Every finding on record at Avondale Health and Rehabilitation Center, LLC

Based on facility policy review, observation, and interview, the facility failed to ensure food was distributed in a manner that prevented the spread of infection when 1 of 10 (Certified Nurse Assistant (CNA) A) staff began placing previously served meal trays on a tray cart ( top 300 Hall Cart) before meals were served for 1 of 34 (Resident #26) residents observed for dining. The findings include: 1.Review of the facility policy titled, Food Safety Requirements, dated 3/26/2025, revealed .(Food Distribution) means the process involved in getting food to the resident.All equipment in the handling of food.handled in a manner to prevent contamination.clean dishes shall be kept separate from dirty dishes. Review of the policy titled, Infection Prevention and Control Program, dated 2/5/2025, revealed .(Staff) includes all facility staff (direct and indirect care functions).others who provide care and service.all staff shall assume that all residents are potentially infected.with an organism.could be transmitted during the course of providing resident care services. 2. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Failure to Thrive, Malnutrition, Depression, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 was unable to complete the Brief Interview for Mental Status (BIMS) assessment, which indicated that the resident's cognition was severely impaired, and was dependent of staff assistance with eating. Observation on the 300 Hall on 7/20/2026 beginning at 11:28 AM, revealed CNA B and CNA A passed all meal trays from the top 300 Hall meal tray cart except Resident #26's meal tray. Observation on the 300 Hall on 7/20/2026 at 12:05 PM, revealed, CNA A removed previously served meal trays from rooms [ROOM NUMBERS] and placed them on the top 300 meal tray cart with Resident #26's meal tray, which had not yet been served. During an observation and interview on the 300 Hall on 7/20/2026 at 12:08 PM, CNA A was asked should Resident #26 have received a tray. CNA A stated, .oh, is [CNA B] not feeding him.yes, I'll feed him . CNA A went to the top 300 Hall meal tray cart where Resident #26's tray was stored with the previously served meal trays, removed Resident #26's tray, carried the tray to the resident's room and began assisting the resident with his meal. During an interview on 7/20/2026 at 12:30 PM, CNA A was asked if previously served trays should be placed on the meal tray cart before all clean trays are passed. CNA A stated, .no.I did that didn't I. During an interview on 7/20/2026 at 2:30 PM, the Registered Dietician (RD) was asked if staff should pass all trays from the food delivery cart prior to picking up previously served trays and placing them back on the cart. The RD stated .yes, clean trays should not be in the same cart as dirty. The RD was asked if placing previously served trays on the cart, prior to passing all trays, could lead to cross contamination between the trays. The RD stated .absolutely under no circumstances this should be done.one little droplet could come off one tray and infect another.

Based on facility policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 3 (300 Hall Medication Cart) medication carts were left unsecured and unattended by 1of 3 (Licensed Practical Nurse (LPN) C) nurses. The findings include: 1. Review of the facility policy titled, Medication Storage, dated 11/12/2024, revealed .All drugs and biologicals will be stored in locked compartments (.medication carts, cabinets, drawers.) under proper temperature controls.Only authorized personnel will have access to the keys to locked compartments.During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key.Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area. Random observation of the 300 Hall medication cart on 7/21/2026 at 1:18 PM, revealed the medication cart was unlocked and unattended, positioned against the wall between rooms [ROOM NUMBERS]. No staff members were noted in sight of the medication cart. During an observation and interview on 7/21/2026 at 1:24 PM, LPN C was sitting at the nurses' station and confirmed she was assigned to the 300 Hall medication cart. LPN C accompanied the surveyor to the 300 hallway and observed the unlocked medication cart. LPN C was asked if the medication cart was left unlocked. LPN C stated, It is. LPN C was asked if a medication cart should be left unlocked when not attended. LPN C stated, No. During an interview on 7/22/2026 at 11:59 AM, the Director of Nursing (DON) was asked who should have access to the medication carts. The DON stated, The licensed nurses only. The DON was asked what she expects staff to do when they leave a medication cart. The DON stated, Lock their cart and make sure they are not showing any protected health information. The DON was asked if medication carts should be locked when unattended. The DON stated, Yes. The DON was asked if leaving a medication cart unlocked and unattended could create the potential risk of an unauthorized person, including residents, to have access to medications. The DON stated, Yes. The DON was asked if access to those medications could be potentially hazardous for those people. The DON stated, Yes. The DON was asked if controlled medications should be stored under double-lock and key. The DON stated, Yes. The DON was asked if the primary lock on the medication cart is not locked, would the controlled medications be stored under double-lock and key. The DON stated, No.

Based on facility policy review, medical record review and interview, the facility failed to report an allegation of abuse for 1 of 3 (Resident #2) sampled residents reviewed for abuse. The findings include: 1. Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 12/2/2024, revealed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Abuse means the willful infliction of.intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse.Alleged violation is a situation or occurrence that is observed or reported by staff or resident.but has not yet been investigated.Mental Abuse includes but is not limited to humiliation, harassment, threats of punishment.The facility will have written procedures that include.Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes .Immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in bodily injury, or.Not later than 24 hours if the events that cause the allegation do not involve abuse. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Quadriplegia, Heart Failure, Dysphagia, Pressure Ulcer, Diabetes Mellitus, Gastrostomy, Anxiety, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. Resident #2 had impairment on both sides and was dependent on staff to perform all Activities of Daily Living (ADLs). Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. Resident was dependent on staff to perform all ADLs. During an interview on 6/12/2026 at 11:52 AM, Resident #2 was asked regarding the incident that occurred on 3/6/2026 with Licensed Practical Nurse (LPN) B. Resident #2 stated, .She raised her fist at me, and the Administrator chose not believe me because there was no witness in the room to see it happen. Resident #2 was asked if he was fearful. Resident stated, I was at that particular time, she was standing near the curtain when I called her a [derogatory name], and that triggered her. She rushed towards me with her fist raised at me . During an interview on 6/12/2026 at 12:21 PM, Certified Nursing Assistant (CNA) C was asked if she recalled an incident with Resident #2 and LPN B. CNA C stated, I heard [LPN B] say he called her a [derogatory name].I went in the resident's room a few hours later and he was acting moody, I asked him what was wrong.He said [LPN B] bowed up like she was going to hit him. CNA C was asked if she reported what the resident had stated occurred. CNA C stated, I probably should have told the Administrator since it involved my charge nurse. During an interview on 6/12/2026 at 1:28PM, LPN B was asked to recall the incident that occurred on 3/6/2026 with Resident #2. LPN B stated, I went in [the resident's room] to administer his medications. I had doubled checked his meds [medications] to make sure I was administering what he was supposed to have. He was asking about an antibiotic that he thought I was supposed to administer. I informed him that I cannot administer anything that was not on his electronic medical record. He became angry and very agitated. I assured him that I would check the computer again. After returning to his room, I told [Resident #2] it wasn't on there. He began to call me a stupid black [derogatory name].I told him he's not going to talk to me that way.I am not nobody's black [derogatory name]. During an interview on 6/12/2026 at 2:45 PM, the Director of Nursing (DON) was asked when she was made aware of the incident involving LPN B and Resident #2. The DON stated, I was made aware the next week because I had been off work when the incident occurred. The DON was asked who all should be notified when there is an allegation of abuse. The DON stated, Ensure to contact the Responsible Party and notify the Police, APS [Adult Protective Services], State Agencies, and Physician/Medical Director. During an interview on 6/12/2026 at 3:03 PM, the Administrator was asked when he was made aware of the incident with LPN B and Resident #2. The Administrator stated, I was immediately made aware of the incident after it happened. The Administrator was asked who informed him of the incident. The Administrator stated, I don't recall the staff member.They said there was a resident that was yelling and screaming at [LPN B]. The Administrator stated, An interview with [Resident #2] was performed to obtain his side of the story.[Resident #2] stated [LPN B] would not give him his antibiotics.I had [LPN B] pull up his medication administration record, and the medication was not due. I explained to [Resident #2] that it wasn't due and informed him that he cannot yell and cuss at the staff. [Resident #2] stated that she acted like she wanted to hit me. I immediately pulled her from the cart.I took her to my office asked her and asked about the allegation. The Administrator was asked what incidents should be reported. The Administrator stated, All allegations of Abuse. The Administrator was asked if this allegation was reported. The Administrator stated, No it wasn't . During an interview 6/12/2026 at 4:25 PM, the Assistant Director of Nursing (ADON) was asked if the physician and Responsible Party (RP) were notified of the allegation of Abuse. The ADON stated, I'm unsure. The ADON was asked who is responsible for notifying the RP and physician. The ADON stated, Someone in management. The ADON was asked who is responsible when the DON is on leave from the facility. The ADON stated, I did not notify the physician that day. ADON was asked should the RP and Physician be notified of allegations of abuse. The ADON stated, Yes, of course.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure infection control practices were followed during medication administration when 1 of 4 (Licensed Practical Nurse (LPN G)) staff were observed during medication administration, when 1 of 1 (LPN A) LPN failed to follow Enhanced Barrier Precautions when administering PEG (percutaneous endoscopic gastrostomy) tube medications, during dining when the facility failed to follow transmission based precautions for 1 of 1 (Resident #159) reviewed for isolation, and when a random observation revealed LPN H failed to perform proper hand hygiene and failed to clean reusable medical equipment. The findings include: 1. Review of the facility's policy titled, Isolation Precautions, revealed .The dietary department should be notified by nursing or other designated person that the precautions are needed, the notification should include the residents name, room number and any other pertinent information . Review of the facility's policy titled, Enhanced Barrier Precautions, dated 12/1/2024, revealed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .employs targeted gown and gloves use during high contact resident care activities .PPE [Personal Protective Equipment- protective items or garments worn to protect the body or clothing from hazards that can cause injury or illness and to protect others from cross-transmission] is only necessary when performing high-contact care activities .High-contact resident care activities include .Device care or use .central lines, urinary catheters, feeding tubes . Review of the facility's policy titled, Transmission-Based (Isolation) Precautions, dated 12/1/2024, revealed .It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' mode of transmission . Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment .Donning personal protective equipment (PPE) upon entry and discarding before exiting the room is done to contain pathogens .Don gloves upon entry into the room .Don gown upon entry into the room . Review of the facility policy titled, Hand Hygiene, dated 12/1/2024, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .The use of gloves does not replace hand hygiene .perform hand hygiene prior to donning gloves, and immediately after removing gloves . Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 12/1/2024, revealed .Resident-care equipment can be a source of indirect transmission of pathogens .Reusable resident-care equipment will be cleaned and disinfected .Disinfection refers to thermal or chemical destruction of pathogenic and other types of microorganisms .Reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include .blood pressure cuffs .Multiple resident use equipment shall be cleaned and disinfected after each use . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Cerebrovascular Disease, Convulsions, Dementia, and Mental Disorders. Review of Physician's Orders dated 12/1/2024, revealed .Phenytoin Sodium [medication used for seizures] .100mg [milligrams] .in the afternoon . PHENobarbital [medication used for seizures] 32.4 MG .three times a day . Observation during the 200 Hall medication administration on 1/7/25 at 2:00 PM, revealed LPN G removed a Phenytoin 100 mg capsule and dropped the capsule on top of the 200 hall medication cart, that did not have a barrier, and placed the capsule into a medication cup. LPN G then removed a Phenobarbital 32.4 mg tablet and placed it into the same medication cup with the Phenytoin 100 mg capsule, that fell on top of the medication cart without a barrier. LPN G locked the medication cart began to enter Resident #1's room to administer the medication. LPN G was asked are you going to administer the Phenytoin and the Phenobarbital to Resident #1. LPN G stated, Yes. LPN G was asked should you administer the medication if it fell on top of the medication cart without a barrier. LPN G confirmed that the medication should not be administered and she should not have placed the Phenobarbital tablet into the same cup with the Phenytoin capsule that fell on top of the medication cart that did not have a barrier. LPN G confirmed that she should have used a barrier when preparing the medication and that both medications were contaminated and should be disposed of and replaced with clean medication. 3. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Aphasia, Gastrostomy, Cerebrovascular Attack, and Seizure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #31 had no BIMS score and was severely cognitively impaired, dependent on staff for ADLs and the use of a feeding tube. Review of the Care Plan dated 10/1/2024, revealed .receiving tube feedings .Enhanced Barrier Precautions are indicated related to enteral tube .Infection Control Practices include standard precautions . Review of the facility's Order Summary Report dated 1/8/2025, revealed .Enhanced Barrier Precautions related to enteral tube every shift .1/8/2025 .Baclofen [used to treat muscle spasms] .5 MG [milligram] .three times day .hydrALAZINE [used to treat high blood pressure] .50 MG .four times day .Valproate [used to treat seizures] .Solution 250MG/5ML .10 ml [milliliter] .three times day . Observation during the 200 Hall medication administration at the 200 hall medication cart on 1/8/2025 at 11:00 AM, revealed LPN A sanitized her hands, and removed the following medications for Resident #31: a. Baclofen (used for muscle spasms) 5mg tablet-1. b. Hydralizine (used for high blood pressure) 50mg tablet-1. c. Valporic Acid Solution (used for seizures) 250mg/5ml- 10 ml. LPN A donned a pair of gloves, crushed each medication and placed each one into a separate medication cup, removed her gloves and sanitized her hands. LPN A then went to Resident #31's room, knocked and entered Resident #31's room, placed a barrier on top of the over the bed table, donned a clean pair of gloves, disconnected the PEG tube, checked placement with auscultation and residual, and administered each medication separately. LPN A flushed the PEG tube with 15ml of water, and reconnected the PEG tube to the enteral feeding, disposed of the trash, removed her gloves, entered the bathroom and washed her hands. LPN A exited the bathroom and returned to the medication cart. LPN A failed to follow Enhanced Barrier Precautions during Resident #31's PEG tube medication administration as evidenced by the failure to use a gown during administration of the medication. Review of the facility's Enhanced Barrier Precautions list revealed Resident #31 was on Enhanced Barrier Precautions List. During an interview on 1/9/25 at 2:34 PM, revealed the Director of Nursing (DON) was asked what should staff do when a medication is dropped on top of the medication cart without a barrier. The DON confirmed the medication should be discarded a replacement tablet should be used. The DON confirmed the contaminated medication should not be placed in a medication cup with a non contaminated tablet and neither should be administered to a resident if contaminated. The DON confirmed that staff should use Enhanced Barrier Precautions when administering medications via PEG tube and staff should wear a gown and gloves. 4. Review of the medical record revealed Resident #159 was admitted to the facility on [DATE], with diagnoses including Methicillin Resistant Staphylococcus Aureus Infection (MRSA), Pain, and Pressure Ulcer of Sacral Region. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #159 was cognitively intact. Review of the Physician's Order dated 12/27/2025, revealed .Infection MRSA .Precaution Type: contact . Observation on the 300 Hall on 1/6/2025 at 11:31 AM, revealed Resident #159's lunch meal was delivered on a regular meal tray. The staff did not deliver a resident a contact precaution meal in Styrofoam. Observation on the 300 Hall on 1/7/2025 at 7:47 AM and at 11:48 AM, revealed Resident #159's breakfast meal was delivered on a regular meal tray. The staff did not deliver a resident in contact precaution meal in Styrofoam. Random observation in the 300 Hall on 1/7/2025 at 8:16 AM, revealed LPN H entered Resident #159's room without a gown on. LPN H returned from Resident #159's room with a multi-use blood pressure machine and cuff, placed the blood pressure machine and cuff on the medication cart. LPN H removed her gloves and did not perform hand hygiene. LPN H picked up the blood pressure machine and cuff, and walked into the resident's room next door. Before LPN H's attempt to take the resident's blood pressure in the next room with the same equipment, she was summoned to the medication cart. LPN H confirmed she had used the same equipment on Resident #159 and her plans was to use the same equipment on the resident next door to Resident #159. LPN H confirmed the blood pressure machine and cuff should have been sanitized before she entered the resident's room next to Resident #159. 5. During an interview on 1/8/2025 at 9:17 AM, the Dietary Supervisor confirmed the dietary procedure, related to the delivery of meal trays to residents on contact precautions, is the nursing staff notifies the dietary department and the resident's meals are delivered on Styrofoam containers. The Dietary Supervisor confirmed the dietary staff was not made aware that Resident #159 was on contact isolation until 1/8/2025 after delivery of lunch meals. During an interview on 1/8/2025 at 10:16 AM, the Assistant Director of Nursing (ADON) confirmed staff should perform hand hygiene after removing their gloves. During an interview on 1/9/2025 at 9:17 AM, the Director of Nursing (DON) confirmed reusable equipment used to take residents' blood pressure (bp) should be cleaned in between residents. The DON was asked, what should staff use to take a resident's bp when on contact precautions. The DON stated, .staff should be using a manual blood pressure cuff that stays in the resident's room and a disposable stethoscope . During an interview on 1/9/2025 at 2:49 PM, the DON confirmed staff should always wear a gown and gloves when entering a resident's room who is on contact precautions. 46047 49269

Based on policy review, document review, observation, and interview, the facility failed to provide sufficient staff with competencies and skill sets to carry out the functions of the food and nutrition services for 4 of 4 staff members (Dietary [NAME] C, D, F, and Dietary Supervisor) working in the kitchen. The facility had a census of 55, with 55 of those residents receiving a meal tray from the kitchen. The findings include: 1. Review of the facility policy titled, Food Safety Requirements, dated 12/1/2024, revealed .Food safety practices shall be followed throughout the facility's entire food handling process .This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include .Distribution and service of food to the resident, including transportation, set up, and assistance .Employee hygienic practices .Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely storage .Labeling, dating, and monitoring refrigerated food, including but not limited to left overs, so its used by its use by date, or frozen (where applicable/ and discarded .Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Staff shall wash hands according to facility procedures. Gloves will be worn when directly touching ready-to-eat food and when serving residents . Review of the undated facility policy titled, Handwashing Guidelines for Dietary Employees, revealed .Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparations .After hands have touched anything unsanitary i.e garbage, soiled utensils/equipment, dirty dishes, After hands have touched bare human body parts other than clean hands (such as face, nose, hair etc) While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks .Before donning for working with food .After engaging any activity that may contaminate the hands . Review of the facility policy titled, Manual Warewashing-3 Compartment Sink, dated 12/1/2024, revealed .Sanitizing solutions shall be tested by a test kit or other device that accurately measures the concentration in MG/L [Milligram per Liter]. Testing will occur periodically but not limited to. When sink is initially filled .Sanitizing procedures for the three compartment sink .Third sink sanitizing .Fill with hot water or use chemical sanitizer: Iodine at 12.5 ppm [parts per minute]; QAC [Quaternary] ammonia at 150-200 ppm. Confirm appropriate temperature or concentration prior to washing and record on sanitation log . 2. Review of the January Kitchen Schedule revealed 3 Dietary Cooks and a Dietary Supervisor scheduled from 1/1/2025 through 1/12/2025 to cover a total of 4 shifts including for: 1. 5:00 AM - 1:30 PM 2. 11:30 AM - 8:00 PM 3. 6:00 AM - 2:30 PM 4. 11:30 AM - 8:00 PM Review of the facility document titled, Meal Times, revealed BREAKFAST 7:20 AM, LUNCH 11:20 AM, DINNER 5:20 PM . THESE ARE THE TIMES THAT TRAYS HAVE TO BE OUT OF THE KITCHEN. Observation and interview in the kitchen on 1/7/2025 at 5:20 PM, revealed Dietary [NAME] D at the steam table serving while cooking food in the deep fryer. The Dietary supervisor was preparing resident trays for the food cart. The Dietary Supervisor stated, we are running a little behind and we are doing the best we can. There were only 2 kitchen staff members observed in the kitchen to cook and prepare the dinner meal, and the meal was not delivered timely. 3. During an interview on 1/8/2025 at 8:26 AM, the Administrator was asked if he was aware of any kitchen staffing concerns. The Administrator confirmed that he was aware of staffing concerns in the kitchen and that CNAs (Certified Nursing Assistants) were cross trained to assist in the kitchen. The facility was unable to provide competency documentation for the kitchen staff.

Based on job description review, and interview, the facility failed to ensure a full-time or part-time Registered Dietitian (RD), or a qualified Dietary Manager (DM) was employed to provide oversight of the kitchen, kitchen staff competencies, residents' prescribed diets, and meals served in a timely manner. This had the potential to affect 55 of 55 residents who received a tray from the kitchen. The findings include: 1. Review of a Registered Dietitian job description revealed .Major Duties and Responsibilities .Provides registered dietitian services in one or more sites according to policies and procedures, and federal and state requirements. Plans, organizes, develops, and directs the nutritional care of the resident in accordance with current federal, state, and local standards, guidelines and regulations. Assesses/Monitors the residents' nutritional status and provides recommendations to clinical/medical staff. Develop and updates nutritional care plans as needed. Observes resident meal service to ensure diets are correct and modifications are followed. Educates residents, families, and staff on nutritional concepts and diet modification. Works with other members of the interdisciplinary team to ensure that modified texture or therapeutic diets are in compliance with the resident's medical condition. Reviews menu changes to ensure compliance with the facility's policy and procedures and state and federal guidelines. Updates diet orders and menu changes as required. Conducts audit of relevant nutritional care on routine basis. Completes nutritional assessments on residents .Completes assigned sections in the Minimum Data Ser (MDS) as per facility policy and procedure and ensures the accuracy of the information provided. Performs regular inspection of food service areas for sanitation, order, safety, and proper performance of assigned duties. Monitors weight changes, nutrition support and skin breakdown, and makes recommendations as needed . Review of a Dietary Manager job description revealed .Overseeing safe and timely meal preparation, including the provision of meals and/or supplements in accordance with residents' needs, preferences, and care plan .Develops work schedules to ensure adequate staff to cover each shift .Follows standards and procedures for preparing food .Ensures safe receiving, storage, preparation, and service of food. Protects food in all phases of preparation, holding, service, cooking and transportation .Ensures proper sanitation and safety practices of staff . 2. During an interview on 1/6/2025 at 8:30 AM, the Dietary Supervisor confirmed that she had been in her current role since 8/2024 and was in the process of obtaining her certification since 8/2024. During an interview on 1/8/2025 at 8:05 AM, the Dietary Supervisor confirmed that the facility had been without a Registered Dietitian (RD) since the week of Christmas. During an interview on 1/08/2025 at 8:26 AM, the Administrator was asked about the facility RD. The Administrator named the former RD until 1/1/2025. The Administrator was asked who the RD was since 1/1/2025 was. The Administrator stated, I'm not for sure. The Administrator was asked if the new RD had been onsite. The Administrator stated, I'm not sure. The Administrator was asked, who is responsible for the kitchen, the ordering, monitoring of resident weights and diets. The Administrator confirmed the RD is responsible. During an interview on 1/09/2025 at 10:20 AM, the Director of Nursing (DON) confirmed that the former RD's last day at the facility was 12/27/2024. During a phone interview on 1/9/2025 at 10:50 AM, the Interim RD was asked when she was hired as the interim RD for the facility. The Interim RD confirmed that she signed a contract this week (week of 1/5/2024) to be the Interim RD of the facility, and she is scheduled to be onsite 1/10/2025. The Interim RD confirmed that she has not communicated with the Administrator or with nursing staff regarding any resident concerns.

Based on policy review, record review, and interview, the facility failed to post the total number of staff, and actual hours worked by the licensed and unlicensed staff responsible for resident care on the facility's Daily Nurse Staffing form for 31 of 31 sampled days. The findings include: 1. Review of the facility policy titled, Nurse Staffing Posting Information, dated 12/1/2024, revealed .It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time .will contain the following information .Facility name .total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift .Registered Nurses(RNs) .Licensed Practical Nurses(LPNs) .Certified Nurse Aides(CNAs) . 2. Review of the facility's Daily Nurse Staffing forms dated 12/2/2024 thru 1/2/2025, revealed there were no total number of RN's, LPN's, and CNA's and no total of the actual hours worked by the RNs, LPNs, and CNAs. During an interview 1/9/2025 at 3:30 PM, the Staffing Coordinator confirmed the facility had not provided the total number of RNs, LPNs, and CNAs, and the total number of hours worked by the RNs, LPNs and CNAs on the Daily Nurse Staffing form.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions when for 2 of 4 (Dietary [NAME] C and Dietary [NAME] D) dietary staff failed to perform hand hygiene, and when 1 of 4 (Dietary [NAME] D) failed to test the sanitation of the 3 compartment sink prior to use, when unlabeled, undated, and expired foods were stored in the kitchen. The facility had a census of 55 with 55 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility policy titled, Food Safety Requirements, dated [DATE], revealed .Food safety practices shall be followed throughout the facility's entire food handling process .Employee hygienic practices .Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely storage .Labeling, dating, and monitoring refrigerated food, including but not limited to left overs, so its used by its use by date, or frozen (where applicable) and discarded .Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Staff shall wash hands according to facility procedures. Gloves will be worn when directly touching ready-to-eat food and when serving residents . Review of the undated facility policy titled, Handwashing Guidelines for Dietary Employees, revealed .Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparations .After hands have touched anything unsanitary i.e [for example] garbage, soiled utensils/equipment, dirty dishes .While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks .Before donning for working with food .After engaging any activity that may contaminate the hands . Review of the facility policy titled, Manual Warewashing-3 Compartment Sink, dated [DATE], revealed .Sanitizing solutions shall be tested by a test kit or other device that accurately measures the concentration in MG/L [Milligram per Liter]. Testing will occur periodically but not limited to. When sink is initially filled .Sanitizing procedures for the three compartment sink .Third sink sanitizing .Fill with hot water or use chemical sanitizer .QAC [Quaternary] ammonia at ,d+[DATE] ppm [parts per minute]. Confirm appropriate temperature or concentration prior to washing and record on sanitation log . 2. Observation in the Kitchen on [DATE] at 8:30 AM, revealed the following: a. 2 unlabeled and undated (12 count) packages of hotdog buns on a rolling bread rack. b. 1 opened and undated box of frozen and exposed cinnamon rolls in the freezer. c. 1 opened and undated bag of roasted potatoes in the freezer. d. 1 opened and undated bag of fries in the freezer. e. 1 opened bag of hashbrown dated [DATE] with no use by date in the freezer. f. 1 bag of diced tomatoes dated ,d+[DATE] with no use by date in the walk-in refrigerator. g. 3 unopened and expired containers of Tuna Salad with use by date [DATE] in the walk-in refrigerator. h. 1 opened and expired container of Tuna Salad with use by date [DATE] in the walk-in refrigerator. i. 1 opened and expired container of Cucumber and Onion salad date opened [DATE] with used by [DATE] in the walk-in refrigerator. j. 2 unopened and expired containers of Cucumber and Onion salad with used by [DATE] in the walk-in refrigerator. k. 1 unlabeled and undated cooked hamburger patty in a plastic bag in the walk-in refrigerator. 3. Observation in the Kitchen on [DATE] at 10:59 AM, revealed 1 unlabeled and undated bag of brown gravy and 1 bag of frozen breaded chicken patties dated [DATE], with use by [DATE], stored in the walk-in freezer. 4. Observation and interview in the Kitchen on [DATE] at 8:05 AM, revealed Dietary [NAME] C washed a knife at the 3 compartment sink and placed the knife in the drying rack. Dietary [NAME] C was asked to perform a sanitation test on the 3 compartment sink. Dietary [NAME] C performed the sanitation test and the test strip did not change color. Dietary [NAME] was asked if she performed the sanitation test prior to using the 3 compartment sink. Dietary [NAME] C stated, No. Dietary [NAME] C was asked if the knife would need to be re-washed and sanitized. Dietary [NAME] C did not answer, but the Dietary Supervisor confirmed that the knife would be rewashed and sanitized. 5. Observation in the Kitchen on [DATE] starting at 11:06 AM to 11:48 AM, revealed Dietary [NAME] D at the steam table serving food without gloves. Dietary [NAME] D walked away from the steam table to obtain chicken salad from the walk-in refrigerator and did not perform hand hygiene before preparing the sandwich or returning to the steam table to serve. Dietary [NAME] D walked away from the steam table on multiple occasions to obtain ice water, a thermometer, sandwich bread, and returned to the steam table to serve food without performing hand hygiene and was ungloved during the entire time of observation. 6. Observation in the Kitchen on [DATE] at 1:15 PM, revealed Dietary [NAME] C in the dishwasher room. Dietary [NAME] C removed soiled trays from the cart, donned gloves, removed and discarded gloves, and did not perform hand hygiene. Dietary [NAME] C removed a clean rack from the dishwasher, placed the dishes on a rolling cart. Dietary [NAME] C failed to perform hand hygiene when going from soiled to clean dishes. 7. During an interview on [DATE] at 1:40 PM, the Dietary Supervisor confirmed that all foods should be labeled, dated, and should be discarded by the use by date. The Dietary Supervisor confirmed that hand hygiene should be performed prior to returning to the steam table, serving and/or handling food, and should be performed prior to handling clean dishes when soiled dishes have been handled. The Dietary Supervisor confirmed that the 3 compartment sink sanitation should be tested prior to use.

Based on policy review, medical record review, and interview, the facility failed to revise a person-centered care plan for 1 of 15 (Resident #25) residents reviewed for weight gain and weight loss. The findings include: 1. Review of the facility's policy titled, Comprehensive Care Plan, dated 12/1/2024, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Coronary Artery Disease, Failure to Thrive, Diabetes, Aphasia, and Dementia. Resident #25's weight log revealed on 6/11/2024, the resident's weight was 156.0 pounds (Lbs). Review of the Care Plan dated 8/27/2024, .Diet as ordered. Weigh with follow up as indicated. Monitor meal intake and offer substitute if resident doesn't eat meal. Double portions at all meals. Adhere to food preferences. Allow adequate time to eat, provide cues, encouragement, and assistance. Dietary consult as needed . Resident #25's weight log revealed the following weights: a. b. On 8/13/2024 - 158.0 Lbs. c. On 9/17/2024 - 161.0 Lbs. d. On 10/15/2024 - 165.0 Lbs. e. On 11/12/2024 - 168.0 Lbs. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 2, which indicated Resident #25 was severely cognitively impaired. Review of the Physician's Order dated 11/25/2024, revealed .Pureed diet [a diet of smooth, soft foods that are blended, mashed, or strained] . Puree texture, Regular consistency, Dysphagia [Difficulty swallowing] level 1. Review of the Physician's Order dated 7/10/2023, revealed .Megestrol Acetate [Megace used as an appetite stimulant] Oral Suspension 625 MG /5ML [milligram per 5 milliliters] .by mouth two times a day for Failure to thrive. Resident #25's weight log revealed on 12/18/2024 Resident #25 weighed 174.0 Lbs. Review of the Nurse's Note dated 12/20/2024, revealed .WEIGHT WARNING: Value: 174.0 [lbs] . Resident is a significant weight gain 8.1 % [percent] x [times] 90 days. Diet: pureed. Avg [Average] documented meal intake is 100% this month. Resident's weight has been steadily increasing .Resident currently on Megace 375 mg [milligram] po [by mouth] BID [two times daily]. Provider and RP [Responsible Party] notified. Will continue weekly weights. Review of the medical record revealed Resident #25's weight on 1/7/2025 was 180 lbs. Review of the weights revealed a significant weight gain of 8.33 % for the last 3 months, and a significant weight gain of 12.22% for the last 6 months. The facility failed to revise Resident #25's care plan to reflect weight gain and failed to care plan resident for Heart Failure. During an interview on 1/9/2025 at 3:00 PM, the Director of Nursing (DON) was asked about Resident #25's weight gain and concerns with resident having a diagnosis of Heart Failure. The DON stated, we are gathering the resident's weights to be reviewed with the Provider, and to see if medications need to be reduced. During an interview on 1/9/2025 at 4:30 PM, the MDS Coordinator confirmed that a care plan should be revised if a resident has a significant weight gain. 49269

Based on observation, medical record review, and interview, the facility failed to ensure a resident's dignity for 1 of 3 (Resident #13) residents reviewed for the use of an indwelling urinary catheter. The findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis (MS), Depression, Anxiety, Urinary Tract Infection (UTI), and Disorder of Bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, that indicated the resident was cognitively intact, dependent on staff for activities of daily living, incontinent of bowel and bladder, and diagnoses of UTI, MS, and the use of an antibiotic. Review of the Care plan dated 12/20/2024, revealed .has an Indwelling Catheter .Bladder disorder and MS . Review of a Physician Order dated 12/29/2024, revealed .Privacy bag in place for dignity every shift . Observations in Resident #13's room on 1/6/2025 at 10:19 AM, 11:16 AM, and 2:45 PM, revealed the urinary catheter bag attached to the resident's bed frame. The urinary catheter bag was not enclosed in a privacy bag and was visible from the hallway. During an interview on 1/9/2025 at 2:34 PM, the Director of Nursing confirmed that an indwelling urinary catheter bag should always be contained or have a privacy cover over it to promote the resident's dignity.

Based on policy review, medical record review, and interview, the facility failed to provide care to ensure that acceptable parameters of nutritional status were maintained for 1 of 15 (Resident #25) reviewed for weight gain and loss. The findings include: 1. Review of the facility policy titled, Nutritional Management, dated 12/1/2024, revealed .Weight related interventions .Monitoring/Revision .The care plan will be updated as needed, such as when a resident's condition changes, goals are met or the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified .The physician will be notified of significant changes in weight, intake or nutritional status . Review of the facility policy titled, Weight Monitoring, dated 12/1/2024, revealed .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight range and electrolyte balance .Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period time) may indicate a nutritional problem. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes. Identifying and assessing each resident's nutritional status .Evaluating/analyzing the assessment information. Developing and consistently implementing pertinent approaches. Monitoring the effectiveness of interventions and revising them as necessary .The physician should be informed of a significant change in weight and may order nutritional interventions .Observations pertinent to the resident's weight status should be recorded int he medical record as appropriate. The interdisciplinary plan of care communicates care instructions to staff . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Coronary Artery Disease, Failure to Thrive, Diabetes, Aphasia, and Dementia. Resident #25's weight log revealed on 6/11/2024, the resident's weight was 156.0 pounds (Lbs). Review of the Physician's Order dated 7/10/2023, revealed .Megestrol Acetate [used as an appetite stimulant] Oral Suspension 625 MG /5ML [milligram per 5 milliliters] . Give 3 ml by mouth two times a day for Failure to thrive. Review of the Care Plan dated 8/27/2024, .Diet as ordered. Weigh with follow up [report to Dietitian and Physician] as indicated. Monitor meal intake and offer substitute if resident doesn't eat meal. Double portions at all meals. Adhere to food preferences. Allow adequate time to eat, provide cues, encouragement, and assistance. Dietary consult as needed . Resident #25's weight log revealed the following weights: a. On 8/13/2024 - 158.0 Lbs. b. On 9/17/2024 - 161.0 Lbs. d. On 10/15/2024 - 165.0 Lbs. e. On 11/12/2024 - 168.0 Lbs. Review of the Nutritional Status Review assessment dated [DATE], conducted by the previous Registered Dietitian, revealed .IBW [Ideal Body Weight] 154 [pounds] .WT: [Weight] 168# [pounds] 11/12 [2024]. Grad [Gradual] weight gain noted. Skin intact. Meds reviewed; Megace [used to as appetite stimulant]. DL1 [Dysphagia Level 1] diet ordered w/ [with] 100% documented meal intake. Cueing w/ meals. Labs reviewed from 8/29 [2024]. ENN [Emergency Nutrition Network]: 1520-1748 kcals [kilocalorie], 76g [grams] pro [protein]. Diet meets ENN. Will continue current plan of care. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 2, which indicated Resident #25 was severely cognitively impaired. Resident #25's weight log revealed on 12/18/2024, Resident #25's weight was 174.0 Lbs. Review of the Nurse's Note dated 12/20/2024, revealed .WEIGHT WARNING: Value: 174.0 [pounds/lbs] Vital Date: 2024-12-18 16:30:00.0 +7.5% change [8.1%, 13.0] Resident is a significant weight gain 8.1% x 90 days. Diet: pureed. Avg [Average] documented meal intake is 100% this month. Resident's weight has been steadily increasing, resident is more alert and interactive with other residents and staff. He eats breakfast and lunch in dining room and is able to feed himself after tray set up assistance is given. Resident also is involved in activities almost daily. Resident currently on Megace 375 mg [milligram] po [by mouth] BID [two times daily]. Provider and RP [Responsible Party] notified. Will continue weekly weights. The facility failed to have an RD or Qualified Nutritional professional to reassess the resident's Weight Warning weight gain to determine if the gain was actual weight gain or fluid related to the diagnosis of heart failure, and the facility failed to notify the resident's physician/practitioner. Review of the medical record revealed Resident #25's weight on 1/7/2025 was 180 lbs. Review of the weights revealed a significant weight gain of 8.33 % for the last 3 months, and a significant weight gain of 12.22% for the last 6 months. During an interview on 1/9/2025 at 3:00 PM, the Director of Nursing (DON) was asked regarding the resident's weight gain and concerns with resident having a diagnosis of Heart Failure. The DON stated, we are gathering the resident's weights to be reviewed with the Provider, and to see if medications need to be reduced. The DON confirmed that she was unaware of resident's ideal weight.

Based on policy review, record review, and interview, the facility failed to reassess the effectiveness of pain medication for 1 of 15 (Resident #41) sampled residents reviewed for pain management. The findings include: 1. Review of the facility policy titled, Pain Management, dated 12/1/2024, revealed .The facility must ensure that pain management is provided to residents who require such services .The facility .will develop, implement, monitor, and revise interventions to prevent or manage each individual resident's pain .monitoring the effectiveness of the medication . 2. Review of the medical record revealed Resident #41 admitted to the facility on [DATE], with diagnoses including Hidradenitis Suppurativa (a chronic skin condition that causes painful lumps, boils and tunnels under the skin), Diabetes, End Stage Renal Failure, Pain, and Cellulitis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #41 was cognitively intact and received Opioids for pain. Review of the Care Plan dated 12/5/2024, revealed .at risk for pain .Administer analgesics [medication to treat pain] as ordered. Notify MD [Medical Director] if unresolved or worsens . Review of the Physician's Order dated 12/3/2024, revealed Acetaminophen Tablet [a pain medication] 325 mg [milligrams] Give 2 [tablets] by mouth every 4 hours as needed for pain. Review of the Physician's Order dated 1/2/2025, revealed Percocet [used to treat moderate to severe pain] Oral Tablet (Oxycodone w[with] Acetaminophen [a pain medication] 10-325 mg Give 1 [tablet] by mouth every 6 hours as needed for pain. Review of the Physician's Order dated 1/2/2025, revealed Pregabalin Oral Capsule [Lyrica-used for pain] 75 mg. Give 75 mg by mouth one time a day for neuropathic [nerve]pain. Review of the Medication Administration Record dated 12/2024 and 1/2025, revealed Resident #41 did not have a pain level documented after the administration of pain medications. During an interview in the Resident's room on 1/9/2025 at 2:49 PM, Resident #41 confirmed staff does not reassess her pain level after administering pain medication. During an interview on 1/8/2025 4:14 PM, the facility's Nurse Practitioner was asked about monitoring the residents' pain and what was expected of staff. The facility's Nurse Practitioner stated, .A pain assessment should be performed when giving the med, on a scale from 1 to 10 and to do a follow up for effectiveness [a follow up for the effectiveness of the pain medication] . During an interview on 1/9/2025 at 2:49 PM, the Director of Nursing (DON) confirmed the procedure for pain medication administration is to assess the resident's pain level before and after administering pain medication, and the results of the pain monitoring should be documented. Resident #41 received pain medication on a routine and as needed basis, however, the facility failed to ensure the resident's pain was reassessed for effectiveness of the pain medication.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 1 of 4 (Medication Room) medication storage areas, when internal medications were stored with external medications and when nasal spray was stored with ear drops. The findings include: 1. Review of the facility policy titled, Medication Storage, dated 12/1/2024, revealed It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms .to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .External Products .drugs for external use are stored separately from internal and injectable medications .Internal Products .Medications to be administered by mouth are stored separately from other formulations .eye drops, ear drops, injectables . 2. Observation in the Medication Room on 1/7/2025 at 2:20 PM, revealed the following: a. Four 1.3 oz (ounce) plastic tubes of glucose gel (an oral medication given to raise blood glucose levels) stored in a plastic container without a divider, along with 1 plastic tube of 1.0 oz hydrocortisone cream (external medication used for skin rashes), and two 1.0 oz tubes of triple antibiotic ointment (medication used for cuts and burns on the skin). b. Two 1.0 oz spray bottles of nasal decongestant spray (nose spray) stored in a plastic container without a divider along with two 0.05 oz of ear wax removal solution and 1 box of 36 single vials of gen-teal tears (eye drops). 3. During an interview on 1/7/2025 at 2:25 PM, Licensed Practical Nurse G confirmed that the glucose gel should be stored separately from the antibiotic ointment and the hydrocortisone cream. During an interview on 1/7/2025 at 2:30 PM, the Assistant Director of Nursing confirmed that eardrops and eye drops should be stored separately with a divider. During an interview on 1/9/2025 at 2:34 PM, the Director of Nursing confirmed that all external medications should be stored separately with a barrier for separation.

Based on policy review, medical record review, and interview, the facility failed to follow the physician orders for 2 of 15 (Resident #31 and Resident #159) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Consulting Physician/Practitioner Orders, dated 12/1/2024, revealed .Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician. A consulting physician/practitioner may include, but not limited to a resident's .Nurse practitioner .For consulting physician/practitioner orders received via telephone, the nurse will .Document the order on the physician order form, notating the time, date, name, title of the person providing the order, and signature and title of the person receiving the order. Call the attending physician to verify the order. Document the verification of the order by entering the time, date, name and title of the physician/practitioner verifying the order, and the signature and title of the person receiving the verification order .Follow facility procedures for verbal or telephone orders . Review of the facility policy titled, Laboratory Services and Reporting dated 12/1/2024, revealed .The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist .The facility is responsible for timeliness of these services . 2. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnoses including Hypertension, Aphasia, Cerebrovascular Accident, and Seizure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed no Brief Interview for Mental Status score was performed due to Resident #31 was severely cognitively impaired. Review of the Nurse's Note dated 1/8/2025 at 6:25 AM, revealed LPN B documented, .On call NP [Nurse Practitioner] called back . check heart rate for the next 6 hours, every hour . NP is aware of resident's history of bradycardia . Review of the Weights and Vitals Exceptions form revealed on 1/8/2025 at 6:09 AM, Resident #31's heart rate was 34 bpm (beats per minute), and at 8:32 AM the resident's heart rate was 35 bpm. LPN B failed to write the practitioner's verbal telephone order for Resident #31's heart rate to be checked every hour for 6 hours. During an interview on 1/8/2025 at 4:41 PM, LPN A was asked about checking and monitoring of resident's heart rate. LPN A confirmed that Resident #31's vitals (vital signs) and heart rate had only been checked once on her shift. During an interview on 1/9/2025 at 8:20 AM, the Medical Director (MD) was asked if he was aware of the resident's heart rate (HR) being in the 30's on the morning of 1/8/2025. The MD confirmed that he was informed in the evening (of 1/8/2025) and asked the facility staff to recheck the resident's HR. The MD confirmed that the resident's HR was 37 and the resident was sent to the emergency room (ER) for further evaluation. During a phone interview on 1/9/2025 at 9:08AM, LPN B was asked about contact with the NP for Resident #31's low HR of 34 on 1/8/2025. LPN B confirmed that she did not write an order, but an order should have been written. During an interview on 1/9/2025 at 2:35 PM, the Director of Nursing (DON) confirmed that an order should have been written, and staff should have monitored residents HR every hour per NP order. The facility failed to follow practitioner's verbal telephone order to monitor resident's heart rate every hour for 6 hours. 3. Review of the medical record revealed Resident #159 was admitted to the facility on [DATE], with diagnoses including Methicillin Resistant Staphylococcus Aureus Infection, Pain, and Pressure Ulcer of Sacral Region. Review of the admission MDS assessment dated [DATE], revealed Resident #159's BIMS score was 14, which indicated resident was cognitively intact. Review of a Progress Note dated 1/6/2025, revealed the ADON documented .resident has been refusing IV [intravenous] [NAME] [Antibiotics] due to c/o [complaint of] diarrhea .ID [Infectious Disease] notified, hold [NAME] and collect stool for C. diff [Clostridium Difficile-a bacterium that causes an infection of the colon] . Review of the Physician's Order dated 1/8/2025, revealed Resident #159 did not have a lab order for stool collection to rule out C. diff. During an interview on 1/9/2025 at 9:54 AM, the Assistant Director of Nursing (ADON) confirmed Resident #159 should have an order in the system to collect a C Diff stool sample. The ADON confirmed Resident #159's C diff stool sample had not been collected. The facility failed to document the order, failed to collect the stool sample, and failed to perform the test for C-diff as ordered by the provider. 49269

Based on policy review, observation, and interview, the facility failed to provide privacy during 1 of 1 meeting with active Resident Council members. The findings include: The facility's Resident Council Meeting Policy, revised 5/15/2023 revealed, .The facility shall provide the Resident Council with a private space to meet .Staff members may attend the council meetings only at the request of the group . Observation on 9/20/2023 at approximately 1:37 PM, revealed, the Resident Council meeting was called to order by the Activities Director, with Resident #1, #11, #19, #25, #39, #40, and #41 in attendance. The Activities Director exited the meeting and entered her office approximately10 feet from the meeting space, sat at her desk with the door to her office remaining open during the Resident Council meeting. Observation during the Resident Council Meeting held in the facility's Dining Room on 9/20/23 at 1:37 PM, revealed 2 staff members sitting at tables at the back of the dining room, Certified Nursing Assistant (CNA) #4 was sitting by the window near the piano eating her lunch and the dietary cook sitting at a table talking on her telephone. CNA #4 exited the room at approximately 1:50 PM. The dietary cook exited the room at approximately 2:00 PM. Observation in the dining room on 9/20/23 at 1:45 PM, revealed [Named] company staff #1 entered the dining room and exited the dining room door going down the 100 hall and returned back through the dining room at 1:47 PM from the 100 hall and entered back into the kitchen. Observation in the dining room on 9/20/23 at 2:16 PM, revealed [Named] company staff #2 entered the dining room twice during the Resident Council meeting. The facility failed to ensure the Resident Council members had privacy during an active meeting of Resident Council. During an interview on 9/22/2023 at 1:16 PM, the Administrator was asked should the Resident Council be provided a private place to meet without staff being present. The Administrator confirmed that the Resident Council meeting should be held in a private place with the option of staff not being present. The Administrator confirmed that the Activities Director should have closed her door to the meeting and no staff should have been present unless approved by the residents and no one should have been walking through the meeting area during the meeting time.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure activities of daily living assistance was provided related to good grooming, personal hygiene, and nail care for 3 of 4 (Resident #3, #6, and #42) sampled residents reviewed for activities of daily living. The findings include: The facility's Activities of Daily Living (ADL), policy dated 3/9/2023, revealed .Care and services shall be provided for the following activities of daily living .Bathing, dressing, grooming and oral care .A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . The facility's Dietary-Dining Services, policy dated 3/8/2023, revealed, .The nursing staff shall be responsible to properly prepare the resident for the dining service .Appropriate hygiene provided prior to meals being served .dignity shall be maintained .Residents shall be assisted with hand hygiene before meals . The facility's Day Shift CNA (Certified Nursing Assistant) Assignment Sheet, dated 5/28/2014, revealed, .Routine patient care .nail care, hair, denture & mouth care .facial hair removed from female patients . 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Alzheimer's Disease, Depression, Anxiety, and Hypertension. Review of quarterly MDS dated [DATE] revealed Resident #6's BIMS was 3 indicating severe cognitive impairment and required extensive assistance with all ADLs. Review of Resident #6's Care plan dated 7/17/2023, revealed self care deficit .related to bathing, bed mobility, dressing, eating, hygiene .Bath/Shower .3x[times]week .alternating days with bed baths . The facility's ADL [activities of daily living] Verification Worksheet, documentation revealed Resident #6 did not receive a shower the weeks of 8/1/2023, 8/7/2023, 8/14/2023, 8/14/2023, 8/21/2023, 8/28/2023, 9/4/2023, 9/11/2023, or the week of 9/18/2023. Observations on 9/18/2023 at 8:45 AM, 12:12 PM, 2:40 PM, and 4:05 PM, revealed Resident #6's mouth had a dark substance around the lips, facial hair, long fingernails with a black substance underneath, untrimmed, and soiled. During an interview on 9/18/2023 at 1:12 PM, CNA #9 was asked when was the last time Resident #6 was bathed and given hygiene care. CNA #9 stated, .she was sponged this morning . During an interview on 9/18/2023 at 4:30 PM, LPN #2 was asked when was the last time Resident #6 had a shower and personal hygiene give. LPN #2 stated, .I don't see documentation for today .she is past due for a shower . 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of Dementia, Chronic Kidney Disease Stage 3, Pain, Personal History of Malignant Neoplasm of the Breast, and Osteoarthritis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was assessed with a Brief Interview for Mental Status score of 12, indicating the resident was moderately cognitively impaired, required extensive assistance with dressing, personal hygiene and was dependent on staff for bathing, and range of motion (ROM) limitations on both side of lower extremities. Review of the Care plan revealed, .Self-care deficit R/T (related to) .bathing .dressing .hygiene .Assist with hygiene . Review of the Day Shift CNA Assignment Sheets for September 2023 revealed the facility could not provide documentation that nail care had been provided on 9/11/2023, 9/12/2023, 9/13/2023, 9/15/2023, 9/16/2023, 9/17/2023, and 9/20/2023. Observations in Resident #42's room on 9/18/23 at 9:55 AM, 9/19/2023 at 10:09 AM and 11:09 AM, and on 9/20/2023 at 8:56 AM and at 9:31 AM, revealed Resident #42 with long jagged fingernails on left hand with a dark brown and blackish dried substance underneath each fingernail. During an observation and interview in Resident # 42's room on 9/20/23 at 9:00 AM, revealed Resident #42 sitting up in her bed feeding herself her breakfast. Resident #42 picked up a sausage with her fingers feeding herself, Resident #42's fingernails were long and jagged with a thick brown and blackish substance underneath each fingernail. CNA #1 confirmed nail care is given daily with bath and showers and as needed when they observe they need care unless the resident is a diabetic. CNA #1 confirmed that if the resident is diabetic the nurses will do the care and services for both fingernails and toenails. During observation and interview in Resident #42's room on 9/20/23 at 9:10 AM, revealed Resident #42 feeding herself her breakfast, Registered Nurse (RN) #1 was shown Resident #42's fingernails and the resident's matted eyes with dried white substance in the resident's eyes and was asked who is responsible for cleaning residents' fingernails. RN #1 confirmed CNAs are responsible for nail care daily unless the resident is a diabetic and then the nurse will be prompted to give nail care weekly or as needed. RN #1 confirmed that Resident #42 fingernails should be neat and a proper length to their preference and should not have any brown or blackish substance underneath their fingernails. 3. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses Hemiplegia, Cachexia, Legal Blindness, and Diabetes. Review of Resident #3's quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status score (BIMS) of 11, indicating Resident #3 was moderately cognitively impaired and required extensive assistance for all ADLs. Review of Resident #3's Care plan dated 8/9/2023, revealed, .assistance with ADL's .self care deficit .related to bathing, bed mobility, dressing, eating, hygiene .Bath/Shower .3x[times]week .alternating days with bed baths . Observations in Resident #3 room on 9/18/2023 at 9:33 AM and 2:45 PM, revealed Resident #3's face with dried white sputum around mouth, eyes appeared closed with white matter around eyes, and a smell of urine. Observations in Resident #3's room of the resident on 9/19/23 at 10:57 AM, revealed Resident #3's face with dried white sputum and with a strong foul smell of urine. During an interview on 9/18/2023 at 3:10 PM, CNA #1 was asked when does Resident #3 receive a bath or hygiene care. CNA #1 stated, .he should have today .he should have a shower 3 times a week and a bed bath on the other days . During an interview on 9/19/2023 at 11:30 AM, Licensed Practical Nurse (LPN) #2 was asked when was Resident #3 given a bath. LPN #2 stated, .he should have a bath daily and a shower 3 times a week .but I don't see where he has had a shower documented in a while . The facility's ADL [activities of daily living] Verification Worksheet, documentation revealed Resident #3 did not receive a shower the weeks of 8/2/2023, 8/7/2023, 8/12/2023, 8/17/2023, 8/21/2023, 8/27/2023, 9/3/2023, 9/10/2023, or the week of 9/17/2023. During an interview on 9/21/2023 at 10:30 AM, the Director of Nursing (DON) confirmed Resident #3 and Resident #6 did not have documentation of a shower for the months of August 2023 and September 2023. The DON stated, .we need to work on the documentation of showers .if not documented it wasn't done . During an interview on 9/22/2023 at 1:35 PM, the Administrator was asked do you feel like soiled fingernails, facial hair, dried white sputum on a resident's face, is good patient care. The Administrator stated, No. RESIDENT #6 PW During an interview on 9/19/23 at 4:55 PM, the Assistance Director of Nursing (ADON) was asked when should a resident be shaved. The ADON confirmed on shower or bath days or as needed, and no female should have facial hair. The ADON confirmed that nail care including fingernails and toenails are done on bath and shower days by the CNAs unless they are a diabetic and then the nurses are prompted to do it weekly are as needed when they see that they are soiled or in need of care. During an interview on 9/19/23 at 5:01 PM, CNA #2 confirmed Resident #42 is extensive to total care with all ADL care and requires the assistance from staff. CNA #2 confirmed Resident #42's shower days are on Monday, Wednesday, and Fridays and nail care should be given at that time unless she is a diabetic and then the nurses will the give care. CNA #2 confirmed that if they see that a resident needs nail care and is a diabetic that they inform the nurse so she can give the care. During an interview on 9/21/23 at 8:00 AM, the Director of Nursing (DON) was asked review the facility's Day Shift CNA Assignment Sheet form and was asked how do I know nail care was completed for Resident #42. The DON confirmed that both the charge nurse and the CNA are to sign and date and mark yes/no if all assignments were completed and if all the assignments were not completed then they are to give a written explanation on the sheet as to why it was not completed. The DON confirmed that if yes/no is not marked and if both the nurse and the CNA failed to sign the assignments are not complete. During an interview on 9/21/23 at 8:35 AM, the DON entered the Private dining room and stated, .this form is a system failure .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were available for administration for 1 of 4 (Resident #22) sampled residents observed during medication administration. The findings include: Review of the facility's policy titled, Medication and Biological Storage, Night/ Emergency Box and Backup Pharmacy, revised 8/2021, revealed .To outline process for medication and biological storage and back-up medications and pharmacy .The nurse shall check the hospital's back-up box/I-Stat .If medication is not available in the back-up box, the medication shall be ordered from the back-up pharmacy . Review of the facility's policy titled, Medication Administration, revised 8/4/2023, revealed .Medications shall be administered by licensed medical or nursing personnel acting within the scope of their practice and per the Physician's Signed Order. While administering medications the nurse shall observe the 8 Rights of Medication Administration .Right Time .Check to ensure the medication is given within the constraints of the order .Patient medications are provided by our contracted provider or an approved backup pharmacy . Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Diabetes, and End Stage Renal Disease. Review of the Physician Order Sheet, dated 9/6/2023, revealed .Flonase (nasal medication used for allergies) 50 mcg [micrograms]/ .nasal spray, suspension .2 sprays in each nostril B.I.D [two times daily] .Rhinitis . Observation on the 100/200 Hall medication cart on 9/20/23 at 7:29 AM, revealed Registered Nurse (RN) #1 confirmed the nasal spray, Flonase, was not in stock and was unavailable for administration to Resident #22. Review of the September 2023 Medication Administration Record (MAR) revealed Flonase was not administered on 9/20/2023. During an interview on 9/21/23 at 11:29 AM, the Director of Nursing (DON) confirmed that if medications are not available in the emergency lock box, the facility has a local back up pharmacy that can be contacted to deliver the medication to the facility. The DON confirmed no resident should go without their medication. During an interview on 9/21/23 at 11:45 AM, RN #1 confirmed the medication was not available for administration on 9/20/2023 and that she failed to order the medication from the back-up pharmacy until the morning of 9/21/2023.

Based on policy review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 4 of 39 (Resident #3, #6, #12, ,and #42) resident rooms. The findings included: The facility's Housekeeping-Cleaning and Disinfecting, policy revised 5/15/2023, revealed, .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible .Routine cleaning of environmental surfaces and non-critical resident care items shall be performed .to keep surfaces clean and dust free .Specific areas include .Resident rooms .floors shall be cleaned last .In some facilities the Nursing staff designated for caring for residents may need to complete the housekeeping duties . Observations in Resident #42's room on 9/18/23 at 9:55 AM, and 10:46 AM, revealed a light brown sticky substance on the floor on the right side of the residents bed extending to underneath the bed and to the heating and air conditioning unit on the left side of the bed. During observation and interview in Resident #42's room on 9/18/23 at 3:10 PM, revealed light brown sticky substance on the floor on the right side of the resident's bed extending to underneath the bed to the heating and air unit on the left side of the bed. The Administrator was asked how often are rooms cleaned. The Administrator confirmed rooms are cleaned daily and are touched up if there are issues. The Administrator confirmed that the room should have already been cleaned and the sticky area should not be there. During observation and interview in Resident #42's room on 9/19/23 at 7:30 AM, revealed a light brown sticky substance stain on the floor on the left side of the resident's bed near the heating and air unit. The Administrator was asked should that area remain there if the housekeeping staff cleaned, swept and mopped the room yesterday and touched up the floor before she left. The Administrator confirmed the area should not be there. During an interview on 9/22/2023 at 1:41 PM, the Director of Nursing confirmed that keeping resident's room clean is a joint effort between housekeeping and nursing to include mopping up spills and picking up trash and wiping substances off of walls. During an observation in Resident #3's room on 9/18/2023 at 9:55 AM, a dark brown substance on the wall beside the bed, floor with dark stains in floor. During an observation of Resident #3's room on 9/19/2023 at 8:30 AM salt/pepper paper, dried red spots scattered on floor around bed, resident sitting in bed alert to self 02 at 3L/MIN, baseboard loose from wall at head of bed, loose black hair in corner of floor at head of the bed. During an observation of Resident #3's room on 9/19/2023 at 3:45 PM revealed salt/pepper paper, dried red spots scattered on floor around bed, baseboard loose from wall at head of bed, loose black hair in corner of floor at head of the bed. During observation of Resident #3's room on 9/20/2023 at 10:30AM food crumbs, napkin on the floor, dark brown spots dried in floor, body odor noted in room. During an observation of Resident #3's room on 9/21/2023 at 9:55 AM food crumbs and debris under bed, brown foot substance on the floor. A brown dark substance on wall beside the bed. During an observation of Resident #6's room on 9/18/2023 at 8:55 AM, overbed table noted with dirty During an observation of Resident #6's room on 9/20/2023 at 8:45 AM dark substance smeared on wall beside toilet. During an observation of Resident #6's room on 9/20/2023 at 2:00 PM, dust noted on the over bed lights, dried dark brown smear on the wall. During an interview with the Administrator on 9/22/2023 at 10:30 AM, the Administrator was asked what was on the wall beside Resident #3. The Administrator stated, looks like BM .should be cleaned . Administrator was asked if this was acceptable. Admin stated No. Admin was asked if floor is dirty he stated YES .needs cleaning .

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 2 of 2 staff members (Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1) left the medications unattended and unsecured, and when external and internal (oral) medications were stored together in the medication cart. The findings include: Review of the facility's policy titled, Medication and Biological Storage, Night/Emergency Box and Backup Pharmacy, revised 8/2021, revealed .All medications are stored in designated areas which are sufficient to ensure proper sanitation .and security .drugs for external use are stored separately from internal and injectable medications . Observation during medication administration on 9/20/23 at 9:43 AM, revealed RN #1 gathered medications for administration to Resident #22, placed the medications in a medication cup, knocked and entered Resident #22's room, leaving a bottle of lactobacilli (a medication used to treat bacteria in the stomach) sitting on top of the medication cart, unattended and unsecured. Upon entering the room RN #1 placed the cup of medications on the over the bed table, exited the room and returned back to the medication cart for a cup of water, leaving the medications unattended and unsecured on the resident's over the bed table. During an interview on 9/20/2023 at 10:05 AM, RN #1 confirmed medications should not be left unattended and unsecured and should be stored and locked in the medication cart. Observation during medication administration on 9/20/23 at 3:20 PM, revealed LPN #1 gathered medications for Resident #48 and placed them in a medication cup, knocked and entered the room, placed the cup of medication on the over the bed table, pulled the privacy curtain, and entered the bathroom to wash her hands leaving the medication unattended and unsecured on the over the bed table. During observation and interview of the 100/200 Hall Med Cart on 9/21/23 at 11:45 AM, revealed a tube of Santyl (a topical medication used to remove necrotic tissue) Ointment 30 gram and a tube of Triamcinolone (a cream used to treat skin conditions) 0.1% (percent) in the same sectioned drawer as oral medications. LPN #1 confirmed the ointments should not be stored in the same sectioned area as the oral medications. During an interview on 9/22/2023 at 12:27 PM, the Director of Nursing (DON) confirmed nurses should remain with medications at all times and medications should remain within sight of the nurse until administration. The DON confirmed that creams and ointments should be stored in separate compartments from oral medications in the medication cart.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 3 of 11 staff members (Certified Nursing Assistant (CNA) #1, CNA #2, and CNA #3) observed during dining failed to knock and/or announce herself before entering a room, failed to use courtesy titles, and referred to residents as feeders. The findings include: The facility's Promoting/Maintaining Resident Dignity Policy, dated 10/24/2022, revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .Speak respectfully to residents . Observation in resident's room on 9/18/2023 beginning at 12:10 PM, revealed CNA #1 placed the meal tray on the over the bed table and stated, I'll get to it baby . Observation during dining on the 200 hall on 9/18/2023 at 12:13 PM, revealed CNA #2 entered Resident #15's room, placed the meal tray on the over the bed table, set up the meal tray, and exited the room. CNA #2 failed to knock or acknowledge herself prior to enter Resident #15's room. Observation during dining on the 200 hall on 9/19/2023 at 8:38 AM, revealed CNA #2 CNA #2 failed to knock or announce herself when entering Resident #7 and Resident #14's room. Observation during dining on the 200 hall on 9/19/2023 at 8:45 AM, revealed CNA #4 was asked are there any more trays to be served, CNA #4 stated while standing in the hallway, I have 2 that are feeders . During an interview on 9/22/23 at 1:41 PM, the Director of Nursing (DON) confirmed staff should address residents with courtesy titles, should not refer to residents as feeders, and should knock and announce themselves before entering a resident's room.

Based on National Pressure Ulcer Advisory Panel (NPUAP) quick reference guide, policy review, medical record review, observation, and interview, the facility failed to identify a pressure ulcer and obtain a physician's orders [REDACTED].#1) sampled residents reviewed for pressure ulcers. The failure of the facility to perform a skin assessment, identify a pressure ulcer, and obtain a physician's orders [REDACTED].#1. The findings include: Review of the NPUAP quick reference guide, revised 4/13/16, defined a Stage 3 pressure ulcer as .Full thickness loss of skin .Slough and/or Eschar may be visible. The depth of tissue damage varies .Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed . The facility's Pressure Injury Prevention and Non-Pressure Ulcer Management policy revised 5/2019 documented, .This facility is committed to the prevention of avoidable pressure injury .A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s) .Licensed nurses will conduct a full body assessment on all residents .Findings will be documented in the medical record .The attending physician .will be notified for the following .Presence if (of) a new pressure ulcer/injury . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #1 was cognitively intact. Resident #1 required extensive assistance for bed mobility, transfers, toileting, and personal hygiene, and had a Stage 3 pressure ulcer. The care plan dated 3/6/19 documented, .Problems .at risk of pressure ulcer related to occasional incontinence, decreased mobility, dx (diagnosis) of over active bladder .Interventions .Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown .Problems .Stage 3 pressure ulcer to the sacrum (unknown updated date) .GOAL DATE: 8/26/2019 Assess and record the size .amount and characteristics of exudates .Treatments as ordered . Review of the Resident #1's weekly skin audits on 5/1/2019, 5/7/2019, and 5/23/2019 revealed there were no pressure ulcers present. Medical record review revealed Resident #1 was admitted to the hospital for Pneumonia from 5/12/19 through 5/16/19. A NURSING ADMISSION/READMISSION FORM dated 5/16/19, after readmission from the hospital, documented, .SKIN CONDITION .Skin color .Normal for ethnicity .Skin Turgor .WNL (Within normal limits) .Skin Temperature .WNL .Ulcer/Injury Present .No .Non-Ulcer Present .No . The BRADEN SCALE FOR PREDICTING PRESSURE INJURY RISK dated 5/16/19 documented a Braden Score of 17, which indicated Resident #1 was at risk for Pressure Injury. A hospital DISCHARGE SUMMARY dated 5/16/19 documented, .Integumentary: Warm, Dry, Pink . There was no documentation Resident #1 had a pressure ulcer in the hospital. Medical record review revealed there was no documentation between 5/16/19 and 5/27/19 that Resident #1 had treatment orders or had any treatment orders for a pressure ulcer. A nurses' note dated 5/28/19 documented, .pt (patient) noted with a sacral wound . There was no documentation of the description of the pressure ulcer. A physician's orders [REDACTED].Begin date: 05/29/2019 .Santyl (A selective agent for removal of dead tissue from wounds) 250 unit/gram topical ointment .1 Time daily .cleanse wound to sacrum with wound cleanser, apply santyl .and dry dressing daily until healed . A WOUND AND PRESSURE INJURY INFORMATION form dated 5/28/19 documented, .Location: sacrum .Onset Date: 05/28/2019 .Type of Wound .Pressure .For Pressure Injury: 3 (Stage) (Full thickness tissue loss .Slough may be present .) .Overall .status .New .Length .3.0 cm (centimeters) .Width .1.0 cm .Depth .0.1 cm .Tissue Type .Slough .what % (percentage) of wound bed is covered .> (greater than) 75% .MD (Medical Doctor) Notified Date .05/28/2019 . A signed statement by Licensed Practical Nurse (LPN) #1 dated 6/25/19 documented, .On 5/27/19 I worked on 300 Hall. Patient (Resident #1) .had [MEDICATION NAME] (a clear dressing for wounds) dressing on her .sacrum. Old dressing was rolled up & (and) coming off. I removed old dressing and replaced it (symbol for with) new [MEDICATION NAME] dressing . Wound care observations in Resident #1's room on 6/25/19 at 2:22 PM, revealed Resident #1 was lying in the bed on her back. The pressure ulcer appeared round, edges were pink and healthy appearing, slightly raised white center of wound, and did not appear open. Interview with LPN #1 on 6/25/19 at 6:44 PM, in the Conference Room, LPN #1 confirmed she failed to assess the wound, failed to review the medical record for a treatment order, and applied a duoderm ([MEDICATION NAME]) dressing to the wound without obtaining a physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on 6/25/19 at 4:04 PM, in the Conference Room, the DON confirmed Resident #1's pressure ulcer was first identified as a Stage 3 pressure ulcer. The DON was asked if a pressure ulcer should be identified prior to a Stage 3. The DON stated, Yes, I would hope so . The DON was asked when the physician was notified of the Stage 3 pressure ulcer. The DON stated, 5/28/19. The DON confirmed she did not know when the Stage 3 pressure ulcer developed. Interview with Registered Nurse (RN) #1 on 6/25/19 at 5:42 PM, in the Conference Room, RN #1 was asked if Resident #1's sacral pressure ulcer on was identified on 5/28/19. RN #1 stated, .yes .I assumed it was something in the chart but (it) was not .she had a wound without any documentation . RN #1 was asked what the stage of the pressure ulcer was. RN #1 stated, .I called (Named DON) .and she (DON) said we're going to have to call it a 3 (Stage). RN #1 was asked if she applied another duoderm ([MEDICATION NAME]) to the wound. RN #1 stated, No, it didn't need another duoderm . RN #1 was asked if a [MEDICATION NAME] was an inappropriate treatment for [REDACTED]. RN #1 stated, I would think so. Telephone interview with Physician #2 (Resident #1's physician) on 6/26/19 at 10:10 AM, Physician #2 was asked if a pressure ulcer should be identified prior to a Stage 3. Physician #2 stated, .should be identified before it gets to a Stage 3 . Physician #2 was asked if Resident #1's Stage 3 pressure ulcer should have been identified prior to 5/28/19. Physician #2 stated, Yes, it should have been identified before (MONTH) 28th . Telephone interview with Physician #1 (this physician took care of Resident #1 while Resident #1's physician was out of the country) on 6/26/19 at 10:35 AM, Physician #1 was asked if Resident #1 had a pressure ulcer on admission to the hospital on [DATE]. Physician #1 stated, I don't see any documentation in the ER (emergency room ) notes and in my notes . Interview with the DON on 6/26/19 at 11:50 AM, in the Beauty Shop, the DON was asked if there was documentation Resident #1 had a pressure ulcer prior to 5/28/19. The DON stated, No . The DON was asked if there was documentation of any wound treatments or dressing changes for Resident #1 prior to 5/28/19. The DON stated, Not that I see between 5/16/19 and 5/28/19. The DON was asked when she was first made aware of Resident #1's sacral pressure ulcer. The DON stated, The 28th (5/28/19). The DON was asked the facility's process when a new pressure ulcer was identified. The DON stated, Measure it, fill out wound sheet, call doctor, and get order for whatever treatment is needed . The DON was asked to describe Resident#1's sacral pressure ulcer when it was first identified. The DON stated, .(it) measured 3 by 1, it was a sacral ulcer, it had some sloughy looking stuff on it . The DON was asked if a nurse should put a dressing on a pressure ulcer without a physician's orders [REDACTED]. The facility failed to identify a new pressure ulcer, failed to document the findings of a new pressure ulcer, and failed to obtain a physician's orders [REDACTED].#1.