Every finding on record at Cortland Acres Health and Rehabilitation

Based on observation, record review and staff interviews, the facility failed to provide an environment free from accident hazards because the gap between the side rail and mattress measured 5 3/4 inches, which is one (1) inch greater than the recommended 4 3/4 inch gap. This failure created an immediate jeopardy situation and had the potential to cause fatal entrapment. In addition, the facility failed to provide an environment free from accident hazards by not having fall prevention measures in place for Resident #94 and not ensuring the sharps container was changed at the appropriate level. This failed practice was discovered during the Long-Term Care Survey process. Resident identifiers: #47, #94. Census: 92. a) On 07/15/26 at 8:25 am observed a Sharps container on Medication Cart (A), was over full. Nurse #126 had difficulty discarding a pill in the container. The drop lid on the sharps box would not fully swing because the sharps box was overly filled. Review of Sharps Disposal Policy: Section 3. (c) Designated individuals will be responsible for sealing and replacing containers when they are approximately 75% to 80% full to protect employees from punctures and/or needlesticks. On 07/15/26 at 8:25 am Nurse #126 verbally confirmed the container was too full and should have been changed out on nights. b) Resident #47 State Surveyor observed a gap between the Resident #47 's bedrail and the mattress at 5:30 PM on 07/14/26. At 5:35 PM, the Administrator confirmed that the bedrail was loose and there was a large gap between the mattress and the bed. At 5:40 PM, Maintenance Supervisor #51 measured the gap between the mattress and the bedrail, it was 5 ¾ inches. A record review showed Resident #47 does not have capacity and has a Brief Interview of Mental Status (BIMS) of 9. The Annual Minimum Data Set, dated [DATE], revealed Resident #47 is dependent for all of her Activities of Daily Living. The Side Rail and Entrapment Risk Assessment, dated 04/30/26, stated, Resident #47 is not able to safely demonstrate the proper use of side rails. No side rails indicated at this time. Upon further review, no informed consent was obtained from the resident representative. There was a physician order for a pressure relieving mattress dated 03/05/26. According to the U.S. Department of Health and Human Services Food and Drug Administration Center for Devices and Radiological Health, the seven areas in the bed system where there is a potential for entrapment are identified as Zone One (1): Within the Rail, Zone Two (2): Under the Rail, Between the Rail Supports or Next to a Single Rail Support, Zone Three (3): Between the Rail and the Mattress, Zone Four (4): Under the Rail, at the Ends of the Rail, Zone Five ( 5): Between Split Bed Rails, Zone Six (6): Between the End of the Rail and the Side Edge of the Head or Foot Board, Zone Seven (7): Between the Head or Foot Board and the Mattress End. Zone Three (3): Between the Rail and the Mattress was the identified area of concern. This area is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails. Hospital Bed Safety Workgroup (HBSW) and International Rescue Committee (IEC) recommend a dimension of less than 120 mm (4 ¾ inches) because the head is presumed to enter the space before the neck. FDA recommends a dimensional limit of less than 120 mm (4 ¾ inches) for the area between the inside surface of the rail and the compressed mattress. The State Agency determined the deficient practice constituted Immediate Jeopardy beginning on 07/14/26. The plan of correction was provided by the administration and stated as follows: A bed rail assessment was completed resident #47 by the unit manager on 7/14/2026 upon discovery. The resident was determined to not require bed rails for bed mobility and the rails were removed on 7/14/2026 at 1830 by the maintenance director. A skin assessment was completed on 7/14/2026 by the unit manager with no injuries or concerns noted to the residents' skin. A pain assessment was completed on 7/14/2026 by the unit manager with no concerns for pain identified. The prescriber and the resident representative were notified on 7/14/2026 by the DON. An audit of all residents with bed rails in place was conducted immediately upon discovery by the facility administrator, facility maintenance director, regional director of maintenance, regional director of clinical operations, and senior administrator to validate no other residents with bed rails had a gap present greater than the FDA recommendation of 4 ¾ inches. No other residents were identified as having a gap in any entrapment zone greater than the FDA recommendation. A side rail and entrapment risk assessment was completed by the DON or designee for all residents with bed rails in place. The DON or designee audited all residents with bed rails in place to validate a signed consent was in place in the medical record, an order is in place from the prescriber for bed rails, and a care plan is in place. Education began immediately with all nursing staff and maintenance related to bed maintenance and inspection, bed rails, and entrapment risks utilizing the facility policy for bed maintenance and inspections and The FDA's Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment with a post-test to validate understanding. Any member of nursing or maintenance that has not completed the education and post-test prior to 7/15/2026 will not be permitted to work until the education and post-test are completed. To ensure continued compliance, the administrator or designee will audit 10 residents 5 times a week for 12 weeks to validate if the resident has bed rails in place there is a prescriber's order, a care plan, and the resident's bed has been assessed for entrapment risks following the FDA's guideline. The DON or designee will audit 10 residents 5 times a week for 12 weeks to validate if a resident has bed rails in place there is a completed side rail and entrapment risk assessment, a prescriber's order, a care plan, and a signed consent in the resident's medical record. The plan of correction was accepted on 07/14/26 at 9:13 AM The facility implemented its Immediate Jeopardy removal plan, and the Immediate Jeopardy was removed on 07/16/26. c) Resident #94 On 07/14/2026 at 10:59 AM, a record review for Resident #94 was completed. The review found the resident had 15 falls documented in the last year. The falls are documented on the following dates: --07/29/25 --08/27/25 --09/02/25 --10/04/25 --10/29/25 --12/17/25 --01/25/26 --03/25/26 --03/26/26 --04/02/26 --04/16/26 --04/21/26 --05/03/26 --05/21/26 --07/05/26 On 07/14/2026 at 5:00 PM, an observation was made in the resident's room. The non-skid strips were not found in the resident's bathroom. At this time, an interview was held with Unit Manager (UM) #34. The UM #34 was asked, why have the non-skid strips not been placed in the resident's bathroom since the fall on 07/05/26? UM #34 stated, the work order is in, maintanence hasn't gotten to it yet. The UM was then asked, if a resident has had 15 falls in the last year, do you think the fall intervention should be in place? The UM stated, well, I understand what you are saying but we wait on maintanence. On 07/14/2026 at 5:36 PM, the Regional Risk Nurse #136 was notified of the non-skid strips not being in place. The Regional Risk Nurse #136 confirmed the fall intervention should be in place. The Regional Risk Nurse #136 stated, we will get that taken care of right away.

Based on family interview, record review, and staff interviews, the facility failed to assess a resident after a fall that led to a recurrence of a left arm fracture requiring surgical intervention. This was discovered during the complaint investigation process. Census: 92 Resident identifier: #102Resident #102An interview with Rehab Manager #96 on 07/16/26 at 11:05AM, she states Resident #102 fell twice in therapy and provided therapy notes from those falls.Record review completed on 07/16/26 revealed the following Physical Therapy (PT) note. The 05/11/26 physical therapy note reads as follows: [Resident #102] lost balance and was supported per Physical Therapist (PT) via gait belt and manual support at left arm briefly. Pt complained of pain in left arm and provided ice in room. Complexities/Barriers Impacting Session: Imbalance, left arm pain; spoke with nursing regarding possible x-ray to check arm. Pt able to move arm within sling; unable to quantify pain, crying but without tears and very scared/frustrated.Further record reviewed revealed the Medication Administration Record (MAR) has a 10/10 pain documented on 05/11/26 at 3:00PM.In a telephone interview with Complainant on 07/16/26 at 12:00PM, he stated his mom called stating she had a fall in therapy on 05/08/26, but did not seem to have any issues from that fall. He states she called him again on 05/11/26 crying in pain and stated that she had fallen again in therapy crying they broke my arm, they broke my arm and they are not doing anything but giving me medicine. Complainant states he reassured Resident #102 that x-rays take time and he was sure they would be doing one soon. On the morning of 05/12/26, she called Complainant again in pain and stating no one was doing anything to help. Complainant states he called at that time and spoke to Social Worker #58 and asked her why an x-ray had not been done. He states she told him she would look into it. On Wednesday morning, Resident #102 called Complainant again in pain. Complainant states an x-ray was done on Wednesday evening, 05/13/26, and the fracture was seen at that time. The facility then sent Resident #102 to the local Emergency department where they did more x-rays and sent her back to the facility due to the complication of the fracture and need for the original surgeon's intervention. Complainant states Resident #102 was sent to Morgantown on 05/14/26 and had surgery to repair the fracture on 05/15/26. In an interview with Social Worker #58 on 07/16/26 at 12:10PM, she states she remembers speaking to the Complainant on the phone, but does not recall the conversation, and did not document it at that time. Further record review of the nursing progress note dated 05/11/26 at 3:03PM reads, Resident observed upset, yelling out, no tears visible. Complaint of left arm pain, states she cannot move arm. A note dated 05/11/26 at 3:15PM with a late entry reads, spoke with Dr. [NAME] regarding resident complaints of left upper extremity pain. Advised that resident observed to be moving arm while adjusting wig, putting pressure on left elbow etc. He states to monitor resident at this time and administer [Pro Re Nata] PRN Tylenol if needed. Advised him resident was ordered Tramadol at hospital and preadmission papers and he states he does not want to order Tramadol at this time.Continued record review of nursing progress notes revealed a nursing progress note dated 05/13/26 at 1:24AM that reads, Resident complain of left upper arm pain post fall from the other day. Left upper arm is swollen. Dr. [NAME] gave orders to obtain x-ray.The x-ray request is dated 05/13/26. The radiology report dated 05/13/26 states: There is a fracture involving the mid humerus with 4.5 centimeters displacement.A review of the Emergency Department Provider notes dated 05/13/26 from [NAME] Regional Medical Center reads: Today, due to her ongoing discomfort, x-ray imaging was obtained and revealed an acute fracture so she was referred here for treatment.A medical record review on 07/16/26 from the [NAME] Memorial Hospital Emergency Department dated 05/14/26 regarding the history of present illness states: Patient reports she was getting rehab at a nursing home following surgery on her arm. States that on Monday when she was doing rehab exercises she almost had a fall but did not hit the ground, reports staff stabilized her by the arm and maybe it broke due to that. States pain was worsening over the past two (2) days, currently tolerable on pain medications.The Post Fall Assessment was completed on 05/20/26.

Based on observation and staff interview the facility failed to provide a clean homelike environment by having visibly soiled and unkempt recliners for residents on the memory unit(B-wing) setting area. This failed practice has the potential to affect more than an isolated number of residents on the unit. Facility census: 92a) During initial tour of the facility on 07/13/26 at 12:30 PM this surveyor observed two cream colored recliners and two brown colored recliners visibly unclean and unkempt in the setting area of B-wing. During an interview with the Administrator on 07/13/26 at 12:45 PM who stated, I'll get that taken care of now, we have plans to get sixteen new ones. confirming the recliners were not clean.

Based on observation, record review,and staff interview, the facility failed to ensure bed rail assessments were completed and informed consents were obtained for Resident #21, #106, #39, #45, #49, #73, #77, #81, #83, #89, and #92; and, the bed rail assessments were not followed for Resident #4, #6, #12, #13, #14, #24, #26, #27, #31, #32, #38, #40 #47, #48, #55, #57, #59, #66, #, This failed practice had the potential to affect all residents. Resident Identifiers: #6, #12, #13, #14, #21, #24, #26, #27, #31, #32, #38, #39, #40, #45, #47, #48, #49, #55, #57, #59, #65, #66, #71, #72, #73, #76, #77, #79, #81, #83, #84, #85, #88, #89, #90, and #92. Facility Census: 92. Findings Include: a) Incomplete Bed Rails Assessments On 07/14/26 at approximately 7:00 PM, a review of bed rail assessments was completed for all residents . The review found the following residents did not have a bed rail assessment nor informed consent obtained; which, was part of the bed rail assessment: --Resident #21--Resident #106--Resident #39--Resident #45--Resident #49--Resident #73--Resident #77--Resident #81--Resident #83--Resident #89--Resident #92 On 07/14/26 at approximately 9:00 PM, the Administrator and the Regional Risk Nurse #134 were notified of the bed rail assessment not being completed and the informed consent not being obtained. The Regional Risk Nurse #134 stated, we will review the resident's records now. We will get those corrected right away. b) Bed Rail Assessments Not Followed On 07/14/26 at approximately 7:00 PM, a review of all bed rail assessments was completed. The review found the following residents did have a bed rail assessment completed; however, the recommendation of the assessment was not followed: --Resident #4 recommendation-padded side rails, not in place--Resident #6 recommendation-side rails, not in place--Resident #12 recommendation-none, in place--Resident #13 recommendation-none, in place--Resident #14 recommendation-side rails, not in place--Resident #24 recommendation-none, in place--Resident #26 recommendation-none, in place--Resident #27 recommendation-side rails, not in place--Resident #31 recommendation-side rails, not in place--Resident #32 recommendation-none, in place--Resident #38 recommendation-side rails, none in place--Resident #40 recommendation-none, in place--Resident #47 recommendation-side rails, not in place--Resident #48 recommendation-none, in place--Resident #55 recommendation-side rails, not in place--Resident #57 recommendation-side rails, not in place--Resident #59 recommendation-side rails, not in place--Resident #65 recommendation-none, in place--Resident #66 recommendation-none, in place--Resident #71 recommendation-none, in place--Resident #72 recommendation-side rails, not in place--Resident #76 recommendation-side rails, not in place--Resident #79 recommendation-side rails, not in place--Resident #84 recommendation-side rails, not in place--Resident #85 recommendation-side rails, not in place--Resident #88 recommendation-none, in place--Resident #90 recommendation-none, in place On 07/14/26 at approximately 9:00 PM, the Administrator and the Regional Risk Nurse #134 were notified the bed rail assessment recommendations were not followed. The Regional Risk Nurse #134 stated, we will review the resident's records now. We will get those corrected right away.

Based on record reviews and staff interviews the facility failed to ensure the drug regimen of each was reviewed at least once a month by a licensed pharmacist. This failed practice was found true for four (4) of five(5) residents reviewed for the care area of Unnecessary Medications review, and has the potential to affect more than a minimal number of residents residing in the long term care facility. Resident identifier: #3. #5. #7, #8 Facility census: 92 Findings include: a) On 07/14/2026 4:13 PM Pharmacy reviews for Resident #3. #5. #7, #8 were requested from the facility. The suruveyor requested medication regimen reviews for the past year. The facility was unable to provide documentation demonstrating that the required monthly Medication Regimen Review had been completed by the consultant pharmacist for the past year (12 months).During an interview on 07/15/2026 at 3:00 PM with the Senior Nursing Home Administrator (SNHA) #180 it was confirmed the facility was unable to provide monthly Medication Regimen Review (MRR)or indicate that MRR was completed.

Based on observation and staff interview the facility failed to ensure proper temperature controls were consistently maintained for one (1) of 1 medication refrigerators. This has the potential to affect residents receiving medications requiring refrigeration. Facility census; 92. Findings included: a). During the initial tour of Medication Room C on 07/13/26 at 2:40 p.m., the medication storage refrigerator temperature log showed no temperatures recorded for the PM on 07/05/26 and 07/09/26. No AM temperatures were recorded on 07/06/26, 07/07/26, 07/09/26, 07/11/26, and 07/12/26. Interview on 07/13/26 at 2:40 PM with Assistant Director of Nursing (ADON) #290 confirmed the Refrigerator Temperature Log contained no recording temperatures noted on the Refrigerator Freezer temperature log as listed above.

Based on observations, recident interviews, the facility failed to ensure food is palatable, attractive and appetizing. This failed practice has the potential to affect more than a minimal number of residents residing in the Long-Term Care Facility as ther is only one resident that is NPO (Nothing by mout). Resident identifier: #38, and #74. Facility census: 92. Findings include: a) Resident #38 Resident #38 on 07/13/26 1:20 pm stated the food used to be wonderful then they sold this building to people in [NAME] and the food went from a five star to a one star in five weeks. b) Resident #74 Resident #74 on 07/13/26 at 10:30 am stated the food was slop and it made me them because they were paying for this food. Resident #74 stated she did get loud in the dining room over what was supposed to be meatloaf but looked like ground up meat with no flavor and looked awful. During a food tasting on 07/13/26 at approximately 1:00 PM the pork chop appeared overcooked; it was tough to cut and the meat was dry and difficult to chew. Observations made in the dining room and halls on 07/13/26 showed residents were not eating their pork chops. During and interview on 07/13/26 at 1:30 PM the Dietary Manager #74 confirmed the pork chops were tough and stated, We are working on making items from the always available menu now for residents wanting something else. During the Resident Council meeting on 07/13/26 at 1:30 PM, the residents attending agreed unanimously that the food served is inedible at times, especially referencing the pork chops that were served for lunch on 07/12/26.

Based on observation, record review, and staff interviews, the facility failed to ensure Resident #42 who had limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. This was true for one (1) of three (3) residents sampled for limited range of motion during the Long-Term Care Survey Process. Census: 92 Resident identifier: #42 Findings include: a) Resident #47 Resident #47 was observed on 07/14/26 and 07/15/26 throughout the day with no elbow splints by State Surveyor. A Therapy Staff Education form dated 03/02/26 reads as follows: Elbow extension splint for right and left elbow for [Resident #47] for 3 hours. Check for redness and irritation. Rolled gauze in bilateral hands. This was signed by four (4) aides. In an interview on 07/14/26 with Certified Nurse Aide #159 at 4:50 PM, she stated she had never seen elbow splints on Resident #47. In an interview with CNA #9 on 07/15/26 at 11:50 AM, she stated she has never seen elbow splints on Resident #47. During an interview with CNA #114 on 07/15/26 at 11:45 AM, she stated Resident #47 had not worn elbow splints in a while. In an interview with Registered Nurse #43 on 07/15/26 at 2:45 PM, she confirmed Resident #47 had not had elbow splints applied yet today. The Quarterly Minimum Data Set (MDS) Section S dated 02/18/26 shows hand contractures on both sides and no other contractures of the upper or lower extremities. The Annual Minimum Data Set (MDS) dated [DATE] Section S shows Resident #47 has contractures in both hands, both wrists, both elbows, both shoulders, both ankles, both knees, and both hips. In an interview with Director of Rehab #96 and Physical Therapy Assistant #99 on 07/15/26 at 2:15 PM, they stated Resident #47 had limited range of motion in February 2026 but did not consider her lower extremities or wrists, elbows, and shoulders to be contracted. She stated Resident #47 has not received physical therapy or occupational therapy services since discharge in March 2026. Resident has not been screened for therapy services again since March 2026.

Based on observations and staff interviews the facility failed to ensure food was stored according to professional food service safety standards by not ensuring items in the freezer were sealed and not exposed to the elements. This failed practice had the potential to affect more than a minimal number of residents in the long-term care facility. Facility census: 92.Findings included:a) On 07/13/26 at 12:00 PM an initial tour of the facility's kitchen found an open box in the freezer containing hamburger patties; the bag of patties was unsealed and exposed to the elements. During an interview at the time of the findings the Dietary Manager #74 confirmed the hamburger patties were exposed to the elements.On 07/14/26 at 9:00 AM, a follow up tour of the kitchen found a box of corn on the shelf with its flap open and the bag of corn was unsealed and exposed to the elements. During an interview at the time of the findings the Dietary Manager #74 confirmed the bag of frozen corn were exposed to the elements.

Based on observation and staff interview the facility failed to ensure residents call lights were within reach while in the bed. This failed practice had the potential to affect more than a minimal number of residents residing in the Long Term Care Facility. Resident identifiers: #40, and #52 Facility census: 92. Findings include:During tour of B-wing on 07/14/26 at approximately 1:00 PM and observation was made of Resident #40 and #52 in the bed with call lights not within reach of the residents.On 07/14/26 at 1:40 PM an interview with Licensed Practical Nurse (LPN)#32 was completed showing the Resident #40's call light was laying across the night stand that was not within easily reach, and Resident #52's whose call light was behind the head board on the floor. LPN#32 placed call lights in reach of the residents and confirmed they were not within reach.

Based on observation, record review and staff interview, the facility failed to implement a comprehensive care plan for Resident #94's fall interventions and Resident #47's bilateral arm splints. This was true for one (1) of three residents reviewed under the care area of accidents and one (1) of two (2) residents reviewed under the care area of impaired mobility. Resident Identifiers: #94 and #47. Facility Census: 92. Findings Include: a) Resident #94 On 07/14/2026 at 10:59 AM, a record review for Resident #94 was completed. The review found the resident had 15 falls documented in the last year. The falls are documented on the following dates: --07/29/25 --08/27/25 --09/02/25 --10/04/25 --10/29/25 --12/17/25 --01/25/26 --03/25/26 --03/26/26 --04/02/26 --04/16/26 --04/21/26 --05/03/26 --05/21/26 --07/05/26 On 07/14/2026 at 5:00 PM, an observation was made in the resident's room. The non-skid strips were not found in the resident's bathroom. At this time, an interview was held with Unit Manager (UM) #34. The UM #34 was asked, why have the non-skid strips not been placed in the resident's bathroom since the fall on 07/05/26? UM #34 stated, the work order is in, maintanence hasn't gotten to it yet. The UM was then asked, if a resident has had 15 falls in the last year, do you think the fall intervention should be in place? The UM stated, well, I understand what you are saying but we wait on maintanence. On 07/14/2026 at 5:36 PM, the Regional Risk Nurse #136 was notified of the non-skid strips not being in place. The Regional Risk Nurse #136 confirmed the care plan was not implemented as it related to fall prevention/non-skid strips. The Regional Risk Nurse #136 stated, We will get that taken care of right away. b) Resident #47 Resident #47 was observed by State Surveyor throughout 07/14/26 and 07/15/26 without Bilateral elbow extension splints. In an interview on 07/14/26 with Nurse Aide (NA) #159 at 4:50 PM, she stated she had never seen elbow splints on Resident #47. In an interview with NA #9 on 07/15/26 at 11:50 AM, she stated she had never seen elbow splints on Resident #47. During an interview with CNA #114 on 07/15/26 at 11:45AM, she stated Resident #47 has not worn elbow splints in a while. It was confirmed by Registered Nurse #43 on 07/15/26 at 2:45PM that Resident #47 had not yet had elbow splints applied for the day. During the record review it was discovered that the resident had a plan for Bilateral Elbow Extension Sprints to be worn at all times. Resident #47's care plan reads: Ensure resident has Bilateral Elbow Extension splints on at all times. May removefor showers.Date Initiated: 06/26/26

Based on document review and staff interviews, the facility failed to provide residents with consistent preferences on the facility's readily available menu. This was found to be true on 2 of 2 menus and has the potential to affect more than an limited number of residents currently residing at the facility. Facility census 90.a) On 03/24/26 at approximately 1:05 p.m., the facility's Traveling Dietary Manager was interviewed. The Traveling Dietary Manager was asked to provide a list of readily available items. The list had the following item listed: it has a choice of egg. When asked what the choice of egg offered to the resident was? The Traveling Dietary Manager replied They can either get an omelet, scramble eggs, hard boiled egg or a hard fried egg Verified with the Traveling Dietary Manager on 03/24/26 at approximately 1:08 p.m., that the posted readily available menu that residents have access to does not have those items listed as choices.b) On 03/24/26 at approximately 1:10 p.m., the facility's Traveling Dietary Manager provided a copy of the always available menu that the kitchen has. This menu does not correlate with the menu that the residents have. Interview with the Traveling Dietary Manager on 03/24/26 at approximately 1:13 p.m. verified that the readily available menus do not correlate.c) On 03/25/26 at approximately 4:00 p.m., the facility Administrator acknowledged the deficiency during the exit interview.

Based on observation and staff interview, the facility failed to provide resident meals at proper serving temperature. This was found to be true on 1 of 1 lunch meals tested. Facility census 90. a) Lunch Meal on A HallOn 03/24/26 at approximately 12:10 PM, the surveyor had a random lunch tray on A hall temperature tested by the Traveling Dietary Manager. The temperature assessment was also witnessed by the facility's Administrator. The food which was tested were mashed potatoes and gravy with steak. Both food temperatures were tested by the Traveling Dietary Manager as 110 degrees Fahrenheit. On 03/24/26 at approximately 12:15 PM, interview with the Traveling Dietary Manager confirmed and verified that the food did not meet the required serving temperature.On 03/24/26 at approximately 12:16 PM, interview with the facility Administrator confirmed that the food did not meet the required serving temperature. This deficiency was also acknowledged by the facility's Administrative team upon exit on 03/25/26 at approximately 4:00 PM.

Based on observation and record review, resident interview the facility failed to ensure that the meals were served timely. Facility census and findings included.A) Resident #43On 10/22/25 at 12:15 PM an observation of Resident #43 in the dining room B, found lunch trays arrived at 1:10 PM. A review of the policy titled Open Style Dining with no date of initiation/review/revised stated that lunch trays are served at 11:30 AM. A confidential interview with a staff member confirmed that the trays should have been delivered by 12:20 PM. Interview from Resident #74, breakfast served 9AM, Lunch 1:45 PM, Dinner 7:20 PM. Interview completed 10/22/25 at 4:35 PM. Interview from Resident #11, food is cold all meals. Observation of meal service 10/23/25, lunch trays A hall were served 12:05 PM, C hall 12:21 PM, D hall 12:35 PM, [NAME] 12:45 PM. Food temperatures were taken of last tray on [NAME], Cod 145 degrees, Potatoes 140 degrees, and Cream Spinach 160 degrees.

Based on observation and staff interview, staff failed to change contaminated gloves after performing perineal care and before touching clean resident gown and linens. This was true for one (1) of one (1) residents observed during perineal care. Resident identifier: # 70. Facility census: 90. Based on observation and staff interview, staff failed to change contaminated gloves after performing perineal care and before touching clean resident gown and linens. This was true for one (1) of one (1) residents observed during perineal care. Resident identifier: # 70. Facility census: 90.Findings included:a) Resident #70On 06/24/25 at 11:05 AM an observation of perineal care for Resident #70 found that Nurse Aide (NA) #14 completed perineal care with no issues observed with the procedure. Upon completion of the perineal care, NA #14 failed to change the contaminated gloves and assisted the resident to put on a clean gown. The surveyor intervened and stopped the continued use of the contaminated gloves. NA #14 confirmed she should have changed her gloves after completed perineal care. NA #14 immediately removed the contaminated gloves, performed hand hygiene, and donned new gloves.

Based on observation, record review, resident interview, and staff interview, the facility failed to provide each resident food prpared in the form to meet their individual needs for Resident's #12, #191, #32, #19, #62, #49, #71, #34, #87, and #46. This created an immediate jeopardy situation due to the risk of choking and aspiration. Resident Identifiers: #12, #191, #32, #19, #62, #49, #71, #34, #87, and #46. Facility census: 91. Findings included: a) Resident #12 On 03/03/25 at 3:18 PM, Resident #12 stated she had difficulty eating the food, especially meats, at the facility sometimes. She stated she had difficulty swallowing and sometimes the food makes her cough. On 03/04/25 at 12:32 PM, Resident #12 was observed eating lunch in her room. Her tray ticket stated her food consistency was to be chopped. She had breaded chicken cut into pieces of various sizes. Review of Resident #12's diet order showed the resident had an order for Heart Healthy CCD [carbohydrate controlled diet] diet, Minced & Moist (MM5) Meats Only texture, Regular/Thin consistency. The facility's policy on therapeutic diets stated as follows: - Diet order should match the terminology used by the food and nutrition services department. - If a mechanically altered diet is ordered, the provider will specify the texture modification. The facility's document titled Crosswalk of DMO [dietary modification orders] diets and textures, the facility used the following texture terminology: chopped, mechanical soft, and pureed. The facility provided the following diet level descriptions: - Chopped diet emphasizes chopped or cut-up meats alongside soft-textured or chopped starches and vegetables. - Mechanical soft, or ground, diet is recommended to have a consistency similar to applesauce. All meats were to be ground, with the addition of extra broth, sauce or gravy to prevent dryness. Sandwiches were to feature ground fillings and bread that are ground. - Pureed diet was to resemble that of mashed potatoes or applesauce. Resident's diet orders on the Order Listing Report were reviewed by the State Surveyor. Diet Levels included: a) Dysphagia Advanced texture - with all food chopped, with all chopped meat and with all food chopped except sandwiches. b) Soft and Bite-Sized (SB6) texture. c) Soft and Bite-Sized (SB6) texture with ground meat. d) Soft and Bite-Sized (SB6) with puree corn. e) Soft and Bite-Sized (SB6) texture with meats only. f) Minced and Moist (MM5). g) Minced and Moist (MM5) with meats only. h) Minced and Moist with Meats Only and Soft and Bite-Sized. I) Regular texture with all food cut into bite-sized pieces. j) Regular texture. k) Puree texture. On 03/04/25 at 1:10 PM, Dietary Aide #16 and Dietary Aide # 34 reported they did not know about Dysphagia Advanced diets, Soft and Bite-Size (SB6) and Minced and Moist (MM5) diet levels. Dietary Aide #16 stated, she had never heard of it They confirmed diet levels used in the kitchen were Regular, Chopped, Mechanical Soft and Puree. Dietary Aide #16 stated,Some cards are wrote up different. Normally they just know it when they see who it is. On 03/04/25 at 1:13 PM, the Certified Dietary Manager (CDM) was asked about the different diet levels on the Diet Order Listing Report. The CDM stated, Not sure I know how to answer. The CDM stated she usually goes by the extension manual. The CDM reported they had just switched over and were in the process of getting our consistency soft to bite-sized. On 03/04/25 at 3:54, the Registered Dietician (RD) was interviewed via phone concerning the facility diet levels. The RD reported she did not recommend the textures of the diets and sometimes they come on a different diets from the hospital. She reported the Speech-Language Pathologist (SLP)recommended the textures. The RD stated, the Minced and Moist texture was closer to Mechanical Soft and the Soft and Bite Size texture and Advanced texture was closer to chopped. The facility SLP was unavailable on this date for an interview per the Director of Rehab. Resident #191 On 03/04/25 at 4:28 PM, Resident #191 was observed eating dinner in her room. She had a hamburger on a bun, coleslaw, baked beans, and a cookie. The food was not altered. The resident's tray ticket stated the food consistency was to be chopped. The resident ate approximately half of the hamburger. The resident ' s diet order was Heart Healthy CCD diet, Soft & Bite-Sized (SB6) texture, Regular/Thin consistency with special directions for ground meat. Resident #32 On 03/04/25 at 5:16 PM, Resident #32 was served dinner in his room. The resident's tray ticket stated the food consistency was to be chopped. The resident had a whole slice with ground meat and cheese, baked beans, carrots, and ice cream. The baked beans and carrots were not altered. The resident stated he only wanted ice cream. The resident 's diet order was CCD diet, Minced & Moist (MM5) Meats Only texture, Regular/Thin consistency. Resident #19 On 03/04/25 at 5:44 PM, Resident #19 was served dinner in the dining room. The resident's tray ticket stated the food consistency was to be chopped. The resident's tray had a whole slice of bread with ground meat and cheese, whole baked beans, and carrot slices. The resident's diet order was CCD diet, Minced & Moist (MM5) Meats Only texture, Regular/Thin consistency. Resident #62 On 03/04/25 at 5:47 PM, Resident #62 was served dinner in the dining room. The resident ' s tray ticket stated the food consistency was to be chopped. The resident had a hamburger on bun cut into quarters. The resident's diet order was Regular diet, Soft & Bite-Sized (SB6) texture, Regular/Thin consistency. Resident #49 On 03/04/25 at 5:49 PM, Resident #49 was served dinner in the dining room. The resident's tray ticket stated the food consistency was to be chopped. The resident had a burger on a bun cut in half. The resident's diet order was Regular diet, Soft & Bite-Sized (SB6) texture, Regular/Thin consistency. Resident #71 On 03/04/25 at 5:50 PM, Resident #71 was served dinner in the dining room. The resident's tray ticket stated the food consistency was to be chopped. The resident's tray had an unaltered burger on a bun and whole baked beans. The resident's diet order was Heart Healthy CCD diet, Minced & Moist (MM5) texture, Regular/Thin consistency. Resident #34 On 03/04/25 at 5:55 PM, Resident #34 was served dinner in the dining room. The resident's tray ticket stated the food consistency was to be chopped. The resident's tray had a burger on a bun cut into quarters. The resident's diet order was Regular diet, Soft & Bite-Sized (SB6) texture, Regular/Thin consistency. Resident #12 On 03/04/25 at 5:59 PM, Resident #12 was served dinner in the dining room. The resident's tray ticket stated the food consistency was to be chopped. The resident's tray had a burger on a bun cut into quarters. The resident's diet order was Heart Healthy CCD diet, Minced & Moist (MM5) Meats Only texture, Regular/Thin consistency. Resident #87 On 03/04/25 at 6:20 PM, Resident #87 was served dinner in the B hallway dining area. The resident's tray ticket stated the resident was to have mechanical soft meat. The resident was served a whole burger on a bun. The resident 's diet order was Regular diet, Regular texture, Regular/Thin consistency with mechanical soft meat. Resident #46 On 03/04/25 at 6:28 PM, Resident #46 was served dinner in the B hallway dining area. The resident 's tray ticket showed the resident was to have ground meat. Instructions were given to puree meat. The ticket stated she was to have cheeseburger on a bun (ground fill/pureed bread), ground baked beans, and ground carrots. The resident was served ground meat, whole baked beans, and chopped carrots. The resident's diet order was Regular diet, Puree texture, Nectar liquids consistency. Resident #2 On 03/05/25 at 1:16 PM, Resident #2 received her lunch meal. The meal ticket was for Mech Soft/Dysphagia. She received Ziti (chopped) with meat sauce, California Blend Vegetables (Chopped), garlic bread (Pureed) and pudding. When her plate was delivered the resident and the resident's daughter (present at the table) were upset because the resident did not want this tray. She refused the tray and told the Dietary Aide (DA) to take it away, that all she wanted was a plain hamburger. The Dietary Aide #21 took the tray away and returned with a whole plain hamburger. The surveyor immediately (03/05/25 at 1:20 PM) went toCorporate Registered Nurse (CRN) #172 and made her aware the resident had received a whole hamburger. CRN #172 immediately went over and explained the hamburger was not on the Resident's diet and she would return with the correctly cooked hamburger. The resident had not eaten the burger. According to the consistency spreadsheet provided by the facility, residents on a chopped diet should have received cheeseburger on a bun (chop fill/soft bread), baked beans, carrots, oatmeal cookie, and milk. According to the consistency spreadsheet provided by the facility, residents on a mechanical diet should have received cheeseburger on a bun (chop fill/soft bread), baked beans (ground), carrots (ground), ice cream, and milk. Receiving food in the wrong consistency could result in choking, aspiration pneumonia which can lead to serious harm and/or death. An Immediate Jepardy was called and a written copy was reviewed and signed by the Administrator on 03/04/25 at 8:17 PM. A plan of correction was received and accepted on 03/04/25 at 10:22 PM. The plan of correction/abatement plan included: Immediate Jeopardy (IJ) Abatement Plan for F805 Facility Name: Cortland Acres Health and Rehab Date of Correction Plan: 3/4/2025 Immediate Actions Taken to Remove the Immediate Jeopardy 1. Resident Safety and Corrective Actions: As of 03/04/25, all residents on physician-ordered mechanical altered diets were immediately assessed by the assigned nurse for adverse effects related to improper texture-modified meals. 2. On 03/4/25, in conjunction with the resident's physician, Director of Nursing, and Speech Therapist, resident diet orders were update as appropriated to mechanical soft diet or chopped diet. 3. Staff Education and Re-Training: Dietary Staff: Immediately or upon arrival to their next worked shift received in- service training conducted on 03/4/25 by the Dietary Manager and/or designee on: Proper preparation and delivery of chopped diet, puree diet and mechanical soft diets Nursing Staff and CNAs: Re-educated on proper meal modifications and verifying consistency of food before serving. In-service was provided by the DON/designee either immediately or upon arrival for their next shift. 4.Monitoring and Quality Assurance Measures: Daily Meal Audits: Beginning 03/4/25, the Dietary Manager and Nursing Supervisor conduct meal service audits at every meal to ensure proper diet consistency compliance. Any discrepancies in meal preparation are immediately corrected, documented, and reviewed in daily safety huddles.Weekly audits of meal service by the Dietary Manager and Director of Nursing (DON) for four weeks, then ongoing monthly audits. QAPI Committee will review compliance data and discuss any identified trends or issues. Administrator and Medical Director notified of all corrective actions and ongoing monitoring efforts. On 03/05/25, the surveyor consulted with the facility's corporate team concerning diet cross walks with differing diets per crosswalk from previously ordered diets. Some diets were upgraded and some diets were downgraded. Diets were changed with nursing input, speech therapy input and physician input. Diets were physician ordered. On 03/05/25 at 3:15 PM, Corporate Registered Nurse #172 gave this surveyor a revised diet list with upgraded diets changed and reported the Speech-Language Pathologist will evaluate residents for the safest and most appropriate diet level. On 03/05/25 at 6:25 PM, the Abatement was completed.

Based on closed record review, policy review, review of facility investigation and staff interview, the facility failed to ensure Resident #89 received Cardiopulmonary resuscitation (CPR) as resident requested and physician ordered when found pulseless, not breathing and skin pale and warm to the touch. The State Agency (SA) found this failure rose to the level of an Immediate Jeopardy This failed practice was true for Resident #89 but had the potential to affect 32 residents who requested CPR and had a physician order for CPR. Resident identifier: #89. Facility Census: 91. Findings included: a) Resident #89 Resident #89 was admitted on [DATE] with diagnoses of Diabetes, dementia, seizure disorder, coronary artery disease and high blood pressure. The Brief Interview for Mental Status (BIMS) was 99 which means the resident could not answer any questions and had severe cognitive impairment. A physician order was written on [DATE] at 10:44 AM CODE STATUS: Full Code. Record review revealed that on [DATE] at 5:56 AM a Nurse Aide called the Licensed Practical Nurse (LPN) #135 to Resident #89's room. LPN #135 observed Resident #89 with absence of a heart rate and respirations, skin pale and warm to touch and was confirmed by the Registered Nurse (RN) #55 on duty. Postmortem care was performed by Nurse Aides. Medical Power of Attorney (MPOA) and Nurse Practitioner were notified. Time of death was at 5:43 AM on [DATE]. A review of the investigative statement by RN #55 for the question, When resident was found to be deceased , did we check code status? RN #55 stated that she was asked to check and confirm death. Went to check on resident she was not breathing, tongue gray/blue, pupils fixed and dilated, no respirations, no carotid pulse times 60 seconds, no sign of life. When I went to pull up the face sheet, I saw that she was a full code, it was 12 minutes later, too long. An additional telephone interview was conducted on [DATE] at approximately 5:00 PM. RN #55 stated that to check a resident's code status she had to go to the nurses' station to retrieve the face sheet. An additional nurse's note was provided by the Corporate Officer #171 stating there was a late entry note made by RN #55 at 3:44 AM on [DATE] (Typed as entered) Late Entry for: [DATE] 5:52 am Notified by CNA that resident had passed away. asked to assess. Upon entering resident's room, noted color was pale, eyes closed, pupils fixed and dilated, no response to verbal stimuli, no respirations, no carotid pulse x60 seconds, no movement, no presence of life. Pronounced at 5:53am. On [DATE] at approximately 4:30 PM all licensed staff currently working were interviewed regarding the education regarding code status. Staff interviews consisted of what do you do when you find a resident unresponsive, not breathing, has no pulse and skin is pale and warm? RN #165, LPN #135, RN #18, LPN #88 and LPN #91 stated they would start CPR and then have someone check the resident's code status on the MAR, POC or EMR profile immediately. CPR Policy The facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation (CPR) original date of [DATE] stated the following: If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a staff member who is certified in CPR/BLS (basic life support) shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g., rigor mortis). Rigor mortis is defined as stiffing of the joints and muscles of a body a few hours after death, usually lasting from one to four days. Usually appears two (2) hours after death. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is DNR or a physician's order not to administer CPR. The facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation (CPR) original date of [DATE] stated the following: If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a staff member who is certified in CPR/BLS (basic life support) shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g., rigor mortis). Rigor mortis is defined as stiffing of the joints and muscles of a body a few hours after death, usually lasting from one to four days. Usually appears two (2) hours after death. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is DNR or a physician's order not to administer CPR. The Interim Nursing Home Administrator (INHA) and Director of Nursing (DON) were notified of the IJ on [DATE] at 7:25 PM. The SA accepted the plan of correction (POC) at 10:25 PM on [DATE] Immediate Jeopardy (IJ) Plan of Correction Facility Name: Cortland Acres Issue: Failure to ensure immediate identification and response to residents' code status, creating the potential for serious injury, harm, or death. Immediate Corrective Actions Taken: Immediate Staff Education: -All licensed nursing staff, CNAs, and relevant personnel were immediately re-educated on the importance of identifying and verifying resident code status. -Education included proper use of the electronic medical record (EMR) system, Medication Administration Record (MAR), and Point of Care (POC) record to confirm code status before initiating emergency interventions. -Training was completed on [DATE] by Assistant Director of Nursing or designee (ADON) with documentation of attendance appropriate staff will be educated either immediately or upon arrival for their next shift. Electronic Record Review & Accuracy Validation: - A facility-wide audit was conducted on [DATE] by Director of nursing or designee to validate the accuracy of code status documentation in the electronic medical record profile, medic and Point of Care system. - Any discrepancies were immediately corrected, and responsible personnel were re-educated. Implementation of a Code Status Verification Protocol: - Ensure staff follow Policy Emergency Procedure Cardiopulmonary Resuscitation - Staff must verify code status using one (1) method of verification: - The electronic medical record profile - The MAR - The Point of Care record Ongoing Monitoring & Compliance Assurance: -The Director of Nursing (DON) or designee will conduct daily audits of resident code status documentation for 7 days, followed by weekly audits for 4 weeks, ensuring accuracy and adherence to protocol. - Any identified concerns will result in immediate staff re-education. - QAPI Committee will review compliance data and discuss any identified trends or issues. - Administrator and Medical Director notified of all corrective actions and ongoing monitoring efforts. After verification of the steps of the POC being Implemented the IJ was abated at 5:03 PM on [DATE]. On [DATE] at 10:00 AM in an interview with the INHA when asked about the late entry having been dated [DATE] when Resident #89 had died on the [DATE], the INHA had no comment.

Based on observation and record review, the facility failed to ensure a dignified exsistance took place during dining. The staaff did not ask the residents in the dining room if they wanted to wear clothing protectors. The staff served Resident #23 and #68 meals in large vegetable serving bowls. Residents were not served meals together when they were sitting together at the same table. This failure was a random opportunity for discovery and had the potential to affect more than a limited number of resdients. Resident identifiers: #23 and #68. Facility Census: 91. Findings included: a) On 03/03/25 at 11:55 AM during the Dining Observation, the residents were not asked if they would like to wear a clothing protector. The clothing protectors were placed on the residents in the main dining room by nursing staff. b) On 03/03/25 at 12:10 PM, Resident #23 was served his lunch meal in a large vegetable serving bowl. No adaptive equipment for a bowl/plate was documented on the resident's tray card or found in the resident's orders. c) On 03/03/25 at 12:15 PM, Resident #68 was served his lunch in a large vegetable serving bowl. No adaptive equipment for a bowl/plate was documented on the resident's tray card or found in the resident's orders. Nursing Assistant #4 stated it was, easier for him to eat out of. d) According to the facility's policy titled, Policy and Procedure Manual for The Dining Experience: Staff Responsibilities, Individuals at the same table will be served and assisted at the same time. On 03/03/25, Resident #68 was not served a tray with his table mate until surveyor intervention after five minutes.

Based on observation and staff interview, the facility failed to provide a clean and home like environment for all residents in the facility. Facility census 91. Findings included: a) On 03/04/25 at approximately 9:30 a.m., observed a stained ceiling located in the main hallway near the main entrance. b) On 03/04/25 at approximately 9:41 a.m., observed a stained ceiling located in the C Hall soiled utility room. c) On 03/04/25 at approximately 9:54 a.m., observed a stained ceiling located in the main hallway near the main entrance. e) Interview with the facility's staff at the time of discovery verified these findings. These findings were acknowledged by the Interiem Administrator upon the exit interview on 03/12/25 at approximately 2:45 p.m. 52481

Based on record review and staff interviews, the facility failed to develop and implement a person-centered comprehensive care plan to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. This was an issue for one (1) of 32 residents whose care plans were reviewed. Resident Identifiers: #52, #293, #74, #43, #60, #64, #16. Facility Census: #91 Findings Include: a) Resident #52 On 03/03/25 at 11: 50 AM observation was made of Resident #52 on a power wheelchair. Throughout the two-week survey he has been observed numerous times on the power wheelchair. On 03/10/25 at 10:45 AM a review of Resident #52's care plan found the following Focus areas were not resident centered. Activities: Focus states the resident prefers to participate in activities such as (left blank) Interventions: interview resident and family as needed to determine the resident's prior level of activity involvement and interest. Provide activities calendar, assist resident to activities functions as needed. Risk for falls: FOCUS states the resident is at risk for falls related to (left blank) Interventions: bed locked and in lowered position, beside table within reach, encourage the resident to wear their glasses when out of bed, lab or diagnostics per physician, placed common items within reach of the resident, refer to therapy for screening, remind the resident to use their call light to ask for assistance with ADLS. Resident #52 is required a best care stander for transfers to and from his power wheelchair. There are no interventions relating to these items. The resident was admitted on [DATE]. The care plan should have been updated to be resident centered. An interview with the Director of Nursing (DON) on 03/11/25 at 4:08 PM confirmed Resident #52's care plan should have been updated. b) Resident #293 On 03/03/25 at 1:30 PM the record review showed Resident #293 had a medical diagnosis of Post Traumatic Stress Disorder (PTSD) and was on Venlafaxine HCL 225 mg (milligram) one time a day for PTSD. On 03/10/25 at 10:50 AM review of Resident #293's care plan found the following Focus areas were not resident centered. Risk for falls: Focus states the resident is at risk for falls related to: . (left blank) Interventions: are generic and not resident centered. Footwear to prevent slipping, gripper socks, therapy for screening, use their call light for assistance, bedside table within reach. Activities: FOCUS The resident prefers to participate in activities such as . (left blank) Interventions: Interview the resident and family as needed to determine the resident's prior level of activity involvement and interest. Provide activities calendar, assist resident to activities functions as needed. History of trauma: Focus the resident reported trauma during their trauma screening related to a history of military combat, PTSD. Interventions: Attempt to determine any triggers that the resident may have related to their past trauma and work with staff to avoid those when possible, trauma screen as indicated. HOSPICE Resident is admitted to hospice services with expected decline in condition due to terminal progressive disease related to protein calorie malnutrition. There are no specific interventions relating to hospice visits, assessments, care, etc. It is not resident centered, only states see hospice POC. The resident was admitted on [DATE]. He is on medication for PTSD, which is not addressed on the care plan, triggers have not been identified. The care plan should have been updated to be resident centered. An interview with the DON on 03/11/25 at 4:08 PM confirmed Resident #293's care plan needed to be updated. c) Resident #74 On 03/04/25 at 1:35 PM record review of Resident #74s care plan found the following areas were not resident centered. Risk for falls: Focus the resident is at risk for falls related to: (left blank) Interventions: lab or diagnostics per physician, refer to therapy for screening Nutritional status: Focus: The resident is at risk for weight loss, malnutrition or poor hydration status related to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, PI injury to left heel, PI stage 2, a-fib, anemia, hypokalemia, gastrointestinal hemorrhage, and GERD w/o esophagitis. Intervention: two cal supplement 90 ml BID (Resident has an additional order for Two Cal two times a day for supplement 90 ml which is missing under this focus) Activities: Focus the resident prefers to participate in activities that are individual or with 1-1 other. Interventions, interview the resident and family as needed to determine the resident's prior level of activity involvement and interest, Assist resident to activities as needed and provide 1-1 visits utilizing cats and reading, and pet therapy dogs. Assist to spend time outdoors. Risk for pain: Focus the resident has a risk for pain or pain related to chronic conditions. Interventions, administer pain medication as ordered, administer pain interview as indicated, attempt nonpharmacological interventions for pain such as repositioning, comfort therapy or passive ROM as tolerated, pain assessment as needed. (no mention of pain due to wound vac dressing changes) Enteral Feeding: Focus the resident is at risk for complications related to the need for an enteral tube feeding. Interventions: Osmolite 1.5 cal 237 ml after each meal with speficics listed, however resident was also on Two cal 90 ml twice a day which is not listed on this focus of the care plan. Feeding is according to the amount of her meals she eats and this was also not care planned. Skin impairment Focus: the resident has a skin impairment of pressure ulcer to coccyx. Interventions are not resident specific as they do not mention the wound vacuum nor the specifics related to that, no intervention to PICC IV, PEG tube, turn and reposition schedule, Resident #74 has an order for: Adaptive Equipment: Dayshift: [NAME] at beginning of shift and doff at end of shift. Edema glove on RUE and Resting hand splints on both hand with skin integrity check. Store splints and edema glove on in top drawer of dresser. No care plan in place for these pieces of equipment. An interview with the DON on 03/11/25 at 4:08 PM confirmed Resident #74's care plan needed to be updated. d) Resident #43 On 03/03/25 at 12:35 PM observation found Resident #43 to have apraxia causing him to be unable to verbally communicate. He can understand questions and shakes his head yes or no. He has a white dry erase board on his nightstand. On 03/10/25 at 10:25 AM review of Resident #43's care plan found the following Focus areas were not resident centered. Activities: Focus states the resident prefers to participate in activities such as individual and with one other person. Interventions: are generic and not resident centered. Assist resident to activities functions as needed providing direction to the location, interview the resident and family as needed to determine the resident's prior level of activity involvement and interest, Provide activities calendar and check to see about puzzle needs. Communication: the resident has risk for complications related to impairment of communication due to a history of cerebrovascular disease (CVA) the resident is rarely to never understood. Interventions: anticipate needs as able, ask the resident yes no questions, observe resident for nonverbal clues that may indicate a care need as able. The resident was admitted on [DATE]. There were no interventions specific for his whiteboard for communicating. The care plan should have been updated to be resident centered. An interview with the DON on 03/11/25 at 4:08 PM confirmed Resident #43's care plan needed to be updated. E) Resident #60 Activities Based upon record review and staff interview, the facility failed to complete a Care Plan personalized for Resident #60's preferred activities. The Care plan stated, ACTIVITIES: the resident prefers to participate in activities such as The sentence in the Care Plan was incomplete. The care plan is not personalized with any resident preferences, or examples. On 03/11/25 at 1:47 PM, an interview with the Director of Nursing (DON) was held, and the Care Plan for Resident #60 was reviewed. When asked about personal preferences for activities for Resident #60, DON responded, Yes, we seem to have a problem with these. (These, referring to Care Plans.) f) Resident #64 A review of Resident #64's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the Interim Assistant Director of Nursing (IADON) confirmed there were no activities care planned for Resident #64. She stated, I'll let her know. G) Resident #85 A review of Resident #85's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the IADON confirmed there were no activities were care planned for Resident #85. She stated, I'll let her know. h) Resident #342 A review of Resident #342's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the Interim Assistant Director of Nursing (IADON) confirmed there were no activities care planned for Resident #342. She stated, I'll let her know. i) Resident #16 Review of Resident #16's diagnoses list showed the resident had diagnoses of depression and anxiety disorder. Review of Resident #16's physician's orders showed the resident had an order for the following medications: buspirone for anxiety disorder, trazodone for depression, and duloxetine for depression. Resident #16 also had the following physician's orders: - Anti-Depressant - Monitor behavior of: (1) Sadness; (2) Tearfulness; (3) Withdrawn. Non-Pharmacological Intervention Codes: (1) Encourage Activities; (2) 1:1; (3) Encourage to verbalize feelings; (4) other-chart in progress notes. Document A) Behavior Code; B) Non-Pharmacological Intervention Code; C) Non-Pharmacological Outcome Code. - Anti-Anxiety - Monitor behavior of: (1) Restless; (2) Agitated; (3) uncontrollable feeling of worry. Non-Pharmacological Intervention Codes: (1) redirect; (2) 1:1; (3) activities; (4) toilet; (5) give food or fluids; (6) reposition; (7) back rub; (8) other-chart in progress notes. - Monitor for side effects of Anti-Depressant medication: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity(skin), excess weight gain If side effects observed, enter a progress note, every shift. - Monitor side effects of antianxiety medication: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, and skin rash. If side effect observed, enter a progress note, behaviors and side-effects monitored every shift. Resident #16's comprehensive care plan had the following focus initiated on 02/18/25, Psychoactive medications: the resident is at risk for complications related to psychoactive (antidepressant, anxiolytic) medications use secondary to diagnoses of: anxiety disorder, depressive disorder. The goal was, The resident will not have adverse reactions to psychoactive medication thru [sic] review period. The interventions were as follows: - Administer medications as ordered - Monitor for behaviors related to medication use - Observe for signs and symptoms of adverse side effects related to medication use and notify MD as indicated On 03/11/25 at 8:40 AM, Assistant Director of Nursing #165 confirmed Resident #16's comprehensive care plan did not contain information regarding the resident's specific signs and symptoms of anxiety and depression nor specific non-pharmacological interventions effective for managing the resident's symptoms. No further information was provided through the completion of the survey. 39043 e) Resident #60 Activities Based upon record review and staff interview, the facility failed to complete a Care Plan personalized for Resident #60's preferred activities. The Care plan stated, ACTIVITIES: the resident prefers to participate in activities such as The sentence in the Care Plan was incomplete. The care plan is not personalized with any resident preferences, or examples. On 03/11/25 at 1:47 PM, an interview with the Director of Nursing (DON) was held, and the Care Plan for Resident #60 was reviewed. When asked about personal preferences for activities for Resident #60, DON responded, Yes, we seem to have a problem with these. (These, referring to Care Plans.) f) Resident #64 A review of Resident #64's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the Interim Assistant Director of Nursing (IADON) confirmed there were no activities care planned for Resident #64. She stated, I'll let her know. G) Resident #85 A review of Resident #85's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the IADON confirmed there were no activities were care planned for Resident #85. She stated, I'll let her know. h) Resident #342 A review of Resident #342's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the Interim Assistant Director of Nursing (IADON) confirmed there were no activities care planned for Resident #342. She stated, I'll let her know. 51553 i) Resident #16 Review of Resident #16's diagnoses list showed the resident had diagnoses of depression and anxiety disorder. Review of Resident #16's physician's orders showed the resident had an order for the following medications: buspirone for anxiety disorder, trazodone for depression, and duloxetine for depression. Resident #16 also had the following physician's orders: - Anti-Depressant - Monitor behavior of: (1) Sadness; (2) Tearfulness; (3) Withdrawn. Non-Pharmacological Intervention Codes: (1) Encourage Activities; (2) 1:1; (3) Encourage to verbalize feelings; (4) other-chart in progress notes. Document A) Behavior Code; B) Non-Pharmacological Intervention Code; C) Non-Pharmacological Outcome Code. - Anti-Anxiety - Monitor behavior of: (1) Restless; (2) Agitated; (3) uncontrollable feeling of worry. Non-Pharmacological Intervention Codes: (1) redirect; (2) 1:1; (3) activities; (4) toilet; (5) give food or fluids; (6) reposition; (7) back rub; (8) other-chart in progress notes. - Monitor for side effects of Anti-Depressant medication: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity(skin), excess weight gain If side effects observed, enter a progress note, every shift. - Monitor side effects of antianxiety medication: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, and skin rash. If side effect observed, enter a progress note, behaviors and side-effects monitored every shift. Resident #16's comprehensive care plan had the following focus initiated on 02/18/25, Psychoactive medications: the resident is at risk for complications related to psychoactive (antidepressant, anxiolytic) medications use secondary to diagnoses of: anxiety disorder, depressive disorder. The goal was, The resident will not have adverse reactions to psychoactive medication thru [sic] review period. The interventions were as follows: - Administer medications as ordered - Monitor for behaviors related to medication use - Observe for signs and symptoms of adverse side effects related to medication use and notify MD as indicated On 03/11/25 at 8:40 AM, Assistant Director of Nursing #165 confirmed Resident #16's comprehensive care plan did not contain information regarding the resident's specific signs and symptoms of anxiety and depression nor specific non-pharmacological interventions effective for managing the resident's symptoms. No further information was provided through the completion of the survey. 51554

Based on observation, record review, policy review, review of information from the National Pressure Ulcer Advisory Panel, The Resident Assessment Instrument Manual, and the Wound Ostomy and Continence Nurses Society, and staff interview, the facility failed to ensure that a resident admitted with impaired skin integrity and identified to be at risk for the development of pressure ulcers, received the necessary preventative treatment and/or services to prevent the development of a pressure ulcer. In addition, the nurse failed to maintain aseptic technique during wound care, creating a potential for cross contamination and infection when performing wound care. This practice was found for one (1) of three (3) Stage 2 sample residents reviewed for pressure ulcers during the Quality Indicator Survey (QIS). Resident #106. Facility census: 87. Findings include: a) Resident #106 Review of the resident's medical record on 09/23/15 at 12:30 p.m., revealed Resident #106 had a healing Stage III pressure ulcer to her coccyx and was being treated by the wound clinic every two (2) weeks. Her [DIAGNOSES REDACTED]. Her initial admitting nursing assessment, dated 05/02/15 at 2:05 a.m., identified a reddened coccyx. On 05/17/15 a Stage II pressure ulcer, measuring 2.5 centimeters (cm) by 2.0 cm by 0.1 cm with necrotic tissue was identified on the resident's coccyx. Resident #106 required visits to an out of State wound care clinic for treatment. Between the dates of 06/26/15 and 07/15/15, the coccyx wound had debridement performed by the wound clinic and the wound was upgraded to a Stage III. (Note: according to pressure ulcer staging definitions from the National Pressure Ulcer Advisory Council, the Resident Assessment Instrument Manual, and the Wound Ostomy and Continenct Nurses Society, once the wound developed necrotic tissue, it had progressed beyond a Stage II pressure ulcer. A pressure ulcer does not display necrotic tissue until at least Stage III. If the wound bed was not visible, the would should have been identified as unstageable due to slough/eschar.) Documentation in the nursing progress notes dated 05/02/15, revealed Resident #106 had occasional incontinence, a reddened coccyx, and occasionally slid down in the bed/chair. The notes also said the resident was occasionally moist requiring an extra linen change once a day, required one (1) aide to assist her for bed mobility to position her extremities and trunk every 2 hours, required two (2) aides to assist to transfer, toileting, and to provide personal hygiene. She could make frequent, though slight changes in body/extremity, but could not make frequent/significant position changes alone. The 5-day Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/14/15, identified in Section M, Item M0150 that the resident was at risk of developing pressure ulcers. The care plan revealed no individualized measurable goals or established interventions to meet the immediate needs of the resident at the time of admission for the identified reddened coccyx. The care plan lacked any interventions for the prevention of pressure ulcers for this resident who was assessed as being at risk for the development of pressure ulcers. During an observation on 09/29/15 at 2:10 p.m., Licensed Practical Nurse (LPN) #148 provided wound care. The LPN obtained supplies from the treatment cart and placed them on the bedside stand. She then proceeded to wash her hands and donned gloves. LPN #148 assisted Resident #106 to hold onto the siderail, then assisted the resident in positioning on her left side and pulled her brief and pants down revealing an unlabeled (no date, time or initials as per facility policy) border dressing to the coccyx area. The LPN proceeded to remove the coccyx dressing and disposed of it in the trash can. The exposed coccyx wound was an open area without drainage with pink surrounding tissue. With the same gloves, the LPN removed a four by four (4 x 4) from the package and sprayed wound cleanser onto the 4 x 4, then placed the entire 4 x 4 over the wound and surrounding skin area. The nurse rubbed the wound and surrounding skin area in a circular motion, but not cleansing the wound from inward to outward. She then disposed of the 4 x 4 in the trash can and dried the wound area with a new 4 x 4 in the same manner. Again, without changing gloves and/or performing hand hygiene LPN #148 proceeded to apply medicated ointment which she related was silver alginate to the wound bed. A border dressing was then applied over the coccyx area. She did not label or date the new dressing as directed by the facility's policy. On 09/29/15 at 2:20 p.m., an interview was conducted with the son of Resident #106. He commented, his Mother was admitted to the facility with a bedsore, but it was healing now. At 2:25 p.m. on 09/29/15, during an interview LPN #148, with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) present, LPN #148 stated, No I did not wash my hands and change my gloves after removing the old dressing and before applying the new wound dressing. LPN #148 further stated, I guess I didn't cleanse the wound inward to outward in a circular motion since you are asking. Yes, I did just put the 4 x 4 on the wound and go around in a circle, not inward to outward. The LPN acknowledged she created a potential for cross contamination when performing wound care and it posed a potential for introducing bacteria into the wound. The nurse also confirmed that not performing hand hygiene and changing her gloves presented an infection control issue. The DON commented the LPN was just nervous with being observed and was not used to doing the wound care on this resident. Also during the interview with LPN#148, the Assistant Director of Nursing, and the Director of Nursing, copies of Resident #106's wound sheets, care plan, skin assessment sheets, wound clinic notes, wound care procedure/policy, and skin care policy, evidence of pressure prevention measures in place since admission and nurse aide (NA) documentation of repositioning and application of barrier cream after incontinence care were requested. No additional information was provided. During an interview with LPN #148 on 09/29/15 at 2:35 p.m., she commented Resident #106 came in with her pressure ulcer. I think her pressure ulcer progressed to a Stage 3 pressure ulcer on 05/19/15, after wound debridement at the wound clinic. The LPN displayed computer documentation of wound measurements dated 05/17/15 of 2.5 cm (centimeter) x (by) 2.0 cm x 1.0 cm, and the latest measurements dated 09/27/15 of 0.5 cm x 0.2 cm x < (less than) 0.3 cm, showing evidence of wound healing. She commented the resident went to the wound clinic about every two (2) weeks for evaluation and treatment of [REDACTED]. At 3:10 p.m. on 09/29/15, during an interview with Resident #106, she commented that she was not sure if she was repositioned every 2 hours, but when asked, said the staff got her up or assisted with repositioning. Resident #106 stated, I can't do much for myself and have to have help turning over in bed or going to the bathroom. During an interview with Registered Nurse (RN) Supervisor #145 on 09/30/15 at 8:30 a.m., she stated, When she (Resident #106) came in, she was only about 80 pounds and did not have a lot of fat on her body. Her wound went from a Stage II to a Stage III after it was debrided. She had barrier cream and side rails so she could turn herself. She did need assistance to turn, but could move herself some. Her interventions on admission were a waffle cushion for her wheelchair, barrier cream and side rails, no speciality mattress was in place, I thought I ordered one for her. RN #145 did not respond when asked if Resident #106 was admitted with a PU, or if her PU could have been avoided with appropriate interventions. Althought requested, no further documentation of skin assessments was provided. During an interview with the Assistant Director of Nursing (ADON) on 09/30/15 at 9:10 a.m., she verified the care plan did not make any reference to Resident #106's reddened coccyx on admission, nor did it establish any goals or interventions to prevent further breakdown or development of a pressure ulcer. She commented, the resident did require one (1) or more assist with bed mobility depending on her mood - that some days she would do more for herself and on other days she needed more assistance. The ADON stated, Skin assessments are done weekly and I will look for some documentation for her skin assessments, but I can't promise that I can find anything. Employee #400 stated in a confidential interview, She was admitted with a reddened coccyx and we dropped the ball because she did develop an avoidable pressure ulcer . They are just going to try and fool you by not giving you what you are asking for and hope you are dumb enough to believe what they say. She was not turned and repositioned like she was supposed to be when she was admitted and she did not have one of the egg crate mattresses until Tuesday morning, when they were afraid you might look after you asked to see her wound care. Which they were glad they did when you did look after you heard about the eggcrate mattress. Once she got the pressure ulcer, then they put interventions in place but nothing was done to prevent it. You are not going to get skin assessments because they were not done. An interview was requested by the DON on 09/30/15 at 10:00 a.m., with herself and the Nursing Home Administrator (NHA). The DON stated, the nursing admission documentation was incorrect because the resident did not have a reddened coccyx on admission, if that is what you are basing this investigation on . Also she had heel protectors and side rails for prevention of a pressure ulcers. The DON further commented, the resident was turned every two (2) hours and provided barrier cream. She stated, All of our beds in the facility have a mattress with an egg crate inside to prevent heel pressure areas. The DON did not reply to the questions of, was there a second nursing progress note stating the initial admission assessment of a reddened coccyx was incorrect and how did the resident develop a Stage II pressure ulcer fifteen (15) days after her admission to the facility. The surveyor explained the only physician's orders [REDACTED]. When asked for evidence showing the resident was, and is, repositioned every two (2) hours and that barrier cream was applied after incontinence care as she stated, the DON stated, It is not documented, they just do it. During an interview with Nurse Manager #110, on 09/30/15 at 10:30 a.m., she stated, Yes, there are mattresses with egg crates in the facility and also low air loss mattresses in the facility for the residents who have, or are at high risk for developing pressure ulcers, which requires a physician order. On 09/30/15 at 11:24 a.m., the DON provided a copy of a letter from Resident #106's attending Physician dated 09/30/15, faxed at 11:22 a.m. on 09/30/15. The letter was in regard to the pressure ulcer stating, noted to be present on (Resident #106's name) on 05/17/15, the ulcer could not have been prevented, in my professional opinion. including complete inability to ambulate due to familial spastic [MEDICAL CONDITION] (wheelchair dependent), urinary incontinence and extreme urinary frequency, along with recurrent vaginitis leading to frequent micro-abrasions from constant perineal cleaning/hygiene. During the interview (the interview was in the conference room with all surveyors present) the DON stated, If you are concerned about since her admitted , I can have him change the date on the letter so it says it is from her admitted , or whatever you want it to say. This surveyor declined to receive another letter with the date changed. A review of the facility's Skin Care Policy on 09/30/15 at 11:36 a.m. found it included, . 2. Skin Assessment will be done: B. Assessment and documentation in the 'skin folder' every shift for 72 hours after admission/readmission. C. q (every) week x (times) 4 after 72 hours assessment (Braden Scale). (The Braden Scale is a tool to predict the individual's risk of developing pressure ulcers.) Review of the facility's wound care procedure on 09/30/15 at 11:40 a.m., revealed Steps in the Procedure, 13. Put on exam glove. Loosen tape and remove dressing. 14. Pull glove over dressing and discard into appropriate receptacle. Wash hands. 15. Put on disposable gloves 22. Dress wound. Pick up sponge with paper and apply directly to area. Mark tape with initials, time, and date and apply to dressing. During the survey, these requested items were not provided: wound sheets, skin assessment sheets, wound clinic notes, evidence of pressure ulcer prevention measures in place since admission and nurse aide (NA) documentation of repositioning and application of barrier cream after incontinence care. Numerous observations of Resident #106 throughout the survey found her up in her recliner in her room, in her bed, or in wheelchair. The staff appeared to be adhering to the care plan interventions of repositioning the resident every two (2) hours and were overheard to be encouraging the resident to shift her weight in the wheelchair. In addition, the pressure ulcer began to heal once appropriate interventions and treatment were initiated after the pressure ulcer was identified on 05/17/15.

Based on record review and staff interview, the facility failed, for one (1) of thirty-six (36) Stage II sample residents, to provide care and services to prevent the development of pressure ulcers for a resident who entered the facility without pressure ulcers, but who was at risk of developing pressure ulcers. Resident #109 was admitted to the facility following hospitalization and surgery for [REDACTED]. This incorrect assessment delayed implementation of care to the areas which resulted in the development of Stage II pressure sores. These Stage II pressure sores subsequently worsened to Stage III pressure sores. Resident identifier: #109. Facility census: 90. Findings include: a) Resident #109 When reviewed on 01/31/11, the medical record for Resident #109 divulged this [AGE] year old male was admitted to the facility from an acute care hospital on [DATE], following surgery for [REDACTED]. Review of the "discharge summary" received at the facility from the acute care hospital revealed, under "Discharge Disposition", "We will have the patient up with assistance, weight bearing as tolerated, decubitus precautions up in chair at bedside, QPI's (unknown abbreviation) off bed and abduction pillows at all times." The resident's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 12/29/10, stated in the areas of "Functional Status" that the resident required the extensive physical assistance of two (2) or more persons for bed mobility and transferring to/from bed, chair, wheelchair, standing position. The resident had no ability to reposition himself. A nursing assessment completed on the day admission to the facility (dated 12/22/10 at 7:12 p.m.), stated the resident "has had no foot problems or care in past seven (7) days." The resident's physician orders, when reviewed, disclosed orders for no pressure ulcer treatment or preventive measures at the time of admission. A nursing assessment entry, dated on 01/02/11 at 11:06 a.m., described the resident as having "2-1/2 cm intact water blister to right heel. 3 cm intact water blister to left heel with slight purple discoloration." This entry further stated, "Partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stg. 2)." This description was noted to apply to both the left and the right heel. Review of the resident's care plan disclosed no mention of pressure ulcers or pressure ulcer prevention was mentioned on the initial plan of care. However, fourteen (14) days after admission (on 01/05/11), a member of the interdisciplinary team added as a problem statement: "Stage II pressure areas to heels, Potential for further skin breakdown." (A Stage II pressure sore is described, by the National Pressure Ulcer Advisory Panel (NPUAP) at www.npuap.org, as a "partial thickness of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister.") Interventions associated with this new problem statement included: "1. Assist with turning/reposition; elevate resident's heels off of bed, heel protectors in bed. 2. Air mattress to bed, check functioning q (every) shift. 3. Administer nutritional supplements as ordered. 4. Monitor / report changes in pressure areas, e.g.: s/s (signs or symptoms) of infection, increasing depth, size, etc." A nursing assessment entry, dated 01/16/11, described the resident's pressure ulcers in this manner: Location: left heel Full thickness of skin lost, exposing the SubQ (subcutaneous) tissues-presents as a deep crater (Pressure Stg. 3). (A Stage III pressure sore is described by the NPUAP as a "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. May include undermining and tunneling.") Tissue type: 0.5 cm necrotic area to left heel. Wound tissue: reddened Drainage: None present Length 4 Surrounding Tissue: white. Healing progress: Worsening Location: right heel Full thickness of skin lost, exposing the SubQ (subcutaneous) tissues-presents as a deep crater (Pressure Stg. 3). Length: 4/5cm in diameter Surface area: 0.7 - 1.0 cm sq. Depth: 0.1cm Wound tissue: reddened Tissue type: granulation tissue Drainage: light odorous Surrounding tissue: white Healing progress: Worsening A facility nurse (Employee #135), when interviewed on 02/01/11 at approximately 10:00 a.m., was asked why this skin breakdown was not recognized prior to progressing to Stage II. Another facility nurse (Employee #139) presented a written document, which identified as having been acquired from the hospital from where the resident had been discharged immediately preceding his admission to the nursing home. Employee #139 stated the information had been received upon request by the facility on the previous evening (01/31/11). This document included an evaluation of the resident dated 12/22/10 at 7:50 a.m., which noted "patient heels pink and spongy bilat (bilaterally)". The resident had been first assessed at the nursing home at 7:12 p.m. on 12/22/10, at which time the nursing assessment stated the resident "has had no foot problems or care in past seven (7) days." Employee #135 confirmed, on 02/01/11 at 10:00 a.m., that the resident's skin condition had been inaccurately assessed by the facility nurse at the time of his admission to the nursing home at 7:12 p.m. on 12/22/11. This inaccurate assessment resulted in a delay in the care and treatment of [REDACTED]. Nursing documentation over the next thirty (30) days confirmed a worsening in the condition of the resident's heels, which subsequently deteriorated from Stage II to Stage III pressure sores. .