Every finding on record at Accura Healthcare of Cherokee, LLC

Based on observations, resident and staff interviews and policy review the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 39 residents. Findings include:1. Interview on 01/06/2026 at 10:48 a.m., Resident #1 stated that he eats his meals in his room and the food is half-ass warm when it comes. He further revealed this happens all the time.2. Interview on 01/05/2026 at 12:45 p.m., Resident #28 revealed she eats her meals in her room and the food is always cold when it arrives to her room. 3. During an ongoing observation on 01/07/26 at 12:22 p.m., the Dietary Manager (DM) dished the room trays in the kitchen and covered the plate. Staff immediately took the room trays to the residents' rooms and delivered them. After the last room tray was served the food temperatures were taken and were as follows:a. Apple Pork Chop- 110 degrees Fahrenheit (F)b. Squash- 116 degrees Fc. Mixed Vegetables- 115 degrees F Review of the facility provided policy titled Food Temperatures dated 2021 revealed the following information: All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 F.Temperatures should be taken periodically to assure hot foods stay above 135 F during the serving process.Interview on 01/07/26 at 12:27 p.m., with the DM revealed it is hard to keep the food on the room trays hot but it should be hot. Interview 01/07/26 at 12:36 p.m., with the Administrator revealed the food should be served at the proper temperatures.

Based on observations, staff interviews and policy review the facility failed to treat residents in a kind and respectful manner ensuring the resident's rights were met for 4 of 8 residents reviewed (#3, #8, #10 and #12). The facility reported a census of 39 residents.Findings include:Observation on 1/7/26 at 8:20 AM showed Staff A, Certified Nursing Assistant (CNA) stood over Residents #8, #10 and #12 while she assisted them to eat breakfast. Observations on 1/8/26 at 8:03 AM showed Staff B, CNA stood over Resident #3 while she assisted Resident #3 to eat breakfast. The Dining Experience policy dated 2021 identified staff will sit next to a person when assisting them with eating rather than standing over them.In an interview on 1/8/26 at 8:24 AM, when asked if she noted any concerns while in the dining room during breakfast on 1/7/26, the Administrator stated, the CNA stood over the residents while helping them to eat. The Administrator reported she gave verbal education to staff. When asked if she knew Staff B stood over Resident #3 this AM, the Administrator stated, no, I can't believe she did it this morning when I already talked to them about it.

Based on observation, infection control policy, and staff interview, the facility failed to use universal infection control policies with all residents during meal service for 3 of 8 residents reviewed (Residents #8, #10 and #12). The facility reported a census of 39 residents. Findings include:Observation on 1/7/26 at 8:20 AM showed Staff A, Certified Nursing Assistant (CNA) assisted Resident #8, #10 and #12 with breakfast. Staff A alternated assistance between residents, using each resident's utensils and handling drinking cups without performing hand hygiene between residents.The Hand Hygiene policy last updated 11/13/24 identified Staff should always complete hand hygiene: (list is not all inclusive) d) After handling contaminated items and equipment such as, dressings, and secretions and excretions from residentsf) When every our hands become physically soiled h) Before eating, drinking, or handling food.In an interview on 1/8/25 at 8:24 AM, the Administrator reported observing Staff A assist residents in the dining room during breakfast on 1/7/26 without performing hand hygiene. When asked whether staff should perform hand hygiene between assisting residents with eating, the Administrator stated she expected hand hygiene to occur and indicated she provided Staff A with a bottle of hand sanitizer.

Based on clinical record review, resident interviews, family interviews, staff interviews, and policy review the facility staff failed to interact with residents in a kind and considerate manner during cares for 2 of 5 residents (Resident #1, and #5) reviewed. The facility reported a census of 33 residents.Findings include: 1. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 Indicating moderate cognitive impairment. Interview on 10/28/25 at 2:05 PM with Resident #1 revealed that she could recall something had happened several months ago, but she could not recall the names of the staff and didn't want to say someone was mean and call them by the wrong name. 2. Review of Resident #9's MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. Interview on 10/28/25 at 9:30 AM with Resident #9 revealed that Staff B Licensed Practical Nurse (LPN) does not treat him with dignity and respect. Resident #9 further revealed that Staff B needs to work on their attitude. Review of a facility provided document titled, CNA meeting dated 8/27/25 documented:Complaints:1. Call lights2. Watch what you are saying to residents-just wet the bed.3. Nightshift can get people up. Review of a facility provided document titled, Annual Employee Performance Evaluation dated 7/8/25 for Staff C revealed:1. Staff C does not accept coaching with a positive outlook, this needs improvement. Review of Staff B and Staff C's personnel files revealed no disciplinary action related to speaking to residents with dignity and respect. Interview on 10/27/25 at 10:55 AM with Staff A LPN revealed that Resident #1 had told her that Staff B LPN does not listen to her. Staff A further revealed that Resident #1 had told her that Staff B and Staff C Certified Nursing assistant (CNA) had told her just to pee herself and then they would clean her up. Staff A then revealed that these issues have been brought to management, and nothing has been done. Interview on 10/28/25 at 8:47 AM with Staff D CNA revealed that she had heard hearsay that staff had asked residents to urinate on themselves and that they would clean it up. Staff D further revealed Resident #9 had a lot of complaints about Staff B, and that grievances had been filled out. Staff D stated while getting report the past weekend that Staff B had stated Resident #9 had hit his call light three times wanting to get up and Staff B stated she was making a point to wait until the morning shift got Resident #9 up. Staff D revealed that she had also heard Staff B, and Staff C were taking resident's call lights away from them. Staff D stated Staff E CNA was about to quit related to nothing being done with Staff B, even with it being turned into management. Interview on 10/28/25 at 9:09 AM with Staff F CNA revealed that Staff B would sometimes come across as rude with her tone. Interview on 10/28/25 at 10:21 AM with Staff G LPN revealed that she had heard of Staff C not answering call lights. Staff G further revealed that she has heard these complaints have gone to the management team. Interview on 10/28/25 at 12:30 PM with Staff C revealed that she had heard Staff B tell Resident #1 to just go ahead and pee yourself, and that they would clean Resident #1 up afterwards. Staff C stated that there was a staff meeting about staff to staff and staff to resident interactions about how they talk to one another. Interview on 10/28/25 at 2:20 PM with the Director of Nursing (DON) revealed that staff and a family member stated that a CNA had taken the call lights from a resident. The DON stated she went and talked with the family member and the staff. The DON further revealed that she did a follow up visit with the family member. The DON revealed it is a concern if staff were telling residents to urinate themselves, and this would be a dignity issue. The DON then revealed that she does get complaints about the gruffness of Staff B.Interview on 10/28/25 at 3:05 PM with Staff B revealed that she had never heard of any staff withholding call lights from residents. Staff B stated she had heard through a day shift staff member that Staff C had told a resident to go ahead and urinate on themselves and that they would clean that resident up afterward. Staff B heard that it happened on a shift they were working, but did not witness or hear Staff C say this. Interview on 10/29/25 at 1:39 PM with Staff E CNA stated during an all staff meeting on 8/27/25 that it was brought up that Staff B and Staff C made Resident #1 urinate in her bed. Staff E further revealed that Staff B and Staff C had moved the call light out of Resident #1's reach. Follow up interview on 10/29/25 at 1:50 PM with the DON revealed that she conducted the meeting on 8/27/25. The DON stated that there were issues with the night shift not getting residents up as often as they should. The DON then revealed that there was an incident where she was told that one of the CNAs took a resident's call light away. The DON stated she was never told which CNA it was as the complaint came from a resident's daughter. The DON confirmed this was for Resident #1. The DON revealed the resident's daughter had reported the complaint to her on the 23rd or 24th of October. The DON revealed that this was not filled out in a grievance form, and that the daughter was upset about the situation. The DON reported that she offered to come in and talk to the daughter, and the daughter did not want to talk at that time. The DON further reported she came in the next nightshift, and no staff could give her an answer as to what happened. The DON stated that none of the nightshift staff would admit it was them. The DON then reported that most of the complaints on Staff B are related to poor bedside manners. The DON stated she had reports that Staff B is rough around the edges. The DON further revealed that she has talked with Staff B multiple times about how Staff B is very dry, and direct when talking to the residents. Interview on 10/29/25 at 2:18 PM with the Administrator revealed that she was present for the meeting on 8/27/25. The Administrator then reported that the call light issue in the meeting was that a staff member did not give the call light to a resident for them to use, and the Administrator thought this was related to Resident #1. The Administrator then revealed this call light issue was related to the evening/overnight shift. The Administrator stated it was reported to her by the DON that staff had encouraged a resident to be incontinent, and that staff would come back and clean them up. The Administrator further revealed there were no particular staff brought up with the concern. The Administrator stated that her understanding was that when the DON investigated the issue with the call light and wetting the bed they were unable to determine which staff member it was that was being accused. Interview on 10/29/25 at 4:10 PM with the DON, and the Administrator revealed that their expectation would be for residents to be treated with dignity and respect at all times. Interview on 10/30/25 at 8:58 AM with Resident #1's family member revealed that Resident #1 told them about being told to urinate in the bed, and taking the call lights away from her. The family member then revealed it was taken care of, and it had never happened again. The family member revealed that the facility addressed it with the staff, and it was taken care of. Review of a facility provided policy titled, Promoting/Maintaining Resident Dignity dated 1/30/24 revealed: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure residents with impaired cognition were unable to exit the facility unattended for 1 of 4 residents reviewed for elopement (Resident # 1). This failure resulted in the resident leaving the facility without staff knowledge and therefore causing an Immediate Jeopardy to the health, safety, and security of the residents. The facility failed to ensure residents needing a mechanical lift were provided safe and appropriate transfers to prevent injuries for 4 of 4 residents reviewed (Resident # 2, #5, #6 & #7). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 17, 2024 on December 17, 2024 at 9:17 a.m The Facility Staff removed the Immediate Jeopardy on October 17, 2024 through the following actions: a. The facility floor nurse checked all facility windows and doors in the chronic confusion or dementing illness (CCDI) unit (memory care unit) and all were intact and working properly. b. Frequent checks were initiated on Resident #1. c. Administrator conducted a door alarm check, and all doors and alarms were working properly. d. Administrator reviewed elopement binder was current. e. Administrator completed education on the facility elopement policy. f. Administrator changed all facility door codes for exits and CCDI unit. g. Administrator initiated a sign off sheet for facility floor nurses to conduct door alarm checks at shift change. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 36 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of Alzheimer ' s Disease, psychotic disorder and Schizophrenia. The MDS showed a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the assessment. Review of progress notes revealed the following: a. 10/17/24 at 6:50 a.m., Staff member in the parking lot calls facility stating someone was coming around the south side of the building. Staff exits to assess the situation. Noted that this resident was outside. Staff times 2 assisted resident back into the building and back to the CCDI unit. No injuries noted. Frequent checks by staff initiated. b. 10/17/24 at 9:50 a.m., Reported patient was observed outside of the facility around 6:15 a.m Facility unsure exactly how she eloped and continuing to review the incident. c. 10/17/24 at 10:01 a.m., Nurse was notified Resident #1 was outside this morning just after shift change. Assessment completed. Head to toe assessment completed no redness or bruising noted, no open areas noted, no areas of concern at this time. Resident #1 was dressed appropriately for the cool weather with two pairs of pants, socks, tennis shoes, t-shirt, sweatshirt and winter coat. When asked if she was in any pain she responded no. When asked if she fell down she responded no. When asked how long she was outside she reported a little bit. When asked which door she went out she stared straight forward and would not respond each time she was asked. Frequent observation checks were initiated upon return to the facility. Proper authorities were notified and all involved staff were asked to provide statements. Hospice and primary care physician updated no new orders noted at this time power of attorney notified d. 10/18/24 at 1:43 p.m., Resident remains on frequent checks due to elopement that occurred on 10/17/24. Review of the MDS dated [DATE] revealed Resident #1 did not use a wander or elopement alarm. Review of elopement risk assessment dated [DATE] revealed Resident #1 high risk for elopement. Review of the care plan with a date initiated 7/24/24 revealed a focus area of resident is an elopement risk related to disorientation to place, wandering, confusion, Alzheimer ' s Disease, dementia, Schizophrenia, and psychosis. Resident #1 resides in the CCDI memory unit. She is orientated to self. She talks about wanting to go home. The CCDI unit has a locked door to the main nursing home side. Goals include the resident ' s safety will be maintained through the review date and the resident will not leave facility property unattended through the review date. Interventions and tasks include assess for fall risk, distract resident from wandering by offering , structured activities, food, conversation, television and books. identify patterns of wandering. Provide structured activities to include toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Interview on 12/16/24 at 10:20 a.m., with the Director of Nursing (DON) revealed she was informed at approximately 7:00 a.m., on 10/17/24 that Resident #1 had eloped from the facility. The DON explained the night shift staff had witnessed the resident outside as they left the building and notified the day shift. The DON arrived shortly after the incident and completed an assessment on Resident #1 with no injuries noted. Resident #1 was wearing 2 pairs of pants, a long sleeve shirt and sweatshirt over that. The DON revealed the resident may have been holding her winter coat while she was outside. The DON further revealed the staff working that night received disciplinary action as they had propped open the doors to the CCDI unit and now the doors are programmed to alarm if the door is open longer than 15 seconds. Review of written statement by Staff A, Licensed Practical Nurse (LPN) revealed the staff did have the door propped open a few times in the night, but this nurse could see up and down the hallway and into the living room at those times. No one was wandering but there were a lot of behaviors during the night. Interview on 12/16/24 at 11:30 a.m., with Staff A, LPN revealed she was working the night Resident #1 got out of the facility. Staff A revealed the staff had propped the door open but she was sitting where she could see what was going on in the CCDI unit the entire time. She revealed she never seen Resident #1 leave out of the CCDI unit. She is still unsure how Resident #1 got out of the facility that night. Staff A revealed the facility staff would prop the door open on the CCDI unit as the staff felt like they were confined in the CCDI unit and they didn ' t like that feeling. She further revealed she received disciplinary action for propping the doors open to the CCDI unit and the door alarms were changed so they can no longer prop the doors open. Review of written statement by Staff B, Certified Nursing Assistant (CNA) revealed the door was propped open throughout the night here and there but the nurse was aware and could see the hallway, living room and dining area in the CCDI unit. Stated there had been several behaviors occurring that night. Staff B verified she las checked on Resident #1 was approximately 5:50 a.m., and Resident #1 was in her room. Review of written statement dated 10/18/24 at 1:30 p.m., by Staff C, CNA revealed Staff C began to explain that they were confused as to how Resident #1 had left the unit. Staff C asked Staff B if the secured door to the CCDI unit was propped open at all. Staff B responded yeah, but just while she took the trash out. Staff C informed the charge nurse of the door being propped open for a short time and that Staff C was initiated frequent checks on Resident #1. Review of facility provided policy titled Missing Resident Elopement Process updated 7/12/2021 revealed the following information: a. If for any reason, door alarms are turned off, the staff will continually visually monitor the door or doors. b. When a resident is located, the following procedures will be followed: i. An incident report will be reviewed at monthly safety committee meetings and each quarter with the Quality Assurance Committee. c. Education and Training- all staff will be educated on proper identification, assessment, and treatment of residents identified as an exit seeking risk. This education will occur during orientation and annually thereafter. Interview on 12/16/24 at 12:22 p.m., with the Administrator revealed the doors to the CCDI unit should have never been propped open. Staff working that night when the resident eloped received disciplinary action for propping the doors open. 44420 2. The Care Plan for Resident #2 showed on 3/25/21 the facility initiated resident requires assist of 2 staff with hoyer lift for toileting and transfers. The Progress Note dated 10/22/2024 at 12:40 PM for Resident #2 documented the following: The CNA (Staff G, CNA) was transferring resident from wheelchair to bed via hoyer by self. States she had the sling hooked up to hoyer properly, lifted resident in air, heard a pop, one of the loops got unhooked and resident fell out of sling to floor. The Employee Corrective Action Form showed on 10/23/24 Staff G, CNA received a written warning. The form documented the following: Incident/Infraction: On 10/22/24 you provided a transfer with a patient lift independently, in result the resident slipped out of the lift. Per facility policy the resident handling/transfer, it is the responsibility to ensure that an employee is preventing or minimizing the risk of injury to the resident or employee. Two staff members must be utilized when transferring residents. Expectations Moving Forward: Employee will follow the facility mechanical lift policy and ensure that resident safe handling/transferring is being followed by having a second person assisting when providing any resident transfer. In an interview on 12/16/24 at 12:02 PM, the Administrator reported they were unsure how Resident #2 fell from the hoyer. They thought it was because the sling was not placed all of the way around the hook. 3. The MDS assessment dated [DATE] for Resident #5 documented diagnoses of spinal stenosis, weakness, chronic pain, and signs of cognitive functions and awareness. The MDS showed a BIMS score of 12, which indicated moderate cognitive impairment. The MDS identified Resident #5 with limitation in movement and impaired range of motion to lower body. The MDS also showed Resident #5 dependent on a helper for all efforts when repositioning and for transfers. The Care Plan for Resident #5 showed on 12/4/24 the facility initiated use of a mechanical lift with assistance of two persons for toileting and transfers. Observation on 12/16/24 at 11:51AM revealed Staff D, Certified Nurse ' s Aide (CNA), and Staff E, CNA used a EZ Way Mechanical lift to transfer Resident #5 from the bed to the wheelchair. Staff D locked one wheel of the mechanical lift before she used the mechanical lift controller to raise the resident out of the bed. Staff also failed to lock the wheelchair brakes before lowering the resident down into the wheelchair from the mechanical lift. Failure to lock the brakes caused the wheelchair to roll back as the lift lowered the resident into the wheelchair. Staff E attempted to steady the wheelchair by placing her body against the wheelchair. 4. The MDS assessment dated [DATE] for Resident #6 documented diagnoses of a stroke, dementia and unsteadiness on feet. The MDS showed a BIMS score of 6, which indicated severe cognitive impairment. The MDS also showed Resident #6 dependent on a helper for all efforts when repositioning and for transfers. The Care Plan for Resident #6 showed on 8/15/23 the facility initiated use of a mechanical lift with assistance of two persons for transferring the resident between surfaces. On 12/4/24 the facility initiated use of a mechanical lift with assistance of two persons for toileting. Observation on 12/16/24 at 12:19 PM revealed Staff D, Certified Nurse ' s Aide (CNA), and Staff E, CNA used a EZ Way Mechanical lift to transfer Resident #6 from the bed to the wheelchair. Staff D locked two wheels of the mechanical lift before she used the mechanical lift controller to raise the resident out of the bed. Staff E also locked two brakes of the mechanical lift before she lowered the resident into the wheelchair. 5. The MDS assessment dated ,d+[DATE] for Resident #7 documented diagnoses of difficulty in walking, dementia, and disorientation. The MDS showed Resident #7 unable to complete a cognitive assessment. The MDS also showed Resident #7 dependent on a helper for all efforts when repositioning and for transfers. The Care Plan for Resident #7 showed on 8/18/23 the facility initiated use of a mechanical lift with assistance of two persons for transferring the resident between surfaces. Observation on 12/16/24 at 12:42 PM revealed Staff D, Certified Nurse ' s Aide (CNA), and Staff E, CNA used a EZ Way Mechanical lift to transfer Resident #7 from the bed to the wheelchair, and weighed the resident using the lift scale. While Staff D and Staff E placed a sling beneath the resident, Staff D stated, I know the sling is way too big. Staff placed the mechanical lift, attached the straps, and locked two wheels then used the controller to raise the resident out of bed. When lifted off the bed observation showed the beginning of the crossed webbing of the sling exceeded the top of the resident ' s head. Staff noted the scale indicated the resident weighed 164.4 pounds (Ibs). When the resident ' s placement reached over the center of the wheelchair, Staff E locked two brakes of the mechanical lift then lowered the resident. The extra material of the sling caused the resident to be positioned improperly within the sling which required staff to manipulate the resident ' s position in order to sit properly within the wheelchair. When asked how staff knew what size sling to use, the CNA ' s indicated the sling size would need to be looked up. Visual observation of the EZ Way sling tag indicated the sling as an extra large. When asked if Resident #7 required an extra large sling, both CNA ' s reported they did not know. When asked about Staff D ' s comment of the sling being too big, Staff E stated it was the only one left. When asked if sling sizes were often an issue, Staff E stated, yes we don ' t have enough sizes especially after the laundry staff leave. In an interview on 12/16/24 at 2:23 PM, the Administrator reported staff could look up the proper size sling by reviewing the lift binder. The EZ Way Smart Lift Operator ' s Instructions last revised on 10/24/24 indicated: a. The wheels of the lift should never be locked when lifting or lowering a resident. b. When lowering a resident into a wheelchair, the wheels of the wheelchair should be locked. c. A medium size sling is required for residents weighing between 90 and 220 Ibs. d. An extra large sling is required for residents weighing between 280 and 450 Ibs. e. The start of crossed webbing of the sling is positioned at the nape of the neck. In an interview on 12/16/24 at 3:32 PM, Staff F, Registered Nurse stated, I was always taught mechanical lift wheels should be locked when lifting and lowering a resident. The Administrator reported staff recently received education related to mechanical lifts due to a mechanical lift incident involving a resident. The Administrator revealed the education failed to include information about mechanical lift and wheelchair locks during transfers. The Administrator reported the facility used lifts from different manufacturers and expected staff to follow the lift operator ' s instructions for the brand of lift used. The Administrator also reported that she planned to purchase additional slings, attach sling weight information for sizing directly to the lifts, and educate staff on sling size and wheel lock information.

Based on observation, infection control policy and staff interview, the facility failed to initiate a legionella water program for the facility. The facility reported a total census of 34 residents. Findings include: Interview on 10/9/24 at 1:13 p.m., with Staff A, Maintenance Director revealed he did not do any testing or monitoring of the program. He only checks water temperatures once a week. Review of facility provided policy titled Legionella undated revealed the facility will utilize sound clinical and infection control practices to quickly identify and treat any potential Legionnaires' related illnesses. Sound engineering, preventive maintenance and housekeeping practices will be utilized to minimize the risk of exposing residents and team members to the legionella bacteria. The following information under Minimizing Growth of Legionella in Domestic Water System included: a. Flush toilets and run faucets for a minimum of 30 seconds in all vacant resident rooms periodically(monthly) b. For resident rooms, or other rooms with plumbing fixtures that are used for offices and or storage, flush toilets and run faucets and shower heads for a minimum of 30 seconds periodically (monthly). Interview on 10/9/24 at 1:55 p.m., with the Administrator revealed the facility should be following the policy and flushing toilets and running water.

Based on record review, resident and staff interviews and facility policy review the facility failed to provide physician ordered leg wraps for edema for 1 of 1 resident reviewed, (Resident #21). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 documented diagnoses of lymphedema, cellulitis and obesity. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Interview on 10/9/24 at 1:22 p.m., with Resident #21 revealed he has not had any wraps on his legs for the swelling. Resident #21 stated the facility had put some other kind of edema stuff on his legs but he was not able to use that anymore as that was too tight and pushed all the edema up into his knee area. He has been trying to keep his legs up when he is sitting in his chair. Review of a signed Physician Order dated 10/4/24 revealed an order for ace wraps bilaterally from toes to knees placed daily on and removed as needed or bedtime. Review of Resident #21's Progress Notes revealed the following: a. On 10/4/24 at 3:58 p.m., revealed order received from Nurse Practitioner to apply ace wraps to bilateral lower extremities (BLE) from toes to knees. On in the morning and off at bedtime. b. On 10/5/24 at 8:50 a.m., ACE wraps BLE toes to knees two times a day for edema- not available. c. On 10/5/24 at 10:43 p.m., ACE wraps BLE toes to knees two times a day for edema- not available. d. On 10/6/24 at 6:37 a.m., ACE wraps BLE toes to knees two times a day for edema- on order from the pharmacy. e. On 10/6/24 at 10:19 p.m., ACE wraps BLE toes to knees two times a day for edema- not available. f. On 10/7/24 at 12:47 a.m., noted that edema wear is too tight on resident legs. Edema pushed up to the resident knee with tight, hard edema. Resident instructed to not put it on tomorrow and see how it goes. BLE continues red and warm to the touch, resident complain of pain when they are down. g. On 10/7/24 at 9:26 a.m., ACE wraps BLE toes to knees two times a day for edema- not available. h. On 10/8/24 at 6:32 a.m., ACE wraps BLE toes to knees two times a day for edema- on order from the pharmacy. i. On 10/8/24 at 10:17 p.m., ACE wraps BLE toes to knees two times a day for edema- not available. j. On 10/9/24 at 9:45 a.m., ACE wraps BLE toes to knees two times a day for edema- ace wraps not here yet. Review of Resident #21's October 2024 Treatment Administration Record (TAR) revealed the following information: a. ACE wraps to bilateral lower extremities toes to knees two times a day for edema with a start date of 10/4/24. b. The TAR revealed the ACE wraps were not available on 10/5/24-10/7/24 and 10/8/24-10/9/24. Interview on 10/9/24 at 1:39 p.m., with Staff B, Registered Nurse revealed the order the facility received for Resident #21 was for ace wraps on his legs and they should have been on. Staff B further revealed the wraps have been given to the nurse and education provided and the staff will be putting them on the residents legs today.

Based on clinical record review and staff interview, the facility failed to refer a resident with a negative Level I result for the PreAdmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 2 out of 2 residents (Resident #6 and #14) reviewed for PASRR requirements. The facility reported a census of 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses anxiety disorder, depression and psychotic disorder. The MDS included a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Review of the active diagnosis list in the clinical record revealed the following diagnoses; a. Anxiety disorder, b. Major depressive disorder, c. Delusional disorders. The clinical record lacked an updated PASRR to include delusional disorders or psychotic disorder. Interview on 10/08/24 at 12:39 p.m., with Staff B, Registered Nurse (RN) revealed the delusional disorder should have been on the PASRR. 44420 2. The The MDS assessment dated [DATE] for Resident #14 documented diagnoses of Major Depressive Disorder, dementia and stroke. The MDS included a BIMS score of 5 indicating severe cognitive impairment. Review of the active diagnosis list in the clinical record revealed the following diagnoses; a . Major Depressive Disorder, c. dementia. Review of the Physician's Orders showed Seroquel for tearfulness/paranoia related to dementia with other behavioral disturbances. The clinical record lacked an updated PASRR to include Major Depressive Disorder, dementia and Seroquel.

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 36 residents. Findings include: 1) During initial tour of the kitchen on 7/10/23 at 10:47 a.m. the Dietary Supervisor (DS) worked in the kitchen. The following were noted: a. A stainless steel table where the robo coupe sat had multiple papers and binders with crumbs around and under the items. b. The shelf underneath had pans sitting upside down on it and the shelf had a dusting of a white substance. c. The door by the freezer had dirt and grit around the baseboard and the bottom of the door frame on both sides. d. Vinyl baseboard loose and not adhering to the wall intermittently from the doorway of the store room around to the area where the 3 compartment sink sat. e. The storeroom had a white sheeting on the shelves that appeared to be worn in places and unsanitizable. Some areas where items sat were sticky. f. The top of the hand washing trash receptacle was dirty. g. The oven hood did not appear to be free of grease, and the dietary supervisor said it looked like it needed some attention. On 7/12/23 after the noon meal service the DS got a flashlight to better visualize the stove hood. It revealed a thick buildup of grease throughout. The DS stated since they had someone cleaning it she didn't think about it and never looked up. On 7/13/23 at 10:14 a.m. the Administrator stated she had not looked at the stove hood. She provided a bill showing the hood cleaned 4/20/23. She said they could have it cleaned more often if necessary. On 7/13/23 at 11:20 a.m. the DS had cleaned the kitchen hood and said she had to scrub it to get it clean. It then appeared free of grease. A Fire Suppression Systems: Hoods and/or Rooms report dated 2/13/23 documented inspection of the kitchen hood. The hood was last steam cleaned 10/2022 and was free of a buildup of grease. An invoice with a service date of 4/20/23 indicated the kitchen hood exhaust system, 1 fan, duct work, 1 hood inside and out were cleaned. Due to revised EPA regulations, they no longer cleaned filters. They recommended putting them in the dishwasher or handwashing in a dish sink. A Kitchen Hood Exhaust System Cleaning report documented the next service (not) due (until) November 2023. 2. On 7/12/23 at 11:34 a.m. Staff C Dietary Aide (DA) had her front hair out of the hair net. She also wore a thick band of bracelets on each wrist and several rings, one larger and more protruding. On 7/12/23 at 12:01 p.m. the DS started serving in the main dining room. The DA assisted with the noon service with the front of her hair hanging out of the hair net. The 2017 food Code included: 4-202.18 Filters or other grease extracting equipment should be designed to be readily removable for cleaning and replacement if not designed to be cleaned in place. 2-402.11 Food employees should wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covered the body hair, that were designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens; and unwrapped single service and single use articles. 2-303.11 Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.

Based on observation, facility record review, resident and staff interview, the facility failed to review and revise the plan of care for 2 of 14 residents reviewed (Residents #13 & #30). The facility reported a census of 36 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #13 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident had moderate cognitive impairment. The MDS also documented Resident #13 had diagnoses of peripheral vascular disease (narrowing or blockage of blood vessels), stroke, pseudomonas (a type of bacteria), ulcerated varicose veins, cellulitis (skin infection), and chronic venous insufficiency (damage to leg veins). Observation on 7/10/23 at 11:10 AM revealed a sign hung on Resident #13 ' s door indicating that she was on Transmission Based Precautions (TBP) and a plastic storage cart with a bottle of hand sanitizer and box of gloves on top and isolation gowns, and wound supplies in the drawers. Observation on 7/10/23 at 12:30 PM revealed Resident #13 sitting in her wheelchair at a table in the dining room with 3 other ladies finishing lunch. Clinical record review of resident ' s Progress Notes revealed the following: On 5/31/23 staff educated the resident on the contradiction of using Imodium with C-difficile (a bacteria that causes diarrhea). On 6/6/23 staff received signed lab orders from the physician indicating that the stool sample was positive for C-difficile. Review of the readmission Care Plan with an initiation date of 6/29/23 failed to identify a problem focus area or directives to address the resident having C-difficile and being on TBP. In an interview with the consultant Director of Nursing (DON) on 7/13/23 at 1:05 PM stated that he would expect that the care plan would have been updated immediately on learning resident was C-diff positive. 2. The MDS assessment dated [DATE] for Resident # 30, documented diagnoses of anemia, hypotension (low blood pressure), depression adrenocortical insufficiency (not enough of certain hormones), pulmonary embolism (blood clot in lung), acute respiratory failure, weakness, diarrhea, and abnormal weight loss. Review of residents clinical record Skin Assessments revealed the following: On 5/23/23 documentation of 1cm x 1cm shearing wound to right buttock that was first noted 5/16/23. A check mark that the care plan was current and up-to-date with wound interventions. On 5/30/23 documentation of 0.5cm x 1.6 cm shearing wound to right buttock. There was a check mark that the care plan was current and up-to-date. On 6/6/23 documentation of 0.5cm x 1.6 cm shearing wound to right buttock. There was a check mark that the care plan was current and up-to-date. On 6/13/23 documentation of 1cm x 2 cm shearing wound to right buttock. There was a check mark that the care plan was current and up-to-date. On 6/20/23 documentation of 0.5cm x 2.2 cm shearing wound to right buttock. There was a check mark that the care plan was current and up-to-date. On 6/27/23 documentation of 0.5cm x 2.2 cm shearing wound to right buttock. There was a check mark that the care plan was current and up-to-date, and the physician was contacted for new orders. On 7/11/23 documentation of 0.2cm x 1cm shearing wound to right buttock. There was a check mark that the care plan was current and up-to-date. There was also documentation that the physician was contacted with an update of some improvement noted to the area, however, a new area on his lower right buttock has developed. Review of residents clinical record Progress Notes revealed the following: On 6/14/23 open area on right buttock from shearing is getting worse. Resident sits in his recliner all the time and refuses to sleep in his bed. No signs or symptoms of infection noted. Fax sent to physician to get order for Tegaderm foam dressing. On 6/20/23 the wound is stable. Physician notified of status and request for new treatment orders. On 6/27/23 the wound is in decline and physician notified of status and request for new treatment orders. Resident has 3 new open areas on his right buttock due to shearing and 1 on his left buttock. Review of residents clinical record Orders revealed the following: Tegaderm foam to right buttock, change every Tuesday, Friday and PRN with start date of 6/16/23 and end date of 6/29/23. Cleanse wounds on buttocks with wound wash, apply skin prep and cover with foam dressing every Tuesday and Friday with a start date of 6/30/23. Review of residents Care Plan, with a revision date of 4/30/23 revealed a focus area of potential impairment of skin integrity due to fragile skin, weakness, incontinence and lack of mobility. The goal was to maintain or develop clean and intact skin by target date of 7/31/23. The care plan lacked documentation of resident ' s wounds and changing treatments. In an interview with the consultant Director of Nursing (DON) on 7/13/23 at 1:05 PM he stated that he would expect that the care plan would have been updated with wound changes and treatments as they occurred.

Based on observations, staff interviews, Centers for Disease Control and Prevention (CDC), and policy review, the facility failed to follow the standards of care for providing proper care of 1 of 1 residents reviewed (Resident #13) with Clostridioides difficile (C.diff). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #13 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident had moderate cognitive impairment. The MDS also documented Resident #13 had diagnoses of peripheral vascular disease (narrowing or blockage of blood vessels), stroke, pseudomonas (a type of bacteria), ulcerated varicose veins, cellulitis (skin infection), and chronic venous insufficiency (damage to leg veins). Observation on 7/10/23 at 11:10 AM revealed a sign hung on Resident #13 ' s door indicating that she was on Transmission Based Precautions (TBP) and a plastic storage cart with a bottle of hand sanitizer and box of gloves on top and isolation gowns, and wound supplies in the drawers. Observation on 7/10/23 at 12:30 PM revealed Resident #13 sitting in her wheelchair at a table in the dining room with 3 other ladies finishing lunch. In an interview on 7/11/23 at 9:50 AM, the resident stated staff wear gowns and rubber gloves when caring for her. When asked about washing their hands, the resident stated she thinks that they mostly use hand sanitizer. In an interview on 7/11/23 at 12:30 PM Staff B, housekeeping stated he was not really doing anything different to clean Resident #13 ' s room. He stated he used a disinfectant that they have been using since COVID and that it is used in all the rooms. Review of facility document titled Clostridium Difficile (C. Diff), updated 10/19/23, revealed that a resident with C. diff. should be placed in a private room and that gloves and gowns should be worn on entering the resident ' s room. It also stated that hands must be washed immediately with an antiseptic soap (rather than hand sanitizer). Lastly, the document indicated that equipment and room must be cleaned with bleach 10/1 ratio. Review of CDC guidelines revealed that to clean the C.diff germs, a mixture of 1 part bleach to 9 parts water should be used. On 7/11/23 at 12:45 PM Interviewed ICP who stated that Resident #13 should have been put in a private room, but for whatever reason the admission team did not. She stated that housekeeping is to be cleaning this resident's room last and using a bleach solution to clean. She stated she was aware that resident is going out to the dining room to eat, but that she knows she is to be washing her hands. She stated staff are using bleach wipes to clean the toilet/bathroom when resident uses the toilet. She stated her expectation was that staff would follow the guidelines and policy.

Based on observations and staff interviews the facility failed to ensure that food prepared and packaged shall be clearly dated, at time the original container became opened. The facility identified a census of 34 residents. Findings include: An initial kitchen tour conducted on 4/18/22 at 10:04 AM, of the kitchen revealed the following containers previously opened and stored in the kitchen ready for service: a. Sour cream with no open date. b. Four containers of 1 gallon salad dressing with no open date. c. Four bottles of salad dressing with no open date. d. A 5 pound container of cottage cheese with no open date. e. Two containers of BBQ sauce with no open date. f. Three containers of mustard with no open date. g. Caramel sauce with no open date. h. A jar of cherries with no open date. i. Cornbread muffin mix with no open date. j. Streusel coffee cake topping with no open date. k. Container of honey with no open date. l. Bag of walnuts with no open date. m. A 32 ounce (oz) bottle of red food coloring with no open date. n. A 32 oz bottle of green food coloring with no open date. o. Bag of marshmallows with no open date. p. Lemon pudding mix with no open date. During the initial kitchen tour on 4/18/22 at 10:04 AM, Staff A, Cook stated, we have labeling issues, won't deny that ever. We don't always have time to label everything with a date that we opened it. I know that we're supposed to. In an Interview on 4/20/22 at 12:17 AM, the Dietary Manager (DM), reported she expected staff to label food with the date it is opened. The DM stated, I'm just as guilty. It has been so busy lately. We just haven't gotten it done. In an interview on 4/20/22 at 1:43 PM, the Administrator acknowledged that food should be labeled with the date it is opened. In an interview on 4/20/22 at 2:23 PM, the Administrator reported the facility lacked a food storage policy. She stated, we follow standard guidelines. The 2017 Food & Drug Administration (FDA) Food code included marking the date or day the original container is opened with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified.

Based on observations, interviews and record review the facility failed to implement interventions to prevent accidents and hazards for 2 of 12 residents reviewed, ( Resident #31 and #7). Resident #31 was at risk for aspiration related to a diagnosis of dysphagia. The care plan indicated he required close supervision with meals and he was observed to eat a meal without interventions as directed on the care plan. Resident #7 fell to the floor in the shower room when the brakes on the shower chair were not all engaged. Resident #7 required supervision with meals and was observed to have 2 separate meals served to her in her room unattended. The facility reported a census of 34 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive deficit. The resident required limited assistance with the help of one for transfers and hygiene needs and set up with the help of one staff for meals. The current Care Plan included diagnosis of [CONDITION(S)] disease of nervous system, extrapyramidal and movement disorder and anxiety disorder. The resident was at risk for falls and required frequent cueing and reminders. On 11/4/21 an intervention was added to the Care Plan to make sure all of the brakes were locked on shower chair before transferring. According to a Nursing Note dated 11/4/21 at 7:20 AM, Resident #7 had been in the shower room and was lowered to the floor by an aide. The resident had been shaking during the transfer and lost her balance. The shower chair had the front brakes locked but the back brakes were not locked and the chair moved while being transferred. An Incident Report dated 11/4/22 at 7:20 AM stated the resident was shaking during transfer and lost her balance and the chair moved. The resident stated the chair moved when she was standing up. The report stated the floor had been wet, the front brakes on the shower chair were locked but not the back brakes. On 4/20/22 at 10:48 AM, Registered Nurse (RN) Staff B acknowledged she filled out the Incident Report and remembered when the CNA was transferring the resident from the shower chair to the wheel chair the resident became unstable and the CNA lowered her to the floor. She remembered the brakes on the shower chair were not all engaged. A Disciplinary Report dated 11/4/21 indicated Staff C had been educated about making sure all 4 of the wheel brakes were locked on the shower chair prior to transferring a resident. In an observation on 4/19/22 at 9:49 AM, Resident #7 was sitting in a recliner in her room with basin in her lap. Certified Nursing Assistant (CNA) Staff D said the resident hadn't been feeling well and had vomited the night before. On 04/19/22 at 11:39 AM resident #7 did not come out to the dining room for lunch and her lunch plate was delivered to her room. At 11:52 AM the lunch plate was still in front of her there was no staff with her to supervise. On 04/20/22 at 8:37 AM the resident was in her recliner, her legs and arms were shaking. A breakfast plate was on the bedside table next to her. She said the staff would usually help her with her meal and supervisor her but they served the meal to her in her room because she wasn't feeling well. On 4/20/22 at 11:10 AM, CNA Staff C said she remembered the fall the resident had in the shower room in November and said she had forgotten to lock all of the brakes on the shower chair. She said she was transferring the resident from the shower chair after she had completed the shower and had dressed the resident. The resident was wearing her shoes and when she had the resident stand up, the resident was shaking. Staff C asked her to sit back down onto the shower chair. She thought she had the back locks on but not the front and the chair moved, the resident became weaker and started to lower to the floor. Staff C said she had a gait belt on the resident and held onto that as she lowered her to the floor. Staff C said she had noticed Resident #7 was having worse trembling lately, and she was having trouble getting her food to her mouth and drinking out of a cup. On 4/21/22 at 11:07 AM The Director of Nursing (DON) said Resident #7 had been refusing to come out for meals more often and it's been addressed at doctor rounds. They have also been addressing the increase in tremors and the doctor has been trying different medications to help with this. The DON said she would expect staff to follow the interventions on the Care Plan which at this time says that supervision is needed with meals only as needed. She said staff are trying to encourage her to come out into the dining room and they have requested a speech therapy consult to address her meal refusals and the increased tremors. 2) According to the MDS dated [DATE], Resident #31 had a BIMS score of 6 (severe cognitive deficit). The resident required extensive assistance with the help of 2 staff for bed mobility, transfers, and toileting. He required set up and supervision for eating. The Care Plan updated on 3/29/22 included diagnosis of dementia, history of [CONDITION(S)] (TIA), chronic obstructive pulmonary disease, abnormal posture and dysphagia, oral phase. A focus area dated 3/29/22 included detailed recommendations from speech therapy to provide close and full supervision for entirety of meals. Staff were instructed to cue the resident to take small bites, take a drink after every couple of bites, use tongue to clear cheeks, and to eat slowly. According to the National Institution Health (NIH) people with dysphagia have difficulty swallowing and may even experience pain while swallowing (odynophagia). Some people may be completely unable to swallow or may have trouble safely swallowing liquids, foods, or saliva. Retrieved on 4/21/22 from: What Is Dysphagia (Difficulty Swallowing)? | NIDCD (nih.gov) In an observation on 4/19/22 at 11:39 AM, Resident #31 was in the dining room and feeding himself. He had a sandwich and took several large bites without swallowing. He still had food in his cheeks and then took a spoon full of mashed potatoes. At 11:42 AM he had not taken in any liquids and a staff member walked passed him but did not intervene. At 11:48 AM he was still eating and hadn't taken any drinks. A Quarterly Nursing assessment dated [DATE] at 9:07 noted rales could be heard in his lungs bilaterally and rhonchi noted on auscultation bilaterally. Lung sounds were diminished bilaterally. From 4/5/22 through 4/20/22, at the time of this writing, the chart lacked follow up lung assessment. On 4/21/22 at 10:43 AM the Administrator said she expected staff to follow the Care Plan interventions related to meal supervision for Resident #31. On 4/21/22 at 11:10 AM The DON agreed Resident #31 was very enthusiastic when eating his meals and he did require encouragement to slow down and take drinks between bites. She said he also refuses to wear his dentures and this has been a challenge to make sure that he is getting his food chewed appropriately. She said they have put him on a list of referrals for speech therapy to evaluate and make recommendations. She said staff are expected to follow the Care Plan interventions and encourage him to slow down, chew food thoroughly and take drinks between bites.

Based on observations, interviews and clinical record review the facility failed to implement a comprehensive person-centered careplan for one of eight residents reviewed, ( Resident #31). The facility failed to make sure the resident was wearing heel boots while in bed as stated in care plan. The facility failed to make sure the air overlay on the resident's bed was working properly. The facility reported a census of 36 residents. Findings Include: The Minimum Data Set (MDS) completed with an Assessment Reference Date of 2/9/21 showed a Brief Interview for Mental Status score of 4, which indicates severe cognitive impact. The MDS showed Resident #31 required extensive assist with the use of two staff for bed mobility, total dependence with the use of two staff for transfers, has impairment on one side on lower extremity. The MDS showed a [DIAGNOSES REDACTED]. A review of the Care Plan showed the resident was to wear heel protectors while the resident was in bed with an initiation date of 12/30/2019. The Care Plan showed the resident to have a pressure-reducing mattress with an air mattress overlay with an initiation date of 5/20/19. During an observation on 2/15/21 at 11:28 AM the resident was lying in bed. The air overlay control box was in the off position, air overlay contained no air support for the resident. During an observation on 2/16/21 at 9:42 AM the resident was lying in bed without his heel protectors on. Heel protectors were sitting on the nightstand to the right of the bed. The resident had an air overlay on top of his mattress. The overly was not turned and contained no air support for the resident. During an observation on 2/16/21 at 3:19 PM, the resident's air overlay on his mattress was not turned on and contained no air support. During an observation on 2/17/21 at 8:40 AM the resident's air overlay on his mattress was not turned on and offered no air support. During an observation on 2/17/21 at 9:15 AM the resident was in bed without his heel boots on. The heel boots were not seen in the room. The resident was resting in bed, the air overly control box attached to the footboard of the bed was in the off position. The air overly was flat and contained no air support. During interview with Staff A, Certified Nurses Aid (CNA) on 2/17/21 at 9:20 AM she stated she was not sure if the resident was to wear heel boots while in bed during the day, but she knew the resident wears them at night. Staff A was asked if she ever checks if the air overlays are working properly and filled with air. Staff A stated she does not check them, that she only checks the ones on hospice residents. She stated that this was the only non-hospice air overly on that hall. Staff A was then asked if the resident's air overly was turned on and she looked down at the control box and stated no and then turned it on. During interview on 2/17/21 at 11:14 AM with Staff B CNA stated the CNA would look in the Kardex to see if a resident is to be wearing heel protectors while in bed. Staff B stated she was unsure if the resident was to be wearing them or not and would have to look it up in the Kardex. Staff B stated she does not check the air mattress regularly, she would just notice if they were flat when giving care to the resident. Interview with the Director of Nursing (DON) on 2/17/21 at 1:26 pm showed the DON was aware of the situation with the air overlay being shut off for three days on the Resident #31's bed. The DON stated she expects staff to be checking to make sure the air mattress are working properly. The DON stated staff should be checking the Care Plan and Kardex to make sure they know if a resident requires heel boots on while in bed. The DON stated they have addressed the issue and added a task on the Medication Administration Record [REDACTED]. A review of the undated General Orientation form showed the CNA is orientated on the use of the Kardex and Care Plan by the nurse manager or MDS Coordinator.

Based on record review and staff interview, the facility failed to notify the residents family of changes in residents condition and new orders for 1 of 4 active residents reviewed, (Resident #2). The facility reported a census of 39 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment, dated 5/13/20, Resident #2 had [DIAGNOSES REDACTED]. The MDS documented Resident #2 scored 12 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required extensive assistance with activities of daily living (ADL's) including bed mobility, dressing, and toilet use, transfers and personal hygiene. The Care Plan dated 5/16/20 with a goal target date of 7/28/20, identified Resident #2 with impaired cognitive function/forgetfulness at times. Resident voices needs, feelings, concerns as desires, as able and as health allows. Goal was resident will be able to communicate basic needs as health allows through the review date. Interventions included: a. Communicate with the resident/family/caregivers regarding residents capabilities and needs as needed. b. Ask yes/no question in order to determine the residents needs as needed. c. Encourage resident to voice needs as chooses and as able to. d. Observe resident for verbal and nonverbal expressions/communication. e. Present just one thought, idea, question or command at a time as needed. The Progress Notes dated 6/23/20 at 10:45 a.m., documented the resident had a possible vasovagal episode at the end of shower when staff raised the hoyer lift. Resident became weak and nonresponsive to staff. When resident began to come around and have verbalizations and awareness after about 3 minutes resident urgently thought needed a bowel movement and was passing significant gas. Once on the bed pan was not able to have bowel movement. Resident blood pressure is very quiet however and heart rate chronic irregular with [MEDICAL CONDITION]. Feet were purple and cool but was cold from shower as well. Resident embarrassed by episode and reassurance provided. Resident stated she had never experienced that before. The Progress Notes dated 7/3/20 at 10:24 a.m., documented resident up with assistance with hoyer for shower this a.m. vagal episode noted prior to repositioning back to bed. Episode passed quickly and resident dressed and assisted into wheelchair to visit with family on phone at window. No further episodes noted. The Progress Notes dated 7/4/20 at 2:32 p.m., documented resident repositioned. Resident #2 opened her eyes but did not respond. Breathing is slow and steady. No signs or symptoms of pain or discomfort. Resting in bed at this time. The Progress Notes dated 7/5/20 at 9:14 a.m., documented resident is lethargic this morning, able to answer yes/no questions but speech is garbled with attempts to say more. Resident refused morning scheduled medications. The Progress Notes dated 7/5/20 at 1:43 p.m., documented a verbal order for Tylenol 650 milligrams suppository rectally every 6 hours as needed for pain/fever ordered. The Progress Notes dated 7/5/20 at 8:50 p.m., documented held resident medications this evening because resident was not making sense with words and showed signs of not being able to swallow very good. The Progress Notes dated 7/6/20 at 1:51 a.m., documented resident was having a hard time breathing, her oxygen level was 86% on room air. Resident still unable to make words that she wants to say and gets frustrated when unable. The Progress Notes dated 7/21/20 at 2:57 p.m., documented received new orders for [MEDICATION NAME] 1,000 milligrams three times a day oral (2 tablets of 500 milligram) for continued pain, resident is aware. The Progress Notes lacked any documentation regarding the family notification of any of the mentioned new orders or changes in condition. During an interview on 7/29/20 at 4:10 p.m. the Director of Nursing confirmed and verified the clinical record lacked any documentation that the family was notified of the new orders or changes in the residents condition and it was the expectation of the nurses to notify the family of changes or new orders.

Based on observation, menu review, and staff interview the facility failed to serve the menu as written in the Chronic Confusion and Dementing Illness (CCDI) unit for 1 meal. The facility reported a census of 39 residents, with 16 residents in the unit. Findings include: The menu for Monday 7/15/19 included marinated pork loin, baked potato, carrots, bread and margarine, pudding parfait. During an observation on 7/15/19 at 11:30 a.m. the noon trays arrived in the unit. Nursing staff passed the trays consisting of pork, baked potato, carrots and pudding with whipped cream. Neither the cart or the resident's plates included bread. During an interview on 7/15/19 at 12:35 p.m. Staff E, Certified Nursing Assistant (CNA) confirmed they did not have bread on the cart for the residents in the unit. During an interview on 7/16/19 at 12:21 p.m. the Dietary Supervisor stated they did not take bread and butter back to the residents in the unit the day before and they should have.

Based on record review and staff interviews the facility failed to complete a comprehensive care plan for 1 of 1 resident's reviewed, (Resident #33). The facility reported a census of 39. Findings include: The Minimum Data Set (MDS) completed for Resident #33 with an Assessment Reference Date (ARD) of 6/28/19 showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS stated no toileting program had been attempted and the resident was frequently incontinent with urine. The resident's [DIAGNOSES REDACTED]. The Admission assessment dated [DATE] indicated the resident had been incontinent longer than one year and the resident was incontinent 1-2 times daily. The resident was incontinent of large amounts of urine during the day and the night. The Admission assessment dated [DATE] indicated the resident had been incontinent longer than one year and the resident was incontinent 1-2 times daily. The resident was incontinent of large amounts of urine during the day and the night. Frequent incontinence was documented in the bladder continence task. The Care Plan intervention, with a revision date of 4/23/19, indicated the resident required the assist of 1 staff as needed for toileting. The Care Plan lacked documentation regarding urine incontinence. The Kardex printed on 7/17/19 noted the resident required the assist of 1 staff as needed for toileting. The Kardex lacked documentation regarding urine incontinence. The Skilled Progress Note dated 11/21/18 at 8:28 p.m. noted the resident sometimes was incontinent of bladder. The resident wore briefs and was able to tell staff when he needed to go. The Skilled Progress Note dated 11/25/18 at 2:35 p.m. noted the resident was incontinent of bladder at times but was able to remain continent with assisted toileting. During an interview on 7/17/19 at 11:26 a.m., The Director of Nursing (DON) stated the Care Plan should reflect everything that was needed to take care of a resident. The DON stated she would expect incontinence to be on the Care Plan. During an interview on 7/17/19 at 2:35 p.m., the DON reported there was no policy for comprehensive care plans.

Based on record review and staff interview the facility failed to provide the necessary care and services to ensure resident's maintained or improved their ability to ambulate for 1 resident reviewed, (Resident #32). The facility reported a census of 39 residents. Findings include: According to the Minimum Data Set (MDS) assessment, dated 5/28/19, Resident #32 scored 12 on the Brief Interview for Mental Status, indicating some cognitive impairment. The resident required extensive assistance with transfer and ambulation. The resident's [DIAGNOSES REDACTED]. A Rehab Communication form dated 5/27/19 recommended/instructed the resident to ambulate to and from all meals with the front wheeled walker, gait belt, assist of 1 and wheelchair following. An activity of daily living (ADL) walk in the corridor report documented between 6/1/19 and 6/18/19, showed the resident did not walk on 6/8/19. The report documented the resident walked only 1 time on 6/1, 6/3, 6/5, 6/7, 6/9, 6/10, 6/11, 6/12, 6/13, and 6/15/19. The report documented the resident walked 2 times on 6/2, 6/4, 6/14, 6/16, 6/17, 6/18/19. The report only documented the resident walked 3 times on 6/6/19. A Cardiovascular surgeon's report dated 6/18/19 documented the resident's first postoperative followup. The report included the resident did not get as much exercise as she would like at the nursing facility. The assessment and plan included they would like her to walk to and from all meals with nursing staff to help with strengthening, and indicated she wrote an order for [REDACTED].>A physician progress notes [REDACTED]. During an interview on 7/16/19 at 10:20 a.m. the Director of Nursing stated they already had the resident on a walk to dine program when they received the order from the cardiology clinic (but the clinical record lacked any additional documentation in (MONTH) of the resident walking). A Rehab Communication dated 6/19/19 recommended/instructed the resident be independent in the facility using her front wheeled walker. A census form showed the resident on hospital leave from the facility 6/22-27/19. A Rehab Communication form dated 7/2/19 recommended/instructed to please walk the resident using her front wheeled walker and contact guard assist 3 times a day, 7 days a week. An ADL walk in the corridor report documented between 7/1 and 7/17/19 showed the resident walked only 1 time 7/2, 7/4, 7/6, 7/7, 7/10, 7/11, 7/12 and 7/14/19. The report documented the resident walked only 2 times on 7/3, 7/8, 7/9, 7/13, and 7/15. The report documented walking 3 times only on 7/1/19. During an interview on 7/17/19 at 3:17 p.m. the resident stated she would like to walk more but she had to have a staff person walk with her and they usually only had time 1 or 2 times a day. During an interview on 7/17/19 at 11:25 a.m. the DON stated they had no additional documentation of walking the resident and stated refusals should be documented.

Based on record review and staff interviews the facility failed to submit a Pre-Admission Screening Record Review (PASRR) with a significant change for 1 of 3 residents reviewed (Resident #29). The facility reported a census of 39. Findings include: The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/19 showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident's [DIAGNOSES REDACTED]. The MDS showed the use of antipsychotics for 7 out 7 days in the look-back period. A PASRR due to a status change was completed on 2/10/2016. A level II evaluation was not required at the time. The resident had a [DIAGNOSES REDACTED]. The rationale stated if an exacerbation related to mental illness or a discrepancy in the reported information, a status change should be submitted to for further evaluation. Per the medical [DIAGNOSES REDACTED]. The Psychosocial Note dated 7/20/18 at 1:36 p.m., indicated telehealth services and mental health services were offered to the resident. The resident refused the services at the time stating, I don't need to talk to anyone else, I feel comfortable talking to the staff here and my doctor. This had been added to care plan at that time. Resident #29's electronic record showed an order for [REDACTED]. A Pharmacy review dated 9/25/18 sent to the physician requesting the [DIAGNOSES REDACTED]. The physician indicated the behavioral symptoms present a danger to the resident or others and one or both of the following: The symptoms were identified as being due [MEDICAL CONDITIONS] such as; auditory, visual, or other hallucinations, delusions, paranoia or grandiosity. The additional response stated the resident became psychotic with unrecognized Urinary Tract Infections (UTIs). Per the medical [DIAGNOSES REDACTED]. The Progress Note dated 10/7/18 at 3:03 p.m., stated the nurse received a fax from the physician with orders: [MEDICATION NAME] 2 mg every 6 hours as needed. The fax stated to go ahead and discontinue after 14 days per Centers for Medicare and Medicaid Services (CMS) F758. The fax directed staff to contact the physician if the resident became psychotic again. The [DIAGNOSES REDACTED]. The behavioral symptoms present a danger to the resident or others and one or both of the following: The symptoms are identified as being due [MEDICAL CONDITIONS] (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity). A linked Progress Note dated 10/7/18 at 3:13 p.m., stated the resident became psychotic with unrecognized UTIs. The pharmacy review dated 3/15/19 showed a reduction from 2 mg of [MEDICATION NAME] twice daily to [MEDICATION NAME] 1 mg every morning and 2 mg every evening. The chart lacked documentation regarding notification to PASRR regarding the change in resident's mental status. During an interview on 7/17/19 at 11:35 a.m., The Director of Nursing (DON) reported she was new to PASRR's and she just started doing them in the last two weeks. She stated she would expect to have a significant change PASRR completed if there was a change in [DIAGNOSES REDACTED]. The form labeled PASRR and Level of Care Screening Procedures for Long Term Care Services with a revision date of 2/9/16, stated a significant change in status would occur for individuals who exhibited behaviors, psychiatric, or mood related symptoms suggesting the presence of a [DIAGNOSES REDACTED]. The manual stated the nursing facility must submit a Level I form.

Based on record review and staff interviews the facility failed to review and revise the resident's care plan to meet the resident's needs for 1 of 15 resident's reviewed, (Resident #18). The facility reported a census of 39. Findings include: The Minimum Data Set (MDS) completed with an Assessment Reference Date (ARD) of 5/14/19 showed a Brief Interview for Mental Status score of 8, indicating moderate cognitive impairment. The resident's [DIAGNOSES REDACTED]. The Progress Note dated 5/5/19 at 6:10 p.m., noted the charge nurse was notified by an unknown person that two residents were on the lawn and they believed they fell . Resident #18 was observed on his back with the wheelchair lying next to him on its side. The resident reported he saw another resident fall so he was going to help her. When he stood up the ground was uneven and he fell . The intervention was for the resident to have no outside time. The Progress Note dated 5/6/19 at 4:20 p.m. Fall follow up regarded review of the Care Plan interventions and effectiveness of the new intervention. The nurse discussed he may only go out on the porch and he indicated that he understood. The Care Plan lacked documentation of the intervention that the resident may only go out on the porch. During an interview on 7/11/19 at 11:26 a.m., the Director of Nursing (DON) stated the Care Plan should be revised within 24 hours. Following a fall the resident would get an immediate intervention and then it would be reviewed by the Quality Assurance (QA) committee the next morning. The DON said she would expect the intervention of the resident can only go out on the porch to be on the Care Plan. The DON reviewed the care plan and affirmed this intervention was not on the Care Plan. The policy labeled Care Plan Frequent Update, with no date provided, stated the resident's care plan would be updated whenever there was a change in the plan of care. The policy continued to state whenever a change in Physician orders [REDACTED]. The policy labeled Fall Risk Assessment and Prevention, with no date provided, indicated the fall risk assessment score to be completed on Admission, upon Re-Admission, quarterly, with any significant change in status and annually with the MDS. The process section stated after a fall risk was determined, the nurse should review the resident's condition and put appropriate interventions into place then update the care plan.

Based on record review and staff interviews, the facility failed to provide adequate supervision and direct the nursing care so the resident ' s needs are met in the CCDI (Chronic Confusion and Dementing Illness) unit. The facility reported a census of 6 residents residing in the CCDI unit during the period of 12/22-12/30/2011. The facility reported a current census of 4 residents. The 6 residents required supervision, toileting and bathing. Two of the 6 residents required response from alarms in order to prevent falls and 1 resident had sexual behavior tendencies. Based on staff interviews, the facility scheduled and had only 1 staff person to supervise residents and provide care which did not meet the residents' needs. 1. Resident #1 had a Minimum Data Set assessment with a reference date of 12/26/2011. The assessment identified Resident #1 with severe cognitive impairment and behaviors of daily wandering; inattention fluctuated, and disorganized thinking. The assessment indicated the resident could ambulate independently but required supervision (oversight, encouragement, or cueing). The resident had a problem with balance not steady but able to stabilize without human assistance during transitions and walking. The resident utilized a walker. A Fall Risk assessment dated [DATE] identified a score of 15 and on 12/27/2011 had a score of 11. A score of 10 or higher indicated a high risk for falls. A Quality Assurance Monitoring Tool dated 12/30/2011 at 3:00 p.m. indicated the resident fell on the floor onto left side and hit head. The resident obtained a large goose egg on the left side of the head, swelling of left shoulder, a large skin tear to the left hand. The tool indicated the prior interventions included a walker and one staff member. A staff member had witness the fall. The Nurse ' s Notes reflected no entry for 12/30/2011. The next entry was dated 1/2/2012 (no time) and indicated the resident returned from the hospital following an admission related to a subarachnoid bleed. A hospital history and physical examination [REDACTED]. The resident had a large hematoma on the left side of the scalp with no laceration and a minor abrasion to the area and a skin tear to the left hand. The resident opened eyes and moaned. The resident cried out in pain. A CT (Computerized Tomography) scan revealed tiny amount of acute probable subarachnoid bleed in the left temporopariental area of the head but no fractures. The cervical spine had moderate and severe degenerative changes but no fractures. The scan was repeated for follow up on 1/2/2012 which showed a decrease in size (6 millimeters by 6 millimeters) stable for almost 3 days. The Nurse ' s Notes of 1/2/2012 (no time) reflected the resident returned to the facility but did not return to the CCDI unit. The resident depended upon staff for transfers, did not bear weight and would not sit up in the wheelchair. On 1/17/2012 at 11:55 a.m., Staff W (Nursing Assistant) stated she had not witness the resident fall on 12/30/2011. Staff W stated had worked alone in the unit at the time of the fall and had always worked alone. Staff W confirmed 6 residents resided in the unit at the time of the fall. Staff W stated she opened the unit door and called for help; a nurse then came to the unit. At 3:35 p.m. Staff W stated the resident had been in his/her room prior to the fall, had left the room without the walker and fell in the hallway on 12/30/2011. On 1/17/2012 at 1:00 p.m., Staff B1 (Nursing Assistant) stated she always worked the day shift alone in the CCDI unit and the unit never had more than 6 residents residing there at one time. Staff B1 stated if she needed help then, she opened the door and called for help. Staff B1 stated she wore a panic button necklace around her neck to call for help if an emergency occurred. At 7:10 a.m. on 1/18/2012, Staff B1 stated she bathed residents during the day shift and bathed Resident#3 while other residents slept. The bath usually only took 10 minutes without any other staff present in the unit during the bath. Staff B1 stated she did not kike to leave the ladies unattended very long time because there was a resident with sexual behaviors directed toward staff. Two of the 6 residents had alarms (Resident #3 and Resident #4). On 1/17/2012 at 3:50 p.m. Staff S (Nursing Assistant) was interviewed and stated she worked the evening shift alone in the CCDI unit and gave baths to residents. The baths took approximately 15 minutes and no other staff monitored the residents living on the unit while she bathed the residents. During a telephone interview on 1/23/2012 at 1:50 p.m., the Director of Nursing stated the facility had no policy/procedure to monitor incidents, accidents, and falls. 2. Resident #3 had an admitted into the facility as 11/11/2011. The admission MDS with a reference date of 11/21/2011 indicated the resident had short and long term memory impairments and required limited staff assistance with transfers, ambulation and activities of daily living. The MDS identified [DIAGNOSES REDACTED]. The Fall Risk Assessment document dated 11/11/2011 indicated the resident with a score of 13 and a score of 17 on 11/22/2011. A score of 10 or higher indicated a high fall risk. A Quality Assurance Monitoring Tool and the Nurse ' s Notes dated 12/23/2011 at 3:10 p.m. indicated the staff left the resident alone in the dining room (busy with another resident) and the resident stood up, fell and hit head on the floor. Staff had not documented if the personal alarm had sounded to alert staff the resident attempted to rise from the chair. The resident had been found with the left shoulder on the floor and had a goose egg present on the left side of the head. On 1/17/2012 at 11:55 a.m., Staff W (Nursing Assistant) was interviewed and stated she worked alone in the CCDI unit with 6 residents when Resident #3 fell on [DATE] at 3:10 p.m. Staff W stated the alarm had not sounded and the staff person heard the resident fall while she and a volunteer passed gifts to residents. The alarm remained attached to the resident and to the chair. Staff W stated the resident should not be left alone and required supervision. Staff W stated she pressed the panic alarm when the resident fell and Staff O came to the unit. On 1/17/2012 at 3:25 p.m., Staff O (Licensed Practical Nurse) was interviewed and stated the alarm string needed shortened and she believed she had shortened the alarm string. The intervention had not been documented on the fall form or the Nurse ' s Notes. A nursing assistant report sheet indicated an entry dated 12/26/2011 for the 2:00 p.m. to 10:00 p.m. shift. The report indicated the resident " still " complained of left shoulder pain the assistant informed the nurse. The nursing assistant report sheet for 12/26/2011 for the 10:00 p.m. to 6:00 a.m. shift indicated the resident had left shoulder pain all night. The Nurse ' s Notes dated 12/26/2011 at 3:00 a.m. indicated the resident had no complaints of pain/discomfort and no new injuries after the fall. An entry dated 12/27/2011 at 4:30 p.m. indicated the resident had shoulder pain. A Quality Assurance Monitoring Tool dated 12/27/2011 at 9:30 a.m. indicated the resident ' s alarm sounded and the CAN found the resident on the floor in the room by the sink and toilet after attempted to self transfer to the toilet. The tool indicated the resident had left shoulder pain similar to before the fall. The staff placed a wedge cushion in the wheelchair for a new intervention. The nursing assistant communication sheet dated 12/27/2011 during the 6:00 a.m. to 2:00 p.m. shift indicated the resident had fallen while the nursing assistant assisted Resident #4. On 1/17/2011 at 1:30 p.m., Staff E1 (Nursing Assistant) stated at the time of the fall, she had another resident who had become incontinent of bowel and had to provide care for that resident. Staff E1 stated she had been informed the facility planned to hire additional staff to work in the CCDI unit. The Nurse ' s Notes entry dated 12/28/2011 at 11:00 a.m. indicated the resident voiced left shoulder pain. An entry dated 12/29/2011 at 9:00 a.m. described the left shoulder pain, swelling redness and yellow discoloration present. The nurse notified the physician and obtained an order for [REDACTED]. The hospital radiology reported dated 12/29/2011 indicated general osteoporosis present and a comminuted fracture of the distal clavicle. Another x-ray dated 12/30/2011 indicated the left clavicle had communited fracture of the distal and 1/3 of the clavicle with an approximate overlap of 2.8 inches. The Care Plan lacked documentation related to the 12/27/2011 fall, fracture or the use of the immobilizer for 2 weeks. The Care Plan lacked documentation of the wedge cushion placed in the resident ' s wheel chair. On 1/18/2012 at 8:55 a.m., the DON (Director of Nursing) stated each resident had 1 care plan located on the resident ' s chart. The DON stated she used verbal communication to notify staff of new interventions. The DON stated the nursing assistants did not have care plans to carry with them. On 1/18/2011 at 9:12 a.m., the Administrator stated once the CCDI had 6 residents in the unit, then the facility no longer accepted any new additional residents pending hire of additional staff to schedule to work in the unit. Staff A stated he had supervised residents in the CCDI during times when the nursing assistant bathed residents. The Administrator stated he requested staff from the floor supervise residents while CCDI unit staff bathed residents.

Based on observation, record review and staff interview, the facility failed to assess skin impairment and provide timely intervention for one (1) of six (6) residents reviewed (Resident # 5). The facility reported a census of twenty seven (27) residents. Findings included: According to a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' included: Obesity, Depression and Diabetes. A Minimum Data Set (MDS) with an assessment reference date of January 24, 2011, identified Resident #5's cognition as intact and had no impairment of memory. The same MDS indicated the resident required total dependence on staff and two (2) plus physical assistance from staff for bed mobility, transfer, dressing and toilet use. The MDS further documented the resident required extensive assistance with personal hygiene, had been frequently incontinent of urine, had been at a risk for developing a pressure ulcer and had a weight of three hundred ten ((310) pounds. A care plan dated October 27, 2010 indicated the resident had been at risk for changes in skin integrity due to Diabetes, impaired mobility and incontinence. The same care plan instructed staff to assess the resident's skin condition weekly. A facsimile to a Physician dated August 29, 2010 revealed the Resident #5 had a "...very red..." buttocks and had requested an order for [REDACTED]. Review of a MAR indicated [REDACTED]. Further review of MAR's dated October and December 2010, and a MAR indicated ...affected area..." two times a day. Observation on February 2, 2011 at 8:07 A.M., revealed Staff G (Certified Nurse Aid-CNA) and Staff I (CNA) completed perineal care for Resident # 5. Further observation revealed the resident had a moderate sized reddened area with at least three opened areas on his/her lower left buttock area (where the buttock and thigh meet). During ongoing observation Staff G stated she needed to go and get the nurse to apply the resident's [MEDICATION NAME] ointment. Staff G stated normally the ointment had been in the resident's room and the CNA's had been applying the ointment to the resident's buttocks, but since the surveyor had been in the building the ointment had been moved from the resident's room. Continued observation revealed Staff B (Registered Nurse- RN) entered the residents room at 8:12 A.M. and applied [MEDICATION NAME] cream to the resident's buttocks. During interview on February 2, 2011 at 11:25 a.m., Staff G stated Resident #5' left lower buttocks had impaired opened areas of skin for approximately two (2) weeks. Staff G stated the opened area's had looked as if the areas had been getting worse. During interview on February 2, 2011 at 1:00 P.M., Staff B stated nurses in the facility had done the weekly skin assessments for the resident's. Staff B stated she had done weekly skin assessments during the resident's bath times or when in the resident's room. Staff B stated she had put Resident #5's [MEDICATION NAME] cream on Resident #5's buttocks each time she worked. During the same conversation the Surveyor requested Staff B measure the open areas on the Resident's buttocks. Staff B stated she had not noticed the open area's on the residents bottom on February 1, 2011 when she applied the [MEDICATION NAME] cream. During interview on February 2, 2011 at 1;38 P.M., Staff I stated the nurse usually had CNA's apply the resident's [MEDICATION NAME] ointment to Resident #5's buttocks. Staff I stated the nurses had applied the ointment when they had time, but it had been "...chaos..." for the nurses. Observation on February 2, 2011 at 1:46 P.M., revealed Staff B measured Resident # 5's impaired/opened areas on his/her left lower buttock. Staff B identified the impaired areas as follows: A. 0.2 x 1 centimeter (cm) open area with a dark pink center B. 0.5 x 1.5 cm yellow scab C. 0.6 x 2.5 cm open area with dark pink center D. 1.5 x 2 cm dark yellow scab E. 1.5 x 1.5 dark yellow scab In addition to above , Staff B measured a 6.5 x 5 cm area of redness that surrounded the impaired area's as described . During interview on February 2, 2011 at 1:58 P.M., Staff C (Licensed Practical Nurse-LPN) stated she had noted open area's on Resident #5;s buttocks approximately one (1) week ago. Staff C stated sometimes the resident had scabs on his./her bottom and the scabs would fall off when the resident moved around, Staff C confirmed she had not filled out a skin sheet or documented an assessment of the resident's impaired areas on his/her buttocks, but had passed the message on in report to a nurse on a different shift. During interview on February 2, 2011 at 2:02 P.M., Staff M (CNA) stated she had observed Resident #5 had open areas on his/her bottom for approximately one (1) month or longer. Staff M stated she had reported the impaired areas on the resident's buttocks to two (2) different nurses. A facility policy for Pressure Ulcer Skin Assessment included procedures for staff to assess a new pressure ulcer as soon as discovered and document all pertinent information such as location, size and the condition of the surrounding skin. The policy further included procedures to notify a Physician and obtain orders. During interview on February 2, 2011 at 3:09 P.M., Resident # 5 confirmed his/her left buttock had been painful. During interview on February 2, 2011 at 3:20 P.M., the facility Director of Nursing stated she expected nurses to fill out a skin sheet and notify a Physician when impaired skin issues had been assessed. During interview on February 2, 2011 at 4:00 P.M., the DON confirmed Resident # 5's assessed skin impairments as measured on February 2, 2011 had been Stage 1 (reddened area) and Stage 2 (all other measured areas) pressure ulcers. Review of a facsimile to a Physician dated February 2, 2011 revealed Staff B had notified a Physician in regards to the impaired skin conditions on Resident #5's left buttock. Further review of the facsimile revealed a Physician had ordered the resident be seen by an ET ([MEDICATION NAME][MEDICATION NAME] Therapy (wound nurse) ) nurse to evaluate and treat the impaired skin.