Every finding on record at Center at Waterfront LLC

The facility reported a census of 54 residents. The facility identified five Certified Nurse Aides (CNA) employed for more than 12 months. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for the five CNAs reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. Findings included: - Review of CNA personnel files revealed the following: CNA O, hired on 08/15/24, lacked an annual performance evaluation. CNA P, hired on 09/13/24, lacked an annual performance evaluation. CNA Q, hired on 10/02/24, lacked an annual performance evaluation. CNA S, hired on 08/11/24, lacked an annual performance evaluation. Certified Medication Aide (CMA) R, hired on 10/01/24, lacked an annual performance evaluation. During an interview on 01/14/26 at 02:55 PM, Administrative Nurse D reported she expected 100 percent compliance in having the annual performance evaluations completed annually. The facility policy Inservice Training Program, Nurse Aide, dated 04/02/24, documented in-service training would be based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews.

The facility reported a census of 54 residents and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent potential for food borne bacteria. Findings included:- On 01/13/26 at 08:00 AM, the initial tour of the main kitchen revealed trash on the floor behind the ice machine. Observation of the refrigerator revealed one bag of pork chops left open; observation of the freezer revealed one bag of hamburger patties left open to air. On 01/14/26 at 11:20 AM, Dietary Staff CC prepared to serve food with gloves on. Dietary Staff CC grabbed the plated holders and then placed the plate in the holders. She then picked up bread to put on the plates, grabbed trash off the counter to throw away, and then picked up lettuce, tomatoes, and cheese without changing gloves or washing her hands. Dietary Staff CC obtained a utensil to place the hamburger on the bun, but ended up touching the hamburger patty and ground meat with the same soiled gloves, then touched the bowls to put the corn in, with the same gloves touching the ground ham. On 01/14/26 at 11:30 AM, when asked about the process of serving the food, Dietary Staff CC refused to answer the question. In an interview on 01/06/26 at 08:00 AM, Dietary Staff BB said his expectations were for staff to wash their hands and replace their gloves. The policy Dietary, revised on 02/08/21, documented on the same day food products are delivered to the facility, they are to be inspected for safety and quality. Each item is to be accurately dated upon receipt. When items are opened or in use, the use-by dates are to be labeled upon them, followed by storing the item in the proper area. When storing raw meat, it must be properly sealed and separated from all other foods during storage.

The facility had a census of 54 residents. The sample included 14 residents with three residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for transfers for Resident (R) 64, R7, and R97. Additionally, one resident reviewed for facility discharge, the facility failed to complete a recapitulation of R66's stay in the facility. Findings included:1. R64's Electronic Medical Record (EMR) recorded R64 was transferred to the hospital on [DATE] hospitalization. R64's EMR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R64 and/or his representative.2. R7's EMR recorded R7 was transferred to the hospital on [DATE] hospitalization. R7's EMR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R7 and/or her representative.3. R97's EMR recorded R97was transferred to the hospital on [DATE] hospitalization. R97's EMR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R97 and/or her representative. 4. R66's EMR recorded R66 was discharged to home on [DATE]. R66's EMR lacked evidence of a completed recapitulation outlining the course of his stay at the facility. During an interview on 01/14026 at 04:14 PM Licensed Nurse (LN) G reported the facility should do a bed hold and revealed she was unsure if there was a form and thought Social Service Designee (SSD) X would complete the bed hold. During an interview 01/15/26 09:32 AM LN J reported that a provider would go over the discharge medications with the resident/family when a resident discharged . LN J reported that the family/resident would sign a discharge summary that was completed by the interdisciplinary team prior to discharge. During an interview on 01/15/26 at 09:40 AM Administrative Nurse F revealed the discharge summary in EMR was still in progress for R66 dated 12/06/25. Administrative Nurse F reported the therapy section was incomplete as they did not evaluate R66 as he was admitted to facility for one day. Administrative Nurse F reported that R66 should have received a signed copy of his discharge summary. During an interview on 01/15/26 at 10:17 AM SSD X reported that all the bed holds were completed by the Administrative Staff C the admission Coordinator. SSD X reported all discharge summaries were printed off and reviewed with the patient/family before they discharged with the nurse, and the patient/family should receive a copy. During an interview on 01/15/26 at 10:20 AM Administrative Staff C revealed she would document in EMR about a bed hold and the resident/family is not provided a copy of the bed hold when they go to the hospital. Administrative Staff C reported she was told at the last state survey she only needed to write a note in EMR and revealed she had not provided a written/signed bed hold form for R64, R7, and R97.During an interview on 01/15/26 at 10:50 AM Administrative Nurse D reported she expected staff to complete the discharge summary and the resident/family to receive a copy after signing. Additionally, Administrative Nurse D reported she expected to follow the regulation for the bed hold. The facility's policy Bed Hold dated 02/15/19 documented before this facility transfers a resident to a hospital this facility would provide written information to the resident/representative that specifies the duration of the state bed-hold policy at the time of admission and time of discharge/transfer related to hospitalization. Receipt of signature documentation would be maintained in the EMR. The facility's policy Discharge Policy and Procedures dated 03/28/24 documented discharge instructions should be given to the patient.

The facility reported a census of 54 residents. Thirty-nine medication administrations were observed. Based on observation, interview and record review the facility failed to ensure a medication error rate of less than five percent when 30 errors were identified, resulting in a medication error rate of 79.62 percent. Findings included:1. Resident (R) 67's January 2026 Medication Administration Record/Treatment Administration Record (MAR/TAR) documented six oral medications scheduled at 08:00 AM. On 01/14/26 at 10:13 AM, observation revealed Licensed Nurse (LN) L administered the 08:00 AM scheduled medications to R67, outside of the one-hour before or after protocol. R67 received six late oral medications. 2. R56's January 2026 MAR/TAR documented seven oral medications scheduled at 08:00 AM. On 01/14/26 at 10:29 AM, observation revealed LN L administered the 08:00 AM scheduled medications to R56, outside of the one-hour before or after protocol. R56 received seven late oral medications. 3. R98's January 2026 MAR/TAR documented five oral medications scheduled at 08:00 AM. On 01/14/26 at 10:38 AM, observation revealed LN L administered the 08:00 AM scheduled medications to R98, outside of the one-hour before or after protocol. R98 received five late oral medications. 4. R38's January 2026 MAR/TAR documented 10 oral medications scheduled at 08:00 AM, and two intravenous (IV-administered directly into the bloodstream via a vein) medications scheduled at 08:00 AM. On 01/14/26 at 10:47 AM, observation revealed LN G administered the 08:00 AM scheduled medications to R38, outside of the one-hour before or after protocol. R38 received 10 late oral medications. On 01/14/26 at 11:13 AM, observation revealed LN G administered the 08:00 AM scheduled IV medications to R38, outside of the one-hour before or after protocol. R38 received two late IV medications. During an interview on 01/14/26 at 11:00 AM, LN L revealed the medications were over an hour late when administered. LN L stated she did not have a certified medication aide on the schedule. During an interview on 01/14/226 at 11:52 AM, LN G reported she knew she was late administering medications and reported she would do the best she could with what staff she had. During an interview on 01/14/26 at 12:00 PM, Administrative Nurse D verified the medications were scheduled for 08:00 AM and confirmed the facility did not have a liberalized medication pass time. Administrative Nurse D said she expected all medications to be administered on time. The facility policy Medication Administration, dated 08/22/22, documented all medications are to be administered as prescribed by the attending physician.

The facility reported a census of 54. Based on observation, interview and record review the facility failed to ensure adequate infection control related to Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for residents with indwelling medical devices including urinary catheters ( a tube inserted directly into the bladder to drain urine) and peripherally inserted central catheters (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) and residents with wounds. Findings included:- The Facility Matrix identified the following 10 residents with characteristics which met the criteria for staff to follow EBP and to use appropriate PPE, which included gloves and gowns:Resident (R) 38, R89, R45, R67, R70, and R82 were identified with indwelling urinary catheters.R38, R79, and R85 were identified with PICC lines.R41 had an unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure ulcer. Initial tour of the facility on 01/13/26 at 08:00 AM revealed a lack of signage to identify residents who required EBP. The facility had no visible setup for personal protective Equipment (PPE-gowns and gloves for use with EBP) readily accessible to staff to apply before entering residents' rooms to provide direct care to the residents of the facility. On 01/13/26 at 11:20 AM, Certified Nurse Aide (CNA) V entered R79's room, washed her hands, put on gloves, and emptied the resident's urinal. She did not apply a gown as indicated for R79, who had a PICC line. CNA V reported the resident's door should have a sign on the door to indicate the staff should wear PPE related to EBP. On 01/14/26 at 09:00 AM, Licensed Nurse (LN) K entered R79's room to administer daptomycin (antibiotic medication to treat infection) 1000 milligrams (mg) through his PICC in his right upper arm. LN K washed her hands, put on her gloves, removed the PICC line outer secure positioner, and cleaned the hub without applying a gown. LN K stated there were no signs to make staff and visitors aware of EBP and the PPE to be used, though she expected there to be some when EBP was required. She confirmed the resident met the criteria for EBP due to his PICC line. She confirmed she did not use the proper PPE for EBP and said that staff did not wear gowns when giving the residents of the facility direct care. On 01/14/26 at 03:14 PM, LN F and Consultant KK verified the staff should wear PPE to give direct care for residents who had surgical openings, PICC lines, indwelling catheters, and wounds. The facility policy titled Infection Control, dated 01/29/25, did not address EBP.

The facility identified a census of 54 residents. The sample included 14 residents with one sampled for baseline care plan. Based on observation, interview, and record review, the facility failed to complete a thorough baseline care plan for Resident (R) 97 to include contact isolation for clostridium difficile (C-diff: contagious bacteria characterized by foul-smelling frequent loose bowel movements) and for R70 to include fall interventions. Findings included:- R97's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion), and C-diff. R97's 12/22/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, which indicated severely impaired cognition. R97's MDS documented he required total dependence for toileting hygiene. R38's MDS documented he was always incontinent of bowel and bladder. R97's 12/26/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R97 triggered secondary to assistance required in activities of daily living (ADLs). Contributing factors included generalized weakness, and decreased safety awareness. Risk factors included further ADL decline. The resident received physical and occupational therapy and required staff assistance to get onto and off the toilet. He was always incontinent of bowel and bladder. R97's 12/31/25 Discharge Return Anticipated MDS documented BIMS not assessed, staff interview documented moderately impaired cognition. R97's MDS documented he required maximal assistance with toileting hygiene, and he was frequently incontinent of bowels. R97's 01/09/26 Entry MDS was completed on 01/13/26. R97's 01/09/26 Base Line Care Plan revealed the area to document if the resident was on isolation/transmission-based precautions was answered no. R97's Physician Orders documented contact enteric precautions for c-diff every shift for isolation until 01/14/26, dated 01/13/26 at 11:57 AM. During an observation on 01/13/26 at 12:11 PM, a contact precaution sign was on the R97's door, and personal protective equipment (PPE- gowns, face shields, and/or eyeglasses/goggles, and gloves) was observed outside the room. R97 sat in his chair, and his spouse was visiting. R97's family member reported she did not know what the contact precautions were for. During an interview on 01/14/26 at 04:21 PM, Certified Nurse Aide (CNA) M reported she would look at the care plan for reasons a resident would be on isolation precautions. She reported she was educated by the nurse on 01/13/26 that R97 had C-diff. CNA M reported she was unsure of a baseline care plan. During an interview on 01/15/26 at 12:37 PM, Administrative Nurse F (Infection Preventionist) reported she did not complete the baseline care plan for R97 on 01/09/26, and she reported that isolation/ transmission-based precautions should have been answered yes. Administrative Nurse F reported she documented C-diff precautions on the care plan in the EMR on 01/13/26 after the survey began. Administrative Nurse F reported the care plan should have had the C-diff precautions documented immediately. The facility did not provide a policy for baseline care plans. - R70's Electronic Health Record (EHR) revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), and diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). R70's admission Minimum Data Set dated 01/14/26 was in progress. R70's Baseline Care Plan revealed R70 was at risk for falls related to impaired mobility secondary to weakness and debility. R70 was also at risk for falls related to her current drug regimen. R70's Nurses Progress Notes dated 01/09/26 at 07:45 PM documented R70 was found sitting on the floor in front of her power recliner with the footrest still up. R70 was attempting to get up off the floor, with the indwelling catheter (tube placed in the bladder to drain urine into a collection bag) still hooked to the recliner. R70 did not have any injurie R70's Nurse Note, dated 01/10/26 at 05:02 AM, documented R70 attempted to get out of bed all night. Since her fall on 01/09/26, a mattress was placed to the left of her bed for safety. R70 was found on the mattress beside the bed with the bed in the lowest position, with the urinary catheter pulled out. R70 was lying naked on the mattress on the floor. She had no injuries. R70's Baseline care Plan lacked intervention for the fall on 01/09/26 and 01/10/26. On 01/14/26 at 08:15 AM, during an observation, R70 laid in bed. A therapist was in her room setting up her breakfast tray. Further observation revealed a mattress on the left side of the bed on the floor with no sheet covering the mattress. During an observation on 01/15/26 at 09:20 AM, R70 remained in bed with her eyes closed. There was a full mattress on the left side of the bed, and a sheet. Interviewed on 01/15/26 at 10:45 AM, Administrative Nurse D said during the risk management meeting every morning, staff discussed the falls, but they did not have the information on the investigation to change the care plans. The policy High Fall Risk Protocol, dated 1/22/19, documented each patient staying in this community would be provided services and care which ensured the environment remained as free from accident hazards as possible, would receive adequate supervision, and would receive assistive devices to reduce accidents. Every patient will be assessed for the causal risk factors for falling at the time of admission, upon return from a health care community, and after every fall.

The facility reported a census of 54 residents. The sample included 14 residents with one resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to offer and provide assistance with facial hair removal for Resident (R) 38. Findings included:- R38's Electronic Medical Record (EMR) revealed diagnoses of metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), bacteremia (presence of bacteria in the blood), and muscle weakness. R38's 01/05/26 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R38's MDS documented he required touch supervision assistance with personal hygiene. R38's 01/07/26 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R38 triggered secondary to assistance required in activities of daily living (ADLs). Contributing factors included generalized weakness, and decreased safety awareness. Risk factors include further ADL decline. R38's Care Plan, dated 12/30/25, directed staff to provide assistance with grooming, bathing, and personal hygiene as per the resident's preferences. Review of R38's Shower Sheet, dated 12/30/25 and 01/05/26, revealed the area to document if the resident was shaved lacked a yes/no answer on either shower sheet. During an observation and interview on 01/13/226 at 02:56 PM, R38 laid in his bed. He had unkempt, shaggy facial hair, and he reported that he wished that the staff would offer him a shave. R38 reported he could not shave himself. During an observation on 01/14/26 at 08:04 AM, R38 laid in his bed; his unkempt, shaggy facial hair remained unchanged from the 01/13/26 observation. Observation revealed an electric razor on his windowsill, not in reach for the resident. During an interview on 01/14/26 at 04:26 PM, Certified Nurse Aide (CNA) N reported that when a resident required a shave for facial hair, it would be completed and/or offered on their shower day or as needed. CNA N reported the shower list had not been updated since last week, so was unsure when R38 would receive a shower. CNA N reported that R38 slept a lot and had not asked to be shaved, but therapy would complete a lot of the resident's ADLs. CNA N reported she did not realize R38 had an electric razor in his room. During an interview on 01/15/26 at 08:45 AM, Licensed Nurse (LN) W reported he expected the staff to complete morning care, including facial hair removal. LN W reported the staff should ask the resident if they were able to answer, and if not, ask the family what their preferences were for facial hair removal. During an interview on 01/15/226 at 8:57 AM, Consultant Staff JJ reported that the therapy staff would complete morning care, but not every day. Consultant Staff JJ reported she had therapy sessions with R38 a few times and had not assisted R38 with shaving during those therapy sessions. Consultant Staff JJ reported the nursing staff would provide residents with ADL care, unless the therapy staff wrote on the communication board in the resident's rooms that day, then the therapy staff would complete ADL care. During an interview on 01/15/226 at 12:37 PM, Administrative Nurse F revealed she expected the staff to provide assistance when needed or requested by the residents. She expected the staff to shave residents who were unable to shave themselves. The facility policy ADL Care Provided for Dependent Patients, dated 02/15/19, documented a patient who is unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal hygiene.

The facility reported a census of 54 residents with a sample of 14 residents which included two reviewed for accidents/falls. Based on observation, interview, record review, the facility failed to thoroughly investigate a fall to identify causative factors in order to implement appropriate immediate interventions following falls for Residents (R)64 and R75.Findings included:- R64's Electronic Health Record (EHR) documented diagnoses which included repeated falls, unspecified injury to the head, cerebral infarction (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), atrial fibrillation (irregular heartbeat), scalp laceration, mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), generalized weakness, and a need for assistance with personal care.R64's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. He did not display any behaviors or reject care. R64 used a walker as an assistive device. He required substantial/maximal assistance of staff for toilet transfers and was frequently incontinent of urine and occasionally incontinent of bowel. He reported occasional pain that rarely interfered with therapy activities. He exhibited shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring) and with lying flat. The resident had a fall prior to admission. He experienced one non-injury fall and two falls with minor injuries after admission; he had skin tears. He received antidepressant (medication used to treat mood disorders) and antiplatelet (medication used to thin the blood) medication. R64 did not receive therapy and/or restorative nursing programs.The Falls Care Area Assessment (CAA), dated 10/20/25, documented the resident was at risk for falls as evidenced by falls during the lookback period. He was admitted to the facility following hospitalization for frequent falls due to balance issues, CVA, and atrial fibrillation. He had a head injury. R64 was at risk for falls due to decreased mobility, weakness, a history of falls prior to admission, and he had three falls since admission. R64's Baseline Care Plan, dated 10/10/25, directed staff the resident was at risk for falls due to impaired mobility secondary to weakness and debility. The plan noted he had a history of falls prior to admission. His drug regimen was a contributing fall risk factor. R64's Progress Notes, dated 10/25/25 at 01:33 PM, documented the resident transferred to the hospital due to a change in condition following a fall. The resident sustained a head laceration to the right rear of his head and a skin tear to the top of his left wrist/forearm measuring approximately five inches. R64 reported pain in his head. The documentation included the resident was alert to self. R64's EHR lacked documentation of a thorough investigation to determine the causative factors that contributed to the fall or the implementation of interventions to prevent further falls.Upon request, the facility was unable to provide the fall investigation.On 01/14/26 at 04:22 PM, Licensed Nurse (LN) F reported R64 had a witnessed fall on 10/25/25 at 09:15 AM. She confirmed the EHR lacked details of the fall, and investigation documentation was not available for review. LN F said R64 was out of the facility, currently admitted to the hospital.On 01/15/26 at 10:45 AM, Administrative Nurse D confirmed the facility did not have documentation of an investigation to determine the cause and/or contributing factors of R64's fall. She stated the facility staff were trying to get the fall investigation information collected from the current staff. She confirmed the employees were not interviewed at the time of the fall.Review of the facilities policy titled High Fall Risk Protocol, dated 04/22/19, documented every resident will be assessed for falling after every fall, and the care plan will be updated.- R75's Electronic Health Record (EHR) documented diagnoses which included traumatic pneumothorax (accumulation of air and blood in the area around the lungs), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), a history of pulmonary embolus (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream), hypertension (high blood pressure), atrial fibrillation (rapid, irregular heart beat), and atherosclerotic heart disease (a buildup of fats, cholesterol, and other substances in an don the artery walls).R75's Minimum Data Set Tracking/Discharge Roster documented the resident admitted on [DATE]. R75's Baseline Care Plan, dated 01/12/26, directed staff R75 was at high risk for falls. He had a fall with a major injury. The plan directed staff to place a Call Don't Fall sign in the resident's room to remind him to call for assistance. Staff were to ensure adequate lighting and cue the resident to transfer and change positions slowly. The resident had Occupational Therapy (OT) and Physical Therapy (PT) evaluations to treat as indicated.R75's Nursing Note, dated 01/13/26 at 01:38 PM, documented the nurse was notified R75 had an unwitnessed fall. Upon entering the resident's room, R75 was lying on his back next to his recliner with a Certified Nurse Aide (CNA) and another nurse at the bedside. The nurse assessed the resident's range of motion (ROM) and then assisted R75 to his wheelchair. The resident stated he had hit his head. R75 stated he was trying to get up when he fell. The resident was alert and oriented to self on assessment.R75's EHR lacked documentation of a thorough investigation to determine the causative factors that contributed to the fall or the implementation of interventions to prevent further falls.On 01/14/26 at 02:08 PM, CNA S reported R75 was admitted two days ago. She stated he was at risk for falls. CNA S reported the resident moved a room closer to the nurses' station for closer observation, and interventions to prevent falls included a call light within reach, and staff were to encourage him to call staff for assistance when needing to get up. She stated she was not aware of R75 being a fall risk prior to the recent fall. CNA S said if a resident fell, staff should fill out paperwork and try to determine the cause of the fall.On 01/15/26 at 10:43 AM, Administrative Nurse D stated she expected the staff to initiate an investigation to determine the root cause of the fall and place an immediate intervention to prevent further falls. She said staff should also identify any injuries or skin conditions on assessment and document the characteristics of the injury with description, measurements, and treatment. She confirmed the resident's EHR lacked the root cause analysis to determine causative factors to develop appropriate interventions to prevent further falls.Review of the facilities policy titled High Fall Risk Protocol, dated 04/22/2019, documentation included every resident will be assessed for falling after every fall, and the care plan will be updated.

The facility reported a census of 54 residents. Based on observations and interviews, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. Findings included: - During the initial tour of the kitchen on 01/13/26 at 08:00 AM, observation of the outside garbage bins with Dietary Manager BB revealed one shred bin and one trash bin, both had a lid up. On 1/13/26 at 08:00 AM, during an interview, Dietary Manager BB said he was not sure why the bins were open; they are usually closed. The facility did not provide a policy regarding waste disposal.

The facility reported a census of 53 residents with three sampled for elopement (when a resident leaves the premises or a safe area without authorization and/or any necessary supervision). Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure a safe and secure environment and prevent an elopement for cognitively impaired Resident (R)1, who was at moderate risk for elopement. On 03/13/25 at approximately 11:40 AM, R1 left the second floor, went to the first floor, and then exited the facility. Between 11:45 AM and 12:00 PM, R1's representative called the facility to alert the facility that she had received a call from a community member who reported they saw R1 outside the facility. Upon learning this information, staff conducted a search, and staff located R1 outside the facility. R1 returned to the facility uninjured. The facility's failure to ensure R1 had interventions in place in response to his elopement risk as well as the failure to provide adequate supervision to prevent an elopement placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented he had a diagnosis of weakness, insomnia (inability to sleep), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R1's Entry Tracking Record documented he was admitted on [DATE]. R1's Discharge Assessment noted he was discharged on [DATE]. R1's Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. He had inattention behaviors which were continuously present but had no rejection of care or wandering behaviors. The MDS documented R1 required staff supervision or touching assistance when walking and used a wheelchair for mobility. The Cognitive Loss/Dementia [a progressive mental disorder characterized by failing memory and confusion] Care Area Assessment (CAA), dated 03/10/25, documented the resident had cognitive impairment. The Functional Abilities CAA, dated 03/10/25, documented the resident had sustained a non-injury fall, after admission, while attempting to ambulate to the bathroom. The CAA noted he had decreased safety awareness and remained at risk for falls due to decreased mobility, impaired cognition, and weakness. R1's EMR revealed a Wandering Risk Assessment, dated 03/04/25, which documented a score of five which indicated the resident was at a moderate risk for elopement. R1's Wandering Risk Assessment, dated 03/12/25, documented a score of six which indicated the resident was at a moderate risk for elopement. R1's Wandering Risk Assessment, dated 03/13/25 after the elopement incident, documented a score of 11 which indicated the resident was at a high risk for elopement. R1's Care Plan dated 03/04/25, documented R1 required one staff assistance with locomotion and used a wheelchair and walker. The plan noted R1 was in a new environment. R1's Care Plan lacked interventions related to R1's moderate elopement risk. R1's Care Plan, revised 03/13/25 after the incident, instructed staff the resident had a history of wandering, was in a new environment and had a BIMS of 10. The plan directed staff to encourage R1 to dress in sweatpants so he would believe he was in his pajamas and would not attempt to go outside. Staff were to provide one to one care and involve R1 in activities. The plan directed staff to redirect and reorient R1 as needed. The undated and unsigned [R1] Elopement Report Narrative provided by the facility documented that on initial admission, R1 was identified with a moderate risk for wandering and was placed in an observation room near the nurse's station on the second floor. On Thursday, 03/13/25 at approximately 11:45 AM, the facility was notified by R1's representative that she had been contacted by a citizen who reported seeing R1 outside of the facility. Staff conducted an immediate search and located R1 within minutes on the east end of the facility property. R1 was not injured. The current temperature was approximately 73 degrees Fahrenheit (F) with clear, sunny skies. The document noted R1 was dressed appropriately for the weather conditions but did not know where he was. R1 immediately agreed to return to the building with staff. Staff notified R1's representative that R1 was safe and had returned to the building. R1's representative later reported that R1 told her he had exited the facility by walking down two flights of stairs. Staff checked all the stairwells in the building which were secured and could not be accessed without a code being entered on a keypad to unlock those doors; the doors additionally would sound an alarm when opened and no alarms had sounded. One staff member, Certified Nurse Aide (CNA) M initially reported she last saw R1 at 11:40 AM, but the next day (03/14/25) recanted that statement and stated she last saw R1 on 03/13/25 at approximately 10:15 AM when she checked his blood sugar. CNA M stated that at 11:40 AM on 03/13/25 when she delivered lunch trays, she noticed R1 was not in his room. Upon learning of what R1 reported to his representative, staff checked all stairwell doors which were locked; a subsequent test of the door alarms showed that all were functioning properly. The report noted that earlier in the morning on 03/13/25, at approximately 10:45 AM, there was a door alarm that sounded at the end of B Hall on the second floor. The report documented that staff immediately responded to that alarm, secured the door, and conducted a head count to ensure all patients were present. All residents including R1 were present at that time. The report noted that the maintenance director regularly tested the door alarms and had not found any malfunctions. The report noted that after the incident, R1 was assessed as a high risk for wandering and was placed on one-to-one (1:1) care by a staff member, and R1's Care Plan was updated. In addition, R1's photograph was placed behind the reception desk so staff could watch for him trying to exit the building. The report noted a later conversation with R1's representative revealed that she believed that if R1 dressed in sweatpants, he would think he was actually wearing pajamas and that would help prevent him from wanting to leave the building so sweatpants were provided to R1 and he continued to wear the sweatpants as tolerated. According to Wunderground.com. the temperature between 11:45AM and 12:00PM on 03/13/25 in Wichita was 78 degrees F. Observation of the area revealed there is a pond on the west end of the building. On 04/01/25 at 10:23 AM, Licensed Nurse (LN) H stated staff knew which residents were at risk for elopement by doing elopement and/or wandering risk evaluations and if the resident was in an observation room. LN H stated the observation rooms were for residents whom staff needed to keep a close eye on. LN H said if a resident eloped, she would contact the Director of Nursing and the resident's family. She stated that staff would begin looking for the resident in hallways, rooms, and elevators. LN H said if the resident was not located in the facility, staff would contact the police. On 04/01/25 at 11:05 AM, Certified Medication Aide (CMA) R stated staff knew which residents were at risk for elopement because the resident would go into an observation room. CMA R said to prevent an elopement, staff would provide close supervision for the resident and/or keep them occupied with an activity like a game or coloring. On 04/01/25 at 12:51 PM, Social Services X said a stranger used R1's phone to call his representative in California. Social Services X said R1's representative had used an elder service to assist with R1's placement in the facility and called that service when she received the call from the community member. Social Services X said the facility received the alert regarding R1's elopement from that service and notified staff immediately but the resident was already back in his room at that time. On 04/01/25 at 01:20 PM, Administrative Nurse D stated R1 had a moderate risk of elopement on 03/04/25 and 03/12/25 and verified that the facility did not include staff instruction for R1's elopement on his care plan until 03/13/25, after his elopement. Administrative Nurse D said the facility investigated the elopement and believed R1 went on the back elevator from the second floor to the first floor and then exited the building through the exit door on the east side of the building. Administrative Nurse D said the facility became aware that R1 was outside when R1's representative called the facility and informed them. Administrative Nurse D further stated that each of the stairwells had locked doors. She said the door alarms had sounded earlier before R1's elopement but at that time, all residents were accounted for. Administrative Nurse D stated the wind, or staff going in and out for breaks may have caused the door to alarm. On 04/01/25 at 01:03 PM, Administrative Staff A stated that R1's representative, who lived out of state, called the facility at approximately 12:00 PM and talked with the nurse on duty. Who then alerted staff to begin looking for R1. Administrative Staff A said staff found R1 in a nearby business parking lot and returned him to the facility at 12:02 PM. The resident was assessed and found to have no injuries. Administrative Staff A said staff placed R1 on 1:1 where he remained until his discharge on 03/22/25. The facility's Elopement or Missing Resident policy documented the definition of elopement as when a cognitively impaired resident leaves the physical structure of the facility without associate knowledge and/or supervision and the resident lacks the safety awareness and is unable to distinguish or identify his or her safety needs. The policy noted that in the case of a door alarm, staff would immediately go to the door indicated on the enunciator system and check both inside and outside the door to determine who or why the door alarm sounded. The policy documented that under no circumstance would a door alarm be deactivated until the source of the activation had been determined. The policy further noted that residents who were identified as an elopement risk would have an individualized care plan to minimize the risk of elopement. On 03/31/25, the facility completed corrective actions to address R1's elopement which included: 1. An in-service on 03/13/25 by the Nursing Home Administrator/Designee to all staff who were in the building to ensure that the facility follows the facility's elopement policy. 2. An in-service on 03/13/25 by the Nursing Home Administrator/Designee to all licensed nursing staff to ensure that elopement assessment and care plans were updated for all new admissions. Care plans for all residents identified as high risk for elopement were updated. 3. Elopement drills continued to be conducted quarterly to ensure that staff members were aware of what to do when there was an elopement. 4. A binder at the front desk was updated on 03/13/25 to include pictures and information of residents who were at high risk for elopement. This was reviewed and updated daily for new admissions. 5. Wander risk assessments were reviewed on 03/13/25. This was reviewed and updated daily for new admissions. 6. R1 remained on 1:1 until he discharged . On 04/02/25, the corrective actions were verified during the onsite survey. Since all corrective actions were completed prior to the surveyor's entrance on 04/01/25, the deficient practice was cited as past noncompliance and remained at the scope and severity of a J.

The facility reported a census of 60 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchen, on 03/13/24 at 01:51 PM, the following areas of concern were noted: 1. The bottom of the reach-in refrigerator next to the coffee machine had food debris on the bottom shelf. 2. The shelf underneath the coffee and tea machine had a plastic, slightly raised shelf cover which had a dark brown stain. Staff used the shelf to hold plastic pitchers and other clean containers. 3. The shelves underneath the tray line which held clean plates and clean plate covers, had a build-up of food debris. 4. The shelf underneath a worktable which stored boxes of oatmeal, cream of wheat and other types of cereal, had a build-up of food debris. 5. The shelf underneath the toaster had a large build-up of crumbs. 6. Four cutting boards were deeply grooved. On 03/18/24 at 12:23 PM, Dietary Staff BB confirmed the areas of concern were things which needed to be taken care of. The Dietary Aide Daily Cleaning Schedule, undated, included: The dietary aides are responsible for cleaning the entire surface of prep areas and for cleaning and sanitizing shelving and wiping down the insides of the reach-in coolers every shift. The facility failed to prepare and serve food under sanitary conditions for the residents of the facility appropriately to prevent the potential for food borne bacteria.

The resident reported a census of 60 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff. Findings included: - During the initial tour of the kitchen on 03/13/24 at 01:51 PM, as well as a follow-up visit on 03/18/24 at 12:23 PM, the following areas of concern were noted: The parameter of the kitchen floor contained a large amount of food debris. Several areas around the parameter of the kitchen floor had ground-in dirt. The kitchen floor beneath the steam table, cooks' line and tray lines all had a large amount of food debris. The kitchen floor had three drains which contained food debris and trash. On 03/18/24 at 12:23 PM, Dietary Staff BB confirmed the areas of concern were things which needed to be taken care of. The Dietary Aides Weekly Cleaning schedule, undated, included: The floor drains were to be cleaned on Sunday, Wednesday and Friday. The Cooks Daily Cleaning Schedule, undated, included: The cooks are responsible for sweeping and mopping the floors on the cook line and tray line every shift. The facility lacked a policy related to cleaning of the kitchen floors. The facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff.

The facility reported a census of 60 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure staff notified the State Ombudsman of four of the four discharged /transferred residents reviewed. Resident (R)62 who left the facility against medical advice, and R 60, R18 and R 44 who transferred to acute care. Findings included: - Review of Resident (R)60's medical record revealed diagnoses included acute kidney failure with renal dialysis (procedure where impurities or wastes were removed from the blood) diabetes (procedure where impurities or wastes were removed from the blood) and heart disease. The resident admitted to the facility on [DATE] and discharged to acute care on 01/08/24. On 03/14/24 at 2:45 PM Administrative Staff A, confirmed lack of notification of the state ombudsman when residents were transferred/discharged from the facility. The facility lacked a policy for notification of ombudsman. The facility failed to notify the state Ombudsman when residents discharged /transferred from the facility as required. - Review of Resident (R)62's medical record revealed diagnoses that included pancytopenia (a low number of red and white blood cells, usually due to a problem with bone marrow) fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance) and malignant (cancerous) neoplasm (tumor) of the breast. The resident admitted to the facility on [DATE] and left the facility against medical advice on 02/29/24. On 03/14/24 at 2:45 PM Administrative Staff A, confirmed lack of notification of the state ombudsman when residents were transferred/discharged from the facility. The facility lacked a policy for notification of ombudsman. The facility failed to notify the state Ombudsman when residents discharged /transferred from the facility as required. 31078 - R18's signed physician orders dated 02/20/24 revealed the following diagnoses: Peripheral Vascular disease(PVD slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), osteomyelitis (local or generalized infection of the bone and bone marrow) in the left ankle and foot, diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) with foot ulcer. Review of R18's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on 02/09/24 and returned on 02/13/24. Review of R18's Electronic Medical Record lacked evidence of written notification of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long Term Care Ombudsman. Observation on 03/13/24 at 10:05 AM revealed the resident was in his electric chair rolling in the halls. The resident had an amputation on his left leg below the knee. On 03/14/24 at 02:45 PM, Administrative staff A reported he was unaware of the need to inform the Ombudsman of hospital admissions. On 03/18/24 a facility policy regarding the Ombudsman notification was requested. No policy was provided. The facility failed to notify the Long-Term Care Ombudsman, as required, of R18's discharge from the facility to the hospital. This placed the resident at risk for impaired rights and/or advocate involvement. 34056 - Review of Resident (R)44's electronic medical record (EMR) included a diagnosis of metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Activities of Daily Living (ADL) Function/Rehabilitation Potential Care Area Assessment (CAA), dated 01/24/24, documented the resident was dependent on staff for assistance with ADLs. The Discharge MDS, dated [DATE], documented the resident discharged from the facility to an acute hospital with return anticipated. The Entry MDS, dated [DATE], documented the resident readmitted to the facility from an acute hospital. The care plan for ADLs, dated 01/17/24, instructed staff the resident had a decline in his ability to perform ADLs. Review of the resident's EMR revealed the resident admitted to an acute hospital on 02/09/24 with a diagnosis of sepsis (systemic infection of the blood). The resident's EMR lacked a signed bed hold for his hospital admission on 02/09/24. On 03/14/24 at 02:40 PM, Administrative Nurse D stated she was unaware of the need to inform the Ombudsman of hospital admissions. On 03/14/24 at 02:45 PM, Administrative Staff A stated he was unaware of the need to inform the Ombudsman of hospital admissions. The facility lacked a policy for Ombudsman notification for resident discharges. The facility failed to notify the Long-Term Care Ombudsman, as required, of R44's discharge from the facility to the hospital.

The facility census totaled 60 residents with 17 included in the sample. Based on observation, interview, and record review, the facility failed to develop comprehensive assessments by the failure to complete the Care Area Assessments (CAAs) for further investigation and development of the comprehensive care plan for seven of the residents included in the sample. Resident (R)40 for respiratory status, R18 for medications, activities of daily living, and pain, R22 for skin issues, R29 for Activities of daily living, pressure ulcers and medications, R43 for pain, R3 for pain, urinary catheter, and skin conditions, and R35 for medications. Findings included: - Resident (R)18's signed physician orders dated 02/20/24 revealed the following diagnoses: Peripheral Vascular disease(PVD- abnormal condition affecting the blood vessels, osteomyelitis (local or generalized infection of the bone and bone marrow) in the left ankle and foot, and diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) with foot ulcer. The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident used a motorized wheelchair for mobility. R18 required substantial/maximum assist with toileting, transfers, and dressing. R18 received as needed pain (prn) medication for frequent pain at 4/10 scale. He had infection in one foot and no open sores, Medications included anticoagulant (medication to prevent blood clots), diuretic (medication to promote the formation and excretion of urine), opioid (narcotic pain medication), insulin (a hormone produced in the pancreas which regulates the amount of glucose in the blood). and intravenous (IV) antibiotics (medication to treat infections). The Care Area Assessment (CAA) dated 02/20/24, revealed no CAAs triggered for further investigation to develop the comprehensive care plan. Observation on 03/13/24 at 10:05 AM, the resident was in his electric chair. The resident had an amputation on his left leg below the knee. Observation on 03/14/24 at 11:10 AM revealed the resident sat in his electric chair in his room. On 03/14/24 at 11:50 AM, Certified Nursing Assistant (CNA) M reported the resident was a two-person transfer with a slide board. He used a urinal for toileting. On 03/14/24 at 11:57 AM, administrative nurse DD reported the corporate nurse worked on assessments prior to her arrival and marked the CAAs as they would be care planned but did not complete the summary areas of the CAAs. On 03/14/24 at 11:30 AM, administrative nurse D reported the facility utilized the Resident Assessment Instrument (RAI) manual when completing the CAAs. On 03/14/24 at 11:57 AM, administrative staff A reported there were two MDS nurses. One of the MDS staff left soon after the administrator started in mid-February 2024. Shortly after, the other nurse went on maternity leave. A corporate nurse was to complete the MDS's. He was not aware they were not complete. On 03/18/24 at 09:10 AM, administrative nurse D acknowledged the CAAs, and the Care Plans were not updated. She reported one of the MDS coordinators quit and the other went on leave. They have a new MDS Coordinator but was unable to catch them up. The facility had no written policy for completion of the MDS or CAAs and utilized the Resident Assessment Instrument (RAI) manual when completing the CAAs. The facility failed to develop comprehensive assessments by the failure to complete the Care Area Assessments (CAAs) for further investigation and development of the comprehensive care plan for R18. - Resident (R)22's signed physician orders revealed the following diagnoses: cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling), and skin tear. The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident was dependent on a wheelchair for mobility with an above the knee amputation on one leg. The resident required partial/moderate assistance for daily care. R22 received pain medication on schedule and as needed for frequent pain at 04/10 pain scale. The resident was dependent on oxygen and received continuous positive airway pressure (CPAP, a device that delivers pressurized air into your nose and mouth to keep your airways open and prevent breathing interruptions.) at night. The resident had a skin tear with dressing treatment. Medications included insulin injections (a hormone produced in the pancreas by the islets of Langerhans, which regulates the amount of glucose in the blood), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), antibiotics (medication to treat infections), diuretic (medication to promote the formation and excretion of urine), opioid pain meds (narcotic pain medication), and antiplatelets (medication to prevent blood clots). The resident received intravenous (IV) antibiotics per midline access. The Care Area Assessment (CAA) dated 02/29/24 revealed no CAAs completed for further investigation to develop the comprehensive care plan. On 03/12/2024 at 08:03 AM, review of the Skin/Wound Note revealed the resident was seen for wound evaluation this shift, a scab within the original wound came off and become an open area. The resident reported she rubbed the tubigrip (elastic tube dressing), dressing and ripped the scab off. The right thigh area one had a skin tear and the wound tissue type was epithelial (new skin growing in a superficial wound), and yellow slough (dead tissue), with the wound edge attached, scant serosanguinous drainage (clear flood that comes out of wound), ( peri-wound pink and blanchable, fragile. no erythema (abnormal redness of skin) observed, no signs of infection., The resident reported pain to the area at the time of the dressing change which resolved when the dressing change completed. The right thigh, area two, revealed a skin tear wound with the tissue type of epithelial and yellow adherent slough, wound edge attached, with an exudate of scant serosanguinous drainage, peri-wound (around the wound) was pink and blanchable, and determined as fragile. The right thigh area third skin tear wound had a tissue type of epithelial tissue, and the wound edge attached, with no exudate. The resident reported the area becomes swollen when resting her leg down and when lymphedema wraps (elastic wraps to put pressure on areas of swelling) intact. Review of the wound care orders, dated 03/13/24, documented for the right calf open area, clean the wound with normal saline, apply a skin barrier film to the peri-wound, then apply hydrofera blue (antibacterial wound dressing) moistened with normal saline to the wound bed, cover with a dry dressing and change on Monday, Wednesday, and Friday. The orders for the right anterior thigh wound, cover the wound bed with hydrofera blue classic (antibacterial wound dressing) (moistened with Normal saline), cover with ABD (thick, padded dressing), wrap with Kerlix and ace wrap and change every three days. On 03/14/23 at 9:00 AM, observation revealed Licensed Nurse (LN) K entered the resident room to provide wound care. She set her dressing supplies directly in a chair beside the resident. The resident sat in a wheelchair. LN K provided wound care. On 03/14/24 at 11:40 AM, Certified Nursing Assistant (CNA) M reported the resident was a two-person transfer. She had an amputation of her left leg above the knee but was able to bear weight and pivot transfer. On 03/14/24 at 11:57 AM, Administrative nurse DD reported the corporate nurse worked on assessments prior to her arrival. The corporate nurse marked the CAAs as they would be care planned but did not complete the summary areas of the CAAs. On 03/14/24 at 11:57 AM, Administrative staff A reported there were two MDS nurses. One of the MDS staff left soon after the administrator started in mid-February 2024. Shortly after, the other nurse went on maternity leave. A corporate nurse was to complete the MDS's. He was not aware they were not complete. On 03/14/24 at 11:30 AM, Administrative nurse D reported the facility utilized the Resident Assessment Instrument (RAI) manual when completing the CAAs. On 03/18/24 at 09:10 AM, Administrative nurse D acknowledged the CAAs, and the Care Plans were not updated. She reported one of the MDS coordinators quit and the other went on leave. They have a new MDS Coordinator but was unable to catch them up. The facility had no written policy for completion of the MDS or CAAs and utilized the Resident Assessment Instrument (RAI) manual when completing the CAAs. The facility failed to develop comprehensive assessments by the failure to complete the Care Area Assessments (CAAs) for further investigation and development of the comprehensive care plan for R22. - Resident (R)40's signed physician orders revealed the following diagnoses: acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), and chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident used a walker for mobility. The resident required partial/moderate staff assistance to toilet, shower, dress, and personal hygiene. The resident had no pain, no falls and received insulin, antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), antibiotic (medication to treat infection), and antiplatelet (medications that prevent blood clots from forming), medications daily. The resident received continuous oxygen therapy. The Care Area Assessment (CAA) dated 02/28/24 revealed no CAAs for further investigation in developing a comprehensive care plan. The physician order dated 01/11/24 revealed oxygen to be on at (1-5) liters per minute (continuously), delivered through (NC) may titrate to greater than or equal to 88% every shift and prn. Okay for therapy to titrate every shift for shortness of breath (SOB) and as needed for SOB/decreased blood oxygen saturation. On 03/13/24 at 12:24 PM, R40 was eating lunch in his room, and had oxygen (O2) on per nasal cannula. The resident exhibited shortness of breath while he ate. On 03/14/24 at 09:00 AM revealed the resident was in bed with his O2 on per nasal cannula. On 03/13/24 at 12:25 PM, the resident reported he had pneumonia (inflammation of the lungs), and was currently on antibiotics to treat the pneumonia. On 03/14/24 at 10:30 AM, Certified Nursing Assessment (CNA)M reported the resident was moderate assistance of one staff. He always wore oxygen. On 03/14/24 at 11:57 AM, Administrative nurse DD reported the corporate nurse worked on assessments prior to her arrival. The corporate nurse marked the CAAs as they would be care planned but did not complete the summary areas of the CAAs. On 03/14/24 at 11:30 AM, Administrative nurse D reported the facility utilized the Resident Assessment Instrument (RAI) manual when completing the CAAs. On 03/14/24 at 11:57 AM, Administrative staff A reported there were two MDS nurses. One of the MDS staff left soon after the administrator started in mid-February 2024. Shortly after, the other nurse went on maternity leave. A corporate nurse was to complete the MDS's. He was not aware they were not complete. On 03/18/24 at 09:10 AM, Administrative nurse D acknowledged the lack of completion of the CAAs, and the care plans were not completed. The facility had no written policy for completion of the MDS or CAAs and utilized the Resident Assessment Instrument (RAI) manual when completing the CAAs. The facility failed to develop comprehensive assessments by the failure to complete the Care Area Assessments (CAAs) for further investigation and development of the comprehensive care plan for R40. 28560 - Review of Resident (R)29's medical record revealed a diagnosis that included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal cognitive function. The resident received antibiotic (medication used to treat infections) antidepressant (medications use to treat depression), and anticoagulant medication (medication used to treat the blood from forming clots). The resident was at risk for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) development. The resident admitted with two stage two (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers. The resident was dependent on staff for activities of daily living. The Psychoactive (medications that affect mood) Medication Care Area Assessment (CAA), dated 02/21/24, was undeveloped. The Pressure Ulcer CAA dated 02/21/24, was not developed. The Activity of Daily Living (ADL)/Functional Rehabilitation CAA dated 02/21/24 was not developed . Interview, on 03/14/24 11:25 AM, with Administrative Staff A, revealed the since mid-February 2024, corporate nurses completed the MDS for the facility. Interview, on 03/14/24 at 11:57 AM, with Administrative Nurse DD, confirmed with the CAA was not developed, the MDS would not be complete. The facility followed the Resident Assessment Instrument (RAI) manual when completing the CAAs. The facility failed to ensure staff completed the CAAs to develop a comprehensive care plan as required. - Review of Resident (R)3's medical record, revealed diagnoses that included atrial fibrillation (rapid irregular heartbeat), lymphedema (swelling caused by an accumulation of lymph that leaked from blood vessels), and muscle weakness. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. The resident was dependent on staff for bed mobility and at risk for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and had a skin tear and moisture associated skin damage (MASD- inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva or mucous). The resident received scheduled pain medications and described her pain as occasional and mild. The resident had a urinary catheter (device used to drain urine from the bladder). The Pressure Ulcer Care Area Assessment (CAA) for the MDS dated [DATE], was not developed. The Pain CAA, for the MDS dated [DATE], was not developed. The Urinary Incontinence and Indwelling Catheter CAA for the MDS dated [DATE] was not developed. Interview, on 03/14/24 11:25 AM, with Administrative Staff A, revealed the since mid-February 2024, corporate nurses completed the MDS for the facility. Interview, on 03/14/24 at 11:57 AM, with Administrative Nurse DD, confirmed with the CAA was not developed, the MDS would not be complete. The facility followed the Resident Assessment Instrument (RAI) manual when completing the CAAs. The facility failed to ensure staff completed the CAA to develop a comprehensive care plan as required. 34056 - Review of Resident (R)43's electronic medical record (EMR) included a diagnosis of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She received scheduled and non-medication interventions for pain. The resident reported frequent pain in the past five days of the look back period which affected her sleep, day to day activities that interfered with her therapy. She reported her worst pain in the five days was a seven out of a scale of 1-10 pain scale. She received opioid medications (a class of drugs that derive from, or mimic, natural substances found in the opium poppy plant. Opioids work in the brain to produce a variety of effects, including pain relief) during the assessment period. The Pain Care Area Assessment (CAA), dated 03/06/24, triggered back lacked an analysis of findings. The care plan for pain, dated 02/28/24, instructed staff the resident had acute (sudden on-set) and chronic (persisting for a long time) pain. Staff were to acknowledge the resident's presence of pain and discomfort. Review of the resident's EMR revealed the following physician's orders: Norco (an opioid medication combined with Acetaminophen), 10-325 milligrams (mg), by mouth (po), every (Q) four hours, for pain, ordered 03/02/24. On 03/13/24 at 08:29 AM, the resident stated she had a lot of pain which she took pain medication to relieve. On 03/13/24 at 08:39 AM, Licensed Nurse (LN) I stated the resident took pain medication every four hours. On 03/14/24 at 11:57 AM, Administrative Nurse D confirmed the pain CAA had not been completed for this resident who had pain and received opioid pain medication. The facility follows the Resident Assessment Instrument (RAI) manual when completing the CAAs. The facility failed to complete the Pain CAA for this resident who had pain and received pain medication. - Review of Resident (R)35's electronic medical record (EMR) included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) with psychotic disturbance (any major mental disorder characterized by a gross impairment in reality perception), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and mood disturbance (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. He received antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) medication during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 02/29/24, triggered but lacked an analysis of findings. The Psychosocial Well-Being CAA, dated 02/29/24, triggered but lacked an analysis of findings. The Cognitive Loss/Dementia CAA, dated 02/29/24, triggered but lacked an analysis of findings. The care plan for psychotropic medications (a group of drugs that affects behavior, mood, thoughts or perception) medications, dated 02/22/24, instructed staff to monitor for adverse reactions to the medication. Review of the resident's electronic medical record (EMR), revealed the following physician's order: Seroquel (an antipsychotic medication), 25 milligrams (mg), by mouth (po), every day (QD), for forgetfulness and possible dementia, ordered, 02/27/24. On 03/13/24 at 08:39 AM, Licensed Nurse (LN) I stated the resident took antipsychotic medications daily. On 03/14/24 at 11:57 AM, Administrative Nurse D confirmed the Psychotropic Drug Use, Psychosocial Well-Being and the Cognitive Loss/Dementia CAAs had not been completed for this resident who had dementia with psychotic disturbances. The facility follows the Resident Assessment Instrument (RAI) manual when completing the CAAs. The facility failed to complete the Psychotropic Drug Use, Psychosocial Well-Being and the Cognitive Loss/Dementia CAAs for this resident who had dementia with psychotic disturbances.

The facility reported a census of 60 residents with 17 selected for review, which included two residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide one Resident (R)29, reasonable accommodations to his physical environmment, when he could not access the mirror. Findings included: - Review of Resident (R)29's medical record revealed diagnosis that included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, mask-like faces, shuffling gait, muscle rigidity and weakness). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal cognitive function. The resident required supervision or touching (helper to provide verbal cues of touching/steadying assistance as resident completes the activity) for personal hygiene. The Activity of Daily Living (ADL)/ Functional Rehabilitation Care Area Assessment (CAA), dated 02/21/24, was not developed. The Care Plan, reviewed 03/04/24, instructed staff to provide assistance as needed with grooming, bathing, and personal hygiene. Observation, on 03/14/24 at 09:57 AM, revealed R29 seated in his wheelchair in his room. The resident responded appropriately to questions. The resident had areas of unshaven facial hair. The resident stated he had difficulty seeing the mirror to shave due to the location in the bathroom as he did not stand to shave. Interview, on 03/14/24 at 11:07 AM, with Licensed Nurse (LN) J, revealed staff assisted R29 with set up for grooming. Interview, on 03/14/24 at 12:43 PM, with Certified Nurse Aide (CNA) Q, revealed R29 required staff assistance with shaving. Observation, on 03/18/24 at 07:31 AM, revealed R29 had several days growth of facial hair. The resident stated he preferred to be clean shaven but could not see the mirror to complete the task. Interview, on 03/18/24 at 07:45 AM, with CNA N, revealed R29 did ask her for assistance shaving this morning. Interview, on 03/18/24 at 10:30 AM, with Administrative Nurse D, revealed she would expect staff to provide grooming assistance per resident preferences. The facility policy ADL Services reviewed 03/14/24, instructed staff to provide assistance with ADL every shift as appropriate, to include shaving. The facility failed to provide reasonable accommodations to his physical environmment, when R29 could not access the mirror.

The facility reported a census of 60 residents. Based on interview and record review, the facility failed to notify one Resident (R) 167, a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare covered Part A stay. Findings included: - On 03/14/24, Administrative staff A provided a list of discharged Medicare A residents with three residents chosen for review. One Resident (R)167 had no NOMNC completed when Medicare Part A services were terminate to let the resident know how many days of the 100 days available remained. On 03/18/24 at 10:20 AM, Administrative Nurse D reported the Social Service Designee (SSD) was responsible to complete the beneficiary notices (NOMNCs), however had quit about six weeks ago. Review of the facility policy for Notice of Medicare Non-Coverage, dated 06/20/23, revealed the facility must deliver a completed copy of the Notice of Medicare Non-Coverage to beneficiaries/enrollees receiving covered skilled nursing. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. A NOMNC must be delivered even if beneficiaries agree with the termination of services. The provider must ensure the beneficiary or representative signs and dates the NOMNC to demonstrate the beneficiary or representative received the notice and understands the termination decision can be disputed. The facility failed to give one resident, R167, a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare covered Part A stay, as required.

The facility reported a census of 60 residents with 17 residents sampled, including three residents reviewed for hospitalization . Based on interview and record review, the facility failed to provide the two Residents (R)18 and R 44 and/or their representative with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital. Findings included: - Review of Resident (R)44's electronic medical record (EMR) included a diagnosis of metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/24/24, documented the resident was dependent on staff for assistance with ADLs. The Discharge MDS, Return Anticipated MDS, dated [DATE], documented the resident discharged from the facility to an acute hospital. This discharge was return anticipated. The Entry MDS, dated [DATE], documented the resident readmitted to the facility from an acute hospital. The care plan for ADLs, dated 01/17/24, instructed staff the resident had a decline in his ability to perform ADLs. Review of the resident's EMR revealed the resident admitted to an acute hospital on 02/09/24 with a diagnosis of sepsis (systemic infection of the blood). The resident's EMR lacked a signed bed hold for his hospital admission on 02/09/24. On 03/18/24 at 08:24 AM, Licensed Nurse (LN) I stated a bed hold would need to be signed when a resident transferred to the hospital. On 03/14/24 at 02:40 PM, Administrative Nurse D stated the nurses did not complete bed holds for residents when they transferred to the hospital. On 03/24/24 at 02:45 PM, Administrative Staff A stated he was unaware of the need for residents and/or their representatives to sign a bed hold when transferred to the hospital. The facility policy for Bed Holds, revised 03/15/24, included: The facility will provide all residents with notice of bed-holds upon admission and at the time of transfer to the hospital and if applicable the resident's representative at time of transfer to the hospital. In cases of emergency transfer, notice will be offered within 24 hours. The facility failed to provide the resident and/or his representative with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital. 31078 - Review of R18's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on 02/09/24 and returned on 02/13/24. Review of R18's Electronic Medical Record lacked evidence of written notification of the facility-initiated hospitalization transfer and bed hold to R18 or his representative. Observation on 03/13/24 at 10:05 AM revealed the resident was in his electric chair. The resident had an amputation on his left leg below the knee. On 03/14/24 at 2:30 PM, Administrative Staff B reported when she is aware of a resident being transferred to the hospital, she should fill out a short online report about the bed hold. She might talk to the family if available, but reported she would get signatures for any bed holds. The nurses could also complete a bed hold form when a resident transferred to a hospital. On 03/14/24 at 02:40 PM, Administrative Nurse D reported the nurses do not complete bed holds on residents. On 03/14/24 at 2:45 PM. Administrative Staff A reported he was unaware of the bed holds not being completed on the residents who were discharged to a hospital with return anticipated. He reported he never really worried about it because with the census, the facility would always have a bed for whatever resident needs to return after hospitalization . The facility policy for Bed Holds, revised 03/15/24, included: The facility will provide all residents with notice of bed-holds upon admission and at the time of transfer to the hospital and if applicable the resident's representative at time of transfer to the hospital. In cases of emergency transfer, notice will be offered within 24 hours. The facility failed to provide the resident and/or his representative with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital.

The facility reported a census of 60 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to develop baseline a care plans for three residents, that included one Resident (R)20 regarding not having a baseline care plan, R214, regarding failure to include dialysis (procedure where impurities or wastes were removed from the blood), and R 221, regarding failure to include psychotropic (alters mood or thought) medication. Findings included: - Review of Resident (R)20's medical record, revealed diagnoses included aftercare for extraction of knee joint prosthesis, diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic kidney disease, and atrial fibrillation (rapid, irregular heartbeat). The resident admitted to the facility on [DATE]. The medical record lacked a Baseline Care Plan. Interview, on 03/18/24 at 10:30 AM, with Administrative Nurse D, confirmed the lack of a Baseline Care Plan. The facility policy for Person Centered Care, dated 10/20/17, included: The facility will complete and implement a baseline care plan within 48 hours of a resident's admission to assist and promote continuity of care and communication among staff. The facility failed to complete a Baseline Care Plan as required. 34056 - Review of Resident (R)221's Physician Order Sheet (POS), undated, included a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Admission Minimum Data Set (MDS), was not completed. The care plan for behaviors, dated 03/05/24, lacked staff instruction regarding the use of antipsychotic medication. Review of the resident's electronic medical record (EMR), revealed the following physician's orders: Aripiprazole (an antipsychotic medication used to treat psychosis-related conditions and symptoms), 20 milligrams (mg), by mouth (po), at bedtime (HS), for dementia with psychosis, ordered 03/04/24. The order was discontinued on 03/06/24. Aripiprazole, 20 mg, po, every day (QD), for dementia with psychosis, ordered 03/06/24. On 03/14/24 at 08:47 AM, Certified Nurse Aide (CNA) P stated will get restless around evening time and will have behaviors such as yelling out or being non-cooperative with staff in regards to his cares. On 03/14/24 at 08:52 AM, CNA O stated the resident could have behaviors at times which was why he had a sitter with him throughout the day. On 03/14/24 at 12:32 PM, Licensed Nurse (LN) H stated antipsychotic medications should be included on the care plans. All nurses were able to add to the care plans. On 03/18/24 at 09:07 AM, Administrative Nurse D stated it was the expectation for antipsychotic medications be included on the care plans. The facility policy for Person Centered Care, dated 10/20/17, included: The facility will complete and implement a baseline care plan within 48 hours of a resident's admission to assist and promote continuity of care and communication among staff. The facility failed to include antipsychotic medications on the baseline care plan for this dependent resident who took antipsychotic medication. - Review of Resident (R)214's electronic medical record (EMR) revealed a diagnosis of end stage renal disease (ESRD-a terminal disease of the kidneys). The Admission Minimum Data Set, was in progress. The baseline care plan, dated 03/06/24, lacked staff instruction regarding dialysis. Review of the resident's EMR revealed a physician's order, which included: Resident will receive dialysis at a local dialysis center on Tuesdays and Saturdays, ordered 03/06/24. Review of one Dialysis Communication Form, dated 03/12/24 and provided by the facility, was incomplete. The form lacked information including the name of the resident's physician, the contact person for the resident at the facility, the facility phone number, face sheet, medication list, vital signs (VS), medications received before dialysis and medications sent with the resident to the dialysis center. No other Dialysis Communication Form was made available. On 03/14/24 at 12:32 PM, Licensed Nurse (LN) H stated dialysis cares should be included on the care plans. All nurses were able to add to the care plans. On 03/18/24 at 09:07 AM, Administrative Nurse D stated it was the expectation for dialysis cares to be included on the care plans. The facility policy for Person Centered Care, dated 10/20/17, included: The facility will complete and implement a baseline care plan within 48 hours of a resident's admission to assist and promote continuity of care and communication among staff. The facility failed to include dialysis cares on the baseline care plan for this resident who received dialysis two times per week.

The facility reported a census of 60 residents with 17 selected for review, which included two residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide one Resident (R)29, assistance with facial shaving. Findings included: - Review of Resident (R)29's medical record revealed diagnosis that included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, mask-like faces, shuffling gait, muscle rigidity and weakness). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal cognitive function. The resident required supervision or touching (helper to provide verbal cues of touching/steadying assistance as resident completes the activity) for personal hygiene. The Activity of Daily Living (ADL)/ Functional Rehabilitation Care Area Assessment (CAA), dated 02/21/24, was not developed. The Care Plan, reviewed 03/04/24, instructed staff to provide assistance as needed with grooming, bathing, and personal hygiene. Observation, on 03/14/24 at 09:57 AM, revealed R29 seated in his wheelchair in his room. The resident responded appropriately to questions. The resident had areas of unshaven facial hair. The resident stated he had difficulty seeing the mirror to shave due to the location in the bathroom as he did not stand to shave. Interview, on 03/14/24 at 11:07 AM, with Licensed Nurse (LN) J, revealed staff assisted R29 with set up for grooming. Interview, on 03/14/24 at 12:43 PM, with Certified Nurse Aide (CNA) Q, revealed R29 required staff assistance with shaving. Observation, on 03/18/24 at 07:31 AM, revealed R29 had several days growth of facial hair. The resident stated he preferred to be clean shaven but could not see the mirror to complete the task. Interview, on 03/18/24 at 07:45 AM, with CNA N, revealed R29 did ask her for assistance shaving this morning. Interview, on 03/18/24 at 10:30 AM, with Administrative Nurse D, revealed she would expect staff to provide grooming assistance per resident preferences. The facility policy ADL Services reviewed 03/14/24, instructed staff to provide assistance with ADL every shift as appropriate, to include shaving. The facility failed to ensure R29 received assistance with shaving as needed when he could not effectively see the mirror to ensure clean shaven appearance to enhance personal wellbeing.

The facility reported a census of 60 residents with 17 residents selected for review, which included three residents reviewed for skin issues. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)3, of the three residents received appropriate treatment for an unidentified skin injury and sanitary dressing change. Findings included: - Review of Resident (R)3's medical record, revealed diagnoses that included atrial fibrillation (rapid irregular heartbeat), lymphedema (swelling caused by an accumulation of lymph), and muscle weakness. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. The resident was dependent on staff for bed mobility and at risk for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and had a skin tear and moisture associated skin damage (MASD- inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva or mucous). The Pressure Ulcer Care Area Assessment (CAA) for the MDS dated [DATE], was not developed. The Care Plan, reviewed 03/12/24, instructed staff the resident had a potential for skin breakdown related to impaired mobility. Staff instructed to monitor, remind, and assist the resident to turn and reposition frequently and as needed or requested. A Skin Evaluation, dated 02/29/24, revealed a right thigh wound with drainage, and open area to buttock, bilateral (both) upper extremity bruising and bilateral lower extremity edema (swelling resulting from an excessive accumulation of fluid in the body tissues) and bruising/discoloration. A Skin Evaluation, dated 03/04/14, assessed R3 with a right thigh open wound with drainage, an open area to her buttock, and bilateral lower extremity bruising, edema, and discoloration. On 03/01/24, the physician instructed staff to apply xeroform(Vaseline infused) gauze and a dry dressing daily and as needed to the right anterior (front) thigh abrasion(scraping or rubbing away of skin). On 03/15/24, the physician instructed staff to cleanse R3's coccyx (area at the base of the spine) open area with normal saline, and apply calcium alginate (a substance that turns into a gel and absorbs drainage) to the wound bed and cover with a dry dressing daily and as needed. Interview, on 03/13/24 at 8:25 AM, with the R3 revealed she had lymphedema in her lower extremities and received therapy. The resident sat positioned in bed eating breakfast. Observation, on 03/18/24 at 07:54 AM, revealed R3 positioned in bed. Administrative Nurse F and D assisted the resident to turn on her side. Upon turning, the sheet beneath the bed saver pad, contained a large area of yellow tan drainage. The resident did not have a dressing on her coccyx and was incontinent of bowels. Administrative Nurse F provided incontinent care, then removed her gloves and donned another pair of gloves without sanitizing/ cleansing her hands. Administrative Nurse F cleansed R3's coccyx wound with normal saline and applied xeroform gauze. Administrative Nurse F stated the resident had MASD, and the open area was shallow. The resident repositioned on her back and Consulting Provider HH, examined the resident's right anterior upper thigh area, and noted an area of fluid seepage. Administrative Nurse F stated the drainage on the sheet probably came from this area and provided wound care. Administrative Nurse F and D assisted the resident to turn for a bed change and noted a dressing on her right posterior (back) thigh. The dressing was undated and contained serosanguineous drainage (bloody drainage) across the entire surface. Administrative Nurse F removed the dressing and assessed the area as a previous blister that opened, with an exposed shallow surface and measured the area as 3.2 by 2.3 centimeters (cm). Administrative Nurse F cleansed the area and applied a dry dressing, and stated she would notify the provider, and obtain orders for daily wound care. Interview, on 03/18/24 at 10:30 AM, with Administrative Nurse D, confirmed the area on the resident's posterior thigh had not been assessed until today and the dressing should have had a date on it, and she would expect staff to document the wound and provide treatment. The facility policy for Pressure Ulcers, revised 08/04/22, included: The facility will provide the necessary requirements to ensure that a resident receives the treatment and care in accordance with professional standards of practice. The facility failed to ensure sanitary dressing change for R3 and failed to identify and treat the posterior thigh wound and failed to provide sanitary bed linen to prevent the spread of infection .