous facility. When they had last checked the billing days from the previous facility, it showed Resident #8 had used only 32 days. It was updated later by that facility to show she had 62 days had been used. The DON was asked if they had issued a Notice of Medicare Non-coverage (NOMNC) CMS-10123. She stated that they did not because they were under the impression, based on the first utilization review, that she had only used 32 days. Based on their calculations with the first utilization review of Medicare days from Resident #8's previous facility and her stay at Arcadia, they thought she had 8-10 days left when she voluntarily transferred to the ALF facility. They were unaware there was a bill sent to them until they received a certified letter from the sister of Resident #8, which was received on 1/12/2024. When asked if they should have issued a NOMNC, the DON stated that the days would have run out here if they had known about the 62 days utilized previously, so Resident #8 likely should have been issued a NOMNC. On 1/16/2024 at approximately 3:15 PM, the Director of Nursing brought a statement that noted an accounting of the Skilled Bed Days utilized by Resident #8. She stated that, on admission of Resident #8, the previous long term care facility had only billed for Skilled Nursing Care from 5/11/2023-5/31/2023. This is what they had when Resident #8 was admitted to the facility. The Resident was discharged on 9/12/2023, and, when she left, the facility was unaware of the update to the previous facilities billing, so they thought she had bed days left. She validated that a Notice of Medicare Non-Coverage (NOMNC) was not issued because they thought Resident #8 had bed days left when she discharged . The facility Central corporate billing office found this in October and billed the family. The facility wasn't aware she had run out of Medicare days when she discharged from the facility.

Based on observations, resident interview, staff interviews, record review, and policy review, the facility failed to ensure the interdisciplinary team assessed and determined a resident was capable of self-administration of medications prior to allowing 1 of 33 sampled residents to self-administer medications. (Resident #106) The findings include: An observation and interview was conducted with Resident #106 on 6/20/2023 at 4:22 PM. A partial bottle of lanthanum carbonate, a partial Symbicort inhaler, and a bottle of Dakin's solution was observed to be sitting on the overbed table. Resident #106 stated he administers the lanthanum carbonate (a phosphate binder) himself because it must be taken when he eats. Further observations of Resident #106's room was conducted on 6/21/2023 at 2:00 PM. The medications remained on the overbed table, even though the resident was out of the facility. (Photographic evidence obtained.) Resident #106's record revealed no physician's order or assessment regarding the self-administration of the medications. A progress note dated 6/10/2023 indicated the resident had completed his own wound care. An interview was conducted with Employee A, a licensed practical nurse, on 6/21/2023 at 2:09 PM. Employee A stated the resident obtains medications on his own from a pharmacy. She confirmed there were some pills in the bottle of lanthanum carbonate after shaking the bottle. She stated there was no lock box in the resident's room. An interview was conducted with Employee B, a licensed practical nurse and unit manager, on 6/21/2023 at 2:27 PM. Employee B stated she was not aware of the process for residents to self-administer medications. An interview was conducted with the Director of Nursing (DON) on 6/21/2023 at 2:27 PM. The DON stated the resident should have been assessed to self-administer medications and she would expect staff to observe the medications at the bedside. The DON confirmed the resident had not been assessed to self-administer the medications. A review of the facility policy for self administration of medications states, A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. Should the resident's attending physician permit the resident to administer his/her medication(s), the following conditions the following conditions will apply: a. The physician's order must be given prior to self-administration; b. Storage of medications in the resident's room must be such that it will prevent access by other residents; c. Only the medications permitted for self-administration shall be left at the bedside; d. The Interdisciplinary Care Plan Team must record in the resident's medical record that self-administration has been authorized and shall identify the name, strength, and quantity of each medication retained at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide the necessary services needed to maintain personal hygiene to dependent residents for 2 of 3 residents sampled for Activities for Daily Living (ADL). (Residents #481 and #479) The findings include: Resident #481: On 06/19/23 at approximately 12:58 PM, an observation and interview were conducted with Resident #481. She complained of not receiving any help with a bath. Resident #481's hair appears matted and oily, and her general skin appearance noted an oily sheen. Resident #481's husband at bedside reported that he is upset that no one has helped her get a bath and confirmed no information was received upon admission about her plan of care, including bathing. On 06/20/23 at approximately 12:04 PM, an interview was conducted with Resident #481, in which she stated, I had therapy this morning, it went good, but I still haven't had a bath, haven't been offered any assistance with getting one since being here , I asked for some supplies a few days ago, but they didn't bring me any washcloths or towels, all I have is an empty basin, but what good is that going to do. I just need someone to help me, set me up so I can wash off. On 06/21/23 at approximately 10:19 AM, an observation of Resident #481 was made after she returned from hallway after visiting with husband. Resident #481 in bed, states I still haven't had a bath yet, remains in same gown, and confirms that she did not receive a bath at all. A review of Resident #481's Electronic Health Record (EHR) was conducted. Resident #481 was admitted to the facility on [DATE] from an acute hospital stay at a local hospital due to a fall at home in which she sustained a left hip fracture that required an Open Reduction and Internal Fixation (ORIF) procedure. An ORIF is a surgical procedure that puts pieces of a broken bone back into place using screws, plates, sutures, or rods to hold the broken bone together. Resident #481's 5 day Minimum Data Set (MDS) dated [DATE] reveals, Shower/bathe self: requiring substantial/maximal assistance. A review of Resident #481's care plan in the EHR includes, Requires assistance with self-care and mobility related to medical diagnosis with a goal stating I will have care needs met through the next review as evidenced by being clean, well-groomed and odor free daily. Date Initiated: 06/16/2023, and interventions allow resident to propel own wheelchair, discourage resident from attempting to ambulate independently, encourage resident to ambulate with care staff, provide adequate lighting. A review of Resident #481's Bathing Task reveals that the resident was not documented as bathed from the time of admission on [DATE] until 6/21/23 at 1:24 PM. On 06/21/2023 at approximately 1:00 pm an interview was conducted with LPN C, in which she was asked to explain bath schedules and how are they assigned, she replies, baths are assigned upon admission going by the 'shower schedule sheet', then it is input into the computer under task with specified dates and shift to be performed. Usually, I or the ADON input this into the computer, the admission nurse can do it if we aren't here, but we double check when we return. If a resident refuses a bath, the CNA documents the refusal under task in the EHR and on the 'shower schedule sheet', then has the nurse for the day to sign off on it as well, the ADON keeps a file of the 'shower schedule sheets'. A review of the Shower Schedule Sheet shows that bath/shower days and the shift to be received are assigned based on the room number a resident is admitted to, with Resident #481 assigned as Tuesdays, Thursdays, and Saturdays on the day shift. LPN C continues to explain, if a residents preference differs from the facility schedule, then it is changed on the task tab in the EHR as well as on the 'shower schedule sheet' paper. There is a question on admission assessment for shower preferences and the admission nurse goes over this with the resident or the family verbally upon admission, and they should receive a copy but doesn't know if [Resident #481] received this information or not. Residents or their families are usually notified of the scheduled bath days by the admission nurse. She stated that baths are double documented once under task on the EHR and again on the shower schedule sheet because nursing leaders want the CNA's or whoever gives the bath to document it both places, so that it can be monitored at a quick glance. LPN C was then asked when she would expect resident #481. LPN C accesses the EHR and confirmed Resident #481's bath/shower schedule under the task tab is set to occur on the 7am-3pm shift on Tuesdays, Thursdays, and Saturdays, and confirms the same schedule set for resident #481 on the paper shower schedule sheet. She confirmed that Resident #481 should have had a bath on Saturday 06/17/2023, but it was not documented as occurring. Nurse E sitting nearby at the nurses station during this interview voluntarily stated, I was [Resident #481's] nurse but I did not see if the resident had a bath that day or not, I was not told that she didn't by the CNA, and I don't remember signing the shower schedule sheet. LPN C confirms only one entry in the EHR for Resident #481 receiving a bath for the date of 06/20/21, and that it should have been more. RESIDENT #479: On 06/19/23 at approximately 12:40 PM, an observation was made of Resident #479 lying in bed with a food-stained gray T-shirt on, hair matted, and unshaven with dried brownish-yellow residue noted on bilateral sides of his beard. Resident #479 states, They haven't even gave me a bath since I've been here. I went and complained to someone in administration with short hair, earlier this morning because they haven't done anything for me since I got here. On 06/20/23 at approximately 11:50 AM, an interview was conducted with Resident #479. Resident #479 explains that physical therapy (PT) and occupational therapy (OT) came in yesterday, they did some exercising in the bed, and had him sit up to the edge of the bed, and OT had him to brush his teeth and do some weight lifting. Resident #479 states, a CNA changed my brief today but did not offer me a bath, did not wash my hair, or offer to shave. Resident #479 was wearing the same gray t-shirt as yesterday and appeared unkempt with food stains on shirt, unshaven, and with greasy hair. Resident #479 confirmed that no one has still discussed bath or shower days with him. A review of Resident #479's electronic health record (EHR) revealed Resident #479 was re-admitted to the facility on [DATE] with a primary diagnosis of Pleural Effusion. Resident #479's MDS reveals an entry date of 06/15/2023 with the section Shower/bathe self scored as Dependent. A review of Resident #479's care plans included the following: Requires assistance with self-care and mobility related to medical diagnosis: Goal- will have care needs met through the next review as evidence by being clean, well-groomed and odor free daily; interventions include- allow resident to propel own wheelchair, discourage resident from attempting ambulation independently, encourage resident to ambulate with care staff, provide adequate lighting. Dated 05/24/23; revised 6/20/23; target date 8/22/23. A review of bathing documentation for Resident #479 on 06/19/23 reveals no bath documented as completed since admission on [DATE]. He is scheduled for baths to be performed on Tuesday, Thursday, and Saturday during the day shift. On 06/21/2023 at approximately 1:00 pm an interview was conducted with LPN C. LPN C confirmed that Resident #479 is scheduled to receive baths on Tuesdays, Thursdays, and Saturdays on the 7am-3pm shift and that he should have received a bath on Saturday 06/17/2023 and on Tuesday 06/20/2023, but maybe not on Thursday 06/15/2023 depending on what time he was admitted . LPN C was made aware of Resident #479's complaints of not receiving a bath since admission. LPN C agrees there is no additional clarifying documentation in the EHR from the CNA or a nurse on 06/17/2023 to clarify if the bath was received or not. Review of facility policy titled Shower/Tub Bath - Dependent Resident states: The purposes of this procedure are to promote cleanliness and comfort, to relax the resident, to stimulate circulation, and to observe the condition of the resident's skin. Key Procedural Points: 1. Be sure that the bath area is at a comfortable temperature for the resident. 2. Insofar as practical, encourage the resident to participate in the bath care. 3. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. 4. Use the emergency call signal to summon assistance, if needed. 5. Observe the resident's skin for any redness, rashes, broken skin, tender places, irritation, reddish or blue-gray area of skin over a pressure point, blisters, or skin breakdown. 6. Trim the resident's toenails or fingernails unless otherwise instructed by the staff/Charge Nurse. 7. Should the resident become ill, faint, or uncooperative during the procedure, turn off the shower or open the drain plug. Cover the resident and summon the staff/Charge Nurse by using the emergency call system. Review of facility policy titled Shower/Tub Bath - Independent Resident states: The purposes of this procedure are to promote cleanliness and comfort, to relax the resident, to stimulate circulation, and to observe the condition of the resident's skin. Key Procedural Points: 1. Be sure that the bath area is at a comfortable temperature for the resident. 2. Observe the cognitive and functional ability of the resident to be independent in the shower/tub. 3. Assure the call bell is within reach of the resident and instruct the resident how to use the emergency call system to common assistance. 4. Observe the resident's skin for any redness, rashes, broken skin, tender places, irritation, reddish or blue-gray area of skin over a pressure point, blisters or skin breakdown. 5. Assure the care plan is up to date to reflect the resident's functional status and level of assistance/supervision needed. 6. If needed, assist the resident with the necessary equipment and supplies to perform the procedure and take them to the bath area. 7. Provide privacy to the resident, close the door/draw curtain. 8. Observe resident intermittently to ensure safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record reviews, the facility failed to provide appropriate care and treatment in accordance with professional standards to meet the physical needs for 2 of 5 residents sampled for non-pressure related skin conditions. (Residents #481 and #479). The findings include: Resident #481: On 06/19/2023 at approximately 12:55 PM, an observation was made of 2 adhesive gauze dressings to Resident #481's left hip after the resident voiced concerns that staff had not changed the dressings since admission. The dressings were not dated, timed, or initialed. When the resident was asked what the dressings were for, she stated, from surgery, I fell and broke my hip and they had to do surgery to repair it. On 06/20/2023 at approximately 12:00 PM, a second observation was made of 2 adhesive gauze dressings to Resident #481's left hip with no date, time, or initials. The dressing appeared to be the same dressing noted on the prior observation and was lifting on the sides. The resident confirmed that it was the same dressing and it had not been changed. When asked if staff assessed the area or offered to change it, she stated, no, I don't have any idea of what's going on or how it's supposed to be cared for. On 06/20/2023 at approximately 4:00 PM, an interview was conducted with Resident #481 in which she explained that she notified an unknown staff member upon returning from therapy just now, to please get a nurse to come look at the dressings on her left hip, stating it's hurting my skin, she said that she would let them know. On 06/21/2023 at approximately 10:15 AM, an interview was conducted with resident #481 who stated, a nurse or something came in last night and removed my dressings and said they were just going to leave it open to air. An observation of the site (left lateral hip area) reveals 2 surgical incisions each approximately 3 inches in length and currently uncovered. The upper incision appears well approximated with staples present, the lower incision appears well approximated with staples present, and both surgical incisions with minor redness near approximated edges. A review of resident #481's electronic health record (EHR) revealed no current, completed, or discontinued order for any wound treatment to left hip. A review of Resident #481's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation of wound care to the left hip. The record reveals Resident #481 was admitted to the facility on [DATE] from an acute hospital stay at a local hospital due to a fall at home in which she sustained a left hip fracture that required an Open Reduction and Internal Fixation (ORIF). An ORIF is a surgical procedure that puts pieces of a broken bone back into place using screws, plates, sutures, or rods to hold the broken bone together. A review of Resident #481's 6/16/23 care plan in the EHR includes the following care plan: Potential/Actual Alteration in Skin integrity as evidence by risk factors decreased mobility and fracture with a goal stating I WILL HAVE A DECREASED RISK OF SKIN BREAKDOWN THROUGH THIS REVIEW PERIOD, with a target date of 09/14/2023 The care plan interventions include, assist with positioning as resident allows and tolerates, CNA to provide skin checks during delivery of care, CNA will report and skin changes, irritations or breakdown to Nurse, pressure reduction mattress, preventative treatment as ordered to bilateral heels, and provide and encourage adequate hydration and nutrition to maintain good skin turgor. A review of Resident #481's admission assessment dated [DATE] at 3:00 pm by Nurse C reveals the following documentation: Does resident have any skin issues? Yes. Skin conditions: Left hip ORIF with 2 incisions closed with staples. Moderate bruising to left hip and thigh. Moderate bruising to left upper arm. Scratch to left lower arm. Medium size bruise to right lower abdomen. Bilateral lower legs have some edema present. General skin condition: Warm Thick toenails Edema describe below). If edema present, describe: bilateral lower leg dependent edema. A review of resident #481's hard chart revealed a paper form titled Baseline Care Plan dated 06/16/2023, but does not address surgical incision wound care. On 06/21/2023 an additional record review of resident #481's current orders, MAR, and TAR revealed a new verbal order for Cleanse left hip and thigh incision area with Normal Saline, pat dry and cover with dry dressing. Use paper tape to secure per resident request, every evening shift dated 06/20/2023 at 2:02 pm and entered into the EHR by the Assistant Director of Nursing (ADON). Resident #481's MAR reveals this order as completed once on the evening shift of 06/20/2023 by Nurse E. On 06/21/2023 at approximately 10:30 AM, an interview was conducted with Nurse E, a Licensed Practical Nurse (LPN) assigned to care for Resident #481. When Nurse E was asked about Resident #481's wound care to left hip, she states, I looked at it yesterday and it was dry and intact, I took the dressings off yesterday around 6pm, I didn't cover it back up, but I did clean it with normal saline, and left it open to air. When asked to confirm the wound care order for Resident #481, Nurse E confirmed that the wounds should be covered at this time, and she did not cover it back up yesterday after removing it but should have. Nurse E was asked to explain the process of wound care or how orders are received when a resident is admitted . She stated, Usually the unit manager gets an admit packet and puts in orders, and allergies into the chart, so that all we have to do is an assessment and a skin sweep, and activate the orders. If the resident has a wound, we notify the Nurse Practitioner (NP) and they put in the order. If the NP is not here, we contact telehealth and they order it, and can even view the wound on the tablet. Nurse E continued to explain that if a resident is admitted with a wound, it should be addressed, and orders should be put into the chart. Nurse E confirmed there was no order for the care of Resident #481's wound prior to 06/20/2023, and stated, I wish that the wound care nurse had to see every new admission. Nurse E agreed that if it was not ordered and care was not documented that it was not done. Nurse E continued to explain that the Assistant Director of Nursing (ADON) is the primary wound care nurse and that LPN C, Unit Manager, will sometimes assist Nurse G with wound care. Nurse E states, [The ADON] put in an order yesterday for [Resident #481's] wound care, but I'm not sure how she knew to do that. On 06/21/2023 at approximately 1:00 PM, an interview was conducted with LPN C, Unit Manager, in which she was asked to explain the admission assessment process and how they identify and care for a newly admitted residents immediate needs. LPN C states, a baseline care plan is started by the unit manager, then handed off to the admission nurse who finishes it and gets the resident or family to sign. LPN C reviewed Resident #481's baseline care plan and agreed with surveyor findings that no skin or wound care is noted and confirms the admission paperwork sent from the local hospital does include a surgical wound to the left hip. LPN C continued to explain that the wound care nurse sees every new admission and sends out a weekly report via email to department heads, but Resident #481's assessment would not show up on the email until next week because Resident #481 was admitted on Friday. LPN C verifies that there was no documentation in the EHR by the wound care nurse for this resident. LPN C states, I don't think we even got a report from the hospital on this resident, sometimes we don't even know what all is wrong with the patient because the hospital doesn't send everything. When asked to review Resident #481's History and Physical (H&P) that was sent from the hospital upon admission to the facility, she confirmed that it did show a surgical incision to left hip and confirmed the primary admission diagnosis of Left Hip Fracture with Surgical Repair. LPN C continued to review Resident #481's hospital paperwork and stated, according to this, that dressing shouldn't have been removed until 7 days post operation. LPN C was asked if that order was entered into Resident #481's EHR upon admission or included in the baseline care plan so that staff would know how to care for Resident #481's basic needs. LPN C responds, not that I can see in the record, the admission nurse would have to activate orders for that. LPN C continued to explain, I know the NP saw her Monday. LPN C agreed that care for Resident #481's surgical incision should have been ordered upon admission into the facility and included in the baseline care plan but was not. On 06/21/23 at approximately 1:55 PM an interview with the ADON. She was asked to explain the process of assessment upon admission and caring for a resident with a wound. She stated, it depends on what type of wound first, but the nurses should assess each newly admitted resident and document any abnormal skin findings. If it's a surgical wound we would use the initial surgical incision care orders that come from the hospital or ortho doctor, etc., then they are entered into the EHR by either myself, the Unit Manager, or the admission nurse. If the resident is not admitted with orders for wound care, then we assess the wound and contact the NP for confirmation to continue the current order, change the order, or discontinue the order. [Resident #481] was admitted on Friday and was seen on Tuesday morning by me, and I contacted the NP and verified to continue the order and she said she would see the resident upon next round. The wound care nurse or alternate would assess the resident the next workday (because they work Monday- Friday) and obtain orders. The admission nurse should assess skin and document findings, if wound care is not present then they should contact the doctor or NP for further orders, and not wait for the wound care nurse. The ADON denied the facility uses any standing orders regarding wound care. The ADON agreed that any topical medication used for wound care would also require an order and this was not done on Resident #481. The ADON confirmed there is no documentation by the wound care nurse or any other nurse to support Resident #481's surgical wound being monitored, dressings changed, or wound care being performed since admission, other than on 06/20/23 by Nurse E. On 06/22/2023 at approximately 11:35 AM an interview was conducted with the wound care nurse. She explained that she usually sees every newly admitted resident with a Pressure Ulcer or any complicated wound that would require close monitoring, packing, that is infected, or is a dehisced surgical incision. She stated, I'm not certified in debridement so our Physician Assistant (PA) would do that. We usually round every Tuesday. She explained that she does not assess or round on every new admission with skin issues and also does not round on any resident that is receiving wound care from outside the facility. The nurse stated that her expectations in regard to a new admission with a skin tear or a surgical incision is that, the admission nurse would assess the resident and implement orders from either the 3008 or contact the doctor or nurse practitioner to get an order for wound care and enter it into the EHR. Resident #479: On 06/19/23 at approximately 12:40 PM, an observation was made of an adhesive gauze dressing to Resident #479's left forearm/elbow area. The dressing was not dated, timed, or initialed. When the resident was asked why the dressing was in place, he explained that it is covering a wound. Resident #479's confirmed that the wound to his left forearm/elbow area was present upon arrival to this facility. When Resident #479 was asked if staff here are caring for the wound and performing dressing changes, he states, no, they've only changed it once since being here. Resident #479's wife at bedside then states, it's from him hitting it on the bedrail at the hospital, it did look really bad, because it ripped a big piece of skin off, but I haven't seen it lately though because no one has done anything for it, that dressing has been there for days, I went and complained to someone in administration earlier this morning because they haven't done anything for him since he got here. On 06/20/23 at approximately 12:00 PM, an observation was made of Resident #479 with an adhesive gauze dressing in place to left forearm/elbow area, with a handwritten date on the exterior surface of the dressing of 6/19/23. Resident #479 was asked if his wound to the left forearm/elbow area is improving, in which he responded, I don't know because I haven't seen it. He was then asked to describe and confirm if wound care was completed since the dressing now included a date, he states, I don't think it was changed. On 06/20/23 at approximately 4:10 PM, an observation and interview were conducted with Resident #479, who states, I finally had a bath today and went to therapy, it was great. Resident #479 was observed sitting up in a chair at bedside, an adhesive gauze dressing remains in place to left forearm with the same appearance as earlier. An additional adhesive gauze dressing was noted to the right inner thigh with no date, time, or initial. Resident #479 explained that the dressing is in place due to a reaction he had to a medication while he was in the hospital that caused itching, which caused drainage. The resident's wife at bedside confirmed the dressing to his right thigh has not been changed since admission. A review of Resident #479's EHR was conducted and revealed no current, completed, or discontinued orders for wound treatment to left forearm/elbow area or right thigh since admission. A review of Resident #479's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation of wound care to left forearm/elbow area or right thigh. The record reveals Resident #479 was re-admitted to the facility on [DATE] with a primary diagnosis of Pleural Effusion. A review of resident #479's care plans included the following: POTENTAL/ACTUAL ALTERATION IN SKIN INTEGRITY with goal to have decreased risk of skin breakdown through this review period, with interventions include: assist with positioning as resident allows and tolerates, CNA to to provide skin checks during delivery of care, CNA will report any skin changes, irritation or breakdown to nurse, pressure reduction mattress, preventative treatment as ordered to bilateral heels, provide and encourage adequate hydration and nutrition to maintain good skin turgor. Date Initiated 05/24/23; revision on 05/24/23 with target date of 08/22/23,Potential for bleeding r/t anticoagulant therapy. A review of Resident #479's admission nursing assessment dated [DATE], reveals, Left ear small scab, Left forearm skin tear, General facial petechiae, Bilateral arms bruising, petechiae, Left hand swelling and bruising, Right hand bruising, Right arm IV sites x 3, Left shin skin tear, Petechiae/discoloration bilat lower legs, Edema, legs. A review of the provider progress note assessment dated [DATE] at 1:23 pm reveals, Skin: Warm and dry, no rashes, Scatter bruising. A review of Resident #479's H&P from a local hospital dated 06/06/2023 states, LUE has 3+ weeping edema as well as a 10cm skin tear. A review of resident #479's Patient Transfer Form dated 06/15/2023 from a local hospital reveals a documented skin tear to left forearm. On 06/21/23 at approximately 9:45 AM, an observation noted that Resident #479's left forearm/elbow area and right inner thigh dressings were no longer in place. Resident #479 reported that the dressings were not changed yesterday and that an unknown nurse or someone over the nurses came in this morning about 30 minutes ago and said that she was going to have someone else come in and put a bandage on it. Observation the left forearm/elbow area reveals a skin tear, approximately 10 cm in diameter with skin-flap missing, dried blood and yellow crusty drainage present, the wound is uncovered or open to air at this time. The right inner thigh wound had a scabbed circular area of less than 1 cm in diameter, no drainage noted. Per Resident #479, the nurse said that she was going to leave that dressing off. On 06/21/23 at approximately 10:54 AM, an interview was conducted with Nurse E, who confirmed that she was assigned to care for Resident #479 today. Nurse E was asked about the wound to Resident #479's left forearm/elbow area and she stated, I just did his wound care. Nurse E was then asked to explain or verify the orders for Resident #479's wound care. Upon review, she stated, well, I don't see any orders right now but I cleaned it with normal saline and applied triple antibiotic ointment to it and covered it with a dressing, The wound care nurse went in and removed the dressing to his left elbow and his right thigh this morning and got with me and told me to make sure that I get his wound care done on his arm. Nurse E continued reviewing Resident #479's EHR for wound care orders, explaining that she would expect an order to either be on the MAR or TAR. Nurse E confirmed there is no order for wound care and no other documentation to support or confirm that wound care, dressing change, or continued assessment of the wound has been performed on Resident #479 since admission. Nurse E agreed that an order should have been in place for Resident #479's wound care based on the admission assessment and prior to treatment. On 06/21/2023 at approximately 1:00 PM, an interview was conducted with LPN C, Unit Manager, who was asked if an order was obtained or entered into Resident #479's EHR upon admission or included in the baseline care plan so that staff would know how to care for Resident #479's basic needs and wounds. LPN C confirmed the admission paperwork sent to the facility does notate a skin tear to the left forearm/elbow area. LPN C verified that there was no documentation in the EHR by the wound care nurse for this resident. LPN C agreed with the surveyors findings that care for Resident #479's skin tear should have been addressed upon admission, an order should have been obtained or verified with the doctor or NP then placed in the residents chart/EHR and included in the baseline care plan but was not. Review of facility policy titled admission Orders states: It is the policy of the facility to provide care and services related to admission orders, according to state and federal regulations. PROCEDURE: 1. The facility will have physician orders (standardized form 3008) for the resident's immediate care, at the time of a resident's admission. 2. The admitting nurse will call the attending physician and clarify all orders on admission. 3. The admitting orders will be and entered into the facility electronic medical record. 4. The EMR transmits electronically to the pharmacy and the nurse will call the pharmacy to ensure receipt of the resident's medications on the next pharmacy delivery. Review of facility policy titled Skin Tears, Care of states: The purpose of this procedure is to provide guidelines for the care and antisepsis of breaks in the skin, minor lacerations, and abrasions. Procedure Guidelines: 1. When a skin tear is discovered, render the following care: a. Wash hands or sanitize hands with ABHR (if not visibly soiled) and put on gloves. b. If wound is bleeding, apply compress gently. c. If the bleeding does not stop, or if the wound needs medical attention, notify the physician. d. If appropriate, wash the site with soap and water, then wash hands or sanitize hands with ABHR (if not visibly soiled). e. Treat per center protocol or MD order. f. Remove gloves and discard into appropriate receptacle. g. Wash hands or sanitize hands with ABHR (if not visibly soiled). 2. Perform wound care per Center protocol. a. Complete an Exception Report UDA. Review of facility policy titled Dressings Sterile states: Purpose: The purposes of this procedure are to provide guidelines for sterile dressing changes to protect wounds from injury and to prevent the introduction of bacteria; Step #22. Apply the ordered dressing and secure with tape; Reporting and Documentation - The following information may be documented in the resident's electronic medical record: 1. The date and initials of the person that performed the procedure. 2. Type of dressing used and wound care given. 3. If the resident refused the treatment and why. Review of facility policy titled Dressings Non-Sterile states: The purposes of this procedure are to provide guidelines for non-sterile dressing changes to protect wounds from injury and to prevent the introduction of bacteria: Step #19. Apply the ordered dressing and secure with tape. Reporting and Documentation - The following information may be documented in the resident's electronic medical record: 1. The date and initials of the person that performed the procedure. 2. Type of dressing used and wound care given. 3. If the resident refused the treatment and why. Review of facility policy titled Care Plans- Baseline states: A baseline plan of care shall be developed for each resident admitted . Policy Interpretation and implementation: 1. To assure that the resident's immediate care needs are met and maintained, a Baseline Care Plan is developed upon admission. 2. The admitting nurse reviews the attending physician's order (e.g., diet, medications, treatment, etc.), and implements a nursing care plan to meet the resident's immediate care needs. 3. To assure that the resident's immediate care needs are met and maintained, a Baseline Care Plan is developed upon admission. 4. The admitting nurse reviews the attending physician's order (e.g., diet, medications, treatment, initial goals, therapy services, social services, PASRR recommendation, if applicable, etc.) and implements a nursing care plan to meet the resident's immediate care needs. 5. Baseline Care Plans are used until the Comprehensive Care Plan has been completed. 6. The center must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: o The initial goals of the resident o A summary of the resident's medications and dietary instructions o Any services and treatments to be administered by the center and personnel acting on behalf of the center o Any updated information based on the details of the comprehensive care plan, as necessary.