**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. On 10/18/22 at 2:55 p.m., Resident 197 was observed sitting up in her wheelchair. She was alert and oriented to person, place, and time. Resident 197 indicated she had a dressing on her right arm from a PICC (peripherally inserted central catheter). Resident 197 indicated the insertion site had become infected, and she was put on antibiotics at the hospital which she continued upon her arrival to the facility on [DATE]. The dressing was observed at this time. It was a bordered foam dressing, dated 10/12/22. Resident 197 indicated that the dressing had not been changed since she had gotten to the facility. On 10/18/22 at 3:00 p.m., RN (registered nurse) 12 and RN 13 came to resident 197's room to assess the dressing to resident 197's right arm. RN 12 indicated, since it was a PICC dressing site, they usually did not remove the dressing for up to 5 days. The dressing had been in place for 7 days. RN 12 removed the old dressing. The site was crusted over with no signs or symptoms of an infection. RN 12 indicated she would clean it and place a new dressing on resident 197's right arm. On 10/19/22 at 9:33 a.m., a comprehensive record review was completed for Resident 197. She had the following diagnoses which included, but were not limited to pulmonary fibrosis, cerebral ischemia, morbid obesity, vitamin B deficiency, vitamin D deficiency, hyperlipidemia, abnormal weight loss, diverticulosis of large intestine, essential hypertension, weakness, edema and adult failure to thrive. A nursing progress note dated 10/13/22 at 5:45 p.m., included an admission assessment of Resident 197 which included a complete head-to-toe assessment that did not make note of the PICC line dressing. An admission nursing Observation assessment was completed on 10/14/22. The dressing was not documented on the skin assessment. The record lacked documentation of physician orders for instructions/care for the dressing to her right arm. Although Resident 197 had an active physician order for Keflex (an antibiotic medication) 500 mg (milligrams) four times daily which ended on 10/16/22, there was no indication or diagnosis for it use. The record lacked documentation that neither a baseline or comprehensive care plan had been initiated to address the care requirements for the dressing on her arm. D. On 10/24/22 at 10:37 a.m., a comprehensive record review was completed for Resident 47. He had the following diagnoses but not limited to muscle weakness, cardiac murmur, nausea with vomiting, difficulty in walking, unsteadiness on feet, amnesia, pain, abnormal weight loss, cognitive communication deficit, generalized anxiety disorder, painful urination, and aftercare following joint replacement surgery. On 6/27/22 at 12:30 p.m., an Event document was created secondary to Resident 47 having sustained a laceration that measured 1.5 cm (centimeters) long by 1.5 cm wide to his left buttock. The Event note indicated the laceration was acquired due to moisture. Resident 47 had a physician's order dated 6/27/22 for Calmoseptine (methol-zinc oxide) 0.44-20.6% ointment three times daily, apply to buttocks with each episode of incontinence following perineal care. The record lacked further assessment of the area. On 10/24/22 at 2:55 p.m., the Assistant Director of Nursing (ADON) provided a record of a wound management note created 10/24/22 at 12:29 p.m. However, the documentation was backdated to 6/27/22. The late Event Note indicated on 6/7/22 the wound measured 1.5 cm long by 1.5 cm wide. On 7/5/22, the wound measured 0.5 cm long by 0.5 cm wide. The record lacked further documentation related to the wound on resident 47's left buttock. Resident 47's care plan lacked information related to the left buttock wound. E. On 10/18/22 at 10:31 a.m., Resident D was observed sitting up in her wheelchair. On 10/18/22 at 2:42 p.m., a comprehensive record review was completed for Resident D. She had the following diagnoses, which included, but were not to, hemiplegia and hemiparesis (paralysis/weakness) following cerebral infarction (stroke) affecting right dominant side, dysphagia (unable or trouble speaking) following cerebral infarction, vitamin D deficiency, hyperlipidemia, restless leg syndrome, essential hypertension, constipation, retention of urine, urinary tract infection and weakness. Resident D admitted with an indwelling catheter on 10/5/22, but later received and ordered to discontinue the use of the catheter on 10/12/22 with instructions to complete a bladder scans every 8 hours and as needed if unable to void and in/out catheterize if residual in the bladder was greater than 250 milliliters (ml). The record lacked documentation that Resident D received bladder scans as ordered on 10/13/22, 10/14/22, 10/16/22, and 10/17/22. On 10/14/22 between 7:10 p.m. and 10:00 p.m., Resident D was noted to have 270 ml recorded from the bladder scan. The record lacked documentation indicating that an in and out catheterization was completed due to greater than 250 ml of residual. On 10/15/22 between 6:00 a.m. and 7:00 a.m., Resident D was noted to have 278 ml of residual urine recorded from the bladder scan. The record lacked documentation that an in and out catheterization was completed for Resident D. The record lacked that her bowel/bladder comprehensive care plan had been revised to reflect the removal of the catheter and bladder scans. On 10/24/22 at 12:12 p.m., the Administrator (ADM) provided a copy of current facility policy titled, Comprehensive Care Plans. The policy indicated, .Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan and .Comprehensive care plans need to remain accurate and current, new interventions will be added and updated during CCM meeting and newly recognized problems will have a care plan developed and added after CCM meeting On 10/25/22 at 10:28 a.m., the DON provided a copy of current facility policy titled, Physician- Provider Notification Guidelines, reviewed 12/1/21. The policy indicated, .to ensure the resident's physician or practitioner (may include NP PA or clinical nurse specialist) is aware of all diagnostic testing results or changes in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care This Federal tag related to Complaint IN00392899. 3.1-37 A. Based on observations, interviews, and record reviews, the facility failed to ensure a resident received appropriate care and services to prevent complications with his biliary drainage catheter (a thin, hollow tube which is inserted into the liver through the skin which collects bile that is drained from the liver), which resulted in actual harm when a full physician order set with care instructions for flushing the tube was not re-initiated after a hospital stay and the tube became obstructed for 1 of 1 resident reviewed for biliary drainage catheter (Resident 13). B.Based on interviews and record reviews, the facility failed to ensure neurochecks were assessed after a resident fell for 1 of 1 resident reviewed for post fall procedure (Resident 98). C. Based on observations, interviews, and record reviews, the facility failed to ensure a resident, (Resident 197) received a comprehensive admission assessment to address a PICC dressing for 1 of 3 residents reviewed for new admissions. D. Based on observations, interviews, and record reviews, the facility failed to prevent the development of MASD (moisture associated skin damage) for a resident who was at risk for skin breakdown, which resulted in the development of a new wound that was not assessed in a timely manner for 1 of 4 residents reviewed for general skin conditions (Resident 47) . E. Based on observations, interviews, and record reviews, the facility failed to prevent the potential for complications/harm when a resident did not receive bladder scans and in/out catheterization as ordered for 1 of 4 residents reviewed for catheters (Resident D). Findings include: A. On 10/18/22at 2:55 p.m., Resident 13 was observed as he sat in his wheelchair (WC) beside his bed. At that time, he indicated he had recently returned from the hospital. He indicated, I wish I could have a new body, and pointed to the right side of his abdomen. It hurts. He pulled up his shirt and his biliary catheter tube was observed, the drainage bag rested on the WC pad beside him with a dark yellow fluid observed inside. Resident 13 indicated he was having a lot of trouble with the tube. During a continuous observation on 10/19/22 from 1:45 p.m., until 1:56 p.m., the following was observed: At 1:45 p.m., Resident 13 was observed as he sat in his WC beside his bed. His call light was illuminated at this time, and he indicated he wanted to lay down. The biliary drainage bag rested on his lap and contained a dark yellow fluid. At 1:47 p.m., Registered Nurse (RN) 8 answered Resident 13's call light and indicated she needed to get some assistance to transfer him into bed as she believed he was a two-person assist. At 1:49 p.m., RN 8 and Certified Nursing Assistant (CNA) 24 entered the room. RN 8 indicated Resident 13 had a lot of tubes, so they preferred to have him assisted by two people to not pull on the tubes. He has oxygen, a urinary catheter, and a biliary drain. CNA 24 indicated Resident 13 had been incontinent of bowel and she needed supplies to clean him up. RN 8 left the room to get supplies as requested. At 1:52 p.m., with RN 8 out of the room, CNA 24 positioned Resident 13 in his WC beside his bed. She removed his oxygen tubing, unlatched the catheter drainage bag from under the WC and tossed it onto the floor. CNA 24 stood behind Resident 13's WC, put her arms under his arm pits and assisted him to stand. He rocked forward several times, then shakily stood to his feet. As he stood his biliary drainage bag slid off his lap and hung to his knees. CNA 24 had to let go of one of Resident 13's arms to move around the WC which remained between them so that she could position herself in front of him and help him pivot to sit on the bed. As he turned, the biliary drainage bag was on the opposite side of the bed, and CNA 24 reached over and pulled it to the other side of the bed before Resident 13 sat on it. At 1:56 p.m., RN 8 re-entered the room and indicated, oh you already got him in bed. During an interview on 10/19/22 at 1:57 p.m., RN 8 indicated, usually transfer need to be completed with a gait belt in place in case they become unsteady. Resident 13 had just returned from the hospital and had not been evaluated by therapy yet, so he should have two people assist with a transfer, also because of all his tubes. During an interview on 10/19/22 at 1:57 p.m., CNA 24 indicated, before Resident 13 went to the hospital he was a 1-person assist so she thought it was ok to go ahead and transfer him. She indicated she didn't need a gait belt because she, had a good hold of him, even though she had to let go of him to come to the front of the WC, and to reposition his tubing. On 10/20/22 at 9:30 a.m., Resident 13 was observed. He sat in his WC beside the bed. There was a very pungent odor around him and he indicated he wanted to get laid down and cleaned up. He indicated he had a lot of pain and pointed to the area where his biliary drain was. He lifted his shirt. The dressing around the tube was observed at this time. There was a dark yellow/greenish stain at the center of the dressing around the tube, which spread outward in a more pink/reddish color. Resident 13 put his head in his hands and indicated, it hurts a lot. There was no date or initial on the dressing, and there was a white patch next to the dressing. On 10/20/22 at 10:26 a.m., RN 23 was notified of the drainage noted to Resident 13's dressing. At that time, she indicated, she was not familiar with Resident 13, she did not usually work that floor, she had just been pulled to that floor earlier that morning. RN 23 indicated she had put a lidocaine patch (a topical pain patch) on but that was it. She reviewed Resident 13's orders at this time and indicated there were no additional orders related to his biliary catheter besides monitor the drainage output and an order to cleanse the tubing. On 10/20/22 at 10:28 a.m., RN 23 entered Resident 13's room to assess the site. She observed the drainage around the tube, and indicated it was green in color, and more soiled than it should be. It appeared the dressing needed to be changed. Resident 13 indicated he was in pain, and RN 23 indicated she would bring him something for the pain. During an interview on 10/20/22 at 11:10 a.m., RN 23 indicated she had spoken with the ADON (Assistant Director of Nursing), who had called the NP (Nurse Practitioner). Resident 13 had been on several courses of antibiotics recently, so she was told to remove the dressing and observed the site for further signs/symptoms of infection. She prepared a medication cup of Resident 13's PRN (as needed) pain medication. On 10/20/22 at 11:30 a.m., (after allowing time for Resident 13's pain medication to become effective), RN 23 entered the room with supplies for a dressing change. She had a printed current physician order which indicated, cleanse tube area around tube with antibacterial soap and water or 1/2 water 1/2 hydrogen peroxide mixture daily. She indicated there were not specific orders or instruction for the dressing change, the order she had was the only order related the care/treatment of the biliary catheter beside monitoring for output. RN 23 failed to notify the physician and/or get clarifying orders for the dressing change before proceeding. When asked if she should notify the physician, she indicated, she had already spoken to the ADON. During the dressing change, which lasted approximately 30 minutes, Resident 13 expressed that he was still in a great deal of pain, especially as pressure, tugging, or wiping was completed around the site and to the tube. He clenched the bedsheets in his fists, he grimaced his face, and at one point, put his hand out to stop RN 23 and asked for a minute to catch his breath. The insertion site was observed have some redness around the tube, and Resident 13 indicated it was very tender. RN 23 finished the treatment, cleaned up her supplies and left the room. During an interview on 10/20/22 at 12:02 p.m., Resident 13 indicated the tube had been having a lot of trouble lately, he was not sure how often it was changed or should be changed. On 10/21/22 at 9:43 a.m., Resident 13 was observed as he sat in his WC beside his bed. He indicated he was feeling, ok, but still tired and in pain. The dressing from the previous day was observed in place, however there was a yellowish discharge noted to the center of the dressing surrounding the tube. During an interview on 10/21/22 at 11:26 a.m., RN 22 indicated he was not sure about Resident 13's dressing, but he had already been down to flush the catheter earlier that morning. When asked about the orders for flushing, RN 23 reviewed Resident 13's order set and indicated there was no order for flushing, and he had not noticed it before. RN 23 indicated it was important to flush the tube because if it was not, it could cause a build-up and that created pain for the resident. RN 23 indicated it appeared the flush orders had not been re-activated after his hospitalization, but it was something they had been doing before. On 10/21/22 at 11:38 a.m., RN 23 contacted the NP and received a new order to flush the biliary catheter twice a day, as before. During an interview on 10/24/22 at 10:33 a.m., the Medical Director (MD) indicated he was Resident 13's attending physician in the facility. Resident 13 had a chronically placed biliary catheter because he was a poor surgical candidate. With any type of tubes such at the biliary drain or urinary catheter, it was important to understand and adhere to transfer and positioning protocols to ensure the tubes aren't tugged on and become dislodged. Additionally, it was important to flush the tube to ensure it was patent and draining bile properly so that it did not get stopped up which could cause infection and would build up pressure also causing pain. On 10/19/22 at 10:00 a.m., Resident 13's medical record was comprehensively reviewed. He was a long-term care resident, admitted in 2019 with active diagnoses which included, but were not limited to; sepsis, unspecified severe protein-calorie malnutrition, urinary tract infection, other mechanical complication of bile duct prosthesis, displacement of bile duct prosthesis . He had physician orders which included, but were not limited to; a. cleanse tube area around tube with antibacterial soap and water or 1/2 water 1/2 hydrogen peroxide mixture daily, daily started 8/3/22. b. monitor biliary drain output every shift, started 4/11/22 The record lacked documentation of physician orders to monitor the dressing/incision site, and/or orders to flush for obstruction prevention. A nursing progress note, dated 5/1/22 at 7:40 a.m., indicated Resident 13's biliary tube had large amounts of green colored drainage. Resident was complaining of pain and discomfort. There was drainage at the insertion site of the tube, but no drainage was coming through the tube. 911 was called for transport to hospital. The corresponding hospital admission H&P (history and physical) dated 5/27/22 indicated, .apparently, the biliary drain had been pulled out approximately 6 to 8 cm [centimeters]. Patient does not know how this happened. Staff was unaware until today. Patient is having abdominal pain. He is unable to tell me how long he had been having abdominal discomfort or unwilling to elaborate on history. Apparently had a recent hospitalization between 5/1 and 5/7 for abdominal pain and biliary drain malfunction, which was replaced by IR [interventional radiology] on 5/3/22. He has chronic biliary drain secondary to common bile duct stricture from chronic pancreatitis. In either case upon my assessment, patient's only complaint is abdominal pain . I presume he does not want to communicate at present time considering his pain A nursing progress note, dated 5/24/2022 at 10:45 a.m., indicated, .received call from [Specialist Medical Doctor] regarding [Resident 13's] Biliary Drain. The physician explained he should have a routine exchange every 3 months with daily maintenance of 10 ml [milliliters] flush . he did not plan any more invasive procedure and [Resident 13] will have his biliary drain long term On 8/3/22 Resident 13 was sent back from the hospital after a routine biliary exchange with the following instructions, . Patient Education: a biliary catheter is a tube that drains bile. The tube goes through your skin and into your liver. It drains bile out of the body into a bag . Treatment/Procedure/Equipment (Home Care Orders) Flushing means rinsing your tube. This prevents it from getting blocked. Flush your tube 2 times a day with normal saline 10 ml, vigorously forward, without aspirating. Clean your tube/area around tube with antibacterial soap and water or 1/2 water 1/2 hydrogen peroxide mixture 0-1 times a day A nursing progress note dated 9/22/22 at 9:04 a.m., indicated Resident 13 had a fever and was sent to the ER and he was re-admitted on [DATE] after being treated for sepsis, secondary to a UTI (urinary tract infection). On 10/04/22 at 1:29 p.m., Resident 13 was seen by the NP for follow up after his recent re-admission to address his common bile duct stone and biliary drain, which had been replaced 9/25. The NP gave instructions/orders to use sodium chloride 0.9 % (flush) injection syringe with alcohol swab cap, and to flush biliary drain with 10 cc two times a day However, the record lacked documentation that the flush orders had been initiated. On 10/16/22 at 7:15 p.m., Resident 13 was sent to the ER for after it was noted to have dislodged. The corresponding hospital Discharge summary dated [DATE] indicated Resident 13's biliary drainage tube had become obstructed and was replaced. Upon his return, the record continued to lack documentation of physician orders to monitor the dressing/incision site, and/or orders to flush for obstruction prevention. A nursing progress note dated 10/22/22 at 2:25 p.m., indicated Resident 13's biliary tube had become dislodged again, and was sent to the ER. The corresponding hospital summary dated 10/22/22 indicated Resident 13 had been treated for an obstructed biliary drainage tube. here for evaluation of drainage around the biliary tube site that began this morning. Patient had this drain repositioned about 5 days ago and this morning noticed that it looked out of place and was draining, area is painful . attempted to contact Wellbrooke with no answer . tube replaced. The patient was given return precautions and instructions for follow up . instructions from care team: his biliary tube was replaced by IR today. Please be sure it doesn't get tugged on, pulled on, etc to avoid displacement again Resident 13's comprehensive care plans were reviewed and lacked documentation of a care plan for his biliary catheter. The record lacked documentation of orders or instructions for routine exchange. The record lacked documentation the physician had been notified of pain during the dressing change observation. On 10/19/22 at 1:48 p.m., the Director of Nursing (DON) provided a copy of current facility policy titled, Guidelines for Resident Transfers and Assistance, dated 5/10/17. The policy indicated, .to ensure the safety of residents and staff when performing mobility/transfer tasks . upon admission the admitting nurse and/or therapy department shall determine the type of transfer device needed as well as the amount of assistance required to assist with mobility based on observation and data collection. The following area will need to be observed: cognition, weight being status, resident's weight, upper and lower body strength, trunk stability, skin condition and mobility status During an interview on 10/25/22 at 10:28 a.m., the DON indicated there was no specific skills check off for nurses to complete related to biliary catheter care, however, if there was a question or concern with the biliary catheter system or procedure, the nurse should not continue until orders or treatments were confirmed with the MD. At this time she provided a copy of current facility policy titled, Biliary Drain Site Care and Dressing Change, dated 3/18/22. The policy indicated, Keep the skin around the drain clean and covered with 4 x 4 gauze dressing. The dressing should be changed per order by physician .DON provided last copies and indicated no skills check of for biliary tube .carefully remove the old dressing to avoid pulling on the drain. Note: soreness, redness, drainage or odor at the sire where the drain goes into the skin. If any of these signs are noted, change the dressing more frequently and contact the physician for further orders B. On 10/20/22 at 9:56 a.m., Resident 98 record was reviewed. She was admitted on [DATE]. A progress note, on 10/7/22 at 7:00 p.m., Registered Nurse (RN) 12 charted she was notified Resident 98 was on the floor. She was found face-down on the right side of her bed, between the bed and the window. Resident 98 was sitting in bed while eating dinner, when she slid out of bed and onto the floor. RN 12, an LPN (unidentified), and three RCAs (resident care assistants) (unidentified) lifted the resident back into bed using a Hoyer pad. Resident 98 had no apparent injuries. No loss of ROM (range of motion) or deformity noted to any extremity. She was PERRLA (pupils equal, round, reactive to light and accommodation). Her neuro status was at baseline. The Nurse Practitioner (NP), the DNS (Director of Nursing Services), and the family notified. A voicemail was left for family, requesting a return phone call. A fall mat was placed on the right side of bed and the bed was placed in position to facilitate safety. Her call light was within reach. On 10/7/222 at 9:25 p.m., RN 30 charted Resident 98 was encouraged and educated to sit up in a chair for meals to assist with ongoing safety related to prior fall. On 10/12/22 10:50 a.m., the Social Services Director (SSD) charted the initial care plan meeting was with herself, therapy, nursing, and the resident's daughter. The resident declined to attend. Discussion indicated the resident was refusing any out of bed activities due to fears of falling and statements of, I'm tired. Currently, on a low air-loss mattress and working with PT/OT (physical therapy/occupational therapy). She was refusing to work on any out of bed activities with them. She was total care for bed mobility and all ADLs and used a Hoyer lift. On 10/13/22 at 11:08 a.m., the DNS charted that the Interdisciplinary Team (IDT) met. Resident 98 was found on floor beside her bed. She had been on a low air loss (LAL) mattress, and she rolled off the side of bed. No injury was noted. Interventions were updated to include keeping bed at lowest position to facilitate safety and use of mat beside her bed. On 10/20/22 at 12:39 p.m., Resident 98's chart was reviewed. She was admitted on [DATE]. Resident 98's diagnoses included, but were not limited to, pressure ulcer of sacral region, stage 4 (full thickness skin loss with exposed bone, tendon or muscle) (primary diagnosis), protein calorie malnutrition, type 2 diabetes (blood sugar disorder), morbid (severe) obesity due to excess calories, necrotizing fasciitis (serious bacterial infection that destroys tissue under the skin), acute candidiasis (yeast infection) of vulva and vagina and diarrhea (loose or liquid stool). Resident 98's fall care plan goal indicated she would be free from falls with major injury. Neuro checks were provided by the Assistant Director of Nursing Services (ADNS), on 10/19/22 at 1:31 p.m. Upon review the neuro checks were determined to be incomplete. a. The initial neuro check was completed on 10/7/22 at 7:00 p.m. b. The second neuro check after 15 minutes was completed on 10/7/22 at 7:15 p.m. c. The third neuro check after 15 more minutes was completed on 10/7/22 at 7:30 p.m. d. The fourth neuro check after 15 more minutes was completed on 10/7/22 at 7:45 p.m. e. The first neuro check after 30 more minutes was completed on 10/7/22 at 8:15 p.m. f. The second neuro check after 30 more minutes was completed on 10/7/22 at 8:45 p.m. g. The third neuro check after 30 more minutes was completed on 10/7/22 at 9:15 p.m. h. The fourth neuro check after 30 more minutes was completed on 10/7/22 at 9:45 p.m. i. The remaining neuro checks had dates and times but the assessments were blank: 1. On 10/7/22 at 10:45 a.m., (meant to be 10:45 p.m.) the assessment was blank. 2. On 10/7/22 at 11:45 p.m., the assessment was blank. 3. On 10/8/22 at 12:45 a.m., the assessment was blank. 4. On 10/8/22 at 1:45 a.m., the assessment was blank. 5. On 10/8/22 at 5:45 a.m., the assessment was blank. 6. On 10/8/22 at 9:45 a.m., the assessment was blank. 7. On 10/8/22 at 1:45 p.m., the assessment was blank. 8. On 10/8/22 at 5:45 p.m., the assessment was blank.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/17/22 at 2:18 p.m., Resident 14 was observed lying in bed. He was able to answer yes and no questions only. His hands were tremoring during the observation. His bedside table was not within reach. He did not have an indwelling catheter as ordered. On 10/18/22 at 9:26 a.m., Resident was observed lying in bed. His bedside table was not within reach. Resident 14 able to answer yes and no questions. His hands were observed to be tremoring. On 10/18/22 at 2:52 p.m., a comprehensive record review was completed. Resident 14 had the following diagnoses but not limited to schizophrenia, parkinson's disease, UTI (Urinary Tract Infection), PE (Pulmonary Embolism), dementia, mood disorder, psychotic disorder, anxiety, hypothyroidism, vitamin deficiency, hyperlipidemia, bladder neck obstruction and reflux uropathy, benign prostatic hypertrophy, unspecified fall, and age-related cognitive decline. Resident 14 admitted to the facility on [DATE]. He admitted with an indwelling catheter. Prior to discharging to the facility, the resident's healthcare representative expressed concerns about resident having an indwelling catheter, indicating that he would pull the catheter out. On 10/18/22 at 1:35 p.m., during an interview with the DNS, she indicated that prior to resident admitting, he had hand restraints at the hospital due to attempting to pull his catheter out at the hospital. The DNS informed the hospital that resident would have to be restraint free for at least 24 hours before he could be admitted to the facility. A progress note dated 9/20/22 at 7:30 p.m., indicated that resident 14 was observed lying in bed with his indwelling catheter on the floor. Inside the bathroom, the nurse noticed blood in the bathroom along with blood-soaked clothing. Resident 14 was bleeding from his urethra. The nurse documented that resident 14 was observed to have an abrasion to the top of his head measuring 3.0cm by 2.0 cm. Resident 14 was sent to the hospital for evaluation. Resident 14's discharge paperwork indicated that the emergency room staff questioned a fall due to the abrasion on his head, therefore, completed a CT scan of his head. The emergency room phoned the nurse at the facility, and she was unsure if resident 14 fell or not. He was found in bed and bleeding was observed in the bathroom. The emergency room replaced the indwelling catheter and sent resident 14 back to the facility. On 10/20/22 at 11:05 a.m., during an interview with the ADNS, he indicated that resident did not have a fall. He indicated that resident did have an abrasion to his head. The record lacked an event or investigation in the origin of the abrasion on his head. The ADNS indicated that the abrasion should have had an event and investigation to find out what caused the abrasion on his head. On 10/20/22 at 11:20 a.m., the ADNS provided a copy of an event with the creation date of 9/20/22 at 7:30 p.m. The event was recorded on 10/20/22 at 10:57 a.m. On 10/21/22 at 11:13 a.m., during an interview with the ED and DNS regarding resident 14's abrasion. The ADNS providing a copy of an event that was completed on 10/20/22 and a lack of documentation into the origin of the abrasion. No further information was provided. 3. On 10/24/22 at 9:59 a.m., Resident 21 was observed sitting up in her wheelchair and leaning to her right side, resting on the arm of the chair. Resident was not wearing a wander guard. RN 12 assessed resident 21 for a wander guard and could not find one on her person or wheelchair. RN 12 indicated that she would get one and place it on resident 21. On 10/24/22 at 10:12 a.m., a comprehensive record review was completed for resident 21. Resident 21 had the following diagnoses but not limited to chronic obstructive pulmonary disease, hypertension, hypertensive heart disease with heart failure, hypothyroidism, vitamin B deficiency, other specified depressive disorders, major depressive disorder, restless leg syndrome, peripheral autonomic neuropathy, vascular dementia, insomnia, altered mental status, difficulty in walking, repeated falls, lack of coordination, abnormal weight loss, age-related physical debility, and chronic pain. A quarterly nursing observation dated 9/28/22 indicated that resident was at risk for elopement due to a history of elopement seeking, attempts to leave the campus, exhibits periods of pacing, agitation or wandering toward an exit, and resident wanders. Resident 21 had orders to have a wander guard and to check placement and function of the device. Resident 21 had a care plan dated 4/14/22, addressing risk for elopement. An intervention dated 4/12/22 indicated for resident 21 to have a wander guard and to check placement and function as ordered. Observed an elopement binder at the front desk. It included a profile of resident 21. The picture was pixilated and resident 21's face was unrecognizable. Included in the binder were other residents who were no longer residing in the facility. A policy titled Guidelines: Elopement Risk Assessment and Prevention date 9/28/16 was provided by the DNS on 10/25/22 at 2:06 p.m., it indicated .each resident will be assessed for elopement risk upon admission, quarterly and with change in condition. An elopement risk binder with be kept at a secure location known to staff that contains a resident elopement risk profile about each resident who may be at risk for elopement. Facilities with wander alert detection systems should place a wander alert bracelet on the resident . 3.1-45(a) Based on observation, interview, and record review, the facility failed to ensure a resident was not outside smoking at a smoke-free facility and did not sign out for a leave of absence when leaving the building for 1 of 1 resident reviewed for smoking (Resident 32) and failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 3 of 3 residents reviewed for accidents (Resident 14, 21, and 32). Findings include: 1. On 10/18/22 at 4:06 p.m., Resident 32 was observed outside the facility building smoking a cigarette. She was at the edge of the parking lot almost behind a car. No staff were with her. Resident 32 indicated she was a nurse and was alert and oriented x 4 (person, place, time, and event). She was not wearing a coat and indicated she needed to have her daughter bring her one. The temperature outside was 42 degrees. She was observed going directly back into the facility. Her smoking materials were not safely stored by the facility because the facility was smoking-free according to the Director of Nursing Services (DNS) during entrance conference. On 10/19/22 at 1:31 p.m., the receptionist indicated the Leave of Absence (LOA) books were at the nurse's station. On 10/19/22 at 1:37 p.m., Licensed Practical Nurse (LPN) 10 provided the [NAME] 1 LOA book where Resident 32 resided. A review of the LOA book, including every page and the front and back flaps revealed Resident 32 did not sign out LOA. She did not have a sign-out sheet in the LOA book. On 10/19/22 at 1:51 p.m., RN 23 indicated there was only one LOA book for the [NAME] 1 halls. On 10/19/22 at 1:59 p.m., Resident 32 indicated she had not signed out LOA when leaving the building. She indicated she was in the parking lot, smoking after lunch today. She usually takes a couple of puffs and discards the cigarette. On 10/19/22 at 2:07 p.m., LPN 10 indicated she was aware Resident 32 left the unit and she only found out a week ago that she was smoking. Resident 32 did not tell the staff each time she went out to smoke. She was non-compliant with it. She didn't sign out. LPN 10 thought that if Resident 32 signed out in the LOA book and left the property it was ok if she smoked. On 10/20/22 at 3:03 p.m., Resident 32's chart was reviewed. A progress note, dated 10/19/22 at 2:51 p.m., the Director of Social Services (DSS) indicated that Resident 32 was seen outside on facility property smoking on 10/19/22. The DSS and ADNS went to the resident's room to ask if she had cigarettes. She initially said, no. When she was told she was seen smoking, she indicated she did have smoking materials. The DSS asked the resident if she would provide her cigarettes and lighter for her family to pick up. She agreed and allowed the DSS to search her belongings for additional smoking supplies. None were found. The DSS asked how she was procuring her cigarettes, Resident 32 stated she ordered them off of Amazon. She was offered a nicotine patch, she refused stating she was allergic to the adhesive. The Nurse Practitioner (NP) will order nicotine gum to assist with cravings. Her family was notified that Resident 32 had smoking supplies in building and they will need them picked up. A new care plan was created on 10/20/22 at 3:30 p.m. The problem indicated Resident 32 demonstrated non-compliance with physician orders and/or plan of care as evidenced by smoking on facility property. The goal was stated as Resident 32's preferences would be honored to the extent that non-compliance with physician orders will not result in injury to self or others. On 10/19/22 at 3:43 p.m., Resident 32's record was reviewed. She was admitted [DATE]. Her smoking status indicated she was a former smoker. Her diagnoses included, but were not limited to, osteomyelitis (bone infection) of vertebra (spine), sacral and sacrocoocygeal (sacrum and coccyx), not facility acquired stage 4 pressures ulcers of the sacral region and left hip, and other chronic pain. Her medications included, but were not limited to, baclofen (muscle spasms), Dakin's solution 0.125% (treatment for stage 4 pressure ulcers), jantoven (warfarin) 4 mg (anticoagulant), and oxycodone-acetaminophen 5-325 mg (for pain relief). On 10/19/22 at 2:13 p.m., the Assistant Director of Nursing Services (ADON) indicated he was not aware Resident 32 was a smoker. The facility had no smoking assessment or smoking care plan because they are a smoke-free facility. They will probably request the family to pick up the smoking materials. Until then, we could keep them in the med cart. Smoking could have been an issue for her because of her pressure wounds she arrived with. On 10/19/22 at 2:47 p.m., the DNS indicated Resident 32 stated she had no cigarettes or matches or lighter. Resident 32 should not have put herself and others at risk with smoking. The DNS indicated the resident should have signed-out before leaving the building. On 10/19/22 at 3:05 p.m., the DNS indicated a note was put in Resident 32's chart. The DNS indicated the resident told her, she was ordering cigarettes on Amazon. The Director of Social Services Director (DSS) searched the resident's room. The resident was offered a nicotine patch and she refused it. The facility will be ordering nicotine gum for her. It should arrive tomorrow. Her daughter was coming to take all her money and bill fold. Resident 32 indicated to the DSS that she was caught smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure enough medication was administered to manage pain resulting in harm when the resident was in acute pain and yelling out during a wound treatment for 1 of 2 residents reviewed for pain management (Resident 98). Findings include: On 10/20/22 at 9:56 a.m., Resident 98 record was reviewed. She was admitted on [DATE]. A progress note, dated 10/6/22, indicated Resident 98 was seen by the Nurse Practitioner (NP) 28 at 10:41 a.m. Her findings included, but were not limited to, the resident was seen for an initial visit related to an infected sacral wound. The resident was in the hospital due to a fall and developed the sacral wound. Went to the extended care facility (ECF) for rehabilitation, her wound got worse, she went back to the hospital but refused a surgical debridement. She was admitted to this facility with 2 intravenous (IV) antibiotics for ongoing wound care. The resident did not have osteomyelitis. Upon examination, resident indicated minimal pain, no fever, cough, or shortness of breath. On 10/9/22 at 11:47 a.m., Registered Nurse (RN) 23 charted Resident 98 had a yellow running discharge from her vagina while changing her dressing. Resident complained of pain and itching. She notified the Nurse Practitioner (NP) 28 and received orders for Diflucan (antifungal) 100 mg daily for 7 days and Nystatin (antifungal) cream. On 10/13/22 at 11:08 a.m., the DNS charted that the Interdisciplinary Team (IDT) met. The wound to Resident 98's sacrum was reviewed. Resident was admitted with a Stage 4 ulcer with osteomyelitis (bone infection). She completed all the IV antibiotics per the physician's orders. The wound continued to have moderate amounts purulent drainage. The wound bed was 75% slough (dead tissue that needs to be removed) and 25% necrosis (dead tissue). Her treatments continued with Dakin's solution (strong, topical antiseptic) and ABD pad per her physician's orders. The peri-wound was macerated (tissue broken down at the cellular level) due to very frequent loose jelly like stools. Resident continues on low air loss (LAL) mattress and multivitamins. A new order was received to give Pro-Mod (oral protein supplement) and Ensure (nutritional supplement). On 10/20/22 at 12:54 p.m., Resident 98's physician's orders were further reviewed. Starting on 10/04/22, give 1 tablet of hydrocodone-acetaminophen 5-325 mg PRN for pain 4 times a day. This order was open ended. Starting on 10/4/22, the order indicated to encourage the resident to turn and reposition while in bed three times a day from 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 6:00 a.m. This order was open ended. Starting on 10/4/22, a daily pain assessment should have been completed between 7:00 a.m. to 3:00 p.m. This order was open ended. Starting on 10/4/22, a pressure reducing mattress and pressure reducing cushion to Resident 98's wheelchair. These orders were open ended. Starting on 10/5/22, cleanse sacral wound with wound cleanser or normal saline (NS), apply skin prep to peri-wound, apply Dakin's moistened gauze and cover with island dressing as needed (PRN). Change when dressing becomes dislodged or soiled. Resident 98's diagnoses included, but were not limited to, pressure ulcer of sacral region, stage 4 (full thickness skin loss with exposed bone, tendon or muscle) (primary diagnosis), protein calorie malnutrition, type 2 diabetes (blood sugar disorder), morbid (severe) obesity due to excess calories, necrotizing fasciitis (serious bacterial infection that destroys tissue under the skin), acute candidiasis (yeast infection) of vulva and vagina and diarrhea (loose or liquid stool). On 10/20/22 at 12:39 p.m., Resident 98's care plans were reviewed. The care plans were dated 10/12/22. Resident had a sacral pressure ulcer, stage IV. The staffing approaches included, but were not limited to, administer analgesics (pain relief) per MD (medical doctors) order, assess and record the condition of the skin and surrounding skin of the pressure ulcer, observe for and report signs of pain related to pressure, encourage fluids unless contraindicated, and observe and report signs of infection (like localized pain, redness, swelling, tenderness, drainage, odor, and fever). Resident was at risk for skin breakdown related to decreased mobility, weakness, incontinence, chronic venous insufficiency (decreased blood flow), necrotizing fasciitis, and history of vaginitis. The staffing approaches included, but were not limited to, avoid shearing skin during positioning, turning, and transferring, pressure reducing mattress to the bed, pressure reducing cushion to the wheelchair, encourage and assist to turn and reposition for comfort and as needed, use moisture barrier product to perineal area as needed, float heels as needed, conduct weekly skin assessment and pay particular attention to bony prominences, keep linens clean and dry, keep resident as clean and dry as possible, minimize skin exposure to moisture, and use a lifting device as needed for bed mobility. Resident demonstrated hearing loss. The staffing approaches included, but were not limited to, hearing aids as indicated, refer to Speech Therapy for evaluation of need for communication device as appropriate, refer to physician to assess for wax buildup, and monitor for changes in hearing, refer to audiologist for a hearing evaluation as needed, ensure resident is near the activity leader/speaker during activities of interest and care-giving, use written communication as needed, and communicate with resident in a clear, concise manner. Increase volume to ensure resident receives the message. On 10/20/22 at 4:48 p.m., LPN 14 indicated Resident 98's dressing would be changed during the night due to her soiling it after a bowel movement (BM). He would be checking her around midnight. On 10/21/22 at 12:02 a.m., LPN 14 provided hydrocodone-acetaminophen 5-325 mg for Resident 98. At first, she refused. After a sip of cold water, she accepted the pain medication. He was talking loudly directly in her ear because she was hard of hearing (HOH). The resident was able to hear and understand him. He asked her to drink all the water so the medication would work faster. Resident 98's response was, please don't hurt me. She had a worried look on her face. On 10/21/22 at 12:34 a.m., LPN 14 indicated he did not do wound measurements. The wound team did the wound assessments and measurements. On 10/21/22 at 12:35 a.m., Resident Care Assistant (RCA) 29 was observed in in Resident 98's room putting on gloves. On 10/21/22 at 12:36 a.m., LPN 14 indicated he would be discarding the soiled dressings and lightly salt the wound with 4 x 4 Dakin's, then lightly pack the wound with 4 x 4 Dakin's-soaked gauze and use abdominal (ABD) pads and tape. On 10/21/22 at 12:39 a.m., RCA 29 tried to tell Resident 98 we were going to change your dressing. Resident 98 indicated she could not hear her. RCA 29 did not clarify or speak directly into her ear. She stopped talking to her. On 10/21/22 at 12:40 a.m., 12:42 a.m., 12:43 a.m., and 12:44 a.m., Resident 98 used a loud, pleading voice, Why me? LPN 14 and RCA 29 were in the room. They did not speak with her. On 10/21/22 at 12:47 a.m., Resident 98 indicated loudly, in a pleading voice, she should not have to go through this. LPN 14 was talking to her, but not in her ear. She indicated loudly, I cannot hear you. On 10/21/22 at 12:48 p.m., Resident 98 had a teary, worried expression and loudly pleaded, Lord Jesus, help me! On 10/21/22 at 12:47 a.m., LPN 14 washed his hands with no concerns and put on gloves. He told Resident 98 he was going to put the head-of-the-bed (HOB) down and turn her on her side. On 10/21/22 at 12:49 a.m., Resident 98 indicated she did not know what he was saying. As she was turned, she made loud groaning sounds. On 10/21/22 at 12:51 a.m., LPN 14 indicated to the resident, she had had a BM and he needed to clean her up. He indicated he was sorry. Resident 98 responded in a loud voice, you are not sorry. On 10/21/22 at 12:52 a.m., LPN 14 indicated the soiled dressing was, dated 10/20/22, with no time or initials. He indicated the area below her dressing was an open area of skin where her BM was, acid was eating her skin. The area was observed to be a large, raw, open skin area with several spots of blood. LPN 14 used A and D ointment for that area. Resident was openly crying now. On 10/21/22 at 12:56 a.m., LPN 14 removed the soiled dressing and washed his hands. On 10/21/22 at 12:57 a.m., after putting on clean gloves, LPN 14 used his gloved, dry gauze covered finger to wipe inside the deep area of the wound but not in the undermined areas. He did not use normal saline (NS) or wound cleanser. Resident 98 was calling out in pain. He changed gloves, did not wash his hands, and used skin prep around wound. Resident 98 was continuing to call out in pain. LPN 14 changed gloves, did not wash his hands and placed a Dakin's-soaked gauze in the wound. He used sterile cotton swabs to push the dressing up to the wound edges, but not in the undermined area. He changed gloves, did not wash his hands, and placed another Dakin's-soaked gauze in wound with sterile cotton swabs. It was pushed against the wound edges but did not enter the undermined area. He changed gloves, did not wash his hands, and placed ABD pads over the wound. He put A and D ointment on the raw, open area of skin under the ABD with a gloved finger. Resident 98 was continuing to cry out for help from Jesus. On 10/21/22 at 1:03 a.m., LPN 14 placed tape over the ABD pads. He indicated in a normal (not loud) voice to Resident 98, we are almost done and thank you for your patience. He did not talk in her ear. She did not respond. He was observed dating the dressing. He used scissors, there was no observation of them being cleaned, to cut the tape slightly at the distal mid-portion nearest to the rectum. He indicated he used alcohol wipes or sanitizer wipes to clean the scissors if we have them. He indicated those were his personal scissors and he was observing leaving them in the gauze squares box. On 10/21/22 at 1:05 a.m., LPN 14 and RCA 29 placed a clean disposable brief on Resident 98. When she was turned from side and side, she continued to call out in pain. The staff continued to reposition and re-centered her on the bed. On 10/21/22 at 1:09 a.m., LPN 14 indicated to the resident, we are going to pull you up in bed now. Resident 98 indicated loudly, what are you saying? He did not speak into her ear. After she was pulled up in bed, she called out loudly, how long Lord? On 10/21/22 at 1:11 a.m., LPN 14 was observed to clean his scissors in the resident's bathroom with water only. He placed them in the gauze squares box with the 4 x 4s. Then washed his hands. On 10/21/22 at 10:51 a.m., Resident Care Assistant (RCA) 15 indicated she was finishing a bed bath for Resident 98. She indicated when she turned Resident 98 to clean her back, she was screaming. On 10/21/22 at 10:38 a.m., the Assistant Director of Nursing Services (ADNS) indicated Licensed Practical Nurse 14 was probably trying to hurry with the sacral wound dressing change because the Resident 98 was in pain and did not take the time to clean or dress the undermined portions of the wound. On 10/25/22 at 4:50 p.m., NP 28 indicated Resident 98 refused surgical debridement when she was at the hospital, prior to coming to the facility. She had no report from the staff that the resident had been uncomfortable or in pain with dressing changes. She discontinued the order for scheduled Tylenol. She talked to Resident 98's daughters frequently. They had not reported she was in pain; we can increase her Norco to 2 pills prior to a dressing change. The staff could have reviewed the planned procedure into the resident's ear for her understanding before doing the dressing change. NP indicated she talked with the resident frequently. On 10/25/22 at 7:25 p.m., the Medical Director indicated while Resident 98 was in the hospital, the surgical team wanted to debride her wound, but the resident refused. She had a complicated wound and may not survive it. We relied on wound care experts because she had necrotizing fasciitis (serious bacterial infection that destroys tissue under the skin). He believed her to have hyper-responses to pain, but the pain medications had room to be increased for possible pain relief. For this wound, she would almost need conscious sedation (combination of medicine to help her to relax, a sedative, and to block pain, an anesthetic) to change the dressing without pain. Long term acute care might a better option than long term care. On 10/26/22 at 1:13 p.m., NP 28 indicated she discontinued the scheduled Tylenol per Resident 98's family request and had now increased the dose of scheduled Norco from, 5/325 mg to 7.5/325 mg four times a day. The family had wanted the Norco to be PRN (as needed) because when she took it in the hospital, she was loopy. The resident indicated she had pain with the dressing change. Scheduled Tylenol twice a day with Norco 30 min prior to twice a day dressing changes. If it is a PRN dressing change, then give Tylenol 30 minutes prior to the dressing change. The daughter indicated her mom complained of pain, but not severe. She believed the Resident's pain was mostly when she was moved or turned. She indicated she had not been in the resident's room during a dressing change. A current policy, titled, Dressing Changes, dated 5/11/22, was provided by the ED, on 10/24/22 at 12:02 p.m. A review of the policy indicated, .To ensure measure that will promote and maintain good skin integrity while maintaining standard measures that will minimize/control contamination .Dispose of gloves in plastic bag or trash can. Wash hands with soap and water .If using scissors make sure, it is clean with antiseptic after contact with soiled dressings. Remove gloves and discard. Wash hands with soap and water 3.1-37(a)