Every finding on record at Centre Pointe Health and Rehab Center

Based upon interviews, observations, and record review, the facility failed to provide activities of daily care who is dependent for care and services for 1 of 5 residents reviewed. (Resident #115)The findings include:An interview was conducted with Resident #115's representative on 1/5/2026 at 3:30 pm, who expressed concerns that her mother is not receiving the care and services she needs on a daily basis. She expressed concerns that her mother does not get her teeth brushed daily, she is often in the same clothes for days, she has matted hair to her scalp and is unable to get it untangled. During this interview, it was observed that Resident #115 was lying in bed with a grey t-shirt on, a brief and a sheet covering her lower extremities. Her hair was unkempt and matted to the back of her scalp.On 01/06/2026 at 09:30 am, an observation of Resident #115 revealed she was lying in bed, with her eyes closed and oxygen in use. She was in the same grey t-shirt from yesterday with a stain on the front of her shirt and her hair was unkempt and disheveled. Resident #115's teeth had food particles with a yellowish colored build up around her lower front bottom teeth.At 2:00 pm, an observation was conducted with Resident #115, who was observed lying in bed, continues to be in grey t-shirt with a stain on the front, and only an incontinence brief on her lower half. Resident #115 hair was still unkempt and disheveled.At 4:00 pm Resident #115 was lying in bed eyes with her daughter at her bedside. The daughter stated she had a bath just a few minutes ago. Resident #115's hair was brushed but it was still matted at the scalp on the back of her head. She is wearing a new blue t-shirt and has a new incontinence brief on.On 01/07/2026 at 09:15 AM, Resident #115 was lying in her wearing the same navy-blue shirt from yesterday afternoon and an incontinence brief on and her hair was disheveled and appears unkempt. Further observations at 12:30 pm and 4:30 pm revealed no change in the situation. An additional observation on 1/8/26 at 8:15 AM revealed no changes.On 1/8/2026 at 09:00 AM an interview was conducted with Staff Member E (Certified Nursing Assistant), who stated that Resident #115 is totally dependent on staff assistance for eating, bathing, changing, and dressing and that she is incontinent of bowel and bladder. Staff E stated that there are times she will become combative when providing care for her. When asked if she has any training with residents who are combative with care, Staff Member E stated that they have not had any training or in-services on how to deal with combative residents during care. On 1/6/2026 at 10:00 am, a record review was conducted for activities of daily living for Resident #115. Her shower days are scheduled for every Tuesday, Thursday, and Saturday. A thirty-day look back period for showers noted Resident #115 only received 5 showers and 1 bed bath.Resident #115's plan of care reveals she has an activities of daily living self-care deficit related to impaired functional mobility, generalized weakness, and decreased endurance with the goal that she will have needs met and that she will be clean, and well groomed. Interventions include assist as needed to reposition, face her when speaking, provide diet as ordered, encourage her to participate to the fullest extent possible, encourage the use of call light, and explain all procedures.

Based on observation, resident interview, staff interview, record review, and policy review, the facility failed to ensure the interdisciplinary team assessed and determined if a resident was capable of self-administration of medications prior to allowing the practice for 4 of 25 sampled residents. (Resident #43, #112, #67 and #7)The findings include:Observations:An observation of Resident #43's room was conducted on 1/5/26 at 11:30 AM, 1/6/26 at 9:46 AM and 2:10 PM, 1/7/26 at 9:30 AM and 12:30 PM, and 1/8/26 at 8:30 AM. A bottle of over-the-counter eye drops was observed to be sitting on the bedside table.An observation of Resident #112's room was conducted on 1/5/26 at 12:30 PM, 1/6/26 at 8:45 AM,1:45 PM and 3:00 PM, 1/7/26 at 9:00 AM and 12:45 PM, and 1/8/26 at 8:20 AM. A bottle of over-the-counter eye drops and a prescription bottle of Ipratropium Bromide 0.06% (nasal spray) were observed sitting on the bedside table.An observation of Resident #67's room was conducted on 1/5/26 at 12:39 PM, 1/6/26 at 9:00 AM and 1:00 PM, and 1/7/26 at 9:15 AM, 12:00 PM, and 4:30 PM. A bottle of throat antiseptic spray, aspirin, ibuprofen and eye drops were observed on the bedside table.An observation of Resident #7's room was conducted on 1/6/26 at 4:30 PM and revealed an inhaler on the bedside table. (Photographic Evidence Obtained of all observations)Record Review:A review of Residents #7, #43, #67 and #112's electronic medical records revealed no physician's order for self-medication administration and no assessments for self-medication.Interviews:An interview was conducted on 1/7/26 at approximately 9:45 AM with Staff A, Licensed Practical Nurse (LPN). LPN A confirmed that there were no residents that were permitted to self-administer medications.Policy review:A review of the facility policy for self-administration of medications by residents revealed each resident who desires to self-administer medications is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the resident.

Based on record review and staff interview, the facility failed to ensure the long term care ombudsman received a copy of the transfer notice for 1 of 2 residents reviewed for hospitalization. (Resident #156)The findings include:A review of Resident #156's medical record revealed the resident was transferred to the hospital on [DATE]. A review of the Nursing Home Transfer and Discharge Notice dated 11/8/25 revealed the that section the notice indicating the ombudsman received a copy of this transfer was blank. An interview was conducted with the Administrator on 1/7/26 at 4:45 PM. He stated the facility did not have evidence of transfers and discharges being reported to the ombudsman monthly. The former case manager that was working in the facility would not respond to the facility.

Based on interviews, review of the electronic medical record (EMR), and review of the facilities policies and procedures, the facility failed to ensure each resident requiring a Preadmission Screening and Resident Review (PASARR) Level II screening had the evaluation completed for 1 of 1 residents sampled. (Resident #122)The findings include:On 1/7/26, a review of Resident #122's EMR revealed that the resident had multiple mental disorder diagnosis including Alzheimer's disease, depressive episodes, and cognitive communication deficit. The facility completed a PASARR Level I evaluation on 6/19/25, which recommended a PASARR Level II screening. However, the EMR contained no documentation that the facility completed the recommended PASARR Level II screening.On 1/8/26 at approximately 11:52 am, Staff C (Social Services Consultant) was interviewed. Staff C confirmed that the completed screening was not present in the EMR and had not been completed, Staff C stated that the facility faxed the request for a PASARR Level II screening that morning.A review of the facility's undated policy entitled PASARR Guidance stated: Referral for Level II resident review evaluation is required for individuals previously identified by PASRR to have a mental disorder or intellectual disability, or a related condition who experience a significant change.

Based on observation, interview, record, and policy review, the facility failed to ensure that residents received wound care and treatment in accordance with professional standards of practice in 1 of 1 resident sampled for wound care. (Resident #122)The findings include:On 1/5/26 at approximately 2:45 PM, Resident #122 was observed seated in a wheelchair in the hallway. There was an undated dressing on the resident's left shin which had lifted along the bottom edge and was dripping a dark red fluid. The dark red fluid drained from beneath the dressing, ran in a thin stream down the resident's leg, and dripped onto the floor. An approximate silver dollar sized pool, with several smaller drops of the dark red fluid, had formed on the floor beneath the resident's feet. At 3:45 PM, an additional observation of Resident #122 noted that staff had applied a new bandage dated with the current date.On 1/6/26, Resident #122's electronic medical record (EMR) was reviewed. The EMR contained no documentation regarding the dressing on the resident's left shin and no skin care orders for treatment to the area.On 1/6/26 at approximately 4:45 PM, Staff D, Licensed Practical Nurse (LPN), was interviewed. Staff D confirmed that she was Resident #122's nurse. She was asked why Resident #122 had a dressing on her lower left leg and whether it was related to a wound or a skin condition. Staff D stated that she was not aware of any dressing on the resident's left leg. Staff D was asked to show documentation in the EMR explaining why the resident's leg was draining and required a dressing. Staff D stated that the EMR contained no documentation regarding the dressing.On 1/6/26 at approximately 5:00PM the facility's Director of Nursing (DON) was asked whether the EMR contained documentation of a draining wound or skin condition requiring a dressing on Resident #122's left shin. The DON stated that the resident had a pressure ulcer to her coccyx with treatment orders; however, the DON found no documentation in the EMR of a draining skin condition or wound on the left shin requiring dressing. The DON stated that skin assessments for long term care residents were documented on paper and may not have been scanned into the EMR.On 1/7/26, a skin sweep (an assessment used to document areas of compromised skin integrity) was completed for Resident #122. The skin sweep contained no documentation of a skin condition or wound to Resident #122's left leg. The resident's most recent quarterly Care Plan included interventions for skin inspection, including observing for redness, open areas, scratches, cuts, bruises and report changes to the nurse.On 1/8/26 at approximately 9:30 AM, the DON confirmed that the facility had no documentation of any skin condition or wound to Resident #122's left shin.The facility's undated policy entitled Weekly & (as needed) PRN Skin Check. The policy stated: 1. The skin check should be documented on the Weekly & PRN Skin Check. If a new area is identified the appropriate Change in Condition should be initiated. 4. If there are any new areas identified: a. Complete a Change in Condition 5. Maintain in resident Electronic Medical Record.

Based upon observation, record review, and interviews the facility failed to demonstrate an infection prevention and control program that identifies, investigates and monitors all infections at the facility. Additionally, the facility failed to follow hand hygiene procedures when initiating intravenous medication administration for 1 of 1 residents reviewed. (Resident #7) The findings include: Infection tracking program: Upon review of the facility's infection control tracking and monitoring logs for 2025, there was no data of infections available for the months of July, August, and September 2025, only two infections were documented for the month of October 2025, and zero infections were documented for the months of November and December 2025. No facility mapping of infections to monitor for patterns is available for any of the months in 2025. An interview was conducted with Director of Nurses / Infection Control Preventionist on 1/8/2026 at 10:30 AM. She revealed that she and the clinical management team review all orders and clinical reports in a daily clinical meeting. They review for clinical summaries for each resident and look for any abnormal labs, abnormal vital signs, changes in condition status, symptoms that may be indicative of an infection, and any new antibiotic physician orders received. She further states that she tracks the infections through the electronic records portal for infection control and the system tracks and flags for an active infection when new antibiotic orders are noted. She reviews the data, cultures, labs, and symptoms, and monitor the time out for 3 days. Once the symptoms are resolved and / or antibiotic is completed, they close the active infection out. She also completes a mapping of infections and looks for any patterns that may occur. If a culture or lab is received and requires a change in an antibiotic, she contacts the physician and updates them on the sensitivity report. She stated she communicates with the clinical team every day in the morning or at evening team meetings and reports to the team every month in their Quality Assurance meetings. If there is an outbreak of an infection, they monitor all residents for symptoms. If they have the same infection, we cohort them together in the same room. If the infection requires a resident to be isolated, then we isolate them, manage their symptoms, track and map the infections to control the outbreak. She also reports to the Department of Health any outbreaks of infections such as influenza, Norovirus, and Covid. She stated that she provides education to staff on hand hygiene, perform spot checks with the blue light and the glow germ, donning and doffing protective equipment correctly, and types of infections that requires contact and droplet isolation. When asked to explain why there was no tracking or monitoring available to review for the months of July, August, September 2025, she explained that the facility went to electronic tracking but that she still writes out her line listing by hand, and the Administrator has her copies in the QAPI binder. Upon asking for clarification of the October 2025 tracking report revealing only two infections for the month of October and zero infections for November and December 2025 she did not offer any clarification or explanation and could not demonstrate the infection control line listing data from the QAPI binder prior to exit conference. The facility's infection control policy states the facility will use a systematic method of collecting, consolidating, and analyzing data concerning the distribution and determining factors of a given disease, complication, or event above the background rate. The procedure includes: gather information from each unit at least once per week, initiate a resident specific infection surveillance worksheet if infection appears likely, summarize information from the infection surveillance worksheet on the monthly line listing report, Tabulate infection data according to the following and document on the appropriate month on the annual infection rate summary, calculate incidence rates and compare to previous rates within the facility, present information at the next scheduled infection control prevention tea meeting, develop conclusions, recommendations, actions, and follow ups, report to risk manager / quality improvement committee as needed, provide staff training, and review and revise action plan as needed. Resident #7 On 1/7/26 at approximately 2:05 PM, Staff B, Licensed Practical Nurse (LPN), was observed administering Resident #7's scheduled intravenous (IV) antibiotics. Staff B was observed performing all steps in the administration of Resident #7's IV medication. At no time after entering the resident's room did Staff D remove her gloves, perform hand hygiene, and don a new pair of gloves, even though she was observed touching the resident's waste basket and bedside table. At approximately 2:10 PM, Staff B was asked about the facility's infection control policy and asked whether she should perform hand hygiene after touching the resident's bedside table and waste basket. Staff B stated that she should have washed her hands and put on a new pair of gloves after touching those things. At approximately 2:20 PM, the facility's Director of Nursing (DON) was asked about the expectations when nurses administer IV medications to the residents. The DON stated that she expects all nurses to follow the infection control policy and use aseptic [clean] technique when administering IV medications. The facility's undated policy entitled Infection Prevention - Hand Hygiene stated: The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient microorganisms. Hand hygiene to occur including but not limited to the following activities: Contact with contaminated items or surfaces. Initiating/completing a clean [aseptic] procedure.

Based on observations, interviews, and record review, the facility failed to follow physician orders for tube feeding start time and formulary for 1 of 2 residents reviewed for tube feeding. (Resident #5) The findings include: During a tour of the facility conducted on 08/26/24 at 11:32 AM, Resident #5 was observed with a tube feeding pump present in his room, but there was no tube feeding formulary hanging or infusing. An additional observation was conducted on 08/26/24 at 12:08 PM, which revealed Resident #5 had Osmolite 1.5 tube feeding formulary infusing through the tube feeding pump at 65 milliliters per hour (mL/hr) with the water flush running at 240 milliliters (mL) every 4 hours. (photographic evidence obtained) An initial review of Resident #5's medical record revealed a physician order written on 06/07/24 for Enteral Feed every shift for Nutritional Support Osmolite 1.5 at 55mL/hr x 22hrs. Down at 8:00 AM up at 10:00 AM. water bolus 200mL every 4 hours. During tours of the facility conducted on 08/27/24 at 10:30 AM and 12:06 PM, the surveyor observed Resident #5's tube feeding was not infusing. An additional observation conducted on 08/27/24 at 1:36 PM revealed Resident #5 had Osmolite 1.5 tube feeding formulary infusing through the tube feeding pump at 65mL/hr with the water flush running at 240 mL every 4 hours. (photographic evidence obtained) An observation conducted on 08/27/24 at 4:45 PM revealed the staff had changed the tube feeding rate to 55mL/hr and the water flush rate to 200mL every 4 hours. An interview was conducted with Staff A, Registered Nurse, on 08/27/24 at 4:48 PM. Staff A stated she had realized the tube feeding was running at the incorrect rate earlier and had changed the rate to the match the physician's order. An interview was conducted with the Administrator and the Director of Nursing on 08/28/24 at 9:15 AM. They stated they had conducted an audit on 08/27/24 of all residents receiving tube feeding and had discovered Resident #5 was receiving his tube feeding and water flush at incorrect rates. A review of the facility policy titled Enteral Feeding: Pump Method, dated 06/08, revealed the following, Purpose: to administer enteral feeding per physician's orders; Procedure: verify physician's order; turn on pump and set proper rate

Based on record review and interview, the facility failed to properly offer and document influenza, pneumococcal, and COVID-19 vaccinations for 3 of 5 residents reviewed for vaccination status. (Resident #43, 100, and 326) The findings include: During a review of the resident's vaccination statuses on 08/28/24, the following areas of concern were noted: Resident #43 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. The medical record revealed the only vaccination consent form present was dated 08/03/22 and included consents for influenza, pneumococcal, and COVID-19 vaccinations. This consent form indicated Resident #43 refused all the offered vaccinations. However, the signature on the form was from a nurse, not Resident #43's designated representative. Resident #100 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. The review of Resident #100's medical record revealed the only vaccination consent form present was undated and included consents for influenza, pneumococcal, and COVID-19 vaccinations. This consent form was signed by Resident #100, but did not indicate if Resident #100 requested or refused the offered vaccinations. Resident #326 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. The review of Resident #326's medical record revealed the only vaccination consent form present was dated 08/14/24 and included consents for influenza, pneumococcal, and COVID-19 vaccinations. This consent form was signed by Resident #326, but did not indicate if Resident #326 requested or refused the offered vaccinations. An interview was conducted on 08/28/24 at 3:38 PM with the facility's Infection Preventionist concerning these oversights. For Resident #43, she stated there should have been a vaccination consent form signed by the resident or their representative at the time of the most recent admission. For Resident #100, she stated the vaccination consent form should have been dated and should have included whether Resident #100 wanted to receive or refuse the vaccinations. For Resident #326, she stated the vaccination consent form should have been dated and should have included whether Resident #326 wanted to receive or refuse the vaccinations. A review of the facility policy titled Pneumococcal, COVID-19, and Annual Influenza Vaccine Information and Request, dated 04/21, revealed the following, Purpose: to document resident request or refusal of these vaccines, When: upon admission, Instructions: ask the resident or legal representative to enter a check mark indicating request or refusal of the vaccines and ask the resident or legal representative to sign and date the form.

Based on observation, record review, interview and facility policy review, the facility failed to procure physician's orders for 1 of 3 residents reviewed for Continuous Positive Airway Pressure (CPAP) use. (Resident #1) The findings include: On 7/1/24 at 10:42 AM, an observation was conducted inside Resident #1's room. The resident had a CPAP machine on night stand. A review of Resident #1's medical record was conducted. This review indicated the resident was readmitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease and sleep apnea. The resident's active physician's order did not include a CPAP machine. Further review of the physician's orders revealed an order discontinued on 5/16/24 that stated CPAP at night with settings at 10/15 MM with heated humidification, nose mask, or full face mask, apply at bedtime and remove in am. The resident's care plan indicated interventions included CPAP settings at night with settings at 10/15 MM with heated humidification, nose mask, or full-face mask, apply at bedtime and remove in am. On 7/1/24 at 3:30 PM, an interview was conducted with Director of Nursing (DON). The DON stated she would expect someone who was care planned for CPAP to have a physician's order. The DON reviewed Resident #1's physician's orders and verified there was no active orders for a CPAP. A review of facility's policy Continuous Positive Airway Pressure, dated 2017, was conducted. Policy stated procedure: verify physician's order, order should include level of CPAP, frequency of use, oxygen liter flow if applicable and route of administration. The policy further stated record in medication of treatment record.

Based on record review and interviews, the facility failed to provide treatment to a pressure ulcer upon admission to the facility for 1 of 3 residents sampled (Resident #1). The finding include: On 4/30/24, a review of Resident #1's medical records was conducted. Records revealed Resident # 1 was discharged to hospital on 2/26/24 and readmitted to facility on 3/7/24 with a new diagnosis of an unstageable pressure ulcer of the sacral region. The resident was incontinent of bladder and bowel upon admission to the facility on [DATE]. Admission orders did not include treatment specific for the pressure ulcer until 3/9/24. A physician's order dated 3/9/24 stated Dakin's external solution (a dilute solution used as an antiseptic to cleanse wounds in order to prevent infection), apply to sacrum topically every day shift for wound care, cleanse wound area with Dakin's solution, pat dry, skin prep perimeter of wound and apply santyl ointment (a debriding ointment that contain an enzyme to allow for wound healing and growth of healthy tissue) to eschar ( a dry, dark scab) of wound and hydrogel to redden area of wound, cover wound with foam dressing. On 4/30/24 at 12:52 PM, an interview was conducted with Staff A, a Physician Assistant (PA) and facility's wound care specialist. During the interview, she reviewed Resident #1's physician's orders and stated Resident #1 should have been admitted with orders for the care of the pressure ulcer. Staff A verified Resident #1 did not have orders for care of the unstageable pressure ulcer until 2 days after arrival to the facility. On 4/30/24 at 3:26 PM, an interview was conducted with Director of Nursing (DON). She was asked the reason Resident #1 did not receive treatments for the pressure ulcer upon arrival to the facility on [DATE]. The DON stated that Resident #1 had the wound cleaned and a barrier cream applied so he did have the skin treated on 3/7/24. Further review of the orders with the DON indicated an order of Barrier cream to scrotum/peri area every shift and as needed after each incontinence episode every shift for skin impairment dated 2/9/21 and re-started on 3/7/24. The DON stated this order was consistent with facility protocol for skin care for residents who were incontinent. The DON verified an order for Dakin's (1/2 strength) external solution, apply to sacrum topically every day shift for wound care cleanse wound area with Dakin's solution pat dry, skin prep perimeter of wound and apply santyl ointment to eschar of wound and hydrogel to redden area of wound, cover wound with foam dressing dated 3/9/24, two days after arriving to facility.

Based on interviews and record review, the facility failed to ensure that wound care documentation was completed for 2 of 3 residents sampled for wound care (Resident #2 and #3). The findings include: Resident #2 On 4/30/24 at 10:05 am, an interview was conducted with Resident # 2. During the interview, she stated facility staff was not consistent with her wound care. On 4/30/24, a review of Resident #2's medical records was conducted. There was a physician's order for nystatin-triamcinolone cream twice a day for skin management with a start date of 4/24/24. The Medication Administration Record (MAR) was reviewed and revealed that, on the 4/25/24 evening shift and 4/27/24 day shift, the documentation was not completed. Another physician's order indicated to apply zinc barrier cream to the buttocks, groin and perineal area, clean with soap and water, pat it dry and apply zinc ointment two times a day for excoriation and skin breakdown with a start date of 3/24/24. The MAR was reviewed and revealed that, on 4/21/24 at 9:00 am and 6:00 pm, on 4/25/24 at 6:00 pm, and on 4/27/24 at 9:00 am, the documentation was not completed. Resident #3 On 4/30/24 at 10:30 AM, an interview was conducted with Resident #3. During the interview, he stated the facility had missed some of his wound care treatments. On 4/30/24, a review of Resident #3's medical records was conducted. There was a physician's order for Triad Hydrophilic Wound Dress Paste, apply to sacrum and both buttock topically every shift for skin management, evaluate for pain prior to, during, and after treatment and medicate as needed, monitor site for signs and symptoms of infection and notify the Practitioner as needed with a start date of 4/4/2024. The MAR was reviewed and revealed that the documenation was not completed for the daytime applications on 4/16/24 and 4/21/24 and for the evening applications on 4/14/24, 4/15/24, 4/20/24, 4/21/24, and 4/25/24. On 4/30/24 at 3:26 PM, an interview was conducted with Director of Nursing (DON). During the interview, the DON reviewed Resident #2 and #3's MAR's. She stated there was facility protocols to document if treatment was given, if it was refused, or the reason it was not given. The DON further stated facility would educate staff that did not document the MARs.

Based on observations, interviews, and electronic record reviews, the facility failed to follow the care plan for 1 of 1 residents sampled for positioning and mobility. (Resident #40) The findings include: On 6/19/23 at approximately 2:15 PM, an interview was conducted with Resident #40. During this interview, the resident stated The staff is supposed to put my splints on my feet every day, but they do not always do that for me. Observation of the resident's feet confirmed that no splints were currently applied to Resident #40's feet. Further observations made on 6/21/23 at approximately 12:30 PM, on 6/22/23 at 8:30 AM, and on 6/22/23 at approximately 12:30 PM noted no splints applied to Resident #40's feet. The splints were observed in the room and available for use but never applied to the resident's feet. A review of Resident # 40's electronic medical record revealed an order dated 3/15/23 stating, Restorative Nursing for Splinting Apply/don Hip abductor splint and Bilateral AFO's (ankle foot orthosis) to both ankles for fixed contractures of hip and ankle. Splint applied daily while patient in bed and while in wheelchair, to patient tolerance. Remove splints for ADL care and hygiene, as well as skin integrity checks, and laundering of splint. Further review of Resident #40's record revealed that the resident had a care plan for assistance with her ADL's (activities of daily living) initiated on 05/04/2022 with an included intervention of Splinting- apply hip abductor splint BL AFO's ankle foot orthosis for contractures. Apply daily while in bed and w/c (wheelchair) as tolerated. Remove as needed for cleaning, hygiene, and skin checks and encourage to keep splints on. This was last updated on 06/22/2023. On 6/22/23 at approximately 1:52 PM, an interview was conducted with Nurse B, a Licensed Practical Nurse (LPN), and Staff C, a Restorative Certified Nursing Assistant (RCNA), concerning the applying and documentation of Resident #40's splints daily. Nurse B stated that he fills in as the restorative nurse as needed and that the Certified Nursing Assistants (CNA) on the floor help to fill in for the restorative aide when she is not here to put the splints on the residents. Nurse B stated it is in the restorative task in Point Click Care (the electronic documentation program the facility uses) for the splints to be applied and the floor staff has the responsibility to document and apply the splints. Staff member C, RCNA stated that, when she is in the facility, she goes around and makes sure the splints for the residents are applied, and if the floor CNA has not put them on yet, she applies them. Staff Member C went on to state that she is not able to apply every resident's splints every day, so the floor staff helps out by applying them. When asked if she documented in the tasks for applying the splints, Staff Member C stated that she does not always complete her documentation daily. On 6/22/23 at approximately 2:23 PM, an interview was conducted with the Director of Nursing (DON) concerning the restorative program and the applying of the resident's splints. The DON stated that it was her expectation that the Restorative Aide document and apply the splints daily. The DON went on to stated that the facility only has one restorative aide due to the recent resignation of the second restorative aide. She also went on to state that they are in the process of hiring another aide to fill the position. The DON confirmed that the documentation for applying Resident #40's splints had not been completed daily, and that if it was not documented then it was not done.

Based on interviews and record reviews, the facility failed to ensure that pain management was provided to 2 of 2 residents reviewed, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. (Residents #202 and #83). The findings include: Resident #202 On 06/21/23 at 12:23 pm, an interview was conducted with Resident #202, who stated he had gone all weekend (6/17/23-6/18/23) without any effective pain medication because the facility ran out. He also stated that he was seen by the Nurse Practitioner (NP) when he was first admitted to the facility and when he brought up needing pain relief medications, she questioned him about all of his recent emergency room (ER) visits as though he was drug seeking prior to admission. He stated this made him feel like a junkie. He stated, I ain't no junkie and I don't want to have to take pain meds, but I have a big kidney stone, cellulitis on my lower legs and a UTI and it all really hurts. He stated that, when he asked for a pain pill, he was told they ran out and they would call the nurse practitioner on 6/16/23. He went all weekend without any pain meds because the nurse practitioner did not call the facility back until 6/19/23. He stated, I thought a doctor was always supposed to be on call. He again stated he did not like the way his doctor and nurse practitioner made him feel about needing pain meds. When he told her he was getting it every 4 hours, he claimed that the NP stated, I'm not doing that and prescribed it for every 6 hours. He said he was in a lot of pain over this past weekend and would like to know that will not happen again. A review of the History and Physical from HCA Capital Hospital dated 6/9/23 for Resident #202 revealed Sepsis due to complications from a Urinary Tract Infection/bacteremia with ESBL Klebsiella pneumoniae. His urogram showed right sided hydronephrosis and a kidney stone in his right kidney. He had a cystoscopy and a right ureteral stent placement. On 6/6/23, his blood and urine cultures grew ESBL Klebsiella pneumoniae. He is currently on IV meropenem. The sepsis was documented as resolved. His leukocytosis was trending down. He is ordered to continue IV meropenem for 2 weeks from the date of negative blood culture. A review of the Medication Administration Record for June 2022 revealed no pain medications was provided on the 6/17/23 or 6/18/23. He did have an active order for 5mg hydrocodone, but the resident stated this is not effective. On 06/22/23 at 11:09 AM, an interview was conducted with the Director of Nursing (DON). She looked up the resident's chart and stated he had Tylenol and Hydrocodone orders written on 6/19/23. I asked her why the resident went all weekend without pain medications. She stated the nurses are supposed to call the physician a few days prior to running out of the medication. The pharmacy delivers every evening around 9 pm. All the nurses would have to do is call the pharmacy and get the code for the Pyxis machine and they can access the medication that way. She agreed that the resident should never have gone without their medications over the weekend. Resident #83 On 06/22/23 at 10:59 AM, an interview was conducted with Resident #83, who stated the facility ran out of his pain medication yesterday and he has not had any for about 24 hours. A review of the current physician's orders for Resident #83 revealed an order for oxyCODONE-Acetaminophen Oral Tablet 10-325 MG (Oxycodone w/ Acetaminophen), give 1 tablet by mouth every 4 hours as needed for pain. On 06/22/23 at 11:09 AM, an interview with the Director of Nursing was conducted while she looked up Resident #83's chart. The DON stated he last had his Oxycodone 10 mg at 11:30 am on 6/21/23. The DON acknowledged the resident should never have gone without their medications.

Based on observation, interviews, and review of the facility's policy and procedure, the facility failed to ensure that medications were left unattended at the resident's bedside for 1 of 4 residents sampled for medications (Resident #11). The findings include: On 01/17/2023 at 11:10 AM, an interview was conducted with Resident #11 who was in her room. Observed on her bedside table next to her breakfast tray was an unattended medication cup which contained several pills. The resident stated that she takes her medications after her breakfast. (Photographic evidence obtained) On 01/17/2023 at 11:15 AM, an interview was conducted with Staff Member F, a Registered Nurse, regarding medication administration procedure. She stated that once the medications are pulled, the patient is then identified, the patient is administered the medications, and the nurse must verify the medications were taken. She was asked what had happened this morning for Resident #11. She stated that the resident wanted to take her medications after her breakfast. The nurse was informed that the resident had not taken her medication. Staff Member F stated she would see to it that the medications were taken. On 01/17/2023 at 12:10 PM, an interview was conducted with Staff Member E, a Licensed Practical Nurse, regarding medication administration. Staff Member E stated that medications should never be left unattended. They are to observe medications being taken. Staff Member E stated it is against policy to leave medications unattended. On 01/18/2023, Resident #11's medical record was reviewed which revealed a new order dated 1/17/2023, Self administration of Medication Evaluation, the order was noted to be In progress. There was no indication that the evaluation was completed or reviewed by the physician. A review of the facility's policy and procedure entitled Medication Pass Guidelines, CCHC 0322 (not dated), indicates 9. Administration of Medication Remain with resident until administration of medication complete.

Based on observation, interview and record review, the facility failed to ensure staff adhered to established infection control policies for cleaning resident equipment and appropriate personal protective equipment (PPE) on 2 of 5 hallways within the facility. (hallways 300 and 500) The findings include: 300 Hallway From survey entrance on 1/24/2022 through survey exit on 1/27/2022, observations of the 300 hallway's closed doors and posted signage noting enhanced PPE precautions to include eye coverings revealed the hallway was under enhanced infection control practices due to multiple residents being under droplet isolation for active Coronavirus Disease 2019 (COVID-19) infections. On 1/26/2022 at approximately 11:00 AM, Housekeeper E was observed on the 300 hallway providing cleaning services in resident rooms with no eye protection in place. On 1/26/2022 at approximately 11:00 AM, an interview was conducted with Housekeeper E which revealed she was aware she should be wearing her face shield but must have forgotten it in the break room. 500 Hallway On 1/26/2022 at approximately 8:30 AM, the 500 hallway was observed. Personal Care Attendant (PCA) D was observed coming in and out of the rooms of Resident #132 and Resident #390 with a rolling cart containing equipment for obtaining resident vital signs. PCA D was observed obtaining Resident #132's blood pressure, temperature, and pulse rate. The PCA then proceeded to Resident #390's room and obtained the resident's blood pressure, temperature, and pulse rate. During this observation, the PCA did not sanitize the equipment before, during, or after use. On 1/26/2022 at approximately 8:30 AM, an interview was conducted with PCA D in which she stated she was hired in September 2021 and had been trained to wipe the equipment between resident contact with disinfectant wipes. She pointed to a holder on the cart where wipes would be stored, however there were no wipes observed. PCA D reported she was out of the wipes and sometimes uses paper towels to clean resident equipment. On 1/26/2022 at approximately 3:55 PM, Certified Nursing Assistant (CNA) F was observed on the 300 hallway with a rolling cart containing equipment for obtaining resident vital signs. CNA F was observed to enter the room of Resident #38 and Resident #84 and obtained the blood pressure, temperature, and pulse rate for each resident. CNA F did not sanitize her equipment between residents and the rolling cart did not contain any disinfectant wipes. On 1/26/2022 at approximately 3:55 PM, an interview was conducted with CNA F in which she stated she was trained to use disinfectant wipes to sanitize equipment between resident contact but did not have any today. She reported wipes were kept at the nursing station. An observation at this time confirmed several containers of disinfectant wipes were on the counter at the nursing station. A review of the facility's Environmental Services Guidelines Manual concerning the subject of approved cleaning products revealed the purpose is To define what cleaning products are to be used by the facility and for what general department. According to the procedure for nursing equipment, Micro-Kill disinfectant wipes are to be used on equipment and glucometers. A review of the Centers for Disease Control and Prevention's webpage on Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated on 2/2/2022 and accessed on 2/9/2022 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html was conducted. According to section 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection, the subsection on Environmental Infection Control stated, Dedicated medical equipment should be used when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. All non-dedicated, non-disposable medical equipment used for the patient should be cleaned and disinfected according to manufacturer's instructions and facility policies before use on another patient. The subsection on Personal Protective Equipment revealed, HCP (health care personnel) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e. goggles or a face shield that covers the front and sides of the face).

Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety during 2 of 2 observations of the kitchen. The findings include: On 1/25/2022, at 12:15 PM, an initial tour of the kitchen was conducted in the presence of the Certified Dietary Manager (CDM). An observation of the internal thermometer inside the reach-in cooler which contained yogurt, milk and nutritional supplements revealed a temperature of 54 degrees Fahrenheit (F). An observation of the temperature log posted on the front of the reach-in cooler revealed the last temperature recorded by staff was yesterday (1/24/2022) morning in which the temperature was noted as 40 degrees F. At this time, the CDM reported the facility just served lunch and the cooler had been opened frequently. When asked about the temperature log posted on the front of the refrigerator, the CDM explained that the morning temperature is recorded as soon as the kitchen opens at approximately 5:00 AM, and the afternoon temperature is recorded at the time the kitchen closes, which is at approximately 6:00 PM. On 1/26/2022 at 11:30 AM, a follow-up tour of the kitchen was conducted in the presence of the CDM. An observation of the internal thermometer inside the reach-in cooler revealed a temperature of 52 degrees F. At this time, the CDM performed a temperature check of a yogurt from inside the reach-in cooler which revealed a temperature of 48 degrees F. The CDM then performed a temperature check of a milk carton which revealed a temperature of 52 degrees F. An observation of the temperature log posted on front of the reach-in cooler revealed the PM temperature had already been recorded as 40 degrees F. When asked why this temperature was recorded prior to the kitchen closing, the CDM responded, That shouldn't be. When asked how long the cooler had been out of temperature range, the CDM replied she did not know. On 1/26/2022 at approximately 12:12 PM, an interview was conducted with the facility's Registered Dietician regarding the safety of the ready-to-eat food items stored within the reach-in refrigerator. The RD determined the yogurt and milk was not safe for residents to consume and needed to be discarded. A review of the U.S. Food & Drug Administration Food Code 2017 was conducted. According to Chapter 3, Part 3-5 Limitations of Growth of Organisms of Public Health Concern, Subpart 3-501 Temperature and Time Control, revealed cold ready-to-eat foods must be held at a temperature of 41 degrees F or less.

Based on observations, staff interviews and policy review, the facility failed to ensure that all medications and biologicals were stored in locked compartments for 2 of 2 random medication cart observations on the 500 Hall. The findings include: On 1/26/2022 at 8:06 PM, medication cart #1 on the 500 Hall, which was assigned to Licensed Practical Nurse (LPN) A, was observed to be unattended and unlocked. LPN B also observed that the cart was unlocked and unattended and locked the cart. 1/26/2022 at 8:18 PM, an interview was conducted with LPN B. She acknowledged that LPN A's medication cart (#1) was unlocked and unattended on the hall and stated that is not the facility's standard practice. On 1/26/2022 at 8:10 PM, an interview was conducted with Licensed Practical Nurse (LPN) A. LPN A stated she thought she had locked medication cart #1. She further stated the medication cart should be locked anytime the nurse steps away from it. On 1/26/2022 at 8:16 PM, medication cart #2, which was assigned to LPN C, was observed to be unlocked and unattended in front of the nurses' station. LPN C was observed sitting behind the nurses' station and charting on a computer. There were no residents in the vicinity at the time, however the computer and height of the counter obstructed LPN C's view of the cart. On 1/26/2022 at 8:16 PM, an interview was conducted with LPN C. She confirmed that the medication cart should be locked when a nurse walks away from it. A review of the ID1: Storage of Medications policy and procedures revised 8/2014 was conducted. According to the policy, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. According to part B of the procedures, Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access.

Based on record review, staff interview and policy review, the facility failed to document care of the catheter in a effort to prevent urinary infections for 1 of 2 sampled residents with urinary catheters. (resident #7) The findings include: Review of resident #7's record revealed the resident returned from the hospital with a urinary catheter on 6/5/19. The record revealed no physician orders for the catheter and no orders for care of the catheter. The record revealed no documentation of catheter care. The resident was diagnosed and treated for [REDACTED]. An interview was conducted with the Director of Nursing (DON) on 6/12/19 at 2:44 PM. The DON stated catheter care should be documented in the electronic record on the medication record or treatment record and will include a physician order. She reviewed the record and confirmed there were no orders for catheter care and no documentation of catheter care. An interview was conducted with employee B (Licensed Practical Nurse) on 6/13/19 at 9:16 AM. She stated she completed the readmission form for resident #7 on 6/5/19 and she worked the floor on 6/5/19. She assesses the resident upon return from the hospital and completes a body audit. If the resident returns with a catheter they will put orders for the catheter and catheter care. She stated the unit manager told her she was going to complete the readmission orders [REDACTED]. She stated they do not have the documentation to show the care was done. Review of the undated facility policy for Foley catheter use revealed catheter care will be performed every shift and as needed. Documentation of physician orders, nurse's actions of evaluation, insertion or removal will be maintained in the medical record.

Based on observation, interviews, policy and record review the facility failed to ensure residents allowed to self-administer medications were assessed to be clinically appropriate for 1 of 1 residents randomly sampled, Resident #46. The nurse left resident medications at the bedside. The findings include: During the initial tour of the 300 hall on 6/10/2019 at approximately 2:10 PM, four pills were observed in a container on resident #46's bedside tray table. Two additional pills were observed on the ground near the resident's bed. (Photographic evidence obtained) An interview was conducted with resident #46 at the time of the observation. When asked if staff normally administer her medications, she replied yes. An interview with Licensed Practical Nurse D, (LPN D), the nurse on the 300 hall med cart, was conducted on 6/10/19 at 2:14 PM. When asked to explain the presence of the pills and the time they were to be administered, she responded that they were from the 9:00 AM medication pass and that she'd put the pills in the resident's mouth, but she must have spit them out. When asked if resident #46 had a history of [REDACTED]. When asked to help locate the staff who delivered and picked-up the resident's lunch tray without notifying a nurse about the unadministered medications, she responded that it's not necessarily the staff assigned to the hall that pass and collect trays. When asked if she knew which, if any, of the medications the resident took, she stated that there was one pill missing, but was unable to say which pill. LPN D then sifted through the med cart and responded that it was [MEDICATION NAME]. Review of the facility's policy titled Self Administration of Medication, undated, revealed within the procedure that The nurse will obtain a physician's order for each resident conducting self-administration of medications. A review of resident #46's medical record revealed no physician's order for the resident to self-administer any medications.

Based on staff interview, clinical record review of electronic records and physical chart, and policy review, the facility failed to have a baseline care plan in place for 1 of 8 (#173) new admissions. The findings include: Resident #173 was admitted to the facility on [DATE]. Hospital progress notes dated 6/5/19 indicate the resident was confused with a history of [MEDICAL CONDITION] (stroke) and [MEDICAL CONDITION] (eye condition). She presents for fall from bed. She was found to have a C1 (cervical) fracture and small subdural hemorrhage (brain bleed). A review of the care plans in the electronic record revealed care plans initiated on 6/11/19 including refusing to wear cervical collar and a plan to return home after discharge. No baseline care plan was found. An interview was conducted with the Director of Nursing (DON) on 6/12/19 at 1:37 PM. She was asked about where baseline care plans could be found for new admissions. She said the baseline care plans would be in the electronic record within 48 hours. The DON printed the care plans for resident #173, and was asked to review the care plans and indicate the ones initiated within 48 hours. The DON stated these electronic care plans were not initiated within 48 hours, all of them are dated 6/11/19. A follow-up interview with the DON was conducted on 6/13/19 about 9:00 AM. The DON said she found out that baseline care plans were kept in the physical chart and discussed by the care plan team with residents. She then said that Resident #173 did not have one in her physical chart. A review of the undated policy from the facility's Clinical Guidelines Manual with the Subject 'Baseline, Resident Centered Comprehensive Care Plans, and Care Plan Summary'. The Purpose: completion and implementation of the baseline care plan within 48 hours of a residents admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission, and to ensure the resident and representative. If applicable are informed of the initial plan for delivery of care and services by receiving a written summary. Procedure: #1 The Baseline care plan must be developed within the first 48 hours of admission and must include health care information necessary to properly care for each resident immediately upon their admission.

Based on observation, interview and record review, the facility failed to provide the necessary treatment and services to promote healing and prevent infection of resident wounds by failing to prevent the development of a pressure wounds and failing to ensure pressure wounds were assessed when identified for 3 of 3 sampled residents (#1, #2, #3), failing to prevent the worsening of pressure wounds for 2 of 3 sampled residents (#1, #3); failing to obtain wound care orders when pressure wounds were identified for 2 of 3 residents (#1, #3); failing to document weekly skin assessments in accordance with facility protocol for 2 of 3 residents(#1, #2); and failing to document the provision of wound care treatments in accordance with written physician orders [REDACTED].#2, #3). Findings include: Review of the facility wound protocol provided by the Director of Nursing (DON) documented all residents would be placed on a weekly skin check by the licensed nurse, and that each resident would be checked from head to toe and signed off on their Treatment Administration Record (TAR). The protocol also stated that wound documentation should address type of injury, the pressure ulcer stage, a description of the pressure ulcer's characteristics, the progress towards healing and identification of potential complications, if infection was present, the presence of pain, and a description of dressings and treatments. Resident #1 Resident #1 was admitted [DATE] from an acute care facility with [DIAGNOSES REDACTED]. The nursing admission skin assessment, dated 1/23/18, documented no alternation in skin integrity. The Minimum Data Set (MDS) assessment, with an assessment reference date of 1/30/18, documented resident #1 had no pressure ulcers on admission, but was at risk for skin impairment. The MDS assessment also showed resident #1 required extensive assistance with at least one person assistance for bed mobility, toileting, and maintenance of a urinary catheter, and documented a pressure reducing device to the resident's bed as the treatment in place. The (MONTH) Treatment Administration Record (TAR) failed to document a weekly skin assessment in accordance with facility protocol, and fifteen days following the admission of resident #1, on 2/7/18, skin impairment was noted on residnt #1. The Licensed Practical Nurse (LPN) documented an open area to the left buttock f resident #1 without any measurements or wound description included in the documentation. There was also no documentation of wound care orders initiated following the identification of the skin impairment on 2/7/17. There was no further documentation related to the open area to the resident's left buttock until 2/12/18. On 2/12/18 a wound assessment was conducted by a Registered Nurse (RN), who documented an in-facility acquired unstageable pressure wound to the coccyx and sacrum of resident #1, with documentation of eschar (dead tissue) present and wound bed color to be black. The RN documented resident #1 had black eschar tissue covering the sacrum, coccyx, and parts of the left and right buttocks. The wound was documented as measuring 16 centimers (cm) x 10cm x unknown depth. Physician orders [REDACTED]. Physician order [REDACTED]. On 2/15/18, the facility's wound care physician conducted an initial evaluation of the wound and documented an unstageable necrotic pressure wound measuring 12.5cm x 11cm x 0.1cm with 80% necrotic tissue and 20% granulation tissue. Wound care orders were changed to include application of santyl and calcium alginate to bilateral buttocks twice daily with recommendations to off-load wound and reposition the resident per facility protocol. Nursing entry, dated 2/15/18, documented presence of odor to the wound, low air loss mattress in place; and documented resident refusing to be turned. On 2/19/18, the facility's wound care physician documented the wound to be the same, performed a surgical debridement, and changed the wound care orders to include a Dakin's wet to dry dressing. Nursing entry, dated 2/19/18, documented presence of odor to the wound. On 2/21/18, the facility's wound care physician documented the measurements to be 12 x 9.5 x 0.1cm with 80% necrotic tissue and odor to periwound radius. Nurse's note, dated 2/21/18, documented resident to be alert with confusion and poor intake. Nurse's note, dated 2/22/18 at approximately 5:00am, documented a malodorous sacral wound with low grade temperature, medicated with tylenol and rechecked to show normal temperature. Nurse's note, dated 2/22/18 at approximately 8:00am, documented febrile during night with treatment of [REDACTED]. physician's orders [REDACTED]. On 2/23/18, nursing notes documented elevated white blood cell count, grossly abnormal liver and renal lab values, blood pressure 70/40, temperatue of 101 degrees, oxygen saturation of 70% on room air, diaphoretic, and weak/thready pulses. A physician order [REDACTED].#1 to the emerency room for low blood pressure, low oxygen saturation rate and fever. In an interview with the DON on 4/4/18 at approximately 2pm, she stated a treatment order was obtained by the LPN on 2/7/18 when the wound was first identified, but that the nurse had failed to enter the order into the computer system. She further stated the resident was refusing to be turned; however, review of nursing notes failed to document resident was being repositioned and failed to document any refusals to turn and reposition until 2/12/18. Review of Minimum Data Set (MDS) assessments, Section E0800, on admission with reference date of 1/30/18, 30 day assessment with reference date of 1/20/18, and discharge assessment with reference date of 1/23/18 failed to document rejection of care. Review of hospital records revealed resident #1 presented to Emergency Department on 1/23/18 with fever and [MEDICAL CONDITION] with [DIAGNOSES REDACTED]. Resident remained in the acute care hospital until 3/2/18, receiving surgical debridement of the sacral decubitus ulcer and intravenous antibiotics for wound infection and urinary tract infection, when the resident was discharged to a long term acute care hospital to continue wound care and antibiotic therapy. Resident #2 On 4/3/18, at approximately 11:00am, resident #2 was observed seated in a cushioned wheelchair, and a low air loss mattress was observed on the resident's bed. Interview with resident #2 revealed he had acquired a pressure wound since his admission to the facility. The resident stated he needed assistance to turn and reposition in bed, but stated the staff is not consistent with assisting with the turning. Record review revealed resident #2 was admitted [DATE] from an acute care hospital. The nursing admission assessment, dated 3/9/18, documented an open area to the coccyx without any wound measurements or description of the wound's appearance. The assessment also failed to document the interventions put in place after identification of the skin impairment. The MDS admission assessment for resident #2 showed the resident had bowel incontinence and required extensive, two person assistance with bed mobility. On 3/10/18, physician orders [REDACTED]. Review of the TAR for resident #2 documented the wound care was performed on 3/10, 3/11, 3/13 and 3/15. There was no documentation of a dressing change being provided on 3/12 or 3/14. The TAR also contained an area fro nurses to document weekly skin checks, but the scheduled skin check for 3/12/18 was blank, indicating the assessment had not been performed. The medical record failed to include an assessment of the wound's measurements and appearance until 3/15/18, 6 days after admission. The wound assessment pressure grid, dated 3/15/18, documented an in-facility acquired Stage 2 pressure wound of the resident's right buttock measuring 3.5 centimeters(cm)x 3.0cm x 0.1cm, and an unstageable pressure wound, present on admission, of the left buttock measuring 2.5cm x 1.0 cm with unknown depth. The facility's contracted wound care physician conducted an initial evaluation of resident #2 on 3/22/18 and documented an unstageable pressure wound to the right buttock measuring 3 x 3.5 x 0.1cm; and a Stage 2 pressure wound to the left buttock measuring 1 x 0.4 x 0.1cm. Wound care treatment orders were updated by the physician. The resident was discharged home with home health services on 4/4/18 with an unhealed in-facility acquired pressure ulcer to his right buttock measuring 2.5 x 3.8 x 0.1cm. Interview with the facility's DON on 4/3/18 at approximately 2pm revealed the nurse conducting the admission assessment was responsible for performing a skin assessment and obtaining initial treatment orders for any skin impairment discovered. She stated the wound care nurse would see the resident the next day to conduct an assessment of the wound that included measurements and wound appearance and was documented on a pressure grid. Resident #3 Resident #3 was identified by the facility Director of Nursing (DON) to be 1 of 5 current residents with an in-facility acquired pressure ulcer. Resident #3 was originally admitted on [DATE] from an acute care setting for orthopedic surgery aftercare. The resident's MDS assessment documented bowel incontinence and extensive assistance required with bed mobility. The nursing admission skin assessment documented an open area to the resident's coccyx measuring 3.1 centimers (cm) x 3.5cm. There was no description of the wound's appearance. The medical record failed to document any wound assessment until 3/7/18 (6 days after the wound was identified). The medical record and TAR failed to document wound care orders for the treatment of [REDACTED]. A wound assessment, dated 3/7/18, documented a Stage 2 pressure wound to the resident's coccyx measuring 1cm x 1cm x 0.1cm. The wound bed was noted to be [MEDICATION NAME] tissue without drainage or odor. The assessment documented the wound was present on admission, but documented the date identified to be 3/6/18 although resident #3 was admitted on [DATE]. A physician order [REDACTED]. The TAR documented the treatment was provided on 3/8/18. The resident discharged to the hospital on [DATE] for another orthopedic procedure and returned to facility on 3/23/18. On 3/23/18, the nursing admission skin assessment documented a stage 2 wound to the resident's sacrum with dressing intact, wound appeared pink, moist with no signs of infection, and documented right heel with dressing intact to prevent pressure ulcer with no broken skin noted in area. The pressure wounds were not assessed to include measurements or description of wound drainage, wound edges, or peri-wound tissue. The medical record failed to document the provision of any wound care on 3/23/18 or 3/24/18. A physician order, dated 3/25/18, was obtained for application of silver alginate daily and as needed for wound care. The resident's (TAR) documented the wound care was provided on 3/25/18 and 3/26/18, with a wound assessment completed on 3/26/18. The assessment documented the presence of two sacral wounds present at the time of the resident's readmission, which was in conflict with the nursing admission assessment that documented one sacral wound on admission. The wound assessment measurements were documented on page 1 as: ulcer of the sacrum measuring 1cm x 0.3cm x 0cm and a pressure ulcer of the sacrum measuring 4cm x 3.0cm x 0cm. Page 7 documented a summation as follows: noted areas to sacrum x 2 and right buttock area. Sacrum 1 measures 1.4 in width and 3.0 in length. Sacrum 2 measures 1.0cm in length and 0.5cm in width. No drainage or odor. Noted sheering to right buttock area - apply barrier cream. An interview was conducted on 4/4/18 at approximately 11:00am with Employee D, the Licensed Practical Nurse who had documented the measurements, she could not explain why she had documented different wound measurements, but stated she recalled the measurements she documented in the summation to be the accurate ones. A physician order, dated 3/27/17, was obtained to cleanse wound daily and apply silver alginate daily and as needed for wound care. The TAR documented dressing changes on 3/27/18, 3/29/18, 3/30/18 and 3/31/18. Review of the (MONTH) TAR for 4/1/18 documented 8DC1 (code to see nurse's notes). Nursing notes documented resident refused dressing change at 2:30pm due to pain with no further documented attempts to perform the dressing change to the wound. Further review of the medical record included a physician order, dated 3/28/18, to apply skin prep to bilateral heels. Review of the TAR for (MONTH) and (MONTH) failed to demonstrate the treatment had ever been provided. On 4/3/18, a change in condition was documented for a 1 x 2.8cm eschar area to the resident's left heel. On 4/3/18 at approximately 5pm, a dressing change to the sacral wound was observed. The dressing in place to the sacrum was observed to be saturated with serosanguinous drainage and was dated 4/2/18. There was a strong foul odor noted upon removal of the dressing by the nurse. The wound appeared to be approximately 5cm x 4cm with yellow slough and blackened area noted to wound bed. The wound bed was cleansed and a silver alginate dressing was reapplied. The wound appeared to have worsened by increase in size, increase in drainage, presence of slough, and presence of odor, as compared to the prior assessment on 3/26/18. On 4/4/18 at 9:00am, 12 days after the resident's pressure wound was identified, the facility's contracted wound care physician was making rounds. An interview with the wound care physician at approximately 9:10am, revealed she had been consulted on 3/29/18 to assess resident's surgical wound, but was not aware of any pressure ulcers. The physician was observed to perform an assessment of the resident's sacrum and bilateral heels approximately 9:30am. The physician noted the large amount of drainage with foul odor, and assessed the sacrum wound to be an unstageable pressure ulcer measuring 5cm x 4.5cm x 0.2cm with 70% slough and 30% granulation tissue present. The physician stated the blackened area was necrotic tissue, and stated she should have been consulted for the wound. The physician also noted a stage 2 to the resident's left heel measuring 1 x 1.5cm. The physician changed the wound care orders to the sacrum to include the application of both santyl and calcium alginate.