Every finding on record at Colonial Park Manor

Based on interview and record review, the facility failed to develop a grievance policy, appoint a grievance official, and maintain documentation of the results of all grievances. These deficient practices had the potential to affect all 68 residents who currently resided in the facility.Findings included: A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2026, revealed the facility admitted Resident #21 on 06/22/2025. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. An annual MDS, with an ARD of 05/10/2026, revealed the facility admitted Resident #36 on 04/19/2019. The MDS indicated the resident had a BIMS score of 15, which indicated the resident had intact cognition. During the Resident Council meeting on 07/14/2026 at 1:31 PM, with four residents in attendance, Resident #21 and Resident #36 stated they did not know what a grievance was nor how to file a grievance. During an interview on 07/14/2026 at 2:35 PM, the Business Office Manager stated the facility did not have a grievance policy. During an interview on 07/15/2026 at 3:00 PM, the Social Services Director (SSD) stated if a resident had a concern (grievance), she would notify the appropriate department and once a resolution was reached, she would inform the residents during their Resident Council meeting. The SSD stated there was no documentation of how a grievance was resolved or the resident's response to the resolution. During an interview on 07/15/2026 at 3:10 PM, the Administrator stated the facility did not have a grievance policy. During an interview on 07/16/2026 at 1:12 PM, the Director of Nursing (DON) stated he expected that if a resident had a concern (grievance), staff would resolve the concern within a reasonable amount of time and document what was done to resolve the resident's concern. The DON stated he was unaware if there was a grievance log or form. According to the DON, outside of the Resident Council, a resident's grievance was followed up on informally. During an interview on 07/15/2026 at 3:10 PM, the Administrator stated when a resident had a concern (grievance) they brought their concern to either a charge nurse, Resident Council, or the SSD. The Administrator acknowledged there was no way a resident could file a grievance anonymously. The Administrator stated the resident's concern, follow-up, resolution, resident notification and response to a concern was not documented. The Administrator acknowledged the facility did not have a grievance official. During a follow-up interview on 07/16/2026 at 1:41 PM, the Administrator stated she expected the grievance process to allow residents to file grievances and anonymously if they chose to do so and for the staff to communicate the resolution to the resident and document the response.

Based on interview, facility policy review, and review of Occupational Safety and Health Administration (OSHA) guidance, the facility failed to ensure all staff were fit-tested for N95 respirator masks (masks used to protect residents and staff from the transfer of microorganisms that can cause infectious disease) prior to initial use and at least annually thereafter. This deficient practice had the potential to affect all 68 residents who resided in the facility. In addition, the facility failed to ensure a urinary catheter bag was not directly on the floor for 1 (Resident #64) of 1 sampled resident reviewed for catheter use.Findings included: 1. A facility policy titled, Staff Fit Testing for N95 Respirator Policy, implemented 03/05/2025, revealed, OSHA requires all healthcare facilities utilizing N95 respirators to provide Fit Testing to all staff on an at-hire and annual basis. An OSHA document titled, Part Number:1910, Part Number Title: Occupational Safety and Health Standards, Subpart: 1910 Subpart I, Subpart Title: Personal Protective Equipment, Standard Number: 1910.134, Title: Respiratory protection, specified, 1910.134(f)(2) The employer shall ensure that an employee using a tight-fitting facepiece respirator is fit tested prior to initial use of the respirator, whenever a different respirator facepiece (size, style, model or make) is used, and at least annually thereafter. During an interview on 07/16/2026 at 4:51 PM, Licensed Practical Nurse (LPN) #11 stated she had been employed at the facility since 2017 and could not recall the last time she was fit tested for N95 use. LPN #11 stated they had not been tested in the last year or two. During an interview on 07/16/2026 at 4:54 PM, LPN #6 stated he was last tested for N95 use around 2022 or 2023 by the Director of Nursing (DON). During an interview on 07/16/2026 at 10:20 AM, the Infection Preventionist (IP) stated it had been a little over a year since the last N95 fit testing was completed. During an interview on 07/16/2026 at 1:36 PM, the Director of Nursing (DON) stated N95 fit testing used to be done annually at the facility. The DON stated they did not have much knowledge of the policy or guidance on N95 fit testing. The DON stated the last N95 fit testing was conducted around the time they took over in March of 2023. During an interview on 07/16/2026 at 2:39 PM, the Administrator stated she expected the guidelines to be followed, so she expected N95 fit testing to be done annually.2. A facility policy titled, Urinary Catheter Infection Prevention Policy Nursing & Infection Prevention, dated 07/2026 revealed, Infection prevention measures are to always be in use and practice with the insertion and maintenance of indwelling catheters. The section of the policy titled, 4. Maintenance specified, Maintaining a closed, continuously sterile drainage system is essential. Bacteria may enter through collection ports and/or migrate from the periurethral area. An admission Record revealed the facility admitted Resident #64 on 07/30/2021. According to the admission Record, the resident had a medical history that included diagnoses of senile degeneration of the brain, urinary tract infection, retention of urine, and benign prostatic hyperplasia with lower urinary tract symptoms. A quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/10/2026, revealed Resident #64 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS assessment also indicated the resident had an indwelling urinary catheter. Resident #64's Care Plan Report, last reviewed 06/05/2026, included a focus area that indicated Resident #64 had a urinary catheter and diagnosis of urinary retention. Resident #64's Order Summary Report with active orders as of 07/14/2026 revealed an order started on 06/22/2023 for an indwelling urinary catheter. An observation on 07/13/2026 at 11:23 AM revealed Resident #64 was seated in a recliner chair with their indwelling urinary catheter bag attached to a trash can liner and lying on the floor next to the chair. The observation revealed the drainage valve of the catheter bag was in contact with the floor. An observation on 07/14/2026 at 3:46 PM revealed Resident #64 was seated in a recliner chair with their indwelling catheter attached to a trash can liner and lying on the floor next to the chair. The observation revealed the drainage valve of the catheter bag was in contact with the floor. During a concurrent observation and interview on 07/14/2026 at 3:47 PM, Certified Nursing Assistant (CNA) #1 observed Resident #64's indwelling catheter bag on the floor and stated the catheter bag should not be on the floor next to the resident's recliner. CNA #1 stated the catheter bag would normally be hung on something; however, Resident #64's recliner chair did not have anything to secure the catheter bag hook. During a concurrent observation and interview on 07/14/2026 at 3:51 PM, Licensed Practical Nurse (LPN) #2 observed Resident #64's indwelling catheter bag on the floor and stated she thought the catheter bag was on the floor because the hook on the catheter drainage bag had broken. LPN #2 stated Resident #64's indwelling catheter bag placed on the floor would be potential for infection due to the possibility of bacteria entering into the catheter from the floor. During an interview on 07/14/2026 at 3:52 PM, Certified Nursing Assistant (CNA) #3 stated he was assigned to Resident #64's care; however, he had not yet been in the room to notice the indwelling urinary catheter bag on the floor. CNA #3 stated the catheter bag should not be on the floor. During an interview on 07/16/2026 at 10:56 AM, the Infection Preventionist (IP) stated Resident #64's indwelling urinary catheter bag should not be on the floor. She stated staff had been educated that it could pose a potential for infection; however, she was unsure why the resident's indwelling catheter was observed on the floor. During a follow-up interview on 07/16/2026 at 12:48 PM, the IP stated an indwelling urinary catheter drainage bag should not be hung on a trash can due to potential contamination and infection. During an interview on 07/15/2026 at 4:20 PM, the Director of Nursing (DON) stated the facility previously utilized a knitted bag to prevent the residents' catheter bags from being on the floor; however, he was unsure why that was stopped. The DON stated he expected the drainage bag to have been hung in an alternate location off the floor to prevent infection.

Based on interview, record review, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a serious mental illness diagnosis for 1 (Resident #10) of 1 resident reviewed for PASARR requirements.Findings included: An undated facility policy titled, Preadmission Screening for Individuals with a Mental Disorder/Intellectual Disability (PASARR), revealed, Purpose: Ensure each resident in a nursing facility is screened for a mental disorder (MD- also referred to as mental illness) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. The policy also indicated, The initial screening is referred to as a Level I identification of individuals with MD or ID and is completed prior to admission to the facility. The purpose of the Level I pre-admission screening is to identify individuals who have or may have MD/ID or related condition, who would then require PASARR Level II evaluation and determination prior to admission to the facility. An admission Record revealed the facility admitted Resident #10 on 05/01/2025. According to the admission Record, the resident had a medical history that included a secondary admission diagnosis of recurrent unspecified major depressive disorder with an onset date of 05/01/2025. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/14/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was not currently considered by the state level II PASARR process to have serious mental illness. An Oklahoma Health Care Authority Nursing Facility Level of Care Assessment for Resident #10's 05/01/2025 admission, revealed the section addressing Level I PASARR screening was completed to reflect that Resident #10 did not have a diagnosis of serious mental illness. The resident's diagnosis of recurrent unspecified major depressive disorder was not reflected. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 07/15/2026 at 2:00 PM, the DON stated the PASARR for Resident #10 was completed by the previous DON. He stated the diagnosis of major depressive disorder was present on admission and should have been included on the Level I PASARR. During an interview on 07/16/2026 at 9:00 AM, State PASARR Representative (Rep) #13 stated Resident #10's diagnosis of major depressive disorder was required to be indicated on the PASARR. He stated the major depressive disorder was not communicated to his office. During an interview on 07/16/2026 at 9:33 AM, State PASARR Rep #12 stated Resident #10's diagnosis of recurrent unspecified major depressive disorder should have been reflected on their Level I PASARR. During an interview on 07/16/2026 at 1:12 PM, the DON stated he expected PASARRs to be completed according to regulations prior to admission and accurately with all diagnoses. During an interview on 07/16/2026 at 1:41 PM, the Administrator (ADM) stated she expected PASARRs to be completed prior to admission or the day of and communicate all diagnoses and medications to the state PASARR office. She stated the purpose of the pre-admission screening was to decide the level of care needed and if a resident was appropriate for the facility setting.

Based on interview and record review, the facility failed to ensure beneficiary notices were completed with resident name and services provided for informed decision making for 3 (Residents #72, #77, and #78) of 3 sampled residents reviewed for beneficiary notices.Findings included: A facility policy titled, Advance Beneficiary Notices, dated 08/22/2022, indicated, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. The Centers for Medicare and Medicaid Services (CMS) document titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2024) indicated in the section, Completing the SNF ABN that, The SNF ABN has the following 4 [four] sections for completion: 1. Header 2. Body 3. Option Boxes 4. Signature and Date. The instructions also specified, B. Patient's Name: SNFs [skilled nursing facilities] must enter the first and last name of the patient receiving the notice, and a middle initial should be entered if there is one on the patient's Medicare card. The instructions indicated, B. 'Care' Section: In this section, the SNF utilizes the appropriate check boxes to indicate that care that it believes may or won't be covered by Medicare. These include Physical Therapy, Occupational Therapy, Daily Skilled Nursing Care and Other. If Other is checked, the SNF must enter the exact nature of the service that had previously been provided. The description must be written in plain language that the patient can understand. The undated CMS document titled, Notice Instructions for the Detailed Explanation of Non-Coverage (DENC) CMS-10124 indicated, Patient's Name: Fill in the beneficiary's/enrollee's first and last name. Member number: Fill in the beneficiary's/enrollee's medical record or identification number. The beneficiary's/enrollee's Medicare number must not be used. {Insert type}: Insert the kind of service being terminated, i.e. [id est - that is], skilled nursing, home health, comprehensive outpatient rehabilitation service, or hospice. 1. A SNF [Skilled Nursing Facility] Beneficiary Notification Review form completed by the facility indicated that Resident #77's Medicare Part A skilled services episode start date was 03/02/2026, the last covered day of Part A service was 05/14/2026, and that the facility initiated the discharge from Part A services when the resident's benefit days were not exhausted. The SNF Beneficiary Notification Review indicated the facility provided Resident #77 a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (Centers for Medicare and Medicaid Services [CMS] Form 10055) and a Notice of Medicare Non-Coverage (NOMNC) (CMS Form 10123). Resident #77's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) dated 03/02/2026 indicated that beginning 03/02/2026, the resident may have to pay out of pocket for this care. The form indicated the resident selected Option 1 (for the daily care listed above to be provided and for Medicare to be billed for an official decision on payment); however, the types of care for which the resident might have to pay out of pocket were not documented on the form. Additionally, the field designated for documentation of the resident's name was blank, and the resident's signature, dated 03/02/2026, was not fully legible, making it difficult to confirm for which resident the form was completed Resident #77's Notice of Medicare Non-Coverage form, signed 03/11/2026, indicated the resident's Part A services would end on 05/19/2026 at midnight. The Patient Name and Patient Number fields on the form were blank. The section of the form designated for documentation of the services for which coverage was ending was left blank. 2. A SNF [Skilled Nursing Facility] Beneficiary Notification Review form completed by the facility indicated that Resident #78's Medicare Part A skilled services episode start date was 03/02/2026, the last covered day of Part A service was 04/24/2026, and that the facility initiated the discharge from Part A services when the resident's benefit days were not exhausted. The SNF Beneficiary Notification Review indicated the facility provided Resident #77 a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (Centers for Medicare and Medicaid Services [CMS] Form 10055) and a Notice of Medicare Non-Coverage (NOMNC) (CMS Form 10123). Resident #78's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) dated 03/02/2026 indicated that beginning 03/02/2026, the resident may have to pay out of pocket for this care. The form indicated the resident selected Option 1 (for the daily care listed above to be provided and for Medicare to be billed for an official decision on payment); however, the types of care for which the resident might have to pay out of pocket were not documented on the form. Additionally, the field designated for documentation of the resident's name was blank. Resident #78's Notice of Medicare Non-Coverage, signed 04/21/2026, indicated the resident's Part A services would end on 04/24/2026 at midnight. The Patient Name and Patient number fields were blank. The section of the form designated for documentation of the services for which coverage was ending was left blank. 3. A SNF [Skilled Nursing Facility] Beneficiary Notification Review form completed by the facility indicated that Resident #72's Medicare Part A skilled services episode start date was 06/01/2026, the last covered day of Part A service was 06/26/2026, and that the facility initiated the discharge from Part A services when the resident's benefit days were not exhausted. The SNF Beneficiary Notification Review indicated the facility provided Resident #72 a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (Centers for Medicare and Medicaid Services [CMS] Form 10055) and a Notice of Medicare Non-Coverage (NOMNC) (CMS Form 10123). Resident #72's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) dated 06/01/2026 indicated that beginning 06/01/2026, the resident may have to pay out of pocket for physical therapy and daily skilled nursing care. The form indicated the resident selected Option 1 (for the physical therapy and daily skilled nursing care to be provided and billed to Medicare for an official decision on payment). The field designated for documentation of the resident's name was blank Resident #72's Notice of Medicare Non-Coverage, signed 06/23/2026, indicated the resident's Part A services would end on 06/26/2026 at midnight. The Patient Name and Patient number fields were blank. The section of the form designated for documentation of the services for which coverage was ending was left blank. During an interview on 07/16/2026 at 9:31 AM, the Business Office Manager (BOM) stated he was responsible for the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form, and the Assistant Director of Nursing (ADON) completed the Notice of Medicare Non-Coverage forms. The BOM stated the SNF ABN form was provided upon admission on ce they talked with the resident or their family and started the admission packet, went over resident rights, went over the number of skilled days and the number of days approved, went over therapy if applicable, and got the resident's intentions for discharge or if they would remain in the facility. The BOM stated the importance was to inform the family what the steps might be like with Medicare and to give them information. The BOM stated it would be important to have a resident's name on the form. The BOM stated the forms not having the residents' names was an oversight on his part because he had all the forms in a folder. The BOM stated Resident #77's SNF ABN form was not complete without the resident's name and the services provided. The BOM stated it was the same for Resident #78; the SNF ABN form was not complete. The BOM stated Resident #72's SNF ABN form should have the resident's name on it but did not. During an interview on 07/16/2026 at 10:01 AM, the ADON stated the Notice of Medicare Non-Coverage form was provided 48-72 hours before discharge. The ADON stated the importance was to notify the residents their benefits were ending and for discharge planning. The ADON stated Resident #77's Notice of Medicare Non-Coverage form should have the resident's name on it. The ADON stated he was not aware that the information that he went over verbally was supposed to go on the form. The ADON stated Resident #78's Notice of Medicare Non-Coverage form did not have the resident's name, and the services provided were not specified on the form. The ADON stated Resident #72's Notice of Medicare Non-Coverage form did not contain the resident's name and did not provide the details of the services provided for the resident to make an informed decision. The ADON stated none of those Notice of Medicare Non-Coverage forms were complete. During an interview on 07/16/2026 at 1:25 PM, the Director of Nursing (DON) statedthe purpose of the beneficiary notices was to let the residents or family know the services they had been receiving were about to end and to provide information regarding the appeal process if they felt they were being discharged too soon. The DON stated the form should include the resident's name. The DON stated the form should contain the details of services provided so the residents or family could make an informed decision. The DON reviewed the forms for Residents #72, #77, and #78 and stated none of the forms contained the name of the resident for whom the form was completed, and they did not contain details to enable the residents to make an informed decision. The DON stated he expected the Notice of Medicare Non-Coverage forms to be completed thoroughly. During an interview on 07/16/2026 at 2:45 PM, the Administrator stated she expected the beneficiary notices to be thoroughly completed, including the resident's name and details of the services provided. The Administrator stated the importance of the beneficiary notice form was for the residents to know what those benefits were being used for. The Administrator reviewed each resident's form and stated Resident #78's forms were not complete and thorough, and without the resident name, that while the person providing the form may know who the form was for, she would not. The Administrator stated Resident #77's forms were not complete and thorough. The Administrator stated Resident #72's Notice of Medicare Non-Coverage was not complete.

Based on observation and interview, the facility failed to ensure daily staff postings included the resident census on 3 of 3 days that daily staff postings were observed. In addition, the facility failed to maintain the posted daily nurse staffing data for 18 of 18 months.Findings included: An observation on 07/13/2026 at 3:00 PM revealed a whiteboard in the front lobby of the facility that reflected the daily staffing assignments but not the resident census. An observation on 07/14/2026 at 6:00 PM revealed the whiteboard in the front lobby reflected the daily staffing assignments but not the resident census. An observation on 07/15/2026 at 2:00 PM revealed the whiteboard in the front lobby reflected the daily staffing assignments but not the resident census. During an interview on 07/15/2026 at 2:20 PM, the Administrator (ADM) stated the facility did not have a policy on the required daily staff postings. The ADM stated the facility had a whiteboard next to the front nurses' station that gave the date and what staff were on duty and what units each staff member was assigned. She stated the facility did not retain a copy of the daily staff postings other than what was on the whiteboard each day. The ADM verified the whiteboard did not include the daily resident census and could not be retained, because the whiteboard was changed daily according to the assignments.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control measures were used: a. when transporting clean linens/laundry; b. when providing catheter care for 1 (#25) of 3 sampled residents who were reviewed for catheter care; and c. to devise and implement a plan to prevent the growth of and monitor for Legionella in the facility. The DON identified 68 residents who resided at the facility, four residents with catheters, and one resident with pressure ulcers. Findings: 1. On 03/26/25 at 9:47 a.m., laundry aide #1 was observed to return from delivering laundry/linens on north hall. During an observation of the laundry room the laundry aide stated they did not cover laundry/linens when they deliver them. They stated they did not know they should. On 03/26/25 at 6:49 p.m., the administrator stated laundry personnel were to cover the laundry/linens when delivered. They stated they did not why they did not cover the laundry. 2. On 03/26/25 at 10:32 a.m., LPN #2 was observed to provide catheter care for Resident #25. During the catheter care, LPN #2 was observed to clean the meatus of the penis, place the cloth back in the wash tub to re-wet the cloth, and using the same cloth cleaned the area again. A Catheter Care, Urinary policy, revised October 2010, read in part, The purpose of this procedure is to prevent catheter-associated urinary tract infections.Infection Control Use standard precautions when handling or manipulating the drainage system. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag.Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. Be sure the catheter tubing and drainage bag are kept off the floor.Steps in the Procedure .For the male: Use a clean washcloth.Change the position of the washcloth with each cleansing stroke.Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. Resident #25 had diagnoses which included benign prostatic hyperplasia and urinary retention. A care plan, dated 02/24/25, showed Resident #25 had a concern for a catheter related to urinary retention. The interventions were to change the catheter monthly and clean daily with soap and water. On 03/26/25 at 1:36 p.m., LPN #2 stated they maintained infection control by keeping the catheter bag off the floor, used proper personal protective equipment, and used clean technique. They stated it was not clean technique to reuse the same cloth for cleaning the genitalia twice. They stated it was not good infection control. On 03/26/25 at 6:45 p.m., the DON stated using the same cloth twice after re-wetting the cloth in soapy water did not ensure infection control. 3. A Legionella Surveillance policy, reviewed/revised 05/30/24, read in part, It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections.Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems.In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies.Diagnostic testing .Investigation for a facility source of Legionella, which may include culturing of facility water for Legionella.Physical controls: Cooling towers and potable water systems shall be routinely maintained. At-risk medical equipment shall be cleaned and maintained in accordance with manufacturer recommendations. Non-potable water systems shall be routinely cleaned and disinfected. Nebulization devices shall be filled only with sterile fluid (e.g., sterile water or aerosol medication). Temperature controls: Cold water shall be stored and distributed below 68 degrees Fahrenheit. Hot water shall be stored above 140 degrees Fahrenheit and circulated at a minimum return temperature of 124 degrees Fahrenheit. A Water Management Program policy, reviewed/revised 12/10/24, read in parts, A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, Director of Nursing, and Assistant Director of Nursing.Team members have been educated on the principles of an effective water management program, including how Legionella and other water-borne pathogens grow and spread. Education is consistent with each team member's role. The water management team has access to water treatment professionals, and state/local health officials. A water management program was not provided by the end of the survey. On 03/26/25 at 2:31 p.m., during a phone interview with the maintenance supervisor they stated they had no knowledge of the water management needs until 03/26/25.

Based on record review and interview, the facility failed to ensure assessments were accurate for 2 (#67 and #42) of 2 sampled residents who were reviewed for hospice services. The DON identified five residents who received hospice services. Findings: 1. Resident #67 had diagnoses which included malignant neoplasm of the right kidney. A physician order, dated 12/22/23, showed the resident was ordered hospice services for renal cancer. A hospice certification form, dated 06/19/24 through 08/17/24, showed the physician certified the resident's prognosis was six months or less if the disease ran its normal course. A quarterly assessment, dated 07/06/24, showed the resident did not have a condition or chronic disease that could result in a life expectancy of less than six months. A hospice certification form, dated 08/18/24 through 10/16/24, showed the physician certified the resident's prognosis was six months or less if the disease ran its normal course. A quarterly assessment, dated 10/06/24, showed the resident did not have a condition or chronic disease that could result in a life expectancy of less than six months. A hospice certification form, dated 12/16/24 through 02/13/25, showed the physician certified the resident's prognosis was six months or less if the disease ran its normal course. An annual assessment, dated 01/07/25, showed the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. The care plan, reviewed 01/22/25, showed the resident received hospice services. On 03/25/25 at 3:55 p.m., the ADON stated they were the interim MDS coordinator. They stated the resident was admitted to hospice services on 12/22/23. They reviewed the the assessments dated 07/06/24, 10/06/24, and 01/07/25 for Resident #67. The ADON stated they did not know why the assessments had not accurately reflected the resident had a condition or chronic disease that could result in a life expectancy of less than six months. 41220 2. Resident #42 had diagnoses which included Alzheimer's disease and dementia. An annual assessment, dated 06/16/24, showed in section J Resident #1 was not on hospice, but section O showed Resident #1 was on hospice. A quarterly assessment, dated 12/17/24, showed in section J Resident #1 was not on hospice, but section O showed Resident #1 was on hospice. On 03/26/25 at 6:19 p.m., the MDS coordinator stated Resident #1 was on hospice and the assessments were inaccurate.

Based on observation, record review, and interview, the facility failed to ensure assessments for entrapment were completed and informed consent was obtained for the use of assist bars/side rails for 1 (#28) of 1 sampled resident who was reviewed for the use of assist bars/side rails. The DON identified 14 residents who utilized assist bars/side rails in the facility. Findings: On 03/24/25 at 2:05 p.m., Resident #28 was observed in bed with bilateral assist bars/side rails in the up position. The assist bars/side rails were observed to be approximately 12 inches wide. On 03/25/25 at 8:53 a.m., Resident #28 was observed in bed with bilateral assist bars/side rails in the up position. On 03/26/25 at 10:43 a.m., Resident #28 was observed in bed with bilateral assist bars/side rails in the up position. A Bed Safety policy, dated December 2007, showed the facility should obtain consent for the use of assist bars/side rails from the resident and/or legal representative. The policy showed assist bars/side rails could be utilized if after assessment and consultation with the physician it was determined they would assist the resident with repositioning and no other reasonable alternatives could be identified. Resident #28 had diagnoses which included muscle weakness. An Assist Bar Evaluation form, dated 12/05/24, showed the recommendation was for the resident to utilize an assist bar to serve as an enabler to promote independence. The evaluation did not show the risk of entrapment had been assessed. An admission assessment, dated 12/17/24, showed a staff assessment for mental status was conducted and Resident #28 was severely impaired in cognition for daily decision making. The care plan, revised 03/24/25, showed staff were to encourage the use of prescribed assistive devices. Review of the electronic clinical record did not show a physician's order for the use of the assist bars/side rails or an informed consent had been obtained for the use of the assist bars/side rails. On 03/26/25 at 1:57 p.m., LPN #1 stated Resident #28 utilized the side rails to assist with positioning and the DON or ADON completed assessments for the use of side rails. On 03/26/25 at 2:06 p.m., RN #1 stated they had completed the Assist Bar Evaluation dated 12/05/24. They stated they thought the resident and/or family member had been asked about the use of the assist bars/side rails upon admission to the facility. They stated they completed the assessment, but it did not specifically address the risk of entrapment or alternatives attempted prior to the use of assist bars/side rails. On 03/26/25 at 2:16 p.m., the DON stated Resident #28 utilized bilateral assist bars on their bed. On 03/26/25 at 2:17 p.m., the ADON stated the family had requested bilateral assist bars/side rails to assist the resident with bed mobility. The ADON stated they did not obtain an informed consent for the use of assist bars/side rails. On 03/26/25 at 2:19 p.m., the DON stated they completed the care plans in the facility. The DON reviewed the care plan for Resident #28 and stated the care plan indicated to encourage use of prescribed assistive devices but that would not apply because the assist bars/side rails was not prescribed. They stated they had not completed a care plan for the use of assist bars/side rails. They stated the only assessment for the use of assist bars/side rails was completed on 12/05/24. On 03/26/25 at 4:56 p.m., the DON stated they did not have documentation to show informed consent had been obtained prior to the installation of the assist bars/side rails.

Based on observation, record review, and interview, the facility failed to: a. monitor the temperature of the medication storage room for 1 of 2 medication rooms observed; b. ensure medications were secured for 2 of 6 medication/treatment carts observed; and c. ensure glucose test strips were dated when opened for 2 of 6 medication/treatment carts observed. The DON identified two medication rooms and six medication/treatment carts in the facility. Findings: 1. On 03/25/25 at 1:39 p.m., the medication room on the [NAME] hall was observed with the CMA supervisor. No documentation of the medication room temperature was observed. A Medication Storage in the Facility policy, effective July 2015, read in part, Mediations 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.The Facility should maintain a temperature log in the storage area to record temperatures at least once a day.The Facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC [Centers for Disease Control and Prevention] Guidelines. On 03/25/25 at 1:40 p.m., the CMA supervisor was asked for the room temperature log. They stated they did not know the medication room temperature required monitoring. On 03/25/25 at 1:50 p.m., the DON stated the temperature of the medication room may have been monitored by environmental services. On 03/25/25 at 2:00 p.m., the DON stated there was no log for the temperature of the medication room. 2. On 03/25/25 at 12:18 p.m., the North Hall treatment cart at the back nurses station was observed to be unlocked and unattended. RN #1 was observed at the nursing station with their back to the cart. On 03/25/25 at 12:24 p.m., RN #1 was observed to leave the nursing station to deliver the hall trays. The DON was observed to walk past the unlocked cart to deliver hall trays. On 03/25/25 at 12:29 p.m., the DON was observed to walk by the unlocked treatment cart. On 03/25/25 at 12:30 p.m., RN #1 was observed to walk by the unlocked treatment cart with a hall tray. On 03/25/25 at 12:31 p.m., the DON and RN #1 were observed to walk by the unlocked treatment cart. On 03/25/25 at 12:32 p.m., RN #1 was observed to lock the treatment cart. On 03/26/25 at 9:37 a.m., RN #1 was observed to prepare medications for a resident. RN #1 was observed to enter the resident room and not lock their cart. On 03/26/25 at 4:47 p.m., the North Hall treatment cart was observed to be unlocked and unattended at the nursing station. On 03/26/25 at 4:49 p.m., RN #1 was observed to lock the treatment cart. On 03/25/25 at 12:32 p.m., RN #1 stated they locked their carts when they walked away from them. They stated it was an accident they failed to lock the cart. On 03/26/25 at 9:41 a.m., RN #1 stated the cart was not to be left unattended and unlocked. On 03/26/25 at 12:29 p.m., the DON stated the protocol was to keep the medication/treatment carts locked and the staff knew to lock the carts when unattended. On 03/26/25 at 4:51 p.m., RN #1 stated they were just not thinking and knew to lock the cart. 3. On 03/25/25 at 1:54 p.m., the North hall treatment cart glucometer strips were observed to be opened and not dated. On 03/25/25 at 2:00 p.m., the East Hall treatment cart glucometer test strips were observed to be open and not dated. On 03/25/25 at 2:00 p.m., LPN #2 stated they had not open the test strips on 03/25/25 so they dated the test strips for 03/24/25. On 03/26/25 at 12:31 p.m., the DON stated we were to date items when they were opened. They stated the expectation was the staff would throw out any item on the cart that was not dated when opened because there was no way of knowing when it was opened.

Based on observation, record review, and interview, the facility failed to ensure regular inspections of beds and bed rails were completed to identify areas of possible entrapment for 1 (#28) of 1 sampled resident who was reviewed for assist bars/side rails. The DON identified 14 residents who utilized assist bars/bed rails. Findings: On 03/24/25 at 2:05 p.m., Resident #28 was observed in bed with bilateral assist bars/side rails in the up position. The assist bars/side rails were observed to be approximately 12 inches wide. On 03/25/25 at 8:53 a.m., Resident #28 was observed in bed with bilateral assist bars/side rails in the up position. On 03/26/25 at 10:43 a.m., Resident #28 was observed in bed with bilateral assist bars/side rails in the up position. The Bed Safety policy, dated December 2007, read in part, Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. An Assist Bar Evaluation form, dated 12/05/24, showed the recommendation was for the resident to utilize an assist bar to serve as an enabler to promote independence. Resident #28 had diagnoses which included muscle weakness. An admission assessment, dated 12/17/24, showed a staff assessment for mental status was conducted and Resident #28 was severely impaired in cognition for daily decision making. On 03/26/25 at 2:16 p.m., the DON stated Resident #28 utilized bilateral assist bars on their bed. On 03/26/25 at 2:27 p.m., the maintenance supervisor stated their staff were responsible to install assist bars/side rails. They stated the only thing they did after installation was removal of the assist bars/side rails if needed. They stated they ensured they were safely installed but the maintenance department did not routinely monitor assist bars/side rails or beds for safety. They stated they addressed issues with the beds or assist bars/side rails as reported by staff. On 03/26/25 at 2:57 p.m., maintenance worker #1 stated they did not perform regular inspections of the residents' beds but if they were in a resident's room they would check to see if the assist bars/side rails were loose and would ensure they worked correctly. Maintenance worker #1 stated they did not document when they checked assist bars/side rails. On 03/26/25 at 5:19 p.m., the administrator stated they did not have documentation of regular inspections of the residents' beds or assist bars/bed rails. On 03/26/25 at 5:53 p.m., the administrator stated they had a room checklist but it did not document that the bed or assist bar/side rails were regularly inspected for possible entrapment.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan included the use of assist bars/side rails for 1 (#28) of 19 sampled residents whose care plans were reviewed. The DON identified 68 residents who resided in the facility. Findings: On 03/24/25 at 2:05 p.m., Resident #28 was observed in bed with bilateral assist bars/side rails in the up position. The assist bars/side rails were observed to be approximately 12 inches wide. On 03/25/25 at 8:53 a.m., Resident #28 was observed in bed with bilateral assist bars/side rails in the up position. On 03/26/25 at 10:43 a.m., Resident #28 was observed in bed with bilateral assist bars/side rails in the up position. Resident #28 had diagnoses which included muscle weakness. An Assist Bar Evaluation form, dated 12/05/24, showed the recommendation was for the resident to utilize an assist bar to serve as an enabler to promote independence. An admission assessment, dated 12/17/24, showed a staff assessment for mental status was conducted and Resident #28 was severely impaired in cognition for daily decision making. The care plan, revised 03/24/25, showed staff were to encourage the use of prescribed assistive devices but did not show the use of assist bars/side rails. On 03/26/25 at 1:57 p.m., LPN #1 stated Resident #28 utilized the side rails to assist with positioning. On 03/26/25 at 2:19 p.m., the DON stated they completed the care plans in the facility. The DON reviewed the care plan for Resident #28 and stated the care plan indicated to encourage use of prescribed assistive devices, but that would not apply because the assist bars/side rails was not prescribed. They stated they had not completed a care plan for the use of assist bars/side rails.

Based on record review and interview, the facility failed to perform fall assessments after falls and initiate interventions to help prevent falls for one (#36) of three sampled residents reviewed for falls. The administrator identified 70 residents residing in the facility. Findings: An Assessing Falls and Their Causes policy, revised October 2010, read in parts, .Documentation .When a resident falls, the following information should be recorded in the resident's medical record .Completion of a falls risk assessment . A Falls Clinical Protocol policy, revised October 2010, read in part, .Treatment/Management .1. Based on the preceding assessment .the staff and physician will identify pertinent interventions to try to prevent subsequent falls .5. If an individual continues to fall, the staff .will re-evaluate the continued relevance of current interventions . Resident #36 had diagnoses that included muscle weakness and abnormalities of gait and mobility. A Fall Risk Evaluation for Resident #36, dated 08/13/23, documented resident was at risk for falls. A review of Resident #36's clinical record documented falls on 08/11/23, 08/12/23, 08/23/23, 08/31/23, 09/12/23, 09/14/23, 10/17/23, and 11/03/23. There were no Fall Risk Evaluations completed after falls on 08/23/23, 08/31/23, 09/12/23, 09/14/23, 10/17/23, nor 11/03/2023. The care plan, reviewed 11/03/23, documented the Resident #36 was at risk for falls. The care plan documented to follow the facility fall protocol and provide a safe environment. There were no interventions for preventing falls between 08/11/23 and 11/03/23 on the resident's care plan or selected on the incident report forms. On 11/30/23 at 9:17 a.m., the DON acknowledged there were no interventions for preventing falls on Resident #36's care plan. They stated the care plan should have been reviewed and updated after each documented fall. The DON reported it was facility policy for fall assessments to be done on admission and quarterly. The DON acknowledged the policy stated fall assessments were to be conducted after each fall, and that the policy had not been followed.

Based on observation, interview, and record review, it was determined the facility failed to provide written information to residents and/or their representatives on formulation of advanced directives for two (#27 and #30) of two residents who were sampled for advanced directives. The administrator (adm) reported 65 residents resided in the facility. Findings: 1. Resident #27 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 07/19/19, documented the resident was intact in cognition and required supervision to extensive assistance with activities of daily living. The resident's information page in the electronic medical record documented the resident was to be a full code status. The resident's physical chart did not document an advance directive or an acknowledgment of receipt of information regarding formulation of an advanced directive. On 09/30/19 at 5:14 PM, the adm reported she asked residents or their representative whether or not the resident had an advanced directive or do not resuscitate (DNR) directive during the admission process. She stated she did not provide any written information on formulation of an advanced directive or DNR. The adm reported she did not have any documentation of verbal information provided to residents or their representatives. On 10/02/19 at 3:18 PM, the resident was observed in his wheelchair in the dining room. The resident was asked if he wanted the facility to attempt to revive him if his heart stopped and/or he stopped breathing. The resident shook his head to indicate No. The resident was asked if anyone from the facility had spoken with him regarding this or had provided him any information regarding advanced directives. The resident shook his head No. 2. Resident #30 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/22/19, documented the resident was severely impaired in cognition and required limited to extensive assistance with activities of daily living. The resident's clinical records documented the resident was to be resuscitated in the event of a [MEDICAL CONDITION] (full code) and did not document an advanced directive. The records did not document acknowledgement of information regarding advanced directives had been provided to the resident or resident representative. On 09/30/19 at 3:00 PM, the resident was interviewed in his room. He stated he got depressed at times, but his medications helped. The resident stated he wondered why he still had to live at the facility. 3. On 10/02/19 at 2:03 PM, during a resident council meeting, six residents were asked about advanced directives. Two of the six residents reported they did not have an advanced directive and no information was provided to them regarding advanced directives on admission. Three of the residents stated they had an advanced directive when they were admitted . One resident did not answer the question.

Based on observation, interview, and record review, it was determined the facility failed to ensure assessments accurately reflected the residents' status for four (#14, 20, 43, and #64) of 21 sampled residents whose assessments were reviewed. The facility failed to accurately assess: a) resident #14 for smoking tobacco. b) resident #20 for gradual dose reductions (GDRs). c) resident #43 for current diagnoses. d) resident #14 and #64 for antipsychotic medication use. The director of nursing (DON) identified 65 residents who resided in the facility. Findings: 1. Resident #20 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 10/06/18, documented the resident was moderately cognitively impaired and had no mood symptoms and/or behaviors. The assessment documented the resident was independent with most activities of daily living (ADLS), had a [MEDICAL CONDITION], and received an antipsychotic medication. The assessment documented a GDR was contraindicated on 03/07/18. A monthly pharmacist medication regimen review, dated 01/11/19, documented a recommendation to reduce [MEDICATION NAME] 5 milligrams (mg) to 2.5 mg. The review documented the physician contraindicated the reduction on 02/06/19. A quarterly assessment, dated 07/08/19, documented the resident was moderately cognitively impaired and had no mood symptoms and/or behaviors. The assessment documented the resident was independent with most ADLS, had a [MEDICAL CONDITION], and received an antipsychotic medication. The assessment documented a GDR was contraindicated on 03/07/18. On 10/01/19 at 3:15 PM, the resident was observed watching TV in his room. He stated he did not have symptoms of depression or agitation. On 10/02/19 at 2:10 PM, the minimum data set (MDS) coordinator confirmed the MDS assessment did not include the correct GDR contraindication date. 2. Resident #64 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A physician order, dated 08/01/19, documented to administer [MEDICATION NAME] 10 milligrams (mg) at bedtime. An admission assessment, dated 08/08/19, documented the resident was severely cognitively impaired, had hallucinations and delusions, and required limited assistance with activities of daily living. The assessment documented the resident received antianxiety and antidepressant medications. The antipsychotic medication was not included on the assessment. On 09/30/19 at 12:30 PM, the resident was observed lying on her bed. The resident stated she did not have any problems related to her medications. On 10/02/19 at 2:07 PM, the minimum data set (MDS) coordinator confirmed the antipsychotic was not included on the assessment. 3. Resident # 43 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/06/19, documented the resident was intact with cognition and required extensive assistance most activities of daily living. The assessment documented the resident had a current [DIAGNOSES REDACTED]. On 09/30/19 at 5:05 PM, the assistant director of nursing (ADON) stated the [DIAGNOSES REDACTED]. On 10/01/19 at 8:15 AM, the resident was observed in the lobby in his wheel chair. On 10/02/19 at 3:02 PM, the MDS coordinator stated the the pneumonia [DIAGNOSES REDACTED]. She stated the last time the resident had pneumonia was (MONTH) 2019. 4. Resident #14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A care plan, dated 06/08/17, revised date of 09/26/19, documented the resident was a cigarette smoker. An annual assessment, dated 03/28/19, documented the resident was intact with cognition, required supervision with most activities of daily living (ADLs), and did not use tobacco. A quarterly assessment, dated 06/26/19, documented the resident was cognitively intact and was independent with most ADLs. The assessment documented the resident had received an antipsychotic medication three days during the assessment period. The assessment documented antipsychotics were not received. On 10/02/19 at 3:06 PM, the minimum data set (MDS) coordinator stated the resident would periodically try and quit smoking and would use nicotine patches to try to quit. She reported records did not show the resident was using nicotine replacement rather than smoking at the time of the annual assessment. The MDS coordinator stated the quarterly assessment captured when the resident was on [MEDICATION NAME] (antiemetic/[MEDICATION NAME] medication) for three days. She said she was instructed to code this medication as an antipsychotic medication.

Based on observation, interview, and record review, it was determined the facility failed to notify the Department of Human Services (DHS) to refer residents for a level II preadmission screening resident review (PASRR) after receiving new mental illness [DIAGNOSES REDACTED].#50 and #64) of two residents reviewed for PASRR services. The director of nursing (DON) identified 13 residents who received antipsychotic medication. Findings: 1. Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 08/08/19, documented the resident was severely cognitively impaired, had hallucinations and delusions, and required limited assistance with activities of daily living (ADLS). The assessment documented the resident received antianxiety and antidepressant medications. The resident's electronic health record documented on 08/16/19 the resident received a new [DIAGNOSES REDACTED]. The resident's medical record did not contain documentation DHS was notified of the resident's new [MEDICAL CONDITION] diagnosis. On 09/30/19 at 12:30 PM, the resident was observed lying on her bed. The resident stated she did not have any problems related to her medications. On 10/02/19 at 2:10 PM, the minimum data set (MDS) coordinator stated the facility should have called DHS when the resident received the [MEDICAL CONDITION] diagnosis. 2. Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An entry in the resident's electronic record, dated 11/01/17, documented the resident had received [DIAGNOSES REDACTED]. The record did not contain documentation DHS was notified of the new [DIAGNOSES REDACTED]. The record did not contain a PASRR level II evaluation for the resident. The quarterly assessment, dated 08/08/19, documented the resident was severely cognitively impaired and required limited assistance with most activities of daily living. The assessment documented the resident had a [MEDICAL CONDITION] and received an antipsychotic medication. On 10/01/19 at 2:50 PM, the assistant director of nursing (ADON) reviewed the resident's clinical record regarding PASRR II referrals. She stated DHS was not notified of the new [DIAGNOSES REDACTED].

Based on observation, interview, and record review, it was determined the facility failed to develop comprehensive care plans to address the residents' current needs for two (#17, and #64) of 21 residents whose care plans were reviewed. The facility failed to have care plans which addressed: a. hospice care for resident #17. b. use of antipsychotic medication for resident #64. The director of nursing (DON) identified 65 residents who resided in the facility. Findings: 1. Resident #17 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident was moderately impaired in cognition, required extensive assistance with most activities of daily living, and total dependence with bathing. A nursing note, dated [DATE], documented an order for [REDACTED]. The resident's clinical record did not contain a care plan related to hospice or end of life care. A nursing note, dated [DATE], documented the resident had expired. On [DATE] at 5:25 PM, the assistant director of nursing reported a care plan for end of life/hospice should have been developed and implemented for the resident. 2. Resident #64 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A physician order, dated [DATE], documented to administer [MEDICATION NAME] (an antipsychotic medication) 10 milligrams (mg) at bedtime. The care plan, dated [DATE], did not include the resident's use of an antipsychotic medication. An admission assessment, dated [DATE], documented the resident was severely cognitively impaired, had hallucinations and delusions, and required limited assistance with activities of daily living. The assessment documented the resident had depression, dementia, and [MEDICAL CONDITION] and received antianxiety and antidepressant medications. The antipsychotic medication was not included on the assessment. On [DATE] at 12:30 PM, the resident was observed lying on her bed. The resident stated she did not have any problems related to her medications. On [DATE] at 2:09 PM, the minimum data set (MDS) coordinator confirmed the antipsychotic medication was not included on the care plan.

Based on observation, interview, and record review, the facility failed to follow the dietitian recommended serving sizes for pureed foods. The director of nursing (DON) identified nine residents who received pureed meals. Findings: On 10/02/19 at 11:39 AM, the dietary manger (DM) was observed to prepare the pureed meal. The DM was observed to use a blue handle scoop to obtain nine scoops of pulled pork and placed them in the blinder. On 10/02/19 at 12:10 PM, cook #1 was observed to use a blue handled scoop for serving the pulled pork. The cook stated the scoop was a #16 (1/4 cup). The cook referred to the menu hanging in front of the table regarding scoop sizes for the pureed diet. She stated the menu documented to use a #6 (3/4 cup) scoop for the pulled pork. On 10/02/19 at 2:10 PM, the DM stated the cook did not serve the correct serving size for the pureed diets.

Based on observation, interview, and record review, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment for the residents. The facility failed to ensure: a) medication was administered in a sanitary manner. b) the glucometer was cleaned after use. c) two step [MEDICAL CONDITION] (TB) screens were administered to staff. The director of nurses (DON) identified 65 residents who resided in the facility. Findings: 1. On 10/01/19 at 8:13 AM, during an observation of medication (med) pass, certified medication aide (CMA) #1 was observed to crush meds. While transferring the crushed meds to a med cup, the CMA spilled some of the crushed med on the top of the med cart. The CMA was observed to scrape the meds from the top of the med cart into the med cup and administer the med to a resident. On 10/03/19 9:33 AM, the DON stated the nurse should have started over on the med pass and destroyed the first set of medication. She stated the CMA should not have given the resident medication which had spilled on the cart surface. 2. On 10/02/19 at 11:01 AM, licensed practical nurse (LPN) #1 was observed performing a finger stick blood sugar test. The LPN was observed to not clean the glucometer after use and placed it back in the drawer of the treatment cart. On 10/02/19 at 11:14 AM, LPN #1 stated she should have cleaned the glucometer after use. On 10/03/19 9:34 AM, the DON stated the glucometer should have been cleaned before and after use. 3. Five employee files were reviewed for required on-boarding documentation. Four of the five files did not document the employees received two-step [MEDICATION NAME] (TB) tests. On 10/03/19 at 11:05 AM, the business office manager stated she was only recently made aware a two step TB test was required.

Based on record review and interview, it was determined the facility failed to conduct a compressive assessment when a significant change had occurred for one (#17) of 21 residents whose assessments were reviewed. The facility failed to complete a significant change assessment when the resident was admitted to the care of hospice services. The director of nursing (DON) identified six residents who required significant change assessments during the previous three months. Findings: Resident #17 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident was moderately impaired in cognition, required extensive assistance with most activities of daily living, and total dependence with bathing. A nursing note, dated [DATE], documented an order for [REDACTED]. The resident's clinical record did not document a significant change assessment was completed within 14 days from the resident's admission to hospice. The clinical record did not document a care plan related to hospice or end of life care. A nursing note, dated [DATE], documented the resident had expired. On [DATE] at 8:59 AM, the minimum data set coordinator confirmed she did not complete a significant change assessment for the resident.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident received an intervention to maintain nutritional status within acceptable parameters for one (#2) of two residents sampled for nutritional status. The director of nursing (DON) reported 21 residents received nutritional supplements. Findings: Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 03/11/19, documented the resident was moderately impaired in cognition, required set up and supervision with most activities of daily living (ADLs), and weighed 166 pounds (lbs). The assessment documented the resident had not experienced a significant weight loss. The care area assessment (CAA) triggered nutrition as an area to be care planned. A care plan, dated 04/08/19, documented the resident had a potential nutritional problem related to a history of protein calorie malnutrition, [MEDICAL CONDITION], altered cardiac function, cognitive deficit, and self care deficit. A quarterly assessment, dated 06/10/19, documented the resident was moderately impaired in cognition, required set up and supervision with most ADLs, and weighed 158 lbs. The assessment documented the resident had experienced a significant weight loss of more than 5% in the last month or loss of 10% or more in the last six months and was not on a physician prescribed weight loss program. The assessment documented the resident had no pressure ulcers. On 07/25/19 the resident's weight was documented as 154.4 lbs. A dietitian note, dated 07/27/19, documented the resident had a 10.6% or 18 lb weight loss over 180 days. The note documented the weight loss was gradual and progressive. The note documented a recommendation to provide three ounces of Med Pass at bedtime for one month for weight support and maintenance. On 09/26/19 the resident's weight was documented at 152.6 lbs. The resident's clinical record did not document the Med Pass recommendation had been addressed by the physician. On 09/30/19 at 12:11 PM, the resident was observed in the dining room at the noon meal. He was observed attempting to bite an egg roll. The resident was unable to bite the egg roll and set it aside. Staff members were observed to bring him a meat sandwich on white bread. He was observed to eat some of the lunch meat but left much of his food untouched. On 09/30/19 at 12:51 PM, the resident was interviewed and stated he did not have any trouble eating despite having no teeth. He stated he did not like the food the facility served. The resident stated he had lost weight but was not sure how much. He stated he did not know if the staff were doing anything to help with his weight loss. On 10/02/19 at 4:26 PM, the DON reviewed the dietary notes and confirmed the physician had not been made aware of the recommendation to add Med Pass for one month.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident received care and services to prevent pressure ulcers and promote the healing of pressure ulcers for one (#36) of one resident sampled for pressure ulcers. The facility failed to ensure: a) interventions were in place to prevent pressure ulcers after the resident returned from the hospital with a [DIAGNOSES REDACTED]. b) the physician was notified at the time two pressure ulcers, one each on the resident's left and right heels, changed from suspected deep tissue injuries (SDTI) to unstageable pressure ulcers with eschar. The facility failed to notify the physician after a right heel pressure ulcer increased in surface area. The facility failed to notify the physician when the edges of the eschar lifted off the two pressure ulcers and of the eschar being completely removed from the bed of the left heel two weeks later. The facility failed to notify the physician when yellow/white drainage from the right and left heels was noted and when the left heel was first noted to have slough on the wound bed. The facility failed to notify the physician of an unstageable pressure ulcer with eschar on the left heel the week before the assessment documented no opened areas or pressure ulcers to the left heel. c) assessments were conducted timely and described the pressure ulcers' appearance and the correct staging. A physician order, dated 08/20/18, documented orders for treating a stage III pressure ulcer for resident #36. The director of nursing (DON) identified one resident with pressure ulcers. Findings: The facility's pressure ulcer staging definitions, which were documented on each weekly skin assessment and monthly nursing assessment, documented the following: Suspected Deep Tissue Injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.'' 1. Resident #36 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/13/17, documented the resident was severely cognitively impaired; required limited assistance with bed mobility, transfers, dressing, eating, and toilet use; and required supervision with walking in his room and on the unit. The assessment documented the resident was occasionally incontinent of urine and bowel, was at risk for pressure ulcers, but did not have any pressure ulcers. A nurse note, dated 01/02/18, documented the resident was readmitted to the facility for skilled services for status [REDACTED]. A daily skilled nursing assessment, dated 01/09/18, documented the resident's bilateral heels had the beginnings of pressure sores. The assessment documented the right heel had purplish darkened discoloration which was tender upon assessment. The assessment documented the left heel was reddened. A daily skilled nurse note, dated 01/09/18, documented the resident's right heel was dark colored, non-blanchable, and measured 4.0 x 4.0 x 0.0 centimeters (cm). The note documented the left heel was reddened, but blanchable. A physician order, dated 01/09/18, documented to float heels while in bed every shift for pressure ulcers. A physician order, dated 01/09/18, documented to apply skin prep spray to bilateral heels topically every shift for pressure ulcers. A quarterly assessment, dated 01/09/18, documented the resident was severely cognitively impaired; required extensive assistance of two people for bed mobility, transfers, and toilet use; required extensive assistance of one person for locomotion on the unit and eating; and walked only once or twice with the assistance of one person. The assessment documented the resident was at risk for pressure ulcers and had one unstageable pressure ulcer with SDTI in evolution. The assessment documented the most severe tissue type for the pressure ulcer was [MEDICATION NAME] tissue. The care plan, dated 01/09/18, documented the resident had an unstageable pressure ulcer to his right heel and a stage II pressure ulcer to his left heel which were present when he returned from the hospital. The care plan documented he was at risk for potential further pressure ulcer development related to poor circulation, decreased mobility, and decreased cognitive function. The care plan documented the resident's pressure ulcers would show signs of healing and remain free from infection through the review date. The interventions included to monitor nutritional status, serve diet as ordered, monitor intake and record, administer treatments as ordered and monitor for effectiveness, obtain and monitor lab/diagnostic work as ordered, report results to the physician and follow up as indicated, and to treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. The plan documented the resident required supplemental protein, amino acids, vitamins, minerals and to administer as ordered to promote wound healing. The plan documented to float heels when in bed and document weekly skin assessments. A monthly nurse assessment, dated 01/22/18, documented the right heel had a SDTI. A daily skilled nursing assessment, dated 01/28/18, documented the right heel had a SDTI. The assessment documented the pressure ulcer had a hard darkened area to heel and was being treated with skin prep. The assessment documented the left heel was blanchable. A weekly skin assessment, dated 01/29/18, documented the right heel was 3.4 x 3.3 x 0.0 centimeters (cm), un-stageable, no exudate, and the wound bed was dark in color. This was the first regularly scheduled pressure ulcer assessment since the pressure ulcer was discovered on 01/09/18. This was the first documentation the right heel pressure ulcer was described as an unstageable pressure ulcer. Before this date the ulcer was described as a SDTI. A physician order, dated 02/02/18. documented to administer L-argineine, vitamin C, and a multivitamin plus zinc for wound healing. A weekly skin assessment, dated 02/05/18, documented the right heel was 3.4 x 3.3 x 0.0 cm, un-stageable, had no exudate, and the wound bed was dark in color. A weekly skin assessment, dated 02/12/18, documented the right heel was 3.4 x 3.3 x 0.0 cm, un-stageable, had no drainage, and the wound bed was hard and dark in color. A readmit from the hospital nursing assessment, dated 02/19/18, documented the left heel was 3.4 x 3.3 x 0.0 cm and un-stageable. The assessment documented 'left heel' but the measurements were in line with the right heel measurements. No other description of the 'left heel' pressure ulcer was documented and the right heel pressure ulcer was not documented. This assessment of the pressure ulcer was captured on the minimum data set (MDS) as a new unstageable pressure ulcer and present on admission. The MDS coordinator stated the nursing assessment was incorrect because it documented left heel instead of right heel. The MDS coordinator stated she had not realized it at that time. The medical record did not document a weekly pressure ulcer assessment for the weeks of 02/26/18 and 03/05/18. A weekly skin assessment, dated 03/12/18, documented the right heel was 3.4 x 3.3 x 0.0 cm, un-stageable, had no exudate, and the wound bed was dark in color. The assessment documented the left heel was 1.5 x 2.0 x 0.0 cm, un-stageable, had no exudate, and the wound bed was dark in color. This was the first weekly skin assessment of the left heel. A nurse note on that day documented the physician was notified of the new unstageable pressure ulcer on the left heel and no treatment changes. A weekly skin assessment, dated 03/19/18, documented the right heel was un-stageable, measured 3.4 x 3.3 x 0.0 cm, had no exudate, and the wound bed was dark in color. The assessment documented the left heel was 1.5 x 2.0 x 0.0 cm, unstageable, had no exudate, and the wound bed was dark in color. A weekly skin assessment, dated 03/26/18, documented the right heel was 3.5 x 2.0 x 0.0 cm, not staged, had no drainage, and the wound bed was dark in color. The assessment documented the left heel was 2.5 x 3.2 x 0.0 cm, not staged, had no drainage, and the wound bed was dark in color. The left heel surface area had increased 5.0 squared (sq) cm in size. There was no documentation the physician was notified of increase in size of left heel. A weekly skin assessment, dated 04/02/18, documented the right heel was 3.5 x 2.0 x 0.0 cm, was not staged, had no drainage, and the wound bed to bilateral heels were dark brownish/black. The assessment documented the left heel was 2.5 x 3.2 x 0.0 cm, not staged, had no drainage, and the wound bed was dark brownish/black. The medical record did not document a weekly pressure ulcer assessment for the week of 04/09/18. A significant change assessment, dated 04/13/18, documented the resident was severely cognitively impaired; required the extensive assistance of two people for bed mobility, transfers, and toilet use; required the extensive assistance of one person for locomotion on the unit and eating; and walked only once or twice with the assistance of one person. The assessment documented the resident was at risk for pressure ulcers and had two unstageable pressure ulcers due to SDTI in evolution and one of these pressure ulcers was present on admission or reentry. The assessment documented the most severe tissue type for the pressure ulcers was [MEDICATION NAME] tissue. A weekly skin assessment, dated 04/16/18, documented the right heel was 3.3 x 3.2 x 0.0 cm, not staged, and had no wound bed description. The surface area of the right pressure ulcer had increased 3.56 sq cm since last time it was assessed two weeks earlier. The assessment documented the left heel was 1.9 x 1.5 x 0.0 cm, not staged, and had no wound bed description. The assessment documented the bilateral pressure ulcers had improved. The assessment documented the physician was notified of an abscess to the right groin, but no documentation about the increase in size of the right heel ulcer. A weekly skin assessment, dated 04/25/18, documented the right heel was 3.0 x 2.5 x 0.0 cm, not staged, had no exudate, and the wound bed had darkened, hardened skin with the edges coming up. The assessment documented the left heel was 1.5 x 1.5 x 0.0 cm, not staged, had no exudate, and the wound bed had darkened, hardened skin with the edges coming up. There was no documentation the physician was notified of the pressure ulcers hardened skin coming up. A weekly skin assessment, dated 05/02/18, documented the right heel was 2.8 x 2.5 x 0.0 cm, was not staged, had no exudate, and the wound bed had hard black eschar. The assessment documented the left heel was 1.5 x 1.5 x 0.0 cm, was not staged, had no exudate, and the wound bed had black eschar. There was no documentation the physician was notified of the appearance of eschar on the right and left heels. This was the first time the word eschar had been used in the description of the pressure ulcers. Until now the terms hard, brown, black, and unstageable had been used. A weekly skin assessment, dated 05/09/18, documented the right heel was 2.2 x 3.0 x 0.0 cm, not staged, had no exudate, and the wound bed had hard black eschar. The assessment documented the left heel was 1.0 x 1.5 x 0.0 cm, not staged, and the wound bed had hard black eschar. A weekly skin assessment, dated 05/16/18, documented the right heel was 2.2 x 3.0 x 0.0 cm, not staged, had no exudate, and the wound bed had hardened black eschar. The assessment documented the eschar appeared to be coming up on the edges and was still connected by tissue. The assessment documented the left heel was 1.0 x 1.5 x 0.0 cm, not staged, had no exudate, and the hard eschar had come off and was opened to air with skin prep applied every shift. There was no description of the wound bed after the eschar was removed. There was no documentation the physician was notified of the eschar tissue which had came off the left heel. The physician order [REDACTED]. A weekly skin assessment, dated 05/23/18, documented the right heel was 2.5 x 2.9 x 0.0 cm, un-stageable, and had yellow/white moderate drainage with no odor. The assessment documented the wound bed had hardened black eschar which appeared to be lifting up off the right heel. The assessment documented the left heel was 1.4 x 1.0 x 0.0 cm, unstageable, had yellow/white moderate drainage with no odor, and the wound bed had yellow slough. There was no documentation the physician was notified of the yellow/white drainage from the right and left heels. There was no documentation the physician was notified the left heel had yellow slough. The eschar was documented as coming off the left heel last week. A nurse note, dated 05/26/18, documented the resident's right heel wound had a silver dollar sized hard scab which was loose and had a foul odor. The note documented the physician was notified and received new treatment orders. A physician order, dated 05/26/18, documented to apply [MEDICATION NAME] 10% to bilateral heels every shift. A nurse note, dated 05/27/18, documented the right heel had a round disc of hard black eschar which when moved to the side of the wound bed, yellow adherent slough could be seen. The note documented the pressure ulcer had no drainage. The note documented the left heel had a clean, pink wound bed without drainage or signs of infection. The note documented [MEDICATION NAME] applied to both heels. There was no documentation the physician was notified of the change in condition related to the left heel being assessed as having a clean pink wound bed. A weekly skin assessment, dated 05/30/18, documented the right heel was 2.5 x 2.5 x 0.2 cm, un-stageable, had no exudate, and the wound bed was pink with 100% slough. The assessment documented the left heel was 1.5 x 1.5 x 0.0 cm, stage II, had no exudate, and the wound bed was pink. The assessment documented the left heel had improved from an unstageable ulcer to a stage II ulcer. A physician order, dated 06/01/18, documented to apply hydrogel to the left and right heels one time a day. A physician order, dated 06/05/18, documented to cleanse the right and left heels with wound cleaner, pat dry, apply hydrogel to wound bed, cover with gauze, and secure with tape one time a day. A weekly skin assessment, dated 06/07/18, documented the right heel was 2.5 x 3.0 x 0.2 cm, unstageable, had no exudate, and the wound bed had dry yellowish/white hardened slough. The assessment documented the left heel was 0.8 x 1.0 x 0.1 cm, stage II, had no exudate, and the wound bed had dry yellowish/white hardened slough. The left heel went from having a pink bed on 05/30/18 to having hardened slough on this assessment. There was no documentation of physician notification of the left heel having slough. A weekly skin assessment, dated 06/13/18, documented the right heel was 2.6 x 2.9 x 0.2 cm, unstageable, had no drainage, and the wound bed had softened yellowish/white slough. The assessment documented the left heel was 0.8 x 0.9 x 0.1 cm, stage II, had no exudate, and the wound bed had yellowish/white slough. A weekly skin assessment, dated 06/20/18, documented the right heel was 2.6 x 2.9 x 0.2 cm, unstageable, had scant amount of exudate with no odor, and the wound bed was red. The assessment documented the left heel was 0.8 x 0.9 x 0.1 cm, stage II, had no exudate, and the wound bed was red. There was no documentation the physician was notified of the change to the wound bed. A weekly skin assessment, dated 06/27/18, documented the right heel was 2.6 x 2.9 x 0.2 cm, unstageable, had scant amount of exudate with no odor, and the wound bed had moist yellow slough. The assessment documented the left heel was 0.8 x 0.9 x 0.1 cm, stage II, had no exudate, and the wound bed had dry yellowish-white slough. A weekly skin assessment, dated 07/04/18, documented the right heel was 2.6 x 2.9 x 0.2 cm, unstageable, had scant amount of exudate with no odor, and the wound bed had moist yellow slough. The assessment documented the left heel was 0.8 x 0.8 x 0.1 cm, stage II, had no exudate, and the wound bed was dry and pale pink. A weekly skin assessment was not documented for the week of 07/09/18. A monthly nursing assessment, dated 07/12/18, documented the right heel was 2.6 x 2.9 x 0.2 cm and unstageable and the left heel was 0.8 x 0.8 x 0.1 cm and a stage II ulcer. The assessment did not document any other description of the pressure ulcers. A quarterly assessment, dated 07/14/18, documented the resident was severely cognitively impaired; required the extensive assistance of two people for bed mobility, transfers, and toilet use; required the extensive assistance of one person for locomotion on the unit and eating; and did not walk. The assessment documented the resident was at risk for pressure ulcers and had . The assessment documented one pressure ulcer was unstageable due to the coverage of the wound bed by slough and/or eschar. The assessment documented the most severe tissue type for any pressure ulcer was slough and the pressure ulcer with the largest surface area was 2.9 x 2.6 x 0.2 centimeters (cm). A weekly skin assessment, dated 07/18/18, documented the right heel was 2.0 x 1.9 x 0.2 cm, unstageable, had a moderate amount of exudate with no odor, and the wound bed was moist and red with yellow slough. The assessment did not document about the left heel. On 07/18/18 the physician order [REDACTED]. A physician order, dated 07/19/18, documented to apply skin prep three times a day to the left heel until healed related to the stage II pressure ulcer. A weekly skin assessment, dated 07/25/18, documented the right heel was 2.0 x 1.9 x 0.2 cm, unstageable, had a moderate amount of exudate with no odor, and the wound bed was moist and red with yellow slough. The assessment documented the physician was notified and the treatment was changed to collagen and alginate. The assessment did not document about the left heel. A physician order, dated 07/25/18, documented to cleanse the right heel with wound cleanser, pat dry, apply collagen, apply alginate, and cover with [MEDICATION NAME] heel dressing one time a day every Monday, Wednesday, and Friday for an unstageable pressure ulcer. A weekly skin assessment, dated 08/01/18, documented the right heel was 2.0 x 1.9 x 0.2 cm, unstageable, had a moderate amount of exudate with no odor, and the wound bed was moist and red with yellow slough. The assessment documented the left heel had no open areas. A weekly skin assessment, dated 08/08/18, documented the right heel was 1.9 x 1.8 x 0.2 cm, unstageable, had a moderate amount of exudate with no odor, and the wound bed was moist and red with yellow slough. The assessment documented the left heel had no open areas. A monthly nursing assessment, dated 08/14/18, documented the left heel was a stage II pressure ulcer and was 0.7 x 0.7 x 0.1 cm. No other description noted. There was no documentation the physician was notified of the stage II pressure ulcer measuring 0.7 x 0.7 x 0.1 cm. On 08/15/18 at 10:49 a.m., registered nurse (RN) #1 was observed providing treatments to the resident's pressure ulcers on his right and left heels. The resident was resting in his reclined recliner with his heels off-loaded by a pillow. The RN cleansed the right heel pressure ulcer with wound cleanser and gauze. The RN measured the right heel and said it was 1.8 x 1.9 x 0.2 cm. The right heel pressure ulcer was observed to be unstageable and the wound bed was pink and had approximately 20% of slough. The edges were observed to have a small amount of brown eschar. A treatment of [REDACTED]. The RN then cleansed the pressure ulcer on the left heel with wound cleanser and gauze. The RN sprayed the left heel with skin prep. The left heel pressure ulcer was observed to be unstageable and covered with hard yellowish/tan eschar. There was no documentation the physician was notified of the left heel pressure ulcer covered with eschar until 08/20/18 when the treatment order was changed. A weekly skin assessment, dated 08/15/18, documented the right heel was 1.9 x 1.8 x 0.2 cm, unstageable, had a small amount of serous fluid with no odor, and the wound bed was moist, red and with yellow slough. The assessment documented the left heel had no open areas and had an order for [REDACTED]. On 08/20/18 at 11:10 a.m., RN #1 was asked what the measurement was of the left heel pressure ulcer which she measured on 08/15/18. She said she could not remember but would measure it then. The RN was observed to measure the left heel ulcer. The yellow/tan eschar was covering the ulcer. She said it was 0.7 x 0.8 cm. She was asked why she did not document the left heel assessment when she documented the right heel assessment the previous week and why there were no documented weekly assessments related to the left heel since the one on 07/04/18. She said she considered the ulcer healed out. The RN was asked if the pressure was healed if it was covered with eschar. She said the wound consultant told her over a month ago to continue the current treatment as long as the pressure ulcer had an opened area. The RN said the wound consultant told her once the wound was covered it was considered healed and to change to skin prep treatment. The RN said she stopped measuring the ulcer at that time. The RN was asked if the left heel had eschar after the order was changed to skin prep the previous month. She said the pressure ulcer had always had a scab on it. The surveyor informed the RN that documentation was not found of the pressure ulcer being healed or resolved. The surveyor asked about the order for the left heel which documented to apply skin prep until healed. She was asked if the physician had assessed the resident's heels. The RN said she knew the physician had seen the pressure ulcers but she had not been with the physician during those times. She said the physician made rounds on the Friday evening shifts. She said the evening nurse went with the physician on rounds. On 08/20/18 at 11:56 a.m., the DON was asked what the facility had done to prevent the resident from getting pressure ulcers at the time the resident came back to the facility from the hospital after having hip surgery. The DON searched the medical record and said she could not find where the facility had any interventions in place when the resident came back from the hospital. She said interventions were not put into place until they knew he had SDTI. The DON was asked if the resident had a pressure relieving mattress on his bed. She said the resident did not have a pressure relieving mattress because it was the mattress the resident and his wife brought from home. The DON said the resident and his wife insisted on their own mattress because they wanted to sleep in the same bed. The DON was interviewed about timely physician notification of changes related to the resident's pressure ulcers. The DON was asked if the resident's left heel pressure ulcer was considered healed or resolved. She said she thought his left heel was healed. She said the last time she saw the heel was on 07/25/18 with the wound consultant. She said the heel was pale dry skin with no eschar. She was asked if the nurse should have notified the physician if the ulcer was a stage II or had eschar. She said they should have notified the physician any time a wound changes. She was informed the 07/12/18 and 08/14/18 monthly nursing assessments identified the left heel ulcer as a stage II pressure ulcer measuring 0.8 x 0.8 x 0.1 and 0.7 x 0.7 x 0.1 cm. She was informed the left heel ulcer was assessed on 05/30/18 and was changed from an unstageable pressure ulcer to a stage II pressure ulcer. She was informed about the observation of the ulcer having dried eschar on 08/15/18 and on 08/20/18. The DON was asked if the physician should be notified when a SDTI pressure ulcer changes to an unstageable ulcer due to sloth or eschar. She said the physician should be notified. On 08/20/18 at 2:30 p.m., LPN #1 was asked if the physician was involved in the assessment and evaluation of the resident's pressure ulcers. She said the physician examined the ulcers when he made rounds. She said she went with the physician on rounds. She said the physician had examined the wounds on several occasions. There was no weekly skin assessment documented for the week of 08/20/18. A nurse note, dated 08/20/18, documented the resident's left heel had a yellow scab measuring 0.8 x 0.8 cm. The note documented the physician was notified and received a new treatment order. The note documented the right heel had yellow slough in the wound bed and hard yellow crust on the edges of the wound. The note documented a new treatment order was received for the right heel. On 08/20/18 at 12:48 p.m., the minimum data set (MDS) coordinator was asked about the MDS assessments which coded a pressure ulcer as being present on admit. The MDS coordinator said the assessment she had gone by to code the MDS was incorrect. She said the nurse mistakenly documented the right heel assessment as the left heel. A physician order, dated 08/20/18, documented to cleanse a wound with wound cleanser, pat dry, apply [MEDICATION NAME] Cream 1%, cover with [MEDICATION NAME], and secure with tape twice a day to the left heel stage III pressure ulcer. On 08/21/18 at 9:50 a.m., the physician was asked if he was involved with assessing the resident's pressure ulcers. He said he had examined the resident's heels at various times and believed the treatments were appropriate, but did not always document it. He was asked if would have changed the treatment from skin prep if the ulcer had eschar. He said possibly; he would have to see the wound. He said he could not recall if he was contacted when the resident's heels went from SDTI to having eschar. He said he was satisfied with the facility notifying him of changes with the resident's pressure ulcers. A physician order, dated 8/21/18, documented to cleanse wound with wound cleanser, pat dry, apply dime size amount of Santyl Ointment 250 units/gram to wound bed, cover with gauze, and secure with tape one time a day to right heel unstageable ulcer.