Every finding on record at Brentwood Center For Health & Rehabilitation, LLC

Based on observations and interviews, the facility failed to adequately maintain the facility in good repair and sanitary condition for 4 of 4 Units. (Passport, LTC both Long Hall and Short Hall, Eagle, and Sebago). Findings:1.On 3/2/26 between 9:00 a.m. - 9:10 a.m., a surveyor observed missing tiles in Whirlpool room near Sebago and Eagle units. Observed multiple areas of frayed carpet and dirty carpet all throughout the facility. Eagle Unit Dining Room has marred walls. 2. On 3/2/26 at approximately 2:00 p.m., a surveyor observed the following: room [ROOM NUMBER]A - The wall is marredroom [ROOM NUMBER]- Hand Sanitizer on wall is missing cover. room [ROOM NUMBER]A - The heater on wall is missing the cover and is exposed, and the sheet rock is unpainted. 3. On 3/4/26 - 12:10 p.m. during observational rounds with Administrator, the following were observed and confirmed: The carpeting in both Passport/Long Term Care Hall and the Eagle/Sebago Hall is badly worn and stained. room [ROOM NUMBER]A - The overbed light is not working, and the bathroom has a hole in the wall. room [ROOM NUMBER] - The divider curtain is stained. room [ROOM NUMBER] - A urinal & bed pan on the bathroom floor behind the toilet.room [ROOM NUMBER] - Night stand door not able to be closed due to broken hinge. room [ROOM NUMBER] - Heavy amount of dust on TV arm.105A - Light over bed does not work. Common Dining room has tape on ceiling in three places, and observed a torn ceiling tile in front of the clock

Based on observations and interviews, the facility failed to ensure that the resident's environment was free of accident hazards related to broken floor heaters for 2 of 3 days of survey.Findings:1. On 3/2/26 at 10:15 a.m., observations of floor radiators missing the coverings exposing piping and sharp metal fins in rooms [ROOM NUMBER].On 3/2/26 at 10:37 a.m., the above information was confirmed with the Maintenance Director.2. On 3/3/26 at 7:02 a.m., observation of a broken radiator exposing piping and sharp metal fins in the TV room on the Passport Unit. At this time, it was observed with the Director of Clinical Operations.

Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of all residents residing in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's).Findings:Review of Payroll Based Journal staffing report revealed the facility triggered for Excessively Low Weekend Staffing during the fourth quarter 4 (July 1, 2025 through September 30, 2025).On 3/2/25 at 1:35 p.m., review of weekend staffing from July 1, 2025 through September 30, 2025 with the Facility Administrator, it was confirmed that the facility did not have enough staff to meet resident needs on the shifts they were short.

Based on record review, observations and interviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 4 of 4 medication cart narcotic bound books reviewed (Eagle unit, Passport unit Short Hall and Kitchen Hall).Findings:1. Eagle unit Controlled Substance Book #2 with shift counts were reviewed, which indicated the facility counts at the change of each shift, approx. 3 times a day. The person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 6/22/25, 9/5/25, 9/12/25, 9/24/25, 10/26/25, 12/14/25, 1/5/26, 1/6/26, 1/8/26, 1/15/26, 1/25/26, 1/26/26, 1/31/26, 2/1/26 and 2/6/26. 2. Passport unit Controlled Substance Book #8 with shift counts were reviewed, which indicated the facility counts at the change of each shift, approx. 3 times a day. The person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 10/3/25, 10/7/25, 10/14/25, 10/15/25, 1/1/26, 1/4/26, 1/13/26, 1/14/26, 1/16/26, 1/19/26, 1/21/26, 1/22/26, 2/10/26, 2/20/26 and 2/21/26.3. Short Hall Controlled Substance Book #5 with shift counts were reviewed, which indicated the facility counts at the change of each shift, approx. 3 times a day. The person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 4/12/25, 4/24/25, 4/29/25, 5/6/25, 10/1/25, 12/11/25, 1/1/26, 2/1/26, 2/2/26, 2/7/26 and 2/10/26.4. Kitchen Hall Controlled Substance Book #5 with shift counts were reviewed, which indicated the facility counts at the change of each shift, approx. 3 times a day. The person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 1/1/26, 1/2/26, 2/1/26, 2/2/26 and 2/9/26.On 3/3/26 at 8:46 a.m., during an interview, the above was confirmed with the Regional Director of Clinical Operations.

Based on observations, record review and interviews, the facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use for 3 of 3 medication carts observed (Eagle, Passport and Kitchen hall medication carts), and 1 of 4 medication rooms observed (Sebago Unit), and the facility's Pixis machine (an automated, secure, medication dispensing cabinet used to manage, store, and track pharmaceuticals).Findings:1. On 3/2/26 at 8:26 a.m., observation of the Sebago medication room with Registered Nurse (RN) #1 the following medications were expired and available for use:1 bottle of Lactaid tabs with expiration date of 12/251 bottle of Vitamin B6 tabs with expiration date of 7/251 bottle of Aspirin 325mg (milligram) with expiration date of 1/26. 2. On 3/2/26 at 8:44 a.m., observation of the Eagle unit medication cart with RN #2 the following medications were expired and/or unlabeled with open or discard date and available for use:2 bottles of Naproxen 220mg tabs with expiration date of 1/262 opened and undated Lantus Solostar pens with manufacturer's instructions of: once in use, store the pen at room temperature for up to 28 days. 1 opened and undated Novolog insulin with manufacturer's instructions of: dispose after 28 days, even if there is insulin left. 3. On 3/3/26 at 7:44 a.m., during observation of the Passport medication cart with the Certified Medication Technician (CNA-M), an opened and undated Tresiba flex pen with manufacturer's instructions to: Discard 8 weeks (56 days) after first use, even if insulin remains, was available for use. At this time, both the surveyor and the CNA-M discussed the undated pen with the Licensed Practical Nurse (LPN) #1. 4. On 3/3/26 at 8:30 a.m., during observation of the Kitchen Hall medication cart with the LPN #2, the cart contained one opened bottle of Naproxen Sodium 220mg tablets with expiration date of 1/26. 5. On 3/3/26 at approx. 12 p.m. a review of the facility's Pixis machine medication expiration dates revealed the following medications were expired:5 tabs of Amiodarone 200mg with expiration date of 2/28/261 vial of Cefepime 1 gram for injection with expiration date of 2/28/262 fentanyl 25 mcg (microgram) patches with expiration date of 2/28/263 tabs of Ropinirole 1 mg with expiration date of 2/28/26. At approx. 12:30 p.m., both the Surveyor and LPN #1 observed the above medications in the Pixis and were available for use.On 3/3/26 at approx. 2 p.m., the above was discussed with the Regional Director of Clinical Operations.

Based on record reviews and interviews, the facility failed to ensure physician orders were organized and updated to reflect resident's current needs by failing to discontinue inactive physician orders for 2 of 7 sampled residents. (Resident #5 and #23)Findings:1. On 3/2/26 at 7:47 a.m., and on 3/3/26 at 9:10 a.m., Resident #5 was observed receiving oxygen via a nasal cannula with the oxygen concentrator set at 1.5 liters per minute.Resident #5's active provider orders, as of 3/3/26, contain three orders for oxygen:> Oxygen at 2 liters per minute as needed to maintain oxygen saturation level at 90 percent. Active 5/10/25> Oxygen at 2 liters per minute as needed for shortness of breath Indicate O2 Sats (%), Start and Stop Times in Supplementary Documentation. Active 5/10/25.> Oxygen at 2 liters per minute continuous every shift for shortness of breath. Active 5/10/25.2. On 3/2/26 at 11:50 a.m., during a resident representative interview for Resident #23, it was discussed that Resident #23 had been on hospice for years but is no longer receiving hospice services.Review of Resident #23's medical record showed a social services note dated 10/20/25 stating, Resident #23 was discharged from [NAME] Hospice on 10/17/25. Review of the care plan showed a hospice care plan which was resolved on 10/20/25.Resident #23's active provider orders, as of 3/3/26, contain two orders relating to hospice services:>Refer to [NAME] hospice, active 10/24/23>Refer to [NAME] for eval and treat for palliative care as appropriate. DX: Pain management, active 10/17/23On 3/3/26 at 2:02 p.m., during an interview, the Regional Director of Clinical Operations reviewed and confirmed the above findings.

Based on observations, interviews, and policy reviews the facility failed to maintain an Infection Control Program designed to help prevent the cross contamination and/or development of infection for residents requiring Enhanced Barrier Precautions (EBP), failing to wear correct Personal Protective Equipment (PPE) during tracheostomy care, and failing to properly label and store urinal collection devices for 2 of 3 days of survey, on 3 of 3 units (Residents #7, #9, and #73). Findings: 1. On 3/2/26 at 7:59 a.m., observation of Resident #7 in his/her room with an indwelling catheter. Further observations showed no evidence of appropriate EBP signage. On 3/3/26 at 10:00 a.m., in an interview, the Infection Preventionist (IP) confirmed the above information. 2. On 3/3/36 at 7:05 a.m., observation of 2 unlabeled urinals hanging on the side rail by the toilet in the Passport Unit shower room. At this time, the above information was confirmed with the Director of Clinical Operations. 3. On 3/2/26 at 8:25 a.m. during an interview with Resident #73 he/she stated they have a catheter and the surveyor observed no EBP signage posted. On 3/2/26 at 11:38 a.m. observed Resident #73's room again and he/she still had no signage posted on their room for EBP. On 3/2/26 at 11:36 a.m. during an interview with the Infection Preventionist he/she confirmed with the surveyor that there is no signage and there should be, and that he/she is working on this. On 3/2/26 at 1:15 p.m. review of the facility's EBP policy and procedure titled Clinical Services, sub-titled Subject: Precautions to Prevent Infection, on page 2, under Enhanced Barrier Precautions which stated, Enhanced Barrier Precautions, which falls between Standard and Contact Precautions, and requires gown and glove use for certain residents during specific high-contact resident care activities that have been found to increase risk for MDRO (Multi-drug resistant organism) transmission. Residents defined at risk are those infected or colonized with a CDC (Centers for Disease Control) novel or targeted MDRO when contact precautions do not otherwise apply and those with indwelling medical devices and/or wounds even if the resident is not known to be infected or colonized with a MDRO. 4.On 3/3/26 at 9:20 a.m., a surveyor observed (Licensed Practical Nurse) LPN1 perform routine tracheostomy care for Resident #9. The LPN wore a disposable gown and gloves but did not wear face protection during the procedure. The surveyor asked if LPN1 would normally wear face protection during trach care. LPN1 stated he/she would wear a mask, though had not worn one during the surveyor's observation. Clinical record review for Resident #9 revealed diagnoses of stroke, persistent vegetative state, chronic respiratory failure with hypoxia and tracheostomy. In December, 2025, a sputum culture was completed and found multi-drug resistant organisms including ESBL (extended-spectrum beta-lactamase) Klebsiella pneumoniae, carbapenem-resistant Pseudomonas aeruginosa, and Stenotrophomonas maltophilia. On 3/3/26 at 11:30 a.m., in an interview with the Regional Director of Clinical Operations, the surveyor discussed the observation. The Regional Director of Clinical Operations confirmed that LPN1 should have been wearing a face shield while performing tracheostomy care. A review of the United States Centers for Disease Control (CDC) recommendations for Long-term Care Facilities, Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO), dated 4/2/24, stated Enhanced Barrier Precautions are to be used for all residents with any of the following: infection or colonization with an MDRO when contact precautions do not apply, and wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. In addition to use of gloves and gowns, face protection may also be needed if performing activity with risk of splash or spray.

Based on interviews and record reviews, the facility failed to review and revise the care plans by an interdisciplinary team (IDT), that included, to the extent possible, participation of the residents and/or his/her representative after each assessment for 3 of 24 residents reviewed for care planning (Residents #7, #66, and #68).Findings: 1. Review of Resident #7's medical record contained a Quarterly Minimum Data Set (MDS) version 3.0 dated 1/14/26. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of the Quarterly MDS assessment. On 3/4/26 at 1:40 p.m., the Regional Director of Operations confirmed Resident #7's IDT meeting was not held within 7 days of completion of his/her Quarterly MDS. 2. Review of Resident #66's medical record contained a Quarterly Minimum Data Set (MDS) version 3.0 dated 12/30/25. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of completion of the quarterly MDS assessment. On 3/4/26 at 1:40 p.m., in an interview with the Regional Director of Operations the above information was confirmed. 3. On 3/2/2026 at 8:43 a.m., during an interview, Resident #68 stated he/she has not met with his/her care team and does have concerns he/she would like to bring to them. Resident #68's medical record contained an annual Minimum Data Set (MDS) version 3.0 dated 2/11/26, quarterly MDS dated [DATE], 8/13/25, and 5/13/25, and an admission MDS dated [DATE]. The record lacked evidence of IDT meetings being held within 7 days of the above MDS assessments. On 3/4/26 at 1:35 p.m., the social worker confirmed with the surveyor that the meetings were not done within 7 days of completion of the MDS assessments.

Based on record reviews and interviews, the facility failed to ensure written bed hold and transfer/discharge notices were provided to the resident or their legal representative for a facility-initiated transfer/discharge for 2 of 3 sampled residents transferred/discharged to an acute care facility (Residents #8, #9). In addition, the facility failed to ensure residents had a discharge summary which included recapitulation of the resident's stay, diagnoses, course of illness/treatment or therapy, and reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for 2 of 6 residents reviewed for transfer discharge. (Residents #96 and #97)Findings: 1. Documentation in Resident 8's clinical record indicated that he/she was transferred to an acute hospital on [DATE] and subsequently admitted . The clinical record lacked evidence that the facility issued a written bed hold notice and a transfer/discharge notice to the resident and/or legal representative. On 3/4/26 at 1:40 p.m., the above was confirmed with the Regional Director of Operations. 2. Documentation in Resident #9's clinical record indicated that he/she was transferred to an acute hospital on [DATE], 11/29/25, 1/27/26, and subsequently admitted . The clinical record lacked evidence that the facility issued written bed hold and transfer/discharge notices to the resident and/or legal representative for the transfers on 11/29/25 and 1/27/26. The record lacked evidence that the facility issued a bed hold notice to the resident and/or legal representative for the transfer on 11/9/25. On 3/4/26 at approximately 11:00 a.m., the findings were confirmed by the Interim Director of Nursing. 3. On 2/26/26 at 3:35 p.m., in an interview with a surveyor, the spouse of Resident #96 stated at the time of discharge, on 11/10/25, the facility did not provide discharge instructions, including a pre and post discharge medication reconciliation, follow-up appointments, or referrals for home health services. On 3/4/26, a review of the clinical record noted Resident #96 lacked evidence that a recapitulation of stay had been completed which included discharge instructions, follow-up appointments, or medication reconciliation. On 3/4/26 at 4:00 p.m., in an interview with the surveyor, the finding was confirmed with the Administrator, Social Worker, and Regional Director of Operations. 4. A review of Resident #97's medical record showed he/she was discharged on 11/10/25. Further review of the clinical record lacked evidence of a completed discharge summary which included his/her recapitulation of stay to include discharge instructions, discharge medications/instructions, follow up appointments, and therapy recommendations. On 3/4/26 at 4:28 p.m., in an interview with the Director of Clinical Operations and Regional Director of Operations.

Based on observations and interviews, the facility failed to ensure a resident's call bell was within reach for 1 of 1 sampled resident for 2 of 3 days of survey (Resident #59).Findings:1. On 3/2/26 at 7:45 a.m., Resident #59 was observed lying in bed with the call bell wrapped around the bed rail facing outside the bed rail, and not within reach for the resident.On 3/2/26 at 7:48 a.m., Certified Nursing Assistant (CNA) #5 confirmed in an interview with the surveyor that the resident could not reach her call bell. 2. On 3/3/26 at 1:35 p.m., Resident #59 was observed lying in bed with the call bell on the floor, and not within reach for the resident.On 3/3/26 at 1:37 p.m., Registered Nurse #1 in an interview with a surveyor, confirmed the above finding.

Based on performance evaluation reviews and interviews, the facility failed to complete an annual performance evaluation, at least every 12 months, for 1 of 5 sampled employees. (Certified Nursing Assistant (CNA) #4)Finding:CNA#4 was hired in December of 2023. A review of his/her employee file lacked evidence of a completed annual performance evaluation for 2025.On 3/4/26 at 9:12 a.m., in an interview with the Director of Clinical Operations, it was confirmed that CNA #4 did not have an annual performance evaluation in 2025.

Based on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the mandatory yearly dementia, abuse and neglect, and residents rights training for 1 of 5 CNA's reviewed. (CNA#2)Findings:On 3/4/26 a surveyor reviewed the following employee file:CNA #2 was hired in February of 2021. Review of the CNA's employee in-service/attendance record lacked evidence of dementia, abuse and neglect, and resident rights training for the year 2025.On 3/4/26 at 11:22 a.m., during an interview with the Director of Clinical Operations, the above information was confirmed.

Based on observations, record review and interviews, the facility failed to provide respiratory care as ordered by the Provider and failed to ensure the plan of care was updated in the area of Oxygen for 1 of 3 residents sampled for respiratory care (Resident #5).Findings:On 3/2/26 at 7:47 a.m., observation of Resident #5 receiving oxygen via a nasal cannula with the oxygen concentrator set at 1.5 liters per minute (LPM). At this time, during an interview, Resident #5 stated he/she utilizes oxygen all the time but is not sure what his/her LPM should be set at.Review of Resident #5's medical record contained a current provider order dated 5/10/25 for Oxygen at 2 liters per minute continuously every shift for shortness of breath. Review of the oxygen saturation documentation for 3/1/26 states Resident #5's oxygen saturation was 94% on room air, no utilizing oxygen as ordered. The current care plan for Chronic Obstructive Pulmonary Disease (COPD) relating to smoking, initiated on 3/13/24 with a target date of 5/24/26 instructed nursing staff to: OXYGEN SETTINGS: O2 via (nasal cannula) at (1-2)L (liters) prn (as needed) to maintain O2 saturation at or above 90% and[Resident #5] has intermittent oxygen therapy relating to Ineffective gas exchange secondary to COPD.On 3/3/26 at 9:10 a.m., in an additional observation, both the surveyor and the Registered Nurse (RN#1) observed Resident #5 receiving oxygen via a nasal cannula with the oxygen concentrator set at 1.5 LPM. At this time, the surveyor asked RN#1 how many LPM's resident #5 should be receiving. RN#1 reviewed the current providers order and confirmed he/she should have 2 LPM stating, I'm gonna bump it up. I believe (he's/she's) always been on 2, even when (he/she) was up front.On 3/3/26 at 2:02 p.m., during an interview, the above observations were discussed with the Regional Director of Clinical Operations. She then reviewed and confirmed the current care plan was not revised to reflect the current orders for Oxygen therapy.

Based on record review and interviews, the facility failed to accurately assess, coordinate care with a physician, and document a residents wound for 1 of 4 residents reviewed for wound care from 11/30/25 to 1/5/26. (Resident #1).Findings:Resident #1 was admitted to the facility in November 2025. A review of the clinical record showed he/she had a NSG[Nursing ]Admission/readmission Evaluation form completed the day of his/her admission which stated that resident had a skin issue located on his/her left buttock and that the type of issue was pressure related.On11/30/25 and 12/7/25, Daily Skilled Note/Evaluation stated that resident's skin is not intact and there is a pressure ulcer on his/her left buttock.Clinical record shows Daily Skilled Note/Evaluation's completed on 12/2/25, 12/3/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/20/25, 12/22/25, 12/23/25, 12/24/25, 12/25/25, 12/28/25, 12/29/25, 12/30/25, 12/31/25, and 1/1/25. These daily skin notes/evals stated that his/her skin is intact. On 1/5/26 at 11:02 a.m., a skin check note stated that no skin issues were identified. On 1/5/25 at 2:06 p.m. a skin issue note stated that Resident #1 has a stage 3 pressure ulcer/injury with full thickness skin loss.On 1/6/26 at 12:25 p.m., in an interview with 2 surveyors present, the Director of Nursing Services confirmed that the pressure ulcer was present upon admission, was never thoroughly assessed, was not reported to a physician, and was not cared for appropriately.

Based on record reviews and interviews, the facility failed to notify the physician, obtain physician orders, and care plan for a resident was admitted to facility (November) with a pressure ulcer to January for 1 of 4 residents reviewed for wound care (Resident #1).Findings:Resident #1 was admitted to the facility in November 2025. A review of the clinical record shows resident had a NSG[Nursing] Admission/readmission Evaluation form completed the day of admission. A review of the evaluation shows Resident #1 had a skin issue present on admission, located on left buttock and type of issue was pressure related.Review of Resident #1's clinical record shows a Daily Skilled Note/Evaluation completed on 11/30/25 and on 12/7/25 which indicated that the reason for his/her daily skilled care is for Pressure Ulcer Care and Rehab services. It also indicated that the skin is not intact and there is a pressure ulcer on his/her left buttock.During a clinical record review, a wound care nursing note dated, 1/5/26 stated a new skin issue on the left sacrum. Stage 3 pressure ulcer/injury with full thickness skin loss . acquired in house. On 1/6/25 at 11:30 a.m., during an interview with the Wound Care Nurse and 2 surveyors present, he stated on 1/5/26 a Certified Nursing Assistant came to him regarding concerns of a wound on Resident #1's buttocks. He states this was the first time he has heard of this. The wound care nurse completed an assessment, alerted the provider, obtained orders for wound care, and alerted the Director of Nursing. Review of facilities policy Pressure Injury Prevention Management Program#4 Based on resident evaluation process, an individualized comprehensive care plan will be implemented by the interdiciplinary team.-Residents will have a preventative care plan implemented upon admission that is interdisciplinary.-Residents with an actual pressure injury identified on admission/readmission will have a care plan implemented that documents interdisciplinary approach to the healing of the pressure injury following facility protocols as well as appropriate preventive measures.On 1/6/26 at 2:15 p.m., In an interview with the Director of Nursing Services and 2 surveyors present, the above information was confirmed.

Based on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 4 residents reviewed for wound care. (Resident #2)Findings:Review of Resident #2's clinical record shows a physician order to Monitor JP (Jackson Pratt) Drain every shift for prophylaxis with the start date of 11/22/25.Review of Resident #2's Treatment Administration Record for the month of December lacked evidence of completed documentation for his/her JP Drain on the 3 p.m. to 11 p.m. shift for 12/30/25. Further review shows missing documentation on the 11 p.m. to 7 a.m. shift for 12/1/25, 12/3/25, 12/10/25, 12/14/25, 12/15/25, 12/16/25, and 12/22/25.On 1/6/25 at 1:48 p.m., In an interview with the Director of Nursing Services and 2 surveyors present, the above information was confirmed.

Based on observations, review of the plan of correction, and interviews, the facility's quality assurance committee failed to ensure that the plan of correction for identified deficiencies from the survey, dated 10/20/25, were effective in the areas of deficiencies for Quality of Care related for pressure ulcers and Resident Records - Identifiable Information. Deficiencies for Quality of Care related for pressure ulcers and Resident Records - Identifiable Information were again identified during complaints survey dated 1/6/26.Findings:1. During the Recertification Survey, dated 10/20/25, a deficiency was cited for Quality of Care related to wound care, for 2 of 3 residents reviewed for wound care.The facility's Plan of Correction, with a completion date of 11/25/25, indicated that the wound care nurse/designee completed a house audit of residents with wounds to ensure no other residents were affected by this practice. The Director of Nursing Services (DNS)/designee educated the licensed staff of the facility wound care policy/procedure. The wound care nurse/designee will complete daily audits (Monday-Friday) x 60 days then weekly x 30 days of new wounds or new admissions with wounds are being followed per wound care policy/procedures. The results of these audits will be reviewed monthly with the QAPI committee to ensure compliance. The DNS is responsible for compliance. During the complaints survey on 1/6/26, a Quality of Care concern was re-cited related to wound care for 1 of 3 residents reviewed for wound care. Resident #1's clinical record contained evidence that he/she had a pressure ulcer upon admission on [DATE] and there were no doctor's orders for care and treatment of the wound. 2. During the Recertification Survey, dated 10/20/25, a deficiency was cited at Resident Records - Identifiable Information for the failure to ensure that clinical records were complete and contained accurate information for 2 of 3 residents reviewed for wound care.The facility's Plan of Correction, with a completion date of 11/25/25, indicated that the wound care nurse/designee completed a house audit of residents with wounds to ensure no other residents were affected by this practice. The DNS/designee educated the licensed staff of the facility on completing and following wound care MD orders and treatments. The wound care nurse/designee will complete daily audits(M-W-F) x 30 days, then random weekly audits x 30 days of residents with wound care treatment orders to ensure compliance. The results of these audits will be reviewed monthly at QAPI committee to ensure compliance is maintained. The DNS is responsible for compliance.During the complaints survey on 1/6/26, Resident Records - Identifiable Information was recited for failure to follow their Plan of Correction to ensure that clinical records were complete and contained accurate information. Resident's #2's clinical record did not contain complete and accurate information related to wound care.On 1/6/26 at 3:45 p.m., during an exit interview with two surveyors present, the Administrator and the DNS discussed and confirmed that the facilities Plan of Correction for the above cited areas have not been effective as indicated on the facilities Plan of Correction with a correction date of 11/25/25. Deficient practices were identified at the time of the 1/6/26 Complaint visit, after the POC's anticipated date of compliance.

Based on record review and interviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 4 sampled residents reviewed for wound care (Resident #1).Findings:Resident #1 was admitted to the facility in November 2025. Further review of the clinical record showed he/she had a NSG [Nursing] Admission/readmission Evaluation form completed the day of his/her admission which stated that resident had a skin issue located on his/her left buttock and that the type of issue was pressure related. A review of Resident #1's medical record lacked evidence of a baseline care plan that included the instructions necessary to properly care for him/her, in the area above.On 1/6/25 at 2:15 p.m., In an interview with the Director of Nursing Services and 2 surveyors present the above information was confirmed.

Based on record review and interviews, the facility failed to ensure that a care plan was developed for 2 of 3 sampled residents reviewed for wound care (Resident #2 and #3).Findings:1. Review of Resident #2 clinical record revealed he/she has a chronic abscess to his/her right lateral thigh requiring wound care. On 8/31/25 a nursing note stated, resident returned from ER at 10:30 with 2 new orders of abx (antibiotics) for cellulitis, packing is to stay in place for 48-72 hours. As of 10/20/25 the clinical record lacked evidence of a care plan in place for his/her wound including goals and interventions.2. Review of Resident #3 clinical record revealed on 6/24/25 a wound on his/her left foot, second toe and on 7/19/25 an unstageable pressure ulcer on his/her right foot, both requiring wound care. As of 10/20/25 the clinical record lacked evidence of a care plan in place for his/her wound including goals and interventions.On 10/20/25 at 12:35 p.m., the above information was confirmed with the Director of Nursing and the Director of Clinical Operations.

Based on record review and interviews, the facility failed to obtain physician orders for wound care, for 2 of 3 residents reviewed for wound care (Resident #1 and #2). Findings: 1. Review of Resident #2 clinical record indicated he/she has a chronic abscess to his/her right lateral thigh. On 8/30/25 a nursing progress note stated Resident #2 has a right thigh abscess that was previously healed on 8/19/25. The nurse was called to the resident's room and found that his/her right lateral thigh appeared swollen and now having drainage resulting in Resident #2 being sent to the emergency room (ER). On 8/31/25 a nursing note stated, resident returned from ER at 10:30 with 2 new orders of abx (antibiotics) for cellulitis, packing is to stay in place for 48-72 hours, additional instructions left in binder for [RN #1 Unit Manager]. Resident #2's clinical record lacked evidence of the emergency room discharge instructions and provider's order for this wound care or any wound care orders for the right lateral thigh from 8/31/25 until 9/11/25. Documentation in the skin and wound section revealed on 9/5/25 the right lateral thigh was assessed and measured by RN#1. On 10/20/25 at 2:18 p.m., during an interview, RN#2 stated, resident #2 has a chronic right lateral hip wound and remembers when he/she returned from the ER. The discharge summary said there was a dressing on his/her hip and it's supposed to be packed, leave it in place with the dressing on it for about 3 or 4 days, then take it off and have the wound Dr. take a look and they're supposed to do new orders. At this time, RN#2 stated she has not provided any wound care on that wound until 9/11/25 when the doctor wrote orders. RN#2 reviewed Resident #2's orders, including current, discontinued and completed orders and could not locate any wound care orders for the right lateral hip from 8/31/25 until 9/11/25 and confirmed she physically had the emergency room discharge summary in her hand and is now unable to find it in the hard chart or the electronic medical record. On 10/20/25 at 2:37 p.m., during an interview with 2 surveyors and the Director of Nursing, RN #1 Unit Manager stated that on 9/5/25 he had unpacked, assessed and repacked the wound. He reached out to the on-call provider to obtain wound care orders. The provider asked him to take a photo of the wound and pack it until a provider could assess it in person. RN #1 was unable to provide orders or documentation of this encounter. The surveyor asked if wound care was provided and physician orders were obtained from 8/31/25 through 9/11/25 when the wound was reviewed by the provider. He stated he was unable to find any information that wound care was provided with the exception of his assessment on 9/5/25. 2. Review of Resident #1's medical record contained a nursing note dated 10/9/25 which stated, Called to patient room for questions regarding NPWT (negative pressure wound therapy). On assessment, wound vac appears to not be functioning correctly r/t dressing malfunction. Supplies due to be delivered tomorrow, wound packed with VASHE soaked gauze per provider in lieu of new NPWT dressing. Review of provider orders lacked evidence of any orders for VASHE soaked gauze. On 10/20/25 at 11:32 a.m., during an interview, the above was confirmed with the Director of Nursing who stated RN#1 had called the provider and got verbal orders for the VASHE dressing but failed to write the order.