Every finding on record at East Carolina Health and Rehabilitation Center

Based on observation and interviews with staff, residents, and a family member, the facility failed to ensure linens were available for 4 of 4 residents who were interviewed or their family member was interviewed regarding linens (Residents # 9, # 10, # 11, and # 12).The findings included:a. Record review revealed Resident # 9 was last admitted on [DATE] and a readmission Minimum Data Set (MDS) assessment, dated 4/12/26, coded Resident # 9 as cognitively intact. Resident # 9 was interviewed on 5/12/26 at 10:35 AM and again on 5/14/26 at 8:42 AM and reported the following. Within the last two to three weeks, her bed linens needed to be changed because she had gotten jelly on the linens during breakfast. The staff did not have any bed linens to change them, and she had to wait for them to be replaced until later that night. Resident #9 indicated obtaining washcloths and towels was also a problem. She had watched the nurse aides cut up towels to make washcloths and therefore she purchased her own towels or washcloths for personal use.b. Record review revealed Resident # 10 was admitted to the facility on [DATE] and her last quarterly MDS assessment, dated 3/29/26, coded the resident as moderately cognitively impaired. Resident # 10 was interviewed on 5/12/26 at 11:15 AM and reported that linens were an everyday problem and that the staff did not have towels. She was wanting linens for a bath and hygiene purposes. During a follow up interview on 5/12/26 at 12:07 PM, Resident # 10 reported she had incontinence care that morning and was pleased with that but wished to have a bath. According to Resident # 10, because of linens not being available, the staff could only provide incontinence care and not a full bath that morning. The resident reported a lack of linens had been a problem for awhile.c. Record review revealed Resident # 11 was admitted to the facility on [DATE] and a Social Worker's note, dated 5/5/26, noted Resident # 11 was alert and oriented. Resident # 11 was observed to have a dirty pillowcase on 5/12/26 at 12:01 PM and was interviewed. He reported linens were a problem and that there had been no washcloths or towels that morning. Resident # 11 indicated he had kept a used washcloth from yesterday, let it dry out, and used it that morning to wash his face. Resident # 11 reported a lack of linens tended to happen every other week but did not specify when the linen problem started.d. On 5/12/26 at 12:25 PM an interview was conducted with a Family Member of Resident # 12 who reported she had noticed there would be the same food stains on the bed sheets from day to day. The family member did not specify that she had reported the problem to anyone or how long the problem had been occurring.Nurse Aide (NA) # 4 was interviewed on 5/12/26 at 11:31 AM about linens and reported the following information. She routinely went to the linen room to obtain linens in the morning to place on her linen cart. NA #4 indicated there were no towels or washcloths when she arrived for work that morning in the linen room to place on her linen cart. A few of her assigned residents had linens in their rooms and she used those, but not all her residents had linens. Therefore, she just had to wait until linens were available. NA # 4 pointed to rooms on her assignments that had unmade beds and said she was unable to make beds because there were no sheets. She further reported they had been told that one of the dryers had been broken but there had been a problem with having enough linens for a long time. It was observed at the time of the interview with NA # 4 that there were no linens on her linen cart.NA # 5 was interviewed on 5/12/26 at 11:35 AM and reported the following information. She had been working at the facility for about a month and having enough linens had always been a problem. Since 7:00 AM that morning she had not had any washcloths or towels and therefore she had been cleaning residents' faces with incontinence wipes. She also could not find bed sheets. NA #5 indicated someone had said the dryer was broken. Problems with having enough linens had been a problem in the past and the problem had been reported. NA # 5 did not specify to whom the problem had been reported. The staff would be told to use what they had. NA # 5 did not specify who told staff this. During a follow up interview with NA # 5 on 5/12/26 at 11:45 AM, NA # 5 reported that she knew Resident # 10 was wanting a bath, but she could not bathe her without the linens.NA # 6 was interviewed on 5/12/26 at 11:55 AM and reported the following information. She had not had washcloths or towels since 7:00 AM that morning. NA #6 indicated there had been one or two residents who had some washcloths or towels in their drawers and she had used those. Some of her residents were independent and she was unsure what they were doing. If push came to shove she would use the incontinence wipes but some of the residents did not like incontinence wipes on their face. NA #6 stated she had worked for six months at the facility and having enough linens had always been a problem. The previous day one of the nurses had said something to her about unmade beds but she had not had linens to make the beds. The issue of not having sufficient linens had been reported because they had meetings and the issue was brought up. NA # 6 did not specify which staff attended the meetings or specific details of the linen discussion.NA # 7 was interviewed on 5/12/26 at 12:20 PM and reported she had six washcloths and six towels when she started her shift that morning and she was responsible for providing care to eight residents. NA # 7 did not specify that she had reported a problem with having less linens than the number of assigned residents.NA # 8 was interviewed on 5/12/26 at 12:22 PM and reported the following information. She had worked at the facility for seven months and having enough linens had been a problem for all that time. She did not have washcloths and towels when she started to work that morning and still did not. She was waiting until the facility got some or was using incontinence wipes for baths. NA # 8 did not specify if she had told anyone while she was waiting for linens that there was a problem.NA # 9 was interviewed the following day on 5/13/26 at 8:10 AM and showed the surveyor that she had seven washcloths, no towels, no sheets, and no pillowcases on her linen cart at that time. NA #9 reported that when she first arrived there were not even seven washcloths, but someone had put out seven washcloths between 7:00 AM and 8:10 AM. While interviewing NA # 9, the Assistant Director of Nursing (ADON) was observed to approach the cart and put a small stack of towels on the linen cart.NA # 5 was interviewed on 5/13/26 at 8:12 AM and showed the surveyor her linen cart which was observed to have cut up towels for washcloths. NA # 5 reported she had to cut the towels in order to have washcloths because there had been no washcloths or towels when she arrived at 7:00 AM.During an interview with NA # 10 on 5/13/26 at 10:15 AM, NA # 10 reported the following information. She only worked on an as needed basis at the facility, and she did not like to work at the facility specifically because of the linen problem. She would have to scavenge around in rooms to find linens. It had been a daily problem for months finding linens. NA # 10 indicated she would get wet wipes run them under hot water and then use them as washcloths when there were none. A nurse once instructed her to use a pillowcase to clean someone, but she did not want to do that and therefore sometimes she cut up towels. NA # 10 did not specify how the problem had been reported or that she had done so herself but reported that both the Administrator and the Director of Nursing (DON) knew. NA # 10 did not specify how the Administrator and DON had known. On 5/12/26 at 12:09 PM a linen cart on the 400 hall was observed with no towels or washcloths. Another linen cart located on the 400 hall was observed to have no towels or washcloths on 5/12/26 at 12:10 PM. On 5/12/26 at 12:17 PM there were three linen carts in a cubby hall near an exit on the 200 hall and there were no washcloths and towels.Laundry Employee # 1 was interviewed on 5/12/26 at 11:40 AM and it was observed at that time that there were no linens in the linen room. Laundry Employee # 1 reported that one of the dryers was broken and she could not dry all the linens that needed to be dried. Laundry Employee # 1 reported that the dryer had been working when she left the previous day at 2:00 PM but was not working when she returned that morning (on 5/12/26). The Rehabilitation (Rehab) Director was interviewed on 5/14/26 at 12:50 PM regarding whether the therapists had enough linens to work with rehab residents on performing their activities of daily living. The Rehab Director reported having sufficient linens was a problem and at times an occupational therapy session had to be moved or rescheduled to a later time until linens could be obtained. At those times, the therapists would not be able to find linens on the carts, and they would go to the linen room where sometimes there were none there either. The Rehab Director indicated this happened about twice per week. The Rehab Director did not specify how long this had been an issue. She (the Rehabilitation Director) had not reported the issue directly to the Administrator but stated she knew that the Administrator had been told about the issue.On 5/14/26 at 1:30 PM, the Director of Nursing (DON) was interviewed and reported that she thought someone had said there was a problem with the dryer the previous week, and that may have contributed to some linen problems, but she had not been aware of any continuous problems. The DON indicated if the staff had let her know that there was a problem with having towels or washcloths, then she would have purchased some herself to meet any immediate needs.On 5/12/26 at 11:45 AM the Administrator was notified regarding some of the staff's comments and observations about a lack of linens. The Administrator reported that no one had reported a problem to him so that he was aware, and he had made rounds that morning.During a follow up interview with the Administrator and the Corporate Nurse Consultant on 5/12/26 at 5:30 PM, the Administrator and the Corporate Nurse Consultant indicated they had not been aware of on-going linen problems. The Administrator reported that periodically they checked all rooms for hoarded linens to see if unused linens were placed in drawers rather than being placed back in circulation to avoid problems with linen availability.On 5/13/26 at 8:40 AM the Corporate Nurse Consultant reported that they received a shipment of linens that morning that staff were putting out. The Corporate Nurse Consultant also reported that the Environmental Services Manager had suddenly quit and that the Maintenance Director was filling in for this position.The Maintenance Director was interviewed on 5/14/26 at 3:20 PM and reported the following information. He used to order linens and then the Environmental Services Manger took over ordering around December 2025. About two months ago, the Environmental Services Manger went on a leave of absence and had ordered linens right before her leave. This was the last time linens were ordered. The Maintenance Director indicated they just found out during the current week that the Environmental Services Manger would not be returning. When he used to order linens, he ordered monthly linens along with other supplies and chemicals. During the current week, one of the dryers had been broken for about three days and it took some time to get a repairman in to fix it. They were currently in the facility working on the dryer. The Maintenance Director stated typically, the facility kept linens in back up for times like that, but the backup supply had been depleted when the Environmental Services Manger had been out on leave. When he was ordering in past times, he typically liked to keep a backup supply of the following: 12 to 24 dozen washcloths, 6 to 7 dozen towels and a couple dozen of other linens. The Maintenance Director further reported he had ordered linens the week before last but they had not arrived. Currently while the dryer was broken, a sister facility had been trying to help with the drying of the linens.On 5/14/26 the Administrator had a personal emergency which required his absence and he was not available for further interview on 5/14/26 following the Maintenance Director's interview.

Based on record review and interviews with staff, Responsible Party (RP), Physicians, and Wound Nurse Practitioner, the facility failed to obtain supplies and implement the Wound Nurse Practitioner's treatment plan for a resident with a pressure sore. This was for 1 of 3 sampled residents reviewed for pressure sores (Resident # 4).The findings included:Record review revealed Resident # 4 was admitted to the facility on [DATE] and had diagnoses which included a history of surgery and radiation treatment for a brain tumor in 2015 which resulted in aphasia (inability to speak) and quadriparesis (muscle weakness in arms and legs.) Additionally, Resident # 4 had diagnoses of seizure disorder, hypertension, dysphagia (trouble swallowing), and gastrostomy placement (a tube inserted into the stomach for liquid nutrition to be given).Review of Resident # 4's care plan, last updated on 4/20/26, revealed staff identified Resident # 4 was at risk for pressure sores due to decreased mobility, incontinence, and being dependent on staff for positioning. This had been added to the care plan on 5/4/21 and remained part of the resident's active care plan. Although not all inclusive of interventions, the care plan noted Resident # 4 required a low air loss pressure relieving mattress on the bed to promote skin integrity.On 4/17/26 at 6:20 PM the facility Wound Nurse entered a nursing note that Resident # 4's Responsible Party (RP) had talked to her about a concern regarding a scab on the resident's foot. She (the facility Wound Nurse) had looked at the area and there was no need for treatment.The facility Wound Nurse was interviewed on 5/13/26 at 10:51 AM and reported the following information. Resident # 4's RP was present on 4/17/26 and had been concerned about an area on the resident's foot that was scar tissue. It was not an active wound. She (the Wound Nurse) had looked at Resident # 4's skin that day and saw no signs of open wounds on any part of her body. The resident's air mattress was working when she was in the room and was routinely checked by the nurses to make sure it was operating properly.Resident # 4's RP was interviewed on 5/13/26 at 11:29 AM and reported the following information. She had visited on both 4/17/26 and 4/18/26. On the afternoon of 4/18/26 Resident # 4's mattress seemed sunken in the middle of the bed. She mentioned it to Unit Manager # 1 who looked at it, performed some functions, and let her know it would take some time for the mattress to start to function completely again. She left that day but was called the following week and informed that Resident # 4 had a pressure sore. She was concerned the malfunctioning of the air mattress had contributed to the problem and the pressure sore had worsened in only a few short weeks.Unit Manager # 1 was interviewed on 5/13/26 at 2:58 PM and reported the following information. She recalled Resident # 4's RP mentioning the problem with the air mattress on 4/18/26. When she looked at it, the mattress was not totally deflated. She could still feel air in it. The electrical plug appeared to have come partially out of the wall socket and therefore she put it all the way back into the socket. After she did that, she could feel air start circulating. She checked the settings and she let the direct care nurses know to keep a check on it.Review of the manual for Resident # 4's low air loss mattress revealed the following information. The mattress had both air cylinders in conjunction with foam. On top of the air cells was a high-density foam coupled with a one-inch-thick gel infused memory foam layer. The mattress did not rely on air alone to provide pressure relief.On 4/19/26 at 11:38 PM Nurse # 4 entered the following information in a nursing note. Resident # 4 had a nickel size fluid filled blister present on her left buttock and one on her right buttock which had burst. Orders were obtained to cleanse the right buttock with wound cleanser, apply calcium alginate, and cover with border gauze. The left buttock was to be painted with betadine.Orders were entered on 4/19/26 into Resident #4's electronic medical record for the following: Clean the left buttock blister with wound cleanser and paint with betadine or skin prep every day. Clean the right buttock with wound cleanser and apply calcium alginate followed by a border gauze.Nurse # 4 was interviewed on 5/13/26 at 10:42 AM and reported the following information. On 4/19/26 a Nurse Aide had alerted her that something seemed wrong with Resident # 4's air mattress. She looked at it. It was not completely without air but seemed lower in the top to the middle when compared to the bottom. A maintenance employee was in the facility, and he worked on it twice. The second time he replaced the motor, and it was working. It was fully functional by 9:00 or 10:00 AM that morning after he worked on it.The Maintenance Employee was interviewed on 5/13/26 at 9:10 AM and validated he had worked on the air mattress and restored it to fully functioning order on 4/19/26. He had checked on it before he clocked out at 3:00 PM and it was continuing to work fine.On 4/20/26 at 5:35 PM the facility Wound Nurse entered a nursing entry noting the following information. Resident # 4 had a large MASD (moisture associated skin damage) area across her buttocks. Treatments were in place, the RP was notified, and the resident's air mattress was functioning properly.During an interview with the facility Wound Nurse on 5/13/26 at 10:51 AM the Wound Nurse reported the following information. When she assessed Resident # 4 on 4/20/26 her buttocks were dark and it appeared as if the skin had been sheared. She thought it might be moisture related but sent a photograph to the Wound Nurse Practitioner who reported the wound looked like a [NAME] Ulcer and to obtain labs to determine more about the resident's status. (A [NAME] Ulcer is rapid, unavoidable skin breakdown that often appears in the final weeks or days of life.)On 4/20/26 Resident # 4's care plan was updated to reflect that she had developed a wound to her right and left buttocks. Although not all inclusive, some of the interventions included referring the resident to the facility's Wound Physician and providing treatments per the treatment administration record.On 4/23/26 the Wound Nurse Practitioner (NP) documented she initially saw Resident # 4 and included the following information in her note. Resident # 4 had a pressure ulcer to her bilateral buttocks which measured 6.5 cm (centimeters) X 13 cm X 0 and was 60 % slough (unhealthy tissue in a wound bed) and 40 % granulation tissue (healthy tissue in a wound bed.) The Wound NP further noted, Patient presents with acute onset of bilateral ulcer in a butterfly distribution, first noted approximately three days ago (4/20/26) with rapid progression to eschar (dead tissue in a wound bed) formation. The wound's characteristics and accelerated deterioration are atypical for a standard pressure injury particularly given the patient's prior history of intact skin and low incident of wound development. While currently classified as an unstageable pressure injury, the sudden presentation raises concern for underlying systematic or perfusion related etiology. Recommend further medical evaluation to assess for contributing factor such as acute illness, vascular compromise, or end of life changes. The Wound NP further noted that the recommended plan should be to clean the wound with Dakin's solution and apply Calcium Alginate with Silver to the base of the wound. Then silicone bordered gauze should be applied. (Dakin's solution is an antiseptic used for wounds and helps prevent infection. The silver component of calcium alginate with silver has antimicrobial qualities.)The Wound NP's 4/23/26 recommendation was not entered as an order into Resident # 4's electronic medical record.Review of the record revealed the 4/23/26 wound treatment plan was not initiated. The previous orders, dated 4/19/26, remained in effect and the Treatment Administration Record (TAR) reflected the 4/19/26 treatment orders continued.On 4/27/26 a significant change Minimum Data Set assessment was completed. The assessment coded Resident # 4 as severely cognitively impaired, totally dependent on staff for bathing, hygiene, and turning in bed, incontinent of bowel and bladder, and as having an unstageable pressure sore.On 4/30/26 the Wound NP again documented she saw Resident # 4 and made the following notations. The pressure sore measured 5.5 cm X 14.5 cm X .4 cm and was 90 % slough and 10 % granulation tissue. She had debrided (the removal of dead or infected skin tissue from a wound to promote healing) 100 % of the wound. The Wound NP further noted that further clinical assessment and review of her labs indicated Resident # 4 was medically stable and without signs consistent with end-of-life skin failure. She (the Wound NP) had learned that the air mattress had been malfunctioning prior to the onset of the wound and given that information the wound was consistent with inadequate pressure offloading. The Wound NP also noted the treatment plan should be changed again to the following: Cleanse with [NAME] (a saline-based wound cleanser containing pure hypochlorous acid), apply Santyl and calcium alginate to the base of the wound and then secure a silicone bordered gauze over the wound. (Santyl is a chemical debriding agent utilized to remove unhealthy tissue while preserving healthy tissue).The Wound NP's 4/30/26 recommendation was not entered as an order into Resident # 4's electronic medical record.Review of the record revealed the Wound NP's 4/30/26 wound treatment plan was not initiated. The previous orders, dated 4/19/26, remained in effect and the TAR reflected the 4/19/26 treatment orders continued.On 5/4/26 the Wound NP again documented she saw Resident # 4. The Wound NP noted the following information. Resident # 4's pressure ulcer measured 5.5 cm X 13.5 cm X 1.2 cm with 90 % slough and 10 % granulation. She (the Wound NP) again debrided the wound. The treatment plan was the same as noted on 4/30/26.Review of the record revealed the Wound NP's 4/30/26 and 5/4/26 wound treatment plan was not initiated. The previous orders, dated 4/19/26, remained in effect and the TAR reflected the 4/19/26 treatment orders continued.The facility Wound Nurse was interviewed on 5/13/26 at 12:55 PM regarding why the Wound NP's treatment plan was not initiated and reported the following information. She (the Wound Nurse) enters the orders into a resident's electronic medical record after the Wound NP changes the plan, but she waits until she can obtain the supplies before she changes the order to the most recent plan. She had trouble getting the supplies for all the items which the Wound NP wanted in the treatment plan for Resident # 4, and therefore she did not enter the orders on 4/23/26, 4/30/26, or 5/4/26. There was a personal representative through their supplier who told her to quit coming to him directly. Some of the items ordered had just arrived the previous week and had not arrived in time for her to enter the orders. The facility's supply manager also had trouble obtaining items and she had to get the Director of Nursing involved. The Wound Nurse thought the Santyl came from the pharmacy. The Wound Nurse did not specify that she had consulted with the Wound NP about the facility's inability to obtain the recommended supplies.The Central Supply Manager was interviewed on 5/13/26 at 3:25 PM and reported the following information. She routinely ordered supplies once per week on Mondays and every staff member was aware of that. There were certain items which she could access online and order without having approval from the corporation's representative. For instance, she could order Dakin's solution without a corporate representative's approval. For some other items, there would be a notice that said access denied if she attempted to order and she must go through a corporate representative to get the request to go through. The Wound Cleanser [NAME] was an example of that. The corporate representative also must be able to see the order in the electronic system to know for whom the item was prescribed before they approved the order to be sent. She first received a request for Dakins on 4/30/26 and it was ordered on 5/4/26 (Monday) and sent on 5/5/26. She had never been requested to order calcium alginate with silver. The Central Supply Manager indicated she had received a request for the Vashe wound cleanser on 4/30/26 and she was blocked from ordering it. The corporation's representative had requested a list of residents who needed this item and the list was emailed. She knew that the list of residents who needed the Vashe was sent to the corporation's representative, but the facility did not receive the Vashe until 5/12/26.On 5/13/26 at 2:06 PM the Director of Nursing (DON) was interviewed and reported the following. The Wound Nurse should be entering the wound care orders into a resident's electronic medical system after the Wound NP sees the resident and changes the plan of treatment. If the supplies were not available, then the Wound Nurse should ask the provider to give approval to continue use of the current treatment until the new treatment items arrive. Then this order should be entered into the electronic record. The DON explained the supplier must see the resident's specific order to send the supplies. Since the treatment orders had not been entered into the electronic system, this had partially contributed to the problem of not receiving the treatment supplies. Some items were supplied through their corporate supplier, and others came through a third-party supplier. At the time of the interview, the DON was not sure which supplier sent the Santyl. The DON indicated the best practice was that the supplier would also be called in addition to entering the treatment orders. As she recalled, the Wound Nurse had come to her about the problem of not knowing who to ask about getting some needed supplies around 4/30/26 or 5/1/26. She (the DON) had learned that the order needed to be in for any supplier to send wound supplies.On 5/7/26 at 4:36 AM Nurse # 2 entered a nursing entry noting the following change in condition for Resident # 4. She had 2 episodes of vomiting, chills, and was not responding per her baseline. Her blood pressure was 72/44, temperature 97.2, pulse 94, and respirations 20. Orders were received to send Resident # 4 to the hospital for evaluationReview of hospital records for the hospital admission initiated on 5/7/26 revealed the following information. The records included a picture of the resident's wound upon admission. It appeared in a butterfly shape extending from the left buttock to the right buttock. It was documented to be boggy and with odor. A CT (computerized tomography) exam was done on 5/7/26 noting that Resident # 4 had myositis (a rare condition where the body's immune system attacks healthy muscle tissue causing inflammation). There was also a 4.4 cm X 2. 8 cm X 1.0 cm intramuscular fluid collection in the left gluteal (buttocks) area suggesting abscess or developing abscess. Findings also suggested cellulitis of the buttocks, a question of a kidney infection, a distended gallbladder, suspected thromboembolic disease (blood clots) in the pulmonary artery (the artery that carries blood from the heart to the lungs in order for the blood to become oxygenated.) At time of survey, Resident # 4 remained hospitalized .The Wound NP was interviewed on 5/14/26 at 11:20 PM and reported the following information. She did not think that failing to implement her treatment plan had caused Resident # 4's pressure sore to worsen. The treatment plans, which had never been implemented, were intended to help debride the wound faster but she was physically doing that when she visited. Therefore, changing the orders to her treatment plan may have hastened the debriding process but overall did not hurt the outcome of the wound. The Wound NP was also interviewed about the origin of the pressure sore and whether it was an avoidable wound and reported the following. Originally, she had thought the pressure sore might have been due to end of life, but the resident's labs did not reflect an unstable condition. The resident did have contributing factors such as being in a vegetative state, requiring a tube feeding, and impaired mobility which placed her at risk for pressures sores. When she learned the air mattress had not been fully functional before the pressure sore developing, this was suspicious to her that maybe the malfunctioning of the air mattress had contributed. The Wound NP stated she could not say whether the pressure sore was avoidable.Resident # 4's physician was interviewed on 5/13/26 at 10:38 AM and reported the following information. He had not had an opportunity to review all the problems Resident # 4 had been diagnosed with at the hospital on 5/7/26 but he did not think that being on an air mattress that lost air for a short amount of time would have caused her to have developed the pressure sore.The facility's Medical Director was interviewed on 5/14/26 at 2:05 PM and the results of Resident # 4's 5/7/26 CT scan were shared with him as he was interviewed about his opinion on whether Resident # 4's pressure sore was avoidable. The Medical Director reported the following. He had not personally seen the resident or reviewed her record, but it was his opinion that it was unlikely that being off the air mattress would have caused the pressure sore. If the resident had an abscess in her muscle, then the abscess could have been causing pressure and friction on the outer skin which resulted in the formation of blisters with which the resident initially presented. Therefore, according to the Medical Director, if that was the case, then the pressure ulcer would not have been avoidable.

Based on record review, and interviews with staff and Responsible Party, the facility failed to 1) identify in their accident investigation that an assigned staff member had not been on duty when Resident # 2 fell and thereby evaluate how this might have contributed to the accident occurring in order to take corrective action and 2) failed to toilet Resident # 2 at bedtime as directed by the resident's care plan in order to try and prevent future falls. This was for 1 of 3 sampled residents reviewed for falls (Resident # 2).The findings included:Resident # 2's hospital Discharge summary, dated [DATE], noted Resident # 2 was alert and oriented times two (indicating she knew who she was and where she was). Resident # 2 had diagnoses, which although not inclusive, included Alzheimer's disease and multiple myeloma.Record review revealed Resident # 2 resided at the facility from 4/23/26 until her discharge on [DATE].Record review revealed Resident # 2's admission Minimum Data Set assessment had not been completed and finalized due to her short residency.Resident # 2's facility care plan, which was initiated on 4/23/26, identified Resident # 2 was at risk for falls. On 4/23/26 an intervention was added to the care plan directing staff to place common items within reach of the resident.On 4/26/26 at 2:05 AM Nurse # 1 entered the following information in a nursing note. Resident # 2 was found on the floor. Her call light had been on. She had been needing to go to the bathroom, but the Nurse Aide did not make it in time.A review of a facility's investigative report regarding the incident revealed the following information. The fall occurred on 4/25/26 at 11:20 PM. Nurse # 1 had heard a loud commotion from the hallway and upon her arrival to the resident's room, Nurse # 1 found the resident lying on her left side on the floor. Resident # 1 was assessed and found to have no injuries or complaints of pain. Resident # 1's bed had a soiled incontinence pad. Resident # 2 reported she needed to go the bathroom bad and the call light had been pressed, but the Nurse Aide had not come fast enough. Resident # 2 had then attempted to go the bathroom on her own.Nurse # 1 was interviewed on 5/14/26 at 9:18 AM and again on 10:41 AM. Nurse # 1 reported the following information. She (Nurse # 1) had arrived just a few minutes late to work for her shift which began at 11:00 PM on 4/25/26. She had been no more than 5 minutes late and was counting the medication cart. She heard a crash as if someone had hit the floor. She went to the room and found Resident # 2 on the floor. After she assessed the resident, she asked for help to get Resident # 2 off the floor. She was told by some of the Nurse Aides that Resident # 2 was not their resident, to which she responded someone was going to help her get Resident # 2 off the floor. She did not recall which Nurse Aides had responded and told her that Resident # 2 was not their assigned resident. Eventually two Nurse Aides helped, and she did not recall who they were. Resident # 2 said she was trying to get to the bathroom. Resident # 2's call light had been on when she fell. Nurse # 1 did not specify how long the call light had been activated.According to an interview with the DON (Director of Nursing) on 5/14/26 at 9:20 AM, Nurse Aide (NA # 1) had been assigned to care for Resident # 2 beginning at 11:00 PM on 4/25/26 and had clocked into work at 11:41 PM on 4/25/26.Nurse Aide (NA) # 1 was interviewed with the Director of Nursing (DON) and Nurse Consultant on 5/14/26 at 10:20 AM. NA # 1 was interviewed regarding whether she had alerted anyone that she would be late for work on 4/25/26 in order that staff know as they were making assignments. NA # 1 reported the following information. She had tried calling the facility but could not get an answer. She then texted a coworker but found when she arrived at work that the coworker had not been on duty, and therefore no one had gotten the message that she was late. She never knew that Resident # 2 had fallen because she was not at work when she fell.During the interview with Nurse # 1 on 5/14/26 at 10:41 AM, Nurse # 1 was interviewed regarding whether she was aware that NA # 1 was going to be late in order that someone else monitor her residents and respond to call lights for help until NA # 1 arrived. Nurse # 1 reported she had not known this information. Nurse # 1 was further interviewed regarding whether she had checked on Resident # 2 when she arrived at work and before Resident # 2 fell. Nurse # 1 responded she had just had time to count and check on five residents before the accident occurred and she had not checked on Resident # 2.During an interview with the DON on 5/14/26 at 9:20 AM and 10:37 AM the DON reported the following information. If a staff member was going to be late, then they should call and make sure to speak to an actual nurse at the facility in order that someone be aware of the need to cover their residents while they were not yet on duty. The DON indicated when she calls the facility at night, she was able to get through. Therefore, she (the DON) was unsure why NA # 1 was reporting she could not get in touch with someone.The DON and the Nurse Consultant were interviewed on 5/14/26 at 10:50 AM regarding their process of investigating falls and how they identified further interventions to prevent future accidents. The DON reported that falls were routinely discussed in a clinical meeting which was attended by her and other administrative staff members. The circumstances were discussed and an attempt was made to identify the root cause. After an incident, a resident's care plan was then updated to reflect interventions that might help to prevent future accidents. Resident # 2's fall had been discussed and her care plan updated. The DON indicated when a care plan was updated then the Kardex is automatically updated with information as well. The DON did not specify which day the clinical team had met to discuss the fall, if an optimal time for bedtime toileting was determined for Resident # 2, and whether it had been specified that the toileting responsibility was for staff on the 3:00 to 11:00 PM shift or the staff coming on duty at 11:00 PM. During the investigation of Resident # 2's fall, she had not spoken to Nurse # 1 about Resident # 2's fall and had not been aware that the assigned Nurse Aide was not present when the resident fell nor that the nurse had not been made aware of the Nurse Aide's absence. Therefore, they had not recognized this as a potential problem that may or may not have led to the fall occurring and thereby sought to take corrective action. The Nurse Consultant pointed out that even if Nurse Aide # 1 had been present on duty, the fall may still have occurred due to the resident's urgency to go to the bathroom and decision not to wait for assistance.Review of Resident # 2's care plan revealed following the 4/25/26 fall, a new intervention was created on 4/26/26 that reflected Resident # 2 had fallen on 4/25/26 and that direct care staff were to toilet Resident # 2 before bed.Resident # 2's Kardex was also noted to have an update that Resident # 2 had fallen on 4/25/26 and staff should toilet the resident before bed. It did not specify a particular time the toileting should occur and what time the resident generally went to bed. (A Kardex is a quick reference for direct care staff which gives instructions regarding resident care.According to assignment sheets NA # 2 was assigned to care for Resident # 2 on 5/3/26 during the 3:00 PM to 11:00 PM shift. NA # 2 was interviewed by phone on 5/13/26 at 7:50 PM and reported the following information. She did not recall having Resident # 2 and did not know anything about taking the resident to the toilet at bedtime.On 5/4/26 at 3:15 AM Nurse # 2 documented the following information in a nursing note. Resident # 2 was found on the floor and said she had been trying to go to the bathroom. Resident # 2 reported she had hit her head and had mild swelling. She was transferred to the hospital for evaluation.According to assignments, NA # 3 had been assigned to care for Resident # 2 on the shift which began at 11:00 PM on 5/3/26 and ended on 5/4/26 at 7:00 AM. NA # 3 was interviewed on 5/13/26 at 1:59 PM and reported the following information. She had checked on Resident # 2 around 12:00 AM and whispered to her that she was going to check her. She had been asleep. She was dry when she checked her and went back to sleep. Less than two hours later, she went by the room and found that she was on the floor. NA # 3 was interviewed regarding whether she knew anything about the resident needing to be toileted at bedtime and reported the resident wore briefs and she had not been aware of any toileting instructions for the resident.Nurse # 2, who had been assigned to care for Resident # 2 beginning at 11:00 PM on 5/3/26 until 7:00 AM on 5/4/26, was interviewed on 5/13/26 at 5:30 PM and reported the following information. The resident wore briefs and she did not know anything about directions that the resident should be toileted at bedtime. When she was found on the floor, Resident # 2 said she was trying to get her son and to go to the bathroom. Her brief had been dry when she was found. The resident had some swelling on her head. She (Nurse # 2) called the RP (Responsible Party) who wanted Resident # 2 sent to the hospital for evaluation. Resident # 2's Responsible Party (RP) was interviewed on 5/12/26 at 3:40 PM and reported the following information. She had been concerned about Resident # 2 having two falls during the twelve days she resided at the facility and was worried the facility staff were not monitoring the resident. It was her understanding that Resident # 2's roommate had called for help on 4/25/26 when Resident # 2 fell. During the second incident, she wanted Resident # 2 checked at the hospital and the hospital determined Resident # 2 had not had any injury from the fall. She decided to take Resident # 2 home rather than have her go back to the facility.On 5/14/26 at 12:50 PM the Rehabilitation Director was interviewed regarding Resident # 2's physical ability to be toileted and reported the following information. Resident # 2 had been working with therapy and was able to scoot to a seated position and then stand and pivot to an upright position. Then she could walk with a walker to the bathroom, but she needed someone to go with her for safety.During an interview with the DON on 5/14/26 at 10:50 AM and 11:10 AM the DON validated that NA # 2, who reported she did not recall the resident or taking her to the bathroom, had been assigned to care for Resident # 2 on the 3:00 PM to 11:00 PM shift of 5/3/26. The DON was interviewed how the direct care staff knew that they were supposed to toilet the resident at bedtime given that three of three staff members were reporting they knew nothing about the toileting intervention to prevent falls. The DON reported the Kardex contained basic care information for the Nurse Aides to reference and every Nurse Aide should be referencing the Kardex when they started their assignments.

Based on record review and interviews with staff and Physician, the facility failed to have effective systems in place to ensure ordered medications were acquired from the pharmacy and available for administration and the backup supply of medications was utilized for medications that had not been received from the pharmacy for 1 of 1 resident whose medications were reviewed (Resident #1).The findings included:Resident # 1 was admitted to the facility on [DATE] with diagnoses that included panhypopituitarism (a rare disorder when the pituitary gland stops producing most or all its essential hormones) and sleep apnea for which he was documented as wearing a CPAP (a continuous positive airway pressure) machine.Review of Resident # 1's orders, dated 3/23/26, revealed he was ordered to receive dexamethasone one (1) milligram (mg) every day for his panhypopituitarism. (Dexamethasone suppresses the immune system.)Review of Resident # 1's May Medication Administration Record (MAR) revealed on 5/6/26, Nurse # 5 did not document that she had administered the resident's dexamethasone as scheduled at 9:00 AM. Instead of a check mark, which would have indicated administration, there was a 9 by the dexamethasone dose. According to the MAR's legend, 9 corresponded to other. There was no explanation of other found on the MAR. Review of physician progress notes revealed on 5/6/26, Resident # 1's physician saw Resident # 1 due to the nursing staff noting that the resident was drowsier and mildly tachypneic (increased respirations). On 5/6/26 the physician left new orders for Resident # 1 after evaluating him. One of the orders was for an albuterol sulfate inhalation nebulizer treatment for one time only.On 5/6/26 an order was entered into Resident # 1's record for Albuterol Sulfate Inhalation Nebulization Solution; One inhalation one time only for wheezing/ shortness of breath for one day.Review of Resident # 1's MAR revealed Nurse # 5 indicated a 9 (other) by the albuterol sulfate inhalation nebulizer on 5/6/26 at 1:41 PM rather than checking that it was administered. There was no explanation of other on the MAR itself. At 1:41 PM Nurse # 5 wrote pharmacy aware in a electronic medication note. Nurse # 5 was interviewed on 5/13/26 at 4:33 PM and reported she did not recall why she did not give the dexamethasone to Resident # 1 on 5/6/26, but she did not have the albuterol to administer.Nurse # 6 was interviewed on 5/14/26 at 10:00 AM and reported the following information. He was orienting (process of introducing someone to a new job) Nurse # 5 on 5/6/26. Resident # 1 had missed his dexamethasone because the facility was out of Resident # 1's supply of the medication and the pharmacy had not refilled his supply. Therefore, the dexamethasone had not been given. Nurse # 6 indicated that sometimes the pharmacy was slow in sending things. The resident had also not received the albuterol nebulizer treatment because they were waiting for the pharmacy to send it also. Nurse # 6 did not specify what led to the pharmacy being slow in getting dexamethasone refilled or why he and Nurse # 5 did not obtain both dexamethasone and albuterol from the facility's backup supply.Review of Resident # 1's record revealed he was discharged to the hospital on 5/6/26 at 9:00 PM without receiving these two medications.The Director of Nursing (DON) who just began in her role in December 2025, was interviewed on 5/14/26 at 10:00 AM and reported the following information. Both the dexamethasone and the albuterol had been in the facility's back up supply on 5/6/26 and should have been pulled from the backup supply and administered to Resident # 1. She had made a copy of all the medications that were available in the backup supply and put the list as a reference in a book on each medication cart. That way, the nurses could reference the list if they needed something and easily know how to obtain it from back up. The DON indicated she had informed the nurses about the backup list placed on the medication carts. The DON did not specify when the list had been placed on the medication carts and the information shared with nurses, but according to the DON, the list had been in place when Resident # 1's missed his medications on 5/6/26. Resident # 1's Physician was interviewed on 5/14/26 at 2:05 PM and reported the following. The resident had no negative outcome to either missed medication on 5/6/26 and he saw Resident # 1 on 5/6/26. Resident # 1 seemed drowsier and usually wore a CPAP machine. If he had not worn it correctly or been noncompliant, then there may have been a chance he was retaining some carbon dioxide. The Physician indicated the albuterol had been meant to see if Resident #1 would pep up with the treatment.

Based on record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours for 2 of 142 days reviewed for staffing (12/28/25 and 1/24/26).The findings included: Review of the facility's daily nurse staffing sheets from 11/1/25 through 3/22/26 revealed the following: a. On 12/28/25 the daily nurse staffing sheet indicated a daily census of 85. Review of the daily nurse staffing sheet revealed there was no RN working on any shift that day. b. On 1/24/26 the daily nurse staffing sheet indicated a daily census of 77. Review of the daily nurse staffing sheet revealed there was no RN working on any shift that day. In an interview with the Scheduler on 3/25/26 at 10:10 am, she stated she used the schedule to complete the daily nurse staffing sheets. The Scheduler stated if she had no RN coverage she would leave the RN space blank on the daily nurse staffing sheet for the number of RNs scheduled to work. She stated did not have RN coverage for 12/28/25 and 1/24/26. The Scheduler further stated she was unaware there could be no blank spaces on the daily nurse staffing sheets. The Scheduler was not sure what she needed to do when there was no RN coverage. An interview with the Director of Nursing (DON) on 3/25/26 at 10:30 am revealed she was unaware there was no RN coverage for 12/28/25 and 1/24/26. The DON stated there should be an RN for 8 consecutive hours in the building and she would be monitoring this more closely in the future. An interview with the Administrator on 3/25/26 at 12:02 pm stated his expectations were the facility should have an RN for 8 consecutive hours in the building.

Based on record review and staff, Medical Director, and Consultant Pharmacist interviews, the facility failed to provide ongoing Abnormal Involuntary Movement Scale (AIMS) assessments for potential adverse reactions to antipsychotic medications for 1 of 5 residents reviewed for unnecessary medications (Residents #3).The findings included: Resident #3 was admitted on [DATE] with diagnoses including dementia with severe behavioral disturbance and agitation.Review of Resident #3's physician orders revealed she had an order dated 4/21/25 for haloperidol lactate (a first-generation antipsychotic injection used for the rapid treatment of acute psychosis, schizophrenia, and severe agitation) 2 milligram (mg)/ milliliter (ml) give 0.5 ml by mouth two times a day for behaviors.Review of Resident #3's electronic medical record (EMR) revealed the last AIMS assessment on file was dated 7/29/25. There were no other AIMS assessments found in the Resident #3's EMR after that date. Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively impaired and exhibited behaviors. She was coded for antipsychotic medication.An interview was conducted with Unit Manager #1 on 3/23/26 at 3:09 PM. She stated she began working at the facility in January 2026. The Unit Manager stated when the new company took over the facility (in November 2025), some assessments were not scheduled. Unit Manager #1 further stated AIMS assessments should be completed upon initial admission, at readmissions, and completed quarterly. Unit Manager #1 indicated Resident #3's quarterly AIMS should have been completed but was not.An interview was conducted with the Director of Nursing (DON) on 03/23/26 at 3:30 PM. The DON stated the facility changed ownership in November 2025 and she began working at the facility in December 2025. She stated staff were working to get all assessments correct and up to date. The DON stated that AIMS assessments were expected to be completed at the time of initial admission, at readmissions, with new medication prescriptions, as well as scheduled and completed quarterly. She further stated the unit managers were responsible for completing the AIMS assessments.An interview was conducted with the Pharmacy Consultant on 3/25/26 at 9:57 AM. The Pharmacy Consultant stated AIMS assessments should be completed at the start of the antipsychotic medication; if no changes were made to the medication dose, then again at 6 months. The Pharmacy Consultant stated his medication reviews included reviews of physician and psychiatric progress notes for any medication related side effects and if no issues were noted, he did not make recommendations. He further stated he left AIMS assessment information up to the treating physician to make recommendations.In an interview with the Medical Director on 3/25/26 at 10:16 AM he stated AIMS assessments should be completed at the minimum of every 6 months. He stated the physician and/or psychiatrist generally monitored antipsychotic medications. The Medical Director further stated Resident #3 had been in the hospital earlier this month, which could have interfered with the timing of her AIMS assessment, however it should have been completed at the 6-month mark regardless.An interview was conducted with the Administrator on 3/25/26 at 1:08 PM. He stated he expected that all assessments needed for antipsychotic medications, including AIMS assessments, were completed timely and were reviewed as necessary.

Based on record review and facility staff interviews, the facility failed to accurately code Minimum Data Set (MDS) for 1 of 62 residents reviewed for accuracy of assessments (Resident #84). The findings included:Resident #84 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (ischemic stroke).Review of a physician order dated 1/16/26 for Resident #84 documented [brand name of formula] enteral nutrition (delivery of nutrients directly into the gastrointestinal tract, typically through a feeding tube) at 60 milliliters (ml) per hour every 12 hours from 6 p.m. to 6 a.m. and 200 ml water flush every four hours. Review of Resident #84's February 2026 Medication Administration Record (MAR) revealed [brand name of formula] enteral nutrition at 60 ml per hour per feeding tube every 12 hours from 6 p.m. to 6 a.m. and 200 ml of water flush every 4 hours per feeding tube had been documented as administered. A review of Resident #84's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 was not coded for having a Feeding Tube or the Percent of Intake by Artificial Route. During an interview with the Regional MDS Consultant on 3/25/26 at 10:50 a.m. she stated the Dietary Manager completed the Nutrition section of the MDS and it should have been completed by the MDS Coordinator. The MDS indicated Resident #84 had a feeding tube, this had been an error, and it should have been coded correctly including the amount of intake by artificial route. During an interview with the Administrator on 3/25/26 at 12:02 p.m. he stated the MDS assessments should have been coded accurately to reflect the feeding tube and the amount of intake by artificial route.

Based on record review and an interview with the Pharmacy Consultant, the Pharmacy Consultant failed to identify and report irregularities when conducting monthly drug regimen reviews for 1 of 5 residents reviewed for unnecessary medications (Resident #3).The findings included: Resident #3 was admitted on [DATE] with diagnoses including dementia with severe behavioral disturbance and agitation.Review of Resident #3's physician orders revealed she had an order dated 4/21/25 for haloperidol lactate (a first-generation antipsychotic injection used for the rapid treatment of acute psychosis, schizophrenia, and severe agitation) 2 milligram (mg)/ milliliter (ml) give 0.5 ml by mouth two times a day for behaviors.Review of Resident #3's electronic medical record (EMR) revealed the last AIMS assessment on file was dated 7/29/25. There were no other AIMS assessments found in the Resident #3's EMR after that date. Review of the Pharmacy Consultant monthly drug regimen reviews for Resident #3 dated 10/10/25, and monthly pharmacy reports dated November 2025 through February 2026, revealed no documentation of the need for the facility to complete AIMS assessments. An interview was conducted with the Pharmacy Consultant on 3/25/26 at 9:57 AM. The Pharmacy Consultant stated AIMS assessments should be completed at the start of the antipsychotic medication; if no changes were made to the medication dose, then again at 6 months. The Pharmacy Consultant stated his medication reviews included reviews of physician and psychiatric progress notes for any medication related side effects and if no issues were noted, he did not make recommendations. He further stated he left AIMS assessment information up to the treating physician to make recommendations.

Based on record review and staff, Dialysis Dietician/Nurse Practitioner, and Medical Director interviews, the facility failed to ensure medications were administered in accordance with physician orders for 1 of 9 residents reviewed for medications (Resident #7).The findings included:Resident #7 latest admission date to the facility was 10/8/2025 following a hospitalization from 10/3/2025 to 10/8/2025 for dialysis access complications and anemia. Resident #7 admitting diagnoses included end stage renal disease (ESRD) requiring hemodialysis, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and moderate protein-calorie malnutrition. A care plan dated 10/08/2025 addressed ESRD and fluid volume management, including administering medications as ordered, monitoring vital signs, and providing diet as ordered. The care plan was revised on 03/05/2026 to include activities of daily living (ADL) assistance needs. The care plan did not include interventions addressing medication availability, administering medications on dialysis days, or medication refusals.Further review of physician orders revealed an order dated 6/12/2025 for Sevelamer Carbonate (phosphate binder used to control elevated phosphorus in people with chronic kidney disease) 0.8 gram packet give one (1) packet by mouth three times daily with a meal.On 11/11/2025 a physician order was written for Carvedilol (used to treat heart failure, hypertension and heart attack) 6.25 mg, 2 tablets twice daily and Sertraline (used to treat depression and anxiety) 50 mg daily.On 2/12/2026 a physician order specified Sevelamer HCl (phosphate binder) 800 mg 3 tablets with meals and Sevelamer HCl 800 mg 2 tables with snacks twice daily. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented diagnoses including ESRD requiring dialysis and moderate protein-calorie malnutrition, with severe cognitive impairment requiring cues for decision-making.A review of Medication Administration Records (MARs) for January 2026 and February 2026 revealed that on 01/07/2026, 01/19/2026, 01/28/2026, 02/06/2026, 02/11/2026, 02/13/2026, 02/16/2026, 02/18/2026, 02/20/2026 and 02/20/2026, the Sevelamer, Sertraline 50 mg and Carvedilol 6.25 mg were documented as not administered because the resident was out of facility or at dialysis at the time of medication administration.On 3/11/2026 a physician order was written to discontinue Sevelamer and start Velphoro (phosphate binder) 500 mg with instructions to administer one tablet three times daily with meals and one tablet with a snack. Velphoro serves the same purpose as Sevelamer except the Velphoro is less pills per dose.An interview with the Dialysis Dietician/Nurse Practitioner on 3/24/2025 at 11:10 am revealed that Resident #7 was switched from Sevelamer to Velphoro because his phosphorous levels were not controlled and she believed facility was not administering medication as ordered. She stated that Resident #7 phosphorous levels were still not controlled and latest phosphorous level was 6.5 on 3/11/2026. She stated that they like patients to be 5.5 or less. She indicated that Resident #7's phosphorous levels were well controlled prior to his coming to this facility. She stated that Resident #7 does not take any medication while at the dialysis facility. She confirmed that Resident #7 did not take the medication at the dialysis center because the resident did not always eat while at dialysis and medication must be taken with food. She further stated that Resident #7 could have taken the medication upon his return to the facility with his meals or snacks.According to the National Kidney Foundation, high phosphorous levels harden blood vessels and increases the risk of heart disease, stroke and death. At an interview on 3/25/2026 at 9:50 am the Director of Nursing stated that if nurses hold a medication or if the medication is not available from pharmacy, the nurse should call the on-call provider and make them aware. She stated that at the direction of the on-call provider they should either hold the medication for that day or administer it to the patient upon their return to the facility.An interview with the Nurse Unit Manager on 3/25/2026 at 10:30 am revealed that Resident #7's? resident medications were held when the patient was out of the facility for dialysis. She stated that if they were held, they were not given when he returned to the facility. She stated they do not contact the Medical Director or on-call provider when they hold medications. She stated that the resident has dialysis on Mondays, Wednesdays and Fridays and his chair time started at 11:15 am and returns around 4:00 pm. She stated that the resident had several medications held during that time including a 2:00 pm blood pressure medication Carvedilol which was held every Monday, Wednesday and Friday.A 3/25/2026 interview with Medical Director at 10:53 am revealed that it was his expectation that nursing staff contact the on-call doctor or himself if a patient misses medication due to being out of the building. The Medical Director stated that he had not received any communication regarding Resident #7 being out to dialysis and missing doses of his medication. He stated that if nursing staff held a medication they should contact on-call providers, tell them which medication was held and which ones still needed to be given. The Medical Director indicated now that he was aware they could adjust medications times so that they are not given while Resident #7 is at dialysis. The Medical Director stated that he did not follow Resident #7 dialysis care and allowed the dialysis center to make any medication changes or follow up on labs.

Based on observation, record review, and resident and staff interviews, the facility failed to ensure the resident call light system was functioning properly for 3 of 97 residents observed for resident call system (Resident #78, Resident #4, and Resident #94).The findings included:Record review of maintenance related purchase orders revealed on 2/9/26 light bulbs were ordered and a delivery date of 2/10/26 was noted.a. Resident #78 was admitted to the facility on [DATE] with diagnoses that included inflammatory and immune myopathies (a group of rare, chronic diseases where the body's immune system mistakenly attacks its own healthy muscle fibers), generalized weakness, and abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was cognitively intact. Resident #78 required substantial/maximal assistance for oral hygiene, upper body dressing, personal hygiene, rolling left and right, and wheeling 150 feet. She was dependent on others for toileting hygiene, shower/bathing herself, lower body dressing, putting on/taking off footwear, sitting to lying, lying to sitting on side of bed, sitting to standing, and chair/bed to chair transfers.A grievance for Resident #78 dated 2/24/26 indicated her call light was not working. The resolution included that maintenance looked at the call light and deemed it to be in working order at that time; the grievance was signed by the Administrator. An interview was conducted with Resident #78 on 3/24/26 at 11:35 AM. Resident #78 stated her call light had not lit up on the outside of her door for approximately one month. She explained that when she thought her call light was not working she asked a staff member (unsure name and date) to check the light above her door. She stated she informed her nurse aide and her nurse that the call light was not working. She indicated she was unsure of names of the staff or the exact date she informed them. Resident #78 stated a maintenance staff member (unsure of name and date) came and informed her a part had to be ordered; however, no one came back to fix it. She stated she was given a handheld bell to ring by the Activities Director. An observation of Resident #78's call light was conducted on 3/24/26 at 11:36 AM. When the call light was pressed, it did not illuminate on the outside of her door in the hallway. A handheld bell was observed in her room.An interview was conducted with the Activities Director on 3/25/2026 at 12:08 PM. She stated she found out about Resident #78's call light not working during a Resident Council meeting in February 2026. The Activities Director stated she went to Resident #78's room to check her call light and it wasn't working. She stated she told maintenance about it verbally and gave Resident #78 a handheld bell to use until her call light was fixed.b. Resident #4 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), generalized weakness, neuromuscular dysfunction of the bladder (a condition where nerve damage disrupts the communication between the brain, spinal cord, and bladder muscles), and abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was severely cognitively impaired. Resident #4 required substantial/maximal assistance for personal hygiene, rolling left and right, sitting to lying, and lying to sitting on side of bed. She was dependent on others for toileting hygiene, shower/bathing herself, upper and lower body dressing, putting on/taking off footwear, sitting to standing, chair/bed to chair transfers, and tub/shower transfer.Resident #4 was not interviewable. An observation of Resident #4's call light was conducted on 3/24/26 at 11:38 AM. When the call light was pressed, it did not illuminate on the outside of her door in the hallway. A handheld bell was observed in her room.c. Resident #94 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc degeneration: lumbar region (a common condition where the soft, rubbery cushions {discs} between the bones {vertebrae} in your lower back wear down), kyphosis (an abnormal, excessive outward curve of the spine that causes a rounded, hunched-over posture), and generalized weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was moderately cognitively impaired. Resident #94 required substantial/maximal assistance for toileting hygiene, shower/bathing herself, upper and lower body dressing, personal hygiene, rolling left and right, lying to sitting on side of bed, sitting to standing, and chair/bed to chair transfers. She was dependent on others for putting on/taking off footwear, toilet transfer, and tub/shower transfer.An observation of Resident #94's call light was conducted on 3/24/26 at 11:38 AM. When the call light was pressed, it did not illuminate on the outside of her door in the hallway. A handheld bell was observed in her room.An interview was conducted with Resident #94 on 3/24/26 at 12:31 PM. She stated her call light hadn't worked properly for a few weeks; she was unsure of the exact date it stopped working. Resident #94 stated she informed her nurse aide about her call light not working (unsure of name and exact date) and the nurse aide gave her a handheld bell. She further stated a maintenance staff member (unsure of name) looked at her call light and told her, He would get it later. Work orders dated January 2026 through March 2026 were reviewed. There were no work orders for Resident #78, Resident #4, and Resident #94 related to call lights in need of repair.During an interview on 3/24/26 at 11:54 AM with Nurse Aide #1 who was assigned to Resident #4 and Resident #94, she stated she was not aware their call lights were not working. She stated if she found a call light was not working, she would report it to maintenance verbally. During an interview on 3/24/2026 at 3:23 PM with Nurse Aide #2 who was assigned to Resident #78, she stated she did not know Resident #78's call light was not working. She further stated if she found something that was not working, she would report it to maintenance verbally. An interview was conducted on 3/24/26 at 11:44 AM with Nurse #1 who was assigned to Resident #78, Resident #4, and Resident #94. Nurse #1 stated she was not aware these residents' call lights were not working. She stated if she found something that needed repair, she would notify maintenance verbally and write it in the maintenance communication book which was kept at the nurse's station. Nurse #1 further stated she would inform the nurse aides that a resident's call light was not working properly so the nurse aides could check on the residents more frequently until the call light was fixed.An interview was conducted on 3/24/26 at 12:01 PM with Unit Manager #1. She stated she was not aware that Resident #78's, Resident #4's, and Resident #94's call bells were not working. Unit Manager #1 stated if something needed repaired, she expected staff to put the maintenance request into the web-based building management system utilized by the facility (a web-based system specifically designed for senior living and healthcare facilities to help operators manage maintenance, regulatory compliance, and vendor services through a central, mobile platform); a resident should also be given a handheld bell until their call light was fixed. An interview was conducted on 3/24/26 at 3:24 PM with the Maintenance Director. He stated he was notified of the call lights not working for Resident #78, Resident #4, and Resident #94 (unsure of date and how he was notified). He stated he fixed the call lights twice, but they kept blowing out. The Maintenance Director stated he realized it was a problem with the inside panels. He stated he switched out the panel but had to order more bulbs because they kept burning out. The Maintenance Director stated he did not have documentation of the dates and times he worked on (fixed) the call lights and stated he should have kept a record. A follow-up interview was conducted on 3/25/26 at 10:54 AM with the Maintenance Director for clarification of the light bulb invoice. He stated the invoice was created on 2/9/26. The delivery date on the invoice of 2/10/26 was not the actual delivery date. The Maintenance Director stated the shipment was delayed and was delivered on 3/18/26.During an interview with the Director of Nursing (DON) on 03/25/26 at 12:33 PM she stated she was unaware of Resident #78's, Resident #4's, and Resident #94's call lights not working. The DON stated her expectation was that if staff discovered a call light was not working properly, they notified maintenance verbally, entered it into the web-based building management system, and gave a resident a handheld bell to use until the call light was fixed.In an interview with the Administrator on 3/25/26 at 1:08 PM, the Administrator stated he expected repairs to be done timely. The Administrator did not explain what specific period of time equated to a timely manner.

Based on record review and staff interviews, the facility failed to ensure daily nurse staffing sheets were complete and accurate for 36 of 53 days reviewed for 12/1/25 through 3/22/26 (12/12/25, 12/17/25, 2/2/26, 2/4/26, 2/5/26, 2/6/26, 2/9/26, 2/10/26, 2/11/26, 2/13/26, 2/15/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/21/26, 2/24/26, 2/25/26, 2/26/26, 2/27/26, 2/28/26, 3/3/26, 3/4/26, 3/5/26, 3/7/26, 3/9/26, 3/10/26, 3/11/26, 3/12/26, 3/13/26, 3/14/26, 3/15/26, 3/17/26, 3/18/26, 3/21/26, 3/22/26). The findings included:Review of the facility's daily nurse staffing sheets for 12/12/25, 12/17/25, 12/28/25, 1/24/26, 2/2/26, 2/4/26, 2/5/26, 2/6/26, 2/9/26, 2/10/26, 2/11/26, 2/13/26, 2/15/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/21/26, 2/24/26, 2/25/26, 2/26/26, 2/27/26, 2/28/26, 3/3/26, 3/4/26, 3/5/26, 3/7/26, 3/9/26, 3/10/26, 3/11/26, 3/12/26, 3/13/26, 3/14/26, 3/15/26, 3/17/26, 3/18/26, 3/21/26, 3/22/26 revealed the following:On 12/12/25 the total number for each staff discipline (Registered Nurse (RN), Licensed Practical Nurse (LPN), Nursing Assistant (NAs) and total hours worked for each staff discipline for the evening (3:00 pm - 11:00 pm) and night shift (11:00 pm - 7:00 am) were blank. On 12/12/25 the census was blank. On 12/17/25 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 12/17/25 the census was blank. On 2/2/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/4/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/5/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/6/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/6/26 the census was blank. On 2/9/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/10/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/11/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/13/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/15/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/16/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/17/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/18/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/19/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/19/26 the census was blank. On 2/21/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/24/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/25/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/26/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/27/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/28/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/3/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/4/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/5/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/7/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/7/26 the census was blank. On 3/9/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/10/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/11/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/12/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/13/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/14/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/14/26 the census was blank. On 3/15/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/15/26 the census was blank. On 3/17/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/18/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/21/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 3/22/26 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. In an interview with the Scheduler on 3/25/26 at 10:10 am, she stated she used the schedule to complete the daily nurse staffing sheets. The Scheduler explained she would have to start and stop working on the daily nurse staffing sheets to find staff coverage for staff call outs. She explained she forgot to go back and complete the daily nurse staffing sheets for the dates in question. The Scheduler further stated she was unaware there could be no blank spaces on the daily nurse staffing sheets. An interview with the Director of Nursing (DON) on 3/25/26 at 10:30 am, revealed the Scheduler was responsible for completing the daily nurse staffing sheets. The DON revealed she was unaware the daily nurse staffing sheets were not completely filled out. The DON indicated the daily nurse staffing sheets should be completed with the total number of staff for each discipline for each shift and the total hours worked for each discipline for each shift, and the census. An interview was conducted with the Administrator on 3/25/26 at 12:02 pm. He stated the daily nursing staffing sheets were supposed to be completed by the Scheduler. The Administrator stated his expectations were that the daily nursing staffing sheets were completed correctly.

Based on observation, record review, and interviews with resident, staff, and a representative from the company that manufactures the mechanical lifts used at the facility, the facility failed to ensure a resident was safely transferred by a mechanical lift. A mechanical lift sling broke while Resident # 3 was being transferred resulting in Resident # 3 sustaining a fractured humerus (large bone of the upper arm). This was for 1 of 3 residents reviewed for accidents (Resident # 3).The findings included:Resident # 3 was admitted to the facility on [DATE]. The resident had diagnoses which included stroke and chronic pain.Resident # 3's quarterly Minimum Data Set assessment, dated 7/18/25, coded Resident # 3 as cognitively intact and as totally dependent on staff for transfers.Resident # 3's care plan, last updated on 8/29/25, included the information that Resident # 3 required total staff assistance for transfers.On 1/7/25 at 12:33 PM Nurse # 4 documented the following information. Two Nurse Aides were transferring Resident # 3 with a mechanical lift when one of the four straps broke, and the resident was lowered to the floor. The resident hit her head and her left shoulder. The Nurse Practitioner was made aware, and the resident was sent to the hospital for evaluation.Nurse Aide (NA) # 3 was one of the Nurse Aides who had been assisting in the transfer on 1/7/25. NA # 3 was interviewed on 9/10/25 at 3:11 PM and reported the following information. As he and NA # 4 were transferring Resident # 3 with the mechanical lift one of the straps tore away from the body of the sling where the strap was joined into the body of the sling. He had not noticed anything wrong with the sling or strap prior to the transfer, and they had been using the correct size lift sling also.NA # 4 was one of the Nurse Aides who had been assisting in the transfer on 1/7/25. NA # 4 was interviewed on 9/10/25 at 3:19 PM and reported the following information. On the day of the incident one of the straps broke away from the body of the lift sling where the strap joined the body of the sling. She had not noticed anything wrong with the lift sling prior to the incident. They lowered the resident to the floor and called the nurse immediately.Nurse # 4 was interviewed on 9/10/25 at 3:05 PM and reported the following information. It was reported to her that one of the straps broke and the resident was lowered to the floor. Resident # 3 bumped her head and left arm on the bed rail while going down. She did not recall what the sling looked like specifically that day. In general, she thought some of the slings had looked thin. After the incident Resident # 3 was sent to the hospital.Resident # 3 was interviewed on 9/9/25 at 10:00 AM and reported the following information. She recalled earlier in the year NA # 3 and NA # 4 were helping transfer her in the mechanical lift when the sling broke and she was dropped. It hurt when they dropped her. As she recalled it was her collarbone area that was broken.Review of 1/7/25 hospital records revealed Resident # 3 was evaluated in the hospital ED (Emergency Department) for left shoulder pain. The ED physician documented the following information. The resident was on Eliquis (an anticoagulant medication) at the facility. She was transferred to the ED for assessment following a fall. He had spoken to the facility staff who reported that a strap on the mechanical lift had broken, and the resident did not fully fall out of the lift. Her left arm dropped, and she hit her head on the bed rail. She was then lowered to the ground. X-rays and a CT (computerized tomography) scan were done. Resident # 3 was identified to have a left humerus fracture. An orthopedic consult was done, and the resident was not deemed to need surgery. Her arm was placed in a sling for immobilization with plans for an orthopedic follow up in three weeks. A CT of the head showed no evidence signs of hemorrhage. The resident's facility medications were reviewed by the ED physician who noted the resident already had orders for Cymbalta (used for chronic pain), baclofen (a muscle relaxer), and gabapentin (a seizure medication used to treat chronic pain) and also had orders for acetaminophen and tramadol (a controlled medication used for pain control) to be used as needed for pain. She was discharged back to the facility on 1/7/25 at 5:01 PM in stable condition according to hospital records. On 9/10/25 at 3:40 PM a Representative from the manufacturing company of the mechanical lifts was interviewed and reported the following information. It would be hard to say what had occurred with the sling without viewing the sling. It could have been that the sling was worn from normal use and laundering, or it could have been defective. The Representative indicated when incidents occur, the facility was welcome to call one of their regional representatives and the representative would come and view the sling to see if they could determine what had occurred.The Director of Nursing (DON) was interviewed on 9/8/25 at 7:38 AM and reported the following information. The lift sling was assessed by the facility after the incident, and it had been broken. The weight limit for all their slings was 600 pounds and Resident # 3 had not exceeded the weight limit of the sling. After the incident the Administrator and the Maintenance Director looked at all the lift slings and any old slings were thrown away by them. New slings were ordered by the Administrator. Every resident had a lift sling. If a lift sling was sent to laundry for laundering, the laundry personnel checked the sling before it was returned for use. There were two laundry staff members during the day and then a staff member who worked from 3:00 PM to midnight in the laundry room. These laundry staff were available to give the lift slings to a Nurse Aide after laundering. There was an in-service for the laundry room staff incident regarding checking the lift slings after laundering. The Administrator and the Maintenance Director were interviewed on 9/11/25 at 9:07 AM. The Administrator reported the following information. He had obtained the broken sling after the 1/7/25 incident and saw that it was ripped at the seam. The hook itself was not broken. He did not want the sling to ever be used again and therefore he threw it in the dumpster that day. The sling wasn't very old. Slings were replaced every six months. Resident # 3's weight had not been an issue because the sling went up to 600 pounds. After the incident, maintenance went through every sling in the facility to ensure they were in good condition and did not find other slings in disrepair. He (the Administrator) ordered new slings as well. Because the slings were seen by laundry the most, the laundry staff were inserviced to check the slings after they went through the laundry each time they were laundered to ensure they remained in good condition after the laundry process.The Administrator presented a corrective action plan which they had implemented on 1/7/25 and completed on 1/8/25. A review of the corrective action plan revealed it did not include training for the nursing staff regarding the safety of the slings. Therefore, the corrective action plan was not accepted.

Based on observation, record review, and interviews with staff and Physicians the facility failed to notify the physician when residents developed pressure sores for 2 of 3 sampled residents with pressure sores (Residents # 1 and Resident #8).The findings included:1. Resident # 1 resided at the facility from 3/11/25 until her discharge to the hospital on 8/29/25. Resident # 1's diagnoses included cellulitis of the lower extremities, lymphedema, venous insufficiency, chronic kidney disease, anxiety, and gout.Resident # 1's electronic record included pictures as part of the documentation regarding Resident # 1's sacral pressure sore development and assessment. The first picture was recorded on 4/4/25. In the documented picture, the sacral pressure sore appeared to have both black and yellow slough tissue in the wound bed.The electronic record did not include orders on 4/4/25 for the treatment of the pressure sore or that the physician was contacted.The Wound Care Nurse was interviewed on 9/9/25 at 4:15 PM and on 9/10/25 at 11:13 AM and reported she (the Wound Care Nurse) kept written notes that had not been included in the resident's electronic record. The Wound Care Nurse referenced these notes and reported the following information. Resident # 1 had been noncompliant with care. Resident # 1's sacral pressure sore was first identified by her on 4/1/25. She had been caring for the resident's legs on 4/1/25 because the resident had cellulitis. On 4/1/25 she saw the sacral pressure sore and measured the pressure sore. It was 7 cm (centimeters) X 6 cm and was not stageable because it had black necrosis (dead tissue). The Nurse Aide had not let her know about the pressure sore before she (the Wound Nurse) found it. She (the Wound Care Nurse) had been working closely with the Wound Physician, who visited every week, and the Wound Physician had educated her that black necrosis would need to be removed for healing to take place. In working with the Wound Physician, she had been told that skin prep would be an appropriate measure for necrotic tissue. Therefore, she applied skin prep for the first few days when she found the pressure sore with the plan that the Wound Physician would look at the pressure sore when the Wound Physician was next at the facility. She (the Wound Care Nurse) did not call and talk with the Wound Physician or the primary physician. She did not enter orders into the resident's record for skin prep to the pressure sore. On 4/4/25 Nurse Aide (NA) # 1 came to get her (the Wound Care Nurse) and told her that NA # 2 was applying a cream on the resident's bottom and that she (NA #1) thought it needed something more than a barrier cream. She again looked at the pressure sore and decided to use Santyl (which is a chemical debriding topical cream) and she dressed and cared for the pressure sore on that date. She again did not call the physician and notify the physician of the new pressure sore. On 4/8/25 the Wound Physician was notified when she was there to make rounds. On 4/8/25 the Wound Physician initiated a plan of care and orders were received.A review of the Wound Physician's 4/8/25 treatment plan revealed the orders included more than just the Santyl which the Wound Care Nurse had last initiated on 4/4/25. Both Santyl and calcium Alginate were to be applied to the wound bed daily per the Wound Physician's plan of care.The Wound Care Physician was interviewed on 9/10/25 at 4:32 PM and reported the following information. If she (the Wound Care Physician) had been contacted on 4/1/25 when Resident # 1 first was observed to have an unstageable wound to her sacrum she probably would not have ordered skin prep. The facility could contact her at any time to consult about orders. According to the Wound Physician, if she had been contacted on 4/1/25 she would have needed to consider how long it would be before she could actually see the resident and taken that into consideration in ordering what needed to be applied in the interim.During an interview with the Director of Nursing (DON) on 9/11/2025 at 7:55 AM the DON reported the following information. The facility does have standing orders for wound care. Nurses are supposed to apply Wet to Dry dressings until they can contact the physician for further orders if they identify new wounds. The facility also has protocols to use based on the appearance of the wound bed and the nurse should still contact the physician and obtain orders when a resident has a pressure sore. The DON indicated all this information is kept in a binder at the nursing desk and the nurses should know that.2. Resident # 8 was initially admitted to the facility on [DATE]. The resident had diagnoses which included diabetes, hypertension, history of stroke, dysphagia, and pain.On 7/28/25 a documented skin assessment showed no areas of skin breakdown.According to the record, Resident # 8 was hospitalized from [DATE] to 8/4/25 for altered mental status and a urinary tract infection.Upon the resident's return on 8/4/25 Nurse # 3 documented a nursing assessment. The assessment form included an area which included directions note all skin issues. On this part of the assessment form, Nurse # 3 noted sacrum. There was no further information about the size or description of what the issue was with Resident # 8's sacrum skin. There was no documentation the physician was notified on 8/4/25.Nurse # 3 was interviewed on 9/10/25 at 2:20 PM and reported she recalled Resident # 8 had an open area on the sacrum which was not deep when she was readmitted . She did not recall specific details other than that. Nurse #3 indicated would have told the Wound Care Nurse and did not recall anything else she did.On 8/4/25 the Wound Care Nurse documented a skin assessment and noted Resident # 8 had a 5.02 cm X 3.84 cm deep tissue injury to her right heel. A heel protector and specialized boot was applied. The Wound Care Nurse did not note any area of skin breakdown to Resident # 8's sacrum and she did not note the physician was notified.During interviews with the Wound Care Nurse on 9/9/25 at 4:15 PM and 9/10/25 at 11:13 AM the Wound Care Nurse reported she assessed Resident # 8's skin on 8/4/25 and she did not see an area of skin breakdown on 8/4/25 on the resident's sacrum. She did have a deep tissue injury to her right heel and she knew that skin prep would be appropriate for that. She began doing that daily with the plan for the Wound Physician to see the resident. She did not call the physician and notify the physician of any pressure sores. The Wound Care Nurse was also interviewed about how other nurses would know to do treatments when she was not there if the physician had not been consulted and orders been entered, and the Wound Care Nurse had not recognized that as a problem.There were no documented orders or treatment for any pressure sores from 8/4/25 to 8/9/25.On 8/10/25 at 9:00 PM Nurse # 2 documented Resident # 8 had a sacral wound which was observed to be open with no bleeding. The area was cleansed with normal saline and a dressing applied.Nurse # 2 was interviewed on 9/11/25 at 11:19 AM and reported the following information. She did not recall the specific appearance of Resident # 8's pressure sore on 8/10/25 when she got the one-time order to dress the pressure sore. She did recall it was open and appeared to be more than a stage one. She had told the oncoming nurse about the pressures sore and assumed that the information would be passed along to the Wound Care Nurse and physician.Review of orders and the treatment records revealed Nurse # 1 obtained a one-time order on 8/10/25 for the sacral dressing she applied and documented the dressing change on 8/10/25 on the MAR (medication administration record).Following the one-time sacral dressing application order on 8/10/25 there was no documentation the physician was consulted following the 8/10/25 one -time order for the dressing change to the sacrum until the resident was seen on 8/20/25 by the Wound Physician. On 9/11/25 at 12:05 PM the shift change report was reviewed with the Director of Nursing (DON). According to the DON, Nurse # 2 had worked a double shift which included 7:00 AM to 11:00 PM on 8/10/25. There was a notation on the shift change report that the information had been passed along to the nurse who started work at 11:00 PM on 8/10/25 that the resident had a sacral wound. According to the DON, Nurse # 3 cared for Resident # 8 on the following day of 8/11/25 starting at 7:00 AM.Nurse # 3 was interviewed on 9/11/25 at 12:15 PM and reported she could not recall specifically what she did when the information had been passed along to her in shift change report that Resident # 8 had a sacral wound on 8/11/25. She reported she would have passed the information along to the Wound Care Nurse.From 8/11/25 until 8/20/25 there was no further documentation the physician was notified about pressure sores.On 8/20/25 the Wound Physician documented she saw Resident # 8 and found a dressing to the resident's sacrum dated 8/12/25 on 8/20/25. The Wound Physician further documented the following. Resident # 8 had a Stage 4 pressure sore to the sacrum which measured 2.3 cm X 2 cm X 1 cm. There was 90 % slough and 10 % granulation tissue in the wound bed. The Wound Physician noted the area had not been known to exist by her or the Wound Care Nurse until that date (8/20/25). The treatment plan was for a medical honey and calcium alginate to be applied daily. The Wound Physician also noted Resident # 8 had deep tissue injury to her right heel which measured 5.1 x 4.7 x Not Measurable cm. The treatment plan was for a daily application of skin prep.The Wound Physician was interviewed on 9/10/25 at 4:32 PM and clarified she was not aware of the resident's sacral pressure sore until 8/20/25 and on 8/20/25 there was a dressing that was dated 8/12/25. The Wound Physician reported the facility could contact her at any time to obtain orders.The Wound Care Nurse was interviewed on 9/10/25 at 11:13 AM and reported the following information. She did not recall an old dressing being on Resident # 8's sacrum when the pressure sore was found on 8/20/25. She did not know about the pressure sore until 8/20/25. She had been on vacation from 8/11/25 to 8/15/25.On 9/8/25 an order was entered into the electronic record per the Nurse Practitioner for a hospice referral.During an interview with the DON on 9/11/25 at 7:55 AM, the DON reported the following information. Resident # 8 had been declining recently. She used to eat and be involved in activities in the facility but had stopped eating and attending activities. Resident #8 also had some underlying medical problems and recent gynecological bleeding problems that had not fully been diagnosed yet. Regarding the care of Resident # 8's pressure sores, the DON reported the nurses should contact the physician about new pressures sores and obtain orders to treat any new pressure sores.On 9/10/25 at 1:30 PM the Wound Care Nurse was observed as she provided wound care for Resident # 8. Resident # 8's right heel appeared to have both pink and black tissue in the wound bed and was approximately the size of a baby food jar lid. The sacral pressure sore wound bed appeared to be pink and healing. During the interview with the Wound Care Physician on 9/10/25 at 4:32 PM the Wound Care Physician reported Resident # 8's sacral pressure sore had improved, and she did not think a lack of notifying the physician and carrying out wound care orders had resulted in the resident having a negative outcome. During an interview with the facility Medical Director on 9/11/25 at 11:45 AM, who served as the resident's primary physician, the physician reported the following information. The NP who had given the hospice order was not available that day. If Resident # 8 was appropriate for hospice services and also a diabetic, then it might be that the wounds would not heal regardless of treatment. She had not been aware of problems with communication about wound care to the facility's Wound Physician.

Based on observation, record review, and interviews with staff and physicians the facility failed to 1) ensure Nurse Aides reported skin breakdown to a nurse prior to the wound bed being unstageable (Resident # 1); 2) ensure effective communication amongst nursing staff and the Wound Physician to ensure orders were obtained, initiated, and carried out for pressure sore treatments per the Wound Care Physician's plan of care (Resident # 1 and Resident #8); 3) ensure further diagnostic studies were completed per the Wound Care Physician's directions when a wound continued not to heal (Resident # 1), and 4) ensure the settings of a pressure relieving air mattress were set correctly for pressure relief (Resident # 8). This was for 2 of 3 of three sampled residents with pressure sores (Residents # 1 and # 8). The findings included:1. Resident # 1 resided at the facility from [DATE] until her discharge to the hospital on [DATE]. Resident # 1's diagnoses included cellulitis of the lower extremities, lymphedema, venous insufficiency, chronic kidney disease, anxiety, and gout.Resident # 1's admission Minimum Data Set assessment, dated 3/17/25, coded Resident # 1 as cognitively intact and as needing substantial to maximum staff assistance for bathing needs. The resident was coded as needing partial to moderate assistance with turning in bed. Resident # 1 was not coded as having a pressure sore upon admission. She was coded as having verbal behaviors.Resident # 1's care plan, initiated on 3/12/25 and last updated on 8/29/25, included information that Resident # 1 had a pressure sore to her sacrum for which she required treatment. The care plan also included information that Resident # 1 had the potential to show verbal and physical aggression and that she could be resistive to wound care. Staff were directed on the care plan to educate the resident about possible outcomes of noncompliance.Resident # 1's electronic record included pictures as part of the documentation regarding Resident # 1's sacral pressures sore development and assessment. The first picture was recorded on 4/4/25. In the documented picture, the sacral pressure sore appeared to have both black and yellow slough tissue in the wound bed.The electronic record did not include orders on 4/4/25 for the treatment of the pressure sore.A review of Resident # 1's April 2025 Medication Administration Record and Treatment Administration Record revealed no documented treatment from 4/1/25 through 4/11/25. Documentation on these records showed that sacral pressure sore treatment began on 4/12/25.The Wound Care Nurse was interviewed on 9/9/25 at 4:15 PM and on 9/10/25 at 11:13 AM and reported she (the Wound Care Nurse) kept written notes that had not been included in the resident's electronic record. The Wound Care Nurse referenced these notes and reported the following information. Resident # 1 had been noncompliant with care. Resident # 1's sacral pressure sore was first identified by her on 4/1/25. She had been caring for the resident's legs on 4/1/25 because the resident had cellulitis. On 4/1/25 she saw the sacral pressure sore and measured the pressure sore. It was 7 cm (centimeters) X 6 cm and was not stageable because it had black necrosis (dead tissue). The Nurse Aide had not let her know about the pressure sore before she (the Wound Nurse) found it. She (the Wound Care Nurse) had been working closely with the Wound Physician, who visited every week, and the Wound Physician had educated her that black necrosis would need to be removed for healing to take place. In working with the Wound Physician, she had been told that skin prep would be an appropriate measure for necrotic tissue. Therefore, she applied skin prep for the first few days when she found the pressure sore with the plan that the Wound Physician would look at the pressure sore when the Wound Physician was next at the facility. She (the Wound Care Nurse) did not call and talk with the Wound Physician or the primary physician. She did not enter orders into the resident's record for skin prep to the pressure sore. On 4/4/25 Nurse Aide (NA) # 1 came to get her (the Wound Care Nurse) and told her that NA # 2 was applying a cream on the resident's bottom and that she (NA #1) thought it needed something more than a barrier cream. She again looked at the pressure sore and decided to use Santyl (which is a chemical debriding topical cream). She dressed and cared for the pressure sore on that date by doing so. During the interview with the Wound Care Nurse, the yearly calendar was reviewed with the Wound Care Nurse, and it was pointed out that the dates of 4/5/25 and 4/6/25 would have corresponded to a week-end. The Wound Care Nurse reported she worked week-days and that the floor nurses would have cared for the pressure sore on the week-end. The Wound Care Nurse was interviewed regarding how the primary care nurses would have known that the resident had a sacral pressure sore or what treatment orders should be followed if there were no orders entered into the resident's record. The Wound Care Nurse reported she had not recognized that as a problem.NA # 1 was interviewed on 9/10/25 at 2:50 PM and reported the following information. She did not recall a specific date but recalled that NA # 2 had called her to look at Resident # 1's bottom. NA # 2 was putting a barrier cream on an open skin area the resident had, and NA # 2 wanted her (NA # 1) to look at it. At the time, the open skin area was black and white, and she (NA # 1) told NA # 2 that it needed to be reported to the Wound Care Nurse. The Wound Care Nurse was notified that day.The Wound Care Physician was interviewed on 9/10/25 at 4:32 PM and reported the following information. She perceived the Wound Care Nurse to be very diligent in her work and very reliable but if she (the Wound Care Physician) had been contacted on 4/1/25 when Resident # 1 first was observed to have an unstageable wound she probably would not have ordered skin prep. The facility can contact her at any time to consult about orders. According to the Wound Physician, if she had been contacted on 4/1/25 she would have needed to consider how long it would be before she could actually see the resident and taken that into consideration in ordering what needed to be applied in the interim.Interview with the DON (Director of Nursing) on 9/11/25 at 11:10 AM revealed the following. NA # 2 was not available for interview during the survey. Nurse # 1 had cared for Resident # 1 on 4/5/25 (Saturday) and Nurse # 2 had cared for Resident # 1 on 4/6/25 (Sunday).An attempt was made to interview Nurse # 1 on 9/11/25 at 11:33 AM and she could not be reached for interview.Nurse # 2, who had cared for Resident # 1 on 4/6/25 (Sunday), was interviewed on 9/11/25 at 11:19 AM and reported the following information. She did not work full time at the facility, and she would not have known Resident # 1 had a pressure sore in order to do a treatment for the resident if there had been no orders. She did not ever recall caring for a pressure sore for Resident # 1.According to the record, Resident # 1 was seen by the Wound Physician on 4/8/25 for the first time. The Wound Physician documented the following information. The resident had a pressure sore with a duration of greater than four days. It measured 7 cm x 6 cm with a not measurable depth. It was 70% black necrotic tissue and, 20 % thick devitalized necrotic tissue, and 10 % granulation tissue. The Wound Physician's treatment plan for the sacral pressure sore included the following. The pressure sore was to be cleaned and an application of Santyl and Calcium Alginate was to be applied to the pressure sore on a daily basis or as needed for soiling.According to Resident # 1's electronic record, the Wound Physician's 4/8/25 treatment plan was entered in the resident's orders on 4/11/25 with a start date on the resident's MAR for 4/12/25.During the interview with the Wound Care Nurse on 9/9/25 at 4:15 PM and 9/10/25 at 11:13 AM the Wound Care Nurse reported the following information. When the Wound Physician made rounds, the Wound Physician would report to her (the Wound Care Nurse) the treatment orders/plan. She would start doing the treatments, but she would not enter the orders into the electronic record immediately. After the Wound Physician left, the Wound Physician would write the treatment plan orders and enter into a document that she (the Wound Care Nurse) would then download. From the downloaded document, she (the Wound Care Nurse) entered the orders. This was not always done on the same day that the Wound Physician visited and saw the resident. Therefore, that was why Resident # 1 had no orders from 4/8/25 until 4/11/25. Once the orders were entered they appeared on the MAR which was utilized for documentation of treatments in addition to medications.Continued review of Resident # 1's electronic record revealed the Wound Physician continued to follow Resident # 1 and on 5/30/25 orders were changed to include the application of a wound vac to the sacral pressure sore three times per week.During the interviews on 9/9/25 at 4:15 PM and 9/10/25 at 11:13 AM the Wound Care Nurse reported the following information. Resident # 1's pressure sore did not heal over several months and the Wound Physician ordered the wound vac. Resident # 1 was non-compliant and at times the wound vac seal would not work regardless of efforts to apply the dressing correctly. When the seal would break or there were problems with the wound vac, the resident would not report the issue although she was alert and oriented because she was non-compliant with the care.On 8/1/25 the Wound Physician documented the following assessment and notes. The sacral pressure sore measured 4 cm X 2.8 cm by 4.1 cm and also had undermining of 1.5 cm at the 12 o'clock position in the wound bed. (Undermining in a wound is when the edges of the wound are not connected to the lower tissues and there is an empty space beneath the edge of the wound.) The treatment still included the wound vac. Additionally the Wound Physician noted she performed a culture swab on 8/1/25. She further recommended obtaining lab work in the treatment plan to include the following: a complete blood count, an ESR (erythrocyte sedimentation rate), and a c-reactive protein. (These lab tests can help detect a possible infection and inflammation). Additionally, she recommended the resident have a x-ray of her lumbar sacral spine and coccyx to evaluate for underlying osteomyelitis or other pathology due to the resident having a chronic wound with pain.On 8/6/25 the Wound Physician documented the following assessment. The sacral pressure sore measured 6 cm X 1.4 cm X 4.6 cm with undermining of 1.3 cm at the 3 o'clock position in the wound bed. The wound bed included 10 % slough, 10 % granulation tissue, 60 % viable tissue which included subcutaneous/muscle/or fascia tissue, and 20 % skin. The Wound Physician noted the resident's lab work and x-ray were still pending and the wound culture had demonstrated that the resident had staph aureus in the wound. The antibiotic Doxycycline was ordered to be administered twice daily for 14 days.A review of Resident # 1's August 2025 MAR revealed the resident received the prescribed Doxycycline.On 8/13/25 the Wound Physician documented the following assessment. Resident # 1's sacral pressure sore measured 4.5 cm X 1.5 cm X 3. 5 cm with a total surface area of 6. 75 square cm. There was 2.5 cm undermining at the 12 o'clock position in the wound. The wound bed included 10 % slough, 40 % granulation tissue, 30 % viable tissue, and 20 % skin. The labs and the x-ray were still pending.On 8/20/25 the Wound Physician documented the following assessment. The sacral pressure sore measured 6.5 cm X 4.8 cm X 5.5 cm with a total surface area of 31.20 square centimeters. (This indicated a 24.45 square centimeter increase in total surface area in the wound bed since the Wound Physician's last assessment on 8/13/25.) The Wound Physician noted in her documentation that the lab work and x-ray were still pending.During the interview with the Wound Physician on 9/10/25 at 4:32 PM the Wound Physician reported the following information. Noncompliance could have contributed to the poor healing of Resident # 1's pressure sore. She was exceedingly unhappy if she was not on her back and would not let the staff turn her. At times she would wiggle, and the wound vac tubing would kink and turn off the vacuum. The wound started to become more painful and she had requested the labs and the x-ray to investigate if there were further problems below the wound also contributing. She thought the Wound Care Nurse was working on getting the x-ray and labs. On 8/20/25 the wound bed seemed to [NAME] even more and she became louder about the need to get the x-ray and the labs.On 8/29/25 the Wound Physician documented the following assessment. Resident # 1's sacral pressure sore measured 6.5 cm X 4.8 cm X 5.5 cm. The total surface area was 31.20 square cm. There was 2.7 cm undermining at the 12 o'clock position in the wound bed. The wound bed included 20 % slough, 40 % granulation, 40 % subcutaneous and muscle tissue. The physician's goal for the wound had not been met. Part of the problems which contributed to the lack of progress were documented to be patient non-compliant and nutritional compromise. The physician noted the labs and x-ray were still pending.Review of lab work revealed the labs were completed on 8/29/25 with the following results noted. Resident # 1's white blood count was 12.72 (normal 4.50 to 11.0). (At times an increase in white blood cells can indicate infection.) Resident # 1's c-reactive protein was 119.1 (normal <5.0). Resident # 1's ESR was 66 (normal <30). (Elevated ESR lab values and elevated c-reactive proteins can indicate inflammation in the body). Additionally, the resident's hemoglobin showed a panic value of 6.4 (normal 12.0 to 16.0).During an interview with the DON (Director of Nursing) on 9/11/2025 at 7:55 AM the DON reported the following information. She had made rounds with the Wound Physician on 8/29/25 and she was made aware of the need for the x-rays and the labs on that date. The labs were obtained, and the resident was sent to the hospital based on her lab values. The x-ray was never done at the facility since she was transferred to the hospital and the DON had not known about the need prior to that.Review of hospital records for Resident # 1's hospitalization of [DATE] to [DATE] revealed the following information. The resident underwent conservative treatment for anemia and blood loss. Additionally Resident # 1 was diagnosed with osteomyelitis and underwent surgical debridement of the sacral pressure sore with administration of intravenous antibiotics. She was discharged to another facility for continued care on [DATE].During an interview with the Wound Care Nurse on 9/11/25 at 9:40 AM the Wound Care Nurse reported the following. When a resident had an existing pressure sore then she would print out the previous orders the Wound Physician had given during the previous week and carry it with her as she made rounds with the Wound Physician. As the Wound Physician would make treatment changes based on a new assessment, she (the Wound Care Nurse) would make notations about any new orders or changes. She was on vacation for a portion of August 2025, from 8/11/25 to 8/15/25. She did not recall the Wound Physician mentioning the needed labs and the needed x-ray in August 2025. The first she recalled about the needed lab and x-ray was when the DON talked to her about it on 8/29/25. The Wound Care Nurse reported she kept all the printed out records with notes from the weekly wound rounds in a binder. During the interview she reviewed her printed out records where she and the Wound Physician had made rounds on 8/1/25. There was a written notation on the printed out record that Resident # 1 needed the lab work and the x-rays. According to the Wound Care Nurse, the notation had been made by the physician, and she did not notice it. The Wound Care Nurse was also able to locate the printed out record for the date of 8/20/25 and it included the information that the labs and the x-ray were needed. She was not sure what happened that she had not seen the orders, transcribed them and made sure they were done.During the interview with the DON on 9/11/2025 at 7:55 AM the DON reported the following information. The facility does have standing orders for wound care. Nurses are supposed to apply Wet to Dry dressings until they can contact the physician for further orders if they identify new wounds. They should also contact the physician for changes in a wound. The facility also has protocols to use based on the appearance of the wound bed and the nurse should still contact the physician and obtain orders. All this information is kept in a binder at the nursing desk and the nurses should know that. Once orders are obtained then they are placed into the electronic medical record so they can be initiated. When the Wound Physician made rounds the protocol should be that the Wound Physician writes the orders on a physician order sheet so they can be entered into the electronic record that day or she can also enter them into the electronic record herself. The primary physician does not need to approve the Wound Physician's orders in order for them to be initiated. She did not routinely read all the Wound Physician's notes and if the Wound Physician had come to her about the need for the x-ray and lab work she would have made sure it was done. When Resident # 1 had resided at the facility she had been alert and oriented. She had also been noncompliant with some aspects of her care to include refusal of therapy and refusal of medications. The DON was also interviewed about the Nurse Aides not reporting the pressure sore before it was found by the Wound Care Nurse to be unstageable and the DON reported that the Nurse Aides are going to tell you what is going on. According to the DON, NA # 2 had been assigned to Resident # 1 on the date the Wound Care Nurse reported she found the pressure sore and she (the DON) did not know why NA # 2 had not gone to the Wound Care Nurse. During an interview with the facility Medical Director on 9/11/25 at 11:45 AM, who served as Resident # 1's primary physician, the physician reported the following information. She did not recall being made aware of problems with providing wound care for Resident # 1's pressure sore. In general, if a resident was non-compliant and uncooperative with care, then it was her opinion that any problems that might have arisen with a wound could not be attributed as harm to the resident.During an interview with the Administrator on 9/11/25 at 10:30 AM, the Administrator reported the following information. No one had reported any problems with wound care at the facility or communication about orders between the Wound Physician and the staff. If he had known, he would have put a corrective action plan in place.2a. Resident # 8 was initially admitted to the facility on [DATE]. The resident had diagnoses which included diabetes, hypertension, history of stroke, dysphagia, and pain.On 7/28/25 a documented skin assessment showed no areas of skin breakdown.According to the record, Resident # 8 was hospitalized from [DATE] to [DATE] for altered mental status and a urinary tract infection.Upon the resident's return on [DATE] Nurse # 3 documented a nursing assessment. The assessment form included an area which included directions note all skin issues. On this part of the assessment form, Nurse # 3 noted sacrum. There was no further information about the size or description of what the issue was with Resident # 8's sacrum skin.Nurse # 3 was interviewed on 9/10/25 at 2:20 PM and reported she recalled Resident # 8 had an open area on the sacrum which was not deep when she was readmitted . She did not recall specific details other than that. She would have told the Wound Care Nurse.On 8/4/25 the Wound Care Nurse documented a skin assessment and noted Resident # 8 had a 5.02 cm X 3.84 cm deep tissue injury to her right heel. A heel protector and specialized boot was applied. The Wound Care Nurse did not note any area of skin breakdown to Resident # 8's sacrum.During an interview with the Wound Care Nurse on 9/10/25 at 11:13 AM the Wound Care Nurse reported she assessed Resident # 8's skin on 8/4/5 and she did not see an area of skin breakdown on 8/4/25. She did have a deep tissue injury to her right heel and she knew that skin prep would be appropriate for that. She began doing that daily with the plan for the Wound Physician to see the resident. She did not call the physician and obtain orders for the right heel deep tissue injury on 8/4/25.On 8/9/25 orders were entered into Resident # 1's electronic record to apply skin prep to the right heel deep tissue injury daily. The first documented treatment of skin prep to the right heel was on 8/10/25.There was no documented treatment for any area on the resident's sacrum from 8/4/25 to 8/9/25.On 8/10/25 at 9:00 PM Nurse # 2 documented Resident # 8 had a sacral wound which was observed to be open with no bleeding. The area was cleansed with normal saline and a dressing applied.Review of orders and the treatment records revealed Nurse # 1 obtained a one time order on 8/10/25 for the dressing she applied and documented the dressing change on 8/10/25 on the MAR (medication administration record).Following the dressing application of 8/10/25 there were no orders or plan to treat the Sacrum pressure sore until 8/20/25. There were no documented dressing changes until 8/20/25.Nurse # 2 was interviewed on 9/11/25 at 11:19 AM and reported the following information. She did not recall the specific appearance of Resident # 8's pressure sore on 8/10/25 when she got the one time order to dress the pressure sore. She did recall it was open and appeared to be more than a stage one. She had told the oncoming nurse about the pressures sore and assumed that the information would be passed along to the Wound Care Nurse and physician. She did not routinely work at the facility full time. She was not aware of any protocols the facility had.On 9/11/25 at 12:05 PM the shift change report was reviewed with the DON (Director of Nursing). According to the DON, Nurse # 2 had worked a double shift which included 7:00 AM to 11:00 PM on 8/10/25. There was a notation on the shift change report that the information had been passed along to the nurse who started work at 11:00 PM on 8/10/25 that the resident had a sacral wound. According to the DON, Nurse # 3 cared for Resident # 8 on the following day of 8/11/25 starting at 7:00 AM.Nurse # 3 was interviewed on 9/11/25 at 12:15 PM and reported she could not recall specifically what she did when the information had been passed along to her in shift change report that Resident # 8 had a sacral wound on 8/11/25. She reported she would have passed the information along to the Wound Care Nurse.On 8/20/25 the Wound Physician documented she saw Resident # 8 and found a dressing to the resident's sacrum dated 8/12/25 on the date of 8/20/25. The Wound Physician further documented the following. Resident # 8 had a Stage 4 pressure sore to the sacrum which measured 2.3 cm X 2 cm X 1 cm. There was 90 % slough and 10 % granulation tissue in the wound bed. The Wound Physician noted the area had not been known to exist by her or the Wound Care Nurse until that date (8/20/25). In part of the documentation the Wound Care Physician documented noted to be present on admission per staff. In another part of the documentation the Wound Physician noted not present upon admission. The treatment plan was for a medical honey and calcium alginate to be applied daily. The Wound Physician also noted Resident # 8 had deep tissue injury to her right heel which measured 5.1 x 4.7 x Not Measurable cm. The treatment plan was for a daily application of skin prep.The Wound Physician was interviewed on 9/10/25 at 4:32 PM and clarified her notation that read not present upon admission should have read noted present upon admission because it was her understanding the area had existed upon admission on [DATE]. She was not aware of it until 8/20/25 and on that date there was a dressing that was dated 8/12/25. That was disturbing to her that a dressing could have been on for eight days and therefore she had documented it. She did not recall how soiled the dressing was. The wound bed did not look infected.The Wound Care Nurse was interviewed on 9/10/25 at 11:13 AM and reported the following information. She did not recall an old dressing being on Resident # 8's sacrum when the pressure sore was found on 8/20/25. She did not know about the pressure sore until 8/20/25. She had been on vacation from 8/11/25 to 8/15/25.On 8/22/25 the first orders for more than a one- time treatment were entered into the electronic medical record for the resident's sacral pressure sore. The order was for the medical honey and calcium alginate to be applied daily. The first application of this dressing was documented on 8/23/25.During an interview with the Wound Care Nurse on 9/9/25 at 4:15 PM and 9/10/25 at 11:13 the Wound Care Nurse reported she would have done the dressing change to Resident # 8's sacrum on 8/21/25 and 8/22/25 per the directions of the Wound Physician. She had not entered the order into the electronic system until she downloaded the Wound Physician's instructions on a date following 8/20/25.On 8/27/25 the Wound Physician noted the following assessment and plan. Resident # 8's right heel deep tissue injury measured 5.2 cm X 5 cm X not measurable depth. There was a plan to change the treatment to an application of medical honey and calcium alginate daily. Resident # 8's sacrum pressure sore was noted to have improved and measured 2.3 cm X 1.5 cm X 0.7 cm and included 60 % granulation tissue and 40 % slough. The treatment plan remained the same for the sacral pressure sore.A review of the record revealed the new treatment plan for Resident # 8's right heel never got transcribed as an order into the electronic record. According to treatment documentation the skin prep continued.On 9/8/25 the Wound Physician documented the following assessment. Resident # 8's right heel had improved and measured 3 cm X 4.7 cm X 0.3 cm. The wound bed included 60 % necrotic tissue and 40 % granulation tissue. The treatment plan was to apply calcium alginate with a nickel thick layer of Santyl to the right heel daily. Resident # 8's sacral pressure sore had improved and was 1.4 cm X 1.6 cm X 0.1 cm. It was 100 % granulation tissue.On 9/8/25 an order was entered into the electronic record per the Nurse Practitioner for a hospice referral.During an interview with the DON on 9/11/25 at 7:55 AM, the DON reported the following information. Resident # 8 had been declining recently. She used to eat and be involved in activities in the facility but had stopped eating and attending activities. She also had some underlying medical problems and recent gynecological bleeding problems that had not fully been diagnosed yet. Regarding the care of Resident # 8's pressure sores, the DON reported the nurses should contact the physician and obtain orders to treat any new pressure sores. There was a protocol to follow. Orders should be entered into the system and be followed.According to the electronic record, orders were entered to start on 9/11/25 for the calcium alginate and Santyl to the right posterior heel. The orders, which should have been discontinued on 8/27/25 for skin prep to the right heel, were discontinued on 9/10/25.On 9/10/25 at 1:30 PM the Wound Care Nurse was observed as she provided wound care for Resident # 8. The Wound Care Nurse reported she would apply the calcium alginate to the right heel but she did not yet have the Santyl that was part of the Wound Physician's treatment plan on 9/8/25. This was because the order had not been entered on 9/8/25 and therefore the pharmacy had not sent the Santyl yet. Resident # 8's right heel appeared to have both pink and black tissue in the wound bed and was approximately the size of a baby food jar lid. The Wound Care Nurse was observed to care for Resident # 8's sacrum pressure sore as per the Wound Care Physician's orders. The wound bed appeared to be pink and healing. During the interview with the Wound Care Physician on 9/10/25 at 4:32 PM the Wound Care Physician reported Resident # 8's sacral pressure sore had improved, and she did not think a lack of communication and not carrying out orders had resulted in the resident having a negative outcome. It was her expectation that the treatment plan be carried out when she made the rounds and not days later. She routinely put the treatment plan in her notes and provided her notes to the facility before leaving the parking lot on wound round days.During an interview with the facility Medical Director on 9/11/25 at 11:45 AM, who served as the resident's primary physician, the physician reported the following information. The NP who had given the hospice order was not available that day. If Resident # 8 was appropriate for hospice services and also a diabetic, then it might be that the wounds would not heal regardless of treatment. She had not been aware of problems with communication about wound care. The Wound Physician could enter her own orders in the electronic system and did not need her (the primary physician's approval).2b. Review or Resident # 8's quarterly Minimum Data Set assessment, dated 8/10/25, revealed the resident weighed 188 pounds.On 9/9/25 at 10:27 AM Resident # 8's air mattress was observed to be on a setting for an individual that weighed 420 pounds. (The air mattress had settings which correlated to a resident's weight.) On 9/10/25 at 1:30 PM Resident # 8's air mattress was again observed to be on a setting for an individual that weighed 420 pounds. The Wound Care Nurse was interviewed at the time and reported the setting was incorrect. She reported that at times the staff might turn the setting higher to make the mattress firmer in order to turn and reposition her easier. The Wound Care Nurse reported the setting should be at 150 pounds because that was the weight setting closest to the resident's weight. The Wound Care Nurse was interviewed regarding who was responsible for checking the settings and reported that everyone was accountable to look at it and make sure it was right when they cared for Resident #8.During the interview with the Wound Care Physician on 9/10/25 at 4:32 PM the Wound Care Physician reported that if the air mattress was set for a weight more than what an individual weighed then this meant there would be more pressure on the resident.

Based on record review, resident, Resident Representative (RR), and staff interviews, the facility failed to invite a resident to participate in the development of his plan of care for 1 of 3 residents were reviewed for care planning (Resident #271). The findings included: Resident #271 was admitted to the facility on [DATE], and his diagnosis included non-traumatic brain dysfunction, renal insufficiency, diabetes, and hypertension. Resident #271's care plan dated 11/22/24 revealed a goal to discharge to the community by the next review period with a target date of 12/11/24. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed resident #271 was cognitively intact. An interview with Resident #271 was held on 12/16/24 at 2:18 PM during which he stated he had never been invited to participate in the development of his plan of care. An interview with Resident #271's Resident Rrepresentative was held on 12/18/24 at 2:02 PM, she stated she had not ever been invited to participate in the development of Resident #271's plan of care. The Social Worker was interviewed on 12/17/14 at 4:04 PM and stated Resident #271 had not had a care plan meeting. Her expectation would have been a care planning meeting was held that included Resident #271 and his representative within 21 days after admission which would have been by 12/12/24. The Social Worker also stated this Resident should be on her care plan meeting scheduled for the week of 12/30/24 but could not produce evidence that the meeting had been scheduled or anyone invited to participate. The Administrator was interviewed on 12/18/24 at 3:48 PM at which time he stated he would expect a care planning meeting to be held within 21 days of admission that included Resident #271 and the resident representative. The Social Worker is tasked with scheduling and facilitating care planning meetings.

Based on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days following the Assessment Reference Date (ARD, last day of the assessment period) for 1 of 2 residents reviewed for assessments (Resident #48). Findings included: Resident #48 was admitted to the facility on [DATE]. Review of Resident #48's MDS assessments revealed a quarterly MDS assessment with an ARD of 11/15/24 in the electronic health record with the status of in progress. During an interview on 12/17/24 at 12:45 PM MDS Nurse #1 and MDS Nurse #2 stated quarterly MDS assessments were to be completed no later than the ARD plus 14 calendar days. Due to staffing challenges, they were behind with Resident #48's quarterly MDS assessment and it was not completed timely according to the Resident Assessment Instrument (RAI) manual requirements as the assessment was still in progress. During an interview on 12/18/24 at 8:23 AM the Administrator stated MDS assessments should be completed according to the RAI manual's schedule.

Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment for antipsychotic use, hospice status, and wound status for 3 of 18 resident assessments reviewed (Resident #50, Resident #58, and Resident #173). Findings included: 1. Resident #50 was admitted to the facility on [DATE]. Review of Resident #50's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was assessed to have received an antipsychotic medication during the 7-day look back period. Review of Resident #50's Medication Administration Record (MAR) for November 2024 revealed Resident #50 did not receive an antipsychotic medication in November 2024. During an interview on 12/17/24 at 12:54 PM MDS Nurse #1 and MDS Nurse #2 stated due to staffing difficulties they were pulling answers forward from the previous assessment and then validating the information to save time when completing MDS assessments. Risperdal was discontinued on 10/2/24 for Resident #50 but the question was not corrected and was miscoded on the 11/12/24 MDS assessment. During an interview on 12/18/24 at 8:23 AM the Administrator stated MDS assessments should be accurate to the resident's status. 48230 2. Resident #173 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure. The hospice admission paperwork revealed she was admitted to hospice on 11/26/24. Resident #173's payor source on her face sheet in the record was hospice Medicaid dated 11/26/24. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #173 was severely cognitively impaired and was not coded for hospice services. In an interview with MDS Nurse #1 on 12/18/24 at 1:40 PM she stated Resident #173's MDS should have been coded for hospice as she was admitted to hospice on 11/26/24. In an interview with the Administrator on 12/18/24 at 10:33 AM he stated that the MDS should be coded accurately according to the resident's situation and Resident #173 should have been coded as receiving hospice services. 3. Resident #58 was admitted to the facility on [DATE] with diagnoses that included cutaneous abscess of left lower limb. A review of the hospital discharge summary dated 10/21/24 revealed he was discharged with a wound from surgical abscess removal. No other wounds were noted. A review of Resident #173's wound care sheets indicated he was admitted to the facility with a surgical wound from abscess removal in the hospital. No other wounds were noted. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #58 was moderately cognitively impaired and had a stage III pressure ulcer. In an interview with the Wound Care Nurse on 12/17/24 at 1:19 PM she stated Resident #58 did not have a pressure wound. She indicated he had a wound from an abscess removal done in the hospital. An interview with MDS Nurse #1 was conducted on 12/18/24 at 8:51 AM during which she stated the quarterly MDS for Resident #58 was miscoded for a pressure ulcer because he did not have one. In an interview with the Administrator on 12/18/24 at 10:33 AM he stated that the MDS should be coded accurately according to the resident's situation and Resident #58 should not have been coded as having a pressure ulcer.

Based on record review and staff interviews, the facility failed to develop and implement a comprehensive care plan for a resident that exhibited aggressive verbal behaviors, a resident prescribed an antipsychotic medication, and a resident that had a surgical wound, for 3 of 18 residents reviewed for development and implementation of a comprehensive care plan (Resident #55, Resident #62 and Resident #58). The findings included: 1. Resident #55 was admitted to the facility on [DATE] with diagnosis that included cerebral infarction, encephalopathy, and cognitive communication deficit. A review of the comprehensive care plan dated 10/3/23 and last revised on 7/30/24 did not reveal a comprehensive care plan about behaviors. A review of Resident #55's Minimum Data Set (MDS) dated [DATE] revealed he was mildly cognitively impaired and did exhibit verbal behavioral symptoms directed toward others. An interview with the Social Worker on 12/17/24 at 1:37 PM, revealed Resident # 55 was referred to Psychiatric Therapy for counselling on 7/19/23, 3/20/24, 10/16/24, and 11/27/24 to address his verbal outbursts towards other residents. The Social Worker further stated she missed adding behavioral outbursts to Resident #55's care plan on the 07/30/24 care plan update. Her expectation would be that behaviors would be included in Resident #55's care plan. An interview was conducted with the Administrator on 12/18/24 at 3:43 PM, he stated he would expect behaviors to be added to the care plan. 2. Resident #62 was admitted to the facility on [DATE] with diagnosis that included hypertension, cystitis, dementia, psychotic disturbance and mood disturbance. A review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. The assessment also revealed Resident #62 received an antipsychotic medication. Review of the December 2024 Medication Administration Record (MAR) revealed an antipsychotic medication was started on 8/30/24 and was prescribed to be given two times per day for a dementing illness with psychosis. The MAR indicated the medication was given two times a day as ordered. A review of the comprehensive care plan dated 10/1/24 and last revised on 12/16/24 did not reveal a comprehensive care plan had been established for the use of antipsychotic medication. An interview with the Social Worker on 12/18/24 at 12:00 PM revealed she would not put information regarding antipsychotic medication on a care plan unless the resident exhibited behaviors related to the side effects of the antipsychotic medication. The Director of Nursing was interviewed on 12/18/24 at 1:09 PM, she stated she would expect an antipsychotic medication would be included in the comprehensive care plan. The interventions would be added if behaviors related to the medication were exhibited. An interview with the Administrator on 12/18/24 at 3:45 PM revealed he would expect an antipsychotic medication to be included in comprehensive care plans. 48230 3. Resident #58 was admitted to the facility on [DATE] with diagnoses that included cutaneous abscess (pocket of infection under the skin) of the left leg. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #58 was moderately cognitively impaired, and the assessment did not indicate the resident had a surgical wound. A review of Resident #58's record revealed there was not a care plan for wounds. In an interview with the Wound Care Nurse on 12/17/24 at 1:19 PM she stated Resident #58 had a wound from a surgical abscess removal done in the hospital. She was unaware he did not have a wound care plan. An interview with MDS Nurse #1 was conducted on 12/18/24 at 8:51 AM when she stated she was aware Resident #58 had a surgical wound. She was unaware he did not have a care plan for wounds. MDS Nurse #1 indicated nursing would have implemented a wound care plan on admission. In an interview with the Director of Nursing (DON) on 12/18/24 at 9:03 AM she indicated she did not see a care plan for wounds for Resident #58. She stated he should have had a care plan for wounds implemented by nursing upon admission. In an interview with the Administrator on 12/18/24 at 10:33 AM he stated Resident #58 should have had a wound care plan implemented upon admission.

Based on observations, record review, and staff interviews, the facility failed to store the wet syringe separately from the barrel when Nurse #3 did not separate a bolus enteral feeding syringe (a large 2 part syringe used to administer oral medications or liquid feedings) used for medication administration through a gastrostomy tube (a hollow tube inserted directly through the skin of the abdomen into the stomach to deliver nutrition, hydration, and medication) for one of one resident (Resident #21). The deficient practice occurred for one of one staff member observed for medication administration via a gastrostomy tube. Findings included: During an observation of medication administration on 12/18/24 at 1:52 PM Nurse #3 entered Resident #21's room to administer medications via a gastrostomy tube. Nurse #3 administered the medication using a 2-part piston and barrel bolus enteral feeding syringe through a gastrostomy tube, rinsed the piston and barrel syringe with water and replaced the piston into the barrel and then placed the wet syringe back into a plastic storage bag. An interview conducted with Nurse #3 on 12/18/24 at 1:52 PM revealed she stored the syringe with the piston inserted into the barrel and did not separate them to dry. She stated she was not supposed to leave the piston and barrel separated to dry and stored them together and placed them in the plastic storage bag. During an interview with the Director of Nursing (DON) on 12/18/24 3:26 PM she stated Nurse #3 should have separated the bolus feeding syringe that was used to administer medication to Resident #21 to prevent the growth of bacteria in the syringe during storage.

Based on observations, record review, and staff interviews, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #3, the Wound Nurse, and the Wound Physician failed to apply a gown before entering residents' rooms to provide high contact care activities for two of two residents (Resident #21 and Resident #58). The deficient practice occurred for three of three caregivers observed for infection control practices. These deficient practices placed residents at risk for infection. Findings included: Review of the facility policy on EBP, dated 4/1/2024, revealed in part EBP was an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employed the use gloves and gowns during high contact resident care activities. The policy further stated EBP use included care for residents with indwelling medical devices during high contact resident care. High contact care was further defined to include feeding tubes. 1. During an observation of medication administration on 12/18/24 at 1:52 PM Nurse #3 entered Resident #21's room to administer medications via a gastrostomy tube. Nurse #3 performed hand hygiene upon entering the room and donned (put on) a clean pair of gloves but did not don a gown. Nurse #3 administered the medication using a bolus enteral feeding syringe (a large 2-part syringe used to administer oral medications or liquid feedings) through a gastrostomy tube (a hollow tube inserted directly through the skin of the abdomen into the stomach to deliver nutrition, hydration, and medication). Review of the careplan for Resident #21 dated 7/17/24 revealed she was care planned for EBP related to a feeding tube. In an interview with Nurse #3 on 12/18/24 at 3:22 PM she stated the facility did not practice EBP for indwelling devices and was not aware she should have worn a gown for a Resident #21 when she administered medications via a gastrostomy tube. An interview was conducted with the Wound Physician on 12/18/24 at 2:45 PM. During the interview she stated the facility should have followed EBP for a resident with an indwelling device. She stated Nurse #3 should have worn gloves and a gown when she administered medications to Resident #21. She further indicated that there was risk for transmission of multidrug resistant organisms (bacteria) or other bacteria from the healthcare provider to the resident and vice versa and infection could be spread to other residents or staff members. She went on to state EBP should have been followed because it was recommended by the Centers for Disease Control and Prevention (CDC) to prevent the spread of infection. During an interview with the Director of Nursing (DON) on 12/18/24 3:26 PM she stated Nurse #3 should have worn gloves and a gown to provide care to protect the resident from infection. The DON stated staff were trained on EBP on hire and as needed. She stated EBP signage was not posted for residents with indwelling medical devices because it was not required. The DON further stated residents that were on EBP were care planned and staff had access to the careplan. In an interview with the Administrator on 12/19/24 at 11:17 AM he stated all staff were educated on EBP upon hire as it is part of the infection control training they received. He further stated Nurse #3 should have worn a gown when she provided care to Resident #21. The Administrator further indicated staff were trained on infection control on hire and that included EBP. 48230 2. A review of the facilities policy titled Enhanced Barrier Precautions (EBP) dated 4/1/24 stated in part: For residents for whom EBP are indicated (ie: wounds), EBP is employed when performing the following high-contact resident care activities: wound care: any skin opening requiring a dressing. During an observation on 12/18/24 at 2:02 PM, the Wound Care Physician and Wound Care Nurse entered Resident #58's room to provide wound care without donning gowns. The Wound Care Physician performed a wound treatment with an ultrasonic mist machine that sprays mist onto the wound to help with wound healing. She provided this treatment for three minutes wearing clean gloves and no gown. Afterwards, the Wound Care Nurse went into the hall to collect supplies to cover the wound. The Wound Care Nurse collected the supplies, put on clean gloves and entered the room again without donning a gown. She proceeded to apply the ordered wound dressing to the wound. The care plan dated 7/2/24 indicated Resident #58 was on EBP. The goal was for EBP to be maintained by staff during high contact resident care. Interventions included staff to don disposable gown and gloves for chronic wound care. In an interview with the Wound Care Physician and the Wound Care Nurse on 12/18/24 at 2:19 PM the Wound Care Physician stated she was unaware that the resident was on EBP and if she had known she would have worn a gown. The Wound Care Nurse stated she was unaware that the facility used EBP, that she was not trained on EBP and had worked there since May of 2024. An interview with the Director of Nursing (DON) was conducted on 12/18/24 at 2:29 PM. The DON stated the Wound Care Physician and the Wound Care Nurse should have worn gloves and a gown to provide wound care to protect the resident from possible infection. She further stated they did not use EBP signage. The DON indicated that staff should know which resident needs EBP based on the policy, education they received, and the Residents needs. In an interview with the Administrator on 12/18/24 at 2:34 PM he stated all staff were educated on EBP upon hire as it is part of the infection control training they received. He further stated the Wound Care Physician and Wound Care Nurse should have worn a gown when providing wound care to Resident #58. The Administrator indicated the facility did not use EBP signage but that staff were trained on the policy upon hire.

Based on observation, record review, and interviews with staff, Physician, Psychiatric Nurse Practitioner, and the facility's Pharmacy Consultant the facility failed to 1) analyze Resident #2's falls to determine causative factors and implement interventions to reduce the risk for further falls and 2) ensure a paraplegic resident (Resident # 1) did not roll out of bed during care. Resident # 2 was identified to have an impacted arm fracture (a fracture that generally occurs following a fall). This was for two of three sampled residents reviewed for accidents. The findings included: 1. Resident # 2 was admitted to the facility on [DATE]. Resident # 2's diagnoses in part included vascular dementia, bipolar disorder, personality disorder, chronic kidney disease, and hypertension. Resident # 2's quarterly Minimum Dat Set assessment, dated 1/11/24, coded Resident # 2 as the following. The resident was severely cognitively impaired; dependent on staff for bathing and dressing; required substantial to maximum assistance for transfers and going from a sitting to standing position; required partial to moderate assistance with rolling in bed, going from a sitting to lying position, and going from a lying to sitting position; had a history of one fall without injury since the last assessment, and required substantial to maximum assistance to walk 10 feet. Resident # 2's care plan, dated 3/7/24, noted Resident # 2 had a history of falls related to poor balance and unsteady gait. One of the care plan interventions directed to determine and address causative factors of the resident's falls. On 1/11/24 at 6:39 PM the wound care nurse, who was no longer employed at the facility, documented in a nursing note the following information. Resident # 2 had an unwitnessed fall in her room. The resident reported that God had told her to walk. Resident # 2 was noted to have a nose bleed and no other injuries. The medical Nurse Practitioner was notified and instructed that Resident # 2 be monitored. On the date of the 1/11/24 fall, a review of Resident # 2's vital signs log revealed the following: 1/11/24 at 10:25 PM pulse was 57; on 1/11/24 at 10:26 PM pulse was 59. Resident # 2's blood pressure registered 109/57 on 1/11/24 at 10:25 PM. The day following the fall, Resident # 2's pulse was documented to be 59 at 12:11 AM on 1/12/24 and her blood pressure was 113/63 while lying down. On 3/28/24 the DON (Director of Nursing) provided the facility's investigation documentation into the 1/11/24 fall. The notes were dated 1/12/24 and read, Therapy evaluate. Wearing proper footwear at all time. Make sure bed to lowest position while in bed with call bell within reach but has cognitive changes. Up in chair during day to engage in activities. Nursing focal rounds. The rehabilitation manager was interviewed on 3/27/24 at 2:40 PM and reported the following. There was no documentation Resident # 2 had been evaluated or screened by therapy staff since the date of 12/7/23. That was the date of the last documented screen. At that time, therapy was not indicated because the resident did not have the cognitive abilities to follow commands and participate. A review of physician orders revealed that at the time of the 1/11/24 fall Resident # 2 was receiving Risperdal (an antipsychotic medication) 1.5 mg (milligrams) two times per day. This dosage had been prescribed since 12/15/23. Resident # 2 was also ordered to receive Minipress (a hypertension medication) 1 milligram daily. This dosage had been prescribed since 6/21/22. On 1/15/24 the medical Nurse Practitioner (NP) noted she saw Resident # 2 for a fall and that nursing staff were reporting Resident # 2 had been deteriorating mentally for the last 6 months. The NP noted the resident's medications were reviewed and that her current medications would be continued. On 1/17/24 Resident # 2's medical physician saw Resident # 2. At that time the physician noted the following. All meds were evaluated individually and felt to have a positive risk/benefit ratio. There were no side effects reported by nursing at this time. The nursing staff were to let her know if there were problems. At time of the assessment, the physician noted the resident's pulse was 54. On 1/17/24 Resident # 2 was also seen by the Psychiatric Nurse Practitioner who noted staff reported Resident # 2's hallucinations had worsened. On 1/17/24 Resident # 2's Risperdal was increased to 2 mg two times per day. On 1/21/24 at 8:16 PM the wound care nurse documented in a nursing note the following information. Resident # 2 had been found on the floor and was bleeding from her head. She was transferred to the hospital ED (Emergency Department) for evaluation. Review of hospital ED records revealed Resident # 2 had lab work, CT (computed tomography) studies of her head/ spine, and an EKG (electrocardiogram) performed. According to the ED notes, the CT scans were negative. On 1/22/24 at 1:32 AM a facility nursing entry noted Resident # 2 returned at 11:50 PM on 1/21/24 with her head bandaged and her x-rays had been clear. On 3/28/24 the DON (Director of Nursing) provided the facility's investigation documentation into the 1/21/24 fall. The notes on the investigation were made on 1/22/24 and read, Therapy evaluate. Make sure wearing proper footwear at all times. Make sure bed to lowest position while in bed with call bell within reach but has cognitive changes. Up in chair during day to engage in activities. Nursing focal rounds. Resident was sent to the hospital for evaluation. On 1/22/24 Resident # 2 was seen by the medical NP again who noted the following. Resident # 2 had fallen over the weekend. The NP noted Resident # 2 was sent to the ED because she had hit her head, and all scans were negative. The resident could not tell the NP how she had fallen. The NP noted she had reviewed the medications, and they would be continued. Two days after the 1/22/24 fall, on the date of 1/24/24 at 12:00 AM Resident # 2's pulse was documented to be 51. Her blood pressure was documented to be 106/67 at that time while lying down. On 1/25/24 at 12:28 AM Resident # 2's pulse was documented to be 59 and her blood pressure was 128/73 while lying down. On 1/26/24 at 8:38 AM Nurse # 2 documented in a nursing note the following information. The nurse had been exiting the room across the hallway when she saw Resident # 2 on the floor. The resident was not able to verbalize how she had gotten on the floor. She was assessed and found to have no injuries. Nurse # 2 was interviewed on 3/27/24 at 11:05 PM via phone and reported the following. The staff had recently seen Resident # 2 prior to her being found on the floor. She (the nurse) was exiting the room across the hall when she looked into Resident # 2's room and saw that she was on the floor. She was assessed and not found to have any injuries. On 3/28/24 the DON (Director of Nursing) provided the facility's investigation documentation into the 1/26/24 fall. The notes on the investigation were made on 1/26/24 and read, Therapy evaluate. Make sure wearing proper footwear at all times. Make sure bed to lowest position while in bed with call bell within reach but has cognitive changes. Up in chair during day to engage in activities. Nursing focal rounding. There was no documentation Resident # 2's medications were evaluated in relation to her falls. On 1/29/24 at 4:42 AM there was a note in the vital sign log that Resident # 2's pulse was 58 and irregular. Beside this documentation, there was a note which read, new onset. At the time her blood pressure was 132/74 while lying down. On 1/31/24 Resident # 2 was seen by the Psychiatric NP who noted staff reported no new concerns. On 2/2/24 at 6:25 AM Nurse # 2 documented the following in a nursing note. She had been called to the room at 4:30 AM by a Nurse Aide. Resident # 2 had been found lying on the floor. Resident # 2 reported she had hit her head and her head hurt. A total physical assessment was performed and there were no contusions, bruising, or bleeding noted. The resident was able to move all her extremities. The on- call provider was contacted and ordered the resident to be evaluated at the hospital. The resident was transported to the ED at 5:50 AM. Review of Resident # 2's hospital 2/5/24 discharge summary revealed following the fall on 2/2/24 she was hospitalized from 2/2/24 to 2/5/24. The hospital physician noted Resident # 2 had been admitted for recurrent falls. It was identified that Resident # 2 had orthostatic hypotension and bradycardia. (Orthostatic hypotension occurs when an individual's blood pressure suddenly drops when they stand up from a sitting or lying position and can cause someone to feel dizzy or faint. Bradycardia is an abnormally low heart rate). On the discharge summary the physician further noted the following. Resident # 2's medications were reviewed and her Risperdal and prazosin (Minipress) were discontinued due to the side effect of orthostatic hypotension. Her EKG's (electrocardiogram) had shown she had bradycardia (a low heart rate). Cardiology was consulted and recommended a zio patch and to replete her electrolytes. She was to follow up with cardiology. The physician further noted, repeat blood pressure check and monitoring at facility. (A zio patch is a patch which monitors an individual's heart activity.) On 3/28/24 the DON (Director of Nursing) provided the facility's investigation documentation into the 2/2/24 fall. The notes were dated 2/2/24 and read, Therapy continued. Make sure wearing proper footwear at all times. Make sure bed to lowest position while in bed with call bell within reach but had cognitive changes. Up in chair during day to engage in activities. Nursing focal rounding. Resident was sent to the hospital for further evaluation. Upon Resident # 2's return to the facility on [DATE] her Minipress and Risperdal were not continued. On 2/14/24 Resident # 2 was seen by the Psychiatric NP, who noted since Resident # 2's return to the facility she had been experiencing distressing hallucinations. The Psychiatric NP noted Resident # 2's Risperdal would be restarted at 2 mg twice per day. Review of physician orders revealed on 2/14/24 Resident # 2's Risperdal was restarted at 2 mg twice per day. On 3/28/24 at 9 AM the Psychiatric NP was interviewed and reported the following. She was not aware the hospital thought that Resident # 2's medications were contributing to orthostatic hypotension and falls. She was not aware Resident # 2 had sustained four falls in less than a month's time period. The Psychiatric NP was interviewed regarding if there were other medications that might not cause the orthostatic hypotension and stated she could try other alternatives that might not. The facility's Consultant Pharmacist was interviewed on 3/28/24 at 1:15 PM and reported the following. She was familiar with Resident # 2 and knew she had undergone multiple attempts at Risperdal drug reduction and failed. She had severe psychiatric problems. She was not aware of any other medications that would help with Resident # 2's psychiatric problems and not contribute to orthostatic hypotension, and she was not aware of any other good medication alternative to the Risperdal for Resident # 2. The consulting pharmacist thought the Minipress probably had contributed more to the Resident's orthostatic hypotension than Risperdal. Between the dates of 2/5/24 and 3/4/24 there were no documented falls or accidents for Resident # 2 within her medical record. On 3/4/24 at 1:58 PM the ADON (Assistant Director of Nursing) documented in a nursing entry that Resident # 2 complained of left arm pain with movement and the medical Nurse Practitioner had ordered an x-ray to be completed. On 3/4/24 the medical Nurse Practitioner noted the following. Resident # 2 was complaining of left arm pain. The nursing staff were unaware of any recent falls or traumatic injury to her left arm. When attempts were made to gently rotate and lift Resident # 2's arm, the resident screamed in pain. There was no bruising, swelling, or abrasions noted. The medical NP noted she would order an x-ray of the resident's arm. On 3/4/24 at 10:26 PM Nurse # 9 documented the following in a nursing note. Resident # 2's x-ray result had returned and showed she had an impacted fracture of the humerus (arm bone) and shoulder. She was transferred to the hospital for care. Review of hospital records for the dates of 3/4/24 to 3/7/24 revealed the following. The hospital physician noted Resident # 2 had a mildly displaced, moderately impacted, mildly comminuted and minimally angulated left metaphyseal/humeral neck fracture. (A comminuted fracture is where the bone is fractured into more than one piece. An impacted fracture is where the ends of bones are driven into each other from the injury.) According to the hospital physician, the resident was seen by an orthopedic who recommended immobilizing Resident # 2's arm in a sling. Surgery was not recommended. While hospitalized , Resident # 2 was also found to have a pulmonary embolism for which she was treated. She was discharged on [DATE]. On 3/7/24 the ADON noted at 2:57 PM in a nursing entry that Resident # 2 had returned with her left arm in a shoulder sling. Swelling and bruising were noted. She had no complaints at the time of the ADON's assessment. NA # 3 and NA # 4 were interviewed on 3/27/24 at 4:15 PM together. These two NAs reported they had worked together to care for Resident # 2 on the 3:00 PM to 11:00 PM shift of 3/3/24. The Nurse Aides reported the following. Resident # 2 had been fine on their shift and had no complaints of pain nor did she fall. She hallucinated at times and believed that Jesus would tell her to get up and walk. Nurse 7 was interviewed on 3/27/24 at 5:59 PM. Nurse # 7 had cared for Resident # 2 on the 3:00 to 11:00 PM shift on 3/3/24. Nurse # 7 reported the following. Resident # 2 was in bed on 3/3/24 and did not fall. She was okay during the shift. She had worked with Resident # 2 a few times. When she worked with her, Resident # 2 could not stand up and walk by herself. She did not recall speaking to the Director of Nursing or Administrator about how Resident # 2 could have injured herself after Resident # 2 was determined to have a fracture. Nurse # 1 was interviewed on 3/28/24 at 8:09 AM and reported the following. She had cared for Resident # 2 on the night shift which began at 11:00 PM on 3/3/24 and extended to 7:00 PM on 3/4/24. Nothing had happened on that shift of which she was aware. She (Nurse # 1) generally worked at the facility about five times per month part time. When she had worked with Resident # 2, the resident had been fine since her 2/2/24 fall. She could walk some but was unsteady. At times Resident # 2 would come to her room's door and staff would have to redirect her. She (Nurse # 2) was not aware of what had occurred to cause Resident # 2's fracture. After Resident # 2's fracture was identified, none of the administrative staff had talked to her about the events of her night shift which began on 3/3/24. NA # 5 was interviewed on 3/27/24 at 11:10 PM and reported the following. She had cared for Resident # 2 on the night shift which began at 11:00 PM on 3/3/24 and extended to 7:00 AM on 3/4/24. Resident # 2 had not fallen on her shift. With every round check, Resident # 2 had been in bed and had no complaints. NA # 1 was interviewed on 3/27/24 at 12:25 PM and reported the following. He had cared for Resident # 2 on the 7:00 AM to 3:00 PM shift on 3/4/24. When he arrived Resident # 2 was in bed. He helped feed Resident # 2 breakfast. She did not have to move her arm at that time to eat, and she did not complain of anything. After breakfast he went into provide care. He began to remove her gown for care and had barely pulled on the gown to remove it. As he moved her arm, she began to scream. She complained her arm was hurting. He immediately stopped and got a nurse. Medication Aide # 1 was interviewed on 3/27/24 at 12:15 PM and reported the following. She had been the Medication Aide on 3/4/24 on the shift which began at 7:00 AM. There had been nothing in the morning's nursing report about her arm hurting. NA # 1 had alerted her on 3/4/24 that Resident # 2 was having pain in her arm when he started to prepare to bathe her. She informed a nurse that the resident was having pain in her arm, and they obtained an order to x-ray her arm. MA # 1 further reported that before the fracture, Resident # 2 thought she could walk but she really could not do so. The staff had to keep an eye on her. On 3/27/24 at 12:10 PM, Resident # 2 was observed in bed. She appeared confused. She was not able to say how her arm had been hurt. The Director of Nursing was interviewed on 3/28/24 at 8:00 AM and reported the following. She had verbally talked to the staff who had cared for Resident # 2 on the shifts before Resident # 2 had a fracture. No one had said anything had happened to cause the fracture. She did not investigate further because she thought the fracture was due to the fall which had occurred on 2/2/24 and had not been identified at the time of the 2/2/24 fall. During a follow up interview with the Director of Nursing on 3/28/24 at 10:30 AM the DON reported Resident # 2 would remove her heart monitor. Without the data, the cardiologist would not see her and therefore Resident # 2 had not had a follow up appointment with cardiology. The DON was interviewed about how the facility reviews falls and reported that every Friday all disciplines look at the past week's falls. They discuss such things as therapy screens, medications, proper footwear, and communication with the physician. She recalled that she had talked to Resident # 2's medical director about Resident # 2's fracture. The resident's physician, who serves as the facility's medical director, was interviewed on 3/28/24 at 2:15 PM and reported the following. Generally, an impacted fall occurs when an individual puts out their arm to break a fall. The pressure on the bones to break the fall then breaks the bone. The physician reported in general if someone falls, then they would push with their arms and/or legs to get themselves up. She was unsure if Resident # 2 would have the physical capability to get herself off the floor if she had fallen. As medical director she did not recall anyone speaking to her about the events that transpired before the fracture occurred or discussed her medical opinion regarding the fracture. The physician noted that there was no indication in the record that the 2/2/24 fall had contributed to the fracture. The physician was also interviewed about the frequency of Resident # 2's falls since January 2024 and the resident's medications. The physician reported that at times the medical NP sees the resident in between the physician's visits, and she (the physician) had not realized the number of falls Resident # 2 had sustained until the discussion with the surveyor. She further reported that Resident # 2 had been on Risperdal for a long time, and she felt that Minipress had contributed more to her orthostatic hypotension than the Risperdal. The facility's Administrator was interviewed on 4/5/24 at 8:53 AM and reported the following. The facility talked about falls every day. He could not recall specifics of their daily discussions. 13030 2. Resident #1 had multiple diagnoses some of which included paraplegia, cerebral vascular accident with left sided weakness, aphasia, and post percutaneous gastrostomy tube placement. Documentation on the most recent quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 had moderately impaired cognition and was dependent on staff for all activities of daily living. Resident #1 was also coded on the same assessment as having range of motion impairment on both sides of upper and lower extremities. Documentation on a care plan dated 2/8/2024 for Resident #1 revealed a focus area for a high risk for falls relative to muscle weakness and cerebral vascular accident with left hemiparesis. Documentation in an incident note dated 2/21/2024 at 12:49 PM revealed, [Nursing Assistant #1] (NA #1) called this writer in the resident's room, on arrival, Resident (#1) is seen lying down on the floor with head up. Quick assessment done, noted resident to be bleeding from the right-side forehead. Code green activated, Vitals done [Blood Pressure] 115/70 [millimeters mercury] [pulse] 68 [beats per minute] [Temperature] 97.5 [Fahrenheit] [Respirations] 18 [Saturation of Peripheral Oxygen] 97 [Room Air]. Resident points to the head if asked if in pain. Dressing applied with cold pack. 911 called, [Medical Director] paged in the building came at bedside to assess [patient]. Wound Nurse, DON (Director of Nursing), ADON (Assistant Director of Nursing) at bedside relatives made aware 911 arrived and transferred resident to hospital. Documentation in a hospital emergency department note dated 2/21/2024 revealed Resident #1 was treated for a superficial forehead laceration on the right side with tissue adhesive and returned to the facility. An interview was conducted with NA #1 on 3/27/2024 at 12:44 PM. NA #1 explained that he had been giving Resident #1 a bath when he fell out of bed on 2/21/2024. NA #1 revealed the short upper side rails were up and Resident #1 was on his left side and grabbing onto the side rail with his right hand. NA #1 stated that it was usually not a problem to give Resident #1 a bath by himself but on this occasion the arm of Resident #1 must have gave out and he rolled off the bed so fast I couldn't catch him. An interview was conducted with the Rehabilitation Manager on 3/29/2024 at 1:46 PM. The Rehabilitation Manager revealed there had not been a recent rehabilitation screen for Resident #1, but Resident #1 did have a bed rail/ assist evaluation completed on 2/28/2024. The Rehabilitation Manager stated that after the fall from the bed the abilities of Resident #1 had not changed but Resident #1 had the upper side rails changed from a short rail to a half rail to aid in bed mobility and positioning. The Rehabilitation Manager revealed Resident #1 had no ability to move his entire left side and on his right side he had no lower or upper body strength but could grip with his right hand for a brief amount of time. NA #1 was interviewed again on 3/27/2024 at 2:38 PM. NA #1 revealed he had pulled Resident #1 to the middle of the bed prior to him falling, but Resident #1 just couldn't hold himself using the rail and he rolled so quickly NA #1 was not able to catch him. NA #1 stated that Resident #1 did have a different side rail now after the fall. An interview was conducted with the DON on 3/27/2024 at 2:45 PM. The DON stated that Resident #1 would not have fallen from the bed had good body mechanics and positioning been used by NA #1. The DON stated that an in-service was conducted with all the nurse aides to include NA #1 on falls prevention with positioning during the provision of activities of daily living. The DON was interviewed again on 3/28/2024 at 10:38 AM. The DON explained that she verbally questions the staff as to what happened in each fall or injury a resident has but does not document these interviews. The DON explained that the facility interdisciplinary team meets every Friday to go over the falls in the facility and to discuss interventions. The DON explained the interventions usually included having a therapy screen, keeping the bed in the lowest position, frequent monitoring by staff, call bell in place, and appropriate footwear.

Based on record review, staff interviews, and physician interview, the facility failed to assess and identify for pressure injury areas for 1 of 4 residents reviewed for pressure ulcers (Resident #38). Upon admission to the hospital, the hospital identified the presence of four pressure areas. Three areas were deep tissue wounds and one was unstageable. Following readmission to the nursing home, treatment records were not consistently documented as completed. Immediate jeopardy began on 6/25/20 when the facility failed to assess and identify pressure injury areas for Resident #38. Resident #38 was sent to the hospital and 4 pressure injury areas were identified as present on admission. The immediate jeopardy was removed on 4/12/21 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that the education and the monitoring systems put in place to remove the immediate jeopardy are effective and to correct current deficient practice as identified in 1.b. Findings included: 1.a. Resident #38 was admitted to the facility on [DATE]. She was discharged to the hospital on 6/25/20 and returned to the facility on [DATE]. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set, dated dated dated [DATE] indicated Resident #38 was moderately cognitively impaired and was coded as total dependence for most activities of daily living except was independent with locomotion on the unit. She was coded as always incontinent for bowel and bladder. She was also coded as at risk for development of pressure ulcers or injuries. Resident #38's care plan revised on 6/25/20 revealed a focus for the potential for pressure ulcer development related to a history of ulcers, immobility, bowel and bladder incontinence, fragile skin, weight loss and decreased oral intake. Care plan interventions for this goal included to follow facility policies and protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility weekly skin assessments revealed a skin assessment dated [DATE] which identified no skin injuries or wounds were identified. Nurse #11 had completed Resident #38's weekly skin assessment on 5/30/20 and he was interviewed on 4/09/21 at 12:48 PM. He stated he completed skin assessments whenever the 'system popped up' for him to complete them and he did not remember this particular assessment. Resident #38's facility weekly skin assessments revealed no skin assessments from 5/30/20 through 7/18/20 were documented under the skin assessment tab in the electronic medical record. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The June 2020 Treatment Administration Record (TAR) revealed no treatments completed for Resident #38's right leg, heel, or foot. Review of the hospital history and physical dated 6/26/20 read that Resident #38 presented to the hospital on the evening of 6/25/20 with lethargy, altered mental status and abnormal lab. Resident #38's hospital records dated 6/26/20 and 6/30/20 revealed she had 4 pressure injury areas identified as present on admission. These four pressure injury areas were: (1) a deep tissue injury (DTI) to the right lateral, distal foot; (2) a DTI to the right distal, lateral, proximal foot; (3) a DTI to the right lateral ankle; (4) and an unstageable area to the right heel. Resident #38's facility nursing admission/readmission assessment dated [DATE] read that she had an unstageable right heel pressure injury; a pressure injury DTI to the right lateral foot; a pressure injury unstageable to the right lateral foot; and another pressure injury DTI to the right lateral foot. An interview with the Nursing Assistant (NA) #3 on 4/09/21 at 12:29 PM revealed she provided care for Resident #38 in June 2020. She stated she gave her daily baths and if she had seen anything on her right leg, foot or heel, she would have reported it to the nurse. She stated the resident wore socks and padded boots which she removed during bathing. An interview with Nurse #2 on 4/09/21 at 12:41 PM revealed the hall nurses were responsible for completion of Resident #38's weekly skin assessment. She stated the NAs were also responsible for notifying the nurse of any wound concerns noted during resident care. Nurse #2 stated the hall nurse was responsible for assessment of any skin or wound areas and initiating a referral to the Wound Care Nurse. She did not remember if she had performed any skin assessments on Resident #38 during June 2020. An interview with Wound Care Nurse #1 on 4/09/21 at 8:16 AM revealed she was responsible for ensuring wound care was provided for Resident #38. She stated the hall nurses were responsible for completing the weekly skin assessments and referrals to her for any observed wounds. She stated she had not been notified in June of any pressure areas for Resident #38's right leg, foot, or ankle prior to her return from the hospital on June 30. She stated she became aware of Resident #38's right leg pressure areas after she returned from the hospital on June 30. Her assessment and treatment orders for Resident #38 on 6/30/20 included: an unstageable pressure injury to the right heel, a DTI to the right lateral foot, an unstageable pressure injury to the right lateral foot, and a DTI to the right lateral foot. An interview with Resident #38's current physician on 4/09/21 at 10:57 AM revealed she was not the resident's physician in June 2020. She stated the resident had multiple comorbidities, poor nutrition, and very fragile skin. An interview with the Director of Nursing (DON) on 4/09/21 at 9:39 AM revealed she had become aware in December 2020 that weekly skin assessments had not been completed and had been working to correct this. She also revealed she was not employed at the facility in June and had no knowledge of whether Resident #38 had pressure wounds or not. An interview with the Administrator on 04/09/21 at 3:30 PM revealed he was unaware of any concerns related to wound care for Resident #38. The Administrator was notified of Immediate Jeopardy on 4/09/21 at 3:30 PM. On 4/10/21 the facility provided the following credible allegation of Immediate Jeopardy removal. East [NAME] Rehabilitation and Wellness Credible Allegation for F686 for removal of Immediate Jeopardy completed on 4/10/21 I. Resident #38 is the only identified resident who has suffered or is likely to suffer a serious adverse outcome as a result of noncompliance II. Resident #38 had a full body skin assessment performed to ensure that any pressure ulcers are properly identified. No new skin injuries were identified at this time. This assessment was completed on 4-9-2021. This assessment was completed by the Treatment Nurse. B. Every other resident in the facility had a full body skin assessment performed by a nurse. The skin assessments were performed to identify any new skin injuries. Any new skin injuries will be reported to the treatment nurse and attending physician as identified. These assessments were completed on 4-9-2021. The DON or ADON will review all performed skin assessment to ensure that any new areas are properly reported to the treatment nurse and attending physician. C. The facility licensed nursing staff were inserviced on the weekly skin assessments that are to be completed. The facility licensed nursing staff were also inserviced on the process of informing the treatment nurse regarding any new skin injuries to a resident. The inservices were performed by the DON and ADON and will be completed on 4-12-2021. D. Upon admission to the facility, the newly admitted resident will have a skin assessment performed by a licensed nurse. After the initial skin assessment is performed on admission a weekly skin assessment will be performed by a licensed nurse on a weekly basis. E. The aides who are employed by the facility will be inserviced on the procedure of reporting any noticed skin issues to their nurse and how the nurse will handle that information. The licensed nurses will be inserviced on what to do when their aides report new skin conditions to them including a visual assessment, documentation and notifying attending physician, treatment nurse and nursing management. These inservices will be performed by the DON or ADON and will be completed by 4-12-2021. F. The facility treatment nurse will be doing the admission skin assessment, in the event that the treatment nurse is not working then the cart nurse will perform the skin assessment. The treatment nurse has already been notified regarding this and was reminded on 4-9-2021. G. The med cart nurses will be responsible for completing the weekly skin assessment. The nurses were inserviced by the DON/ADON on this and this inservice will be completed by 4-12-2021. H. Staff are going to be inserviced during a mandatory inservice that they will attend at the facility. If any are unable to attend, then the DON or ADON will call those staff members and perform the inservice via phone. I. On March 31st an inservice was given to the licensed nurses regarding how to assess, stage and describe pressure ulcers. The DON and/or ADON will also make rounds with the treatment nurse to ensure pressure ulcers are assessed and staged appropriately. J. The DON and/or ADON will be monitoring the skin assessment to ensure that they are completed in a timely manner. They will review the skin assessments 2 times a week to ensure completion. We will have the above completed by 4-12-2021 The credible allegation was verified on 4/13/21 as evidenced by record review and staff interviews. Interviews were conducted with a sample of staff members to verify education was conducted for all employees regarding completion of weekly skin assessments and the procedure of reporting any noticed skin issues to their nurse and how the nurse will handle that information. Documentation of in-service records were reviewed. A sample of weekly resident skin assessments was conducted. All of the evidence indicated the facility had removed the Immediate Jeopardy by 4/12/21. 1.b. The July 2020 TAR revealed treatments as follows: 1.[MEDICATION(S)] ointment (antibacterial ointment) started on July 1. To be applied to the right heel every Monday, Wednesday, and Friday. This was initialed as completed as ordered except was not signed as completed for July 31. 2. Cleanse right lateral foot DTI and apply skin preparation and cover with a dressing daily. This was initialed as completed July 1 through July 31, except July 5 was not initialed as completed. 3. Apply Santyl ointment (a [MEDICATION(S)] agent) to the right ankle daily. This was initialed as completed July 1 through July 31, except July 5 was not initialed as completed. 4. Apply Santyl ointment to the right lateral foot in 2 areas daily. This was initialed as completed July 1 through July 31, except July 5 and July 31 were not initialed as completed. An interview with Nurse #11 on 4/09/21 at 12:48 PM revealed he did treatments if it 'popped up in the system' for him to do them and he did not remember if he had ever completed a treatment on Resident #38. He also revealed if he had completed a treatment, he had signed as completed on the TAR. An interview with Wound Care Nurse #1 on 4/09/21 at 8:16 AM revealed she did not know if the unsigned were completed or not. She stated if she was not at the facility, it was the responsibility of the hall nurse to complete the treatments. She also stated if she completed a treatment, she signed it on the TAR.